Hey, Sugar!

A Diabetes Review

By Ruth Werner
[Pathology Perspectives]

When I describe my job—being an educator about pathology for massage therapists—I often get quizzical looks, especially from health-care professionals. They seem surprised that people in the massage therapy profession would need to be well-educated about diseases. “Why on earth do massage therapists have to know about pathology?” asked my doctor, my dentist, and the ER nurse down the street. I have a one-word answer: diabetes.

Diabetes: Definition and Statistics
Diabetes mellitus comes from two Greek word roots meaning “flowing through” and “sweetness.” This refers to the frequent urination we see in someone with untreated diabetes, and the fact that their urine is loaded with sugar. In short, the meaning of this name is “sweet pee.”
Diabetes occurs in several subtypes, but this column will focus on the most common version, type 2 diabetes mellitus, or DM2.  
DM2 has been diagnosed in 21 million Americans, and it probably affects 8 million more who don’t know they have it yet. It costs $245 billion each year in direct and indirect expenses. It is utterly intertwined with three other common conditions: hypertension, atherosclerosis, and chronic renal failure. It can lead to peripheral neuropathy, skin ulcers, systemic edema, birth defects, peripheral artery disease, and kidney failure. It is the leading cause of new blindness among people 20–70 years old. It causes more amputations than any other disease, and largely because of diabetes, about 90,000 people in this country are currently on the waiting list for a new kidney.
Diabetes is not an equal-opportunity disease. It is much more common among African Americans, Hispanics, Native Americans, Pacific Islanders, and Asian Americans than it is among whites.
It is safe to say that every massage therapist will have clients with type 2 diabetes. It is vital that we be well-informed about this condition for two reasons: first, because people with diabetes like massage and want to use it as part of their disease management strategy; and second, because our clients need us to make informed decisions about bodywork that are in their best interests.  

Insulin Review
To talk about the mechanisms behind diabetes we need to do a quick review of insulin. Let’s start with an afternoon snack.
It’s 3:30 p.m. You’ve been working hard all day, and the tuna sandwich you had for lunch is long gone. You are hungry. Two things happen: you go in search of a snack, and your pancreas secretes glucagon, which tells your liver to release some glucose, both to burn while you’re working, and to tide you over until you locate something to eat.
Success! A handful of candied almonds, just the thing. Your teeth satisfyingly crush the nuts, and chemicals in your stomach begin to dissolve the bits and pieces you swallow. Within a few minutes, nutrients enter the small intestine, then the bloodstream, and ahhhhh. (This takes a little longer if the nuts are not covered in sugar.)
Now your hunger is eased, and your blood sugar goes up. This is the signal for the pancreas to release insulin, a hormone that carries sugar into waiting, hopeful, hungry cells at dedicated cell receptor sites. Glucose provides efficient fuel for cellular activity, which is especially important for muscle and nerve cells. And cells have no access to glucose without insulin to unlock the receptors on the cell membranes.
Insulin brings blood glucose back into normal range, and the cycle begins again.
But what if the pancreas can’t make enough insulin? Or what if the cell receptors stop working? Or what if there’s not enough insulin and the cells are insulin resistant?

Signs, Symptoms, and Complications
DM2 occurs when any combination of low insulin production or insulin resistance develops. The earliest signs and symptoms connected to this are easy to miss. Frequent hunger (because cells have such limited access to sugar—the fastest and most efficient form of fuel) can lead to weight gain initially, but this may turn to weight loss later in the disease process. Overactive kidneys lead to frequent urination, which leads to more-than-usual thirst.
These three signs: hunger, thirst, and frequent urination, are often the earliest indicators that something in the system isn’t working well, but these are subtle and easy to miss.
The more commonly recognized signs of diabetes, other than a blood glucose reading, are the complications it brings about.
With no access to sugar, the working cells have to revert to burning other sources of fuel (i.e., protein and fat). This produces much more metabolic debris, so waste accumulates in the bloodstream along with excessive sugar—this is hyperglycemia.
Now blood vessels and kidneys have to function with sugary, waste-filled blood. This is hard on the arteries—think of it as having sand in the circulatory system—and this opens the door to atherosclerosis and hypertension.
The kidneys, which have to filter excess sugar out of the bloodstream, must operate under excessive pressure because of that hypertension. Eventually they can’t keep up. Renal failure is practically a foregone conclusion for untreated DM2.
The accumulation of fatty plaques is not limited to the big arteries near the heart, as we see in more typical cardiovascular disease. People with diabetes can accumulate atherosclerotic plaques virtually everywhere, including the arteries of the legs—leading to painful or numbing peripheral neuropathy.
Poor circulation is damaging to the skin as well, especially in the feet. People may notice that sores in general are slower to heal. Diabetic ulcers are the result of chronic ischemia and nerve damage that interferes with pain signals. Even minor foot injuries like blisters or ingrown toenails can become threatening in a person with diabetes: infections here are difficult to fight off. This is why diabetes leads to some 73,000 foot or leg amputations each year.
Thickening of the capillaries that supply the eye, along with sugar in the lens, contributes to progressive vision loss and possible blindness.
Many other complications can also arise because of diabetes, but the ones mentioned here—especially kidney and cardiovascular disease—are usually the most threatening.

One of the truly frustrating things about DM2 is that it is a treatable, preventable disease. The problem is that to treat it or prevent it requires exercise, which makes insulin receptors more receptive, and it requires that people eat in a way that bucks our cultural trends, and this is fabulously difficult to do.   
We are bombarded daily with media about food and eating. Every women’s magazine in a grocery store check-out stand has a miracle diet headline on the cover—usually right next to a picture of a cake or a fancy dessert recipe. It’s safe to say that as a culture we fetishize food—especially food that is perceived as decadent or indulgent. This is our media trend, and it is a potentially life-threatening message for people with diabetes.
But lots of people appear to have the answers. Do a Google search for “diet to treat diabetes” and you will get 30 million results. And yet, we still have almost 30 million Americans with diabetes.
Type 2 diabetes can often be managed with diet and exercise, if the person can establish and sustain habits that are helpful and supportive. Nothing changes overnight in this condition; patients must take control of their own situation and work for long-term benefits.  
Currently, the main treatment goals for DM2 focus on stopping its progression and limiting secondary organ damage as much as possible. This starts with diet and exercise, but usually also involves medication and possibly supplemented insulin. Some nutritional specialists have had success with reversing this condition, but it is safe to say that what works for one patient is not guaranteed to work for the next one.

Implications for Massage
The answer to the question, “Is massage therapy OK for people with    ?” is always “It depends.” It depends on the type of manual therapy, and in the context of diabetes, it depends on many variables about the client’s health, complications, and general resilience.
If we think about what risks are present with a client who has diabetes, the worst ones that leap to mind are the consequences of inadequate disease management. Examples might include things like diabetic ulcers on the feet, which can progress to extremes partly because of an impaired ability to sense potential damage. Skin ulcers of any kind are dangerous for massage therapy, because of the risk of infection that could lead to gangrene and a need for amputation.
Even if the skin is healthy and intact, massage therapists need to have an idea about kidney and cardiovascular health. Poorly managed diabetes is a setup for heart disease and renal failure, and both of these conditions—and the medications that manage them—have repercussions for massage therapy decisions. We need to consider that clients with advanced diabetes have a compromised fluid management system. Their circulatory and urinary systems may not be able to keep up with challenges, so any massage that intends to move a lot of fluid is not a good choice in this situation.
Even if a client’s diabetes is well-managed, some practical decisions about insulin, hypoglycemia, and massage therapy must be considered. Blood sugar often appears to drop during or after a massage session. How much, and for how long, is hard to predict. Because our clients with diabetes may have a difficult time regulating blood sugar, it’s important for them to know this might happen. Our clients must not skip their insulin dose because they’re getting a massage. Even though both interventions reduce blood sugar, we do not allow massage to interrupt a person’s prescribed medication use. But because some people experience sudden episodes of hypoglycemia after a massage, it is a good idea to find out in advance how they’d like to deal with that. Some clients will keep sugar tablets or a favorite candy with them; others will prefer a quick sip of milk or juice to get some sugar into their system. I hope it’s obvious that diet soda and sugarless candy are not good options in this situation.
Another thing you can do to reduce the risk of a precipitous drop in blood sugar is to try to schedule massage sessions for the middle of your client’s insulin cycle: not right at the beginning when they’ve just taken insulin before a meal, and not later when they’re getting hungry and blood sugar is dropping, but as close to the middle—the most stable part of the hormone cycle—that you can manage.
These actions—planning ahead in case of a drop in blood sugar and working to schedule sessions in the middle of the insulin cycle—help engage our clients in the decision-making process. People with diabetes often do best when they can take charge of their own care, and massage therapy fits well into this model.  
Are there benefits we can reliably offer? The research on massage therapy and diabetes is scattered, inconsistent, and mostly small in scale. But within our evidence base we can point to studies that demonstrate that massage therapy is a popular choice for people with diabetes for stress and anxiety relief. Some small-scale studies suggest that massage may positively affect diabetes biomarkers, that it may be an appropriate intervention for people with diabetes and peripheral artery disease in the legs, and it may even improve balance and gait for people with foot problems.
Diabetes doesn’t progress in exactly the same way in any two people, and every person with diabetes will have their own unique challenges with managing it. We cannot rubber stamp whether massage therapy is appropriate for a person with this condition. It is the job of every massage therapist to carefully weigh possible risks and benefits, to plan appropriate accommodations, and to involve the client in setting achievable goals for relaxation, wellness, and long-term successful management of this condition. To do that, we need to know not just about the pathophysiology of diabetes, but also about the function of virtually every system in the body. If we do that well, our clients can benefit from reduced stress and improved function.
Why do massage therapists need to know about pathology? Diabetes. That’s why.

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Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.