Do you have to be a Mental Health Expert to Tackle Diabetes Distress?
We asked Dr. Lawrence Fisher (see bio below), lead researcher and clinician in the Embark Trial to share his insights on providing best care to people with diabetes. Learn more by joining our ReVive 5 Diabetes Training Program where the team shares evidence-based tools and the step-by step approach utilized in the Embark Study.
Do you have to be a mental health expert to address diabetes distress?
Dr. Lawrence Fisher
Definitely not.
We believe that addressing the emotional side of diabetes is part of comprehensive diabetes care. It is part of living with and managing diabetes over time. Ideally, emotional care is incorporated into regular diabetes check-ups and problem-solving encounters.
Diabetes health care professionals have unique insights into the daily struggles that people living with diabetes experience. They have tremendous awareness, understanding and knowledge about diabetes self-management, including the distress that many people with diabetes experience with varying degrees over a lifetime. Diabetes specialists realize that recognizing and addressing distress is an integral part of providing care and helping people manage their lives around diabetes.
Frankly, there is no other option – Diabetes care professionals are the front line clinicians when it comes to helping people manage their diabetes, and that includes the emotional side of diabetes as well.
However, addressing diabetes distress effectively can be challenging, even for the most experienced diabetes health care professional. After all, most clinicians don’t receive formal training to address the emotional part of diabetes self-management. It makes sense that some additional training and support would be of benefit. That is why we need training programs like ReVive 5, so health care professionals have a safe place to increase their comfort level, enhance their skills, and learn time-efficient strategies that can be applied in clinical practice.
In addition, very few mental health professionals have any experience with diabetes and we have learned that very few people with diabetes follow through on referrals to mental health professionals. Frankly, there is no other option – Diabetes care professionals are the front line clinicians when it comes to helping people manage their diabetes, and that includes the emotional side of diabetes as well.
We also asked, How does addressing diabetes distress impact glucose levels?
This straightforward question has a relatively complex answer – like most things in clinical care. Many studies have shown that there is a modest but significant correlation between distress and A1C – the higher the distress, the higher the A1C and vice versa. But this is an ‘association’ and it DOES NOT mean that one CAUSES the other. We believe that the only modest association between distress and A1C can be explained, at least in part, by examining two related issues.
First, there is a relatively high rate of distress among people with diabetes with A1C levels of 7% or less. The distress that some people in this A1C range feel are associated with fears of hypoglycemia and struggles with eating. In fact, in a recent study, we discovered that about a quarter of participants with an A1C of 7% or less reported significantly elevated levels of diabetes distress. So even people who are reaching target glucose levels can experience significant levels of distress.
The second reason is really interesting, and it has implications for intervention. As mentioned above, in two recent studies, we reported a significant but modest association between distress and A1C. But as we delved into the findings, we discovered that reductions in distress associated with a clinical intervention were only ‘indirectly’ linked with reductions in A1C.
Most importantly, we found that reductions in distress were highly related to improvements in diabetes self-management, which, in turn, were significantly related to reductions in A1C. To say it simply, the reductions in distress were due to improvements in self-management behaviors which led to reductions in A1C. This is a critical point – because it suggests that health care providers can have the biggest impact by combining distress reduction AND management interventions to improve glucose management as well as help people improve their quality of life.
ReVive 5 Diabetes Training Program Expert Faculty
Dr. Lawrence Fisher’s most recent work focuses on diabetes distress and depression, disease management, and how adults and families struggle over time to manage chronic health conditions.
He has served as a professor in the Department of Family & Community Medicine at the University of California, San Francisco for over 25 years, and he is the Director of The Behavioral Diabetes Research Group at UCSF. He has conducted multiple cross-sectional and longitudinal NIH- and ADA-supported clinical research with adults with diabetes and their families. He maintains an active clinical practice at UCSF, has published over 190 peer-reviewed articles on diabetes and related topics, and frequently speaks to both professional and lay groups at local, national, and international meetings and workshops
Join us to gain the confidence and learn the skills needed to support people with diabetes to move forward in their self management and discover the expert within.
Speakers Interviews – Learn more about the ReVive 5 Team
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The use of DES products does not guarantee the successful passage of the certification exam. CBDCE and ADCES do not endorse any preparatory or review materials for the CDCES or BC-ADM exams, except for those published by CBDCE & ADCES.
Why I Transformed my Approach to Diabetes Self-Management Education
When I was hired to be a part of the Embark Trial Team at UCSF, I felt confident in my approach to self-management education for people living with type 1 diabetes. After all, I had been providing diabetes care and education for over 20 years.
Little did I know that participating in this Trial would change my practice approach.
The Embark Trial, simply explained, was designed to evaluate if addressing diabetes distress and supporting an increased level of self-management confidence for people living with type 1 diabetes improved outcomes.
As part of the Embark Trial Team, I attended trainings which outlined the philosophy and novel approach of the intervention. The research team repeatedly emphasized that even though we were diabetes specialists, we were not to provide answers or solutions for the type 1 participants during the group classes or individual interventions. In addition, they taught us to use an innovative step-wise approach for glycemic management along with custom log sheets and strategies to address diabetes distress.
Putting this new approach to the test.
As part of the intervention team, I provided a group training and met individually with each participant for up to 30 minutes for about six sessions. During these sessions we would explore issues that they would like to address and guide them in problem solving.
For example, if a person with diabetes asked, “why are my blood sugars so high in the morning”, I couldn’t suggest to them that they probably needed to increase their basal insulin.
Instead, I encouraged them to draw on their own knowledge about their diabetes and ask, “Why do you think your blood sugars are elevated in the morning?”
Another example is I would ask participants to scroll through their insulin pumps to find their basal and bolus insulin settings. They would ask me, “how do I find those?”
Instead of providing step by step instructions, I encouraged participants to start looking through their pump settings to see if they could discover it themselves.
Guess what? Participants of all ages and backgrounds were able to figure it out without any hands-on instruction from the “fixer”.
Even though the coaching was provided over the phone and on zoom, with each accomplishment, I could feel them glowing with the pride of self-discovery.
The participants were gaining a sense of agency and mastery.
And I was transitioning from being a “Fixer” to becoming a “Coach”. It felt great.
To be honest, it took a lot of pressure off of me to be the “all knowing” diabetes professional. This approach freed me from feeling like a failure if I didn’t know all the ins and outs of insulin pumps, CGMs, carb counting ratios and more. It felt very collaborative and I felt more authentic.
More importantly, I was able to tap into the individuals expertise by REALLY listening, asking meaningful questions and helping them find solutions. It turns out that people with diabetes have a lot of expertise in themselves. Unfortunately too many times, during provider visits, even though they try to share their worries, concerns and emotions, they often aren’t really seen and heard.
The study also provided simple conversational tools that the diabetes specialists could use to help participants address their diabetes distress. We often feel stuck or not sure how to best help people struggling with the real life distress that comes with living with a chronic condition 24/7/365. The approach used in this study empowered me to try new approaches that really made a difference.
As diabetes health care professionals, we can’t know everything, but we can gain needed skills to help address distress and encourage individuals figure it out for themselves. Being a part of this study help me grow my “Coach” approach and let my “Fixer” know that it can relax, we will call upon it as needed.
Now, we are excited to share the tools and approaches used in this study with our community of diabetes health professionals.
We have reassembled the training team and created a resource binder of fantastic tools that we are excited to share this all with you in our ReVive 5 Diabetes Training Program. Join us to learn a step-wise, proven approach to address hidden barriers to diabetes self-management and glucose management.
Learn from the Experts that Constructed this Approach
Live Virtual Sessions Air June 17 & June 24th
Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!
The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.
Question of Week | To Prevent Hypo’s, JR Stopped Taking Bolus Insulin
Click Here to Test your Knowledge
JR is 26 years old with type 1 diabetes for over a decade. JR keeps missing appointments and when you finally get a hold of them on the phone, they start crying and say “I am afraid my blood sugars will go too low, so I stopped using my bolus insulin”. They explain that they were too embarrassed to come in and have their data downloaded. Based on this information, what would be the most helpful approach?
- Provide reassurance and recognize that JR is dealing with childhood trauma.
- Encourage JR to start using half their usual dose of bolus insulin to get started.
- Recognize JR’s effort to prevent low blood sugars and explore their feelings.
- Remind JR that all of the downloaded data and reports are confidential.
Click Here to Test your Knowledge
The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.
Indigenous Peoples’ Day | Remember – A Poem by Joy Harjo
To recognize Indigenous Peoples’ Day, we are honored to share a treasured poem by one of my favorite poets and writers, Joy Harjo. Plus, we also share an interactive map of Indigenous Lands (credit to NPR).
In 2019, Joy Harjo was recognized as the United States poet laureate and served three terms. Harjo is an internationally renowned performer and writer of the Muscogee (Creek) Nation.
She lives in Tulsa, Oklahoma and is the author of nine books of poetry, including the highly acclaimed An American Sunrise, several plays and children’s books, and two memoirs, Crazy Brave and Poet Warrior. Her many honors include the Ruth Lily Prize for Lifetime Achievement from the Poetry Foundation, the Academy of American Poets Wallace Stevens Award, two NEA fellowships, and a Guggenheim Fellowship.
You can learn more about Joy Harjo on her webpage, www.joyharjo.com.
Remember
Joy Harjo
Remember the sky that you were born under,
know each of the star’s stories.
Remember the moon, know who she is.
Remember the sun’s birth at dawn, that is the
strongest point of time. Remember sundown
and the giving away to night.
Remember your birth, how your mother struggled
to give you form and breath. You are evidence of
her life, and her mother’s, and hers.
Remember your father. He is your life, also.
Remember the earth whose skin you are:
red earth, black earth, yellow earth, white earth
brown earth, we are earth.
Remember the plants, trees, animal life who all have their
tribes, their families, their histories, too. Talk to them,
listen to them. They are alive poems.
Remember the wind. Remember her voice. She knows the
origin of this universe.
Remember you are all people and all people
are you.
Remember you are this universe and this
universe is you.
Remember all is in motion, is growing, is you.
Remember language comes from this.
Remember the dance language is, that life is.
Remember.
Which Indigenous lands are you on? This map will show you.
Indigenous Peoples’ Day is a time of reflection, recognition and celebration of the role Native people have played in U.S. history. One way to mark the day — and to learn about Indigenous history year-round — is to learn which Native lands you live on.
DiabetesEd Online University | Closed for Renovations Today, October 5th
DiabetesEd Online University is closed today to make the switch to our new platform.
We can’t wait to share our new look with you on Thursday, October 6th.
Students will be able to experience our New and Modernized learning platform starting Thursday! Since we will be busy setting up our new site, Bryanna and I may be delayed in answering emails and phone calls today. We appreciate your patience during this exciting renovation process.
Our main website and shopping cart will remain open.
We know for many of you, losing a day of progress can feel overwhelming and we appreciate your patience during this transition.
We invite you to use the following tools as part of your study plan while we make this transition.
• Free Webinars – This page offers some helpful info on test taking and other topics.
• CDCES Coach App – this app has a lot of great tools such as free quizzes that you can use to test your knowledge while the website is down.
• Cheat Sheets – We know that a great resource page full of accurate and helpful cheat sheets can save busy diabetes specialists time.
• Medication PocketCards – Download here to use as a study tool and resource.
However, with any move, there are some details that need to be wrapped up.
Other Important Info for University Students
If you are currently enrolled and active in DiabetesEd Online University for the past 1 year, you will be able to experience the new platform as soon as we make the switch in October. You will be prompted to create a new username and password as part of the process.
When we flip the switch over, you will notice a new fresh home page, more intuitive navigations, and some additional bells and whistles.
Still have questions? Please email us at [email protected] or chat with us at www.DiabtesEd.net.
More to come! We will be sending you ongoing communications to keep you posted on our progress and enhancements.
Thank you, Beverly and Bryanna
Question of the Week | Best approach for distress & DKA?
RJ is in the hospital for the 3rd time this year in DKA. You ask RJ to complete the diabetes distress survey tool and immediately recognize that RJ is experiencing high levels of diabetes distress.
When working with RJ to assess what is happening, which of the following approaches could be used as a conversational tool?
- Use closed-ended questions to create a safe space for the interaction.
- Keep your clinical reports and records handy to use for reference.
- Accept RJ’s current self-management regimen without judgement.
- Avoid use of too many feeling words because it might embarrass RJ.
Click Here to Test your Knowledge
Want to learn more about this question? Join our NEW
ReVive 5 Diabetes Training Program | 14 CEs
Whether you are a novice or an expert in providing diabetes care, we invite you to attend this exciting training program that provides the essential steps to address diabetes distress combined with an innovative approach to glucose management that will revolutionize your practice.
“ReVive 5” breathes new life into our relationship with diabetes, bringing a fresh perspective to both the person with with diabetes and the provider.
By addressing old habits that no longer serve us, we have the opportunity to create a new life tool kit toolkit in partnership with the person living with diabetes.
The ReVive 5 program is built on sound research and will revolutionize your approach to diabetes self-management education.
Join our Team of Experts | Starts Nov 1st, 14 CEs
Team of Experts:
ReVive 5 is taught by a team of 3 Interdisciplinary Experts:
- Lawrence Fisher, Ph.D., ABPP, Professor Emeritus, UCSF
- Susan Guzman, PhD
- Beverly Thomassian, RN, MPH, CDCES, BC-ADM
Training Program Includes:
- 14.0 CEs – Includes the 4 Session ReVive Training Program, Certificate and 5 FREE bonus courses to supplement content
(Four 1.5 hour training sessions (6.0 CEs) plus Five bonus courses worth 9.0 CEs) - Quarterly 1 hour follow-up sessions with an expert -dates to be announced
- A comprehensive set of assessment tools, educational materials, log sheets and resources.
Don’t worry if you can’t make it live. Your registration guarantees access to the recorded version in the Online University.
All hours earned count toward your CDCES Accreditation Information
Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!
The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.
DiabetesEd Online University Closed for Renovations on 10/5/22
DiabetesEd Online University will be closed to make the switch to our new platform on Wednesday, October 5th, 2022. We can’t wait to share our new look with you on Thursday!
We are so excited to announce that on Wednesday, October 5th, we will be making the transition from our old DiabetesEd Online University to our New and Modernized learning platform! Please make sure to login and save your CE certificates that are older than a year ASAP!
To complete this final step, the Online University will be closed on Wednesday.
Our main website and shopping cart will remain open.
We know for many of you, losing a day of progress can feel overwhelming and we appreciate your patience during this transition.
We invite you to use the following tools as part of your study plan while we make this transition.
• Free Webinars – This page offers some helpful info on test taking and other topics.
• CDCES Coach App – this app has a lot of great tools such as free quizzes that you can use to test your knowledge while the website is down.
• Cheat Sheets – We know that a great resource page full of accurate and helpful cheat sheets can save busy diabetes specialists time.
• Medication PocketCards – Download here to use as a study tool and resource.
However, with any move, there are some details that need to be wrapped up.
Please download CE certificates before October 3rd, 2022.
If you are enrolled in our Online University, please log into your account and download any course certificates that you completed more than a year ago. After the switch, we will only be storing certificates earned after September 2021, so please download your certificates into a file on your computer. Not sure how? See the steps under the “Read More” section below.
Keep an eye out for an email with instructions on creating a new login name and password so you can enjoy the enhanced online features without interruption. Also, after we make the switch, expect to receive a notification to update your username and password. Your current courses from the past year, test results, and resources will automatically be migrated to the new site.
Other Important Info for University Students
If you are currently enrolled and active in DiabetesEd Online University for the past 1 year, you will be able to experience the new platform as soon as we make the switch in October. You will be prompted to create a new username and password as part of the process.
When we flip the switch over, you will notice a new fresh home page, more intuitive navigations, and some additional bells and whistles.
If you are considering joining our Online University, now is the time to make your move. We will be making modest increases to some of our course prices for the first time in over ten years to match the increased costs of this enhanced service package.
If you enrolled more than 1 year ago and you . . .
- Want to purchase new courses or extend expired courses, you will need to re-register in our new DiabetesEd Online University after we go live.
- Want to get your historical CE certificate? Please login to your account ASAP to download CE certificates for your records. After the switch, we will only be storing certificates earned since September 2021. Not sure how? See the steps under the “Read More” section below.
Read More: Steps to log in and Get your Past CEs
- Go to the Student Login page at https://www.diabeteseduniversity.net/oltpublish/site/signin.do
- After logging in, you will your “Completed Items” list on your Dashboard. All completed courses will also be marked complete by a red ribbon icon, which lets you know you can print your certificate. To view all the completed courses, click the “View All” at the bottom of the completed box.
- Click the link that says “Print Certificate” and your certificate will open in a new tab. Either save to your computer or print from there.
Not sure when you enrolled? See the steps under the “Read More” section below. to check to see your enrollment and expiration dates.
Read More: Steps to Find Enrollment Start and End Dates
- Login to your account and under the “My Items” list on the left side of the page, click “Enrolled Courses”
2. Click the title of the course you want to check the status of. If you are enrolled in a Bundle, you only need to select one course within the bundle to verify.
3. After you click the course title, on the bottom right side of the page, you will see a box that says “Course Access” which will have your start and end dates to verify when you originally enrolled and when the course will expire.
Still have questions? Please email us at [email protected] or chat with us at www.DiabtesEd.net.
More to come! We will be sending you ongoing communications to keep you posted on our progress and enhancements.
Thank you, Beverly and Bryanna
Coach Bev’s 7 Takeaways | New ADA/EASD Type 2 Management Guidelines
The content of this newly published guideline is thoughtful, person-centered, and offers a clear clinical path for the management of type 2 diabetes. I tip my hat to the authors in gratitude for their dedication and vision.
Besides having lots of attractive infographics and a fantastic summary of the research, this guideline offers evidence-based strategies to get glucose to the goal with an emphasis on taking a person-centered approach to pharmacologic and lifestyle interventions. We invite you to enjoy a detailed review by joining our webinar or reading this brief summary of the findings that impressed me most.
- Metformin doesn’t have to be the initial therapy.
This medication has enjoyed the number one seat in the ADA guidelines for over a decade. And for good reason. In addition to being low cost ($4 a month), it does not cause low blood sugar or weight gain and it lowers A1C by 1-2% points. Although it lowers LDL cholesterol, it is not officially recognized as a cardiovascular risk-lowering medication.
The guidelines state, that in addition to lifestyle interventions if there is a history of CV disease, heart failure, or kidney disease, we need to turn our gaze elsewhere and consider an SGLT-2 Inhibitor or a GLP-1 Receptor Agonist.
- Embrace Diabetes Self Management Education (DSMES) as being as important as other aspects of care, including pharmacotherapy.
This endorsement of the significance of DSMES in improving outcomes and quality of life in people living with diabetes is powerful. Research has demonstrated that people with diabetes who receive DSMES, including counseling by an RD/RDN, experience an A1C drop of 1-2%. In addition, they are less likely to be hospitalized, engage in more preventive behaviors, and know when to reach out for help. They go on to say that DSMES needs to offer on an ongoing basis, using a variety of delivery approaches, and should be accessible in all communities. - If GFR is 20 or greater and the UACR is 30mg/g or more, start SGLT-2 Inhibitors.
It doesn’t get much bolder than that statement. There is the fine print, that recognizes that clinicians can use their discretion and judgment, but the data is clear. The use of SGLT-2 slows the progression of kidney disease and can delay the need for dialysis. Even if glucose levels are at target, in the presence of renal failure, starting an SGLT-2 is indicated. Since the leading cause of death for those with kidney disease is CV events, if SGLT-2 can’t be tolerated for clinical reasons, using a GLP-1 with CV benefits would be the second choice. - In the presence of heart failure, start an SGLT-2 Inhibitor.
All four of the available SGLT-2 Inhibitors are effective “glucoretics” helping rid the body of excess sugar and fluid. This action has a significant impact on improving not only glucose levels but decreasing fluid overload thereby improving cardiac function. This class of medication is so effective at treating heart failure, that 2 of the 4 SGLT-2 meds are indicated to treat heart failure even in the absence of diabetes. - Weight loss Goals Intensified
Traditionally, in the recommendations, weight loss targets range from 5-7% for people with diabetes. However, these new guidelines suggest we aim for at least 5-10% weight loss with even better outcomes if people can lose 10-15% or more significant weight loss can lead to diabetes remission, improved metabolic profiles, and fewer complications. In the past, achieving these targets was usually linked to very low-calorie diets or metabolic surgery. However, with higher doses of the GLP-1 RA and the Dual GLP GIP Agonist, Tirzepatide, we have additional tools in our toolkit to get the job done.
6. The placement of Tirzepatide (Mounjaro)
In the new ADA/EASD Algorithm, there are 2 hierarchies of medication effectiveness, glucose, and weight impact. As its trade name suggests, tirzepatide is at the top of the mountain of both lists (along with semaglutide) for its glucose-lowering properties and weight loss efficacy. This medication was studied in people with diabetes (Surpass) and people without diabetes (Surmount).
In the diabetes group, at the highest dose, A1C dropped by over 2% and people experienced a 10% or greater weight loss. In the non—diabetes group, people experienced up to 20% weight loss. This medication is currently only approved for people with diabetes, but don’t be surprised if we see it on the market as a weight loss intervention for people without diabetes in the near future.
7. Keep it person-centered and Address Social Determinants of Health. The last version of the guidelines recognizes that we have to consider the needs, values, and goals of the individual PATIENT. In this newer version, they ditched the word “PATIENT” and finally replaced it with the term “PERSON”. This consensus statement also recognizes the importance of considering inequities in access to diabetes care and resources. They offer a comprehensive list of all of the social determinants of health to consider when providing care.
There is so much more to this article. I hope I have inspired you to read the complete ADA/EASD Consensus document or join our webinar on December 1st to learn more.
Meds for Type 2 Update; New ADA/EASD Consensus Statement
Level 2 | 1.25 CEs
Airs live on Wednesday, December 1st at 11:30 am PST
Plan on joining this exciting webinar that walks participants through the newly released, “Management of Hyperglycemia in Type 2 Consensus Report by the ADA and EASD”. These updated guidelines will be incorporated into the 2023 ADA Standards of Care, but you can get a early sneak peak by joining Coach Beverly on December 1st, 2022. She will highlight the revised guidelines with a focus on new elements and exciting changes on how we approach medication management for type 2 diabetes. Together, we will explore clinical factors to consider when determining the best strategy to improve glucose management in people with type 2 diabetes and other co-conditions. There will be a special focus on cardiovascular risk reduction and renal protection and addressing clinical inertia.
Objectives:
- Describe the role of Diabetes Care and Education Specialists in advocating for optimal therapeutic approaches.
- Discuss the application of the new ADA/EASD Guidelines to improve glucose and reduce CV and renal risk.
- List strategies to initiate and adjust oral and injectable therapy using a person-centered approach
Intended Audience: A great course for health care professionals seeking evidence-based information that improves the quality of life and outcomes.
Don’t worry if you can’t make it live. Your registration guarantees access to the recorded version in the Online University.
All hours earned count toward your CDCES Accreditation Information
Sign up for Diabetes Blog Bytes – we post one daily Blog Byte from Monday to Friday. And of course, Tuesday is our Question of the Week. It’s Informative and FREE! Sign up below!
The use of DES products does not guarantee the successful passage of the CDCES exam. CBDCE does not endorse any preparatory or review materials for the CDCES exam, except for those published by CBDCE.
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