• Fresh Views

    5 Simple Strategies to Practice an Attitude of Gratitude

    We both love a magnificent sunset! It’s always something we express gratitude for.  This one was captured during a trip to Destin, FL.

    Gratitude and attitude are not challenges; they are choices.- Robert Braathe

    In this season of thanksgiving, today we’re sharing 5 of our favorite simple strategies to practice and attitude of gratitude. Expressing gratitude is a topic we have written about several times as a tool that can be used in solution-focused encounters with clients. And it is a practice that we both embrace regularly. 

    How can you get started with gratitude? 

    Here are 5 strategies to help develop daily gratitude habits

    1. Have gratitude reminders. These are simple cues to remind you to focus on gratitude daily. Maybe it’s an alarm on your phone, a bracelet or wristband, a photo, a magnet or even a post it note. And with that reminder, pause, take a breath and focus on being grateful in that moment.
    1. Keep a gratitude journal. We both have found this to be a good personal practice to express gratitude more readily and find things to be more grateful for. Some log entries in their journal weekly, and others daily. Our personal goal is to identify at least 3 things daily for which we’re grateful. While the goal is to write in the journal daily, sometimes life happens and weeks may go by without an entry, but we pick right back up with our entries. 
    1. Start a gratitude box. Keeping a box (jar, album, folder, or whatever works for you) filled with notes, pictures, and moments you are grateful for can bring a boost when needed. Tami keeps a folder on her desk and a file on her computer filled with nice notes and photos, as well as  an album on her phone of messages and moments she’s grateful for to refer back to when she needs a reminder. Deb has a bulletin board in her office that displays happy memories in photos, ticket stubs, quotes, flyers etc. that she can look at during working at any time.
    1. Voice or write down one (two, or three) good things that happened in your day. On the homefront, this is a gratitude practice Tami used with her son over the years. In the days when she would take and pick him up from school, she found that the drive time was a good time to learn about his day. That conversation always began with these words, “Tell me something good that happened today.” He knew he needed to answer that, acknowledging something good, before talking about the challenges of the day. 
    1. Use gratitude apps. There are a number of apps with a range of capabilities including sending reminders, sharing uplifting thoughts, and organizing memories for which you are grateful. We shared some favorites in this post. 

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    8 Tried and True Solution-focused Strategies for Eating Healthy Through the Holidays

    With Thanksgiving celebrations and the holiday season at hand, today we’re sharing 8 tried and true strategies to enjoy the special foods that accompany holiday gatherings without compromising blood glucose. These 8 solution-focused strategies have worked for our clients and we hope are helpful for you.

    Strategy 1: Take a healthy dish or treat to share, or a healthier version of a favorite. Maybe it’s something like the caprese kabobs Tami made for an event that you see pictured below. Just a couple of grape tomatoes, fresh basil (or spinach) leaves, and a fresh mozzarella ball speared with a small skewer with a balsamic dressing to drizzle. Offering to bring something healthy can reduce stress by knowing that there’s at least one item to suit personal preferences and needs.(And chances are the host will welcome an addition to the party spread!)

    Strategy 2: Share a side dish that incorporates seasonal vegetables. Many of the food traditions associated with Thanksgiving and the winter holidays are laden with carbs and calories. One of our well-loved low carb favorites is roasted vegetables. Whether you choose to roast one type of vegetables (our vote is roasted Brussels sprouts) or a combination of winter vegetables (such as butternut squash, brussels sprouts, radishes (yes radishes!), parsnips, carrots, and red onion) they’re low in carbohydrate, high in flavor, and won’t keep you hanging out in the kitchen. Cut the vegetables into even size pieces/chunks for even cooking, then toss with some olive oil, kosher salt, and black pepper. Roast at 425 degrees in an even layer on a sheet pan until fork tender (about 20-25 minutes). These roasted carrots were delish!

    Strategy 3: Try the Two- to Three-Bite Taste Test 

    Many clients we’ve worked with over the years have shared success keeping their blood glucose in range by sticking with tiny tastings, or 2-3 bites, of foods they may not be sure of exactly what’s in them or foods that are rich in carbohydrate. They can still enjoy the experience without too much worry of sending blood glucose out of range.  This is also a great strategy when traveling over the holidays. You can read more about that here.

    A patient Tami’s worked with in the past  loved cheesecake. Prior to developing diabetes she’d eat an entire giant slice when she  dined at her favorite restaurant. Once diabetes entered her life, she still wanted to try to  work in cheesecake on occasion, and realized  that portion control was important. She agreed to try the two- to three-bite taste test. She reported back that she discovered she really  savored the first three bites of her cheesecake, but after that the pleasure decreased. Based  on her discovery, she decided to eat just three  bites of cheesecake at the meal, count and  incorporate the carbohydrate accordingly, 

    Strategy 4: Make a swap or two. Consider the foods that are often at holiday gatherings and determine where you can make a swap or two for health. One client who is planning ahead shared that she’s planning to swap in broccoli casserole (made with reduced fat ingredients) on her plate in place of mashed potatoes and a corn casserole to reduce carbs.

    Strategy 5: Eat off a smaller plate.  As we shared in our July 3, 2019 post, when you are ready to sample the celebration spread, if there’s a choice on plate size, go with a smaller plate (maybe the ones that are out for salads or desserts). This strategy helps manage portions, and make those portions appear larger on the full small plate. 

    Strategy 6: Fill half of your plate with veggies of the non-starchy variety

    Aim to fill at least half of the plate with non-starchy veggies (such as veggie salads, green beans, broccoli, roasted vegetables from Strategy 2), one fourth of the plate with lean protein foods (such as a turkey), and one fourth with carbohydrate foods (this is mashed potatoes, stuffing, corn on the cob, or a sweet treat may fit). This simple strategy has brought success for many when navigating picnics and celebrations. 

    Strategy 7: Cruise by the foods that aren’t worth the carbohydrate or calories.  Before filling your plate with a little bit of everything, cruise the buffet or party spread to see what’s available, and then decide which foods you really want, and what portion of each works for you, We encourage asking yourself, “Is it worth the carbohydrate or calories?” If the answer is “no,” then it may be best to pass it by. If the answer is “yes,” then decide what portion fits your carbohydrate budget before adding it to your plate.

    Strategy 8: Focus on fellowship and laughter. We believe that laughter is the best medicine, and we try very hard to practice what we preach. Scientists have shown that laughter is a great stress reliever and causes mental relaxation. Laughter can even improve blood pressure, pain, and immunity. Most importantly it strengthens human connections when we laugh together. There is now actually “laughter therapy” defined by the National Cancer Institute as therapy that uses humor to help people cope with medical conditions by relieving pain, stress and improving well-being. Here we are embracing this strategy a few years back on holiday escape!

    Evaluate what went well. After each event, reflect on what went well and how you can repeat that at future gatherings. This is a helpful solution-focused strategy for anyone! Also think about what didn’t go as planned, and what changes can be made at future gatherings to keep blood glucose in range. You can read more in our blog post on Bright Spots and Landmines.

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Perspective over comparison

    No one can make you feel inferior without your consent. – Eleanor Roosevelt

    The trees in Kentucky are bringing their showy fall foliage. Each does not think about competing with the tree beside it. They just do their thing and bring their color.

    Our last post focused on the impactful words that Tami keeps on a post-it note stuck to her computer monitor: Progress, not perfection. These words build on how the growth mindset draws attention to one’s own progress. Today we turn our attention to 3 more impactful words shared by a mentor over the years: Perspective over comparison.

    Accepting oneself can be hard! 

    In life it can be easy to default to comparing yourself to others. Just last week Tami heard these words from a patient, “I’m bad…I don’t eat the way I’m supposed to. I don’t keep my blood sugars as well controlled as my friend who also has diabetes.”  It’s so easy to get caught up in creating our own opinions of ourselves and how we measure up to others. We can play the comparison game all day long but how helpful is that really? Comparison can leave us feeling down. 

    Being realistic about personal strengths and challenges is often easier said than done. Striving to be honest with ourselves and accept who we are, our abilities, and acknowledge when we’ve reached our limits is the goal. Without acceptance it’s impossible to move forward. In a 2018 #DSMA Twitter Chat we asked participants about their strengths. One individual with diabetes replied:

    “I am strong when it comes to seeking support. When I am down, I am self-aware enough to address my hardship. I’m not afraid to be vulnerable.”

    Another replied:

    “My strength is that I refuse to give up. I am tenacious and do not take no for an answer.”

    Acceptance is critical when living with a chronic condition like diabetes

    When encountering clients/patients facing this comparison scenario, diabetes care and education specialists (DCES) can step alongside as a think partner and give perspective to the circumstances. We can offer caring, support and encouragement.

    People need to feel safe when engaging with their care team to acknowledge what they can do, along with what is challenging for them. This past week in an educational symposium for people with diabetes that Tami spoke at, the participants voiced loud and clear the theme of feeling judgment from their healthcare providers. DCES have a unique opportunity to support those that live with diabetes as they learn to accept changes and new challenges in dealing with diabetes. And, practice acceptance, understanding that people react to challenges differently. It’s critical to accept the person in front of you as they are, without judgment.

    An individual typically can recognize and clearly identify things they are able to do or achieve and feel happy. We can then encourage focus on those strengths, do more of what is working, and leverage those strengths, skills and qualities to create new opportunities. 

    In the same Twitter Chat mentioned above, another participant shared:

    “I concentrate on the lifestyle. The day to day life of a person with diabetes. I work for overall health through exercise, and diet for BGL [blood glucose] results. The support I receive takes care of the rest. So, cure or not, let’s make it as good as we can and support the other.”

    Diabetes care and education specialists can learn a lot from simply asking people what strengths they have to help them live well with diabetes, keeping top of mind, it’s all about perspective over comparison.

    Here are 6 solution-focused questions you can incorporate to focus on perspective, strengths, and self-acceptance:

    1. What would success look like for you (e.g. in life, in living with diabetes etc)?
    2. What strengths do you have and use to help you manage your diabetes every day? 
    3. How can you use your strengths to create opportunities for success?
    4. What is one thing you have come to accept in your life that took some time to process?
    5. How did you feel when you were finally able to accept that challenging situation?
    6. How could you use those experiences and feelings to move you forward to accept a new challenge now?

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Progress, Not Perfection

    Progress not perfection on a recent mountain trek Tami and her husband took on a Tennessee get away

    Continuous improvement is better than delayed perfection.” – quote attributed to Mark Twain

    This is Tami writing today. I sat down at my desk to take a quick look at my email and glanced down at a post-it-note I had stuck to my computer monitor several years ago. It had simply written on it: Progress, not perfection.These impactful words were instilled in me by a long-time mentor and I keep them posted as a continual reminder.

    I’ve found this “progress, not perfection” mindset encourages focus on smaller achievements…instead of focusing solely on the end goal. It has allowed me to get things done in a quality manner without fixating on an ideal outcome that might not necessarily happen. A personal example, when working on one of my book manuscripts, thinking about the end goal of a finished book and the desire for it to be “perfect” left me feeling anxious and overwhelmed. However, when breaking the work into manageable chunks I could recognize progress. 

    “Progress, not perfection” can help us lean into the realistic and practical, and  acknowledge, accept and enjoy things.. even if they aren’t perfect. In one of our recent blogs on the “growth mindset” we shared how the growth mindset draws focus to one’s own progress. People who have a growth mindset believe that even if they struggle with certain skills,their skills can improve over time. Managing diabetes is not about being “perfect”. Life happens. The reality is that things will not always be perfect. But progress is the goal. For instance, progress toward achieving a healthy A1C or progress toward spending  more time in range.

    In taking a solution-focused approach to diabetes care and education, we can step alongside our clients/patients and support them in fostering this growth mindset and focus on progress, not perfection. 

    • For example if you hear a client/patient someone say “I’m not good at counting carbs”, you can encourage them to shift to saying, “I”m not good at counting carbs YET.”  
    • Or maybe you hear “I can’t walk 30 minutes for exercise – I get too tired”, you again can encourage them to shift saying “I can’t walk 30 minutes for exercise YET” and turn focus to their progress, that they’ve increased from 5 minutes duration to 15 minutes. 

    It’s not about perfection, but about progress and getting better. It’s about acknowledging and giving credit where credit is due. It’s about growing over time. Will you join us in adopting a “progress, not perfection” mindset? 

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Celebration!

    “Love recognizes no barriers. It jumps hurdles, leap fences, penetrates walls to arrive at its destination full of hope.”

    ~Maya Angelou

    We at A Fresh POV for You are taking some time off to celebrate the wedding of Tami’s son Andrew to his new bride Jessica.  We’ll be back soon with more solution-focused information.

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Adopting a Growth Mindset is a Game-Changer

    #ADCES22 conference is in the books! We not only had a great time reconnecting with colleagues and friends, we also learned a lot. We were particularly interested in sessions that incorporated solution-focused tenets to see how our ideas and practices align. One that particularly struck us was the keynote speaker, Heidi Grant, PhD from Columbia University Motivation Science Center and author of 9 things successful people do differently, who spoke on what successful people do differently. Today’s blog is a little longer, but we think it may transform your thinking.

    When getting ready to do something, or pursue a goal, people bring  2 mindsets

    • Fixed mindset. The first, a fixed mindset – is about proving your ability, demonstrating your skills to others, and comparing yourself to others. The minute something goes wrong, you start to question yourself, and thoughts can turn to, “Maybe I don’t have the ability” when things are hard, which becomes a self-fulfilling prophecy. This can lead to anxiety which makes it even harder to move forward. You think you can’t do something, so you don’t do it. 
    • Growth mindset. On the other hand, a growth mindset is rather than thinking about proving your ability, the focus is on IMproving your ability over time and developing skills. Those with a growth mindset are more concerned with ” how am I doing TODAY,” compared to yesterday or last week, as opposed to comparing self to others. 

    Adopt a growth mindset

    We believe that a growth mindset aligns with using a solution-focused approach, in which we encourage small steps to move someone forward in the direction of their goals. The growth mindset draws focus to one’s own progress. According to Grant, “The growth mindset is the single best predictor of persistence and resilience in the face of setbacks and challenges.” We frequently write about persistence and resilience in solution-focused practice. Grant referred to the growth mindset as a “super power” when it comes to persistence and resilience.

    In taking a solution-focused approach to diabetes care and education, we can step alongside our clients/patients and help them recognize a fixed mindset and shift to foster this growth mindset. For example if you hear someone say “I’m not good at this”, you can encourage them to shift to saying, “I’m not good at this YET.” Or, “It’s not about doing good, it’s about getting better.” This shift helps to create the desire to do something and move forward. It’s a journey and about growing over time. The more one does this shifting, the less they’ll have to do it. It will become a habit.

    One solution-focus tactic to help to evaluate progress over time is to incorporate scaling questions. For example, on a scale of 0 to 10 where 0 is not confident and 10 is very confident, compared to yesterday, how confident are you that you can work towards your goal.

    Dr. Grant noted that there are not many things as impactful as a mindset with which you approach a task. Those that adopt a growth mindset experience:

    • More willingness to take smart risks ( willing to make mistakes, learn and grow)
    • More persistence and resilience
    • Creativity
    • Deeper thinking
    • Interest and enjoyment

    Growth mindset language

    We frequently touch on the power of person-first, strengths-based language. When we think of language associated with a growth mindset, Dr. Grant encouraged use of these words:

    •  Grow
    •  Progress
    •  Become
    • Over time
    • Develop
    • Improve

    Be a realistic optimist

    Of course, pessimism  – which is believing you’ll fail – can be challenging. As can unrealistic optimism – which is believing you’ll succeed easily. Realistic optimism on the other hand, is believing you’ll succeed, but at times it can be difficult. We call attention to this as it’s important to help clients build realistic optimism. We can help prepare people for their journey. The future is something to be achieved. A simple formula is to vividly imagine the future is similar to the Miracle Question we’ve shared in prior blogs. We can encourage clients to consider how they will feel, what they willI be doing, and how they will overcome obstacles. Using  future-visioning questions as we’ve shared, can help move clients towards their desired future. 

    Make if-then goals

    As Dr. Grant noted, two of the biggest obstacles to achieving a goal are 

    •  Knowing EXACTLY what to do (not being specific enough)
    •  Missing opportunities to act

    As we all know, there is a “knowing-doing” gap. People often know what they “should” do, but don’t do it for many reasons.There are times when the goal “could” have happened but the opportunity is missed. One solution is to make “if-then plans” (forming implementation intentions) – a very effective form of planning to overcome this gap. For instance, “If (or when) situation X occurs, THEN I will perform Behavior Y”.

    For example, IF I go into the breakroom and there are donuts, THEN I will have a cup of coffee.”  Advance planning is very effective. By incorporating eliciting questions a client can be guided to develop several if-then plans. By asking “What else?” you can drill down to make a very specific plan. Creating these plans can equip your client to have them ready in their back pocket when potentially challenging situations arise. By creating if-then plans you’re also helping the client to practice problem-free talk. If-then is similar to using exception questions, which we’ve shared in prior blogs. A successful if-then plan replaces challenging habits with positive changes and helps to develop small changes over time.

    Our challenge to you as a think partner with your clients/patients

    • Guide them in building resilience with a growth mindset.
    • Equip them to be ready to act with realistic optimism.
    • Support them in learning to bridge the knowing-doing gap with if-then plans.

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    #ADCES22 Wrap up!

    Deb and Tami are all smiles after our presentation at #ADCES22

    August 12-15 brought us a fresh point of view in Baltimore, MD at #ADCES22!  What an incredible conference, and so good to be back with friends and colleagues we haven’t seen in- person in 3 years.

    We were honored to present to a full room late on a Friday afternoon! Our presentation highlighted 7 tactics for your toolbox, so to speak, to transform primary care visits.Since the majority of type 2 diabetes is managed in primary care, it seems the best place to start to change the way we engage with clients/patients is in the primary care setting. In case you missed the 7 tactics, and are wondering, here you go…

    7 practical tactics for your primary care toolbox:

    Tactic 1: Open the visit with a question focused on what’s going well or how you can provide support

    Tactic 2: Elicit exceptions by asking “exception questions”

    Tactic 3: Use person-first, strengths-based language

    Tactic 4: Practice problem-free talk

    Tactic 5: Ask eliciting questions

    Tactic 6: Ask future-visioning questions

    Tactic 7: Use scaling questions to scale progress

    As we mentioned during our presentation, these tactics can largely be applied in other practice settings as well. 

    Celebrating with friends after our presentation

    Stop back by in 2 weeks when we’ll share perspectives on embracing a “growth mindset” – a particularly impactful concept we learned about at the conference and one where, we believe, the tenets of a solution focused practice align.

    View of Baltimore’s Inner Harbor

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Bar

  • Fresh Views

    ADCES Preview of Transform primary care visits : New tactics for your toolbox

    Problem talk can create problems. Solution talk creates solutions. – Steve de Shazer, pioneer of solution-focused brief therapy

    Our last blog wrapped up a series of posts on transforming primary care encounters by taking a solution-focused approach when managing type 2 diabetes in the primary care setting. This series has received overwhelming positive feedback. We were excited when an abstract we submitted on the topic to ADCES22 conference was accepted for presentation! If you will be attending the conference in Baltimore, we’d love to have you join us on Friday August 12 at 4:45 pm where we will share 7 tactics for your diabetes education toolbox to transform primary care visits. In large part, the tactics can be applied to other practice settings as well. 

    Without a doubt, managing diabetes is complex. We know that constant focus on “problems” can erode confidence. So clients/patients may turn to us, their healthcare team, looking for guidance to do something different. Stepping alongside our clients/patients as a “think partner” allows working together to identify solutions to move the individual forward towards achieving their health goals.

    Implementing solution-focused tactics leads to greater individualization of care through a brief intervention. We’ll give you a sneak peek of what we’ll share in our presentation…

    7 practical tactics for your primary care toolbox:

    Tactic 1: Open the visit with a question focused on what’s going well or how you can provide support

    Tactic 2: Elicit exceptions by asking “exception questions”

    Tactic 3: Use person-first, strengths-based language

    Tactic 4: Practice problem-free talk

    Tactic 5: Ask eliciting questions

    Tactic 6: Ask future-visioning questions

    Tactic 7: Use scaling questions to scale progress

    We’ll be discussing each of these, providing a multitude of practical tips to implement them, and provide real-life examples.

    Action Plan for Change

    1.Identifies solutions (instead of problems) and how to make the exceptions happen more often.

    2.Focuses on doing more of things that are going well (not on doing new things).

    3.Identifies small steps to take toward what is desired (instead of what is NOT wanted).

    4.Identify strengths one has/uses to help manage diabetes every day.

    5.Considers how positive thinking and action affects life.

    6.Recognizes what worked.

    Stop back by in 2 weeks when we’ll share our favorite behavioral sessions we attended at the ADCES22 conference!

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Transform Primary Care Encounters: Discovery Learning from Data

    CGM tracing showing time in range (in green) and time out of range (in red)

    The real voyage of discovery consists not in seeking new landscapes, but in having new eyes. – Marcel Proust

    We kicked off 2022 with this series we’re wrapping up today:  Transforming primary care encounters by taking a solution-focused approach when managing type 2 diabetes in the primary care setting. Along the way we’ve shared a multitude of tips and tactics to add to your toolbox so speak. Today’s blog wraps up the series as we focus on discovery learning from  diabetes data in a solution-focused way.

    While there is a multitude of diabetes data that we can learn from, today we’re focusing on structured blood glucose monitoring (BGM) and professional continuous glucose monitoring (CGM).

    DISCOVERY LEARNING FROM  STRUCTURED BGM

    Both of us spent a large portion of our career in the  primary care setting where we routinely used structured BGM.There are 3 profiles that we have routinely used with clients/patients to help them to discover and learn about their blood glucose patterns and how favorite foods and physical activity affect them. We call this “discovery learning” because on their own, using “personal experiments” people are uncovering aspects of their diabetes themselves. And when people learn by doing, they are able to make health decisions that work for them. They are identifying “what’s working well” and are able to apply solution focused tactics to “do more of what’s working” and focus on successes instead of problems. Discovery learning is a great way to incorporate a solution-focused approach into practice. Let’s look at some examples

     When using BGM there are several profiles or checking patterns you can apply.

    7-point profile

    This one can be helpful to use for 3 days prior to a visit, for instance. This profile uses 21 strips, or 7 checks (before and after each meal and at bedtime) 3 days in a row. See the table below. The concentrated focus helps to measure the magnitude and frequency of short term fluctuation in blood glucose. It can be helpful in reducing the therapeutic inertia (Read more about therapeutic inertia in our blog here.) 

    5-point profile

    Similarly is the 5-point profile which requires fewer strips (15), if supply of adequate test strips is a concern. The 5-point profile includes 5 checks daily for 3 days, as you see in the table below – checking before and after breakfast and supper, as well as after lunch.

    Paired checking

    This is one of our favorite profiles for discovery learning. It can be used to focus on one thing, such as how a food/meal impacts blood glucose. We’ve had many clients/patients use paired checking to learn how their Friday night pizza affects their blood glucose. One example that stands out was an individual who routinely ate ½ of a medium hand-tossed pepperoni pizza (4 slices). After seeing the spike in his blood glucose, he decided to go with 2 slices and a side green salad, and saw his blood glucose fall back into range. We encourage patients to conduct their own “experiments”, if you will, to learn how food (type, portion) or adding in more physical activity affects them.

    Paired checking can also be used around 1 meal time each day, rotating amongst the meals over the course of the week, to give a good look at blood glucose patterns.

    Follow-up on personal experiments

    At the follow-up to see what the individual learned from structured BGM, ask solution-focused questions in a non-judgemental way, such as:

    I know you really like cheesecake and were planning to try paired checking to see how 3 bites satisfied you and affected your blood glucose, as compared to eating a whole piece. What did you learn? Did that change your plans? What are some options if your glucose spikes?

    What have you learned during your discovery? And follow up with, How can you do more of that?

    DISCOVERY LEARNING FROM PROFESSIONAL CGM

    Another tool available to support people with type 2 diabetes to engage in discovery learning is by using professional CGM. Professional CGM is owned by the clinic, not the person with diabetes, for intermittent CGM use. Similar to the personal experiments described with BGM, a person can choose to view their data before and after favorite foods, different activities, or even before and after sleep or a stressful event. The benefit of professional CGM is that the individual doesn’t have to do a fingerstick as the unblinded professional CGM can be connected to their smartphone and they are able to see their data in real time for up to 10 days. We’ve written about discovery learning and CGM previously. There is also a blinded professional CGM where the person reviews the data at the end of session retrospectively. While not as useful for discovery learning and personal experiments, if they keep good records of food and activity they can identify trends and patterns. 

    Examples of personal experiments:

    Favorite foods – While wearing the CGM your client might decide to eat different breakfasts each day of the week, and view their data on their smartphone before and again two hours later to see if they stayed in their target range (typically 70mg/dL-180mg/dL). They might choose their favorite high carb breakfast one day, and then a low carb version the second day, and then something in-between the next day.The beauty of personal experiments is that they can be anything that matters to the person.Through this personal discovery, they are able to learn what is working and make decisions.regarding their next steps.

    Physical activity – Similar to evaluating the impact of food on glucose values, the same can be done for physical activity. The client can check their smartphone to know their glucose value and their trend arrow direction (are they staying steady, trending up or down) and then choose a variety of physical activities to evaluate the impact. Some questions they may ask are: What happens when I start physical activity when I have a trend arrow going down but my glucose is in range? Or what happens when I complete my physical activity and my trend arrow is going up? Many people discover that their glucose values actually increase following physical activity, but then come down later and using CGM can help them to plan how they respond.

    Stress – Using CGM can really help clients understand the impact stress can have on their glucose. We’ve shared in our presentations about a friend who’s CGM values went straight up during a stressful event when she had nothing to eat or drink (the fire alarm went off, she ran out of her condo but forgot to get her cat …good news in the end it was a false alarm and the cat was fine!). Viewing data during stressful times can help people remove some of the guilt they experience with glucose fluctuations and help them to realize that diabetes is a challenging condition to manage.

    Follow-up on personal experiments

    Similar to BGM, use your solution-focused tools when discussing data. Focus on what went well, what the individual learned, and remember that all data are valuable.  Data are just numbers and not judgements and do not define a person as “good” or “bad.” Help your clients value data to support their learning and to modify their health behaviors, even when their choices may not be choices you would suggest. People need to be ready to make big changes, and over time, data can help them get there!

    I see you changed how much you walked after dinner, what did you learn? 

    You were in target range after these three meals, how did you do that? How can  you do more of that? And what else?

    We’ve written before about the 42 different factors that affect glucose (see Bright Spots and Landmines) and how Bright Spots are very similar to “exceptions” in a solution-focused approach, a time when things are going well. Author Adam Brown mentions that he would not have been able to identify these 42 factors without the use of CGM to guide him and reveal glucose changes that were unknown before. There is nothing more helpful for someone trying to make a challenging health behavior change than personal data to help them identify what they can do and what is reasonable for them.

    Stop back by in 2 weeks when we’ll share a sneak peek at our session we’ll be presenting at the ADCES22 conference in Baltimore, MD!

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Transforming Primary Care Encounters: The Prediabetes Conversation

    “The secret of living well and longer is: eat half, walk double, laugh triple, and love without measure.” ~ Tibetan Proverb

    As we revisit our series on transforming primary care encounters, we’d like to take a step back, if you will, to the diagnosis of prediabetes. In our clinical experience there is a vast difference in these early conversations in the health care setting – sometimes a stern warning to change habits “or else”, to almost no recognition of the elevated blood glucose at all, with no discussion about the potential risk of developing type 2 diabetes. Deb discovered that both of her parents had been living with prediabetes for years, but neither of them had even been told of their lab levels except, “things look good.” As with a new diagnosis of type 2 diabetes, we believe that incorporating a solution-focused approach with a prediabetes diagnosis is equally as important. 

    If you’ve read our previous blogs you know that  a solution-focused approach is the opposite of a more traditional “problem-focused” approach. The goal is to help the individual recognize exceptions (times when their problems did not happen) and help them to focus on health behavior changes by doing “more of what works.” How can we use this approach in the prediabetes conversation?

    Using a solution-focused approach at the prediabetes diagnosis conversation

    The ADA 2022 Standards of Medical Care indicate that screening for prediabetes should start at age 35, but earlier for those with risk factors. We are advocates that everyone who meets the criteria for a prediabetes diagnosis deserves the information as early as possible so they may decide what types of health behavior changes they are willing and able to make. Thus, using a solution-focused approach from the beginning is critical to set the stage for a lifetime of ongoing conversations. A clinician’s approach to this conversation can make the difference in early action to help prevent or delay type 2 diabetes – and thus potential prevention of long-term complications, reduction in medication, and living a healthier life.

    Current guidelines suggest enrolling individuals with prediabetes into a National Diabetes Prevention Program (DPP) given DPP study outcomes that showed a 58% reduction in risk of progression to type 2 diabetes with lifestyle intervention. Research shows that participants who lose 5-7% of their body weight and add 150 minutes of exercise per week cut their risk of developing type 2 diabetes by up to 58% (71% for people over 60 years old). 

    The guidelines also recommend metformin for those with a higher BMI, higher A1C, and history of gestational diabetes. Since many don’t want to take medication, there is a great need for open discussion from the beginning to use shared decision-making to lay out the facts, what is known, what the research indicates, and their overall level of risk.  

    We know that patients (clients) greatly value what their primary care provider (PCP) recommends to them, so having these open discussions can help the PCP identify what the individual is willing and able to do. If they might benefit from medication, and are likely to be challenged to engage in physical activity or choose more healthful foods, then medication might be a beneficial option. It’s important to balance goals from the PCP perspective against the capacity of the person with the new diagnosis. Asking questions and engaging in problem-free talk can be more impactful than giving a list of instructions. Maybe you simply state, “I know this is hard to hear, how can I help?” and “What information would you like to hear from me today as you start to learn about prediabetes?” 

    As we shared in our type 2 diabetes diagnosis blog, the American Diabetes Association encourages four critical conversations that promote “early positive conversations about the nature of diabetes.” We believe that applying this during the prediabetes diagnosis can be equally as valuable. These conversations address many tenets we value in a solution-focused approach, including person-centered, strength-based language, problem-free talk, listening, and building a partnership with clients.

    4 critical conversations

    There are four critical conversations that need to happen early in the diagnosis. We’ve modified these questions to fit prediabetes and encourage you to build upon these questions at each visit. Start small with a few comments and then build upon them as the person is learning to accept the diagnosis and is ready to learn more. At diagnosis, conversation #1 is the most significant. (adapted from ADA Overcoming Therapeutic Inertia)

    1. Prediabetes may progress to type 2 diabetes over time, as your body’s insulin production changes.

    I want you to know that prediabetes is an opportunity to make health behavior changes that may prevent or delay type 2 diabetes. However, it’s important to know that even if you follow every guideline you may still develop type 2 diabetes.

    1. Your treatment plan will change over time as your prediabetes changes.

    You may need to add a medication as your prediabetes changes. This is not a personal failure, just a part of how the progression to diabetes may happen.

    1. You can’t do this alone.

    I am here to help you.

    1. Share your difficulties with following diabetes prevention guidelines.

    Managing prediabetes day in and day out can be hard. Share anything that may be getting in the way of managing your diabetes and also share your successes.

    Close the conversation with a scaling question.

    On a scale of 0-10 where zero is no stress and 10 is the worst stress you’ve ever experienced, where are you right now?

    Use their answer to finish the visit and provide one action for them to focus on.

    If 0-4:  Encourage doing some research online at trusted sources like the ADA, CDC or ADCES.

    If 5-7:  Identify one strength they already have and build upon it

    What is one thing you do for yourself every day that makes you feel healthy? How can  you do more of that?

    If 8-10: just encourage them to breathe and take some time to let it sink in and to come back with questions in one week

    I know how hard this can be, take some time, write down questions you have, and let’s meet and talk more next week.

    Create a supporting environment

    Reinforce that small changes can help move them in the right direction, and that you don’t expect perfection. If they do the best that they can do, that’s the best they can do.  Remind them that you are partners on this journey. We believe that creating a supportive environment from day one, can empower people to learn to live with their diabetes.

    Stop back by in 2 weeks as we wrap up our series on incorporating a solution-focused approach when managing type 2 diabetes in the primary care setting. We’ll focus on interpreting diabetes data in primary care in a solution-focused way.

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

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