Dr. Diana Guthrie on Winning the AADE’s 2011 Living Legend Award and How Complementary and Alternative Medicine Can Benefit People with Diabetes
by adam brown, lisa vance, and kelly close
We recently interviewed Dr. Diana Guthrie, the 2011 winner of the AADE Living Legend Award, and a strong proponent of holistic, complementary, and alternative approaches to diabetes management. Her career has spanned 55 years, including time as a nursing instructor with the American Red Cross, a professor at Wichita State University, and an American Association of Diabetes Educators (AADE) board member. Her unparalleled credentials include certifications in holistic nursing and healing touch, a master’s degree in public health, and licenses as a professional counselor and marriage and family therapist.
The AADE Living Legend Award, established in 2008, recognizes outstanding contributions to diabetes education; past recipients have included Dr. Francine Kaufman (see our interview with Dr. Kaufman in diaTribe #7), Dr. James Gavin III (see diaTribe #35 for our dialogue with Dr. Gavin), and Dr. Frank Vinicor (2008). In this interview, Dr. Guthrie’s discussion of stress management was particularly fascinating; in some cases, she has seen blood sugars decline by over 150 mg/dl in just 20 minutes through stress reduction! We also appreciated Dr. Guthrie’s perspective on the great work being done by AADE and what it can do even better, what keeps her up at night, and what she finds most exciting about new therapies. Although her support for complementary and alternative medicine might be considered unorthodox or even controversial, we appreciated her fresh perspective and hope to hear more about these approaches at this year’s AADE annual meeting in August (we enjoyed a memorable panel discussion at AADE 2010 on how these therapies may be especially useful in people with long duration diabetes).
the living legend award and dr. guthrie’s background
ADAM BROWN: Thank you so much for joining us. To start, congratulations on winning the Living Legend Award! Can you talk about what it was like to receive the award and what that meant to you?
DR. DIANA GUTHRIE: Oh my goodness! It was more than I expected. There are certainly people more qualified than I am to receive such an award. But I was absolutely thrilled to death on receiving it. It’s a great honor just to be recognized by your peers – I thought that was the most wonderful thing.
Adam: How is the award winner selected? Is it a committee at AADE?
One of my major interests is in stress management, and there’s no question that adults who are highly stressed have a more difficult time in managing their diabetes.
Dr. Guthrie: From my understanding, somebody submits your name and qualifications and then the board votes on it. They tell me the board was unanimous in their approval. I thought that in itself was fantastic.
Adam: That’s really exceptional. But, we have long known how beloved you are in the diabetes community, and that you really seem to understand patients, families, technologies, and therapies – so we’re sure the award didn’t come as a surprise to many! Which part of your work makes you the most proud?
Dr. Guthrie: My work with medicine and children and what I have learned from parents and kids themselves. I think that information has really enhanced my practice and has driven me.
Adam: We noticed that you are also a marriage and family counselor. That’s not an area in which a lot of diabetes educators seem to have training. How has that informed your work?
Dr. Guthrie: It has helped me to ask the right questions and get information faster. By using the right terminology and understanding the psychosocial expectations of patients, I can see how everything intertwines with their management. One of my major interests is in stress management, and there’s no question that adults who are highly stressed have a more difficult time in managing their diabetes.
changes in the diabetes field
Adam: Your career in diabetes has spanned more than 50 years. What do you think has been the most striking change that you have seen over that time period?
Dr. Guthrie: Probably the medicines that allow for increased flexibility and the ability to maintain diabetes control and enhance the patient’s quality of life.
Adam: When you look at the field of diabetes, what do you think are some big changes that you would like to see? What areas need the most work?
Dr. Guthrie: What I think we need to work on the most is an emphasis on holistic approaches. We should move towards integrating the old with the new, and we need to have much more education on complementary and alternative medicine. There are some things that are available to us that can be helpful for individuals and their families with diabetes. But we also need to be careful of those things that might be harmful, like supplements. One might be very helpful for someone who craves sweets, but another might be harmful or unhelpful.
Adam: So when you look at the diabetes landscape today, what do you think worries you the most? What excites you the most?
Dr. Guthrie: What worries me the most is people’s hesitation in trying new things. It’s good to be cautious, but it’s also good to read and try to learn what can be useful for you as an individual. We now have therapies that are available for increased flexibility and better diabetes management. It’s exciting to see the better recognition of the erratic absorption of medication, the control of glucagon output, and how individuals handle food. It’s also great learning more about the closed-loop system for those that are completely insulin dependent.
Adam: What is your take on some of the newer therapies like incretins or SGLT-2s?
Dr. Guthrie: I’ll be very interested to see all of those things being studied in type 1 diabetes. Even though most of the evidence is in people with type 2 diabetes, it could benefit people with type 1 diabetes, particularly those with bouncing blood sugars.
Adam: What do you think are some of the most effective stress management techniques that you emphasize with patients?
Dr. Guthrie: One of the most interesting things is how controlled breathing works as a stress management tool. Deep abdominal breathing not only helps lower blood pressure, but it also helps with test taking. There is actually research related to breathing effectively to increase short-term memory, especially if kids are cramming for a test.
Adam: At the AADE annual meeting in 2010, I remember being fascinated by a panel discussion on living with advanced duration diabetes. Many of the panelists with long-standing diabetes recommended stress reduction techniques such as yoga, tai chi, and mindfulness meditation. Would those types of techniques fall into the deep breathing category of stress management?
Dr. Guthrie: They certainly incorporate breathing. The idea is that you take careful thought of what’s going on. But there are different ways of relaxing. I use feedback-enhanced relaxation training, and I remember an appointment with a 15-year old. Her mother was not going to bring her in because her blood sugar was over 300 mg/dl. But she wanted to come in for a session, and I got her hooked up to the biofeedback machine. When I rechecked her blood sugar at the end of the 20 minutes of biofeedback-enhanced relaxation, she was down to 140 mg/dl.
Patients are able to do that by calming themselves and thinking positive thoughts. They don’t have to take medication for anxiety or depression. The term we use is “empowerment” – they can do these things on their own and monitor themselves with blood sugar testing. Once they get to the range where they need less medicine, they can decrease their medication through their own self-management or contact their health professional. This is people with type 1 or type 2 – I’ve just seen it over and over and over again.
Adam: That’s really interesting and not something you hear a lot about. Can you talk a little bit more about what biofeedback-enhanced relaxation entails?
Dr. Guthrie: It is a mechanism that gives information that is not readily available and indicates increased relaxation. For example, your hands becoming warmer. You could be responding to music or focusing on a machine with different colors and images that makes you feel calmer. The feedback mechanisms could be things like temperature, blood pressure, electromyography, etc. When people get tested, I ask them if their hands sweat or if they get cold. When they have that sweaty response, it is usually the galvanic skin response, so we measure that. Sometimes, I use two or three different feedback mechanisms to be sure someone is relaxing. Very often, however, I could just use hand temperature. I also have different tapes to help people relax – these might be self-discovery imagery or peaceful imagery. You just see their blood sugar come down.
Adam: Let’s say I come in to you with an A1c of 8%, and I feel stressed all the time. What would you recommend I incorporate into my daily routine to improve my health and diabetes management?
Dr. Guthrie: After doing a careful assessment and getting a background history, I would find things that you are interested in – things that you would be willing to attempt and would help you on the diabetes management side, along with the relaxation practices that you were choosing. Then, I’d look at your A1c and compare it to your blood sugars. I would also make sure that you were not putting down false information on your blood sugar test records.
After assessing which approach might be most appropriate, I’d basically hook up the machine and say, “You have two minutes with the music and you can pick the type of music that you think is most relaxing to you.” Or if you picked the imagery, you would listen to the tape that’s most relaxing and we’d allow the machine to lead us. Then it’s just practice – it usually takes kids four to six weeks and adults six to ten weeks to really learn these practices and call on them at will.
Adam: That’s interesting that it takes such a long time to really master the techniques. Besides slow breathing, calming music, and imagery, are there any other relaxation techniques?
Dr. Guthrie: Yes, you can just focus. Visualization and focus on a particular object would be another thing you could do. You could also do certain types of activities like Tai Chi or Chi Gong – if you are focusing on a sequence of positions, then your mind is off your problems. When I am working with patients, I often say, “What are you doing for relaxation?” I’ll even ask a whole class to share what they do. And I’ll emphasize that there is no one thing that works for everyone – it’s what works for that individual. It might be exercise, or it might be a relaxation technique like focusing on how many minutes or how many miles. Just calming or quieting thoughts or anything that gets the person away from stressful thoughts that can trigger an autoimmune reaction and bring those stress hormones into play. It leads to better results.
herbs and supplements
Adam: Do you recommend any particular herbs and supplements for people with diabetes?
When a patient has a craving for sweets, I may tell them about gymnema sylvestre – this is an herb that makes sweets not taste as good. It’s an herb that’s mainly been studied in India and actually has some blood sugar lowering effects for people with type 2 diabetes. It is used by over 80% of the diabetic population in India.
Dr. Guthrie: When a patient has a craving for sweets, I may tell them about gymnema sylvestre – this is an herb that makes sweets not taste as good. It’s an herb that’s mainly been studied in India and actually has some blood sugar lowering effects for people with type 2 diabetes. It is used by over 80% of the diabetic population in India. They are reporting no known side effects and no known interactions with other medications. There are also a few papers found in the US literature. (Editor’s Note: A recent review of complementary and alternative diabetes therapies explains that gymnema sylvestre has been used for over 200 years for the treatment of diabetes. The leaves of the plant are chewed, “which can suppress the sweet taste sensation.” The article also mentions evidence that the herb may drop blood sugar by causing individuals with type 2 diabetes to secrete more insulin. However, the authors conclude that there is not enough definitive evidence supporting use of gymnema sylvestre in people with diabetes. As with any supplement, we encourage you to speak with your healthcare provider about a product’s risks and benefits.)
Adam: We’ve read a bit of research on fenugreek, as well. Do you have any thoughts on that?
Dr. Guthrie: There has been a fair amount of research on fenugreek, and it seems quite acceptable and certainly useful. Dr. Laura Shane-McWhorter, author of the American Diabetes Association Guide to Herbs and Nutritional Supplements, also recommends it. (Editors’ Note: The same aforementioned review of complementary and alternative diabetes therapies also addresses fenugreek. The authors explain that several trials in people with type 1 and type 2 diabetes “suggest a potential effect,” but future studies need better quality before conclusions can be drawn about fenugreek.)
One thing that’s missing is information on the different remedies that actually lower blood sugar, other than supplements. An example is something like a massage. There isn’t much research on massage for people with type 2 diabetes. It is semi-known that things happen to people when attempting any of these things. We do see lower blood sugars and that certainly makes a lot of sense – having less adrenaline means you are not feeding yourself a lot of glucose from the liver to raise your blood sugar.
skepticism from the medical community
Adam: Much of your career has focused on complementary and alternative approaches like stress management or relaxation techniques. Do you find that there is skepticism within the medical community, or even from patients themselves saying, “This won’t work for me” or “This is not scientific” or “There is not a lot of research.” How do you address this?
Dr. Guthrie: I think that all the time, but less and less so. A series of surveys came out in 1993 and 1997 and more recently in 2007-2008. Basically, information on complementary and alternative medicine is being used more frequently, and more physicians are willing to suggest it to their patients: “Well, why don’t you try going out and getting a massage?” or “Why don’t you try doing some kind of activity that decreases your heart rate?” When it comes to evidence-based diabetes care, there is no doubt that they need to have more information and more research to be sure it’s safe and effective. But in the long run, I think we will continue to see it. It may be especially useful in cutting down the costs that we have in healthcare practices to help people be healthier and live better lifestyles in a very, very safe way.
One example is vitamin E. People were throwing that at patients right and left, and then we found out that at certain levels, the antioxidant factors become pro-oxidant factors. We need more research on the therapies themselves – there are over 400 herbs that are known to lower blood sugar levels, but I think we have only tested maybe 10-15% of them. Metformin, for instance, is a former herb.
Adam: Absolutely. But for the average endocrinologist or nurse educator, these methods probably aren’t in their top three or five priorities, right?
Dr. Guthrie: I think that that’s true, and their hesitation in doing this is quite puzzling to me. Well, maybe it’s not so puzzling, but from the standpoint of not doing any harm, it’s almost like they aren’t even willing to listen. I think people will have to develop their own comfort level or at least identify a person that is certified. Any time I talk to patients and they come up with something, or I suggest something, I say, “This is what you need to read. You need to find out if this seems like it would be useful for you.” This is especially important in the first three to five days. They keep journals of any positive or negative responses that they get from using either a specific modality or herbal supplement.
Of course, a person with diabetes must be extra careful to watch how their blood sugars respond. I tell them their blood sugars are like biofeedback: they can tell whether a specific food is going to raise their blood sugar too high and too fast, or if that particular modality is going to be more useful for them.
diabetes prevention and education
Adam: Turning to a slightly different topic, what else do you think we could be doing on the diabetes prevention front? Do you think complementary and alternative approaches could help prevent type 2 diabetes and obesity?
Dr. Guthrie: They might help. Especially people that are taking yoga, or doing different activities that add to flexibility and circulation, or anything that relates to decreased stress on the body or improved healing – all of these will decrease overall blood sugar responses. In the prevention process, they say lifestyle changes are the most important. Eating nutritious food is one of the key things that is taught by holistic nurses as well as healing touch and therapeutic touch practitioners. There are diets that are more appropriate for certain builds and certain types of people. Knowing the foods that best respond with your personal genetic typing is important. Additionally, there are things that you could put in your lifestyle that would keep you from stressing out and increasing blood sugar with illnesses and infections and challenges.
Adam: I guess the tough part is reaching people before it’s too late…
Dr. Guthrie: I think that’s a very good comment. To get education in early, I’ve spoken to younger children at a number of schools and also given out healthy snacks. We’ve gone in and done some relaxation practices and also handed out healthy snacks to children. You might be a bit surprised at what was in those snacks, and what was considered healthier compared to what they’ve been eating.
With obesity being such a problem, it’s important to start with kids, as well parents and other adults. Then, we need to do those things that may be less challenging to them and more supportive. We also need to help them feel more comfortable with their environment, food structures, and lifestyle.
Adam: What can an organization like the American Association of Diabetes Educators (AADE) do even better? Is there a way to deploy more resources to help achieve even more?
Dr. Guthrie: That’s a hard question. One of my soapboxes is that since many endocrinologists have interests in problems other than diabetes – even though that’s probably their breadbasket type of work – I would like to see AADE have a certification line for physicians. They currently have them for nurses, pharmacists, and dietitians. A line for physicians could be handled the same way with all basic information, and then physicians could develop their own questionnaires.
This way, people could know if their physician was certified specifically in managing diabetes. The College of Endocrinology is doing a wonderful job, as is the American Diabetes Association (ADA) and AADE. But this would allow people to recognize that a certain family practice physician might not have any background in endocrinology other than what he studied in medical school. I think that’s one of the weaknesses in the healthcare armamentarium that AADE could handle very well. I also think more education and research is needed in complementary and alternative modalities, and the recognition that those modalities can be integrated in a very safe and effective way.
Adam: What about reimbursement for education and educators?
Dr. Guthrie: Yes, and that is certainly coming about. You may have heard about having a code for a multi-teamed interaction with the patient. I told my husband about that because he is an advisor for the Endocrinology Coding Conference. I think he can get something started. If we were not only paid for the patient but also for the health professional’s time, it would induce more clinics with team support. Then you could deal with the psychosocial, medical, and nutritional management of these patients.
As clinics do this, they do better overall on their average A1c, if you want to use that as a marker. To me, that marker also says patients are educated, they are handling some of the stresses in their life, they know the resources, and they have ongoing phone support 24 hours a day, 7 days a week. That helps keep them out of the emergency room and the hospital, which lowers costs.
Adam: What are some good sources for more information on complementary and alternative medicine?
Dr. Guthrie: They can go to the National Center for Complementary and Alternative Medicine at http://nccam.nih.gov. They can also contact the Holistic Nurses Association or they can contact the Healing Touch Program and Healing Touch International. If they contact either one of those programs, they can find Healing Touch practitioners within the confines of their city/state and get information from them individually.
The other group is Therapeutic Touch, which was started by Dolores Krieger. Again, it’s to focus on the modality that helps a person to really, really relax. Her research shows that it even amplifies or increases the size of red blood cells. Also, Yale University, Wichita State University, and the Teacher’s College of New York have Internet courses for people working on their advanced preparation. These are especially useful for nurses looking for more education in the diabetes field. Other universities are starting to work on these types of specialties too.
Adam: That’s really encouraging to hear. Dr. Guthrie, this has been fantastic. Thank you for speaking with us so much about complementary and alternative medicine. It’s not an area we have focused on, but given your reputation and your wonderful Living Legend Award, we wanted to meet you – it’s been a privilege and you have given us a valuable new perspective.
Dr. Guthrie: Thank you so much for listening.