Know Your Numbers, Outlive Your Diabetes: An Expert Interview with Richard A. Jackson, MD, and Amy L. Tenderich, MA

April 05, 2007

Editor's Note:
Surveys reveal that approximately 60% of patients with type 2 diabetes are not achieving glycemic goals.[1,2] A new book, Know Your Numbers, Outlive Your Diabetes: Five Essential Health Factors You Can Master to Enjoy a Long and Healthy Life, offers a positive, step-by-step approach to guide patients with type 2 diabetes in the management of their health. Kristin M. Richardson, Editorial Director, Medscape Diabetes & Endocrinology, talked to the book's authors -- Richard A. Jackson, MD, Assistant Professor, Harvard Medical School, Boston, Massachusetts; Investigator, Joslin Diabetes Center, Boston, Massachusetts, and Amy L. Tenderich, MA, diabetes blogger; journalist; author, Millbrae, California.

Medscape: You write in your book that now is the best time in history to have type 2 diabetes because of new pharmaceutical interventions and technologies, and yet the statistics on people reaching goals are dismal. For example, attainment of glycated hemoglobin (A1C) seems flat over the past 20 years. Why do you think people have such a difficult time reaching therapeutic goals for type 2 diabetes?

Richard A. Jackson, MD: I think it's because they often don't really know what the goals are. I'm involved in outreach programs at the Joslin Center, and we go into communities and do diabetes programs with free testing, so we get people who are interested in their diabetes. We ask, "Have you heard of an A1C? Have you had an A1C test?" And only about 10% of people are what we call "A1C aware." Blood pressure is a little better. Microalbumin -- hardly anyone has heard of it. People have had eye examinations, but they're not sure about the results.

One of the fundamental points in our book is that first you have to find out where you are before you can get to where you're going. Patients should be getting messages about the importance of A1C and blood pressure and other targets from their doctors, but doctors have more stresses on the time they can spend with patients. So I think people really need to know where they are, but they don't. Instead of telling everybody to do the same thing, we start by having each person find out where they are, so that they can focus their energies in a more productive way.

Amy L. Tenderich: I have a college friend, a very educated guy, who was recently diagnosed with type 2 diabetes, and he was floundering. He started e-mailing and calling me, and after a few months of going back and forth, he called and said "I'm so frustrated. I have this meter they gave me, and I'm testing now and then, and the numbers are always kind of high, but I don't know why I'm doing this. Do I just write down the numbers and save them until I see my doctor, and then he tells me what they mean?" I was shocked. I blew a gasket. They sent him home with this machine, which is a very useful tool, but they didn't explain how to use it. I think that people give up. They stop testing because they don't really know why they're doing it.

Medscape: Which is why you have made the tactical decision in your book to focus on the 5 tests: A1C, blood pressure, lipids, microalbumin, and eye examinations.

Dr. Jackson: Right, it's because of their great utility. If you were running an insurance company and wanted to insure people with diabetes, and were trying to figure out their risk, these are the 5 numbers you'd want to know. And the numbers aren't so complicated that people can't understand them.

We use the idea of a diabetes health account in the book, in which patients keep track of their assets and their debts. Maybe someone has a hard time getting their A1C where they want it, but if their blood pressure is really good, and their cholesterol is really good, and the other measures are all right, then their diabetes savings bank is in pretty good shape. By looking at more parameters, it gives people more areas where they can put away some health savings.

Ms. Tenderich: A point that we're making throughout the book is that people have this vague idea that they have to eat better and lose weight and exercise, but they think that it's all or nothing. These 5 measures can really help home in on an individual's biggest health issue and how to get a handle on it. They're a great tool to use. Sometimes doctors will tell people "Ah, you don't need that test." That's wrong, and patients should have the right to insist on these tests.

Medscape: You write in the book that "your doctor doesn't treat diabetes, you do." Do you think that this perspective threatens physicians?

Ms. Tenderich: Rich, I'm letting you take that one.

Dr. Jackson: If the patient knows these numbers and understands them, it makes the physician's job easier. And if a physician thinks that you only need an A1C once a year, it's just not right. That means you need to...

Medscape: Find a new physician.

Ms. Tenderich: Right.

Dr. Jackson: My impression is that today people spend less time with a single physician providing care than they did in the past. Physicians are changing jobs more frequently, patients are changing because employers change. So the patient really comes to rely on him or herself. I think that if a patient has this knowledge, it's actually very rewarding for the physician.

Medscape: Has that been your experience, Amy?

Ms. Tenderich: I'm a type 1 diabetic, and we're in a somewhat different situation because we are forced to be very intense about our diabetes. In terms of the book, it was actually Rich's idea to look at yourself and your diabetes as a "business," and think of your doctor and your health care team as consultants -- helping advise you how to reach your goals. You get so much more out of your appointments if you know why you're there: you're there because you realize that your A1C is creeping up, or because you know that your blood pressure is slightly off and you want to tackle it, and you want specific advice.

Dr. Jackson: Or you've heard about a new medication and you want to know if it's appropriate. Or maybe you just want to touch base. There are lots of reasons to use your doctor, but your doctor shouldn't tell you how you are doing. You should know that yourself.

Medscape: Another topic you address in the book is the issue of insulin use in type 2 diabetes, which is getting a lot of attention lately.

Dr. Jackson: I was actually just talking to a group of physicians in the health clinic locally about how to start people on insulin. Some patients fear it and physicians sometimes also fear starting patients on it. I told them that if you focus on the A1C it becomes easier, because the patient's A1C is going to be better using insulin. We use the example in the book of someone who is taking oral medications whose A1C is 8.5% and someone who is taking insulin whose A1C is 7.5% The person taking insulin is going to have a 35% lower chance of developing complications. So a person taking the pills has the "bad diabetes," and the person taking the insulin has the "better diabetes." If you start with the building blocks of knowing the test results, it goes a little easier.

And giving insulin to people with type 2 is much easier than type 1. They still have some of their own insulin, they get hypoglycemia less often, and their body responds better. If you start early, type 2s can often start on one daily dose of a basal insulin, which is an easy step up -- rather than waiting until their A1C is much higher, and then you'd have to start insulin before meals and figure out more complex doses. And then there is the argument that we mention in the book: insulin is actually the most natural medicine we have. I think that if you explain that to people, it often makes sense to them, and they get a little more comfortable with the idea of insulin therapy.

Medscape: Do you think physicians still use insulin as a threat? "If you don't work on your lifestyle, you'll have to go on insulin."

Ms. Tenderich: I hope not.

Dr. Jackson: I think maybe they do sometimes. I think one of the things that puts physicians off insulin is that if they're seeing another patient in 15 minutes, and the nurses aren't trained in how to use insulin, it might be a question of time. How are they going to teach someone how to do this? The insulin pens make a big difference. They don't have to be refrigerated and the tiny 31-gauge needles make a big difference; you can promise that the injections just about don't hurt. People may not view the insulin pen as a shot or an injection but as a device, and I think that really makes acceptance easier.

Ms. Tenderich: I just wanted to add a couple of things about insulin and type 2s. My sister-in-law happens to be a nutritionist in Europe, and she works with a lot of type 2 diabetics. They are trying to get people on insulin earlier because they think the outcomes will be better and also because they feel that it will, in some ways, force patients to really tune into their diabetes -- take it more seriously, and treat it. One of our patient stories in the book that Rich provided is a woman with type 2 who was unhappy with her control. She was feeling fatigued and her sugars were bouncing around, but she was reluctant to try injections. So she tried injections first on an orange in the clinic, and the staff explained that she could try injections with the understanding that if she really hated it, or wasn't ready for it, she could come back and say so and stop using the insulin. She took home a couple of injections, and after a few days she felt so much better; she realized that it really wasn't that painful or difficult. It's a little inconvenient, of course. I mean, we'd all rather not have the diabetes.

Dr. Jackson: The main message people hear about diabetes is that it's getting worse and worse, and that's because more and more people are getting it. But even though we don't have as many people meeting A1C targets as we would like, data on heart attacks, amputations, kidney disease, and eye disease show that those parameters are all improving. So if you have diabetes, you can do a lot to keep yourself healthy.

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