Diabetes Forecast

The Secret to Dealing With Setbacks

What you need to know to bounce back from adversity

Eric Hinders/Mittera

Dina Carter, RN, may be a registered nurse, but even she doesn’t like needles. When Carter was recruited to lead resilience-training classes for African Americans with type 2 diabetes in Austin, Texas, she was nervous.

It was 2007, and the class was part of an experiment run by University of Texas health education researcher Mary Steinhardt, EdD. Steinhardt’s goal was to see if teaching people with diabetes strategies to improve their resilience, or ability to bounce back from setbacks, would have a bigger impact on their health than standard diabetes education.

Steinhardt recruited members of African American churches in the Austin area. Some of the participants took a typical diabetes education class. The rest were given a resilience-oriented curriculum that taught them ways to improve their social support networks, make small behavioral changes, and build a positive mindset regarding their diabetes.

Carter, then 58, was both an instructor and a participant. But for the first few sessions, she told her fellow participants she’d forgotten the logbook she was supposed to be using to record her blood glucose levels. “I was afraid to stick myself,” she says. “And I was ashamed to let them know that I was a nurse and I was afraid.”
When she finally admitted the truth in class, she found she wasn’t alone—and that she was using an out-of-date meter that required a large drop of blood, making monitoring her blood glucose more painful than it needed to be.

Over the course of the eight-week program, she and the other participants formed a tight-knit group. “We bonded, we learned how to problem-solve, and we learned that we had a lot in common,” Carter says. “We came to realize we could manage diabetes and make changes. If you stumble, you can always come back and start again.”

Snapping Back

That’s resilience in a nutshell: the ability to recover from setbacks, to rebound from bad news or difficulties. The term, which has been the focus of attention in psychology circles for decades, has been applied to everything from grief to post-traumatic stress disorder to, yes, a life-changing diagnosis such as diabetes. “Resilience includes emotional regulation, coping ability, and social support,” Steinhardt says.

The importance of resilience has sparked a growing movement to incorporate the latest resilience research into diabetes prevention and treatment. “Having diabetes is so demanding and so nonstop that anyone with diabetes has challenges to overcome,” says Marisa Hilliard, PhD, a pediatric psychologist at Baylor College of Medicine in Houston.

Born to Bounce Back?

So where does resilience come from? Although it’s possible to build resilience, some researchers look at it as a personality trait; in other words, it’s a quality you’re born with.

To understand the impact of resilience on people’s chances of developing diabetes, Casey Crump, MD, PhD, an epidemiologist and family practice physician at the Icahn School of Medicine at Mount Sinai in New York, looked at a surprising source: Swedish military exams.

In Sweden, military service is mandatory for men. Since the 1960s, nearly all Swedish men have been interviewed by trained psychologists as part of their evaluation for military duty. The half-hour interview is designed, in part, to measure their capacity for resilience in combat and to see if they’d make good leaders.

Because of the way the Swedish health system works, it’s possible to link the scores men were given as teenagers to their health outcomes much later in life. “We were able to link longer-term outcomes to much earlier assessments of stress resilience for nearly the entire male population,” Crump says. “We found that low stress resilience is pretty strongly associated with a high risk of developing type 2 diabetes later in life.”

What wasn’t clear from the study, published in 2016 in the journal Diabetologia, is why. There could be a few things going on: One possibility is that people with less innate resilience might be more likely to turn to smoking or adopt unhealthy eating habits to deal with stress in their lives, says Crump.

Another possibility is that more-resilient people are less physically affected by stress. When we encounter stressful situations, a hormone called cortisol is released in the body. Cortisol helps the body access the resources—glucose, for example—that it might need to fight or flee from danger. The hormone is ideal for escaping predators, but when it’s released on a regular basis, it takes a toll. High cortisol levels are associated with depression, as well as insulin resistance, weight gain, and type 2 diabetes.

Perhaps people with more resilience are simply less likely to get stressed, so they stay healthier. “People with stress resilience have lower physiological responses to stress and more well-adapted lifestyle factors,” says Crump. “They’re probably exposed to less persistent high levels of cortisol over the course of their lifetime.”

Steinhardt, too, sees stress playing a big role in type 2 diabetes. Stress can create a vicious circle that makes it harder to care for your diabetes. “It’s important to acknowledge that type 2 diabetes is a chronic stressor,” she says. “When individuals with diabetes are stressed, they often eat more, skip visits to the doctor, and don’t take their meds.”

Growing Resilient

Although some people might naturally have more resilience than others, experts say there is plenty of evidence that everyone can develop more of it. Some even argue that looking at resilience as a trait is limiting, or even discouraging. “If you think about resilience as something you have or don’t have, there’s not a lot of hope there,” Hilliard says.

Crump, the researcher who found a connection between resilience as a young adult and type 2 diabetes rates, says that resilience can be acquired. “There is a good body of evidence that shows stress resilience is modifiable,” he says. “It’s not innate and unchanging.”

That means programs such as the one in Austin that changed Carter’s approach to her diabetes are full of promise. By teaching people how to make small, positive changes, build or discover supportive networks in their communities, and be mindful of stressful circumstances in their lives, the course helped reduce stress levels. That’s essential for people with diabetes, as well as those at risk for prediabetes and type 2. “It’s important to recognize stress management is an important part of the prevention of diabetes across the life course,” Crump says. “People with risk factors should include stress reduction as part of their health plan.”

Not all researchers approach resilience this way. Hilliard, for example, tells teens with type 1 diabetes—and their parents—that resilience is a goal you can work toward, not a quality you’re born with. “We define resilience as the achievement of a positive outcome despite challenges or adversity,” she says.

Indeed, the program designed by researchers at the University of Texas is just one piece of evidence showing that resilience can be taught. “Some of us are born into the world with a greater capacity to bounce back from adversity. Some people are great in a crisis. In that sense, it’s a trait,” says Steinhardt. “But I can grow my resilience. We all have different dispositions, but within what we’re born with, we can grow.”

Whether innate or learned, resilience can help people with diabetes tackle their disease. The people who participated in Steinhardt’s study saw concrete results, according to a paper published in 2015 in the American Journal of Health Behavior: People who took part in the resilience-based education program checked their blood glucose more often, had lower blood glucose levels, and reported a more positive outlook on life.

Carter’s A1C (a measure of blood glucose) hovered around 8 percent when she started the program and had dropped nearly two points by the end. Thanks to the lessons she learned and the supportive community she found, she’s managed to keep her blood glucose at American Diabetes Association–recommended levels ever since. “I’m not on insulin and I’m only taking one pill,” she says. “I’ve improved a whole lot since 2007.”

Teens With Type 1

Baylor College of Medicine psychologist Marisa Hilliard, PhD, is focused on another group for whom resilience is crucial: teens who have been diagnosed with type 1 diabetes. A diagnosis alone can be difficult. And then there are kids who have extra challenges to deal with, such as difficulty accessing health insurance or medication.

Hilliard says parents and health care providers can help by focusing on what teens are doing right in terms of achieving resilience—what she calls their “diabetes strengths.” “There are things teens can do well, maybe naturally. Maybe they have lots of social support and talk easily with their friends about their diabetes,” Hilliard says. These things can help teens bounce back from a type 1 diagnosis.

The larger idea is to recognize and reinforce natural resilience and teach skills that will help teens manage a particularly stressful time in their lives. “It’s not rocket science. It’s behavioral science,” she says. “When you recognize or reinforce behavior, people tend to do more of it. And the data shows that the more you can support teens, the more they develop good habits later in life.”

How to Be More Resilient

As part of her resilience workshop, Mary Steinhardt, EdD, a University of Texas health education researcher, gives participants some key recommendations for building resilience:

  1. Adopt a positive mindset. Focus on positive emotions: awe, wonder, hope. Doing so will help keep your spirits up in hard times.

  2. Take small steps. Making a new healthy habit, such as taking the stairs, part of your routine is easier than trying to fix everything all at once.

  3. Stay connected. In the game of life, “your family and friends are your cheerleaders, and your health care providers are your coaches,” Steinhardt says. Staying connected to the community around you is a key part of resilience.

  4. Seek kindness. Surround yourself with people who are kind to you—and be kind to yourself, too.


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