Diabetes Distress: Coping with the
Emotional Toll
[Link] F. Velasco RND,MAP,REB
CEO, Nutrition & Emotional Wellness Center
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What do you Feel when your Blood
Glucose Level is....
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Internal Factors..
• Hyperglycemia • Hyperglycemia
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Other Factors Causing Diabetes
Distress...External Factors
FAMILY
POOR
INADEQUATE
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STRESS IS INTERNAL AND EXTERNAL
BGL
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Can Changes in Blood Sugar Cause
A. Rapid Changes in Mood?
B. Can cause Mental Health symptoms
• Having diabetes can cause a condition
called diabetes distress which shares
some traits of stress, depression and
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anxiety.
When you are sick it is especially important
to:
[Link] worry about your blood sugar - just
rest and get better
[Link] your blood sugar more often, drink
plenty of clear liquids such as soup broth
and diet sodas and check with your
physician if you feel too ill to take care of
yourself, or your blood sugar is outside of
the target range
[Link] drink fruit juice
8
From Burden to Burnout
to Distress to Depression
What irks me the most
Burden
is that after all that work,
my numbers still don’t
Burnout make sense! Should I
even bother?
Taking care of my
Diabetes Distress
children, my family, my
job, and my diabetes--it
can be overwhelming.
Depression
Sometimes I feel like
I’ve had enough! After
10 years with diabetes, I Even though I try my
just want a break. I need best to do all the things
a vacation from I’m supposed to do, I
9 diabetes!” know there’s no
guarantee.
Since being diagnosed with diabetes, I don't
enjoy the things I used to. I'm often sad. I
should:
[Link] ignore it, and wait for these feelings to
go away
[Link] this to myself, because it's my
diabetes and I have to deal with it
[Link] to my doctor and seek help
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Depression is a sign of
personal weakness.
[Link]
B. False
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The American Diabetes Association recommends the following
blood glucose targets:
The ADA recommends targeting pre-meal plasma
glucose levels of 70-130 mg/dl*, peak post-meal
plasma glucose levels of less than 180 mg/dl, and an
A1c of less than 7%.
*The goals may be different in individuals treated with
insulin or medications that cause the release of insulin
from the pancreas. To minimize the risk of low blood
sugars (hypoglycemia) in such individuals, many
providers will recommend a pre-meal blood sugar
(plasma glucose) target of 90-130 mg/dl and post meal
blood sugar (plasma glucose) of less than 180 mg/dl.
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Newly Diagnosed Patient with Diabetes
Emotional and Psychological Response
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Isolation- Why Me? - Irrational Hope- Losses - Peace of Acceptance
Mind- Body Connection and
Person Centered Care
• Conducting
regular screenings
for mental health
conditions
CONNECTION
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Good News ...Diabetes Distress is
Live with Diabetes or Leave with Diabetes
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• Just as you take insulin to ensure your
blood glucose levels are where they
should be, it’s important to take measures
to prevent mental health crises by being
aware of how you are feeling mentally and
[Link] like taking care of your
body, taking care of your mind is equally
as important to living a healthy life. When
left untreated, mental health conditions like
depression and anxiety can make diabetes
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worse. Likewise, existing diabetes can
• fear of hypoglycemia or a very low level of
blood sugar, may cause significant worry.
Diabetes distress can also be affected by
external factors like family and societal
support and health care services. It is
estimated that 33 to 50 percent of people
with diabetes will experience diabetes
distress at some point. [3] While diabetes
distress cannot typically be treated with
medication, experts say that improving
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diabetes management to reduce stress,
• Treatment and Therapies
• Mental health conditions - just like
diabetes - are treatable. Having both at the
same time doesn’t make either one less
treatable, they just require different
treatments. Ask your diabetes care team
about a referral to a mental health care
provider like a psychiatrist, psychologist or
18 therapist. Together, your doctors can help
you find a treatment plan that works for
• Cognitive-behavioral therapy (CBT).
CBT has two main aspects. The cognitive
part works to develop helpful beliefs about
your life. The behavioral side helps you
learn to take healthier actions. CBT often
works well for depression, anxiety and
bipolar disorder, but it can also be used for
other various conditions.
• Family therapy helps family members
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communicate, handle conflicts and solve
problems better. Forms of family therapy
• A diabetes diagnosis can cause prolonged
stress which may possibly cause a rise in
blood sugar. Stress can also make
following your diabetes maintenance
routine more difficult. Experts suggest
looking for patterns; be aware of your
stress level each time you log your blood
sugar and see if a pattern emerges. If you
notice a pattern, you can learn to spot your
stress warning signs and take action to
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prevent stress and keep your blood sugar
• 1 Ducat, L., Philipson, L. H., & Anderson,
B. J. (2014). The mental health
comorbidities of diabetes. JAMA, 312(7),
691–692. doi:10.1001/jama.2014.8040
[Link]
PMC4439400/
• 2 Eating Disorders. (n.d.). Retrieved from
[Link]
21
• 3 Fisher, L., Polonsky, W. H., Hessler, D.
• 1 Ducat, L., Philipson, L. H., & Anderson,
B. J. (2014). The mental health
comorbidities of diabetes. JAMA, 312(7),
691–692. doi:10.1001/jama.2014.8040
[Link]
PMC4439400/
• 2 Eating Disorders. (n.d.). Retrieved from
[Link]
22
• 3 Fisher, L., Polonsky, W. H., Hessler, D.
• What is the emotional connection between
diabetes?
• Diabetes doesn't just affect you physically,
it can affect you emotionally too. Whether
you've just been diagnosed or you've lived
with diabetes for a long time, you may
need support for all the emotions you're
feeling. This could be stress, feeling low
and depressed, or burnt out.
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• Focus on things you can control
• If you're finding yourself worrying, it might
help to try to focus on the things that you
can control in your life. Here are some
tips:
• know your sick day rules
• go to appointments if your healthcare
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team ask you to
• Things you can’t control
• Focusing your mind on things out of your
control won't change things. This can lead
to worry, so gently try to redirect your
attention.
• You might be feeling nervous, because
your condition may make you more
25 vulnerable to becoming unwell. But you
don’t have control over this, so try to be
• Everyone can feel stressed from time to
time. But having diabetes to manage as
well as everything else in life can feel very
overwhelming. Stress can affect your
blood sugar levels, so it's important you
know how to recognise when you're
stressed and how to deal with it. We can
help you cope with stress when you have
diabetes
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• Being diagnosed with diabetes can come
as a shock. First reactions may be
disbelief, feeling overwhelmed, even
anger. Usually these feelings ease after a
while and diabetes becomes part of life.
But sometimes these feelings don’t go
away easily. If you feel this way, you're not
alone.
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• There are lots of people out there to
support you – your family, your friends,
• Talk with your family and friends. Tell those
closest to you how you feel about having
diabetes. Be honest about the problems
you're having in dealing with diabetes.
Just telling others how you feel helps to
relieve some of the stress. However,
sometimes the people around you may
add to your stress.
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Does emotion affect glucose levels?
• Yes, emotions can affect your blood sugar.
Anxiety, fear, even that happy feeling you
had when you got that new job can be
stressful sometimes. When we’re stressed
– whether it’s physical stress or mental
stress – our bodies produce hormones
such as cortisol that can raise blood
glucose even if we haven’t eaten.
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• The other day, I was driving and was
suddenly overcome by a feeling of intense
sadness; I started to cry. At the time, Gina
McKelvey | The LOOP BlogI thought I was
reacting emotionally to a stressful week; I
had been looking for a home to purchase,
and my offer on a townhome I really liked
had been rejected. Then, my Low
Predictive alert sounded on my pump, and
I realized the reason for the sudden
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change in my emotions was because my
High or Low
• There is a Reason: Your Brain!
• Well, there is an explanation! Your brain,
the center of your thoughts and emotions,
needs glucose to do its job. If you don’t
have enough glucose to “feed your brain,”
your brain can go “haywire”. Even though
it seems like you are overly emotional, this
is really a physical response to low BG
(hypoglycemia). You don’t have to be
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below a certain number, like 70 mg/dL, to
experience this. Your BG may be in the
know the rudeness is not “me,” but my
brain’s reaction to lack of sugar/energy.
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• Sense of Humor: Critical when Living with
You may tell your friends and family, “If I
start acting like Oscar the Grouch (insert
your choice of character) for no reason, it
might be because my BG level is
dropping, or because my sugar is too high.
Try not to take it personally and just guide
me through the process of testing my BG
and treating the low/high as indicated. I
apologize in advance if I act mean and
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nasty, and I truly appreciate your love and
Breaking from the Negative Emotions
of Diabetes
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Quality of Life beyond the Numbers
• Diabetes is a demanding disease. As I’m
approaching my 10th year with diabetes
I’ve experienced many hardships mostly
because once every 15 minutes, I have to
deal with my diabetes. I have to stop what
I’m doing, think about how I’m feeling, try
to remember when and what I last ate,
think about what I’ll be doing next, and
decide whether to test my blood. Then,
depending on the results of the test (or my
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guess as to my sugar level), I’ll plan when
• The good news is that there are things you
can do to cope with diabetes and manage
stress. Here are 10 tips that can help.
• Pay attention to your feelings. Almost
everyone feels frustrated or stressed from
time to time. Dealing with diabetes can
add to these feelings and make you feel
overwhelmed. Having these feelings for
36 more than a week or two may signal that
you need help coping with your diabetes
• People living with type 1 or type 2
diabetes are at increased risk for
depression, anxiety and eating disorders.
[1]
• Rates of depression across the lifespan
are 2 times greater for people with
diabetes than in the general population.
• People with type 1 diabetes are twice as
likely to live with disordered eating. [2]
37 • In women with type 1 diabetes, bulimia
is most common eating disorder while
Learning Goals:
• To increase awareness and confidence in
addressing emotional issues in diabetes self-care
management
• Talking Points:
@Emotional burden of living with diabetes
@Establishing relationships that are empowering
and non-judgmental
@Enhancing skills in self-care management
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Outcomes
Outcomes Under
Controlled by
Our Control
Patient Choices
Diagnosis/
Description
Assessment
Outcomes
are
dependent
Treatment/ on Prediction
Intervention how good
you are
Outcomes Choice
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Interpersonal Connectedness –
How We Maintain Connection
Circumplex model1
Assured–Dominant
People can be categorised along
Dominance
two independent dimensions
• Dominance
• Agreeableness/sociability
Cold– Warmth Warm–
Hearted Agreeable
Interpersonal complementarity2
• Dominance evokes submission
• Friendliness evokes friendliness
Unassured–Submissive
[Link] & Markey. Assessment.2009;16:352–361
[Link] et al. Personality and Social Psychology Bulletin,2003;29:1082–1090
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Motivational Communication
• Non-Judgmental Curiosity is defined as: A
willingness to understand a person’s behaviour
through the lens of their own experience (why do
you do what you do) without a value judgment
(behaviour is neither right or wrong – it is).
• If a person feels judged, they will become
defensive. If a person feels guilt/shame, they will
become avoidant.
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Motivational Communication
Ask
“Understanding”
Listen
Summarize
Invite
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Why Understanding First?
• Healthy behaviour is abnormal
behaviour
– Pleasure principle
– Path of least resistance
– Preference for short
term gain regardless of long term
consequences
– Environment pulls for unhealthy
behaviours
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Low Hanging Fruit
• Medication adherence is one of the fundamental
health behaviours of relevance to self-management
and chronic disease outcomes
• WHO estimates nonadherence to medication at 30%
- 70% of medications for chronic conditions
Adherence to Long-Term Therapies: Evidence for Action. World Health organization, 2003. ISBN 92 4
1545992
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Needs and Concerns Analysis
• Assess the patient’s view of the needs for medication
• Assess their concerns about the potential side-effects
Concerns
High Low
High Ambivalent Accepting
Needs
Low Sceptical Indifferent
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Horne R, et al. Inflamm Bowel Dis 2009;15:837–44
Decision Aid: SURE test
Yes equals 1 point
No equals 0 points Yes No
If the total score is less than 4, [1] [0]
the patient is experiencing decisional conflict
Sure of myself Do you feel SURE about the best choice for you? □ □
Understanding Do you know the benefits and risks of each
information option? □ □
Are you clear about which benefits and risks
Risk-benefit ratio □ □
matter most to you?
Do you have enough support and advice to make
Encouragement □ □
a choice?
46 Légaré F, et al. Can Fam Physician 2010;56:e308–14
Human Nature
• Patients want to be as normal as possible
– This means making the psychological footprint of diabetes
as small as possible
• Clinicians want their patients to be as healthy as
possible
– This means making the psychological footprint of diabetes
large
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Negative Impact of Diabetes on
Aspects of Life
% of people with diabetes rating impact on at least one aspect of life
as slightly to very negative
Type 1 Type 2
(A) (B)
Aspects of life rated
• Physical health
• Emotional well-being
• Financial situation
• Leisure activities
• Work or studies
• Relationship with friends,
family, peers
Niccoluci et al. Diabetic Medicine. 2013;30:767-777
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From Burden to Burnout
to Distress to Depression
Burden
Burnout
Diabetes Distress
Depression
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Diabetes Related
Problems of
Distress
Living
Screen for
Psychopathology
Caseness
Well-Being
Resiliency
Positivism
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Vallis, M. 2015©
Disease-Specific Distress
• Diabetes Distress Scale (Polonosky et al., 2005)
– Emotional Burden
– Regimen Distress
– Physician Related Distress
Provider Related
– Interpersonal DistressDistress
Fisher, et al. Clinical Depression Versus Distress Among Patients With Type 2 Diabetes: Not
Just a Matter of Semantics. Diabetes Care, 2007;30:542-48
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Emotions
• Primary Emotions
– Natural, appropriate emotional responses to live
experiences
– Expressing and “sitting with” lead to transformation
(grief)
• Secondary Emotions
– Often come from our thoughts when we review
experiences
• Interpersonal Emotions
– Emotional displays that serve a purpose in terms of
eliciting reactions from others
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The Role of the Diabetes Care Provider
• It’s not your job to change the Patient:Provider role and
self-efficacy
• Identify
• Educate
• Recommend
• Support
• Replace the function
– If you can understand behaviour you can negotiate choices
• Keep the conversation going: The 4 S’s
• Self-Image
• Self-Efficacy
• Social Support
• Stress Management (discharge, calming, expression, connection)
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Why Don’t Recommendations Work?
• Whose idea is it to change, usually?
• Provider
• Who does the work of change?
The individual
• Typically, how excited by the work of change is
the individual
Low
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Collaborate and Empower
Collaboration leads to change in three ways:
1) Bond (working together in a respectful way);
2) Task (agreeing on who does what to get to the
goal);
3) Goal (agreeing on the value of final outcome);
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Determine Readiness
• Is the behaviour (or lack of it) a problem for you?
• Does the behaviour (or lack of it) cause you any
distress?
• Are you interested in changing your behaviour?
• Are you ready to do something to change your
behaviour now?
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Getting to the Behaviour
Readiness Assessment
Not Ready Ready Ambivalent
Expectation of Expanding on
change off the Go Right readiness
table to Behaviour Personal/meaningful
Modification reasons to change
Understand the Willingness to work
behaviour hard - connect to
Personal principles
meaning Delay of gratification
Seriousness,
personal
responsibility,
controllability, Decisional Balance
59 optimism
Working With the Behaviour:
Behaviour Modification
• Goal Setting/Action Plans
– FIRST STEP Goals
• Shaping
– NEXT STEP goals
• Stimulus control
– Personalized healthier built environment
• Reinforcement Management
– Incentives that transfer external to
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internal drive
