By Patrick Totty
It’s said that only two things in life are certain: death and taxes. But for a majority of people with diabetes, there is a third certain thing: burnout.
Burnout has many descriptions: “I’m sick and tired of the diabetes management grind.” “I’m bummed out by the relentless demands the disease makes.” “I hate facing spending the rest of my life watching everything I eat, constantly measuring my blood sugar, and dragging myself out to exercise rain or shine.”
“People become fed up, overwhelmed,” says Dr. Bill Polonsky, PhD. “When you’re first diagnosed it’s as though you’ve just been given a new job that you’ll have to do 24 hours a day, 52 weeks a year, with no pay or vacation that you have to do for the rest of your life. Who wouldn’t resent that? Who wouldn’t grow tired of it?” Dr. Polonsky is President of the Behavioral Diabetes Institute in San Diego, CA.
There are three main things to consider about burnout. One, almost everybody with diabetes experiences it. Dr. Polonsky says that in his 30 years of dealing with people’s diabetes burnout, “I would say that it’s weird not to go through burnout, at least occasionally.”
Two: It is almost always preceded by months and years of diligent diabetes management that often starts as a honeymoon but winds up in divorce court. You work hard to reduce your A1c, regularly exercise, and eat a healthy diet. There’s a feeling of elation when you reach hard-won goals. But once you get there you can feel like poor Alexander the Great, who, after he had conquered India, pleaded to no one in particular, “What new worlds are left for me to conquer?”
At this point there are no new worlds left for you to conquer. You’re no longer pushing to reach distant goals. Now you’re in maintenance, which is a far different, tedious affair.
But there’s also an opposite cause of burnout. “It’s when you’re putting out your best efforts and still not getting the results you’re hoping for—weight loss, better glucose results, etc.,” says Dr. Polonsky.
There are some external factors, too. Ones that add to the threat of burnout include feeling isolated, that you’re having to struggle and do everything by yourself and on your own. Also sabotage—being surrounded by people who are constantly negative or disparaging about your condition.
That brings us to the third, and most disturbing aspect of diabetes burnout: People who go through burnout often give up completely on trying to manage their diabetes. They decide to stop all the old routines and begin eating what they want whenever they want it, and sloughing off on regular exercise and blood sugar checks.
But there are some excellent ways to prevent a descent into burnout or to make your way back from one. One is understanding how common feelings of anger and frustration are among people with diabetes. Dr. Polonsky introduces this concept when he speaks to large groups: “I ask audience members to describe just one thing about managing diabetes that drives them crazy. Everybody has an almost instant response. I’ve never run across anybody who can’t name at least one thing that drives them nuts.”
The most common complaints he hears is, “My best efforts don’t work.” Or, “I’ve tried a new diet and I haven’t lost an ounce.” “Much of this comes from the numbers they’re getting from a blood glucose meter as opposed to, say, a continuous glucose monitor. Blood sugar numbers can be wacky from time to time for a simple reason: You are not a pancreas. You can’t do what a functioning pancreas does. You shouldn’t confuse BG meter numbers with self-esteem points.”
That said, Dr. Polonsky says that sometimes listeners take his advice about blood glucose meters too seriously: “I once handed out little stickers to put on blood glucose meters that read, ‘Remember, it’s just a number.’ Afterwards, one fellow came up and asked me if he could have 30 of the stickers. When I asked him why he needed so many, he said, ‘They’re pretty small and it’s going to take that many to cover the glass on my meter.'”
Down With 100-Item Checklists!
That question and audience reaction allow Dr. Polonsky to introduce a different way for people with diabetes to think. What if their concepts of proper diabetes self-management might actually be harming them?
He describes “Bang for Buck,” a list of the 100 or more different self-care behaviors for managing diabetes that most people learn about in a good diabetes education program. “But not all of them are equally important and it’s impossible for anybody who has diabetes to do them all.” The problem with trying to do them all, he says, leads either to unsustainable perfectionism—a fragile undertaking since psychologically even one flaw undoes everything—or becoming exhausted and feeling that you’re “bad” because you can’t do them all.
One illustration of how people can get lost in the thickets of 100-item must-do lists is his memory of a young woman with an A1c of 11% who attended one of his educational sessions. She had listened closely and afterwards told Dr. Polonsky that she was ready to get her act together. “Given what you’ve said is doable,” she told him, “so I’m going to start drinking more water from now on.” She added that she refused to take medications. He responded, emphatically, “First, drinking more water is probably number 100 on the list of 100 things you can do manage diabetes. But if you won’t take your medications, which is your choice to make, you are not going to get anywhere with your diabetes.”
Dr. Polonsky knows that the reason why some people don’t want to take diabetes medications is that while they believe there are probable benefits to them they worry too much about the negatives. “But the positives profoundly outweigh the drawbacks.”
He suggests a personal “Bang for Buck” list of the top five to 10 most powerful things each person with diabetes can do to best manage the disease. “Enlist your healthcare provider’s help to figure out what those top things should be for you. Your goal is a healthy ‘good enough.’ Good enough really is good enough. Simplifying your approach to diabetes not only eliminates perfectionism or ‘I’ve been very bad,’ it goes a long way toward removing some of the stresses that lead to burnout. You can’t do it all and you don’t have to do it all.”
Not a Do-It-Yourself Task
“You never want to whittle down your list on your own. You must consult with your healthcare provider. Most people don’t necessarily know what’s most important. When you bring it up, most people will cast their eyes downwards and say, ‘I guess I should be eating better.'” But eating is not as important as your overall numbers, not smoking, and taking your medications. If you refuse to take your recommended meds, you’re out of your mind. You pancreas is pooping out and needs all the help it can get.”
Besides helping people create their own “Bang for Buck” list, Dr. Polonsky advises adding one cardinal rule to the list: “Find somebody in your household or online who’s looking out for you and can help you through the tough times.” Another mitigation: Bond with other people who have diabetes, both informally (say, via phone or Zoom chats) and more formally in a support group (which you should be able to find via your healthcare provider or an internet search for diabetes support groups in your area).
Dr. Polonsky notes that there is a constant stream of terrible news about diabetes, which doesn’t help diabetic people’s morale. “But there’s also good news out there.”
For example, he cites a multi-year Swedish study that compared the heart attack risks for every type 2 person in the 10-million population kingdom with those same risks among 1 million non-diabetics. On the surface, the study results showed that type 2s’ risk for cardiovascular disease was quadruple that of the non-diabetic control group—not at all a reassuring conclusion.
However, looking further into the study, Dr. Polonsky observes that the type 2’s who suffered increased CVD occurrences “were all people whose diabetes was unmanaged and running wild.” The good news underlying the study’s results showed that type 2’s whose diabetes was under control (A1c < 7%, no smoking, healthy diet, etc.) ran the same risk of mortality—not more—as the people who did not have type 2.
So good (not perfect) control can help type 2s sustain as low a level of cardiovascular risk as that of non-diabetic persons. That’s one great incentive for staying the course. That’s not to say that you can’t take an occasional break. Soldiers who have been involved in a fiercely fought campaign at some point need to leave the frontlines and rest. Your struggle with diabetes is one such fierce campaign. But remember, like any good soldier on leave, at some point you have to return to the fight.
Dr. Polonsky’s book, “Diabetes Burnout—What to Do When You Can’t Take It Anymore,” is a classic in the field of diabetes self-help.
The Behavioral Diabetes Institute’s mission statement acknowledges that “many people become overwhelmed, frustrated, or ‘burned out’ by the daily difficulties of diabetes and by the unending, often burdensome self-care demands, potentially leading to anger, guilt, depression, fear, feelings of hopelessness.” Learn more at https://behavioraldiabetes.org