- Diabetic patients with complaints of fatigue need focused evaluation, note specialists
BY Ruwan Laknath Jayakody
rkers involved in diabetes care should understand that diabetes and fatigue are interrelated, and since lifestyle interventions resulting in weight loss, the awareness and treatment of sleep disorders and depression, and regular physical activity may reduce fatigue, patients presenting with the complaint of fatigue should not be neglected and need focused evaluation, as this symptom impairs the physical and mental wellbeing and quality of life of patients.
These observations were made in an editorial on “Why does my diabetes make me so tired?” which was authored by D. Karuppiah (attached to the Diabetes and Endocrinology Unit of the Teaching Hospital in Batticaloa) and S. Pathmanathan (attached to a similar Unit at the National Hospital in Colombo) and published in Sri Lanka Journal of Diabetes Endocrinology and Metabolism 10(2) in August 2020.
“Fatigue is a common symptom of diabetes and it has an impact on the patients’ self-care. As fatigue is a non-specific and universal symptom, it frequently turns out to be a neglected complaint.“
Kalra and R. Sahay’s “Diabetes fatigue syndrome“ noted that easy fatigability implies the occurrence of physical and/or mental exhaustion at a level of work or stress that should ordinarily not cause such exhaustion. “Although fatigue in patients with diabetes is assumed to correlate with glucose homeostasis (a self-regulating process by which biological systems maintain stability while adjusting to changing external conditions), this symptom is not limited to uncontrolled diabetes. There could be numerous biological, physical, and psychological factors that contribute to diabetes-related fatigue. The presence of systemic, low-grade inflammation in diabetes is also a potential contributing factor for fatigue.”
“Clinicians are familiar with the standard way in which patients with diabetes are approached, where, often, modern medical care is focused on achieving number-driven targets, namely, glycaemic (the effect that food or a meal has on blood sugar/glucose levels after consumption) targets, blood pressure targets and lipid targets, etc. Unfortunately, this way of approach fails to improve health outcomes and also does not enable the patient to feel satisfied with the process. Therefore, when dealing with diabetes-related fatigue, patient involvement and empowerment are more important than a physician-focused approach.”
“Taking a thorough history and doing a thorough examination will help sort out the possible contributing factors for the symptom of fatigue. An unhealthy lifestyle, including inappropriate dietary habits, poor sleep hygiene, lack of exercise, and substance abuse, are clearly associated with diabetes-related fatigue. While there have been no trials in patients with diabetes, there is evidence which shows that regular exercise may be an effective strategy for decreasing fatigue among patients with cancer.”
According to C. Fritschi and A.M. Fink’s “Fatigue in adults with type two diabetes — An overview of the current understanding and management approaches”, the possible physiological mechanisms underlying these effects could be that both cancer and type two diabetes are associated with higher levels of inflammatory cytokines (small proteins that are crucial in controlling the growth and activity of other immune system cells and blood cells, and which, when released, signal the immune system to do its job, and further, cytokines affect the growth of all blood cells and other cells that help the body’s immune and inflammation responses) and that exercise may have anti-inflammatory properties.
“Similarly, weight loss either by a low caloric diet or gastric bypass surgery (helps one lose weight by changing how one’s stomach and small intestine handles the food one eats as, after the surgery, the stomach will be smaller, and one will feel full with less food as the food one eats will no longer go into some parts of the stomach and the small intestine that absorbs the food) has been associated with improvement in fatigue among obese individuals in both the general population and those with diabetes. The increased consumption of fibre, omega-three fatty acids (found in foods such as fish and flaxseed, and in dietary supplements such as fish oil) and vegetable-based proteins, with reductions in saturated fats and calories may help to reduce low-grade inflammation and related fatigue.” However, per Fritschi and Fink, extreme caloric restriction does not appear to have a beneficial effect on cytokine profiles despite weight loss.
“Sleep disturbances are a common yet undetected problem in patients with diabetes. Improving glycaemic control will prevent nocturia (a condition in which one wakes up during the night because one has to urinate)-induced awakenings and thereby help to reduce fatigue.”
H.A. Hassaballa, A. Tulaimat, J.J. Herdegen and B. Mokhlesi’s “The effect of continuous positive airway pressure on glucose control in diabetic patients with severe obstructive sleep apnoea (common sleep-related breathing disorder which causes one to repeatedly stop and start breathing while one sleeps, as one’s throat muscles intermittently relax and block one’s airway during sleep, with a noticeable sign being snoring)” showed that continuous positive airway pressure therapy for obstructive sleep apnoea among patients with diabetes has been associated with improved sleep, as well as glycaemia (blood sugar/glucose level/concentration which is the measure of glucose concentration in the blood of humans or other animals) and fatigue.
“Apart from the assessment of glycaemic control and screening for macro and microvascular complications, evaluation for medication-related factors causing fatigue should be kept in mind. Hyperglycaemia (high blood sugar/glucose level) is a known factor for diabetes-related fatigue. Equally, glycaemic variability and recurrent hypoglycaemia (low blood sugar/glucose level) also play a central role in this symptom.
“Insulin (a hormone created by the pancreas that controls the amount of glucose in the bloodstream at any given moment and also helps store glucose in the liver, fat, and muscles, and regulates the body’s metabolism of carbohydrates, fats, and proteins) and sulphonylureas (a class of oral medications that control blood sugar levels in patients with type two diabetes by stimulating the production of insulin through the stimulation of the cells in the pancreas) are the most common culprits for hypoglycaemia, especially when there is a mismatch between the meal intake and the treatment regimes. Statins (drugs that can lower cholesterol, which work by blocking a substance that the body needs to make cholesterol), anti-hypertensives (a class of drugs that are used to treat hypertension/high blood pressure), beta-blockers (medications that reduce blood pressure and which work by blocking the effects of the hormone epinephrine/adrenaline, and causes the heart to beat more slowly and with less force, and also helps widen the veins and arteries to improve the blood flow), and diuretics (help rid the body of salt/sodium and water, and help the kidneys release more sodium into the urine as sodium helps remove water from the blood, thereby decreasing the amount of fluid flowing through the veins and arteries, and thus reducing blood pressure) are the other potential causes for drug-related fatigue in patients with diabetes.”
“Meticulous care should be taken to exclude other medical illnesses contributing to diabetes-related fatigue such as anaemia, heart failure, renal failure, and rheumatologic (autoimmune and inflammatory diseases that cause one’s immune system to attack one’s joints, muscles, bones, and organs) conditions. Patients suffering from other endocrinopathies (disease of an endocrine gland/a hormone-related problem) including thyroid disorders, hypo and hypercalcaemia, vitamin D deficiency, hypogonadism (occurs when the sex glands/gonads produce little if any, sex hormones and cause a low sex drive/libido) and Cushing’s syndrome (a disorder that occurs when the body makes too much of the hormone cortisol/stress hormone over a long period of time) can also present with non-specific symptoms, especially fatigue. There should be a high degree of clinical suspicion, but a good clinician would easily recognise the clues for these illnesses through a sensible history, examination, and focused laboratory investigations.”
“Living with a chronic disease like diabetes is challenging for both patients and the family. The inability to cope with the demands of diabetes care and the economic burden of medication costs further impair physical and mental wellbeing. Moreover, the prevalence of depression is high among patients with diabetes, which requires proper evaluation and treatment.”
- Lasselin, S. Layé, S. Dexpert, A. Aubert, C. Gonzalez, H. Gin, and L. Capuron’s “Fatigue symptoms relate to systemic inflammation in patients with type two diabetes” found that the increased production of pro-inflammatory cytokines was linked to type two diabetes and insulin resistance, especially among obese patients, which is associated with high fatigue levels. “These pro-inflammatory cytokines are the primary therapeutic target for evolving pharmacological intervention for diabetes-related fatigue. Disease-modifying anti-rheumatic drugs have been shown to decrease fatigue and improve physical and psychological function in patients with various rheumatological disorders.”
- Cavelti-Weder, R. Furrer, C. Keller, A. Babians-Brunner, A.M. Solinger, H. Gast, A. Fontana, M.Y. Donath, and I.K. Penner’s “Inhibition of interleukin-Onebeta improves fatigue in type two diabetes” showed promising results with anti-inflammatory drugs among patients with diabetes.
