[HD: The following post started out titled “Ketogenic Diet – Diabetes Cure?” I initially intended to write a post primarily about the effects of a ketogenic diet on diabetes. But, my preamble about why I don’t like treating diabetes turned out to be way too long (shocker, right?), so I present it to you now as a standalone post. That means you’ll have to wait a little longer for the ketogenic diet article, which I think will be engaging for anyone with an interest in this field, even if you don’t plan to adopt that eating strategy. At the end of the post today, I’ve included a sneak peek at Part 2. Must have been feeling generous today…]
I’m going to share a secret with you: I do not enjoy treating diabetes. In fact, I downright dislike it, and I’ve grown my practice in other areas of Endocrinology to the point where diabetes comprises only a small part of my practice. Before you jump all over me about how diabetics are people too, let me make it clear that I don’t dislike my patients with diabetes. In fact, some of my favorite patients are diabetics I’ve been treating for years. After years of these folks dealing with the disease, I don’t always have new advice to offer at an office visit, so we’ll often spend half the time shooting the breeze about our lives. I find that thoroughly enjoyable.
So why do I prefer to avoid treating diabetes? I’ll get to the more substantive reasons in a moment, but first we need to talk about the logistical aspects of managing diabetes that make it difficult. Even if diabetics comprise only 20% of one’s practice, they will consume 80% of the practice’s resources. Again, I’m not blaming the people with diabetes, but it is what it is. Take a look at just a slice of what goes into managing diabetes:
- We (physician and/or clinical staff) write a prescription for a glucometer, lancets (to prick the finger), and test strips. We need to calculate how many lancets and test strips to dispense, based on how many times per day the patient tests and/or how many times per day we want her to test. We have to make sure that we document in the chart note how often the patient is testing, or the prescription may be denied if the insurance company requests the chart note and doesn’t see proper justification.
- Insurance companies are constantly changing which meters and how many test strips they will cover, which means we have to rewrite and recalculate the prescriptions.
- For patients on the newer non-insulin drugs, insurance companies frequently change what they will pay for. 80% of the prescriptions I write will come back to me, rejected, or asking for a prior authorization to be filled out.
- In an Endocrinology practice, most of our patients will be on insulin. With the dose of insulin changing all the time, we need to make sure the prescription is regularly updated and gives the patient enough insulin to increase the dose as needed. Prescriptions are needed for insulin vials or pens, as well as syringes/needles or pen needles. There are numerous kinds of syringes and needles out there, and people tend to have preferences, adding to the workload. To top it off, insurance companies (see a theme here?) switch their “preferred” insulins on what seems like an every-few-month basis.
- When a patient comes in to be seen, we need to download the meter so we can review the blood sugar data to make recommendations. With all the different meters out there and all the different software to manage them, it is guaranteed that at least a few meters every day will fail to download properly due to bugs or software upgrades.
- Patients on insulin pumps and/or continuous glucose monitors (CGMs) require an extraordinary amount of work to manage, as they have a ton of data to review every visit. There are several variables that can be adjusted on an insulin pump (basal rates, carb ratios, correction factors, active insulin time) each time, and not all of our patients are comfortable adjusting pump settings themselves on their own time, so we need to walk them through it. And we need to get all of this done – plus a foot exam, plus managing any diabetes related conditions (hypertension, hyperlipidemia, etc.) – in 20 minutes. Almost impossible.
- There are all kinds of mechanical issues with pumps and CGMs that need troubleshooting, about which I am not as knowledgeable as is my diabetes educator nurse. But she sees her own patients by appointment and is not immediately available to come in and help.
- Patients want to email or phone in their blood sugars (or nowadays upload their pump/CGM data to the cloud) and have us review them outside of scheduled visits and make recommendations. We just don’t have the time to provide this free medical care.
I could go on, but I think you get the point. A physician needs to have a real passion for diabetes in order to put up with the aforementioned workload, and I do not have that passion. Some Endocrinologists choose the field because of diabetes, and some choose it in spite of diabetes. I am squarely in the latter group. Setting aside all of the logistical management challenges, of which I was only minimally aware when I made the decision to pursue Endocrinology as a career, are there more fundamental reasons for disliking diabetes?
Why this Endocrinologist hates diabetes
To delve into this issue, we need make a clear distinction between Type 1 and Type 2 diabetes. They are different animals and have completely different pain points.
Type 1 can be very difficult to control, in part due to the complete lack of insulin-producing ability of the pancreas. Fluctuations in blood glucose levels tend to be extreme, as there is no pancreatic “reserve.” So if there is no insulin on board from an injection, then there is no insulin on board at all, and blood sugars can skyrocket. For this and other reasons, Type 1 diabetes is often associated with chasing blood sugars all over the place, trying to smooth them out as best we can.
The thing about Type 1 is that we expect it to be more labile and – to some extent – unpredictable. Sure, there are tenets of management that guide us, but sometimes the blood sugars just do weird things in Type 1 diabetes. So our mindset – our approach to the disease – is different than our approach to Type 2. We learn to accept a fair amount of volatility in our toughest Type 1 patients, and we try to help them accept the concept of being “good enough.” Once we get to “good enough,” then that has the potential to feel like a win, as opposed to focusing on all the days when they were “bad.”
In my experience, there is a “typical” Type 1 diabetic within different age ranges, which can increase or decrease the difficulty factor in managing the disease. I’m going to make some generalizations here, recognizing that there are plenty of exceptions to the rule:
First, there are teenagers who just don’t care. Fortunately, I stopped seeing them when I finished my fellowship; I won’t see anyone under 18 for diabetes. I’d like to make it 25, but adding another scheduling rule to the ones that already exist would make my receptionists apoplectic. Frankly, I just don’t know how to talk to aloof teenagers who feel no sense of urgency to get their disease under control. The pediatric Endocrinologists do this all day, and I’m quite sure they do it better than I ever could, so I leave it to them.
When I see an 18 or 19-year-old kid who just “graduated” from pediatric Endocrinology to adult Endocrinology, I usually expect a quick visit. They tend to be pretty healthy other than having blood sugars in the 200s-300s, so there isn’t as much to do, especially if they are still in don’t-care mode. Sometimes, they come in realizing that it’s time to get serious, and I love those visits, as I feel like I have the potential to help them. Occasionally I even do. But it’s usually not until some point in their 20s that they come in and say, “OK, doc, I know I need to deal with this better. What can we do about this?”
Next, there are Type 1 diabetics in their 30s to 50s; they are usually interested in good control and are the most likely to be on a pump +/- a continuous glucose monitor. They may be frustrated with the disease, but unlike the teens-early 20s folks, they know that ignoring it will ultimately hurt. These are the people I can usually help.
Finally, there are Type 1 diabetic patients in their 60s to 80s. I find that they either have great control and I can’t tell them much that they don’t already know; or, they have poor control and I can’t tell them much that they don’t already know. One of my octogenarians has frequent low blood sugars on a pump. Our conversation goes the same way every time:
Me: You should really consider backing off on your basal rate before your daily walk, since you almost always seem to go low during the walk.
Her: Yeah, but I forget to turn it down. Or after the walk, I forget to turn it back up.
Me: What about using an alarm reminder?
Her: [Shrugs and makes a constipated face]
Me: Well, maybe we should just decrease your basal permanently then, and let you run a little higher.
Her: Yeah…I don’t really want to run higher…
Me: So what would you like to do? What do you think is the best way to handle this?
Her: [Changes the subject at this point to something only tangentially related to her blood sugars]
You would think that, after years of having this conversation with her, I would just stop trying. But something inside compels me to give it “one more try.” At that moment, I always get the sense that this will be the time that whatever I say will break through whatever the barrier is and make a difference. And I’m wrong every time. But you know what? This woman is a tough old bird, and I like tough old birds, which somehow makes my failure less painful.
Type 2 diabetes – a lifestyle disease
This is actually the perfect segue into what really exhausts me about managing Type 2 diabetes, so let’s dive right into that. Because Type 2 is generally associated with obesity and poor lifestyle choices, it can be quite frustrating to have the same conversations about their poor choices, especially when things are not changing much. Then, the patient gets frustrated with me because “all you want to do is increase my medications.” Sometimes, as with my octogenarian patient above, I feel like I can break through the wall and help the patient in front of me reach that “a-ha” moment. So I continue to bang my head against that wall, with very little to show for it when it comes to results.
I think the medical profession has done Americans a great disservice by softening our emphasis on the fact that Type 2 diabetes is essentially a lifestyle disease. Yes, people with Type 2 diabetes may have a genetic predisposition to developing it, but it tends to only present itself in the context of weight gain. Yes, there are some aspects of the pathophysiology of obesity which may be beyond our control, but weight gain is – more often than not – due to poor diet and lack of exercise. Cruel reality dictates that the absolute best treatment for Type 2 diabetes is weight loss. Unfortunately, it’s super-easy to gain weight, but magnificently hard to lose it.
Not only is weight loss difficult under ordinary circumstances, but when we start adding medications to lower the blood sugar, it often gets even harder. This is partly due to the fact that people with very high blood sugars are losing a lot of that sugar in the urine. They are literally urinating out calories, which may be keeping further weight gain at bay. When we start glucose-lowering medication, the sugar that was being lost in the urine is now being retained inside the cells of the body. So the body is retaining glucose (calories) that it was previously urinating out, leading to weight gain.
In addition, many of the medications we use for diabetes have the potential to cause weight gain by other mechanisms, notably: insulin, sulfonylureas (glimepiride, glipizide, glyburide), and pioglitazone. We have other medications that are weight-neutral or even weight-negative, but sometimes we just have to use some of the weight-positive meds to get the blood sugars down to normal.
So where does this leave me? It is, after all, all about me. I have a patient who needs to lose weight, but she also needs her blood sugar lowered yesterday. I’m going to go out on a limb here and also state that she has tried to lose weight in the past and has been mostly unsuccessful. What do I do, short of funneling her toward the bariatric surgeon? I have tried weight loss medications, partial meal-replacement diets, formal weight management programs, dietician visits, counseling the patient myself…but it is rare for any of my patients to lose a significant amount of weight and keep it off.
In my experience, the problem is usually not a lack of patient education about what to do; it’s that our current strategies just don’t work very well. It’s not that the advice to eat less and move more is bad, but people just aren’t very good at following it in a way that is sustainable, producing lasting results. On top of that, I give them diabetes medications that may impede their progress. Remember, Type 2 diabetes has the potential to improve significantly with simply a better lifestyle. Eventually, this better lifestyle would lead to much happier patients and an Endocrinologist who wouldn’t cringe when she sees a morning full of diabetics on her schedule.
So, again I ask: what can we do to control blood sugar and reduce weight, which will ultimately lead to better long-term control of glucose levels by reducing insulin resistance?
[HD: Read on for a sneak peek at Part 2 of this post, “Ketogenic Diet – Diabetes Cure?” Then come back soon for Part 2 in its entirety]
…what can we do to control blood sugar and reduce weight, which will ultimately lead to better long-term control of glucose levels by reducing insulin resistance?
Enter the Ketogenic Diet!
Those of you who are familiar with not only my writing style, but also what gets my quack-o-meter dialed up to 11, are probably thinking, “Ooh…I can’t wait to see HD rip KD a new one. Let’s get it on!” As much as I enjoy debunking extreme diets based on lousy/no science (hcg diet, anyone?), I also enjoy presenting ideas that are extreme, but also may have merit. This is one of those times.
So what is a ketogenic diet (KD)? There are plenty of sites where you can dig into the details, so I’ll present a quick overview. In general, it’s a very low-carbohydrate diet that tends to be high in fat. There are various iterations, but a common macronutrient percentage-of-daily-calories breakdown would be 70/20/10 fat/protein/carb.
70% fat?! That sounds revolting! I’m clicking back over to my Twitter feed now. See ya!
Listen, I’m with you. I don’t have any desire to eat ketogenically. I trim every last bit of fat off my steak before a bite enters my mouth. However, if I was overweight with diabetes and I had already tried “everything,” I think I would be receptive to hearing more. So, for those of you with some residual interest, read on. The rest of you, I hope the Kardashians did something really interesting today…
Hey, doctors and other health-care practitioners, do you enjoy treating diabetes? Why or why not? Where are your pain points? Does the busywork with all the supplies and rejected prescriptions feel overwhelming? People with diabetes, how do you feel about your disease? Do you have it all figured out? Are you burned out from having to deal with it all the time? Does it feel like a second full-time job? Is it surprising to learn that your doctor may not enjoy treating diabetes? Comment below!
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