[Diabetes-talk] Some thoughts on priorities to be adopted in diabetes management.

[Michael Park]

  Hi there.

Having put the "fits one, fits all"-approach to bed finally, I want to 
start sharing some thoughts I have concerning diabetic counselling but I 
want to stress, by way of a prolegomonon to this post, that I am not an 
expert, because an "ex" is a has been, and a "spert" is a drip under 
pressure and I would like to believe I am neither. LOL! But I must 
concede that anyone reading what I have to say here, is entitled to 
their own oppinion.

Ideally, when a diabetic comes to me for counselling, I would want to 
get that person to see a diabetologist first, before seeing anyone else. 
However, it is not always possible since, if the person has the 
resources to go to private care, the waiting list to see the 
diabetologist is an awefully long one, firstly, because there are lots 
of people who want to see the diabetologist at the same time, and 
secondly, there are really very few qualified and competent 
diabetologists in the country. I certainly would not want a general 
practitioner to manage my own condition, and without unduly slamming 
general practitioners, there are fortunately some of them at least, who 
would also willingly concede that diabetes management is not their 
forte, all the more, because diabetes is a type of condition which 
requires ongoing multi-disciplinary and specialised management and 
supervision.

If you are on the state health care system such as I am, it is quite a 
circus and a mission to get to see a diabetologist. I for one, have 
literally had to claw my way there, and thereby hangs another very long 
story that I am not going to go into right now.

As I see it, the diabetologist is not only a specialist in the treatment 
of diabetes, but he is also the logistical head of a 
multi-disciplinarian team, the members of which are to treat the 
diabetic in accordance with the broader treatment framework laid down by 
the diabetologist. Even when I counsel diabetics, I must as a pastoral 
counsellor, do this in accordance with the treatment framework as 
determined by the diabetologist. Of course, it goes without saying, that 
the counsellee is ultimately responsible for outcomes and that this 
particular responsibility does not fall on the shoulders of any members 
of the support team. Where a person is simply not interested in 
complying, I have had to be rather forthright and tell the person that I 
am not prepared to waste my time either.

Ideally then, the first referral should be to a diabetologist, but for 
reasons that I have already indicated, this is not possible. So we 
resort to the second best strategy which effectively amounts to putting 
the cart before the horses. This strategy, in broad essence, amounts to 
putting some sort of interim diabetic management system and monitoring 
into place.

What we normally end up doing, is to refer the counsellee to a 
dietition. Fortunately, and in the event of a person being on the state 
health care system here, we do have a dietition in our church who is 
prepared to consult with members only, free of charge, provided of 
course, that the member does not have the funds to pay for the services 
of a dietition, and this then overcomes the difficulty we have getting 
the counsellee to the dietition, since the dietition at our primary 
health care facility does not inspire confidence in me, having seen some 
of the results apparently emanating from there, and I can only make my 
judgements based on the results that I see when, in the course of my 
ministry, I also deal with fellow diabetics.

I normally and ideally prefer to refer to the dietition at the diabetic 
clinic itself, but if we are not yet at the diabetic clinic, I am not 
able to make that referral.

Although I can make free referrals to the dietition at our church, I 
normally try and somehow wangle the money for full payment of services, 
because as Jesus himself said, "the worker is worthy of his hire" and 
she also has to eat, otherwise she would not be such a good dietition 
either.

I therefore don't tell my counsellees of the free facility so that they 
don't end up taking undue advantage of the service, but if I cannot 
persuade them to come up with the funds and provided that the difficulty 
is genuine, then I will let them understand that I have "wangled" a free 
consultation for them.

What I would normally do with the counsellee's permission, is to contact 
the family and try and raise the funds to pay for the services of the 
dietition and I can usually do this at the hand of some pretty 
compelling arguments, if necessary.

The corner of diabetes management as I see it, is regular testing, as 
has been indicated a number of times over on this list, and at least to 
get the counsellee onto some sort of generic diet to get started. I for 
one, am of the view that a generic diabetic diet is non-existent, and 
that the "diabetic diet" inasmuch as its existence may be argued for, is 
only a starting point and the diabetic has to conduct certain trials 
within the context of acceptable diabetic management norms to find out 
what is OK and what is not so OK. Remember that no two diabetics have 
bodies that work exactly the same and therefore, it is likely that a 
given food is going to have one effect on one diabetic and another 
effect on another diabetic.

In my case, for instance, I have to strictly stick to my Bazmati rice, 
which is a very unrefined rice, because if I have even a small portion 
of the white and refined rice like Aunt Caroline's, for instance, my 
sugar literally shoots through the ceiling. There are other diabetics 
who have a less pronounced reaction to that same white rice and it is OK 
for them to have that rice once in a while. Similarly, and I don't know 
if you have it over there, white bread baked from highly refined flour, 
is an absolute "no-no" for me under all circumstances. When I have 
bread, I always have a low GI bread which is in the nature of things, 
very course, but actually quite tasty. White bread by comparison, is 
quite tasteless and therefore, by not having it, I don't miss anything.

Another thing that I have to watch for is depression. I have recently 
been treated for major depression which I believe, has been brought on 
by diabetes. I still experience bouts of depression when my sugar drops 
too low or if my sugars are volitile and this factor alone, without the 
need to specifically test, will tell me that my blood sugar is not OK. 
Therefore, in order to deal with the depression factor, the rest of 
diabetes aside for the moment, it is imperative that I try and maintain 
very stable blood sugars at all cost. This is best achieved by 
substituting all snacks in the day time with a fruit so that my snacks 
in the day are fruit only and in the main, apples. At night though, when 
it comes to the late night snack, and when I am less active, I have a 
greater variety of things that I can have. The strategy that my support 
team have suggested to me therefore, is designed to combat both the 
possibility of depression and hypoglycaemia. Sometimes I don't do what I 
am told and then I get into trouble true and proper, and not unduly either.

the other day, for instance, I absolutely craved a wholewheat cheese 
scone which in this particular instance, would have been OK for 
diabetics. I got my way and had my scone in the afternoon instead of the 
fruit I was supposed to have. needless to say, the nursing sister who 
helps me with my management, on getting to learn about the thing, chewed 
my head off in no uncertain terms, and as I said before, deservedly so.

Coming back for a moment to the link between diabetes and major 
depression, in particular, I must just point out that credible web sites 
such as the web site of the Center for Diabetes and Endochronology, for 
instance, maintain that diabetics stand a 30% greater chance of 
developing major depression. In this regard, see

"Core Concepts in Diabetes Mellitus
Michael A.J. Brown – Accredited Diabetes Educator"
http://www.cdecentr.co.za/B_AboutDiabetes.asp

Now I am not saying that the same regimented program holds true for 
everyone that I counsel. I only mention my own situation here to 
illustrate generally, what we can expect to encounter in the process of 
trying to implement a diabetes management strategy.

The idea is that if we can manage to at least get the person we counsel 
to a dietition and if we can get the person to start blood sugar 
monitoring, our ultimate visit to the diabetologist, whether public or 
private, will not just be the routine exercise in futility that visits 
to the diabetologist entails for most diabetics I know. At least, when 
we arrive at our destination, we are in a position to start asking 
intelligent but vitally necessary questions. If these things are not in 
place, we have a situation where the diabetologist is and remains 
ignorant of the true facts and where we ourselves are and remain 
ignorant of the true facts, producing in the end, a group of losers.

There are just two other things I want to mention in brief, before 
closing off this post. The first is that when we begin to establish some 
sort of a management routine, it is asumed that the relationship between 
the counsellor and counsellee is characterised by brutal honesty. What 
does not pay rent, must come out and it is therefore of paramount 
importance that things should actually be said as they really are. Even 
though I do counselling, I myself, am in ongoing counselling because 
there are issues which pop up from time to time and which need to be 
discussed. What I mean by brutal honesty, is that if I have not done 
what I have been told to do, I must own up to that fact, but on the 
positive side, and given the fact that my situation is not always 
understood by everyone I deal with, ongoing counselling is a place where 
I can discuss those issues in a safe environment. Let me illustrate, and 
pardon the lengthy example.

We have our church services from 9:30-11:00 on a Sunday morning and from 
18:00-20:00 on a Sunday evening. For the sake of brevity, my meal times 
on a Sunday are as follows: breakfast at 06:00; midmorning snack 
(fruit): 09:00; lunch (main meal for the day): 12:00; afternoon snack 
(fruit): 15:00; supper: 18:00; late night snack (which can be anything 
which is diabetic friendly): 21:00. On week days, because of the general 
routine, meals are one hour later.

In order for me to get to the evening services, I have to leave home at 
16:00 as this is the only time when I can get a lift. This is one hour 
after my fruit and the service goes bang across supper time and if we 
are delayed in getting back, it even goes over my late night snack time.

It is imperative that I eat every three hours. For one, eating like that 
removes the temptation of eating things which I should not have, and for 
another, this is the best strategy, given my present circumstances, to 
combat hypoglycaemia and to try and keep my sugar stable.

My nursing sister friend agrees with me that it would be inappropriate 
to pull out the lunch box and eat in the middle of the service. We also 
feel that taking glucose over that time is an inappropriate remedy since 
it is into the blood stream one minute, pushing my blood sugar up to the 
heavens, and gone the next, causing my blood sugar to drop to the lowest 
depths. This is not OK either.

Although as a college student, I am actually required at both services, 
we have managed to get me exempt from the evening one till such time as 
we can sort out the hypoglycaemia problem.

The other thing about brutal honesty that should be remembered, is, as I 
pointed out in the course of a talk which I gave at the diabetic clinic 
back in August on the subject of keeping a diabetic diary, that every 
diabetic must firstly be honest with themselves. If you are not honest 
with yourself, there isn't a snowball's hope that you are going to be 
honest with the doctor either. And if you are not honest with the 
doctor, you are wasting your time and the doctor's time and you are not 
getting helped in the process either. By way of light relief, I always 
ask the question "How do you know when a diabetic is lying?" The answer 
is "when he tells you he is following the diet."

We now come to my last point to which I have already alluded while 
discussing the previous point, and before getting to that point, I 
cannot resist telling a story about "He said "finally!"", which is what 
this is all about.

My father once attended a conference characterised by the fact that the 
speakers who were boaring at best, all suffered from bad cases of verbal 
bauberygmus. Some people might prefer, for the sake of clarity, to call 
it oral flatulence. It was an extremely hot and humid day in Durban, 
where the conference took place, much like the humid days that I would 
imagine, one would encounter during summer on the Florida or Texas 
coasts. There was no air conditioning. Only some fans turned round and 
round in the room and these were, given the heat and humidity, rather 
ineffectual.

The speakers droaned through their speeches and my father experienced 
various comatose states as he endured them all.

Finally, one speaker got up to speak. This was just after the lunch 
session. Of all of the speeches, this was the longest and the most 
boaring. This speech was different from the rest though, in one very 
significant respect: it was frequently punctuated by the word "finally".

it was on the occasion of one of these "finallys" being uttered that my 
father, in a semi-comatose state, promptly leaped to his feet and at the 
top of his voice, so that there could be no doubt with the rest of the 
delegates as to what was being said and who said it, shouted "He said 
finally!"

Well, I am saying "and finally" here when I say that for the diabetic, 
in my considered view, counselling is an ongoing process for life. It 
does not necessarily have to be a formal sit-down thing, but it is there 
to give an opportunity to discuss new problems that may arise from time 
to time.

Monitoring to determine patterns, experimentation within the parameters 
of a so-called diabetic diet, and ongoing counselling, in my book, form 
the foundation for a sound diabetes management strategy.

-- 
Michael Park
"I will bring the blind by a way they did not know; I will lead them in paths they have not known. I will make darkness light before them, and crooked places straight. These things I will do for them, and not forsake them." (Isaiah 42:16 NKJV).

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