{"id":314,"date":"2013-11-15T11:51:56","date_gmt":"2013-11-15T00:51:56","guid":{"rendered":"http:\/\/blog.panicola.com\/?p=314"},"modified":"2013-11-17T18:49:19","modified_gmt":"2013-11-17T07:49:19","slug":"nyt-the-challenge-of-diabetes-for-doctor-and-patient","status":"publish","type":"post","link":"https:\/\/blog.panicola.com\/?p=314","title":{"rendered":"NYT: The Challenge of Diabetes for Doctor and Patient"},"content":{"rendered":"

..or why managing diabetes doesn’t fit with how doctors have been taught, and therefore generally like, to treat patients >>> we need a radically new approach not involving doctors, busy doing other things – see Iora Health post re. health coaches<\/a>.<\/p>\n

The good news:<\/strong> lifestyle change for the obese or those with prediabetes may have lower progression to diabetes
\nhttp:\/\/archinte.jamanetwork.com\/article.aspx?articleid=1485081<\/a><\/p>\n

The average news:<\/strong> childhood obesity is plateauing [PN: ??from a scandalously high base]
\nhttp:\/\/www.nytimes.com\/2012\/12\/11\/health\/childhood-obesity-drops-in-new-york-and-philadelphia.html?_r=0<\/a><\/p>\n

The bad news:<\/strong>\u00a0Intensive lifestyle change for diabetics did not\u00a0reduce the risk of stroke or heart attack, even though these patients were able to lose weight, improve their overall quality of life, take fewer medications and even decrease costs.<\/p>\n

Lifestyle changes \u2014 diet and exercise \u2014 require huge and ongoing investment efforts for patients; we\u2019d like to think it pays off for the big-ticket clinical outcomes. Hopefully future studies will show benefits.<\/p>\n

 <\/p>\n

OCTOBER 17, 2013,\u00a03:43 PM<\/p>\n

The Challenge of Diabetes for Doctor and Patient<\/strong><\/p>\n

By\u00a0DANIELLE OFRI, M.D.<\/a><\/address>\n
\n

My patient was miserable \u2014 parched with thirst, exhausted and jumping up to go to the bathroom every few minutes. His vision was blurry and he\u2019d been losing weight the last few weeks, despite eating voraciously. I\u2019d only just met him, but I was able to diagnose diabetes in about a minute. What was unusual was that this was a scheduled office visit; usually, patients with such overwhelming symptoms are the provenance of emergency departments and urgent care centers.<\/p>\n

A quick shot of insulin and five glasses of water and my patient felt like a new man, with no need to go to the E.R. But now, of course, the hard work would begin. A new diagnosis of diabetes is an enormous undertaking \u2014 lots to explain, major life changes to contemplate, myths to dispel, consultations with a nutritionist and a diabetes nurse.<\/p>\n

Two days later I had another new patient for a scheduled visit \u2014 thirsty, tired, losing weight, eating and drinking like mad, eyes so blurred he could hardly see. We\u2019d barely gotten past the introductions before I\u2019d made another new diagnosis of diabetes. Another shot of insulin, another five glasses of water, and then the plunge into the thicket of diabetes education.<\/p>\n

Most of my regular office visits with diabetic patients \u2014 even newly diagnosed patients \u2014 don\u2019t involve such dramatic presentations. More often the disease is found when we screen patients who have risk factors like obesity or a family history of the disease, or who have commonly co-occurring illnesses like hypertension, heart disease or elevated cholesterol.<\/p>\n

These two patients highlighted the outsized role that diabetes plays in the primary care setting. The tidal wave of diabetes over the last two decades has made it one of the most common diseases that internists and family doctors treat. Right now feels like a good-news-bad-news time on the diabetes front, which in a general medical clinic can sometimes feel like the only front there is.<\/p>\n

The good news is that childhood obesity rates have\u00a0begun to inch downward in some cities<\/a>, including\u00a0among poor children<\/a>, the first positive sign in the obesity epidemic in years. Obese children are potential future diabetic patients, so even incremental progress is a public health victory to celebrate.<\/p>\n

Also good news is a\u00a0study in which adults with obesity and pre-diabetes were able to lose weight<\/a>\u00a0with sensible lifestyle changes and coaching. This took place in a primary care setting, not a research setting, so this also suggests that we might be able to bend the curve of new diagnoses of diabetes.<\/p>\n

But there\u2019s also bad news. Intensive lifestyle changes for patients with diabetes, disappointingly,\u00a0did not reduce the risk of stroke or heart attack<\/a>, even though these patients were able to lose weight, improve their overall quality of life, take fewer medications and even decrease costs. Lifestyle changes \u2014 diet and exercise \u2014 require huge and ongoing investment efforts for patients; we\u2019d like to think it pays off for the big-ticket clinical outcomes. Hopefully future studies will show benefits.<\/p>\n

Even with all the research and new treatments available, combating diabetes can feel like a Sisyphean task. The bizarre contradiction of junk food being cheaper than healthy food, combined with a bombardment of advertising \u2014 especially toward children \u2014 make it a challenge even for motivated people to eat healthfully. Sugary drinks in monster-size containers abound. And our fixation with screens large and small keeps us increasingly sedentary.<\/p>\n

But even with all the uphill challenges, there are successes, even if not perfect ones. Both of my patients who came to my office with florid diabetes that week have improved. Perhaps it was the concreteness of their symptoms that motivated them, but they have both made steady progress getting their diabetes under control.<\/p>\n

Over the past few months they\u2019ve been eating more moderately, and exercising more regularly. We\u2019ve been calibrating their medications so that their blood sugars have left the stratospheric levels and are now only moderately elevated. Medication side effects, cost of glucose meter supplies, real-life logistics, and concomitant issues of blood pressure and cholesterol control have made it a challenge to get to normal. We\u2019d still be dinged as \u201cfailures\u201d in the quality-measures department for not achieving the recommended clinical goals, but both patients feel vastly better and are much healthier now.<\/p>\n

So there\u2019s bad news and good news. But the real news for these two patients \u2013 and for many, many more like them \u2014 is that diabetes is a marathon, not a sprint. Although there have been a flurry of life changes right now, diabetes is something they will live with for the rest of their lives. They will always have to be cognizant of what they eat. They will have to keep track of medications, glucose levels, carbohydrate intake, doctors\u2019 appointments, exercise, and weight. \u00a0They will have to be on the lookout for the many complications that diabetes can bring. This of course is not news to anyone who has diabetes or treats diabetes, but for these two patients this was news.<\/p>\n

Now, we gear up for the long haul, the messy, complicated, occasionally gratifying business of living with a lifelong chronic illness.<\/p>\n

Dr. Danielle Ofri\u2019s newest book is\u00a0\u201cWhat Doctors Feel: How Emotions Affect the Practice of Medicine.\u201d<\/a>\u00a0She is an associate professor of medicine at NYU School of Medicine and editor in chief of the\u00a0Bellevue Literary Review<\/a>.<\/p>\n

http:\/\/well.blogs.nytimes.com\/2013\/10\/17\/the-challenge-of-diabetes-for-doctor-and-patient<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

..or why managing diabetes doesn’t fit with how doctors have been taught, and therefore generally like, to treat patients >>> we need a radically new approach not involving doctors, busy doing other things – see Iora Health post re. health coaches. The good news: lifestyle change for the obese or those with prediabetes may have … Continue reading NYT: The Challenge of Diabetes for Doctor and Patient<\/span> →<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14,9,10,13,22,3,20],"tags":[],"class_list":["post-314","post","type-post","status-publish","format-standard","hentry","category-complex-adaptive-systems","category-healthcare","category-healthy-habits","category-nutrition","category-policy","category-rapid-learning-health-systems","category-research-methodology"],"_links":{"self":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/314","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=314"}],"version-history":[{"count":5,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/314\/revisions"}],"predecessor-version":[{"id":382,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/314\/revisions\/382"}],"wp:attachment":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=314"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=314"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=314"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}