The Effect of Stress Management Exercise toward Blood Glucose

Level Control in People with Type 2 Diabetes Mellitus in Sub

District of Pancur Batu in 2018

Amira Permata Sari Tarigan, Afniwati Afniwati And Endang Susilawati

1Departement of Nursing, Medan Health Polytechnic. Jl. Bunga Ncole no. 95, Medan 20136, Indonesia
amirapstar77@gmail.com

Keywords : Type 2 Diabetes Mellitus, stress management exercise, blood glucose level

Abstrak : Stress is one of the important factors that can affect the increase of blood Glucose level in people with type
2 diabetes mellitus (Type 2 DM). Therefore, an effort is needed to manage the stress in people with type 2
DM. The purpose of this study was to analyzed the effect of stress management exercise toward blood
glucose level control on people with type 2 DM in the Sub District of Pancur Batu. The type of this study
was quasi experimental with one group pretest posttest design. The number of samples were 20 people with
type 2 DM who were taken by purposive sampling technique. The data was analyzed by using the paired t-
test. The result showed that there was a difference in average blood glucose levels of people with type 2
DM before and after they receiving stress management exercise (P value = 0,001, α=0,05). In conclution,
stress management had an effect on controlling blood glucose level in people with type 2 diabetes melitus.

1. INTRODUCTION
Diabetes mellitus is a group of metabolic diseases
characterized by an increase in blood glucose levels
(hyperglycemia), which occurs due to abnormal
insulin secretion, insulin activity or both (Smeltzer
and Bare, 2008)
Diabetes mellitus if not managed properly will
result in various chronic complications, such as
cerebrovascular disease, coronary heart disease, limb
blood vessel disease, disorders of the eyes, kidneys
and nerves. People with diabetes mellitus have 2
times greater risk of developing coronary heart
disease and cerebral vascular disease, 5 times more
prone to ulcer/gangrene, 7 times easier to suffer from
terminal kidney failure, and 25 times easier to
experience blindness due to retinal damage than non
diabetic patients. Efforts to heal back to normal are
very difficult if it has been complicated, because the
damage that occurs generally will settle. Prevention
efforts are needed earlier to overcome these
complications and it is hoped that it will be very
useful to avoid the occurrence of various unfavorable
things (Riskesdas, 2013)
The prevalence of diabetes mellitus in the world
showed a very significant increase. According to data
from the International Diabetes Federation (IDF) that
in 2010 the total population of the world suffering
from diabetes was 200 million, this number has
doubled in 2015 to 415 million. IDF through the 2015
Diabetes Atlas also stated that Indonesia was ranked
seventh in the top 10 countries with the largest
number of diabetics.
The Ministry of Health's Data and Information
Center stated that the proportion of diabetics in
Indonesia in 2013 has almost doubled compared to
2007. The proportion of people with diabetes mellitus
in Indonesia were 6.9%, impaired glucose Tolerance
(IGT) were 29.9% and Impaired Fasting Blood
Gglucose (IFBG) were 36.6%. The proportion of the
population in rural areas who suffer from diabetes
mellitus is almost the same as the population in cities.
The prevalence of diabetes mellitus increased from
1.1 percent in 2007 to 2.1 percent in 2013. In 2015
the number of people with diabetes in Indonesia
according to the IDF was 10,021,400 people.
In North Sumatra, the number of people
diagnosed with diabetes in 2013 amounted to 160,913
people or 1.8% of the population and an estimated
44,698 people suffered from diabates but were not
diagnosed (Riskesdas, 2013)
Lloyd et al (2005) stated that stress has an
influence on the incidence of diabetes, both in terms
of onset and exacerbation of diabetes it self. Bjorntop
(1997) stated that the psychological reaction that
occurs when someone experiences stress is a feeling
of helplessness, this will activate the hypothalamo-
pituitary-adrenal axis (HPA), which in turn will cause
various endocrine abnormalities such as high cortisol
which has the opposite role of insulin. At the same
time, there is thickening of the visceral adipose tissue,
where this situation will cause resistance to insulin,
resulting in an increase in blood glucose level.
According to Lloyd et al (2005) Diabetes mellitus
is also a chronic disease that requires self-
management of the diabetics themselves to carry out
daily care such as following a diet plan, preparing and
remembering the schedule and dosage of taking
medication, which is also the case. can be a source of
stress for a diabetics.
Emotional distress is common in outpatients with
diabetes, affecting 20–40% of the patients. Mindfulness
Based Stress Reduction (MBSR) resulted in a reduction of
emotional distress and an increase in health-related quality
of life in diabetic patients who had lower levels of
emotional well-being (American Diabetes Association,
2013)
Napora J, (2013) said that diabetes management is
a continuous process, for many diabetics this process
may be complicated again by the impact of the stress
it experiences, because excessive stress results in an
increase in blood glucose level.
Research conducted by Surwith R.S. (2002)
showed that stress management training carried out
on patients with type 2 diabetes mellitus can improve
the control of blood cavern levels in the long term.
The Health Profile of Pancur Batu Health Center
showed that in 2016, Diabetes mellitus ranked 2nd
in The chronic disease with the highest prevalence in
2016. Interviews were conducted for people with
diabetes mellitus in Pancur Batu, most of them felt
stressed, anxious and afraid of complications from the
disease. The diabetics also did not know how to deal
with the stress they experienced.
Based on this background, it was needed to
conduct research on "The Effect of Stress
Management Exercise toward Blood Glucose Level
in People with Type 2 Diabetes Mellitus in the Sub
District of Pancur Batu.
2. METHOD OF RESEARCH
This type of research was quasi-experimental with
One Group Pretest - Posttest Design which aimed to
see the effect of stress management exercise toward
blood glucose level control of people with type 2
diabetes mellitus.
The location of this study was in Sub District
Pancur Batu, North Sumatera in 2018. The sample
used was 20 adult people with type 2 diabetes
mellitus and their blood clucose level was above 200
mg/dl.
First, the researchers worked with officers in the
Community Health Center identified the people
diagnosed with type 2 diabetes mellitus in the
working area of the Sub District of Pancur Batu. The
researcher explained about the research activities that
will be carried out and asked their willingness to
become respondents. then, the researchers measured
the respondents' blood glucose level. Researchers
taught the stress management and provide leaflets to
respondents. All respondents were asked to do stress
management exercise at least 3 times a day and at
any time if they felt stressed. Blood glucose level was
measured again after 7 days.
Data was analyzed by computerization, using the
SPSS program. Univariate analysis to described the
characteristics of respondents such as gender, age and
blood glucose level of respondents. Bivariate analysis
was used to find out the effect of the stress
management exercise toward blood glucose level
control in people with type 2 diabetes mellitus. Paired
t- test was used in this study to see differences in the
mean blood glucose level of respondents before and
after receiving stress management exercise.
3. RESULT AND DISCUSSION
3.1. Characteristics of Respondents
Description of respondents’ characteristics can seen
at the table below :
Table 1: Characteristics of Respondents
Characteristics n %
Gender
Male 5 25
Female 15 75
Age (year)
50-54 5 25
55-59 7 35
60-64 6 30
65-69 1 5
70-74 1 5
Total 20
 The majority of respondents in this study were
female as much as 75%, in terms of age, all
respondents were above 50 years old, the majority of
them were 55-59 years old as much as 35%.
The majority of respondents were female as much
as 75 %, it was in line with RISKESDAS data (2018)
that showed the number of women who suffer from
diabetes higher than men (women= 1,8 %, men =
1,2%). This might be related to the stress experienced
by women. Women were more easily stressed. Some
studies said that women tend to have higher stress
than men because they think about problems
excessively.
All respondents were over fifty years old and the
majority were 55-59 years old. Diabetes mellitus tend
to occur in the elderly. It was in accordance with the
theory of Guyton and hall (2012) who said that
diabetes mellitus increase at the age above 40 years
due to reduce body tissue sensitivity to insulin.
3.2. Blood Glucose level of Respondents
Before receiving the stress management exercise, all
respondents' blood glucose level were above 200
mg/dl. The average of respondents’ blood glucose
level was 383.10 mg/dl. After the stress management
exercise, the average of respondents’ blood glucose
level was 277,80.
Table 2 : Description of respondents’ blood glucose level
before and after stress management exercise
Blood Minimum Maximum Mean SD
Glucose
Level
Before 201 590 383,10 118,48
SME
After 83 558 277,80 134,60
SME
3.3. The Effect of Stress Management
Exercise
To see the effects of stress management exercised
toward respondents’ blood glucose control used pair
t-test statistics and bootstrap techniques. The test
result showed that there were differences in mean of
respondents’ blood glucose level before and after
receiving stress management exercise as much as
105,30 mg/dl with p value =0,001 and @=0,05, as
seen in the table 3 :
Table 3 : Difference in average of respondents’ blood
glucose before and after stress management exercise
Variable Mean SD P Value
Blood Glucose
Level before SME
105,30 99,91 0,001
Blood Glucose Level
after SME
The blood Glucose level of respondents before stress
management exercise were very uncontrolled. The
average blood glucose level was 383.10 mg/dl, with
a range between 201- 590 mg/dl. This condition
might be caused by respondents did not apply
diabetes management properly, such as
pharmacological therapy, nutritional therapy,
physical exercise and education. Most respondents
consume traditional medicines that have not been
clinically tested about the benefits and dosage.
Respondents also rarely checked blood glucose
levels regularly, they usually go to community health
centers to get the medical services if they feel sick.
In this study, respondents were taught to manage
stress and were asked to apply it to everyday life.
Observations on stress management actions carried
out by respondents were carried out for 7 days. The
blood glucose levels of respondents were checked
again after 7 days.
Paired t-test showed that there were significant
differences in the average blood glucose levels of
respondents before and after receiving stress
management exercie. The blood glucose level
decreased by 105.3 mg/dl (p value = 0.001, α=0,05).
The data showed that stress management exercise
have a positive influence on controlling blood
glucose level.
Result of this study in accordance to Bjorntop P.,
1997 who said that the psychological reaction to
stressor of defeatism or helplessness lead to the
activation of the hypothalamo-pituitary-adrenal
(HPA) axis, leading in turn to various endocrine
abnormalities, such as high cortisol that antagonize
the action of insulin.
A study that conducted by Astuti in 2016 stated
that Progressive Muscle Relaxation (PMR) could
decrease blood glucose level.. The result of study
showed that before receiving progressive muscle
relaxation the average of blood glucose lezel was
238,40 mg/dl, and after was 125,68 mg/dl (p value =
0,001, α=0,05).
Stress management training was associated with a
reduction in HbA1c., stress management program in a
“real-world” setting can result in clinically significant
benefits for patients with type 2 diabetes. (Surwit
Richard S., et.al, 2002). Boardway et al. Found that
adolescents receiving stress management training
improved stress level, but metabolic control,
adherence, coping styles and self efficacy about
diabetes were unchanged.
Stress management exercise is very useful for
managing the stress that experienced by people with
type 2 diabetes, They feel more relaxed and free from
pressure. In a relaxed state, insulin could more
effectively regulate blood glucose level.
3.4. Research Limitations
The limitation in this study was the absence of a
control group. It is preferable in a quasi-experimental
study to use a control group to see differences in
treated. In the absence of a control group in this
study, researchers were unable to control other factors
that might have an influence in decreasing
respondents' blood glucose level, such as diet,
physical activity and drugs consumed by respondents.
4. CONCLUTION
Based on research conducted on 20 sample adult
people with type 2 diabetes mellitus in Sub District
Pancur Batu, it was found that there were significant
differences in the average of blood glucose level
of people with type 2 diabetes mellitus before
and after receiving stress management exercise.
The result also show that the Stress management
exercise had an effect on controlling blood
glucose level in people with type 2 diabetes
mellitus.
REFERENCES
American Diabetes Association, 2013. The Effects of a
Mindfulness-Based Intervention on Emotional Distress,
Quality of Life, and HbA1c in Outpatients With Diabetes
(DiaMind). Diabetes Care 36(4) : 823-830
American Diabetes Association, 2014. Diagnosis and
Classifications of Diabetes Mellitus. Diabetes Care
(Supp. 1) : S81-S90
Astuti P., 2014. Teknik Progressive Muscle Relaxation
Mempengaruhi Kadar Glukosa Darah Penderita
Diabetes Melitus Tipe 2. Journal of Health Sciences
Vol 7 No. 2
Bjorntop P., 1997. Body fat distribution, insulin resistance,
and metabolic diseases. Nutrition 13 (9) : 795-803
Boardway R.H., et.al., 1993. Stress Management Training
for Adolescents with Diabetes. Journal of Pediatric
Psychologi 18: 29-45
Chamberlain J. J., et al., 2016. Diagnosis and Management
of Diabetes : Synopsis of the 2016 American Diabetes
Association Standards of Medical Care in Diabetes.
Annals of Internal Medicine 164 (8): 542-552
Hans Tandra, 2008. Segala Sesuatu yang Harus Anda
Ketahui tentang Diabetes. PT Gramedia Pustaka
Umum. Jakarta
International Diabetes Federations, 2015. Diabetes Atlas
2015. http://www.diabetesatlas. org/resources/2015-
atlas.html. 7th Editions.
Lloyd C., et al., 1999. Association between stress and
glycemic control in adults with adults with type 1
(insulin-dependent) diabetes. Diabetes care
22(8):1278-1283
Lloyd C., Smith J.,Weinger K., 2005, Stress and Diabetes :
A Review of the Links. Diabetes Spectrum 18(2):121-
127
Manaf, 2009. Insulin: Mekanisme Sekresi dan Aspek
Metabolisme. In Sudoyo, A.W., et al., Buku Ajar Ilmu
Penyakit Dalam Jilid III. Interna Publishing Pusat
Penerbitan Ilmu Penyakit Dalam. Jakarta, 5th Edition
Napora J., 2013. Managing Stress and Diabetes. Diabetes
Support Group.
Kemenkes RI, 2015. Pusat Data dan Informasi 2014 :
Waspada Diabetes, Jakarta
Perkeni, 2011. Panduan Penatalaksanaan Penyakit Diabetes
Melitus. Jakarta
Powers, 2010. Diabetes Mellitus. in Jameson J.L. Harrison
Endocrinology . McGraw-Hill Companies, Inc. USA,
2th edition.
Price Sylvia A, 2005. Patofisiologi: Konsep Klinis Proses-
Proses Penyakit. EGC. Jakarta, 6th edition.
Purnamasari D. 2009. Diagnosis dan klasifikasi diabetes
melitus. in: Sudoyo A, et al.,. Buku ajar ilmu penyakit
dalam jilid 3. Interna Publishing. Jakarta, 3rd edition
Reinhart, 2001. Effect of Positif and Negative support
received and provided on adaptation to Chronic Visual
Impairment. Aplied Development Science
Riset Kesehatan Dasar. 2013. Jakarta: Badan Penelitian dan
Pengembangan Kesehatan
Smeltzer and Bare, 2008.Brunner & Suddarth's Textbook
of Medical Surgical Nursing. Lippincot. Philadelphia
Surwit R. S., et.al., 2002. Stress management improves
long-term glycemic control in type 2 diabetes. Diabetes
care 25:30-34
Waspadji, 2009. Komplikasi Kronik Diabetes: Mekanisme
Terjadinya, Diagnosis dan Strategi Pengelolaan. In
Buku Ajar Ilmu Penyakit Dalam, Jilid III. Pusat
Penerbitan Ilmu Penyakit Dalam. Jakarta, 5th edition