"[I] hope you can see that this concept of diabetes distress is very much centered in the disease, not the person."
Today, we are talking to Dr. Michael Vallis about diabetes distress, fear of hypoglycemia, and psychological insulin resistance.
Dr. Vallis is a psychologist based in Halifax, Canada. He is an Associate Professor in Family Medicine at Dalhousie University. His main area of expertise is adult health psychology, with an emphasis on obesity, diabetes, cardiovascular risk and gastroenterology.
Shireen: Podcasting from Dallas, Texas. I am Shireen, and this is a Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.
Shireen: In today’s episode, we are talking with Dr. Michael Vallis about diabetes distress, fear of hypoglycemia, and psychological insulin resistance. Lots to chat here. Stay tuned.
Shireen: Dr. Michael Vallis is a psychologist based in Halifax, Canada. He’s an associate professor in family medicine at Dalhousie University. His main area of expertise is adult health psychology with an emphasis on obesity, diabetes, cardiovascular risk, and gastroenterology. Welcome, Dr. Vallis.
Dr. Vallis: Thank you very much. Pleasure to be here.
Shireen: Pleasure to have you on. So, Dr. Vallis, tell us a little bit more about how you got into this field and just what made you want to get into it? What made these issues really special for you?
Dr. Vallis: Yeah, that’s a really interesting question and for me, when I was going through my training, which was quite a long time ago now, what appeared to me was that I found it very difficult to really provide a diagnosis to people.
What I’m saying is that when I would interview Individuals learning about psychology in the practice of psychology, when I started to listen to people’s stories, what was really impactful to me was how much sense their stories made. And it really allowed me to sort of develop this idea that if you could understand a person, then you can support and help a person.
So I kind of got into the direction of sort of normal psychology. So how do people tick? What makes people tick on a day-to-day basis? As opposed to abnormal psychology, where you would work inside a mental health clinic with people who are really struggling with problems. Where it would be very appropriate to say, well, this person needs help in figuring out how to cope differently with life.
The problem the person is presenting is inside the person. I started to see that the problems that many of the patients that I was seeing when in my training was due to the conditions that they had. In particular, diabetes, cardiovascular disease, other chronic medical conditions.
So then when I started my practice, I naturally gravitated towards understanding people’s stories. Only to discover that in medical sciences we do too much diagnosing and not enough understanding. So that’s kind of where I have sort of centered my career is working with people who, rather than the metaphor I use, is the typical mental health model is the abnormal person in a normal world. As a matter of fact, we call it psycho pathology.
Pathology of the psyche, there’s something wrong with the individual. And what I work with really is normal people in abnormal worlds, your body’s not supposed to fail you. And so, all of the psychological phenomenon that we’ve discovered and developed a real focus on, kind of comes from that, that if you were in this situation, you would probably feel similarly. And that’s kind of where I’ve really made my focus.
Shireen: I came across an article that you were a part of in 2018, its titled Diabetes and Mental Health, which specifically discusses this connection between psychiatric disorders and diabetes. Was there any particular reason why you wanted to be a part of that research? What was the motivation there?
Dr. Vallis: That’s another good question. That’s actually an interesting kind of piece because that was actually part of the Canadian Clinical Practice guidelines for the management of diabetes produced by Diabetes Canada. And in fact, what we did in that was try to link the together.
So we had two parts to that chapter that focus, one was on what are the psychological aspects of living with diabetes? To what extent does diabetes produce these psychological problems? And then what about people who do have psychiatric disorders, how do they live with diabetes? And how does that impact their ability to manage their disease?
Shireen: We know that diabetes is a difficult condition for both individuals and their families. This article mentions a few of these challenges that I hope you can elaborate for our listeners. So first, can you explain to the listeners what diabetes distress is?
Dr. Vallis: Absolutely. The best way to do that would be to just reflect on the following question, and you can ask anyone living with diabetes this question. What words do you use to describe what it’s like to live with diabetes?
And I pretty much guarantee you, the words you will hear will be negative words. Stressful, scary, depressing, costly. I’ve rarely heard people say fun, exciting, thrilling. I wish I could give this to my best friend. Nobody says that. So what that tells us is that this is a difficult disease because you live with diabetes on a day-to-day basis, an hour to hour basis, you make hundreds of diabetes related decisions a day.
You have to do this every single day of the year, regardless of what’s happening. There is a burden. So we started recognizing this a number of years ago. People started to use the word burnout and then people said, well, maybe they’re depressed. And so there was a, for a quite a period of time, you know, screening for depression in diabetes. But then as we started to really focus in on this experience, we realized it was the diabetes that was causing this.
So when we think about diabetes distress, here’s a good way for the listeners to think about it. If diabetes was a weight that you carried in a nap sack on your back, is it a one pound loaf of bread? Is it a five pound sack of potatoes? Is it a 50 pound iron anvil. Or is it a two ton truck? I find when I ask that question, people get it and they will tell you. So this assesses what we call burden. To what extent does diabetes burden people? And we look at that in terms of emotional burden.
Regimen distress. Regimen means all of the work. So take these medications, take this insulin, test your blood sugars, make your meals this way, exercise in that way. All of that work of diabetes is called the regimen distress. And then we talk about social support distress. When you walk around the world, how do you navigate relationships within families, within workplaces?
And then the final aspect of diabetes distress is what we call patient provider distress. To what extent do we cause distress. Many people living with diabetes will tell you that going to see their doctor or their nurse or their diabetes center is like being called into the principal’s office. So there’s distress in that element.
So I hope you can see that this concept of diabetes distress is very much centered in the disease, not the person. So we’re not blaming the person, we’re trying to understand the distress through the lived experience, and then we try to match strategies to help the person. To what extent can we help people navigate relationships?
if they have that as part of their distress, to what extent can we help the healthcare system be more sensitive to the emotional needs of people living with diabetes? Can we make the burden of the regimen easier? And how do we give people opportunities to support the emotional weight of the disease?
Shireen: I see your point to where this is a largely a factor of that lived experience, but to an individual, how does one identify the difference in this diabetes distress as you described it, and as opposed to other mental health conditions? How does one differentiate?
Dr. Vallis: Yeah. Yeah. Great question. Two comments. One is ask yourself if you didn’t have diabetes, would you be experiencing this? And if your answer is, oh, you know what? I had this long before I was diagnosed with diabetes. This really has nothing to do with my diabetes. I have a traumatic history from my past. I was in a serious accident that that created this pain that I have. That’s completely depressing, you know? No, this isn’t diabetes.
So individuals themselves, and many people will say to you, if I didn’t have diabetes, I wouldn’t be talking about these issues.
And then the second point is, to what extent does it wear a person down? And so diabetes distress, can develop into clinical depression. And so that’s why in those guidelines, those 2018 guidelines, we recommend monitoring people for diabetes, distress and depression to, so we can support the where the person is and we can screen them for distress and identify if it leads to depression.
Shireen: Another concept, that I would like for you to talk about is can you really explain to our listeners again, what is fear of hyperglycemia? Hypoglycemia? Excuse me.
Dr. Vallis: Thank you. Yeah. That one is actually super important and it’s important for the following reason. We psychologists distinguish between sort of regular stress and traumatic stress.
Regular stress, they can be serious issues. They can be things like financial stress. They can be occupational stress, et cetera, et cetera. But when you think about over time, they just sort of fade into the background. So you might’ve said, oh yeah, you know, my twenties was very stressful.
My last year was a stressful year. And you might say, well, what was stressful about it? Oh, you know, and you’re just talking in generalities. And then there’s traumatic stresses. These are, these are burned into your brain. And so, you know, if you’ve ever been in a horrific accident, if you’ve ever been held hostage, if you’ve ever had anything that’s really sort of traumatic.
And I think the audience can see, these are the big issues. You know, you ask somebody who’s been sexually assaulted. When did that happen? As opposed to saying, what was the most stressful part of 2022 for you? You’d have to think hard, but if you’ve been sexually assaulted, you’d say it was, November 20th, it was seven o’clock at night. I was exactly here. I was wearing a…flashbulb memory.
And so this is closer to what the experience of hypoglycemia is. Because hypoglycemia means your blood sugar has gone so low, you cannot treat it yourself. So now you’ve become incredibly vulnerable. So this is a tremendously fear-based disorder.
And so we’ve discovered that clinicians in diabetes tend to, to think about it just like a medical problem. They don’t recognize how much fear is attached to this because what will happen is that you can solve this problem. You can solve the problem of hypoglycemia by letting your sugars go high. So people will overcompensate when it goes slow.
And what I like to say is that hypoglycemia management first is a fear management, then a glycemic management issue. And the evidence has been coming very clear from some major studies that have been done in the last few years that look at the experience of hypoglycemia. Just how common it is and just how much it has an impact.
So again, we would invite people living with diabetes. If you’ve had a hypoglycemic experience to really reflect on this. To what extent have you been able to cope with it? Have you kind of rolled with it and now you’re back to normal? Or do you go through life kind of thinking like.
Well, I’m leaving the house now at 8:00 AM. I’m not sure when I’m going to have lunch. You know what? I don’t want my sugars to be kind of close to nor ‘ll let it go a little higher, so I know I won’t go low. That’s the kind of fear of hypoglycemia. We strongly encourage healthcare professionals to recognize, and people living and affected by diabetes to recognize this fear of hypoglycemia as a legitimate concept.
Shireen: How would you say one can cope with that? To exactly what you said ether they would try to overcompensate and just make sure it’s on the higher side and try to avoid the lows. What would you tell somebody? Whose sort of listening and is fearful in that way.
Dr. Vallis: I think the first thing is really one of acceptance. One of recognizing this as a legitimate phenomenon.
It may be overstated, but sort recognizing a problem is halfway there to the solution to the problem. And in some ways, it’s actually true. You can’t cope with something if you’ve got your head buried in the sand. So avoidance becomes a really dangerous coping strategy.
By the way, it’s very common and it does, because diabetes, if you ignore it, it just gets worse, right? So, you know, it does require, that’s why diabetes can be such a stressful disease. It does require action to take care of. So the first thing would be to acknowledge it and then, what are your strategies for managing it?
And this is where monitoring your blood glucose levels, which many people think is just a task that you do for the clinic. Actually, is like your speedometer in the car. So if you are afraid that you’re going be driving so slow that your speed goes so low that you’re going to get smashed in the back by the cars coming up on you.
Well, you could look at the speedometer and tells you how much you have to push the gas to get back up. And if we could look at monitoring blood glucose in exactly the same way. And so if we see it as a problem and we think, okay, how can I cope with it? What can I put into place? So carrying some kind of glucose with you at any point.
So if you go low, you can treat it. Letting other people know so that they could understand. So for instance, let’s say you’re in the mall. It’s Saturday morning at 10:00 AM and you see this elderly person who appears to be drunk, walking down the mall.
First thought, do you have diabetes? Because that person is probably low and they’re slurring their words and they’re staggering a little bit because they’re kind of going out. So let your loved ones know. Develop an action plan. Monitor your blood sugars, and seek help from your healthcare providers because this is a very manageable problem.
Shireen: I love the fact that you mentioned that it is in fact a manageable problem. So though there may be fear associated with it, it’s still very much something that can be managed.
Dr. Vallis: Exactly.
Shireen: Can you also let us know what leads to, and just switching gears a little bit to psychological insulin resistance and why is this belief so common?
Dr. Vallis: Yep, that’s a great one. So that applies primarily exclusively to type two diabetes. So anyone who lives with Type one diabetes knows that really you require insulin to survive. And prior to the discovery of insulin, nobody survived Type one diabetes. And so you could imagine the diagnosis of type one diabetes, insulin is your lifeline, so that’s just a given.
But type two diabetes primarily is asymptomatic. You don’t really feel it when it’s at diagnosis. And so what ends up happening is that then the individual tries to manage. And most people would say, I just want to be normal like everybody else, so I don’t want to sort of do, I don’t want to take a lot of drugs. I don’t want to take injections. I don’t want to do any of those things.
And they try to keep it at that level, but for many people, type two diabetes progresses. Over time it gets worse. And so the treatments need to step up. And so this concept of psychological insulin resistance is really important because many people with type two diabetes might think, well, if I need more medication, it must be because I’m failing.
And so they would have what we call this common sense belief. If you’re on 80 milligrams and I’m on 40 milligrams, you must be sicker than me. If you’re on three pills and I’m on one pill, I’m healthier than you. Oh my goodness! You have to inject insulin.
So there’s a lot of attitudes that people have make perfect sense. People would say eight is greater than four. So somebody who needs eight drugs must be sicker. In fact, with a disease like diabetes, the more medications you’re on, the more likely you’re going to be healthier because the doctor’s not going to ask you to go on the medications unless it’s decided that you need them.
So this concept is really one of helping the individual identify what their attitudes are so they can talk it through with their clinicians. So we can help people recognize that the way that you manage diabetes is you treat to target. If you need two injections a day and I need six injections a day, they’re equal.If you’re on 40 milligrams and I’m on 80 milligrams and we hit the same outcome, they’re equal.
But that doesn’t make a lot of common sense, which is why we think it’s so important for people to identify and be supported in that sort of education. So when somebody says, oh, you take so many pills. The answer is, of course I do, because I want to be healthy. I want to live a long and prosperous life. These are the way that I do that.
And when I have conversations with my doctor, just say to your doctor, doctor, can you help me understand? Do I need all these medications? Is this the best dose? And then use your relationship with the clinicians to help you figure out what doses you need in order.
And that’s challenging for many people because many of us will compare ourselves to others. So if I found out you had diabetes and I have diabetes, and I always say, well, how are you treating you? Oh, you have all you poor person, you’re on six pills, right? That’s just sort of the natural, we call it social comparison, but because it’s a medical disease, we need to think about the treatment.
So psychological insulin resistance is something that is really common. And what I like about these terms, again, I go back to my first comment is to normalize, right? If you could live with diabetes with no medications, that would be great. And we would do anything that we can to help you be on the minimum number of medications. But the reality is this is a disease, and we know that without medical therapies, diseases don’t get better on their own.
Shireen: And also, what I think about is when you compare yourself apples to apples, like that, people’s bodies are different, right? And the needed medication as a result is different.
Even we see differences across ethnicities and backgrounds and different things. All of that shapes into the way you manage the diabetes. And so, comparing it apples to apples makes it incredibly hard. But then I can see the flip side to it, where somebody has that. Whose already feeling all these other feelings around from denial to fear to some of the other things that we talked about today, is bound to take that toll to say, I am weak.
Which also, I like that you’ve mentioned that. And you mentioned the piece also about the medical professionals. So I do want to talk about that one next. But do you have any suggestions for how medical professionals themselves should approach this situation with patients? And again, just talking about the psychological insulin resistance. What can a doctor do?
Dr. Vallis: Oh, that, that’s a great, great question. And the first thing that the doctor can do is establish collaboration with the person. So here’s the best way to think about it. The doctor is an expert in medicine. You are an expert in you and the two experts need to work together. And if you work without your doctor, bad things are likely to happen.
If the doctor works without you, bad things are likely to happen. And so this is the model self-management support. So this is how we call diabetes management. We recognize that diabetes is a self-managed disease. What do I mean by that? The outcomes, how well you function isn’t dependent on what the doctor does inside the office.
The outcomes are dependent by the choices you make when you leave. So that’s on you. You are the expert there. So the doctor can give you the medical knowledge, give you the guidance, but then has to listen to you, and then the two of you have to put your heads together. And that’s the only way that we can address issues like cultural diversity, like the new develops of medication j
The field is really optimistic because we’re getting lots of great technologies and lots of great medications. But we need to help the person recognize do they need them? Why do they need them? How do they use them? So it’s really about what we call collaborate to empower. We empower the individual living with diabetes to take action, but to be guided by their clinician.
And so if we respect the expertise of the individual and we respect the expertise of the clinician, we actually believe that, that can make a really good team. And when you involve the family, the team gets even better.
Shireen: And next question for you. How do certain personality traits contribute to the increased risk of type two diabetes?
Dr. Vallis: Such a really good question. And I think we have to understand that people differ and people differ in terms of things like optimism. People differ on terms of things we call neuroticism. So are you a worrywart? Are you obsessive? So you wouldn’t be surprised to know that people who have an obsessive trait actually live really well with diabetes.
People who naturally like to keep records and count and exactly the same thing every single day, they develop diabetes. And people say, we’d like you to do this every day. And they say, great. I do this, although I just have to switch out. But now let’s talk about somebody who doesn’t like to wear a watch. They just want to be a free spirit.
They just like to go with the wind and then they’re told that they have to be structured so that personality doesn’t fit well because there is a structure. If you’re a sort of optimistic, then you’ll sort of maintain that optimism to moving through the course of your life with diabetes.
But if you tend to be pessimistic, then you might start to see the glasses as half empty rather than half full. And again, one of the things that we really like about medicine is that doctors have a really good sense of the range of personalities. If you talk to physicians, they’ll say, oh yeah, we see lots of people like this. Lots of people like that.
So just recognizing that, and again, I come back to the fact that you are not responsible for your personality. It’s sort of kind of genetic and environmental and developmental, and so you don’t choose to have your personality. And all you have to do is ask a parent who has more than one child.
So two people get together and have children, and if they have more than one child, you’ll see what personality is because they’ll tell these two kids are not the same. And then you ask the parent, at what point in the child’s life did you know that your two children weren’t the same personality?
And you know, parents will say to you like two weeks. When my child was two weeks old, I knew that the second child was very different than the first child.
Shireen: Lovely. One more question for you on this Dr. Vallis. So, how can those with diabetes navigate their psychological emotions without feeling like a burden on their families, on their friends?
Dr. Vallis: Yeah, that’s a really important question. Part of the acceptance of the diabetes, right? What we call disease acceptance is really to recognize that you didn’t choose this. This is your life and you are entitled to live your life fully. And it’s really important for us to promote that sort of worth, dignity, self-esteem.
Some people, have easy lives. I’m sorry. It’s just the way it is. Some people they seem to be born with silver spoons in their mouths. They kind of go through life as though it’s a downhill slope, pretty easy to walk downhill. Other people, it’s like they’re on the level so they kind of walk along and other people, their lives are like going up a mountain and it’s a hard slog and we just have to respect that you know what? You know what life entails and you’re entitled to take action.
There is a difference between self-care and selfish. Many people struggle with that and think by focusing on themselves, maybe by imposing on others in order to live well, that that is selfish. In fact, it’s not. It’s self-care, and I think all of us kind of know at some level. It’s like, here’s who I am, and maybe this sounds a little bit harsh, but at some point in your life, most of us get to a point in our life where we say, look, you know what?
This is who I am. You’re just going to have to accept me for who I am. Now we usually call that wisdom. And what I’d like to suggest is that we can claim that at any point, you don’t have to wait till late in life to say, I finally realized that I need to stop bending myself into pretzels to try to please other people because other people are going to accept me or not.
And I think what we need to think about is really protecting yourself. And if you have diabetes, then in fact you have this option. And imagine someone living with diabetes saying to you, I’ve never been healthier since I’ve been sick. Where the diagnosis of diabetes at calls their attention to the need for them to take care of themselves.
They then take care of themselves and they actually have a better life for doing so. Isn’t that an interesting sort of perspective? But it does require people to basically say, look, this is who I am and if I need to do these things. And it’s like, if you can’t accept that, then how much of a support person are you?
It’s not the number of people who show up at your funeral that counts. It’s the numbers of tears shed that counts. It’s not about how many people are around. People actually do not need very many support people to live really well, but they need good supports to live well.
And so if you’re struggling in, you know, these relationships where you’re feeling like you gotta turn yourself inside out in order to get approval, maybe you need to look at towards people who can give you the approval. And small numbers of solid, solid friends are actually much better than large numbers of acquaintances and certainly better than a number of conflictual kind of relationships.
Shireen: Wow, those, some very interesting thoughts there. Dr. Vallis. I feel like this conversation can go on. Thank you so much for sharing that. I will totally snatch that last one that you said. It’s not the number of people that show up to your funeral, it’s the number of tears. So you’re talking about quality over quantity. Absolutely. Love it.
With that Dr. Vallis we’re at the end of the episode. How can our listeners connect with you and just learn more about your work.
Dr. Vallis: Sure. So, if you Google my name, it will come up. I do operate out of the Dalhousie University in Halifax. I’m quite active in Diabetes Canada and their associations and so you can reach out.
I’m from Canada. And in Canada Diabetes, Canada is the, the equivalent to the American Diabetes Association, which is a really great organization that really collects together a lot of people. There are a lot of people actually like me. There’s a psychologist in San Diego called Dr. Bill Polansky who runs the Diabetes Institute.
It’s a great organization, a lot of publics facing supports that could be offered there. And so, I think if people actually start to kind of open yourself up. If you feel like some of these topics, we’ve talked about are relevant then this is becoming a strong recognition in diabetes that we need to make our medical care much more sensitive to the psychological care.
Shireen: Thank you so very much Dr. Vallis for your time. And with that, to our listeners who’ve listened to this episode, felt inspired, held head over to our social media. Find this podcast post, go to our Facebook and answer this brief question. For those of you that have loved ones with diabetes or have diabetes yourself, share any suggestions of how you’ve been able to manage diabetes distress perhaps in your life or again, for a loved one.
Head over to our Facebook, find this podcast post. Comment below and let us know again, how exactly have you been able to manage any kind of diabetes distress that has showed up for yourself or for a loved one? With that, Dr. Vallis, thank you so very much again for your time.
Dr. Vallis: You’re very welcome.
Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media at Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions, and to chat and connect with us about your journey and perspective.
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