Acceptance And Diabetes
Acceptance and Diabetes:Helping patients integrate diabetes into their livesMark Heyman, PhD, CDEDirector, Center for Diabetes and Mental Health
Case Studies in Avoidance and Diabetes3
Meet Alana Alana is a 21 year old collegestudent who was diagnosedwith type 1 diabetes about 8years ago She’s extremely anxious aboutand overwhelmed by her schoolwork and to cope she binge eats Alana believes that she has tomake a choice betweenmanaging her diabetes andfocusing on school – and schoolusually wins4
Meet Craig Craig is 54 years old and hasbeen living with type 2 diabetesfor over 20 years and iscurrently on dialysis He needs to lose weight andlower his A1C before he canget on the transplant list Craig’s diabetes-related shameand embarrassment is hisbiggest barrier to making thesechanges5
Meet Grant Grant is 35 years old and wasdiagnosed with type 1 diabetesabout 4 years ago Over the past year, he has beenin the hospital with DKAbecause he was not takinginsulin regularly Grant recently started a newjob and has not been able to tellany of his co-workers that hehas diabetes6
Avoidance vs. Acceptance(and how does it relate to diabetes)?7
“You can’t stop the waves, butyou can learn to surf.” Jon Kabat-Zinn8
Avoidance and Diabetes Diabetes can feel overwhelming People develop coping strategiesfor diabetes-related stress One of the most common copingstrategies is avoidance9
Types of Avoidance Behavioral Avoidance Cognitive Avoidance Emotional Avoidance10
Common Presentations ofDiabetes Avoidance Check blood glucose infrequentlyand ‘forget’ to take medications Hide diabetes from others Cancel appointments withhealthcare team Mindless food choices11
Acceptance and Diabetes Negative emotions and thoughtsabout diabetes are not easy tocontrol However people can control howthey engage with these negativethoughts and emotions Acceptance means ‘making room’for discomfort12
What Acceptance andDiabetes Is Not Enthusiasm about having diabetes Ignoring or pushing away negativediabetes-related thoughts, emotionsor experiences Satisfaction with the status quo13
Common Barriers toAcceptance Mindlessness Cognitive fusion Cognitive inflexibility Difficulty with distress tolerance14
Key Takeaways Avoidance is a common coping strategy Avoidance takes on many forms Acceptance means ‘making room’ as opposed to avoiding15
Polling QuestionAccording to a study published in 2014, whichof the following was shown to be an independentpredictor of frequency of blood glucose monitoring?A. Insulin useB. AgeC. Avoidance behaviorD. Diabetes durationPolonsky, W. H., Fisher, L., Hessler, D., & Edelman, S. V. (2014). What is so tough about self‐monitoring of blood glucose? Perceived obstaclesamong patients with Type 2 diabetes. Diabetic Medicine, 31(1), 40-46.16
Assessing Acceptance17
Assessment Tools Acceptance of DisabilityScale (modified) Acceptance and ActionQuestionnaire (AAQ-2) Patients’ language18
Acceptance ofDisability Scale (ADS)ADS is a self-report inventorydeveloped to assess four factorsof individuals with physicaldisabilities: Enlargement of scope of values Subordination of physique Containment of disability effects Transformation fromcomparative values to assetvaluesRichardson, A., Adner, N., & Nordström, G. (2001). Persons withinsulin‐dependent diabetes mellitus: acceptance and copingability. Journal of advanced nursing, 33(6), 758-763.19
ADS and DiabetesADS has been used to assessacceptance in people withdiabetes by replacing the word‘disability’ with the word‘diabetes’: Enlargement of scope ofvalues: ‘There are many thingsa person with my type ofdiabetes is able to do’ Subordination of physique:‘My diabetes affects thoseaspects of life which I caremost about’Richardson, A., Adner, N., & Nordström, G. (2001). Persons withinsulin‐dependent diabetes mellitus: acceptance and copingability. Journal of advanced nursing, 33(6), 758-763.20
ADS and Diabetes(cont.) Containment of disabilityeffects: ‘Almost every area oflife is closed to me because ofmy diabetes’ Transferring from comparativevalues to asset values:‘Though I can see the progressI am making in my rehabilitation,this is not very important as Ican never become normal’Richardson, A., Adner, N., & Nordström, G. (2001). Persons withinsulin‐dependent diabetes mellitus: acceptance and copingability. Journal of advanced nursing, 33(6), 758-763.21
Acceptance & ActionQuestionnaire - 2 AAQ-2 is a 10-item scale thatassesses a person’sexperiential avoidance andimmobility and acceptance andaction.Bond, F. W., et al. (2011). Preliminary psychometric properties of theAcceptance and Action Questionnaire–II: A revised measure ofpsychological inflexibility and experiential avoidance. Behaviortherapy, 42(4), 676-688.22
Acceptance & ActionQuestionnaire - 2Bond, F. W., et al. (2011). Preliminarypsychometric properties of theAcceptance and Action Questionnaire–II:A revised measure of psychologicalinflexibility and experientialavoidance. Behavior therapy, 42(4), 676688.23
Language patients useOften, the best way to assess acceptanceand diabetes is by listening to the languagepatients use. Some examples include: I’m not very good at managing diabetes I’ll focus on diabetes when I feel lessoverwhelmed No matter how hard I try, I can’t control myfeelings about diabetes I can’t handle diabetes If I felt less anxious, I could managemanage my diabetes .24
Key TakeawaysOften, the best ways to assess for acceptance is to listen to howpeople talk about diabetes: Flexible or Rigid Empowered or Helpless Integrated or Segmented25
Polling QuestionWhich of the following has NOT been shown tobe correlated to non-acceptance of diabetes?A. Increased HbA1cB. Reduced self-care behaviorC. Depressive symptomsD. Diabetes durationSchmitt, A., Reimer, A., Kulzer, B., Haak, T., Gahr, A., & Hermanns, N. (2014). Assessment of diabetes acceptance can help identify patients withineffective diabetes self‐care and poor diabetes control. Diabetic Medicine,31(11), 1446-1451.26
Promoting Acceptance in People with Diabetes27
Tools and TechniquesYou Can Use Creative Hopelessness Mindfulness Cognitive and Emotional Defusion28
Creative HopelessnessTrying to ‘control’ difficult thoughts andfeelings about diabetes can get in the way ofdiabetes management and living life Ask what the person has been doing to‘control’ their diabetes-related thoughtsand emotions Assess how this ‘control’ has beenworking and how it has not been working Suggest that ‘control’ may not be the mosteffective strategy and that there might beanother wayHarris, R. (2009). ACT Made Simple: An Easy-To-Read Primer onAcceptance and Commitment Therapy. Oakland, CA: New Harbinger.29
MindfulnessPaying attention in a particular way, onpurpose, in the present moment,nonjudgementally Mindfulness is the opposite of avoidance There are several types of mindfulnessincluding physical, cognitive and emotional A primary goal of mindfulness is for theperson to be an observer of their ownexperiences Mindfulness can increase capacity fordistress toleranceHarris, R. (2009). ACT Made Simple: An Easy-To-Read Primer onAcceptance and Commitment Therapy. Oakland, CA: New Harbinger.30
Cognitive & Emotional DefusionTaking a step back and seeing thoughts andemotions for what they are, nothing moreand nothing less. In a state of fusion, thoughts and emotionscan seem like the absolute truth that drivesbehavior without choice In a state of defusion, the person has theability to choose their behavior rather thanhaving their thought/emotion choose itfor them Encourage people to use the phrase ‘I’mhaving the thought/feeling that ’Harris, R. (2009). ACT Made Simple: An Easy-To-Read Primer onAcceptance and Commitment Therapy. Oakland, CA: New Harbinger.31
Polling QuestionIn a study conducted in 2007, patients whocompleted a mindfulness-based intervention hadan average A1c reduction of:A. .23%B. .48%C. .86%D. 1.8%Rosenzweig, S., Reibel, D. K., Greeson, J. M., & Edman, J. S. (2007). Mindfulness-based stress reduction is associated with improved glycemiccontrol in type 2 diabetes mellitus: a pilot study. Alternative Therapies in Health and Medicine, 13(5), 36.32
Key Takeaways Acceptance is a skill that can be learned and needs to be practiced There are techniques you can teach your patients that can help These techniques are experiential – you can teach them better if youuse them in your own life!33
An Update on Alana Alana has come to realize thatjust because she has a thoughtor an impulse to avoid, she doesnot necessarily have to ‘buy’ it She is working to accept thatsometimes she is going to feeldistress and there is not alwaysa way to make it go away Alana is starting to understandthat she values her health andcan make choices to manageher diabetes34
An Update on Craig Even though Craig has somesignificant health problems hehas not let these problemsdefine him He has been using his desire toget a kidney transplant asleverage to allow him to acceptthe challenges he isexperiencing on his road totransplant Craig has started eatingmindfully35
An Update on Grant Grant has started taking insulinregularly and, for the most part,has stopped ignoring the fact hehas diabetes Even though it was difficult, hetold his new co-workers aboutdiabetes and was pleasantlysurprised by their reaction Grant still finds himselfstruggling with trying to controlhis negative emotions arounddiabetes36
“Arriving someplace more desirable at somefuture time is an illusion.” Jon Kabat-Zinn37
Questions?38
Questionnaire - 2 Acceptance & Action 23 Bond, F. W., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoi
Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia American Diabetes Association. Facts and Figures. Available at: http://www.diabetes.org/ada/facts.asp. Accessed January 18, 2000. Diagnosed Type 1 Diabetes 0.5 - 1.0 Million Diagnosed Type 2 Diabetes 10.3 Million Undiagnosed Diabetes 5.4 Million Prevalence of Diabetes in the US 3
Clinical Diabetes. 2017 Jan; 35(1)51-54. Speight J, Conn J, Dunning T, Skinner TC, Diabetes Australia. Diabetes Australia position statement. A new language for diabetes: improving communications with and about people with diabetes. Diabetes Res Clin Pract 2012 Sep; 97(3): 425- 31.
Type 2 Diabetes Type 2 diabetes, which used to be called adult-onset diabetes, can affect people at any age, even children. However, type 2 diabetes develops most often in middle-aged and older people. People who are overweight and inactive are also more likely to develop type 2 diabetes. Type 2 diabetes usually begins with insulin resistance—a
Diabetes in the United States More than 29 million people in the U.S. have diabetes 8.1 million people with diabetes are undiagnosed 9.3% of the U.S. population 1.7 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010 Every 19 seconds, someone is diagnosed with diabetes
TABLE 57-3. Proposed Classification System for Diabetes in Pregnancy Gestational diabetes: diabetes diagnosed during pregnancy that is not clearly overt (type 1 or type 2) diabetes Type 1 Diabetes: Diabetes resulting from β-cell destruction, usually leading to absolute insulin deficiency a. Without vascular complications b.
National Center for Chronic Disease Prevention and Health Promotion Division of Diabetes Translation. CS220221. National Diabetes Fact Sheet, 2011. Data Sources, Methods, and References for Estimates of Diabetes and Prediabetes. Attention: In the. National Diabetes Fact Sheet, 2011, we defined undiagnosed diabetes and prediabetes based on both
The North Carolina Diabetes Advisory Council supports efforts to find a cure for type 1 diabetes. A major focus of this guide and the Diabetes Advisory Council is on type 2 because it is more common and is preventable. For the remainder of this document, references to “diabetes” will be referring to type 2 diabetes unless indicated otherwise.
6 gestational diabetes. This type of diabetes accounts for 90 - 95% of the diabetes population.4 However, with the proper education and motivation these individuals can manage their diabetes with diet and exercise alone.5 3) Prediabetes is a condition in which the body’s glucose levels are elevated but not to the point of a diabetes diagnosis.
