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 two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions. In today’s episode, we will talk with Dr. William Polonsky. This episode will be discussing stress, anxiety, and burnout, their connection to diabetes, and tips to overcome them.

Dr. Polonsky is president and co-founder of the Behavioral Diabetes Institute, the world’s first organization wholly dedicated to studying and addressing the unmet psychological needs of people with diabetes. Besides being a licensed clinical psychologist, he’s also a certified diabetes care and educational specialist and an associate clinical professor of medicine at UC, San Diego. Welcome, Dr. Polonsky. 

Dr. Polonsky: Thanks. Great to be here.

Shireen: A pleasure having you on. Dr. Polonsky diving right in, tell us what led you to build the Behavioral Diabetes Institute.

Dr. Polonsky: Well, I think we must have been out of our minds, who knows, but, in truth, I’ve been a diabetes psychologist for more than 30 years, and I realized we had a chance, in the early two thousands to finally bring together all the different things I do. And of course, I have some wonderful colleagues, especially my colleague, Dr. Susan Guzman, that we could have a facility and do something that actually no one in the world was doing, which is again, to have this center devoted to addressing these unmet emotional needs of people with diabetes, both as clinicians, seeing patients with diabetes every day, but also as researchers trying to understand the psychological, motivational behavioral issues and diabetes.

Also as, healthcare trainers, so we train healthcare providers and helping them well, appreciate the personal, [and] emotional side of diabetes and how they could do a better job of supporting their patients to be successful. So, we brought all that together into this institute and we’ve been proud of it every single day.

Shireen: That’s interesting that you’re taking that holistic approach. I do wanna talk a little bit about diabetes management and anxiety. Not only do we have to worry about what today’s blood sugars will do to our well-being 10 to 20 years from now we also have to worry about how the food we ate just moments ago or the exercise we’re about to do, or the insulin we took an hour ago is going to impact our blood sugar. Help us understand how anxiety is interrelated with all of this and the constant worry, that leads to that kind of anxiety. 

Dr. Polonsky: Yeah. You know, I hate to even call it anxiety, but I understand what you’re saying. There’s. There’s a, there’s, a significant amount of stress associated living with diabetes every day. I think fundamentally it’s because what people who don’t have diabetes don’t appreciate is that the day you develop diabetes, you know, what happened to you is the universe just said, Hey, congratulations. I have a new job for you to do. There’s no pay, there’s no vacations you should probably pay attention every day.

You know, for the rest of your life, and good luck with that. And by the way, you can add that job, on top of all your other jobs in your life, all of your other life responsibilities. So it’s understandable when you’re having to juggle all those extra balls that would get old and that would get tiring. And that’s when people start feeling. Pretty stressed out and overwhelmed

Shireen: Interesting. Let’s talk a little bit about that anxiety and that stress associated with it. What does a healthy level of anxiety look like? At [what] point does that anxiety become unhealthy? 

Dr. Polonsky: Yeah. You know, it’s funny, I think I’m gonna keep pushing back when you use the word anxiety because to me anxiety is unhealthy. But when we think about it as simply as stress, like being in a challenging situation, that’s different to have a moderate or healthy level of stress in your life. To feel a moderate level of feeling challenged in your life is something that to some degree we all need, and to some degree is how we see (…) every person with diabetes, how they sometimes, easily, sometimes not so easily, have to find this really funny point of balance or point of compromise between thinking about your health and your diabetes, all the.

On the one hand, saying, the heck with this, I hate this. I don’t wanna think about it. I’m just gonna ignore it completely. And so how do you find that middle ground? And I think what you brought up before was very important because I’m not gonna think about my blood sugars every time I eat. I’m not gonna be thinking about everything I eat every time I eat, but how do I find some balance, I’m doing it enough so I make it more likely I’m gonna live a long and healthy life. It’s, when I think about getting anxious when I think about feeling stressed out it’s that struggle people find between how do I, again, pay attention to my health, but not too much that it drives me crazy. Does that make sense?

Shireen: Mm-hmm. How do you know when you’re sitting in stress versus anxiety?

Dr. Polonsky: That’s a good question. I’m again, the problem when you ask a psychologist about anxiety, I guess. So when we see people feeling, I’ll just say too anxious or overwhelmed, what happens? Well, number one, the extreme end, what we call diabetes burnout. People get so stressed out and so full of anxiety about: “Am I doing the right thing?” “Am I okay?” “Am I paying attention to this?” They’ll just say the heck with the whole thing and they’ll just quit. I mean, again, it’s very similar to what we call job burnout.

Just say, this is too much. I can’t deal with this anymore. I’m taking a break. The problem, of course, is when you are so burned out, you decide to take a break forever and that leads to, of course, pretty bad outcomes because (…) you start ignoring. You know, the health demands of trying to manage diabetes, odds are pretty good. Your blood sugars, your blood pressure, your cholesterol’s gonna climb and climb and climb. You’re gonna end up, at significant risk for long-term complications down the road. It’s a little different between type 1 and type 2, but I hope what I’m saying makes sense. It’s, (…) there’s a certain level of tension, there’s a certain level of, peace one has to make of saying, I have this extra job and I can take it on.

It will be an effort and it will be somewhat challenging, but rarely will people say when they’ve been successful that they feel anxious about it. It doesn’t mean it’s wonderful and they’re having a good time with this, but they’re the anxiety is relatively absent.

Shireen: Interesting. Can you also speak in, you know, when you’re talking about the diabetes piece in particular, can you speak to if there is a link between blood sugar levels and feeling that level of stress and then leading into that level of is there a link there? What have you seen?

Dr. Polonsky: Sure. There, well, there’s a fair amount of, research evidence I can tell you about as well. Is there a link between stress and blood sugars? And the answer is yeah. Absolutely but there’s two different kinds and this is what [is] important. So one thing is, does being stressed out or getting really anxious, I’ll use your term– “Does it have a direct impact on causing blood sugars to go up?” and under certain conditions, the answer is yes. So, for example, if you’re really in some major traumatic bodily stress, for example, surgery. Odds are pretty good that will cause your blood sugars to rise, but day-to-day stress really affects people differently. For some people, just emotional stress will cause blood sugars directly to rise through hormonal changes. For other people, it doesn’t seem to have a much impact. Now hopefully that wasn’t confusing cuz I got to say one more thing. But there’s this other fairly consistent relationship between high levels of stress and [a] negative impact on your blood sugars.

And that’s because when you have high levels of stress or anxiety, it tends to affect what you’re doing all day, it tends to affect how much mental or physical energy you have to deal with your health or deal with diabetes. And so what we see is and everyone who’s watching this right now understands this. When you get stressed out, you don’t tend typically say, boy, I could really use some carrot sticks to make me feel better. There’s a tendency to go for foods that aren’t gonna be the healthiest choice for you, that are gonna probably drive up blood sugars. You’re probably when you get particularly stressed out, you may give up healthy habits like, well, I don’t have time.

I don’t have time to exercise today. I don’t have time to check my blood sugars or even take my medications. So under stressful conditions, sometimes your health and your diabetes care falls to the bottom of the pile of things you might be wanting to worry about at that point in time. So, therefore, that kind of stress indirectly through how you live your life leads to higher blood sugars. Does that make sense? 

Shireen: It does. And I want to, I wanna talk now about, so, you know, you’re, you’re talking about the lifestyle component. Eating, wanting to eat carrot sticks when you’re really, really stressed, it’s like, doesn’t happen that often. How can anxiety affect our lifestyle? Diet choices exactly to what you alluded to when managing diabetes. Can you provide tips to identify our own personal symptoms of anxiety and really to help us develop that awareness and understanding around it? 

Dr. Polonsky: So probably not, I’m trying to think what you’re asking, cuz it seems like you’re, maybe this is gonna be your next question, but you want to talk about solutions, right? I mean, you really want to get to what can you do about some of this, right?

Shireen: But we need to identify it first to be able to do something about it. 

Dr. Polonsky: Maybe, maybe. So I’m not sure that’s true. Again, when I think about how people struggle around making less-than-healthy choices in what they eat every day. A lot of it is driven by circumstances and not by anxiety. It’s very funny. I remember a long time ago I used to run a weight management program for people [with] diabetes, and we used to do this funny thing where say, you know when you: “what drives you to want to start binge eating?” “What, you know, what drives you to make really unhealthy choices in what you eat?” and someone will say, well, it’s definitely when I get depressed and someone else will say, it’s definitely when I get scared about something and someone else will say, it’s definitely when I feel happy. And the more we talked about it, it became kind of funny. It was sort of like, well, actually any feeling well might lead you to make those choices.

So it’s often not as straightforward as saying, anxiety directly leads to someone making a less-than-healthy choice. That’s why I don’t mean to drive you crazy here. I don’t mean to, make this difficult, but it’s hard for me to think about it in that way. But we can still talk about solutions. You know, for people who are struggling with their weight, when they’re struggling with making unhealthy choices and what they eat,– “how do we understand what’s really going on and what can you do about that?” That’s something we’ve all been talking about and researching about and thinking about forever.

And it remains we’re, we’re humbled in the face, especially when we talk about. If we think about people with type 2 diabetes who are struggling with their weight, for example, we are to a large degree, humbled in the face of how to help people lose weight and keep it off. There’s this tendency to think because there’s a million people who wrote, who wrote books about this, that it must be some simple answer and I just haven’t figured it out, or I don’t have enough self-discipline or willpower. That’s just not true. In truth, we don’t really have truly powerful and successful behavioral interventions that can help people lose significant amounts of weight and keep it off. We have medications that can help people do that. 

We have interventions that seem to help some people lose weight and keep it off, but we are still humbled in the face that we’re dealing with metabolic activities that we don’t really even understand. You know, the, there’s a genetic propensity for struggling with one’s weight. There’s all sorts of other factors, so I. As a psychologist, I’m always sharing that with my patients because I wanna say, if you’re having a tough time managing your weight, number one, welcome to a very big club and know that it’s probably not your fault. It’s not because you have been undisciplined or bad or being too anxious. It has to do because this is a very difficult and challenging task that, well, at this point, the majority of Americans are facing.

Shireen: Speaking of the majority, I wanna get into and talk about developing, generalized anxiety disorder, especially after a diabetes diagnosis. What does that correlation look like and what have you seen sort of lead to it? 

Dr. Polonsky: Yeah. It’s so funny cuz I keep wanting to change the subject. There is not much of a relationship. I mean, there have been lots of studies that have looked at, if we look at clinically diagnosable anxiety conditions like the one you mentioned, generalized anxiety disorder and whether or not that’s more frequent or prevalent amongst people with diabetes compared to people who don’t have diabetes?

The answer seems to be not really. There’s some relationship if we looked at things like depression, but in terms of anxiety disorders, not really. There are very specific kinds of anxiety that are related to diabetes, and that’s anxiety around low blood sugars, what we call the hypoglycemic fear syndrome, where people can be so scared of having a low that, something terrible might happen to them. They just keep their blood sugars high all the time and that really is an anxiety disorder for many people. But it is interesting, a generalized anxiety disorder. Not really more common in people with diabetes. The combination’s still bad. You don’t really wanna have a generalized anxiety disorder and have diabetes, but it’s prevalent everywhere.

Shireen: I do wanna touch on what you just mentioned a minute ago around depression. You mentioned there, there being studies around that. Can you speak to the correlation between depression and diabetes? And I’ve kind of heard it both ways. Is one causing the other and then back. So can you walk us through some of that?

Dr. Polonsky: Yeah, and again, I, you’re gonna have to interrupt me cuz I can get into this way too long. This has been a subject we’ve been studying forever. You know, we used to believe from very early research that people with diabetes were at a tremendously higher risk for depression compared to people that didn’t have diabetes. We’d say triple the risk compared to people who didn’t have diabetes, double the risk. And we’d go, oh my God, what’s going on? And we realized that was a mistake in how we were measuring things and the most recent research, I was a co-author on a paper published just a few months ago that looked at depression rates and people with diabetes around the world.

Does suggest people with diabetes are at somewhat of an elevated risk, but not nothing like what we used to think and if we look at just data from the US, it’s even more mixed. There’s some suggestion that it might be people with diabetes aren’t really at much-elevated risk at all compared. It’s really still a bit confusing. But there is, if I had to put it all together and I think about that large review from around the world, we’d have to say people with diabetes are somewhat of an elevated risk, but it’s again, not gigantic. We do know that if you do have diabetes and you have a significant clinical depression, if you really have a diagnosable depressive disorder, like what we call major depressive disorder, that’s [a] really bad combination with diabetes and we know that.

Well, think about what depression does to you. Depression kind of just sucks the oomph out of us. You know, you may not have the energy to do anything. There’s what we call anhedonia. Nothing really gives you much pleasure anymore not, and of course, there’s just this sadness and misery and gloom and so we know that depression for many people makes it harder to make and maintain healthy behavior changes like again, trying to follow a diabetes-friendly way of eating or keeping up a regular activity program or bothering to check your blood sugars. We know the combo is, pretty bad but let me mention one last thing about that. Our more recent evidence suggests that we’ve made a big mistake that a lot of people who might be told or might think that they have a depression disorder and have diabetes. Oftentimes it’s not depression. What they have is what we call diabetes distress, that they’re really just fed up, overwhelmed, freaked out often feel just doomed by diabetes, but their diabetes burnout, if you will, has become a big, big thing.

That’s an important difference because the solution there is not, here’s a couple antidepressants to take. It’s, let’s talk to a healthcare provider about what’s driving you crazy about diabetes. Let’s understand how frustrating and aggravating, stressful, [and] anxiety-provoking this is for you, and let’s brainstorm what we can do about that by working together. So it’s a very different kind of intervention.

Shireen: Interesting. We’re coming up to, we’re at the end of this episode here, and I do wanna squeeze this question in Dr. Polonsky with you is, you know, we’re, we’re talking about diabetes and then we’re talking about stress. We’re also talking about anxiety on this episode, having to pay close attention to what you’re eating and having lots of new things to learn, and remembering all of those different things. Can you talk about, if there is an association between that level of stress and insulin resistance?

Dr. Polonsky: Huh. well, you know, it’s funny cuz you actually brought this up before, which is about to, and if you excuse me for coming back to it says depression cause diabetes or say just depression cause insulin resistance, which is the heart of type 2 diabetes. And again, there’s been a couple [of] studies that suggest depression may actually increase your risk for developing type 2 diabetes, not type 1. If that’s true, we don’t really know what that would be. 

Depression by itself will never cause type 2 diabetes on its own, but it’s one more straw on the camel’s back that might be contributing to that. Do we have any evidence of depression all by itself might cause insulin resistance directly? We don’t have any evidence like that. It might be the depression if it contributes to significant weight gain in susceptible people that might contribute to insulin resistance, but, we got a lot to learn. We don’t really know.

Shireen: What tips would you provide to listeners who are listening to this episode? Perhaps stress, perhaps, have anxiety related to their chronic condition, be it diabetes or another, or a caregiver who’s managing that for someone? What tips would you provide to them? 

Dr. Polonsky: Sure. Oh, I’m so glad we’re finally talking about this. My favorite subject, because it would be pretty sad if we didn’t get to this. You know, there’s two things that you made me think of. One is we, you mentioned about how much stuff there has to do once you learn you have diabetes, and in fact that’s true. If you go to a good diabetes education program and just listen and just write down all the different changes you should make in your life. All the different tasks you should take on. There’s probably more than a hundred things. And one of the things we also know is that tomorrow morning you’re not gonna be able to do all a hundred of those, even if you felt like it.

One of the things that we failed to do is we failed to save for any particular individual. You know, of those hundred things we can put them in order of priority and. Why don’t we just pick the top 2, 3, 4 things that are gonna be, provide you with the biggest bang for your buck. In other words, we can help people feel less overwhelmed by saying, don’t even try and do everything, you know, let’s, let’s just see if we can focus on one or two things, or three or four things that really are gonna help you get to a safer place with your diabetes. And that don’t have to overwhelm you with what you have to do every day. You don’t have to watch every single morsal that goes in your mouth, for example, but you know, probably should quit smoking if you’re a smoker and , you know, if you’re seeing a good doctor and if you suggested the right medication, well taking, it’s a really good idea,

So we could talk about that. We could talk about other dietary interventions, physical activity things, but by putting them in order of priority and saying, Hey, let’s just tackle them one at a time. Oh, it’s such a relief when people get to hear that. The last thing I’ll mention though, that we know they can really make a difference if you’re living with diabetes and you’re feeling overwhelmed or you’re feeling stressed out or you’re feeling really anxious. 

If in any way possible, just don’t do diabetes alone, you wanna have people in your life who were supporting you and supporting you in the right way, not nagging you and being policemen, but people who get it and can, you know, give you an attaboy when you need it. And that can be loved ones in your own house. It could be friends; it might be p people you meet in support groups. It could be folks you meet online and in Facebook groups or other places with people who, who get it and who can understand where you’re coming from. And that sense of being not so alone with diabetes is huge and seems to be the key to how people can feel better about taking on that job of diabetes, and being successful over time. 

Shireen: With that, Dr. Polonsky, we are unfortunately toward the end of this, uh, episode at this point, I would love for our listeners to know how can they connect with you and just learn more about your work.

Dr. Polonsky: Well, the easy, easiest thing to do is just come to our website, which is behavioral diabetes.org, behavioral diabetes.org. That’s the website for the Behavioral Diabetes Institute you can find out about all the different things we do, all the different things coming up. We have a lot of print materials. Almost everything we have is free. Some of them are pretty fun and that would be the single best way to get connected with us. So thanks for asking. 

Shireen: Absolutely. Lovely. And it was such a pleasure having you on. Thank you so very much for your time, Dr. Polonsky. And to our listeners who are listening to this episode, have head over to our social media after you hear this episode, find the podcast post on our social media channels, on Facebook, on Instagram, and go on there and answer this super simple question, “Do you have a support system or community to fall back on when you are stressed when you’re anxious?“ and it doesn’t even have to be related to diabetes. Just knowing that you have someone, tag them below and we’ll see you there after the episode. Dr. Polonsky, thank you so much.

Dr. Polonsky: Thanks.

Shireen: Thank you for listening to the YumlisPodcast. Make sure to follow us on social media at Yumlis_ on Instagram and Twitter and atYumlish 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. You can also visit our website, Yumlish.com for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week’s show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we’ll see you next time. Remember, your health always comes first.

Stay well.

Connect with Dr. Polonsky:

• Behavioral Diabetes Institute
• Linkedin