Treating type two diabetes.

I recently found a booklet published by DUK in 2009 with the above title. Being a fair-minded person I decided to read it, rather than exercising the other options, and found it quite useful in some ways. In fact, I would recommend it to some HCP’s purporting to specialise in diabetes care and who are fond of quoting DUK. On the other hand it was published four years ago and much could have changed by now.

I don’t think many of us would disagree with the definition of diabetes mellitus as “a condition in which the amount of glucose {sugar] in the blood is too high because the body cannot use it properly“. It goes on to say that “glucose comes from the digestion of starchy foods such as bread, rice, potatoes, chapattis, yams and plantain, {you see they do know] from sugar and other sweet foods and from the liver which makes glucose“. Now that begs an interesting question. Why do they ignore the starchy part of that statement?

To progress – I am sure few of us here would disagree with another statement  “The main aim of treatment of both types of diabetes is to achieve, blood glucose, blood pressure and cholesterol levels as near to normal as possible. Now that is an interesting one. In this context normal must mean non-diabetic. But we know that the NHS are willing to accept far higher bg levels. That is because they have failed to achieve their targets year after year for T1s as well as T2s. Now they are shifting the emphasis to cholesterol levels and there is a noticeable campaign to achieve in that area, by prescribing statins for all and to persist even when side-effects occur.

Much of the rest of the booklet concerns T2 medication. It was probably made necessary by the sudden proliferation of medications where previously there had been very few. Readers are told that when first diagnosed they will “probably be advised  to follow a healthy {sic} diet and “do regular physical activity. This will probably be tried for several weeks or months before deciding whether you need to take medication”. Does this actually happen?

I know there are reasons, age, infirmity and other conditions which might rule it out but there is something else which I feel is too often the major factor – TARGETS. I am sure everyone understands that. Can they afford to give the patient sufficient time to try diet and exercise? A very well informed and confident patient might insist but too many probably just accept what the Dr or more likely, nurse dictates and is sucked into the medication vortex.

This booklet mentions seven classes of drugs and within each class there are several alternatives all having different effects and side effects. There are probably more by now. Does anyone on medication feel confident that a practice nurse is familiar with all of this and has the time and interest and incentive to keep up to date with it all? Not in my experience. Even an experienced diabetic nurse in a hospital would struggle, but at least she might have some help at hand. What of the GPs? Yes indeed. What of  them?

I understand that very little time is given to diabetes in the training of doctors. In many practices diabetes care is left entirely to the nurses. In my Practice the Drs refuse to answer questions about diabetes but instead refer you back to the nurses on the grounds that they “attend more courses”. Drs are not even involved in prescribing  diabetic medication as many Practice Diabetes nurses are also Nurse Practitioners and thus able to prescribe in their own right.  So how do the GP’s gain experience of diabetes? Short answer – they don’t. Sometimes they officiate at the Annual Review and mumble their way through the tick sheet but again-any questions are referred back to the nurse. How will the Dr. recognise diabetes symptoms? He/she won’t and patients just have to hope that the  relevant tests are ordered and results correctly interpreted. This has a knock-on effect for the hospital clinics. They will see far fewer T2 cases than before. I don’t give much for most patient’s chances of a referral, more and more often referrals are instigated by consultants dealing with complications as a result of poor diabetes management in the Practice. Even diabetologists must be losing touch with ordinary T2 patients and only dealing with the most difficult and unusual cases is not altogether a good thing for any of us. These are the people whose opinions drive policy. A diabetologist told me that he advises all T2s to take all their medication in the morning. This certainly wouldn’t work for me but suggests he is used to seeing mostly non-compliant or very forgetful patients – those who don’t try to manage the condition for themselves.

One of the results of all of this is to assume that patients are robots or idiots who cannot be trusted to manage their own oral medication. I find this ludicrous because, failure to achieve control with oral medication leads to insulin use. This means putting a potentially, in certain circumstances, lethal weapon, the insulin pen, in the hands of people who couldn’t be trusted with a pill. What I mean by this is that patients need to take control of their own medication to ensure it works for them. Of course they would seek medical advice about when to take medication and how it reacts with other medication but in many cases its more flexible than people think. First the Dr is often “best guessing” in some case, of course medication has to be taken before or after meals or at night but  doses can be split and taken to fit in with the individual’s lifestyle. The Nurse or Doctor can only work by trial and error unless the patient is observant of effects and prepared  to be proactive in their own treatment. This isn’t always welcomed at first but its worth persevering. Less is sometimes more. For example, when a particular medication seemed not to be working for me it was increased, three times in all. It still didn’t work. What it did, however, was to cause weight gain which increased  insulin resistance and almost led to my being put on insulin unnecessarily. I now take one-sixth of the dose but only when it is needed, which is occasionally. This is with the nurse and the doctor’s full concurrence. It took a long time to achieve – you have to show that your theories work, but its not impossible.

I often read of people having hypos at one end of the day and high readings at the other. The solution seems obvious but nothing can be taken for granted – it must be pointed out to the HCP. I now take the minimum medication to keep my levels stable because of my drug-induced eye condition. Its a balance – diet, exercise and minimum meds. In a lot of ways I use the meds as others use insulin. They are more flexible and mistakes are not so dangerous. On the other hand there isn’t one of them which doesn’t carry some risk – even Metformin. So, probably best avoided if possible. If not take control. HCP’s don’t have total autonomy and must follow the guidelines set out for them.   The risk/benefit ratio must be considered. In the end its your body – only you can decide. Doctor’s know this and may try to persuade you to take various medications but must respect your decision.   Keep on taking the tablets – or not.

Kath

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This entry was posted in Blood glucose, Diabetes news, Low carb diet, Sugar, Type two diabetes. Bookmark the permalink.

2 Responses to Treating type two diabetes.

  1. Great post Kath and a lot of food for thought indeed,many of us including myself have found that to take control of our condition that we have to think outside the box and research the advice given thoroughly and also take into consideration relevant Anecdotal evidence from others who are in a similar position and then we have to become our own ‘Expert’ in our condition,be it diet or medication,we have to make an informed choice as we cannot simply rely on our HCP’s to always have the right answers or appropriate treatment for us as an individual although a ‘Blanket’ one size fits all approach seems to be name of the game in my poor experience of Diabetic treatment in my local PCT area.

    Paul

  2. Jan says:

    Super post Kath, one that will give both diabetics and non diabetics a very interesting read. Through greater understanding and knowledge more informed choices can be made.

    All the best Jan

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