Compliance: Easier Said Than Done!

Chronic disease is exactly that, chronic. Therefore, a diagnosis of any "chronic" disease is a life-altering circumstance. I spend the majority of my days doing my best to take care of patients with diabetes (among other conditions such as thyroid disorders, pituitary disorders, etc...). It is not uncommon for myself, as well as other physicians, to characterize a patient as non-compliant. Essentially, this means that the patient is not following the physicians recommendations. Many times, these patients' condition is not controlled due to barriers that are preventing their success, such as depression, lack of dedication, poor insight into the disease, failure to adjust to the change in lifestyle that comes with the condition, or denial about long-term health consequences. Addressing these barriers will hopefully facilitate future success in preventing complications. In an attempt to live the life of one of my patients I recently wore an insulin pump for 72 hours; this was an extremely insightful experience!

The hours leading up to the insertion of the insulin pump, which is a small catheter underneath the skin (smaller than an IV) connected to a reservoir of insulin (for me it was saline), was surprisingly nerve racking. I was uncertain what it would feel like physically and emotionally to be connected to this device. What would it feel like to check my own blood sugar? To actually go through the motions of counting carbs to figure out my correct "insulin" dose? My co-Fellow and I met with the Medtronic rep who walked us through the information of how to use the pump...basal/bolus settings/adjustments, etc. Already I had learned a lot, and felt better prepared to treat my patients, and the pump wasn't even inserted yet. Next, the pump was inserted underneath my skin. It was basically painless...in a geeky short of way, I was actually excited to go through this exercise.

It was late afternoon, a few hours since the pump had been inserted, I started feeling hungry and sensed that maybe my blood sugar was running low (I have been told I get "cranky" when this happens). I scrambled to grab my supplies to self monitor my blood sugar for the first time (this means taking a lancet and pricking my finger and using the blood to be read by a machine, for those of you not familiar). Since I had never done this on myself before, I failed miserably...At first not enough blood, then the finger at the wrong angle. Whew, I finally got it. I was relieved that my blood sugar was in the normal range. I can imagine that over time this may get easier to do, but also may become harder (both emotionally and physically). Off to dinner I went...

The menu arrived and I picked out my appetizer and main course. I subsequently pulled out my carb counting book. Wow, that is a lot of carbs I ordered. I figured about 130 carbs, so I programmed the pump to give the correct units (somewhere around 10 units). It felt like I was giving myself a lot of units, despite the fact that many of my patients are on much higher amounts of insulin. I wondered how my patients feel as they go through this process of checking their blood sugar prior to eating at a restaurant and then have to time the insulin appropriately to cover the meal. I imagine everyone probably has their own routine (go into the bathroom at a certain point, etc...). So far I was off to a decent start. I was determined to keep up my "compliance."

Prior to bedtime I struggled to successfully check my blood sugar again, I just need some practice I guess. Oops, I forgot to log into my blood glucose book. This is the finger stick diary that we rely on patients to bring to their appointments so we can adjust their blood sugar (the machine and newer devices work well, too). Changing for bed, without getting into too much detail, was slightly challenging with the plastic tubing but I eventually figured it out.

Prior to working out the following morning I set my temporary basal rate, which made me feel proud that I had done as I was taught. I think doctors tend to have a type A personality and probably obsess about doing well in tasks, maybe this is no different. Although, it is common to hear that doctors are generally not always the best patients. I wonder what characteristics are common in "good" patients, or are there a set of unifying traits?

The last 36 hours of my social experiment to live the life of one of my patients went relatively smooth. I settled into the role and at times forgot that I was attached to the pump, except when I ate and gave myself the "insulin" dose. I had some powerful interactions with patients during these days. I showed 2 of my patients who currently have uncontrolled diabetes that I was wearing the pump, and they were amazed that I was going through the process of checking my finger sticks as well. This opened up a discussion about what it felt like to be wearing the pump, what it is like to sleep with it on and remove it prior to a shower, and so on. I know for sure, that one of these patients is in the process of being set up for a pump which will ideally improve her diabetic control and hopefully prevent long-term complications of this chronic disease.

I like to think that I always have respect and empathy for my patients, however, I now have a whole new perspective. I now know what it feels like to wince prior to checking the blood sugar in anticipation of the needle stick, the feeling of people looking at you as you read your carb counting book in a restaurant, and continuously feeling that in order to take care of yourself requires a lot of work and commitment.

While the diagnosis of a chronic disease certainly requires a new dedication to an individual's health, preventing chronic conditions (at least those that are preventable) also takes motivation.

As we approach 2012, it is inevitable that most people will have a New Year's Resolution that entails a health related goal. For those with a chronic disease, keep working to gain the best control possible by eating right (e.g. low salt for hypertension, or less sweets for those with diabetes), increase physical exertion (for everyone), and discuss any barriers that you may be having with your physician.

I realize it has been almost a year since I have written an entry, it has been tough to be compliant! Twitter has been the downfall to these entries, much less time consuming to tweet. Hope you got something out of this, I certainly did.

Happy and Healthy to everyone!

Recipes for Longevity!

Fresh and inspired from a trip to two of the must see world destinations-The Galapagos Islands and Machu Picchu! During our trip several fellow travelers mentioned these as being on their "bucket list," essentially places to visit before they die (for other examples see the movie with Jack Nicholson and Morgan Freeman). Of course, the topic of creating a "bucket list" got me thinking about life expectancy. Typically diet, exercise and genetics are the focus when discussing longevity in our society. I wondered about the longevity of the species in both these "bucket list" places.

The Galapagos Archipelago contains a fascinating array of species, mostly studied and classified by Charles Darwin. Birds, reptiles, fish and mammals all coexist in an ecosystem that is magical to observe. The process of evolution is clear-everything from the mating techniques to the diet. Swimming with sharks, watching the sea lions play in the sand/water and observing the various birds (blue footed boobies, frigates,etc.) are experiences that I will always remember but it was the tortoises that were most intriguing for me based on their longevity.

A Galapagos tortoise has a life expectancy of over 100 years with some living for 170 years! Of course I questioned why tortoises outlive humans, even by a lot, when we humans have the benefit of extensive medical knowledge and resources. Our naturalist guide told us that tortoises can slow their metabolic rate when needed and their heart may only beat a few times over 10 minutes. They are herbivores that feed on primarily cactus, vegetation and berries. On wetter islands they are found in herds (good social support) and on the drier islands they can go up to 18 months without food and water by breaking down fat to create water. Interestingly studies of human centenarian hot spots, called Blue Zones, demonstrate that those that live the longest have a plant based diet, a strong investment in family, and consistent low-intensity activity-sounds similar to the tortoise existence. The message is clear, a focus on lifestyle can help prevent chronic disease (not always) and taking a multitude of medications may only be putting a band aid on the underlying issues (poor diet, stress, etc). The lessons for longevity from the animals of the Galapagos Islands were further confirmed as we traveled through the gorgeous landscape of Peru.

Everyone who has visited the mountains of Peru, specifically Machu Picchu, have similar comments about it being a spiritual and magical destination and I am in total agreement. After reaching the top of one of the Inca ruins (about 11,000 feet above sea level), our tour guide stated that Inca's usually lived over 100 years of age. The Inca civilization reached its apex in the mid-late 1400's so surely they didn't have access to the medical treatments we have today. Again, I wondered why these people outlive many humans today in the 21st century. While reviewing some of the characteristics of the centenarians in the blue zone areas it appears that purpose and hard work are important characteristics in longevity.

The Inca people lived, and live, an existence rich in symbolism. It is impossible to walk the streets and explore the ruins without identifying the main symbols of this culture. The main symbols are the lama, puma, snake and condor. The lama signifies an unconditional love of service-the Inca people use its wool, meat and milk to survive. The lesson of the puma is passion to be eternally present, essentially to live in the moment. The snake represents a love for wisdom and reminds the people to learn and teach something daily. The condor reminds the Inca people of a will of liberation and spiritual transformation as they glide through the air. These principles remain in the Inca descendants of today. The streets are filled with both men and women in their late 70's-80's (at least) who sell their fruits, vegetables and crafts in markets after usually walking miles to get there early in the morning. I was certainly impressed by the strength and passion of this population.

The lessons I took home from both of this places, and will attempt to practice, are too extensive to try and put into words. My main goals as I return to my reality is to embrace my sense of purpose in society, to work hard at my profession, spend valuable time with friends and families, live in the present (my biggest challenge) and continue to focus on a healthy diet of fruits and vegetables.

I hope this entry was valuable and will help us all add both quantity and quality to our lives.