Psychosocial Aspects of Diabetes | Comprehensive Case Management Certification

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox I'd like to welcome everybody to today's presentation on the psychosocial aspects of diabetes. I am Dr. Donnelly Snipes. In this presentation, you're going to learn about the diabetes type 1, type 2 and gestational diabetes. We're going to explore complications and causes of diabetes type 1 and type 2, obviously gestational. We have a good idea. We will learn about how blood sugar alterations can impact mood, cognition and energy identify chronic conditions associated with uncontrolled diabetes describe emotional issues associated with having a diagnosis of diabetes will describe social issues associated with having diabetes and explore common treatment goals for persons with diabetes type 1 or type 2. And you may be thinking to yourself, well, why is it that we're talking about diabetes? We're for the most part mental health clinicians. Some, some of you may be social workers and you're going to find the answer as we go through a lot of our clients may have diabetes or may be at risk for diabetes, or may have developed diabetes and it's not diagnosed yet. And they're presenting with mood issues that are being caused by fluctuations in their blood sugar and their insulin levels. We want to be aware of all the biophysiological causes of mood disorders as well. Nearly 10% of the population has diabetes. I know I've got at least three people in my family that are actively diagnosed with diabetes. 84 million adults aged 18 years and older, or 34% of U.S. adults. Let that sink in. One in three U.S. adults have have pre diabetes. A lot of our clients that are coming in, well, let me go down to the next one. People with mood and psychotic disorders are at an increased risk of developing diabetes. And it emphasizes a bidirectional relationship of diabetes and mental health issues, which I thought was really interesting when I was looking at the research. They're not exactly sure why they think it may be some somehow associated with inflammatory changes associated with the diabetes developing or causing the development of depression. And when people are depressed, it causes sometimes inflammation within the body, which can trigger an autoimmune response. Also, when people are depressed, they tend to eat for comfort less than they eat for hunger, which can lead to weight gain and other factors that are associated with the development of diabetes. However, as clinicians, when somebody comes into our office and they're talking about what's going on with them, if they have diabetes. They may have worked with a diabetes social worker right when they got their diagnosis, or they may not have. They may not understand all the repercussions, mental health, socially and physically, of diabetes. They also may be struggling with complications as, you know, start to have problems managing their diabetes, which generally happens for a lot of people as they get older. And that may cause an increase in frustration, anxiety, depression, etc. Which may cause them to present in clinic. We want to be aware of all of these things so we can address the issue and help them figure out how to work through and identify necessary resources. Type 1, which is also known as juvenile onset or autoimmune diabetes, is a chronic condition where little or no insulin production is observed due to an autoimmune reaction against the pancreas. We know autoimmune disorders are on the rise in a big way. Therefore, it would not surprise me if we started seeing more cases of type 1 diabetes, especially in older adolescents and young adults. Type 1 diabetes can be caused by pancreatic diseases, genetics, or autoimmune destruction of pancreatic cells. It can appear at any age. It's not just, you know, we talk about juvenile onset, but it doesn't mean it has to occur when somebody's under 18. Generally, if we're looking at when it appears, there are two noticeable peaks for type 1 diabetes between 4 and 7 years old and between 10 and 14 years old. And, you know, 10 and 14 is when people start going through puberty. There's a lot of changes going on in a kid's body as, as they go through childhood. But we do know there are two peaks. Four and seven years old. Let's think about what's happening in that kid's life right now. They are in preschool, they are in kindergarten. They are in, you know, first, maybe second grade. They may be referred to the school counselor because of disruptive behaviors or because of irritability or something like that that they didn't have before. And it may be misdiagnosed as failure to adjust to the new setting. When students go from preschool and kindergarten, which is a lot more loosey goosey, to the highly structured, unfortunately, first grade, it can be a hard transition. We do want to consider that there may be other things going on if the symptoms present. So we want to make sure we kind of screen for these things just to make sure that it is a psychosocial adjustment issue and not an underlying. Medical issue that needs a rural same thing. 10 years old. 10 and 14 years old is the end of Basically, when people are in middle school and for some the beginning of high school, this is a time that is tough for a lot of kids. So they're going to typically be a little bit more irritable anyway if the child presents for irritability and depression. You know, we do want to look at what else is going on with little, little Jane or little Jim Bob. I said we need to screen. Obviously we're not physicians, we're not going to take a blood test, we're not going to do a urine test for diabetes. That's something a medical doctor would do. But how do we know when to refer? Well, as we talked about in the last class, I would love it if everybody went to get, you know, their, their blood levels checked for their hormones, their vitamin D levels, you know, thyroid functioning, if they presented with signs of mood disorders, because those things are so pivotal in how we feel. But it doesn't happen a lot. So, you know, I would love that if that was part of a standard intake for a lot of people that's not going to be full, mainly for time and cost reasons because, you know, a lot of people may not be able to afford to get another physical or if they don't have coverage for their physical, they may not be able to afford it. But anyhow, ideally we want to rule these things out. So if you're talking to a family, if you're talking to a child and a caregiver or an older child who can, you know, speak for themselves, a four year old may have more difficulty with this talk about the symptoms. Has the person shown increased thirst, frequent urination, extreme hunger, unintended weight loss? You know, those two things kind of, they don't intend to lose weight and they're hungry all the time. Bedwetting in children who previously didn't wet the bed during the night, we know that bedwetting can signal other things, but that's going to be something that is a point that a parent probably brings up if that started happening. Irritability and other mood changes, fatigue and weakness and blurred vision. Now these last three, irritability, mood changes, fatigue and blurred vision are all things that can impact a child's interpersonal relationships at, you know, at home, but also at school. And it's probably going to be more marked at school where the child is having difficulty focusing in class. All of these things just kind of give us a clue that something else might be going on. There's no way to prevent type 1 diabetes. So, you know, just do the best you can. If the Body's autoimmune system decides to attack those pancreatic cells, you know, so be it. There's nothing we can do at this point, but the earlier somebody intervenes and starts getting that diabetes under control, the better the prognosis for the kid in the long term or the person. Type 2 diabetes is what we generally talk about. Most people who have diabetes have type 2 diabetes. Type 2 diabetes develops due to a combination of insulin deficiency and ineffective use of insulin. Okay, so basically when we eat food and our blood sugar goes up, in order for our cells to be able to use the blood glucose, the body has to secrete insulin. If there's not enough insulin, then the blood sugar is going to stay high or go higher, the cells aren't going to be able to use it, and the person's going to feel awful. That's the really overly simplistic diet discussion. What can cause type 2 diabetes? Diets that lack certain nutrients such as magnesium, calcium, fiber and potassium. These are pretty common nutrients that are present in a healthy, colorful diet. If you think your client is not eating well and you know, up on my bandwagon again, we have to fuel our body with the building blocks that it needs to make the neurotransmitters and hormones to keep us healthy. If somebody's not doing that, they may need a referral to a nutritionist. If they're smoking. This can impair insulin sensitivity and production. It can lead in combination to the development of diabetes, smoking itself. There's not a one to one correlation, but we do know that smoking impairs insulin sensitivity. Sleep issues. That's my other soapbox that I get on all the time. And I thought this one was really interesting and really poignant because think about how many times it applies to all of us. Losing one to three hours of sleep per night for as few as three nights in a row can increase insulin resistance and make us more pre diabetic, if you will. Now, that doesn't mean it's going to happen to everybody, but it is important to recognize that your body does not effectively use insulin when it starts getting chronically fatigued. Now, how many of us just. You don't have to show hands, but how many of us are chronically fatigued? We didn't get, you know, all seven plus hours of sleep we needed last night or the night before or the night before that. Well, if that's the case, then guess what? You're probably not handling insulin as well. Think about new mom. Well, new parents, not just new moms, new Parents, if they've got an infant in the house, they don't sleep for like six months. Think about parents, caregivers when their children are sick. You know, I know when mine are sick, especially when they were little, you know, ear infection, two or three days. We were up and down throughout the middle of the night, so we were sleep deprived. Think about other issues that cause sleep deprivation. And again, we're only talking about one to three hours a night. We're not talking about missing a whole night's sleep. Think about the shift workers that you work with. My husband was in law enforcement on midnight shift for many, many, many, many years, and he was chronically sleep deprived at the same time. He also was severely hypoglycemic. You know, you think there's a correlation? Probably. So since he's gotten off midnight shift, his ability to have accurate or adequate insulin levels seems to have stabilized quite a bit. Unfortunately, this one we can't change. Being over 45 years of age might increase the risk of insulin resistance. They're not sure why, but they do see an increase in diagnoses of people with type 2 diabetes after the age of 45. The use of steroids. And when I say steroids, people are like, oh, I wouldn't use steroids. Those are awful. We're not talking about, you know, steroids to shoot up, to get big at the gym. We're talking about things like prednisone that can be prescribed for arthritis, blood disorders, breathing problems, severe allergies, skin diseases, cancer problems, and autoimmune issues. Imagine that what you're using to treat the autoimmune issue could actually cause a. Cause a problem related to autoimmunity. But I digress if somebody is using them for a long period of time. Now, my daughter had croup one time and she was on prednisone for four or five days. That's not a big deal. What we're talking about is people who are on these steroids for a long period of time. Also people with Addison's disease, they are going to be on steroids for the rest of their lives, which greatly increases their risk of type 2 diabetes. When you're doing your assessment, if you have the luxury of modifying your own intake assessment screen for some of these things, know that it may set your patient up for a variety of issues, not just diabetes. Underlying health conditions like high blood pressure, previous episodes of stroke or heart disease, polycystic ovarian syndrome can all increase a person's risk of developing insulin resistance, which can lead to eventually type 2 diabetes. Polycystic ovarian syndrome is a lot more common, but nobody talks. Well, not nobody. It's not talked about nearly as much as I would love to see it talked about. The same thing with Cushing's syndrome. It's not talked about nearly enough. With pcos, women will present. Obviously it's women because it has to do with the ovaries present with symptoms of depression. They tend to have hair loss, weight gain, oily skin, acne, and facial hair. Not all of those symptoms have to be present, but you're going to see a lot more of those in people with pcos. PCOS is a evidence of a hormone disruption that can be treated. It's really, you know, not as hard to treat. They figured out ways to treat it now, and it can reduce the risk of developing type 2 diabetes. And if you have somebody come into your office, especially, you know, a female that show that has a little bit of extra weight or more and thinning hair, automatically kind of think pcos. Has this person been tested? If they have PCOS and they don't have diabetes yet, if we make that referral, we can help prevent them from developing diabetes later on. And treatment's going to be a whole lot more effective if they can get their hormones under control and get the. Well, get their hormones under control, which will help with mood. Cushing's syndrome is caused by too much cortisol. Well, you've got people not saying that they have Cushing's syndrome, but think about people in our society who are stressed constantly. That HPA axis is on overdrive all the time. Whether they have PTSD and, or they have just chronic, you know, high levels of stress, they are really, as we would say, high strung. They can start having too much cortisol in their system, maybe not to the level of Cushing's syndrome, but it does start teetering on that risk factor. Once they move into the level where they're diagnosable with Cushing's syndrome, which is hypercortisolism, then their risk for type 2 diabetes goes up a lot more. Menopause is another hormonal disorder that's associated with the development of type 2 diabetes. Because estrogen and progesterone levels affect how your cells respond to insulin. A lot of people, when they go through menopause, if they feel down, if they feel blue, they may blame it on menopause alone. Look for those symptoms of diabetes, especially the increased hunger, the increased thirst, increased urination. Those are really important to take a look at. A lack of exercise and, you know, there's a lot of research on the benefits of exercise. But sedentariness can actually affect how your body responds to blood sugar and affects the insulin levels. Obesity has also been correlated with the development of type 2 diabetes because a lot of times people who are qualify as clinically obese do have a high level of insulin resistance. Adults may present for mental health care when diabetes is the underlying cause of their mood and or energy changes. Keeping that in the back of your mind, pregnancy complications. When somebody has is pregnant, even if they haven't had diabetes, they can develop gestational diabetes. If you've been pregnant, you're well aware of that nasty syrup you've got to take to do your sugar test. It's so important because high blood sugar levels are dangerous for both mother and baby. It can contribute to miscarriage, stillbirth and birth defects. Diabetic ketoacidosis, diabetic eye problems and pregnancy induced high blood pressure and preeclampsia, all of those things. You don't want to be dealing with that when you're pregnant. Being pregnant is hard enough. Most OB GYNs test for it and are very good about monitoring gestational diabetes. A lot of times the gestational diabetes resolves itself once the person gives birth. But mothers who gain a lot of weight when they're pregnant and don't lose it do increase their risk of type 2 diabetes. Because again, you're going back up to what's that other risk factor? Obesity. I've known a few friends of mine who, they would gain 80 pounds with a child, they'd lose 30 of it, have get pregnant again, gain another 60 pounds, lose 30 or 40 of it. So they ended up, you know, 100, 150 pounds heavier than they were before they started having children, which increased their risk of diabetes later in life. Women who have diabetes often have more difficulty getting and staying pregnant. That could be another reason that somebody presents in treatment because they're so frustrated they've had a bunch of miscarriages or they can't seem to get pregnant. And that's really exasperating and disappointing for many women who want to have babies. One thing that's interesting is gestational diabetes is not the cause of an increased risk of type 2 diabetes. It's correlated. We know that if you have gestational diabetes, there's increased risk for developing type 2 diabetes, but they found that the increased risk of type 2 diabetes generally has been there all along. And that's what causes the gestational diabetes? So the person may have been pre diabetic and then getting pregnant was sort of the straw that broke the camel's back, so to speak. And that kicks off the sequence of events and the person eventually develops type 2 diabetes. Hypoglycemia, I talked about earlier, that means not enough blood sugar. Basically all of us have probably gotten hypoglycemic a little bit at times and we've gotten a little shaky and been like, I gotta eat something. Symptoms are shakiness, nervousness or anxiety, sweating, chills, clamminess, irritability or impatience, dizziness and difficulty concentrating, hunger or nausea, blurred vision, weakness or fatigue, anger, stubbornness or sadness. Some of these things describe me on my best day. But no, I'm kidding. Hypoglycemia is one of those signs that your body is not producing insulin in a way that is helpful for your body. Hypoglycemia is a warning sign that somebody could eventually develop type 2 diabetes. They need to keep that under control. A lot of times people who are hypoglycemic are categorized as pre diabetic. Keeping hypoglycemia under control is really important psychosocially because of all of these side effects, the nervousness and anxiety. You know, how many of our clients experience nervousness and anxiety and difficulty concentrating and maybe weakness, fatigue and irritability because they just don't eat right, they don't eat enough, or they eat breakfast and then they go all day long, full bore until, you know, seven o' clock at night when they finally stop at the drive through on the way home from work and grab something to eat. You know, during that period, they probably became hypoglycemic at some point and it increased their problematic symptoms, Psychosocial aspects. So what can we do? We want to routinely monitor patients and their families for diabetes related distress at diagnosis, when treatment targets are not met, or at the onset of diabetes complications. If somebody already has diabetes, you know, maybe they're coming to you right after their diagnosis and they're gonna have a lot to deal with because it can be an overwhelming diagnosis. They may start thinking the worst. You know, having a pump installed and amputations and yada, yada, yada. Helping them get a realistic assessment of what life's going to be like and what they need to do and kind of slow the brakes on or pump the brakes on. The catastrophic thinking, you know, let's start addressing some of those and help them separate catastrophic thinking from realistic thinking. If they follow their treatment plan. When treatment targets are not met, when they are not able to keep their A1C levels in check or, you know, whatever, whatever the endocrinologist treatment targets are, then we may need to work with them to figure out why. And we talk about patients and families because especially with young people, you know, it affects the whole family. But if somebody is diabetic and their spouse or partner is not, they still may need to have alterations made in the home environment with what they eat and what they keep around the house in order to help the person with diabetes stay on their treatment plan. It is really hard for people, adult or child, to not sneak a piece of cake or a cookie or this or that if it happens to be available, especially if it's something that they really like. It's going to be important for the whole family to be cognizant and conscious of the things that this person should not be eating a lot of. And I make the analogy when I'm talking. You know, if your loved one was diagnosed with a lethal peanut allergy, you wouldn't be keeping lethal nut allergy. You wouldn't be keeping nuts all over the house because you liked them. You would know that that was detrimental to their health. And if you wanted nuts, you would go somewhere else and get it. And when the, when there are diabetes complications and there can be, especially as people get older or like I said, if you have somebody who's diabetic who's trying to get pregnant or has a miscarriage, or you know, starts to develop peripheral neuropathy, there are a lot of different things that can happen and that may cause a lot of health related anxiety that needs to be addressed in both the patient as well as their significant others so that everybody understands what's going on. What can we do to stop it, if anything? And what are the next steps to get back on the right track? There can be psychological problems such as temporary adjustment disorder with somatic complaints. When you get one of these diagnoses, some sort of health diagnosis, you tend to notice things a little bit more. Every ache, pain, cramp, this that we want to help people step into being mindful, but also being mindful of the big picture and not getting stressed out every time they have a twinge. They may withdraw socially because they're depressed, they're angry, they resent the fact that other people don't have this issue. They feel self conscious because they have a pump, whatever it is. They may also struggle with anxiety or depression. I know for me, if I were diagnosed with diabetes, I would struggle with anxiety, with checking my blood sugar because I am terrified of needles. I'd have to get over it, but that would be an issue that I would have to work through in order to be able to regularly test my own blood. And depression is that sense of hopelessness and helplessness. Remember that a diagnosis of a chronic illness constitutes a loss, a loss of optimal physical functioning, which results in grief. The person's going to have to go through the grieving reaction. Some people, it's not going to be a big deal. Other people, it's going to be completely devastating, and they're going to have a hard time dealing with it. Part of that depends on their health literacy as it relates to the disease of diabetes. And that's going to be important for us to help people link with health literacy resources so they can understand the realities of diabetes and not just the. You know, we don't want them going on certain websites and reading and going, oh, my gosh, you know, my world is going to end. I don't want them to get freaked out. I want them to be cognizant of the dangers, but also aware of the hope and possibilities as long as they follow their treatment plan. We do know that quality of life declines as the number and severity of complications increases. My aunt, for example, has a pump, and it's gotten to the point that her pump does not adequately manage her insulin levels. So that's been a huge issue for her and her endocrinologist and her family to try to manage that because her pump stopped functioning as optimally as it should. And one night she went to sleep and she went into a diabetic coma. And. And I don't understand all of the ups and downs of insulin and blood sugar and whatever, but the short version was she had to go to the hospital for multiple days, and that's how they figured out that the pump wasn't working. But that was very traumatic for everybody else who lived in the family, which is why I keep saying, we need to talk with the family about what to expect, what to look for. I have another person in my family who has diabetes and is of that mindset that he's going to eat whatever he wants, gosh darn it, and he'll just take a little extra insulin. God love him, he's older, and he's just decided that that's the way it's going to be. And for some family members, that can be very hard, very frustrating, because they're seeing him do this and go, you can't do that. That's not, no, that's bad for you. But he's, you know, 80 some year old adult and he's going to do what he's going to do. Helping family members not get enmeshed and not feel guilty or feel like they have to take responsibility is important. Cognitive dysfunction, mild impairment of cognition can happen with hypoglycemia. Mild impairment of cognition or severe impairment of cognition is also linked. You know, they've, they've linked later life dementia with multiple episodes of severe hypoglycemia. Therefore, controlling diabetes is really important to controlling or to preventing one of the risk factors for dementia. When you have people who have diabetes, if they start to, you know, not think as clearly, they seem to be getting confused a little bit easier. You may want to have them check their blood sugar to see where they're at and make sure they didn't take too much insulin. It's, they have to do a lot of math. It's easier now. There are a lot of apps that do it for you. But it's important to recognize that blood sugar will impact cognition. There can be psychosocial and educational disruptions associated with management and complications. Impairment in functioning at work or at school may be largely due to the inability to concentrate effectively and use optimal learning strategies to organize and encode information. They've shown especially in children with type 1 diabetes who had very early onset. They tend to have, well, 24% of them showed neuropsychological deficits. There were actually structural changes in the brain as a result of the diabetes. The child who develops diabetes before age 5 is particularly vulnerable to the effects of repeated hypoglycemia. But it is important to remember that people with diabetes can get older. You know, they do, and as we get older, we tend to have an age related slowing in our cognitions that's perfectly normal. We do want to separate cognitive dysfunction from diabetes from age related forgetfulness. People can have difficulty managing their blood sugar as they get older. If they are living independently and they forget to check their blood sugar, or they have difficulty doing the math to figure out how much insulin to take, or if their mobility impacts their ability to go out and get their insulin or impacts their ability to get food that they need to sustain their body, then they may have more difficulty with blood sugar. We do need to make sure that people who have diabetes have access to healthy food as well as their medicines. We want to consider the burden of treatment and patient and family levels of efficacy when making treatment recommendations. If patients don't feel like they are able to make dietary changes. They have no idea where to begin. They may need to be referred to a nutritionist and a case manager that can help them make those choice, make those plans initially until they get the hang of it. If they don't feel confident calculating how much insulin that they need to take, then they need assistance with that. We want to look at issues of autonomy and independence related to self management. How autonomous do they want to be sometimes? And I don't know if they would do it or not. But with people who don't feel comfortable or able to take their blood and give themselves insulin injections on a regular basis, they may be referred for the installment. I don't know what the word is, of a pump, implantation of a pump early on in order to manage it. I don't know if that's an option or not, but I can see where that might be something to consider. Some people have what's called hypoglycemia, unawareness. They fear becoming hypoglycemic, they fear the effects of it, they fear the diabetes. So they basically just turn a blind eye to it. They're like, nah, you know, there's no problem here, just you know, I'm a little tired today. We want people to be cognizant, especially people who are hypoglycemic, pre diabetic, that the more times and the worse their hypoglycemic episodes become, likely the worse off they're going to be and the more likely they're going to be to actually develop full blown diabetes. Family cohesiveness and conflicts can influence the psychological and self care behavior of, of children, but also of adults. And Matt points out that, you know, some people don't want to believe the effects of diabetes and have a difficult time accepting that they're going to have to make changes and figuring out what they need to do to manage blood sugar. Depending on somebody's cognitive level and their efficacy level and their motivation, you know, we have to put all that together. You're gonna have to have different strategies for increasing their health literacy so they can comply with their treatment plan. But if you've got conflicts in the family, as stress goes up, blood sugar becomes more variable. That's going to impact the child's management of diabetes or the person's management of diabetes. We know that when we're depressed, when we, we tend to not take as good of care of ourselves as we probably should and that's going to impact the self care behavior of the person with diabetes, if there are conflicts, you know, maybe one person in the family's mad because they can't have ice cream in the house anymore. You know, it could be a sibling or something. That family conflict could be perceived and taken personally by the person with diabetes. We do want to look at helping the entire family embrace this as an opportunity to live a healthier lifestyle and help them figure out, okay, these things that you're not going to have around the house anymore or that you're not going to get to do anymore, which there's generally not a lot of things. If they're really important to you, how can you make them happen? Well, for ice cream, you can go out and get ice cream on your way home from school or something where you're not subjecting that person to it. If that's not on their menu for the day, treat the person rather than just the blood glucose values and give every person a sense of complete well being. You can have somebody on this really strict regimen that manages their blood glucose, you know, within 10 points and not saying that, but really narrowly, and it is just monitored, great. But they may look at their quality of life and be like, this is not what I want to live like. We want to make sure that we're treating the whole person and helping them see what parts of their life that are important to them, that are still there. They're completely unchanged by the fact that the person has diabetes and the parts of their life that are affected by the diagnosis. How can we mitigate the negative impact of the diabetes? Exercise is good for people with diabetes, but it also means they have to pay attention to their blood sugar levels. So it can be a mixed bag for some people, if you will. Physical management goals have people develop and stick to a healthy eating and activity plan. They're going to work this out with their doctor and we can help increase motivation and compliance, address social and environmental factors impacting their ability to comply with treatment. If the person goes to school or goes to work, making sure that they have healthy meals available to them so they're not having to try to figure out, oh my gosh, what do I eat now? If they're in school, you know, sometimes you eat lunch at 11 o' clock in the morning and you don't get out of school until 4 o' clock and that might be too long for that person to go without eating. So can they have a snack at the nurse's office or what can they do? Where are they going to store their supplies so they can Test their blood sugar when they are at school. If the school will not let them keep the needles, the blood testing supplies on their person, which I don't think most schools do, have the person learn to test their blood sugar and keep a record of the result. It's really important that they do it. They don't just go by how they're feeling. They need to get that number, recognize the signs of high and low blood sugar and know what to do about it. When is it that the person needs to have orange juice and when is it that person needs to have insulin. Have them learn how to self administer insulin by syringe, pen or pump, depending on the person and their needs and whatever the endocrinologist says, have them be aware of and monitor feet, skin and eye problems to catch them early. If they have more blurred vision, if they start seeing spots, if they have wounds that won't heal, if they start having pain, tingling or numbness pain, their feet or their fingers, but especially their feet, these are really big issues that need to be addressed. Toot sweet. We want to help them prevent diabetic ketoacidosis. Keto ketoacidosis A lack of insulin makes the body unable to use glucose. So the body turns to using fat for fuel and ketones build up. If you've been on a low carb diet, you know that that's kind of the goal of a lot of low carb diets is to have your body turn to fat to fuel and you want to get in a state of quote ketosis that is very mild compared to ketoacidosis, which those ketones build up to way high levels and can be very life threatening. People need to know how to manage this. Prevent hypoglycemia, which is associated with irritability and long term cognitive impairment. There are a lot of things that people can do. They have the little glucose wafers that you can buy to just keep with you. If, you know, somebody thinks that they may not be able to eat on a regular schedule. Like I said, when my husband was in law enforcement, he never knew when he was going to be able to take his lunch break or if he was going to be able to take his lunch break. So he learned to keep snacks in his car so he could keep his blood sugar more stable. You want to help them prevent vascular complications associated with depression and anxiety and related to oxygenation and circulation. We really don't want them to start having problems with their blood pressure which can lead to stroke and other things. Prevent nervous system Complications, which is. But the neuropathy that I was talking about and the nervous system complications can also be associated with depression related to altered activities of daily living. This neuropathy, if somebody starts having a lot of numbness in their feet, for example, obviously their mobility is going to be changed and that can have significant effects on their activities, their self perception and their mood. And we want to address financial barriers to treatment compliance. If they can't afford their insulin or they can't afford their medication, other medications that are needed to help them stay compliant or they can't afford healthy food. You know, you see where I'm going. Get them set up with social service programs that can help them access those things for medication. I've said this a bunch, I'm going to say it again. If your client can't afford a medication, insulin, psychotropic or otherwise, figure out who makes the medication. Go to that pharmaceutical company's website and search for patient assistant program or just go online and search for the name of the medication and patient assistance program. Generally if there's a program for it, there usually is. You can print out a one page sheet and the doctor will fill it out. It'll be submitted and the person will generally start being able to get their medication either for free or for like four or five dollars. If for some reason it's not covered under a patient assistance program. Download things like Goodrx to see where the best prices for the medication is. Look at formularies at different places like Walmart, Publix, Costco, Walgreens, cvs, yada yada. Anywhere that has a pharmacy. A lot of them have formularies where they have any of these prescriptions. You can get a 30 day supply for $4 or $5 or something. That's the other place to look. Sometimes it takes a little digging, but generally regardless, whatever the medication is, you can generally find a way to make it relatively affordable. Engaging in physical activity can help the person maintain a good weight for them. It can improve mood because it increases serotonin and releases endorphins. It improves sleep because it increases serotonin, which, which makes more melatonin available and also helps people kind of shake out the kinks and reduce their cortisol levels. It improves memory, maybe due to increased oxygenation, I don't know. Here. It helps people control their blood pressure. It's been shown to improve cholesterol levels and exercise itself without any changes in diet. Has been shown to improve insulin sensitivity. Now, am I saying now you don't have to change your diet? If you just start exercising? Oh, heck no. But for our purposes, it's important to recognize how powerful exercise can be at helping people stave off the development of complications of diabetes and improve their body's ability to manage blood glucose. It's important to control blood pressure and cholesterol. Diabetes tends to lower good cholesterol and raise bad cholesterol levels, which increases the risk for heart disease and stroke and all kinds of other problems like dementia that are associated with those things. For psychological well being, we want to help people manage their stress and this will help keep their cortisol levels down, which can help keep their blood sugar levels under control when the HPA axis is triggered. That's our threat response system. It dumps cortisol and norepinephrine and it tells the body, let's dump a bunch of blood glucose because we need to fight or flee. So when we get stressed, our blood sugar levels go up. If somebody with diabetes is getting regularly stressed, it's going to contribute to the ups and downs and erraticness of their blood sugar. So what are we addressing here? Well, general life stresses that can increase cortisol help them practice mindfulness, distress tolerance skills, give them a good toolbox to try to manage that stress, diagnose diagnosis, adjustment and management issues. Well, once they get the diagnosis, they're going to have to adjust to it and that's going to be a stressful period. But we can help them along the way. Part of that is through increasing their health literacy about diabetes and about their treatment plan and empowering them and making them feel efficacious at managing this so they are in control of the diabetes instead of the diabetes being in control of them. And they may have some related stress reactions from cohabitants and friends that may be worried about them or may start nagging them about what they're eating or, you know, there are a lot of different psychosocial stressors that can can happen that we want to pay attention to. Have people with the person with diabetes just kind of keep a log of their irritants and their stressors to identify things that might be contributing to having them increase increase cortisol levels. They may also expression experience depression and grief. And this can be really related to activity and eating changes. It can be related to getting the diagnosis and it can be related to blood sugar levels. The depression part, we want to help them make a connection between their blood sugar levels and their mood and energy and also learn how to engage in the activities that they want to with their diabetes. You Know, I have this but or, and I am still a runner, I have this and I am still a, you know, hiker, whatever it is the person wants to do. Key barriers to treatment include dysfunctional health beliefs and lack of appropriate diabetes education. Low feelings of self efficacy. Let's set those goals small. And, you know, if people can knock through them really fast, then great. If they don't go through them so fast, at least they're still feeling like they're making progress. Increasing that self efficacy about slowing the progression of the diabetes as well as self efficacy about their ability to stick to the treatment plan is really important. They may be looking at the meal plans or whatever and going, I don't know if I can stick to this. You know, this, I used to eat fast food every day, or whatever the case may be. So we want to help increase their feelings of self efficacy by helping them focus on their successes. If they were able to do it for one meal, for a whole day, if they're able to keep their A1C levels stable, whatever their targets are. But we want to set the time frames to be really small initially so people start feeling like, okay, maybe I can do this. Emotional distress and mood disorders can also serve as barriers to treatment. As we said in the first slide, depression can actually worsen diabetes and diabetes can worsen depression. There's that bi directional relationship. If a client is depressed then or, and or has generalized anxiety, you know, it can impact the prognosis for their compliance with treatment as well as for their, you know, ability to manage their blood sugars. Problematic eating can be another barrier to treatment. A lot of us are emotional eaters or we snack or we graze or we eat unhealthfully. We stop by fast food and we eat in the car on the way home or whatever it is. Those are not good things. We need to make sure that the person is mindfully eating. They may have a lack of social support. Well, this one's easier to get around because there are a lot of support groups both in person and online for people with diabetes. There can be functional limitations that occur because of the diabetes or the person may have had them to begin with. You know, people who are blind do develop diabetes. Sometimes it happens. People who are older may have problems with this dexterity, so giving themselves injections may be difficult. Or if they have low health literacy and that can mean they don't understand what they're supposed to do. Or as I said earlier, they can't do the math to figure out how much insulin to take a Disruption in routine. Some people are just resistant to changing their routines and they don't want to have to take their blood sugar and, you know, stop and do this before each meal or after each meal. And they don't want to have to think about what to eat all the time. They don't want to not be able to go out and, you know, drink like crazy on Friday night. And they may feel very angry about that. So helping them increase their motivation or reduce their resistance, use the decisional balance exercises or any tools you have in your tool chest. Because once they know about the possible consequences of diabetes, if that's not motivating, then we need to step back and go, okay, what is this behavior telling us? If this person is not willing to change their behavior even though they know they could have limbs amputated or go blind or whatever, then there's obviously something else here. What is this behavior telling us that we need to address and what are the benefits of this behavior that outweigh the benefits of longer life? And deficits in problem solving or coping skills can also be key barriers. For example, when I talked about the child that had lunch at 11 o' clock and didn't get home until 4 and that was too long to go and their blood sugar would drop, if you have good coping skill or good problem solving skills, then you can say, all right, what are our options here? Let's talk with the school nurse. Maybe the child can go get a snack from the school nurse or get permission to keep a snack in their locker. You know, you can work with school administration, but if you don't have problem solving skills or you don't have a good feeling of self efficacy, you may not think of it or may not feel comfortable going to the school administration and going, I need this reasonable accommodation. Psychosocial care should be integrated with collaborative patient centered medical care and provided to all people with diabetes and not just when they initially get their diagnosis. There should be someone ideally that they could touch base with once they get their diagnosis. Henceforth and forevermore, we need to assess patient and family symptoms of diabetes distress, depression, anxiety and disordered eating, and of cognitive capacities at the initial visit, at periodic intervals, and when there's a change in disease, treatment or life circumstance. Assessing both patient and family symptoms of diabetes distress is going to be really important. And that's generally the overarching term for stress and anxiety caused specifically from the diagnosis. We want to monitor patient performance of self management behaviors as well as psychosocial factors impacting the person's self management. With teenagers, for example, they may normally be very compliant with their treatment plan, but then they get a boyfriend or a girlfriend and they're not wanting to show that they've got diabetes. So they may start ignoring and not not taking their blood sugar like they're supposed to, or eating things that they're not supposed to because they're trying to manage some sort of external image. There are a lot of other factors that could affect a person's self management. So if their self management changes, they were doing really well and all of a sudden they're sliding. We want to take a look at what's going on that might be motivating that we want to assess life circumstances that can affect physical and psychological health outcomes and their incorporation into intervention strategies. As we talked about in the presentation. Help them manage their stress because that'll help them manage their diabetes. Help them manage their psychiatric disorders because that'll help them manage their diabetes. Help them make sure they have food and medicine availability and access to medical care to address concurrent health issues including pregnancy, menopause and any other things that come along. And then take a look at other things like shift work that may also add extra stress and contribute to disruption of the circadian rhythm, which can also disrupt blood sugar stability. Between writing notes, filing insurance claims, and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of TherapyNotes or by just using the promo code CEU when you sign up for a free trial at therapynotes.com. 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 at allce.com/podcastce. That's allce. Com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce. Com sponsor. Thank you.