Type 2 Treatment

I feel the same frustration about postprandial lipids. I mention them and people simply ignore the issue, mostly because we all have simple ways of measuring BGs and not such an easy time measuring lipids.

I don’t know for sure how bad they are, but I think they should be discussed.

It’s the same way with glycemic variability. There has been evidence for years that it’s not just the A1c that is important, but whenever I mention it people — including some well-informed people on other lists — repeat the statement that all that matters is the A1c.

Some folks probably do understand it. Others don’t. I blogged about glycemic variability here:

http://www.healthcentral.com/diabetes/c/5068/10513/peaks-matter/

“My book goes into more of the science behind diabetes than Bernstein’s does, and I sort of resent reading that it’s written for dummies.”

Gretchen:

If your book is written so that just about any one can understand it, then you did a great job! Keeping it simple really does make an impact when trying to educate people. I plan on reading your book(s). I may want to refer to it in my monthly articles at dLife.com.

Jenny:

I find some of your statements to be over reaching. My (GP) family doctor treats me for my type 2 diabetes (He is in his early 50’s). Dr. R was very frank and straight forward regarding the dire consequences I faced if I did not lose weight, get control of my blood sugar, and get control of my A1C. He even told me that even with tight control I could still face amputations, kidney failure, etc.

Dr. R did not tell me that medications would do all of the work. He did tell me that many of his patients initially begin to eat right, lose weight, and exercise, but then they realize how well their medication(s) keep their blood sugar in line. This is where they begin to lose the “sense of urgency” regarding their condition and begin to slack off. I have experienced this same pattern.

Travis

Travis,

Count yourself VERY lucky.

When my old doctor measured my blood sugar in the office near 250 mg/dl she shrugged it off as “nothing to worry about” and refused to prescribe me a meter, so I had to pay for my own strips for years.

I have so many friends in this region who have A1cs like 7.2% who tell me that their doctors tell them they need do nothing more as they are in “great control.”. My email box is full of letters from people who have had to fight with doctors to get any help at all, despite blood sugars going well over 200 after meals.

Just today I got an email from a physician who told me he was adding my blog to his side bar and lamenting the trouble his profession has got itself into.

I don’t say there aren’t good doctors out there, only that there are a lot who are not good, and the tragic part is that their patients don’t know their doctors aren’t good, but will find out about it the hard way.

After reading a lot of these posts I realized how lucky I am to find the doctor I have. When I was diagnosed my blood sugar was over 800 and I was in the e.r. for 12 hours on iv’s. They released me from the e.r. with a script for Glucaphoge and a meter. My doctor at the time wasn’t even in the states as he went to visit family for Christmas. He got back and the same day he got back, he immediately hospitalized me. Never taught me anything, didn’t have me go through the classes nothing. I started doing my own research and no matter what I did my sugars wouldn’t go down to normal. I tried the low carb, the no carb etc and just didn’t work and all he did was keep upping the Glucaphoge. I got frustrated with this and asked him about insulin and he said no way. So I changed doctors. The new doctor was pretty aggressive for a while, but then he started to just get down right nasty with me. Used to get mad at me when I went to e.r. with blood sugars that wouldn’t register on my meter, then the e.r. doctors would admit me because ketones were off the charts, but yet he kept getting mad at me. I convinced him to let me try insulin. The insulin wasn’t making a difference and I kept asking him about changing dosages and he kept telling me I didn’t need insulin just needed to change my diet, etc. I had changed my diet, I wasn’t eating a lot of carbs, sugar, etc. My blood sugar still wasn’t under good control. So once again I get frustrated with him and I search for a new doctor. Found Dr. Anderson. One visit with him, he added Lantus to my mix of insulins, changed my dosage on the fast acting insulin and wow in a matter of 3 months my sugar was under control. First time in 3 years. By this time I have also begun to notice I was losing feeling in my toes, my heart beat was skipping beats, and I was having trouble telling when my bladder was full. So Dr. Anderson starts running tests. The 3 years doctor’s spent playing with me and not taking my diabetes serious, caused me to have peripheral neuropathy and autonomic neuropathy. I have been with Dr. Anderson for almost 3 years now and he sees me every 3 months for routine diabetic lab work. I can page him 24 hours a day and he will be there. He listens to me and takes any and all of my concerns seriously. He has come to realize that I have a pretty good grip on my diabetes and I know my body extremely well. If I find some new research on diabetes I want to try, he will read through the research and together him and I will put out heads together and figure out how to attack this. Just Thurs night when I had to page him because my sugar was high, he said to me if your sugar doesn’t get under control in a few days, make an appointment and you and I will put our heads together and figure out what the next step is going to be. He never just tells me ok you have to do this. He always wants my input on it and if I am not comfortable doing it, then he won’t tell me it has to be done that way. Guess I got lucky when I finally found him. He isn’t even an endo, he is just a GP. I have seen all the endos in my area and I always end up going back to Dr. Anderson as they won’t listen to me and hate it when you question them. This is my body and if i am uncomfortable with something I am going to voice my opinion. I actually had one endo that kicked me out of his practice for doing my own research and questioning him. He told me I was a non complaint patient.
So to all the Dr. Anderson’s in the world I say thank you.

I think your friend’s husband is living in his own world. He probably hasn’t read a thing on the subject of diabetes, and his doctor is either as dumb as he is (and probably is) or doesn’t care, which may very well be true. A doctor (and old endo) told me, “There is no real drawing line for diabetes, you know.” “Really,” I said, “then how can you ever tell a patient that he doesn’t have diabetes?” This jerk graduated from Yale in 1966. He should retire. He would be doing the public a favor. Your friend’s husband should stop by a good book store and buy Dr. Berstein’s Diabetes Solution. The fact is that doctors are covered up with work, get their training from drug reps, and don’t know how nor have time to help patients with their diets, exercises, weight, or anything else. You just have to educate yourself, and for the most part, be your own doctor.

After reading these posts I too have got to just give thanks that I went to the Dr. that I went to a little over a year ago. Went in for a physical, which I hadn’t done in years, he sent me for blood work and about a week later had to go back in to see him after his nurse called and said that he needed to see me again ASAP. I was immediately put on Humalog Mix 75/25 (12 unit shot once a day) and told that I would be scheduled, as soon as my insurance approved it, for diabetic training. By the time that was scheduled I had done a lot of research on my own, which was backed up and added to by the training that I went through. Since then, with my diet and lifestyle changes, I have been able to switch to Metformin and drop the shot. I am sure, though, that if I go back and my numbers start going higher that he will not hesitate to put me back on the shots. Not all Dr.s have the attitude of your friends husband’s. If that was my Dr. I would have still been giving myself a shot. Diabetic training, I believe, made a huge difference in my life. Sounds like he needs some of that.

I am also a type 2. I do not simply give myself an extra dose of medicine when I overeat or whatever. I am very fortunate, though, to have a very caring doctor. One that takes time to talk, to listen to me, to answer my questions, to really care about me. I know not every doctor does this. He may not after another couple of years.

I don’t like going to the doctor, I admit that. Hadn’t been for a number of years before my wife made me get a physical last year. Now I don’t dread it nearly as much. Finding a good doctor makes a lot of difference.

I am sure that if your doctor doesn’t want to be bothered, that there is another one in your area that would love to have you as a patient and is willing to take the time to listen to you and not be judgmental.

Gretchen, I read this discussion this morning and have just ordered your book from Amazon. How nice to have an author like you as part of this community! I have had diabetes since 2000 and I know the book is for the newly diagnosed, but like so many I am still trying to learn more, get better control, etc., so I can gladly read a helpful book for newbies!

As you’ve noted, passive treatment (or non-treatment) is standard for T2 in the US – at least, for people who fit the traditional T2 profile (55 or older, overweight/obese and/or family history of diabetes and/or personal history of hypoglycemia), who are diagnosed by GPs they have had for some time. (Note that most GPs do not have extensive knowledge of diabetes or diabetes care.) Those of us who are diagnosed T2 at a younger age, or who have younger doctors, or whose doctors’ lives are touched by diabetes – may be treated more aggressively.

Glucose testing is a big “elephant in the closet” of T2 management. Many insurance companies do not cover testing (or sufficient testing) for T2s, many T2s are not sent to CDEs or given sufficient education about diabetes, and have no idea what the numbers from their meters mean (or what they can do to affect them). This has been recently reported in a number of studies as “testing in T2 only increases anxiety and does nothing to improve BG/A1C” – an extremely dumbed-down analysis, if you start looking at how rarely the test subjects are testing, and that they are not given any education on what to do with the numbers (other than, maybe, to report them to the doctor). The long and short of the story is that, by and large, T2s do not test sufficiently and do not know enough to modify their behavior based on the readings.

In addition, there are five separate classes of oral medication – each of which works differently, and each of which may be preferred or contraindicated depending on the cause of hyperglycemia (and any other medical issues the patient may have). Unfortunately, medical practice regarding T2 diagnosis is not sufficiently developed to insure that general practitioners (and possibly even endos?) routinely test to determine the underlying cause(s) of persistent and/or postprandial hyperglycemia. This, along with insurance companies’ treatment of all of these classes of drugs as interchangeable, results in physicians not prescribing the correct oral antihyperglycemic and the correct type of diet plan for the patient in question.

Finally, insurance companies don’t always cover sufficient follow-up exams for T2 diabetics. ADA standards suggest 3-6 month follow-ups, depending on lab results and level of “control” – and many GPs are either not informed enough, or not proactive enough, to push for greater levels of care. Add to this that insurance companies have no vested interest in the long-term prognosis of any individual patient, since that patient is likely to be insured by a different company (or uninsured) by the time complications take hold.

Here’s where things get a bit tricky: we are each of us upset seeing someone close to us not taking or receiving optimal care for his/her diabetes, and we would like to see them paying closer attention to their health (and better care for their health) – but there is a limit to how far we can push, depending on the available disposable income (above rent/mortgage, taxes, utilities, transportation, insurance, basic food) and the person’s willingness to take an active role in his/her care. We also have to contend with the attitudes of a previous generation – in which patients entrusted their doctors with their care, and believed that the doctor always knew best – and the time pressures of anyone employed in today’s rat-race-you-need-to-be-more-productive-and-are-expendable-if-you-aren’t culture.

Those numbers don’t sound OK to me but I also think that most people don’t like to be told what to do or think, especially if they haven’t asked for any advice. She might really appreciate knowing there are things he can do to feel better, or she might tell you to mind your own business! You could try sharing more of your own experience though – not necessarily “hinting” or telling her what she should be concerned about, but just talking about how it’s been for you, and what you’ve learned. Obviously T1 and T2 are different, but we all have to deal with BG issues and the exhaustion that can come with high numbers! You can ask her, too, how she feels about what she’s telling you – it sounds like she already has some concerns about how tired he is, so maybe she already kind of knows something is not quite right.

Just a note about your last comment. I think this is a biggie, and when I was pressured to put in more and more time at work (given shorter and shorter deadlines), I talked to my doctor, who actually gave me a note to take to my supervisor–who totally understood anyway and is working with me to improve things, but the company is still one of those “rat-race-you-need-to-be-more-productive-and-are-expendable-if-you-aren’t” types. What my doctor said to me about it, though, is that, with a condition like this, we need time to manage it, even what she called “thinking time,” time to consider what we need to be doing to stay healthy, and time to do those things. But I loved the idea of “thinking time” and that my doctor “prescribed” it for me.

I worked as a tech writer and editor for 15 years before I finally just couldn’t take it anymore – the expectations can be brutal! Your doctor sounds like a real keeper. Congrats and good for you, for holding your ground on this one. It’s important!

Thanks, Sweetpotater. I’ve put in more than full-time again this week even though part of the mega-project was given to someone else, but once this deadline is over hopefully we can manage my assignments a bit better.

The problem with this job and the one you had is that deadlines loom no matter what, and barring, I would hope, a catastropic emergency, even if I took a “sick day,” the deadline would still be there and still be mine to deal with. So yeah…and with a company that routinely takes poorly done manuscripts on too-short deadlines…this will be a hard one to keep on top of, staying at JUST full-time.

Yes, my doctor is good, at least in her attitudes about a lot of things, like this. She knows that I am very proactive about my health, so in our sessions it’s more like we are conferring than like she is giving me “doctor’s orders.”

Ellie, I want your doctor!!! That’s exactly what I need to explain to people - that I do things a bit more slowly these days and I am juggling so many more things. My doctor doesn’t seem to understand at all - after being diagnosed and in hospital he booked me off work for 3 days so that I could learn about diabetes and adjust to having it. He then expected me to go back to work in another town away from all my support, and cope. AND at this stage I was diagnosed as having Type 1 and was on insulin!!!

Is this what his doctor ordered or is this just what he is willing to do? Because he really should be having his A1C blood levels checked every three months and seen by a doctor every three months about, and checking his blood more than just in the AM…you could hint that his levels are too high and that maybe he should check with his doctor about it. This is just a few suggestions…I also get my eyes checked once a year, control with diet and exercise even though I’m on medication and see a diabetic nutritionist every other month . It doesn’t sound like he is really taking care of his diabetes and that could be a reason why he is soooo tired.