THE VIEW FROM THE OFFICE
TAKING CARE OF YOUR DIABETES
Diabetes is common, all too common. The first thing to say about it is that it can be prevented. The Healthy Lifestyle (Formula for Health) that I have previously described [see below] has been shown to prevent up to 93% of all cases of type 2 (adult-onset) diabetes. Now that's a bargain. No fuss, no mess. Think about it. If you already have type 2 diabetes, you can make it go away by changing to a healthy lifestyle.
From a physician's point of view, diabetes is the most complicated disease we manage in primary care. There can be so many complications. Our job, and yours too, of course, is to prevent each and every complication. To achieve this we need teamwork--you and your physician working together.
One of the things that makes diabetes so complicated is that there are so many experts out there who are publishing "guidelines" for an ideal world. The American Diabetes Association (ADA), for example, is a very well-intended organization which has done a lot of good work. They publish a set of guidelines ("Standards of Care") for diabetes based on the recommendations of experts, which make diabetes so complicated that no one could do it in the real world. They were apparently conceived for the world of specialists where they have a lot more time to manage their patients--an hour or more. In primary care we average only 15-20 minutes. The ADA recommended standards, if followed to the letter, would take on average about 2 hours per visit. I did a survey in a prior practice of mine in Pennsylvania in a rural setting (Hershey) among primary care physicians. It turns out that not one was following the published ADA guidelines--because they just didn't have the time. The reality, moreover, is that no one has ever done a study to see either if the specialists themselves are actually following the ADA "standards of care" or whether, if they do, it really makes a big difference in patient outcomes.
Well, my prevailing principle in medical practice is to Keep It Simple. With that in mind, I have reduced the necessary steps for high-quality care of diabetic patients to 6 simple steps, which I make easy to remember by giving it the little memory clue the first six letters of the alphabet "ABCDEF". Here is all that you need to keep track of for your diabetes:
A = Hemoglobin A1c; this is the basic measure of sugar control in diabetes. It is a test that assesses your average glucose level for the past 3 months. The goal is to keep the hemoglobin A1c at 7.0% or below.
B = Blood Pressure; Blood pressure control is extremely important in diabetes to prevent the development of renal failure. The goal is to keep your blood pressure averaging < 140/90 mm Hg.
C = Cholesterol. The primary measure of cholesterol that is used for patients with diabetes is what we call your "bad" cholesterol or LDL cholesterol. For diabetic patients the goal is to keep your LDL below 100 mg/dL. It usually takes medication, a statin, to do this.
D = is for MDRD method of assessing kidney function. This is the only letter of our mnemonic that is not intuitive. The MDRD stands for the Modified Diet in Renal Disease study, which is where this method of assessing renal disease and its progression in diabetes was developed. The MDRD number is your estimated glomerular filtration rate (it may be easier to refer to your kidney function as GFR)--i.e., how many milliliters of fluid can your kidneys filter every hour. The goal is for this number to be anywhere above 60. Most adults start with a normal GFR between 100-120. You won't really run into serious problems until it falls below 30, which is when you will want to consult a kidney specialist and start getting informed about dialysis options and procedures. As soon as it crosses below 60 you want to track it regularly. Some medication doses may have to be adjusted. The important thing to know is that kidney failure and the need for dialysis can be prevented. The secret is to keep good control of your blood pressure and monitor your renal function with the MDRD number.
E = eye checks by an ophthalmologist. You should have one at the time your diabetes is first diagnosed, and then every 2 years thereafter. This is to check for diabetic eye disease which is a major cause of blindness; it is preventable. Your ophthalmologist may suggest a different interval for follow-up checks ranging from every year to every 3 years. Your doctor needs to have a copy of the ophthalmologists latest report in his chart for you. You can help by asking your ophthalmologist to be sure to send your doctor a copy.
F = foot exams. A major complication of diabetes is loss of circulation and nerve function in your feet. This in turn can lead to repeated injury (since you won't feel any pain) and ultimately to difficult to treat foot ulcers, and finally, if these can't be controlled, to amputation of a part of your foot or leg. Your doctor should perform a good foot exam at least every 6 months looking for signs of severe fungus infections, bacterial infections, ulcers, or other sores or breaks in your skin. Just doing a good visual inspection of your feet on a regular basis has been shown to reduce the rate of amputations in diabetics by 50%.
And that's it. It's really not all that complicated. There is absolutely no reason why you cannot track these 6 measures yourself. And, if it is not your doctor's usual practice to check any of these things, you can simply ask. If you are prepared and aware, you can insure that every thing that needs to be done is done. What you need, in a nutshell, is to ask for 3 blood tests--a hemoglobin A1c (should be checked every 3-6 months), a cholesterol panel, and a kidney function test (creatinine, which is how they calculate the MDRD number). You can check your own blood pressure at home; this is a really good idea. Then just ask your doctor to check your feet every 6 months and review with them when they received the last report from your eye doctor, whether you had any changes from diabetes in your retina, and when you are due for your next eye check up.