An Impossible Goal in Diabetes Management
Numbers are powerful tools for people with diabetes. The numbers on your blood glucose meter, for example, give you important information about what’s going on in your body. They can also help you understand the effects of actions you’ve taken, such as eating meals, performing physical activity, or taking insulin or other medicines. The numbers on the lab reports you get from your doctor, such as your HbA1c test result, expand on the information you get from your meter.
A number of medical organizations have published ranges of blood glucose levels that they encourage most people with diabetes to strive for. The American Diabetes Association currently recommends that most nonpregnant adults with diabetes aim for an HbA1c test result below 7%, a blood glucose level between 70 and 130 mg/dl before meals, and a blood glucose level lower than 180 mg/dl one to two hours after meals. These ranges were established based on studies showing, on the low end, the level at which hypoglycemia (low blood glucose) begins to be a risk, and, on the high end, the level at which diabetes complications begin to be a risk, particularly if high blood glucose levels occur frequently or are chronic. Similarly, lab reports come with reference ranges, which indicate, broadly, levels that point to a possible problem, and levels that do not.
Knowing these goal ranges – and understanding how they were established – should help to enable people with diabetes to stay healthy and avoid complications. (Of course, it’s also necessary to know how to meet these goals and have the skills to do it.) But anyone who has diabetes knows that even with very attentive self care, out-of-range numbers sometimes occur. The challenge is to use these numbers as information, to help you detect or correct a potential problem. But that can be hard for anyone, and for a person who tends to be a perfectionist, it’s especially difficult. The tendency of perfectionists is to view out-of range numbers as a judgment of them personally, an indication that dire consequences are right around the corner, or proof that they are incapable of managing their diabetes, no matter how hard they try. And these reactions make diabetes management even more difficult that it already is.
Origins of perfectionism
The desire for perfection can come from a variety of sources, including the person with diabetes, the pressures from a well-meaning parent or spouse of the person with diabetes, and/or a person’s doctor. In her article “Striving for Perfection in Diabetes Management,” Dr. Fran Cogen, director of the Childhood and Adolescent Diabetes Program at Children’s National Health System in Washington, DC, writes, “Some teens, especially those with very high standards who may lean toward perfection, may find difficulty in managing diabetes to their satisfaction. Perfectionism also may be a symptom of obsessive-compulsive disorder, which may come to the surface with a diagnosis of diabetes.”
Hannah Cleeton, who was diagnosed with Type 1 diabetes in November 2012 at age 18, has been struggling to manage her diabetes while also adjusting to living away from home and attending college. She says, “I’ve always been a perfectionist. I feel like there has been some slight pressure from my family to perform well in school and with my health. I think I fear letting them down, so I push myself towards perfection.”
The emotional consequences of Hannah’s perfectionism are that she feels depressed and angry when her blood glucose level is over 200 mg/dl. “High glucose makes me feel like I did something wrong and am actively damaging myself,” she says. But “…when my glucose is between 80–120 [mg/dl], I feel good about myself and the world around me.”
Rachel Kerstetter is another self-described perfectionist who was diagnosed with Type 1 diabetes at age 22 in August 2011, just a couple of months after graduating from college, getting married, and beginning a career in public relations. Rachel says there are pros and cons of being a perfectionist. “Perfectionism helped me get healthy quickly and helps me manage life with diabetes,” she says. “But being too much of a perfectionist can cause undue stress, which directly affects the way my diabetes acts.
Well-intentioned feedback from family members about a person’s diabetes management can sometimes backfire. The line between advice and criticism is fine, and while a parent may say something out of concern such as, “That seems like a high-carb breakfast. Are you sure you should be eating all that?” a son or daughter may only hear, “You’re not doing a good job of managing your blood sugar.”
Kids – and sometimes adults – who feel criticized and unsupported may react by rebelling or just giving up on their diabetes self-care. Or they may respond by trying even harder to please their parents, which can lead to lying about blood glucose monitoring results or other aspects of diabetes management if anything other than “perfect” results seem to upset their parents.
Because the support of family members is so crucial to good diabetes management, it’s important for family members to learn to communicate with one another in ways that are constructive rather than potentially destructive. For families with children who have diabetes, a good pediatrician can often be a big help with this.
The focus on intensive blood glucose control for patients with Type 1 diabetes increased 20 years ago when the results of the Diabetes Control and Complications Trial (DCCT) were made public. The study showed that when people with Type 1 diabetes kept their blood glucose levels (as measured by the HbA1c test) close to 7%, their risk of developing diabetes-related eye, nerve, and kidney disease were drastically reduced. Follow-up studies have also showed that intensive blood glucose control also reduces the risk of heart disease.
On the plus side, these groundbreaking results allowed people with diabetes to imagine a future free from devastating complications. But on the down side, working toward near-normal numbers on a consistent basis is a lot of work, and there are no guarantees of consistent results. According to Hannah, “Being a perfectionist makes diabetes hard, because it is simply an imperfect disease with imperfect conditions.” When doctors or other health-care providers set too-rigid guidelines for their patients to follow, the results are more likely to be frustration and giving up in defeat than improved control. Goals must be attainable for people to maintain the motivation to keep working toward them.
Many perfectionists recognize that their way of thinking can have some serious drawbacks. Feeling constant pressure to achieve very high standards can set a person up to feel frustrated and overwhelmed (possibly leading to giving up entirely), to having low self-worth, and even to becoming depressed. But it is possible to develop coping skills and relationships that will enable you to strive for excellent diabetes control while accepting that perfection is not possible.
One very effective way to gain perspective and feel less stressed is to talk with other people who are going through the same (or similar) experience as you are. When I was a new mother, for example, I used to meet a group of female friends at a local coffee shop every Friday morning for an hour to chat. Sometimes we would talk about movies, books, or husbands, but mostly we would talk about our children, sharing stories of sleepless nights, teething, temper tantrums, etc. At the end of that hour, I always felt revived. I left the group knowing that I was not alone and that I could keep doing this crazy motherhood thing.
This same kind of “talk therapy” works just as well when it comes to diabetes management. Finding someone to talk to who understands what it feels like to have high blood glucose or what it feels like to have to prick your finger in the middle of a restaurant is priceless. Where do you find such a person? Possibilities include online support networks, hospital-based support groups, campus-based groups (for college students), Meetup groups, and informal groups that you form yourself as you meet others with diabetes in your daily life. Even having a regular phone call with someone who understands can provide a lot in the way of emotional support.
Sometimes peer support isn’t enough, however. Particularly if you’re feeling depressed or having significant life problems in addition to diabetes, working with a licensed psychologist or social worker can be a big help. This professional can give you individual attention to help you identify what’s going wrong in your life and how you can change things.
One of the approaches that mental health-care providers often encourage is learning to reframe diabetes management as a process rather than an outcome. Dr. Cogen says, “Perfectionists tend to view control as an accomplishment or an endpoint (for example, ‘My diabetes is under control’) rather than looking at their current level of control as a point on a continuum (‘I am managing my diabetes well right now’).”
It is also helpful to step back and look at the bigger picture – such as your overall blood glucose control for the entire day or week – rather than scrutinizing the details on an hour-by-hour basis. And it’s helpful to remember that diabetes is a piece of the whole, and that a happy, balanced life includes much more than just good diabetes management.
Finding the right doctor
Finding the right doctor for your diabetes care can also be a big help in maintaining the energy and motivation needed to manage your diabetes, without falling into the trap of thinking you need to do it perfectly.
Andi Kravitz Weiss, MPH, of the health-care marketing agency ?MicroMass Communications in North Carolina, says, “It’s important for women with diabetes to feel invested in their treatment plan. They should feel empowered to talk to their doctor about specific aspects of their diabetes they want to focus on. This also means choosing a doctor who values partnering with patients in this capacity.”
The right doctor for you may be an endocrinologist, or it may be an internist, family practice doctor, or general practitioner who is interested in and knowledgeable about diabetes care. Regardless of specialty, you need a doctor who is able to increase your understanding of managing diabetes, offer useful tips, and suggest different treatments when what you’re doing isn’t working.
You also need a doctor whose communication style fits your needs. For example, can you understand your doctor’s explanations and instructions, or are they vague or too complicated or technical? Do you feel that your doctor is really listening to you when you talk, or does he seem distracted or interrupt you? And does your doctor show empathy – that’s to say, does he acknowledge your feelings and concerns and take them seriously? Or do you sometimes (or often) feel ignored or dismissed?
The doctor-patient relationship is ongoing, and if it doesn’t feel right, shop around for one that does. It took Rachel Kerstetter a few tries before she found a doctor she was happy with, but she eventually found her current endocrinologist, and she describes their interactions as follows:
“I get my labs done a week or two before my appointment and view my results online, along with any comments my doctor has made about them,” she says. “Usually her comments start with, ‘Your labs look good,’ and she’ll recommend steps to improve something that might be off. Last time it was low vitamin D, so she recommended that I add a supplement. She won’t comment on minor changes in my A1C and always says ‘Looks good’ when it’s under 7%. We have different goals however; she’s happy with anything under 7%, whereas my personal goal is 6% (or under of course).”
(For tips on finding a doctor you’re happy with, click here.)
Keeping things in perspective
What’s most important is to set attainable, realistic, behavioral goals for yourself. This can be challenging for perfectionists who want to have the best grade, to win every game, and to have the perfect A1C, but it can be done. As an example, when I became a mother, I set the following goal: “I want to decrease my number of low blood sugar episodes.” I had a history of episodes of low blood glucose that had resulted in trips to the emergency room and even a car accident. I didn’t want to put my child in jeopardy, so I made a commitment to frequent blood glucose monitoring. I’m pleased to report that I have not had a dangerous low blood glucose episode in the 12 years since I set that goal and committed to it.
More commonly, however, people do have setbacks or slipups, even as they work hard toward their goals. So don’t tell yourself that you will never again have a low blood glucose reading. Instead, tell yourself that you will check your blood glucose level more frequently and take any other steps necessary – such as not skipping meals and always having glucose tablets available – to avoid low blood glucose as much as possible. Having a plan to deal with setbacks or mistakes is just as important as having a realistic goal and a plan for meeting it.
Remember also not to let your blood glucose readings determine your self-esteem. Blood glucose results are important, but they are neither “bad” nor “good.” They are just information. People with diabetes are living long lives free from complications, but it’s not because they’re perfect and have everything worked out. Most do it by plugging along, day after day, using the resources they have, and seeking out new ones when they need them.