Diabetes and Mental Health Counselor Continuing Education

Hey there, everybody, and welcome to this presentation on diabetes and mental health. I'm your host, Dr. Donnelly Snipes. In this presentation, we'll explain the importance of screening for diabetes in mental health populations, identify mental health and physical complications of untreated diabetes, explore the functions of the clinician, case manager, social worker, identify important treatment targets, and explore motivational enhancement strategies. How big is this problem? Why are we even talking about this? An estimated 34.2 million people have diabetes. That's about 10.5% of the U.S. population. It's about 1 in 10 people. An estimated 26.9 million people of all ages have actually been diagnosed with diabetes. That's about 8.2% of the US population. But an estimated 7.3 million adults age 18 years or older have diabetes and are undiagnosed. So this last statistic only applies to adults. So we don't know how many children are have diabetes but are undiagnosed. So these are big numbers. These are big, big numbers. By the time they're diagnosed, 50% of people with type 2 diabetes already show signs of complications. Wow. Okay, so this is one of the reasons that we're talking about this today, because if you're working with somebody and you just take some time to do a brief screening to determine whether they need a referral to their medical provider, you may help with early identification and help prevent, prevent some of these signs of or some of these complications. Diabetes, which is the destruction or malfunction of beta cells, may begin 10 years before the diagnosis, and complications may start five years before the diagnosis. So we have a really large window where we can get in here and say, oh, I wonder if there's something going on. Cardiovascular disease causes 52% of death and disability in people with type 2 diabetes. And people with type 2 diabetes have a 200% increased risk of stroke. Kidney disease impacts 33% of people with type 2 diabetes and accounts for 11% of deaths in people with type 2 diabetes. And life expectancy is reduced on average, but by up to 10 years in people with type 2 diabetes and 20 years for people with type 1 diabetes. Those statistics sound really awful. Okay. You know, by anybody's measure. However, it's important to recognize that effectively controlling their blood sugar, their A1C levels, treatment compliance, and early identification and intervention can mitigate, if not eliminate, a lot of these problems. So as clinicians, we have a twofold responsibility, if you will. Number one is screening for those who haven't been diagnosed. For those who have been diagnosed, one of the Things that we are called to do is to help the person minimize risk factors and remain treatment compliant, working with their multidisciplinary team. Neuropathy or nerve damage impacts up to 50% of people with diabetes, contributing to slow wound healing, lack of awareness of wounds, erectile dysfunction and chronic pain. Limb amputation occurs in approximately one out of every 40 people with diabetes who develop a foot ulcer. And up to 70% of people die within five years of having an amputation. Now, it's not so much the amputation, it's the fact that the people who have the amputation often already were having much more difficulty controlling their blood sugar. So despite the amputation, their blood sugar management still remains a problem, which contributes to additional complications which can eventually contribute to their demise. 98% of those with type 1 diabetes and 78% of those with type 2 diabetes have some degree of retinal damage, although fewer than 5% suffer severe vision loss. So that's an optimistic statistic if you want to look at it that way, because a lot of people are hear diabetes and they think blindness and that's really not all that common, especially again if people are treatment compliant and manage their A1C levels. Uncontrolled diabetes is also a significant risk factor for the development of dementia as the result of vascular damage. So it's not just physical as we think of it, physical complications, we also see cognitive complications as well, as you're going to find out, emotional complications. Approximately 33% of people with diabetes have psychological and or social problems with which impair their ability to self manage their diabetes. What does that mean? That means that some people may be too depressed or maybe too anxious to be treatment compliant. Some people may be too stressed out to be treatment compliant or they're so stressed out in their life that that HPA access dysregulation makes it even harder to manage their blood sugar levels, which contributes to their diabetes. So you're going to see how all of the mental health, the social stress, the physical stress and diabetes all interact. We can't extricate them. Comorbid mental health issues do does increase mortality in people with diabetes. Anxiety reduces the quality of life and activates that HPA axis. Remember, the HPA axis is your stress response system. When the HPA axis is activated, blood sugar regulation becomes more difficult. And we're going to talk about this in depth in a few minutes. Eating disorders Patients with either anorexia or bulimia are significantly at risk of complications, particularly retinopathy and nephropathy. And mortality if using insulin omission as a method of weight loss. I had never heard of using insulin omission as a method of weight loss, but apparently it's a problem. So if you're working with a population or with a person who you suspect may have anorexia or bulimia or an eating disorder, especially if they are diabetic and you know, they're using, injecting insulin, it's important to monitor and make sure that they are still using their insulin and they're not, and, and they're not skipping doses. Depression is A, approximately 200% higher in people with diabetes than in the general population. Why is this now? We already talked a little bit about anxiety and we're going to talk about that more in a minute. But with depression, they found that people with diabetes often have lower dopamine levels. And we know that serotonin's not the only player in the depression game. So lower dopamine contributes to lower energy and potentially feelings of apathy, lower motivation, and, and depression. Serotonin is implicated in regulation of blood glucose. Some studies have found that SSRIs may improve A1C levels in people with diabetes and depression. This is not a across the board. It helps everybody. So don't think, hey, that's the magic pill. No. But it is important to recognize that SSRIs, psychotropic medications do impact blood sugar. And so when you take it, when you modify your dose, when you miss a dose, it's important to recognize that the impact that may have on your blood sugar. Likewise, depression may increase the risk of developing type 2 diabetes by 60%. People who don't have diabetes but have major depressive disorder are at a greater risk of developing diabetes, and the exact causative factors are unknown. For some people, when they're depressed, they may engage in unhealthy eating habits that could contribute, but there's likely greater pathology. There's, there's a lot more to it than just unhealthy eating habits or, or weight gain because we know that there's a, there are a lot of people out there who are, have a higher BMI and they don't have diabetes. We know that there's people out there with a high BMI and depression and don't have diabetes. So we can't see, say that there's a causative factor. But we do know that there's definitely an increased risk of developing type 2 diabetes in people who have major depressive disorder. So we need to screen for that. We need to be aware of that. And I actually did not touch on this very much in the presentation, but it occurs to me now, if you're working with someone who has postpartum depression, that's something else that we need to be aware of. And because postpartum, postpartum direct depression can go on for quite a while and we need to be aware that that may also correlate to gestational diabetes. So we need to look at the connection, the correlation we need to look at if somebody has gestational diabetes, do they develop depression? Do they develop postpartum depression? What's the connection? And if that postpartum depression is inadequately controlled, does it contribute to the, the continuation of diabetes postpartum? Just some things that I start thinking about. What's the function of the counselor or case manager? What we are not dietitians, we are not medical doctors or endocrinologists. We are not going to do a lot of the treatment planning for someone with diabetes insofar as managing their blood sugar levels. We have a role in helping address stress, depression, anxiety, grief, treatment compliance, a lot of the behavioral issues. So it's important that we know what our lane is and we stay in our lane. And I'll use the term clinicians to represent counselors, case managers and social workers and anybody else who is in the supportive role in the team. Clinicians may need to assist people who have not yet been diagnosed. They're in pre contemplation. Contemplation. They may either not know they've got a problem or think they might, but they really don't want to know, they don't want to get the test. So as clinicians we can increase motivation, we can encourage them to go get tested. We may need to assist people who've been recently diagnosed and are grieving or anxious about the diagnosis. Finding out that you've got depression, I'm sorry, you've got diabetes, can trigger depression, can trigger anxiety, can trigger grief. When you realize that you've got something that is going to change your life for the rest of your life, it can be a very stressful situation. People may feel discouraged or anxious about their diabetes and assume that complications are inevitable and perhaps avoid necessary self care behaviors. So there is a certain subset of people that get the diagnosis of diabetes and they're just like, oh, I've seen people go down this road, there's, there's no hope. And it's important for us to help them see, understand, be aware of the facts in the situation, what treatments are out there what complications do they have, what options and what can they actually do to affect their outcome? We may need to assist people who've been diagnosed for a while and are either treatment non compliant or are having increasing difficulties managing their blood sugar or experiencing complications. Sometimes changes in life circumstances, aging changes in health circumstances, whatever the case may be, may make it more difficult for people to manage their blood sugar. We, my husband and I had friends who had insulin pumps, and despite having insulin pumps, several, several of them ended up having problems because even the insulin pump was not being effective at controlling their, their blood sugar. So we do need to be sensitive to this fact and help people be as treatment compliant as possible, as well as helping them change their routine. If They've been doing XYZ for 15 years to manage their blood sugar and now that's not working, they need to be motivated and supported in making that change to that new treatment plan. And people who are having difficulty with treatment compliance is another area. This is someone who has either given up or is having the treatment plan that they've got may be too difficult for them in some ways. So we need to help them figure out how to make it work. One study that I looked at indicated that some people will run their blood glucose way high at night in order to avoid hypoglycemia overnight. And as a result, their glycemic control deteriorates. So they will eat a lot of food that intended to increase their blood sugar right before they go to bed so it doesn't get too low before they wake up. And those spikes and drops in blood sugar are just not good. And it negatively impacts the body's internal ability to regulate that blood sugar. So we do want to pay attention to this as well. When we're working with somebody who has diabetes, whether it is controlled through nutritional means or they're using insulin or whatever the case may be, regularly assessing their eating behaviors can be helpful, especially if they're having difficulty or if they're not maintaining their A1C levels. So screening, I told you this would be really simple. And we are not diagnosing. We are, you know, we don't want to freak somebody out and tell them that, oh my gosh, you've got diabetes. That is not our place. And the screening does not say whether they have it or not. It just indicates if they might be at risk. So if someone has a significantly increased person, thirst, frequent urination, extreme hunger, unexplained weight loss, fatigue, irritability, blurred vision, slow healing sores, really dry skin, frequent infections, Such as gum or skin infections or vaginal infections, impotence or erectile dysfunction, especially that's come on recently and has come on close to the same time as some of these other symptoms and. Or numbness or tingling of the hands and feet. We want to ask people about these. If they've just got one symptom, okay. You know, there could be a lot of things causing it. We want to inquire about whether they. How long it's been going on, whether they've talked with their doctor, if they've got multiple symptoms. We do want to encourage them to connect with their medical provider and get assessed. Why are some of these things bolded? Because unexplained weight loss, weight loss, fatigue, irritability, and dry skin can also be symptoms of thyroid dysfunction as well as depression. We don't want to assume one thing over the other. Likewise, we don't want to look at these symptoms and go, oh, this is just depression, you know, and ignore everything else when we might be missing some undiagnosed diabetes. Now, for people who get hypoglycemic, in particular, they also may experience shakiness or rapid heartbeat when their blood sugar drops. Why is that? Well, the body uses blood sugar as fuel. When the body starts running out of fuel, the brain, the HPA axis, registers that as a threat. It's like we're getting ready to run out of gas. So it activates and causes the liver to dump a bunch of blood glucose. Basically, that's overly simplified, but it spikes the blood sugar levels. So as a response to a threat, in order to keep the body factory functioning, in order to keep the lights on, the HPA axis turns on that backup generator. And that can contribute to people feeling an anxiety response when that HPA axis is kicked off. A lot of times people are feeling anxious or angry. That's our threat response, our stress response. So it would make sense that when that happens, when our blood sugar gets too low, threat response kicks in, we start feeling shaky and having that rapid heartbeat. Counselors, social workers, case managers can assist with health education and referrals. If people might have diabetes, we can educate them about the importance of early intervention. We can make referrals to dietitians if they're having difficulty maintaining their. Their eating habits or their A1C levels. We can make referrals, obviously, to their doctor for testing. We can work with them to create plans to help them achieve their personal and physical treatment goals. Now, what do I mean by that? In order to achieve goals they have in their rich and meaningful life. We can help them create those plans and we're going to talk about living in the and they can have diabetes and live a rich and meaningful life. So we can help them create those personal goals. In terms of physical treatment goals, this is what I'm referring to here, is maintaining compliance with the treatment plans that the doctor and the dietitian and whomever else have set forth. Because if they're not physically healthy, if they're not able to manage that A1C level effectively, it's going to be hard to achieve those personal goals. If the body isn't able, then they're going to have a hard time achieving their personal goals. So we do want to have a focus on both that rich and meaningful life and treatment compliance, diabetes management. We can help people increase and maintain motivation. Some of these changes are hard, some of these changes are unpleasant. Some of these changes are. May not seem like they're working or you know, they take this initial treatment plan and they're still having difficulty regulating their blood sugar. That can feel very frustrating and the person may start feeling hopeless and helpless. So we can assist with maintaining motivation for trying maintaining motivation for treatment compliance and we can help them to address challenges that arise in the implementation of their treatment plans. One of the big things that occurs with people who are diagnosed with diabetes, if they've got to start injecting insulin, is the injection itself. Again, we're not teaching them how to inject, but we can help them address their fears and the challenges that are associated with doing that. The, the cognitive part part of it. Counselors, social workers, or case managers can also be responsible sometimes for overseeing, coordinating and implementing interventions for treatment adherence. A person with diabetes doesn't see their doctor once a week. They don't often see their dietitian once a week, especially once the initial treatment plan is established. A counselor or a social worker or a case manager, they, they may see at least once a week. So we have more frequent contact points with that person in which we can assess motivation, we can assess success, we can acc. We can assess problems they're having with implementation of their plan as well as secondary issues that are developing as a result of the diabetes, such as depression, anxiety, grief, etc. But many times when people have a physical, chronic physical condition, there is a person who serves as the single point of contact for the entire treatment team. So let's talk about treatment targets. One of them is often being active in order to modulate blood sugar and improve insulin resistance, resistance problems, mood and self esteem. Now the American Heart association recommends approximately 150 minutes per week. Now, the Alexander Valley Healthcare was one resource that I found online. And they suggested in general, people with diabetes, when they exercise, will often check their sugar every 30 minutes and stop exercising if their blood sugar is less than 70 or if they start feeling shaky, weak or confused. This is not a recommendation I am making because everybody's target blood sugar levels or baseline blood sugar levels can be somewhat different. And it's important that we know what the doctor recommends for their activity. But the point of this slide is activity is generally part of the treatment plan and a lot of people don't like to exercise. One, this is one of those places where we can help people figure out, all right, what can I do that is active that I wouldn't actually hate? You know, let's break it down and how can I, how can I get motivated and stay motivated to do that? And as clinicians, we can help people, we can help them figure out, you know, things they like to do, like gardening or maybe riding on a recumbent bike while they watch a television show they like or going walking with a friend. And then how do they stay motivated to do it? And we'll talk about that at the end. Another treatment target is healthful eating. Again, not a recommendation for any particular person, but just in general, letting you know what people with diabetes are pretty probably being encouraged to do by their medical treatment team, focusing on something that looks a lot more like a Mediterranean type diet with a lot of non starchy vegetables forming the foundation of what they're eating. And here we go with that microbiome again. You thought we were done with that after last week, but we're not. People with diabetes have a decrease in butyrate producing bacteria and an increase in opportunistic bacteria. So we start seeing an imbalance in that microbiome. In people with diabetes, there's an inverse association between A1C blood levels and B adelicentis, a bacteria that was increased by metformin. So A1C levels go up as that bacteria goes down. We want to see it the other way. We want to see that bacteria go up and A1C levels go down. The medication metformin has been associated with increasing the levels of that good bacteria, which, so we're seeing a direct connection between the microbiome and blood sugar. So it's not just the microbiome and mood or, or the microbiome and digestion. It's important for people with diabetes to monitor their blood sugar with regularity. And identify patterns, what happens to their blood sugar when they exercise, when they're under stress, when they're sleep deprived, to see. So they can identify vulnerabilities to blood sugar dysregulation, if you will, as well as identify things that help them maintain their blood sugar. The goal for a lot of people is to have an A1C of 7% or less to prevent microvascular disease. So think of. I know I've talked about A1C a lot and I haven't defined it yet. A1C is kind of like a semester grade. It measures the average blood sugar levels over the past 3, 3 months by measuring the percentage of red blood cells that have sugar coated hemoglobin. But on a day to day basis, the person with diabetes can have a pretty good idea, you know, not great, but a pretty good idea about their A1C level if they're keeping their blood sugar within normal ranges or if it's spiking above or below where they're supposed to be. It's also important for them to take prescribed medications. And again, this one is in bold and italicized. They need to take the medications the doctor tells them to take for their diabetes. That's important. Aspirin is often recommended to address not only cardiovascular risk and inflammation, but also blood sugar regulation. If the person has high blood pressure, they need to control that as well. People with diabetes have a 200% greater chance of developing hypertension, which contributes to cardiovascular disease and dementia. And people with diabetes and high blood pressure are 400% more likely to develop heart disease. High blood pressure increases blood sugar, so they're going to make each other worse. It's important to recognize when you're blood pressure's high. A lot of times, not always, but a lot of times that's indicative of that HPA axis being activated. What happens when you get stressed? Your blood pressure goes up. When that stress response system kicks off, blood pressure goes up, blood sugar goes up. So we do need to recognize that taking those medications and as clinicians who don't prescribe, we can also help people develop cognitive behavioral tools to help manage and stay mindful of their blood pressure and cholesterol lowering medications, generally called statins. Diabetes tends to lower the good cholesterol and raise bad cholesterol. So keeping cholesterol in check is also important. But the other reason that prescribed is bolded and italicized is, is to highlight the fact that a lot of medications and herbs and over the counter supplements and yada yada are going to affect blood sugar. So it's really important that people are not taking their prescribed medications and then willy nilly adding in other things that may either work against their medications or exacerbate the effect of their medications. Oral health. This is another thing that we don't usually talk about in counseling, but we need to recognize that gum disease both contributes to and worsens high blood glucose levels. So oral health is really important. And if you're thinking about people who are depressed, what goes in depression a lot of times, activities of daily living, self self care, bathing, brushing is often. It's important that people maintain their oral health even if they don't have diabetes, but especially if they have diabetes or pre diabetes. Smoking cessation is also important, and that's a whole other presentation. But in short, the medial medial habanula in the brain contains some of the highest densities of nicotinic receptors in the brain. Doses of nicotine that activate the medial habanula markedly evaluate markedly elevate blood glucose levels and impair the function of pancreatic cells and increase the chance of development of diabetes by 40%. So basically this is saying that if you've got diabetes, smoking's gonna make it worse. And if you don't yet have diabetes, smoking could contribute to the development of diabetes by up to 40%. Smoking is also another assault on the blood vessels for, especially for people with diabetes, which can enhance circulatory complications. Alcohol moderation or cessation. Alcohol, like nicotine, is going to have systemic impacts. Alcohol increases inflammation, blood pressure and bad cholesterol. All things that diabetes already does by itself, thank you very much. Additionally, glycemic control is impaired by alcohol use. In some people. When they use alcohol, they fall asleep and they don't measure their blood sugar. So that's one problem over there. It's just a behavioral issue caused by intoxication. Moderate amounts of alcohol may increase blood sugar, but excess alcohol has actually been found to cause hypoglycemia, especially for people with type 1 diabetes, or again, those who fall asleep after drinking. If you're working with somebody who is at risk of developing diabetes or has diabetes, asking about alcohol consumption is reasonable. Opioid awareness and avoidance. Opioids can actually contribute to hyperglycemia, too much blood sugar and impaired insulin secretion. If the person that you're working with has chronic pain or is going in for surgery or something, this is important for them to be aware of and make sure that their doctor is aware that they have diabetes so they can effectively prescribe medications that will not significantly negatively impact their A1C levels. Additionally, I mean especially if they're going in for surgery when they're under anesthesia, that's going to affect their blood sugar levels and the doctor needs to know that they have diabetes. Oh, and here's another favorite topic that you didn't think you were going to hear about today, but you're, you are. Sleep improvement and sleep apnea treatment. Sleep deprivation is associated with hyperglycemia and development of insulin resistance or pre diabetes. Sleep deprivation or inadequate sleep can come from stress, can come from poor circadian rhythms, can come from poor sleep hygiene or from sleep apnea. And we need to. So again, it's important for us to assess people's sleep quality because it's going to impact their treatment. The inadequate sleep also, you know, in addition to all the other stuff it does, just like when the blood sugar gets too low and the body is getting ready to run out of gas to keep the body factory going, inadequate sleep does the same thing. When the workers are too tired, the HPA axis kicks off and says hey, let me just give you a little shot of adrenaline to keep you going. So inadequate sleep contributes to is another thing that contributes to excessive activation of the HPA axis and impaired glucose control. Altered circadian rhythms are also associated with alter alterations in eating patterns, ghrelin and leptin levels. Circadian rhythms, if you remember back to that video that we did, are not is just about sleep. Circadian rhythms impact our hormone regulation, impact our eating, our cravings, our motivation, our energy levels, just about everything. So if circadian rhythms are out of whack, then we may see altered eating patterns and altered levels of the hunger and satiation hormones. Illness prevention is another treatment target. Health education, motivation for prevention, mindfulness and early intervention. We're not doctors, we're not going to treat but we can remind people why it's important to stay healthy, why it's important to wash their hands and to socially distance. Diabetes can impact the way the body responds to just about every situation and including illnesses. People with diabetes already have systemic inflammation so the immune system is already sort of hyperactivated and they tend to be more susceptible to illnesses and when they get illnesses can experience more inflammation. Shingles have is a virus that you can have in your body and it makes blood sugar harder to control for up to six months. So if you know somebody who's had shingles or if your client gets shingles, educating them about the fact that okay, for the next six months or so your Blood sugar may be more difficult to control. That gives them an awareness to be more attuned to their blood sugar, but it also gives them a little bit of a light at the end of the tunnel. So, okay, you know, this is going to be a long tail effect of the shingles, but it will end at some point. So I just have to endure. And the flu or Covid or other viruses are also things that we want to make sure that people are able to avoid as much as possible because they're going to be more susceptible and the diabetes may contribute to additional inflammation. Now, this is another thing that I found to be absolutely fascinating when evaluating people for diabetes. Doctors are now being encouraged to also evaluate the number of adverse childhood experiences they had. They found that a key candidate for a common pathway between diabetes and depression could be the activation and disturbance of the stress system or that HPA axis. Chronic stress activates the HPA axis and the sympathetic nervous system, so it sends them into fight or flight. This increases the production of cortisol, the stress hormone. Chronic hypercortisolemia. Chronically having cortisol levels that are too high and prolonged activation of the SNS or the stress system promotes insulin resistance where the body kind of quits recognizing insulin, visceral obesity and can lead to metabolic syndrome and diabetes type 2. Chronic stress and complex PTSD contribute to HPA axis activation and behavioral consequences, which can worsen diabetes and associated mental health issues. Remember, people who have complex ptsd, or dare I say even regular ptsd, are often hypervigilant, often have difficulty getting adequate quality sleep, often have that HPA axis on, at least to a certain extent in the background. They have difficulty relaxing because they don't feel safe. So that contributes to chronic stress. And then we have, if you want to call it run of the mill, chronic stress. People who have very, very stressful lives because for whatever reason that they just get up and every day it's something, all of these things can contribute to that HPA axis hyperactivation and worsen diabetes. It can contribute to anorexia or hyperphagia. Some people, when they're stressed, have no appetite. Some people want to eat. It contributes to cravings for food and other substances. Why is this? Well, food and other substances can increase those dopamine levels. We already established that people with depression and people with diabetes tend to have low dopamine levels. Anxiety is another side effect of chronic stress and traumatic stress. People who don't feel safe are going to feel anxious. Anxiety is correlated with HPA axis activation. Depression can also happen at a certain point. You can only be anxious or stressed out for so long before you start to get exhausted. And that depression can contribute to lack of maintenance of treatment compliance, it can contribute to poor eating, it can contribute to, you know, lots of treatment non compliance. And finally, just purely that chronic stress, that excessive activation of the HPA axis producing that excess cortisol disturbs neurogenesis or the creation and replenishment of neurons in the hippocampus. We've talked about this in the video on the impact of trauma on the brain. The neurological impact of trauma results in hippocampal shrinkage. Well, we're seeing that hippocampal shrinkage is also important when it comes to diabetes because the hippocampus is involved in depression and as well as diabetes affective and cognitive treatment targets for people. Problem solving. We can help people who have diabetes or who are on at risk of developing diabetes prepare for the unexpected accidental ingestion of more carbs than expected or even maybe sometimes on purpose ingestion. Accident. I know my grandfather in law has a habit of eating stuff that he probably shouldn't and just assuming he's going to give himself more insulin and that's not what we wanted to see, not what we want to do. But sometimes people will do it accidentally and they get a regular soda instead of a diet soda and they're like oh my gosh, you know, that was a big, big oopsie. How do they plan for that? Making sure they've got enough insulin, Making sure they've got what they need to test their blood sugar. Incorrect insulin calculation is another problem that happens. And it happens. Let's not pretend it doesn't. Let's plan for it. So when there is an incorrect insulin calculation, having the resources available to combat it, what do you need to have in your rescue kit in order to deal with it? You need to have insulin with you. And you also need to have things like orange juice or something that can quickly raise blood sugar levels. If you forgot your insulin somewhere, you know you didn't bring it with you and you need it, how can you address that? What do you do in order to address your blood sugar levels in the moment? And then again if the blood, if your blood sugar drops, if you become hypoglycemic, you're out shopping all day long and all of a sudden your blood sugar just tanks or you're working out and your blood sugar tanks, what do you do? And again, you're going to have something hopefully in your rescue kit that rapidly increases blood sugar levels. This is something people need to work out with their dietitian, with their doctor. But we need to encourage them to regularly evaluate their rescue kit. Make sure that it is stocked if you will and identify things that we haven't picked up on yet. The and and figure out how to solve those problems. One of our friends who had difficulty regulating her her A1C levels was a state trooper and sometimes she'd be on a call for six, seven, eight hours or something and not able to go get meal. Recognizing that doctors who have diabetes, airline pilots, anybody who may not be able to eat at regular time intervals if they have diabetes needs to be aware of how that impacts their their blood sugar levels and ways to mitigate the negative impact. Quality of life. Encouraging people to embrace those dialectics. Embrace the concept of living in the and I can have diabetes and live a rich and meaningful life. I can have diabetes and not feel like I'm being deprived from everything that I love. Talking with them about dietary moderation, including moderation or elimination of smoking and alcohol. Obviously somebody who has diabetes isn't going to be able to eat brownies and ho hos every single day. That's just not on the menu, literally. However, in most cases, people who have diabetes are able to occasionally partake of small amounts of some of those things and it's important for them to communicate with their doctor. But for many people, if they believe that they can have a little bit occasionally, they don't feel nearly as anxious or depressed or deprived than if you tell them you can't have that ever again. Exercise and I mentioned this earlier, this is one place that we can increase motivation and help people figure out how to do it in a way that is part of their rich and meaningful life. Gardening, walking your dog, playing with your dog, cleaning house. There are a lot of things you can do that actually get your heart rate up that don't involve going to the gym. What is it that you like to do? Playing pickleball is a big thing that has become very popular lately. Basketball, playing with your kids, hula hooping. Get a one of those little exercises that you can put under your desk. Any movement is better than no movement. It may not be exactly the intensity that the doctor wants, but it's a step in the right direction. Sleep. We need to work with people to help them improve their sleep quality and make referrals. If they've got apnea or sleep disorders that may need to be addressed by a sleep specialist, we can increase motivation for blood sugar monitoring in people who have an aversion to it. And if they are unwilling to be treatment compliant with blood sugar monitoring, encouraging them to communicate with their physician about the possibility of consistent blood glucose monitoring devices that are, you know, implanted or attached or however they're done. We need to talk with them and, and help them address their quality of life. Knowing that they have a chronic disease, you know, what does that mean to how you perceive your quality of life? And addressing any complications from the disease, knowing what they have and what they've got to deal with, but also knowing what they can do to prevent complications or, or mitigate them. So there's a lot of health education that is, is an important part of counseling people who have a recent diagnosis of a chronic illness personal goal achievement, like we talked about earlier, encouraging them to embrace those dialectics and figure out, okay, I have diabetes and I can have a rich and meaningful life, as well as recognizing that progress is not to. That they need to focus on progress, not perfection. When they first start their treatment plan, they may not manage their A1C perfectly. Okay, well, there's going to be a adaptation period where their treatment plan gets monkeyed with a little bit by the doctors to figure out what exactly needs to be done. And there are going to be times where they miss their insulin or they calculate their insulin wrong or something. Okay, mistakes may happen. We're not asking you to be perfect. We're asking you to make progress to, toward controlling that and ideally have a plan for how to mitigate any errors, mistakes or problems that come up. We need to talk with people about their grieving process. When you get a diagnosis of a chronic illness, there is a grieving process. You are no longer seeing yourself, your body, your life, as you did 20 minutes ago before the doctor told you. So, allowing people to process this, what does that mean to the vision that you had of your rich and meaningful life prior to the diagnosis? How has it changed now? And what parts may need to may you need to grieve to address depression. We want to help them feel empowered. Remember, the core of depression is often hopelessness and helplessness. I get it. We want to help them feel empowered, hopeful, empowered, and able to take proactive, positive steps toward maintaining their health. They're not going to ever get rid of the diabetes, but a lot of people are able to significantly improve a lot of their symptoms through treatment compliance. Treatment compliance. To manage the physiological causes of low mood, we need to help them see the connection between depression and diabetes. Help them see the connection between their blood Sugar levels and their anxiety symptoms or their depression symptoms. So they recognize that their quality of life is going to be a lot higher. Their energy, their mood, their cognitive, cognitive functioning. It's going to be a lot higher if their blood sugar levels are more moderated. In terms of addressing anxiety about the disease, about people's reaction to the disease, and any other anxiety that they may have, encouraging them to use facts, control and probability. What are the facts in this situation? What aspects of it can I control? And if I do, what is in my power? If I'm treatment compliant, what is the probability that these bad consequences are going to happen? And it's important for people to really realize that they have a lot more control than they may think they do. Another intervention we can use with anxiety, because remember, when people are anxious, even if it's not about the disease, when people are anxious, their HPA axis kicks off, which is going to increase blood sugar levels, which is going to make a 1C modulation more difficult. Biofeedback can be very helpful. Whether it is vagus nerve massage or deep breathing, or whatever they want to use to trigger that vagus nerve to trigger that relaxation response is going to be helpful. And I use the term biofeedback very generally to reflect either people's heart rate, their pulse, their blood pressure, or simply the rate and depth of their breathing when they notice that those things are going up. Stopping, being mindful of the stress response, stopping and saying, okay, I need to slow down, I need to take some deep breaths. I need to do whatever I need to do in order to trigger that relaxation response. I find for me, wearing a heart rate monitor is a lot more effective than my watch because my watch is not as accurate. The heart rate monitor gives you much more current, accurate feedback of your heart rate. And that's my perfect personal, preferred method of biofeedback. When I'm relaxing, when I'm triggering that vagus nerve or that relaxation response, I can see my heart rate come down and recognize that as part of the relaxation response. And finally, motivation for change. Change is hard. Change causes crisis. Crisis causes change. Well, the diagnosis of diabetes is a crisis for a lot of people. Most people don't get that diagnosis and go, okay, whatever. You know, it causes some upset, some turmoil, some consternation, and it indicates a need for a change. There's a physical crisis going on as well as potentially a emotional crisis. So helping people examine all of the dimensions of motivation and how treatment compliance is, is going to help them achieve their rich and meaningful life. Motivation is Generally not global, although you can talk about global. How will treatment compliance in general help you in these areas? It's also important to look at each individual behavior. People may have no qualms and may be very motivated to take their medication and to eat healthfully, but maybe not so much to exercise and monitor their blood sugar. So we do want to take a look at not only the global treatment compliance, but also specific behaviors we may need to address in terms of increasing and maintaining motivation. So physically, we want to ask people, how will treatment compliance help you improve your energy, improve your A1C levels, improve your sleep, reduce inflammation, and prevent physical complications? You know, so logically, how will physically, how will doing this help you actually feel better physically? Affectively, how will treatment compliance help with your depression? Remember I mentioned that diabetes causes contributes to depression, and it's important to recognize that diabetes also contributes to inflammation. So as an inflammation is associated with depression, so as we reduce inflammation, as we help people feel more empowered, their depression may remit somewhat. How will treatment compliance help with your anxiety? Well, if people can recognize that they're empowered and they're capable of preventing some of these complications and they can live a rich and meaningful life and have diabetes, that's going to help them hopefully reduce their anxiety effectively, it can help increase happiness. Treatment compliance can help people increase their happiness because they're not feeling so depressed, so anxious, because they have more energy to do things that actually make them happy. Cognitively, how does it make sense that treatment compliance will improve their symptoms and help them live a rich and meaningful life? How does this logically make sense? And how will treatment compliance help them maintain their cognitive capacities? Environmentally? What can they do in their environment to make living with diabetes easier, such as removing high glycemic index foods from their proximal environment, remembering to check their blood sugar, potentially looking into wearable glucose monitors, and using mobility and independence modifications as needed. And finally, the final aspect of motivation is relational. Who can be supportive of their recovery? In studies, it was found that support was highest for those in the contemplation stage and lowest for those in the action stage, which really doesn't make a lot of sense to me. But it's important to recognize that because when people are in the action stage, they're making those hard changes and that's when they really need support in contemplation. They're thinking about doing something about it and their loved ones are like, oh, this is a problem, problem. You need to take steps. But it's almost like once the person starts taking steps. The loved ones say, cool, you got this. We need to make sure that support continues through that action stage. We can also have people explore why diabetes control is important to their relationships. You know, if they control their diabetes, they can see their grandchildren grow up. They can have energy and ability to engage in their preferred activities with self significant others. You know, have them make a list. Diabetes impacts people multi dimensionally, physically, affectively, cognitively, environmentally and relationally. Counselors, social workers and case managers can assist people with diabetes through screening for diabetes and associated issues. So not just screening for diabetes, but we also want to screen for depression. We want to screen for anxiety, we want to screen for CPTSD and adverse childhood experiences and trauma that may be yet undiagnosed. We want to provide health education to help the person feel empowered. We want to assist with goal setting and planning, motivational enhancement and maintenance and addressing grief and anxiety issues associated with having a chronic illness.