Hi everybody,
This is going
to be my 100th post on my blog. Gonna be a pretty long one..I have
been thinking about future of diabetes!! No No not the diabetic patients, i
mean physicians treating diabetes, what will be the fate of ever growing number
of diabetes clinics. In the early 90’s Diabetes was considered a disease of the
affluent, an urban epidemic but the current experience says Diabetes affects everyone
, rich or poor, urban, rural or even the tribal... with a scenario like this it
is obvious that there would be mushrooming of clinics and centres to treat this
epidemic. End result is heavy competition! This has now come to such an ugly
phase where labs start offering multiple tests at a very low rate. This
situation makes me think
Have all lab owners become too decent to forget all
their profits and work for the benefit of public?
Lab reagents have all of a sudden
become cheap?
If lab tests are so cheap were we
all getting cheated all these years?
Or is there a real big compromise
on the quality of reporting?
Well
the last one sounds logical to the reasoning mind.. if the 4th
option is the answer then how to deal with the situation in the absence of a
WORKING centrally controlled monitoring system.. The answer is again simple!
Don’t get fooled by ads. Go by the quality of lab. Am not supporting labs with
exorbitant rates. I am just telling make sure you get good quality reports even
if you pay a little more!
Next
most important aspect in Diabetes is the high degree of confusions and myths
among the general population. Most common questions are
1) When
do i suspect diabetes?
2) How
to diagnose/ confirm diabetes?
3) How
does a patient go about doing this test?
4) If
am diabetic what do i do next?
5) How
does a patient monitor his/her diabetes?
6) How
much time to give your doc before switching over?
7) How
do you know that you are on the correct treatment?
8) When
do we use insulin?
There might be many more questions
but i personally feel these 8 questions are more important in Diabetes. To
answer all these questions without bias is a difficult task. Why??? Because
each of these questions have some international guidelines as an answer. But in
a country like India how much of these guidelines can be followed in routine
practice? What do i do now? Well i won’t talk about guidelines here but will
discuss these topics in a more practical way (obviously will keep all required
guidelines in the back of my mind).
So lets start!
1)
When
do i suspect diabetes?
(Every obese person is a Diabetic unless
proved otherwise)
Age more than
40
Overweight (height in cms – 100 = ideal body weight)
All people in
desk jobs. Here i would like to add that guidelines say all those with less
physical activity are at risk. With such rampant disorder like diabetes i feel
this criteria is literally useless. Everybody should suspect diabetes whether
he is a CEO of an company or Manual Labourer.
Family
history of diabetes
Ladies
who have had Gestational diabetes (treated at that time with just diet or with
insulin. The risk is the same!)
Of
course everybody knows, poor wound healing, blurring of vision & recurrent infections
` patients
on steroids for other disorders like asthma, arthritis, post transplant
patients etc
Patients
with other endocrine disorders.
2)
How
to diagnose/ confirm diabetes?
Tough decision
both for the physician and the patient. Recent guidelines say we can use HbA1c
as a diagnostic tool. But i would prefer to use the age old glucose tolerance
test (GTT). Only difference is that i would prefer to take 3 samples instead of
the conventional 5 samples.
Why should i
prick the patient thrice?
HbA1c estimated using HPLC method is most reliable. The
fact is not many labs in our country use this method.
By doing GTT i
can diagnose the earliest stage in prediabetes (known as IFG – impaired fasting
glucose)
Personally i
feel that by combining GTT (3intervals ) and HbA1c i can diagnose the patient’s
glycemic status. If i advise the patient only fasting and post prandial blood
sugar i have to repeat the test thrice to report diabetes with confidence. That
would make is 6 pricks. So GTT once a year till the patient is diagnosed
Diabetic is always better.
3)
How does
a patient go about going this test?
Whenever you plan to do GTT – DO NOT GO ON DIET, DO
NOT JOIN A GYM, SLEEP WELL BEFORE THE DAY OF TEST. Follow a normal diet and exercise pattern. On the
day of test go on empty stomach ( minimum 8-10 hours fasting). The technician
will first draw bllod and then give you 75gms of glucose. DONT GULP IT ! drink
it in sips. If you try to gulp it you will have nausea and vomiting. You can
have water during the test period.
DO NOT SMOKE
DO NOT EXERCISE
DO NOT HAVE BREAKFAST
DO NOT HAVE TEA/COFFEE
DO NOT TRAVEL.
The second sample will be taken after 1 hour and again
after 2 hours. So the total duration of test is 3 hours.
4)
If am
diabetic what do i do next?
DO NOT PANIC! STAY
CALM! YOU CAN MANAGE DIABETES!
In the initial consultation go
through investigations of diabetes and also the baseline functions of organs
that might be affected in Diabetes.
These include
Kidney
Urine
routine
Blood
urea
Serum
creatinine
Spot
microalbuminuria
Liver
Liver
function test
Blood profile
HbA1c
Lipid
profile
Hemogram
Electrolytes
Heart
Baseline
ECG
Nerves
Biothesiometry
Blood vessels
Doppler
Eye screening
Dental screening
These investigations will help
you and your doc to compare the changes from the baseline. This will go a long
way in deciding the correct line of treatment. Whenever you check blood sugars always
check fasting and post prandial blood sugars. Never estimate fasting or post
prandial alone. The values may be misleading!
5)
How does
a patient monitor his/her diabetes?
Very simple!
Buy a glucometer, calibrate it. Check
your blood sugars twice weekly. Check blood sugar if you are feeling hypoglycaemic.
Check blood sugars if you feel your sugar might be high.
Check HbA1c once in every 3
months
Check your lipid profile, spot
microalbumin once in 6 months.
Check your liver function test,
hemogram, urine complete, ECG , Doppler, biothesiometry once a year.
Get your eyes and teeth screened
once a year.
Consider the cost involved in
doing these tests as investments for your healthy future and not as mere
expenditure.
Disclaimer – the periodicity of
the test may vary depending on the medication you are taking for diabetes,
hypertension and cholesterol.
6)
How
much time to give your doc before switching over?
Tricky question!!!
I
might get beaten up by my colleagues for my answer! But what the heck!!
Here it goes
Actually there is no time frame .
Consider changing your doctor if
He
does not explain you Diabetes
Does
not give you proper instructions on diet
Does
not tell you how to take the tablets
Does
not mention & insist on the time gap between taking tablets and food
Does not tell
you to repeat HbA1c every 3 months
Keeps changing
tablets every visit despite good sugar control
Does not
provide you a mode of contacting him in case of doubt. ( email or contact
person in his absence)
Does not
explain symptoms of hypoglycaemia and what to do at that time.
Now again coming back to time
frame , before taking a decision ask yourselves one question...
have you followed all
instructions given by your doc at all times? If you have neglected your doc’s
advice even once then the mistake is on your part.
If you feel you have followed
everything strictly then i feel 3 visits spaced 2 months apart with adequate investigations
should put you on the right track.
7)
How
do you know that you are on the correct treatment?
HbA1c less than 7 or showing a decreasing trend
No or very minimal hypoglycaemic symptoms
Other parameters are also taken
care of
No retinal changes during yearly
reviews
No microalbuminuria
Treatment is always combined with
insulin sensitizers ( unless contraindicated)
8)
When
do we use insulin?
If your initial
blood sugars are very high in type 2 diabetes. It is definitely possible to
step down from insulin to tablets after satisfactory blood sugar control.
Insulin is not addictive
Insulin is not habitual, so don’t
be scared!
Type 1
diabetes
Uncontrolled blood
sugars
Pregnancy (
remember baby is more important)
Steroid usage
Planning for
surgery
While treating
ulcers , wounds, infections
Fluctuating sugars
There is also a view that using
insulin intermittently will give some rest to the overworked pancreatic beta
cells. There has been evidence that patients on intermittent insulin do better
with oral tablets for diabetes.
Thanks
for your patient reading! I am sure that this post would have been helpful to
atleast some of you. Every diabetic would have faced one of these questions
some time or the other. Feel free to comment. I have presented this topic in a
way i feel is simple. I hope all of you find it easy to understand. Feel free to contact me for any queries at riyaz.arka@gmail.com
