Does a history of ACEs correspond with poorly controlled Diabetes?

Dear Colleagues,

I am working with a group of primary care doctors in England who specialise in Diabetes management. We have a hypothesis that emotional distress associated with higher ACE scores will lead to poorly controlled diabetes due to the use of food as a way of coping with emotional distress.

Has anyone got any advice, experience they can share or can anyone point me towards academic papers that explore this theme?

Many thanks and best wishes

Dr Warren Larkin

Original Post

Fascinating, dreadfully important question ;-D

Not easy to address: "Do people self-medicate their emotional distress resulting from ACEs using food?"  Deceptively simple, but ..

Guess you're familiar with the general literature on self-medication (I remember a number of studies just addressing use of opiates as emotional self-medication in the journal Addiction a few years ago)?

Sfaik the conclusion is that there're so many different factors that must be considered for any one factor to be "the" factor; and you'd also be aware that if one does a google scholar search using "diabetes etiology coping "adverse childhood experiences"" one comes up with over 500 citations to evaluate -- just published since 2017. So, you're asking if anyone's been lucky enough to come up with the handful of studies that have shown ACEs to be overwhelmingly significant in demonstrating that  poor self-care through poor dietary control results in diabetes -- "sensible conclusion" (so long as poor dietary control in and of itself produces diabetes???  I know a lot of people with diabetes would challenge that).

Well, I'm sorry, but the only work I know of is reviewed in the attached paper (mentioning Tamayo, 2010),  but the topic is fascinating and I've marked it to follow -- please let me know what other material you find --- I wish you every bit of luck, not an easy topic to research :-D

fwiw you might find some other articles of interest on this list,

https://www.ncbi.nlm.nih.gov/p...mp;from_uid=20809937

Attachments

Paul Metz posted:

Fascinating, dreadfully important question ;-D

Not easy to address: "Do people self-medicate their emotional distress resulting from ACEs using food?"  Deceptively simple, but ..

Guess you're familiar with the general literature on self-medication (I remember a number of studies just addressing use of opiates as emotional self-medication in the journal Addiction a few years ago)?

Sfaik the conclusion is that there're so many different factors that must be considered for any one factor to be "the" factor; and you'd also be aware that if one does a google scholar search using "diabetes etiology coping "adverse childhood experiences"" one comes up with over 500 citations to evaluate -- just published since 2017. So, you're asking if anyone's been lucky enough to come up with the handful of studies that have shown ACEs to be overwhelmingly significant in demonstrating that  poor self-care through poor dietary control results in diabetes -- "sensible conclusion" (so long as poor dietary control in and of itself produces diabetes???  I know a lot of people with diabetes would challenge that).

Well, I'm sorry, but the only work I know of is reviewed in the attached paper (mentioning Tamayo, 2010),  but the topic is fascinating and I've marked it to follow -- please let me know what other material you find --- I wish you every bit of luck, not an easy topic to research :-D

fwiw you might find some other articles of interest on this list,

https://www.ncbi.nlm.nih.gov/p...mp;from_uid=20809937

Thanks Paul. I appreciate your support and thoughts on this. Not a simple area to get to the bottom of as you acknowledge. I will let you know if I find anything noteworthy. Best wishes. Warren 

Esther Gilbert posted:

I know you’re correct. I’d like to hear what you find. I worked in geropsych home care as a Clinical Social Worker. I wished that we had taken stock of what we’d found. I wonder whether my old supervisor and the agency would permit research like this. I will ask.

Many thanks Esther!

Dr Warren Larkin posted:
Paul Metz posted:

Fascinating, dreadfully important question ;-D

Not easy to address: "Do people self-medicate their emotional distress resulting from ACEs using food?"  Deceptively simple, but ..

Guess you're familiar with the general literature on self-medication (I remember a number of studies just addressing use of opiates as emotional self-medication in the journal Addiction a few years ago)?

Sfaik the conclusion is that there're so many different factors that must be considered for any one factor to be "the" factor; and you'd also be aware that if one does a google scholar search using "diabetes etiology coping "adverse childhood experiences"" one comes up with over 500 citations to evaluate -- just published since 2017. So, you're asking if anyone's been lucky enough to come up with the handful of studies that have shown ACEs to be overwhelmingly significant in demonstrating that  poor self-care through poor dietary control results in diabetes -- "sensible conclusion" (so long as poor dietary control in and of itself produces diabetes???  I know a lot of people with diabetes would challenge that).

Well, I'm sorry, but the only work I know of is reviewed in the attached paper (mentioning Tamayo, 2010),  but the topic is fascinating and I've marked it to follow -- please let me know what other material you find --- I wish you every bit of luck, not an easy topic to research :-D

fwiw you might find some other articles of interest on this list,

https://www.ncbi.nlm.nih.gov/p...mp;from_uid=20809937

Thanks Paul. I appreciate your support and thoughts on this. Not a simple area to get to the bottom of as you acknowledge. I will let you know if I find anything noteworthy. Best wishes. Warren 

Perhaps you're merely "visiting" the wrong university.

Why don't you speak to Louise from University College Dublin, I'm sure together you'll easily find some British resources to address this issue, but you'll need to get some practice-based research established to get the empirical evidence to go further with it.

Dear Warren,

I’m a family doctor who retrained as a somatic psychotherapist specializing in trauma and chronic illness. I’ve been looking at the research linking trauma to many kinds of chronic illnesses with a special interest in type I diabetes and some findings in type 2 diabetes along the way.

I haven’t focused a lot on diet but have been curious about the role of stress and trauma triggers in relation to blood sugar levels and long term complications.

While disordered eating is certainly one effect of trauma, I suspect it is only one of many factors that influence risk for diabetes, blood sugar levels and long-term complications.

I’ve heard from some type one diabetics over the years that their blood sugar levels can vary significantly from day to day even when they eat the same things and do the same things multiple days in a row. I don’t know if this is also true in type 2 diabetes.

One of my theories is that both type 1 and type 2 diabetes reflect states of disordered metabolic physiology and that blood sugar levels (and variability as well as ease of control) are unique to each individual’s history and therefore triggers, just as stressors that trigger symptoms of PTSD are unique to each individual. Some studies support this (see attached).

I’ve also wondered if a younger age of onset reflects greater exposure to stressors / trauma and whether complications in general might be greater in those with a history of more adversity. I've included a few references on this topic as well. 

Depression is twice as common in diabetes 1 and 2 (see Holt, below), affecting 1 in 4. QOL is worse, complications are increased, life expectancy reduced. There is a higher risk of diabetes with depression and depression effects are long lasting & recurrent. This may be one effect of trauma that influences eating habits in diabetes as well as in those who do not have the illness.

Attached are a few studies that might be of interest, even though they don’t address diet and eating habits.

Dahlquist, 1991: stress in year before diagnosis is the only factor affecting age of onset

Gonder-Frederick study indicated that IDDM subjects' BG response to an active stressor was idiosyncratic but significantly reliable over time.

Holt: overview of Depression in diabetes

Riazi (a book chapter from 2000): blood sugar levels appear to be idiosyncratic with some individuals having hyperglycemia, others hypoglycemia and some with no response to similar stressors. They also cite a 1950s study by Hinkle (see attached) showing that all individuals have changes in glucose levels in response to stress. The response is just higher in diabetes (p 690)

Yehuda 2015 cites a study (see attached, Yehuda 2009) showing that “there are different responses in glucose use following glucocorticoid injection in those with PTSD compared with unaffected individuals”.

Attachments

Dr Warren,

I disagree, I think this is an easier field in which to conduct "research", at least applied / clinical, than I at first thought after reading your initial request, IF

  • one initially defines what the "problem" is
  • one defines the population(s) in which this problem is occurring
  • one clearly outlines the proposed mechanism(s) thought to give rise to the problem

You at first defined the problem is, or hypothesised that, people with ACEs histories use food to deal with the negative affect residual after surviving a development marked by ACEs. Thus, one needs measures of both ACEs and state of emotional distress, and an ongoing behavioral diary of food intake, including type of food. The question was unclear, however, whether or not the ACEs is thought to have an etiological role in the development of diabetes, or whether such a history is linked to ongoing non-adherence to recommended healthy eating. Surprisingly, the role of obesity in the development of diabetes went unaddressed, yet obesity is also more common in those with ACEs histories. So, what is the problem

  • use of food to cope with negative affect, or
  • non-adherence to recommended healthy eating plans, or some combination of these

Is the population of interest

  • only those with ACEs histories who have diabetes who do not adhere to healthy eating plans, or, more generally,
  • those people with diabetes who do not adhere to healthy eating plan -- you will find many more of the latter than the former, and you will find many people with ACEs histories who have diabetes who DO adhere to recommended eating plans, but who have other dysfunctional coping behaviors; while other people with ACEs histories and diabetes who do not have such problems.

What is the proposed mechanism underlying the problem behavior --

  • some sort of "self-medication", or 
  • something arising from disturbed sense of self specific to some people with ACEs histories?
  • some more general mechanism -- you're likely to find many people with diabetes who do not adhere to recommended healthy eating plans who share this mechanism in common, whether or not they have a history of ACEs

Looked at in these ways one can perform more specific literature searches, not be overwhelmed by all those thousands of results Google Scholar produces, and, lo and behold, find programs already existing in Britain to address some of these issues. As I said, speak to Louise, she can help direct you in some areas, and discuss how issues specific to people with ACEs histories "might" be able to be addressed IF it's necessary, which I suspect it might not be, at least regarding the question of non-adherence to healthy eating plans.

And Veronique, yes, also people with T2DM "can vary significantly from day to day even when they eat the same things and do the same things multiple days in a row", certainly true for me -- person with high ACEs score who's also had T2IDDM (for the non-medicos, Type 2 Insulin-Dependent Diabetes Mellitus) for over 20 years, these things often being stress-related, but usually leading to HYPER- rather than hypoglycemia.

Dr. Warren,

Thank you for your work and great question. My response pertains to independent research conducted in the U.S, along with global research on food, the food industry and health trends.

Having researched trauma and resilience for over 15 years, treated individuals across the lifespan as a therapist in addition to being a survivor of complex trauma, generational poverty and an eating disorder, I would say it's both and.

Two years ago I attended a national School-Based Health conference in DC. A nurse presented on improving proper use of insulin pumps among youth and teens. I was one of two or three clinicians in a room full of nurses. The presenter joked about the parallel of the ratio of nurses to social workers saying the way to get kids to use their pumps was to hire more therapists! She definitely believed the primary barrier to successful diabetes management was social-emotional health.

Recently I compiled data across several addictions and included obesity rates. Of all known, diagnostically supported addictions, tobacco and alcohol use were the two highest percentages. Beating both of those rates combined and then some was the rate of obesity which may or may not be the result of a disordered relationship with or 'addiction' to food. Because the DSM does not (cannot due to big pharma stakeholders and major food corporations; my theory) classify Binge Eating Disorder as an addiction, we are prevented from truly seeing and treating the behavior as such, despite diagnostic criteria practically shouting 'this is an addiction!'. Therefore when someone does not adhere to a medical plan to treat symptoms of obesity, which can include diabetes, it may be due to the fact that we're overlooking contributing factors like social-emotional health, trauma history, co-occurring mood disorders and the presence of dependence on processed food products to cope with a spectrum of those symptoms. How many studies do we need on the effects of processed sugar and dairy before we start accepting fact? Not to mention fast food branding lighting up the same parts of our limbic system as when we see a friend or relative. Cheap, heavily and strategically marketed processed food is the most readily available drug on the planet. And diabetes medications have become increasingly profitable. 9 billion in insulin sales for one company; not too shabby. Hmm? How 'bout that?

Don't take my word for it; investors are pretty excited: "The global anti-diabetic drug market is expected to witness significant growth during the forecast period. This growth is attributed due to increasing prevalence of diabetes and rising demand for oral anti-diabetic drugs. In addition, sedentary lifestyle, increasing the percentage of obesity, high-stress levels are considered as a major driving factor for the growth of oral anti-diabetic drugs market." 

This headline is by far my favorite: Drug Companies Look to Profit from DSM 5 The article explains the exciting financial prospects for stakeholders in drugs that came out to treat Binge Eating Disorder (which may be habit forming, in case you needed another addiction). Two clinical trials were complete ahead of schedule so the drug was developed and tested just two months after the release of DSM 5. And again, how 'bout that?

In addition, consider the following factors as reasons why an individual may have difficulty managing diabetes:

  • Food Insecurity and access; can the individual afford the prescribed food plan? 
  • Does kale taste as good as pizza? If not, what other resources for pleasure or comfort does the individual have access to? How might that answer impact the desire to make food changes?
  • Family culture and dynamics: How does the family eat? What does the family eat? Why? And what are the potential consequences for the individual if they change or attempt to change their eating habits?
  • Does the individual have co-occurring mood disorder or other mental health diagnosis; biological or as a result of trauma or both?
  • What are the incentives or motivations for the individual in managing their symptoms? Is there a potential secondary gain for not managing their symptoms, such as; maintaining a relationship or connection, receiving care and attention from loved ones, receiving care and attention from medical providers, seeing the illness as a form of rest they had no other means to obtain?
  • Rule out passive suicidal ideation 
  • Are there other co-occurring addictions such as alcoholism sometimes masked as 'functional' alcoholism. If so, what are the contributing factors to the addiction? Trauma? Stress? Loss?

Meanwhile, Overeaters Anonymous has been quietly prescribing a whole foods, sugar and white carb elimination diet along with the 12 Steps for over 30 years. OA welcomes people with any form of disordered relationship with food rather than waiting for science to prove why some of us have been in a life long love triangle with Ben & Jerry. We can advocate for awareness and change while empowering ourselves with knowledge and resources. Meaning, those of us struggling with any aspect of the human condition can always awaken to choice and discover new choices even if supermarkets never stop selling Sugar Smack.

World Peace offers the greatest profits of all.

Thanks again for your question and your work.

 

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Veronique MeadTracy Glaser-BaconCarey S. Sipp (ACEs Connection Staff)Paul Metz
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