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Diabetes: A Medical Disease with
a Behavioral Treatment
A very important concept that I share with all clinicians and healthcare workers is that diabetes is a medical disease with a behavioral treatment.
People with diabetes have a chronic disease state for life that comes with its own mental health burden. Diabetes brings with it changes in daily routines that are going to impact how we think our way through the day, and those adjustments are going to have a mental health impact such as changes in our relationships with food: food is a coping mechanism for many people, and for others food is a social catalyst. Food is also a cultural symbol and expression for many, and changing that can have a profound impact on mental health. There is a ton of stigma that comes with diabetes in our culture, especially right now. We’ve all heard the jokes that a particularly sugary meal should come with a side of diabetes--or that a person of a particular physical body composition clearly has diabetes. Well, these all make a diabetes diagnosis very stigmatizing. Diabetes also causes life to be a series of pass/fail assessments. Every time you take medication you wonder if it is going to work. Meal choices are the same way—you wonder how will this affect me and impact my blood sugar? Every dosage decision makes us wonder how it will impact us, just as every physical activity, emotional state and metabolic state will. It is incredibly hard to think of any aspect of life that does not impact one’s blood sugar and therefore brings about an opportunity for a pass/fail assessment. Living in that constant state of assessment is very stressful. When we add to that burden the frequent doctor’s appointments and interactions with our clinical world--where judgments are being made based on lab values and the attainment of clinical goals--this all adds significant stress.
Timing and changes in routine can be another piece of the invasive nature of diabetes that encroaches into areas of our life. This may require changes to our work or school routines to accommodate our diabetes, and just the fact that we have to ask for accommodations for school work and identify as a person with a disability can be very stressful. We are exposed to a lot of increased daily risk. Risks of high and low blood sugars, risks of poor choices in what we eat and what activities we partake in. All of these concerns are bigger and more immediate than, “will I gain weight, will I look good in my jeans, or will I potentially have health problems decades down the road?” The ramifications of these decisions that are mundane for some become more immediate with diabetes. Will I have a low blood sugar event this afternoon? Will I have high blood sugar in an hour? Will I be able to fully function today? Will I have a health complication in three years? There are physiologic and neurochemical impacts. We see changes in our bodies as people with type 1 diabetes--some of which we can help to change, but many of which we can’t, and there is always that heightened awareness that adds stress. There are the constant ongoing physiologic changes diabetes has on our bodies, and the neurochemical states that medical science is just beginning to understand.
The economic impacts of diabetes cannot be underestimated. People with diabetes spend on average of 12% of their income on their care. Nationwide, diabetes is the number one health care cost. This can put a massive amount of stress on a person living with diabetes, and on a household with a family member living with diabetes, or a marriage where one or more of the partners lives with diabetes--especially if all members involved didn’t necessarily come into that situation with diabetes.
Maslow's Hierarchy of Needs In order to understand the impact of stress and diabetes on one’s mental health we have to understand the hierarchy of needs. Below we see Maslow’s hierarchy of needs. The pyramid allows us to visualize how one's needs and priorities are structured, with a base of physiology. This is what we basically need as human organisms to stay alive: food, oxygen, hydration, sleep, warmth, and excretion. Once those are met we can then begin to move up to the next level. safety do we have shelter? do we have resources? Finances? a job? do we have enough things to be comfortable and secure? do we have security? Do we have relational security? do we have a level of stability ? Once we’ve established that safety and stability we can then move up a level to 'belonging'. This is where we’re building friendships, families, and group identities. We develop a sense of intimacy when we have achieved the ability to build those stable relational connections. We build esteem and a sense of achievement and success. We develop respect both for ourselves and for others on that base esteem, and we begin to self-actualize. This is where we can begin to indulge in activities of creativity and complex problem solving, and fully explore our liberties, This is also where we develop our sense of morality. I say we can 'indulge' because while many of us identify these are our rights as people, the reality for most people on the planet is that these are considered indulgences. Many people simply do not have the resources to give this their time, attention, energy and resources.
Maslow’s theory is that if any of the levels below are compromised then the levels above cannot be fully attained. For example, if someone doesn't feel safe (they are struggling with housing or they’re not financially stable or there is a threat to their physical safety), they are not going to be able to successfully engage with their friends. They will also not be able to build a healthy family (one to which they can connect for intimacy) which, in turn, is going to have a huge impact on their esteem and self-respect. They’re not going to be able to achieve success to the level they otherwise would, which is going to have a huge impact on their well-being. They’re probably not going to be able to freely express themselves creatively, explore their liberty, and exercise their morality or have useful problem solving skills because their baser needs are not being met.
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