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In Practice: With diabetes, patient decided to play hardball

November 07, 2011|By Steve Dudley, Special to the Los Angeles Times
  • It's often hard for patients who are newly diagnosed with Type 2 diabetes to make lifestyle changes, such as curbing candy habits.
It's often hard for patients who are newly diagnosed with Type 2 diabetes… (Kirk McKoy, Los Angeles…)

A short while ago, Lars came in for a visit. He's a friendly, happy-go-lucky guy with a desk job in some sort of marine industry.

The bulk of his visits have revolved around his passion for softball. He plays on three teams year round, and from time to time his competitive edge gets the better of him and he twists an ankle or pulls a muscle and comes in to get patched up. I remind him he's 45, not 25, that it's not Game 7 of the World Series, that he should go a little easy on himself. He doesn't like to hear that: Softball is serious business.

This visit, however, was for his yearly physical. I checked his vital signs, poked and prodded him, and told him that things were checking out pretty good, and I put in a plug for him to lose 20 pounds. Then my nurse drew some blood for lab work.

I wasn't expecting to find anything of concern, but the next day, when I looked at his labs, I was surprised to see that his glucose level was markedly elevated.

I asked the lab to run one more test, the glycosylated hemoglobin (HbA1c) level, which gives a better picture of what someone's glucose has been doing over time. I like to see the number be under 6.0, but his was significantly higher — indicating that Lars had early Type 2 diabetes. I dashed off a letter to him expressing my concerns and asking him to return for a discussion.

I knew I had my work cut out for me as I tried to explain glucose metabolism, what the HbA1c test means and diabetes management, all in a 15-minute appointment. His eyes started to glaze over like a Krispy Kreme doughnut.

But I kept at it, explaining as best I could that his body wasn't processing sugar as efficiently as it should and that the excess sugar in his blood was not good for him. He told me he felt fine. That's always a tough one. When someone comes in with a sore throat, they're happy to take what I prescribe just to make the pain go away. It is an entirely different matter to convince someone with no symptoms at all that he has a serious condition and needs to make some big changes.

I try to stress the fact that in many cases, diabetes can be improved, even reversed, with proper attention to "lifestyle" changes, as we in the business call them. For diabetes, it's a two-pronged approach: diet and exercise. I asked Lars how much exercise he got standing out there in right field. Maybe he could step it up a notch, throw in some cardio at the gym.

Then, in the short time we had left, I hit the high points about healthy eating, emphasizing avoiding sugars and limiting carbohydrates (which are pretty close to sugar once you get them into your body). I asked him if he thought he could modify his diet to a small degree. If he'd been eating nothing but cardboard and tofu, then perhaps he was stuck with it and could blame it all on genetics (which is indeed a factor). But like most of my patients, Lars had a few areas he could improve on, and he said he was up to the challenge.

"No more candy bowl on the desk?" he asked.

"Nope."

"No more cans of Coke?"

"How many do you drink?"

"About three a day."

"You gotta cut them out too."

"Cookies?"

"You know they're not good for you. Save them for special occasions."

I even gave him a cursory lesson in how to check his blood sugars with a glucometer. He was hesitant to stick his fingers but agreed to try.

As he left, I wondered how much of my advice he would take to heart. I wasn't too optimistic. After all, I had been after him for years to lose weight, and he hadn't budged. Why should I expect him to go through all the hassles of changing his diet and checking his blood sugars when he felt fine? That seems like a lot of work for very little payoff: a lab report with better sugar numbers and maybe a word of two of encouragement from the friendly family doctor.

Patients generally have good intentions when they promise to step up to the plate and make some serious changes, but reality hits once they leave the office. People are quite attached to their eating and exercise habits. I've seen it over and over again: the bashful admissions at follow-up appointments that fries and white bread are still on the menu, the workout resolutions that have yet to come to pass, the protestations that it's all just too difficult. I expected Lars' resolve to wither under the fun of gathering at the local burger shack after his softball games. And that candy bowl, a comfort during his stressful days at work, would he really swap that out for celery sticks?

Yet when he came back for a follow-up three months later, to my delight he had done pretty much everything I had suggested.

He had managed to drop a good 10 pounds by tacking on some gym workouts and cutting back on his portion size at dinner. He was avoiding most of the sugars he had admitted to eating but was also very aware that carbohydrates needed to be limited too.

The candy bowl? Gone. The cans of Coke? Down from three a day to perhaps two a week, and I said that was fine, we all need to cheat a little.

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