Team Approach with Diabetes Patients The team approach is optimal for working with patients with diabetes. Assessing the psychological and physiological effects of stress, stress management, and biofeedback on blood glucose control are necessary. In addition to a physician with special expertise in diabetes, the team consists of at least a certified biofeedback practitioner, a certificate diabetes practitioner, a certified diabetes educator, and the patient. The team works together in evaluating the effects of treatment on the physiological and psychological aspects of glycemic control. Most biofeedback practitioners do not have expertise in diabetes education and management. However, when they treat patients with diabetes, they need to know the basic physiology of diabetes and the fundamentals of diabetes management. The psychologist practitioner carries out an initial interview with the diabetic to determine stress -related physical and emotional symptoms. One assesses the patient's perception of the effects of the stress on his or her blood glucose and his or her perceived capabilities and management strategies. Psychological testing also may be used to assess the person's level of depression, anxiety, anger, and current stress. The practitioner also conducts a psychophysiological assessment. Practitioners differ on the specifics of this assessment but often monitor multiple modalities. These often include muscle tension, skin conductance, and blood flow in the hands (via skin temperature), heart rate, and breathing during the resisting baseline, and during and after various standard office stressors. Our laboratory measures frontal electromyography (EMG), heart rate, blood pressure, and finger temperature while patients sit quietly with their eyes closed. The practitioner provides biofeedback, relaxation therapies, and stress management. Relaxation and biofeedback can help patients feel more in control of their physiology, psychological state, and their illness. Furthermore, decreased plasma levels of stress hormones and sympathetic activity mediate lowered arousal and diminished hyperglycemia The diabetes educator (and or physician) can interpret blood glucose values because he or she understands the effects of hypoglycemic medications, diet, and exercise on blood glucose. This person also obtains information about the person's diabetes care regime.The diabetes educator studies: History 1. Family history of diabetes 2. Other medical problems 3. Use of prescription and nonprescription medication Medical Treatment Regimen for Diabetes, Knowledge, and Management 1. Diet: usual caloric intake, restrictions, time of meals, types and amounts of food eaten, meal- planning skills, , compliance problems 2. Activity /exercise. Types. Acute / Chronic Complications of Diabetes, Knowledge and Management 1. Hypoglycemia: frequency of episodes , signs and symptoms, and usual causes With this information, one identifies the patient's knowledge, current self, management, self - care deficits and problems, and capabilities to make appropriate decisions and manage his or her disease. This information provides the basis for instructing the patient about diabetes care and addressing problems with daily management during later session Starting at the time of diagnosis, patients with diabetes need to adjust their life-style and behavior significantly. They must incorporate diabetes management behavior into their daily routine. Psychological adjustment to IDDM and NIDDM often is problematic. Therefore, counseling and supportive psychotherapy can be useful during the early weeks and months after diagnosis. However, beginning a biofeedback -assisted relaxation program may not be appropriate. Adding the clinic appointment for biofeedback and home practice requirements necessary to learn relaxation techniques might overload the resources of the patient. Furthermore, it would be difficult to attribute improving in glycemic control to the biofeedback and relaxation because the patient is starting multiple new behaviors concurrently.Another reason for deferring biofeedback during the fist year after diagnosis is the so-called diabetic "honeymoon period". This phenomenon is the partial or complete remission of the signs and symptoms of diabetes soon after the onset of IDDM when the pancreas temporarily produces insulin. The blood glucose level may stabilize at close to normal, and the need for exogenous insulin may decrease significantly or completely. This period may last one, several, or, rarely, 12 months (Krall&Baser, 1989). One could mistakenly attribute a decrease need for exogenous insulin to the biofeedback and stress management treatment instead of to temporary pancreatic insulin production. When the honeymoon period ends and the patient's beta cells are not longer capable of producing insulin, the patient could misattribute the renewed need for exogenous insulin as a total failure of the self-regulation process. Within a stepped -care model consider starting more conservative relaxation therapy or office-based biofeedback -assisted relaxation sooner than 12 months after diagnosis for selected patients. For example, one could start with audio cassette relaxation instructions and printed patient education about relaxation. The material should include information to avoid misattributions about the honeymoon period. Patients must at least partially accept the idea that stress can negatively impact on glycemic control. Increased average blood glucose, a wider range of values, an increase in fasting blood glucose, and sometimes more frequent hypoglycemia are common stress effects reported by patients. Ifa patient is unaware of or rejects the correlation between stress and blood glucose, then perhaps stress is not affecting that person's blood glucose. However, if he or she does not understand stress and is unaware of the potential or its effects, the person may misunderstand its impact. In this case, educate the patients about stress and its relationship to blood glucose. This can improve the chance for treatment to help normalize blood glucose levels. The goals of biofeedback-assisted are to: 1) Increase the person's ability to perceive and effectively manage stress. 2) Decrease the neural and endocrine systems' effect s on blood glucose and insulin. 3) Reduce average blood glucose and increase the percentage of fasting blood glucose values at target range. 4) reduce dosage of hypoglycemic medication if blood glucose levels are well controlled at entry.Relaxation therapies involve slow, diaphragmatic breathing, meditation, autogenic phrases, and/or progressive muscle relaxation. One also may use "positive imagery" with other relaxation therapies. Measure the person's blood glucose before and after at least the first relaxation session. In our program, most sessions include instruction and practice of autogenic phrases. About one -fourth of the sessions include progressive relaxation. There are no long term follow-up studies with diabetic population treated with biofeedback or relaxation. However, we suggest periodic refresher sessions as is common practice when treating other chronic disorders. The practitioner and the patient determine the timing of the follow-up office sessions. One periodically evaluates control described earlier.