How I'd Treat Type 2 Diabetes
Traditionally, treatment of type 2 diabetes went something like this:
You're diagnosed and told to "watch your sugar," or you're told to lose weight and come back in a month, or three months. When you do, usually little has changed, because watching your sugar or trying to lose weight when you've been trying to lose weight for decades but haven't succeeded doesn't do much for most people.
Today things have improved a bit, and you're usually prescribed a blood glucose (BG) meter and told to test a few times a day. But you're not told what to do with that data. If your BG levels have been very high, you might be given some medication right away. And then you're told to come back in a month or two. You might be told to go to diabetes education classes and to see a dietician, or you might not.
When you return for the second visit, you're basically told the same things: lose weight, exercise more, and test a couple of times a day, with no real instruction about what to do with the test results.
I'd like to propose a new paradigm for type 2 diabetes treatment, one that emphasizes intensive testing in the early days after diagnosis, then tapering off as you gain understanding of the disease.
Here's how my plan would work:
1. At the first meeting, you would be told your starting A1c, told what it represents, and given the normal range of A1c, which would be your target. Then you would be given a meter and enough strips to test just twice a day and told to test fasting and two hours after your largest meal of the day. All this information would be written down and handed to you as you left, because you might not remember it. Most of us are so shocked by the diagnosis that we're in a sort of fog for a while.
Of course this isn't intensive, but I think most people are in too much shock right away to do much else to begin with. You might be told to stick with your current diet for a couple of days, testing after meals, so you'd see what happens when you eat the way you've been eating. Then you'd be asked to reduce calories, reduce carbs, reduce fats and notice what changes occurred.
2. Month 2. At the second meeting, about a month later (if you felt you were ready for this earlier, that would be scheduled), you'd start the intensive part of the treatment, with the help of a certified diabetes educator (CDE). First you'd be asked if you were willing to do a little work in order to gain control over your diabetes. The CDE would explain that it would involve a lot of record keeping, but if you used the results to modify your diet and exercise patterns in the way that worked best for you, you might be able to avoid taking drugs, or you might have to take fewer drugs than if you didn't do so.
The CDE would provide you with a continuous glucose monitor. Your insurance would pay a small rental fee for the monitor, as well as paying for a month's worth of sensors. The CDE would show you how to insert the sensor for the monitor and would instruct you to write down everything you ate, every bit of exercise you did, and every stressful event or sickness that occurred during the month.
3. After two weeks, you'd come back to make sure you were doing things correctly and to ask any questions you had about the monitor.
4. Month 3. After another two weeks you'd come back and turn in the monitor. You'd now be given a prescription for enough strips to test 8 or 10 times a day to continue your investigations of diet and exercise and BG levels.
The CDE, or a technician, would download the results from the monitor and input all your food, exercise, and stress data. The software would combine this information into graphs, and a week later you'd come back and review the graphs with the CDE. From the graphs, you'd get a good idea of when your BG peaked after low-fat meals, high-fat meals, small meals, and huge meals, so you'd know when best to test with your regular BG meter.
Together you'd see if you could see any patterns that could be changed. Did you always go high on weekends? After parties? During stressful work weeks? When worrying about going to the dentist? Did you stop losing weight, or even gain some weight, after days when you ate certain kinds of food? Did you start losing again after other kinds of days?
The CDE would try to focus on the meals that were most successful in controlling BG and aiding with weight loss and would urge you to eat more of them and less of the other meals.
If at any time it was clear that you weren't doing anything with the results of your BG tests, for example, if it was clear you continued to eat three jelly doughnuts for breakfast every day, the CDE would prescribe just two strips a day again. The CDE wouldn't be judgmental and tell you that you were a "bad diabetic" but rather would say that the intensive testing wasn't having positive results right now and so it made sense not to prick your fingers so often.
5. Month 4. Now you'd have another A1c test, to see if the modifications in your diet were having an effect. Your weight would also be checked. If the system was working, you'd be given a prescription to test three times a day. If you usually ate the same kinds of foods at about the same time of day and did the same amount of exercise, you should know when the best times to test would be. If you felt you still needed more intensive testing, you could request more strips.
If the A1c and weight showed that the intensive testing hadn't been helping, the CDE would explain again how to use the test results to modify your diet/exercise patterns, and you'd be given a second chance for intensive fingerstick testing. If that didn't work either, you'd be cut back to the two strips a day.
6. Month 7. Now you'd come back for another A1c and a discussion of your progress. The CDE would explain that as time passed and you had a good idea of what things made your BG go up (or down), you wouldn't need to test as often.
Some days you might not need to test at all. If you found your fasting BG was between 80 and 90 every day, there would be no point in checking it every day. Every other day should be OK for a bit, and then maybe even less often. The CDE would explain how you could do this and stockpile the strips to do intensive testing every so often, just to make sure things were working as you expected them to.
You would also be instructed to do more intensive testing when anything in your life changed, like new foods, new stress levels, illness, or new types of exercise, as well as random spot checks.
At this point, or perhaps even earlier, you would be urged to join a patient support group organized by the CDE, at which patients could share tips and tricks for getting good control. Those who succeeded at lowering A1c or weight would get group recognition. Those who had Internet access would be given URLs of online groups that do the same thing.
7. As time went on, you'd have periodic A1c tests and discussions about your control, but the more you learned about your situation, as long as you didn't require insulin, the less you'd need to test.
The point of this approach would be to do the intensive testing early in the treatment, when you have the most viable beta cells remaining so you have the greatest chance of getting control without a ton of drugs rather than waiting until your beta cells have all died and you need insulin, which requires more testing, to control the disease.
Diabetes is an expensive disease, as the media continues to point out. And the number of people with diabetes is increasing. As more and more people are diagnosed with type 2, and as more and more expensive technology becomes available, the total costs of the disease will skyrocket. When the disease is not controlled, the high costs of treating the side effects will be an additional burden.
I worry that at some point there may be a backlash, that people with diabetes won't be allowed to have any test strips at all. Already the British and others have done studies trying to show that BG testing in people with type 2 doesn't result in better control. One study even suggested returning to urine testing!
Of course testing doesn't help if you're not told what to do with the results, which most people aren't. And of course it won't help much if you are allowed only one or two strips a day at the beginning when you don't know when to test. I think intensive testing until you learn a lot about your own particular form of the disease would be a better use of resources than continuing to prescribe strips for years with no training on how best to use them.
Obviously, this intensive training would require more diabetes educators. Not necessarily CDEs. We could train fellow patients to explain the basics to other patients, as they do online, with a CDE nearby to help if the questions became too technical for the layperson to answer.
With proper education and the proper tools, I think we could control this disease at a lower cost than what society is paying today.