Diabetes care requires full patient, family involvement

My patient for today was a 52-year-old man with known type 2 diabetes for about five years. He presented with chest pain, had an abnormal cardiac catheterization and had a three-vessel coronary artery bypass graft. Using an approved postoperative intensive insulin therapy protocol, he did fine with respect to glycemic control until he was taken off the insulin drip and managed with glargine and pre-meal sliding scale rapid acting insulin.

His big problem was that he was indeed big (BMI 43) and together with his wife, had no education about diabetes management. I can’t be sure if he received no education or was simply in denial, but the end result was the same. He had undergone expensive, but necessary intervention that might well have been prevented if his primary care physician had more time and resources to stress the importance of patient education in the long-term management of his diabetes.

Don’t get me wrong; this is no easy task, aggravated by patient expectations that the doctor has to take care of his medical problems. Unless we have the time and resources to educate the patient about the disease and his/her role in its management, it is hard to make progress. My approach, and there are many others, is to have the patient check capillary blood glucose fasting each day and, for a different meal each day for four weeks, check CBG before meals and two hours after meals. Over four weeks most folks have a similar meal pattern. The goal is to have the patient understand what meals do to CBG and then begin to learn how to adjust the content of the meal accordingly. It is a slow but worthwhile process if it works which, in my practice, is unfortunately not often enough.

No matter what approach you take, I am convinced that diabetes care is suboptimal unless the patient and family are all involved in the education process.