"My Feet Hurt!" - Type II Diabetes Mellitus (Part I)

In the first episode of our type II diabetes series, our patient Tabby joins us for a discussion on receiving and coming to terms with a diagnosis of diabetes.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===

1. Introduction
2. Chapter 1 - Screening for Diabetes
3. Chapter 2 - Diagnosis/Breaking the News
4. Chapter 3 - Setting Expectations After the Diagnosis
5. Chapter 4 - Shame, Stigma, and Support
6. Conclusion

=== Learning Points ===

1. Screen all adults >35yo for diabetes every 3 years. You might screen other patients if  they have risk factors placing them at higher risk
2. Begin conversation about diabetes before ordering tests
3. Ensure that you have enough time to listen to and address patient's concerns about a new diabetes diagnosis
4. Be attentive for signs of distress in patients with diabetes, which could affect their care.

=== Our Expert(s) ===

Dr. Tracy Rabin is an Internist and Pediatrician who joined the Yale faculty in 2011 as a member of the Section of General Internal Medicine (YSM Department of Internal Medicine), and currently serves as the Director of the Office of Global Health, and the Associate Program Director for Global and Community Health in the Yale Primary Care Internal Medicine Residency Program (YPC). She co-directs the Makerere University-Yale University (MUYU) medical education capacity building collaboration which is based at the Makerere University College of Health Sciences/Mulago National Referral & Teaching Hospital in Kampala, Uganda.

=== References ===

1. [American Diabetes Association] Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers: https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022  
2. Diabetes Distress Scale: https://diabetesdistress.org/take-dd-survey

=== Recommended Reading ===

1. [CDC] 10 Tips for Coping with Diabetes Distress: https://www.cdc.gov/diabetes/managing/diabetes-distress/ten-tips-coping-diabetes-distress.html 

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts for furthering the medical education of residents and clinicians in early stages of their careers. Building on the work of other medical education podcasts, Primary Care Pearls includes contributions from patients themselves, who have the autonomy to share their own experiences of how their primary care physician directly impacted the quality of their care.

Hosts: Katie Gielissen, Maisie Orsillo
Post-Production Assistant: Helen Cai, Christina Liu
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: the Mini Vandals, Wes Hutchinson, E's Jammy Jams, Futuremono, Ammil, Emmit Fenn, Humam-Huma, Patrick Patrikios, Jesse Gallagher, Emily A. Sprague, Corbyn Kites

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

[00:00:00] Katie: Hi and welcome to primary care. Pearl's a podcast made by learners for learners and led by our patient stories today. 

[00:00:08] Tabby: I'm not playing. My feet hurt. I fell down the stairs. My legs were twisted behind me. . And I cried. I cried. I cried. Because I realized that I've waited too long. I've waited too long. Should Should've done something

[00:00:42] Katie: We're talking about diabetes. Part one in our three part series on type two diabetes type two diabetes is one of the most common diagnoses we encounter in the primary care office.

According to the most recent data from the centers for disease control, approximately one in 10 Americans have diabetes. Of these individuals over 90% have type two. Despite efforts to improve screening and diagnosis, it is thought that over 7 million people with diabetes remain undiagnosed

[00:01:16] Maisie: during our discussion today, we'll be joined by Tabby a patient living with diabetes. 

[00:01:22] Tabby: I tabbed with a blunt. My age is 32. I go by Tabby 

[00:01:43] Maisie: We'll also be joined by an expert from the Yale school of medicine

[00:01:47] Rabin: My name is Tracy Rabin, and I'm a med- peds physician. I'm the associate program director for global and community health in the Yale primary care internal medicine residency program. And I'm also the director of our diabetes clinic within our resident and faculty practice.

[00:02:04] Maisie: With the conversation facilitated by our resident interviewer, Dr. Alyssa Chen

[00:02:09] Alissa: I'm a third year resident in internal medicine and the Yale primary care program and will be chief next year. 

[00:02:17] Maisie: My name is Dr. Maisie Orsillo and I'm a second year internal medicine, primary care resident at Yale. And I'll be co-hosting this episode with our faculty interviewer, Dr. Katie Gielissen. 

[00:02:28] Katie: I'm Katie Gielissen I'm an assistant professor of medicine and pediatrics at the Yale school of medicine, and I'm a primary care doctor. 

[00:02:36] Maisie: And we hope that through this discussion, that listeners will become more familiar with the screening criteria for diabetes, making a diagnosis of diabetes and how these conversations impact patient's lives.

Aside from elevated BMI type two diabetes is the most common diagnosis we will see in our primary care office. Therefore, knowing when and whom to screen for diabetes is an essential skill for any primary care physician. So, Dr. Gielissen are you excited to talk about diabetes? 

[00:03:03] Katie: I can't express to you how excited I am to talk about diabetes.

It's one of my favorite things to teach, and it's  one of my favorite things to treat in the office. 

[00:03:23] Maisie: And I'm so excited to talk about this because not only do I learn so much from working with both you and Dr. Rabin,  but living with type one diabetes myself, I always really enjoy connecting with patients over their shared lived experience and, coming to a common understanding of how they can better manage their diabetes. So super excited. 

[00:03:42] Katie: Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice.

If you or a loved one is suffering from anything covered in today's episode, please be sure to discuss it with your medical provider onto the show

Chapter 1: Screening for Diabetes

[00:04:03] Katie: So let's begin by hearing a bit about who should be screened for diabetes

the standards related to screening for diabetes have actually been changing over the last couple of years. So as of the 2022 American diabetes association, standards of care guidelines we think about screening For diabetes in several categories of folks.

first off, anyone who is 35 years of age or older should be screened for diabetes. That's actually, that's one of the biggest changes because the age used to be higher for adults. So 18 and over who are overweight We should be screening them for diabetes if they have an additional risk factor, at least one additional risk factor.

 And we think about folks who have a history of cardiovascular disease things think about folks with hypertension with low HDL cholesterol or high triglycerides folks who are not particularly physically active. So generally, so thinking about testing for folks 18 and over who meet those criteria.

And also individuals who were diagnosed with gestational diabetes during a prior pregnancy uh, should be screened for diabetes.

And then also there's a recommendation that people living with HIV should also be screened for for diabetes.

[00:05:21] Alissa: For people who are previously pregnant had gestational diabetes. Is there a timeline in which you rescreen them like after the pregnant.

[00:05:28] Rabin: So I usually think about probably about six months or so the pregnancy. And then, but the most important thing is that those are individuals who be, should be screened every three years. And that's, for life. So thinking about them as being a category of folks who are at higher risk over time 

[00:05:44] Alissa: and then those people with risk factors, how often should we be screening them?

[00:05:49] Rabin: Yeah. Typically I think about screening those folks at least annually. Although certainly if people start to develop symptoms of hyperglycemia, then you'd be more concerned about.

[00:06:00] Katie: That was a lot of information.

So let's pause and review. Who should be screened? 

Number one, everyone who is 35 years of age or older, 

Number two women with a history of gestational diabetes.

Number three, patients living with HIV who are currently on or about to start art. 

Number four, individuals meeting criteria for overweight who have one or more risk factor. 

[00:07:04] Alissa: When we're screening, what tools do we have available to us?

[00:07:08] Rabin: So there's a number of tools that we have. I think probably the most common tool that folks use would be a hemoglobin A1C. There's also the fasting glucose. There's also a random blood glucose. So any of these, there are different criteria for each of these.

But there's also the oral glucose tolerance tests that can be used as a screen diabetes. It's much less commonly used in our practice. It's a little bit more labor intensive for the patient. But yeah, any one of those would be appropriate testing to be using.

So how do we know someone might have prediabetes? Results indicating prediabetes are an A1C of 5.7 to 6.4%, a fasting blood sugar of a hundred to 125 or an oral glucose tolerance test result of 140 to 199. Dr. Gielissen, which of those tests do you. prefer to Use

Dr. Gielissen: in general, I prefer to do an A1C mostly because, uh, you can check at any time of the day you'd like to, um, unlike a fasting glucose test, which needs to be checked after a period of a fasting of at least eight hours. And of course, an oral glucose tolerance test is a two hour long test where patients have to wait to get their final result.

[00:07:40] Maisie: let's hear a little bit from our patient about her experience with screening.

[00:07:45] Tabby: The doctor had mentioned to me that he says you're borderline and That was just, it you're borderline diabetic and we moved on to something else.

Didn't really understand what that meant at the time. I was pretty young. So he said it, I didn't understand it. I didn't have any symptoms. I forgot about it. I just act like it wasn't there.

[00:08:25] Alissa: how do you talk about pre-diabetes with your patients when they meet criteria?

[00:08:29] Rabin: Yeah, so pre-diabetes it's an interesting concept, right? 

[00:08:33] Katie: According to some reports, this term was created to help stir action around a strong risk factor for development of diabetes. 

[00:08:40] Maisie: Interesting. Isn't there a bit of controversy around this? 

[00:08:43] Rabin: There's a lot of debate about whether it is harmful or helpful to tell someone that they have this diagnosis. What are the criteria for pre-diabetes? We're looking at blood sugars, we're looking at A1C sort of on a continuum and we've decided that this cutoff point is the line between diabetes and pre-diabetes. I think probably the most important message to get across to people, whether you use the term pre-diabetes or not, is that, the results that I see in your blood work show me that you are at a higher risk of developing diabetes in the short term, then you may have been previously.

I think that's the most important message is to let people know that they've moved on that continuum into an area where really there, there are some great interventions that can be done in terms of, again, diet and exercise, and even thinking about medications at that point. There are things that can be done to delay the onset of diabetes to stave off this diagnosis.

my experience I've seen people really react poorly, you know, thinking about now I have another diagnosis that I'm carrying around now.

There is some other thing uh, can almost Be more psychologically burdensome. You think about the concept of diabetes distress, almost thinking about the pre-diabetes distress. That's not necessarily an entity that I've seen in the literature, but I know That there is controversy about whether we should use that word or not.

 [00:08:33] Katie: According to some reports, this term was created to help stir action around a strong risk factor for development of diabetes[00:10:32] Katie: even the American diabetes association, the ADA says that prediabetes should not be considered a clinical entity in and of itself, but it is part of the lexicon and many patients may be familiar with this term.

[00:10:46] Maisie: regular screening based on patient characteristics and risk factors can help detect diabetes earlier in the course while it is not fully established that early detection improves long-term outcomes ,we know that as in Tabby's case, patients can have a long asymptomatic period and treatment of diabetes can affect outcomes. That impact morbidity and mortality in our patients, especially cardiovascular disease and microvascular disease. Prior to the diagnosis, early detection of insulin resistance provides us opportunities to partner with our patients and work on lifestyle modification.

Chapter 2: Diagnosis/Breaking the News

[00:11:23] Katie: well said Maisie, let's transition to making the diagnosis of type two diabetes and how it impacts our patients. 

[00:11:30] Tabby: I found out I ultimately had diabetes when I moved from Pennsylvania to Connecticut. I didn't have a primary care doctor and.And when I got here and they put they gave me a primary care doctor.

That's when I started really starting to take tests and understanding that I had diabetes, but again, I had no symptoms. And it was just told to me you have diabetes, here's a pamphlet. If you want to know anything, the best thing for you to do is just look it up on Google was what I was told. And if you have any questions, call the office and that was that.

[00:12:30] Katie: How did that feel to get information that way 

[00:12:33] Tabby: it was confusing? It was very confusing. I cried about it. I laughed about it. I dismissed it. my first initial thing was to shut down because I feel like I'm going to get another pamphlet. I felt like someone was going to say to me, go on Google and find out all your information. In my head, I shut down, even though that primary care doctor was more than willing to help me and not give me a pamphlet and take the time out to actually teach me what's going on again, I had no symptoms, so I have no symptoms.

I'm okay.

[00:13:44] Alissa: I think Tabby talked about this so well, is that the diagnosis of diabetes can be really huge for a patient. And so when you're having that first conversation with a patient and you're diagnosing them with diabetes, what are your goals in that first conversation?

[00:13:59] Rabin: That's a good question. I mean, I think that the, the conversation really should be starting before the test gets sent explaining to the patient and this goes really for any time that we're doing we're doing testing or imaging really explaining to the patient what it is that we're looking for.

And so I like to to explain to patients that, some of the tests that we're sending are going to be looking to see how their body is handling sugar and that they may have heard of a condition called diabetes. There. They may have family members who who have diabetes or other significant individuals in their lives.

So I like to to, even at that point before I even order the test, just try to get a sense of what people know about it. And if they have any particular concerns about having a test done in the first place. 

[00:16:11] Katie: You know, I think that is a fantastic Pearl. When I'm sitting in an exam room with my patient, it's just so easy to order the tests and not take the time to talk about what they could mean.

But when you have a test that could potentially impact someone for the rest of their life, especially if you think there's a reasonable concern, they might have diabetes. It's really on us to prepare them for that result.

There are four tests available to diagnose diabetes. In order to make the diagnosis, two different tests can be ordered on the same blood sample. And if both of them are abnormal, there's no need to repeat testing on a different day, which is something older guidelines used to recommend

The first test is hemoglobin A1C, which measures glycosylation of red blood cells. And it gives you an estimate over three months, how the blood sugars have been an A1C of greater than or equal to 6.5% is considered a diagnosis of diabetes. The second is a  fasting blood glucose and a value greater than or equal to 126 milligrams per deciliter is consistent with a diagnosis of diabetes.

the third is an oral glucose tolerance test. This is a test that checks the blood sugar levels before and two hours after the patient drinks, 75 grams of glucose, a result greater than or equal to 200 milligrams per deciliter is considered consistent with diabetes. And lastly, you can check a random glucose and this should only be done in the setting of symptoms of hyperglycemia, a result greater than or equal to 200 milligrams per deciliter is considered consistent with diabetes.

[00:16:34] Rabin: I think I think even for, for those highly motivated and energized patients, to give them a sense of there are changes that, we may be able to make with respect to your diet and thinking about how exercise and movement fit into your life. 

These are all things that we can work on. But even in that first visit, if I have the opportunity, I like to set an expectation with folks to say that, diabetes is a chronic disease. It's something that most people will live with for many years. And over that period of time, their needs are going to change.

Their body's needs are going to change. They may do fine with no medication. They may be able to control it with diet and or exercise for some period of time. In the beginning over time, they may need They may need insulin. They may need injectable medication. if I have the opportunity to talk about this, I do like to share that, none of those things represent a failure on the part of the patient.

It's just that it's a progressive disease. It's a chronic disease, it's a progressive disease and everyone's body reacts differently. Everyone's body is going to have different needs over time. And I think one of the reasons I feel strongly about trying to set that up even at the beginning is because you see so many patients who come in and they're at a stage where maybe they need to start on insulin or they need to intensify their therapy.

 and you just see them feel so devastated and feel like it's my fault. I did all of these. I was trying so hard and I didn't do a good enough job. And I feel like if we can try to get at that from the very beginning, then it's going to lead to less emotional distress down.

[00:28:54] Alissa: when you're having that first with that patient, who's just been diagnosed the diabetes. do you close the visit and had, and give them expectations for the future and what their future with diabetes might be like, or the future of their diabetes?

[00:29:09] Rabin: I think that also is very patient dependent, right? Because I think, we've all had the experience of sharing news with patients and it may be more or less difficult news for them to take. So there are some folks for whom you say, your blood work results show that you have diabetes, and that may be the last thing that they hear.

Tabby: Nine times out of 10, you're si tting there as a patient and you're so nervous and got yourself worked up. You don't remember nothing You talk. 

Rabin: And so anything else beyond that really needs to be saved for another time and just really focus the rest of that visit on managing emotions or managing, how am I going to tell my family member, it really depends on how someone reacts to the news. That said there certainly are some patients who hear the news and their first response is all right, so what do I need to do? Where are we going to go? Let's get this under control.

Make sure that you have the time to speak to your patient, even if you have to schedule them at the end of your roster for the day in the middle whatever you have the most time. If you have to fill two spots for them as two patients do that. Because this is news. It's almost like to the patient.

You're telling them you have cancer. It's very serious to tell someone they have diabetes If you just tell them when you got diabetes and we're moving on, don't do that because it's a blow. It's really a blow. Let them know that you're there for them. Let them know all the resources that are available to them. Don't just slap a pamphlet in front of them. If that's the only thing you have go through the pamphlet with them.

Explain to them. Look, do you understand what this means? Do you understand what it means to take your sugars? Do you know what range you should be in? What do you know about diabetes? Make them feel comfortable 

[00:29:52] Maisie: Sharing the diagnosis of diabetes should include space for the patient to express their emotions and reactions to the diagnosis. When they are ready, it is important to prepare them for the chronicity and progressiveness of the disease. As we learned from Tabby, we can really make a difference in how this bad news can be shared in a manner that makes the patient feel supported.

Chapter 3: Setting Expectations after the Diagnosis

[00:22:13] Katie: I think that's great wisdom, Maisie, as we know, type two diabetes can be a long-term health condition that affects patients to varying degrees. Some patients may not even have symptoms, especially early in their course, given this, how do we orient them to diabetes and prepare them to work with their doctor over the long-term. 

After you got your diagnosis what changed about your life?

[00:22:38] Tabby: Nothing. Because again, I pretend like I didn't have it. I was having no symptoms. It was kinda like I'm saying. You have a cold, you need to take this cold medicine, but you don't feel like you have one in my mind. It wasn't registering. Why take this cold medicine? If I don't feel like I have a gold.

I believe I started on a kind of a pill. Yes I did. Yes I did. And If anybody knows me, they know that I've never been a medicine girl ever. It was even hard for me to take Tylenol. I lay there. I'm hurting. Take Tyler on norm. Okay. So it went from that to here, take this medicine because you need it.

But I'm not feeling it. I don't feel anything. So it's I'll take it today. I'll take it tomorrow and stop a week. I come back for two weeks. It wasn't a real necessity to me. I was still eating what I wanted to eat, drink what I wanted to drink. Best times for me is in the middle of the night when I'm thirsty.

I'm not realizing that my extreme thirst is telling me that my sugars are high. So what do I do? I go get another cup of juice that doesn't work. What happens? I go get another cup of juice and before I know it the pitcher’s gone and I'm like, did I drink all that? Yeah, I did.

Maisie: I think it's helpful to go through symptoms that patients may be experiencing when we think about screening for prediabetes or diabetes. So some things that I like to ask about are, if patients are experiencing excessive thirst, if they're urinating more frequently than usual, if they're really if they're having any vision changes or maybe increased hunger, uh what are some other things you look out for? Dr. Gielissenn?

So those are definitely things I ask about Maisie. Some other things that might be good to ask about are unexplained, weight, loss, numbness, or tingling of the hands or feet and recurrent yeast infections of the genital area.

[00:24:07] Alissa: like Tabby, like a lot of patients struggle when they don't have symptoms of diabetes yet we're finding in our testing that they have it. How do you handle that?

When talking to a patient? 

[00:24:18] Rabin: certainly, I'm, I'm sympathetic to the issue and our patients are dealing with so many different concerns, so many different priorities at the same time. And it's understandable to think that if you're not having symptoms of a specific condition that may not feel like the biggest priority for you to be focusing on at any one given point in time.

And so if somebody is not having symptoms and feels and they're struggling with really implementing changes that would help them control their sugars. Then I like to talk to them about some of the downstream effects of uncontrolled diabetes 

Dr. G: So there are a number of downstream sequela we wanna screen for in patients with type two diabetes. So I'm gonna list each of those and then Maisie, why don't you jump in and tell us how we're gonna screen for those. So number one, retinopathy.

And so we wanna make sure our patients are getting an annual dilated eye exam with their optometrist or ophthalmologist

number two, peripheral neuropathy. .

And so for that, we can do a comprehensive foot exam in the office checking for any sores or ulcers, and also performing a monofilament exam,

number three, cardiovascular disease.

So it would be helpful to calculate a patient's ASCVD risk score, discuss starting statin therapy, uh, around age 40 and discuss daily aspirin or clopidogrel therapy. If a patient has an aspirin allergy starting at age 50, as well as discussing smoking cessation

number four nephropathy.

So we can perform an annual spot urine album into creatinine ratio,

number five gum disease and other mouth problems.

So patients should ideally see their dentist at least once a year, if not every six months

and number six cancer.

And so we wanna make sure we offer all patients age appropriate cancer screenings.

[00:25:18] Katie: Do you have any advice for somebody who just got a diagnosis of diabetes? 

[00:25:23] Tabby: Yes. Listen to what your primary care doctor says. Okay. Even though you have no symptoms, it still there. I promise you. It's still there. Take it easy, take a couple of days, get yourself together because sometimes it feels oh my God, this is something that I can't handle or it's going to be too much. Or I can't stick myself with a needle. I can't stick my fingers every day. You can, you absolutely can. And when it gets to the point where you start to feel it, you're going to wish you did it.

[00:26:06] Katie: What helped you transition to like being like, yeah, I have diabetes and this is something that I want to work on.

[00:26:13] Tabby: Okay. Funny thing is I've worked as a CNA. I worked in nursing homes and I've always had problems with my feet. Could never find a right shoe. Could never find the right insert. But when your a CNA it's go, go, go, go, go.

There was plenty of times where I would go to the break room and my feet would be throbbing. So it's take a couple aspirin, suck it up and keep going. 

It wasn't until very recent that I got to the point actually, where I can not feel my feet. I have no placement of where my feet are going. They get very numb and my legs are hurting me. I cannot stand or walk for more than five minutes. And it hit me when I was at my primary care doctor's appointment.

And it was suggested maybe we should use a Walker or something? And it hit me like a ton of bricks. I'm like Tabby, you're 32 years old. And we're talking about getting your Walker and. Well, It really hit me was is that I'm not playing. My feet hurt. My legs hurt and previously a week or so before that doctor's appointment, I fell down the stairs. I fell down the stairs. My legs were twisted behind me. . And I cried. I cried. I cried. Because I realized that I've waited too long. I've waited too long. Should Should've done something. I should have realized that diabetes is serious. It doesn’t mater how young you are, you have to take care of yourself.  

[00:28:14] Maisie: that's heavy. I mean, when you're so young, You know, and to already be feeling those complications she's so right in the fact that you can't really ignore it away, sadly

[00:28:25] Katie: Yeah. And I think, uh, for a lot of our patients, it's just very easy to ignore. I think can become more real in these moments where there are symptoms, 

[00:28:40] Maisie: it's kind of like with high blood pressure too, you know, unless you're having symptoms of constant headaches or chest pain, or Something, you know, if you're asymptomatic for years, you feel like, why, why do I need to take all these meds You know? I feel fine.

Chapter 4: Shame, Stigma, and Support

[00:30:08] Katie: I think it's so important to talk a little bit about the emotions associated with diabetes. So let's try to better understand the emotional toll diabetes can take on our patients and how it impacts how they engage in care and seek support from close friends and relatives. 

[00:30:24] Tabby: Um, I talked to my mother about it and it comes out that my mother has had diabetes for years prior to me actually finding out. And my mother did the same thing.

She act like she didn't have it. She wasn't educated on it. She was ashamed to show me that she was taking insulin and sticking her finger. So when she came to visit for the holidays, she disappear and you're like, where's mom and she's upstairs in the bathroom giving herself an insulin shot or, taking it. It wasn't really open. so it would have been a big help if I had known from her that she had had it because she could have told me a lot of things that I didn't know.

My biggest thing was I felt ashamed. I felt ashamed that I was so young and I had diabetes. So didI spread it with everybody. Absolutely not. That I tell my mom, no, we were both keeping a secret. So I would secretly at night look up things. And if I was having symptoms, like sometimes the top of my legs would go numb for hours and I would not know why.

And I looked it up was I offered to go to speak to someone about it from my primary care doctor. Absolutely. Was I given appointments? Absolutely. Did I go, no, I was too embarrassed, ashamed. I was so young and I did not want to be. In that category. And I'm speaking about African-Americans I didn't want to be in that category to want to be a statistic, and I didn't want anybody to look at me that way.

Oh well, we have an African-American young woman come in. Of course she has diabetes kind of thing. That's what was in my head. I just, it was, I kept it a secret. I kept it a secret. I didn't advertise it. I didn't say anything to anybody. Never

[00:33:06] Katie: Dr. Rabin mentioned earlier about an entity known as diabetes distress. Maisie. Can you share how you think about diabetes distress and how you can monitor for this in our patients? 

[00:33:18] Maisie: Yeah. You know, when, when I think about diabetes distress as a term, I really try to think about how all-encompassing diabetes is. I mean, it really impacts every facet of your life. I think about particularly when patients are going out and interacting with friends and family and they need to consider the foods that they're enjoying.

If they're going to consume alcohol or not, how they're going to give their injections, if they're on fast acting insulin and they're out of the restaurant, how are they going to discreetly do that? There's a lot of thought and that thought then weighs heavily on people to the point where they're, you know, having a low level of cortisol at all times, that's, you know, that's stressing them and that's very real.

And that's why I think the diabetes distress tool is so helpful to use in clinic with patients to really get a sense of how much it's impacting their life. 

[00:34:09] Katie: So thankfully there are some validated instruments out there we can use to assess for the presence of diabetes distress, including the problem areas and diabetes or paid scale and the diabetes distress scale or DDS.

[00:34:23] Maisie: If someone is that stressed about their diabetes, it sometimes makes it easier to hit the point of saying, you know what, it's easier to just Just ignore this.

You know, I can't, it's just so overwhelming. And I mean, I can really identify with that as a diabetic myself, and I've been diabetic for like what almost 18 years now and, and on insulin lifetime, obviously. Um, and I know that that aspect of having to think about things when you go out and do social activities is very real.

Like I remember when I was, well, let's see, I was diagnosed when I was like 10. So when I was maybe 12 years old, I went out for ice cream and it was still in the early phases where I needed to do carb counting and read the nutrition labels. And back then you had to, you didn't have a pump. I had to calculate on little napkins or pieces of paper, how many carbs were in the meal and then give my insulin.

And, uh, I remember I was at an ice cream shop and they don't have nutrition labels, and I was. Oh, I don't know. I only know how much ice cream, like it is in one cup. And I know how many carbs is in one cup of coffee, ice cream, plain coffee, ice cream. And they didn't have it And I was like, I can't compute any other ice cream. besides coffee. It's 15 grams and a cup.

[00:35:41] Katie: Did you, did you ultimately have ice cream 

[00:35:43] Maisie: I 

[00:35:44] Katie: and you 

[00:35:45] Maisie: I survived? by no, you can, you can really feel that with patience, I really try to give people that autonomy, right. Because you're the one living with this. And if you feel like from the get go, It's super burdensome and overwhelming and very restrictive.

It's a very hard to maintain that. And because so much of diabetes management is the lifestyle piece. If you make that as approachable as possible, and people feel like they can do it, it makes a huge difference. I think 

[00:36:32] Katie: your mom knows now that you do have diabetes.

So what allowed you to move past the stigma and be able to share it with people you care about? '

[00:36:43] Tabby: cause I started to realize that having diabetes is not the end of it. And I also thought to myself, if something happens to me, I need them to know what's going on because I don't want to pass out in front of someone because my sugars are too low or they're too high.

And I'm sleeping and no one, and my wife tries to wake me up and she can't, she doesn't know why. I think that being that my wife. Also had diabetes helped me a lot. It's kinda like when you have when you're deciding you want to exercise and the best thing to do was to go with someone, right?

So the best thing that could have happened to me, and I know this sounds horrible, but finding out that my wife had it, so it was kind like, oh, you do I, so it was Does your leg go numb? Does your feet hurt you? Does this hurt you? Do you have these cravings? So it was like a diabetes buddy

[00:37:48] Katie: when you shared your diagnosis with your wife or your mom, how did they react to that? 

[00:37:53] Tabby: When I told my mom I kinda told her in shame because again, I didn't know that she even had, so when i, I kind of said, well, you know, mom, the doctor says I have diabetes. And it just went silent and I was thinking to myself, oh my God, you shouldn't have said anything.

This is why you haven't, you shouldn't have said anything. And then she said to me, so do I. What?

So she says to me, I've had diabetes for years. I said you did. Yeah. Why don't you tell me? I don't know. I don't want you to worry about me. 

[00:38:48] Katie: How did it make you feel to know that she had it for all those years? 

I felt that my mom could possibly hold something so critical. So silently that it scares me because I'm thinking to myself what else?

[00:39:12] Tabby: And for her to tell me that she had it for years It didn't click to me because I'm thinking to myself. I never see you take your sugars. I never see you take insulin. And then I remember her always having a black bag and she was, I'll have to put this in the refrigerator. Never opened it. I didn't think of anything of it.

I don't know what it is. Most of the time we see her, it's the holidays, we're excited about seeing her and do we, things, nobody thought about it. 

[00:39:55] Alissa: is there any coaching give about patients tell their family about their diagnosis?

[00:40:01] Rabin: Yeah. That's it's a great question. Um, Because certainly stigma from family stigma, from community members, that's a huge barrier that many patients face in terms of being able to do the things that they want to do or need to do to take care of themselves. I think it always starts with how much did the other people who live in your home about your diabetes and what do they play a role in helping you? Are they supportive? 

I think trying just to understand what the situation is is a great way to then set up the conversation about what are the barriers that the patient sees to including family members in in helping to support them in managing their diabetes as well. So getting a sense of where things are at the moment, what the patient sees as the biggest barriers.

 I love having multiple generations of family in the clinic visit. I love asking people to bring their mother, bring your wife, bring your, bring your child. And then let's talk about it together.

So I think because there is so much that that, family gets involved in. So I'm happy to support patients in having those conversations, but always starts with trying to understand where they are at a given point in time.

[00:41:29] Maisie: what's really great to hear is that Tabby found ways to combat her diabetes distress by seeking support from trusted loved ones. And the CDC actually recommends some strategies for combating diabetes distress, including that patients pace themselves, ask for help and share their concerns with their providers.

[00:41:47] Katie: Let's hear one last piece of advice from Tabby. 

[00:41:50] Tabby: Listen to understand your patients will tell you everything. Don't, over-talk them. Give them a chance to explain your patients. If you listen to understand what tell you everything, even if they don't say it out loud, take your time with your patients.

[00:42:08] Katie: as she was saying it while I was interviewing her, I'm like, I hope I do that. 

[00:42:12] Maisie: I mean, it's sort of that old anecdote, right? Of like, you're are you a waiting to talk? you know what I mean Or are you listening? And then you're going to respond sometimes people are just waiting to talk. I think that's very common actually in medicine, right. Because we have, we have an agenda 

in our head, ultimately you have kind of in your mind, what questions you want to ask, what things you want to follow up on.

And sometimes think more often than not patients feel that And it's, it really is on us to set the tone and, and say that, okay, whatever the patient is bringing up to me right now, This is very important to them and I need to leave my agenda at the door and instead just be present with that particular concern, right.

Building that relationship is so valuable. 

[00:42:54] Katie: Yeah, I think, uh, sometimes I catch myself doing that where I'm not fully present with my patient in the room, and I think I've gotten better over time as I practiced. Um, and it's helped me a lot to make that connection, which is so important in primary care being fully present with them and hearing completely what they're saying. It really makes the relationship much deeper. 

[00:43:16] Maisie: You create the relationship, you build authenticity and trust and you ultimately provide better care because you're spending that extra two minutes, but you're really hearing the person and knowing what is of greatest importance to them and their health.

Conclusion

[00:43:33] Katie: So in summary type two, diabetes is a common and chronic disease that we most certainly will encounter in the primary care setting.

But despite its commonality, we must see each patient as an individual with their own distinct story and needs. Part of the joy and honor of caring for such patients is getting to know them, their strengths and challenges and understanding where we can help them most. And that concludes our episode for today.

[00:44:00] Maisie: We just want to make sure you walk away with some key points from today's show. 

One screening for diabetes should start at age 35 for those with no risk factors and take place every three years. Other individuals who should undergo screening are those with higher risk of developing diabetes, including those with a history of gestational diabetes.

Patients with HIV who are on or are about to start art, And those who qualify as overweight and have at least one known risk factor two breaking the news of a diabetes diagnosis can be extremely stressful for our patients. And it really is a memorable time in their lives. So take the time to listen to their concerns and help them frame diabetes as a long-term disease that will take time and working together as a team, but make sure to have a positive spin and remind them that they can do this.

Three diabetes distress has a real impact on our patients and can affect their ability to engage in care and impact their relationships. So be attentive for the presence of distress in your patients and screen for it. If you are concerned

[00:45:13] Katie: Be sure to tune in next time, wherever you listen to your podcast to catch part two of the type two diabetes series where we'll be discussing non-insulin medications, 

[00:45:24] Maisie: we hope you enjoyed this episode, which was made possible by contributions from our patient Tabby, our resident interviewer, Dr. Alyssa Chan and Dr. Tracy RayBan, who provided faculty peer review for the project and served as our expert. Special thanks to Keval Desai, one of the key writers for this episode and our producers, August a logo, Helen sigh and Joshua on Django as well as our faculty advisor, Dr. Katy, Gillison 

[00:45:48] Katie: that's me. Be sure to follow us at PC pearls on Instagram, where you can expect to get sneak peeks, additional learning content and the most up-to-date details on show release times. 

Maisie: And don't forget, you can head to our link tree@linktree.com slash PC pearls and click on, send us a voice message to send us your questions, reflections and personal experiences. We'd love to hear from you. And if you could please leave us a rating and a review. Don't forget to subscribe to primary care pearls, wherever you get your podcasts so that you can stay up to date on new episode releases.

Thanks again for joining us today. Farewell from all of us here at the primary care pearls podcast. And we'll catch you in the next one.

Outtake

Thanks again for joining us today. Farewell from all of us here at the primary curls. primary care. Oh my gosh. Maisie. I'm sorry, my friend, 

maybe we should have an outtakes episode.