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Dr. Jen's Diabetes Diary

The Diary of a Diabetes Psychologist

Couple in BedEncountering problems with sexual response is a common experience for both men and women with diabetes. Not only can diabetes affect your physical functioning, there can also be psychological factors that interfere with a full and rewarding sex life. Problems with sexual function can be very distressing and affect the quality of your life as well as your relationships. Although help is available, many people (both with and without diabetes) find sexual difficulties an embarrassing topic to talk about in the context of a health appointment, and therefore refrain from being open with their doctors or nurses about their difficulties. This article will help you to become more familiar with the different ways your sexual responses may be affected, give you strategies to help you tackle the psychological difficulties that might be getting in your way, and empower you to talk to your doctor or nurse about how they can help you.

Male Sexual Problems

Erectile dysfunction (also known as impotence) means you are not able to obtain or keep an erection long enough for sexual intercourse. An erection is caused by the flow of blood into the penis and the blocking of the small blood vessels, making the penis hard. In one study more than 50% of males with diabetes admitted difficulties with sexual function, rising to more than 75% for men over the age of 70. To put this into context, about 1 in 10 men over 40 years old have erectile dysfunction, whether they have diabetes or not. Many factors along with diabetes can contribute to difficulties with sexual response. These include:

  • Drinking alcohol.
  • Smoking.
  • Taking illegal drugs.
  • Medications such as certain antidepressants.
  • Injury to the penis.
  • Damage to the spinal cord.
  • Nerve damage caused by operations to the bladder, bowel, or prostate gland.
  • Poor blood supply to the penis due to blockage of the artery caused by peripheral arterial disease.
  • Producing less testosterone than your body needs.
  • High blood pressure.

Female Sexual Problems

Women with diabetes are also at risk from difficulties with sexual response, and although these are visually not as obvious as for men, they are just as upsetting and difficult to contend with.

Physical problems are:

  • Dry vagina caused by high blood glucose levels.
  • Greater proneness to yeast infections, making sexual intercourse uncomfortable.
  • Loss of skin sensation around the vagina area, reducing the pleasure experienced.

In addition to physical explanations for sexual difficulties, there are also emotional reasons why you may be encountering problems relating sexually to your partner. These affect both men and women. Some of these are:

  • Stress.
  • Depression and low mood.
  • Anxiety and worry.
  • Conflict with your partner.
  • Issues regarding how sex is viewed in your religion or culture.
  • Homosexuality.
  • Bereavement.
  • Illness or ill health.
  • Being in an accident.
  • Previous abuse.
  • Infertility.
  • Disability.

Gain Support for the Physical Side of Sex

The first step is to have a physical examination by your General Practioner or healthcare team, and take advantage of medical treatments or aids they recommend to you. For men with diabetes, Viagra and similar prescription medications can be incredibly helpful and they have no adverse impact on diabetes control. Do not buy any medicines to treat erectile dysfunction over the Internet. It may seem appealing as you can get help anonymously without having to approach a potentially embarrassing topic at clinic, but there is no guarantee what you are buying is genuine. It is also important your healthcare team is aware of all the medications you are taking.

Other general guidelines for improving sexual response for both men and women are:

  • Weight loss, smoking cessation, and cutting down on alcohol intake.
  • Improving glucose control or changing some of your medicines. If the sexual difficulty coincided with a sudden worsening of your glucose control or with starting a different drug, it is important to look at these factors.

It is natural to feel embarrassment about discussing sexual problems with healthcare professionals. Remember, they have heard similar problems before and will not be fazed by them. Indeed, they will respect you are able to be open about it and seek help. Remember, the first line will be the most challenging; once that is done, the clinician will steer the conversation for you. Some ideas for conversation starters are in the box below.

Conversation Starters for Discussing Sexual Problems

  • I’m having problems in bed.
  • I’m struggling with sex/my sex life.
  • My [penis, ‘equipment’, etc.] isn’t working as it should.
  • I’ve got something I’m a bit embarrassed to mention …. (The clinician may pre-empt what you are about to say.)
  • I was hoping you might be able to help me with this problem I am having.
  • I think I’ve got ED/erectile dysfunction.
  • I can’t get a hard-on.

How to Manage the Emotional Impact of Sexual Difficulties

If your healthcare team has checked you out and there are no obvious physical problems, then shifting focus to psychological strategies can be helpful. Enjoyment of sex goes beyond the act of intercourse that culminates in an orgasm. Enjoyment of the sexual experience involves a whole range of factors, including your experiences of sex, your appearance, and your confidence physically and sexually, and so on. Early traumatic experiences involving sex and negative beliefs about sex inherited from family values and attitudes can hinder the sexual experience.

I’ve worked with many people with diabetes who had resigned themselves to not having the sexual relationship they really wanted; however, by working together, we figured out how they relate to sex and what’s getting in the way of them having a fulfilled sexual relationship. I have a five-step programme (which works just as well over the phone/by Skype as in person) for tackling the emotional side of sexual difficulties and would love to support you (and/or you and your partner) with finding freedom in your sexual relationship. If you are currently struggling with sexual difficulties (or any other emotional issue related to your diabetes), remember you can take advantage of a totally free “Diabetes Clarity Session” — a 30-minute telephone/Skype call with myself or a member of my team to get clear on a plan for getting better. I really want to do all I can to help you achieve your best health and wellbeing this year.

You may use this article on your website, or for your own e-zine; however, there's one thing you MUST include: Dr. Jen Nash is a Clinical Psychologist chartered with the British Psychological Society. Dr. Jen helps her clients find solutions with simple and highly-effective psychological strategies to gain freedom from the frustration and stress of living with diabetes. To sign up for her free Diabetes Diary, visit www.PositiveDiabetes.com.

TestingWhat turns difficulties with food into an eating disorder? Put simply, an eating disorder is diagnosed if your attitude towards food causes you to change your eating habits and behaviours in a way that may cause damage to your health. The most common eating disorders are:

Anorexia Nervosa: when someone tries to keep their weight as low as possible, for example by starving themselves or exercising excessively.

Bulimia Nervosa: when someone binge-eats and then tries to control their weight by deliberately being sick or using laxatives (medication to help empty the bowels), diuretics and enemas.

Eating Disorder Not Otherwise Specified (EDNOS): an eating disorder that does not meet the criteria for any specific eating disorder. This includes binge eating disorder, when someone feels compelled to overeat but doesn’t use any compensatory behaviours (such as self-induced vomiting, laxatives, diuretics or enemas).

One type of eating disorder not otherwise specified that is specific to people with diabetes that use insulin is the reduction or omission of insulin. This behaviour is often referred to as ‘diabulimia’ in the media, although most health professionals avoid this term because it is confusing on many fronts. For instance, bulimia involves making yourself sick, which many individuals with diabetes who manipulate insulin do not do. EDNOS-DMT1 (Diabetes Mellitus Type 1) is a preferable term, although the condition is not clinically recognized yet. With insulin omission, whether by decreasing, delaying, or completely omitting prescribed insulin doses, a person with diabetes can induce hyperglycaemia and rapidly lose calories in the urine in the form of glucose.

Insulin manipulation can be done in quite a secretive way, so it often goes undetected by healthcare professionals. Unfortunately, it can also easily be misunderstood and the patient labelled ‘non-compliant’ with treatment. However, individuals who are manipulating their insulin are struggling with an eating disorder.

Signs to Look Out for That May Suggest Insulin Omission

  • Recurrent episodes of Diabetic Ketoacidosis (DKA)/ Hyperglycaemia.
  • High HbA1c.
  • Frequent hospitalizations for poor blood sugar control.
  • Delay in puberty or sexual maturation, or irregular periods.
  • Frequent trips to the toilet.
  • Frequent episodes of thrush/urine infections.
  • Nausea and stomach cramps.
  • Loss of appetite/eating more and losing weight.
  • Drinking an abnormal amount of fluids.
  • Delayed healing from infections/ bruises.
  • Easy bruising.
  • Dehydration and dry skin.
  • Dental problems.
  • Blurred vision.
  • Severe fluctuations in weight.
  • Fractures/bone weakness.
  • Anaemia and other deficiencies.
  • Early onset of diabetic complications, particularly neuropathy, retinopathy, gastroperisis, and nephropathy.
  • Anxiety/distress over being weighed at appointments.
  • Fear of hypoglycaemia.
  • Fear of injecting/extreme distress at injecting.
  • Injecting in private/out of view.
  • Avoidance of diabetes-related health appointments.
  • Lack of BS testing/reluctance to test.

Causes of Eating Disorders

Causes of eating disorders are complex, and there is rarely one specific cause. Rather, as with other emotional difficulties there are biopsychosocial reasons for their development and continuation. The reasons that disordered eating may develop in the general population (i.e. non diabetes-specific reasons) are:

Biological

  • Having a family history of eating disorders, depression or substance misuse.
  • Being female (although men are also increasingly vulnerable and do also develop eating disorders).
  • Being Overweight.
  • Experiencing early puberty compared to peers.

Psychological

  • Being overly concerned with being slim, particularly if combined with pressure to be slim from society or for a job (which can happen, for example to ballet dancers, models, or athletes).
  • Certain characteristics, for example having an obsessive personality, an anxiety disorder or low self-esteem, or being a perfectionist.
  • Dietary restraint and dieting.

Social

  • Being criticized for one’s eating habits, body shape, or weight.
  • Particular experiences, such as sexual or emotional abuse, or the death of someone special.
  • Difficult relationships with family members or friends.
  • Stressful situations, for example problems at work, school, or university.
  • Disturbed family functioning.
  • Disturbed parental eating attitudes.
  • Peer and cultural influences.

Eating disorders are often blamed on the social pressure to be thin. However, although this can be a contributing factor for some individuals, the causes are usually more complex. Many people do feel a pressure to be slim but do not go on to develop an eating disorder.

If you are struggling with an eating disorder it is not your fault. You are likely to have difficulty in managing and regulating your emotions, and a distorted view of your own body image. You are concerned about your body weight and shape and are likely to believe that you are overweight when you are actually at a normal or low weight. You probably fear gaining weight or becoming fat, and have a concerned attitude towards food, calories, and eating. Thoughts about food, weight, and shape are likely to be on your mind much of the time, and your success in controlling your eating behaviour and weight can become a main way you feel good about yourself.

Considerable evidence has also accumulated to suggest that living with type 1 diabetes in itself is a risk factor for disturbed eating behaviour and eating disorders (Nielsen, 2002). Eating disorders have been found to be twice as common in teenage girls with type 1 diabetes as in their peers without diabetes (Colton, 2009). It is also argued that the diabetes treatment goals can ‘teach’ or intensify some of the vulnerability to an eating disorders mindset (Goebel-Fabbri, 2009).

Diabetes management increases the focus on controlled food intake, and can be experienced as restrictive. This means you are following an eating plan which is not completely dependent on responding to your own internal cues for hunger and fullness. This results in these cues becoming less reliable. If you under eat, you are likely to feel deprived, which can trigger overeating and binge eating episodes. Knowing that bingeing is not good for your health or weight, you may then intensify your efforts to control your food intake and weight, getting trapped in a cycle of dieting, further binge eating, and weight control behaviour.

Not only this, but at puberty, when weight and shape concerns intensify, diabetes can become more difficult to manage due to hormonal changes and resulting insulin resistance. Diabetes then may constitute a pathway of risk for the development of disturbed eating behaviour.

Insulin Manipulation or Omission

Insulin manipulation is the most common method of purging in girls with type 1 diabetes and becomes progressively more common through the teen years. This behaviour is reported by 2% of pre-teen girls, 11–15% of girls in the mid-teen years and 30–39% of those in the late teenage and early adult years (Colton, 2009).

The reason most frequently cited by women with type 1 diabetes for deliberate insulin omission is weight control. However, other motivating factors may include:

  • Fear of hypoglycaemia.
  • Denial of having diabetes.
  • Embarrassment about blood glucose testing or insulin administration in front of others.
  • Desire to have a break from diabetes management.
  • Fear of needles.
  • Secondary weight gain.

Overcoming Insulin Omission and Other Eating Disorders

I have a 10-step programme for breaking free of these patterns of behaviour.

  1. Get ready to change.
  2. Keep a diary.
  3. Develop an insulin/food plan.
  4. Reduce binge eating.
  5. Reduce vomiting/laxative use.
  6. Examine your thinking.
  7. Problem-solve.
  8. Expect challenges.
  9. Increase self-esteem.
  10. Speak up.

I’d love to support you in working through the 10 steps of this programme. If you are currently struggling with insulin omission (or any other emotional issue related to your diabetes), remember you can take advantage of a totally free “Diabetes Clarity Session”  — a 30-minute telephone call with me or a member of my team to get clear on a plan for getting better. I really want to do all I can to help you achieve your best health and wellbeing this year.

You may use this article on your website, or for your own e-zine; however, there's one thing you MUST include: Dr. Jen Nash is a Clinical Psychologist chartered with the British Psychological Society. Dr. Jen helps her clients find solutions with simple and highly-effective psychological strategies to gain freedom from the frustration and stress of living with diabetes. To sign up for her free Diabetes Diary, visit www.PositiveDiabetes.com.

Motivational StairsI have lost count of the times people with diabetes have said to me, “I would love to change my behaviour around diabetes, but I just have no motivation.” They know what they should be doing to care for their health, but they cannot seem to summon up the how. So when I tell them, “You are one of the most motivated people I have ever seen,” they tend to stare at me in utter disbelief! But then I explain. They are motivated to do all sorts of things in life:

  • Watch the latest film at the cinema.
  • Devote some time to engaging in an enjoyable pastime or hobby.
  • Pet their cat or dog.
  • Eat a delicious meal in the company of loved ones.
  • Go on holiday.

I am confident there is not a single person reading this who finds that the concept of ‘motivation’ enters their mind when they are thinking of doing these fun activities! In fact, the average person would be ready, willing, and eager to get started and feel the enjoyment that these events bring.

The crucial difference with these things is they are a short-term route to good feelings and instant pleasure. The problem with health-promoting activities such as exercising, eating healthily, or testing your blood glucose, is they often do not result in pleasure in the short term — instead working up a sweat is uncomfortable, the salads are more boring than the chips, and testing your blood glucose is more pain than it is worth.

No one feels motivated to do something if the costs seem to outweigh the benefits. Go to the gym in the evening or spend a cosy night in front of the television? I am sure you can see what I mean!

Here are my top tips for staying motivated with any aspect of your diabetes health care:

  1. Link an activity that feels like a struggle with one that naturally feels effortless.

    You could:

    • Test your blood glucose and then phone or e-mail a friend you love to chat to straight after.
    • Plan your exercise so it’s immediately followed by watching your favourite TV programme.
    • Make the doctor’s appointment you have been putting off for months just before you sit down with you morning tea or coffee, and make a rule that you can’t have one until you’ve done it.
    • Stick to your healthy eating plan for three days and reward yourself with a visit to your favourite museum, gallery, park, or shop.
  2. Imagine, and keep imagining, how great you will feel once you’ve accomplished your goal.

    Whether it is losing a certain amount of weight, getting to the HbA1C level you are aiming for, or in a regular routine of exercising more. Having a photo, picture or object that symbolizes or is a reminder of your goal can be effective when you feel like you are losing motivation, perhaps because your goal is taking too long or the results seem too slow.

  3. Kindness Statement.

    Keep your inner voice kind and supportive. It is so easy to find yourself talking to yourself in a negative way, and even worse, listening to it. Form a kindness statement that you find motivating and remind yourself of it often. Examples may be, “If this was easy, then everyone would be doing it!”, “Only I can change my life. No one can do it for me”, “Change is challenging but each day I’m moving closer to my desired goal.”

  4. Remind yourself of successes you have achieved in the past, and how you can transfer this experience to your current goal.

    Keep a success journal and track all of your successes, no matter how small and in whatever area of life you like. Examples could be: learning to drive, making a new friend or nurturing an existing relationship, learning how to use a computer, raising your child, having a successful work meeting, learning a new recipe, mastering a new skill, planning a holiday or family day out — you get the idea!

You might like to think back over times you have changed in the past and fill in the following worksheet.

Example Worksheet: Learning From Change

  • Change I want to make.
    Lose one stone in weight by avoiding snacking between meals.
  • What is your main reason for making this change?
    Feel fitter, look better, be healthier
  • Thinking over times you have made a health change in the past, how did you do it?
    Cut out sugar in my tea — ensured I didn’t have any in the house, kept reminders by the kettle.
  • What helped you to stay on track?
    Telling others of my plans, talking to other non-sugar takers and seeing what their experiences were like.
  • What things got in your way?
    Going to a friend’s house — had to remember to tell her I no longer took sugar.
  • Which strategies were the most successful?
    Using a sugar substitute when I really fancied some sweetness.
  • How will you respond to the urge to go back to an old behaviour?
    Remind myself of how good it will feel to succeed this time, distract myself with an activity.
  • How do you expect to feel when you have succeeded?
    Fantastic!
  • What might you miss about your old behaviour?
    Having a cake with tea when I meet a friend. I could plan to buy myself a non-food treat instead, e.g., a magazine or a new product I have not tried before.
  • Have you told people about your plans? If not, why not?
    No, will tell my partner and ask her for support.
  • Can you think up some responses you can give if tempted to stray from your plans?
    “I’m really enjoying feeling more in control of my health.”
  • Are there any friendships that may be affected when you make this change?
    Mum might be a bit miffed if I don’t eat snacks she has made when I visit her. I could always ask her to wrap it up and tell her I will eat it later, or share it with my partner.

You may use this article on your website, or for your own e-zine; however, there's one thing you MUST include: Dr. Jen Nash is a Clinical Psychologist chartered with the British Psychological Society. Dr. Jen helps her clients find solutions with simple and highly-effective psychological strategies to gain freedom from the frustration and stress of living with diabetes. To sign up for her free Diabetes Diary, visit www.PositiveDiabetes.com.

Eating a Hot DogDo you ever find yourself feeling down, unhappy, or restless, and before you know it, you are eating something you hadn’t planned to? If so, you’re not alone. “Emotional eating” or “comfort eating” is really common, both for people with and without diabetes. As an attempt to feel better (temporarily at least) it’s okay to use food like this some of the time. However, when food starts to feel like it controls you, rather than you being in control of food, and particularly if you have weight to lose, it can be helpful to consider your eating behaviour from a different angle. What is your ‘relationship’ with food? This article will help you understand the way you relate to food and diabetes weight loss is not just a simple formula of “eat less and move more”. There are numerous reasons why the relationship you have with food may be complex and these can be divided into biological, psychological, and social factors.

Biologically, we are fighting against our evolutionary history. Our bodies have evolved to store food in times of plenty to sustain us in times of scarcity and this is at odds with our modern day lives in which food is more than abundant. Our bodies simply haven’t caught up with our contemporary western world.

Psychologically, the connection between emotion and food is one that is established from birth, from the very first time you cried and your mother comforted you with milk. As you grew up, you may have been given sweets to cheer you up after the upset of hurting yourself, or been cooked your favourite dinner when you’d fallen out with a friend. Food is not just a fuel; it has been conditioned as a soother of emotions for as long as you can remember. So now when you’ve had an argument with your partner, or a bad day at work, there can be an impulse to reach for food as a way of calming, distracting, or comforting yourself.

Further, being able to limit food intake to maintain a socially desirable slim body shape is valued in today’s western societies; therefore, eating choices aren’t just made on nutritional content or taste but are complicated by their connection to personal sense of self-worth.

Socially, shared eating experiences are a way of bonding, celebrating, and showing love within our families and communities. Births, deaths, marriages, and all occasions in between are marked by food. Family members may offer food (and keep offering, long after we’ve said no thank you!) as a substitute when it is difficult for them to express love through a hug or saying “I love you”.

So fast forward to the diagnosis of diabetes and you are suddenly required to sharply focus on food and be thoughtful about changing or limiting previously enjoyed food choices. Your doctor, nurse, and dietician will tell you healthy eating is one of the crucial elements of optimal diabetes control; but given the link between food and emotions, it’s hardly surprising that encouragement by healthcare professionals to cut down on fatty sugary food is sometimes difficult to implement.

You know in your head what you should be doing, but it’s hard to break away from the conditioning and pattern of food as an instant route to pleasure, distraction and satisfaction.

However this pattern can be changed. The goal is to reach a place in which you can make a decision about whether or not to eat when you are feeling emotional, rather than it just being an automatic response. An important point to remember is that everyone — of every shape and size — can use food to deal with his or her emotions, and occasionally it can be fine to use food in this way. The danger is when food becomes the only way to deal with emotions. The next article in this series will examine strategies to help you gain control over your eating, the central role of your thoughts in eating behaviour, and how authentic emotional expression can help.

You may use this article on your website, or for your own e-zine; however, there's one thing you MUST include: Dr. Jen Nash is a Clinical Psychologist chartered with the British Psychological Society. Dr. Jen helps her clients find solutions with simple and highly-effective psychological strategies to gain freedom from the frustration and stress of living with diabetes. To sign up for her free Diabetes Diary, visit www.PositiveDiabetes.com.

Health Professional Medical ClipboardAs we discussed last time, everyone’s experience of hypoglycemia is unique. This week’s article is my top five strategies for helping you to overcome your difficulties with hypoglycemia.

  1. Tell your healthcare team.

    If you frequently experience low blood glucose levels, the first thing that may be needed is a change to your diabetes regime — medication type, the dosage, or the timing of medication and/or food. Your doctor will be able to help with this.

    Also, if you are experiencing less warning signs than previously, there are ways of recovering these, through avoiding all hypos for as little as a few weeks. This needs careful planning to avoid the opposite problem of overly high blood glucose levels, but is very possible with guidance.

  2. Immediately before checking your blood glucose, guess what the number will be.

    Increase your confidence in your hypoglycemia awareness by estimating what yours is before you actually test. Write down what your guess is, then test and write down the actual result. If you often guess incorrectly, then use the following strategies to help you.

  3. Learn your unique ‘alarm bells’ that are your own warning signs of hypos.

    Everyone has their own individual ‘alarm bells’ that is their body’s way of telling them that they are low. Keep track of what you notice going on for you when you have a hypo (obviously best thought about after you have recovered from one!). Is it a physical symptom (heart racing, tingling in a certain part of your body, sweating, shaking, or heart palpitations), or a change in your mood or in your ability to think clearly?

  4. Find out what works best for treating your hypoglycemia.

    Experiment! Some people like to try chocolate, but because of the high fat content, it can be slow to raise blood glucose levels. Fast acting sugars contained in glucose tablets and glucose drinks can act more quickly. There’s nothing worse than eating a snack and it not working, so try a variety of foods and see what works best for you. Once you’ve found what works best for you, always carry some of this with you.

  5. If you tend to think you are having reactions, even when you are not, try a breathing exercise.

    If you think you may get yourself into the anxiety cycle described earlier, then a quick relaxation exercise can help control your panic, so you can discover whether you are experiencing hypoglycemia.

    Try the following quick exercise:

    • Sit comfortably in a chair.
    • Close your eyes.
    • Take a slow, deep breath in so your lungs are full.
    • Hold this breath for the count of 3 seconds.
    • Breathe out as fully as possible for a count of 5 seconds.
    • Repeat this sequence for two more breaths.
    • Open your eyes and notice any subtle differences in how you feel, in your body and your mind.
    • With a bit of practice, over time, you will be able to notice a feeling of relaxation.
    • Once you feel comfortable with the technique, begin to practice this when you are having hypoglycemic symptoms that you are not sure whether or not are real.
    • If they weaken, it is likely it is a false alarm, but in the beginning always test your blood glucose level to see if you are correct.
    • With frequent practice, over time, you can expect the false alarms to occur less frequently.

You may use this article on your website, or for your own e-zine; however, there’s one thing you MUST include: Dr. Jen Nash is a Clinical Psychologist registered with the British Psychological Society. Dr. Jen helps her clients find solutions with simple and highly-effective psychological strategies to gain freedom from the frustration and stress of living with diabetes. To sign up for her free Diabetes Diary, visit www.PositiveDiabetes.com.