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Practice makes near perfect at bedtime

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October 23, 2016
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The Whole Story

My sister got a call from the hospital at which Mom has been recovering after valve replacement surgery. After a couple of days of perfect sinus rhythm, her care team suddenly wanted consent to insert a permanent "on demand" pacemaker. The issue was a single episode of about eight seconds of no heartbeat. While the idea of a pacemaker had been broached before, it was earlier in Mom's recovery. Since then, as far as we all could tell, things had quieted back down to "normal".


What the nurse did not tell my sister over the phone was the rest of the circumstances regarding this event: was Mom awake or asleep at the time? Was she on the BiPAP machine or off it? What were the rest of the details? As an obese woman with Type 2 diabetes and high cholesterol, Mom is in the high risk pool for sleep apnea. Inserting a pacemaker when a CPAP or BiPAP machine would have been overkill. For me, making an intelligent decision requires knowing what was ruled out, and why.


Similarly, it is useful -- if not vital -- to know the circumstances and medical history of a person newly-diagnosed with prediabetes or diabetes. Has the individual experienced the typical syndrome that often precedes a type 1 diagnosis: excessive non-deliberate weight loss; excessive hunger, thirst, and urination; continuous feeling of fatigue (or drop in physical/mental performance)? Since this syndrome is much less common in type 2 diabetes, it should signal the diagnosing physician to test c-peptide levels and check for GAD antibodies. Is the patient overweight or obese -- or does he or she exhibit one or more other components of metabolic syndrome (disproportionately large waist; high blood pressure; high LDL cholesterol; low HDL cholesterol)? If so, the physician should also check serum insulin levels (and possibly leptin levels); if diagnosis is made early enough in the progression, elevated insulin levels suggest insulin resistance and an appropriate course of therapy. In addition, an Oral Glucose Tolerance Test (OGTT) may help pinpoint which of the five classes of oral antidiabetic drug, and what dietary and dosing therapies, would be most effective at controlling his or her blood glucose levels.


While it is still somewhat controversial, genetic analysis may also help clarify the (possible) source(s) of persistent hyperglycemia. If c-peptide levels are normal and the GAD test comes back negative, the presence of gene forms known to be associated with type 1 diabetes should suggest a need for ongoing re-evaluation and a possible diagnosis of LADA. Conversely, matching the gene test to otherwise anonymized patient records can build a knowledge base from which later generations of physicians will be able to determine the underlying causes of hyperglycemia and prescribe appropriate therapy.


Another area in which the details can make or break patient health is in nutritional planning. Mom has spent several days on a "soft diet" which, despite its "diabetic" status, is loaded with high-glycemic carbs, and its protein loaded into milk and nutritional shakes which Mom is refusing (let's face it: cafeteria milk is so warm as to taste spoiled, and drinks such as Boost and Glucerna are not exactly tasty). The nursing staff is not too concerned over the carbiness of the meals "because we can control her blood glucose level with the insulin drip". (Mom's diabetes is generally controlled by Avandia and glipizide.) Umm, yeah, right. They're dripping Lantus, not Novalog. By the time a correction hits, Mom is likely to already be on the downswing from a lengthened glycemic curve. Couldn't the hospital nutritionists figure out a diet that would have Mom wanting to consume the protein? Something in which the high-glycemic carbs are not presented, so she doesn't have the option of ignoring the high-protein foods she needs? (Does anyone reading this see parallels to that of young children wanting their potatoes and desserts, but ignoring the meat and cheese on their plates?) It's the same thing with my diet: most specialty cookbooks present recipes that are low-sodium, low-sugar/low-carb/low-glycemic-index, or high protein, but not two of the three, much less All Of The Above.


Top that all off with our willingness and our ability to make changes in our diets and our lives -- whether temporary or permanent -- to improve our health and our long-term quality of life. Those are other factors which need to be taken into consideration when developing an appropriate therapy for any condition that can be managed by a combination of diet, exercise, and lifestyle change in lieu of (or in addition to) pharmaceuticals.

In the end, we and our caregivers -- physicians, nurses, CDEs, family, and friends -- need to acknowledge and address us as whole persons, with individual medical and psychological needs, and individual physical, psychological, social, and financial constraints in order to present us with the therapy options we are most likely to follow, which will give us the most desirable results under those conditions. It is only then that we will begin to see better long-term prognoses and better quality of life for all of us with chronic medical conditions.

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