Steve Freed: This is Steve Freed with Diabetes in Control and we’re here at the American Diabetes Association 77th Scientific Session 2017 and we’re here to present you some really exciting interviews with some of the top endos from all across the world. And with us we have a very special guest, Dr. William Polonsky, who is very well known and he’s an expert speaker. Let’s talk a little about who you are and what you do.
William Polonksy: So I am a diabetes psychologist. I’m also a certified diabetes educator. I’m a socio-clinical professor at the University of California at San Diego, and I’m President of the Behavioral Diabetes Institute. I worked in the field of diabetes as a psychologist for just about 30 years now and focus all of my time worrying about the psychological, emotional, motivational issues in diabetes both as a clinician and a researcher.
Steve Freed: There are a couple questions I want to ask you about your presentation, but I get excited when I have you in front of me and I’m always interested in what you have to say. We know that diabetes is an epidemic, we know that diabetes is a lifestyle disease, we know if you don’t know what a carbohydrate is, you are doomed for failure and we know a lot of people with diabetes have depression and that affects their blood sugar. What do you try to accomplish with a patient, how do you do it? Because it is very difficult, number one is to get people to change lifestyles, if you’ve been doing the same thing for 40-50 years to get them to change their eating habits, to get them to change their physical therapy, that’s gotta be a high priority, number 1 or 2 on your priority list when you talk to patients or medical professionals.
William Polonsky: It’s actually usually 3 or 4 but it’s a very important thing. You know one of the biggest issues that we face, I’m thinking with you, type 2 diabetes, is that it’s really an easy disease to ignore. It’s a disease that’s so easy to say, “You know I’ll worry about this when something falls off or when something really terrible happens,” because as we know, high blood sugars doesn’t hurt, high blood pressure, high cholesterol, can’t really feel it. So we are dealing with a relatively invisible disease and all of our interventions are really about prevention. The problem with that of course is that we as human beings respond better to immediate short-term, tangible, positive things. And the idea that we are talking about a disease where you can say, “Hey Joe, listen if you can take the following medications, rebound with your life in terms with your life with what you’re eating and how you’re exercising. Try to be vigilant and lose a little weight, maybe not too much and just stay on track every day for the next 10, 20, 30, 40 years. If things work out right, here’s what in it for you, here’s what’s most likely to happen…nothing.” Because really what we’re after is the avoidance of long-term complications, I mean there’s more but that’s really the critical thing we tend to focus on. And the avoidance of nothing down the road isn’t that inspiring to us as human beings. We’re looking for immediate tangible reinforcers. So how do we take an invisible disease and make it visible so it can become more of a priority in people’s lives. One of our old strategies was to yell at people and berate them and try to scare the crap out of them, right? In general, that doesn’t work very well. So a lot of the work we do is to try to find something else. How do we help people to become enthused and engaged with their diabetes? And there’s a number of approaches we use but I would say one of the critical ones I want to share with healthcare providers is to ask them to think creatively as we have done which is how do you think about providing people with metabolic feedback and that can be blood sugars, A1c, or whatever it is and think about it as a motivational tool. Because we see it as the single most underused motivational tool there is. How do you talk to people about their A1c or about their blood sugars in a way that turns people on rather than turns people off? Because we know for so many people this can be a turn off, blood glucose monitoring can really be de-motivational. And we see that happening but it doesn’t have to. When we can talk to people about their numbers in a way that’s sensible to help people to see that look we can help you to see how your actions can make a positive difference. The psychological concept behind that is called perceived treatment efficacy, when we can help people to see that their actions are making a positive difference, it helps you to be engaged. People with diabetes see it all the time. If you’re on a diet and you weigh yourself everyday and the number on that scale is moving down, you’re going to be enthused about staying with that diet but if that number never moves or you don’t own a scale, you’re going to lose that “umph” pretty fast. Those are the kinds of things, maybe I’m speaking to vaguely about this, but those are the strategies we try to build that can make a difference.
Steve Freed: In your presentation, I can see now why you’re giving that particular presentation about CGMS because now you just mentioned you have to have a way to show them because they can’t feel it, but they can see it now. How important is that number 1 for type 2’s who are not on insulin, who basically… let’s start with prediabetes, how important is that in preventing diabetes in a prediabetic. It’s certainly not approved for that at this point.
William Polonsky: Prediabetes, I don’t know about, to me that’s too difficult, we’ve played with that and I find that too challenging. But if we’re talking about people with diabetes who aren’t insulin, for example, that’s different. As you know, just to back up CGM for a moment, we had this long running battle about is blood glucose monitoring you know, SMGB, is that useful for folks not on insulin? And if you look across studies, you have to say well it looks like it’s not so useful and that’s why we’ve seen insurance companies and countries beginning to cut back on reimbursement because the conclusion is really there isn’t much of an impact on glycemic control. I find that the study to be convincing and completely wrong because what they basically shown is that SMBG done poorly, has no impact. So if you give someone a meter and you don’t tell them what the numbers mean, or help them to figure out what to do with it and their physician doesn’t know what to do with it and even make sure that those physician never even see those numbers, it’s just a waste of time. In fact it is a demotivational thing to do, but it doesn’t have to be. If we show people how to make use of these data, and we have a couple good studies showing that people, even newly diagnosed, you can have an enormous impact on their engagement with their disease, on self-care behavior changes, on A1c over the course of time. When you support people that understand their data, when you ask them to be checking blood glucoses in a way that makes sense using structured testing, or paired testing so people can see how meals affect them, how exercise affects them, then everything changes. But oddly enough, people don’t seem to be appreciating it that much. And to me that’s the promise of CGM, now we can do it in an amazing way, where people aren’t sticking their fingers so much, where you’re getting data every 5 minutes, where you can show people trends and people can see with support, with guidance that, “wow my actions really do make a difference, positively or negatively. And with small changes I can really show an impact on that.” and that can be lifestyle but it can really help people see “Gee, maybe those medications my doctor’s been telling me to take and maybe they can make a difference too.” But it isn’t just use berating people, it’s sharing with them, helping them to see that let’s look together at how you can see if it’s working or not working. It’s making the invisible visible. This is the opportunity.
Steve Freed: So you’re very positive on this, CGM, and using it as a treatment, as a therapy. If it’s done properly. Obviously if you just throw it to them, it doesn’t have a meaning because they’re not doing anything when they see the number they’re not reacting because they don’t know how to react. So we are back to education when it comes to diabetes as a key element. The CGM for type 1 diabetics… you know type 1 diabetes is a completely different disease. People get depressed, frustrated, burned out, when it comes to type 1 diabetes, especially if they’re not in control, even if they are in control, because they have to do so much on a daily basis, on a daily hour. How do you talk to those patients? How do you get them out of their depression besides pharmaceuticals?
William Polonsky: I wrote a whole book about diabetes burnout actually, so it’s my favorite subjects. There’s actually some controversy now about whether people with diabetes really are at an elevated risk for depression. They do tend to score higher on depression questionnaires, but some of the more recent data that I’ve been involved in suggests a lot of what looks like depression may actually be diabetes distress. That distinction, while we’re still arguing about that, is important because if it’s really not major depressive disorder but really just people saying I’m overwhelmed and freaked out and frightened and discouraged about this disease; antidepressants aren’t going to fix that. So we have found a couple of things that really make a difference. I would say the most important one is, we do a lot of work on what’s called evidence-based hope, where we think people are pretty discouraged. People are very surprised when we can provide that with real evidence, easy to explain evidence, that with good care, odds are you can have a long and healthy life with diabetes. That’s obvious to you and me I think, but that’s not so obvious to even healthcare providers who aren’t spending full time in diabetes and certainly it’s not obvious to patients. Providing people with not just the scary messages, like here’s what’s going to happen if you don’t take good care of yourself, actually here’s what going to happen if you do take good care and stay engaged with this treatment that there’s no good reason why your life expectancy should be different from someone who doesn’t have diabetes. The risk of long-term complications becomes so incredibly small. Wwe have such good news to share with patients that we don’t tend to do. That sense of hope that we think is the first step that’s often missing that’s really key.
Steve Freed: Let me ask you a question. In my experience, and everybody’s different so you can’t make any general statements for everybody, especially for type 1 and type 2 diabetes. A lot of the times I find that people will do for others what they won’t do for themselves. I had a couple of patients that had dogs. I couldn’t get them to increase their physical activity. They didn’t have enough time. I called their vets and told them we’re doing a study and you need to tell them that they need to walk their dogs three times a day for 20 minutes. And all three of those people actually did it most of the time. To me that just kinda blew my mind. That for their own health to prevent loss of limbs, heart attacks, cancer they didn’t do it, but for their dog they would. Do you see that at all in your practice?
William Polonsky: I just love that you’re doing that, that’s wonderful. That makes so much sense. When we think about what helps people to be successful. First of all i want to think about that idea but one of the other major things is when they have people in their life who are rooting for them, when they have people in their life who care about them. Often times, it’s doing for others that can matter but I think at the heart of what you’re saying it’s that touchy feely stuff, it’s love. When you feel like someone cares about what you’re doing, everything gets easier. It’s a fundamental thing we’ve seen in behavior change research for decades, someone is rooting for you that’s amazing. It’s really one of the undiscussed reasons why people with diabetes do so much better in clinical trials. Clinical trial data is extraordinary in terms of, if you look at the effect with our medications. We don’t see that A1c benefit outside of clinical trials in the real world. There’s people in that trial who are holding you accountable but they’re rooting for you and that sense of just care and love. As healthcare providers, we are often uncomfortable to use those kind of words but it’s the fuel in the engine to a large degree, in a lot of cases.
Steve Freed: A patient walks into a doctor’s office and the doctor has 15 minutes. If you had to pick out three things to help him communicate with that patient, what would you tell him to either do or not to do?
William Polonsky: Well, first of all in real life they’re not going to have 15 minutes to talk about diabetes, they’re going to talk about why their elbow hurts and everything else, so they’re lucky if diabetes comes up at all. I think the most honorable, and important thing to do when you’re ever seeing a patient with diabetes, the one thing if you don’t have anything else is to take time to ask that patient one question, which is, “Can you tell me, Mrs. Smith, one thing about diabetes that’s driving you crazy? Or that’s bugging you?” and you may not be able to fix it, but that you honor your patients by even asking that question and they’re more likely to feel engaged and be engaged and be interested in anything you have to say after that, that by including them in your agenda and letting them know that’s important and by normalizing by your question that I presume there is probably is something that is annoying you about this disease, you’re already 10 steps ahead, anything else you do is beautiful after that. So, just start with that.
Steve Freed: I wanna thank you for your great tips. Looking into the future I’ve got to sit down with you for a couple hours or days and pick your brain because obviously how many diabetes psychologists are there in the U.S.?
William Polonsky: Who are actually practicing? Very very few, I mean very few.
Steve Freed: Are there more than 10?
William Polonsky: We have to think about those who work with adults versus those who work in pediatrics. There’s actually probably a couple dozen who work in pediatrics but who work with adults? I’d be hardpressed to think there’s more than 15 maybe in the whole country.
Steve Freed: And how many of those have published books?
William Polonsky: A lot fewer, maybe 5? Maybe less.
Steve Freed: When was your last book?
William Polonsky: Well, I’ve been too busy doing publications, I haven’t had time to do a book in 5-6 years.
Steve Freed: What is your favorite book you’ve written?
William Polonsky: My first book, Diabetes Burnout, which feels older than the skies these days.
Steve Freed: Nothing’s changed since then, except for maybe CGM.
William Polonsky: That poor book needs a refresh at this point, but the issues are still there and still real and I know still touch people because I hear from folks all the time.