Routine Follow-up Visits to Your Physician

Abstracted from Dr. Bernstein’s book “Diabetes Solution”
© 2007 by Richard K. Bernstein, M.D.

Taking responsibility for the care of your own diabetes may free you from habits that have been with you for many years. It also requires the establishment of new habits, such as exercise and blood sugar self-monitoring, that are easier to abandon than to follow.

Once your blood sugars have become controlled, it may only take a few months for you conveniently to forget about the pain you used to have in your toes, or the parent or friend who lost a leg or vision due to complications of diabetes, and so on. As time goes on, you will find that with diabetes, as with life in general, you will gradually tend to do what is easiest or most enjoyable at the moment. This backsliding is quite common. When I haven’t seen a patient for six months, I’ll usually take a meal history and find that some of the basic dietary guidelines have been forgotten. Concurrently blood sugar profiles, glycosylated hemoglobin levels, lipid profiles, and even fibrinogen levels may have deteriorated. Such deterioration can be short-circuited when I see patients every two months. We all need a little nudge to get back on track, and it seems that a time frame of about two months does the trick for most of us. I was not the first diabetologist to observe
this, and your physician may likewise want you to visit him at similar intervals.

Dosage requirements for insulin or ISAs(insulin sensitizing agents) may change over time, whether due to weight changes, to deterioration or improvement of beta cell output, or just to seasonal temperature changes. So there’s an ongoing need for readjustment of these medications. Again, two month intervals are appropriate.

What are some of the things that your physician may want to consider at these follow-up visits?

First of all, your doctor should try to answer any new questions that you may have. These may cover a host of subjects, from something you read in the newspaper to new physical complaints or dissatisfaction with your diet. Write down your questions in advance, so that you won’t forget them.  Your physician will, of course, want to review your blood sugar data sheets covering a period of at least two weeks. It makes no sense for your doctor to review prior data, as that is old history. If he or she wants to adjust your medications or meal plan, the changes should be based upon current information. Remember, however, that the data must be complete and honest. This means, for example, that if you spent a few hours shopping or overate, it should be noted on your data sheet. It doesn’t make sense, and can be dangerous, for your doctor to change your medications based upon high blood sugars caused by a few unrecorded dietary indiscretions.

Your physician will also want to draw some blood. At each visit your HgbA1C (glycated hemoglobin) should be checked. You need not be fasting for this test. Up-to-date physicians are now performing this test in the office using a small drop of finger-stick blood. Results can be had in about 6 minutes. At least once annually, a complete lipid profile including LDL sub-particles should be performed, and fibrinogen levels should be checked; C-reactive protein also should be measured. Kidney function studies including crystatin-c should also be performed. You’ll recall that these require a 24-hour urine collection, which must be completed on the day of the visit (see Chapter 2). Remember that the “normal values” for lipid profiles are based upon fasting determinations. So if your physician has planned such tests, try to book an early-morning appointment, and don’t eat breakfast. If you skip breakfast, be sure also to skip your preprandial insulin or ISA if you usually use these medications to cover breakfast. Do not omit glucose tablets or Humalog (lispro) needed to correct low or elevated blood sugars. Also remember to take your basal dose of ISA or long acting  insulin, as their purpose is merely to hold blood sugar level while fasting. Your physician may also want to perform other blood tests from time to time, such as a blood count and a chemical profile. If you are taking a statin drug for elevated levels of small dense LDL, liver function tests should be performed.

A partial physical examination, including weight, should be performed every two months. Usually the most important element of these visits should be examination of your feet. Such an examination is not merely to look for injuries, blisters, or what have you. Equally important is the discovery of dry skin, athlete’s foot, pressure points from ill-fitting shoes, ingrown or fungus-infected toenails, and calluses.  Your shoes should also be examined for areas where they have been stretched by prominences on your toes, suggesting that they are smaller than your feet. Any of these can cause or may indicate problems that could lead to ulcers of the feet and should be corrected. Dry skin is best treated with daily applications of animal or vegetable oils such as vitamin E oil, olive oil, emulsified lanolin, mink oil, emu oil, or any proprietary oil other than mineral oil. The cure for ill-fitting shoes is new shoes (possibly custom-made) with a wide toe box with a deep rise. Calluses frequently require the purchase of custom orthotics that redistribute the pressure on the bottoms of your feet. Grinding off calluses is not the solution, as calluses are a symptom, not a cause, of excess pressure. Their removal is the most common cause of amputations in patients that I see at my hospital’s wound care clinic.

Resting blood pressures, repeated every few minutes until the lowest reading is obtained, are mandatory at every visit if your blood pressure is even slightly elevated. If your blood pressure is usually normal,  it should be checked every twelve months anyway. Over the course of a year or two, other aspects of physical examination should be performed. The tests need not be done all at one visit, but may be staggered. These include oscillometric studies of the blood circulation in your legs, an electrocardiogram, tests for sensation in your feet, and a complete eye exam. The eye exam should include papillary reflexes, visual acuity, intraocular pressure, the Amsler grid test, a test for double vision, and examination of your lenses, anterior chambers, and retinas through dilated pupils. This last exam must be performed with certain specialized equipment that should include direct and indirect ophthalmoscopes and a slit lamp. If your physician is not so equipped, or if he has previously found potential vision-threatening changes in your eyes, you should be referred to an ophthalmologist or retinologist.

If your initial physical exam disclosed diabetic complications such as early signs of neuropathy, carpal tunnel syndrome, or Dupuytren’s contractures, examination for these complications should be periodically repeated. The R-R interval study should be repeated every eighteen months, even if it was initially normal.

The best treatment for the complications of diabetes is prevention.  The second best treatment is detection in the very early stages, while reversal is still possible. For these and the reasons mentioned above, I strongly recommend visits to your physician every two months, or at least every three months.