Diabetes Counseling | Comprehensive Case Management Certification

Foreign. I'd like to welcome everybody to today's presentation on diabetes counseling and case management. I'm your host, Dr. Donnelly Snipes. In this hour, we're going to explain the importance of screening for diabetes in mental health populations. Identify complications of untreated diabetes, explore the functions of the clinician or case manager, identify important treatment targets, and explore motivational enhancement targets and strategies. So we've got a lot to cover. By the time they're diagnosed, 50% of people with type 2 diabetes already show signs of complications. Diabetes, which is the destruction or malfunction of beta, beta beta cells in the pancreas, may begin 10 years before the diagnosis, and complications may start up to five years before somebody has a diagnosis. So unfortunately, without rigorous pre screening and, and, you know, regular pre screening, a lot of people go on to develop diabetes and don't even know it. So by the time they actually, you know, figure out they've got symptoms, there are already also experiencing complications, which is why it's so for every person that's in a position to do so, to screen for diabetes, mental health, you know, behavioral health, social work, you know, medical clinics, even optometrists, since one of the complications of diabetes is retinopathy, so, you know, wherever people are seen, it is important to screen for diabetes. Cardiovascular disease causes 52% of death and disability in people with type 2 diabetes. People with type 2 diabetes have a 200% increased risk of stroke. You know, so there is a lot of potential complications. And we know that stroke can contribute to the development of depression as well as dementia. Kidney disease impacts 33% of people with type 2 diabetes and accounts for 11% of deaths in people with type 2 diabetes. Now remember, kidneys are one of our organs that filter out the toxins. When toxins build up in our body, it contributes to systemic inflammation, which also contributes often to mood disorders. So when the body funk body system starts to break down, it can cause mood and behavioral health symptoms, which is why we care about this. Now remember, in terms of the quiz, you don't need to know all of these statistics. I just want you to kind of have a general idea of the scope of the problem. Comorbid mental health issues increase mortality in people with diabetes. So when people have depression, they may, for example, not be as motivated to be treatment compliant, which can, you know, mean their diabetes progresses more quickly. People with anxiety, you know, comorbid anxiety may experience more difficulties because their HPA axis is regularly hyperactive and which makes it more difficult to control blood glucose. Same thing can be said with ptsd. They've also found that people with schizophrenia have a much more difficult time remaining treatment compliant, not only because of exacerbation of their schizophrenia symptoms, but also because the antipsychotic medication that they may be taking can wreak havoc with blood sugar as well. Disease related anxiety reduces quality of life and activates the HPA axis. We may not be dealing with somebody with generalized anxiety disorder. They may have a lot of anxiety surrounding the, the diabetes itself. You know, every time they haven't have some blurry vision, you know, maybe because their allergies are acting up, they may fear that they're developing diabetic retinopathy. Every time they have a tingle or a pain here, they may think that their diabetes is suddenly becoming a problem. Now it's very important for people with diabetes to be mindful of how they feel emotionally as well as physically to watch out for symptoms because, you know, peripheral neuropathy, pain in the extremities or numbness in the extremities can be a big issue for people with diabetes. But it's also important to go back to basics and remember to look at the facts of the situation right now. You know, think about what else could be causing this symptom that I'm having. Look at what aspects of that situation you have control over, such as testing your blood sugar, you know, calling your doctor about it. And you know, if given the facts in this current situation and if you're doing the things that you can to address it, what is the probability that the worst case scenario is actually going to play out? So I really encourage people to focus on what I call FCP facts, control and probability. Depression is approximately 200 times higher in people with diabetes than in the general population. Now part of this may, may be due to some other issues that we're going to talk about later that have to do with grieving, having a chronic illness. But we also have to remember that di diabetes is considered an autoimmune issue. And we know that there is a high correlation between, between systemic inflammation present in autoimmune issues and systemic inflammation and symptoms of diabetes. Diabetes is also associated. They're not exactly sure how with lower dopamine levels. And again, we know that dopamine is our, one of our motivation chemicals. It keeps us, you know, wanting to do something over and over again. Dopamine also helps with attention and energy levels. So let's think about some of the criteria for diagnosing clinical depression. Difficulty concentrating, fatigue, apathy. Those all can be due to lower dopamine. Serotonin, you know, are one of our other favorite neurochemicals to talk about. Both central serotonin, which is the serotonin in the brain, as well as peripheral serotonin, because we have serotonin receptors throughout our body. But both central and peripheral serotonin is implicated in regulation of blood sugar. Interestingly, SSRIs, your selective serotonin reuptake inhibitors, may improve blood sugar levels or A1C levels in people with diabetes and depression. So they find that if somebody has, you know, diabetes and depression concurrently, it may indicate that they've got a low level of serotonin. And the SSRI may improve not only their mood but also their blood sugar, which, you know, that's a double winner. Life expectancy is reduced in people with diabetes. Right now they are making strides very quickly with treating diabetes. But right now, the statistics that they have out there indicate that people with type 2 diabetes have about 10 years reduced from their life, and people with type 1 diabetes have about 20 years reduced. And you may say, why is the difference? Well, hypothesizing, people with type 1 diabetes probably develop it much earlier in life, so they're living with it for much longer and it's taking a toll on their, on their body for much longer. Type 2 diabetes generally isn't diagnosed in, until somebody is, you know, fully an adult, sometimes not even until later in life. 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. And you may be going, well, why do we care about the erectile dysfunction? Well, because, you know, if, if you had that question, that can be hugely problematic in relationships as well as to a person's self esteem. So we do need to recognize that. And when I say a person, I mean both people in the couple. The person with the erectile dysfunction problem may feel impotent. Well, obviously. And the person who is, you know, doesn't have that problem may feel like, you know, they are not alluring enough to excite the other person anymore. So it's important that we educate them about erectile dysfunction, but also make sure that they recognize that it is a potential symptom of diabetes complications. Lack of awareness of wounds is another big issue. Because of that peripheral neuropathy, not, not having as much feeling in fingers and toes and stuff, people with diabetes may get injuries and not realize they have them. So that obviously, if you don't realize you have it, you may not take care of it in a timely fashion. Additionally, wounds heal more slowly. The nerves aren't there, sending the signal to the brain constantly going, hey, we still have a problem down here. Send, send those inflammatory cytokines. You know, it's a much, much reduced correspondence with the brain. Limb amputation occurs in approximately 1 in 40 people with diabetes. And, you know, a lot of people with diabetes will develop a foot ulcer, but of those people, one in 40 may need to have an amputation. Unfortunately, 70% of people, up to 70% die within five years of having an amputation. So that is heart wrenching to me to think about that. And I'm not exactly sure why they didn't speculate why, except for potentially the. The fact that at. By the time the diseases progressed to where a person needs an amputation, the pancreas is pretty much not working anymore. And I'm just hypothesizing at this point. I have a very good friend who unfortunately just had an amputation two years ago. And, you know, this was a devastating statistic for me to read. 98% of those with type 1 diabetes and 78% with type 2 will have some degree of retinal damage, eye damage, but fewer than 5% suffer severe vision loss. So that's a good thing. If people start developing peripheral retinopathy, they may assume that that means they're going to go blind. And it's important for us to be able to help them get the facts in their situation with when they caught it and the steps that they can take. What is the likelihood that they actually will progress to blindness? So since fewer than 5% will actually get to that stage, Uncontrolled diabetes is also a significant risk factor for the development of dementia as the result of vascular damage. So what can we do? Well, we may have clients that we're dealing with in various stages of living with diabetes. We can be working with people who have not yet. Oops, sorry, not yet been diagnosed. And that is really important for a really important time for us to be screening for the symptoms of diabetes. So if we notice there's a symptom, since there is so much overlap between diabetes and mood issues, that we can also make sure the person is getting a physical to rule out any potential causes. We also may be dealing with someone who may have an inkling that they've got diabetes or something's wrong, but they are not yet ready to start taking action. They're in pre contemplation or contemplation, and they either don't want to admit or even contemplate that they've got a problem or they realize they're contemplating the fact that, yeah, you know, my grandfather had it, my dad had it, so there's a chance I may have it, but. But I'm not ready yet. So we can use some motivational enhancement in this stage to provide people information about how far we've come in the ability to manage diabetes and how important it is for early intervention in order to prevent complications and extend their life and quality of life. We may be dealing with people who've been recently diagnosed and are grieving and or anxious about the diagnosis. We may be dealing with people who've been diagnosed for a long while and are either treatment non compliant or are having increasing difficulties managing their blood sugar or they're experiencing complications or all of the above. So sometimes people may be referred to us because the doctors are like, you know, we really need to help you get squared away with this treatment plan. We also may have be dealing with people who are having trouble with treatment compliance. It's not that they are not wanting to do it or have given up all hope, but they may not understand what they need to do. So in screening, you know, in our general assessment, our intake assessment, increased thirst, frequent urination, you know, more frequent than, than, than normal, extreme hunger, unexplained weight loss, fatigue, irritability, blurred vision, slow healing SC sores, dry, especially dry, itchy skin, frequent infections in their gl gums or skin infections or vaginal infections, impotence or erectile dysfunction or numbness and tingling in the hands and feet. Now I have carpal tunnel syndrome and it is not uncommon, especially during planting season for, for my hands to go numb, you know, while I'm sleeping. I wake up and, you know, the tips of my fingers are numb, especially in my right hand, and I know what that's caused by. So we want to make sure that people recognize and understand when we do this screening, if we refer them to a physician, you know, for further follow up, that just because they have a symptom or even a few symptoms doesn't necessarily mean they've got diabetes. But it's better to check it out, be safe than sorry, so to speak. Now, the things that are bolded, unexplained weight loss, fatigue, irritability and dry skin, especially the first three, the weight loss, fatigue and irritability are very common symptoms in mood disorders, which is one of the reasons we may be seeing people. They may be, you know, just having difficulty coping with life right now and present for behavioral health intervention, when in reality they need, they may need multidisciplinary intervention. Dry skin is kind of interesting. They found an association between that and depression. But they've also, you know, we also know that hypothyroid can cause dry skin. So, you know, this is another thing that the doctors can rule out. Now these are typically symptoms of diabetes and hyperglycemia. You know, their insulin's not working like it needs to. People with hypoglycemia who are often what in that area of pre diabetes may experience shakiness or rapid heartbeat, which can often be misattributed to anxiety or, or panic attacks. We do want to make sure that people are aware of, you know, what's going on with them. And if they start getting shaky, they think to themselves, you know, when was the last time I had something to eat? And what else might be contributing to this? Not to get them to avoid seeking medical treatment, but to help them manage their anxiety. So every time they're, they have a symptom, they don't go into full on panic. So it's really helpful for a lot of people, especially when dealing with some sort of health anxiety, to help them recognize that, you know, they need to examine their symptoms in context at that moment and figure out, you know, what might be contributing to this right now. You know, if I go to the gym in the morning and I have a really intense workout, I am going to be really thirsty the rest of the day. I just, that's just the way I am. Even if I drink, you know, two water bottles full of water while I'm there, I will likely be thirsty through the rest of the day. And because I'm pounding back that much fluid, I'm also going to have frequent urination throughout the day. But if I don't have that predisposing factor, if I don't go to the gym and have a really hard workout, that I don't have those symptoms. So it's important people to, you know, be able to do backwards chaining just like we do in dialectical behavior therapy for emotional and behavioral reactions. What can we do? Well, we are not medical doctors and we are, most of us are not registered dietitians. So we cannot prescribe meal plans, we cannot prescribe medications, and we will not be making a diagnosis of diabetes. We may, you know, screen for it and say, well, there might be something that needs to be looked at by a physician. We can assist with health education, educating them about diabetes, the course of diabetes, the potential symptoms and indications that there may be a complication coming up. We can educate them about ways to have the highest quality life with diabetes. We can help them create plans to achieve their goals. Their doctor may say, you need to have an A1C of below 7. And these are the things that need to happen to assist you with that. We can take that and say, okay, let's break it down and figure out how to actually make this something that is practical and implementable. We can help them increase and maintain their motivation and address challenges that arise in the implementation of the plan. I've worked with people before who did everything their doctor said and their A1C level still weren't going down. You know, the, to where they needed to be. And you know, one of the interventions there is really simple, well, you need to go back to the doctor and talk to them. There are medications that they can take now that will help with that A1C but you know, so it's important for us to help them brainstorm ways to problem solve when there are challenges to implementing their their health plan. In terms of case management, counselors, social workers or case managers can also be responsible for overseeing, coordinating and implementing care. You know, especially as the disease progresses or if you're dealing with a juvenile, there may be more resources that are needed to ensure that, you know, blood sugar is getting checked and people have supplies they need and all that stuff. For juveniles, you know, they may need to have special accommodations at school so their blood sugar doesn't get too low or they can go to the nurse's office and check it. You know, there are things that may need to happen. Untreated diabetes is a fatal condition as a result of what's called keto diabetic ketoacidosis. This is a complication that's characterized by severe disturbance in carbohydrate, protein and fat metabolism. Poorly controlled type 1 diabetes is a risk factor for chronic complications such as blindness, renal failure, amputations and heart attack. What are our treatment targets? The first one is to encourage people to be active in order to help them modulate their blood sugar, improve their insulin, their cells response to insulin and improve their mood and self esteem. There's lots of research out there that supports the benefits of activity. Now this does not mean going to the gym and doing 40 minutes and target heart rate training zone necessarily. This means moving. You know, what we want people to do is move for about 150 minutes per week. So 30 minutes five times a week. And that can be taking a walk after dinner. It doesn't have to be something, you know, hugely onerous for people who are just starting to exercise. A lot of times it's recommended that they check their sugar before they begin exercising and then every 30 minutes during the exercise process. So, you know, if they're only exercising for 30 minutes, then they check it at the beginning and the end. If they are exercising for an hour, then they're going to have a break in there to check it until they figure out what their blood sugar does when they exercise. Then they may be able to go more on how they feel, but that is between them and their doctor. They need to remember to stop exercising if their blood sugar goes below 70 milligrams per deciliter or they feel shaky, weak or confused. And. And it's really important that they recognize the signs that their blood sugar is out of whack and early signs, preferably. Another thing we can help them with that kind of goes along with, you know, nutrition is blood sugar monitoring and pattern identification. They need to pay attention to what things cause their blood sugar to spike. There's food. You know, obviously certain types of food are going to raise their blood sugar more, but there are also other things like stress or certain medications that they take or illness that may contribute to alterations in their blood sugar. So it's important for them to be curious, to be detectives, to learn for their body and their condition what affects their blood sugar. And then we want to help them with healthful eating. And a lot of people assume that as soon as they get diagnosed with diabetes that they have got to go on a diet of complete rabbit food, as one of my patients said, and that's not necessarily true. Now, obviously this is going to be something you have to discuss with the team, the multidisciplinary team, but a lot of times it's recommended by the physician or the dietitian that people with diabetes consider eating a relatively normal diet where they're not excluding any particular food 100% completely. Now, this isn't always true, but for the majority of people that are able to manage their blood sugar, you know, the occasional ability to have a small piece of cake is. May be important to their quality of life, you know, and with that normal diet, you know, making sure to approach things that are going to increase their blood sugar with, you know, significant moderation. So you're having a very small slice of cake and, you know, obviously checking your blood sugar very afterwards and making sure to take enough insulin. If you take insulin and managing sodium, sodium actually affects blood sugar as well as blood Pressure levels and blood pressure is often a problem for people with diabetes. I did put this little graphic over here in terms of meal planning and this is an educational tool. We want to make sure that if we're showing it to clients that we emphasize the fact that their doctor and or their dietitian are the ones who are going to tell them what they need to eat, you know, in what proportions in general. But the typical plate for someone with diabetes, half of their what they eat is non starchy vegetables. A quarter comes from protein sources and a quarter comes from bread, starch or grain. And they can have three small fruits per day. They want to limit packaged foods, cheese, butter, margarine, oil, and obviously drink enough water. But this doesn't, you know, bread, starch and grain. You know, you see some of the things on here are refined and you know, you have starchy, starchy potatoes. It's a matter of making sure that those are minimized if people are going to eat them or balanced out. And that's not something we're going to get into a lot as behavioral health clinicians. But. But it is important for us to help people realize how they can have a high quality of life and you know, have diabetes now. A1C. They want to have a target of less than 7% to prevent microvascular disease, which contributes to coronary artery disease and high blood pressure and a whole bunch of other things. You can think of a 1C like a semester grade and it measures the average blood sugar levels over the past three months by measuring the percentage of red blood cells that have sugar coated hemoglobin. And that gives the doctors an idea about how stable the person's blood sugar has been. In general, the parallel if their average daily blood sugar is 154, then they're going to have an A1C of 7. If their average daily blood sugar is around 183, they'll have an A1C of 8%. And you can see how it goes up. So it is a method of monitoring over a long period the average in the blood sugar. Because every once in a while there may be a spike here and there, but if the average stays at about 154, that is or lower, that is helpful. We want to help people get motivated to and figure out how to manage taking their medication. Now there are a lot of different medications. I learned that people with diabetes may be on for blood sugar. Obviously some people take insulin, some people have an insulin pump so they don't have to worry about taking it. But they do need to occasionally monitor it. I have several friends and family members who have the pump, but it doesn't always do the best job of controlling their blood sugar. So, you know, just because they've got a pump doesn't mean it's completely hands off, big one. I decrease how much the blood sugar, how much sugar the liver makes, and how much sugar the intestines absorb. They make your body more sensitive to insulin and help your muscles absorb glucose. Other people may be on dopamine agonists. Remember I said they don't exactly know why that helps, but it does. Some may be on what's called DPP4 inhibitors to help the body continue to make insulin, which, you know, we need that pancreas pumping out that insulin at the, at the right rate. And GLP1 receptor agonists increase the beta cell growth. And how much insulin your body uses decreases the person's appetite, how much glucagon their body uses, and slows stomach emptying. So they. People, in order to manage their blood sugar, may be on one or more of these things. It's important that they figure out, you know, how they can make sure that they have that medication with them when they need to take it, that they're taking the right amount and deal with any side effects that they may be experiencing. Other prescribed medications, and I have prescribed, bolded and italicized because we don't want people just randomly saying, oh, well, aspirin, you know, is good to address cardiovascular risk. I might as well take it. No, especially not if they've got diabetes. It's important that they clear that with their physician. And interestingly, interestingly, though, salicylate is often used to address cardiovascular risk and inflammation, but it's also been shown to help with blood sugar regulation. That's another reason we don't want people just randomly taking aspirin, because it may alter their blood sugar levels or reactivity, which may mean that other medications need to be altered. Another issue that we may need to consider is their blood pressure. And yes, blood pressure is not a behavioral health issue, but cardiovascular risk, you know, increasing the risk of hypoxia because of stroke or heart attack, that is a problem. You know, we want to make sure that we're, we're helping people prevent the development of dementia and depression, which are both symptoms or can be symptoms of hypoxia. So with blood pressure, people with diabetes have a 200% greater chance of developing hypertension, which contributes to cardiovascular disease and dementia. People with diabetes and, and high blood pressure are 400% more likely to develop heart disease. So it's really helpful, which is another reason why they want to manage that salt and get a get active to try to prevent. Help them do everything they can through health education to prevent the onset of hypertension. High blood pressure not only does it increase the risk of microvascular problems and cardiovascular disease, but it also increases blood sugar, which makes sense. High blood pressure is often your body's response to a stress or a threat on the body activates that HPA axis. Blood pressure goes up, blood sugar is dumped into the system. So it makes sense that when blood pressure goes up, blood sugar would go up. Cholesterol lowering medications People with diabetes tend to have issues because diabetes lowers good cholesterol and raises the bad cholesterol, contributing again to an increased risk of cardiovascular disease. So some doctors may put people on statins, which are your cholesterol lowering medication. Now why do I have an asterisk by that? Because statins in some studies have been associated with the development of symptoms or side effect of symptoms of depression. So if you have a client with who has started taking statins, whether they've got diabetes or not, that is important to be aware of and you know, screen for, you know, did this just start when you started taking this particular medication? They may still have to take it, but then they can advocate for themselves with their physician to figure out how to deal with those side effects because, you know, people aren't going to likely continue to be treatment compliant if the medication makes them depressed. Oral health now this is another really interesting tidbit that I learned. Gum disease both contributes to and worsens blood sugar levels. Who would have thunk it? So gingivitis can contribute to and worsen high blood glucose levels. When people are feeling, especially if they're feeling clinically depressed, a lot of times they won't pay attention to their oral hygiene. A lot of people who are in active addiction, especially se severe active addiction, don't pay a lot of attention to their oral health. And that can be a huge contributing factor to worsening of the diabetes and the development of complications. So we do want to encourage them to brush their teeth, floss their teeth regularly and go to the dentist twice a year. Now that is not, I say that that is not possible or practical for a lot of the clients that I've worked with. So we do need to recognize that sometimes they won't go to the dentist because they just can't afford it. A lot of colleges that universities that have dental programs may have free clinics for people to go in and get tooth cleaning done. So that is one option for them. And if, you know, they don't have dental insurance or can't afford to get that twice a year. Cleaning. Smoking cessation. Another tidbit. I learned so much putting together this presentation. The CDC actually says on their website now that smoking causes type 2 diabetes. They don't say it's strongly correlated with. They actually say on their website, you can go to that link that smoking causes type 2 diabetes in some people. Smoking is also another assault on those blood vessels that can contribute to the development of high blood pressure and stroke, and as a result, it increases the risk of complications from diabetes. We can. This is one of those areas that we are pretty adept in helping people with smoking cessation, especially if you work with your local health department, a lot of them have programs where people can get nicotine replacement therapy and other things to help them while they're undergoing the process with, you know, counseling to stop smoking. So that can be super helpful if you've ever, you know, known someone, you probably have, who's tried to quit smoking. A lot of people, when they try to quit smoking, gain a lot of weight because they're wanting to have something in their mouth. They're wanting. And they end up, you know, eating a lot more or, you know, sucking on more candy or drinking a lot more, which can wreak havoc with their blood sugar as well. So smoking cessation with somebody with diabetes or pre diabetes, we do need to be extra vigilant to the impact of what they're doing on their blood sugar and make sure they're extra vigilant to the impact of that and help them devise alternatives when they want to put something in their mouth, when they're having that craving or that urge, what can they do besides eating that that can help them through that process in. In a way that won't disturb their blood sugar? Alcohol moderation or cessation. Alcohol increases inflammation, blood pressure and bad cholesterol, just like diabetes does. So ideally, people would quit drinking, but not necessarily in the cards for everybody. Some people say, you know what? That's one of those things I'm not going to cut out completely. All right, well, moderate amounts of alcohol may increase blood sugar, but excess amounts of alcohol actually cause hypoglycemia, especially for people with type 1 diabetes. Or if they drink, you know, a bunch of calories and then fall asleep after drinking and don't check their blood sugar, they can, you know, quickly become hypoglycemic blood sugar is really important to monitor when people drink. And, and if the recommendation from the American Diabetes association, if they are going to drink at all, that they try to avoid ever drinking on an empty stomach. So it buffers that the impact of the alcohol, that's something that they'll need again to discuss with their doctor. Opioid awareness and avoidance. Not everybody can always avoid opioids. You may have to have surgery, you know, you may have to have your wisdom teeth taken out or something and, and occasionally you may feel like you need opioids or during surgery, you know, the protocol is to give you some sort of opioid based pain medication. Opioids can contribute to high blood sugar, hyperglycemia and impaired insulin secretion. So it's really important if somebody's on pain pills, if they're on opioids, to make sure that they are monitoring their blood sugar and you know, ideally looking for alternatives. Sleep improvement and sleep apnea treatment, sleep improvement, sleep hygiene, health education, we can help with that. That's great. If somebody reports that they snore a lot or their significant other says they snore a lot, then they also need to be referred for sleep apnea treatment. Sleep apnea raises blood pressure. It also causes short periods of hypoxia, which you know, can contribute to dementia as well as depression. So sleep apnea is really involved in a lot of mood issues as well as worsening of diabetes symptoms. Sleep deprivation because of poor sleep habits or sleep apnea is associated with hyperglycemia and development of insulin resistance or pre diabetes altered circadian rhythms. So if people aren't able to wake up and go to sleep at the same time, their circadian rhythms get out of whack. Altered circadian rhythms are also associated with alterations in eating patterns and your hunger and satiation hormones, the ghrelin and leptin. There is a certain amount that we can do to help people with that, but you, if even people without diabetes need to be aware that sleep apnea makes them much more susceptible to insulin problems and potentially the development of diabetes. In illness prevention, we can again health education, motivation and early intervention. Diabetes impacts the way the body responds to just about every situation, including illness. Shingles, for example, makes blood sugar harder to control for up to six months after the person is asymptomatic. And you know, we know that shingles is caused by the chickenpox virus. So people who have had chickenpox when they were children may develop shingles as adults. There is a vaccination for shingles that people can get and flu and Covid. We've heard for the past seven months that diabetes is one of the major risk factors for developing severe complications with COVID 19. But we also know that people with diabetes have much more severe illnesses and potential complications with the flu. The flu comes around every year. We don't know what Covid is going to do. But there are, for the, for the flu. There are flu vaccines that people can get and soon there will be available Covid vaccines people can get. And I am not, you know, I personally, this is not a clinical recommendation. I personally am not one that is all gung ho on, let's get every vaccine that we possibly can unless it is necessary. And because of the significant risk, if people with diabetes get shingles or the flu or Covid or certain other illnesses, you know, it is important for them to, you know, seriously consider taking the preventative measure of getting the, getting the vaccinations affectively and cognitively. You know, I've talked about a lot of physical changes or health education issues that we may be able to help people identify and address and that's wonderful. However, coping with, living with diabetes is not just a physical issue, it is a biopsychosocial issue. Another target that is super important is primary problem solving and preparing for the unexpected. Especially if people haven't been living with diabetes for long or if they've gotten too complacent, assuming that their insulin pump, if they have one, is going to do the job, it's important for them to be prepared for that pump to break down or for accidentally ingesting more carbs than expected. Or my grandfather in law has frequently, unfortunately, or in my opinion, too frequently incorrectly calculated his insulin and taken too much. So that sends him into a place of hypoglycemia or if you forgot your insulin, you left it at home, what do you do because you need your insulin? If your blood sugar drops for some other reason that you're not sure why it happened, but you know, it dropped or it spiked, you know, what do you do? What things do you need to have with you, like maybe, you know, backup insulin? What do you, how do you handle these different situations when they arise? And if you work with people who have diabetes, you probably have a list of, you know, the top 20 most common problems that may need to be addressed. Another thing that we need to help people explore cognitively is their quality of life. And you know, some people get the diagnosis that they've got diabetes and they just feel like the walls are closing in on them. Yes, dietary moderation, including smoking and alcohol, are important for managing diabetes. But let's talk about how they can have a high quality of life and comply with. This is where the dialectics come in. Have a high quality of life and comply with the recommendations of the physician and the dietitian. Maybe they hate exercise and the doctor says, you know, you really need to start getting active. All right, well, let's talk about that. What could make getting active fun? What might you actually enjoy doing? And for some people, it may be getting a stationary bike and plopping it in front of the TV or getting one of those recumbent bikes. Those are, you know, a lot more comfortable because they don't make your tailbone sore. Let's talk about what options might you consider? You know, and that's formal exercise. There's also playing with the dog or going on a walk with your partner after dinner. What could you do that you wouldn't hate? Sleep. A lot of people in our culture don't sleep enough. So learning that they have to get adequate quality sleep is really kind of a bummer because they like staying up till midnight and then they have to get up at 5 o' clock in the morning to go to work. So they may struggle with sleep and feel like, okay, I can't ever go out with my friends anymore. Well, we do want to help address the cognitive distortions. It doesn't mean you can't ever go out with them. But most nights you need to get good quality sleep. And on the nights that you don't get enough good quality sleep, you need to be much more aware of your blood sugar the next day. Some people get very frustrated or overwhelmed by the whole notion of blood sugar monitoring. Now they have these devices that they can apply or implant. I'm really not sure how they work that do continuous blood sugar monitoring for people. And that has been a huge godsend for a lot of people that just really hated poking their finger, you know, six times a day. So that's helpful. Let's look at some options that can make blood sugar monitoring less aversive. You know, none of it's going to be probably ideal because you don't. Ideally, you wouldn't have to deal with it. But what could make it less aversive? Having the disease itself can be an issue that people feel like, well, if I've got this, you know, my energy's low, I can't do this, I can't do that. Well, it's possible, but you Know, how likely is it that if you manage it, if you do what you need to do and your treatment compliant, that it will significantly detract from your quality of life? You know, there are people who go skydiving who've got diabetes. There are people who are, you know, divers. There are people who are. Do other stuff. My point being that if you're one of those thrill seekers, it doesn't mean that life has to stop. So we do need to help them reconceptualize, grieve the, the pro, go through the grieving process and recognize that, you know, yeah, they're, they're going to not have the same exact life that they had up until now, but also figuring out what their new life concept looks like with the disease so they can have a rich and meaningful life and have diabetes at the same time. They're not mutually exclusive. And sometimes when people start having complications from the disease, we need to help them explore what that means. And, you know, I will give the example of my friend who had his leg amputated. You know, that was devastating for him. It significantly impacted his, you know, feelings of independence. But encouraging him to explore, you know, all of the facts and go broader than just right now and, oh my gosh, I had my leg amputated. You know, eventually he did get a prosthetic that he was very able to use and, or is very able to use. And it really, you know, once he adjusted to it, it really didn't stop him from doing much that he used to do. So we do want to help them, you know, look at cognitive distortions like telling themselves I'll never be able to have the life that I wanted because of this. Well, let's look at the facts behind that. And again, what are the facts? What aspects of this, these complications are within your control. And for my friend, he was able to get a prosthetic and learn to walk again. And, you know, now he's back to, you know, being a same old ornery self and the chances that, you know, he would have to have the other leg amputated as long as he's managing his blood sugar and things, you know, examining those to figure out, you know, how likely is it that the worst case scenario would happen. Treatment targets also include stress management and HPA axis regulation because, you know, when that HPA axis goes up, blood sugar gets dumped, so blood sugar goes up. Stress management is super helpful, helping people develop really good distress tolerance skills so they're not having blood sugar dumps, you know, 15, 20 times a day, encourage them to examine personal goal achievement. Just because you are living with diabetes right now doesn't mean it needs to preclude you from achieving most of your goals. Now, there may be some things that can't be done by a person with diabetes, and I can't think of anything that would fall into that. But I'm not, I don't want to say that it won't stop you from doing anything. That's one of those extreme words too. But we do want to look at those goals and say, okay, you know, how is this going to impact you and how can you achieve your goals? Maybe in a modified way. One of my friends who, you know, has one of those pumps that doesn't do the best job in the world used to be on patrol as a state trooper and her one day, her pump did not function the way it was supposed to and she, you know, went into a diabetic coma, drove her car off the side of the road and crashed into a pond. So, yeah, that's like major bad mojo there. And after that, the, the department was kind of iffy about letting her go back out on the road. So sometimes if the diabetes becomes more difficult to control, it may limit certain aspects, but it's important to help people figure out, okay, maybe this goal you can't, you know, continue to do anymore, but what other goals do you have that you can going back to hardiness, looking at your total life, what things in life are, what are all the things in life that you're committed to and how can you achieve the most number of goals? We can help them address depression related to their diabetes or just related to life in general through empowerment. Depression is akin a lot of times to a sense of hopelessness and helplessness. So let's look at what do they feel hopeless and helpless about and what parts of that do they have power over? How can we help them feel more empowered over their life, over their disease, over whatever it is that's causing them to feel helpless and hopeless? Anxiety. Going back to that facts, control and probability format, when they start having anxiety, encouraging them to examine, recognize it as, you know, how they feel, accept it non judgmentally, and then say, okay, you know, nurturing this anxiety is going to do nothing but rev up my HPA axis and increase my blood sugar. So I need to figure out, anxiety is my body's way of telling me that there might be a threat, and if there is, I need to address it. So let's look at the facts. Is there actually a threat at this point? In time, in this context, what parts of this situation do I have control over? And what is the probability that whatever I am worried about is actually going to come true? And then that grief process that I talked about earlier, you know, denial, anger, bargaining, depression, and acceptance. Whenever people get a diagnosis of a chronic illness, you know, that is often something that needs to be grieved. Some people go through that grief process real quick. Other people, it takes longer. But it's important to help them recognize that their life as they knew it is, is no more. And I generally don't put it that way when I'm talking to clients, but helping them recognize that their life has changed, and there were parts of that change that they had no control over. And that can feel very unsettling for a lot of people. So helping them work through the stages of grief until they can move to that place of accepting a life with diabetes, a rich and meaningful life, and diabetes at the same time. Motivation for change. Physically, we want. We can help them figure out, you know, why am I motivated? Why do I want to go to all this trouble of starting to exercise or eating right or taking my insulin? Well, physically, if I follow the plan that the doctors have set out or I've set out with the doctors, how will it help prevent me from, you know, developing blindness or other complications? How will it help modulate my blood sugar so I have good energy levels? How will it help improve my A1C levels so I don't start developing other complications affectively, you know, how will following the treatment plan help with my depression, my anxiety, and improve my quality of life and happiness? Interestingly, a study I read found that the quality of life for people with diabetes was highest for those in the maintenance stage, which makes sense. They've, you know, figured out what they need to do, and now they're just. They're maintaining they're stable, but lowest for those in the action stage. And I thought that was interesting, that when they're in the action stage, when they're actually actively making changes in their life, that is when their quality of life is lowest, because that's when they're upsetting the apple cart. Makes sense, but I would have thought pre contemplation, but actually their quality of life is lowest in the action stage, when they're actually having to proactively make those changes cognitively to increase cognitive motivation. We want to ask them, how does it make sense that following my treatment plan will improve my symptoms, will help prevent dementia from cardiovascular disease, stroke, microvascular issues, or severe and Repeated hypoglycemia. Severe and repeated hypoglycemia, even in people without diagnosed diabetes, is associated with an increased risk of dementia. How does it make sense that following this plan, how is it logical that following this plan will help me reduce or address my anxiety or depression resulting from getting the diagnosis or, and, or blood sugar discontrol environmentally, what can I do in my environment to make living with diabetes easier? You know, get the Twinkies out of the house, you know, doesn't mean you can't occasionally have one. But if you have them just sitting there in the, in the cabinet and that can feel like it's taunting you. So remove high glycemic index foods from the environment. Remember to check blood sugar. That can be accomplished for a lot of people with wearable glucose monitors now, but it's important to in the environment, have the tools to check the blood sugar and make modifications to the environment to assist with mobility and independence. And if the person starts developing issues like peripheral neuropathy, slow wound healing and, and, or amputations, you know, you may need to pay attention to what could they bump their toe on or their leg on that might cause a wound that they wouldn't even, you know, notice interpersonally who can be supportive of my recovery or my process. That same article indicated that support was highest for people in the contemplation stage and lowest for those in the action stage. And the authors hypothesized that this was because in the contemplation stage, family members saw the person recognizing a problem and really wanted to encourage them and support them in doing what they needed to do to get healthy. But when they got into the action stage, family members support system often saw the person as cured. Okay, they know what, they know what to do, you know, they're off, let them, let them go. They got this. In reality, the action stage is really where the people needed the most support. And in what ways is diabetes control important to my relationships? Encouraging people to think about, you know, how will it impact those that you love if you, you know, pass away earlier because you didn't manage your, your blood glucose? How will it impact your relationships if you don't manage your blood glucose well, if you don't keep your health good and you know, you don't have the energy and ability to engage in your preferred activities? Maybe you like go like going hiking or something. So those are all methods to increase motivation for change. Diabetes impacts people multi dimensionally. Counselors, social workers and case managers can assist through screening, health education, goal setting and planning, motivational enhancement and maintenance, and addressing grief and anxiety issues associated with having a chronic illness. Alrighty. Thank you for bearing with me through this. It was a little bit long today. Do you have any questions? If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allcet.com com sponsor thank you.