• 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.

  • Fresh Views

    Benefits of Being in Nature

    Teton mountain range in Wyoming

    Nature itself is the best physician.– Hippocrates

    Given that our blog posts are called “Fresh Views”, we are always on the lookout for opportunities to experience these views first hand. You may have read a previous blog where we talked about “imprinting” these fresh views so they’ll stay with us forever. Given the season, we wanted to share some of the benefits we find in nature by sharing some beautiful photos from our time in the great outdoors that have allowed us to reduce our anxiety, improve our mood, and promote a sense of calm for both of us.

    With summer in full swing, we’re both enjoying the opportunity to spend more time in nature. Did you know that there are many benefits of being in nature? Whether for an hour, a day or a week, we find so many benefits spending time in nature. And there is actually scientific evidence that identifies many beneficial effects from spending time in nature and the impact it has on health, including reducing stress and anxiety, improving one’s mental health, and promoting healing. Studies show that 120 minutes spread out over the week may be the ideal amount of time. 

    While we both love our dramatic mountain scenery and listening to the ocean waves crash on the sand, even a local park or garden can do the trick. Any place that gives your mind a break, provides time to reflect on what’s going well for you, gives you the freedom to think of other things in your life that are also going well, and consider how you can do more of that. We find that our mood immediately improves and our sense of self improves.

    Tami and her husband spent some time in Yellowstone and Grand Teton National Parks earlier this summer. Surreal beauty. Coincidentally, Deb is headed to Grand Teton later this summer too.

    Yellowstone National Park

    The cool breeze, peace, and reflection of the mountains was so calming and brought a smile to their faces. This was definitely an image they  imprinted.

    Yellowstone National Park thermal hot spring

    On this trip, Tami and Mike got far more than recommended 120 minutes of being in nature! The thermal hot springs are fascinating and offer other-worldly beauty! Focusing on them and the mountains provided a mental break from the demands of daily life.

    A mother goose protecting her 6 babies under her wings from the rain. Don’t miss the couple of curious goslings sticking their heads out!

    Sunrise in Jackson Hole, Wyoming

    Sunrise in Jackson Hole, Wyoming over a creek where otters were playing. A time to reflect on and appreciate the many sights from the day prior, think about other things in life that are going well, and look forward to what the current day will bring.

    Deb is fortunate to have a California State Park at the end of her street.  She enjoys weekend morning walks along Folsom Lake. On a clear day she can see the  snowy mountains from Lake Tahoe in the distance, and in the spring the lavender Lupine super bloom is often breathtaking. Taking these walks really gives her mind a break and provides an opportunity to reflect and simply enjoy the beauty of nature so readily in her reach.

    View of Sierra Nevada Mountain Range from Folsom Lake, CA
    Lupine Super Bloom, along the shores of Folsom Lake, CA

    And when summer arrives and the lake is full, there is nothing better than being in a boat on the lake, anchoring in a cove, and enjoying the cool water on a hot 105 degree June day. It’s amazing how relaxing with the beautiful scenery around you can really promote calm and lift one’s mood almost instantaneously.

    Enjoying a later afternoon boat ride and a dip in the cool water on a 105 degree day

    While Deb and Mark really look forward to their week in Wyoming and viewing the majesty of the Grand Tetons, they appreciate the nature that is nearby that can provide a much needed respite from the daily grind of life.

    We hope these images of nature have inspired you to find rest, relaxation, and rejuvenation with nature this summer, whether near or far.

    If you would like to try to imprint the images you see, follow these easy steps:

    1. When you find yourself gazing at a striking view or in a most memorable uplifting  moment…pause. Be present in the moment.
    2. Take a deep breath in and a cleansing breath out.
    3. Gaze at the view – noting where you are and who you are with. Take in colors, lighting, sounds, smells (maybe even taste if it’s food or beverage related).
    4. Then take time to appreciate and acknowledge what you see before you and are experiencing (many liken this to having an “attitude of gratitude”).
    5. Allow that view or moment – every detail – along with those positive feelings to etch into your mind’s eye so you can recall them in the future.

    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

    When Life Give You Lemons

    Courtesy of Deb’s backyard lemon tree

    When life gives you lemons, make lemonade. – Proverb

    Hey, it’s Tami writing today!  The life circumstances of these past 2 weeks in my world brought this proverb to mind: When life gives you lemons, make lemonade. If you follow our blog, you know that our primary focus is on taking a solution-focused approach to life to positively impact the future, particularly life with diabetes…rather than focusing on problems. It’s all about how you respond. So when life hands you situations that may initially be perceived as a “problem” (a lemon, if you will), focusing on how that can ultimately be transformed into something sweet (lemonade, or better yet, diet lemonade!) is the game changer.

    So today, here are 5 reflections I want to share, relating from conversations with a couple of friends that have recently unexpectedly lost spouses/partners, Covid-19 rearing it’s ugly head, and transitions galore these last few weeks:

    1. Even in the tough days, try to be present and appreciate every minute of life. We’ve written in the past about the impact of finding joy and expressing gratitude.
    2. Rest and sleep are way more powerful in healing the mind and body than we give it credit for. Personally, the day seems more manageable when I get 8 hours of sleep instead of 6 ½.
    3.  A good belly laugh can make things seem not quite so dark or overwhelming. A perfectly timed meme from a friend has done just that for me. As comedian Milton Berle said, Laughter is an instant vacation. We’ve written about the  benefit of laughter here.
    4. Embrace the power of “can do”. One friend walking through a significant loss shared with me a “track” she plays in her mind, “You HAVE done xx. So you KNOW you can do it. You CAN do it again. You WILL do it.” She shared that this positive self-talk and doing more of what works has given her the momentum to keep moving forward. 
    5. I constantly remind myself that even the tough “lemon” days are part of my story. While I may not fully see it now, how I respond shapes my future. And I can share and use my experiences to impact and encourage others. 

    I hope these reflections that have become evident to me over the last few weeks are in some way encouraging and motivating to you, and can be shared with those clients you work with.

    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

    Summer 2022 Fresh Views

    Happy Summer from us here @A Fresh POV for you as we break to refresh and recharge! We continue towards our Mission to guide healthcare professionals in a solution-focused approach so clients can embrace possibilities, opportunities, and a fresh vision for the future. You will not want to miss our next post on highlights from the upcoming American Diabetes Association Scientific Sessions! 

    If you’ve followed our blog, you know that we enjoy sharing a fresh inspiring view with each post. Here are a few fresh views that we have enjoyed this summer! 

    Tami’s visit to Cherokee National Forest in Tennessee
    View from a favorite local winery near Deb in Lincoln, CA
    Stunning roadside waterfall in Townsend, Tennessee
    View over San Diego marina
    Tami never tires of sunset views from her Kentucky home

    We hope you enjoyed these beautiful “Fresh Views” as much as we did! And we hope you are enjoying your summer.

    If you have any suggestions regarding future blog topics or series please let us know!

    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

    Happy Memorial Day! 6 Solution-focused Strategies for Picnics and Gatherings

    Where did Spring go?! Memorial Day is at hand, and that means it’s time to kick-off summer! If you’ve been following our series on Transforming Primary Care Encounters Using a Solution-Focused approach, we’re going to take a few weeks off from this series,  but will revisit and closeout the series with a few more important considerations and tactics later this summer. 

    Will you be gathering with family and friends on Memorial Day? Sometimes it can be challenging to maintain healthy habits during group gatherings, especially if everyone is not on the same page. It’s helpful to have strategies in your back pocket to pull out. So, today we want to share with you 6 solution-focused strategies for navigating picnics and gatherings that you can share with your clients (or even try out yourself)! 

    #1 – Portion your plate by the healthy plate for diabetes. 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). Then fill half the plate with non-starchy vegetables (such as veggie salads, green beans, or sliced tomatoes), one fourth of the plate with lean protein foods (such as a grilled turkey burger or grilled chicken), and one fourth with carbohydrate foods (this is where potato salad, corn on the cob, watermelon, or a sweet treat may fit). Partitioned paper plates can do the portioning for you. Not sure partitioned paper plates still exist? Here you go, just a click away.  When asked how high one can “pile the plate”…try to keep it no higher than a deck of cards is thick. This simple strategy has brought success for many when navigating picnics and celebrations. And, Tami recalls one client she worked with that embraced this as a “year-round” strategy, purchasing the “old fashioned” partitioned 9-inch paper plates to use at home. He went on to lose over 30 pounds managing his portions and blood glucose in this manner. And he was thrilled that he didn’t have to wash dishes!

    #2 – Stick with small tastings. Maybe there are a number of things on the picnic table that you want to enjoy. And maybe you are not sure exactly what is in some of the dishes or how much carbohydrate they contain. One tried and true strategy is to stick with small tastings. You can sample a number of different items if you choose, fitting them within the plate sections reviewed above. And there’s a lesser chance of sending blood glucose out of range with small tastings versus a serving spoon portion. This is a great strategy for travel as well, discussed in our blog on Traveling with Diabetes.

    #3- Eat fresh and local. We are fans of supporting local farmers and enjoying local produce at the peak of ripeness. When trying to decide what to take to a gathering, think local and fresh. Picnics can be laden with rich casseroles and sides, so taking a fresh, low carbohydrate side that you know will work for you helps to insure there is something you can eat at the event. One of our favorite go-to’s that is ALWAYS the first dish to disappear is this (you may know it as Caprese salad): juicy ripe sliced tomatoes on a platter, topped with a slice of fresh mozzarella cheese, chopped fresh basil (or a dollop of pesto sauce), then drizzled with olive oil and balsamic vinegar. Sometimes we’ll layer sliced avocado on the tomatoes as well. Serve with  salt and pepper grinders alongside so everyone can manage what goes on their salad.  

    A version of the Caprese salad we enjoy made with yellow tomatoes

    #4 – Fill the day with fitness. With the eating and celebrating, fitting in fitness can help manage blood glucose and spend more time in range. Whether it’s participating in a local walk/run, swimming, playing cornhole, or joining the kids in a water balloon toss. How can you fit in fitness during Memorial Day weekend? We are believers in making a commitment to move even more when we know there is a weekend or vacation ahead filled with a few indulgences. Take a walk early in the day. That makes sure that movement doesn’t get pushed out by other holiday activities. And if you find blood glucose out of range 1-2 hours after you eat, take another walk to help lower blood glucose.

    #5 – Bring something to share that incorporates seasonal produce. Many of the food traditions associated with Memorial Day are filled with the best summer has to offer. Not only is flavor at its peak, seasonal produce is packed with nutrients (and lower in cost). Deb has local, fresh grown strawberry stands nearby at this time of year, so makes a weekly journey to purchase and enjoy their sweet flavor.

    #6 – 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.

    Here with our husbands, we enjoyed some laughs atop a rooftop among igloos when we were together a few months ago
    We got some more laughs wrapping up in the furs in the rooftop igloos

    We hope you enjoy some laughter, friendship, family and great food this holiday! We are taking our own advice and will be enjoying some travels, adventures, and connecting with great friends and will be back soon with more content to share.  

    If you have any suggestions regarding future blog topics or series please let us know!

    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

    Transform Primary Care Encounters: “Diabetes Only” Visits

    Success is built sequentially. It’s one thing at a time. – Gary W. Keller

    Building on our last blog about how to have a productive type 2 diabetes (T2D) diagnosis conversation using a solution-focused approach, NOW let’s focus on how to incorporate these techniques into follow up visits. These follow-up visits are ideally “diabetes only” visits. In a brief primary care visit that is addressing multiple issues, it can be too challenging to focus on specific diabetes priorities. The American Diabetes Association recommends scheduling  “diabetes only” appointments to focus on and address diabetes-related concerns. This diabetes only visit is an opportunity to be a think partner with your client to answer questions, address concerns, and map out a plan together.

    Using a solution-focused approach at a “diabetes only” visit?

    Since asking eliciting questions is a primary tenet of a solution-focused encounter, we encourage starting all visits by listening and learning from your client. Even though the client is new to diabetes, they are the expert in that they know what works in their life in other aspects, and they know what they are capable of doing now. (Read more about experts here)

    The goal is to focus on things that are working well, and when something works, do more of it! Help your clients to recognize their strengths by identifying exceptions. We’ve written about exceptions here). “Diabetes only” visits can be structured in a systematic way.

    10-step model for a “diabetes only” visit

    1. Start with a question. “I’m looking forward to hearing how things have been going since our last visit. Can you tell me one thing that went well for you this past week (or since we last met)?”
    1. Explore the reply further. “How do you think you can do more of (that)?”
    1. Personalize. “I want to make sure this visit is successful for you, what do you need to know or learn by the end of the visit?”
    1. Empower. Empower people with diabetes with tailored education and support to ensure their questions, needs and desires are met.
    1. Set a SMART goal.  A SMART goal  helps move the individual towards the direction they want to move based on your conversation. It helps quantify progress with measurable steps and keeps things reasonable and achievable.
    1. Ask a scaling question. “On a scale of 0-10 where zero is never and 10 is all the time, how confident are you that you can achieve your goal?
    • Use their answer to finish the visit and provide one action for them to focus on.
      • If 0-4: Encourage them to revise their smart goal, it might be too difficult to achieve.
      • If 5-7: Identify one strength they already have and build upon it. “What is one thing you do where you feel confident in your actions? How can  you do more of that?”
      • If 8-10:  Encourage them to challenge themselves and consider a goal that might move them closer to their overall health behavior outcomes.
    1. Review  the four critical conversations. As we discussed in the last blog, we encourage you to build upon these conversations at each visit. (adapted from ADA Overcoming Therapeutic Inertia

    Conversation 1: The nature of T2D is to change over time, as your insulin production changes.

    “Although diabetes is progressive, and can change over time, your actions can make a difference in slowing the progression over time.”

    Conversation 2: Your treatment plan will change over time as your diabetes changes.

    “We will work with you to find a treatment plan that achieves health goals while also considering your preferences and values.”

    Conversation 3: You can’t do this alone.

    “Seek help from family, friends and community support resources.”

    Conversation 4: Share your difficulties with managing your diabetes.

    “Your healthcare team is on your side and we will support you in whatever ways you need to manage your diabetes”

    1. Refer for diabetes self-management education and support.
    1. Thank them for coming in and for working hard.
    1. Plan follow-up. Plan the next diabetes only visit.

    Join us next time as we continue our series on incorporating a solution-focused approach when managing T2D in the primary care setting. We’ll continue to help you  build your solution-focused tool-kit. Our goal is to start slow and share small, achievable bite-size practice changes you can implement over time. 

    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

    Transform Primary Care Encounters: Tackling the Diabetes Diagnosis

    “Health is a state of body. Wellness is a state of being.” ~ J. Stanford

    Our prior post in our series on transforming primary care encounters focused on combating therapeutic inertia. Today, we’d like to start from the very beginning – the conversation when the client first learns they have type 2 diabetes (T2D).  When beginning diabetes conversions using a solution-focused approach, we believe you will find that your relationship with your clients can improve and it will create an opportunity for ongoing shared decision-making.

    As a reminder, a solution-focused approach is the opposite of a “problem-focused” approach. The goal is to help the person with T2D recognize exceptions (when their problems did not happen) and help them to focus on their health behavior changes by doing “more of what works.”

    Using a solution-focused approach at the T2D diagnosis conversation?

    When preparing for the diagnosis conversation, first put yourself in your clients shoes. How would you want the conversation to go? What would you want to hear? Also consider your body language, your tone and word choice. We know in a busy primary care office, so much time is spent documenting in the EHR, but for this very important discussion, take a moment and step away from the computer, lean in to your client, show empathy and compassion while you say some very important words. Many are overwhelmed when they hear the news that they have T2D, and often won’t hear much of the rest of the conversation. Ask questions and engage in problem free talk, instead of 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 T2D?” Consider making this appointment brief and bring them back for a follow up “diabetes only” visit once they have time to absorb and process the information. 

    To build upon our blog on therapeutic inertia, we’re including some impactful information from the American Diabetes Association that encourages four critical conversations that promote “early positive conversations about the nature of diabetes.” 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 very early in the diagnosis. We 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. The nature of T2D is to change over time, as your insulin production changes.

    “I want you to know that diabetes is not a personal failure and it doesn’t mean you’ve done something wrong.”

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

    “You may need to add new medications as your diabetes changes. This is not a personal failure, just a part of how diabetes treatment progresses.”

    1. You can’t do this alone.

    “I am here to help you.”

    1. Share your difficulties with managing your diabetes.

    “Managing diabetes 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 diagnosis visit 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 them to do some research online at trusted sources like the ADA, Diatribe, 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.”

    Reinforce that small changes can help move them in the right direction, and that you do not 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.

    Keep reading our series on incorporating a solution-focused approach when managing T2D in the primary care setting. Next time we will focus on the first follow up visit after diagnosis.  Stop back by in 2 weeks as we share more tips to build your solution-focused tool-kit over time. 

    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

    Transform Primary Care Encounters: Stop Therapeutic Inertia

    Where you stand determines what you see and what you do not see; it determines also the angle you see it from; a change in where you stand changes everything. – Steve de Shazer, pioneer of solution-focused brief therapy   

    As we continue our series on transforming primary care encounters, today we’re tackling the topic of combatting therapeutic inertia.  

    What is therapeutic inertia?

    In a general sense, “therapeutic inertia” is a lack of timely adjustment to the treatment plan when a client’s treatment goals are not being met. In the diabetes management arena, therapeutic inertia means being slow to add or change the care plan if a client’s A1C is above target. Delays in implementing the most effective care for each person with diabetes can  happen at any phase of diabetes treatment and can range for instance from referring for diabetes and nutrition education, to starting the first medication, or intensifying medication management, including starting insulin.

    Why stop therapeutic inertia?

    The evidence is clear on two things:

    1. Managing glucose levels early in the course of diabetes leads to better long-term outcomes and reduces risk of complications.
    2. Those who reach their A1C targets soon after they’re diagnosed with diabetes are more likely to keep their glucose in target. 

    This is such a timely and impactful topic that ADA has launched an initiative called Overcoming Therapeutic Inertia. There are many resources for primary care clinicians to learn practical tips to focus on diabetes care in a proactive, timely way to improve outcomes. Learn more here.

    Does shared decision making play a role?

    One key tenet of shared-decision making is that all care decisions are discussed together with the client, and decisions are made together, which will ultimately mean more people with diabetes are following their treatment plan. Research shows us that when people are not involved in their diabetes medication decisions, they often no longer take the medicine.

    When we talk about therapeutic inertia we are addressing both the clinician reluctance to advance therapy and the client’s reluctance to follow through with prescribed therapy. When we add shared decision-making we remove some of the barriers to medication taking. We discuss the potential side effects of the medication, costs, schedule and impact to their lifestyle.  These are important decisions that need to be understood for individuals to embrace new therapy.

    So how does incorporating a solution-focused approach address therapeutic inertia?

    A solution-focused approach that encourages shared decision-making can be a tool to overcome inertia. As we’ve discussed previously, incorporating  a solution-focused approach removes the shame and blame often associated with diabetes. When you discuss the clients goals and outcomes and what is working well for them, together you can identify the best therapy. 

    A solution-focused approach is a questioning approach, asking questions allows you to delve down to identify what is most important. An example of a medication-related question might be: What is most important to you when choosing a medication, the potential of weight gain or the need to check glucose before meals? ”And what else?” questions can be incorporated to learn more. 

    Since asking eliciting questions is a primary tenet, we encourage you to start all visits by listening and learning from your client. Remember, the client is the expert (read more about experts here), and even though they may be new to diabetes, they know what works in their life in other aspects, they know what they are capable of doing now. 

    When incorporating a solution-focused approach, each person will map out their own successful plan based on their lives, needs, strengths and desires. The care plan becomes personalized and directly relevant to the client. If something works, do more of it, help them recognize their strengths by identifying exceptions ( written about exceptions here.)

    This solution-focused shared decision-making can build relationships and guide clients towards achieving goals, thus overcoming therapeutic inertia.

    Next up

    Join us next time as we continue our series on incorporating a solution-focused approach when managing T2D in the primary care setting. We’ll visit the moment of diagnosis with diabetes and share tips/tactics you can use to continue to help you  build your solution-focused tool-kit.

    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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