Emotional Health and Diabetes: A Necessary Conversation
Dr. Cynthia Muñoz, a certified psychologist and an assistant professor of clinical pediatrics, got her PhD in clinical psychology and currently works as a pediatric psychologist in the mental health center of the Los Angeles Children’s Hospital and at the CDM (Center for Endocrinology, Diabetes and Metabolism). Dr. Muñoz is a researcher and has co-developed a social program for teenagers with type 1 diabetes. She is also a member of the Diabetes Education and Mental Health Program steering committee at the American Diabetes Association.
When we met with Dr. Muñoz, we talked about emotional health and diabetes. At the time we spoke, it was particularly fascinating considering the emotional complexities of the holiday season that surround managing diabetes.
BT1: First, the most frequently asked question is—what exactly do we refer to when discussing mental health? What is mental health?
Dr. Cynthia Muñoz: Good question! There are so many things, but a definition that I read and feel reflects it is that mental health includes emotional, psychological and social well-being. It affects the way we think, feel and act. It helps determine how we handle stress, relate to others and make decisions. It is something that affects, well…everything.
When we talk about managing all types of diabetes, we often think about the biopsychosocial (biological, psychological, social and environmental) relationship we have with it. Sadly, we typically don’t put as much of an emphasis on mental health. What relationship do we now recognize between mental or emotional health and diabetes of any type?
What we do know is that mental health affects many aspects or all aspects of daily life, such as the way we think, how we feel, and how we handle stress. Diabetes also requires a lot of decision-making, and we know there is a connection between stress and blood glucose levels. Feelings, thoughts, beliefs, and attitudes—I mean, many things can affect how healthy our bodies are. Problems or challenges with mental health can impact diabetes, and issues related to diabetes can worsen existing challenges concerning mental health or otherwise. There is a connection between diabetes affecting mental health and vice-versa.
Of course. These challenges are directly related for many people who live with diabetes. For example, I live with type 1 diabetes. My body’s response to fear, stress, joy and excitement is quite evident in my case. It seems we are not always aware that these emotions will directly affect our blood glucose levels. Therefore, it is imperative that we also take care of our emotional health, just like our blood glucose levels, diet and workouts. In children, is this response magnified?
Yes. Like what you just mentioned, I think something fundamental to recognize is that emotions affect us—what we feel, think and do. But the impact is different for each person. When we talk about young people with diabetes, it may be that a young person who is under a lot of stress sees a change in their blood glucose levels; it may be that those blood glucose levels go up or down. It depends on the type of stress and how the person manages the situation or their emotions. Children are still learning how to identify what they feel, why a situation affects them, why they feel how they do, what their feelings mean and what it all has to do with their diabetes.
Children rely on external support systems, like caregivers, friends and family, more than adults. Adults have more insight into their feelings and how they impact their blood sugar levels. They have more control over their emotions. So for children, it makes sense that caregivers have a lot to do with knowing how a child’s emotions affect their blood glucose levels. Caregivers have a more hands-on role in helping children respond to blood glucose level changes affected by emotions.
During the holidays, those who live with diabetes tend to get a little more stressed. Why does it seem as if we are more stressed when we live with diabetes?
Well, with diabetes, there tends to be a little more stress around the holidays because there are several things that change, such as schedules. Many people are on vacation. Others don’t get a break, and some spend more time at home than usual. These dynamics can affect stress, and therefore, blood glucose levels. Mealtimes change, and the foods available to us also change. Sleeping times may also vary. Many things happen during this season that are not typically a part of our routines during the rest of the year, which creates stress.
During the holidays, it’s typically easier for adults to say no to certain foods or permit themselves to indulge. They have more experience than children managing foods that dramatically affect blood glucose levels. With children, it is very different. They might not understand what we’re asking them to do over the holidays, whether it’s managing their blood glucose levels against abnormal routines or foods or saying no to certain foods. It’s hard. Children want to eat and play and not think so much about limits. Not to mention, our new normal (the pandemic) throws an additional curveball.
Exactly—the “new normal” we are in has caused unprecedented stress that affects diabetes management. Are there any warning signs or symptoms to know that we must seek help?
Yes! It is crucial for people with diabetes and parents of children with diabetes to maintain communication with your health team. When you realize that stress is already affecting your daily routine, sleep and appetite, you feel very irritated, which affects your communication with your loved ones. When these types of situations arise, you know it is time to seek the help of a professional.
There is a false assumption within the diabetes community that we have direct access to and relationships with experts who can assist us in our emotional health journey, but that’s not always the case. How can people with diabetes and their caregivers get the emotional support they need, primarily through the holidays? Caregivers to children with type 1 diabetes may also need emotional help they’re not getting. Can you speak to that?
Of course. For some parents, it is shocking to receive the news that their children have been diagnosed with diabetes. Especially among newly-diagnosed families, there can be emotional trauma. Navigating the holidays around a type 1 diabetes diagnosis can make the season harder for everyone. During Christmastime, for example, there are a lot of parties and delicious foods that may compel you to think about how your loved one who is managing diabetes feels. You may wonder how the events of the holidays impact them. It’s essential to empathize and recognize how you and others feel. Meanwhile, the holidays should be a period of happiness—it’s a lot to process.
Who are our experts in emotional health?
Experts in emotional health comprise all professionals who help families navigate diabetes. Today’s doctors and nurses must also consider physical, social and emotional health. They are aware of the diabetes experience, but some psychologists specialize in life with diabetes and how it affects our mental health. They may serve people with diabetes more effectively as a result. Mental health experts work with all types of people. When I talk with newly diagnosed families and introduce myself as a psychologist in a diabetes center, I mention that I work with “normal” families because, as a psychologist, many people say we only work with “crazy” people. I specialize in people with diabetes.
How can and should caregivers take care of their emotional health?
When someone has diabetes, it is important to ask them, “How can I help you?” We often think we already know what the person needs, but that is not always the case. We need to identify individual needs. Other essential parts of emotional health management are planning meals and schedules, identifying what supplies you’ll need to pack for any trips, knowing what to do during a party if blood sugar levels are out of whack, helping children with carb-counting and so on. We may think that teenagers already know what they’re doing, but we have to remember they are children and may still need our help. We should take care of ourselves and others, avoiding stress by planning. We should have a plan to handle unexpected problems related to diabetes, such as hypoglycemia. We need to know how to manage it and how to communicate. These are important mental health considerations, not just for individuals with diabetes but for their caregivers. We need to take care of people with diabetes and their caregivers.
Is there a way to deal with stress, or must we learn to live with diabetes and stress?
Yes. We must learn to live with diabetes and stress because there is stress in life. It can be negative or positive stress, though—like a party. A party, hopefully, would be good stress. If we try to prevent stress from existing or not facing it, that can also negatively affect us. It is good to acknowledge this by talking openly about self-care and stress levels. Diabetes is 25/8, not 24/7. Being physically active, exercising, meditating, practicing yoga, taking breaks and breathing in fresh air may seem small, but they help us manage stress a lot.
What advice would you give parents who get stressed by their children’s blood glucose levels?
Parents love their children and want to protect them, ensuring they are well. It’s super important to reflect on this. When you see a really high or low blood glucose level, it is normal to feel worried and stressed as a parent. As parents, we may ask—What happened? What did you do? We are trying to find the glucagon, Baqsimi, for low blood sugars. We worry a lot. It is important to stay calm, breathe deeply and see a blood sugar reading as information. Then, it is about knowing what to do. How much insulin do you give for a high? Do you treat a low blood sugar reading with a glucose tablet or juice? Try to focus on what you need to do to restore blood glucose levels. Maintaining a neutral tone of voice is something I mention all the time when talking with parents and caregivers. You need to put this into practice. In some situations, you may react, but nothing happens. Realize it and say to yourself—if this happens again, I will take a deep breath and do what I have to do to manage blood glucose.
As caregivers, how can we identify that we are experiencing depression and not just a moment of sadness?
Depression does have to do with sadness. The significant difference with depression is that you begin to notice an impact on energy levels. You may have more difficulty getting up in the morning and experience changes in appetite and sleep. With depression, some people sleep more or less than usual. If you begin to notice these changes, talk with your doctor. Let them know how you’re feeling so they can help you identify if what you’re experiencing is depression or something else. From there, you can formulate a plan. You may try to diagnose yourself by going online and researching your symptoms, but it is always best to consult a professional to make an official diagnosis.
Can children with diabetes develop depression?
Yes. Children with diabetes have a higher risk of becoming depressed than children without diabetes. If you are concerned your child may be depressed, take a careful look at their appetite, energy levels and productivity at school. If you notice their grades drop, pay attention and have a conversation with your child. It may be a depression warning sign. Many times, people think that children cannot be depressed. However, when we look at our childhoods as adults, we understand that children can be depressed. We can empathize with our children when we consider our own experiences in youth. It is possible for children to become depressed because everyone is different. Depression is incredibly personal.
In people with diabetes, we don’t just hear about stress being a problem, but diabetes distress. What is diabetes distress, and how is it different from stress?
The term diabetes distress has to do with the impact of diabetes management on your life. With type 1 diabetes, we already know that you are checking your blood sugar and looking at many things all day. There is so much that people with diabetes have to manage every day. These little burdens can affect a person over time, causing burnout.
Finally, at BT1, we know that the ADA has been working very hard for several years on emotional health, so we wonder—what are we going to be seeing from the ADA in the coming months or years?
We will continue this work. We focus on individuals and recognize that mental health is comprehensive. We cannot avoid this topic when we talk about caring for a person with diabetes. We have a resource portal where people with diabetes can look for therapists, or mental health professionals, who specialize or have knowledge about diabetes. That list of specialists will keep growing. We also have a lot of materials that focus on mental health and diabetes.
You mentioned other resources, for example, the diabetes camps. This is another project that continues to grow. Another project I love is Project Power. It is a program that offers information about mental health, emotional and social conditions and opportunities for physical activity. There are many things we have to keep doing for people with diabetes. We want to keep making it easy for them to find mental health professionals with knowledge about diabetes. I know that Beyond Type 1 also has many resources. So, together, we are offering much more information to help.
Can you briefly describe this educational offer and new program and how we can use it to find health professionals and forward it to friends who are watching out for our emotional health?
Of course. We have a Mental Health Diabetes Education program, which provides an opportunity for mental health professionals to receive comprehensive diabetes training. For example, you might be a mental health professional, an excellent psychologist, and know a lot about depression. But that doesn’t necessarily mean that you understand the connection between diabetes, depression and mental health. You may not understand what you can do to help a person, for example, who is very afraid of low blood sugar. This program includes a lot of information about different aspects of managing diabetes and what you can do to help people with diabetes improve their mental health. It is a lot of research-based knowledge.
I believe every mental health professional needs to get more information and consider completing this program. When you have completed it, you can add your information, or your colleague’s, to this comprehensive list. Then, people with diabetes can easily search for professionals in their area who know about diabetes. We know 34,000 people are living with diabetes in the United States alone. When we think about the numbers worldwide, there are millions of people. There are too many people with diabetes and not enough mental health professionals who have proper knowledge about diabetes. There are many myths and misconceptions about diabetes, as already mentioned. Sadly, if the professionals do not learn or educate themselves, they may lack the understanding to help people with diabetes and understand the disease itself. That’s where programs like this come in. They can help a lot!