• 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).


    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?


    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

    Diabetes Technology and Solution-Focused Practice: Online Peer Support Community Intervention to Address Health Disparities

      “I realized that my sugar was like a rollercoaster. It would go up and down very clearly. So I started to go for walks. Not light walks, but fast-paced ones.” ~Study participant

    Since the COVID-19 pandemic began the disparities in diabetes technology use in underserved populations has risen to the forefront. During the recent American Diabetes Association (ADA) Scientific Sessions data were shared about a novel use of an online peer support community combined with continuous glucose monitoring (CGM) use to educate, engage and empower people with type 2 diabetes. Since Deb was a co-investigator on this study, we reached out to Dr. Michelle Litchman, PI, Assistant Professor, University of Utah, College of Nursing to discuss the study findings and impact.

    The ADA abstract: 151-O Using a CGM plus Online Peer Support Community Intervention to Address Health Disparities

    Dr. Litchman, what makes this study unique and important?

    This study was developed based on two separate PCORI-funded projects that incorporated community-based participatory research principles and community advisory boards (CAB). The first CAB partnered with individuals within the Hispanic community to better understand diabetes technology needs and desires. The second CAB included diabetes online community partners to best understand how online peer support could reinforce diabetes technology use and healthy behaviors.

    What were the components of the study?

    We developed an intervention that combined continuous glucose monitoring (CGM) plus an online peer support community (OPSC). To support the needs of Hispanic and Spanish-speaking adults with type 2 diabetes not using insulin, the CGM+OPSC intervention was optimized to be culturally and linguistically appropriate. Participants wore CGM to visualize their daily glucose patterns and engaged in weekly personal experiments. Personal experiments included health behavior challenges related to general diabetes topics (being active, healthy eating, etc.) and were posted to the OPSC weekly. The OPSC were managed by trained Spanish/English bilingual peer facilitators who also lived with diabetes and used CGM. This mixed method study assessed how participants used the intervention.

    Participants completed a 1-week blinded baseline CGM recording (N=31) then engaged in the CGM+OPSC intervention for 12 weeks. Of those that continued into unblinded phase (n=22) study engagement was excellent (N=21).

    What were some of the key outcomes of the study?

    We analyzed exit interviews and identified 3 themes: (1) CGM “personal experiments” helped participants gain knowledge about how diet, exercise, medications, stress, and sleep impacted glucose levels; (2) the OPSC reinforced healthy behaviors through personal experiments, collective learning and social support; and (3) CGM engagement increased OPSC participation and participation in the OPSC resulted in greater CGM utilization, suggesting a positive feedback loop.

    We also found that self-efficacy levels significantly improved when comparing pre to post intervention.

    Tell us about the figure you presented.

    The figure above describes a positive feedback loop in which CGM could help see how glucose levels changed when they engaged in health behaviors, and the OPSC provided structure (personal experiments) and emotional and informational support to reinforce healthy behaviors. The promise of diabetes technology can only be seen with continued use. This study showed that an OPSC is one way to enhance CGM use. It is possible that OPSC could support other diabetes technologies and in other populations or languages.  

    Tell us more about the peer facilitators.

    We hired and trained five Hispanic Spanish/English bilingual individuals who were living with diabetes and using CGM. Having a group of peers that the participants could relate to was critical to the study’s success. The peer facilitators could provide tips and tricks from their own lived experience while also providing encouragement to those who might be struggling. All peer facilitators were supported by the research team and a bilingual certified diabetes care and education specialist. After the study completed, the peer facilitators helped develop training videos to support future research.

    What is the key message you would like readers to take away today?

    Hispanic, Spanish-speaking adults with type 2 diabetes have a great desire to use diabetes technology. However, diabetes technology must be optimized for language, cultural and social support needs. The CGM+OPSC intervention provided participants with the tools necessary to learn, problem-solve, and make healthy behavior changes and is a promising intervention to address health disparities.

    Is there anything else you would like us to know?

    This study would not have been possible without important community partners. We thank the CABs from both PCORI studies who helped guide us to developing this novel intervention.

    Of note, this abstract was awarded “Best Abstract” in the Glucose Monitoring and Sensing presentation group! We congratulate and thank Dr. Litchman for sharing the ADA presentation with us and look forward to future publications.

    Stop back by in 2 weeks to see what we write about as we continue to share about a variety of other technologies that impact and influence diabetes care and education!

    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.

    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

    Diabetes Technology and Solution-Focused Practice: Applied to Blood Glucose Monitoring Discussions

    A field of flowers representing multiple fingersticks associated with monitoring via a meter

    As we continue our series on Diabetes Technology and Solution-Focused Practice, this week we’re focused on conversations around interpreting blood glucose data obtained via monitoring with a blood glucose meter. (You can find a post a few weeks back on continuous glucose monitor (CGM) data discussions here.) While more and more people are using CGM to stay in touch with their glucose levels, monitoring via a blood glucose meter and fingerstick or alternate site blood sample, continues to be an important diabetes technology for many individuals. 

    Focus first on blood glucose in target, rather than the outliers

    How was that accomplished? When evaluating blood glucose logs and patterns, a typical first response may be to focus on the glucose values out of range and try to identify what went wrong at those times. However, what if the first focus was on blood glucose in the target range, and what was going on to accomplish that?

     If we only focus on times that are not working well, we miss identifying successes.

    There are at least 42 identified factors that can impact blood glucose (while in reality there are likely even more if you include mental health and other daily issues). 

    Monitoring is helpful, for instance, to learn how a meal affects blood glucose. By “checking in pairs” pre and 1 ½-2 hours post meal when blood glucose is generally peaking, it’s easy to see and learn the impact of the type of food and portions eaten.There’s so much to learn!

    Glucose numbers provide information

    From our years in practice we’ve learned that people who live with diabetes have different perceptions around monitoring. For some, it can become an obsession – they need to know where their blood glucose is all the time. It can certainly be a mental burden. And others may not want to focus on their blood glucose. Knowing their number may create negative feelings, fear of judgement and guilt. So, they choose to not check their blood glucose to provide a sense of safety and self-preservation.

    We know that glucose numbers are simply that……they are numbers, and numbers provide information.  The goal of monitoring is to generate data to help people make choices and changes. Numbers are not good or bad and are certainly not a test score. You may have recently seen this image below on Twitter and/or the discussion around it. This is NOT a solution-focused approach! 

    Photo credit: Renza Scibllia’s Twitter account

    When working with clients instead of focusing on what is not working well or what is “wrong”, here are 3 illustrations of how to apply a solution-focused twist to the conversation:

    Try this: You’ve been working hard to fit in physical activity (…or fill in the blank). In looking at your blood glucose checks, what small steps can you take in the direction toward the goal of seeing more values in target?

    Try this: You mentioned you’ve had a lot going on and a really stressful few weeks. Yet you were still able to check your blood glucose twice this past week. How did you manage to accomplish that?

    Try this: I see that your A1C is in your target range. How did you manage to do that? (Instead of your A1C is outstanding, A+ as in the above image!)

    We challenge you each week to try incorporating some flips or twists into your conversations and let us know what impact they have. Stop back by in 2 weeks to see what we write about next in this series of technologies that impact and influence diabetes care and education. 

    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

    Diabetes Technology and Solution-Focused Practice: Applied to CGM

     “The future depends on what we do in the present.” – Mahatma Gandhi

    Views of the Sierra Nevada Mountains from Folsom Lake, Granite Bay, CA

    In this week’s installment of Diabetes Technology and Solution-Focused Practice we’re discussing continuous glucose monitoring or CGM. If you’ve been reading our blog, you know we’ve written about CGM before in our posts about Exceptions and Possibilities and also in our series on “Flipping the Paradigm” when applying a solution focused approach to Monitoring

    Focus on “exceptions” rather than “problems”

    When we think about applying a solution-focused approach to CGM, Bright Spots and Landmines by Adam Brown comes to mind. It’s a framework for evaluating diabetes habits and decisions. (You can read our 2019 interview with him here.) As we were identifying our technology themed blog posts, Deb happened to watch a North Carolina JDRF Chapter presentation by Adam (see slides here) that really highlighted the approach we encourage  diabetes care and education specialists (DCES) to take when discussing CGM data. 

    When evaluating CGM data similar to that below, the typical first response may be to focus on the glucose spike and try to identify what went wrong.

    However, when taking a solution-focused approach, we want to turn focus to all of the things that are working well (rather than what went “wrong”). Similar to Adam’s “Bright Spots”, we call them “Exceptions” or times when the problem did NOT occur and when things were going well. Below you can see where Adam focuses on his Exceptions, instead of his “landmines” and identifies all of his successes during the day. If we only focus on times that are not working well, we miss identifying successes.

    CGM creates a great opportunity for discovery learning!

     When CGM was first incorporated as a management tool, the focus was typically on hypoglycemia, and preventing serious events from happening. As CGM has evolved and more individuals with type 2 diabetes are incorporating it into their diabetes care, the focus has broadened and now includes focus on making healthy behavior changes. CGM creates a great opportunity for discovery learning, where people can try different foods or activities and personally experiment to learn what works well for them. While Adam identifies 42 factors that can impact blood glucose, he stated that there are more likely more than 60-100 factors if you include mental health and other daily issues. There’s so much to learn!

    As DCES use CGM in practice with clients with type 2 diabetes, applying a solution-focused approach to CGM data can be motivating and help reinforce habits and choices that result in increased time in range (TIR) and overall quality of life. (The recommended goal for TIR is > 70% of glucose values between 70 and 180 mg/dL) Focusing on their “best day” pattern (the day with the greatest TIR) and working towards increasing TIR is a positive goal to strive for because they can “do more of what’s working” instead of giving up or stopping something they enjoy. Our “fresh view” photo today was taken by Deb on an easy hike near her home. Physical activity is one of many factors that can help one see more TIR. Applying a solution-focused mindset with CGM can help your clients want to learn to use their own data to learn about their diabetes and create a plan that works for them, where they can be successful.

    Do you use CGM in your practice and with your clients? If you do, try focusing on times when they are in their goal range and inquire about their actions and activities during that time. Help them identify what’s working well and what choices will move them towards more TIR. 

    • One mnemonic to facilitate conversation is MGLR, which stands for “more green, less red” when looking at the TIR bar. The goal is to see more green (time between 70-180 mg/dL) and less red (< 70 mg/dL). Talking about TIR can be a great way to have a solution-focused discussion and to help clients identify opportunities to succeed instead of focusing on past failures. 
    • A second mnemonic is FNIR, or “flat, narrow and in-range”, which is a goal for the trend graph. When viewing the trend graph the goal is to have the majority of the data fall within the target range, again typically 70-180 mg/dL without extreme variability swinging from below range to above range. CGM creates an opportunity to move towards a clients goals while providing constant, non-judgemental feedback on their progress.

    We plan to continue to write about a variety of other technologies that impact and influence diabetes care and education including diabetes apps, digital health tools, diabetes devices, online peer support and online coaching. Stop back by in 2 weeks to see what’s up next!

    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. 

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

  • Fresh Views

    JOURNEY: Today’s word to jump-start solution-focused practice

    A journey of a thousand miles begins with a single step.” – ancient Chinese proverb

    Tami and Deb with our friend Karen Kemmis ready to head off to the Kentucky Derby a few years back

    This Saturday September 5 marks the 146th running of the Kentucky Derby! If you are not familiar with this premier thoroughbred horse racing event, it is held annually in Louisville, KY, typically on the first Saturday in May. Yet, due to the pandemic, this year’s Derby was moved to the first Saturday in September in hopes that this “Fastest Two Minutes in Sports” would have an excited crowd cheering on the three-year-old thoroughbreds as they raced the one and a quarter miles to the finish line. The stands typically would be teeming with spectators from around the world oozing with fashion…ladies sporting beautiful dresses and big hats and men decked out in colorful suits…yet this year the stands will be empty. This race is often called “The Run for the Roses” because a blanket of roses is draped over the winning horse. It is the first leg of the American Triple Crown, followed by the Preakness Stakes and then the Belmont Stakes. A horse must win all three races to win the Triple Crown.

    Our husbands sporting their sharp Derby attire

    Not only is this premier horse racing event near and dear to our hearts since we had the opportunity to experience it a few years back, it causes us to take pause and reflect on the JOURNEY to qualify for the “Run for the Roses”.

    Some horses are born with talent, and are simply stronger and faster than other horses in the race. They are considered the “favorites” to win their races. But yet, the “favorite” doesn’t always win every race. Sometimes the winner is a horse with lesser talent so to speak, but who has a trainer that’s able to help maximize the horse’s potential through customized training based on the horse’s particular strengths and weaknesses, and by leveraging factors such as weather and track conditions, to give the horse the desire and best chance to win.

    As is the path to the Kentucky Derby a JOURNEY, without a doubt living with diabetes is a JOURNEY too.

    Today’s word is JOURNEY

    This journey brings not only glucose ups and downs, but twists and curves based on life’s experiences and challenges. When working with clients facing diabetes challenges, it’s key to focus on where they are in their journey and the complex decisions and choices they make on a daily, hourly, and even minute-by-minute basis. 

    We’ve shared before our fondness of Taxonomy of the Burden of Treatment paper (Tran et al) which helps clarify in a visual way the complexity and work required to manage a complex chronic condition like diabetes. When thinking about where clients are on their journey with diabetes, consider all of the factors that are impacting their decisions, choices, opportunities, and challenges. We can be supportive by helping them focus on their strengths, successes, and resilience. Just identifying one thing that is working well for them or finding an area in their life where their hard work is paying off can be incredibly impactful. 

    How often are people with diabetes recognized for the work they do?

    During one presentation at the Association of Diabetes Care & Education Specialists virtual annual meeting the current ADCES Diabetes Care and Education Specialist of the Year, Dr. Diana Isaacs, made a profound statement that resonates with a solution-focused approach: 

    In her practice’s shared medical appointments where participants wear a continuous glucose monitor (CGM), she starts off by thanking everyone for wearing the CGM for the week and recognizing the achievement in doing so. A thank you…it sounds simple, but is so powerful. How often are people with diabetes  recognized for the work they do? Diana focuses on what worked well for them during their week, and asks permission to discuss their challenges. During the session participants are able to focus on the journey of learning how they can make decisions and changes moving forward, based on their discoveries. No matter how small the changes may be, small steps add up.

    What an impactful way to make education meaningful and individualized, with the DCES stepping alongside as a “think partner” helping them take the next step on their journey. 

    As we shared in this blog around Derby time last year, when a client is faced with a scenario they’re trying to sort out, here are 3 key questions you can ask as their think parter:  

    1. What’s going well?
    2. How did you accomplish that?
    3. How can you do more of that? 

    Each week we invite readers to participate in a solution-focused challenge. This week we encourage you to:

    1. Start each session with a client by acknowledging the hard work they are doing managing their diabetes, even if it’s as simple as a thank-you for attending the session.
    2. Discuss with clients the concept of living with diabetes as being  a journey where there is always opportunity to shift directions.
    3. Offer clients support on their journey by sharing resources on peer support groups, either in person or online. Learning how others are moving forward living with diabetes can be life changing. 

    Try out one or more of the strategies we’ve shared, and reach back to  let us know how you’re doing! We’d love to help you de-stress and focus on a positive mindset.

    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 an employee of Dexcom but all comments are her own.

  • Fresh Views

    EXCEPTIONS: Today’s word to jump-start solution-focused practice

    A healthy outside starts from the inside – Robert Urich

    As these crazy and unsettled days wear on, June has silently snuck upon us, bringing with it the first day of summer. Did you know June is also National Fresh Fruits and Vegetables month? We hope you enjoy the picture above of juicy lemons harvested from Deb’s backyard. We are big advocates of finding ways to fit in more fresh fruit (over processed fruit and juice) and fresh vegetables, particularly of the non-starchy variety (which means little impact on blood glucose)! In our experience, many people are challenged with fitting in non-starchy vegetables. And when they’re successful, we’re always curious: How were you able to do that? 

    Today’s word is: EXCEPTIONS

    Today in our series on words to jump-start a solution-focused approach when managing diabetes, we’re focusing on EXCEPTIONS. Exceptions are those times when one’s able to deal with a problem (such as blood glucose out of range, too many carbs) in a way that makes it less burdensome. Exceptions are times when the presenting situation could have happened, but somehow did not.  It’s a time when things could have gone wrong, but didn’t. Most all problems have exceptions. However, some people have difficulty even identifying exceptions because they stay so focused on their problems. Identifying exceptions is essential in order to build future solutions. Exceptions are the tools that help people achieve the life they want. Exceptions are a core tool in solution-focused practice.

    Exceptions are addressed in the book by Adam Brown, Bright Spots and Landmines, which we’ve written about here. There are more than 42 factors that impact blood glucose, and that makes it challenging to stay in range all of the time. Focusing on what is going well, instead of what is wrong, changes the conversation and allows the client to identify strengths and successes, and feel there are those “bright spots” in their life that they can call upon and focus on to know they’ll be successful.

    Here is an example of how you can use exceptions when reviewing continuous glucose monitor (CGM) data

    Meet J.T. She has been experiencing glucose values above range after dinner quite frequently, while the rest of the day has been in-target most of the time. She’s shared CGM graphs similar to the one below, where you can see after dinner at 6pm her glucose rises above target. 

    Today when you meet with J.T. she shares her most recent CGM graph, and you notice that her after meal glucose values are all within her target range. You specifically call this out during your conversation. You might say, “J.T. I notice that your after dinner glucose values are within your target range, how did you manage to do that?”  J.T. tells you that she has been focusing on swapping out starchy vegetables for non-starchy vegetables, like broccoli, squash, tomatoes, and mushrooms, cooking them in a Wok at home with just a small amount of olive oil. She notes that when she eats these non-starchy vegetables she stays in range.  

    This is known as an “exception”, or a time when her typical problem (post-meal above target blood glucose) did not happen. This is when we see “positive differences.” We now want to amplify and intensify these differences. This is the time to focus on the healthy changes being made and time to support and encourage MORE of these choices.

    So you might follow up with, “How was it helpful for you? Or What else was different for you?”

    You might use a scaling question. “ On a scale of 1-10 where 10 is you are confident you could do this again and 1 is the opposite, where would you say you are now?”

    A fave tomato and cucumber salad that Tami enjoys in the summer. She makes it ahead and has it ready in the refrigerator to help her easily fit in more non-starchy veggies at meal time.


    Each week we’re including a solution-focused challenge that can help evolve care and education in a solution-focused manner. Here’s this week’s challenge: Try incorporating some/all of the following guiding questions into conversations with clients to help elicit exceptions:

    1. Are there times when this has been less of a problem?
    2. What is different about the times when this was less of a problem?
    3. What did you (or others) do that was helpful? 
    4. What’s gone better for you today or over the past week?
    5. What thoughts kept you on track?
    6. At a time when you feel more optimistic and satisfied, what will you be doing more of or more often?

    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

  • Fresh Views

    POSSIBILITIES: Today’s word to jump-start solution-focused practice

    Take your mind off the problems for a moment, and focus on the positive possibilities. Consider how very much you are able to do.  ~ Ralph Marston

    Amidst the COVID-19 crisis our world is facing, and the accompanying anxiety and uncertainty,  we are trying to remind ourselves of the many things big and small that we are grateful for. And one of those is that tomorrow is the first day of spring! The change in seasons brings new beginnings and a fresh start. Buds pop open, as pictured on Deb’s peach tree above. And each of those new buds eventually brings beautiful juicy peaches. So with the arrival of spring, we are reminded that no matter what the situation today, there remain new possibilities for the future.

    We hope you find value and inspiration in our series focusing on words to jump-start solution-focused thinking and conversations. If you’re new to our blog, you can read more about our take on the power of word selection here. Last week’s word was “Strengths” – check out our perspective here.

    Today’s word is POSSIBILITIES

    In solution-focused talk, “possibilities” are interwoven with and build upon “strengths”, and what is working well. In theory, by doing “more” of what is “working”, there’s less time to dwell on things that are not going as well or as desired. Building upon strengths ultimately can create possibilities that you may not have even realized existed!

    In a survey we conducted last year, we asked individuals living with diabetes about their experiences with diabetes education services. As we’ve shared before, many people (71% in our survey) are not satisfied with their experiences. Largely, traditional diabetes care and education services have employed a “problem-focused” approach that concentrates on trying to pin-point causes of “problems”. (What caused your low? Why haven’t you been exercising? What led to your time out of range? You get the idea…) Overwhelmingly, the survey respondents expressed desire for their healthcare professionals (HCPs) to focus on non-judgmental communication with individualized, personalized care and education. The desire is that HCPs be positive and express “You can be healthy and we’re here to support your journey!”  Diabetes care and education specialists can play a key role in stepping alongside their clients with diabetes as think partners to envision possibilities. 


    Each week we’re including a solution-focused challenge that can help evolve care and education in a solution-focused manner. This week the challenge is to consider conversations around continuous glucose monitoring (CGM). The expansion of CGM technologies means more people can have access to more data and use that data to learn much more about their diabetes than what a single number shows. In fact, in the previously mentioned survey, when we asked people what they wanted to be doing “more of” in the future, multiple individuals responded with “more time-in-range.” Of course, no one wants to have glucose values that swing up and down or remain above or below target, yet many conversations (while well-meaning), are often focused on pinpointing the cause of the time out of range and  the “whys”, when the cause is usually “diabetes”

    We’ve interpreted and applied learnings from the recent Advanced Technologies and Treatments for Diabetes meeting (ATTD) and presentation by renowned physician Dr. Rich Bergenstal to illustrate how to review CGM data using a solution-focused approach focused on possibilities and building upon strengths. (You can read the complete summary by diaTribe  here.)

    Here are 5 ways to evolve discussions around CGM:

    1. Flat, Narrow, In-Range (FNIR). When reviewing CGM trends, try using the FNIR approach, aiming for tracings that are flat, narrow, and in-range. It creates a goal and something that is possible with education, management, and support. More importantly, it steers clear of negative or disempowering terms while examining data. 
    2. Steady, Tight And in-Range (STAR). Another approach similar to FNIR, again focusing on possibilities of tracings that are steady, tight, and in-range.
    3. More Green, Less Red (MGLR). Are you familiar with the Ambulatory Glucose Profile (AGP)? An AGP report is a standardized glucose report that includes summary statistics, a glucose profile graph and glucose daily calendar graphs. It provides a report format that is consistent regardless of blood glucose monitoring device. Graphs help translate the numbers into a picture for easy, quick interpretation. Try using MGLR particularly with the bar graph that indicates time-in-range. With this approach focus on the green can draw focus to strengths. What and how did you achieve the amount of green we see on the chart? How can you do more of that to see more green and less red? This approach can help build possibilities and define actions.
    4. Thinking fast and slow. What this means is thinking about readings in real time – when one would need to act fast (like responding to a CGM low alert), then taking some time to look at retrospective data and “think slow”, spending time learning to pinpoint strengths and more realistically think about possibilities.
    5. Best Day. Another solution-focused option that we’re fans of is the “Best Day” pattern feature on the AGP report. Focusing on what went well on the “best day” when their glucose values were more in range can guide the individual to focus on their strengths.  Questions you could ask are, “What were you doing on this day to help you have more green and less red? What else was working for you?” This is also a good opportunity to practice “thinking slow” and encouraging individuals to spend time trying to learn from their CGM data.

    So with the arrival of spring, just as Deb’s peach blossoms have the possibility of turning into sweet, juicy peaches as they did last year (pictured below), taking a solution-focused approach to diabetes care and education can be a fresh new start and bring possibilities to light..

    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

  • Fresh Views

    Peaks and valleys in life

    “The Path Out Of The Valley Appears When You Choose To See Things Differently.” ― Spencer Johnson, Peaks and Valleys: Making good and bad times work for you–at work and in life

    Hilltop village of Eze, France

    Provence and the southern coast of France have long been on Tami and Deb’s travel to-do list.  From the beautiful Luberon valley and it’s fields of lavender to the hilltop town of Eze in the French Riviera. We look forward to sharing with you some photos and experiences from the peaks and valleys we encounter on this upcoming journey. There will be many amazing views and lots of time spent soaking up and “imprinting” those views.  As you may know, we use the practice of imprinting (described here in our blog) as a mindfulness exercise. When you are in the moment and enjoying a special view, feeling, experience etc., take a moment and a breath, to capture everything and imprint it in your mind forever.  Not only does it help you appreciate what you have and acknowledge gratitude in the moment, it also creates an opportunity for you later when life may be more challenging.  You can recall your imprinted memories when you feel overwhelmed.

    On the theme of peaks and valleys, peaks and valleys are a routine part of life. And part of life with diabetes without a doubt. However, when life feels like a rollercoaster and the peaks and valleys are constant, that may signal it’s time for a new approach. Peaks and valleys are opportunities for change.

    Let’s use continuous glucose monitoring (CGM) as an example that’s part of life with diabetes for many. When looking at CGM tracings, such as the one below, it’s not uncommon to see peaks and valleys. It’s easy to see those peaks (or time above range) as negative and a “problem.” And as for the valleys “below sea level” – that plunge into an uncomfortable low blood glucose – you don’t care for those either. Rather than thinking about these peaks and valleys as “problems” to be “fixed”, is it possible to take a step back and think differently?

    Continuous Glucose Monitoring (CGM) tracing for a 24 hour period

    While  the many peaks and valleys on this CGM report might create a sense of frustration and fatigue, how might we use a solutions focused approach to manage thinking?

    We know from Adam Brown, interviewed in our recent blog on Diabetes Bright Spots and Landmines, that there are 42 factors that impact blood sugar.  Some of these factors are much easier to measure and manage than others. Maybe you’ve been sick or struggling with a very stressful life event. You need to give yourself permission to just say, “Some days diabetes is like this.  Some days I don’t know why I’m not in range, and I’ll see what happens tomorrow,” without feeling guilt, blame or shame. Sometimes it’s hard to really know what’s happening, and a “problem-focused” approach isn’t going to help.

    In looking at the tracing above, you see blood glucose in range between 10:00 am and 1:00 pm. That’s where to start. What was going on then? What can you learn from this time in range to repeat and help see more time in range in the future?  

    Let’s look at an activity tracker record as another example.

    Activity tracker report of steps taken over 2 different weeks

    In taking a quick glance we see definite peaks and valleys in activity. Rather than focusing on the “problem” of the day there’s only 22 steps tracked, (maybe the activity tracker battery died??), instead let’s focus on the day where there were over 13,000 steps! And the day where there’s over 10,000 steps. What was going on those days? How did this individual successfully fit that many steps in? How can that occur more often to help achieve physical activity goals?

    As you look to the next week, month, or year. We challenge you to consider peaks and valleys as catalysts for positive change.

    And check back over the next few weeks as we share some peaks and valleys that we encounter on our journey.

    Subscribe to our blog and we’ll email you when a new post is published!

    Follow us on Twitter and Instagram @AFreshPOVforYou.

  • Fresh Views

    Traveling with diabetes: Focus on diabetes management successes to feel your best and enjoy the trip

    Coastal view in Makaiwa Bay, Kamuela, Hawaii

    Traveling is an important part of our lives @A Fresh POV for you and we live for new experiences, opportunities to learn something new, and, of course, that ever spectacular fresh view!  It’s the time of year when many are on spring break, heading out for spring break, or have just returned from spring break. In fact, Deb just returned from spring break on the Big Island of Hawaii while Tami had a “stay-cation” this year. And so we thought it might be interesting and good timing to ask others living with diabetes how they incorporate travel successfully into life with diabetes.

    As you read on, you will hear from two amazing women living well with type 1 diabetes for over 55 years between them! They are both diabetes advocates and volunteer for the diabetes community. Diane Bajalia is a PODS leader in Jacksonville, FL for Diabetes Sisters (for which Deb serves on the board of directors) and Fran Damian is a volunteer nurse on the medical team for Diabetes Training Camp. Both find inspiration in their volunteer commitments, but also like to take a break and do a little traveling. They shared some tried and true tips for travelling with diabetes with success.

    What works well for you when you travel to stay on track with diabetes management?


    I suppose the first words of wisdom for traveling with diabetes would be to expect the unexpected and try to be as prepared as possible.  When I fly, my carry-on consists of extra CGM supplies, pump supplies, insulin pens, and a full bottle of glucose tablets, as well as protein bars and nuts. Of course, my Kindle, a toothbrush and some makeup are in there, somewhere, as well.  I also put a few glucose tablets in my pockets when I travel. This allows for quick access to treat a low blood sugar while either dashing through an airport terminal dragging a heavy carry-on bag or sitting in an airplane middle seat.

    I love traveling because it is a change of scenery that involves family, friends and fun new experiences! However, what I don’t change is my relationship with my diabetes and my CGM. I have found that I feel better and enjoy my travels more if I remain engaged with my diabetes. There are so many variables that come into play when traveling with diabetes. Many of them, such as flight delays, restaurant meals, and even airport security issues, are out of my control. However, I can be as prepared as possible and continue to use my CGM to Sugar Surf my way through a vacation. I can continue to walk or workout everyday. And I can splurge with foods and drinks and enjoy myself.


    If traveling by plane, I bring low carb snacks on the plane and carry all my diabetes supplies with me. I don’t check them. I wear a pump so I bring a backup of syringes and long acting insulin in case of pump failure.

    What do you try to do more of because you know it works for you?


    I know, for me, that it is easier to manage my blood sugars with smaller quantities of food at each meal. When I travel, I eat foods that I don’t usually eat so mini portions with mini boluses work best. I know that I have a better chance of an “in range” post prandial blood sugar by starting to eat at 80 and using sugar surfing techniques such as smaller frequent boluses or injections.  

    I also walk or go to a gym as much as possible. The residual effects of this are twofold: I feel great and I know that my blood sugars are going to have an extra boost to stay in range that day.


    Exercise – walk! Find a gym – hotels usually have fitness centers. If traveling for work, I always make time for the gym. My vacations are usually exercise oriented. I don’t ever think being on vacation means I can take a break from exercise.

    Do you have any tips you can share with us?  


    • Easy access to low blood sugar treatment at all times. I leave tablets in my wallet, in my pockets and by my hotel nightstand.
    • Stay calm with airport security … even if it is time consuming, humiliating and frustrating.
    • Walk as much as possible during the vacation.
    • Try new foods and drinks … while keeping an eye on the blood sugar levels.
    • Splurging in moderation is the key for me.


    I’m fortunate my friends all know I have T1d [type 1 diabetes] and respect my need to take care of it. If they don’t understand, they usually are interested in learning. I think it’s important for travel partners to know enough to help if needed, and also to understand there aren’t many foods ” I can’t have”. Enjoy foods and beverages in moderation, exercise, and check blood glucose often, especially if trying new things.  I really love having a CGM and really appreciate it when away from home.

    Do you stay with your routine or do you give yourself a pass and let go?


    I feel better if I stay with my routine. I think it is hard after 30 years to give myself a diabetes care pass because I physically don’t feel good when my sugars are too high or too low. It certainly happens, especially when traveling, but the less often it happens, the better I feel.  

    When I travel, I usually wear my insulin pump. It makes life with diabetes on the road a bit easier for me. However, on my most recent spring break vacation to Mexico, I took a “pass” on my insulin pump. It sat in a drawer at home and I went MDI (multiple daily injections) . Most of the vacation was going to be spent at the pool or beach and I didn’t want to deal with it. I used a combination of Fiasp, Humalog and Tresiba to combat my tacos and tequila. And it worked! DexCom Clarity gave me a “passing” grade of an average blood sugar of 116 for the week.


    I like to feel well, and have energy, so I don’t push the limits too much. It’s important to consider high altitudes and time zone changes as both can affect blood sugar. Check to see how your body is responding.

    Do you find travel good for diabetes mental health and diabetes distress?


    I find any type of vacation good for mental health in general. It is a break from the routines, and stresses, of daily life; it is a break from work, from laundry and cooking, and it is an opportunity to enjoy new experiences with family and friends. However, traveling is not really a break from diabetes. I have been in many situations where I have been unprepared for a low blood sugar (think top of a mountain in Spain), I have forgotten my blood glucose meter (luckily you can purchase those without a prescription), and I have forgotten a syringe to get the insulin out of the vial and into my pump (thank you to the kind Walgreens pharmacist in Milwaukee).  The exception to that is traveling to a diabetes event, a diabetes camp, or some type of workshop filled with people who also have diabetes. I have friends that live all over the US that I have met when traveling to diabetes events. Everyone understands the ins and outs of diabetes care and if you forget something, someone else has it. To me, this is the best way to reduce diabetes distress!


    Yes! Sometimes my diabetes management is even better when traveling. Having time to exercise, menus to choose from, and being away from stressful jobs and other pressure.

    Any suggestions for others?


    Don’t let diabetes stop you from going anywhere – just be prepared! And perhaps expect a little of the unknown.

    5 Tips for Successful Travel with Diabetes from@aFreshPOVforYou

    We thank Fran and Diane for taking the time to chat with us and share their insights with you. Here are 5 travel tips that have helped clients with diabetes that we’ve worked with over the years to have successful travel:

    Tip #1: Wear a medical identification (bracelet, necklace, etc.) that says you have diabetes and notes if you take insulin. Carry a note from your doctor explaining your diabetes supplies, medicines, devices, and any allergies, along with the information for an emergency contact.

    Tip #2: Carry your medical insurance card (and travel medical coverage).

    Tip #3: Keep a closer check on blood glucose. New foods, increased activity, and different time zones can throw your blood glucose off, so check your blood glucose or CGM more frequently, especially before and after meals, alcohol consumption, or physical activity.

    Tip #4: Crossing time zones. If you take insulin and will be crossing time zones, talk with your health­care team before your trip so they can help you plan the timing of your insulin and meals. Keep in mind that westward travel means a longer day (so possibly more insulin will be needed), and eastward travel means a shorter day (so possibly less insulin will be needed).

    Tip #5: If traveling outside the US, make plans for temporary health insurance coverage if your plan is not effective outside the U.S.

    We embrace focus on strengths and things that have gone well, or “Bright Spots” as our previous blog post discussed. The next time you travel, whether it’s a short weekend or a long international flight, think back to your previous travel experiences and identify what worked well for you and times when you were successful. Start your next journey with that in mind. Try to spend more time doing things that make diabetes easier to manage, while still having fun and enjoying your experience. You might want to even consider writing down your diabetes travel successes in your gratitude journal, so you can go back and recall them the next time you travel. We’d love to see your vacation photos so we can enjoy your fresh views! Please share them with us on our Instagram page

    Subscribe to our blog and we’ll email you when a new post is published!

    Follow us on Twitter and Instagram @AFreshPOVforYou.