Body Language
Diabetes educators help patients read subtle physical warning signs to detect and treat the increasingly common disease

By Heather Stringer
March 13, 2003

Norm Hente thought he needed to see an eye doctor when the road signs along the freeway started blurring, but a few months after buying a pair of glasses, he noticed a disturbing trend: The signs were fuzzy again.

This time, Hente's glasses were, in fact, causing the problem. His vision had corrected itself when he started cutting back on fast food and desserts, eating smaller portions and taking an insulin-producing pill once a day. Turns out the medical photographer, then 49, had been diagnosed with Type 2 diabetes, and his vision loss was one of the first noticeable symptoms of the disease.

Hente, who lives in Granite City, Ill., is among a swelling number of Americans with diabetes-a disease that's nearly doubled in prevalence in the past decade, according to the CDC. Of the 17 million Americans who have the disease, about one-third are unaware that they are diabetic. Health care professionals say the dramatic rise in cases is linked to the average American's habit of overeating and sedentary living.

Nurse diabetes educators are on the frontlines in the battle to teach patients how to control the disease. These educators know just how subtle the symptoms can be at first, but gone untreated, diabetes can be deadly.

Although awareness has increased nationwide in the past several years, nurses acknowledge that patients and health providers could be waging a much fiercer war against diabetes if they were armed with better knowledge of how to identify the symptoms and then control the disease.

For nurses who work as diabetes educators, the vast majority of their patients have Type 2. These patients are "insulin resistant," meaning their bodies fail to make enough insulin or do not properly use insulin. More than 90 percent of people with the disease have Type 2, and many can control it with lifestyle changes or oral medication. Type 1 patients aren't as lucky. Their pancreases usually fail to produce any insulin, and they often need daily injections to survive.

For nurses, one of the most trying challenges is knowing that a disease ranked as the fifth deadliest in the country is still difficult to detect in many people.

Misread signs

"The most frustrating part is knowing how many cases are unrecognized," said Sandy Pieschel, RN, CDE, coordinator of the diabetes self-management education program at Torrance Memorial Medical Center in Torrance, Calif.

Pieschel said people often dismiss early warning signs-such as frequent urination or tiredness-as symptoms of aging. Sometimes patients come in for emergency procedures, and when these patients register high blood glucose readings, physicians may attribute the readings to stress.

But diabetes detection has improved as more doctors have started using the hemoglobin A1c test, which monitors the average amount of glycogen attached to a patient's hemoglobin during the past 90 days. This test can pick up diabetes in patients who might show normal readings in a typical glucose test after fasting, Pieschel said.

The International Diabetes Center in Minneapolis has launched an initiative to promote the importance of achieving an A1c of less than 7 percent. Hente was able to keep his A1c levels fairly low with lifestyle changes such as increased exercise and lower calorie meals.

But after several years, these lifestyle changes alone couldn't keep his levels low. His A1c crept up to 8 percent and eventually 10 percent. Hente said he was resistant to taking insulin, but the consequences of uncontrolled blood sugars hit him hard when a friend was forced to have one leg amputated because of untreated diabetes.

Diabetes is the leading cause of lower limb amputations, according to the American Diabetes Association. It's also the No.1 reason why adults aged 20 to 74 are diagnosed with new cases of blindness in the United States. Adults with diabetes are two to four times more likely than adults without diabetes to have a stroke or die of heart disease.

These statistics are why Hente decided to start giving himself insulin injections once a day, in addition to taking two insulin-producing tablets daily.

"I'm a photographer, and I don't want eyesight problems," he said. "If I can keep my A1c below 7, my risk of complications goes way down."

Make adjustments

Like Hente, many diabetics need to have their treatments tweaked at different times. Ellie Strock, ANP, CS, RN, CDE, a nurse with the International Diabetes Center, said that health care providers are often slow to make changes when patients aren't responding to initial therapies.

"A lot of these [patients] feel they have failed, and it really isn't that they've failed," Strock said. "It's that the therapy isn't working."

But finding the ideal treatment requires nurses and doctors to understand myriad new drugs and treatments that are evolving, Strock said. The new combination pills, for example, allow diabetics to take one medication to treat both insulin resistance and insulin deficiency. There are long-acting insulins and rapid-acting ones. Strock is also adamant that nurses should keep experimenting with treatments until a patient's diabetes is successfully controlled.

She recently saw a woman in her 30s, overweight and taking metformin to make her body more sensitive to insulin. The woman also was using glyburide to increase the insulin release in her pancreas. She was taking the maximum dosages, but still had an A1c of 9.5 percent. She'd tried exercising and eating healthier, but it wasn't working. Strock knew that lifestyle changes alone couldn't reduce her levels to less than 7 percent.

After talking with the woman, they both agreed that she was a good candidate for insulin therapy. Although this wasn't the patient's first choice, lowering her levels was a high priority.

For Strock, interactions like this one reveal one of the perks of her job. "There are things we can do to help people," she said. "The most difficult thing is that there are a lot of excellent ways to manage diabetes, but there are a lot of people who donhave it under control. We have the tools available to do it, but we have to educate people how to use these tools."

For M.J. Wainwright, RN, a diabetes educator for Type 1 patients, the challenge is teaching children how to control their disease. Wainwright, who works at Fountain Valley (Calif.) Regional Hospital, said children sometimes are faster learners than adult patients.

"Overall, the kids with diabetes do better than the adults because you can teach them that there's nothing wrong with them," she said. "They learn that there's nothing they can't do."

Wainwright's daughter was diagnosed with diabetes when she was 2. Wainwright said her nursing background forced her to confront the potential complications of untreated diabetes, and she responded by introducing healthy cooking habits to her family.

Her daughter, now 11, tests her blood sugar about five times a day, takes three insulin shots daily and pays close attention to what she eats. Although her daughter has the freedom to eat anything in moderation, she cannot afford to "just pig out," Wainwright said. Her daughter's condition hasn't stopped her from pursuing competitive gymnastics, and for Wainwright, this is an example of the lifestyle that's possible if patients confront the disease head-on.

"It shows that diabetes certainly doesn't have to devastate you," Wainwright said. "I like letting families know that they can control it. You don't have to let it control you, and it doesn't have to change the quality of your life."

Contact Heather Stringer at heathers@nurseweek.com