Twitter Chat Summary: Helping People with Diabetes Move from Denial to Acceptance

The Johnson & Johnson Diabetes Institute, in partnership with The Diabetes Influencers Network, has launched a series of Twitter chats from August through December 2016 geared to diabetes healthcare professionals. Topics will cover the gamut from using social media for career growth to helping clients accept the diagnosis of diabetes to offering guidance on healthy restaurant eating.

These lively Twitter chats will be facilitated by Hope Warshaw, MMSc, RD, CDE, BC-ADM. Warshaw is a Johnson & Johnson Diabetes Institute Faculty member and is serving during 2016 as president of the American Association of Diabetes Educators.

Our recent Twitter chat took take place on Wednesday, August 24 from 9:00 – 10:00 am ET, 8:00 – 9:00 am CT, 6:00 – 7:00 am PT. The topic was: Helping People with Diabetes Move from Denial to Acceptance. Following is a summary of that Twitter chat.

Q1: How can HCPs detect denial of diagnosis of #Diabetes? Words? Body language? #DiabetesINFL 

nutritionjill Stating my #diabetes isn’t bad. “It’s just a bit of sugar” Or “I’m just borderline.” #DiabetesINFL #client #DiabetesDenial
hopewarshaw Actions may be: not practicing #diabetes self-care, not checking BG or taking D-meds. What do you see in clients? #DiabetesINFL
askdrbev Having a high C is a clue that a person is not taking care of their #diabetes management. One reason could be denial. #DiabetesINFL
diabeticpsych Words like ‘can’t’, ‘should’ #diabetesINFL
askdrbev Also known as “dia-denial”, some PWDs “forget” to take their meds or don’t pay attention to eating healthfully. #DiabetesINFL
hopewarshaw Re: food/eating, actions of denial may be lack attn. to choosing healthy foods, unwilling/not changing eating habits. #DiabetesINFL
maureensrn Denial of diagnosis "may" manifest in poor eye contact, limited engagement in education; noncompliance #DiabetesINFL
nutritionjill Not filling Rx or “forgetting to take meds,” ignoring sores that don’t heal, justifying unhealthful food. #DiabetesINFL #client
janekdickinson I use/recmd Motivational Interviewing, where it is referred to as ambivalence. Acknowledges that ppl want hope and health #DiabetesINFL
hopewarshaw Signifying denial: People may not openly share that they have #diabetes w/ family, friends, roommates, work mates #DiabetesINFL
diabeticpsych It’s both actions but ways of thinking about things – ‘I can’t work AND manage #diabetes#diabetesINFL
fiberfriendly denial of diabetes can manifest in poor food choices & other destructive self behavior #DiabetesINFL
maureensrn Denial "may" appear as continued poor health choices, "forgetting" to take medications; missing appointments #DiabetesINFL
janekdickinson Open ended questions! #DiabetesINFL
hopewarshaw What other signs of #diabetes denial have you experienced among ppl w diabetes you’ve worked with? Plz share. #DiabetesINFL
maureensrn Agree with motivational interviewing- assess "where patient is" on learning curve. #DiabetesINFL
maureensrn Possible denial " just tell me what is on a diabetic diet". Looking for quick fix; not invested. #DiabetesINFL
maureensrn Denial of diagnosis may be d/t coping skills and health literacy #DiabetesINFL
nutritionjill Many keep their diagnosis a secret. #DiabetesINFL # client #DiabetesDenial
katieladytherd missing appointments, blaming DM issues on other things #DiabetesINFL
sarhoward eg my cousin, 30+ years with t1d, doesn’t check bg, says he doesn’t always need insulin, #DiabetesINFL
hopewarshaw However, this is a balance….often times ppl need more glucose-lowering meds #DiabetesINFL
janekdickinson I think shame and guilt lead to avoidance/ambivalence.This can be seen in #s that don’t match up, not making eye contact #DiabetesINFL

Q2: Can HCPs working with ppl w #diabetes help them move towards acceptance? If so, how? #DiabetesINFL

hopewarshaw Legitimize that denial is normal and common among ppl w T1 and T2 #Diabetes. Acknowledge takes time to accept dx #DiabetesINFL
hopewarshaw #Diabetes, for some, easy disease to deny. Nearly no physical signs other than self-management actions #DiabetesINFL
nutritionjill I find acknowledging their fears/disappointment & repeating back their words helps. #DiabetesINFL #DiabetesDenial # client
askdrbev HCPs can help PWDs move toward acceptance of #diabetes w/TLC Therapy – Talk, Listen, Counsel. 1st provide diabetes educ. #DiabetesINFL
nutritionjill Show people w #diabetes ways to empower themselves. Focus on what they can do to improve things. #DiabetesINFL #DiabetesDenial # client
askdrbev Listen to PWDs They need to express their concerns openly. Lastly, counsel them by challenging their unreasonable beliefs. #DiabetesINFL
hopewarshaw Acknowledge #diabetes is very challenging disease to manage, complex self-care regimen. It’s tough but doable in time! #DiabetesINFL
maureensrn HCP should accept patient “where they are in learning” ability. Adjust/modify curriculum.
askdrbev Since we can’t change the dx of diabetes, if PWDs change how they think, then they can change how they feel. (That’s CBT) #DiabetesINFL
diabeticpsych Normalizing people’s experiences is so important – so many people think they are the ‘only one’ #DiabetesINFL
janekdickinson Absolutely! By using language that builds on ppl’s strengths and empowers them. Give ppl credit for what they are doing. #DiabetesINFL
sarhoward realize that pwd are very diverse. my cousin manages t1d by foraging for mushrooms, Buddhism… not your typical patient. #DiabetesINFL
maureensrn Acknowledge a persons fear/anxiety/stress/guilt over new diagnosis. Nonjudgemental attitude. #DiabetesINFL
nutritionjill try to help them remove feelings of guilt or at least deal w those feelings. #DiabetesINFL # client #DiabetesDenial
diabeticpsych Normalizing experiences empowers people! #DiabetesINFL
hopewarshaw For ppl w/ T2 #diabetes explain common disease progress as person willing to hear. Mgmt increasingly challenging in time #DiabetesINFL
janekdickinson Give them credit for simply being at this visit. #DiabetesINFL
fiberfriendly acknowledging the challenge & providing strategies that worked for others goes a long way towards #diabetes acceptance #DiabetesINFL
diabeticpsych NYes, and management changes over time and this is normal, not a sign of failure #DiabetesINFL
hopewarshaw With no associated, immediate pain or impact of variable glycemia, it’s hard to accept, limited incentive to accept dx #DiabetesINFL
janekdickinson Focus on what the person enjoys – what motivates them (not what motivates us – the provider) #DiabetesINFL
maureensrn Assess reading ability /comprehension and patients primary concerns first. Meet them at their level; family support #DiabetesINFL
katieladytherd Helping them set small goals to achieve; being open and nonjudmental & work towrds decreasing meds #DiabetesINFL
diabeticpsych Leveraging motivation is empowering and empowerment is key #DiabetesINFL
janekdickinson Build a trusting relationship by accepting where the person is in their journey. Can be hard for diabetes professionals! #DiabetesINFL
hopewarshaw Empathize. Managing T1D = VERY hard work! #DiabetesINFL 

Q3: What physical or emotional signs can HCPs look for to detect #diabetes acceptance? #DiabetesINFL

diabeticpsych Engagement, asking good questions, engaging family members in treatment, doing things they enjoy AND managing diabetes #DiabetesINFL
maureensrn Acceptance may appear as attending classes, compliance with diet and meds; engaged dialogue. #DiabetesINFL
hopewarshaw Listen for changes in language, how a person talks about having diabetes. More open, acknowledge having it. #DiabetesINFL
nutritionjill Lack of behavior change, justifying diet splurges or not monitoring blood glucose. #DiabetesINFL #client
fiberfriendly agree w/ @DiabeticPsych that engaging family members as stakeholders is essential for optimal #diabetes mgmt #DiabetesINFL
hopewarshaw @diabeticpsych: In your JJDI webinar you mentioned concept of “allowing some discomfort.” Can you plz translate, explain. #DiabetesINFL
diabeticpsych Yes! Moving from ‘I can’t to ‘I can…even though it is hard’ #DiabetesINFL 
maureensrn Acceptance can appear as good eye contact; asking questions; having family present; discussing new lifestyle changes. #DiabetesINFL
nutritionjill Comparing their circumstances to others in order to make themselves feel better. #DiabetesINFL #client #denial
askdrbev When PWDs realize that #diabetes can be managed (not necessarily controlled), that is a sign of diabetes acceptance. #DiabetesINFL
nutritionjill Often ppl in denial tell stories of friends whose situations, blood glucose levels, etc are much worse #DiabetesINFL #client
hopewarshaw HCPs need to work on listening more, talking less #DiabetesINFL 
janekdickinson In Motivational Interviewg it’s called “change talk” – really listen to what they are saying & build on change talk.#DiabetesINFL
janekdickinson Being truly present and listening. This is harder than it sounds. #DiabetesINFL
nutritionjill Agree. Reflecting back their words is very helpful. #DiabetesINFL #client 
janekdickinson Change talk = examples of what motivates someone. “I want to be around for my grandchildren.” #DiabetesINFL
katieladytherd when the PWD continues the conversation during an appointment & will talk about those who struggle with their BG and meds #DiabetesINFL
diabeticpsych Meeting patients where they are is a critical piece of motivational interviewing!  #DiabetesINFL 

Q4: Are there stages of acceptance of #diabetes? If so, what are they? Can there be back tracking? #DiabetesINFL

maureensrn Levels of acceptance dependent on past exposures to chronic disease & outcomes. #DiabetesINFL
hopewarshaw @askdrbev: At #AADE16 you talked abt moving from denial, thru anger, to bargaining, to depression b4 acceptance. Explain? #DiabetesINFL
janekdickinson I’ve seen people move in and out of acceptance, so yes, back tracking is possible. espec. based on life around them. #DiabetesINFL
maureensrn Much like “5 stages of dying”, I think #diabetes brings same process- denial, anger, bargaining….. #DiabetesINFL
diabeticpsych Different for everyone, but acceptance in thinking then leads to acceptance in behavior #DiabetesINFL 
hopewarshaw @diabeticpsych, others: are there differences b/w T1 and T2 #diabetes re: path, pace of acceptance? #DiabetesINFL
nutritionjill I see acceptance/start of acceptance when pwd ask me about blood glucose monitoring or how to adjust a recipe. #DiabetesINFL #client
janekdickinson Life happens & sometimes diabetes takes a back seat. Another chance to meet ppl where they r and provide support & guidnce. #DiabetesINFL
askdrbev Not everybody goes thru all these stages, nor do they always go thru in this order. Stage 1 is Denial – cope by ignoring. #DiabetesINFL
nutritionjill Typically T1 go thru stages faster b/c their symptoms are more obvious. Harder to deny. #DiabetesINFL #client #DiabetesDenial
askdrbev Ignoring #diabetes (aka denial) is what I call “Ostrich policy”. Not a coping strategy that helps to manage diabetes. #DiabetesINFL
askdrbev Stage 2 is Anger. Anger is the result of a person’s thoughts, not of the event. Anger is caused by the way you think/feel. #DiabetesINFL
askdrbev When angry, stress hormones are released making blood glucose go up. Instead of being angry, take actions toward managing. #DiabetesINFL
askdrbev Stage 3 – Bargaining is when a person makes a desperate plea to a higher power (or HCP) to reverse their dx of #diabetes. #DiabetesINFL
janekdickinson Goes back to trust – if ppl trust us, they will know they can be open about backtracking and then get back on track! #DiabetesINFL
avivamenche Models for behavior change outline stages. CDE Donna Webb blogs about Prochaska model – #DiabetesINFL
askdrbev Underlying this stage is helplessness based on fear. Help PWD to replace fear w/rational thoughts and return power to PWD. #DiabetesINFL
askdrbev Depression/Diabetes Distress is Stage 4 – When depression is related to living with the demands of #diabetes management. #DiabetesINFL
askdrbev Acceptance – PWD learn to make healthy lifestyle choices using rational thought/action. With acceptance comes empowerment. #DiabetesINFL

Q5: Shame and blame, stigma are increasingly discussed in #diabetes. What do these terms mean to you? How factor into denial? #DiabetesINFL

diabeticpsych People avoid things where they feel shamed and blamed – these feelings are hard to accept, so easier to avoid #DiabetesINFL 
hopewarshaw Accord to DQ&A, @diaTribeNews presented at #AADE16, 52% of T2s, 76% of T1s, report experiencing stigma due to #diabetes #DiabetesINFL
hopewarshaw Accord to @diatribeNews, Issue of stigma focused on “therapeutic visibility”, “stems from deviance from cultural norms.” #DiabetesINFL
fiberfriendly Teaching clients that shame & blame related to T2 #diabetes are not mandatory parts of the dx! #DiabetesINFL
nutritionjill So many of my patients w #diabetes keep it a secret from friends/family. They fear humiliation. #DiabetesINFL #client #DiabetesDenial
janekdickinson Shame/blame = a big problem in diabetes. Even caring pros use words that shame/blame. Lookg at our messges can make a diff. #DiabetesINFL
nutritionjill My job is to help people understand disease process & empower changer. These reduce shame/guilt #DiabetesINFL #client #DiabetesDenial
hopewarshaw Accord to @diatribeNews, neg emotions (guilt, shame, blame, isolation), more prevalent: higher A1c, BMI, poor control. #DiabetesINFL
hopewarshaw Shame and blame particular to T2 #diabetes, is this related to excess weight, unhealthy eating. Your thoughts? #DiabetesINFL
nutritionjill also my job is to listen, reflect, listen, reflect, be a round board. #DiabetesINFL #client #DiabetesDenial
maureensrn remove blame/ stigma of a chronic disease being caused simply by lifestyle behaviors. #DiabetesINFL
janekdickinson We – diabetes professionals – can perpetuate the message that diabetes is “not your fault” rather than shame and blame. #DiabetesINFL
hopewarshaw How can HCPs help ppl lessen shame, blame? Provide accurate info abt why #diabetes happens to clients, public. #DiabetesINFL
diabeticpsych Tools that allow them to make changes and empowering them by showing them that their behavior matters #DiabetesINFL 
sarhoward I think raising awareness of all the other factors that are linked to T2d would help reduce stigma, at least a little! #DiabetesINFL
maureensrn Acknowledge that blame further alienates patient; builds up barrios/walls. Not effective to anyone #DiabetesINFL
maureensrn with ~ 86 million prediabetics, we have to engage all at risk to avoid healthcare epidemic/crisis. #DiabetesINFL
maureensrn To properly address diabetes, it is important that families/communities/ the nation come together in united front. #DiabetesINFL
maureensrn “change” will occur/is occurring when we put personal bias aside and work for greater good->a healthier nation #DiabetesINFL

Q6: Can HCPs encourage family, loved ones to take action to help move ppl w #diabetes to acceptance? What actions? #DiabetesINFL

janekdickinson Encourage communication and support from family members. With full understanding, they can also lose the judgment. #DiabetesINFL
askdrbev If family/loved ones (aka “type 3’s”) become partners in healthy eating & activity, it helps all move toward acceptance. #DiabetesINFL
nutritionjill Encourage family members to make changes together. #DiabetesINFL #client #DiabetesDenial
maureensrn Encourage family activates, healthier eating, avoid shaming…… #DiabetesINFL
diabeticpsych HCPs can help by modeling behavior. If HCPs are collaborative with patient and others see this, they will follow#DiabetesINFL 
hopewarshaw Try not to aid denial by not acknowledging #diabetes but also don’t push at your pace towards acceptance. Your thoughts? #DiabetesINFL
janekdickinson Fam membrs often judge out of fear – if they have open communication and understandg, they are more likely to be supportve. #DiabetesINFL
nutritionjill Encourage family members to ask: How can I help you, Not: You need to change #DiabetesINFL #client #DiabetesDenial
hopewarshaw Work to appreciate, understand the day-to-day challenges, rigor, mental attention managing #diabetes requires. #DiabetesINFL
maureensrn Always invite family members into exam room ( with patient permission). Diabetes is a family issue- avoid isolating PWD. #DiabetesINFL
avivamenche Family support can be very valuable both emotionally and practically. Important to find balance between help & policing #DiabetesINFL
janekdickinson Simply asking, “do you want to walk the dog with me?” rather than “why don’t you ever exercise?” makes a diff!! #DiabetesINFL

Q7: Do age, age of #diabetes dx, family support (or not), socioeconomics impact transition to #diabetes acceptance? #DiabetesINFL

nutritionjill Biggest predictors I see are 1) social support 2) long term desire for good health #DiabetesINFL #client #DiabetesDenial
fiberfriendly family involvement is so key in #diabetes mgmt. Family members can be positive OR negative influencers #DiabetesINFL
hopewarshaw I’m not aware of research that points to objective factors to predict rate of transition to acceptance of #diabetes. You? #DiabetesINFL
janekdickinson I will go with “YES!” for 800. #DiabetesINFL
hopewarshaw If I were to wager a guess, I’d predict age, family support and socioeconomics play role, w family support highest. You? #DiabetesINFL
janekdickinson What’s happening in life (age, etc.) plus how it is handled by pros and family at diagnosis, plus prior exper w/ diabetes #DiabetesINFL
janekdickinson meaning if they’ve seen friends or family with diabetes – good or bad experiences. #DiabetesINFL
maureensrn PWD transition to acceptance at different time periods. Support is priority. #DiabetesINFL
maureensrn Finances can affect access to healthcare/education/mental health services & more. #DiabetesINFL

Q8: @diabeticpsych: In your talk at #AADE16 you discussed mindfulness. Can these techniques speed acceptance? How? #DiabetesINFL

diabeticpsych Mindfulness can be used to facilitate acceptance. Mindfulness is paying attention in the present moment, without judgment  #DiabetesINFL
diabeticpsych Mindfulness aids distress tolerance which is a critical piece of acceptance b/c diabetes is hard sometimes  #DiabetesINFL
nutritionjill #Mindfulness-wonderful skill-helps people fully engage in their lives. Trying to master it #DiabetesINFL #client
nutritionjill Learning to see emotions and physical sensations w/out judgment is a skill & a gift. #DiabetesINFL #client #DiabetesDenial

Q9: @askdrbev: In your talk at #AADE16 you discussed spirituality. Can intro of this by HCPs speed acceptance? How? #DiabetesINFL

askdrbev Teach HCPs new updated holistic approach to #diabetes care: medication, diet, exercise and spirituality. #DiabetesINFL
askdrbev Strange as this may sound, some PWDs (including me) see our #diabetes as a “blessing in disguise” – feeling at peace w/dx. #DiabetesINFL
askdrbev I am a big fan of the Serenity Prayer: Accept the things I cannot change; Courage to change the things I can. #DiabetesINFL
askdrbev Having a positive attitude toward #diabetes can make PWDs feel empowered to manage their self-care. “It is what it is.” #DiabetesINFL
diabeticpsych I agree! Helping people find benefit can really facilitate acceptance #DiabetesINFL
avivamenche Different approaches jive with different personalities. Some might appreciate a spirital approach while other may not. #DiabetesINFL
maureensrn Agree that holistic care in so important. Don’t get tunnel vision when treating a chronic disease. #DiabetesINFL
maureensrn Spirituality indeed plays important role for anyone dealing with chronic disease process #DiabetesINFL

Q10: What are a few tools, resources HCPs can use to help people transition towards #diabetes acceptance? #DiabetesINFL

diabeticpsych Helping people see that their current strategy is not working well. Asking might there be a better way #DiabetesINFL
hopewarshaw Ask open ended Qs, listen carefully to answers. Observe body language when responding. Note self-care actions, engagement #DiabetesINFL
nutritionjill Help patients make changes slowly to gain confidence. This lessens feelings of being overwhelmed. #DiabetesINFL #client
hopewarshaw Don’t tell but rather ASK the person w #diabetes to state what they’re ready to do to self-manage #diabetes #DiabetesINFL
maureensrn phone apps, log books, internet programs- let patient choose what learning style works best. #DiabetesINFL
janekdickinson Seriously check out motivational interviewing. It takes a lot of work/practice, but is worth it. #DiabetesINFL
fiberfriendly connecting newly diagnosed PWD w/ those who have had success in mgmt helps transition towards diabetes acceptance #DiabetesINFL
nutritionjill Ask patients about overall vision of long term health/happiness. Bring self-care into that ideal picture. #DiabetesINFL #client
diabeticpsych Fighting/ignoring #diabetes takes a lot of time an energy. Helping people see the benefits of not ‘fighting’ can help #DiabetesINFL
janekdickinson Learn about and work on changing language. Send messages of hope and strength, rather than shame and judgment. #DiabetesINFL
hopewarshaw Use technique of asking person w #diabetes if willing to do small, doable experiments with self-care behaviors #DiabetesINFL
diabeticpsych Peer support can also be helpful. For many of my pts I am the first PWD they have ever met. Meeting others is powerful #DiabetesINFL
janekdickinson Susan Guzman (PhD Psych) talks about the power of AND. Diabetes is hard AND you can do this! #DiabetesINFL
sarhoward expose pwd to current research on diabetes too, that can help some of us. it varies by patient though. #DiabetesINFL
sarhoward make sure to ID depression first cuz if so, may not be motivated to do any of this. #DiabetesINFL
hopewarshaw Legitimize denial is common. Acknowledge day-in, day-out rigor, challenges of #diabetes self-management. #DiabetesINFL
avivamenche Support groups – in person or virtual (social media – DOC) #DiabetesINFL
askdrbev Gary Scheiner: "3 things needed to manage diabetes successfully: the right tools, the right skills, & the right attitude." #DiabetesINFL
janekdickinson Ask permission before giving advice, suggestions! #DiabetesINFL
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Lauren Harris-Pincus, MS, RDN is a nutrition communications specialist, registered dietitian in private practice, social media consultant, speaker, spokesperson and corporate consultant. She is currently the owner of Nutrition Starring YOU, LLC and Lauren strongly believes that we should “Think Healthy, not Skinny”, and “EveryBODY is unique, your diet should be too”. Lauren was co-host of the Family Food Experts Kitchen radio show, available for listening on iHeart Radio and iTunes. Also known as one of the “NutritionBabes”, Lauren co-founded, a popular Health and Wellness website in 2009. was voted one of Healthline’s Top 100 Health Blogs in 2011, 2012 and 2013.

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Katie Ferraro, MPH, RD, CDE is a nationally-recognized registered dietitian, certified diabetes educator and author with an expertise in nutrition communications and curriculum development. She is the co-author of “Diet Therapy in Advanced Practice Nursing” (McGraw Hill, 2014) and an Assistant Clinical Professor of Nutrition at the University of California San Francisco and University of San Diego’s graduate schools of nursing.

Dr. Beverly S. Adler, PhD, CDE (aka “Dr. Bev”) is a clinical psychologist and certified diabetes educator, author and speaker. She specializes treating the emotional issues of people with diabetes. In her private practice, she provides individual, family and/or group therapy utilizing a cognitive behavior therapy orientation, combined with a spiritual approach. Her goal is to empower her patients to manage their diabetes.

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In August 2016, Dr. Bev was honored to receive the “CDE Entrepreneur of the Year” Award from her Metropolitan NY Association of Diabetes Educators.

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Jackie Newgent, RDN, CDN, is a registered dietitian nutritionist and classically-trained chef. With a passion for helping people (including her father) with diabetes, she’s author of The With or Without Meat Cookbook: The Flexible Approach to Flavorful Diabetes Cooking and the award-winning The All‐Natural Diabetes Cookbook, both published by the American Diabetes Association. Jackie is also author of 1,000 Low-Calorie Recipes and Big Green Cookbook. Her next book, The All-Natural Diabetes Cookbook—2nd Edition, was published in 2015.

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