May/June  2006

The Zen of Science

Diabetes: Managing a disease,
managing a life

We just got an endocrinologist to consult every week in Brush, where I practice. I'm thrilled. Tom will provide a great service to a number of my patients, especially to diabetics, who are some of the most challenging.
Thanks to modern medicine, which has allowed many more diabetics to survive and reproduce, as well as to modern food marketing and lifestyle, which has brought an epidemic of obesity, the incidence of diabetes has skyrocketed. Diagnosed cases increased 47 percent between 1997 and 2002 alone.

Not only are there more diabetics, but managing them didn’t used to be so complicated. Doctors started out believing that the one reason people had high blood sugar was that their pancreas didn’t make enough insulin. So they prescribed insulin and counseled diabetics to restrict their calories. Then along came oral diabetic agents. Scientists figured out that some people responded to oral drugs and some people didn’t. Based on response to oral hypoglycemic drugs, two different types of diabetes (cleverly named Type I and Type II) were identified.

Type I tends to happen to thin folks earlier in life when, in the wake of a viral infection, their pancreas suddenly stops making insulin. These people require insulin from the onset of their illness.

Type II diabetics, who tend to be plumper and usually come down with the malady later in life, start out with some circulating insulin, but their cells are relatively resistant to the hormone’s effects. So, early in the course of the disease, oral medications that make the pancreas squeeze out a little more insulin, as well as drugs that sensitize cells to the effects of insulin, are usually needed to control blood sugar. If they live long enough, most Type IIs will eventually burn out their pancreas and require insulin injections.

Before 1922, when doctors Banting and Best isolated insulin from the pancreas of slaughtered cattle and treated their first patient with the substance, diabetes was always fatal, usually pretty quickly. Everyone expected that once diabetics could get shots to replace the hormone that their pancreas failed to make, they’d be perfectly normal.

It wasn’t until the 1940s, after a large number of diabetics—thanks to modern medicine—had outlived their previously grim prognosis, that doctors found out diabetes is more than just a disease of the pancreas. No matter how carefully their medication regimens and life styles were adjusted, diabetics tended to die early of strokes and heart attacks, and suffered kidney failure, blindness and gangrene at rates far in excess of non-diabetics. Diabetes is not just a malady of the pancreas. It is a disease that ages blood vessels all over the body, causing widespread complications.

The better the blood sugar control, the lower the rate of complications. We doctors do our best, with a wide array of drugs, diet and lifestyle instruction, home glucose monitoring, and a myriad of other laboratory tests, to help diabetic patients keep their blood sugar as close to ideal as possible.

Blood sugar varies from moment to moment, based on oral intake, physical and emotional stress, and exercise. A normal pancreas is part of a whole web of endocrine and neurological feedback loops that keep sugar concentration within the narrow range that allows for best function of the muscles, brain and everything else. Intermittent blood glucose monitoring, paired with various medications and drug delivery systems, does an approximate job of blood sugar control at best. Of course, things are way better than they were before 1922; for that matter, things are way better than they were when I started practice in the 1970s. But there’s still a long way to go.

The doctor is just a small piece of the diabetes control puzzle. No matter how much time we spend with a patient and no matter how smart we are about her illness, what we do is just a tiny fraction of the 24/7 that each diabetic lives with her blood sugar. Ultimately, diabetes management comes down to self-management.

Though hundreds of scientific papers have left no doubt that good blood sugar control is better than not-so-good control, how many times a day, in the name of tight glucose control, can you expect a person to check his blood sugar by poking his finger with a sharp lancet? How many lancets and expensive home glucose monitor test strips will insurance pay for? How many years is the person likely to live? (A newly diagnosed older person, who would not likely suffer diabetic complications for a decade or so, might not need to be so tightly controlled, for example.) How hard does one push a rebellious teenage diabetic about drinking pop? And how likely is pushing or reminding or nagging likely to help anyway? And so on.

This is where the art of medicine comes into play. Setting achievable goals in managing this protean disease depends on knowing the patient, the family, the social situation and sometimes the economic situation. No amount of study of metabolic pathways and drug biochemistry can substitute for what we health care providers, at our best, understand about our patients' lives.

The medical profession is beginning to wise up to the gap between ideal and realistic management of diabetes. An article published last year in The Journal of Family Practice strikes a blow for reality. The authors of the piece, entitled “Time requirements for diabetes self-management: Too much for many?” interviewed eight certified diabetes educators. These professionals, who’d spent an average of 13 years instructing diabetics and their families on how to manage their disease, were asked to estimate the time it would take to perform each task outlined in the American Diabetes Association’s 2002 guidelines for the best self-care. The list included 10 chores: home glucose monitoring, record keeping, taking medication, foot care, oral hygiene, problem solving, meal planning, shopping, meal preparation and exercise. The educators estimated that an optimally compliant diabetic would spend 122 minutes a day doing these things. For good measure they threw in seven more tasks, like blood pressure monitoring, stress management nad dealing with insurance, that added another 21 minutes a day to the job of being a diabetic, for a grand total of 143 minutes.

How does spending two and a half waking hours out of every day to manage a chronic illness strike you? It looks pretty unrealistic to me. The authors of the study agree.

With diabetes, we have the advantage of a glycohemoglobin level to tell us how we're doing. This test, which measures the amount of glucose stuck to the red blood cells, reflects the average blood sugar over the previous two to three months. If the glycohemoglobin is in the normal range or trending downward, we know we’re on the right track, and vice versa if glycohemoglobin is too high. But if we focus on the glycohemoglobin level and forget about the patient, we're doomed to frequent failure.

As a primary care provider I need to know how much I can ask of my patient in managing his disease and set a realistic target based on that knowledge. There is always room to adjust the goal, but not if I’ve lost the patient’s trust because he doesn’t feel that I know what he really needs, wants, and can do. So, though I’m thrilled that my diabetic patients now have the services of a crack endocrinologist, for their own good, they’re still going to be my patients too.

Marc Ringel, MD, is a family practitioner and writer based in Greeley, Colorado.