By Dr. Steven Gershman, DPM
The dreaded doctor visit is over and the results are in. You just received the news you didn’t want to hear “You have diabetes”.
Tips for People Newly Diagnosed With Diabetes
Take a deep breath and don't panic. This isn't a death sentence or some horrible plague that will destroy your life. You can and will survive and even thrive with diabetes if you face it head on and work at it. Yes, it will require some changes in your lifestyle, but it is doable. Many diabetics live long full lives. The old fear of losing limbs is mostly a thing of the past. Ready, set, begin!
If you smoke, STOP IMMEDIATELY! This is an absolute. Diabetes can damage the blood vessels reducing circulation to the extremities, especially the feet. Smoking also reduces the blood flow or circulation to the body and especially the legs and feet. Put the two together and the combination is a powerful damaging attack on the vital flow of blood to the limbs. As the blood flow decreases, the risk of infection and ulcers (open wounds) increases dramatically. This can lead to the slippery slope of amputation.
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TEAM!! Managing diabetes is a team endeavor. You need and will be grateful for all the help you will be offered. You are the star of the show. Think of the members of your team as the supporting cast.
Your team should consist of your primary care provider, an endocrinologist (diabetes specialist doctor), diabetic nurse, dietician or nutritionist, podiatrist (foot doctor), ophthalmologist/optometrist (eye doctor) and may include other medical specialists if required. If you have a spouse or significant other, they too can be a significant part of your team.
Make sure you feel comfortable with each member of your team. You will be interacting often with some members and less with others, but regardless your comfort and ease in communicating and working with each teammate is important.
Medicine has its own unique almost foreign language. You will be bombarded with many new terms and words you may not understand. Being able to understand your team’s discussions and advise is critical to your ability to follow through. So, don't be afraid to question anything you don't understand or even disagree with. Simply listening without really hearing or understanding will be detrimental and can lead to poor control of your diabetes. Communication in medicine, just like in a marriage is fundamental. Hear your team and make them hear you.
Take an honest appraisal of yourself. Are there any factors that may have helped you become diabetic, or factors that you can change to help manage the diabetes? Are you seriously overweight or heading that way? Extra body fat can be a component in raising blood sugar. Is your blood pressure normal or under control if under medical management? Diabetes stresses the heart and blood vessels (cardio-vascular system) and adding high blood pressure can lead to more damage such as heart attack and stroke.
How is your diet? Do you eat out a lot where there is often high fat, salt and high calories in many take out or restaurant foods. Do you eat a lot of prepared foods at home? Again, these often contain high fat, sodium (salt) and dense high calories. Your diet has a major effect on the blood sugar. Many people who are newly diagnosed with diabetes work to improve their diet with a dietician or nutritionist which helps fight diabetes.
Do you exercise? Even a simple walk several days a week will go a long way to lowering your blood sugar. Your muscles burn sugar when you exercise, and it will also help you lose weight. Exercise will also improve your general health and help reduce your risk of heart attack and stroke. Before starting an exercise regimen, you should consult your medical provider.
It's all about the numbers. With diabetes numbers reign supreme. There are a few critical numbers you need to monitor and understand.
The one most often used and monitored is the A1c (glycated hemoglobin). Put simply, this is an AVERAGE, actually 3-month average, of your glycemic or glucose control. It correlates generally with the blood glucose level in that the higher the blood glucose during the 3 months, the higher the A1c. Your medical provider will discuss your A1c, which is calculated from a blood test, and give you a target number that works best for you. There is no one number that works for everyone. In general, the lower the number the better. The key is monitoring it over many months and watching for changes.
A study in Great Britain of over 5000 type 2 diabetic patients over 10 years showed a reduction of the A1c from 7.9 down to 7.0 reduced the rate of microvascular (small blood vessel) complications which affect the eyes, kidneys and nerves, by 25%. For every decrease of A1c by 1 point, lead to a 25% reduction in diabetes related deaths.
In addition, some of the other important numbers you and your provider will monitor are your blood pressure and your kidney function. Diabetes affects the kidneys and can cause nephropathy or kidney disease and possibly failure. A blood test and urine test will monitor your kidney health. Blood creatinine is the important number in monitoring kidney function. The lower the better in general. In addition, a urine test will look for any protein in the urine as when the kidneys are damaged, they will leak protein into the urine. With diabetes long term and regular monitoring are key. As the old saying goes, "eternal vigilance is the price of liberty". Diabetes is a constant long-term battle to maintain your health.
All the above numbers and tests are generally done by your provider, your job is to stay on top of your provider to make certain they keep on top of these tests regularly. Remember you are one of possibly thousands of patients they see. It’s your job to stay on top of them to assure the best management of your diabetes.
Now the test and number YOU are responsible for and can really lead to better control of your diabetes is ----
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HOME BLOOD GLUCOSE MONITORING. A1c is an average over 3 months. We all remember from our school days how averages can be deceiving. You can have a 100 one day on a test and 60 the next day and have an average of 80. Or you can have 80, 2 days in a row and average 80. The average is the same, but would you want to hire a doctor who had the first set of numbers on his or her tests or the second more consistent numbers? What if that 60-test score had been in diabetes knowledge? The bottom line is A1c can be misleading at times. It is easy to obtain and use, so we use it.
However, to really know how well you are managing your diabetes you need to test your glucose at home. The more often you do this the better. By doing it at various times during the day and writing it down you can correlate activity and diet changes to the glucose. The important times to check are so called fasting glucose when you haven't eaten in at least 8 hours such as first in morning. The other critical time is about 2 hours after eating, the so called 2-hour post prandial glucose test. This really shows you how your body handles food and how well your own insulin is working or if your diabetes medications are working well. You should write these numbers down and bring them to your diabetes medical provider on each visit and more often if indicated.
In the past finger sticks have been the manner of testing home glucose. However, this is rapidly changing. There are new modalities coming out constantly including non-invasive monitors that don't require puncturing the skin. There are also insulin pumps that can constantly check your glucose all day as they are attached to you. New technology is making checking your glucose less painful and easier. Talk to your provider about these options.
Take you medication. How basic, yet how complicated. Some patients are able to control their diabetes in the beginning especially with just diet changes, weight loss, and exercise. That is wonderful if you are lucky enough to be able to do this and actually have it work. Unfortunately for many patients this doesn't control the glucose well enough and even if it does initially, over time it is more difficult as diabetes is often progressive.
Understand that medicine in general is an art not a science. What works for one patient may be lethal to another. Efficacy (how well a drug works) and side effects vary tremendously from person to person. Initially your provider will start you on a regimen that they match the best they can to your unique needs. Be prepared for possible side effects or lack of effect. It may take several trials of medications of mixtures of medications before the correct treatment is found. Then, constant monitoring will be necessary by your provider AND YOU. Don't be afraid to stay in close contact with the provider about the effects of the medications and any side effects. You are not bothering them with information and if they make you feel that way TALK to them about it. If they continue this, it is time for a new provider. Treating diabetes is a team approach as noted above, and if a provider is a poor teammate, FIRE them. They work FOR you, remember that. Bottom line, take your medication as prescribed. Don't miss days and don't run out of medication. Stay on top of the refills.
FEET, the foundation. Diabetes effects the feet significantly in several ways. The 2 biggest factors that are often damaged by diabetes that in turn cause foot pathology are poor circulation and nerve damage or lack of sensation in the feet. The large blood vessels feeding blood to the feet often become blocked in diabetics. It is usually a slow progression unless there is a sudden clot. The same mechanism that causes heart attacks, plaque lining the walls of the arteries, occurs in the leg and/or foot arteries causing poor blood flow. Blood is the lifeline to keeping the body and its parts alive. As the blood flow decreases there is damage to the skin, bones, nerves and ability to heal is greatly diminished. A small cut and bruise combined with poor circulation can lead to slow healing requiring months to heal or worse, no healing and loss of limb.
Most diabetics have heard the term "neuropathy”. Basically, this is damage to nerves causing either abnormal sensation such as pain, or burning sensations, or it can cause partial or complete loss of sensation. The feet are often the first part of the body effected by neuropathy in diabetes. It usually starts at the toes and works back up the foot towards the legs over time.
Painful neuropathy, such as diabetic foot pain, can be treated by medications, often quite successfully. However, the more common decrease or loss of sensation is far more difficult to manage and often impossible to stop. Loss of sensation causes loss of the normal protective function of the nerves of the feet. The bottom of the feet normally has very dense nerve fibers as this is where our bodies are in contact with the ground. There is constant feedback through these nerve fibers from the feet to the brain so we can walk and avoid injuring ourselves as we step on objects. If we think of the brain as a computer, the nerves in the feet function as the keyboard or input device giving the critical input to the brain or computer. When there is complete lack of sensation the brain is in effect cut off from the feet. This leads to an inability to protect ourselves from damaging stimuli such as sharp objects. In addition, without the normal protective sensation we overuse the bones of the toes in particular and the joints of the feet also. This causes deformities in time such as hammertoes (bent toes) or bone spurs and arthritis. All this can lead to ulcers or open wounds as the skin is also traumatized. These are hard to heal as the skin is not as healthy in diabetics due to damage to the collagen or cement that holds the skin together.
Another factor that neuropathy causes in the feet is decreased or no skin sweating. Normal sweating keeps the skin moist and healthy. Dry skin is less able to tolerate the constant pounding the feet endure daily. This can lead to skin breakdown or cracks in the skin which are portals to infection. Also, dry skin can callus easier which is also dangerous as calluses can lead to ulcers or wounds.
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So, how do we take care of our feet?
First and foremost, control your glucose. Poor glucose control leads to neuropathy or worsening neuropathy. Also, as the glucose rises the risk of infection from minor trauma or even scratches goes way up. Skin heals slower and poorer quality as the glucose rises.
Check your feet DAILY. The old proverb "an ounce of prevention equals a pound of cure" is right on target here. Picking up any changes in the skin such as new or worsening calluses, redness, cracks swelling etc. should be noted and if getting worse call your podiatrist (foot doctor). Waiting even an extra day with an infection can lead to disaster. If you can't see your feet and have a spouse or significant other or even a friend checks them. Use a mirror for the bottom of your feet or even a cell phone camera to take a picture and view it.
Apply moisturizing cream daily, preferably at bedtime to your feet. This keeps the skin healthy and better able to withstand trauma in the shoes.
SHOES and SOCKS. There are specially designed diabetic shoes that are wonderful for comfort and foot protection. I am not diabetic but wear them myself due to the comfort and superior biomechanics designed into the Orthofeet diabetic shoes. In general, diabetes footwear have multiple widths to avoid cramping of the sides of the feet and toes with the accompanying irritation that can lead to open wounds. Also, large round toe box which accommodates toes and any deformities which are quite common. The leather is soft to avoid skin damage. Also, the best diabetic shoes feature biomechanical insoles designed for support and function to improve gait and avoid pressure areas leading to calluses and wounds.
Fitting shoes is also a big issue. Most people’s feet get larger over the years. Although the bones aren't really getting bigger, the feet tend to stretch out and elongate and widen. Many people, especially women gain at least 1/2 to a full size in length and a full size in width. In general, diabetic shoes that are slightly too large is safer than too small when fitting shoes. Also, feet swell, especially later in the day. So, purchase your diabetic footwear later in the day and wear your normal socks. As a rule, you should have the width of your thumb from the end of your longest toe to the end of the shoe when standing. If you have 2 different size feet go with the bigger size. For the width make sure there is no rubbing on the toes, especially the little toe. If you can’t feel your feet look for any bulging on the outside (little toe) of the shoe. If the toe is sticking out or protruding it is too tight. Click here to learn more about Orthofeet innovative diabetic shoes.
DO NOT wear cotton socks. Despite common information, cotton is a poor fiber inside a shoe. Cotton holds moisture and keeps feet wet all the time leading to fungus in the skin and nails. Acrylic or polypropylene or wool are good fibers. Even better are the specially designed Orthofeet BioSoft diabetic socks. They are made to wick away moisture, anti-bacterial, and have smooth seams. And unlike other brands, they are knitted with bamboo yarns which make them ultra-soft and comfortable. Again, I wear them myself and have never had better socks. Click here to learn more about Orthofeet unique diabetic socks.
Finally, take another deep breath. All this may seem overwhelming at first. But remember, managing diabetes is a MARATHON not a sprint. You are in this for the long haul, hopefully many years. There is a learning curve to all this, much as when you got your first cell phone or computer. Little by little you will get better and more comfortable with all the tasks and changes you will need to undertake. If you follow the tips above for people newly diagnosed with diabetes, the prize at the end is a long healthy life while you manage this disorder. Don't be afraid to lean on your team and if you are lucky enough to have them, friends and significant others. In addition, there are support groups including the American Diabetes Association and your local hospital may have support groups. You can do it!!