November 21, 2012

No Guidance for New Diabetes Patients


For many patients with type 2 diabetes that have had their diagnosis for several years, this news is not new. A new study published online in the journal Primary Health Care Research & Development says that patients that are newly diagnosed with type 2 diabetes feel left in the dark and wonder where to find information to give them guidance. Even though this is a study done in the United Kingdom (UK), it is still applicable for new patients in the USA and other countries.

With the increase in diagnosis of type 2 diabetes, most countries do not have the necessary personnel trained to teach the new people what is necessary to manage diabetes. The patients is the USA may think that certified diabetes educators (CDEs) are available, but many areas of the country are without them and in other areas doctors will not make use of them. This is often because the doctors think they are the only source of information and others have had conflicts with the CDEs.

The authors state, “With type 2 diabetes being most common in older patients it was commonly reported that it was difficult "to break habits of a lifetime". This barrier to changing lifestyle is partnered with negative views of the 'new' diet, with it viewed as mundane and unappealing.” I have heard this said by many patients and the complaint is about bland food.

Recently I asked a woman complaining bitterly about the foods her doctor had recommended to her – why she had stopped using spices and condiments to add flavor back. She looked at me as if to say “your a man and don't know how to cook.”

Her friend who had been agreeing with her said their doctor had taken both of them off highly processed foods and prepared meals from the freezer section. The doctor had ordered them to eliminate as much fat as possible and eat more carbohydrates. He had also said to eat more fish and skinless chicken. I asked how long they had been doing this and they both had been doing this for about six months. I commented that getting away from highly processed foods, was probably the best advice they had received. I then asked if they were testing to see how different foods affected their blood glucose. Both looked at me and stated their doctors had not given them anything to test with or any information about testing.

The next question I was hesitant to ask, but I asked how much weight they had gained since diagnosis. They did not hesitate in saying – one had gained 15 pounds and the other had gained about 20 pounds. Both said they could not keep the weight off even by walking and swimming. I knew they were because they were not that much overweight for their size and bone structure. At that point, the one lady asked how I knew about testing. I said I had type 2 diabetes and was using insulin and tested regularly. She then asked what my last A1c had been and when I said, she stated that hers had still been over 7.0% and the other lady said hers was about 7.0% also.

Since we were in a store that had a pharmacy, I suggested we go to that area and I would show them the meters. After seeing them, both asked how to use them. The pharmacist had seen us and came over to answer questions. She asked which doctor(s) they were seeing after she learned they had diabetes. After they answered, the pharmacist stated that the doctor they were seeing would not give out meters and did not recommend testing. I asked if they were determined to stay with their doctor and both said it sounded like they should consider other doctors. The pharmacist asked if they saw doctors in other areas and both said the same city as mine are located in and I suggested my endocrinologist. The pharmacist volunteered to call the office and see if they could get appointments and she got their names and information and I said I would go home and get my meter and come right back.

When I returned the pharmacist had received appointments for them and was covering what Medicare and their supplemental insurance would cover. The one lady was asking what their out of pocket costs might be if they needed more strips. The pharmacist covered the costs for the meters they had in stock and both agreed it could be worth the extra cost. At that point the pharmacist handed me a marker and said to show them where to use the lancet, which I did. I then used it and explained how to adjust the lancet device to set it to have the least amount of pain and still get a sufficient amount of blood. I then took out a test strip and inserted it in the slot on the meter, explaining why I was doing it in the order I was. I then used the lancet and let them see the blood while I took the meter and carefully pushed the tip of the test strip into the blood. My reading was 98 mg/dl. The pharmacist asked how long since I had eaten and I said about four hours.

Then I changed the device in it to have a clean lancet and asked if anyone wanted to test. The pharmacist said wait and went to get a few alcohol pads and wiped the lancet device down and since the bathrooms were clear across the building, wiped one of her fingers. She had me put a test strip in the meter and while she adjusted the depth on the lancet device and pricked her finger. She took my meter and carefully pushed the tip of the test strip into the blood. The reading for her was 76 mg/dl and she said that she does not have diabetes and therefore it should be lower. Both women then said they would test. The pharmacist again wiped the device after I had replaced the lancet with a new one. Then she adjusted the depth and I inserted a new strip in the meter. The first try was insufficient blood and the pharmacist demonstrated the proper way to get enough blood. The reading was 168 mg/dl for the first person and 198 mg/dl for the second. We talked about when they had eaten and what medications they were taking. The pharmacist agreed that both readings were too high and that depending on their ability and what they desired, to strive for much lower readings. We discussed the different levels that people should consider for the medications they were taking.

The pharmacist said she was busy and if they had more questions they could ask them another day. The one woman said that since it was such a good day, we could adjourn to her place, which had a screened in patio, and they had more questions for me. The other asked if she could stop and get her husband and it was agreed. The four of us would get together in about 20 minutes. Neither had purchased a meter at my suggestion since the office for their appointment would probably give them a meter and I wanted to discuss the different meters with them.

After we were all together, I started by talking about food. The hostess said we get it, we will get off the carbohydrates and back to bacon and eggs or sausage and scrap the bread until we have our meters. She continued that my talk about spices and condiments had given her ideas for other foods and they would be trimmed until they had their meters. Both women agreed and said I had given them ideas, and that they would stay away from processed foods. I asked if anyone had taught them how to count carbohydrates and they admitted they had not had anyone talk about that. I asked what cookbooks she had and if any of them were recent. She said her husband had just bought one they were going to give their daughter. She got up and brought it back. She also brought a diabetic cookbook. I took the Better Homes and Gardens cookbook (must be the tabbed ring binder), flipped open to the meats section, found a page with recipes on both pages, and laid it out for them. One recipe had servings for four and the nutritional information for one serving. We looked at the information and the light came on in both their eyes. The carbohydrates were listed as 22 grams and fat at 40 grams. The hostess said that is as recipe she and her husband would eat and folded the corner. I told her to look at the diabetic cookbook. She said that most of the recipes were not something they would eat and no nutrition information was given. I gave them several more cookbook titles that I knew had nutrition information.

Both women said they were going to go shopping after their appointments the following Tuesday. When she returned the cookbooks, she brought her laptop back and asked for my email address. The other woman reached into her handbag and brought out a pen and small pad. She copied my email address and asked for potential web sites for reliable information. I pulled up several sites and those she was interested in she bookmarked. She said she would email the list to her friend later. I finally gave her my website and both looked at me. Then the hostess said that is the reason you were not afraid to speak out. I showed her my blog on cookbooks and she said no wonder you were not bashful in showing us the information. She looked through several of the blogs and said this was something she would have to read later. I had her bookmark several other blog sites and Health Central. I showed them where to join and this would allow them to select bloggers the they might desire to follow.

Since we had talked about their medications. they were each on one of the sulfonylureas, I asked if they had been told about hypoglycemia. They admitted they did not know what I was talking about. So I directed them to two of my blogs here and here. On the second blog, they followed the link to Joslin and both asked if I knew why they had not been told. I asked if they had been instructed not to take the medication if they were not going to eat a meal and they answered yes. I said then the chances were they may not have had any problems with the number of carbohydrates they were told to eat. I suggested that they maintain that number until they met with the doctor on Tuesday and definitely discuss different medications at that time.

Both thanked me and said they would have to thank the pharmacist also for recommending a change in doctors and making them aware of what they had not been told. We parted company for the day, but they have stayed in contact and expressed how much they appreciated their new doctor. They have changed oral medications, are happy with their meters, and are testing to see how the different foods affect their blood glucose. Yes, they are paying for extra strips out of pocket, but are happy that they are able. Both have been told to learn about insulin in case they do not get their A1c's to at least 6.5%. They are confident they will, but they are asking me questions and are happy that I and others have written about insulin and the related issues. I asked them if they felt they were threatened and both answered no, they felt like the doctor wanted them to learn about insulin so they would be ready if insulin was needed in the future. I said I was happy to hear that and that they were not discounting insulin.

2 comments:

Gretchen said...

Sad what bad advice so many people are receiving.

Bob Fenton said...

Thanks Gretchen.
There are still too many that this is the rule for the guidance received.