This editorial is by Nora Saul, M.S., R.D., C.D.E., Manager of Nutritional Services at Joslin.
We are forever trying to fit round pegs in square holes. We talk a lot about being sensitive to patient’s cultures and we have laws built around preventing discrimination in schools and the workplace for people with diabetes.
But we don’t much take people’s style or personality into account when we recommend treatment. The treatment for diabetes isn’t really very flexible, as much as we would like to think it is. For a great majority of patients, it requires taking medication, testing their blood glucose and eating on a schedule and having consistency in the amount of carbohydrate they have at each meal.
There are people for whom this orderliness and structure is like the oxygen they breath. These organized folks fall neatly into the routines of diabetes management. This is in no way implies that the disease and its manifestations isn’t a burden –only that the style of the treatment recommendations mirrors their desire for organization.
But there are others for whom this is an anathema. I have had countless patients who don’t keep good blood glucose records, not because they are bad people or don’t want to follow directions, but because that is not how they think.
Let me use food as another example, as it is that part of the treatment for diabetes that I know so well.
It takes no regard to appetite or schedules or preference. How often do patients tell me when I ask them what they eat for breakfast –“cereal, fruit, and toast or coffee and a light yogurt”? Ignoring their nutrition value, these breakfasts are not carbohydrate equivalents. We could certainly make them so, but usually the person eating them is basing their intake on how hungry they are on a particular day.
We tell patients who have type 1 to carb count and use ratios to match their insulin to the carbohydrate they eat. This requires doing math before each meal: adding up carbohydrate values in their food and then using a mathematical a formula to estimate the insulin requirements. And it essentially ignores hunger and appetite. To prevent overeating we want people to be attuned to hunger signals and to stop eating if they are no longer hungry, but once insulin is injected they must continue to eat all the food they have selected or face the possibility of low blood glucose.
Perhaps the progress in diabetes management personal accommodation will follow the trends in the development of creature comforts through the ages. Although we had great art in the 1500’s, we didn’t have indoor plumbing unit the late 19 century.
And in the meantime, how do we help the round pegs? Well we can’t change our personalities, but small behavior change is possible. The person who throws all their tax receipts in a shoebox higglepigeldy is probably not going to begin making Excel® spreadsheets of their income and expenditures, but with education they can hand their accountant a neat labeled pile.
So the free spirit may never learn to carb count systematically or eat consistently all the time, but they can learn to judge the amounts they usually eat and make adjustments for bigger or smaller meals, until such time as creature comfort catches up to scientific advance.