Keypoints

• The most important thing about diabetes signs and symptoms is that this disease can present very differently from one person to another.

• People with autoimmune diabetes and those with dysregulated insulin and blood sugar can, with appropriate care, manage their diabetes successfully.

Diabetes affects more than 37 million people in the US and costs about $237 billion in direct medical costs. It’s a leading cause of new blindness, the most common reason people need a kidney transplant, and the No. 1 cause of nontraumatic leg amputations. Yet it’s not the easiest illness to spot. So How can massage therapy help?

Every now and then, one of my medical providers (a dentist, a medical doctor, a physical therapist), will ask me what I do for a living. I reply that I’m a writer and educator about pathology for massage therapists. And more often than not, they chuckle and reply, “Why would a massage therapist need to know anything about pathology?” 

I have a one-word answer: diabetes. 

They think about that for a minute until it dawns on them. Diabetes affects the skin, the cardiovascular system, the urinary system, the reproductive system, the digestive system . . . actually, every system. Furthermore, people with diabetes want massage. They go on vacation, on cruise ships, and to resorts. They do lots of things where massage might be an available and attractive choice. And people with diabetes should be able to receive safe and effective massage wherever they go—to the interdisciplinary clinic or the high-end day spa. But how can we be sure we’re keeping our clients safe in the context of this common disease that causes blindness, amputations, renal failure, heart attacks, stroke, and much more? Diabetes is one of the reasons massage therapists simply must know something about pathology.

November is Diabetes Awareness Month, so let’s take a look at diabetes, or diabetes mellitus, with an emphasis on what this condition does to healthy function and how differently it affects different people. I have collected input from several massage therapists who have generously shared their experiences with diabetes for our benefit, and I am struck by how unique each story is: further evidence that diabetes is emphatically not a one-size-fits-all disease. My deepest thanks are extended to these contributors.

In the accompanying article “Diabetes Complications” (page 50), we explain some of the most serious and most common complications associated with diabetes and explore some of the key decision points about offering safe massage therapy for our clients who live with this disease. If you read both articles, you’ll be well-equipped to offer the safest and most effective massage therapy your clients who have diabetes could want.

What Is Diabetes Mellitus?

Diabetes mellitus is a small group of disorders, including type 1 and type 2 diabetes among others, that all lead to the same end: too much sugar in the blood, or hyperglycemia. The name diabetes mellitus comes from an ancient observation: people with this disease seemed to urinate unusually often—diabetes means “to flow through”—and their urine smelled sweet, like honey. Mellitus means “tastes like honey.” So, diabetes mellitus is literally a synonym for “sweet pee.”

Diabetes Statistics

Diabetes is one of the most common endocrine diseases in the world. Epidemiologists believe approximately 422 million adults in the world have been diagnosed, though this number does not account for children, those with prediabetes, or those who have it but have not yet been diagnosed. 

In the US, about 37.3 million Americans have diabetes, although about 8.5 million people don’t know it. That accounts for well over 10 percent of our total population. An additional 96 million people in this country have prediabetes—a condition that affects one in every three adults and one in every five children. Not all people with prediabetes progress to type 2 diabetes, but their risk is higher than average.  

Diabetes is an expensive disease. According to the Centers for Disease Control and Prevention (CDC), $1 in every $4 spent on health-care costs goes toward caring for someone with diabetes. It costs us about $237 billion per year in direct medical costs, plus another $90 billion in reduced productivity. And with all that investment, diabetes is still a leading cause of new blindness in people under 70, the most common reason people need a kidney transplant, the No. 1 cause of nontraumatic leg amputations, and it is consistently in the top 10 leading causes of death in this country—in 2021 it killed 103,294 people in the US.

Diabetes Pathophysiology

The pathophysiology of diabetes is exquisitely complex, with many delicate threads of sequelae that show how a tiny imbalance in one place can lead to major functional problems in others. We will take a very general look at how diabetes comes about, with a special emphasis on how this might influence choices regarding massage therapy.

To do that, we need to remember that sugar is a remarkable fuel source. Our cells, especially in the muscles, liver, and nerve cells, turn glucose into adenosine triphosphate (ATP), and the leftovers from those chemical reactions are simple: carbon dioxide and water. If our cells cannot access adequate sugar, they don’t thrive. And in some circumstances, our metabolism may shift away from using sugar as fuel and toward breaking down fats and protein stores—to the extent that metabolic waste rises to dangerous levels. 

Here’s the problem: Sugar has no direct access to our hungry cells. A pancreatic hormone called insulin is required to prompt target cells to open their membranes and allow sugar to enter.

Diabetes mellitus develops when there isn’t enough insulin available to help cells get sugar. This can occur in a few ways. In type 1 diabetes, this happens because of an autoimmune attack on the insulin-making cells of the pancreas.

Another reason cells can go hungry is insulin resistance. In this situation, even though insulin levels are normal or even higher than normal, cells are deprived of sugar as a fuel source.

What causes insulin resistance? It’s not entirely clear. A combination of genetic and environmental factors may contribute to this. We also see a statistical correlation between central body fat and sedentary habits to insulin resistance. This is a reversible relationship: We see that if people reduce their central obesity and increase their physical activity, their insulin sensitivity often improves. 

These changes are not always possible for a number of reasons. And when insulin resistance persists, the pancreas may secrete even more insulin, leading to hyperinsulinemia. Insulin regulation is discussed in more detail in the video that accompanies this article. 

Eventually, the pancreas becomes exhausted and insulin levels drop. The cells struggle to maintain their function, sugar accumulates in the bloodstream (which contributes to atherosclerosis, cardiovascular disease, stroke risk, and renal failure, among many other things), and the downward spiral into uncontrolled diabetes continues.

Fortunately, even people with autoimmune diabetes and those with dysregulated insulin and blood sugar can, with appropriate care, manage their diabetes successfully.

Types of Diabetes: Pre, 1, 2, and . . .?

Traditionally, diabetes is described as having two main types: type 1 and type 2. However, new discoveries about autoimmunity and the function of insulin are allowing scientists to become more precise in their labels, so the identified subsets of types of diabetes may expand. 

As we learn more about this disease and the chemical changes that cause it, we may eventually conclude that the type 1 and type 2 forms are more closely related than previously thought. These three factors are often present in all patients: signs of autoimmune activity at the beta cells, the death of beta cells, and insulin resistance.  

The following list covers the most frequently identified types of diabetes.

Prediabetes

Prediabetes is identified when fasting blood sugar levels are higher than normal but not yet in the range of diabetes. It is typically silent: most people who fit this criterion don’t know that they are at risk for type 2 diabetes and a range of diabetes-related complications. Prediabetes can be reversible with weight loss and exercise.

Type 1 Diabetes

Type 1 diabetes is an autoimmune disorder that involves an immune system attack against the insulin-producing cells of the pancreas (sometimes called beta cells). A person with type 1 diabetes simply cannot make enough insulin—most of them make no insulin at all. It is a genetic disorder that is slightly more common in males than females. Type 1 diabetes is usually identified in childhood or early adolescence. 

Type 1.5 Diabetes (LADA)

Latent autoimmune diabetes of adults (LADA) is a form of autoimmune diabetes that is identified in people over age 35. It has aspects of both the autoimmune activity seen with type 1 and the insulin resistance seen with type 2, so some experts suggest the label “type 1.5.” Other proposed names are more descriptive: “slowly evolving immune-related diabetes” (from the World Health Organization), or “slowly progressive insulin-dependent type 1 diabetes mellitus” (from Japan).

The diagnostic criteria for LADA are consistent: age is greater than 35 years, auto-antibodies are found in the insulin-producing cells, and the person becomes insulin dependent within six months of the initial diagnosis. 

Not everyone who develops diabetes after age 35 is checked for LADA, and it may be more common than suspected. Some studies show that 4–12 percent of people diagnosed with type 2 diabetes may in fact have this autoimmune form, or at least show signs of autoimmune activity in the beta cells. This is especially important for patients’ health-care providers to know because it may inform best practices for treatment.

Gestational Diabetes

Mild insulin resistance is a common feature of late pregnancy: It’s part of how metabolism shifts to support the final growth of the baby. However, some people have some level of insulin resistance before they get pregnant but they don’t know it ahead of time. Others may develop severe insulin resistance during their pregnancy. This situation is often silent or easy to miss under the other symptoms related to being pregnant. But if this progresses to gestational diabetes, it carries risks for both the baby and the pregnant person. Gestational diabetes occurs in about 14 percent of pregnancies worldwide. 

Gestational diabetes can cause extra-large babies with the risk of a difficult delivery. Conversely, it can cause premature birth with breathing problems and other challenges. Both the baby and the parent also have a higher-than-average risk of developing type 2 diabetes and diabetes-related complications later in life. 

Type 2 Diabetes

Type 2 diabetes is by far the most common form of the disease, at least by current labeling methods. It typically begins with insulin resistance, leading to temporary hyperinsulinemia, which is later followed by low insulin levels combined with high blood sugar—this is described in more detail in the “pathophysiology” section (page 38). 

Type 2 diabetes appears to run in families and is more common among certain ethnicities, so a genetic component appears to be part of this disease. However, environmental factors like food quality and availability, exercise and eating patterns, and epigenetics and cultural influences may also contribute to the possibility of developing this disease.

More specific risk factors include: 

• Being 20 percent or more over a healthy weight. This is a problematic issue, however, since we lack consensus on what “healthy weight” is and the traditional body-mass index (BMI) numbers are now considered to be inaccurate predictors of disease. That said, central obesity is known to have a statistical correlation to insulin resistance and diabetes risk.

• Having uncontrolled hypertension. 

• Being over age 45. (Although it is important to point out that younger people, including children, also develop type 2 diabetes.)

• Having a family history of diabetes.

• Having a history of blood glucose dysregulation. People who regularly experience bouts of hypoglycemia may have a more difficult time producing insulin in a way that coordinates with their glucose intake.

• Having polycystic ovarian syndrome (PCOS). This is an endocrine disorder involving the growth of benign cysts on the ovaries. People with PCOS also have a higher risk of type 2 diabetes and, interestingly, treating their type 2 diabetes sometimes results in improved fertility.

• Being a part of certain populations. We see that the per capita rate of type 2 diabetes is higher among certain populations, including Native American and Aleut, Hispanic, Pacific Islander, Asian, and Black. However, this may be related to issues beyond genetic profiles: Social determinants of health, epigenetic traits related to traumatic histories, and many other factors may contribute to this pattern.

Double Diabetes

Double diabetes describes people with type 1 diabetes who also become insulin resistant—so even though they supplement insulin, they are still at risk for hyperglycemia and diabetes-related complications. This is typically identified in adults, but there are cases of children also having aspects of double diabetes.

Research into double diabetes has revealed that the divisions between type 1 and type 2 are not as firm as we had assumed—many patients may have autoimmune activity alongside insulin resistance. This opens new pathways for prevention and treatment strategies. 

Signs and Symptoms of Diabetes

The signs and symptoms of diabetes are usually subtle and have a gradual onset, so they are easy to miss. Increasing thirst, constant hunger, fatigue, and unintended weight loss are common. A lot of people don’t pursue a diagnosis until they’ve seen other, more serious signs such as tissue damage like tingling, pain, and numbness in the extremities; slow healing, especially of sores on the legs; vision loss and blurriness; and reduced resistance to common infections like cold or flu. Type 1 diabetes, especially when it affects adolescents, can cause vomiting, nausea, and abdominal pain. It is occasionally misdiagnosed as an eating disorder. 

The most important thing about diabetes signs and symptoms is that this disease can present very differently from one person to another, as we see in the stories contributed by our colleagues who have been affected by this disease.

Diabetes Diagnosis and Monitoring  

Diabetes is typically identified through testing for blood glucose (BG) after fasting. Normal BG numbers after eight hours of fasting are 70–100 mg/dL. The criterion for diabetes is a consistent reading of over 126 mg/dL.

This guideline has a few caveats: 

• If a test is taken randomly (e.g., not after an 8-hour fast), then the number should be under 200.

• Blood from a vein typically gives a more accurate reading than from a finger stick or a continuous BG monitor, and this can only be accomplished in a medical setting.

• Doctors often look for a repeated pattern in elevated numbers before diagnosing diabetes.

• An A1C test looks for long-term trends in how sugar adheres to red blood cells. This gives a larger-picture view of BG and insulin regulation than the more immediate blood tests. 

Diabetes Treatment

The treatment goals for diabetes, regardless of the type, include:

• Improving insulin production, if possible.

• Replacing insulin if production is not possible.

• Improving insulin sensitivity.

• Suppressing the release of glucose from the liver.

• Slowing the absorption of glucose from the diet.

In addition, diabetes treatment involves careful maintenance of the skin, eyes, cardiovascular system, and kidney function.

With most cases of type 1 diabetes, it’s not possible to improve insulin production from the pancreas, so it’s necessary to supplement this vital hormone. Insulin does not pass through the digestive system intact, so it must be injected. This is often done with several daily, self-administered injections into the superficial fascia, or with an attached insulin pump.

For type 2 diabetes, the typical strategy is to start with diet and exercise. It has been seen that losing even a little weight and increasing physical activity helps to make cells less insulin resistant, and these interventions—along with dietary choices and drugs that influence insulin sensitivity—can sometimes be sufficient to reverse type 2 diabetes or prediabetes. 

However, many people with type 2 diabetes do not find these to be adequate to keep their blood sugar stable and to avoid diabetes-related complications, so they may also have to supplement insulin. It is important to understand that this is not necessarily a defeat, and many patients find that once they add this to their treatment, then they feel much better and are more able to take appropriate action in support of their well-being. 

Many patients end up using a variety of medications to help support insulin sensitivity or manage some diabetes-related complications. Metformin and similar insulin-management drugs, antihypertensives, statins, and pain medications for peripheral neuropathy could all be on this list. 

Other diabetes-related treatments are connected to the complications of the disease, including dialysis for renal failure, surgery for cardiovascular disease or to manage skin ulcers, and more.

Implications for Massage Therapy

The decisions about massage therapy for clients with diabetes depend mainly on how it is treated, how well it is controlled, and what secondary problems might have developed. For more specific information about the serious conditions and problems that often develop alongside diabetes, and for ideas about how to offer safe and effective work for clients who have this condition, please see the companion column, “Diabetes Complications,” in this issue (page 50). 

I often conclude pathology articles with the comment that massage won’t “cure” a particular problem, but it could probably make the experience of living with it a lot nicer. That’s also an accurate statement for diabetes. 

Diabetic Emergencies

Diabetes can involve extreme metabolic swings over short periods of time. Because it’s so common, the chances are high that a massage therapist could be present during a diabetes-related emergency. Here are some short descriptions of what diabetic emergencies are, how to recognize them, and what to do if you think a client is experiencing one of these situations.

Hypoglycemia, Insulin Shock

Hypoglycemia, as the name implies, is a state of low blood sugar. Many people experience this from time to time, but repeated episodes can point toward poor insulin regulation. The symptoms of hypoglycemia are probably familiar: shaking and sweating, irritation, or having a hard time putting words or thoughts together. One of the tricky things about hypoglycemia is that these signs are very nonspecific; several other situations can cause the same symptoms: intoxication, hot flashes, or even having a stroke.

Insulin shock occurs when blood sugar levels drop dangerously low. It can happen spontaneously, but it is a possible complication of mismatching an insulin dose with the timing of a meal, resulting in a temporary overdose. This isn’t “shock” in the technical sense of having systemic low blood pressure like we see with circulatory shock. Instead, it refers to a general state of stress, shakiness, dizziness, fast heart rate, and confusion. Left untreated, very low blood sugar can topple over into weakness, difficulty speaking, convulsions or seizures, and unconsciousness. 

A sudden onset of low blood sugar can be treated with quick consumption of a high-sugar food, like fruit juice or candy—but only if the person is conscious (if they are not, it is necessary to call for emergency services; trying to force food or liquid into them is dangerous). Many people with diabetes carry their own sugar tablets for this kind of crisis. It is important for massage therapists to find out ahead of time what their clients with diabetes would like them to do if they have a hypoglycemic episode.  

Ketoacidosis   

At the other end of the blood sugar spectrum is diabetic ketoacidosis (DKA). This occurs when so little insulin is available that we start to break down proteins and fats for fuel. This produces metabolic waste called ketones, and when they accumulate quickly, chemical changes make the blood dangerously acidic. This can cause organ damage—including brain damage—that can lead to coma or death.

DKA is most common in people with type 1 diabetes, but it can also happen for people with type 2. It calls for a trip to the emergency room, where they will probably push fluids and insulin to bring the blood glucose levels down as quickly as possible. 

Hyperglycemic Hyperosmolar Syndrome

When blood sugar levels get dangerously high, especially for people with type 2 diabetes, this can become a life-threatening emergency called hyperglycemic hyperosmolar syndrome, or HSS. This can happen with an illness, fever, or other stressors. HHS causes the kidneys to work hard to shed extra sugar through the urine, which leads to serious dehydration and thickened blood. It also draws fluid out of other organs, including the brain, to try to dilute the sugar in the blood. HHS is a medical emergency and can lead to coma and death if not treated quickly.

Diabetic Coma

A diabetic coma can be the outcome of either dangerously high or low blood sugar. In this condition, the person is nonresponsive. It can be preceded by signs of hyperglycemia (tiredness, increased urination, abdominal pain, hunger, and thirst), or by signs of severe hypoglycemia (tiredness, sweating, accelerated breathing and heart rate, shakiness, anxiety, light-headedness, and hunger). Diabetic coma is a medical emergency that must be treated quickly to avoid the risk of permanent brain damage or death. 

Living with Diabetes

The following stories come from conversations the author had with several generous massage therapists who shared their histories, fears, successes, and challenges with diabetes. It is especially enlightening to look at these contributions in light of what’s known about the surprisingly fuzzy dividing line between type 1 and type 2 diabetes.

The Person Is Not the Label

“Elena” is a woman newly diagnosed with type 2 diabetes at age 39. She knew this was a risk, since she was informed she was in the prediabetes range two years ago. Interestingly, a close female relative was identified with prediabetes at the same time. However, this person dropped some weight and reversed their numbers out of the prediabetes zone, while despite her best efforts, Elena did not.

Elena doesn’t tolerate the antidiabetic agent metformin very well, so she uses some other medications. Unfortunately, the side effects include increased appetite and weight gain, which tends to exacerbate insulin resistance. In addition, she has been prescribed weekly injections of Trulicity, a weight-loss drug that also lowers blood sugar. She finds this curbs her appetite, but it also makes her less sensitive to her blood sugar, so it’s harder for her to stay within a healthy range. 

Elena’s goal is to try to reverse her diabetes so she can get back into the prediabetes range and stay off insulin if she can. Her message to massage therapists: “People have good days and they have bad days. But they are people, they are not their diabetes. Treat the person, not the disease.”

Understand the Client’s Story

“Albert” is a 46-year-old male who was diagnosed with diabetes at age 17. His history is long and complex, but here is a synopsis: He was born with low birth weight and grew up always being encouraged to eat—to the point of becoming overweight. When he was a sophomore in high school, he went through a short period with massive unintended weight loss combined with chronic exhaustion and insatiable thirst. As a senior in high school, he got sick, was diagnosed with flu, and never recovered his energy. Months later, he saw a general practitioner (as opposed to his pediatrician) who, after appropriate tests, told him: “Your blood sugar is 654, I’m surprised you’re not in a coma.” 

Albert went under a doctor’s care, which included a hospital stay with medications to stabilize his blood sugar. He didn’t start using insulin until a year later. Shortly after that, he left home for college. It was a bad combination for him, being only minimally educated about diabetes management and living independently for the first time (e.g., eating a lot of pizza). His condition was poorly controlled until about 10 years later, when he got serious about his health: He joined a gym, hired a personal trainer, and felt the healthiest he’d ever been. He says without this change it would not have been possible for him to go to massage school. 

Long after his initial diagnosis, Albert learned that he probably has type 1 diabetes. He found that after he started using insulin, his mental focus and clarity were much better, and he has seen similar changes for others too. 

Albert’s health is still complex, and difficulties with health insurance have made it much harder. Insulin is less expensive now but in short supply. He has to jump through hoops for every medical decision, and sometimes there are dangerous lags between when a prescription is written and when his drugs are available. And while his kidneys and liver are in good shape, he has had some skin ulcers on his legs that took a long time to heal, and two years ago he had a heart attack.

Albert now supplements insulin and uses an insulin-sensitivity drug. He’s on blood thinners, antihypertensives, and cholesterol-lowering medications. He works as a massage therapist and receives massage once a week. His message for other massage therapists with clients who have diabetes: know if their diabetes is under control and be prepared ahead of time with an easy, sugar-based snack in case they have a sudden drop in blood glucose.

Don’t Let Diabetes Be an Obstacle

“Christine” was diagnosed as prediabetic in her early 50s and with type 2 diabetes around age 60. This came after many years of living in denial and hoping that just a little more exercise and a little less sugar would solve her problem. Both her father and her grandmother had diabetes, and both died of heart disease—likely related to their diabetes. Christine was determined not to go the same route.

When her diagnosis was confirmed, she was prescribed drugs to manage her glucose sensitivity, and she reluctantly accepted them. She didn’t tolerate antidiabetic agent metformin very well and is on a variety of other medications. She does not supplement insulin.

She is now in her mid-60s and doing well. She is overweight—a situation that has persisted since puberty. But her kidney function, cardiovascular health, eyes, and skin are all in good shape. She exercises and is learning some new approaches to her diet that she hopes will contribute to her ongoing goal of not letting diabetes be a major obstacle in her life.  

“I’m Playing Russian Roulette Every Day”

“Michelle” is 53 years old. At 44, she had been having symptoms of a urinary tract infection for a few days, which she treated by drinking a lot of (sweetened) cranberry juice. Over the course of a few days, she developed new back pain and had trace amounts of blood in her urine. That Friday she went to the movies, where she drank soda and ate candy. On the way home, she stopped at an urgent care clinic for some antibiotics, but they referred her to the local emergency room. It turned out that in addition to having a kidney infection, her blood sugar was 500.  

They kept her in the hospital for five days—partly, she says, because they had to convince her she really was in trouble; she was sure that the high BG number was related to the candy and soda at the movies. During that time, they stabilized her blood sugar and educated her about self-care. Later, after working with an endocrinologist, she was informed that she had type 1 diabetes.

Michelle uses two types of injectable insulin and no other medications. She has no other complications other than occasional tingling in her extremities. One tool she describes as a life-changer is a blood glucose monitor: She wears a patch that sends information to an app on her phone. She can check her blood sugar at any time and see how it changes with her food and activity. This is helpful in her work, so she can prevent having her BG drop in the middle of a massage session, and she can be conscientious about keeping her levels within a reasonable range.

By all biological measures, Michelle’s experience with diabetes is a success story: She is healthy, active, and has no physical complications. But she feels she is constantly under threat. “I don’t want to lose my eyesight, I don’t want to lose my feet,” she says. “I feel like I’m playing Russian Roulette every day.” 

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