If your A1C is > 8, it is too late.
As a whole, you are now a vasculopath, and will need to be on at least 5 medications to meet “the numbers”.

The time for referrals

is ten years earlier.
That is when they need to read “the book”.

After that, it is just holding off the inevitable as long as possible.

Igloodoc, your point about wanting an explanation of the details on how to get an overweight diabetic (as an example) to receive the appropriate help highlights quite well the challenges of diabetes, at a high level. It would be fantastic if there was an answer, but there is no single set of directions to follow. It is, generally, very different from other conditions where if you do A, B, and C you will most likely be ‘cured’ or see significant progress.

(I’m trying to keep my comments about diabetes general and over the long-term rather than focusing on direct medical emergencies/interventions or obese folks diagnosed with Type-2.)

As you said, “I have diabetes and it is my responsibility” is a great place to start. Agreed. But this is just the start. Juggling a diabetic on multiple drug regimes in an emergency room cannot possibly be simple, but neither is the long-term treatment.

To generalize and say that every diabetic should be MANDATED to have this same educational experience would be a waste. Although I suppose it would increase book sales!

Back to Home Depot. How many people have garages and back porches full of little “project” materials purchased at Home Depot that they just never quite got started or finished on?

It can work for some, but not everybody. Shoving a one size fits all approach at people isn’t the answer.

Next, the mandate should be to refer the person to the appropriate help – a certified diabetes educator, nutritionist, exercise physiologist, support group or seminar, depression counselor, etc.

Why do I get the sinking feeling that this mandate applies to me and not the patient. And why is that feeling accompanied by the vision of the government doing the mandating. What next? Mandated ER door to therapeutic glucose levels in 1 hour or Medicare won’t pay?

Simplistic approaches to a complex problems just exacerbate the problem with unintended consequences. Take a diabetic steroid dependent asthmatic in a seasonal flair. The steroids elevate the glucose and the Hb A1C. However, breathing trumps glucose every time. The simple (mandated) approach is to chase the glucose with insulin. But the patient lands in the ER having had a hypoglycemic seizure because he chased the glucose while on a steroid taper. Not so simple, is it?

Teaching (or becoming a paradigm shifted health consultant or whatever is the term of the moment) motivated patients is hard enough, and takes a lifetime. Teaching unmotivated patients is virtually impossible, and that truth is in every ER in the land. Diabetes education begins with the simple patient slogan “I have diabetes and it is my responsibility”.

igloodoc

Next, the mandate should be to refer the person to the appropriate help – a certified diabetes educator, nutritionist, exercise physiologist, support group or seminar, depression counselor, etc.

Why do I get the sinking feeling that this mandate applies to me and not the patient. And why is that feeling accompanied by the vision of the government doing the mandating. What next? Mandated ER door to therapeutic glucose levels in 1 hour or Medicare won’t pay?

Simplistic approaches to a complex problems just exacerbate the problem with unintended consequences. Take a diabetic steroid dependent asthmatic in a seasonal flair. The steroids elevate the glucose and the Hb A1C. However, breathing trumps glucose every time. The simple (mandated) approach is to chase the glucose with insulin. But the patient lands in the ER having had a hypoglycemic seizure because he chased the glucose while on a steroid taper. Not so simple, is it?

Teaching (or becoming a paradigm shifted health consultant or whatever is the term of the moment) motivated patients is hard enough, and takes a lifetime. Teaching unmotivated patients is virtually impossible, and that truth is in every ER in the land. Diabetes education begins with the simple patient slogan “I have diabetes and it is my responsibility”.

igloodoc

You bet that many don’t take care for themselves. But keep in mind that there is the whole aspect of diabetes burnout and being proactive in dealing with diabetes at one time and then doing just the bare-bones to live the next. The point being that you can have a person who does care incredibly about themselves but doesn’t want a thing to do with Diabetes; they aren’t mentally ill or skewed to the insane, just fed-up with diabetes.

But I don’t think that means Amy’s point only applies to those who are proactive in their care. Viewing oneself as a ‘health consultant’ instead of a purveyor of medical knowledge is a bit of a context-shift from the current modus operandi. It sets the relationship up as being one of advice and explanation, instead of treating the numbers and handing out directions to follow. It might seem subtle but remember that a diabetes patient has to make dozens of decisions every day about how to treat their disease. They constantly find themselves in situations for which there are no medical directions to follow. Amy said it really well when she wrote

Aim not to manage their diabetes, but to help them succeed in doing so.

Not everyone cares for themselves and some are incredibly driven; but I think you’ll find most people are in between, and I think this advice is aimed for them.

Regards,
Adam

I don’t agree with that premise. If it were true we wouldn’t see people scarfing down triple cheeseburgers with bacon.

1) infection
2) infection
3) infection

In reality, the top three causes are
1) insulin deficiency
2) insulin deficiency
3) insulin deficiency

I will agree with you that mental illness is almost always present in DKA’s. As is substance abuse a common thread. At least in my clinical experience. If you figure out a way to force someone to go to rehab you should publish a book about it. As for the mental illness, I don’t have any easy answers for that one. It’s a common thread in many many illness that end up in the hospital.