Nearly 26 million people in the United States have diabetes, and, chances are, some of your patients are among them.
Given the prevalence of diabetes and its potential consequences on overall health as well as on vision, Dr. Gregory believes that optometrists must understand the pathophysiology and treatment of diabetes and the dietary modifications that should be part of managing this disease. Dr. Gregory is a resident physician at Pitt County Memorial Hospital in Greenville, NC, and is affiliated with the Brody School of Medicine at East Carolina University, also in Greenville. Prior to becoming a physician, she worked as a clinical dietitian.
"Optometrists and other healthcare providers who evaluate and treat patients with diabetes are essential for physicians in the co-management of diabetes," she said. "Optometrists have the unique ability to actually visualize the vessel damage that occurs throughout the body, and therefore, have a great opportunity to correlate the damage with adequate serum glucose control, and to reinforce the importance of adherence to not only medications, but also to the lifestyle changes that are an integral part of treatment."
Diet and lifestyle modifications are always important in the treatment of any form of diabetes, Dr. Gregory said, and regular physical exercise is especially helpful.
"I like to think of it as a crowbar. It's going to get the glucose into the cells without any insulin," she explained. Dr. Gregory added that physicians and patients not only need to understand that physical activity will help lower serum glucose, but that the level of exertion can affect the patient's dietary and medication needs and is part of an ongoing balancing act aimed at preventing hypoglycemia.
Make necessary changes
Medications, including insulin, are usually the mainstay of diabetes treatment, but dietary modifications, such as weight loss, are also necessary to control blood glucose. Carbohydrate counting is a common dietary approach taught to patients in which they learn what is and is not a carbohydrate, how many carbohydrates are in various foods, how much can be eaten, when they can be eaten, and which are best.
But there is more to a balanced diet than counting carbs. Dr. Gregory noted that doctors and their patients also need to discuss protein, fat, and alcohol intake, plus the effects of each on serum glucose.
Further, diet can't be looked at by itself and must be considered in the context of medications patients use to manage their disease. Hypoglycemia is possible with both oral medications and insulin, and dietary needs differ based on the patient's insulin regimen.
Manage glucose levels
One of the most common complications of diabetes is hypoglycemia. Its symptoms can cover the spectrum from mild to severe, depending on how low the serum glucose level drops. Symptoms usually begin when the glucose level falls to about 70 mg/dL. This varies widely, though, and some patients may have "relative hypoglycemia," in which serum glucose levels are poorly controlled. Because their typical glucose level is high, a decrease to what would otherwise be considered a normal level triggers hypoglycemic symptoms in these patients, Dr. Gregory said.
It is essential to measure the glucose level if you suspect a patient is experiencing hypoglycemia, since treatment of a symptomatic individual whose reading has dropped from 200 mg/dL to 100 mg/dL would differ from that of someone with a decrease from 100 mg/dL to 50 mg/dL.
An accurate serum glucose reading is also helpful in making a correct diagnosis. She explained that some of the early symptoms of hypoglycemia are highly nonspecific, such as hunger, irritability, or headache, and may have nothing to do with glucose levels, while symptoms, such as fatigue, impaired vision, and dizziness can, be associated with either hypoglycemia or hyperglycemia.
The treatment for hypoglycemia is to give the patient sugar, and to do it quickly. The challenge is in knowing how much, Dr. Gregory said. She suggested "the rule of 15": Check their serum glucose level, and if it's still low, give them 15 g of carbohydrates, a level found in 4 ounces of juice, non-diet soda, skim milk, glucose gel or tablets, or whatever is available, as long as it works quickly. In a pinch, you could grab two or three sugar packets from the office coffee machine.
After 15 minutes, recheck the glucose level; if it's still low, treat the patient with another 15 g of carbohydrates. Once the patient has stabilized, offer a snack that contains protein and a longer-acting carbohydrate, such as peanut butter or cheese crackers.
If a patient is unconscious, call 911. You may want to check to see if the patient carries a dose of glucagon ([rDNA origin] GlucaGen, Novo Nordisk), an injectable hormone.
Andrea Gregory, MD, RD/LDNE-mail: firstname.lastname@example.org
Dr. Gregory did not report any financial interest in the subject.