Diabetes Expert Shares Top Counseling Skills for Disability Adjustment

I'd like to welcome everybody to today's presentation on disability adjustment as it relates to diabetes. I'm your host, Dr. Donnelly Snipes. Today we'll explain the importance of screening for diabetes in mental health populations, identify complications of untreated diabetes, explore the functions of the clinician in helping people adjust to disabilities or loss of function as it relates to diabetes, and identify important treatment targets, target and motivational enhancement targets. If you're taking this for CEUs, the PowerPoint of the presentation is available in your class at allce.com you can get additional information about most topics, including this1@allce.com Ask Doc Snipes and you can find more videos on diabetes care and adjustment@allce.comdiabetes-list by the time people are diagnosed, 50% of people with type 2 diabetes are already showing signs of complications. That's really important for us to be aware of. One of the things that often comes up early on is, I didn't know I wasn't diagnosed early enough. My doctor missed it. I'm angry at them, I missed it. I, I'm angry at myself. I should have come to the doctor sooner and maybe I wouldn't have these complications. So in addition to just having to wrap their head around the diagnosis of diabetes, they're also having to accept work, to accept the fact that because they didn't do preventative or preemptive care, they may be experiencing complications sooner than they necessarily would have. And, and that causes a lot of consternation, a lot of self blame, a lot of guilt. Diabetes, which causes the destruction or malfunction of beta cells, may begin 10 years before the diagnosis and complications which may start five years before the diagnosis. And that's important. So we have the beta cells being destroyed a decade before the diagnosis and complications starting five years before the diagnosis. We have a big window in there, which is why I know I've said it in every other video that we've done on diabetes. It's so important for us as mental health practitioners to screen for diabetes. Diabetes impacts mood, blood sugar impacts, mood, insulin resistance impacts mood and mood impacts, all of those things. And we see people a whole lot more than their primary care physician. So we are in a perfect place to screen for diabetes and refer. I encourage everybody who's a clinician to strongly encourage their clients to go get a physical. If they haven't had one in the past six months to a year, go get a physical that includes a full blood panel as well as blood glucose testing, just to make sure that everything is functioning as well as it can in the body factory. Cardiovascular disease causes 52% of the death and disability issues in people with type 2 diabetes. People with type 2 diabetes have a 200% increased risk of stroke. Now, remember, percentages can be kind of scary. If four out of every 100 people are likely to have something happen and then somebody with diabetes, people with diabetes, it's eight out of every hundred. That is a significant increase. That's double what it was. But we're only talking about four more people, so we do want to look at some of those numbers. But sometimes numbers can also be used, unfortunately, to motivate people. Kidney disease impacts 33% of people with type 2 diabetes and accounts for 11% of deaths in people with type 2 diabetes. So this is of all the people with type 2 diabetes. Kidney disease is going to impact one out of every three of them. And apparently Brewster wants to join us today. Comorbid mental health issues in people with diabetes increase more mortality for all the reasons that we've discussed, most specifically, including adding stress, which negatively affects A1C levels. Depression is approximately 200% higher in people with diabetes in the general population. And I know we went through some of this last week, but there's also a lot of people here who weren't here last week. Diabetes is associated with lower dopamine levels. Now, that's interesting, because, remember, dopamine is our motivation chemical. It's our I want to do it again chemical. And when people's dopamine levels are lower, not only does it impact their blood sugar, but it also impacts their motivation and their energy and their sleep and their mood. So that's. That's another target that we really want to look at, is regulating. Helping people regulate their dopamine levels as best as they can. What can they do to increase their motivation? Serotonin is implicated in the regulation of blood glucose, not just in the brain, serotonin in the brain, but serotonin receptors throughout the body. SSRIs, your antidepressants, may improve A1C in people with diabetes and depression. And there's some research that says A1 SSRI may also help improve A1C levels in people with diabetes and anxiety for the same reasons. We're reducing stress, we're increasing dopamine levels. Life expectancy is reduced, on average by up to 10 years in people with type 2 diabetes and 20 years for type 1 diabetes. We're finding ways to help people live longer. And so that's one of those statistics that we do want to keep checking up on. Yes, if somebody has uncontrolled diabetes or poorly controlled diabetes, it is going to significantly impact their life expectancy. But we also know so much more now that we're able to help people slow the progression of the diabetes. Neuropathy, which is nerve damage, impacts about 50% of people with diabetes and contributes to slow wound healing. Lack of awareness of wounds, erectile dysfunction, and chronic pain, these are all issues that we can be aware of. If we notice that our client has slow wound healing, we can ask them about it. You know, I'm. You seem to have had that bandage on for a month now. I'm wondering what's going on. That could be one of our first clues that they may have some blood sugar issues. People who have diabetes may have a lack of awareness of wounds. They may knock their leg into a chair and get a bad bruise and not even really recognize it because of the peripheral neuropathy. The. The nerves down there just aren't receptive anymore. They've got numbness. And as a result, especially if they get open wounds like cuts or pressure sores, they may not know it, and that wound may just continue to fester. Erectile dysfunction. We talked about how diabetes impacts the nerves in our ears. Well, the nerves impact our nerve. Diabetes impacts our nerves everywhere. So erectile dysfunction may be an issue. If you are working with a patient who is struggling with this issue, certainly something that we want to rule out. And chronic pain neuropathy, you say, oh, it's numbness. Well, yeah, it's numbness, but it's also shooting pains. And I've had it described as kind of like when your hand goes numb from being cold and you suddenly run it under really warm water. And the. The shooting pains that you get on your nerves as they kind of wake up again. And that is extremely distressing for obvious reasons. Limb amputation occurs in approximately 1 in 40 people with diabetes, particularly resulting from a pressure ulcer or a wound. Up to 70% of people die within five years of having an amputation. By the time somebody's got peripheral neuropathy to the degree that they're not noticing these pressure ulcers and they're getting really bad before they get treated, that means their diabetes is probably pretty advanced and they can get septic. They can have other issues that happen. But limb amputation and blindness are two things that a lot of people are really worried about when they get their diagnosis of diabetes. 98% of those with type 1 diabetes and 78% of those with type 2 diabetes have some degr of retinal damage of eye eye problems, but fewer than 5% suffer severe vision loss. That's another really important thing. If somebody says, oh my gosh, I've got diabetes, I'm worried I'm going to go blind. Well, let's look at the data and talk with your doctor because we don't know how bad their condition is, but we want to encourage them and empower them to get the facts and not make decisions, not try to make facts out of feelings. Hearing loss is 30% higher in those with diabetes because it impacts the nerves in the ear canal. And uncontrolled diabetes is a significant risk factor for the development of dementia as a result of vascular damage. And we covered that a lot over the past few weeks. But people need to be aware when they get that diagnosis. They need to be educated, not scared. We don't want to terrify them because then they're going to feel hopeless. But they do need to be aware and educated about the possible complications, what and what they can do to prevent or slow those complications and what things to look out for if they are at a, they're at a higher risk for stroke. Okay, let's make sure that they know the FAST acronym. Face. One side is droopy arms, one side's not able to move. Speech is slurred or nonsensical. T is time to call 91 1. So face, arms, speech and time to go. Stress triggers that impact all pieces of life. When somebody has diabetes is getting that diagnosis of diabetes. We whether they get it when they are a child, they've got type 1 diabetes. And by the way, some people do develop type 1 diabetes later in life and some we're seeing now children developing type 2 diabetes. So we don't want to just assume we know what kind of diabetes it is. But getting that diagnosis whenever it happens is a lot for a person to take in. Very young children may not have the cognitive struggle with it that older children do. If they have to start wearing an insulin pump, a continuous glucose monitor, it affects their self esteem, it affects their body image sometimes because people can see it even if it's in an inconspicuous place. When they have to change clothes in the locker room or if they have to go get an extra dose of insulin or something, they can feel very exposed. Complications of diabetes. Most people are aware that diabetes has complications and most people, the first thing they think of is amputations. So we want to talk about, educate about what generally causes amputations and diabetes. And what can you do to prevent that? Let's take a look and make sure that they're aware. If they start getting peripheral neuropathy, they're checking their hands, their feet for sores and cuts and problems on a daily basis. And if they need to go into skilled nursing care due to inability to manage their diabetes at home, this is another major stressor. And generally it follows that progression. They get the diagnosis, then they start having complications, then they need to go into skilled nursing care. I want you to think about yourself and your own self image and the things that you want to do in your rich and meaningful life, and then imagine yourself getting this diagnosis of diabetes. Most people don't know a lot about diabetes, so it can sound terrifying. You've got this disease now and you've got to check your blood sugar constantly and blah, blah, blah. And it feels like they're instituting all these tools to, to keep us alive. And it can feel very overwhelming. So we want to step back and help people look at the facts in this context at this time. Fit cat, what's going on? What tools do you have to manage it? And, and encourage them to regularly monitor themselves so they can notice the progression or lack of progression of the disease. And that can be used a lot in therapy to help people recognize, Hey, I, I got the diagnosis five years ago, but I don't seem to be developing any complications. I'm doing pretty good managing my A1C. That's a good thing when they do have complications, because they will, even if those complications come later in life as they age. People who are older, especially elderly people as they define them. People over 65 tend to have more difficulty managing their diabetes because their liver is not functioning the same way, their pancreas is not functioning the same way, their kidneys are not functioning the same way. There are changes in their, in their hormones. There are changes in their entire body that make it more difficult to manage the diabetes. Not impossible, but more difficult. My aunt is in her late 70s right now, and she has had diabetes all of my life. And it's gotten a whole lot harder to manage over the past 10, 15 years for her than it was prior to that. And her. A lot didn't change in her life. A lot changed with her physical health and the need to go into skilled nursing care. Not everybody does. Some people. My husband's grandfather is like 93 or 97, I can't remember, in his 90s, and he's got pretty significant diabetes, but he's still aging in place. So Just because you have this diagnosis doesn't mean you are going to have an amputation. It doesn't mean you're going to have to go into skilled nursing care. And that is so important to emphasize to people when they get the diagnosis. And I find, especially with disability awareness, I start out by asking them, okay, you got the diagnosis. What is it that you know about this condition? And what is it that you're most afraid of about this condition? And then we'll talk about each one of those and I will point them in the direction of education and resources. And then we, I finish with, what do you feel most empowered to do about this condition? What do you feel like you have control over? And let's talk about how you can control that as a counselor or a case manager or a counselor that's doing case management duties. People need health education to slow the disease progression. And some of the things you may take for granted, like knowing how to eat healthy, is not necessarily what everybody knows. So having basic tools to provide education is important. Or refer to someone who can provide health education related to diabetes management. And some endocrinology clinics will have a program, but unfortunately not many. We work with them to create plans so they can achieve the goals that are important in their rich and meaningful life. Living in the. And part of that acceptance, commitment, therapy. Okay, you, you have diabetes. You can have diabetes and live a long life. You can have diabetes and be a cyclist or be a grandparent or whatever you want to be. You can have diabetes and, and do that. So let's figure out how to help you do that. We want to help them address challenges that arise in the implementation. When our blood sugar is all over the place, like we learned about last week, energy levels can fluctuate. People can feel like they're getting dizzy. There can be side effects when they do their, what they perceived as their routine or normal activities that we want to help them make sure they're aware of. Making sure that they have glucose tablets with them when they go to the gym, for example. Making sure obviously if they're, if they don't have a continuous glucose monitor, that they have the ability to monitor their blood sugar both when they go to the gym and if they go out to eat or if they go to a party or what have you. Other challenges that might arise in implementation include someone who really likes their alcoholic beverages. Maybe it's only one or two a night, but they really like them and they're not wanting or willing to give that up. So we need to talk about what that means and encourage them to talk with their endocrinologist about how to best manage their blood sugar. We want to increase and maintain motivation for treatment compliance in those who have recently been diagnosed or have a significant change. When we get that initial diagnosis or when we're told, hey, you're going into kidney failure or you're going to have to have an amputation, we go into a state of grief, we go into state of denial, anger, depression, acceptance. And how long it takes to get to acceptance, we don't know. But a lot of people, when they hit that denial phase, they kind of freeze up and some people pretend that that's not right and they'll try to get second opinions. Other people get this hopeless, helpless attitude and they're just like, okay, well, screw it, there's nothing I can do and I'm going to just ignore everything and do whatever I want. So they may go into this almost self defeating cycle, helping them recognize how they feel and helping them recognize what their behaviors mean. If they are suddenly just, you know, I'm not going to go to treatment, I'm not going to comply with my treatment plan, blah, blah, okay, tell me why you've lost the motivation to do that. And ultimately it probably comes back to, I've been trying to do the right thing, I've been trying to follow my. And I still ended up with this consequence. We can help them explore that from the perspective of, but you delayed it. And yes, it's unfortunate and we're going to have to deal with that. However, let's look at what might have happened had you not even tried to follow your treatment plan. We can coordinate and implement multidisciplinary care plans. This is usually a case manager's job. A lot of diabetes treatment clinics and endocrinologists have a social worker on staff that does this or a case manager on staff that does this. But sometimes it falls to the counselor to make sure that we're helping coordinate the treatment plan and make sure the person's getting to all of their appointments. I know we went through this last week, we're going to go through it really quick this week. Screening if a, when, when a patient comes in your office, if they're complaining of increased thirst, frequent urination, extreme hunger, and I know those first two, of course, if you've got increased thirst, you're going to be peeing a lot more. So they kind of go hand in hand. But when you look at the American Diabetes association, they list them both. Increased thirst, frequent urination, extreme hunger, unexplained weight loss, unexplained fatigue, irritability, blurred vision, slow healing sores. That's another big warning sign. Excessively dry skin. Now remember, hypothyroid as well as just the heat during the winter can cause dry skin. So we don't want to assume that dry skin is something that is necessarily related to diabetes. If they have frequent skin infections such as their in their gums or skin infections, you know, on the rest of their body, impotence, erectile dysfunction, frequent vaginal infections, those can all indicate potential for somebody having diabetes or pre diabetes. Definitely. If you've got numbness and tingling of the hands and feet, you want to refer them quickly to an endocrinologist to get screened for diabetes because there's something going on and we need to figure out what it is because it's not cognitive, it is physiological and we shouldn't, you know, have. Unless your foot goes to sleep while you're sitting in an awkward position, you really shouldn't have numbness and tingling, especially not persistent numbness and tingling. And people with hypoglycemia make it shaky and have a rapid heartbeat. If you notice somebody starting to get super shaky, we want to ask when was the last time you ate? If they complain of frequent symptoms that very much sound like a panic attack, but they're saying, well, I wasn't worried about anything then. We also want to look at making a referral because it could be that their blood sugar is just dropping like a rock. Our treatment targets basically reduce stress in every piece of life. Physical, interpersonal, emotional, cognitive, environmental and spiritual. Any type of stress in any of those pieces can worsen A1C levels. And chronic stress contributes to dysregulation of the stress response and an exponential worsening of blood sugar control and systemic inflammation. Treatment targets. We're not dietitians, we are not prescribers, we are not going to give people a menu. However, we can educate them about particular treatment targets as they re relate to eating, nutrition and exercise. We want to encourage them to be active, to modulate their blood sugar and improve insulin resistance, mood and self esteem. The general target is 150 minutes per week. So that's 30 minutes five times a week or 50 minutes three times a week. And it doesn't have to be super intense. I'm out of breath. Exercise, it's walking, it's getting your heart rate up to in about 60% of your target heart rate zone. For me, I think now that's like 113 beats a minute it's not that difficult to achieve with brisk walking. People with diabetes, if they're not wearing a continuous glucose monitor, should check their sugar every 30 minutes. Stop exercising if their blood sugar drops below a certain level. In General, they say 70 milligrams per deci deciliter, or if they start feeling shaky, weak, or confused. Blood sugar monitoring is another important thing. We want to encourage them to stay active, but they also need to monitor, monitor their blood sugar even when they're not active to identify patterns. And one of the patterns we often see is alterations in blood sugar during periods of emotional stress and periods of sleep deprivation. So we want to help people connect the dots. My blood sugar's been a lot more erratic lately. Okay, well, let's look back over what's been happening since this started and see what changed. Pain, sleep, nutrition, lack of exercise, more exercise. You know, let's see what's going on. We want to encourage them to eat healthfully, considering a, quote, normal diet and generally. And this is one from the Alexander Valley Healthcare center, this is a infographic that they had. The person will be talking with their dietitian and with their endocrinologist about exactly what they should eat and when. But one of the things we found, whether we're working with people with diabetes, people on a diet, people with eating disorders, is a lot of times it is important not to completely eliminate whole groups of foods or even particular foods, because that sets the person up for craving. If you say, okay, I've got diabetes, I can never eat cake and ice cream again, but that's your favorite thing in the whole world, then it's going to be, it's going to feel like a loss, it's going to be difficult to manage, and it's going to be temp, even more tempting. Because you know how when we're told we can't do something or we can't have something, something in our psyche says, okay, I want it 10 times more. Now you can't. They can't generally have the same amount. My husband's grandfather will regularly eat cake and he's gotten a little bit more loosey goosey over the years, but he used to eat a much smaller piece and he would savor it instead of getting this huge hunk of cake and wolfing it down. And yes, it would impact his blood sugar, but he was willing to make that compromise and make that adjustment. And interestingly, sodium is important to manage in, in diabetes as well. The person should have a goal of an A1C that is less than 7%. In order to prevent microvascular disease, A1C measures your average blood sugar levels over the past three months. Remembering blood sugar is increased by foods and stress, Whether it's exercise or lack of sleep. Again, good stress, bad stress, any kind of stress may increase A1C's. So we want to help the person pay attention to that and monitor what is going on that may be helping. And what is going on that may be not helping their A1C levels since they can only get it measured every three months. You've got a treatment window, you've got an intervention window that you can really do a deep dive on. Okay, what happened six months ago, your blood A1C was a 5.4. And last time they checked was a 7.5. So what changed over that period of time? What did you start doing differently? What changed in your life? What stressors increased? There can be a variety of factors. People who are going into menopause or andropause may have more difficulty controlling their A1C levels. And that's not something they did or didn't do. It's just is when our gonadal hormones start altering, it can impact A1C levels. So that's another thing that needs to be looked at. We want to encourage them to take medication that's designed to help them control their A1C. Some of those medications include insulin, bi guanides, I can never pronounce that right. Which decrease how much sugar the liver makes, how much sugar the intestines absorb and makes the body more sensitive to insulin to help the muscles absorb blood sugar so it doesn't just sit there in the blood. Dopamine agonists are also potential medications to help control blood sugar. That means med medications that increase dopamine. If somebody starts taking an increase in dopamine and they start developing signs of restless leg syndrome or tremors, it's important that they talk to their doctor because it could be too high of a dose. There could be other things that are associated with it. But obviously, anytime somebody starts developing tremors, they need to have it looked at. If it's restless legs, we need to help them determine what may be contributing to it, including the medication. When did it start in relation to when you started this dopamine? Agonist? DPP4 inhibitors help the body continue to make insulin and GLP1 receptor agonists increase beta cell growth and how much insulin the body uses decreases appetite and how much glucagon the body uses and slows stomach emptying. We've all heard so much about GLP1 receptor agonists over the past few months to a year. I think most people are familiar with those. However, they do have some significant side effects that people may need assistance figuring out how to mentally deal with. I've got this, you know, I feel bloated all the time or I'm constipated all the time. Obviously they need to talk to their doctor because they need to figure out how to make their body work as well as possible. But there may be some side effects that they've got to figure out how to accept and live their rich and meaningful life. Aspirin may be advised to address cardiovascular risk and inflammation and help with blood sugar regulation. We are not recommending this, but if the doctor has them on aspirin, they may not know why. A lot of doctors don't tell you why. They just say take these pills. So we can tell them that it can help with those things, but not to start taking aspirin unless their doctor recommends it. Make sure they clear it with their doctor because we don't know how that's going to interact with their other, their, their blood sugar as well as their blood sugar medications. People with diabetes have a 200% greater chance of developing hypertension, which contributes to cardiovascular death. And dementia. And dementia. People with diabetes and high blood pressure are 400% more likely to develop heart disease. And high blood pressure increases blood sugar. When we have hypertension, our body registers that as a stressor and it increases blood sugar. When we're stressed, it increases our blood pressure, which increases our blood sugar. So they kind of feed off of each other. Helping people. Now we can't help them completely lower their blood pressure, but it is interesting and it can feel very empowering to people. To do some biofeedback. Just use a regular polar heart monitor, heart rate strap and one of the apps that they have on a mobile phone. Have them put it on and have them take their blood pressure with one of those automatic, you know, drugstore blood pressure cuffs before they start breathing and then encourage them to practice square breathing or something to trigger the vagus nerve and the autonomic nervous system and then take their blood pressure again. And many times there you will see a marked difference in the pre and post blood pressure. So we can help them recognize. Now you may not be able to get it down to what the doctor considers healthy, but when you start feeling stressed, you can trigger that automatic down regulation by consciously choosing to slow your breathing and get grounded in the moment. And that can feel Very empowering for people because at least they know when there's situational things that are increasing their blood pressure and they have a tool to prevent their blood pressure from, you know, skyrocketing cholesterol lowering medications or statins. Diabetes tends to lower good cholesterol and raise bad cholesterol, which contributes to cardiovascular, cardiovascular disease. It is important to note that both blood pressure medications and statins may significantly impact people's mood, their energy and their blood sugar levels. And knowing that is important. If, even if they don't have diabetes, if they start taking blood pressure medications, especially beta blockers and, and, or statins, and your client starts complaining of depression and fatigue and lack of motivation, that could be a side effect of the medication that they're on. Don't tell them to discontinue it. Can't do that. But encourage them to talk with their doctor if the symptoms they're having are sufficient enough to be negatively impacting their quality of life. Now sometimes the doctor is going to say, well, wait it out for three weeks and those symptoms will go away. Okay, well maybe they do. But then if after three weeks the person's still having significant negative side effects, empower them to go back and talk to the doctor and say, hey, it didn't go away. I'm, I want you to help me figure out what to do about this. Oral health is another treatment target. And I know we're, we're counselors, we're not dentists. True. However, educating people about the fact that gum disease both contributes to and worsens blood sugar levels can help them manage their blood glucose, it can help them manage their diabetes. Encouraging them to brush their teeth is important. And encouraging them, if they've got cavities, if they've got something going on in their mouth, to try to see a dentist. And I know dentists are expensive and a lot of people don't have dental insurance, so that can be problem United Way 211. You can call that from wherever you're at or you can go online and look and find clinics in your area that may offer free or reduced cost dental care. If you've got a dental school in your area, a lot of times they will offer free or reduced cost dental care as well. Likewise, people need food to function. And if people are not able to chew their food, then they're going to have weight loss, it's going to impact their A1C levels. If somebody doesn't have the ability to chew their food either because they don't have teeth or they don't have proper fitting dentures. Again, we need to make a referral. Smoking causes type 2 diabetes, according to the CDC. I probably wouldn't go as far as saying causes. I would say it's correlated with, but that's fine, according to the cdc. And smoking does increase the risk of complications. Smoking, all of the chemicals that are involved in that is an assault on the blood vessels and it contributes to hypertension and contributes to increased blood sugar as a result of. We also want to monitor people for signs of hearing and vision loss, which are both associated with worsening diabetes and dementia. As people's diabetes get worse, their hearing and vision can get worse. And as their hearing and vision gets worse, it increases cognitive load, which can and and stress, which can worsen their dementia. So we do want to look backwards and figure out where can we intervene. We want to encourage people to moderate or stop using alcohol. Alcohol increases inflammation, blood pressure and bad cholesterol. Diabetes increases inflammation, blood pressure and bad cholesterol. So you're just, you know, double teaming your body. If you've got diabetes and you're drinking, moderate amounts of alcohol may increase blood sugar, but excess alcohol can actually cause hypoglycemia, especially for people with type 1 diabetes or for those who fall asleep after drinking. Remember, when you drink, you feel kind of buzzed, kind of relaxed for the first half, and then when the alcohol starts leaving your system, it leaves more quickly than your body can adjust to, so you have a spike in the stress response, the HPA axis and blood sugar. We also want to make people aware that opioids will impact their blood sugar levels and can lead to hyperglycemia and impaired insulin secretion. In terms of other treatment targets, sleep improvement and sleep apnea treatment are really important. Just like not everybody with diabetes is overweight, not everybody with sleep apnea is overweight either. We don't want to use body weight as a gauge for how healthy or sick somebody is, because it's not accurate. We want to ask them, do you snore like a freight train? And if they say yes, we probably want to refer them to an ear, nose and throat doctor or back to their GP for a sleep apnea test. If they have a partner, then their partner may, may be able to give you a little bit more information about whether it's like, steady snoring or they're doing that thing where they're choking and then they wake up and gasp for air. Either way, lack of adequate quality sleep is going to increase blood sugar. Sleep deprivation is associated with hyperglycemia and development of insulin resistance. Altered circadian rhythms are associated with alterations in eating patterns and ghrelin and leptin levels are hunger and satiation hormones. Being aware of this is important, helping people understand. Not only does lack of sleep make it more difficult to control, intrusive thoughts and ruminations make it more difficult to be motivated impact your mood, but it also impacts your blood sugar. So sleep is important. Providing health education, motivation for prevention and mindfulness and early intervention is another strategy we can use. Since diabetes can impact the way the body responds to just about every situation, including illness, people who have shingles may have difficulty controlling their blood sugar for up to six months. I didn't do research to see if the same was true for chickenpox, but my assumption would be yes. When people have had another virus like the flu, it can also affect how long it takes to get that A1C back under control. If somebody has had a significant illness and they're having difficulty, their their next A1C comes back high. We want to make sure we empower them to recognize that it can take a minute for the body to re regulate and up to six months in some cases. So yes, let's keep doing the next right thing and maybe try to table that worry until the after the next A1C reading. Interpersonally, we want to help people adjust their self esteem to help them feel empowered to move toward their rich and meaningful life despite having diabetes related complications or even having to go into a long term care facility. Now each one of these things may represent a greater amount of loss or loss of function or ability to do something, but we want to help them explore what they can do. Many people who are in assisted living facilities are still able to go out and go to the gym. They're still able to go out and go to coffee with their friends. Maybe they can't drive anymore, but they can get an Uber. And a lot of people when they hear going into long term care, they feel like they're going to be stuck there and be sort of a prisoner. And that doesn't have to be the case when they have diabetes. You know again, what is it that you want to do in your rich and meaningful life and how can you do it with diabetes? Help the person identify modifications to things important in their rich and meaningful life, especially goals and relationships that may be impacted by the condition. If you always used to go long distance biking or, or hiking or wine tasting with somebody, well that may not be something you can do as easily anymore. Can you do it at all? I don't know. That's on a case by case basis. And if that relationship is important to you, what can you do instead? If you can't go wine tasting, maybe you can go have coffee together or cheese tasting or something, I don't know. Or maybe you can go along for the wine tasting and just not taste the wine. That's not typical, but it's not forbidden either. Recognizing what is it that I can do? I want to spend time with this person. I enjoyed this activity. How can I do it and stick as closely to my treatment plan as possible. We want to help the person identify what they want or need from significant others and caregivers and how to prevent themselves from feeling suffocated or infantilized. Sometimes people, especially right after a diagnosis or right after an amputation or something, loved ones will become like helicopters. And it can feel overwhelming. They may, it may feel like they are watching everything you eat, watching everything you do, and you feel like you're under a microscope. That's going to increase stress. They love you, they want to support you, and they don't realize necessarily that they're adding extra stress. So it's important to encourage the person to talk with their significant others and their loved ones in an assertive manner to say, I know that you care and I need a little bit of space here and that's okay. Help the person develop a level of comfort with handling questions about the disease or complications. If they have diabetes and they have to change how they eat, you know, grandkids may have a, well, grandpa, why aren't you eating cake with us at my birthday party? How do you feel that? And each person is going to have their own way of doing it. Or if somebody has an amputation, people are going to ask. Some people may not ask and may give you this look of pity, and that can be really irritating for people. Other people may ask and you don't feel like answering. So just being aware this will happen. Let's prepare for it. It when this happens, if you're at church and you just had your leg amputated and you come in, in a wheelchair, how are you going to handle it? When everybody starts flocking to you wanting to offer condolences or concern or ask questions, how are you going to handle that? And so the person's prepared. Provide resources to educate family, caregivers and community about the disease. Not this person's disease, because that's HIPAA protected, but about diabetes, because a lot of people have it or are going to have it address the blame and stigma related to the development of diabetes and complications. Right now, especially for type 2 diabetes, there is still a huge stigma of quote, you brought this on yourself because you didn't eat a good diet and you didn't exercise. Well, that's not true. You can have somebody that ate a good diet and exercised, but they had chronic stress and other things going on and ended up developing diabetes. We even people who have, who are overweight or who don't eat the best diet, number one, what good does it do to blame them? But number two, do you know that that contributed or caused their diabetes? Maybe they had CPTSD and developed polycystic ovarian syndrome and that ended up leading to hypothyroid weight gain and diabetes. You know, it's possible. So we need to stop blaming the person with diabetes. We need to encourage support seeking from others with the same condition, whether it's diabetes or hearing loss or amputation or peripheral neuropathy. Talk with other people who are living this so you can hear what works for them, what doesn't work for them, etc and encourage socialization not just with people with diabetes, but you are a person. Yes, you have diabetes, but you are a person. So get out there and socialize and just know you've got diabetes. Helping people get out of that framework of feeling like they are sick, feeling like they are broken in some way, feeling like they've got it plastered across their forehead and they can't socialize with other people is, is really important emotionally. Complications of diabetes may be a wake up call or as I mentioned earlier, a trigger for giving up. Up. If somebody has an amputation, they may become very depressed, they may become, they're going through grief and we need to acknowledge that they're recognizing, recognizing their own mortality, they're recognizing that the disease is progressing and they're recognizing that life ain't going to be exactly the same now because now I have this other thing I've got to deal with. When they have start developing neuropathy, hearing or vision loss, kidney failure, stroke, cardiovascular disease, dementia, all of these things are in general scary diagnoses for people to hear. And when they hear that, they may feel like giving up. And we need to encourage them to recognize, okay, you've got this issue, you've got kidney disease now as a result of the progression of your diabetes, let's look at how quickly it typically progresses in people who are following their treatment plan and help them see that they are empowered to slow the progression. They're not necessarily going to ever be able to get rid of it or fix it. But they are empowered to slow the progression. Grief related to quality of life changes. Helping them use the dialectics and the. And blood sugar monitoring. Some people. I'm terrified of needles. I don't know how I'd be able to take my own blood sugar. If I had to do it, I'd figure out a way. But I would have some grief and some really high anxiety related to it. And quite honestly I'd be pretty ticked off or having to have a pump. This is not what I envisioned for my life and it's a fact now. So how can I live my rich and meaningful life and have a pump? How can I embrace these dietary changes and not feel completely deprived and miserable? How can I live my rich and meaningful life while having the disease? These are all things that we want to help people try to wrap their head around. Anxiety related to the disease is high and that's where the education is really important. Educating them about diabetes and about the progression early on. So they're not making decisions and trying to make facts out of fears. Fears aren't facts. Feelings aren't facts. Facts are facts. So let's really look at what we're dealing with and figure out how to empower you to slow the progression. They may have anxiety related to progression or the complications of disease of the disease. If they had a family member who had an amputation they may see that and be terrified that's going to happen to them. Helping them get focused in the present. What do you have right now? What are your. Are you in at high risk of having an amputation right now? Okay, you're not. How can you prevent that? Helping them recognize their empower to slow the progression. If they're afraid of rejection by friends or family because of disease complications like having an amputation, let's talk with them about the facts in this context at this time. What is the likelihood that people are actually going to reject you? They may be concerned for you, but what is the likelihood they're going to reject you? And anxiety related to environmental changes. If they're going to a long term care facility, all of a sudden they're moving out of their home. They're going to be living in this place with a whole lot of other people and it feels like they're losing a lot of control and that can be terrifying. Helping them focus. Maybe visit the long term care facility ahead of time and meet the director and focus on what they can control. In that situation. They may have Anger or frustration due to inability to follow the care plan. Maybe their neuropathy keeps them from being able to effectively clean their pump or they're having sleep issues or slow healing wounds or medication side effects that, that they're supposed to be figuring out how to deal with. But it seems like nothing they do helps and that can be exasperating. The more angry, angry, angry and anxious they get, the higher their A1C the higher their blood sugar is going to be. So we want to help them get into their wise mind as much as possible and figure out how to be empowered cognitively. We want to help people with problem solving and preparing for the unexpected. For example, accidental ingestion of more carbs, incorrect insulin calculation, if they're not wearing a pump, if they forgot their insulin again and they're not wearing a pump or their pump runs out of insulin, if their blood sugar drops, if they're having unacceptable medication side effects, or if they are going into a really stressful situation. All of these things you can prepare for ahead of time. We also want to help them recognize any contributions of prior traumas to their current reactions. Maybe they had medical trauma in the past and this feels like they're going through the same thing again. They survived cancer or a loved one had cancer and was powerless. It can trigger some of those wounds that are reopened. It's like, oh, I've got this progressive disease now. And it reminds me of when. It could also just remind them of other times when they've generally felt powerless or feared abandonment. So we want to ask them what's. What are your fears that that are contributing to your current irritability, to your current stress levels? Cognitive distortions, catastrophizing. This is going to happen. It's going to be the worst thing in the world. Use facts in this context at this time. Fitcat and probability. Could it happen? Sure, anything can happen. What's the probability that this is going to happen if you do what you are able to to slow the progression and follow your treatment plan. If they're using all or nothing language, my life is completely over. I can never do anything again. We want to help them explore trying moderate language and focusing on what they can do, not just what they can't. If they're personalizing things, focusing on exceptions and if they're mind reading, whether it's about what people are thinking about them or what needs to be done, if they're expecting loved ones know how they what they need, that's mind reading and that's not helpful or Healthy. So help them develop better communication skills. Encourage them to practice mindfulness so they're more aware of the moment. Then they'll be more aware of how they're feeling and their blood sugar and able to monitor that. They'll be more aware of when their stress is going up so they can use down regulation skills and reduce that stress response and reduce the related blood sugar spikes. Encourage them to define their rich and meaningful life and help them, once they define that, start setting goals and working toward achieving those goals environmentally. Again, encourage them to reflect on what they have and what they can do. Look around what's important to you, what do you have right now and what can you do? And empower them to identify accommodations to do. Help them do the things they want. If they have an amputation or peripheral neuropathy or hearing loss, what types of devices or things are available to help you do what you want to do and have that complication? In terms of motivation, we want to encourage them to identify how managing A1C levels will help with their energy, their pain, their headaches, reduce episodes and symptoms of high or low blood sugar and prevent complications. So how does it make sense physically, interpersonally? We want to encourage them to identify who can be supportive of their recovery and again, what is needed from them. Interestingly, support is generally highest for those who are in contemplation and lowest for those in the action stage of readiness for change. As it relates to dealing with diabetes, it's important to encourage them to maintain their motivation even when they're in a groove. We don't just increase motivation and coast off that for the rest of their life. There's going to be ups and downs and we need to help them notice the downs so they can increase it back again and encourage them to focus on in what ways is following my treatment plan important to my relationships? How does it impact my self esteem, my ability to see my grandchildren grow up, grow up, or my ability to have the energy to engage in my preferred activities with my significant others? Emotionally, how will it help with my depression and my anxiety if I'm controlling my A1C, I'm reducing my inflammation, I'm reducing my hyperactive stress response, and I'm improving the balance of neurotransmitters and theoretically improving mood. It also may help improve happiness. They found in a study of people with diabetes, quality of life was highest for those in the maintenance stage, but lowest for those that were in the action stage. So for those people who were just, who were, you know, determined to follow their treatment plan that they just got and they were working it hard and trying to get their A1C under control. They perceive their quality of life as lowest. And this was actually also the place, when we look at readiness for change, where social support was lowest. So when people are in the action stage, we really need to bolster their social support cognitively. How does it make sense that following your treatment plan will improve your symptoms and quality of life, including preventing dementia from cardiovascular disease and stroke, microvascular issues, and severe and repeated hypoglycemia? And finally, environmentally, what can I do in my environment to make living with diabetes and any complications easier and remind myself to follow the care plan? For some people, that means removing high glycemic index foods from the from the environment. Doesn't mean they can't ever have them. But you don't want to have them around at 2am when you get the munchies. Push notifications for medication, eating or activities, remembering to check your blood sugar or having a wearable glucose monitor, mobility and independence modifications so their environment is welcoming and safe and pictures and visual reminders of loved ones and planned activities and planned vacations and things that they have that are important to them. You can learn more about diabetes with the Diabetes Awareness and management playlist@allce.com diabetes list. Next week, we will be discussing understanding the impact of traumatic brain injury and tools for recovery. So we're gonna kind of switch gears a little bit. Diabetes impacts each piece of a person's life. 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 progressive illness. Now, I know I saw a lot of stuff going through the chat room, so I want to answer any questions that came in. Jason, you're very right. It is amazing how much people don't recognize the amount of power they actually do have, especially after getting a diagnosis or news that kind of knocks them off their center. Many times they feel totally helpless and it becomes sort of expanded on what actually is there. They feel helpless. The facts don't bear that out, but they feel helpless and we don't want to invalidate their feeling. You know, when, when you get a diagnosis and it's just like, whoa, okay, not what I expected. You feel off balance and we want to allow people time to grieve, but certainly moving quickly to the place where we're saying, all right, we're going to deal with this stuff. You've got to grieve. Where I'm acknowledging your losses and how much this is awful right now. And, you know, let's look at what you do have the power to do. You're right. Dr. Darlene. Working with people with diabetes is unique and up until I started studying it, I didn't realize, number one, how many of my patients actually had diabetes and how that was significantly impacting their mental health and how their mental health was significantly impacting their diabetes. And it's now one of those things that, that I focus on. If you've got diabetes, that's going to become an integral part of your treatment plan. If that's something you're willing to work on, obviously I'm not going to force them to do it, but it's certainly another one of those holistic strategies towards health and recovery. Alec is so right. Always look up your medications. Drugs. I believe it's drugs dot com. I need to write this down because I talk about this website so much. But you can look at side effects of medications and you can put all your medications in there and it'll tell you what the side effects are. Now that we've got Chat GPT and Perplexity, you can actually ask them. Go to Perplexity AI and ask it. How does XYZ medication impact blood sugar? To get an idea and that can give you some more information and that's true for any herbs or over the counter medications you take. If you've got diabetes, you need to be aware. Sudafed is going to impact your blood sugar or your decongestants are going to impact your blood sugar. Aspirin impacts blood sugar. So we need to just be cautious. You need to be a little bit more cognizant about what you're putting in your body because you're really trying to regulate that. A1C in a tight window. And Jason suggests getting a pharmacy consultation if you're taking medications from many doctors and that can be super helpful. Even if you're taking many medications from one doctor, they're probably not taking the time to explain things to you. So getting a consultation can definitely help you be more, feel more empowered and be more aware of what is a normal initial reaction to medication that'll go away in two or three days. And what do I really need to be aware of? Follow up can be very difficult with clients with physical health or mental health issues. They want it fixed and we can't fix it. Follow up is really important now. If we're talking about treatment compliance, then we want to look at the reason that they are non compliant, do they not, do they not have the knowledge? Do they not feel empowered? Do they not see the issue or the benefit of what we're asking them to do? There's a lot of reasons people may not be treatment compliant if they are not following up and not coming to their sessions. Their same reasons could apply there. But we also want to try to figure out and reach out to them. But also, especially when, when it comes to physical health issues, making sure that they are aware of the resources that they can find online that are peer reviewed. You know, I'm not saying peer review doesn't necessarily mean accurate or correct, but it's a whole lot better than going to just some blog that somebody wrote. But helping them find quality resources can be really important. Mo Many of the clients who are in crisis will not follow up with their doctor and take their insulin. When people are in crisis, they are often having difficulty putting one foot in front of the other. So I'm not surprised they need a case manager or a counselor who can really help them until they get regrounded. When people are in crisis, they're in their fight or flight mode, which means they're not using their higher order thinking. They're not planning, they're not problem solving, they're just trying to survive. And until we can help them stabilize and regroup, it's going to be hard for them to follow up on their own. Even if maybe they know intellectually that they need to do it, they may not remember, they may not have the energy, they may not be able to take the stress of actually trying to call the doctor's office to get a stinking appointment. I know, I hate doing that. And even when I'm not in crisis, I, I really hate making doctor's appointments. And that's something that we can do. We can assist people with, we can prompt them to do. Even with follow up calls, calling them the next day and saying, hey Sam, you know, I was wondering how your night went and did you follow up with Dr. Smith about getting your insulin checked? That can be super helpful. That's what we used to do when I worked at the crisis center. Anybody we talked to the night before, we set a appointment for a reminder call for the day shift to check up on them and see how their night went and make sure that they were implementing any strategies that we had talked about. I agree with you, Vape King. Many people hate going to the doctor. I'm another one of those people. I have a wonderful doctor now. I, I think she's Amazing. But I still hate going. It's just one more thing that I don't want to take time to do. But yes, many people do hate going and encouraging them to identify, explore why they don't like going to the doctor. Is it because the doctor always runs an hour late or is it because they don't like getting poked and prodded? Or what is they don't like wasting the time? They feel like it's a waste of time to go to the doctor. What thoughts are they having that eliminate their motivation for going to the doctor? It's kind of like going to get your car taken in to have the, the oil changed. Sometimes you just need to do it for preventative maintenance. And I, I drag my feet on doing that too. But encouraging people to look at their rich and meaningful life and this is what you want out of life. Do you want to have health? You want to have energy? You want to live to be 110, whatever. Well, in order to do that, you gotta take care of the body factory. And there are things we have to do in, even in our jobs that we don't like doing. But in order to do our jobs, we have to take the good with the bad. We have to do some of the stuff we hate in order to be able to do the stuff we love. And. It doesn't make it go away, but it certainly can help people start looking for a little bit of motivation to, to get it done. Okay, well, I appreciate everybody for being here today. Again, next week we're going to switch gears completely into traumatic brain injury, which I actually have not done a video on before, and, well, not an in depth video. And then we'll, we'll kind of go on from there. So everybody have an absolutely wonderful, amazing rest of your week and I will see you same time, same station next week.