Diabetes treatment and why success does not pay

allnurses Guide · Jan 11, 2006

Interesting thread - I'll have to go and read those articles to properly respond.

However I will say that since my dh was diagnosed with Metabolic Syndrome last Autumn (diabetes, hypertension, hypercholesterolemia) it has been frustrating.

A PA diagnosed him during a DMV physical where sugar showed up in his urine although I'd been telling him for months. He had to pee q1/2h and drank quarts and quarts of oj. He was initially scared and shocked - the PA was quite forceful with him.

However over the months he has become not so concerned. He isn't exercising although we bought a treadmill. He hasn't been watching his diet. He takes his pills faithfully but nothing else is changing.

I cannot keep nagging him. It doesn't work anyway.

I would like some other supportive medical intervention.

In the end, you are responsible for your own choices.

It is hard for family members though - my own dad has had two bypass surgeries and one surgery for an aortic anuerysm - he is diabetic to boot. He still chooses to smoke. He doesn't exercise.

steph

sgckatibug4 · Jan 11, 2006

Hi, I too am a diabetic and have been one for 17years now. I have type I. I live in Tennessee and we are having major cuts in our Medicaid known as TennCare. They have cut thousands of individuals from the program. Those who are still able to receive the assistance are greatly limited to which drugs they can get and what services are covered. I am one of those lucky individuals who as of right now has not been cut. Unfortunately Tennessee would rather pay for emergency room visits than pay for life sustaining medication. It infuriates me that so many people will die just because they don't want to take money away from something else, like our state lottery, to help the situation. I just wonder where all that money is going. When I first became a diabetic I was able to visit a specialist and a nutritionist. Now I see my PCP. He is a good doctor, but I feel I know more about my condition than he does. I actually try my best to keep my blood sugar down. I don't want to have any complications. If my blood sugar gets up to the 180's I literally feel sick. I check it often and take my Humalog when needed. I too drink the regular soda. I just make sure I take enough insulin to cover it. I don't like the taste of the diet soda. I do think that it is the responsibility of the patient to manage their diabetes on a day to day basis. However the patient needs to get check-ups at least every 6 months to have the hemoglobin A1C done. It would really hard to blame a diabetic for their complications because it is a known fact that one becomes diabetic and dosen't realize they are until they address some symptom they are having. They could of had this for several years and didn't know. The complications they have may have come from those years.

grannynurse FNP student · Jan 11, 2006

Interesting thread - I'll have to go and read those articles to properly respond.
However I will say that since my dh was diagnosed with Metabolic Syndrome last Autumn (diabetes, hypertension, hypercholesterolemia) it has been frustrating.
A PA diagnosed him during a DMV physical where sugar showed up in his urine although I'd been telling him for months. He had to pee q1/2h and drank quarts and quarts of oj. He was initially scared and shocked - the PA was quite forceful with him.
However over the months he has become not so concerned. He isn't exercising although we bought a treadmill. He hasn't been watching his diet. He takes his pills faithfully but nothing else is changing.
I cannot keep nagging him. It doesn't work anyway.
I would like some other supportive medical intervention.
In the end, you are responsible for your own choices.
It is hard for family members though - my own dad has had two bypass surgeries and one surgery for an aortic anuerysm - he is diabetic to boot. He still chooses to smoke. He doesn't exercise.
steph

Interesting your comment about being responsible for your own choices. If this is the final bases for treating any chronic disease, aren't you writing off a great number of people? While the NYT series does not come out and say this, the impression is that diabetic suffer less complications and better control of their disease when they are involved in a long term group, which offers both education and support.

You own DH is a clear illustration of the current failure of medicine and nursing to met the chronic long term management of a chronic disease. The PA was forceful with him. Does this mean that he scared him by outlining all of the terrible things that could happen. Did he take the time to teach him how to test his blood sugar and importance of doing it daily, four times a day? Did he teach him the importance of a proper diet and just what was the proper amount of calories for him? Did he discuss his dietary likes and dislikes? Has he had him back for a return follow-up and re enforcement of what he has taught him? Did he teach him the importance of proper ex cerise? Did he teach him the importance of proper foot care and the need for a follow up with a podiatrist? Did he refer him to a diabetic educator. Did he refer him to a nutritionist? Given my own experience, with my own PCP, I seriously doubt he did any of the things I've asked. In a manner of speaking, it is not the PA's fault. He has only so much time and has so many patients to see, and gets payed an insufficient amount of money, he has not the time or inclination. Nor is it entirely your dh fault or lack of personal responsibility. You, for lack of a better word, nagging him, about his illnesses. He tunes you out, just like I or anyone else would because we generally do not respond in a positive manner to nagging, even if you do not see it as nagging. And how can he be personally responsible when he has not received a proper education and follow up? Or the opportunity to enroll in a group of diabetic to address his disease.

Let your dh read my original post and this one. I would be interested in hearing his take. I would be more then willing to receive an e-mail from him. And he should be aware that I am not here to scold him but to address with him, the p[problems that he and I share as diabetics.

Grannynurse:balloons:

allnurses Guide · Jan 11, 2006

Regarding soda . . . my dh also drank alot of Pepsi for most of his adult life. I've always disliked sugared sodas - too cloyingly sweet for me. I also drink my iced tea with only lemon.

I did get my husband to drink diet sodas and he swore he would never be able to do it - hated the taste. However over time, he has adjusted and now regular soda tastes too sweet to him too. :)

It is like when I switched to non-fat milk . .. .I had to start by going from whole to 2% to 1% to non-fat. Now anything other than non-fat tastes too creamy for me.

I believe you can retrain your tastebuds.

steph

grannynurse FNP student · Jan 11, 2006

Hi, I too am a diabetic and have been one for 17years now. I have type I. I live in Tennessee and we are having major cuts in our Medicaid known as TennCare. They have cut thousands of individuals from the program. Those who are still able to receive the assistance are greatly limited to which drugs they can get and what services are covered. I am one of those lucky individuals who as of right now has not been cut. Unfortunately Tennessee would rather pay for emergency room visits than pay for life sustaining medication. It infuriates me that so many people will die just because they don't want to take money away from something else, like our state lottery, to help the situation. I just wonder where all that money is going. When I first became a diabetic I was able to visit a specialist and a nutritionist. Now I see my PCP. He is a good doctor, but I feel I know more about my condition than he does. I actually try my best to keep my blood sugar down. I don't want to have any complications. If my blood sugar gets up to the 180's I literally feel sick. I check it often and take my Humalog when needed. I too drink the regular soda. I just make sure I take enough insulin to cover it. I don't like the taste of the diet soda. I do think that it is the responsibility of the patient to manage their diabetes on a day to day basis. However the patient needs to get check-ups at least every 6 months to have the hemoglobin A1C done. It would really hard to blame a diabetic for their complications because it is a known fact that one becomes diabetic and dosen't realize they are until they address some symptom they are having. They could of had this for several years and didn't know. The complications they have may have come from those years.

TennCare was the best thing since sliced bread or at least it was five years ago when my daughter lived in Chattanooga. I was amazed at the coverage that was given. According to my specialist, I lived there for four months, he saw a decrease in the number of hospitalizations for complications. Yes, there is a degree of personal responsibility. But I also think that we manage better with education and group monitoring and support. And despite being a nurse for more then 30 years, I could use current update and group support. I am waiting for a contact from a group. I received a call from Medicare that I was being enrolled in a group for management of one of my chronic diseases. I and my PCP are guessing it is for my diabetes. And at least three times a week I drink two regular sodas. I know I shouldn't but like you, I can't stand diet. And I am cutting down on my regular soda consumption.

Grannynurse:balloons:

allnurses Guide · Jan 11, 2006

Interesting your comment about being responsible for your own choices. If this is the final bases for treating any chronic disease, aren't you writing off a great number of people? While the NYT series does not come out and say this, the impression is that diabetic suffer less complications and better control of their disease when they are involved in a long term group, which offers both education and support.
You own DH is a clear illustration of the current failure of medicine and nursing to met the chronic long term management of a chronic disease. The PA was forceful with him. Does this mean that he scared him by outlining all of the terrible things that could happen. Did he take the time to teach him how to test his blood sugar and importance of doing it daily, four times a day? Did he teach him the importance of a proper diet and just what was the proper amount of calories for him? Did he discuss his dietary likes and dislikes? Has he had him back for a return follow-up and re enforcement of what he has taught him? Did he teach him the importance of proper ex cerise? Did he teach him the importance of proper foot care and the need for a follow up with a podiatrist? Did he refer him to a diabetic educator. Did he refer him to a nutritionist? Given my own experience, with my own PCP, I seriously doubt he did any of the things I've asked. In a manner of speaking, it is not the PA's fault. He has only so much time and has so many patients to see, and gets payed an insufficient amount of money, he has not the time or inclination. Nor is it entirely your dh fault or lack of personal responsibility. You, for lack of a better word, nagging him, about his illnesses. He tunes you out, just like I or anyone else would because we generally do not respond in a positive manner to nagging, even if you do not see it as nagging. And how can he be personally responsible when he has not received a proper education and follow up? Or the opportunity to enroll in a group of diabetic to address his disease.
Let your dh read my original post and this one. I would be interested in hearing his take. I would be more then willing to receive an e-mail from him. And he should be aware that I am not here to scold him but to address with him, the p[problems that he and I share as diabetics.
Grannynurse:balloons:

Thanks for your response.

The PA is a woman by the way. She is forceful just in general. Sorta like a drill sergeant even in "real life". :)

She did teach him about taking his blood sugar and talked about how to eat well and got him some information about different diabetic diets. She also made him an appt to see a podiatrist and he did go and his feet are fine. She made him an appt with an eye doc too but he missed that one and we have to reschedule.

Initially we both went on the SouthBeach diet and lost weight. We both walked together and jogged at the high school track.

But then his job moved 150 miles away. He gets up at 4 a.m. and gets back at 7 p.m. and is exhausted and so usually doesn't go exercise after work. He also lives in a trailer alone during the week. He attempts to cook healthy but isn't always successful. He also snacks alot during the day since he is a truck driver. He does get a certain amount of exercise out in the woods loading his truck at times and throwing wrappers.

Follow-up with the PA has been not so good as you mentioned.

I will have him read this. And I know nagging doesn't work but it can be very frustrating to watch him load his plate at Christmas dinner or grab a piece of candy. .. . most of the time I don't say anything but I'm not perfect.

Being just a diabetic makes your risk of a heart attack equal to a person who has already had a heart attack. (Recent conference I went to).

As to blood pressure, the new guidelines are the "normal" bp is around 115/75. If your systolic is 20 more, you double your risk and if your diastolic is 10 more, you double your risk.

I am a great believer in support groups and more education. Even so, you still make choices.

steph

DidiRN · Jan 11, 2006

I don't have time at the moment to go to their website, but I had briefly read something a few days ago about somewhere in NY, some department of health was wanting to or had started some kind of program where they would/are requiring that diabetics (or maybe it was newly diagnosed ones) be reported to them so they can keep track of them and make sure they are educated in their disease because of the high rate of non-compliance and the expense of care. Is this the same report? I read it so fast I don't remember the source or alot of details about it.

IMO, I think this is a bit over the top, and close to treading on people's rights, if not already stepping on them. Sounds like they are going in the direction of trying to force compliance on folks and in turn, attempt to save themselves a buck or two.

I am insulin dependent diabetic and have a vested interest in this topic but I am interested in hearing the experiences and opinions of my peers on this topic. For the past three days, the New York Times has run a series of articles regarding the cost of diabetic care, the impact on the city and the diabetics themselves, programs tried and one that is currently being funded by a grant. For those interested, go to their website to read the complete articles.
We all know that there has been an increase in weight, in most adults and children. And we are aware of the fact that there has been a corresponding increase in the number of Type II diabetics. We are also seeing an increase in the hospitalization of those suffering from complications of their poorly controlled diabetes. What most of us fail to realize is the following:
1. Approximately 90% of diabetics are managed by their PCP.
2. Most PCP average eight to ten minutes a visit with their diabetic patients.
3. Medicare, Medicaid and private insurance re-reimburse less for the education and preventive care, then they do for the acute care such as amputations.
4. Most diabetics receive hit and miss education about their disease.
5. Many diabetic do not look at the long term complications, not being able to focus 10 or 20 years down the road.
6. Most diabetic are unaware of the importance of theirA1c test and its importance.
Several hospitals have opened diabetic centers where their outpatients meet in groups with diabetic educators and nutritionists. And they have access to endocrinologist, ophthalmologists and podiatrist. Studies have shown in improvement in the health of those attending such programs, weight loss, reduction in A1c percentage, improved nutrition and lessening of the number of complications. All three types of patients, Medicare, Medicaid and private insurance attend these programs. Now, one would think that with such proof, everyone would be willing to fund such programs. Guess what? No, no no. All but one, at Columbia has been forced to close its doors because of the loss of dollars. Apparently all three forms of coverage would rather spend its money on complications.
What does everyone think? Do you think that one or two education sessions are enough? Do you think it is a matter entirely of personal responsibility? That the people are responsible for the management of their own disease? Do some blame the diabetic for any complication he/she develops because if they managed their disease better they wouldn't suffer complications? How do you feel about the poor funding for the management of a chronic disease like diabetes?
Like I said, I am an insulin dependent diabetes, who also suffers from hypertension and asthma. I suffered a TIA in 1998 and it scared me. I became an insulin dependent diabetic in 2001. I have a problem with controlling my blood sugar because, one I love a drink of regular soda once a day and two I have to take prednisone, which effects my blood sugar. I fortunately have not suffered any complications although I have been a diabetic for fifteen years. Am I responsible for my high blood sugar by drinking that regular soda. Or can I lay the blame on my prednisone. Actually I think it is both. And I am dependent on my SIL for one meal a day, which tends to be high in carbs. What do you all think? Do you think, as a nurse I should be able to do what I have taught other diabetics?
Grannynurse:balloons:

SharonH, RN · Jan 11, 2006

I am insulin dependent diabetic and have a vested interest in this topic but I am interested in hearing the experiences and opinions of my peers on this topic. For the past three days, the New York Times has run a series of articles regarding the cost of diabetic care, the impact on the city and the diabetics themselves, programs tried and one that is currently being funded by a grant. For those interested, go to their website to read the complete articles.
We all know that there has been an increase in weight, in most adults and children. And we are aware of the fact that there has been a corresponding increase in the number of Type II diabetics. We are also seeing an increase in the hospitalization of those suffering from complications of their poorly controlled diabetes. What most of us fail to realize is the following:
1. Approximately 90% of diabetics are managed by their PCP.
2. Most PCP average eight to ten minutes a visit with their diabetic patients.
3. Medicare, Medicaid and private insurance re-reimburse less for the education and preventive care, then they do for the acute care such as amputations.
4. Most diabetics receive hit and miss education about their disease.
5. Many diabetic do not look at the long term complications, not being able to focus 10 or 20 years down the road.
6. Most diabetic are unaware of the importance of theirA1c test and its importance.
Several hospitals have opened diabetic centers where their outpatients meet in groups with diabetic educators and nutritionists. And they have access to endocrinologist, ophthalmologists and podiatrist. Studies have shown in improvement in the health of those attending such programs, weight loss, reduction in A1c percentage, improved nutrition and lessening of the number of complications. All three types of patients, Medicare, Medicaid and private insurance attend these programs. Now, one would think that with such proof, everyone would be willing to fund such programs. Guess what? No, no no. All but one, at Columbia has been forced to close its doors because of the loss of dollars. Apparently all three forms of coverage would rather spend its money on complications.
What does everyone think? Do you think that one or two education sessions are enough? Do you think it is a matter entirely of personal responsibility? That the people are responsible for the management of their own disease? Do some blame the diabetic for any complication he/she develops because if they managed their disease better they wouldn't suffer complications? How do you feel about the poor funding for the management of a chronic disease like diabetes?
Like I said, I am an insulin dependent diabetes, who also suffers from hypertension and asthma. I suffered a TIA in 1998 and it scared me. I became an insulin dependent diabetic in 2001. I have a problem with controlling my blood sugar because, one I love a drink of regular soda once a day and two I have to take prednisone, which effects my blood sugar. I fortunately have not suffered any complications although I have been a diabetic for fifteen years. Am I responsible for my high blood sugar by drinking that regular soda. Or can I lay the blame on my prednisone. Actually I think it is both. And I am dependent on my SIL for one meal a day, which tends to be high in carbs. What do you all think? Do you think, as a nurse I should be able to do what I have taught other diabetics?
Grannynurse:balloons:

How very, very, very coincidental that you should bring this up as we were just discussing this very item at work yesterday. I was complaining about the lack of education and awareness about diabetes. You hear lots and lots about heart disease and breast cancer but is there really a widespread campaign to educate the general public about diabetes? NO. If you think about it, there does not seem to be an urgency about diabetes from the medical community and I think that people, diabetics and nondiabetics alike pick that up. Even if intellectually they hear it, they don't HEAR it.

Breast cancer is a CAUSE. People wear pink ribbons and have 3 day walks to raise money for it. Heart disease is a CAUSE. There are national wear red days and the cereal companies promote their products as a means to reduce cholesterol and be "heart healthy". AIDS is a CAUSE. There are AIDS walks and fundraisers and plenty of media coverage of the AIDS crisis. But not so for diabetes.

I do not think that the general public realizes that diabetes will kill you just as slowly and painfully as the aforementioned diseases and people die of diabetes-related complications in large numbers every year. I bet you the average person has never heard of the terms prediabetes and metabolic syndrome. And I also bet that most people do not realize that type II diabetes is largely preventable and that even if you have prediabetes, that you can delay the progression into full blow diabetes by an average of 7 years with diet and activity changes. How many people realize that hypertension and heart disease are a comorbidity of diabetes? I am sure that many do not. Lately there have been a couple of commercials talking about that but that is fairly recent.

To answer your question, I don't know why. That is what we were pondering. My grad school advisor often mentions that some diseases don't get as much coverage as others because they are not "sexy" enough. And I think she's right. Also you have to look at the people who are most affected by Type II diabetes: African-Americans, Mexican-Americans, Native Americans, the overweight and the elderly. This is not a segment of society that is typically cherished. Someone is going to scream that I am not being fair but I think I am right to a certain extent.

My supervisor challenged me to do something about it, ya know: put up or shut up. So I am going to be a series of Diabetes Awareness topics over the next 6 months at work, that's my little drop in the bucket.

TheCommuter, BSN, RN · Jan 11, 2006

I have a sugary family history, too. Both parents are diabetics and they are ages 47 and 49. All 4 grandparents were diabetics. Several aunts, uncles, and cousins are diabetics.

I have found that my relatives are reasonably educated about the complications of diabetes, but willingly choose to not control it very well. To them, keeping tight control over their condition is a vexing inconvenience. They would rather continue to eat the high-fat diet, drink regular sodas and alcohol beverages, and avoid exercise. My diabetic family members are very noncompliant.

My maternal grandmother died 3 years ago, weighing 411 pounds and sporting a gangrenous leg. She had been a diabetic since 1980. She continued to eat a pork-laden diet and drink regular Pepsi sodas until the day of her death, though she knew she was being noncompliant.

My father, a type 1 diabetic, drank a 6-pack of beer daily until very recently. He is notoriously noncompliant by refusing to take his Lipitor, eating sugary cereals, and not taking his antibiotics for the full course (he wants to save some for the next infection in a few months).

My relatives have received the education, but they simply do not comply. There is only so much the healthcare team can do, so the diabetic needs to put the information to good use by making the necessary lifestyle changes.

TheCommuter, BSN, RN · Jan 11, 2006

Also you have to look at the people who are most affected by Type II diabetes: African-Americans, Mexican-Americans, Native Americans, the overweight and the elderly. This is not a segment of society that is typically cherished. Someone is going to scream that I am not being fair but I think I am right to a certain extent.

Actually, I think you are being very fair by raising this point.

As a person of color, I will also mention another point that may be construed as controversial. The aforementioned ethnic groups tend to be very present-oriented, meaning that they take the day as it comes and avoid pondering the future too intensely. If the doctor attempts to tell the minority diabetic patient that heart disease, hypertension, kidney failure, blindness, and amputation are future complications of uncontrolled diabetes, the patient may often avoid doing the necessary things to prevent these future afflictions. The doctor may see this as noncompliance, but the patient is merely doing something that is culturally ingrained.

Perhaps healthcare providers could utilize cultural sensitivity when attempting to provide effective patient education.

allnurses Guide · Jan 12, 2006

I have a sugary family history, too. Both parents are diabetics and they are ages 47 and 49. All 4 grandparents were diabetics. Several aunts, uncles, and cousins are diabetics.
I have found that my relatives are reasonably educated about the complications of diabetes, but willingly choose to not control it very well. To them, keeping tight control over their condition is a vexing inconvenience. They would rather continue to eat the high-fat diet, drink regular sodas and alcohol beverages, and avoid exercise. My diabetic family members are very noncompliant.
My maternal grandmother died 3 years ago, weighing 411 pounds and sporting a gangrenous leg. She had been a diabetic since 1980. She continued to eat a pork-laden diet and drink regular Pepsi sodas until the day of her death, though she knew she was being noncompliant.
My father, a type 1 diabetic, drank a 6-pack of beer daily until very recently. He is notoriously noncompliant by refusing to take his Lipitor, eating sugary cereals, and not taking his antibiotics for the full course (he wants to save some for the next infection in a few months).
My relatives have received the education, but they simply do not comply. There is only so much the healthcare team can do, so the diabetic needs to put the information to good use by making the necessary lifestyle changes.

I see this too.

My husband is a smart man. High IQ. Knows what he needs to do. Still chooses not to.

He has a 4 year old son who adores him (his 23, 21 and 16 year old kids kinda like him too). Even that is not enough to keep him from getting serious.

I am all for education. But I still think in the end it is up to the individual person.

steph