Integrarea psihoterapiei și a intervențiilor privind stilul de viață în managementul diabetului zaharat de tip 2

Introduction

Type 2 diabetes mellitus (T2DM) represents one of the most significant global public health challenges, with a continuously increasing prevalence primarily driven by lifestyle changes, unhealthy diets and physical inactivity. This chronic disease, characterized by persistent hyperglycemia, affects millions of people and has considerable physical, psychological and economic impacts. However, type 2 diabetes is a manageable and even preventable condition through lifestyle interventions and psychological support⁽¹⁾.

According to the World Health Organization (WHO), diabetes mellitus is a chronic metabolic disease characterized by elevated blood glucose levels, which over time leads to damage to the heart, vascular system, eyes, kidneys and nerves. Over 90% of diabetes cases are type 2 diabetes, a condition marked by inadequate insulin secretion from pancreatic beta cells, tissue insulin resistance (IR), and an insufficient compensatory insulin response^(2,3).

As the disease progresses, insulin secretion fails to maintain glucose homeostasis, leading to hyperglycemia. Patients with diabetes are often obese or have a higher percentage of body fat, predominantly distributed in the abdominal region. In this condition, adipose tissue promotes insulin resistance through inflammatory mechanisms, including increased free fatty acid release and dysregulated adipokines. The primary contributors to the global rise in type 2 diabetes include increasing obesity rates, sedentary behavior, high-calorie diets and an aging population. Organs involved in diabetes development include the pancreas, liver, skeletal muscle, kidneys, brain, small intestine and adipose tissue^(4-6).

Psychological support plays a crucial role in the management of patients with type 2 diabetes. As a chronic condition, it necessitates major lifestyle changes. Adapting to strict treatment regimens, balanced diets, and regular physical activity can induce stress, anxiety, or even depression.

Epidemiological data

Epidemiological data reveal alarming trends that forecast a concerning future for type 2 diabetes. According to the International Diabetes Federation (IDF), in 2019, diabetes caused 4.2 million deaths, and 463 million adults aged 20 to 79 were living with diabetes – a number expected to rise to 700 million by 2045. Diabetes was also the primary driver of at least USD 720 billion in healthcare expenditures in 2019. The majority of individuals affected are between 40 and 59 years old. The incidence and prevalence of the disease vary by geographic region, with over 80% of patients residing in low- or middle-income countries, presenting additional challenges for effective treatment. Patients with type 2 diabetes have a 15% higher all-cause mortality risk compared to non-diabetics with cardiovascular disease (CVD)⁽⁷⁾. The IDF estimates that the global prevalence of diabetes, which was 10.5% in 2021, will increase to 11.3% by 2030 and 12.2% by 2040. Patients with type 2 diabetes face elevated risks of dysfunction and failure in various organs, particularly the kidneys, eyes and nerves, contributing to rising medical costs and decreased quality of life.

Risk factors

Genetic predisposition

Globally, the incidence and prevalence of type 2 diabetes vary significantly by ethnicity and geographic region, with Japanese, Hispanic and Native American populations at highest risk^(8-10).

Studies show higher incidence rates among Asians compared to White Americans^(11,12) and White British populations, where the highest risk is found in Black populations^(13,14). Contributing factors may include modern lifestyle habits, socioeconomic status, direct genetic predispositions and gene-environment interactions.

Obesity, physical inactivity and unhealthy diets

Obesity (Body Mass Index [BMI] ≥30 kg/m²) is the strongest risk factor for type 2 diabetes^(15,16), associated with metabolic abnormalities that lead to insulin resistance⁽¹⁷⁾. There is an inverse linear relationship between BMI and age at diagnosis⁽¹⁸⁾.    

A sedentary lifestyle is another critical risk factor, as evidenced by the Women’s Health Study and Kuopio Ischemic Heart Disease Risk Factor Study, which reported a 34% and 56% reduction in T2DM development among participants who walked 2-3 hours per week or at least 40 minutes weekly, respectively^(19-21). Physical activity delays disease onset through three main mechanisms: (1) enhancing glucose uptake via increased blood flow to skeletal muscles; (2) reducing visceral fat, a known IR-promoting factor⁽²²⁾; and (3) improving glucose absorption by up to 40% through moderate exercise⁽²³⁾.

A Western high-calorie diet rich in fats and carbohydrates raises blood glucose and circulating levels of very low-density lipoproteins (VLDL), chylomicrons (CM), and chylomicron remnants (CMR), all of which are high in triglycerides (TG). This increases reactive oxygen species (ROS), triggering abnormal inflammatory molecule production.

Intentional weight loss remains a cornerstone therapy to improve insulin sensitivity and, in some cases, prevent diabetes onset in individuals with obesity or prediabetes⁽¹⁷⁾. Regular physical activity maintains normal glucose levels, lowers blood insulin, and stimulates counter-regulatory hormones (glucagon, cortisol, growth hormone) that support glycemic balance⁽²⁵⁾.

Stress, anxiety and depression

Emotional imbalances, including anxiety, stress and depression, are strongly associated with T2DM. Individuals experiencing these disorders are at an increased risk of developing diabetes, and those already diagnosed are more susceptible to worsening mental health. People with diabetes are two to three times more likely to suffer from anxiety and depression, directly impacting treatment efficacy.

Depression leads to metabolic dysregulation and diabetes-specific distress, while anxiety raises glycated hemoglobin (HbA1c) levels and increases complication risks. Therefore, psychological interventions are essential for improving treatment outcomes and patients’ well-being⁽²⁴⁾. Stress may also worsen obesity, physical inactivity, and promote unhealthy behaviors like smoking and alcohol use. Studies show that approximately 30% of individuals with T2DM suffer from depression, with higher rates among women, leading to poorer glycemic control and to an increased number of complications⁽²⁶⁾.

Psychotherapeutic interventions for patients with type 2 diabetes mellitus

For patients with type 2 diabetes mellitus, various forms of psychotherapy have demonstrated effectiveness in improving both glycemic control and psychological well-being. Among the most studied interventions are cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based interventions (e.g., MBSR/MBCT) and motivational interviewing (MI).

Cognitive behavioral therapy (CBT) has been associated with significant reductions in HbA1c and depressive symptoms. A meta-analysis of 31 studies, involving 8843 participants, showed an average HbA1c reduction of 0.36% and a decrease in depression scores by 0.72 points compared to standard care⁽²⁷⁾.

Acceptance and commitment therapy (ACT) has shown benefits in enhancing psychological flexibility and self-care behaviors. One study reported significant improvements in diabetes self-management and HbA1c, with long-term effects maintained⁽²⁸⁾.

Mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR), have proven effective in reducing diabetes-related stress and improving quality of life. A pilot study found that nurse-led MBSR significantly reduced both HbA1c levels and diabetes distress⁽²⁹⁾.

Motivational interviewing (MI) has proven effective in improving self-efficacy and diabetes self-care behaviors. A randomized study showed significant improvements in behavioral management and quality of life, although no significant impact on depressive symptoms was observed⁽³⁰⁾.

In conclusion, these psychotherapeutic interventions can be effectively integrated into T2DM management, contributing to better glycemic outcomes and psychological health. Therapy selection should be tailored to individual patient needs and the resources available.

The role of psychological support in managing type 2 diabetes

Psychological support plays a fundamental role in the prevention and management of type 2 diabetes, significantly influencing patient behavior and health. One of the key principles in health education is a patient-centered approach, requiring personalized strategies that consider each individual’s needs, desires and challenges. Patients should be encouraged to understand their condition, recognize associated symptoms, and adopt behaviors that support glycemic control.Stress management is also essential for maintaining a healthy lifestyle. Chronic stress affects both physical and mental health and is associated with depression, anxiety, hypertension and heart disease⁽³¹⁾.

A growing body of evidence supports the integration of psychological interventions and patient-centered education as key components in the management of type 2 diabetes mellitus. Liu et al. (2023) highlight that personalized educational strategies – tailored to patients’ cognitive abilities, emotional states and socioeducational backgrounds – significantly enhance self-management behaviors and treatment adherence. The study emphasizes that mental health status, particularly the presence of depression or anxiety, directly impacts the patient’s ability to engage with and apply health information. These findings affirm the importance of a multidisciplinary approach that incorporates psychological support, health education and behavioral strategies to foster effective long-term diabetes care⁽³¹⁾.

Evaluating and monitoring patient progress are essential components of any educational program. Effective assessment identifies individual and group needs, providing feedback that supports both learning and teaching strategies.

The role of physical therapy in type 2 diabetes management

Beyond pharmacological treatments, lifestyle modification – particularly through physical exercise programs – is a vital aspect of T2DM management. Several types of exercises can be incorporated into physical therapy programs, including aerobic, resistance, and flexibility training.

Short-term aerobic training improves insulin sensitivity in adults with T2DM. Vigorous aerobic exercise over seven days can improve glycemia by enhancing insulin-stimulated glucose disposal and suppressing hepatic glucose production, without reducing body weight (Table 1).

Resistance training in adults with T2DM typically results in 10-15% improvements in strength, bone mineral density, blood pressure, lipid profiles, skeletal muscle mass and insulin sensitivity. When combined with modest weight loss, resistance training significantly increases lean skeletal muscle and reduces hemoglobin A1c (HbA1c) levels more than calorie-restricted, non-exercising groups^(32,33). A recent meta-analysis suggests that high-intensity resistance training is more beneficial than low- to moderate-intensity training for overall glucose management and insulin regulation in adults (Table 1).

The recovery process for diabetic patients is complex, making the role of the physical therapist particularly important. Beyond biomechanical interventions, therapists contribute to emotional balance through strategies that reduce stress, improve sleep and enhance motivation. Postural education, along with breathing and relaxation exercises, can alleviate stress and psychological imbalances.

Low-intensity stretching and bodyweight exercises have shown positive effects in stress reduction. Thus, the physical therapist serves not only as a rehabilitation professional but also as a key support figure in the patient’s recovery and progress.

Structured aerobic and resistance exercise programs have been shown to significantly reduce symptoms of anxiety and depression, while also improving social well-being. Maharaj and Nuhu (2023) demonstrated that moderate-intensity treadmill walking led to marked improvements in emotional health parameters among sedentary women with T2DM⁽³⁴⁾. Similarly, Sanches et al. (2021) found that recreational training in elderly women not only enhanced cardiovascular and metabolic function but also had a positive impact on mood and psychological resilience⁽³⁵⁾. Furthermore, a meta-analysis by Luo et al. (2023) confirmed that mind-body interventions such as Baduanjin can substantially alleviate anxiety and depressive symptoms while improving glycemic control⁽³⁶⁾. These findings underscore the vital role of kinesiotherapy not only in the physical rehabilitation of diabetic patients but also as a complementary strategy for improving mental health and overall quality of life (Table 2).

Conclusions

Type 2 diabetes mellitus is a complex and widespread chronic condition that requires an integrative approach to management. While pharmacological interventions are essential, they are not sufficient on their own. Sustainable and effective management must include tailored lifestyle changes, psychological support, and structured physical activity. Psychological care contributes significantly to improving treatment adherence, emotional resilience, and overall quality of life.

Health professionals must adopt a multidisciplinary strategy that encompasses education, motivation, emotional well-being and physical rehabilitation, through personalized support and active involvement of patients in their care plans.  

Autor corespondent: Dora-Mihaela Cîmpian E-mail: dora.cimpian@umfst.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.