STRUCTURING A TREATMENT PLAN
What are normal blood sugar levels?
What range do we find in nondi abetics?
The answers depend upon whom you ask.
I've seen figures in the scientific literature overthe years ranging anywhere from 60 to 140 mg/dl.
My experience checking random blood sugar readings on nonobese nondiabetics, aswell as figures from large population stud ies, tells me that for most nondiabetics, blood sugar levels cover a pretty narrow range of about75-95 mg/dl (by finger stick),exceptaf ter mealscontaining large amounts of fast-acting carbohydrates.
I usually select a target of 90 mg/dl for most of my patients who take insulin.
This target is not an average, but one we try to maintain 24 hours a day.
Evenif you average 90 mg/dl but your blood sugars are bouncing back and forth between60 and 140 mg/dl, you'restill on the roller coaster.
Our object is to find a treatment plan that will get you off the roller coaster and keep you off.
For those who do not need insulin injections to maintain blood sugars, and those insulin users who have demonstrated very stable blood sugars, I eventually set a target of 80-85 mg/dl.
This assumes that you're comfortable at such levels, that is, not experiencing symp toms of hypoglycemia (low blood sugars).
One of the most important considerations in setting up an initial target is that people who have had high blood sugar levels for many months or years usually experience unpleasant symptoms of hypo glycemia asblood sugars approach normal.
Someone who has grown accustomed to blood sugars consistently over 300 mg/dl may feel "shaky"at 100 mg/dl.
In such a case, we might startwith 160 mg/dl as the initial target.We'd then lowerthe targetto its ultimate value over a period of weeks or months astreatment proceeds.
It's unusual when an initial meal plan and dosage of medication in stantly result in the desired blood sugar profiles.
Some people, a few days into their regimen, may find something objectionable, such as not enough to eat for a certain meal.
Because of this, it's often neces saryto experiment with a plan, making smallchanges basedupon per sonal preferences and blood sugar profiles.
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People tend to become discouraged if they cannot see rapid im provement, and so, where warranted, I try to make adjustments to the regimen everyfewdaysin order to demonstrate that our efforts are ac complishing positive results.To this end, I ask patients to bring or to fax to my officetheir blood sugar profilesabout one weekafter their fi nal training visit, if initial treatment is by diet alone.
If I've prescribed insulin, I like to see profiles within a few days.
I certainly try to make sure that no blood sugars are below70 mg/dl during this trial period.
I ask all new patients to phone me at any time of the day or night if they experience a blood sugar under 70 or become confused about their instructions.
Additional repeat visits or phone callsmay be nec essary every few days or weeks, depending upon how rapidly blood sugar profilesreach our ultimate target.
Many new patients come to my officefrom out of town, some trav eling distances of thousands of miles.
Clearly, frequent office visits would be impractical in such cases.
For thesepatients, I often schedule follow-up "telephone visits" instead of office visits.
Patients will fax their blood sugars to me on Glucograf III data sheets.
These subsequent office or telephone interactions enable me to fine-tune the original plan, and alsoto reinforce the training program by catching any mistakesthat a patient may inadvertently make.
This interactivetraining is much more effective for patients than just read ing a book or hearing a few lectures.*
BEGINNING TREATMENT WITH YOUR DOCTOR OR DIABETES EDUCATOR
Although the protocol will likelydiffer at every doctor's office, in the next several pages, I'll try to give you an idea of how things work at our Diabetes Center. This way, you'll get a generalnotion of how a com prehensive diabetes treatment program should work. In my experience, most patients will cooperate with a treatment plan that shows them concrete results. Greatly improved blood sugars, weight normalization, halting or reversing diabetic complications,
Nevertheless, I record my 4-6 hour training sessions for my patients and give them the tapes. Readers of this book can purchaseCD recordingsof actual train ing sessionsat www.rx4betterhealth.com or (800) 798-6922.
112 BeforeYou Start
and a sense of improved overall health can go a long waytoward con vincingan individual to stickwith a treatment program.
Much is written in the diabetes literature about the key role of pa tient "compliance." Treatmentfailures are often blamed upon "lack of compliance." I think it's unreasonable to expect anyone to comply with a treatment plan that explainslittle and, as in the caseof the stan dard ADA approach, isn't really effective and offers little incentive to continue.
What we must do is set up a sensible,workable plan that you understand and agree with.
When I work with my patients in the office, I don't just havemystaffhand them a photocopied diet and ex pect automatic acceptance.
This is something that has to be negoti ated, worked out.
Do you liketurnips?
Great,we can probably fit them into your diet, but I don't think I've ever eaten one in my life.
Call it "physician compliance," but the point is that it's unreasonableto try to force my personalpreferences on my patients.
Onlywhen one under stands and agrees with the plan can we expectcooperation.
For coop eration to continue, however, patients haveto seepositive, rapid results.
Not all people are able to follow a given treatment plan.
For exam ple, someone who's been overeating carbohydrate for a lifetime may find it next to impossible to begin to followa restricted diet immedi ately,but we have waysaround this (see Chapter 13).
Some absolutely resist exercise.
But for most people we are still able to develop a treat ment plan that works.
If, for example, someone whose blood sugar should be controllable with diet and exercise refuses to exercise, I will instead prescribe medication that lowersinsulin resistance.
YOUR FIRST FEW VISITS
When seeing new patients, for those who livenearby,my preference is an introductory visit followed later by a series of treatment/training visits lasting 2-3 hours each.
The continuity of time is invaluable to showing rapid results.
However, most insurance companies don't like to pay for lengthy office visits— especially for diabetes training — and so it may be necessaryto break down the initial workup and train ing into multiple brief visits.
Although I don't like to, I may do this with local patients; but with patients who livea great distance from my office,it's simply not workable to have successive short visits.
At the first visit I always get a drop of fingertip blood to measure the patient's baseline (initial) HgbA,c.
As time goes on and the patient
Establishing a Treatment Plan 113
sticks with the program, the inevitable progression of reduced blood sugar over the next few months can provide tremendous encourage ment.
My preferred procedure for the first few days of treatment is to break down visits into three sessions.
Introductory Visit Since blood glucose profiles are so essential to formulatinga treatment plan, prior to the introductory visit I usuallyask a new patient to pro cure blood glucosetesting supplies — Glucograf III data sheets and the other supplies listed in Chapter 3.1 provide guidelines for blood glucose self-monitoring (like those you have seen in Chapter 4), and ask the patient to learn how to use the equipment so that later, on the first treatment/training visit, I can look over one or two weeks' blood glucose profiles. I alsomaygive the patient a coupleof largebottlesso that a 24-hour urine specimencan be collected for a subsequent visit.
First Treatment/Training Visit If I haven't done so in the introductory visit, I take a medical history and begin a physical exam gearedtoward uncoveringlong-term com pUcations of diabetes.
For patients who have had diabetes more than about five years, I inevitably find a good number of these long-term sequelae (aftereffects), some of whichmaybe reversed by blood sugar normalization.
The exam will include tests described in Chapter 2.
We check to ensure the patient has purchased the right supplies.
If we haven't done so already, we provide a supply list (Chapter 3) with ap propriate items checked off.
We discuss plans for treatment of medical problems other than blood glucose control.
These may include conditions the patient al ready knows about, but also anything uncovered by blood testing or by the physical exam.
If the patient has already acquired supplies and begun measuring blood sugars,I reviewhis or her technique and cor rect it if necessary.
Second Treatment/Training Visit Many of my patients come from out of town, and so the second visit maytake placethe dayafter the first. For localpatients,however, it will be approximately a week later. At this visit we finish the physical ex amination. We also recheck the patient's blood glucose measurement technique and his use of the Glucograf form.
114 Before You Start
If I feel that the patient should be taking insulin, I give instructions for insulin doses to be taken the night before and the morning of the third visit.
I also providetraining in self-injection (Chapter 16) to pa tients who haveneverinjectedbefore.For those who areveteran insulin users, I evaluate self-injection techniqueand correct it if necessary.
It's my experience that most insulin-using patients have previously been taught improper techniques for filling syringes and injecting insulin.
To this visit the patient is expected to bring the blood sugardata he or she has collected overthe prior week(s), together with a separatelist of what he/she eats on a typical day.
This information enables me to estimateif the patientwill need medication for blood glucose control and tells me about foods the patient likes that might be included in our meal plans.
The blood glucose profile also providesa snapshot of the patient's status before beginning the new treatment regimen.
We can review this at a laterdate to evaluate progress.
As with each of the other initialvisits,the bulk of our time will be devoted to training.* Most important, this is the visit where we negotiate the meal plan (see Chapter 11).
Third Treatment/Training Visit This visit may take place anytime after the second.We ask the patient to come in fasting and to bring a 24-hour urine collection.
At this visit I draw blood for baseline studies and continue training.
I also enter all the "datato remember"at the top of a Glucograf data sheet (Chap ter 5).
I also use this visit to give verbal instructions and a printed handout regarding foot care (seeAppendix D).
Patients to be treated with insulin may be kept fasting until supper on the day of this visit in order to determine if the smallbasal dose of long-acting insulin that was injected that morning is adequate to maintain blood glucose at a fixed level.
On this day, ifthe patient arises with a blood glucose above our target value, she'd have instructions to take a trial dose of fast-acting insulin to bring blood sugardown to the target value.
If blood sugar on awakening is belowthe target, she'd use glucose tablets to bring blood glucose up to target.
By this means, we confirm or correctmy estimation of how much a given amount of in sulin or glucosewill lower or raise the individual's blood sugar.