Type 1 diabetes consists of a loss of B-cells. There is a sudden onset and no prevention. It occurs early in life and there is a peak during puberty. It is life-long and requires insulin-therapy. This type of diabetes is not lifestyle-related.

Type 2 diabetes consists of a loss of B-cells and insulin resistance. It has a late and slow onset. It is related to obesity and occurs more often in older age. There is a strong risk factor in genetics and lifestyle. It is treated through diet (1), exercise (2), medication (3) and insulin therapy (4). This type of diabetes can be prevented by means of diet and exercise.

The goal of diabetes treatment is to avoid extreme blood glucose levels while maintaining quality of life. High blood glucose levels increases the risk of complications. There are several long-term complications of diabetes (e.g. atherosclerosis, foot amputations, hypertension).

Chronically heightened levels of glucose can damage mitochondria. This can promote inflammation and telomere shortening.

The impact of diabetes on the brain are mild cognitive decrements in longstanding type 1 diabetes. There is an increased risk for cognitive decline in type 2 diabetes. About a third of the patients have prolonged coping problems with diabetes. There is also an increased prevalence of emotional distress in somatic disease.

There are three aspects that need to be dealt with for people with diabetes:

1. Medical
   This includes symptom management (1), hospital visits (2), medication (3) and self-tests (4).
2. Social
   This includes role functioning (1), family (2), friends (3) and work (4).
3. Emotional
   This includes regulating distress (1), anxiety (2), depression (3) and anger (4).

Diabetes depends almost entirely on behavioural self-regulation which makes it more difficult to cope with the disease. There are seven self-management behaviours in diabetes:

1. Healthy eating
2. Being active
3. Monitoring
4. Taking medication
5. Problem-solving
6. Reducing risks
7. Healthy coping

There are diabetes-specific stressors:

1. Effort-reward imbalance
2. Lifestyle changes
3. Acute, unpredictable blood glucose excursions
4. Chronic complications
5. Functional limitations
6. Disability
7. Permanence
8. Discrimination and negative support

There is a negative cycle leading to burnout in diabetes. The negative experiences lead to negative beliefs and attitudes about diabetes. This leads to negative emotions which, in turn, leads to giving up. This, again, leads to negative experiences. There are often coping and adaptation problems in diabetes.

Diabetes distress refers to emotional distress specific to the experience of living with and managing diabetes. This is higher in patients with complications and adolescents. Depression can appear similar to diabetes distress. However, diabetes is associated with an increased risk of depression. There is a bidirectional relationship between depression and diabetes.

Stress has neuro-hormonal effects which can be amplified and initiated by lifestyle factors. This influences the risk for diabetes type 2, which, in turn, influences the risk of depression, which can lead to more stress.

There is a psychological and biological pathway to the risk of diabetes. Depression is associated with poorer lifestyle which is associated with increased risk for diabetes and influences the severity of diabetes. There is a higher prevalence of anxiety disorder and symptoms of diabetes.

Fear of hypoglycaemia consists of unpleasant symptoms (1), depersonalization (2), risk of brain damage (3), death (4), becoming dependent on others (5), behaving stupid (6), losing consciousness in public places (7), burden on relationship (8), causing accidents (9), loss of work (10) and absence of work (11). People with diabetes are as afraid of hypoglycaemia as they are of severe and chronic complications.

Active avoidance behaviours include frequent testing of glucose levels (1), underdosing insulin (2), defensive snacking (3). Passive avoidance behaviours include avoiding activities to prevent hypoglycaemia.

People with impaired hypoglycaemia awareness (1), with experience of previous episodes of severe hypoglycaemia (2), people with high trait anxiety (3), with repeated unpredictable lows in glucose levels (4) and people who have witnessed episodes of severe hypoglycaemia (5) are at risk.

There is a higher prevalence of eating disorders in diabetes. A degree of sexual dysfunction is associated with depression and diabetes complications. A poor mental health is common in diabetes and this is associated with poor health outcomes.

Anger and adverse childhood experiences are associated with an increased risk of diabetes.

There is poorer self-reported quality of life (1), poorer adherence to medications (2), fewer self-care activities (3), poorer metabolic outcomes (4), increased risk of diabetes-related complications (5), increased mortality (6) and increased costs (7) in diabetes patients with poor mental health.

There are three levels of psychological care:

1. Psycho-education (individual, group, internet)
2. Psychological treatment (individual, group, internet)
3. Psychiatric treatment (medication)

Periodic monitoring as part of routine check-in medical care improves recognition and discussion of psychological needs.

Taking diabetes into account in CBT has added value. CBT appears to be effective in improving short-term and medium-term glycaemic control.

There are several advantages of internet-based treatment:

1. Lower threshold
2. Less stigma
3. More honest and revealing
4. Flexible and client-friendly
5. Time and cost-efficient
6. Research friendly

The disadvantages are not having access to the internet (1) and attrition (2). Medical psychology can make an important direct and indirect contribution to diabetes care. This ranges from prevention to disease management. Digital solutions can enhance the reach of treatment.