“I feel like people who are from a low-income background or a disadvantaged background, often find barriers to accessing healthcare in general… And so, the changes that I can enact, or the help that I can give them, allows them to spread that beyond themselves, to potentially even their family and even as far as even their community.”
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Dr. Gunasekaran talks to us about her specialty in treating low income diabetes patients and the importance of building a relationship with the patient to help them successfully manage their disease.
Dr. Gunasekaran is an endocrinologist who specializes in diabetes care. She provides care mainly at Parkland Health, a safety net health system, for persons with diabetes.
Shireen: Dr. Uma Gunasekaran talks to us about her specialty in treating low-income patients with diabetes and importance of building a relationship with the patient to help them successfully manage their diabetes.
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 two 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.
Dr. Uma Gunasekaran is an endocrinologist who specializes in diabetes care. She provides care mainly at Parkland Health, a safety net health system for persons with diabetes.
Welcome Dr. Gunasekaran.
Uma: Thank you.
Shireen: A pleasure having you on. So, can you give some insight on how you found your way to medicine as a profession and how you decided to specialize in endocrinology and diabetes treatment?
Uma: Sure. So, um, I've always wanted to help people with health problems and illnesses. So, I was very attracted to medicine for that reason. I really love endocrinology and specifically diabetes, because it's one of those conditions that people develop and it's a lifelong disease and it allows me to develop relationships with patients over decades of their lives.
Shireen: Why did you decide to focus on low-income diabetes patients in your clinical practice?
Uma: I feel like people who are from a low-income background or a disadvantaged background, often find barriers to accessing healthcare in general. And I feel like I can make more of a difference, not only the life of a person who has health difficulties from that background, that many of those people have a larger sort of social or family network that they’re part of.
And so, the changes that I can enact, or the help that I can give them, allows them to spread that beyond themselves, to potentially even their family and even as far as even their community. So, I want to help as many people as I possibly can. So, this is my opportunity to do that by providing care to people from these backgrounds.
Shireen: What would you say is one of the most common challenges you hear from your, from your patients who are largely low income?
How do you tend to address that?
Uma: Um, I think that the biggest issues are time and money. And I would say, honestly, that's more of a universal issue, but more so in this group, a lot of patients of mine are day workers. Um, they they're dependent on today's work to pay for food tonight. And so missing one day of work because they're ill or missing one day of work to come see me, puts them back.
So, they need to find value in being able to be cared for and making their health better. And obviously money is an issue. If you're a day worker, you're paying for transportation, you're paying for food, not only for yourself, but probably some sort of extended family network as well. Many times, in my patient’s families, you find that, you know, grandparents are taking care of your children, you're working two shifts to, to pay for all of these people. Oh, but then I need the childcare, cause grandma had to go somewhere and having to pay for that care. Um, making food choices. How am I going to pay for groceries? How am I going to get to your clinic and miss a day of work? So, it's really about sitting down with a patient and meeting them eye to eye at where they are in their lives.
Uh, I often joke that, uh, in my first visit, I oftentimes don't get to diabetes. It's a lot of just, how can we get to the appointment? How can we help you get medications? How can we make that affordable? Let's talk about your life first. I always tell people, if you are able to figure out how to balance your life, you will find the time to take care of your health.
But if I don't help you with that balance, how can I just expect you to just take on your health and all of your other problems all at once. It's just too hard to do. And we just need to admit that. So, let's just go one step at a time.
Shireen: And what are, what are some of those things that you do in that initial visit as part of setting that up for success?
Uma: Oftentimes I ask them very specifically. Are you able to afford food? Oh, yes, I can. Um, how many meals a day do you eat? Two? Do you eat two meals because that's all you want to eat? Or do you eat two meals because that's all you can have. So, I'm very direct about asking that question. Well, I'd like to eat three that I can't afford that. Let's talk about resources for being able to get you that specifically because diabetes is a condition that does have to do a lot with your diet and the food that you eat and the timing of that food.
How am I supposed to help you with your health? If you can't even tell me when your next meal is? My medications aren’t going to work. You're not going to be able to afford it and you're not going to find value in it. So, let's back up a few steps and just start with, let's talk to my social worker. Let's find out about food pantries.
Can you get SNAP benefits? Um, are you working within your family? What can we do to make that situation better? Housing security is another one. If you don't feel safe where you are, why would you care about taking care of your health? You're too scared about what's going to happen tonight. So, let's once again, reach out to resources, where can you be?
What are the resources? Oh, you have a family as well. Where can all of you be together? That's safe. Once I've kind of established that baseline. Then I move forward to now we're ready to talk about your health because you're empowered to know that you've got sort of the basics covered and now, we can build up from that foundation.
So, in my clinic, I do have a social worker. I have a counselor, I have a part-time psychiatrist, and educators. So, I have a lot of support staff whose only focus is some of these other things. Though my job, yes, is technically to talk about your health and your medications and all these sorts of complicated terms.
I can't do that unless I know that the entire 360 of your life is being taken care of. I'm just a sliver of that. And I need you to find that we are listening, and you can trust us because we're here for all of you, not just for this one part of your health.
Shireen: I love that approach, seeking really that holistic approach around it.
And you're not only looking at it from the medical lens, but you're also looking at what are some of those barriers in the environment that can prevent someone, regardless of what recommendation you provide to them. If there are other things that are more pressing, they're not going to be able to implement anything until those pressing needs are taken care of.
So, I love that holistic approach.
What are some of your priorities when training a patient who has insufficient or even intermittent access to money, to food, to housing, how do you approach that?
Uma: The first thing I do is I set sort of small, realistic goals. What can we do? So, using some of my resources, so maybe in one or two visits, now we have a safer place to stay.
Maybe we have a better source of food, but a lot of times that also comes with some barriers. I have a place to say, but it's 20 miles from here and I have to take two buses to get here. Okay, how are we going to do that? Bus pass discount, dart pass. What can we talk about there? I'm going to a food pantry, but the food pantry just provides high carbohydrate foods.
I mean, I would love for all of my patients to eat tons of vegetables and kale salads all the time, but they're extremely expensive. And also, not available at their local grocery stores. So, I start to talk to them about what foods are you eating. And that way I can balance what my treatment is with what you have access to.
And that's one of the beauties of having a long-term relationship. You start with a patient that maybe didn't have so much access. They had a wound on their foot, they couldn't work. And so they were at home, they were using a food pantry, but now their food is better. Now they're back. And they have more access to food and their diet changed as well.
Now I can change your medications to match that. Now I've built up enough money that we're able to actually shop at a different grocery store instead of the one that's down the street. Let's change your medications again. So, diabetes is always sort of a changing disease, but the treatment also changes with your life changes.
So, it's very important to stay in tune with the patient and what's going on in their lives. Sometimes people feel like I'm a little bit nosy. I'm like, I just am trying to understand what your world looks like. How many kids do you have? Are your kids also overweight or obese? We're not talking about your diet.
We're talking about your family's diet. Do you want your child to be sitting in this chair with me in 30 years? No, you don't. I know you don't. So, what are we going to do to make that different? Stop making a dinner for them and a dinner for you at dinner I'm suggesting for you is a healthy dinner for anybody.
So, start getting your kids to eat with you, have a dialogue with them. Why are you sheltering them from this? They love you, and they want to be part of your life and your health life. So, start putting them in charge. Oftentimes I tell them, put your kids in charge of taking you for a walk. When you come home and you're tired and you sit down, I'm the same way.
I don't want to get up from my couch and go somewhere. If my kids go, okay, it's time. We're going for a 10-minute walk. Let's go. I'm like, okay, they're going. I've had a lot of success with parents going. Yeah, it's a 10-minute walk. I'm like that. I was 10 minutes more than you ever did before. And it makes your child feel like they're helping you and they get to boss you around for once instead of you bossing them around and it really brings more family connection.
And when you tell them we can't do Chef Boyardee every night. We can't have pizza every night, cause it's not good for my health. They go, well, if mom isn't eating it, we should help her out. And we should all eat the same thing too. I was like cook together, choose foods together. Cause that's the habit that they're going to carry for the rest of their life.
So, you're not just influencing yourself. You're helping your children not go down the same path that you're on.
Shireen: How do you view that relationship? You mentioned briefly about, you know, being hungry, nosy, right? How do you feel that relationship and setting that relationship up with trust to where they're able to share that information with you?
Uma: So, I always like to tell my patients that I'm like their health coach what's happening to their body is happening to their body. Not mine. I can surmise what's going on. I can imagine how you're feeling, but I don't know actually what that feels like. So, I need you to be the information source for me so I can better understand that.
But ultimately this is your life, and these are your choices. I can give you tons of advice, but it's your choice, whether you're going to take it. The only thing I ask is always come back to tell me why you did or didn't choose to take my advice. I know you really don't want to do X treatment that I mentioned today.
Can you just think about that and think about your questions and your hesitations and come back to see me next time with them? Let's talk about it again. I'm going to bring it up because I think it's super important. So be ready for it, but you always have the right to say no. The idea here is we’re your diabetes clinic and we’re your diabetes family.
And that's kind of the way I kind of describe it to them, we’re your health family, you need to know the resources we have. If you suddenly find yourself without food or without shelter. And you're just not sure what to do. Call us. I know somebody. When you have a problem, I probably know somebody who can at least start that journey with you.
That's kind of how I start building that trust. And over time, people start to become more honest. They're like, oh doc, you're going to yell at me. Like why in the world am I going to yell at you? Well, I didn't do what you said. Things happen. So, tell me what happened that you felt like you got derailed?
Oh, well, my sugars were really high. I'm like. So, you tell me what's wrong with that. It's not really about criticizing. I have no place to judge it. This is your life. You're leading it the way you're leading it. If you feel disappointed with the outcomes, what can you and I work together and figure out how to make that outcome, something you desire.
When we talk about diabetes, a lot of times it has to do with numbers. Your blood sugar is this number. It is high, it is low, and you have to be very careful with the language that you use because they're just numbers. They're like, oh, my sugar was 320. Okay. And like, what does that mean to you? Well, it's just super high and I'm like, you realize it's just a number, right?
I can say numbers to two and 22, 410. I'm like, they're just numbers. The question is, is how much does that number control you? You are supposed to be controlling your diabetes, not allowing your diabetes to control you. You can view that number with whatever opinion you have, but you need to learn to go.
It's a 322, take two seconds and think about how did I get here. Huh? I ate that thing. I bet that's why it went high. You just learned a lesson now let's move on. Do not let this ruin your day. You made a decision, but you learn something from it. You go, if I eat that my sugar goes high. Next time I have to be careful, lesson learned.
Why are we beating that horse? Now we move on to the next opportunity you have. You'll check your sugar again and go, oh, look at that. It came back down some, good job, me. I was like, don't forget the good job me, and patting yourself on the back. When you do accomplish something. And it's not a perfect blood sugar, it's something where you go.
I did better. So, it's really about setting goals that are realistic. I always say diabetes is not a sprint. It is a marathon. We're not trying to get to the goal by the end of the week. You're not going to see me and everything's going to be perfect in a few days. What you have to go, as you saw me, we made some goals that I think I can actually accomplish.
And then next time I'm going to be super successful. We're going to totally celebrate and go. Okay. One more new goal. That's realistic. It's an, a complete life change. You're 45 years old and you've had habits for 45 years. Do you really think in four days, we're just going to change them? Let's be realistic.
Let's go slow and steady. We'll roll back. Sometimes we'll have barriers. We'll have, ah, took a vacation. Now we have a moment to reset, but if you can appreciate the ups and most importantly, the ups that are happening more than the downs, you're not going to be successful. I spent a lot of time clapping for people when they come into my clinic and go my sugars aren't 430, 350. I'm like, oh my God, 50 points. Did you ever think that would happen? They're like, yeah, but it's not perfect. I'm like, this is going for perfection. We're going for better. There's so much better than last time. Why aren't you celebrating. So, it's really that dialogue. And when they hear that enthusiasm and they hear that you're listening, that's what makes change.
Shireen: I love that you're taking this approach to where you're building that trust you’re, telling them to pat themselves on the back, celebrate their wins because it's hard. It's hard for someone to one, be diagnosed with diabetes, to be able to understand how to navigate it, how to, you know, how to manage it in their day to day.
And I love that you're taking this approach to say there is no shame. Uh, is what I'm hearing is, is essentially to say there's no shame. Tomorrow's another day. Just keep at it. Keep moving forward. Don't harp on what has happened but learn from it so that you're better set up for tomorrow.
Uma: That is correct.
Shireen: Absolutely love that.
So, Dr. Gunasekaran one of the other things that you mentioned around, um, sort of reinforcing that idea, how do you view these sorts of dynamic, just want to take a step back, but how are you viewing diabetes overall and the impact that diabetes having, especially given COVID-19? What are some of the things that you've observed there?
Can you walk us through what you saw over the past couple of years?
Uma: Uh, COVID-19 I would say it was very devastating, um, for everybody, but specifically people with diabetes and unfortunately, people who had diabetes and didn't even know about it. So many people who were being admitted to the hospital, um, who had high blood sugars, you realize they actually probably had it before and now they're coming in and they haven't been treated for that.
Um, here in Dallas County, one of the statistics that was just quite grave. The number one comorbid condition and mortality for people with COVID-19 was diabetes and having a high blood sugar, when you came into the hospital was an indicator and being unable to control your blood sugars while you were in the hospital, because the disease was so severe, also pretended a worse outcome as well, too.
So very difficult. Sort of thing that happened with COVID-19 was after hospital discharge, we had a bunch of new people who just learned that they had diabetes or that their diabetes had gotten worse because of COVID-19. There is some data out there that talked about how COVID-19 itself affects the pancreas.
Um, during the healing phase. So, for a couple of months after maybe you recovered from COVID-19, it may cause your pancreas not to work as well. And after a few months, your pancreas sort of heals from that whole process and gets better and starts to work the way that it was doing before. But those first couple of months are, are hard.
Many people go through extra treatment or more intense treatment and to be pulled back as well, too. So, a very, very difficult time in the diabetes community these past few years.
Shireen: What has been the implications of COVID 19 today? Um, what you see the impact of the past two years into what you see today?
Uma: So, the first part was the sort of new diagnosis part, but also one of the horrible things that we found was that people were not seeking out care during COVID-19.
Uh, they were staying home. Um, they were scared to go to the pharmacy. There was just this fear of potentially contracting this disease that we didn't really know a lot about. So, we had a lot of people who had come in and in very poor condition, heart attack or stroke, I've been out of my medications for two or three months.
I didn't go to see my doctor because I was scared to go to the center. Um, here at Parkland
health, we pushed a lot for telehealth visits to try to keep connecting with patients, trying to use a lot more mail order pharmacy, rather than having people to go in person, making lab appointments at random points during the day.
So, they could come in when it was less crowded to get their stuff done. So really trying to sort of get through that crisis, but we still have a lot of patients who are fearful of coming to health centers, wanting to access care, but having difficulty with that, we've learned a lot during the past few years and tele-health has really picked up and we figured out ways to provide care of more outside of our center.
That's still a problem for us now.
Shireen: You mentioned earlier in the podcast about, you know, talking to the parents and having this sort of a harsh moment with them to say, you know, don't separate yourself from this, that to say, doesn't have to be different for your family. It has to be the same for you and for your family being cooking, exercising, all of that. Um, have you, what have you seen, I guess, in terms of openness from the family to be able to embrace some of those healthy eating or healthy choices or exercise, um, how has, how does that even impact the patient's health and what have you seen there?
Uma: I've seen kind of a mixed bag. Um, sometimes patients bring in their family member with them to the visit.
I've often had children come on their day off with that appointment and I actually speak directly to the kids, and I go, look, this is your one and only opportunity in your life at this point to harass your mom. So go for it. I give you full permission, drag her off the couch and tell her we're going walking.
And she doesn't get to say no. And the patient will kind of look at me and I'm like, I'm sorry. I just told them that they have free reign over you when you come home from work. I’ve usually found the feedback from that experience is very positive. They end up saying that they actually talk about other things during said, walk that maybe they needed to talk about.
The family gets a little bit closer. Sometimes it doesn't work out so well. And I think it's actually the patient's own internal barrier. I don't want to deprive my kids of burgers. I don't want to deprive my kids of the sodas. I mean, they really enjoy the Cheetos and I, you know, they're just kids, let me just let them have it.
And it's really short of deconstructing what that means. You know, a lot of things that happen now in society or rewards or food. Great job. You got an a on the test. Let's go for ice cream. You know what you did a great job this week, cleaning up, let's go out to dinner. It's always a food reward. And in such a high calorie society, every reward is another thousand to 2000 calories, but you're also teaching the next generation that that's the only way you can be rewarded.
So why isn't it? Oh, we could go to the movies. Or we could do some activity together, for young children, stickers, crayons, new coloring book. Let's save up for that. If you get enough stars, we can get, this. That would be a healthier way to do it, but parents are usually imitating their own childhood. That's what they did when they were kids.
So, it's a very hard cycle to break, which is why I like having a counselor in my clinic because the most common reason why I refer someone to my counselor is not because they have a psychiatric disorder. It's actually to cope with having a chronic disease. Everyone just kind of assumes, I tell you, you have a chronic disease.
You're like, oh, great. Thanks for telling me I got this, and I will take care of it. I always say diabetes is something that doesn't go away. You did not get to get up this Saturday and go today. I'm not going to have diabetes. I take a little break. I'll pick it up tomorrow. It is everyday whether you want it or not.
And I ask you to do an incredibly large number of things. I need to take this medicine. I need to check your blood sugar. Don't forget to pick it up from the pharmacy. Be careful what you eat, where are you exercising by the way, did you check your blood sugar again? Did you pack everything when you were going on your trip?
What are you doing out here? Why are you at this place? Are you supposed to be eating here? That's the constant dialogue that's going in your head. I feel like diabetes is a life that you're living outside of your life. There are that many tasks. How are you supposed to put your regular life together with your health life?
It's very complicated and it's not easy to do so. A lot of times I send people to the counselor just to sort of talk through how can I make this work. Oftentimes people also are very hung up about their diagnosis as well, too. What's the most important thing in my life, diabetes? Well, that's a problem.
Number one, you should have said, me. I'm the most important thing in my life. This new job I have, oh, hanging out with my friends, doing stuff with my family. I'm like, that's what I want to hear at the top of the list. Not your diabetes. That's why we call it person with diabetes. You should be introducing yourself.
My name is Uma Gunasekaran. Oh, by the way, I have diabetes. I'm a diabetic. I hate that word. That's not who you are. You are who you are. You tell me, but it is not a disease. You happen to have that disease. So, I always tell people, diabetes is like the subtitle to your life. It is not the main headline of your life.
And if you don't transition in your own mind to that, you're always going to be putting yourself into, I'm never going to be good enough. My diabetes is a perfect and you're harping on something that should just be something that you unfortunately have as opposed to this is my life and this sometimes interferes, but I know how to cope with it.
And so, I feel there's a lot of power to counseling services to help people rebalance their lives. So, they're focusing on their personal goals rather than always just saying my health goals have to come first because they don't have to be mutually exclusive.
Shireen: Absolutely love that approach Dr. Gunasekaran it has been an absolute pleasure.
With that, we are toward the end of the episode. I’d love to know how can our listeners connect with you and learn more about your work?
Uma: Um, so, uh, I am an associate professor at UT Southwestern. So, if you want to learn more about specifically sort of the work that I do, there is a website at UT Southwestern. If you'd like more information about diabetes, we do have the parklanddiabetes.com website, which has tons of information, just about diabetes. Um, there are some videos on there as well, too. So, it's, it's a great website, even if you don't live in the Dallas County area and go to Parkland, there's just information that's available there as well.
Shireen: Lovely. Thank you so very much for your time on this episode today.
Uma: Thank you.
Shireen: And to our listeners out there after this episode, meet us on our Facebook page on our Yumlish page and answer this quick question. Have you ever had to compromise care for your health due to lack of income, food, housing? What has that journey been like for you? Head over to our Facebook page and let us know.
With that Dr. Gunasekaran it has been a pleasure. Thank you.
Uma: Thank you. Thank you so much for having me.
Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @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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