Of the 37.5 million individuals managing diabetes in the United States, only an estimated 6–8 million can be defined as proactive, namely, those that successfully manage their diabetes. The article delves into what is apparently obvious and offers a rational explanation and an answer to this persistent problem.
WHAT IS PROACTIVE MANAGEMENT VS. REACTIVE MANAGEMENT?
This section explores the difference between a proactive and a reactive individual and discusses why it is important to celebrate those that proactively seek to conquer the challenge of diabetes management. Yes, managing diabetes regardless of its type is a challenge, but a challenge that can be overcome. The proactive and reactive terminology (insightful words) merely describes how people manage their diabetes. There are those that effectively manage their condition, those that (for whatever reason) do not, and those that convince themselves they do. This work seeks to explain each path. The resulting naming convention is appropriate as well as informative, and HCPs might find it useful when treating patients with diabetes.
Proactive people manage their diabetes by creating or controlling a situation; in other words, by acting to ensure a positive outcome rather than responding after the fact to correct a negative one. Proactivity is essential for trained athletes who strive for perfection, believing it is a literal state of mind. In other words, if one can consciously pay attention to – much like the athlete perfecting their talent – and deliberately shape their thoughts, this will shape one’s acceptance of diabetes, removing the feelings of being overwhelmed and frustrated or the need to defend one’s actions. In other words, a proactive person seeks to find their path and keep driving down the middle of the rational road rather than sliding off into emotional ditches.
MANAGEMENT IS ABOUT BEING PROACTIVE, WHICH BY DEFINITION IS A STATE OF MIND
Some suggest being proactive is the ability to recognize and ultimately pay attention to issues that most affect them. That is, being proactive is the ability to be aware of the important things while ignoring the rest – a crucial survival skill throughout human history. True attention can help focus awareness on a particular aspect of the environment or on important decisions. However, maintaining focus is a recurrent challenge for individuals of all ages – regardless of the diabetes type they live with. Unfortunately, we have the capacity to deceive ourselves, to ignore reality, and to rationalize away known facts about what we should be doing to control diabetes, in effect leading to denial and justification.
As a result, people have long sought out strategies to help them stay on track. The reactive person, however, responds to an issue after it has happened. Unfortunately, the vast majority of the 37.5 million individuals in the United States managing diabetes (35.4 million among them with type 2 diabetes (T2D) practice reactive behaviors. It is estimated that 6–8 millions of these 37.5 million have achieved full control over their diabetes or are on a clear workable path to achieve diabetes control. Further, 10–12 million have marginal control (are nearly compliant). According to a recent study, few people are successfully maintaining healthy blood sugar levels – a fact that should serve as a wake-up call for the tens of millions within this group as well as for HCPs.
Anecdotally, a recent study in India found that only 30% of those managing diabetes had achieved full control. These results are consistent with estimates from the United States. The study participants were included within the 30% group if they had also managed to bring their blood pressure and cholesterol under control. Although the study did not classify participants as proactive vs. reactive, a logical conclusion can be drawn that the individuals in the 30% group were proactive, particularly with respect to their diabetes and comorbid medical condition.
When one considers the countless array of diabetes-related studies produced by academics, organizations, and governments over the recent decades as well as the millions of dollars spent generating them, the undeniable conclusions are the same – effective management comes down to a state of mind and to a commitment to lifestyle modifications. Moreover, when you include the various self-help groups, blogs, telehealth coaching services, educators, books, websites, podcasts, and other sources of information, the diabetes “info-sharing” economy has become a multi-million dollar business that has produced no meaningful diabetes reduction rates or even effective control. The facts are clear: As a whole, the A1c values and number of emergency hospital visits have not been reduced; rather, studies suggest they have increased.
The facts are, despite all this information and spending, reactive individuals already know that, for example, excessive simple carbohydrates (sugars) are their worst enemy and moderate exercise can help reduce the consequences of diabetes. However, reactive persons decide to rely more on medications to maintain glucose levels rather than effectively controlling them in the first place through lifestyle modifications. It is striking that many, if not most, reactive people know what is required to manage their diabetes but seldom practice ongoing preventative measures.
Although it is true that lifestyle modifications alone are not the sole answer, they do remain the most effective component of long-term successful management. Even pharmaceutical companies that produce diabetes medications, spending millions promoting drugs to lower A1c, recommend lifestyle modifications as being central to successful long-term management. This reality is despite warnings from HCPs, who almost all agree that patients will not change their behavior and implement lifestyle modifications until forced to by negative health consequences. This is the definition of a reactive person.
Many suggest that socioeconomics plays into this behavior. This may be true, but socioeconomics does not necessarily influence or define one’s state of mind. Simply put, reactive individuals tend to manage their diabetes on a laissez-faire basis, ignoring most healthcare recommendations, whereas proactive individuals acknowledge that diabetes is a chronic condition, and that, once diagnosed, it does not magically disappear.
In short, proactive individuals accept the reality that their diabetes is a lifetime challenge and begin their path to manage it. Proactive people know that by having a steadfast commitment to diet, regular medical care, and optimal glucose control, they can manage diabetes and live a long and healthy life. Proactive people know that the first step in effective management centers around lifestyle changes supported by medication, whereas reactive persons address management in the opposite manner. A reactive person responds only after a health crisis or need for a corrective action. For far too long diabetes education has emphasized “correcting” as the response to a situation. Too high or too low glucose numbers and the person can take remediation actions, which mistakenly leads them to believe they are managing their diabetes.
It is not surprising that reactive persons are trained to respond after an issue occurs rather than preventing it. Further, more and more are relying on drugs to address what is clearly a lifestyle issue. So obviously, when there are millions believing they can take a corrective action, they are more inclined to worry only when a correction is needed. An example of a corrective action is the sliding scale for the 10–12 million people in the United States on insulin therapy. Interestingly, a study of over 100,000 people managing diabetes found that nearly 70% of them checked their blood glucose level three times per week (some once a week), whereas 20% checked it at least seven times per week, and 10% – twice daily.
Let’s face it. American lifestyle seems to have been crafted to promote chronic diseases, including diabetes and high blood pressure among many others, and we keep getting better at it. Look at our diet, loaded with processed foods high in saturated fat and sugar. In addition, because food is plentiful and readily accessible, we Americans eat far too much, which is no surprise.
Subsequently, concerned by what food companies label as “healthy”, the FDA is announcing new definitions of what is considered “healthy” with recommendations for added sugars, fats, and sodium. In addition, combine our diet with a sedentary lifestyle, and the result is that nearly 30% of Americans are considered obese by CDC standards, roughly 85 million are classified as pre-diabetic, and 1.5 million are diagnosed with diabetes each year.
To a certain degree, an overreliance on drugs has become the solution for establishing effective strategies for long-term maintenance of acceptable glucose levels. However, there is no consensus on which medication is most effective for reducing blood glucose levels. However, even drugs alone are not enough. A new study suggests that bariatric surgery is over 80% more effective for achieving a remission in overweight individuals with T2D than drugs or lifestyle modifications. Although various HCP tools for managing diabetes are available, there seems to be a unified agreement that there is no one true approach for scaling back high blood glucose besides agreeing that lifestyle modifications are the underpinning.
WHAT CONSTITUTES A PROACTIVE VS. A REACTIVE PERSON?
Perhaps most fundamentally, a proactive person does not accept the fact that diabetes must control them. They educate themselves in that regard and do not rely solely on the healthcare system for limited education. Studies suggest that a mere 10% of persons with diabetes receive adequate education when first diagnosed, and it is at this early stage when many establish their life-long behavior. Educational efforts must be directed toward the moment when people are first diagnosed, not after their diabetes has become uncontrolled.
However, it is during the early stage when the proactive mindset may also be established. Such individuals begin to understand that their lifestyle drives the process. Proactive persons learn quickly that they can take control of diabetes rather than allowing the disease to control them. The proactive mindset promotes individuals to research reliable online sources of diabetes education; education that far exceeds what they receive when first diagnosed or resulting from an annual 15-minute visit with their HCP.
Online, at their own pace and with a simple mouse click or a phone swipe, a proactive person learns the cause of diabetes as well as the role that the pancreas, kidneys, and liver play in the process – all pertinent information. They also start to appreciate how to prepare low-carb foods and shop healthy and may even learn that a certain class of cholesterol fighting statins can increase glucose levels by 10%–15% or modestly raise diabetes risk.
Proactive people learn that snake oil cures do not work and, according to the FDA, mystical diabetes supplements are not all that beneficial and may counteract the effects of other medications. In fact, the FDA is strongly committed to protecting consumers from products that make unlawful claims to treat or prevent diabetes and hold companies accountable for products that place consumers at risk. In 2020 alone, the FDA and FTC sent warning letters to over 10 companies regarding fraudulent diabetes claims. These baseless claims are geared and aggressively marketed to reactive people seeking a silver bullet, which sadly represent the majority of individuals managing diabetes.
In reality, proactive individuals believe in science and education and as a result know that they can manage diabetes and live a long and healthy life with it, or at a minimum can reduce the serious consequences of diabetes. From online education, they learn that there is no current cure for T2D (or type 1 diabetes (T1D)), yet; however, they also know diabetes can be managed, and maybe T2D could go into a remission, or what some call reversing diabetes (a term that incorrectly implies a cure). More important than any gained knowledge – online or otherwise – a proactive person is reading food nutritional labels; effectively managing diabetes begins with labels, and, no surprise, diet is the most powerful tool for diabetes management.
Proactive individuals on insulin therapy master the insulin-to-carb ratio math, likely carry a ratio cheat sheet like a student with cliff notes cramming for an exam, and can recite sliding scale for insulin units. They might even have a CDE on speed dial. Although daily fasting numbers are extremely important to proactive persons, “Time in Range” by far tops their list. These numbers can dictate daily diet alterations, when or when not to exercise, and when to adjust routines based on the day of the week. For example, workdays may be more stressful, leading to increased glucose levels, whereas weekends may include more physical activities, causing decreased glucose levels. Even lack of sleep can influence glucose levels. Once proactive individuals have a full grasp of daily “Time in Range” numbers, they can modify behavior accordingly and normalize routines.
To a proactive person, it is all about anticipating events. The point is that proactive individuals will understand the disease and their limitations or strengths and focus on the issues necessary to manage the disease in short order. That is the persona of a proactive individual – they build confidence through awareness and self-reliance to manage their challenge. For proactive people, “discipline” is their common denominator. Some say it is the state of mindfulness, the quality of being conscious or aware of something. A mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations. For reactive people, it is simply a lack of focus, an attention deficit.
A DISCIPLINED INDIVIDUAL’S MINDSET AS IT RELATES TO DIABETES MANAGEMENT
Using the word “discipline” to describe a proactive person’s management approach is analogical to Occam’s razor, the problem-solving principle that “possible outcomes should not be multiplied beyond necessity”. It is generally understood that when facing competing theories or explanations, the simpler one, with fewer parameters, is to be preferred. Despite running the risk of excessively discussing the personality traits of proactive people, it is worth further exploring these common denominators regarding an individual’s disciplined outlook, however simplistic or obvious the answer seems. The more the HCP understands and recognizes the proactive mindset, the easier it will be to recognize reactive behavior and respond accordingly. The terms proactive and reactive are no more obvious than consistently reminding someone that to manage diabetes they must make lifestyle modifications. The need for lifestyle modifications is and has long been obvious to someone managing diabetes. However, the fact remains that the term “discipline” applies to almost all cases of successful chronic condition management. However, more time, energy, and HCP resources are focused on addressing symptoms and not the root cause of out of control diabetes management.
To be clear: people have not been born highly disciplined; rather, they work incredibly hard at developing good habits. However, biologists suggest behavioral traits can be heritable and thus predetermined, and it is through these behaviors, habits, and personal beliefs that individuals are able to consistently make disciplined decisions. Stanford University Professor, Robert Sapolsky, a renowned biologist / neuroendocrinology researcher and expert in behavioral biology, in addition to providing the author of this work behavior examples – data related to COVID-19 vaccine acceptance – commented, “This is a hell of an important and difficult subject you are taking on.” The good professor’s observation was acknowledged, and the book was crafted accordingly.
One thing is known: Biology plays a major role in mental health and the way in which one recognizes and deals with challenges. Research has clearly demonstrated that optimized nutrition supports and can treat certain mental health issues. So yes, biology plays a dominant role in those that are proactive vs. reactive. Nutrition matters, and we are what we absorb, which is of particular concern as it relates to diabetes.
Although not outlined herein, the book ‘Strive for Perfection’ dives deep into the economics of proactive vs. reactive behavior and the long-term effects on the healthcare system. It has been supported by 4 years of research and surveys conducted by EMIEN HEALTH and reviewed by subject matter experts. Additionally, it reviews the myriad of information provided by the CDC, FDA, and related studies.
By default, proactive people understand that the environment influences their decision-making, that the need for lifestyle modifications is obvious, and that by extension they must interact with and modify their environment and behavior to support their diabetes management goals. Proactive individuals find motivation, which could extend beyond just being healthy or the idea of living longer; it could simply be a competition with the goal of controlling their diabetes or could be based solely on an A1C number or a morning fasting number – “I can beat that number” one day at a time.
However, once proactive individuals make a decision to manage their diabetes, their “discipline psyche / trait” kicks in; the thought of being a victim of the disease is not acceptable and is thus transformed into the driving characteristic for their success. Acceptance of the condition is not a part of their thinking or vocabulary.
As for highly disciplined people, they do not blame others for their life circumstances, and more importantly, they know good decisions are made from the viewpoint of a positive mindset. Quite simply, if someone feels lazy or unmotivated, it is more challenging to make a disciplined decision. Disciplined people — whether they know it or not — have mastered priming their minds and getting into a “peak state”.
Through certain priming rituals or thought patterns, they have the ability to motivate themselves to exercise or work on goals even if they might not feel like doing so at first. From this elevated mindset, it is much easier to overcome procrastination and gain encouragement to tackle the hardest tasks first. They realize that the more they delay the challenging aspects of life, the less likely they are to do anything that is difficult. These individuals are efficient and effective in accomplishing routine tasks, which in turn further develops beneficial habits.
It is simple to say, “just do it”, but change only comes from action. A reactive, less disciplined person can start by first recognizing their level of discipline and then incorporating at least one proactive habit in their daily routine. Reactive people can try to discover motivation in the simplest of tasks, for example staying healthy by taking long walks with family or friends. The point is, they need to find motivation. Research has spoken on the power of motivation with studies suggesting it takes at least 2 months, on average, to form a repetitive habit, and discipline is the cornerstone for that success.
After making a decision to control their diabetes, people must have the discipline to execute the decision, much like keeping a New Year’s resolution. However, finding any form of inspiration is the challenge in this situation and is paramount for success. If not, long-term, they will be unsuccessful.
HCPs will be well served to determine early if a patient is inclined to be proactive or reactive, and the patient’s level of discipline is critical in that regard. There is another important reason for identifying the proactive vs. reactive distinction. For example, a 14-year-old female with T1D and a 68-year-old male with T2D share a common condition, diabetes, but obviously their demographics, socioeconomics, and lifestyles are worlds apart. However, examine the situation in depth, and the two absolutely have something more fundamental in common, namely, their diabetes management outlook.
With respect to the 14-year-old female and her outlook, new research reports that T1D may be tougher on girls than on boys, with higher elevation of blood sugar levels, weight issues, and higher cholesterol and A1C levels. The research also suggested that girls may deal with higher rates of “depression” and have lower overall quality of life scores. Historically, girls have more pronounced body image issues, and as they enter their teens, the pressures of family and social obligations can make them prone to neglecting their diabetes treatment. Too often parents assume that as girls enter their teens, they will be more responsible about their diabetes management, but quite often it is the opposite, and this is precisely the time when they need extra parental support maintaining lifestyle and medication discipline.
Understanding this outlook on another level, regardless of the diabetes type, age, and gender, would yield more useful information for developing forward-thinking treatment plans and effective management advice. One treatment plan does not fit all, but the outlook certainly does. Instructing patients on lifestyle modifications is clearly important, but understanding the patient’s outlook will determine their success.
The point is that HCPs should not make differentiating assumptions based only on age, gender, ethnicity, or diabetes type when developing a treatment plan. Beyond shared diabetes understanding, the outlook of each person is paramount. A few simple but profound questions may represent the difference between long-term successful management and the odds of less than desired results.
One insightful technique is to inquire into the basic diabetes knowledge of individuals asking simple questions. What is an A1c test, and when is it scheduled? What is a fasting number, and how is it established? What is the most important information on a nutrition label? What food type would you consider not beneficial? How often and when should you check glucose levels? Simple but defining questions as to assessing one’s basic knowledge. A proactive person will know the answers without hesitation. A patient that is more knowledgeable, more self-aware about diabetes the more likely they’ll be successful at managing.
As discussed, effective diabetes management is a psychological issue, steeped in biological elements. However, once a decision is made to manage and control their diabetes, people must have the discipline to execute the decision. Reactive individuals might be well advised to include a psychologist on their treatment team and specifically to seek cognitive behavioral therapy (CBT), which is a short-term technique that can help people find new ways to behave by changing their thought patterns.
CBT rests on the assumption that the way people think and interpret life’s events affects how they behave and feel. Experts suggest that CBT can also equip people with coping strategies that help them deal with challenges. However, the question remains, can non-disciplined people learn discipline? Can they find their motivation and execute? Experts believe they can. So, when a patient asks why they cannot seem to manage their diabetes, the HCP might now have their answer without having to constantly repeat “try harder”.
HCPs need to realign their thinking by examining the issue from the outside, and by doing so they might make better decisions for the patient that increase the likelihood of longer-term success. Of course, HCPs should emphasize lifestyle modifications, while at the same time gaining greater insight into the individuals who they are treating.