Derived from Buddhism, the practice of mindfulness refers to training the mind to be aware of each moment’s experience, receiving them all equally, no matter what each moment brings.
Jon Kabat-Zinn, the developer of Mindfulness Based Stress Reduction (MBSR), now found in over 250 hospitals across America, describes mindfulness like this:
Mindfulness is the intentional cultivation of non-judgmental moment to moment awareness. It should not be thought of as a technique but rather as a way of being. It is practiced for it's own sake, and cultivate daily regardless of circumstances (Kabat-Zinn, 1996).
This practice has moved into the mainstream over the past few years, helped in no small part by Kabat-Zinn's work, whose research showed how significant improvement in the management of chronic illness and reduction of symptoms was achieved by teaching patients simple meditation practices (Kabat-Zinn, J. Gen. Hosp. Psychiatry (1982) 4:33-47).
What's That Have to Do With Controlling Diabetes?
OK, so developing awareness of the moment's experience sounds fine, but how is that connected to managing diabetes?
When first diagnosed, most people are informed of the significant lifestyle changes to be made in order to keep their diabetes in check, and avoid future complications that can develop from poorly controlled diabetes.
Kidney failure, blindness, and circulation problems at times leading to amputation, are among the most common. Insulin or oral medications are frequently prescribed to regulate blood sugar. Typically a visit to a Certified Clinical Nutritionist, Certified Nutrition Specialist, or Certified Diabetes Educator is recommended, as this is a highly complex condition, yet interestingly-or terrifyingly- one that is predominately self-managed. What, when and how much to eat are usually on top of the list of recommendations, alongside understanding insulin dosing (if prescribed), and lastly, followed closely by suggestions to exercise, monitor stress levels and get enough sleep.
When receiving a medical diagnosis, especially of a life-altering chronic disease, psychological shock can occur. This protective zone mutes stimuli, inserting a mental pause so the new reality can sink in.
During this state, which can last from a few minutes to a few months, symptoms of shock can manifest in a reduced capacity to focus, be present, listen accurately, encode new and often complex information and suggestions offered in short-term working memory, and later recall what was said. A high percentage of newly diagnosed patients leave their doctor's office with inaccurate, incomplete, or at best, partially understood information. It's not unusual for a newly diagnosed diabetes patient to feel denial, avoidance, fear or paralysis at this juncture.
With this being the internal state, it's not the preferred place to jump-start a proactive stance towards self-care for the rest of your life!
There's no shortage of information about what to do now you've been informed of your changed health status, but surprisingly little about how to achieve such lifestyle improvements.
A paradigm shift is required to change deeply ingrained habitual behaviors, especially around food and exercise, and it takes concerted effort!
Although most of us can manage such changes for a while, sustaining it for life requires a different approach. So this is where I've found mindfulness to be the foundation upon which all optimal behavioral changes rest.
I fully credit my own long-term mindfulness practice in aiding my personal changes post-diagnosis. When I was first diagnosed with Type 2 diabetes four years ago, my Hemoglobin A1c was 13.5. I immediately embarked upon a rigorous research and lifestyle change self-directed program (indebted to my years of psychological and mindfulness experience), choosing to remain insulin-free.
From that platform, within 5 months, through diet, exercise and metformin, my hemoglobin A1c registered 5.9. It has remained at 6 or under since.
Although obvious on the surface, you can't change anything that you're unaware of! Mindfulness is simply a proven system for developing, or increasing, awareness, the precursor to instigating and sustaining change.
Attempting the huge changes advised, without mindfulness on your team, is like running a marathon without building up your muscles first through training.
Isn't Determination Sufficient?
Recognizing a desire to improve is great. Just focusing exclusively on the actual behavior is insufficient. This is one of the main reasons the majority of attempts to begin exercising or eat more healthily fail.
Success rests upon being able to see far more deeply into the motivation for changing the behavior, and the obstacles the mind throws in the way. These mental/emotional obstacles may show up as:
- A sense of deprivation
- Denying yourself once favorite comfort foods, now forbidden
- Doing only what you feel like at the time, maybe losing sight of the big picture
- Self-sabotaging feelings like lacking confidence or faith in yourself that you can do this
Negative emotions like anger, shame, and inadequacy are difficult to experience. Becoming mindful encourages a kind, non-judgmental attitude towards yourself, to not turn away, but to tolerate those unpleasant feelings if they arise.
Mindfulness teaches you to practice letting go of the reinforcing negative story-line of your thoughts, which is responsible for perpetuating the emotional states.
A common experience is not wanting to work-out, feeling negative about the actual activity of exercise. After all, know anyone who claims they can't wait to get to the gym, and do endless repetitions of seemingly useless movements with heavy weights?
Beneath all behavior are the emotional feelings about it.
- Is it enjoyable?
- Why are we doing it?
- How will it benefit me?
At times conscious, sometimes subconscious, these emotionally-laden questions drive our behavioral choices.
It takes mindful awareness to redirect the focus from the actual behavior (shall I drag myself to the gym?) to knowing what emotions are present, and patiently tolerating them until they dissipate. Most emotion is present for only a few seconds in the body. Anything longer is kept there by the mental story-lines that are embellished by continuing to think about the situation.
The practice of mindfulness calms the mind, steadies it so it's less jumpy or restless. Picking up on what thoughts you're exposing yourself to happens sooner. The ability to respond, not to react comes more easily, allowing for a more measured response to the circumstances.
Here's an example of how the quality of patience can be cultivated, starting with quieting the mind.
Patience helps us endure suffering, whether physical discomfort, an unpleasant emotion or a long line in a supermarket checkout. It reduces the risk of reacting impulsively, often with regret afterwards. It allows acceptance of whatever is happening to us, not in a passive, doormat manner, but in a this-being-the-case-how-do-I-proceed way.
From this place, we not only learn endurance and acceptance, but can turn around an unpleasant experience into an acceptable activity. Patience is essential for helping new habits to take root.
If you want, substitute another quality or emotion instead of patience. Frustration, irritation, disappointment can be responded to the same way, or choose another one that you struggle with.
As it can be helpful to have a guiding voice as you’re practicing, you may want to record the instructions, than play them back as you sit:
As you begin to settle yourself down, take notice of how you feel emotionally and physically.
Calm or center yourself, several deep breaths help, as does a quiet room or peaceful outdoors spot.
Sit in an upright position, your feet planted squarely on the floor, hands resting in your lap, or on your thighs. If sitting upright causes discomfort, you can also do this lying down.
Turning your attention inwards, letting it rest softly on the breath, is the initial action of mindfulness meditation. Do this by sitting quietly, and closing your eyes to not be distracted by visual stimulation.
Let your attention rest gently on your breath, following the sensations of the inhalation, then the exhalation. Let your body do the breathing, simply follow the breath with your attention.
To help you focus, you can count the inhalations and exhalations silently to yourself. If you prefer to notice the rising and falling of your belly or chest, then silently note to yourself, rising, falling, rising, falling, accompanying each physical movement.
Stay with this for up to ten breaths, or longer, if possible.
Don’t control or judge how you think you’re doing. Whatever you’re doing is fine.
If you get lost in a thought, or a physical sensation, bring yourself back to focus on the breath as soon as you’re aware of having become distracted.
Your thoughts will not cease, this is a practice not of thought-stopping, but of returning to the breath, non-judgmentally, again and again.
When ready, open your eyes, gently move your body, take one final deep breath. Bring your attention slowly back into the room.
Notice how you now feel, use in this moment. Does it feel any different from before the meditation?
If this script doesn't appeal, there are many beginning meditation recordings you can buy or download.
After the Meditation Exercise.
You’re now in a more receptive place to work with any feelings of impatience (or whichever emotion you chose) that are present.
Non-judgmentally, explore what it feels like to be impatient. You may choose to bring to mind a recent situation that brought up impatience.
What emotions do you notice arising in response?
- Do your thoughts have a theme, for example do you see others getting in your way, which triggers your frustration which in turn leads to impatience?
- Can you sense it in your body?
- Is there a texture or color, perhaps it feels cool, rough, transparent or maybe fiery.
- Is there any movement, does it spin around, expand or contract?
- What happens when your attention rests on this feeling of impatience, does it grow larger or begin to shrink?
There are no right or wrong answers, only what you notice. The more you can notice, the better, it means that you’re able to sustain attention, and connect to your inner experience.
Try to put the situation that triggered impatience (or whatever you chose) in perspective. Impatience (or frustration too) often arises when we feel restrained from instantly having what we want. If you recalled becoming impatient whilest driving, did you perceive other drivers in your way, blocking you from getting where you want to go?
The more important we deem it, the more impatient we feel.
- What will be lost by waiting?
- What might be gained?
Often we gain more by waiting, a clearer perspective, maybe a better decision as more information comes to light. With distance, sometimes the triggering situation dissolves, or fades into nothing. After a little time has passed, the sleep-on-it principal, we view it quite differently, prompting a different response.
Delaying gratification means inserting a pause. If your tendency is to be on the impulsive side, try purposely doing something else first. Occupying your mind with an alternative activity or focus, helps distract you. When your attention returns to the original issue, already you have a little distance from it. Check in with yourself honestly, is it just as crucial to get what you want right now, or has that intensity waned a little?
Practice this, and you’ll notice that over time, you’ll increase your ability to be patient.
The point here being that by developing mindfulness and calming the mind through meditating, you'll find your mind is steadier, more spacious, less jumpy or reactive. You'll develop an increased tolerance for experiencing whatever external circumstances occur.
All identifying information has been altered for confidentiality.
My client, diagnosed 15 years ago with late onset Type 1 diabetes, felt he wasn't controlling his condition as well as he had done initially, and wanted to improve his glucose numbers. He was insulin-dependant, and used a continuous glucose monitoring system and pump. He admitted that visits to his endocrinologist had become something he wanted to avoid, even as he intellectually knew better. He keep is appointments, but begun to space out them out using excuses of family commitments or work.
His numbers steadily increased over the years, his control decreased. His last Hemoglobin A1c registered over 9.5, data neither he nor his endocrinologist were pleased with. The doctor's displeasure was communicated to the patient by sighs, lack of smiling or eye contact, and plenty of admonishment to "increase the insulin, check the accuracy of your dosing" approach. At the end of his appointment my client would slink out of his doctor's office feeling lousy, immediately putting the whole experience out of his mind.
During our conversations, he admitted he often wasn't sure what he was feeling beyond 'lousy', but after some exploration was able to identify the underlying feeling leading to his avoidance of managing his diabetes. The emotion he slowly came to realize, and that his post-appointment behavior corroborated, was shame. He felt ashamed that he'd 'let his doctor down', that his sloppy habits were exposed to another, and that he'd ignored the potential seriousness of his actions.
As I inquired further, he acknowledged he was tracking the glucose trends barely enough to avert hypo- or hyperglycemic episodes, and extending the numerical boundaries of what was acceptable when he did notice. He often struggled to recall specific information to share with either myself or his endocrinologist. It was clear he didn't pay much attention to this data-heavy condition, despite being a professional in a data-heavy industry!
His slide into inertia with managing his diabetes was not surprising. It takes stamina, endurance and total commitment, for life. Unlike most other medical conditions, no single medication does the trick.
Lifestyle changes must be implemented with diabetes. After all, we need to eat three or more times a day! It can't be put off until later.
It was clear that we needed to focus on areas that others on his team weren't. All the medical and educational pieces were in place. What needed attention was his own management of, and relationship to, his condition.
As our relationship was coaching not therapy, a clear inventory of how things were at the time, and what he wanted to accomplish. From that point of clarification, we strategized what he wanted to attain, what behaviors could benefit from attention, and took inventory of what was working but could benefit from being reinforced.
His stated goals initially were wanting to see downward trends on glucose readings, scale back on some of the sloppy eating habits, increase his exercise, resulting in hopefully lowering his insulin.
His goals seemed realistic to me. A quick assessment in order to understand his learning style, I ascertained, among other attributes, that he was more extroverted than introverted, which partially explained his lack of attention to his inner life. He was predominately left-brained, so did well being task-driven, with clear actionable steps given that he could be accountable for to me for during our sessions.
As he indicated little interest in meditation, we put that option aside. After all, you don't have to mediate to become more aware, although it certainly improves the odds.
You just have to learn to pay attention.
To build upon confidence gained from success, we started with where he was most comfortable, data and gadgets. Diabetes fits well in this coaching model, given the benefit of multiple data points from medication, food and resulting glucose readings. Few other circumstances can so readily be charted with hard data!
Taking it slow enough to allow new habits to form, but not too slow it he'd risk losing interest, we avoided focusing on far-off goals, taking a step-by-step approach to enhance success.
Purposely keeping the bar low, I suggested that first, he come up with a doable number of times he could check his numbers daily, hinting that post-prandial (after eating) times might yield the best data. All the data was stored, he just had to remember to look, and record it elsewhere to help with learning to pay attention. He felt that was entirely possible, and we committed to his charting his level after each meal and snack.
Keeping it easy increased his success.
Although dubious at first, after a week of recording his data he began to notice trends that had him pondering what he'd eaten, or whether he'd been physically active that day. With his curiosity engaged, we added in charting his food intake via a log (he found a suitable online one to match his interest in technology).
After about week three of paying more attention to levels and food intake, he began to 'play' more with it, and decided to make some healthier choices regarding lunch. He decided to see what 'the numbers were' by foregoing his sandwich for a salad on three days.
Paying more attention was amply rewarded by being able to chart all the data (glucose level, insulin need, food choice), and seeing the beginning of downward trends.
Through now being accountable, despite his feeling caution regarding his ability to sustain any changes, my directing his attention towards the negative feelings that had caused him to avoid paying attention, he maintained the changes due to his now conscious awareness that feeling shame was unpleasant, not to be repeated.
Seeing the positive downward trend was encouraging to him. As his glucose began to spike less and become more stable over a period of time, he felt ready to initiate more changes, choosing to increase his exercise.
I decided to not push but let him be the judge of what that should be, respecting his former experience in this area, and when he could notch it up.
Knowing his progress would be correlated with the more involved he was, and therefore the more ownership he felt, I allowed him to make the decision to notch up the changes once it seemed that each new level became routine.
I offered suggestions, gauged his response and we either implemented it or decided to shelve it for later on. I gave encouragement to take some calculated risks with new behaviors, or the resurgence of old ones.
Because of the constant reinforcement and interpretation of exactly what was making the difference (developing his awareness and paying deep attention were top of the list), it was far easier now for him to tweak the food/insulin/exercise matrix to maintain acceptable data.
We knew we were on the right track when he shared that his last visit to his endocrinologist resulted in a high five congratulating him on bringing his hemoglobin A1c down to 6.9, the first time under 7 in over 9 years!
Paying attention brings results.
Awareness of the emotional components and the tendency to avoid or shut down towards uncomfortable feelings helps stabilize positive trends and reverse less encouraging ones quickly. Maintaining such a tightrope balancing act requires vigilance.
Accountability, realistic goals and developing mindfulness not only ensure all is kept in your view and tolerated, but also create a strong likelihood of successful outcomes.
Josie Levine PhD is a writer, psychotherapist, coach and consultant for those wanting to improve their health and lifestyle. Her blog is http://
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