We are going to switch gears a little bit today. Instead of our usual discussions relating to surgery, surgical procedures and medical (surgical) tourism – we are going to spend some time talking about Diabetes in a series of posts.
In my role as a nurse practitioner, I became surprisingly familiar with diabetes. I say surprisingly because as an acute care nurse practitioner specializing in surgery, I never expected to have to fill the role of family doctor or family practitioner. However, the prevalence of diabetes in this country (USA) is so incredibly pervasive, particularly undiagnosed diabetes – that every health care provider should become well-versed in the treatment of diabetes, and diabetes related conditions.
Diabetes = Coronary Artery Disease!
Working in heart surgery also means that patient education is critical for diabetics, particularly newly diagnosed diabetics. Now one of the things that complicates the issue significantly is providers’ hesitancy to label people as “diabetics” due to insurance implications and all sorts of other issues. So a lot of primary care providers are dancing around the issue, soft-pedaling the news and generally ignoring or under treating this disease. As someone who treats the complications of these decisions everyday, (heart attacks, ischemic limbs, infections, etc.) I vehemently disagree with this strategy.
How can I get my patient to take this seriously, and treat their diabetes aggressively, if I don’t?
Some of the things we need to do to treat Diabetes effectively are:
1. To detect it (estimates place the number of undiagnosed Americans at greater than 17 million people)
The best way to detect Diabetes is to use the newer generation of tests, specifically the hemoglobin A1c. This test looks at the average glucose levels over several months. This helps to rule out false elevations from acute illness, injury or surgery. It also prevents under diagnosing from the tendency to ‘ignore’ one or two abnormal glucose readings. “Oh, his glucose was 160; we’ll check it again in three months.” That’s three more months that the patient goes untreated. (Despite being abnormal, many of the older guidelines ignore readings of less than 180, and require two or more readings for diagnosis. (Normal glucose is 70 -105 or 110, depending on source.)
2. To treat it – using SAFE and effective medications.
Many people would be surprised to know that the best drugs for treating Diabetes are the older (cheaper) medications such as metformin (Glucophage) which has been used since 1977. It’s readily available on many $4.00 pharmacy plans.
Many of the newer, fancier drugs (Avandia is the best known) have been linked to serious complications such as myocardial infarctions (or heart attacks). Many of the other new drugs have no side benefits. A good prescriber finds the best combination of medications to have the most beneficial effects, limited negative side effects and is cost effective. Why treat five problems with twenty drugs (expensive with multiple drug interactions) when you can do it with four medications?
3. Finally – and most importantly, lets do more to prevent it. Let’s all stop soft pedaling, and speak frankly and truthfully with our patients. Diabetes is a horrible disease, so let’s stop pretending it isn’t.
Instead of trying to be the good, likable provider who turns a blind eye to health destroying behaviors – we need to be direct, and address these issues. A glucose of 200 isn’t ‘good enough’. Testing glucose once in a while isn’t ‘good enough’. You may not like me when I tell you to absolutely, completely stop drinking soft drinks (NEVER drink another soft drink), or to get out and start walking, (or a myriad of other things we’ll talk about) but if that helps reduce your risk of diabetes, prevents diabetic complications and ultimately lengthens and improves your quality of life – then that is a trade-off I am willing to make.
 In my previous practice, all patients had a hemoglobin A1c as part of their pre-operative laboratory work-up. Up to 25% of the patients having heart surgery were found to have elevated A1c levels, and were undiagnosed diabetics.
 Just as medications have side effects – many drugs such as metformin have side benefits. One of the side benefits of metformin is the protective blood vessel effect – patients that take metformin have fewer amputations than patients on other anti-diabetic drugs. Metformin has also been shown to be an important tool in the treatment of certain cancers. Several research studies show that the use of metformin has been linked to decreased tumor growth in breast cancers.
 I am planning for a future article to discuss this in-depth, and present the research. Please contact me if there is other Diabetes related content you would like to see.