Q&A with Eyiuche Okeke, M.D.
Wednesday, December 19, 2012
Eyiuche Okeke, M.D., became interested in diabetes care while watching her many relatives, including her grandmother, struggle with the disease. She is now an endocrinologist at Joslin with a focus on multicultural populations affected by diabetes.
How did you become interested in diabetology?
My family has a strong history of diabetes. My grandmother had diabetes and I watched as many others of my relatives also contracted the disease. I saw the toll it took on them and the effort it took them to control the disease. Working with patients has given me an even greater appreciation of the struggle my relatives had and how far we have come in being able to improve quality of life for people with diabetes.
What’s one thing that you have found that is common among your patients?
The amount of misinformation is astounding. One example which stands out in my mind is how many patients think that their blood glucose (sugar) needs to be between 90 mg/dl and 130 mg all the time. I spend a lot of time explaining that blood glucose is variable throughout the day and that the goals for fasting levels and postprandial levels are very different. I also emphasize to patients that one size doesn’t fit all. Someone with advanced cardiac disease or severe hypoglycemic unawareness may have a different target than a healthy 20 year old.
People say that diabetes is one of the few diseases where medical care takes a back seat to self-care. How can patients best participate in their care?
Often patients think they come to the doctor, and I am going to give them medications and it’s going to “fix” their disease. But with diabetes it is more of a partnership. All the medication in the world won’t control diabetes without the patient playing an active role in self-care behaviors. For example, patients need to know why they are coming and the goals they have for their care. It helps if they know what medications they are on and the reasons they are on them. I also want to know what barriers (what makes it difficult for them) to do all the self care behaviors necessary for control. That is the only way we can work together to get good control and have them stay healthy.
What should patients bring to each visit?
In order for me to make the right changes in their medications, patients need to bring a log of their blood glucose every visit. I have patients I have seen for years who never bring any numbers and it is impossible to get their A1Cs in control because we are always shooting in the dark.
How does education play a role?
Diabetes is a chronic disease that affects every major organ in the body. And medicine only goes so far. In order to take proper care of themselves, patients need to know how to monitor their blood sugars, eat properly, take medications safely and exercise regularly. Although I touch on all of these aspects of care with my patients, I don’t have time to go into depth with them. That is why every patient with diabetes should have access to a diabetes nurse educator and diabetes dietician educator. Nutrition and proper meal planning is essential to management of the disease and for many of our patients weight loss is also a factor.
At the Joslin, we are fortunate that we have all of these professionals on staff as well as having access to exercise physiologists as many of our patients are older and have other disabilities or are afraid to exercise. It is also important to recognize that diabetes has a vast psychological component and that some patients will also require the services of mental health personnel.
Starting insulin is often traumatic for patients. How do you handle that?
For patients with type 2, I try to prepare them for the possibility of insulin right from the beginning. I discuss the natural history of the disease which includes the loss of beta cells in pancreas over time and the need for exogenous (injected) insulin. As the time gets closer I make sure they receive education about how insulin works and its side effects. Many patients have fears or cultural beliefs about insulin that need to be addressed. Patients meet with a diabetes educator to instruct them in its use and answer any further questions they may have.
What place do you think technology has for patients?
Of course continuous glucose monitoring has been a boon for our type 1 patients, but I think it should be used for many of our type 2s who have repetitive lows or hypoglycemic unawareness. Patients with type 2 who are currently on a basal bolus regimen would also be appropriate for the pump.
Aside from a cure, what do you think your patients would like to see happen in diabetes care in the next 5 years?
Reduction in the cost of medical supplies is a big one. Also, an increase in anything that makes care easier and quicker. For example, if there was a way to make checking less painful and cumbersome. In addition, I think we are going to see many more apps developed making it easier for patients to stay on their meal plans or exercise.
What do you tell your patients who are having a difficult time following the lifestyle recommendations?
That they are not alone. I encourage them to take small steps. And, I make sure the rest of the team, nurse, dietitian, psychologist and exercise physiologist is aware of the problem. We work with the patient to come up with a comprehensive plan.
You work with a multicultural population. Is there something special about the way diabetes affects them?
Minority patients have the greatest burden of the disease. The rate of co-morbidities and death is many times higher in this population and unfortunately they often have the fewest resources available to combat it.
Anything else you would like to add?
Yes, we have come a long way. If you have symptoms or a strong family history, get checked. So many people wait until they develop complications. Diabetes is no longer the death sentence it once was. With good control you can live a long, healthy life and do just about anything people without diabetes can do.
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