DIABETES HEALTH: The latest figures show that only five percent of people with diabetes see a diabetes specialist. Is there something seriously wrong here?
Dr. Marcus: In a disease increasing in incidence with the possibility of preventable, catastrophic outcomes, the number is more like three percent. Everyone with diabetes should be seen by a diabetologist or a member of a diabetes health-care team. I also think that the patient (the most important member of this health care team) has the responsibility of making sure that his or her physician is capable and up-to-date.
Physicians love car analogies. An appropriate one would be, if you had a car and it kept breaking down and was constantly in the shop, I doubt you would continue to bring it to the same mechanic. Your body is much more important than your car, and it can’t be replaced or traded in. I am not sure why people continue to put up with poor care, especially when the American Diabetes Association’s standard of care is available for everyone to use as guidelines and a yardstick to measure care.
D.I. Are doctors responsible for poor health care?
Dr. Marcus: It is an unfortunate fact that a large number of doctors are not committed to taking care of patients with diabetes. To do so would mean being accessible to patients and to take an active role in the education of the patient and to empower them with the tools and judgment to make appropriate decisions as to their care. I feel strongly that if a doctor wants to be a part of the patient’s team, it is necessary to listen to them and to set guidelines. The physician may view themselves as the general, but the patient is the king or queen, and a ruler may have many generals.
D.I. Many people think type 2 diabetes is not as serious as type 1. Do you agree?
Dr. Marcus: Absolutely not! It is reasonable to assume that if excess glucose is as poisonous as the DCCT (Diabetes Control and Complications Trial) said, then type 2 diabetes is as serious as type 1 diabetes. It is often the case that people diagnosed as type 2 have had diabetes for more than 10 years and may have insulin resistance from the time of their birth. In our popular culture, where there is a quick fix or a pill for every ill, the patient and doctor tend to be lulled into a fantasy world where if they just take some pills everything will be okay.
D.I. Do you have any innovative approaches to treating type 2 diabetes?
Dr. Marcus: Yes, I do. Most doctors divide the time for inheritance of insulin resistance to type 2 diabetes into five stages. In stages one through three, blood sugars begin to go too high after meals because the muscles are increasingly unable to have glucose enter their cells and be used for energy. In stages four and five, the liver turns a deaf ear to insulin and begins to produce too much sugar. If blood sugars rise above 200 mg/dl at any time, the blood can turn into a tar-like liquid, moving extremely slowly through the body. A natural example of this is molasses, which moves more slowly than syrup because of a high sugar content. These different types of type 2 diabetes require different therapies. In the later stages, insulin is the most effective drug to stop the liver from producing too much sugar. Hence, it is necessary to take insulin, and its use should be viewed as necessary treatment, not a failure on the part of the patient.
In the very early stages, however, some people will respond effectively with diet, coupled with blood sugar measurement and exercise. If this does not work, then it may be necessary to begin to identify poor food choices and therapy with one or more pills, alone or in combination with insulin.
The problem early on (in stages one through three) is not too little insulin, but too much insulin and too little response in the cells. Lowering glucose levels by recognizing which foods cause them to go up (checking blood sugars after, not before, meals) should be the first lesson for patients and their health care team.
D.I. Should all patients with diabetes test their blood sugars at home?
Dr. Marcus: Absolutely. Blood testing is mandatory. There is no way you can have diabetes and think that a 15-minute doctor visit every three months is going to adequately determine what you need to do day after day to stay healthy. It is just not possible. And we know that high blood sugars are the prime cause of diseases such as hardening of the arteries, hypertension, eye disease, nerve damage and kidney disease. We just proved this in the past 20 years, even though for 400 years any cook could tell you that if you heat glucose in contact with protein (nerve, blood vessel, tendon, joints, muscle, etc.), you form a hard crystal in the process we all know as caramelization. Human beings just cook this combination at a lower temperature-98.6 degrees rather than 360 degrees-and that is why it takes longer (15 to 20 years) to come up with same result. Hence it is vital to test 60 to 120 minutes after a meal. Testing your blood sugar provides a little window into what your cells are being exposed to, helping you understand what is happening inside your body and what you need to change your internal creme brulee production. It tells you if the food you ate, the exercise you did and the medicine you took is keeping you healthy-“healthy” meaning a normal blood sugar level, which translates into less inflammation, less sickness and a longer life expectancy.
D.I. You mentioned the importance of food. Is it important for people with diabetes to understand nutrition?
Dr. Marcus: Yes, and especially so on an individual basis. It is always enlightening to see which foods are causing your blood sugar to rise. We all know that fruits and fruit juices make blood sugars go up. But, what about pizza, a Big Mac (95 g. carbohydrate) or a mocha grande (60 g. carbohydrate, 400 calories)? Eating healthy to me is eating smart, and you cannot be smart without gathering information.
D.I. Any final thoughts?
Dr. Marcus: The greatest revolution in diabetes care in my lifetime has been the introduction of methods which allow the patient to monitor their own blood glucose. Non-invasive methods, soon to be available, will force a patient’s doctor to do something about abnormal results and give patients more control of their lives and diabetes. The combination of patient knowledge, along with the demand to do something about it, will improve patient care considerably. If the patient demands that something be done, something will be done. Invention stimulates progress and further invention when there is a necessity. In diabetes, glucose knowledge is that necessity. Education is the key. We need people to understand that from this day on, diabetes does not need to be the cause of all these complications. Most of them are preventable. As Mark Twain said, “Even if you’re on the right track, you’ll be run over if you just stand still.”
Alan O. Marcus, MD, FACP, is director of endocrinology at South Orange County Medical Research Center and a medical monitor for the U.S. Food and Drug Administration for the Implantable Insulin Pump Project and the Subcutaneous Glucose Sensor Project. An associate clinical professor of medicine in the division of endocrinology, diabetes and hypertension at the University of Southern California School of Medicine, Dr. Marcus is also on the extended faculty of John’s Hopkins University. He is a member of the ADA Council on Diabetes and Complications, scientific advisor to the JDF and curriculum advisor for the American Association of Diabetes Educators. Marcus serves as an NIH fellow in endocrinology and metabolism/diabetes at the University of Southern California, Los Angeles County Medical Center.
Editor’s note: A study has shown that between 60 and 80 percent of all diabetes-related complications are preventable with proper education and treatment.
Updated from the June 1995 issue of DIABETES HEALTH.