Confessions of a Diabetic

She gave her best poker face. Delia was one of my fifty year old diabetic patients that I had been seeing for some time. She was coming in for her quarterly visit follow up after her blood work was drawn. She’s white, obese, only on Glipizide because she could not tolerate the Metformin (at least that’s what she said) and she refused to take a medication for her cholesterol or her blood pressure. She said that she didn’t understand why she couldn’t lose weight as she has been dieting every single day. I nod my head in agreement with her. “Me neither,” I said.

When I reviewed her labs, her hemoglobin A1C was 8.7, which is about where it was three months ago. She hadn’t lost any weight since her last visit, even though she keeps stressing that she is trying extremely hard with her diet. She asked me about a ketogenic diet. “My friend started it and she’s lost like thirty pounds. Do you think I should do it?” 

When I confronted her with her test results, she looked frustrated. “I’m doing everything I can,” she said. “I take my medications. I’m skipping breakfast. I’m eating more salads. I’m trying not to eat bread. I just don’t know.” 

“I think we need to put you on more medication,” I told her. 

“Maybe I can work a little more on my diet,” she retorted back. 

“But you just told me that you’re doing everything you can,” I replied back. 

“Well, maybe, I cheated a little.” Her poker face began to break. 

“Cheat in what way?,” I probed.

“Well, I get home so hungry sometimes from work, that I end up eating whatever’s in the fridge.”

“And how often are you doing this?”

“Like, three or four nights a week.” So, basically every work day. “But, I think I can change that.”

That’s the thing about diabetes, the numbers never lie. You can lie to your doctor. You can lie to your spouse. But the numbers never lie. There are a lot of numbers that we deal with as doctors, but I am specifically referring to five of them. The first is the hemoglobin A1C (HbA1C). This number represents your glucose or sugar average over the course of three months, by examining the percentage of your red blood cells, or hemoglobin, that is glycosylated due to the glucose in your blood stream. The life span of a red cell is three months, which is why we examine it quarterly. A HbA1C between 6.5 and 7.5 is considered good control. Anything above that is considered elevated. The second number is your weight. Usually, if you are following through with your diet, this number will respond by going down. If it goes up, chances are that it isn’t muscle weight, unless, of course, you are actually following through with a strength training regimen in addition to your diet, in which case, it still should go down in the majority of cases. The third number that you should know is your blood pressure. Your blood pressure is critically important when managing diabetes. If it’s consistently elevated above 140/90, it is causing damage to you arteries, possibly creating the secondary macro vascular and micro vascular problems typically associated with diabetes, like heart disease and renal damage. Usually, if you are taking your medications as directed and eating right, your blood pressure should either improve or remain controlled. The fourth number is your cholesterol. Your low density lipids or LDL cholesterol is crucial in diabetic management. The LDL is what is commonly referred to as your “bad cholesterol.” This is the cholesterol that is responsible for the premature plaquing that occurs in your arteries when it is high. In diabetic management, it’s important that this number is as close to 70 as possible to reduce the risk of atherosclerotic disease. The final number is you glomerular filtration rate or GFR. This number measures how well your kidneys work. 

“I admit, I ate a little more than I should have at my friends birthday party,” she continued. “It’s hard to when I have cake in my face.” A simple way to keep you accountable with your diet is to take photos of your food. If you have more than you should, you’ll see it. 

Ideally, every diabetic patient should be on at least three medications: metformin for the diabetes, a statin medication or equivalent to manage cholesterol, and an ACE inhibitor to help protect your kidneys. Insulin is usually reserved for patients that cannot be controlled by conventional oral medications. Most patients, like Delia, hate the idea of being on medications, but do little to nothing to actually help their own medical conditions. Diabetes is usually a result of long standing bad habits on the part of patients, and unfortunately, those habits are difficult to change.

Delia goes on to tell me that, no, she hasn’t done anything to change her exercise program. “I have really bad knee pain. I can’t walk until I get that fixed,” she said. I reminded her that we live in Florida and that if you have access to a pool, use it. Of course, nothing changed with Delia, and I knew that from the beginning of her office visit. She can certainly lie to her doctor, but her numbers will always reveal her secret confession about how good she actually is with her diet and habits. Like I always tell my four year old son, it’s always best to tell the truth. 

By: Dr. Juan Borja
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