Another One Of Those Conversations With GP

[AdamJames]

Chalk up yet another one of those visits to the GP in which we start to wonder why we bother to go, and end up taking refuge in a forum like this instead. My GP is the diabetic specialist by the way.

First of all the good, or at least "not as bad as I thought it would be" news: My HbA1c has gone up to 47. I'd got it down to 42 from 90 but now it's gone up again. I expected it to be higher since my fasting readings have often been 9.5 for months. Was also expecting to be told to start Metformin again, but the doc said I narrowly avoided that recommendation.

But a summary of the conversation was:

Me: "I'm expecting it to be a bad result, based on the readings I've been getting".
Doc: "It's 47. That's just within what we like to see for diabetics, so not so bad."
Me: "Wow. I know I've been in the toxic range fairly constantly. Most mornings I've been getting a 9.5."
Doc: "That's be nice thing about the HbA1c. It's more accurate and gives us a better picture. We don't encourage testing at home."
Me: "But how would I know which foods raise my blood sugars and which don't."
Doc: "We don't encourage testing because it can just worry people. And it's the expense of providing the strips as well."
Me: "But I get my own strips"
Doc: "Yes, but we still don't encourage it. It only seems to worry people. Look at you, you were worried about your results but it turns out they aren't so bad. Blood pressure is more important, anyway. Heart problems are the main thing and it's important to keep blood pressure low."

(My blood pressure had also gone up so this was a moot point).

This is the first time I've offered any resistance to what the GP said, and he clearly wasn't happy, and he had a response which he felt was sound - he certainly places a lot of faith in the HbA1c.

What should I do? Print out references to studies which suggest that two groups can both have the same HbA1c but the group who constantly keep spikes below a certain threshold are much less likely to have complications?

How does a patient educate a doctor without causing offence?

Do doctors actually know better - is there good evidence that an HbA1c below 48 leads to a longer and healthier life for a T2 diabetic? Have I just been focusing on fringe studies, but the overall body of evidence actually supports what the GP is saying?

I think an interesting thought experiment would be: can we make a case to support the GP's view? It's very common that we tear views like his down here, but what if we tried to find the evidence to support it? Would we get anywhere?

 

[AdamJames]

I think I'll have a go at the thought experiment and try to back up the GP's view from anecdotal evidence:

My mum is 77 and has T2, and puts her faith in GPs no matter what me and my sister say.

She's never understood nutrition or managed her diet well (recently me and my sister have been getting her much lower carb, higher fat food, but that's such a recent change it can be ignored).

She just takes the pills the doctors give her and gets on with her life, and goes for the checkups when she's told.

At 77 she's never had a problem noticed in her foot checks or her eye checks. She does have arthritis however, and a problem with her heart - I forget the medical name, but I believe she has arrhythmia as a result.

From a GP's perspective, I guess they could be forgiven for thinking "the system" is treating her T2 well? I don't know.

 

[Jenny15]

I've had many conversations like this one with doctors over the years, about every condition I have, not just diabetes. I've settled on the following formula:

-Learn all I can about each condition I have and the available treatments
-Speak up for myself if they say/do or don't say/do anything that is going to have enough of an impact on my health that it's worth ruffling feathers over
-If they say stuff that doesn't really impact the outcomes I need, ignore it for my own sanity

We can't change them, in fact we can't change anyone in this world. We can only look after ourselves.

I need my GP for ordering tests, prescribing meds, and other things like that that only he can do. If I'm unwell with something obvious, he has saved my bacon a few times. He's a good bloke and he means well.

I have fired others for being incompetent or excessively rude. I'm lucky that to some extent I can do that here in the New Zealand system. I realize it's harder to do in the UK.

I applaud your efforts at avoiding medication as much as possible, but if you find you're not getting the results you want through eating and exercise changes, you might want to consider asking for it at some stage. I know a guy who takes just 250mg of Metformin a day and he finds it just the right amount for him.

Hypertension really is something that needs to be treated with meds, or you will end up with kidney damage that might not be bad for now but later in life you will regret it, trust me. Depending on your BP numbers you might be able to get away with not taking meds if borderline. I wasn't, so I took the meds. I tried to stop them once, which resulted in my routine blood tests showing early kidney damage just after a few months. Fortunately they recovered quickly once I restarted the meds.

When I was diagnosed with hypertension I did my due diligence and read about the disorder. In my case I don't consider lifestyle changes & reducing salt intake would make enough of a difference to justify the hassle. It runs in my family and even the slim people who don't add salt to their food have it.

I think your doctor is wrong about the HbA1c being superior to, say, a fasting BG done by the lab. If he would allow you to have one of those tests done, it would remove "home testing" from the equation. If the lab shows it at 9.5, he should do something, fast.

47 is virtually 48, too. I had the same sample taken on the same day get accidentally processed twice, and the result was 62 and 64, respectively. So there you go. IMO 47 is borderline for being considered above the threshold where you probably would want to adjust things.

 

[Brunneria]

I think that no matter how much we know, and how much reading we have done, we are usually conditioned to place Doctors on a pedestal because of their Vast and Superior Knowledge based on Years of Training that we Mere Mortals cannot possibly Understand.

Trouble is, by the time we reach middle age, many of us (I wouldn't dream of saying everyone) has experience of being let down by doctors and the healthcare system.

In my case this includes missed diagnoses (plural) going back 30 years and the loss of a good friend to breast cancer because 'pregnant women often have lumpy breasts. Go away and stop worrying.'
Yeah, right.
That worked out well for her.
And her now motherless daughter.

A few experiences like that, and we learn to start questioning and doing our own research, don't we?

From what I have seen of your posts, you won't ever stop thinking - and that is basically what your doc is asking you to do.
Stop thinking. Stop learning. And trust in the paternalistic care of the NHS.

Works for some. Not me.

As for studies showing that it is better to keep bgs low and steady, I think you will find a few on www.bloodsugar101.com

 

[Jenny15]

I think I'll have a go at the thought experiment and try to back up the GP's view from anecdotal evidence:

My mum is 77 and has T2, and puts her faith in GPs no matter what me and my sister say.

She's never understood nutrition or managed her diet well (recently me and my sister have been getting her much lower carb, higher fat food, but that's such a recent change it can be ignored).

She just takes the pills the doctors give her and gets on with her life, and goes for the checkups when she's told.

At 77 she's never had a problem noticed in her foot checks or her eye checks. She does have arthritis however, and a problem with her heart - I forget the medical name, but I believe she has arrhythmia as a result.

From a GP's perspective, I guess they could be forgiven for thinking "the system" is treating her T2 well? I don't know.

I think GPs would love it if all their diabetic patients were like your dear Mum. IMO if the person only has T2 diabetes, no hypertension, no high lipids, no organ disease just arthritis, then they are not likely to get complications like their less fortunate peers. She has pretty good genes!

It's the people who have diabetes + one or more other conditions that interact with diabetes that need a bit more time from their GPs, IMO.

 

[eggs11]

I don't get the 'it just worries people' reason. Testing myself helps stop me worrying, it's the thing that gives me peace of mind and also acts as a warning if I'm getting complacent with carbs. If people don't test how they can know if their diet changes are working or not? 3-6 months is an awfully long time to wait to find out otherwise. I would be lost without home testing.

 

[dbr10]

I don't get the 'it just worries people' reason. Testing myself helps stop me worrying, it's the thing that gives me peace of mind and also acts as a warning if I'm getting complacent with carbs. If people don't test how they can know if their diet changes are working or not? 3-6 months is an awfully long time to wait to find out otherwise. I would be lost without home testing.

You're absolutely right.

 

[EllieM]

My Dad's 87, and has been T2 for 7 years. He's not overweight but has a bit of fat round his middle. He was told not to blood test and has been on a stable amount of metformin (3 * 500mg) for all this time. He eats moderately low carb (100 to 120g per day?) but doesn't watch his diet rather than regularly not having dessert type stuff). My mother was T1 so he never had a heavy carb lifestyle. The DN at the surgery is happy with his lifestyle and while his blood sugars aren't great (9s when I test him) they're not that bad and honestly for someone like him I think the standard T2 advice is right. It's not going to be the T2 that kills him.

I suspect that there are a lot of elderly T2s like him.

But, for someone younger, who's wanting to have several decades more of healthy life, it's a completely different story.

 

[AdamJames]

I think GPs would love it if all their diabetic patients were like your dear Mum. IMO if the person only has T2 diabetes, no hypertension, no high lipids, no organ disease just arthritis, then they are not likely to get complications like their less fortunate peers. She has pretty good genes!

It's the people who have diabetes + one or more other conditions that interact with diabetes that need a bit more time from their GPs, IMO.

She is on blood pressure pills now you mention it. I think high blood sugar is now thought to be implicated in so many illnesses I wonder what other links there are. Some people have e.g. said that reducing their carbs has helped with arthritis.

 

[Bluetit1802]

She is on blood pressure pills now you mention it. I think high blood sugar is now thought to be implicated in so many illnesses I wonder what other links there are. Some people have e.g. said that reducing their carbs has helped with arthritis.

I think it has more to do with higher circulating insulin levels than higher glucose levels. Too much insulin (caused by too many carbs and insulin resistance) is not desirable. Insulin causes weight gain in many cases, and worse still it is inflammatory - which will never help arthritis and can lead to arterial disease and heart disease and probably many other diseases. So, reduce the insulin secretion and thereby reduce inflammation (which will help reduce arthritis). My theory is that many of the diabetes related complications are as much as or more to do with hyperinsulinemia than hyperglycaemia.

 

[AdamJames]

I don't get the 'it just worries people' reason.

I don't get it and I at first didn't believe it - I thought he was just making it up.

But there do appear to be studies which support his view, regardless of whether the studies have much merit. Here's a summary I just found:

https://www.nhs.uk/news/diabetes/home-testing-for-diabetes/

Note the incomprehensible line in that article: "Aside from the debate over home blood sugar testing for the newly diagnosed type 2 diabetic, it remains vital that diabetics maintain their blood sugar at as balanced a level as possible to avoid the many complications associated with diabetes. This should be monitored and carefully controlled in each individual patient in the best possible way"

What exactly does that mean? You have to ask - is there a better possible way than a personal blood glucose monitor?

It's certainly pretty stunning that a GP would discourage home testing even for a patient, like me, who has made it perfectly clear he is paying for his own kit, and has never asked to have it prescribed.

Perhaps next time I visit I should hand over my meter, my test strips and most importantly my bathroom scales as none of them are giving me the numbers I want and are just pointless sources of worry!

 

[AdamJames]

I need my GP for ordering tests, prescribing meds, and other things like that that only he can do. If I'm unwell with something obvious, he has saved my bacon a few times. He's a good bloke and he means well.

That's pretty much how I see my GP now. I also agree with most of the other stuff you wrote.

 

[AdamJames]

I think that no matter how much we know, and how much reading we have done, we are usually conditioned to place Doctors on a pedestal because of their Vast and Superior Knowledge based on Years of Training that we Mere Mortals cannot possibly Understand.

Trouble is, by the time we reach middle age, many of us (I wouldn't dream of saying everyone) has experience of being let down by doctors and the healthcare system.

In my case this includes missed diagnoses (plural) going back 30 years and the loss of a good friend to breast cancer because 'pregnant women often have lumpy breasts. Go away and stop worrying.'
Yeah, right.
That worked out well for her.
And her now motherless daughter.

A few experiences like that, and we learn to start questioning and doing our own research, don't we?

From what I have seen of your posts, you won't ever stop thinking - and that is basically what your doc is asking you to do.
Stop thinking. Stop learning. And trust in the paternalistic care of the NHS.

Works for some. Not me.

As for studies showing that it is better to keep bgs low and steady, I think you will find a few on www.bloodsugar101.com

Yes to all that. And I get a lot of my thinking from the studies referred to on bloodsugar101. Even if not all studies get the same findings, it surely makes sense to be pessimistic - if one study suggests much better outcomes if you constantly keep levels low, it's best to aim for that.

If I was in clever debating mood with my GP this morning, I think the best thing I could have done was pose him the question:

"You are telling me that I'm doing well because the HbA1c is saying 47. But if you take a fingerprick reading now you'll get 9.5 mmol/l because that's what I woke up with and all I've eaten is eggs and mushrooms. If I'd had a normal person's breakfast I'd be at more like 16 mmol/l right now. Are you telling me, as I sit here in front of you, the glucose level in my blood is not a problem and not causing damage? What evidence is there for that, and against it?"

I'd really like him to answer that.

 

[AdamJames]

But, for someone younger, who's wanting to have several decades more of healthy life, it's a completely different story.

That's a very good point.

Also a very difficult one to tackle. At what age does one 'try less'? That's been something I've battled with, as I try to do a lot to tackle my own T2, but my mum is far less willing and able. It plays on my conscience - as I've learned more for my own sake, should I be doing more to nag my mum to make changes, or would that make her quality of life worse?

She's not less willing because she's being difficult - she just puts her trust completely in the GP and if the GP doesn't say go low carb and test at home, then nothing me or my sister say will change her mind. So I've sort of come to the acceptance that she's of a certain age, she's doing okay in terms of obvious T2 complications, her quality of life is shot in terms of arthritis anyway, so why nag her to try to do the same things I am? Why not just let her watch telly all day and eat the foods she wants and not bother with testing? She's probably going to out live me anyway by the looks of it!

I should say however that she's doing very well since we've persuaded her to change her food shopping quite dramatically though. I think it's been a couple of months now and a wild guess would say she's probably on 20% the carbs she used to be.

 

[AdamJames]

I think it has more to do with higher circulating insulin levels than higher glucose levels. Too much insulin (caused by too many carbs and insulin resistance) is not desirable. Insulin causes weight gain in many cases, and worse still it is inflammatory - which will never help arthritis and can lead to arterial disease and heart disease and probably many other diseases. So, reduce the insulin secretion and thereby reduce inflammation (which will help reduce arthritis). My theory is that many of the diabetes related complications are as much as or more to do with hyperinsulinemia than hyperglycaemia.

I may be imagining it but whenever I visit my mum, in the couple of months since we've taken over her food shopping and she's eating far less carbs, she seems to be 'getting better' in terms of the outward signs of pain from arthritis.

She seems to be in less pain when getting out of her chair, which was always a horrible thing to watch and listen to.

It's so hard to be sure though. She herself says she hasn't noticed a difference, plus I may be seeing what I want to see. Interestingly, when she says she doesn't think her new diet is doing anything, I always tell her that it's up to her when she wants to stop. She can have cream cakes and biscuits and normal bread whenever she wants, I tell her, and she definitely misses them. But so far she keeps saying she'll stick with the diet. I wonder if deep down she's noticing positive things about it?

 

[Kittylitter]

I don't think the GP is going to change his view, so instead of getting him to do that, put your energies into doing what you feel is right for you.

 

[Dexterdobe]

I think I'll have a go at the thought experiment and try to back up the GP's view from anecdotal evidence:

My mum is 77 and has T2, and puts her faith in GPs no matter what me and my sister say.

She's never understood nutrition or managed her diet well (recently me and my sister have been getting her much lower carb, higher fat food, but that's such a recent change it can be ignored).

She just takes the pills the doctors give her and gets on with her life, and goes for the checkups when she's told.

At 77 she's never had a problem noticed in her foot checks or her eye checks. She does have arthritis, however and a problem with her heart - I forget the medical name, but I believe she has arrhythmia as a result.

From a GP's perspective, I guess they could be forgiven for thinking "the system" is treating her T2 well? I don't know.

I'm 63 and I had an erratic heartbeat just like your mum. The heart problem started in a minor way when I was in my 20's and got much worse about five years ago. I've been on a LCHF diet for 6 months and my heart problem has gone. I no longer take the Bisoprolol tablets I was prescribed for it. I should point out that I have also stepped up my exercise and stopped drinking alcohol, but the diet seems to have had the most dramatic effect. We are all different and what worked for me may not work for your mum, but it is certainly worth persevering with the LC diet in the hope she may too see the benefits. (If you can persuade her to run to the shops every day to get her milk stout so much the better).

 

[Resurgam]

I usually use just the fats from the meats I cook for cooking veges eggs etc. but recently I bought a small bottle of groundnut oil and was in agony from aches in my hips and knees, my sciatica flared up too - then I did a couple of roasts, got to the end of the oil and started to use fat again - and now the pains have gone - well almost, but I was doing some demonstration Maypole dancing and morrissing too now I think about it so a twinge or too is to be expected at my age - 67, should know better.
As my normal menu is the one I have been using for years the oil was the single alteration, and I certainly will not be buying it again, nor any seed oil.

 

[AdamJames]

I'm 63 and I had an erratic heartbeat just like your mum. The heart problem started in a minor way when I was in my 20's and got much worse about five years ago. I've been on a LCHF diet for 6 months and my heart problem has gone. I no longer take the Bisoprolol tablets I was prescribed for it. I should point out that I have also stepped up my exercise and stopped drinking alcohol, but the diet seems to have had the most dramatic effect. We are all different and what worked for me may not work for your mum, but it is certainly worth persevering with the LC diet in the hope she may too see the benefits. (If you can persuade her to run to the shops every day to get her milk stout so much the better).

Haha! There's no way my mum will be running to she shops. She doesn't even walk to the shops any more, she's in so much pain when she moves. That's part of how we were able to persuade her to reduce carbs - we order her shopping online to be delivered to her - she tells me what she wants while she's on the phone to me and I'm adding stuff to the order in real time (she doesn't do technology / the Internet) so I can steer her in the right direction.

That's a very encouraging story from you anyhow, well done you.

If my mum ever walks to the shops again that will be a definite sign of improvement.

 

[Daibell]

My two GPs who were the surgery diabetes experts proved to know little about diabetes. I've had two excellent DNs. The first one came from the diabetes clinic and the second current one is a general nurse who listens and talks sense even though not an insulin expert. You can't argue with GPs as they 'know best'. When I challenged my female expert GP that I was T1 and not T2 she told me you are NOT T1 and that 'I have 500 diabetes patients so know what I'm doing'. She refused me insulin but a year later told me I had to go onto it; nice one. I later found out that she had only just come off a diabetes training course for the first time. I think many find DNs are good as they are used to working closely with patients and don't sit themselves on a pedestal. I now only see the DN so don't have to suffer the GP's ignorance of diabetes.