Dr. William Polonsky and the Behavioral Diabetes Institute on Diabetes Distress and Mental Health in Diabetes Care

A Career Built on Listening

For decades, people living with diabetes were described using one word: noncompliant.

If blood sugars ran high or A1C levels increased, the assumption was simple. The patient was not trying hard enough.

Polonsky questioned that assumption early in his career.

In 1988, Polonsky began working as a diabetes psychologist at the Joslin Diabetes Center in Boston. Endocrinologists quickly referred patients to him.

“Every referral came with one of two descriptions,” Polonsky said. “This person is in denial. Snap them out of it. Or this person is noncompliant. Make them behave.”

Within weeks, he recognized a disconnect.

“Not one person I met was in denial,” he said. “They walked into a building that said Diabetes Center. They knew they had the condition. And calling them noncompliant was not just inaccurate. It was disrespectful.”

Instead of seeing defiance, Polonsky saw exhaustion. Instead of denial, he saw people trying to manage a demanding medical condition while living full lives.

That shift in perspective shaped his work for nearly four decades.

Defining Diabetes Distress

In the late 1980s and early 1990s, patients who struggled emotionally were often labeled depressed. Antidepressants were commonly prescribed.

But the emotional strain did not disappear.

“We started listening,” Polonsky said. “Thousands of people taught us what was really going on.”

What they described was not always clinical depression. It was frustration. Burnout. Fear. Overload.

From those conversations emerged a framework that changed behavioral diabetes research: diabetes distress.

“Depression and diabetes distress are very different,” Polonsky said. “And they require very different interventions.”

He explained that depression affects mood, motivation and overall functioning. Diabetes distress, however, stems directly from the daily burden of managing a chronic condition.

“If someone is sick to death of dealing with their disease every day, an antidepressant is not going to fix that,” he said.

Research once suggested depression rates were dramatically higher in people living with diabetes. Newer evidence paints a more nuanced picture.

“Depression may be slightly higher,” Polonsky said. “But not dramatically higher. What is far more common is diabetes distress.”

Diabetes distress can include:

• Feeling overwhelmed by constant decision-making
• Fear of complications
• Conflict with family members who monitor too closely
• Financial pressure related to treatment costs
• Diabetes burnout after years of management

Each person’s experience is unique.

“It is like a fingerprint,” Polonsky said. “Everyone’s distress profile is different.”

Recognizing that distinction changed how clinicians approached mental health in diabetes care.

Why Language in Diabetes Care Matters

Polonsky believes language is not neutral. Words shape how people view themselves.

“The term noncompliance,” Polonsky said, “needs to be killed and burned and buried in a deep pit somewhere.”

But the problem goes deeper than one word.

For years, clinicians described glucose readings as good or bad. Patients internalized those labels.

“We are trying to remove value judgments,” Polonsky said.

Instead of good and bad, he suggests using language such as safe and unsafe.

A glucose reading of 220 is not bad. It may be outside a person’s preferred range. A reading of 40 is not bad. It is unsafe.

The distinction shifts the focus from morality to safety.

“Once numbers become a statement about your worth as a human being, that is when people start tormenting themselves,” Polonsky said.

For those diagnosed with type 1 diabetes (T1D) in childhood, fear-based education was common. They were shown charts of complications. They were warned about what could happen if they did not maintain tight control.

“Those messages stick,” Polonsky said. “They are hard to take out of your skull.”

The result can be perfectionism, anxiety and long-term diabetes burnout.

Technology, Data and Emotional Burden

Modern technology has transformed diabetes care. Continuous glucose monitors (CGM) and automated insulin delivery (AID) systems provide more data than ever before.

In many ways, emotional burden has improved.

“These systems can operate in the background,” Polonsky said. “You do not have to be thinking about it every second.”

Yet constant data can create new pressure. Polonsky said the goalposts have moved now that people can see all their glucose numbers in real time.

With trend lines available around the clock, some people feel increased pressure to maintain perfect numbers.

Time in range offers a more balanced approach.

“Clinicians and researchers from around the world have recommended that if you are 70% in range, you are probably doing just fine,” Polonsky said. “70%, not 100%! That means you’d be out of range about six hours a day. And that is expected.”

Perfection is not required for long-term health.

“We see people tormenting themselves because they feel they must be perfect,” he said.

He encourages patients to work with their health care providers to define realistic goals. That decision should reflect lifestyle, effort and overall well-being.

Founding the Behavioral Diabetes Institute

More than 20 years ago, Polonsky co-founded the Behavioral Diabetes Institute in San Diego.

The BDI is the first nonprofit organization dedicated entirely to the psychological aspects of diabetes.

“There weren’t very many,” Polonsky said, describing the limited number of clinicians and researchers focused on the psychological side of diabetes.

The institute was created to address that gap in care.

Today, the BDI focuses on:

• Research on diabetes distress and diabetes burnout
• Development of the Diabetes Distress Scales
• Training programs for physicians and educators
• Educational materials for people living with type 1 diabetes and type 2 diabetes (T2D)
• Diabetes Etiquette Cards translated into multiple languages
• Online resources and tools

The institute also hosts professional education programs that train clinicians to improve communication and patient engagement.

In addition to his clinical work, Polonsky continues to conduct research, write and present on behavioral diabetes and mental health in diabetes care.

Polonsky recently revised his book Diabetes Burnout.

The second edition will be published by the American Diabetes Association (ADA) and is expected later this year.

Sustaining a Nonprofit Focused on Mental Health

Maintaining a nonprofit devoted to behavioral diabetes presents challenges.

“Sustaining our work has always been our greatest challenge,” Polonsky said. “We are terrible at obtaining charitable grants.”

Over the years, the institute has relied on research funding, professional training and corporate support.

“It has always been a labor of love,” he said.

Despite funding obstacles, the BDI continues its work, grounded in the belief that emotional health is essential for long term outcomes.

Isolation and the Need for Community

After nearly 40 years of working with people living with diabetes, Polonsky has a consistent observation. He said isolation can affect anyone with the condition, but it can be especially pronounced for those living with T1D, who often manage insulin daily.

“More than half the people I see in psychotherapy or counseling don’t need to see me,” he said. “What they need is to meet other people who are living every day with T1D.”

He said isolation remains one of the most overlooked drivers of diabetes distress.

Management often happens quietly. Many adults feel that friends, coworkers and even family members do not fully understand the daily burden.

Although the BDI serves people living with T1D, T2D, and other forms of the condition, Polonsky said peer connection is especially powerful for those managing insulin.

When people connect with others who share that lived experience, something shifts.

“You feel like diabetes doesn’t have to be the enemy,” Polonsky said.

He points to group medical visits as one model that helps reduce isolation. In that setting, multiple patients meet with a physician and care team for extended sessions.

Benefits may include:

• More time for discussion
• Peer connection
• Shared problem solving
• Reduced isolation

Research shows group visits can improve engagement and satisfaction. They also give clinicians more time to listen.

Hope for the Future of Behavioral Diabetes

Despite the emotional challenges many face, Polonsky remains optimistic.

“Things are getting better,” he said. “And most people do not notice it.”

Data from several countries show that people living with diabetes are living longer and healthier lives than in previous decades.

Importantly, improved outcomes are not solely the result of tighter glucose control.

“It is not just about blood sugars,” he said. “It is about blood pressure, cholesterol and everything else as well.”

There is also growing recognition of mental health in diabetes care.

“There is much greater appreciation now for the psychological side of diabetes care,” Polonsky said.

Then he added, “But what took so long?”

When Polonsky began focusing on the psychological aspects of diabetes in the late 1980s, few clinicians were addressing the emotional burden of diabetes in structured or research-driven ways. 

Over time, his work helped bring diabetes distress and behavioral health into mainstream diabetes care. For many living with diabetes, that shift offered language and validation for struggles they had carried quietly for years.

A Lasting Impact on Diabetes Distress and Mental Health

Polonsky did not begin his career intending to reshape diabetes care. He began by listening.

He challenged blame-based language. He helped define diabetes distress. He co-founded the Behavioral Diabetes Institute to ensure emotional health would no longer be overlooked.

His work applies to people living with T1D, T2D, and other forms of the condition. It applies to newly diagnosed individuals and to those who have lived with it for decades.

Today, conversations about diabetes distress, diabetes burnout and mental health are more common because of his leadership. For those seeking research, education or support related to behavioral diabetes and emotional health, more information is available at behavioraldiabetes.org.