Diabetes Self-Management Articles

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Improving Your Diabetes Care Visits

by Laura Hieronymus, MSEd, APRN, BC-ADM, CDE, and Wendell Miers, MD

“A question not to be asked is a question not to be answered.”
—Robert Southey

It is well-recognized that diabetes is a serious, life-long health condition that can affect many bodily systems. It’s also recognized that much of diabetes care must be carried out by the person who has it.

Because caring for diabetes can be complex, it’s no surprise that people with diabetes often see many health-care providers on a routine basis. In fact, many diabetes centers and clinics use a team approach to treat diabetes, ensuring that patients get both the basic care, education, and health screenings they need, as well as specialist care when needed. People who do not get their care at such a center would do well to establish their own diabetes team of providers who can attend to different aspects of their care and are willing to communicate with one another.

A diabetes team starts with a physician, who may be a family practice doctor, who is specially trained in preventive medicine, or a doctor of internal medicine (also called an internist), who has special training in the prevention and treatment of diseases of adults. Some people with diabetes see an endocrinologist as their primary-care doctor; an endocrinologist is an internist with advanced, specialized training in the care of endocrine diseases, of which diabetes is the most common. (Other endocrine problems include thyroid disorders, growth hormone deficiency, osteoporosis, cholesterol disorders, hypertension, and obesity, most of which occur more often in people with diabetes than in the general population.)

Your doctor should be able to refer you to or recommend other professionals for needs such as nutrition education, diabetes education and training, and specialty medical care. Common diabetes team members include a nurse or nurse practitioner, dietitian, and pharmacist. Others may include a physician assistant, exercise physiologist, ophthalmologist, and podiatrist.

At the helm of the diabetes care team is the person who has diabetes. This is the person who is most aware of the effects of diabetes and its treatment on his life, as well as how able he is to carry out the treatment plan recommended by his health-care providers. One of his main responsibilities is communicating this knowledge to his diabetes team members. The other is making sure he understands the recommendations his team members make.

Preparing for a visit
You can get the most out of your medical appointments by preparing for them ahead of time. Particularly if you’re feeling nervous, scared, or rushed, it helps to write down your questions and concerns before you see a doctor or other health-care professional. If you’re seeing a health-care provider for the first time, you should also bring some notes about your medical history to the appointment.

The National Institutes of Health (the Federal agency that conducts and supports medical research) suggests bringing the following to health-care visits:

• A list of your medical concerns, past and present

• A list of any allergies you may have

• All the medicines you take, including any over-the-counter medicines or dietary supplements (herbs or vitamins), and a written list of all of these items

• A description of any symptoms that you have or have been having, including when they started, whether they come and go, and what, if anything, relieves them

• A notepad (to write down information) or a tape recorder (As a courtesy, ask permission to record the visit.)

• If possible, a trusted relative or friend to help you ask questions, take notes, and absorb all the information presented during a visit

The National Patient Safety Foundation, a not-for-profit organization whose mission is to improve the safety of patients, has developed a number of tips and tools to improve communication between patients and health-care providers during health-care visits. The core recommendation for patients is to ask all of the health-care providers they see the following three questions:

1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Follow-up questions such as “This is new to me. Will you please explain that to me one more time?” are also suggested. (To read more tips, visit the Web site www.npsf.org/askme3.)

Asking questions such as these helps to make sure that your voice is heard during your health-care appointments and that you get the information you need. If you don’t understand what your health-care provider is telling you, ask for clarification. Your doctor wants you to be clear on your diabetes treatment plan, so the more you understand, the better it is for both of you!

If you think it would be helpful to you, ask if your provider has any written materials to give you, such as patient information handouts, or can recommend any books or reliable Web sites that can help you understand more about your health condition. Before you leave the office, ask about your provider’s availability to answer questions by phone or e-mail. Make sure you have the phone numbers or e-mail addresses you need and that you understand your provider’s policies regarding these methods of communication.

Diabetes care visits
The three questions listed at left can be a good place to start when you meet with your diabetes care providers. While diabetes may always be your “main problem,” your doctor may have suggestions for focusing on specific parts of your management plan that will have the most impact. For example, if your blood glucose levels are under control but your blood pressure is high, your doctor may ask you to focus on lifestyle changes that can help lower blood pressure the most.

However, because diabetes can have such wide-ranging effects on the body, the following topics will likely be addressed at all or most visits. If your diabetes care provider doesn’t bring up all of these topics regularly, go ahead and ask about them to ensure that they get addressed.

How is my blood glucose control?

You and your doctor should review your overall blood glucose control, based on your recent blood glucose monitoring records. Be sure to bring your logbook with you, and review it before your appointment so you are prepared to discuss your blood glucose numbers and any concerns you have about them. Ask your provider to take a look at your blood glucose monitoring equipment to ensure that you have an up-to-date meter that is in good working order and that you are using the correct strips and other supplies.

Many of the newer meters have compatible computer software that can organize your blood glucose monitoring results into charts or graphs. (In most cases, you will need a cable that you can purchase from your meter company to transfer your numbers from your meter to your home computer.) It can be helpful to upload your meter data at home and bring printouts of your charts and graphs with you to your office visits.

What is my A1C test result, and how does it compare to my previous one?

Your A1C (or HbA1c) test result gives an indication of your overall level of blood glucose control over the past 2–3 months. You should have it checked at least twice a year if you are meeting the treatment goals set out by your doctor, and quarterly if your diabetes treatment has recently changed or you are not meeting your treatment goals. The A1C test requires a blood sample and may be done in your doctor’s office during an appointment or at a lab before your appointment. You and your doctor should review your results together.

Most commonly, A1C test results are given as a percentage, but in the near future, some labs may also give results as an “estimated average glucose” in mg/dl, the same units that appear on your blood glucose meter. This change is intended to make A1C test results more understandable. (Click here to learn more about estimated average glucose.)

Research has shown that an A1C level below 7% (or an estimated average glucose below 154 mg/dl) means a lower risk of complications from diabetes, regardless of the type of diabetes you have. Depending on your test result, therefore, your health-care provider should work with you to either reinforce your current treatment plan or modify the plan if your blood glucose control needs improvement.

How are my cholesterol and triglyceride levels?

Controlling your cholesterol and triglyceride levels is important for your heart health. Levels should be checked once a year for most adults, and you should have fasted (not eaten or drunk anything but water) for at least eight hours before having blood drawn for this test.

There are two types of cholesterol: high-density lipoprotein (HDL, or “good”) cholesterol, and low-density lipoprotein (LDL, or “bad”) cholesterol. A high HDL level protects you against heart disease, while a high LDL level raises your risk of heart disease. High triglycerides also raise the risk of heart disease.

Because people with diabetes have twice to four times the risk of heart disease as the general population, you should be aware of your cholesterol and triglyceride levels, as well as the recommended levels for people with diabetes. (See “Know Your ABCs” for the current American Diabetes Association cholesterol and triglyceride targets for healthy adults with diabetes.)

How is my blood pressure today?

High blood pressure not only increases your risk for heart disease and stroke, but it can also damage the blood vessels in your eyes and kidneys, possibly leading to vision problems and reduced kidney function. The recommended blood pressure goal for people with diabetes is below 130/80 mm Hg.

Achieving and maintaining this goal can take time, effort, and numerous follow-up appointments with your doctor to find a treatment plan that works for you. But the long-term benefits of making the effort are huge, so make sure you let your doctor know that you’re serious about wanting to control your blood pressure and willing to make the effort.

How do my feet look?

Your doctor should perform a comprehensive examination of your feet at least once a year, although many doctors prefer to examine the feet of their patients with diabetes at every regularly scheduled appointment. A comprehensive foot exam includes inspecting the skin, hair, and nails of the toes and feet and checking nerve function and blood flow. You can help your doctor remember to look at your feet by removing your shoes and socks before your doctor enters the exam room.

In addition to your doctor’s exams, you should be examining your own feet on a daily basis for any changes, injury, or anything out of the ordinary. If you discover a wound or have other troubling foot symptoms, contact your doctor’s office immediately; don’t wait until your next scheduled appointment to bring it up.

Are my eyes healthy?

You should have a dilated eye exam by an eye specialist (usually an ophthalmologist or an optometrist) at least once a year. You will want to discuss the results of your exam with both your eye specialist and your diabetes care provider, so be sure to ask your eye specialist to send a copy of the report to your diabetes care provider. Maintaining optimal blood glucose control is key to preventing diabetes-related eye diseases, and early treatment is important to limiting vision loss if any of them occur. Your diabetes care provider can advise you on “tightening” your blood glucose control, if necessary, to protect your eye health.

If you haven’t had a visit to an eye specialist, ask your diabetes care provider for a recommendation or a referral to one, if necessary.

Are my kidneys OK?

Your diabetes care provider should order a yearly microalbuminuria test to assess your kidney health. This test measures even tiny amounts of the protein albumin in your urine, and it’s the best way to catch diabetes-related kidney problems early. A normal microalbumin test result (meaning there is no kidney damage) is below 30 mg/g. A diagnosis of microalbuminuria is given when the test result is between 30 mg/g and 300 mg/g, and a diagnosis of macroalbuminuria is given when the level is over 300 mg/g.

Because albumin excretion may be affected by such factors as strenuous physical activity, an infection, high blood glucose, or high blood pressure on the day of the urine test, a test result showing micro- or macroalbuminuria should be confirmed in two or preferably three separate tests done over a 3- to 6-month period before a diagnosis is made.

Early treatment is the most successful in preventing further damage to the kidneys, so be sure your doctor tells you not just how your kidneys are doing, but also what you should be doing to keep them as healthy as possible.

Do I need a flu shot?

Just about everyone who has diabetes is advised to get a flu shot once a year, usually in the early fall. People with diabetes may or may not be at higher risk of catching the flu, but they are at higher risk of developing potentially dangerous complications of the flu, such as pneumonia. Your health-care provider may give you a flu shot at one of your routine appointments, or some providers set up drop-in hours in the fall, when established patients can stop in without an appointment or schedule an appointment with a nurse just for a flu shot. If you don’t have a routine diabetes appointment set up in the early fall, ask your provider how best to get your flu shot in a timely manner.

Also ask your provider about the pneumonia (or pneumococcal) vaccine, which prevents against pneumonia caused by pneumococcus bacteria. (It does not prevent against pneumonia caused by other microbes or substances.) This vaccine is recommended for all adults age 65 or older and for all persons with diabetes between the ages of 2 and 65. Generally, only one dose is required. People who were vaccinated before age 65 should be vaccinated again at age 65 if five or more years have passed since the first dose.

Discussing your diabetes medication plan
The majority of diabetes treatment plans include one or more diabetes medicines to help lower blood glucose levels. Many plans also include medicines taken for other reasons, such as a daily aspirin to lower heart disease risk. Over time, as a person’s body and lifestyle change, his medication plan will likely need to change, as well. Taking a few minutes to review your plan with your health-care provider and to ask questions will help you stay up to date on your medication regimen and informed about how, when, and why to take the medicines you take.

It is important to recognize that no medicine is completely safe; all have potential side effects. So any time you and your doctor are considering adding to or changing your diabetes medication treatment plan, you should discuss both the benefits of taking a particular medicine, as well as any risks associated with it.

The U.S. Food and Drug Administration (FDA), the organization responsible for protecting the public’s health by assuring the safety and efficacy of drugs sold in the United States, advises using the acronym “SAFER” to guide discussions of medicine use with your doctor. SAFER stands for Speak up, Ask questions, Find the facts, Evaluate choices, and Read the label and follow directions.

Speak up. To prescribe the medicines that will work best for you, your diabetes care team needs certain types of information about you. This includes your health history (health problems you’ve had in the past) as well as any current physical or mental problems you may have. Your team also needs a comprehensive list of all the medicines you currently use, including prescription medicines, over-the-counter (OTC) medicines, vitamins, and other dietary supplements. They additionally need to know about any allergies or sensitivities you may have to certain drugs or drug ingredients. And they need to know about any personal characteristics that may affect medicine use, such as a history of confusion, failing memory, trouble remembering or swallowing, pregnancy, or breast-feeding. Your team will be relying primarily on you to supply this information.

To be sure you remember all of the medicines you take, make a list at home before your appointment, or bring in the medicines themselves, preferably in their original containers (not a weekly pill organizer, for example). If you write out a list, make sure to write legibly, spell product names correctly, and note the doses you take, as well as how often you take them.

Ask questions. The more you know about your medicines, the better able you’ll be to use them correctly. So ask your health-care team any questions you may have about the medicines you already take, as well as medicines that have been recommended to you. Some examples of the types of questions to ask are listed in “Questions About Medicines”. If you don’t understand the answers you get, ask again. It may be helpful to repeat back what you’ve heard to the health-care provider to ensure that you got it right.

Find the facts. In addition to asking your health-care team about drugs and supplements, take advantage of the many consumer resources that provide this type of information. The librarian at your public library can direct you to books with consumer drug information, your pharmacist may have informational materials to give you, and numerous Internet sites provide reliable drug information. (For example, the US National Library of Medicine’s MedlinePlus Web site has information on drugs, herbs, and supplements: www.nlm.nih.gov/medlineplus/druginformation.html.)

Your research may help to answer the questions you have about a particular medicine or help you to formulate questions to ask your health-care team.

Evaluate your choices. The research you do on your own, along with the discussions you have with your doctor, will help you and your team decide on the best medicine options for you. It’s important to consider both the helpful, desired effects of a medicine as well as the possible unwanted effects in making your treatment choices.

Read the label and follow directions. Reading the labels on your medicines is a way to double-check that you have the right medicine for the right person in the right amount. If the packaging or the medicine itself looks different from previous prescriptions of the same medicine (or containers of OTC medicines or supplements), check with your doctor or pharmacist to make sure you have the right product.

Follow the directions on the label for taking the medicine unless your doctor or pharmacist has told you to do otherwise. Let your team know about any unwanted side effects you experience, but don’t stop taking a prescribed medicine without speaking to a member of your health-care team first. (The one exception to this rule is if you develop a severe allergic reaction, in which case you should seek immediate emergency medical care.)

Check with your doctor or pharmacist if you are planning to take an OTC drug, dietary supplement, or vitamin. In some cases, such nonprescription products can interfere with the action of prescription medicines or cause them not to work as well.

Diabetes education and training
Because there’s so much to learn when you have diabetes, your doctor may refer you to group diabetes education classes or for one-on-one meetings with a diabetes educator. In either case, you will learn about — and have the opportunity to ask questions about — how to take your medicines, how to coordinate your medicines with your meals and other parts of your life, how to monitor your blood glucose level, what to do with the results, how to plan meals, and what to take into consideration when exercising with diabetes.

You can get the most out of these sessions by planning ahead the same way you would for any medical appointment: Write down any questions you want to ask, bring a notepad to jot down answers and other information, and consider bringing a friend or family member so the people who are close to you know how best to help and support you in your diabetes care. Many insurance plans cover a portion of the cost of diabetes education and training, as long as it is ordered by a doctor. Use this benefit to get the information you need.

Getting what you need
Your doctor and other providers are there to help you, and they can help you the most if you are honest with them about your symptoms, lifestyle, and willingness or ability to carry out the various parts of your diabetes care plan. Unless they know what parts of your current diabetes plan are difficult for you, they can’t work with you to develop a plan that works better.

If you have a problem you feel embarrassed about, remember that your doctor has almost certainly heard it before from other patients. Think about the most comfortable way for you to bring up the topic, and practice saying what you have to say in private before your appointment. It may also help to bring a booklet or brochure on the topic, if you have one, to get the conversation going. Even if your doctor doesn’t have all the answers for your particular problem, he can refer you to other professionals who can help.

Always remember that you are a consumer of health care. In one way or another, you are paying for the time you spend with your health-care provider. Get the most out of it by coming prepared, asking the questions that are important to you, and following up until you understand the answers.

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Also in this article:
Know Your ABCs
Questions About Medicines
What Is My Average Glucose?

 

 

More articles on Diabetes Basics

 

 


Statements and opinions expressed on this Web site are those of the authors and not necessarily those of the publishers or advertisers. The information provided on this Web site should not be construed as medical instruction. Consult appropriate health-care professionals before taking action based on this information.

 

 

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