Ensuring Good Care
You’ve just been diagnosed with diabetes and you want to take proper care of yourself. After all, you know that if you control your blood glucose levels, you’ll feel better and lessen your chances of developing complications. But there are two problems. The first is that you don’t know enough about diabetes to ask the right questions. And the second? There’s a chance your doctor doesn’t know a lot about diabetes, either.
On the other hand, it’s possible that your doctor didn’t explain much when you were diagnosed because he knew that all you would hear that day was the word “diabetes,” and wanted to give you some time to let the diagnosis sink in.
Short of completing a fellowship in endocrinology, how can you tell if your doctor knows enough about diabetes to give you the proper care? It’s simple: Interview your current or potential doctor. Although taking care of your diabetes day-to-day will be primarily a do-it-yourself project, you’ll need the proper knowledge and tools before you can manage the condition, and that calls for a team of experts to guide you along the road to maintaining good health.
Dr. Rhoda Cobin suggests beginning the interview with your doctor or prospective doctor with the open-ended question, “What’s going on in my body?” Cobin, who is a past president of the American College of Endocrinologists, Clinical Professor of Medicine at the Mount Sinai School of Medicine in New York City, and practices endocrinology in Ridgewood, New Jersey, says that that is the most important question you can ask.
That one question, Cobin says, can open up a dialogue between you and the doctor. It’s a chance for the doctor to tell you about diabetes: how it begins, how it can affect the rest of your body, what needs to be done to manage it, and more. It can also lead to more questions and answers covering a variety of subjects related to diabetes and other health concerns.
It’s also a chance to see if you and the doctor are able to communicate. The doctor needs to tailor his explanation to your needs, taking into account issues such as your age, motivation, education level, particular lifestyle issues, and coping style, Cobin says. If his answers don’t seem to make sense, if you don’t understand what the doctor is saying even after asking for clarification, or if the doctor doesn’t seem to be paying attention to you, you might want to keep on looking.
Some specific questions to ask include the following:
“Where will you send me for diabetes education?”
While many endocrinologists offer diabetes education in-house, general practitioners frequently do not. Most will, however, have access to diabetes education centers through hospitals, pharmacies, or other health-care facilities. Private educators or education centers also are available throughout the United States. If you go to www.diabeteseducator.org/, the website for the American Association of Diabetes Educators, you can click on “Find a Diabetes Educator” on the left-hand side of the page to search for one in your area. You can also search by state for diabetes education programs that are “Recognized by the American Diabetes Association” for meeting national standards of excellence at http://professional.diabetes.org/erp_list.aspx. The cost of education is usually covered by your insurance and Medicare.
Why do you need diabetes education? Well, you didn’t learn readin’, writin’, and ’rithmetic without a teacher, and you didn’t learn to drive without a driving instructor. In the same way, it’s difficult to learn to live the rest of your life with diabetes without education. Diabetes educators — a group that includes nurses, dietitians, social workers, pharmacists, podiatrists, physicians, exercise physiologists, and others — can help you form a management plan that fits your lifestyle and your needs.
“Take a class,” advises Janis Roszler, a registered dietitian and certified diabetes educator. “Not only do you get to hear a variety of experts and learn in a supportive environment, but you’re with people who are in the same situation. They may ask questions you might not think of asking, or are too uncomfortable to ask.” Taking a class — or having one-on-one sessions with a diabetes educator — also helps debunk some of the misconceptions about diabetes. “Treatments and attitudes have changed drastically,” Roszler says. “It’s not your grandfather’s diabetes.” And as you learn more about diabetes, the tasks you are being asked to do to manage the condition make more sense.
“How often should I check my blood glucose levels?”
Sorry, but “Oh, you don’t need to check” is not the correct answer. Monitoring your blood glucose levels can tell you how you react to different foods, exercise, stress, and illness. It can also help you remain in control by showing you whether you have a problem with high or low levels at certain times of day, which may signal a need to adjust your medicine or insulin doses. If you have Type 2 diabetes, which is a progressive condition (meaning that people often need to add medicines or begin using insulin to stay in control as time goes on), monitoring your blood glucose levels can let you know when you need to change your regimen.
How often should you check? Good question. You could check your levels before each meal, plus two to three hours after you first begin eating to see how the meal affected your blood glucose level. You can also check at bedtime, at 3 AM to see if you’re going low in the middle of the night, before and after — and even during — exercise, and in situations such as before you get behind the wheel to drive someplace if you take insulin or a medicine that can cause hypoglycemia (low blood glucose).
How often you check really depends on your situation, including the types of medicine you take, the level of control you are aiming for, and your economic situation. Since test strips can be expensive, even checking the four times a day generally recommended for people using insulin (before each meal and at bedtime) may be beyond your means if you don’t have insurance or have a low income.
In some cases, such as that of people with Type 2 diabetes who control the condition with diet and exercise, blood glucose monitoring may be recommended just one time a day — one day before breakfast, the next day before lunch, the next before dinner, and the next at bedtime, says dietitian and diabetes educator Dana Armstrong, former program director of the Diabetes Care Center in Salinas, California. People with Type 1 diabetes, however, need to check more often, “and this is a tough go without insurance,” she says.
In any case, ask your doctor or educator if he can give you a sample meter and some test strips to start you off. “I don’t think those are unfair things to ask for,” Armstrong says. You can also shop around for an economical store-brand meter that takes less expensive strips. Look for those at places such as Wal-Mart or Walgreens. There is also a brand of strips called the Sidekick Testing System that consists of a vial of 50 test strips with a meter built into the cap.
“What should my blood glucose levels be?”
Running consistently high blood glucose levels is the primary cause of diabetes complications. While there are no guarantees that you can avoid complications altogether, you can greatly reduce your chances of developing them. Long-term studies of people with Type 1 diabetes and Type 2 diabetes have shown that “tight” control reduces the risk of diabetic eye disease, kidney disease, nerve damage, heart disease, and more.
The American Association of Clinical Endocrinologists (AACE) recommends a fasting blood glucose level of below 110 mg/dl, a level of less than 140 mg/dl two hours after you’ve taken the first bite of a meal, and an HbA1c of 6.5% or less. Individual blood glucose readings show what your level is at the time you check, while an HbA1c test shows your average blood glucose levels over a period of about three months.
While these numbers are the goals advised for most people, your doctor’s recommendations may vary depending on a number of variables, including pregnancy, age, and other health considerations. For example, Dr. Helena Rodbard, former chair of the AACE’s Diabetes Care Guidelines Revision Task Force committee and an endocrinologist practicing in Rockville, Maryland, says, “In a patient with hypoglycemia unawareness (a condition in which blood glucose levels fall very low without triggering any of the usual warning symptoms, such as headache, dizziness, or hunger), it is reasonable to aim for higher blood glucose levels than the ones recommended by the guidelines. It needs to be individualized.” At the other end of the spectrum are recommendations for pregnancy, when blood glucose levels need to be “as close to normal as possible,” she says.
It is, Rodbard says, “very important to check blood glucose… [and] it’s absolutely essential if you’re making changes to your regimen. We want to prevent the complications of diabetes. We want people to live longer and better lives, even with diabetes — and it’s perfectly feasible.”
“Will I need to take medicine?”
If your Type 2 diabetes cannot be managed with diet and exercise, you’ll probably be prescribed oral diabetes drugs. People with Type 1 diabetes must always use insulin because their bodies don’t make it anymore, and some people with Type 2 diabetes need insulin to control their blood glucose levels, too.
When you eat, your body converts the carbohydrate in the food into glucose, which is what your cells use for energy. Insulin’s job is to get the glucose out of your bloodstream and into your cells. But when you have diabetes, you either don’t make enough insulin or your body is not as sensitive to the insulin you do make as it used to be. Also, in many people with Type 2 diabetes, the body doesn’t release enough insulin when they first begin eating to keep their blood glucose levels down after the meal.
There are many types of oral diabetes drugs. Some slow down the absorption of carbohydrate from meals, some decrease glucose production by the liver, some stimulate your body to make more insulin, some make your body more sensitive to insulin, some cause excess glucose to be eliminated in the urine, and some have multiple purposes. You may be prescribed more than one oral medicine, or an oral medicine plus insulin. Be sure to ask your doctor the names of the drugs you’re being asked to take, how they work, and if any can cause low blood glucose (hypoglycemia). It’s also legitimate to ask for samples to take while it’s being determined what types of drug(s) work best for you. If you cannot afford the drugs you are prescribed, ask your doctor about the drug manufacturer’s patient assistance program — most have one. If you have Type 2 diabetes, it’s likely that, over time, your drug doses will be increased, more drugs may be added, or different drugs — including insulin — may be needed. That doesn’t mean that you haven’t been taking the right steps to manage your diabetes; it’s simply a natural progression of the condition.
If you are prescribed insulin, you will need instruction on how to balance insulin, food intake, exercise, and other factors. In short, eating makes your blood glucose level rise and insulin makes it come down. Exercise also can make your blood glucose come down (think of it as a natural insulin-sensitizer), while factors such as illness, infection, and even hormone levels can affect your body’s need for and response to insulin.
“What about medical tests?”
Tests to check your average blood glucose values, blood lipid profile (cholesterol and triglycerides), kidney function, and more are done routinely in people with diabetes as a preventive measure. It’s better to catch a potential problem early, when steps can be taken to slow or even reverse damage, than to wait until it has impaired the function of one or more of the body’s organs.
The American Diabetes Association recommends the following schedule for medical tests:
Blood pressure: Every visit. The AACE suggests a blood pressure of less than 130 over 80–80 mm Hg.
HbA1c: At least twice a year in people who are meeting treatment goals; at least four times a year in those who are not meeting treatment goals or whose therapy has changed.
Lipid levels: Once a year, or more often if needed. The ADA recommends an LDL (the “bad” cholesterol) level of less than 100 mg/dl for those without heart disease and suggests a goal of less than 70 mg/dl for those with heart disease. HDL (the “good” cholesterol) recommendations are over 40 mg/dl for men and over 50 mg/dl for women. Why the difference? “Women’s estrogen tends to make [HDL] higher,” Dr. Cobin says. The ADA also recommends a triglyceride level of less than 150 mg/dl.
Microalbuminuria (measures kidney function): Once a year. People with Type 1 diabetes are tested about five years after diagnosis, whereas those with Type 2 diabetes are tested immediately upon diagnosis, since they may already have had diabetes for some time.
Dilated eye exam: Once a year, within five years of diagnosis for people with Type 1 diabetes and upon diagnosis for people with Type 2 diabetes.
Foot exam: Visual exam at each visit and a comprehensive exam once a year.
“Will I need to see any specialists?”
You may need to see one or more specialists immediately upon diagnosis if you have Type 2 diabetes or within five years of a diagnosis of Type 1 diabetes.
Why the discrepancy? “Many people with Type 2…have had diabetes for a significant period of time and not known about it,” says Dr. Fred Williams, an endocrinologist in Louisville, Kentucky, and former chair of the Public and Media Relations Committee for the AACE.
The first specialist somebody with Type 2 diabetes is referred to is an eye doctor — either an optometrist or ophthalmologist — for a dilated eye exam, Dr. Williams says, adding, “It’s striking that so many patients with Type 2 already have complications.” The eye doctor checks for signs of diabetic retinopathy, in which the blood vessels that supply blood to the eye’s light-sensitive retina are damaged. If caught early, it can be treated, but if ignored it can lead to vision loss.
Other specialists you may be referred to on an as-needed basis include the following:
Podiatrist. This foot specialist is recommended “if we identify problems, or if the patient doesn’t see well, can’t trim their nails, or has neuropathy (nerve damage) and shouldn’t be trimming anything,” Dr. Williams says. People with diabetes are prone to nerve damage and reduced circulation in the feet, making it difficult to feel a wound or for a wound to heal. Pressure points or calluses can make the feet vulnerable to further damage such as foot ulcers.
Cardiologist. “Once we identify a problem,” says Dr.
Williams — he does preliminary tests in his office, then refers his patients to a cardiologist, or heart specialist, for a stress test if a problem is indicated. “People with no symptoms at all have had abnormalities on their EKG,” he says, adding that “a significant number have had abnormal stress tests.” Heart disease is the number one killer of people with diabetes.
Nephrologist. A nephrologist, or kidney specialist, might be needed at some point, Dr. Williams says. His patients have an annual test for microalbuminuria, which measures the amount of a specific protein called albumin in the urine. If the level gets too high, it can indicate early kidney damage. Initially, oral medicines can be prescribed to help stop, reverse, or slow down the process; careful blood glucose and blood pressure control can also help.
Neurologist. Dr. Williams’ patients are rarely referred to a neurologist, or doctor specializing in nerve damage. “We can do nerve conduction studies in our office and know what the drugs are for painful neuropathy,” he says.
Wrapping up the interview
To succeed at managing diabetes you must assemble a strong diabetes care team to support you. Creating a partnership with a doctor you can trust and rely on is an essential first step in this process. Doctor appointments can often feel rushed, and you may find yourself walking away feeling like your questions haven’t been answered (or, conversely, feeling overwhelmed with new information). But when you’re diagnosed with diabetes, it’s more important than ever to make sure that you and your doctor are on the same page when it comes to your health care. Once you know which questions to ask, you’ll have to decide whether you’re satisfied with the answers you receive.