Michael Kleerekoper, MD, MACE, has joined the faculty at the University of Toledo Medical School where he is Professor in the Department of Internal Medicine and section chief of the Endocrinology Division. The author of numerous journal studies, Dr. Kleerekoper serves on the editorial boards for Endocrine Today, Endocrine Practice, Journal of Clinical Densitometry, Journal of Women's Health, Osteoporosis International and Calcified Tissue International. Dr. Kleerekoper is also a founding board member of the newly formed Academy of Women’s Health.

It seems so straightforward - why can't I get it right?

The growing epidemic of type 2 diabetes is well documented, as is the importance of diet and exercise in the management of diabetes.

There are, at last count, eight different classes of non-insulin therapy that are available as brand name, generic, combinations, oral and injectable. There are even more options for insulin use - long-acting, rapid-acting and many combinations in between.

Unlike other common chronic disorders such as hypertension and dyslipidemia, with diabetes, the patient has direct access to measurement of capillary blood glucose any time, day or night.

Despite this wonderful array of therapeutic and management tools, I still have great difficulty in obtaining compliance from many of my patients. It is not uncommon for patients to turn up for a regular pre-scheduled visit without either a glucose meter or glucose diary. Of those who do have the data with them, there are still too many who blithely report capillary blood glucose (CBG) values that can vary from 65 mg/dL to 265 mg/dL and higher on any given day, and frequently in any given week or month.

I would like to believe that this is not for want of trying by me, my wonderful support staff and our diabetes educator, but I am no longer confident of that. At the same time, I cannot blame my patients for lack of adherence to the advice and direction that we give them at each visit.

Further confounding my concern is the fact that I have an increasing number of patients who diligently record their CBG values several times a day; download their glucose meters every 2 weeks or so; and then email the data to me. For most blood glucose monitors, the data can be displayed in many ways, including graphical depiction of CBG for every time it is measured. The wide fluctuations are staring the patient in the face, but I have clearly failed to convey the message that these wide fluctuations are potentially harmful in the long term, even if the average CBG is acceptable. Some of them get the message with my return comments, some do not - about 50/50. I keep plugging away and still have some hope that more of them will get the picture eventually.

What to do with those who have poor glycemic control but are unaware of this because they are not checking CBG regularly? My current approach is one of two options to start with:

  • a) Measure CBG shortly before breakfast - (not when they first get up in the morning as so many of them do several hours before they plan to eat) - make a note of what they ate for breakfast, and re-check CBG immediately before lunch. The goal, of course, is to either adjust the breakfast such that the two readings are close to each other, or, for those on pre-meal rapid-acting insulin, increase the pre-breakfast insulin.
  • b) For those on oral medication plus bed-time long-acting insulin, I request a CBG at bedtime and right before breakfast. Management suggestions depend on the disparity, most often a request to increase bedtime insulin if both CBG values are high. Yes, they also get more counseling on their dietary habits.

Patients who regularly monitor CBG eventually get the message.

That leaves the question of what to do with those who simply don't bother unanswered. Often it is not the patient's fault or it's not due to unwillingness since, depending on their insurance coverage, test strips and lancets are not cheap. The focus has to be almost exclusively on diet and lifestyle changes. Changing the diet in this population is also not so easy because food preference is so ingrained in the patient, and they are usually concerned that changing their diets to include better quality foods will increase the cost of their meals. Some large local food stores have begun to address this by providing clear labels on the price tags of many food products that allow the patient to compare the content, such as carbohydrates and proteins, of competing products. (www.NuVal.com)

Any advice you can offer for improving patient compliance with/adherence to sound advice about their role in their diabetes would be appreciated.