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BEGINNING TREATMENT WITH YOUR DOCTOR OR DIABETES EDUCATOR Part TwoArticles - Dr. Bernstein Shares His Insights Part 2 of 4 Although there are only two major types of diabetes— type 1 and type 2—there are so many variations, particularly in type 2, that a treatment plan that works for one diabetic won’t necessarily work for another. Each plan has to be tailored to the individual.Diabetes Solution Revised and Updated
The Complete Guide to Achieving Normal Blood Sugars Richard K. Bernstein, M.D., F.A.C.E., F.A.C.N., C.W.S. Establishing a Treatment Plan
Part 2 continued BEGINNING TREATMENT WITH YOUR Although the protocol will likely differ 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 general notion of how a comprehensive 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, and a sense of improved overall health can go a long way toward convincing an individual to stick with a treatment program. Much is written in the diabetes literature about the key role of patient “compliance.” Treatment failures are often blamed upon “lack of compliance.” I think it’s unreasonable to to expect anyone to comply with a treatment plan that explains little and, as in the case of the standard 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 have my staff hand them a photocopied diet and expect automatic acceptance. This is something that has to be negotiated, worked out. Do you like turnips? 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 unreasonable to try to force my personal preferences on my patients. Only when one understands and agrees with the plan can we expect cooperation. For cooperation to continue, however, patients have to see positive, rapid results. Not all people are able to follow a given treatment plan. For example, someone who’s been overeating carbohydrate for a lifetime may find it next to impossible to begin to follow a restricted diet immediately, but we have ways around this (see Chapter 13). Some absolutely resist exercise. But for most people we are still able to develop a treatment 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 lowers insulin resistance. YOUR FIRST FEW VISITS Introductory Visit First Treatment/Training Visit We discuss plans for treatment of medical problems other than blood glucose control. These may include conditions the patient already 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 review his or her technique and correct it if necessary. Second Treatment/Training Visit 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 provide training in self-injection (Chapter 16) to patients who have never injected before. For those who are veteran insulin users, I evaluate self-injection technique and 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. Most important, this is the visit where we negotiate the meal plan (see Chapter
11). Patients to be treated with insulin may be kept fasting until supper on the
day of this visit in order to determine if the small basal dose of long-acting
insulin that was injected that morning is adequate to maintain blood glucose
at a fixed level. On this day, if the 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 sugar down to the target value. If blood sugar on awakening
is below the target, she’d use glucose tablets to bring blood glucose
up to target. By this means, we confirm or correct my estimation of how much
a given amount of insulin To this visit the patient is expected to bring the blood sugar data he or she has collected over the prior week(s), together with a separate list of what he/she eats on a typical day. This information enables me to estimate if the patient will 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 provides a snapshot of the patient’s status before beginning the new treatment regimen. We can review this at a later date to evaluate progress. As with each of the other initial visits, the bulk of our time will be devoted to training.* * My training program consists essentially of the material covered in this
book. Part 3 next: SETTING A BLOOD SUGAR TARGET We would like to thank the publisher Little Brown and Company and Dr. Richard
K. Bernstein, for allowing us to provide excerpts from Diabetes Solution. 1. Heart of Diabetes Journal to track your progress in managing your diabetes
and reducing your risk for cardiovascular disease;
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