“My Diabetes Management Isn’t As Good As I Want. Am I to Blame?”

John Zrebiec, L.I.C.S.W., is Director of the Behavioral Health Section at Joslin Diabetes Center.

This post is written by John Zrebiec, L.I.C.S.W., Director of the Behavioral Health Section at Joslin Diabetes Center  and Lecturer in Psychiatry at Harvard Medical School and Robert A. Gabbay, M.D., Ph.D.,  Chief Medical Officer and Senior Vice President at Joslin Diabetes Center and Associate Professor Medicine at Harvard Medical School. This post is in response to the New York Times article, “I have diabetes. Am I to blame?” by Rivers Solomon, which was published on October 12, 2016.


John Zrebiec is the Director of the Behavioral Health Section at Joslin

Based on years of treating people living with diabetes, we have seen their tireless efforts at self-management lead to the massive motivation roadblocks of blame and shame, driven by the great American myth that more self-discipline and willpower will reign. As Ms. Solomon eloquently notes, these are elusive qualities that sabotage motivation and engagement in treatment.

Unfortunately, medical professionals have often added to this torment by implying that patients can achieve idealized targets if they just try harder.  We propose an alternative strategy, where the focus shifts from fortifying self-control to changing one’s environment and setting realistic goals in order to make it as easy as possible to manage the complex demands of diabetes.

As Ms. Solomon movingly expressed, she found it impossible not to internalize that she was to blame. We often see patients describe themselves as “bad, lazy or selfish” for not reaching therapeutic goals. This palpable level of shame is fertile ground for depression, destroys self-worth, and is one of the most common reasons for not discussing self-care with healthcare professionals. That is why we propose an individual, family and medical model based upon constructive problem-solving rather than blame and shame.

To those with diabetes, we suggest that persisting with the daily grind of taking care of diabetes stems from the inspiration of more important non-diabetes life goals, such as a promotion at work or walking down the aisle at your daughter’s wedding, rather than anything intrinsically rewarding about checking blood glucose levels several times every day. We need to empower those with diabetes to make these human connections to events, milestones and staying healthy so they can live the life they deserve, and enjoy it with their loved ones. Trying to motivate patients with guilt or shame is counterproductive and unsuccessful.


  1. Very well said, encourage a person with diabetes to live a full, active and productive life while managing diabetes. Somehow during the past 60 years, with ups and many down, I’ve on balance managed T1D fairly effectively while productively employed and enjoying many interests.

    I fully endorse what you suggest about medical personnel leaning more to encouragement rather than over criticizing a patient’s inability to manage a condition that can not be controlled. Set achievable goals and work from there.

  2. It’s about time that someone realized that controlling blood sugar levels is not a simple task. It is an ongoing daily effort and there will be some days that no matter what you do nothing will work. Too bad most “medical professionals” don’t realize that diabetes management is different for each individual. There is no “one size fits all” approach!

  3. FINALLY, someone is listening! I am type 1 diabetic since 1969, I’ve lived & done well through many changes in diabetes management, (diabetic for several months before diet soda was available, for many years before home glucose monitors (blood), before a1c testing, before insurance covered insulin let alone the syringes…). I had the best experiences with my Pediatrician who told my mother to let me be a child first then worry about the diabetes. After that I was not so fortunate, and usually get labeled non-compliant since my a1c levels were not “adequately” controlled. When I try to inform other individuals, lay people as well as health professionals, they all look at me like I’ve grown 2 heads…. Yes, diabetes is very individualized, and I am seeing trends now that harken back to my very early days as a diabetic. Oh, and btw I am a RN of over 20 yrs experience, tell me about frustrating. Thanks bunches for this article and I plan to forward this to as many health professionals that I can.

    • You are right about what youre saying its not an easy task and is an individual task. Each diabetic struggle is different and im type 1 as well and had many down days where no matter what i try it doesnt work.

  4. Thank you for posting this information. My daughter is a type 1 and also has an intellectual disability in the area of abstract concepts, which math is abstract. Diabetes is all about math which compounds things so much for her. She is insulin sensitive. Right now we are trying to understand how to best manage this, it has been a very difficult road. She now has a Dexcom CGM which has literally saved her life. We find keeping her legal is so very difficult. Each day she seems to need glucose tablets or juice. Our life seems to revolve around this. I wish I could take this from her and have it myself which I cannot. I’m so thankful that technology is progressing quickly. Thank you all for the work you do!

  5. I applaud the way you expressed treating Diabetes by focussing in improving quality of life and taking away feelings of guilt of shame. I am the best example to explain how you can become a diabetic as I almost got there. For personal reasons I ‘ve practiced indiscriminate overeating for 20 years and I’ve enjoyed a happy life with plenty of physical activity. I am a very relaxed person and I also worked passionately two jobs for over 20 years. I am a registered nurse and my HBAIC started to climb to 5.8 after my job that I used to adore became the biggest pain in the butt ( the boss took the vacations away). I was experiencing being stressed and out of control of my goals. Everything came back to normal as I ditched the job. Most of the diabetics have a imbalance between sympathetic and parasympathetic system with overuse of the stress system (sympathetic). When you overuse sympathetic system everything that you eat turns to sugar and also the transfer of sugar in muscular and fat cells is inhibited . This transfer of sugar becomes active when the parasympathetic system is active as during siesta or during sleep. there is also an underlying belief of loosing sweetness (la dolce vita), a stressful event triggers a new onset of diabetes. That my be a loss of job, car, affection etc. My exception to the rule was one of my patient that made himself a diabetic by doing carbo load followed by intense running after the meal . He wanted to be ”disabled” because that allowed him to spent time with his two sons .All of these diabetic complications are nothing else but an accumulation of effects produced by the overuse of sympathetic nervous system : foggy mind, vision problem, fast heart rate, increased contractility of the heart , EF greater than 55%, inability of the heart to relax ( diastolic dysfunction), increased blood pressure due to vasoconstriction and activation of RAA system, numbness and vasoconstriction in peripheral and abdominal circulation, digestive and kidney problems due to the same etc.

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