Earlier this week a resident shared that she had lost a close family member to complications of diabetes. That family member was only in her mid-60’s – young given the fact this woman’s life expectancy was 81 years. My mind drifted back 50 years as I recalled my beloved “Nana” who suffered a similar fate. She was 62 when claimed by diabetic complications.
These women lived 50 years apart, yet their outcomes were amazingly similar.
In 1962 the management of diabetes was quite limited. Animal derived insulin had become available in the 1920s and an oral sulfonylurea treatment was developed in 1955, but glucometers would not be created until 1970. For years Nana tested her morning urine by boiling it in a test tube with a reagent and watching for a color change. The color of the liquid indicated the presence of sugar: greenish (light sugar), yellow (moderate) or red/orange (heavy).
My father vividly recalls this morning ritual and remembers the green-to-amber color but is quite certain he never saw the tube turn red. Nana was never on insulin, but took her oral medication and adjusted her diet. She stopped eating the pasta she made for the rest of her family and if the tube was the tell-tale yellow, she ate only lean vegetables for the rest of the day.
More options than ever before
Fast forward to the year 2016 and we have an almost dizzying array of options for management of our patients’ diabetes. Numerous biosynthetic insulins or insulin analogs are available, thus allowing physicians the ability to customize treatment and reduce side effects. Oral medications target different sites of action. The advent of reliable home glucose monitoring, combined with in-office point-of-care hemoglobin A1c testing, allows therapy to be modified while the patient is sitting in front of the physician and the rationale for medication changes can be explained.
Not only have our treatment options improved over the years, our understanding of how diabetes management impacts disease has also expanded. We know that proper diabetic management reduces risk of complications for cardiovascular disease by 50 percent, eye disease by 76 percent, kidney disease by 50 percent and nerve disease by 60 percent.
Through motivational interviewing we can assist our patients in setting goals for self-management whether it relates to nutrition, physical activity, glucose monitoring or medication adherence. We even have novel approaches to care such as group visits where those with a similar diagnosis can learn about disease management in a supportive environment. So many tools, yet so many people are unable to achieve their desired outcome.
Diabetes is not an easy disease to self-manage. It’s actually quite complicated and many situations factor into an individual’s ability to achieve success. For some it’s financial barriers. For others it is access to nutritious foods. For yet others it’s inability to pursue physical activity due to physical limitations or safety concerns where they live. Are there sidewalks? Is the lighting adequate? For most of my patients though, it is because something or someone takes priority over their own health.
Life happens. An employee gets pulled for mandatory overtime shifts and is too tired to cook or exercise when he/she gets home. A daughter is the primary caregiver for her elderly father and struggles to keep up with his appointments, medications and demands, leaving her no energy for herself. A single father is determined to give his children his time and financial resources and oftentimes goes without time and energy for himself.
Life is messy. A myriad of options exist for management and treatment of diabetes, but only if they can not only be pursued, but maintained. And that is the challenge.
Diabetes management at Duke Family Medicine Center
Learn more about Shared Diabetes Medical Appointments at the Duke Family Medicine Center by calling (919) 684-6721.
Donna M. Tuccero is associate program director of the Duke Family Medicine Residency Program. Email donna.tuccero@dm.duke.edu with questions.