One goal of diabetes management is to keep blood sugar levels within a normal range. But, with so many variables—from food choices to physical activity to sleep—affecting blood sugar on a daily basis, it’s common for blood sugar to fall outside of “normal” even for people who have successfully managed their condition for years.
That’s part of the reason why striving for perfection, or getting it 100% right all of the time, in diabetes management isn’t ideal. Instead, leaning into self-compassion and allowing room for out-of-range numbers, mistakes, and off days can actually benefit your mental health, and subsequently, your overall health.
Dr. Harpreet Nagra, licensed psychologist and VP of behavior science at One Drop, joined the Life Without Limits podcast to discuss how to overcome perfectionism in diabetes management.
Host: This is Life Without Limits, the One Drop podcast that gives you the tools, inspiration and support to challenge your limits. We talk with experts across all areas of health to open up more possibilities for you. Lean on us, as you step outside your comfort zone, to work your way toward better overall health and a Life Without Limits.
Kim Constantinesco: Welcome to the Life Without Limits podcast, the show where we talk with experts who can help you manage your health. I’m your host Kim Constantinesco, and today we have Dr. Harpreet Nagra, One Drop’s Vice-President of Behavioral Science and licensed psychologist. She’s here to talk about perfectionism and why it matters when it comes to managing diabetes. Welcome to the show Dr. Nagra.
Harpreet Nagra: Thanks for having me again Kim. It’s good to be here.
Kim Constantinesco: Dr. Nagra, you came on this show about a year ago to talk about overcoming diabetes burnout, and while you were on we touched briefly on perfectionism. So I am very excited today that you’re back to go into more detail on perfectionism. So first, let’s describe what it is. And the great Brené Brown defines it as the belief that if we live perfectly, look perfect and act perfectly, we can minimize or avoid the pain of guilt, judgment and shame. So Dr. Nagra, can you tell us about what perfectionism can look like in people who have diabetes?
Harpreet Nagra: Definitely. I think diabetes is one of those unique conditions where there’s a hyper focus on numbers. You typically have a blood sugar range that you need to strive for. That’s preset for you from the day that you’re diagnosed, and over the course of your health trajectory, health journey, you have to figure out ways to make sure that you’re going to be consistent in that range as often as possible. Many people living with diabetes will talk about the time and range factor here.
But what that does is, it makes you hyper focused emotionally on whether or not you’re doing well at managing your diabetes or if you’re doing poorly. So it very quickly becomes a path to possibly feeling emotionally bankrupt. Because a lot of times what ends up happening is that we already have this sort of – a fear of failing. Once you receive the diagnosis of diabetes, you already feel like, okay, what did I do wrong? How did I get here?
But now that you have healthcare professionals and other medical team members asking you on a fairly frequent basis, and at the earlier stages of your diagnosis they might be much more frequent than at later stages of management. But people constantly kind of evaluating, judging, kind of checking in with you about how you’re doing. So if you have a pre-inclination of some kind towards failure, feeling like, okay, I’m already failing because I have a diagnosis, the focus on numbers amps it up even more so.
I would say in addition to that there’s also very few hospitals, health centers that provide services from mental health professionals or diabetes psychologists that can support the medical providers and newly diagnosed folks with understanding what this diagnosis means.
That it’s not necessarily a failure on the part of the person that led to the diagnosis. But also there is limited options in how folks can talk about and process the emotional and cognitive burden and load that comes with managing diabetes. So there’s a number of other factors that I’ll go into today to talk about exactly how it can lead to a person very quickly feeling emotionally exhausted, overwhelmed and possibly even burnt out or emotionally bankrupt along the way.
Kim Constantinesco: You spoke about having the, quote, unquote, perfect numbers all of the time. And for anyone who is living with diabetes that’s incredibly hard to attain. But can you talk a little about perfectionism as it relates to the things outside of the numbers? So the way we eat, the way we exercise and some of the other key health behaviors in our life?
Harpreet Nagra: Yeah, definitely. So I would say it all goes back to the emotional judgment that we end up making about ourselves as well as the regular opportunities that we get for checking in with ourselves about how well we’re doing at managing diabetes. So there’s I would say already a potential fear of making mistakes that might be present for folks living with diabetes. So if you’re, for example, carb counting but you’re guestimating versus accurately estimating exactly how many carbs are going into your body, you might have almost like an imposter syndrome when the doctor asks you, are you doing regular carb counting?
You might feel like, oh no, I made a mistake because I didn’t pull the book out, and I didn’t accurately look up what the carb counts were. So every single time we’re eating, every single time we’re not accurately carb counting, it might reinforce that thought process of, I’m making a mistake. And ongoing engagement in that thought is what’s going to lead to us feeling like we’re failing at the management. Like, I should be trying harder. Why can’t I try harder at managing my condition?
Related to that I would say there is also the sense of fear of disapproval. So if you are entering that conversation with your healthcare provider feeling like, okay, I’m not doing the best that I possibly can. And the healthcare provider is not giving you a whole lot of validation or reinforcing what you are doing well, it can lead to a fear of disapproval or receiving disapproval from your healthcare provider. Whether that’s true, whether that’s happening in reality or if it’s perceived disapproval, putting yourself in that context where there is a potential for your medical team or your health professional giving you some sort of a negative evaluation or negative judgment, can further exacerbate that need to be perfect at all times. Or wanting to strive more than you possibly can in your day-to-day diabetes management.
Kim Constantinesco: And Dr. Nagra, why is it important to understand perfectionism in condition management?
Harpreet Nagra: Yeah, I would say it goes back to one of the sort of basic cognitive errors or thinking errors that we end up making in relation to diabetes management. A lot of times these fears of failure or making mistakes or fear of disapproval from our healthcare provider, all of that is encouraging this all or nothing type of thinking. And if a person is more inclined to be a perfectionist based on the roles that they’ve served in other aspects of their life, then they – let’s say they have one blood sugar out of range or a few blood sugars out of range, which is completely normal. It’s part of living with diabetes. They might feel like, okay, I am failing at managing this condition overall.
And so that all or nothing thinking is very much in sort of a roadmap towards significant emotional concerns, significant challenges with managing diabetes over time. As well as in experiencing negative health outcomes in relation to diabetes. So some of the things that we know from the research include that folks who experience perfectionistic thinking or who are more prone to perfectionistic thinking and potentially avoid or resist or experience higher levels of anxiety around managing their diabetes condition, they tend to experience higher levels of diabetes related distress. Meaning there is a sense of overwhelm or feeling uncomfortable or wanting to sort of get away and run away, hide from all the different daily tasks that diabetes requires.
These folks also tend to experience a higher A1C over time if the perfectionistic thinking goes unchecked. We’ve also seen just general poor self-management. So not engaging with the day-to-day tasks that might be necessary for ongoing management. As well as some significant mental health concerns as well. So things like – we already know that folks living with diabetes tend to have higher risk for depression symptoms and disordered eating types of behaviors.
But we’ve actually had that confirmed in the research as well. That folks who have perfectionistic thinking and diabetes tend to experience higher levels of depression symptoms, higher rates of eating disorders. And even poor quality of life and just general poor well being.
So it has a significant impact on different aspects, both the physical, emotional and mental health aspects of how one exists in their world with the condition of diabetes. So I can go into more specifics around each of those. But these are some challenging experiences to live with when you’re also trying to manage all the other responsibilities that you have in life, as well as managing diabetes.
Kim Constantinesco: Well, you’ve made it very clear how much perfectionism can impact both our physical and mental health. What might make someone at risk for developing kind of perfectionistic behaviors or attitudes in diabetes management?
Harpreet Nagra: Yeah, so I would say there’s a few key factors here. One is if a person is sort of already genetically predisposed to depression or anxiety symptoms or any other types of mental health concerns, adding in diabetes management on top of that, it’s basically a full-time job. So if some of those tools are not available or the person is having to already utilize significant resources and practice utilizing those tools on a regular basis, they’re going to potentially be at a higher risk for perfectionism around diabetes management.
The other – this group that I’m going to talk about next, they’re often not talked about that much in the literature. But there have been folks who are high achiever in other aspects of their life. So whether it’s in their family life. They have social goals that they want to achieve to have a certain number of friends, social media presence, whatever it might be. They’re perfectionistic in how they display themselves out to the external world there.
They might also have perfectionistic tendencies in how they relate to other people, how they show up at work. They want to be high producers. These folks are definitely at higher risk for perfectionism if diabetes management is on the table. So the real concern there is that there’s a higher likelihood of again, that all or nothing type of thinking. Or feeling like even if I do everything that’s required of me to manage my diabetes, I’m still not going to figure this out.
Or one idea that I hear quite often is that if a person has had diabetes for a certain number of years. Let’s say they’ve had it for 20 years. They feel as though they should have gotten it by now, whatever the “it” is. They should know what the perfect version of managing diabetes looks like for them. However, there’s just so many factors, so many variables that impact a person’s blood sugar, that impacts what their A1C is going to look like. Whether or not they’re going to develop complications.
So all of those are challenging factors that are hardly ever discussed. But the way the sort of medical system is set up and the way that conversations happen between healthcare providers and folks living with diabetes, is that the burden of working through those issues or through those concerns is placed on the person living with diabetes. So even if a person was not at high risk for perfectionism, the way that we have some systems set up in terms of how diabetes is introduced and talked about on a person’s health journey within the healthcare system, they end up feeling that sense of burden. Feeling that sense of guilt of, oh my god, it’s me. It’s not the doctor. I should be doing more. It’s my own fault that I keep screwing this up. Whatever it might be. Whatever negative thoughts might be going through that person.
But there’s always this sort of underlying feeling of, if I went high with my blood sugar, if I went low with my blood sugar, it means that I did something wrong. It’s not how the medication is working or what technology I have access to or what treatment interventions I have access to. Those are sort of all put on the back burner and the burden of proof of making changes and improvements in a person’s diabetes health, they’re all placed on the individual rather than the overall healthcare team and the member working together.
Kim Constantinesco: Wow, those are all very interesting points. And I know we’ve already talked about some of the risks for developing perfectionism as well as some of the consequences. But let’s turn the conversation toward some simple ways to steer ourselves away from perfectionism when it comes to diabetes management. And I know there’s a concept that you wanted to highlight that goes along with this in terms of having a fixed versus growth mindset.
Harpreet Nagra: Yeah, so having a growth mindset refers to believing that you have the intelligence and the ability to manage whatever comes your way. And that you have the ability and again, intelligence to grow in your skill set over time with practice and education. A fixed mindset means that you believe your abilities are absolutely affixed. They’re something that you’re born with. You’re sort of a victim to the situation. And regardless of what you do, whether it’s getting more resources, getting more people providing you with education, there’s nothing that anybody can do to change the situation.
So the real important piece around this that I want to highlight is that with the growth mindset, you are more open to learning and problem solving through different solutions that are going to work for you. So a person with a growth mindset would be more open potentially to ideas that psychology puts forth, such as improving one’s sense of self-compassion. So self-compassion, I always have to define self-compassion because I think a lot of folks confuse it with self-care.
So it’s not about taking a bubble bath or a walk outside, although those are still helpful things to be doing. But self-compassion refers to treating yourself in your mind with kindness in the face of any sort of negative events and being non-judgmental about the personal flaws that might be present for you. Because we all have them. None of us are walking around as perfect human beings. We all have flaws. But being understanding rather than self-critical and not over identifying with the negative emotions that might come up.
So keep the negative emotions in context, limited to the situation that they belong to. And not allowing them to be a way of defining who you are as a person. So the way that this shows up is the next time you have that thought of, it’s been 20 years that I’ve had diabetes. You’d think I would have gotten it by now. An example of a self-compassionate thought in that situation would be to recognize that diabetes changes moment to moment. That blood sugar is temporary. So the way that you react to that temporary blood sugar also needs to be temporary, right. There isn’t this need for you to grab onto a blood sugar that was potentially high or potentially low and say, this is who I am as a person. I’m a bad diabetic. I’m not learning enough because I haven’t learned it in the past 20 years.
Giving yourself the ability to tap into your growth mindset, to know that every single time I’ve had a high blood sugar or a low blood sugar, I’ve learned something from that situation. And I continue to figure out and adapt to how my body has changed over time to these different blood sugars that I’d experienced. So allowing yourself to really pay attention to the lessons that you have learned already in managing your diabetes and applying them and giving yourself a celebration around those smaller victories of, this is what I learned and this is how I’m going to apply it to my ongoing diabetes management. Because it changes all the time.
Kim Constantinesco: Very well said. I want to jump back to something you said earlier. There are a lot of people who do lean into perfectionism as a way to navigate life and whether that’s professionally or personally. Are there some simple ways to practice not engaging in perfectionism? In terms of, what are some of the day-to-day, low hanging fruit ways that we can practice?
Harpreet Nagra: Yeah, so I would say definitely the self-compassion piece is top of the list for what we can do about it. First of all, just paying attention to our thoughts. What is our mind saying to us about ourselves? What are the beliefs that we are walking around with and potentially carrying around as truths about who we are as people? I think once you start that level of reflection and analysis, then you can start figuring out, am I having a self-compassionate thought? Is it a kind thought that I’m having? Or am I beating myself up over something that is not within my control?
So I would say the self-compassion piece is definitely key here. Another way to think about it, another tool that you can utilize is to practice reframing the situation and reframing it in a way where you’re focusing on things, again, that you do have control over versus what you don’t have control over. So an example of this would be, let’s say you’ve been trying to reach a certain weight, and no matter what you do, you wanted to meal prep healthy dishes. You go for a walk for a walk after work every day. Whatever it might be. You’re not seeing any sort of significant progress.
So instead of looking at this from a place of no matter what I do, nothing is going to work because it’s not working. Reframe the situation to acknowledge what you are doing right. You are still taking care of your body to do what’s best for you in this moment. Focusing on things like, when you do go for a walk, what are the other benefits that it has? It may not be directly or immediately influencing the weight that you want to lose. But it is helping you reduce your stress.
So it’s helping melt the stress away. And over time what that does is, the better your stress management, the more likely you are to not overeat, not engage in other behaviors that might negatively impact your mood, negatively impact your sleep levels, sleep patterns. That the culmination of those ideas is what will lead to you losing weight over the long run. So focusing not on the results, but focusing more on the process of what can I do and control in this moment? And using your thoughts to help you shift your attention towards what’s in your control.
Kim Constantinesco: Those are some great tips Dr. Nagra. Now we have been sitting here talking about how to steer away from perfectionism. But I know many healthcare professionals tend to expect perfectionism in condition management. How can someone best talk with their doctor about realistic diabetes management?
Harpreet Nagra: Yeah, and I really wish we were further along in sort of changing the healthcare systems’ narrative around this. Because having worked as a licensed psychologist in a hospital setting, I’ve seen it firsthand. And I end up seeing sort of the emotional impact that it has on people living with diabetes to walk in, potentially feeling great about the last month or so of your diabetes management and wanting to share the positive results with your doctor. And then maybe not getting the type of positive feedback that you were expecting in return.
So I do think there are strategies that we can implement to help improve that communication gap that exists right now between healthcare providers and folks living with diabetes. One of the strategies that I always recommend to folks is to track your own body’s reaction. Nobody knows your body like you do. So your doctor is not living in your body. They might be helping you work through all the sort of challenges that are coming up for you. But they are not living in your body.
So being okay with being the advocate for you and your body, I think is a good first step in making some changes in terms of the communication between you and your healthcare provider. So the way that you would do that is giving your doctor some information about things that they can look out for beyond just blood sugars. So they’re already going to have access to your blood sugar numbers, whether it’s from the labs, A1C labs that they’re doing or CGM data, whatever it might be.
But you can also create logs around your thoughts and feelings and how they impact your blood sugars. So whether you’re just working with blood sugars or if you’ve also got high blood pressure or high cholesterol, whatever it might be. Whatever else you are tracking. Help the doctor understand how these patterns exist outside of the medical office by logging as frequently as you possibly can what those thoughts are, what those feelings are and whatever clinical indicators might be (inaudible) your blood sugar or blood pressure, cholesterol, et cetera.
The way that this helps is that it helps you understand the trends and patterns that are coming up for you in your body. So if you’ve been doing good logging, detailed logging for a significant amount of time, you’ll be able to show that data essentially to your doctor and say, when I go for a walk I see that my blood sugar changes in this way. And that doctor can then utilize that information to validate you around what you are doing well. Validate some of the lifestyle modifications that you have made.
I think a lot of times folks go in and they want the doctor to just hear them. And there are some doctors that are excellent at providing validation and support for patients that they’re working with through just that verbal communication. But others might need a little bit more support around that. And it’s not necessarily the person living with diabetes’ role to have to educate. But I think if you are wanting to improve your relationship with your healthcare provider, it’s okay to walk in with that extra data. To say, emotionally this is what’s going on, and this is how it’s impacting my day-to-day blood sugars. So that’s one way.
Tracking your bodily reaction to different types of behaviors that you’re engaged in, like physical activity, diet, stress, sleep patterns, et cetera. And then also another way to do this is to ask for what you need. I was kind of hinting at this in the previous example. But advocating for yourself and for the type of doctor that you need at whatever season you are in life managing your condition.
So, for example, at different seasons of our life, we might need somebody who is a lot more directive as a healthcare professional. We need them to kind of push us and nudge us. And other times you might need someone who has a softer approach, and they’re there just to validate and support you so you don’t end up burning out. I’ve seen doctors who have been on sort of both ends of that spectrum. What we’re looking for here is really a match between where you are in terms of the season of your life and the diabetes relationship that you have at that time and the healthcare provider’s communication style, interpersonal style. So ask for what you need. If your doctor’s style is not working for you, you don’t have to keep working with them. It’s always okay to get a second opinion or a third opinion. That happens quite often.
And then the final strategy that’s important for us to talk about is to celebrate your smaller victories. Not only with yourself, like with your own family and friends. But also with your healthcare provider. So one thing that I often used to talk about in therapy was that have a little celebration pillow. It doesn’t necessarily have to be something that you go out and buy. But every once in a while take a cushion off of your couch and sit on that cushion and use it as your pedestal and say, I did a really good job of handling that high blood sugar that I had earlier. And I’ve been working on it or I’ve been thinking about it. And this was something that was important for me.
And even if the rest of the day you have more high blood sugars or low blood sugars, whatever it might be, acknowledging the effort that you’re putting into this process is really significant. Because I think without that acknowledgement, you don’t hear that. You don’t hear the validation from other people enough. You might hear every now and then. But just to be able to say, good job to yourself and really feel it and track it and let it soak in, I think has a different level of impact. It’s a compassionate thought that you can provide for yourself that others may not be able to provide for you in some of these other settings.
Kim Constantinesco: Well, and I love what you said and I want to highlight it because I think it’s very important. When you said earlier that no one knows your body as well as you do, so really tuning into that can go a long way when it comes to interacting with the healthcare professionals in your life.
Harpreet Nagra: That’s something that often goes unnoticed. When there’s a doctor in the room and a patient in the room, a lot of times we all end up deferring to the doctor. But folks living with diabetes, they’re in it every single day, right. So from the moment you wake up, you have to check your blood sugars, whatever tool you might be using. But you are in it. You are thinking about it every single moment of every single day. So I don’t think that we should discredit or minimize the experience that people living with diabetes are building every single day.
The best way to become an expert in anything is to spend more hours practicing your skill set. So folks living with diabetes are doing that 24/7. So I don’t think we should discount that in any way.
Kim Constantinesco: So Dr. Nagra, before we let you go, is there anything else that you want to say about perfectionism in general?
Harpreet Nagra: I would say not a single person that I have ever met, and I’ve sat with hundreds if not thousands of folks living with type one and type two and late onset, every single type of diabetes that you can think of. There isn’t a single perfect diabetic out there. Living with diabetes is not something that absolutely requires perfection. If we are going to strive for perfection we should be striving for allowing our thoughts to kind of come through and noticing them and becoming aware of them and what they’re telling us on a regular basis. That is about the extent of it.
Beyond that, I think we’ve focused traditionally way too much on the numbers. And there’s a whole human being behind all of those numbers that diabetes requires us to process and analyze. So I think the more we can focus on the whole holistic human experience, the easier it will be to overcome some of these challenges with diabetes and perfectionism.
Kim Constantinesco: Well thank you so much for coming on the show today. And I want to ask, if people want to follow your work, where can they find you on social media?
Harpreet Nagra: Sure, I am on LinkedIn, Twitter and Instagram. So on Instagram if you would like to follow me, I post occasionally on diabetes related concepts, but on diabetes psychology specifically. And then on Twitter, Diabetes Redefined, it’s another channel, you can follow me on there. And then if you would like to follow some of the work that we’re doing with One Drop to improve the lives of people living with multiple chronic illnesses, including diabetes, Dr. H. Nagra on Twitter would be the place to stop by.
Kim Constantinesco: Thanks for listening to the Life Without Limits podcast. We’re here for you, as you manage your health and find what works best for you. Stay tuned for more great episodes filled with health experts who are ready to support you. We’re in this together.
Host: Thank you for listening to Life Without Limits. If you liked this episode, tell a friend. We’re here to help you take back your time, power in life so you can live to your fullest potential.