Diabetes Parallels

I sometimes notice little diabetes parallels in routine life moments. I just threw a glass jar into the recycle bin in our garage. Ordinarily this is a pretty straight forward thing. I open the door to the garage (in our laundry room) and throw the object in (we don’t have to sort anymore). I don’t need to turn the light on or anything – it’s right there and it has a big opening.

Only tonight the recycle bin was out on the curb (thanks to my son). So when I tossed the glass jar into the dark garage, it hit the concrete floor and shattered. Just like when we take insulin without checking a blood glucose, or treat a low with everything in the refrigerator.

Lessons learned: look before you toss and paying attention pays off.

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one way to ease the burden of diabetes

Diabetes is scary and depressing for 25% of Australian teens with the disease (according to one study). One (pretty simple) way we can lessen the stress for adolescents and others with diabetes is to use language that builds on their strengths and empowers them. This is a subtle way to encourage success, decrease guilt, anger and fear, and hopefully counteract the depressing nature of the disease. Let’s do away with words like “diabetic,” which is a reminder that we’re different; “compliance” and “control” (or “uncontrolled”), which are simply judgments; and “test,” “good/bad” and “diet” which have negative connotations. The choices involved with managing diabetes are complicated and tiring enough. If these kids never heard these words, perhaps their experience living with diabetes would be that much easier. Who knows, but it seems worth a try.

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Diabetes Disclosure

I recently saw this question on twitter: “Should or shouldn’t you disclose your diabetes to your professors or employer?” I was particularly struck by the words should and shouldn’t.

Here’s how I would reword the question:

“Do you disclose your diabetes to your professors or employer? Why or why not?”

Disclosing your diabetes is your choice. There are many factors that play into whether or not someone lets people know they have diabetes and it can vary by person or situation.

I hope that professors will (d0) treat you like an adult. If you need to leave a class for diabetes-related reasons, it wouldn’t matter to the professor as long as you are respectful, get the information you need and hand in your assignments on time. If you find you need to leave class frequently, there may be bigger concerns at play.

When it comes to employers, I may or may not disclose my diabetes. I do make sure at least one co-worker/colleague knows, however. The friends I hike with know I have diabetes and how to treat a low, should I need their help.

Diabetes management – every aspect of it – is about choices. We make those choices every minute of every day, and take safety into consideration. Choosing whether or not to disclose is no different.

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The Computer in the Room

When you are in a health-related appointment do you feel like the computer gets more attention from your provider (physician, nurse practitioner or physician assistant) than you do?

Back in the early 90s hospitals started converting to electronic charting. That means typing notes into a computer, rather than writing them on a paper chart. It also means documenting during visits, rather than waiting until after the patient leaves. The downside to this new(ish) practice is less eye contact with patients, and potentially more attention on a computer than a person.

This is something we discuss in classes at the Diabetes Education and Management Master’s Degree program where I teach. The person with diabetes is the center of the health care team, the most important person in the room, and the reason we do what we do. Therefore, anything that takes our attention away from that person is not what we mean to be doing.

The hard part is that various agencies require health care professionals to document all sorts of information. It really is easier to enter it into the computer right as we go – as we are asking the questions and gathering information. My endocrinologist sits at a table across from me and enters data/information in the computer as he talks to me. This has never bothered me before. The computer is off to the side, so I don’t feel like it’s in the way of our conversation. And he does look at me as well as the screen.

On the other hand, if you feel like the computer is getting in the way of your care or your relationship with your provider, say something. Then again, if you are not comfortable telling your provider that computerized charting during the visit is bothersome to you, discuss it on social media, and trust me, word will get back to health care providers in a hurry.

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Here’s an idea to go along with the whole “Me-ternity Leave” discussion: diabeternity. This could be interpreted as “diabetes for eternity” or as a leave of absence to get diabetes in check. Or both. Or neither.

Last month there was an article suggesting how Me-ternity Leave should go. It’s hilarious and spot on. And it made me think about Diabeternity Leave. Just like it would be nice to have time off without kids, it would be nice to take 12 weeks off of life in order to adjust to and learn about diabetes. But that’s not reality.

So instead we take it on – as patients or parents or caregivers or whatever the case may be. We don’t make excuses or ask for special privileges. We learn how to make choices and poke fingers and take medications and inject and change sets/sensors and interpret numbers and calculate doses. And make choices.

Life is about choices and so is diabetes. Although no one chose to get diabetes, those of us who have it can choose how we respond to it. So until there’s a cure there’s Diabeternity – let’s have fun with it.


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New Dietary Guidelines for Americans

The U.S. Department of Health & Human Services and the U.S. Department of Agriculture have recently released their guidelines for healthy eating. These guidelines are meant to help people prevent health problems.

The guidelines emphasize the importance of eating a “wide variety of fruits, vegetables, grains, and dairy products, while staying away from  processed foods heavy in saturated fats, sugar, and cholesterol” (and trans fats). They also recommend significantly reducing the amount of added sugars and sugar-sweetened beverages from the American diet.

They really highlight the importance of eating a wide variety of foods. They also acknowledge that focusing on “small shifts in what we eat and drink” makes it easier to eat healthy. Another way to make a change is to focus on patterns and not just individual food choices.

These “common sense” guidelines are equally aimed at and important for lay people and health care providers. Although they don’t contain drastically different or new information, they make a basic point about healthy eating for everyone.

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Changing diabetes management in older and elderly people

The results of the DCCT and the UKPDS studies changed lives. They also changed health care practice. Since 1993 we have been carb counting and using basal-bolus insulin dosing (type 1 diabetes). We’ve been starting insulin earlier and/or using a combination of medications (type 2 diabetes). We know the importance of healthy food choices and exercise in managing both type 1 and type 2 diabetes and keeping A1Cs below 7%.

Now that we know what we know, it’s hard to think about backing off on this “intensive management” when we get older. Older people take on new risks as they age (yucky things like decreased hearing, cognitive impairment, worsening eyesight and manual dexterity). If we continue to strive for A1Cs below 7% at this point in life, we risk hypoglycemia, which can lead to falling. While low blood glucose is a nuisance for younger people, it’s downright dangerous for the elderly. Falling could mean breaking a hip or worse yet, there may not be anyone around to help us get up.

It takes the whole team – health care providers, family members and people with diabetes – to accept loosening up blood glucose and A1C numbers in older and elderly people. The trick is to do it in a way that’s not simply “throwing in the towel.” We still want to feel good and have energy, so we don’t want to run high all the time.

This is something to think about as you or your loved one with diabetes ages. And be sure to discuss it with health care providers so you get their buy-in as well. Here are the American Geriatrics Society’ Choosing Wisely treatment guidelines (#3).

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Individualizing care is the opposite of adherence

Both the American Diabetes Association (ADA) and the United Kingdom’s National Institute for Health and Care Excellence (NICE) have recently placed greater emphasis on individualizing care. The ADA uses “patient-centered care” in their standards, and NICE supports having individuals involved in diabetes-related decisions. We’ve been discussing putting people with diabetes at the center of their care for years, and it’s very exciting that these prestigious organizations are getting behind it.

So why are we still seeing and hearing the word “adherence”? It seems like these messages of patient-centeredness are going in one ear and out the other when health care providers still use terminology that is outdated and inappropriate in diabetes care. Adherence, like compliance, means “sticking to” something that someone else wants us to do. How is that patient-centered?

It’s time for health care professionals to take a look at our spoken and written language and figure out how we can align it with the messages we are meaning to send. If we want to give patient-centered care, then let’s also use patient-centered language. Let’s send messages that reflect an empowerment, strengths-based approach.

Some examples include “she is taking her medication about half the time” or “he takes insulin when he can afford it” rather than “she/he is not adhering to the plan” (or even “she/he is non-compliant”). And how about “medication taking” rather than “medication adherence”? These small changes add up to focusing on a person’s strengths, instead of their weaknesses.

Groups like the ADA and NICE have made giant steps toward improving care for people with diabetes, and this is to be commended! The next step is to adopt language that sends messages consistent with a patient-centered focus.

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Diabetes and Surgical Site Infections

Hopefully if you or someone you love has diabetes you already know that high blood glucose leads to infection. High blood glucose also contributes to slower healing wounds. If someone with diabetes has surgery, their risk for infection at the surgical site is higher, especially if their blood glucose level is elevated.

Many hospitals have pre-operative nurses who counsel surgery patients about what to do with their medications on the day of surgery (or the day before). They may also discuss with patients the importance of coming into surgery with a blood glucose level in (or as close as possible to) the normal range (70-110). Regardless, it’s important to have this information tucked away in your head so that if you or your loved one ever needs surgery you can plan.

Surgical site infections are a risk to everyone who undergoes surgery, but those with diabetes have a higher risk. High blood glucose puts people with diabetes at even greater risk. You can lower your risk for surgical site infection by managing your blood glucose prior to surgery.


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The Adolescent-to-Adult Transition in Diabetes Care

There is something referred to as “the adolescent transition,” which is actually the transition to adulthood. “Emerging adulthood” is sometimes defined as ages 18-30.

(Being an adult is mandatory; acting like one is optional.)

The point is that as a teen with diabetes, you will at some point have to “grow up” in terms of your health care. You will communicate with health insurance (oh, and get health insurance coverage), make appointments, see adult health care providers, pay bills, and other fun things like those.

Research has shown a high number of hospital admissions for DKA in those who are transitioning to adult care. There is also a tendency for A1C to go up, office visits to go down, and rates of getting kidney function checked can go down as well.

When you become an adult you get to manage your diabetes on your own. You also get to manage all aspects of your health care. Get a strong handle on how diabetes works now, while you’re still at home. Ask your parents to teach you how to navigate health insurance. Start taking a lead at your appointments while you’re a teen-ager, so it won’t be scary or foreign when you are on your own.

Use your resources. College Diabetes Network is an organization that supports emerging adults with diabetes who are heading to and attending college. The Diabetes Online Community is chock-full of support and camaraderie. Another fabulous option is to get involved in a diabetes camp. And some endocrinology offices have providers who specialize in the transition to adult care, so be sure to ask if yours does.

Most important, stay on top of your diabetes care so that you will feel good, be productive, and live well now and far, far into the future.

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