Doctor-Patient Communication for Diabetes Patients

Today this is even more important, but communication is happening even less. The main culprit is the electronic medical record and the time that doctors need to spend at the computer during the office visit. They have boxes to check and other notes to make. Even the fastest of typists has little time for communication in at 12 to 15 minute appointment.

This doctor still emphasizes the importance of communication and lists 10 points to back this up. I find this statement very valid, especially as a patient. He says, “Communication and interpersonal skills of the physician are the heart and soul of our profession as medical doctors.”

He lists the Golden Rules for effective communication by doctors in the diabetes clinic:

“#1. Recognize the importance of patient empowerment as being fundamental to diabetes management. The physician's role is to provide knowledge and expertise to enable patients make informed decisions. But, it is the patients, themselves who are in charge of their destiny and the decisions and choices they make.

#2. Use appropriate words and language when talking to patients with diabetes. Avoid invoking guilt, laying blame, or using incriminating tactics. Perceived benefits are better than perceived threats. Negative or careless language can be harmful and can demotivate patients.

#3. Allow collaborative care, shared decision making, and "strike a deal" with the patient at each therapeutic juncture encountered. An informed communication style of the physician that included a participatory role for the patient in decision making resulted in significant improvement in patient self-care and glycemic control (glycated hemoglobin [HbA1c] improved by as much as 0.7%). In another study, the improvement in HbA1c was found to be even greater (1.5%) as a result of patient engagement in decision making. By contrast, a dominating and controlling style of communication by the healthcare provider resulted in poor metabolic control.

#4. Be practical and seek realistic goals. Focus on the achievable. Life is not about HbA1c level for every diabetes patient or every time for the regular patient attending the clinic.

#5. Be nonjudgmental. Obese patients were less likely to lose weight if they felt the attending physician was in some way judgmental about their weight.

#6. Consider cultural issues, religious beliefs, and personal values of the patient. With some individuals and in certain parts of the world, religious beliefs are dearly held and may even take precedence over other issues in life. This can present a delicate situation to the unwary practitioner who may need to tread carefully between respecting personal values of the patient, on the one hand, and not compromising medical care provided, on the other.

#7. Reward effort, not just outcome. Even modest encouragement can inspire patients to do more for their cause.

#8. Stay tuned to the patient's feelings and pick up the clues early. On average, a diabetes patient drops 2.6 clues per clinic visit. Subtle hints can be related to anything from loneliness at home to shortage of money. Although the physician does not have to solve every problem, an empathic response to the patient's concerns can improve clinic dynamics and change outcome. Furthermore, missed clues mean lost opportunities and, interestingly, lead to longer, not shorter, clinic visits.

#9. Use visual tools as much as possible: make a simple drawing or show the patient a relevant graph or picture to facilitate understanding and enhance motivation. The mere provision of a poster of HbA1c values marked with target goals improved metabolic control significantly in the patients tested. In another study, the Vision Study, investigators showed that graphic display of self-monitored blood glucose data significantly improved metabolic control, with an impressive 0.93% reduction in HbA1c in the type 2 diabetes patients studied. Patients are more believing in something they can see.

#10. Does your patient comprehend and remember the instructions given at the clinic? Patients have poor recall of decisions made at the clinic and tend to forget as much as 50% of what they are told by their physician. To explore the benefits of checking patient comprehension and recall, Schillinger et al. listened to audiotapes taken at outpatient settings and found a significant improvement in glycemic control in patients whose physicians applied this simple interactive strategy compared with those who were not assessed for comprehension and recall. Asking your patient to restate and summarize your instructions makes good sense and is obviously therapeutically rewarding.”

If doctors would do this, then they should also have a recording to give patients to play back at home to reinforce this as well. The doctors should also have approved printouts of reliable internet sources for the patients to read if they are interested.

It is interesting how little HbA1c level has changed over recent years despite the introduction of numerous antidiabetes agents and advanced diabetes technologies.

The doctor says, “The tips cited above are not meant to be a call for physicians to just "be nicer" to their patients or a ploy to improve customer service at the diabetes clinic. Rather, they emphasize the point that the quality of doctor–patient interaction is an important determinant of glycemic control and healthcare outcome for people with diabetes.”

The doctor continues, “Needless to say, communication is accessible to all physicians and is free of charge to all patients. Furthermore, communication has no cardiovascular risk or any other side effects to consider and so will not require regulatory body approval before release into the "markets." Communication should, in my opinion, be considered a universal first-line therapy in any future guidelines made for the treatment of diabetes. We should also train physicians on the art and craftsmanship of communication with people with diabetes.

CPAP Effective for Older People

Continuous positive airway pressure (CPAP) is effective at treating sleep apnea in older people, a new study has found. I can believe this as most older people have conquered most of their fears and vanity of wearing the equipment and realize the importance of sleep to their health.

Previous studies have established the benefits of CPAP in middle-aged people with OSA (obstructive sleep apnea), but until now there has been no research on whether the treatment is useful and cost-effective for older patients. The new research found that CPAP reduces how sleepy patients feel in the daytime and reduces healthcare costs. The researchers say CPAP should be offered routinely to older patients with OSA, and more should be done to raise awareness of the condition.

Now if the United States would accept the research. The study was published in Lancet Respiratory Medicine. It involved 278 patients aged 65 or over at 14 NHS centers in the UK. It was led by researchers at Imperial College London and the Royal Infirmary of Edinburgh in collaboration with the Medical Research Council Clinical Trials Unit at UCL, and the Universities of Oxford and York. It was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme.

Sleep apnea can be hugely damaging to patients' quality of life and increase their risk of road accidents, heart disease and other conditions. Lots of older people might benefit from this treatment. Many patients feel rejuvenated after using CPAP because they're able to sleep much better and it may even improve their brain function. Patients with sleep apnea sometimes stop breathing for 30 seconds or longer at night before they wake up and start breathing again. In these pauses, their blood oxygen levels fall.

The low oxygen levels at night might accelerate cognitive decline in old people, and studies have found that sleep apnea causes changes in the grey matter in the brain. They're currently researching whether treatment can prevent or reverse those changes.

Weight Loss Drugs May Not Be the Answer

Even with the algorithm from the American Association of Clinical Endocrinologists, the use of weight loss drugs is still not the blockbuster Big Pharma had dreamed they would be.

Obesity experts blame the poor sales of weight loss drugs on:

#1. Doctors' lack of training in how to treat obesity.

#2. Concerns about the medications' safety.

#3. A lack of insurance coverage.

The following are my additions to the above:

#4. Doctors' favoritism of surgery, including bariatric surgery.

#5. The costs of weight loss drugs, often in excess of $200 per month. It is hard to keep people on the drugs as long as 1 year due to price.

#6. Doctors' have this belief that 'willpower' is going to help.

#7. Doctors' are more likely to advise obese patients to eat less and move more, but diet and exercise, by and large, is ineffective for treating obesity.

#8. There are about 50 diseases (includes diabetes) that are caused by obesity. Doctors are happy to replace your knees, but this is not addressing the root problem.

One patient says that the weight loss drugs suppresses your appetite and food that you normally eat is lost when you lose your desire to eat it. The drugs can make you irritable and angry – changing your mood. Sleep can be affected because you are not able to stay asleep and are unable to fall back to sleep quickly.

Many people that undergo weight loss surgery are not properly warned about this being a life-long commitment and many regain the weight later in life and require more surgery

Losing weight when obese is a problem for many people and it seems there is not an easy solution.

Be Careful of People Advising Against Low Carb

Before I learned that the glycemic index for foods was developed by using only healthy people, I was an advocate for using low glycemic foods. Now I only use the index as a guideline and nothing more. Several researchers have also recommended using them as guides because they have discovered that certain chronic illnesses do not yield the same results.

Now the author of the glycemic index, Professor Jennie Brand-Miller, is speaking out against very low-carbohydrate meal plans (diets). She was answering this question - If carbs increase my blood glucose levels, wouldn’t a low-carb diet (or even a very low one) make better sense for managing it? Her answer was “In theory, a low-carbohydrate diet seems a logical choice if your aim is simply to reduce blood glucose levels. But presumably your goal is long-term, optimum health with good glycemic control and reduced risk of chronic disease. If so, very low-carbohydrate diets need a little caution because you will be missing out on the micronutrients, antioxidants, phytochemicals and fibre that plant foods (fruit, starchy vegetables, legumes and grains) provide.”

She then avoids talking about fats of any kind when she continues, “In studies that tracked individuals for long periods of time, those eating the least amount of carbohydrate and very high amounts of protein had almost double the risk of dying during the follow up period, especially from cardiovascular disease. You might also find this very low carbohydrate diet so extreme that it's hard to lead a normal social life and enjoy eating because you have to exclude so many favourite foods (think potatoes, oranges and honey).” Bold is my emphasis.

Then she refers to this from Nutrition in July 2014 which the press release can be read here and my blog on it here. She says that the authors, “Call for a complete reappraisal of dietary guidelines for diabetes management and they present evidence for dietary carbohydrate restriction as the first approach in diabetes management. I do think there is some truth in the benefit of modest reductions in carbohydrate intake (to say 40–45% energy). However, I’m not in favour of further reduction because it’s just too hard for most people to comply. Conversely, I'm not recommending an increase in carbohydrate intake to 65% of calories to someone with diabetes; it strikes me as "pushing the envelope" too far.”

For people that do talk about low carb and at least medium fat, read these blogs by David Mendosa, Managing the Condition of Diabetes, Managing Diabetes with a Strange Fat, and Saturated Fat is Back for People with Diabetes. An article in Medscape talks about different fatty acids and how they affect us.

She concludes her article about low carb diets with this statement. “I believe that very low-carb diets are unnecessarily restrictive (bread, potato, rice, grains and most fruits are off the menu) and may spell trouble in the long term if poor quality food takes the place of high quality carbohydrate. Modestly higher protein/low GI diets strike me as a happy medium between low fat and low carb-diets – you can have your carbs, but choose them carefully.”

Impromptu August Meeting

We do have a scheduled September meeting, but Tim and Allen have been working on something they wanted to present. Last Saturday August 30 Tim called everyone for a meeting. Of the 16 members, only 12 were able to attend, plus Dr. Tom.

Tim said I know many of you have been working with other people with type 2 diabetes and have not been having a lot of success. The community has lost three to diabetes and related issues this summer. Allen, Barry, Bob, and A.J have been involved with two of the three, while Tim and Dr. Tom had been working with the third individual. Tim continued that Allen and Barry are working with a difficult case because the wife is a registered dietitian and preventing them from accomplishing much.

Next, he commented on the fellow A.J and I have been working with and having small success with, but not getting far at present. A.J said it is because he is also listening to the wife of the individual Allen and Barry is having problems getting to reduce his carbohydrates. Dr. Tom spoke then and said two of the three deaths involved patients of his and even he had not expected them to die. The families had stopped all investigations about cause of death and therefore we can only suppose that diabetes has something to do with the death. The third one was identified as caused by diabetes, but not the reason, but it was suspected that extreme hyperglycemia was involved.

Tim asked if this wasn't discouraging. All of us agreed and Allen said he does not understand why some people just will not manage their diabetes. Barry added that they have not been able to reason with the people, especially those getting advice from the dietitian. Allen said this might be the toughest situation that we have encountered. The person with diabetes is not happy with his A1c's, but the wife is and keeps insisting he needs his carbohydrates. Plus she is the one cooking and feeding him the high carbohydrate foods. Barry added that she does not avoid high fructose corn syrup and it is found in several of the foods she prepares.

Jason asked if the husband couldn't just eat less. Barry said he had tried that and she just insists he eat more. Barry said he had tried to convince her that low-carb and medium fat was better, but she just says she isn't convinced and that she is the one that knows nutrition.

We talked a little longer, but could not come to something agreeable, so we broke up with the idea to keeping our research going.

Then on September 1, we got the information we needed and the emails were rapid between us. Allen's comment that the wife must be trying to kill her husband by Munchausen's by proxy syndrome seemed a bit extreme, but it fits the way she is so happy with his A1c. Why else would she reject low carb and insist on the high carb and so heavy on the whole grains.

Dr. Tom asked if there was a way for us to get him to his office without the wife, and that has become our next project.

Factors in Managing Your Blood Glucose – Part 2

This is a continuation of the previous blog.

Activity:

Light activity - Light activity can have a surprising glucose-lowering effect. Walking could be considered light exercise.

High-intensity and moderate exercise - Please read my blog on safe blood glucose levels for exercising. Also talk with your doctor before beginning exercise that fits in this category.

Exercise is often described as something that always lowers blood glucose; however, high-intensity exercise, such as sprinting or weight lifting, can sometimes raise blood glucose. This stems from the adrenaline response, which tells the body to release stored glucose. But this is not a reason to avoid high intensity exercise – studies show it can improve blood glucose for one to three days post-exercise! Please note that in some cases high-intensity exercise can also drop blood glucose very rapidly (2-3 mg/dl per minute), especially if you are taking insulin. This also happens to many people on oral medications until they have been exercising for a couple of weeks or longer. The best way to see how individual exercise sessions affect your blood glucose is to test prior and after exercise.

Biological:

Dawn phenomenon - The “dawn phenomenon” normally occurs in people with type 2 diabetes. The term refers to the body’s daily production of hormones around wake up time. During this time, the body makes less insulin and produces more glucagon, which raises blood glucose. The best way to figure out how dawn phenomenon affects you is to wear a CGM or wake up and test your blood glucose early in the morning. Not everyone experiences dawn phenomenon, but it is common for about 50 percent of type 2 patients on oral medications,

Scar tissue and lipodystrophy – If you are taking oral medications only, this will not affect you. Using the same sites on the body for injections sights can lead to lipodystrophy and scar tissue buildup. These result in erratic absorption of insulin, leading to glycemic variability and making it harder to spend more time in range. To avoid these issues, rotate your injection sites and don't reuse needles.

Insufficient Sleep - In my experience, I have found that I need more insulin on days following less than seven hours of sleep. The highest blood glucose of the day is even higher on days following little sleep. These findings are consistent with many studies, which have found that not getting enough sleep leads to worse diabetes management, insulin resistance, weight gain, and increased food intake.

Stress and illness - Stress and illness can cause the body to release epinephrine (adrenaline), glucagon, growth hormone, and cortisol. As a result, more glucose is released from the liver (glucagon, adrenaline) and the body can become less sensitive to insulin (growth hormone, cortisol). In some cases, people are much more insulin sensitive right before getting sick and can tend to run low blood sugars.

Allergies – Research did not yield any results and apparently is not worthy of study. I do have one friend that suffers from ragweed allergy and has problems with his blood glucose levels during ragweed pollen season.

A higher glucose level (“glucotoxicity”) - Hyperglycemia can lead to a state known as “glucotoxicity,” which can actually cause insulin resistance. People going on insulin after being on oral medications can experience this and spend a few days up to two weeks adjusting insulin to bring this under management.

Periods (Menstruation) - There is not an easy answer to the question of how periods affect women’s blood sugars. Many women report having higher blood sugar levels a few days prior to their period starting, but some women notice a sharp drop in sugar levels. To figure out how you respond, your best bet is to test your blood glucose often during this time of month.

Smoking - Some studies suggest that smoking can increase insulin resistance, and people with diabetes who smoke are more likely than nonsmokers to have trouble with insulin dosing and managing their diabetes. Smokers also have higher risks for serious complications.

Environmental:

Medication or insulin that has gone bad – Some people stop taking oral medications and when they need to restart, use the old medications, and get little or no help. Others ruin their insulin by exposing it to direct sunlight or leaving it in the car on a hot day. The worst part is that it’s hard to know if it has actually gone bad unless you try a new vial. In addition, the insulin may work unpredictably. Unopened insulin should be stored in a refrigerator at approximately 36-46 °F. According to the FDA, insulin can be left unrefrigerated at a temperature from 59-86 °F for up to 28 days.

An accurate blood glucose reading - While this seems fairly obvious, I occasionally find myself testing multiple times in a row, since I do not believe the initial value. In some cases, the second time I get a much lower value, and it’s because I failed to wash my hands. I suggest retesting if you don’t believe the value on the meter.

Altitude – People on oral medications generally notice little difference with being at higher or even lower altitude. People using insulin need to be careful as insulin resistance can increase insulin needs. Others that are climbing or skiing may need less insulin. Testing more frequently may be a necessity.

To the above and the previous blog, I would be remiss if I did not mention attitude. A positive attitude makes diabetes management easier and helps make diabetes burnout and mild depression easier to conquer. Then add developing good habits that become part of a daily routine and burnout seldom happens.

Another blog about the reasons for variability of blood glucose levels is this one.  There are overlaps with the ideas included in the blog from yesterday and this blog of today.

Factors in Managing Your Blood Glucose – Part 1

This was somewhat surprising and made me realize how different each person can be when it comes to factors that affect the management of blood glucose. This is also why I become frustrated by the medical and non-medical professionals that use a one-size-fits-all approach in the advice they give to us. I have even had doctors not want to change a medication when I tell them that a medication is causing a particular side effect.

I am also upset by those that say there are only three things necessary to manage your blood glucose – diet, exercise, and medications. Oh, if only it were that simple. It is more complex than that by a country mile. With a couple of months short of 12 years with diabetes, I know that other factors can override the best of management skills. Even keeping a positive attitude gets tested severely at times. I have learned that blaming myself does not solve the problem and at first I occasionally let this happen.  I have rounded up seven categories that can have an influence on our blood glucose levels. They are human factors, biological factors, environmental factors, food/fluids, medication(s), activity, and health. Some writers only consider five and ignore human and health factors.  There are probably more that I have missed.

Human Factors:

Procrastination – okay, I realize some people don't like this, but I have seen this done and do it myself. I get to researching and writing, and it is time to test my blood glucose and I say to myself – in a bit, and then it is an hour later. I have seen other type 2's on insulin in a restaurant and instead of injecting the insulin before the meal; they wait until after the meal. Own up and admit that you have done something similar. Blood glucose can go high when you procrastinate.

Forgetfulness - We can forget and it is easy. Have unexpected visitors and they stayed longer than normal and you are tired and want to go to bed. What happens? You forget to take your before bed medication(s). None of us intends to do this, but life happens. Again, blood glucose can go high when you forget a medication.

Cognitive abilities -  As people age, cognitive abilities can decrease causing blood glucose levels to go high or low.  These people need help and careful management by caregivers and doctors.

Health Factors:

Hospitalization – This can create all types of blood glucose problems. Hospital food can be notoriously high in carbohydrates, especially the meals for diabetics. Then add to this the reason you are in the hospital. Operations can become bothersome and create high blood glucose levels.

Other diseases – Other comorbid conditions can also affect blood glucose levels at different times. It is wise to discuss this with your doctor to learn if other medications for them can cause higher blood glucose levels. Also consider a talk with the pharmacist if one doctor does not communicate with another doctor and you are not sure if he checks your medication list.

Food/Fluids:

Carbohydrates - Carbohydrates affect blood glucose the most. Accurately counting carbohydrates can be very difficult, and getting the number wrong can dramatically affect blood glucose. The type of carbohydrate also matters – higher glycemic index carbohydrates tend to spike blood glucose more rapidly. Lowering the amount of carbohydrates consumed is often to wisest choice.

Fat - Fatty foods tend to make people with diabetes feel full sooner and curb the desire for carbohydrates. A medium to high fat meal plan with low carbohydrates will generally assist in helping you lose weight.

Protein - If you’ve ever eaten a protein-only meal with very few carbs (e.g., salad with chicken), you may have seen a noticeable rise in blood glucose (20-50 mg/dl). Though protein typically has little effect on blood glucose, in the absence of insulin, it can raise blood glucose. When I am eating a carbohydrate-free, protein-only meal, I still take a bit of insulin to cover it. This can raise blood glucose or have a neutral effect depending on your system and body chemistry.

Caffeine - Many studies have suggested that caffeine increases insulin resistance and stimulates the release of adrenaline. I know that if I have any caffeine in the morning, I’ll see at least a 20-30 mg/dl rise in blood glucose, particularly when I’m more insulin resistant.

Alcohol - Normally, the liver releases glucose to maintain blood glucose levels. But when alcohol is consumed, the liver is busy breaking the alcohol down, and it reduces its output of glucose into the bloodstream. This can lead to a drop in blood glucose levels if the alcohol was consumed on an empty stomach. However, alcoholic drinks with carbohydrate-rich mixers (e.g., orange juice) can also raise blood glucose. When drinking alcohol, make sure you test your blood glucose often and that someone responsible nearby knows you have diabetes.

I include this because many people just have to have their alcohol. Another good precaution would be having a designated driver to avoid legal problems.

Medication(s):

Medication dose - For those of us with diabetes on any medication (pills or insulin injections), the dose of medication directly impacts blood glucose. In most cases, but not always, taking a higher dose of a diabetes medication means a greater blood glucose-lowering effect. Care needs to be taken to avoid stacking if possible.

Medication timing - In addition to dose, medication timing can also be critical. For instance, taking rapid-acting insulin (Humalog, Novolog, Apidra, and Afrezza) 20 minutes before a meal is ideal for me - it leads to a lower spike in glucose vs. taking it at the start of the meal or after the meal has concluded. Note that this works best for me, although this can vary among individuals – please consult your doctor to discuss the optimal timing of insulin. The timing of many type 2 diabetes medications matters a lot – some can consistently be taken at any time of day (e.g., Januvia, Victoza), while others are most recommended taken with meals (e.g., metformin).

Medication interactions - Non-diabetes medications can interfere with your diabetes medications and blood glucose. Consult the information included in both your diabetes and non-diabetes medications. If your doctor does not give you information, have a talk with your pharmacist.

Continued in tomorrow's blog.

Patient Mentors Are Important

Over the last few weeks, I have been doing more research about what patients with type 2 diabetes can do to improve their care and learn at the same time. Since the Certified Diabetes Educators (CDEs) are doing battle between the two organizations and haven't enough trained professionals to meet the need of people with type 2 diabetes to say nothing about those with pre-diabetes, this blog drew my interest.

What this medical student says makes a lot of sense. I am aware of some doctors in the more rural states doing peer diabetes mentor training and some peer-to-peer diabetes workers. In correspondence with one doctor, he is being pressured by a CDE member of the ACDE not to train peer diabetes mentors. He asked the CDE if she would be available to work with the 30 plus type 2 diabetes patients he sees. She said she would not and she already had a full caseload of patients.

If members of the Academy of Certified Diabetes Educators are going to work against doctors trying to improve education for people with type 2 diabetes, then we don't need them and their hoity-toity attitudes. Most CDEs do not have type 2 diabetes, do not properly assess those of us with type 2 diabetes, use a one-size-fits-all education, avoid dealing with anyone talking about depression, and in general do not want to deal with the round pegs that don't fit in the square holes they want to put us in.

Heather Alva writes that she was advised to find herself a mentor for medical practice and she says why not take this idea farther. While this medical student is a person with type 1 diabetes, her thoughts do work well for those of us with type 2 diabetes. I will list a few of her points.

#1. Introducing patients to a person who has controlled their blood glucose and managed a healthy and fulfilling life is a far more powerful motivator than fear alone.

#2. As our population ages and more of our patients have an online presence, these online patient networks may become an increasingly valuable resource.

#3. Consider the positive impact of asking if our chronic disease patients are networking with other patients and of knowing good resources to which we can direct them.

#4. Perhaps it is a kinder practice to link our patients to other patients who are successful individuals who lead rich, happy, fulfilling lives, who have been enriched and deepened by life’s challenges, medical or otherwise.

She covers other points and I suggest reading her blog