• Fresh Views

    Be REAL Series: R is for RESILIENCE

    “If we understood the power of our thoughts, we would guard them more closely. If we understood the awesome power of our words, we would prefer silence to almost anything negative. In our thoughts and words, we create our own weaknesses and our own strengths. Our limitations and joys begin in our hearts. We can always replace negative with positive.” ~Betty Eadie

    Back in February 2020, just before we knew how the world was going to change through the pandemic, we launched a series on the power of words. Our goal was (and still is) to evolve solution-focused vocabulary among our readers to inspire, motivate and provide practical guidance to change messages so we can help people embrace possibilities, opportunities and create a vision for the future.

    Today we begin a 4-blog series called, “Be REAL”, revisiting some of those powerful words and our important messages. The 4 words we’ll focus on make up the acronym REAL: 

    • Resilience
    • Experts
    • Acceptance and 
    • Listening 

    Today’s word is RESILIENCE

    Resilience is one of the skills essential for people with diabetes to develop in order to live well with diabetes. And yes, resilience is a skill. Research shows that resilience is a skill that can be developed over time with practice and support. We think about resilience as the ability to “bounce back” after challenging times. It’s having inner strength when life throws you challenges and still being able to hold your head up.

    Living with a chronic condition like diabetes means living with chronic stress, and that can make managing diabetes more challenging. That’s where building resilience comes into play. Our last blog shared 5 ways to cultivate mental toughness, helping to build resilience.  

    When a diabetes care and education specialist engages in a solution-focused approach to practice, the ability to build resilience is not only possible, but highly likely. When we reinforce and recognize positive behaviors and strengths, people tend to do more of those things more often. In solution-focused practice we call these “exceptions” or times when problems don’t exist and life is working well. 

    People who see themselves as being resilient are typically those who have suffered adversity, faced significant challenges and were able to come out of their struggles stronger and with a different perspective on life. Often those who have faced the biggest challenges are the most resilient. Tami recalls a patient that she worked with over a several year time frame. This individual lived with long-standing diabetes, lost her husband at a young age, dealt with some significant health and financial challenges, and then lost everything she owned in a house fire. Despite the many life challenges she’d experienced, she had developed the ability to bounce back, persevere, and maintain focus on managing her diabetes. Life seemingly brought her a lot of “lemons”, so to speak. (We wrote about working through “when life gives you lemons” in our blog here)

    A key focus in building resilience is on recognizing stressors and building plans to work through the stressful situations and setbacks, and come out on the other side feeling successful, even if it is just one very small success.

    What’s REAL in 2023?

    Who knew how much resilience we would all need and how important our “VIPs” would be in life coming through the pandemic in the time since we wrote our original 2020 blog on resilience! If you didn’t catch it, you can find it here:  2020 Resilience blog.

    Please take a moment and Be REAL with us – share your impressions of resilience and what changes you’ve noticed in the past few years. How has resilience been important to you?

    Join us next week as we focus on the E in Be REAL: Experts!

    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

    Transform Primary Care Encounters: 7 Practical Tips to Get Started

    If it ain’t broke, don’t fix it. Once you know what works, do more of it. If it’s not working, do something different. – Steve de Shazer and Insoo Kim Berg, pioneers of solution-focused brief therapy

    Our last blog spotlighted the power of words and using person-first, strengths-based language in diabetes related conversations in primary care. As we continue our series on transforming primary care encounters by incorporating solution-focused techniques, maybe your interest is piqued by this new approach, but you’re not quite sure how to begin to incorporate it into your practice?  Today we share 7 practical tips to get started. 

    1 – Ask “exception” questions. Exceptions are times when an expected problem does not occur. These are times we want to identify, focus on, and encourage the client to explore. These exceptions help the client move towards their desired future. Here are 2 examples of “exception” questions:

    • You mentioned that you typically struggle to be physically active in the evenings but you were able to go to the gym after work last week? How did you manage to do that?
    • Cooking meals at home has been a challenge for you, yet you cooked two times last week. What changed to allow you to make that happen? And what else?

    2 – Use person-first, strengths-based language. This may seem simple, but is hugely impactful. This means using language that is neutral, non-judgmental, and free from stigma. Language that is inclusive, respectful, and imparts hope. Word choice that fosters collaboration with your client and is person- centered. Focusing on language can remove the stigma associated with diabetes.

    3 – Practice problem-free talk. By incorporating this one impactful change you will already notice how the quality of visits and client engagements will improve – building the therapeutic relationship, hope, and motivation. The conversation at the beginning of an encounter is critical to build the therapeutic relationship. By starting the conversation with the goal of the client, you acknowledge that you are focused on their needs and desires and are committed to helping to meet their goals.  Two great ways you could begin a visit are to ask your client:

    • What would make this a successful appointment for you? 
    • At the end of this visit, what would you need to know/learn to say this was worth your time?

    4 – Ask the Miracle Question.

    The Miracle Question applied to diabetes is one tool or technique in a solution-focused tool-box to help clients envision a future that is more problem-free. 

    • Miracle Question: If you could fast-forward to a time where you feel satisfied with your diabetes management, what will be different in your life that will let you know things are better?

    You can learn more about the Miracle Question applied to diabetes in a previous blog post here. The Miracle Question helps people identify those “exceptions” mentioned in #1. The Miracle Question challenges a person to look past their obstacles and feelings of hopelessness to focus on possibilities, opportunities, and a vision for the future. The goal is to help one identify what they’ve actually known all along, and that they have the power to make choices and changes that can move them forward. By focusing on “exceptions”, goals become different. Focus turns to what is desired in our life instead of what “won’t happen” anymore.

    5 – Ask eliciting questions. When incorporating a solution-focused approach you need to ask eliciting questions to uncover solutions and guide the individual. It is key that these questions are open-ended and help the individual see how they can be successful. Instead of asking  questions that focus on the problems (since living with a chronic condition cannot benefit from a “quick fix”), instead, explore their strengths and resources they already possess and how those resources can apply to their diabetes management.

    • What has been going well since I last saw you?” 

    That one question can  start the visit on a positive note, acknowledge  the work that it took to accomplish that, and then leverage how the client can continue those positive behaviors and build on them for future health success. Questions can also focus on details when the person identifies a success:

    • How exactly did you do that? What exactly did you do differently?

    6- Ask future visioning questions. These questions can focus on the short-term or long-term views of the client’s preferred future. These questions help the individual realize that solutions are possible and help them see their desired future state. As you recall one of the key tenets is the client is the expert about their own life and their own diabetes. (Read more about experts here)

    • What would you like to see yourself doing in the next (day, week, month) to move you forward towards your goals? And what else? 

    Following up with “what else?” encourages people to dig deeper and think through in detail what they are capable of.

    7 – Use scaling questions. Scaling questions are a great tool to move away from all or nothing thinking. They focus on progress, motivation, and confidence.

    • On a scale of 0-10 where 0 is not confident at all and 10 is very confident, how much confidence do you have that you can meet your goal to (insert personal goal here)?  

    If less than a 7, follow up with one of these:

    • What could move you to a 7? 
    • What would need to happen to move you one number higher?
    • What would one number higher look like? 
    • How would others notice you’re more confident?
    • How come you’re not at a lower number? How did you do that?

    Keep reading our series on incorporating a solution-focused approach when managing T2D in the primary care setting. Our next blog will focus on therapeutic inertia. Curious what that means? 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: Benefits for All Involved

    Once you know what works, do more of it. – Steve de Shazer and Insoo Kim Berg, pioneers of solution-focused brief therapy

    As we continue our new series on transforming primary care encounters by using a solution-focused approach, today let’s talk about the benefits of this approach. Benefits to you as a health care provider and more importantly benefits to your clients. We’ve had several primary care providers encourage us to share more on this approach as they found it to be a transformational way of thinking and engaging with clients. 

    What are the benefits to the client?

    Without a doubt, managing diabetes is complex and burdensome. In 2019, we conducted a qualitative research study with Twitter Chat data from a #DSMA chat we moderated around a solution-focused tool called “The Miracle Question”. We first presented these findings in 2019 at the 55th Annual Meeting of the European Association for the Study of Diabetes Conference in Barcelona, Spain. Two compelling comments from participants with diabetes that came out of that study. 

    • “Diabetes interrupts my life… every minute.”
    • “Success would look like people realizing what diabetes is and we can stop with these assumptions and jokes about diabetes.”

    As we’ve written about many times, individuals that live with type 2 diabetes (T2D) have many obstacles to overcome due to the lack of understanding about the condition.We know that T2D has a genetic link and is more common in individuals of color, those with a family history, and that risk increases with aging. While making more healthful behavior changes is critical to living a healthy life, the genetic nature of the condition is not well known in the general community and not discussed enough in medicine, the community at large, and the media.

    The goal is to help the person with T2D recognize exceptions (a time when their problem does not happen) and help them to focus on their health behavior changes by doing “more of what works.” Give our previous blog here a quick read to get up to catch up on the basic tenets of the solution-focused approach and how implementing an approach that focuses on solutions instead of problems can “flip” the conversation in primary care and build stronger relationships.  

    Ultimately, developing stronger relationships will facilitate positive discussions about therapy including medication, food choices, physical activity and more.

    What are the benefits to the provider? 

    Brief intervention. One of the most important benefits of incorporating a solution-focused approach in primary care is that it is a “brief” intervention. With often many competing demands to address during a primary care encounter, you do not need to delve deep into problem-solving mode. Instead you discuss what’s already working well and step alongside the client as a “think partner” to do more of what “works.”

    Ownership transferred to the client. Ideally a solution-focused approach incorporates questions to generate discussion (we’ll share some of these in a future post). . In this way, the primary care provider helps the client elicit “change talk” instead of “telling” the client what to do. Tami had a client this past week that said those very words… “I really like that you’re not telling me what to do, but spending time talking to me and brainstorming ideas so I can decide what I want to do.”  The client will have ownership over their decisions and be more invested in the next steps. This is really the first step in shared decision-making.

    Greater individualization of care. The recent 2022 ADA Standards of Care presents much greater emphasis on individualization and personalization of care. What better approach to individualize the care plan than asking the individual what is working for them and what they think might be the best next steps. Together you can identify small steps towards their goals. 

    Come back in two weeks for our thoughts on the power of language when managing T2D in the primary care setting. We’ll re-introduce the concept of person-first, strengths-based language and use in a solution-focused approach with tips for the primary care team, both clinician and person with diabetes. We’ll continue to help you 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: Do Things Differently in 2022

    Doing things differently leads to something exceptional. – unknown

    Watching the sun set at Wise Villa Winery, Lincoln, California and thinking of new opportunities for 2022

    With the start of the new year, one of our goals is to share the basic tenets of a solution-focused approach and how to incorporate these techniques into a brief primary care visit. We’ve had several primary care providers encourage us to share more on this…so here we go launching a series to slowly guide the evolution of practice! Follow our blog so you don’t miss out on practical guidance and tips to transform primary care encounters. (And if you work in a setting other than primary care, you’ll still want to follow because many of the tips can be applied to other practice settings.)

    Why do we embrace a solution-focused approach?

    Consider this…the traditional medical model of care is “problem-focused” – meaning you need to identify the “cause” to “fix the problem”. However, when faced with a life-long chronic condition (such as diabetes) that requires changes in health behaviors, “fixing a problem” is not so simple. One can quickly feel a sense of failure, feeling at fault where they’ve made “ bad decisions”, or some other negative feeling. 

    In our experience, it is common for those living with type 2 diabetes (T2D) to not want to reveal their health condition because of negativity towards T2D in the press, in the community, as well as from the medical field. Blame and shame are rampant. It is hard to be positive and move forward when viewing your whole life through this negative lens. This is where incorporating a solution-focused approach can be a game changer for both the clinician and the person living with diabetes. The whole conversation is “flipped” from a negative to a positive, helping to identify strengths and solutions instead of rehashing all of life’s issues that are not going well.

    What is a solution-focused approach to care and education?

    A solution-focused approach has its beginnings in counseling psychology, but has made inroads in a number of fields, and we are focusing on application to life with diabetes.  

    Here are 7 key tenets of this approach:

    1. Ask questions.  In a solution-focused approach asking eliciting questions is the key to uncovering solutions and guiding the individual. These questions help the individual realize that solutions are possible and help them see their desired future state.
    2. The client is the expert. Key to this approach is first recognizing the individual is a person that lives with their chronic condition on their own and manages their daily life, so they are not a “patient” in this model. They know what they need and understand their condition and how it impacts their greater life. We recognize they are the center of the team and we value their input. Read more about experts here.
    3. If something works, do more of it. The premise here is that if you do “more” of what is going well, then in general you will have less time and opportunity to engage in what is not working well. Helping the individual recognize their strengths and successes builds confidence needed to manage a complex condition. It can be as simple as opening the visit with the question, “What do you feel like has been going well with your diabetes?”
    4. Focus on exceptions.  Exceptions are times when the problem “might” have occurred but didn’t. This could be something small and often overlooked, but when you can highlight these opportunities you can then focus on solutions that are in front of you. You can read blogs we’ve written about exceptions here.
    5. Small changes move you forward.  The goal is to help the client take small steps to move their goals forward and each small step can lead to more success.
    6. Clients already possess the resources they need for change.  Most people are aware of what works for them and have the ability to identify solutions. We can help people to recognize these resources and help them to develop resiliency to manage their condition.
    7. Language matters. We know and evidence shows that the language we use in healthcare is associated with health outcomes. When people are blamed and shamed for their health condition they are less likely to see their healthcare team and less likely to talk with their care team when they are not meeting health goals. The use of person-first, strength-based language in a solution-focused approach is critical to develop a therapeutic relationship with clients.

    We hope you will see that this approach can help both clinicians and people with diabetes to collaborate in managing diabetes.

    Join us for our series on incorporating a solution-focused approach when managing T2D in the primary care setting. We’ll share how you can incorporate these tenets into a brief visit and how you can build your solution-focused tool-kit over time. 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

    Diabetes Technology and Solution-Focused Practice: Applied to Activity Tracker Conversations

    Tami walked the length of the Sahara Desert!

    Just keep taking the next step and keep having excellence in the ordinary. – Dave Ramsey

    In this week’s Diabetes Technology and Solution-Focused Practice post we’re discussing taking a solution-focused approach to activity tracker and physical activity conversations. We are both huge advocates of activity trackers, and have used several different versions ourselves over the years. Currently, Deb relies on her Apple Watch, while Tami likes her Fitbit (although it’s on it’s last leg…so something new will be coming soon!)  Recent estimates are that about 1 in 5 Americans use a smartwatch or fitness tracker. Whether a smart watch, wrist band, clip on pedometer, smartphone app, or other variety, activity trackers can give extra incentive to get active. They also provide a wealth of statistics on workouts and general health to have the data needed to achieve fitness goals. Many track not only steps and movement, but distance, activity intensity, calories burned, mindfulness, sleep, heart rate, and more. There are even fitness trackers for children with a variety of fun functions beyond tracking activity.

    A Facebook memory popped up the day we were posting the blog – Tami and Deb walking 10,000 steps along the Chicago lakefront with their husbands!

    Focus on “exceptions”, rather than gaps

    When reviewing physical activity frequency, duration, step counts etc with clients, there is  opportunity to implement a solution-focused approach (rather than focusing on “gaps” in activity). For example, when reviewing fitness tracker logs such as the one below, where this individual’s goal was to get 10,000 steps each day – rather than focusing on 3/10, 3/11, and 3/12 where step counts were far below their goal, turn instead to focus on 3/7 where they achieved 7016 steps, and 3/13 where they got 8681 steps. If we focus on the days where activity was low, we miss out on identifying successes

    4 questions we could ask when acknowledging those “successful” days are:

    1. How did you work that many steps into your day? 
    2. What were you doing differently than on 3/10-3/12, for instance?
    3. How can you do that more often? 
    4. What are some other ways you can be more active?   

    A case example from Tami…

    Years back, I worked with a client that was a dentist, and as such was fairly sedentary most of the day. When I began seeing her, she had recently learned that she had type 2 diabetes and was trying to increase her activity, in addition to managing her weight and blood glucose. Over the course of several visits we talked about the huge benefits of physical activity and the value of activity trackers in raising awareness around physical activity. While initially resistant to “exercising”, she eventually agreed to purchase a wrist band activity tracker with an initial goal of wearing it for 2 weeks to learn what her average movement and step count was during the day. She learned that she averaged 1200-1500 steps/day. She found that information enlightening, and immediately started considering how she could be more intentional to increase her movement. When she returned a month later for her follow-up visit with me, she had already increased her average step count to 5000-6000 steps each day. Wow! 

    I acknowledged her mindfulness, intentionality, time, and hard work. In applying the 4 questions above with her, I learned that to increase her activity, she was getting up between appointments and walking around the office. Then, she decided that at home in the evenings while watching TV and knitting, she would get up and walk around the house during commercials. From there, she went on to take-up swimming laps, then added doing a circuit work out at a local gym. She built upon her successes and leveraged those. 

    She was one of those special people you never forget. She had a fantastic sense of humor! She  enjoyed traveling and I frequently would have photos show up in my email of her swimming in a pool on a cruise, swimming in the lake at her lake house, or getting a “hydro massage” after working out at her local gym.  Applying a solution-focused approach to activity and activity tracker conversations assisted her in self-discovery and leveraging her successes in moving more for even greater successes.

    While activity tracking apps can help motivate individuals to make health behavior changes, just like anything else, if we focus on the negatives, success will be more difficult to achieve. When working with clients, help them set realistic goals to achieve to set them up for success, then build upon their achievements in a slow and steady process.

    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.

    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 Mobile Apps

    “You`re only as weak as you let yourself become, and you`re only as strong as you allow yourself to be.”

    Daniel Hansen

    Beautiful bougainvillea, Palm Desert, CA

    In this week’s installment of Diabetes Technology and Solution-Focused Practice we’re discussing mobile apps. In our last blog we focused on using a solution-focused approach to interpreting and discussing continuous glucose monitor (CGM) data. This week’s blog we’ll focus on a new discovery for us – the WW mobile app. We will share insights on other apps in future blogs. We believe that using solution-focused language within mobile applications can improve user engagement with the app, as well as encourage individuals to make progress towards their health behavior goals.

    WW App: Deb’s experience…

    As you may know, Weight Watchers is now known as WW. I have been using their app, the WW app, to help  stay on track during the COVID-19 lockdown. You can learn about the different WW programs and pricing here. There are several options to choose from, I only use the app for logging and motivation.  I was encouraged to continue using the app because of the nature of the messaging. Then I began to wonder if they were incorporating a solution-focused approach? 

    From a weekly in-App push a few weeks ago, the headline was “Why you should do what works: You might already have more tools in your toolbox than you think.” If that doesn’t sound like solution-focused messaging, I’m not sure what does! The post reminds us that people typically focus on what isn’t working well and how to deal with challenges. Of course, that is not motivating, and not helpful when trying to make hard health behavior changes.

    But, what if you “Flip the switch” so to speak? (See our many blog posts from 2019 about “Flipping the paradigm” –  here’s one on healthy eating, and here’s one on healthy coping). The WW message goes on to encourage focusing on the things that come naturally and leverage strengths or what’s worked in the past! Wow! We’ve written about strengths in this blog multiple times (you can read about strengths here), and so believe in focusing on what one does well,  building confidence, and increasing happiness by doing so. 

    Make Strengths your Secret Weapon. According to WW, leveraging your strengths will help you be successful. They suggest asking 3 questions to uncover strengths:

    1. When do I feel like my best self?
    2. What makes me unique?
    3. What comes most naturally to me?

    Those are questions that diabetes care and education specialists (DCES) can easily incorporate into diabetes-related conversations with clients as well. Once those questions are answered, WW suggests creating an “affirmation” to help remember to focus on personal strengths. You can read their post here. One exercise that helps people think through writing their own affirmation includes showing a word cloud to help direct thinking about potential ideas of strengths (including humor, cleverness, bravery, creative etc.). What a powerful visual tool, that would be so easy to employ in any diabetes care and education program! Finally they suggest saying the affirmation out loud every morning or posting on your computer so it will be visible every day. For instance, “I am strong.” “I am resilient.” You get the idea

    I loved this way of thinking about making healthy choices, and reading and engaging with the content. I created my own affirmation and have it posted on my computer with a sticky note so I  glance at it multiple times during the day! Tami has affirmations on her desk and in the kitchen that she sees when making coffee in the morning to start the day off.

    Helping clients create their own affirmation using solution-focused principles is a great opportunity to highlight what is working well already and focusing on their strengths, as well as supporting the development of resilience. 

    Do you recommend mobile apps to your clients? 

    If you have a client interested in weight loss or adopting healthy eating habits, the WW mobile app might be a good option. (We are not endorsed by WW and do not receive any compensation from WW). Knowing the positive strength-based language that is being used is so encouraging. Also of note, WW recently hired Adam Kauffman, formerly of Canary Health,  to head their diabetes program (read the press release here) so we’re excited to see what’s to come in the future.

    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. Tami is employed by the University of Kentucky 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

    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.

    THIS WEEK’S SOLUTION-FOCUSED CHALLENGE

    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

    Flipping the Paradigm: Applying a Solution-Focused Approach to Being Active

    Remember that any exercise is better than no exercise. – Anonymous


    Pisgah National Forest in the mountains of Western North Carolina. It was a beautiful hike to the falls!

    Welcome to week 2 of our 7-week series on applying a solution-focused approach to the AADE7 Self-Care Behaviors for managing diabetes. Last week we shared about taking a solution-focused approach to Healthy Eating – you can read it here.  Today we’re focusing on  Being Active. Being active can take many forms, from simply moving more during the day to intentional bouts of exercise. You can also find ways to incorporate fitness through activities that bring you pleasure or joy (such as our beautiful hike to the falls pictured above).  

    As a refresher, the AADE7 is a framework for organizing diabetes self-management education and support, as well as for identifying key areas for behavior change to manage diabetes. The 7 core behaviors are:

    Our series is focusing on “flipping” the conversation from a “problem focused” (traditional medical) approach to a solution-focused conversation. 

    AADE7 Self Care Behavior #2: Being Active

    “I hate to exercise” may be a familiar comment heard by many diabetes care and education specialists (DCES). (In fact, it’s the title of a great book too, The I Hate to Exercise Book for People with Diabetes) For those who are challenged to fit physical activity into their day we feel empathy and understanding because some days it’s a challenge for us too! Life happens! 

    Some people are born athletes. And physical activity may always be a priority them. If you fall into that category, you might find it hard to understand the challenges other people face with being active. If you can relate, try to take a step back, and think of something that is really challenging for you to engage in. Then try to keep that frame of reference when you’re talking about being active with your clients.

    Beyond lack of enjoyment in exercise, finding time to fit physical activity into a busy, challenging day, can also be hard. As DCES’s, solutions that we may generate and propose to others, may not always be realistic. Using solution-focused talk, together, we can help clients identify what they like, and what makes sense to them. We can also guide them in identifying things that make them happy, and find existing strengths. From there, we can help them create opportunities to be active.

    It’s important to take care to refrain from “all or nothing” thinking, described by Adam Brown in his book Bright Spots and Landmines (we interviewed Adam here). We need to help clients take small steps towards a more active lifestyle and acknowledge their success, even if it doesn’t align with our thinking of what being active means. Let’s flip the focus of the discussion and help people feel successful and recognize their strengths.

    Deb and Diana (Deb’s daughter) hiking in the Dolomite Mountain Range in Northern Italy

    Instead of focusing on what is not working well or what is “wrong”, here are 3 illustrations of how to flip the conversation:

    Try this: I know how hard it is to have a job where you sit at the computer all day. Tell me more about your office and work setting. Let’s think of some ways you can increase your movement and get you up from your chair. 

    Instead of this:  Did you know sitting is the new smoking, sitting all day is going to kill you. You need to move more.

    Try this: You mentioned you’ve been using the MapMyWalk app on your phone. How has this helped you be more active? What else can you do to be more active?

     Instead of this: You’re using the MapMyWalk app but you still not getting 10,000 steps a day.

    Try this: When you’ve been successful adding physical activity into your schedule, what did that look like? How did you do it? How can you do more of that?

    Instead of this: You’re falling short of the goal of getting 150 minutes of exercise each week..

    Focus most of the time and energy on thinking about and discussing what is already good, effective, and successful.

    During a solution-focused conversation, the DCES’s focus is on discussing and exploring what is already working, is effective, and is successful, then leveraging that to identify solutions, rather than focusing on past problems. 

    When you meet again, here are 3 follow-up questions to try:

    • How were you able to focus on solutions to try to fit fitness into your schedule?
    • What kept you on track toward achieving your activity goal? 
    • What was different about the days you were able to be more active?

    We’ll challenge you each week to try incorporating some flips into your conversations and let us know what impact they have.

    Join us next week as we discuss a solution focused-approach to Healthy Coping!

    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