Doctors shake patients' complacency for better diabetes care

WASHINGTON -- "What's the hardest thing about living with your diabetes?" Richard R. Rubin asks each of his patients.

Seldom do they say cite fear of the amputations, kidney failure, blindness and heart attacks that years of uncontrolled diabetes will cause. But often they cite sleepiness from middle-of-the-night bathroom runs.

Let's fix that, Rubin says. And with a few treatment adjustments to stop excess urination from high blood sugar, a grateful patient may be more likely to heed Rubin's prescription for the long-term diabetes control that so many diabetics shun.

Some 17 million Americans have diabetes, and experts estimate a third don't even know it. But at least half of those who are diagnosed don't control their blood sugar well enough to slow diabetes' constant erosion of their bodies.

Now a growing number of frustrated specialists say it's time to shake up diabetes care, telling patients in stark terms that early, aggressive treatment is all that stands in the way of a nasty death. They also want to persuade doctors to push stronger therapies sooner.

"People are still in denial about diabetes," says Dr. Alan J. Garber of Baylor College of Medicine, who is gathering specialists to develop such a campaign.

"Patients don't want a second pill. They don't even always want the first pill," Garber said, and they really balk at insulin shots. "You have to twist their arm."

Why? Complacency plays a role. Type 2 diabetes, the main type, is so sneaky that people often don't realize they're getting worse and thus avoid stronger treatment until their bodies are badly damaged. In fact, in survey after survey, patients tell the American Diabetes Association they know diabetes can kill them -- it claims 180,000 U.S. lives a year -- but admit they don't do enough to control it.

"For whatever reason, they forget it," sighed association medical director Dr. Richard Kahn, who says Garber's campaign to scare people into treatment just might work.

But there's a fine line between making people anxious enough to follow treatment and overwhelming them, cautions Rubin, a psychologist and certified diabetes educator at Johns Hopkins University.

Rubin isn't part of Garber's campaign but of another growing movement in diabetes: researching just what motivates patients to change behavior. Diet and exercise, for example, are more effective than drugs at lowering blood sugar during early diabetes -- and the government just started a 5,000-patient study to prove whether it prevents diabetes-caused heart disease, too -- but keeping the pounds off is difficult.

Hence Rubin's theory that tackling day-to-day diabetes concerns, like late-night bathroom visits, works better than big lectures about blood sugar or weight. "Unless I find something the person is really concerned about and really wants to change, it's all just talk."

While scientists debate improving care, how can patients tell if they're properly treated today? Get those A1C tests. They measure glucose control over time, and patients are supposed to get the $15 to $30 tests every three months -- yet hundreds of thousands skip them.

A normal A1C level is a score of 6; U.S. diabetics average a dangerous 9. Specialists recommend diabetics drop to 7 or below, because every point-drop lowers the risk of diabetes complications about 25 percent.

Typically A1C testing requires a laboratory blood sample; the doctor calls with results a few days later. Metrika Inc. recently began selling on-the-spot tests for use in doctors' offices or at home, contending that immediate results can spur diabetics to seek more aggressive treatment. Aventis Pharma, maker of a once-a-day insulin, is funding a 14,000-patient study that, among other things, seeks to prove if on-the-spot A1C testing helps.

Don't let your doctor shrug off a high A1C test, advises Norman Hente of Granite City, Ill. His was too high for years until Hente -- scared he'd end up like a diabetic friend who lost both legs -- left his regular doctor to enter a specialist's clinical trial of insulin, and dramatically improved.

"People have to take care of themselves," Hente says.

------

EDITOR'S NOTE -- Lauran Neergaard covers health and medical issues for The Associated Press in Washington.