Question from Janice Monachino, BSN, CDE:
A good deal of my work is done in hospital settings, teaching diabetes care. I am troubled by the fact that often the nurses caring for the patients are far from clear as to what the difference is between Type 1 and Type 2 diabetes. They particularly have a problem with elderly patients with Type 1 diabetes, in which they seem to think the age of the patient precludes that the person is totally insulin-dependent. Is this a widespread problem?

Answer from Richard Hellman, MD, FACP, FACE:
Yes it is. But there seems to be considerable evidence that patients are becoming more generally educated about diabetes, in large part because of the increased interest in the media, and also in part because of the internet and the wealth of information immediately available, much of which is inaccurate, but some is excellent. Unfortunately, there is currently less attention paid to diabetes education in the basic curriculum of both nurses and medical students. Diabetes is a disease which costs consume more than 1/6 of the entire health care budget, but the amount of attention paid to it in both education and health policy seems inadequate. We need to do a better job of building the knowledge base of those who come in contact with patients with diabetes and who care for them. The American Association of Clinical Endocrinologists is happy to work with other organizations and other providers of health care to provide a more comprehensive approach to the care of diabetes. It is always worthwhile to remind ourselves that complex subjects, such as diabetes care, are best handled by people who have both knowledge, interest, and experience in these matters, and the development of a team approach to diabetes care has proven to be most effective.

Question from Melissa White, MS, RD, CDE:
So often, when I meet with patients on insulin pumps, their carbohydrate counting skills prove to be very deficient. As a result, they often have very high and variable blood glucose levels. Is this a common problem nationwide?

Answer from Richard Hellman, MD, FACP, FACE:
Indeed it is. Carbohydrate counting is not easy, since it depends in part of the proper analysis of portion size, as well as knowledge of the composition of various foodstuffs. Even the most expert can sometimes make mistakes. An alternate strategy, which is outlined in the 2007 AACE Guidelines for Diabetes on the section of Medical Nutrition Therapy, is having consistent carbohydrate amounts at a given meal. If a patient is willing to do this, this can be just as effective, if not more so, because it is easier to teach and easier to remember. Both techniques can be highly effective, but often the choice of technique has to be matched with the skills, interests, and knowledge of the particular patient.

Question from Debra McConville, APRN, BC, CDE:
So often, I see patients referred from other physicians who have widely fluctuating blood glucose levels, despite large doses of insulin and multiple oral agents. Yet, it seems as if their basic knowledge is often minimal, particularly regarding dietary issues. Is there a more systematic approach to such patients?

Answer from Richard Hellman, MD, FACP, FACE:
Unfortunately, though diet and exercise is always the base from which we should start planning the care of people with diabetes, both patients and doctors often forget this. It is easier to prescribe a pill than change one’s lifestyle. A patient can out-eat any therapy for diabetes. On the other hand, for an obese Type 2 patient, quite often a weight loss of 15 pounds may greatly reduce hyperglycemia and may eliminate the need for a good deal of the glucose-lowering therapy the patient is on. A stepwise approach to medical therapy is often best, and both the American Association of Clinical Endocrinologists and the American Diabetes Association have rational approaches to how to select the initial agent, the proper interval to wait before beginning another, and the alternatives that are available so that the scenario you have described is avoided.

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