Diabetes is a common issue for many Americans. For singers, the condition itself and medications to treat it can have additional effects.
Our previous article addressed the depression associated with the chronic stress of being a performing artist. That chronic stress has other effects on our bodies, including poor metabolic health. Many of the contributing factors to stress in a performer’s life, from the physical demands of performing to the inconsistent sleep schedule and the sleep deprivation of late nights, contribute individually to illness. Consider your sleep schedule: have you ever had a gig or a concert that ended late at night? Or your food schedule: what do you eat before and after a performance?
You have probably heard of insulin, the medicine that is always used by those with Type 1 diabetes, because their bodies cannot make insulin on their own. But it is also sometimes used to treat those with uncontrolled Type 2 diabetes, which is when a body is resistant (insensitive) to the insulin it makes. Insulin is more than just a medication—it’s also an important hormone vital for managing your body’s energy resources, especially blood sugar.
The more sensitive you are to your own insulin, essentially, the healthier you are. Sleep deprivation is one of the factors that drives your body to become less sensitive, or resistant, to insulin. Another way to turn up insulin resistance is by overloading your body with ultra-processed carbohydrates.
Insulin resistance, a.k.a. “metabolic syndrome,” may progress into Type 2 Diabetes Mellitus (T2DM), especially if combined with the standard American diet (SAD). The sugar tsunami that regularly washes over you when you consistently eat out of a box or a bag eventually swamps your metabolic sandbags, thus overwhelming the body’s ability to maintain balanced blood sugar. Also, if you have a family history of diabetes, you’re at higher risk. And T2DM is common: an estimated 11% of Americans have T2DM and more than 30% have metabolic syndrome, more than 100 million Americans!
What to Look For
Initially, the first signs of metabolic syndrome or even T2DM are silent, which is why annual checkups with your healthcare provider, where your insulin and glucose are tested, are important. One of the most common of the outward signs is high blood pressure. Another is weight change—and although weight gain is associated with metabolic syndrome, sudden weight loss (without changing your diet) can be associated with T2DM. But sometimes weight isn’t associated with it at all! Constant thirst (called polydipsia) and frequent trips to the bathroom to empty your bladder (called polyuria) are strongly associated with T2DM. Constant hunger can also be a sign, because elevated insulin resistance makes you hungry, and frequent infections may also be indicators.
Left untreated, other symptoms appear, some of which affect your ability to perform. Diabetic neuropathy may include hearing loss—can you imagine singing without being able to hear your accompanist? Progressive blindness is yet another manifestation of diabetic neuropathy. How difficult would it be to learn a new piece if you could not see your music? And peripheral neuropathy, tingling and/or numbness in the hands or feet, could adversely affect your control and ease of movement and expression on stage.
I Have T2DM, Now What?
Fortunately, there are a number of things that can be done to mitigate and even reverse T2DM. However, before you start any lifestyle changes, counsel with your healthcare provider! A combination of what you eat, when you eat, how you move, how you sleep, how you manage stress, and what medications you take can make a huge difference. The goal is to make yourself sensitive to insulin and to keep your blood sugars in a healthy range.
Resistance training (yes, weightlifting) is a very powerful way to improve insulin sensitivity, as is intermittent fasting (IF). We cannot emphasize enough the need to counsel with your healthcare provider before starting IF. Avoiding ultra-processed foods and/or sugary drinks will significantly reduce the body’s need for insulin too. All of that considered, let’s talk about the medications commonly used to treat T2DM.
Medications
Medications can be an extremely helpful tool for the treatment of T2DM. These medications have a goal of lowering the level of sugar in the blood, increasing insulin sensitivity, preventing further damage to organ systems caused by high sugars, and decreasing the risk of heart and kidney disease. The mechanisms by which each of these medications achieve these goals vary.
Some examples of common medications used for the treatment of T2DM:
- Sodium glucose co-transporter 2 inhibitors (SGLT2i): empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana)
- Glucagon-like peptide 1 receptor agonist (GLP1a): semaglutide (Ozempic), liraglutide (Victoza), dulaglutide (Trulicity)
- Glucagon-like peptide 1 receptor agonist/ glucose-dependent insulinotropic polypeptide (GLP1a/GIP): tirzepitide (Mounjaro)
- Biguanides: metformin (Glucophage)
- Insulin: glargine (Lantus, Basaglar), lispro (Humalog), aspart (Novolog)
Safety Considerations
As mentioned in previous columns, all medications have safety considerations. The safety of medications used for the treatment of T2DM depends on many factors, including a person’s past medical history, medication allergies, administration timing, frequency, and understanding of the medication. It is important to note that these medications are widely used and mostly well tolerated. If you have any concerns about side effects, it is important to speak with your healthcare provider.
Common Side Effects That May Affect Singers
Metformin, GLP1a, and GLP1a/GIP have actions primarily in the liver and gastrointestinal tract among other sites of action. Because of this, gastrointestinal side effects may be more common with these medications. Diarrhea is a common side effect of metformin use, which can be worsened by formulation type, timing of administration, or history of preexisting gastrointestinal disorders. Nausea has been commonly seen with the use of GLP1a and GLP1a/GIP, which can be prompted or worsened by eating foods high in fats, overeating, or dose changes. Bloating caused by either of these medications could have an effect on lung capacity, impacting a singer’s overall power. Additionally, bloating can increase discomfort in restrictive costumes.
SGLT2i medications work mainly in the kidneys, increasing the excretion of sugar from the blood through the urine. When starting the medication, an increase in urination may occur, which increases the risk of dehydration. Taking the medication with a large glass of water and staying hydrated throughout the day can prevent dehydration or dry mouth that could impact a performance.
Insulin works primarily on the liver, skeletal muscle, and adipose tissue to utilize and store sugar found in the blood, thus lowering the concentration. Insulin is incredibly effective at lowering blood sugar, which can increase the risk of blood sugars going too low. Signs of low blood sugar may include dizziness, lightheadedness, or shakiness. It is always important to monitor blood sugars, and especially if taking insulin, and to work with your healthcare provider to ensure you are on the most effective and safest dose.
Mitigating or Treating Side Effects
T2DM should not go without appropriate treatment. The balance of risks vs. benefits should be a discussion to have between every patient and their medical provider. Depending on the medication, there may be important lifestyle strategies to help minimize the risk of side effects.
For example, eating more frequent, smaller meals with the use of GLP1a can decrease the risk or severity of nausea. Staying hydrated while taking an SGLT2i can decrease the risk of dehydration. All users of these medications should talk with their prescribers to discuss personal strategies to ensure the benefits of taking a medication for T2DM outweigh the risks.
Case
David is a tenor singing for the Minnesota Opera. He was recently diagnosed with T2DM, a condition that has run in his family for two generations. During the winter months in Minnesota, it can be challenging for David to keep his physical activity as consistent as in the summer months. After six months of improving his physical activity and eating fresh foods, David and his healthcare provider decided it is time to start dulaglutide to help assist with bringing his blood sugars down and prevent other complications from uncontrolled diabetes.
Considering dulaglutide works in the gastrointestinal tract, what side effect should David monitor prior to his upcoming performance?
a.) Signs of low blood sugar (lightheaded, dizziness, shakiness, etc.)
b.) Nausea
c.) Palpitations
d.) Increased hunger
Answer: b
