COVID19 has changed the way we do business, how we finish out the school year, and how we engage with others. Unfortunately, changes in routines can also create conflict. The anxiety and uncertainties only compound to a sense of “new normal” many of us are figuring out as we find ourselves sharing a space, while practicing social distancing.
Eating disorders are some of the most challenging mental illnesses and are serous, life-threatening conditions. Affecting one in 20 people during their lifetime, eating disorders frequently occur in people with other mental illnesses, including depression, anxiety disorders and substance abuse issues and as with other mental illnesses, early identification and early intervention are keys to recovery.
NAMI joins NEDA this week in support of the aim to ultimately prevent eating disorders while reducing the stigma surrounding these conditions and improving access to treatment.
NAMI recently spoke with Andrea Vazzana, Ph.D., a clinical psychologist and eating disorders specialist, to learn more about eating disorders and how to help a friend or loved one living with one of these conditions.
NAMI: What is the current prevalence of eating disorders in America?
Vazzana: Overall, over 10 percent of young women currently meet criteria of one of the eating disorders, anorexia nervosa, bulimia nervosa or eating disorder NOS (not otherwise specified). The new Diagnostic and Statistical Manual (DSM5), set to publish in May this year, includes binge eating disorder as a mental illness. Men can also live with eating disorders. While the prevalence of men to women was previously thought to be a ratio of 1-to-10, it is now believed that the ratio is closer to 1-to-6, meaning that six times more women than men have the condition. Although not as common in men, it is important to recognize that more men are now being treated for these mental illnesses.
Some believe that eating disorders are more prevalent in women because of what is called the “thin-ideal”. Biology and environment are both contributors to this condition, and researchers have found that the cultural pressure to equate thinness with beauty, as well as some sports that encourage low body fat and thinness, are factors. It is not always the ideal cultural “think” to equate thinness in men and therefore that social factor is often removed. Still, there are some sports and cultures where being thin is idealized and therefore a contributor.
What are the types of eating disorders and are there any recent changes in prevalence and conditions?
Vazzana: Eating disorders NOS, will be changing with the new DSM, to be published in May. The criteria and diagnosis will change. Binge eating will be a full-blown disorder all on its own. Binge eating disorder is similar to bulimia in that it includes the binging, but not the purging, aspect of the condition.
What are the most common co-occurring disorders (mental health conditions)?
The most common is depression and dysthymia, what some consider a less-severe but often longer lasting condition than depression. Half to three-fourths of those with eating disorders meet the criteria for depression in their lifetime, and there is a direct relationship to malnourishment and depression.
In addition to depression, the other most common co-occurring conditions are anxiety disorders, specifically social phobias and, with people living with anorexia, OCD, which impacts about 25 percent of individuals with this condition.
Substance abuse, particularly alcohol abuse, is co-occurring in about 5 percent of people living with anorexia and from 25-40 percent of people living with bulimia.
Personality disorders are also common co-occurring conditions, particularly for people living with bulimia.
What are current treatment options available and what are likely outcomes?
Recovery from eating disorders is possible. The right treatment choice depends on the type of eating disorder, but treatment approaches are often similar for the various conditions, and coordination of care between mental health care providers, nutritionists and medical professionals is important, depending on the individual’s treatment plan. Nutritional guidance, as well as individual and family counseling, is an important treatment options to consider.
The best rates of recovery for people living with bulimia involve cognitive behavioral therapy (CBT) where the focus is often on normalizing weight and eating behaviors and challenging distorted thinking patterns that are usually associated with this condition. One of the goals is to interrupt the thought pattern that leads to individuals evaluating themselves in terms of shape and weight. Individual therapy is often another key to recovery.
The best rates of recovery for people living with anorexia include treatment plans that incorporate family-based therapy, often the Maudsley Method, which is often used for adolescents and children with Anorexia still living at home. This intervention involves parent coaching to encourage feeding their children to help restore their weight—eating meals with them and encouraging eating. With anorexia, it is important that the individual restore their weight as soon as possible; the longer they are in a danger zone of thinness and malnutrition, the worse the outcome. Early intervention is key; people living with anorexia (about 5 percent) have the highest probability for mortality, including death by suicide.
In addition to psychotherapies, medications, specifically, selective serotonin reuptake inhibitors, SSRIs, a type of antidepressant medication, are sometimes used in patients that are responding to CBT as an adjunct therapy.
What myths are the most common and what stereotypes exist that create barriers to understanding and treatment?
The myths surrounding eating disorders are vast and include myths primarily around race, age and social economics.
When people think of anorexia, they often mistakenly think of young, white, high social status females. This is not the case. There are 5-10 million people in America who have eating disorders, and one out of 6 are men, who more deeply experience the negative aspects of stereotypes and have unique barriers to treatment and acceptance.
We also know that eating disorders do not just affect white women. The rates are as common in young Hispanic and Native American women as they are in Caucasian women. With African American and Asian American women, however, there does seem to be a lower prevalence, with the exception of pre-adolescent African American girls. With Caucasian girls, the prevalence is lower and rates increase with puberty and continue to increase as into early adulthood.
Age is another myth; eating disorders do not just affect teens and young adults. More and more are being diagnosed for the first time in middle age. And unless effectively treated, eating disorders will last into adulthood for many.
How can someone help a friend or loved one who may have or one who is living with an eating disorder? How should they/could they intervene if needed and how can the provide support?
Regarding intervention, the key to remember is that the earlier the better. In terms of identifying a problem, it is important to know that it is common to have body dissatisfaction. Most women are more critical. However, when they go beyond dissatisfaction and they are harshly critical and disparaging of their bodies, and when there is noticeable evidence of over-thinness and over concern about food and weight, there may be a problem.
Some people mistakenly wait to intervene, thinking that the individual may grow out of their condition. The best thing to do is to let them know about your concern. You have observed behavior—talking poorly about their body, other signs—and you just want to be honest. Saying something like, “I have noticed these things and I am concerned about your health,” without being judgmental, can be the most natural first step. Because individuals living with eating disorders are generally already self-critical, it is important to so separate the illness from the individual. Try not to focus comments on appearance but rather focus comments on health by expressing concerns and the need for further medical evaluation. Recognizing that people with eating disorders often consider being thin with success, being persistent and consistent while avoiding criticism and comments on thinness, is important.
After an individual is in treatment for an eating disorder, one of the best things a family member or parent can do is to get family-based treatment or therapy. During meals, families and friends should try not to be angry even if they see their friend or loved one struggling with eating. Working to avoid impatience can be challenging, but neutral and supportive reassurance offer the best outcomes.
It is important that friends and family strive to avoid commenting on appearance. Avoid comments like, “You’re gaining some weight, that looks great!” Compliment other things, perhaps superficial aspects of clothing, conversations, other activities and contributions, but avoid mentions of size or appearance if possible.
What do you think is the most important thing for people to know about eating disorders?
The importance of intervening early! Treatment works best the earlier you can begin it. The longer the condition persists, the more deadly it becomes with more physical complications to manage.
Andrea Vazzana, Ph.D.,is a clinical assistant professor of child and adolescent psychiatry at the NYU School ofMedicine and a licensed psychologist at the Child Study Center.
What does it mean to accept your partner’s influence? And how do you do it?
In the Japanese martial art of Aikido, there’s a central principle called Yield to Win, which is a method of using your opponent’s energy and actions against them to win a fight, rather than strong-arming them into submission. It allows you to conserve energy and choose much more effective and efficient tactics.
But we definitely don’t want you using Aikido moves on your partner!
For our purposes, yielding to win means accepting, understanding, and allowing your partner’s perspective, feelings, and needs into your decision-making process as a couple. It means really listening to your partner and forming compromises so that you both feel satisfied.
Which is really more like yielding to win-win, and that’s we’re aiming for.
When men learn how to accept their partner’s influence and work toward a win-win solution, the outcomes are wonderful in heterosexual marriages. In a long-term study of 130 newlywed couples, we discovered that men who allow their wives to influence them have happier marriages and are less likely to divorce.
And this critical skill is not limited to heterosexual couples at all. In fact, research shows that same-sex couples are notably better at it than straight couples. Straight husbands can learn a lot from gay husbands, and they’d be wise to do so.
Rejecting influence is a dangerous move
Marriage can absolutely survive moments of anger, complaints, or criticism, and even some longer periods of negativity if conflict is managed in a healthy and respectful way. They can even flourish because conflict provides an opportunity for growth as a couple. But couples get in trouble when they match negativity with negativity instead of making repairs to de-escalate conflict.
As Mahatma Gandhi famously said, “An eye for an eye will make the whole world blind.”
Clearly, counterattacking during an argument does not solve an issue or help to form a compromise. It does not allow your partner’s influence in the decision-making process. Our research shows that 65% of men increase negativity during an argument. And the Four Horsemen—criticism, defensiveness, contempt, stonewalling—are telltale signs that a man is resisting his wife’s influence.
This is not to insult or belittle men, and usually, it’s not a personality fault or cognitive shortcoming. Rather, it is to enlighten men as to some instincts and tendencies they might have, but of which they aren’t aware.
There are simply some differences in how men and women experience conflict (for example, men are more prone to stonewalling, and 85% of stonewallers in our research were men). It takes two to make a marriage work and it is vital for all couples to make honor and respect central tenets of their relationships. But our research indicates that a majority of wives—even in unhappy marriages—already do this.
This doesn’t mean women don’t get angry and even contemptuous of their husbands. It just means that they tend to let their husbands influence their decision making by taking their opinions and feelings into account.
Unfortunately, data suggests that men often do not return the favor.
If heterosexual men in relationships don’t accept their partner’s influence, there is an 81% chance that a marriage will self-implode.
Men, it’s time to yield to win-win.
What men can learn from women
Some say that men are from Mars and women are from Venus. While this is a common saying that cannot be true (obviously, we’re all from Earth and we have much more in common than we think), men and women often do feel different from each other.
This difference can start in childhood. When boys play games, their focus is on winning, not their emotions or the others playing. If one of the boys get hurt, he gets ignored and removed from the game. You see this in team sports all the time. Maybe someone comes to help carry the injured player off the field, but the game must go on.
But here’s the difference. In The Seven Principles for Making Marriage Work, Dr. John Gottman explains that “the truth is that ‘girlish’ games offer far better preparation for marriage and family life because they focus on relationships.” And that isn’t necessarily about gender roles, but about learning emotional intelligence.
Developing emotional intelligence is the first step
The husband who lacks emotional intelligence rejects his partner’s influence because he typically fears a loss of power. And because he is unwilling to accept influence, he will not be influential, and that dynamic will result in gridlock.
On the other hand, the emotionally intelligent husband is interested in his partner’s emotions because he honors and respects her. While this husband may not express his emotions in the same way his partner does, he will learn how to better connect with her by listening to and validating her perspective, understanding her needs, and expressing empathy.
When his partner needs to talk about something, an emotionally intelligent husband will set aside what he’s doing at the moment and talk with her. He will pick “we” over “me,” which shows solidarity with his partner. He will understand his partner’s inner world and continue to admire her, and he will communicate this respect by turning towards her.
His relationship, sex life, and overall happiness will be far greater than the man who lacks emotional intelligence.
The emotionally intelligent husband can also be a more supportive and empathetic father because he is not afraid of expressing and identifying emotions. He and his partner can teach their children to understand and respect their emotions, and they will validate their children’s emotions. And our Emotion Coaching parenting program is based on the power of emotional intelligence, which we can all benefit from learning.
How to accept influence
It’s most likely that men who resist their wives influence do so without realizing it. It happens, and that’s okay, but it’s time to learn how to accept influence. It is both a mindset and a skill cultivated by paying attention to your partner every day and supporting them. This means working on three essential relationship components: building your Love Maps, expressing your fondness and admiration, and accepting bids for connection.
And when conflict happens, the key is to listen intently to your partner’s point of view, to let them know that you understand them, to ask them what they need, and to be willing to compromise. One way to do this is for each of you to identify your core needs and search, together, for where those needs overlap. Then you can find common ground upon which to make decisions together.
That’s how you accept influence. Want to have a happy and stable marriage? Make your commitment to your partner stronger than your commitment to winning.
If you do that, you win, your partner wins, and, most importantly, your marriage will thrive.
At the same time, it can be hard to know if the worries and racing heart you experience at the thought of, say, meeting new people, is run-of-the-mill stress, or if you’re actually experiencing some level of anxiety and could benefit from seeing a professional.
“I can’t tell you how many people I see who say, ‘I don’t know if I should be coming in here,’” clinical psychologist Robert Duff, Ph.D., author of Hardcore Self Help: F**k Anxiety., tells SELF. “On a broad scale, [talking about anxiety] is positive, but I don’t blame anyone for the confusion.”
Figuring out how serious your anxiety is can be tough because anxiety is a normal and essential part of being a human.
“Anxiety is a reaction to a situation we perceive as stressful or dangerous,” Monique Reynolds, Ph.D., licensed clinical psychologist at the Center for Anxiety & Behavioral Change in Rockville, Maryland, tells SELF. This produces a stress response in your body—specifically, your brain’s hypothalamus triggers your sympathetic nervous system to release norepinephrine (aka adrenaline) and cortisol (a stress hormone) to get you out of harm’s way.
This is actually a good thing when there is a real threat of danger present. “A major part of our brain’s job is to keep us alive, and fear and anxiety are a big part of that,” Reynolds says. For example, the anxiety you would feel at seeing a truck hurtling towards you would make you move from its way more quickly.
But if you have anxiety, that stress response can kick in when it shouldn’t. “You feel very much the way you do when in a dangerous situation…[but] there’s no real danger there,” Duff says. Instead of being helpful, this misfiring of your fight or flight reaction can hinder you.
While a little anxiety can also help you to perform at an optimal level under stress, giving you a burst of adrenaline and hyper-focus to finish a business proposal before deadline or nail that dance number at a performance, living in a constant heightened state of anxiety can be distracting at best and debilitating at worst. When anxious thoughts are interfering with your life and causing you significant distress, that isn’t something you should just chalk up to nerves and push through. That’s something you can get help with.
Anxiety is the most prevalent mental illness in the United States, and it comes in various forms.
Anxiety affects about 40 million American adults each year, according to the Anxiety and Depression Association of America (ADAA). But it’s not as cut-and-dry as saying that anxiety is simply when you feel nervous all the time. This mental health condition comes in many forms.
Generalized anxiety disorder (GAD) is characterized by having excessive worries and fears for months, according to the National Institute of Mental Health (NIMH). Per the ADAA, GAD affects 6.8 million U.S. adults each year. Panic disorder involves spontaneous bouts of debilitating fear known as panic attacks, along with intense worry about when the next attack will come, according to the NIMH. Per the ADAA, it affects 6 million American adults each year. Social anxiety disorder (also known as social phobia) happens when you have a marked fear of social situations in which you might be judged or rejected, as well as avoiding these situations or experiencing symptoms like nausea, trembling, or sweating as a result.
Then there are other issues that are closely related to anxiety, like obsessive-compulsive disorder, which involves intrusive thoughts and urges, and posttraumatic stress disorder, which happens when people have a prolonged stress response to harrowing situations.
These are just some of the various anxiety and anxiety-adjacent disorders out there. That these issues can present in myriad ways can make it even harder to know if what you’re experiencing is anxiety that could benefit from outside help.
“Some people feel they can control their anxiety, some feel it’s something they ‘should’ be able to manage, some feel shame, some fear they might be ‘crazy,’ and others downplay how much their anxiety is impacting them,” Reynolds says.
If anxiety interferes with your daily life—whatever that might look like to you—that’s reason enough to see a mental health professional.
“When your world starts to become limited because of anxiety, that is a good signal that it’s time to seek treatment,” Reynolds says. “What is it doing to your life, your relationships, your sleep, health, work, and ability to learn and pursue things that are important to you?”
This “functional impairment,” as Reynolds calls it, can show up in different ways in different people. Is anxiety making you avoid doing things with loved ones because you’re too nervous to go outside? Do you skip school or work out of fear of what people may think of you? Can you not get enough sleep because you’re up all night worrying about the next day? Is your anxiety over certain tasks, like paying bills, leading to procrastination so extreme it comes with consequences, like getting your lights turned off?
Keep tabs on whether you’re blowing up at people, too. Anger and irritability can sometimes be a sign of anxiety. “We often forget that fight or flight includes ‘fight,’” Reynolds says. “If you have a shorter fuse or are always on edge for triggers, it could be related to anxiety.”
So, too, could physical issues. “We think of ourselves as these disembodied heads floating around,” Reynolds says. “We forget that there is a big feedback loop between the nervous system and the body.” Every part of you, from your head to your stomach to your feet, has nerves to regulate important processes, which is why your sympathetic nervous system’s stress response can be so far-reaching. You even have an entire nervous system reserved for gastrointestinal function, known as your enteric nervous system, which may help explain why there’s such a strong link between issues like irritable bowel syndrome and anxiety.
Constant fatigue can also kick in if your anxiety is in overdrive. “The physical reaction to anxiety, by nature, is supposed to be short-term. The body is supposed to come back down to baseline,” Duff says. “But a prolonged period of anxiety depletes your resources and exhausts you.”
“If your anxiety is bothering you and you are suffering, you deserve to get help,” Duff says. That’s true whether or not you think your anxiety is serious, whether or not you think you meet diagnostic criteria you read online, and whether or not your friends and family treat your anxiety with the weight it deserves. And if your anxiety is getting to the point where you’re worried for your safety, call 9-1-1 or the National Suicide Prevention Lifeline (it’s available 24 hours a day, seven days a week at 1-800-273-8255), or go to the emergency room, Reynolds says.
Seeing a therapist can be anxiety-inducing on its own, but it’s worth it. Here are a few ways to make it easier.
Knowing what to expect at your first therapy session may make the experience less scary. Although every professional is different, you’re likely to get a lot of questions at the first visit. Ultimately, your psychologist or therapist’s goal is to learn what troubles you’re having so that they can create a plan to help you build the skills you need to address your anxiety.
They’ll also want to figure out which kind of therapy best matches your needs. Different forms, like cognitive behavioral therapy, which aims to help people change negative thought patterns, work for different people.
Since the cost of therapy can be prohibitive, know that there are resources to help you find affordable treatment, like the National Alliance on Mental Health’s HelpLine at 1-800-950-6264. The HelpLine is available Monday through Friday, from 10 A.M. to 6 P.M., and you can explain your specific situation to the staffer or volunteer who answers. They may be able to refer you to local organizations that offer more affordable treatment. You can also try the Substance Abuse and Mental Health Services Administration (SAMHSA) treatment locator tool, which can help you find mental health providers who take various forms of insurance, offer payment assistance, or use a sliding scale. Resources like GoodTherapy also allow you to limit search results to therapists who use sliding scales.
And don’t stress about meeting some arbitrary threshold of anxiety for your appointment to be worth the effort. “Somebody with anxiety [may] think there is a risk to seeing someone. ‘If I go and don’t have an anxiety disorder, there’s something bad about that,’” Duff says. “That’s not true. If you are suffering and seeing some of these signs, that’s enough.”
It may be that all you need is a few sessions, or you may meet weekly for months or years based on your goals. Your psychologist or therapist might decide medication would help you live your healthiest, happiest life, or just having someone to talk to might work for you. Also, if you decide you’re not really into the person you’re seeing but you still want help, there’s absolutely nothing wrong with trying someone else, Duff says.
Ask yourself what kind of life you want to live and what’s holding you back from achieving it, Reynolds says, adding, “If there’s anything related to fear and anxiety, it’s a great sign that maybe you need support around those things.”
4 Ways to Help your Child Deal with T1D Management
What Is Motivational Interviewing? It is one of the most effective ways to decrease ambivalence in clients suffering from long-term illness and the incredible burden associated with it. Many of these skills focus on simple bite-size steps that will begin building self-esteem and feelings of hope. Actively practicing these skills can greatly increase the level of success your child feels over time.
1. Create achievable, realistic goals.
Why? When you place too much on someone’s plate and pair it with severe negative downside, you have a solid recipe to create indecision and apathy.
How? If your child is struggling with daily tasks, don’t talk about things like the A1C blood test constantly. Instead, focus on the next meal, day, or week to help create the right habits.
2. Empower your child rather than manage your child.
Why? Success does not mean blood sugar within the desirable range; it means helping your child take active steps required to create the right habits. Exclusively trying to manage your child’s outcome based on good blood sugar or other fact-based outcomes can put a lot of uncontrollable elements onto your child’s plate and ultimately create hopelessness or low self-esteem.
How? As you talk to your child, work to identify areas of pride or success and incorporate asking about these items while you check in on insulin levels or carb intake. Additionally, try to elicit ideas from your child on how to manage a certain situation (e.g. how much to eat or how much insulin to take). This will support their confidence in their ideas instead of always looking to you for the answers.
3. Listen to your child.
Why? Your child has a 24/7 job that they did not apply for and they cannot quit. Creating an atmosphere that allows your child to safely explore conflicts and face difficult realities is critical to successfully managing T1D.
How? Show empathy, and then communicate your empathy. As a parent raising a child with T1D, it can be easy to hyper-focus on the next blood sugar reading or meal. Simply saying, “That makes sense. I can see how frustrating that would be.” can go such a long way.
4. Roll with Resistance.
Why? Managing T1D can be extremely discouraging. Your child might do everything right and still have a high blood sugar reading at the next meal. Helping your child understand that managing T1D is a roller coaster and not every blood sugar reading will be in the desirable range will help tremendously.
How? Normalize your child’s experience: “You ate the right amount, took the correct dose of insulin, and you still have high blood sugar. That happens all of the time.” Also, spend your mental energy on controlling what you can control and let everything else run its course.
These tips are helpful and supported by research but can be incredibly hard to implement consistently. If you ever need help or want someone to talk to, give us a call at (612) 223-8898 or schedule an appointment here.
Despite all the advances in medical science and technology, there is still no cure for diabetes. A person with diabetes has to live with it and manage it all their life. The challenge, of course, is being diligent and consistent with diabetes management. Type 1 diabetes is challenging to manage because it is so comprehensive. Research shows that the adherence rate for chronic conditions is about 50%. Despite extensive studies and research, that number has not changed significantly over the past 3 decades.
What is adherence? How does it apply to people with type 1 diabetes? How can a person with type 1 diabetes improve their adherence? And how can mental health professionals help? These questions were answered by Dr. Katherine Fan, a psychiatrist and pediatrician, at the 2016 Asian Outreach Day. Dr. Fan spoke with attendees about the factors that affect a person’s short and long-term dedication and commitment to managing their diabetes. Here’s a recap of her talk:
What is Treatment Adherence?
Adherence is the active, responsible, and flexible process of self care and self management with a goal of overall health and wellness. An adherent patient strives to achieve good health by working in close collaboration with health care staff, instead of simply following rigidly prescribed rules.
In the context of type 1 diabetes, adherence can also be known as “collaborative diabetes management”, “patient empowerment”, or “self care behavior management”. It can be useful to break down diabetes adherence into a number of areas:
- Glucose monitoring
- Administration of medication / insulin
- Dietary intake / carb counting
- Physical activity
- Follow up visits
This may help the patient, medical care providers, and support system prioritize and focus on which parts to work on.
Also, it is important to distinguish between Adherence and Compliance. Compliance implies a paternalistic relationship between and patient and his/her doctor. The patient takes a passive role in diabetes management, simply following doctor’s orders and doing what they say. On the other hand, adherence is more of a partnership between a patient and his/her doctor, as well as his/her support network. In fact, the patient is an active participant in planning and management.
Factors Impacting Adherence
What makes a person with diabetes more or less likely to adhere to their diabetes management plan? There are 4 main types of factors that diabetes adherence:
Treatment and Disease Characteristics
Complexity of treatment: The more complex the regimen, the lower the adherence rate. For example, if a patient has to take 10 different kinds of medication, 4 times per day, it is difficult to integrate this routine into daily life.
Duration of disease: The more chronic the illness, the lower the adherence rate. This may seem counterintuitive, but patients who have been diagnosed longer actually tend to have lower adherence rates than those recently diagnosed. Managing a condition over long periods of time may lead to a more casual attitude, or it may lead to burnout.
Delivery of care: Diabetes care can be delivered a number of ways: via a multidisciplinary team, a single general-care provider, or community treatment, to name a few. Research has shown that patients with diabetes seen specifically for their diabetes received more counselling on diet and adherence than patients with diabetes seen for an acute illness.
Age: The teenage years tend to be hardest time to stick to a diabetes management plan. In contrast, parents of young children with diabetes are more likely to be adherent.
Self-esteem: Research has shown that high levels of self-esteem are related to high levels of adherence to physical activity regimens, adjustment of insulin doses and dental self-care
Self efficacy: Self-efficacy is defined as an individual’s belief in their ability to succeed specific or accomplish a task. A healthy sense of self-efficacy can play a major role in approaching goals, tasks, and challenges. The more a patient is able to advocate for him and herself, the better the outcome.
Stress: Stress and emotional state is also correlated with treatment adherence. The less stresses a person experiences, the more likely he or she will adhere to diabetes management.
Comorbid conditions: A comorbid condition is one that occurs at the same time as another illness or condition. Comorbid conditions such as depression, alcohol abuse, eating disorders, and others can adversely affect diabetes adherence. This effect is not limited to mental conditions: physical comorbidities also tend to lower the adherence rate of diabetes.
Patient-provider relationship: The better the relationship between a patient and his or her provider, the higher the patient’s adherence rate will be. Patients and providers who communicate with each other tend to have improved relationships.
Social support: The benefits to have a social network for a person with type 1 diabetes are well known. Greater social support means better levels of adherence. For children and teens with type 1 diabetes, great parental involvement also means better levels of adherence.
Stressors:The more stress a person has in their life, the harder it is to prioritize and manage diabetes
Conflicts: People with diabetes are as multifaceted as everyone else. Frequently, they are called upon to choose between giving attention to diabetes self-management or to some other life priority. They can face time pressures and social pressures during school events, work events, family events, holidays, and more.
Lifestyle factors: A person’s lifestyle can directly affect their diabetes adherence levels. Are they sedentary or active at work? Do they work long hours? Do they travel a lot? How much time do they spend in front of the television? Do they have a hobby? Different circumstances require individuals to adjust and maintain their diabetes management.
Socio-economic status: The economically disadvantaged and ethnic minorities may find it particularly challenging to visit healthcare providers or to live a healthy lifestyle. They may have limited access to fresh fruits and vegetables, small living spaces. Their schools may not provide opportunities for physical activity. What’s more, financial constraints may prevent them from going to a gym. Those factors, combined with their local climate, may make regular exercise challenging.
The Diabetes Adherence Team: What can we do?
There are four kinds of players on any diabetes management team: the Patient, the Parents (or family/friends), the Physician, and the Environment. All players have a role to play in diabetes adherence. When each “player” contributes in a positive way, it leads to better adherence and better outcomes. Here are tips on how each team player can work to enhance adherence and wellness:
It takes a team to manage diabetes, but adherence starts with the patient. As the person with diabetes, you’re going to be living with your body for a long time, so take care of it! Here are some things the patient can do to make diabetes adherence easier:
- Be informed and understand your condition. Understand what it does to your body, and understand the complications that can occur if one does not manage the condition and stick to the plan.
- Identify your strengths and future goals. Don’t see diabetes as something that defines you, but something that is a part of you. You cannot change it but you can manage it.
- Stress proof your life. Work on areas such as sleep, nutrition, exercise, hobbies, mind-body exercise, healthy coping strategies, and more. Also, develop a support network of family, peers, school, religion, and/or support groups.
Parents (and family) play a huge role in enhancing adherence. Here are some things parents can do to help their child with T1D:
- Understand the developmental needs of your child and recognize where they are. Remember, each child is different! At any given age, a child may be a different levels with respect to cognitive, motor, social-emotional, and physical skills.
- Be informed and stay involved. Invest in your relationship with your child! Additionally, help your child be informed and involved. Help educate your child’s school, as well as caretakers, friends, and family.
- Balance “take control” and “letting go”. We all want to be there for our kids, but we want our kids to take responsibility and be independent so that when they leave home, they can take care of themselves.
- Create a supportive home environment. Avoid judgement words such as “good” or “bad” sugar/A1C. Instead, use phrases like “in or out of range”.
- Foster a positive attitude about the condition.
- Model self care. Kids learn by watching!
- Focus on incentives, not threats or fear tactics. Consequences are for behaviors that you want to stop, while incentives are for behaviors that you want to foster.
- Don’t be shy about asking for professional help!
Physicians play an important role. A physician who can help enhance adherence is one who:
- Keeps it simple and simplifies treatment regiments as much as possible
- Makes sure patients understand the consequences of non-adherence
- Connects with the patient in a way they understant
- Enhances patient communication via phone, text, etc..
- Leaves bias out of the relationship and avoids judgement. Patients already feel shame and guilt, and when they feel judged, it negatively affects the doctor-patient relationship.
Some environmental factors are difficult, if not impossible, to control, so focus on things that you can control. For example, you may not be able to enhance access to health care, but you can provide diabetes awareness and education. You can educate not only yourself and your family, but also the broader community. Parents can help educate their children’s school teachers and friends. Adult patients can start support groups online and in real life. Technology can also improve diabetes awareness and education.
The role of Mental Health Clinicians
How can mental health clinicians help patients achieve overall wellness?
- They can support the patient and the patient’s family, not just during diagnosis, but throughout their journey.
- Acceptance is the first step towards adherence. Mental health clinicians can help patients work on accepting their condition and coping with it.
- Mental Health Clinicians can help the patient process some of the emotional factors that come with diabetes: anger, fear, guilt, shame, stress, sadness
- They can facilitate communication and conflict resolution, between you and parents and friends, between doctor and patient
- They can help identify other emotional disorders that can complicate diabetes management, such as depression, anxiety, eating disorders, or substance abuse.
Mental health clinicians can provide treatments such as cognitive behavioral therapy, motivational interviewing, behavior modification plans, or family therapy. Diabetes affects the mind as well as the body. Mental health is an important step towards the journey to your best self. Never be afraid to ask for help from a mental health professional!
A diagnosis of Type 1 diabetes can affect the whole family. It’s important to listen to, and communicate with, all members of your family – especially any other children – and get help and support if you or anyone else needs it.
While you’re getting to grips with your child’s diabetes, it’s easy to forget about the needs of your other children. But, they, too, will be affected by their sibling’s diagnosis. They may feel that their brother or sister is getting special treatment, worry that their sibling will get really sick or be scared that they’ll develop diabetes themselves.
Rivalry and jealousy are common in most families, and a child with diabetes can cause upset between siblings. In the early days, after diagnosis, it’s only natural for you to be anxious and focus your attention and care on your child with diabetes. But, regular hospital visits, attention to diet and everything else that goes with diabetes has a longer-term impact on all the family.
Advice for coping with sibling rivalry
- Try to listen to both sides equally and be sensitive to their claims that it’s ‘not fair’.
- Be clear about what you expect from each of them.
- Try to give them the same amount of attention.
- If you feel it’s appropriate, get siblings involved with diabetes management, so that they feel part of it.
- Try not to put family life on hold.
It can be a challenge to manage a child’s diabetes when they go from one home to another. Whatever your feelings about your ex, the two of you need to work together to make sure your child’s diabetes is well managed.
- making sure both of you learn about managing your child’s diabetes from your paediatric diabetes team – second-hand information can be confusing or inaccurate
- how you’ll keep each other updated about any changes to your child’s treatment or routine
- how you’ll involve new partners.
As a lone parent, you may have particular difficulties because all the pressures fall on you alone.
- who you can call if you need help
- who can help you in an emergency
- who can support you when you’re struggling emotionally
- who can babysit when you need time off
- involving siblings in your child’s care, being careful not to give them too much responsibility.
When your child is diagnosed with diabetes, it’s natural for grandparents, aunts and uncles, etc to be as upset and worried as you are. They may be in constant contact, asking for updates or how they can help – or they may leave you alone to concentrate on your child.
Advice for dealing with extended family:
- Keep one person up to date. This person can then update everyone else: group texts and emails work well for this.
- Ask for the help you need. Perhaps you’d like someone to look after your other children, do a bit of shopping for you or walk the dog? People often want to help, but don’t know what to do.
- Think about the future. Your family will be living with Type 1 diabetes from now on, so how can your extended family best support you? If your child is used to staying over with relatives, it’s important that they still do so. If grandparents and other family members are worried about looking after them, try involving them in your child’s diabetes care. You could also bring them to clinic appointments to help them learn more about diabetes and ask questions for themselves. Most of all, be honest with them, tell them how you feel and ask them to help you keep your child’s life as normal as possible.
Is Type 1 diabetes hereditary? Will my other children get it?
Research has shown that Type 1 diabetes is caused by a combination of genetic and environmental factors. If one family member has Type 1 diabetes, there’s a slightly increased risk of another family member developing it, too. But, many people diagnosed have no family history of diabetes. It’s natural to worry that your other children will also develop Type 1 diabetes, but try not to let this worry affect you too much. Talk to your diabetes team or contact theDiabetes UK Carelinefor support.
Diabetes support for you and your family
If you’d like some diabetes help, you can:
- ask your diabetes team for advice
- contact theDiabetes UK Careline
- connect with other parents on theDiabetes UK Facebook page
- Visit theDiabetes Support Forum
- join aDiabetes UK group
- contactDiabetes UK’s Peer Support serviceto talk to specially trained volunteers with first-hand experience of living with diabetes (including parents)
By Becky Upham
Medically Reviewed by Rosalyn Carson-DeWitt, MD
Managing type 1 diabetes can take a physical, emotional, and financial toll on your relationship, whether you’re dating, married, or in a long-term partnership. Although every relationship has challenges, there are some issues that can seem especially tricky when you have a chronic condition like type 1 diabetes.
A qualitative study published in March 2013 in Diabetes Care found that people with type 1 diabetes and their partners feel that the condition impacts their relationship, posing both emotional and interpersonal challenges — and that partner support is a vital source of support for those living with the condition.
If you find that your type 1 diabetes has taken a toll on your relationship, there are steps you can take to help reconnect with your partner and get back on track.
Common Relationship Challenges
Here are some common issues that people who have type 1 diabetes and their partners may face, as well as tips to help address these concerns and maintain a healthy relationship.
Lack of support Diabetes requires many daily management tasks. If your partner isn’t aware of what all those tasks are and why each is important, it can be difficult for them to support you, says Mark Heyman, PhD, a certified diabetes educator and the founder and director of the Center for Diabetes and Mental Health in Solana Beach, California. “I encourage people to educate their partner or have a healthcare team who can help educate their partner about each step in managing type 1 diabetes. Your partner needs to be able to offer support — not only when you aren’t feeling well, but also in the day-to-day,” he says. “That means support in making healthy choices when it comes to eating, exercise, and other activities. It can be really hard to manage type 1 diabetes when you feel like you’re all on your own.”
Feeling micromanaged On the other hand, you may sometimes feel like you’re receiving too much support. It may seem like your partner is constantly asking you about how you feel and what you ate, and monitoring your every move. “It usually comes from a place of caring and not always knowing how to help,” says Dr. Heyman. In those cases, it’s important to let your partner know what’s helpful for you and what’s not helpful, he says.
“For example, you might tell your partner, ‘It’s really not helpful for you to be looking at my blood sugar numbers all the time and commenting on them. What would be more helpful for me is if we could plan time this weekend to take a walk together or prepare a healthy meal,’” says Heyman. “That does two things: It helps you set boundaries with your partner around how they interact with you about your condition, and it also gives them a concrete way to help you manage type 1diabetes, which can help relieve some of the anxiety your partner may have,” he says.
Lack of spontaneity Because type 1 diabetes involves a lot of planning, it might feel like there isn’t enough spontaneity in your relationship. While it may feel counterintuitive, doing a little planning in advance can help you be spontaneous. “Having supplies packed and ready to go can help if a last-minute trip or fun activity comes up,” says Heyman. Keep extra insulin and anything else you might need in a bag, he suggests. “If you want to take off on a weekend road trip, it’s nice to know you can just grab that bag and have everything you need to stay healthy,” he says.
“If one of you would like to be more spontaneous, ask the other person, ‘What can we do together to make you more comfortable with that?’” he says. “You may be amazed at the ideas that can come about if one of you just asks the question.”
Intimacy challenges A study published in May 2018 in International Journal of Environmental Research and Public Health found that people who have type 1 diabetes may be at an increased risk of sexual disorders. Communication is key in helping with these issues, says Heyman. “You have to let your partner know how you’re feeling, just as in any relationship,” he says.
“Lots of things can impact the desire for intimacy. There are times when you just don’t feel well. Maybe there are fears about having low blood sugar while you’re being intimate,” he says. The more you can communicate about what you’re experiencing and what your partner may be able to do to help, the better. “Being able to talk about it may lead to increased intimacy; often communication can make you feel closer to your partner,” says Heyman.
Financial strain The cost of managing type 1 diabetes can vary, but according to the American Diabetes Association, people who have diabetes spend approximately $9,600 a year on diabetes-related medical costs. This may include anything from doctor visits to medications and supplies. These extra expenses can add stress to your relationship. Communicating and planning are key, says Heyman. “Have a really frank conversation about your financial health and what your goals are. How does diabetes impact this? How can we manage it?” he says.
Sometimes there can be resentment if one of you feels “stuck” in a job you don’t like because you can’t afford to lose your health insurance. Talk about the situation and brainstorm together, suggests Heyman. “Is there a solution that can be agreeable to everybody, and if not, can you find a compromise?” he says. Bottom line: Staying healthy is critical to living your best life.
Dealing with low blood sugar When you’re experiencing low blood sugar, you don’t always act like yourself, says Heyman. “You may become aggressive or defiant,” he says, which can be concerning, medically dangerous, and stressful. “It’s helpful for couples to set rules around how they’re going to deal with an episode of low blood sugar — before it happens,” he says.
Sometimes you may be in the middle of a low blood sugar episode and not realize it, or think you’re just fine and your blood sugar will correct itself, he says. Developing rules that are “non-negotiables” are a good idea.
“For example, if your partner thinks your blood sugar is low, agree that you’ll check it. If your partner sees that your blood sugar is low or if you’re exhibiting signs that it is, agree to take the snack they offer you without question,” he says. “Agreeing and sticking with rules like this can go a long way in easing tension and letting your partner know that their concerns are heard and you’re going to be okay,” says Heyman.
Find Support — for Both of You
Your partner needs to understand that sometimes you just don’t feel well. “High blood sugar doesn’t always feel good and low blood sugar is not only dangerous, it just doesn’t feel great,” says Heyman. “That can be a hard thing to communicate to people; diabetes can be a very invisible disease. Someone may look fine even if they’re not feeling well, and explaining what the different symptoms feel like can be challenging.”
Seeking social support, either in person or online, where you can get other couples’ perspectives on what these things are like and how they handle them, is a good idea, says Heyman. “Online communities are a great source of support,” he says. Beyond Type 1 and Type One Nation are two helpful resources for people with type 1 diabetes.
“Diabetes can be overwhelming and frustrating. You can experience lots of emotions that go along with that,” says Heyman. Having a partner you can count on and who can understand and empathize can go a long way.
Everyone agrees: Stress is terrible. It’s the thing that keeps you awake at night and unable to enjoy your day. Sometimes stress helps us prioritize the things that need doing now, but more often than not, it’s a terrible feeling that sucks the life out of you. At its worst, stress can increase your chances of heart attack, harm your immune system, decrease sexual function, and wreck your digestive system. Stress can come from your work, your personal life, or your environment, and it can manifest in a multitude of (not great) ways.
Battling stress is a part of caring for yourself and your body. How do you get out from under the crushing weight of stress and get your life back on track?
The Art of Self-Care
The best way to combat stress is to practice the art of self-care. Self-care can be hard for a lot of people, especially those with busy lives who are used to putting work and the needs of others ahead of their own needs. Moms are especially prone to struggling with putting themselves first. Self-care is as much a part of thriving as eating and sleeping. It’s caring for yourself mentally, replenishing that spring of mental wellness and energy so that you’re able to do the things you need to do. When you’re busy, schedule time for self-care the way you would a doctor’s appointment.
So what counts as self-care? Anything that leaves you happy, satisfied, and rejuvenated: massages, time spent with a friend or romantic partner, watching a movie you enjoy, or anything that makes you laugh. Examine the things that make you genuinely happy and fulfilled, and when you find yourself lagging, indulge.
Practice Changing the Way You Think
Getting out of a funk is hard to do. When you’re super stressed, it’s easy to fall into a black hole of negative thinking. Practice changing the way you think. If you’re plagued by negative thoughts, flip them around into something positive. It’s hard to do, especially when you feel buried by worry. The more you practice, the more you’ll lean towards positive thinking naturally. You’ll be happier in the long run.
Kick Social Media
There’s a ton of evidence that social media is bad for us. Deleting Facebook from your phone, or drastically reducing your time on Facebook, can lower your cortisol levels (that’s the hormone associated with stress). Increased cortisol can lower your immune system, encourage obesity, and impair memory. Excessive social media use has been linked with anxiety and depression. That’s a lot to put up with just to see what your cousin had for lunch.
Take a 24-hour break from all the noise and pressure from social media. If your hands are still twitching to use your phone, replace Insta with an app designed to help you reduce stress and anxiety. Some apps walk you through mindfulness or meditation. Others help you breathe, or they play soothing sounds.
Take Care of Your Body
There’s definitely a connection between mind and body — just ask anyone who has experienced being hangry. When you’re stressed, taking care of your body can absolutely help get you back to balanced. If you’re working under a deadline, you might be tempted to forgo eating healthy for something quick, like vending machine food. Sugar bursts and crashes can exacerbate stress. Take some time to eat food that will give you energy without burning out quickly, like protein.
Physical activity can help you work through feelings of stress. It’s as simple as taking a quick walk to clear your head. A walk can help you calm down, catch your breath, and head back into a stressful job or project with a much clearer head.
Sleep is a powerful tool to relax and unwind. Follow practices that lead to a good night’s rest:
- Don’t eat before bed
- Give yourself time to settle
- Prime your bed for comfortable sleep
- Keep distractions or stimulating objects (like your cell phone) far away from your bed.
Like a lot of the other suggestions in this article, they’re small changes. Those small changes can lead to a big difference in your life — one that will leave you more relaxed, fulfilled, and able to take on your goals with increased gusto.
Happiness is an elusive concept, we all want it but not many of us can define what it actually is and even fewer how to get it.
Unfortunately, a lot of us fall into the trap of the ‘I will be happy when’mentality. It’s an easy fix supported by our own psychology and propagated by the modern world. You end up thinking; ‘I will be happy when I have lost 10kg’s’, ‘I will be happy when I find a partner’, ‘I will be happy when I get that new car’ and so on. The difficulty is that you will be happy briefly, or at least you think you will. But this feeling won’t last long and then you will be onto the next thing that you believe you need to feel happy.
Now, don’t get me wrong, being healthier and finding positive relationships are good goals, but when you anchor your entire life onto the ‘i’ll be happy when’ philosophy you will always be left wanting more and the happiness you seek will likely remain elusive.
I am not promising that trying the following tips will immediately fix everything, but remember that you are the author, editor and viewer of your own life. You choose what you do from day to day. You filter experiences based on what you expect to see and you choose what you focus on and remember. So maybe just try some of these and see how you feel, who knows it could really make a difference, they have to me over the years.
- Try something new.
Now this doesn’t have to be big, in fact it can be tiny and in any aspect of your life. Try a new route from work and see what different sights there are, or people you meet. Maybe it will simply turn out to be quicker. Try a new restaurant, try a new activity. Go big and visit a country you have never been to before, go brave and ask that person out, or end a toxic relationship. Novelty can help reinvigorate you, it can give you new perspectives, new experiences. You may meet new people, who in turn give you new ideas. It can give you new things to consider and talk about. Maybe just try one new thing a month and see what changes.
- Start Small
This is really important, people often make the mistake of trying to change everything at once. You set yourself giant targets and when you don’t achieve them in a month you start giving up and feel like you have failed. Instead focus on the tiny wins. If you want to lose weight, don’t think “I want to lose 2 stone”, start some exercise and if you feel a bit better then thats your target. Maybe your clothes feel a bit looser or you have little bit more energy. There is nothing wrong with big bold targets, but don’t measure your progress by it. Instead, break it into smaller goals and celebrate when you achieve them (perhaps not with a cheesecake though).
- Count the Good Things
Try this experiment with a friend, when you are somewhere you haven’t been before, ask them to look around and memorize everything that is red. Once they have done that, ask them to close their eyes and list all the things around them that are blue. A lot of people will struggle because they simply haven’t paid attention or focussed on the blue things around them. This is how our minds work. Very simply, we see what we expect to see and remember based on our preconceptions, your mind filters to make it more efficient. Now this is great from a survival perspective however it can cause problems. If we expect to have a bad day we will unconsciously only look for the things that confirm this. If we think we are unlucky we will look for things that prove our bad luck streak. Instead try something very simple, everyday before you go to sleep, think through your day and focus on five good things that have happened. They could be anything from ‘a nice walk in the sunshine’ to ‘meeting someone new’. There are always at least five events you can find that haven’t been awful or disastrous. Try this for a while and you may be surprised how it starts to change your mindset. You will start to look for more and more of the good and likely feel more positive.
- Say no….and yes more
This might sound like contradictory advice, but a lot of us spend a significant amount of time trying to second guess what other people want us to do. We try and make decisions on their wants and needs. We might do this for lots of reasons; we care for them, love them, live with them, dislike them and so on. Instead I want you to make decisions about how you feel and what you want. Have the confidence to say no to things you don’t want to do and yes to things that you do want to do. You may have avoided things in the past as you are worried that friends and family might judge you or it might change their view of you, but it’s not their life! It’s not about being selfish, just recognising that to be a good friend to others you need to first look after yourself and that you are entitled to do what makes you happy.
- Read a Book
In a world of social media and access to non-stop entertainment, books have sometimes fallen out of favour. Books give you a window into a different world or another persons life, a glimpse into history, they stimulate your imagination and mind. The focus required to read without distractions is sometimes considered a form of meditation; you can’t half read like you do with some TV programmes, it requires all of your attention. Books have the time to be more descriptive and delve deeper, ask questions that mass media are unwilling to, they can put you in the shoes of another world changing your perspective on life. Books have literally changed the course of history so why not give one a go.
- Stop and Meditate
We spend so much time running around thinking about work, family, friends worrying about what we have to do next, dwelling on something we did last week, rarely just stopping and taking in where we are and how we feel right now. Meditation can be practiced in many forms and its worth learning more about it. Essentially though, meditation asks you to focus on the moment you are in now, your place within it and the internal feelings and thoughts going on at that moment. Acknowledge them and then work to find stillness and quietness. Learn to slow down and quieten your mind to stop if from jumping from thought to thought like a over excited animal. Simply give yourself 5 minutes a few times in your day to just stop and look around you, admire the view and really take it in. Ask yourself, where are you now and how do you actually feel?
In anything, anywhere and anytime, just do it. Stop worrying about what to do and stop giving yourself the excuse that you have no time. Everyone has 10 minutes to take a brisk walk even if it’s to pick up the kids, 20 minutes for a run, 15 minutes for some Yoga, weights or just some stretching in your living room before you crash in front of the TV. The physical and psychological benefits of exercise are documented on an almost daily basis and finding information could not be easier online. Just start, today, you will not regret it.
- Think about your Food
Like with little changes you don’t have to stop eating all your favourite foods (pizza) immediately but perhaps just cut down on some of the worst offenders. You know what they are. Fast food, packaged cheap food full of salt and sugar. Reduce your meat intake for the sake of your own gut and the environment, eat…….some…….greens. It really isn’t rocket science, you just have to eat a balanced diet, there is so much information online and healthy food isn’t that expensive anymore. Now I know this is difficult when you don’t have time or money to cook, but a bag of salad is instant and chicken takes 10 mins to cook. Like above, focus on little changes that you can maintain and see how you feel after a few weeks. It should be no surprise that the food you put into your body can dramatically affect your internal state.
“No-one is useless in this world who lightens the burdens of another” Charles Dickens
Giving money is great and I applaud you for doing it, but also try and give your time. Stop and talk to people and really listen to them. Volunteer for something nearby. Your time is the most precious resource you have, far greater than money, and spending it to help others is an amazing way to improve the world around you and you will be surprised how good it makes you feel. Give to charity, help others, give anything you can and as much or as little as you want to. There are always people more and less fortunate than you, don’t judge or compare just give.
- Spend time with your Friends and Family
There have been numerous surveys over the years conducted with terminally ill patients each one asking them about the meaning of their life, what made them happy and what they wished they could change about how they lived their lives. With each study there are some things that just keep coming up. For a start “I wish I worked more” is never in the list and almost always at the top is wishing they had spent more time with their friends and family. Good relationships are believed to even lengthen your life and none of us can get through this alone.
Remember though people come and go into your life, don’t be afraid to make new friends or say goodbye to toxic relationships. Never worry about calling that friend or relative you haven’t spoken to for years. They are just like you and will be busy with their lives and wondering if they should call you. Always try and make time for a coffee or beer or just a chat with your friends and family, they are literally the anchors of your life. They reflect who you are and how you live your life and are the ones standing with you in your time of need and you in theirs.
One more thing before you go, another common theme from these studies is patients often comment how they wished they had lived true to themselves and had the bravery to live their lives as they wanted to and not how they thought others wanted them to.
So here is a little experiment to leave you with, in Australia, the life expectancy is just over 82 years which is actually only 718,320 hours, this really doesn’t sound like much does it? But it gets more powerful when you divide that by three. A third for sleep and at least a third for work leaving you with less than 240,000 hours of free time…..then subtract how ever many years you have lived.
Life is genuinely very short and you should strive to live your own life and as positively as possible.
“Happiness is not something you postpone for the future; it is something you design for the present” – Jim Rohn