Saturday, March 1, 2014

The Nutrition Debate #188: “Older Patients with T2DM and Comorbidities…”


A recent Diabetes in Control.com headline got my attention. Diabetes in Control is a weekly digest of articles primarily for physicians who treat patients with type 2 diabetes. The headline was, “Older Patients with T2DM and Comorbidities Dont Feel Heard.The lede was, “Most adults with T2DM have at least one comorbid condition, and almost half of them have three or more.” The most commonly reported chronic comorbid conditions were hypertension, arthritis, retinopathy, hypercholesterolemia (high cholesterol), coronary artery disease, and neuropathy. All patients in the study were ≥ 60 years old, white, highly-educated and had good glucose control.

The source for the story was this piece in Clinical Diabetes. The protocol for the study was that all the patients had been diagnosed withT2DM at least one year previous and also diagnosed with one or more additional chronic conditions. According to the Control article, diabetes is now the 7th leading cause of death in the United States but its management and complications account for 23% of current health care expenditures. So, whats all the fuss about? Wheres the disconnect?

First, this is progress. The study was making an important point. I can tell you from recent personal experiences how difficult it is for a “new” patient to sometimes get the attention and cooperation of a physician when, in their professional opinion, the “proper care” differs from “my opinion.” Some physicians dont take the time to look at the record (as in, history of lab reports and clinical examinations) to see what “my preferences” for a treatment protocol are.

This is, to a certain degree, understandable. I am just a layman with no professional training and no professional liability for malpractice, sanctions from medical practice boards, or loss of reimbursement from Medicare and supplemental insurance for not following professional practice standards and guidelines. But, Im spoiled. My doctor (now deceased) in New York, who treated me for over 20 years, set me on the course of eating Very Low Carb and oversaw the complete transformation of my progressively worsening T2DM from “out-of-control on 3 oral meds” to “in-remission” on a minimum dose of  just one (Metformin). He has my everlasting gratitude. My “new” doctor in New York is also great. He has reviewed my “history” and tells me to just keep on “doing what I’m doing.  Bottom line: The physician and the patient have to determine the risks and benefits of following treatment guidelines. But not every doctor is willing to do that. The Control piece said:

Many participants also felt that their preferences for care were not taken into account by their provider. Participants also reported feeling that their care was not addressed to their individual needs and medical history, and desired more tailored treatment regimens specific to their needs. Generally speaking, patients want to have more interaction with their providers so that they can discuss the difficulties they are experiencing and vocalize their preference for treatment.”

The Control piece concludes, “Effective patient-provider communications and shared decision-making have been shown to not only improve patient satisfaction, but also increase adherence to treatment plans and improve health outcomes.”

Setting aside the “empathy” and “older age” aspects of these criticisms (I personally have not felt either in my interactions), I note how “their [the patients] preferences were not being listened to,” is a recurring theme. My first reaction, to be unbiased, was, “Why should the physician listen to me and “my preference” for a treatment protocol? Then, two things came to mind. I am dead set about not taking a statin (again). I did 5 or 6 years ago (before I knew better), but my doctor discontinued it all by himself. Today, however, even with the new AHA/ACC guidelines (see #180 and #181 here and here), I am still considered (by most doctors) a candidate for a statin. Personally, I consider my latest lipid test lab results to be stellar: TC = 207, HDL = 90, LDL = 110, TC/HDL ratio = 2.3 and triglycerides = 34. And my Trig/HDL ratio (0.38), a powerful statistical indicator of cardiovascular risk, is also stellar. And, when they were last tested, my LDL particles were Pattern A (large, buoyant and fluffy). Many doctors would not prescribe a statin with these “labs,” but some would, and the new AHA/ACC guidelines dictate that I should take one. But “my preference” is a definite “no.”

 
Then theres the question of diet. What should I eat? Should I follow what has worked for me for the last 11 years, resulting in my losing and keeping off (currently) 130 pounds? Should I eat what my doctor, and the government, and the practice specialty guidelines tell me to eat? Once again, “my preference” tells me that I know more about what diet I should eat than my doctor does. My n = 1 experience, aided by frequent testing with a blood glucose meter before and after meals for years, has taught me what to eat. What experience (or training!) does my doctor have to dictate what I should eat? Well…

As reported in this Medscape Physician Lifestyle Report 2014, 68% of overweight or obese doctors eat a Typical American, AHA, or Mediterranean style diet. Just 14 percent eat a “Weight Loss (calorie restricted or otherwise) Diet,” 11% various other diets and only 5% a “Paleo” style diet. Atkins or Very Low Carb or Ketogenic diets were not even mentioned. So, why should I follow my overweight doctors advice when he doesn’t know how to lose weight and improve his own health?!!!

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