I continue to learn an incredible amount of information after reading the work of my co-bloggers on this site. David Mendosa is in San Diego covering the 2011 Scientific Sessions of The American Diabetes Association. His most recent blog "Diabetes Causes Nothing" was written after attending one of Dr. William Polonsky's sessions discussing the psychological aspects of diabetes. Having met Bill at a number of diabetes conferences and events, I know how inspiring he is and more importantly, "on point" in terms of what really counts in diabetes care. These issues truly matter to me as I interact with children and adolescents with diabetes on a daily basis.
How can I make the most of these interactions?
How do I motivate my patients to take care of their diabetes?
What medical regimen works best for each individual?
Conventional split mixed insulin 2 or 3 shots/day?
Multiple injections via basal/bolus therapy?
Insulin pump therapy?
Oral medications, only?
Oral medications and insulin?
Do my patients learn to control or manage their diabetes? And do these words (control and manage) mean different things to different people?
As I write this blog, I am thinking of the thousands of letters I dictate to families and physicians each year, where I summarize "good, fair, poor control, etc." How can one possibly truly control a situation where there are so many variables? To perform a valid experiment, one needs to manipulate an independent variable along with a control! Just what can we "control" in diabetes?
1. Diet (well, some people)
2. Exercise (do it, or not)
3. Medication (Socioeconomic factors may come into play. Does the insurance company cover the insulin that the doc may wish to prescribe? Can our families afford the necessary paraphernalia that accompanies diabetes care?)
4. Healthcare teams (Suppose the team you choose won't accept your insurance etc?)
What can't we control in diabetes? This is a huge topic for discussion in all my clinic visits. My families ask this same question over and over again.
Given the same meal (exact same carbohydrates), same routine, same insulin, why are blood sugars not always in range? Why are there fluctuations in blood sugars when my child is following the exact same "game plan" as the day before?
ANSWER: We have no real control of our bodies' internal processes.
We can't tell the adrenal gland to stop producing epinephrine and nor-epinephrine when we get anxious, scared, or excited. Likewise, we can't tell our liver to "hold the glucagon" when we have an impressive low that has been treated with the appropriate number of carbohydrates that eventually results in a huge spike secondary to our body's overcorrection. We can't tell our ovaries to stop ovulating/having menstrual periods and messing up our pump basal rates (unless we use oral contraceptive medications and plan ahead). We simply cannot "order" our bodies to control blood sugars when the pancreas either produces too little or no insulin at all. The body has many mysterious cellular interactions of which we still have no total understanding!
So, what do we really do? We ask our patients and families to manage their diabetes in the best way possible. We may not be able to control it; but we certainly can come up with management strategies and try to work around what we cannot actually control. Of course, one hopes that outstanding management will help lead to improved stability of blood sugars, decreased fluctuations and ultimately an excellent hb A1c. By asking caregivers and people with diabetes how they manage their diabetes, we are really getting at the heart of the issue. What can we, as healthcare professionals, do to maximize diabetes management and thus, realistically help our patients enjoy a better quality of life?
At the moment, there is no cure for diabetes; however, there are a multitude of management strategies! Both JDRF and ADA are starting to direct more efforts into these areas. The key is to avoid the guilt and frustration attendant in diabetes care. The statement: "I can't control my diabetes, what I am doing wrong?" could be better answered in a manner that eliminates the fear, judgment, and disappointment that patients bring with them to our offices. Perhaps, the appropriate answer is:
"Let's figure out the best way to help you manage your diabetes rather than attempting to control (at times) uncontrollable variables leading to frustration and unhappiness (and sometimes depression)." By eliminating the "control" factor and concentrating on the management, we may be able to eliminate the emotional baggage that accompanies chronic disease.
My immediate action will be tomorrow, as I see my first patient of the day, to avoid the use of the term control and stress the more achievable goals of "management," thus enabling me to provide practical strategies to improve glycemia and quality of life.
Published On: June 28, 2011