Monday, August 31, 2009

Diabetes Management

A Diabetes Educator’s Perspective
By Suma Vitta

This article is provided by Mrs. Suma Pradeep Vitta. Suma is a Registered Dietitian and a Certified Diabetes Educator and works as a consultant at a local endocrinologist office at Brookwood Hospital and Eye foundation in Birmingham, AL. She can be reached at .(JavaScript must be enabled to view this email address) .

Unfortunately, diabetes is a very common disease in our Indian population.  Though there is always a genetic predisposition to any disease, life style factors play a very important role in the manifestation of this disease.  Modest lifestyle changes can help any person with diabetes to manage this disease and prevent long term complications. The disease when not managed adequately can be devastating, as persons with diabetes have a high risk factor to develop heart disease. Uncontrolled blood sugars can also lead to kidney disease, neuropathy effecting the eyes, feet, etc.

A diabetes educator is a health care professional who provides comprehensive diabetes education.  The areas of education include nutrition, physical activity, blood glucose monitoring, etiology and complications associated with diabetes, stress management, insulin, medication management etc.

There are two different types of diabetes. In Type 1 diabetes, the body does not produce any insulin because of the destruction of beta cells that produce insulin. However, in Type 2, the body still produces some insulin, but insulin resistance is quite evident and may be due to obesity, sedentary life style and other bio chemical imbalances. Type 1 diagnosis is rather abrupt and immediate and usually identified at a young age, but symptoms of type 2 diabetes can be very subtle and patients may not seek medical attention until symptoms become more evident or are faced with other co morbid factors associated with diabetes.

There appears to be a big population of patients with “Prediabetes” whose fasting and after-meal blood sugars are not high enough to be diagnosed as diabetic but are in the high risk category for developing diabetes in the next 8-10 years.  It will to be a great advantage if persons with high risk factors recognize this state and seek medical assistance early on to prevent possible complications. The concern with type 2 diabetes is that patients seek medical attention when other co morbidities already have manifested, so it is so very crucial that a type 2 diabetic gets a full medical evaluation upon diagnosis. This should also assess a patient’s health with regards to heart disease, kidney functions, neuropathy /disease of the nerves especially associated with eyes and the feet so that interventions could be geared toward preserving organ functions, hence improving one’s quality of life. This article will mainly focus on interventions for persons with Type 2 diabetes.

The following are some of the essential management tools and general guidelines that persons with diabetes should be aware of to help them manage their disease. A certified diabetes educator will be helpful to a patient to provide education and follow-up services in the following areas:

1. Monitoring:  Blood sugar monitoring is a very essential tool in managing diabetes but often ignored by patients. The modern blood glucose monitors are user friendly and take minimal amount of blood to give patients an accurate reading. Patients also should know that other than finger prick alternate sites as the forearm, palm etc can be tested too.

A diabetes educator can very well demonstrate recommended sites for glucose monitoring. He/she can help with the interpretation of blood glucose results, with having a record of your blood sugars and effectively communicating the results with the endocrinologist /MD and fine tune medications and lifestyle, resulting in tighter blood sugar control.  Along with daily blood glucose monitoring, one should also get their Hga1c checked periodically. Hga1c reflects average blood glucose value in the last 3 months, persons with diabetes need to get Hga1c checked quarterly or at least twice a year.

2. Meals:  Nutrition plays a very important role in diabetes management.  A patient with diabetes should always see a Registered Dietitian at the onset of the disease and try to have routine follow-ups to adequately understand and implement appropriate nutrition interventions. Weight loss is extremely important for adequate blood glucose control, a modest weight loss of 5-8% for an over-weight or an obese patient helps in minimizing devastating complications. When it comes to meal planning, nutrition management is highly specific and sensitive and is to be catered to individual needs.

Moderate lean protein from whole beans, fish, lean chicken, turkey, complex carbohydrates (high fiber), heart healthy fats in moderation, low fat dairy and liberal amount of low starch vegetables, usually are incorporated in a patient’s meal plan. A nutrition regimen is individualized based on a person’s caloric needs, bio-chemical indices as their lipid profile, kidney functions, blood pressure status, weight loss goals, activity level, personal choices and socio-economic status.  Carbohydrates are the preferred energy source but one has to understand that since the body’s ability to properly utilize sugar or glucose is diminished, one has to be careful in terms of the amount and quality of carbohydrates eaten at a time.

Inclusion of good amount of lean protein is vital along with some fats to increase the satiety value and delay the rapid digestion and absorption of carbohydrates.  Select high fiber carbohydrate as whole grain, legumes, oats, whole fruits, whole wheat flour etc. On a 1500-1600 cal meal plan, approximately 3 carbohydrate choices a meal and 1-2 carbohydrate choices between meals is suggested.  Approximately 6-7oz of lean protein or more may be recommended based on blood sugars and kidney functions.  A dietitian will further help you read labels, count carbohydrates and fats and also provide tips on eating out on follow-up sessions.

3. Movement:  Exercise therapy is the most important and most effective tool in weight loss as it helps in blood glucose, blood pressure and lipid management.  A person with diabetes can see a great improvement with their blood glucose levels in a short period of time, even before significant weight loss is observed.  It is however quite important that a person with diabetes talk to their educator about individualizing exercise regimen especially if with neuropathy, chronic high blood pressure, eye disease or other co morbidities.  It is worth to have a personal trainer for first few months who will be able to assess your individual needs and recommend a proper exercise regimen to aid in gradual weight loss and to increase lean body mass.
4. Medication: It is very important that patient understands the importance of taking medications as prescribed. Some Diabetic pills make your pancreas release more insulin and some are designed to make your insulin more active, geared toward the uptake of glucose.  All of these medications work as long as your body is producing insulin, a Type 2 diabetic may require insulin at later stages when the pancreas for several reasons may not produce adequate amounts of insulin.  It is very important that patients, who are solely on insulin or on multiple shots, should take insulin as prescribed by the physician to adequately manage their blood sugars and prevent life-threatening complications. It is equally important for a patient to talk to the pharmacist about adverse reactions or side effects associated with certain diabetic pills and communicate with the physician if chronic side effects persist.

5. Management:  A patient with diabetes or any other disease should realize that the therapy that was initiated at the time of diagnosis will not hold good for the rest of their lives.  Based on blood sugars and other co morbidities medication therapy along with nutrition, exercise and other modalities will change to meet a patient’s ongoing changes in his or her medical condition. A patient should be proactive to actively communicate any ongoing concern with the healthcare provider immediately so that proper interventions could be placed. Though a patient receives guidance and care from the healthcare professionals, it is the patient who has to implement self care techniques such as blood glucose monitoring, consistent exercise regimen, healthy eating etc. in order to prevent complications and enjoy life to the fullest. Stress can affect blood sugars, blood pressure and may result in other co morbidities; one should effectively talk to their health care providers to seek assistance in managing this issue effectively through counseling and /or with medication management.

6. Motivation is the key to success: It is easy to succumb to our individual weaknesses or societal pressures.  To succeed in any aspect of our lives all of us need internal motivation. This philosophy holds well in any type of disease management. Human beings are bestowed with needed intellect, compassion and power to excel in anything that they put their mind and effort.

We will always experience difficulties following a certain regimen in life - may be at times getting poor support from family members or for the most part at social events and poor support from people who may not agree with our philosophy regarding nutrition ,exercise, and so on and so forth.

Regardless of how bad the situation is we cannot point finger at anyone or anything for our failures with lifestyle issues because no matter what, we are the one who will have to face the consequences of long term non-compliance. There are few situations where in no matter how compliant you are, situations may not go right as we wish, but as a human being it is vital that we do our share in taking care of ourselves and beyond that we cannot worry about.  We all are truly conscious about caring for cars and all the other material comforts around us.  For example, we care for our cars by putting the right type of fuel and oil to ensure longevity of the vehicle. It is even more important to care for the vehicle that God gave us—the human body to put the right types of fuel and right combination of fuel so that this vehicle will stay in the top condition until we leave this material world and also help us achieve our goals and enjoy life.  Staying in good company of friends who share positive attitude toward life, having a nurturing environment at home and outside, empowering yourself with needed knowledge, seeking assistance, education and support form your educator and other health care professionals will enhance motivation and make a person more compliant with lifestyle issues.