1. Failure to make the proper diagnosis.
| Standard criteria for diagnosing Type 2 diabetes | ||||
|---|---|---|---|---|
| Test | Results (mg/dl) | |||
| Normal | Impaired Fasting Glucose |
Impaired Glucose Tolerance |
Diabetes | |
| Fasting Glucose | <110 | 110-125 | 126 | |
| Glucose Tolerance (2 hr after 75g glucose) |
<140 | 140-199 | 200 | |
| Random Glucose | 200 with symptoms |
|||
If your physician uses ambiguous terms such as "mild diabetes", "prediabetes", or "a little sugar", press for a clearer description of your condition. Other classifications of diabetes, besides those mentioned above, include Type 1 and gestational. Diabetes may also be the result of genetic defects, pancreatic disease, endocrine disease, drugs, and infection.
A good diagnosis, that is effectively communicated, contributes to good management.
2. Failure to set target glucose levels.
What should you be aiming for? The American Diabetes Association recommends target blood glucose levels of 80 to 120 mg/dl before meals and 100 to 140 mg/dl at bedtime. They advise a target HbA1c of less than 7%, or no more than 1.5% above a particular laboratory's normal value. Your personal goals should be set by your physician and reevaluated during office visits.
3. Failure to work with willing patients.
If you're reading this, chances are you're already willing to do whatever is necessary to control your blood sugar. Physicians pressed for time may direct more attention to those who express the greatest concern about their therapy. Be sure you communicate your interests and concerns to your physician.
4. Failure to set time limits for therapy effectiveness.
Therapies are selected based on the magnitude of your blood sugar, how long it's been elevated, and what you're willing to do to bring it into your target range. If diet and exercise alone aren't effective, a combination of those therapies and oral medications may be chosen. Type 2 patients whose blood sugar fails to be controlled under these conditions are candidates for insulin therapy. Make sure your physician places time limits on the effectiveness of the therapy you and she have selected, and do not procrastinate before advancing therapy.
5. Overuse of oral hypoglycemic agents with insulin.
This author recommends only selective use of oral diabetes medications while on insulin, since there are no long-term studies showing whether combination therapy produces fewer long-term complications than treatment with insulin alone. Also, combination therapy may increase the risk for side effects.
6. Failure to encourage home glucose monitoring.
No matter the therapy; diet and exercise, oral medications, or insulin, all people with diabetes benefit from regular monitoring of their blood glucose at home. Some insurance companies and experts do not support home monitoring for all diabetic patients. However, this author endorses the practice, especially during illness or when symptoms of hypoglycemia develop.
7. Failure to recommend monitoring throughout the day.
Blood glucose levels may fluctuate significantly during the day. Hyperglycemic and hypoglycemic episodes may not be recognized if monitoring takes place at only a few prescribed times. Check glucose levels throughout the day before meals, at bedtime, and periodically at 3 AM. (Less invasive monitoring devices are on the horizon.) Monitor more often during sick days.
8. Failure to adapt insulin dosages.
A mixture of Regular and NPH insulins, one faster-acting to manage morning glucose, and one slower-acting to cover glucose loads during the day, is often prescribed. These combinations are available premixed (70/30, 50/50) for convenience. Optimal control is not always achieved with these fixed-combination insulins. Patients should work with their physicians to determine the best mix for them.
9. Overuse of sliding-scale insulin.
The sliding scale method administers a dose of insulin dependent on the rise in blood glucose. This can immediately lower blood glucose resulting from unusual circumstances such as unplanned exercise, illness, rotating work shifts, or travelling. When not used in conjunction with basal insulin, however, it may result in treating hyperglycemia from previously inadequate control. Overuse of sliding-scale insulin may mask the need to adjust basal insulin doasages.
10. Failure to routinely screen for complications.
Visits to your physician should not concentrate solely on blood glucose management. Complications of diabetes; retinopathy, nephropathy, and neuropathy, can be prevented or delayed with early recognition and treatment. Annual ophthalmologic exams, starting at time of diagnosis, are essential. At least once a year, physicians should perform tests to access the health of the foot. Periodically, your urine should be checked to access the health of the kidney.