But No One Told me I am Diabetic, Doc!

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Hi. It’s Dr. Louella in a sombre mood today. I keep thinking about this patient I had today in chronic disease clinic; a young guy in his thirties.

No drama here. I started off with my usual verification of what the patient suffers with. I’ve been doing that a while now, since discovering that patients attend our clinics for years with only a vague idea of what they’re being treated for.

I don’t know if it’s a Trinidadian thing with the responses I receive but I’ve asked this question so many times that I’m no longer surprised…

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‘What are you suffering with sir/madame?’

Some patients get offended. They start to stammer that I am the doctor and therefore I should know. So I let them know it’s a big file (we use handwritten patient notes) and we would move a lot faster if they tell me rather than me having to go through all these notes.

Furthermore I remind them that they are the patient. It is their health and their responsibility to know what they are afflicted with.

‘So, would you like to tell me, sir/madame, what are you suffering with?’

There are other patients who begin everything with ‘they say’. For example that, ‘They say I have diabetes’. When I try to confirm that they mean that they have been diagnosed with diabetes, they respond consistently, ‘So they say’. So in my estimation, they are in huge denial!

Sometimes I would make a check in the notes only to find that they have had this said to them for five years or more. I let them know that ‘they’ say it only because it is true and it’s very important they learn to accept it and deal with it.

Then there are those patients who try to respond correctly but leave out diagnoses. When I check the notes there may be an additional diagnosis such as ischaemic heart disease or chronic kidney disease that they are clueless about and which they sometimes deny vehemently.

So then I need to backtrack to find out where that came from, if they were diagnosed at hospital or presumed to have the disorder or what. I need to know if a diagnosis is true or not to convey this to the patient sitting in front of me.

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Finally there are patients who give additional diagnoses to what are documented. Something may have happened since the last visit or more likely they had been suffering with some disorder and didn’t think it necessary to inform us.

Our patients attend several different doctors, clinics and institutions simultaneously. Very little official information is shared between these groups.

It is often up to the patient to let us know what is going on. To some of them it is a secret. Others forget or don’t think it relevant. Me, I grab up this stuff, because I want to know everything.

I use the diagnosis as a starting point to inform and educate the patient. It’s not that you maybe sometimes could probably have hypertension. You HAVE it and you need to deal with it. It’s not about a bunch of numbers but really debilitating complications that you could get but we are trying to prevent.

Getting back to the case at hand… When I had my usual discussion with this young man about his diagnoses today, I was a bit thrown. He knew he was overweight and had elevated cholesterol but knew nothing about having had diabetes.

But it was staring at me in his notes! He was newly diagnosed as a diabetic on the previous visit. Apparently he had not been told. Oops! That was a problem. And he seemed intelligent enough that he would have remembered.

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I proceeded to take the time to double check his blood investigations. Those results pointed to pre-diabetes, which as I explained to him, was in between ‘normal’ and ‘diabetic’. He was becoming diabetic. Steps had to be taken to try to prevent, or at least delay, full blown diabetes.

(The term ‘Impaired Glucose Tolerance’ is an older term that was and is still used for this condition. I much prefer the simpler ‘pre-diabetes’ when dealing with patients as ‘pre-‘ indicates ‘before’.)

While advising the patient about his condition, I needed to reassure him as well. He had been started on the appropriate medication (metformin). I actually increased his meds for now because his glucose level was high.

I advised him strongly about weight loss, that that in itself may reverse his condition and referred him to the dietitian (they make our life so much easier).

I spoke a lot about exercise because I know that if you’re not into it, it could take you a while to get started. I wanted to get him thinking that this thing was doable.

I threw out different ideas of different types of exercise he could attempt and explained how the day-to-day routine he described was physical activity but not intense enough to be classed as exercise. And he had the size to show for it.

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In the end he was really grateful for the information. But of course, other patients were waiting.

I really feel passionate about helping younger patients prevent and manage chronic diseases. That’s why I spend extra time with them.

It is often more difficult for them to come to terms with their illnesses than older adults. They want to enjoy their youth and do not want to be saddled with strict diets and medication.

I let them see that I take their health seriously and they should too. But I also try to inspire hope within them because without it they wouldn’t even try.

I will continue to ask patients the question ‘What are you suffering with’ or seek verification from the patient as to his/her diagnoses because it is important. It is only when people properly understand what is going on with them can they make informed decisions and live healthier lives.

I feel better now that I’ve shared that. I’d like to think I am making a difference in this world, one dot at a time. Dr. Louella is out!!!

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The Very Basic Rules of Health

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474657739Hi folks. Dr. Louella here. Did you miss me? I wasn’t feeling too well these past couple days. Took two days off work. When I was younger, people, usually the younger ones, would say, “You’re a doctor and you’re sick!” and look in amazement. I would simply explain to them that we are human beings like everyone else and the same imperfect medicine we apply to them applies to us too.

But it’s worse when you’re a doctor. I recently read an article from the UK which expressed the same things I experience. You’re both doctor and patient, there’s no one to turn to, you’re not objective when it comes to yourself, you shun any unpleasant treatment.

So why was I not well? It comes from breaking the basic rules of health, as I am going to discuss with you, and indeed I have discussed with many of my patients. Let’s put aside all the fancy medicine for a moment, all the gadgets and the tests, the antibiotics, the vitamins and the painkillers.

The basic rules of health are to eat well, drink plenty water, sleep well, be active, exercise and don’t be stressed.

So which one did I break? … not enough rest. I am frequently guilty of that. Caused me to faint at a bank. Also think I strained my abdominal muscles lifting some very heavy books. I’m still in pain.

Now, do not take these basic rules lightly. Many people come to me run down saying they think they need some vitamins. Now, vitamins are still controversial but there’s no harm in taking them because we do have deficiencies in our diet that we are not aware about. But vitamins ain’t food! We can last a lifetime on food alone but certainly not on vitamins alone.

Are you having three square meals a day? Basic. No, you miss breakfast because you can’t eat that early in the morning or more likely because there is no time. Well have a juice or a fruit or a cup of milk, something. Pack up breakfast and take it with you to the office. You miss lunch because you’re too busy or dinner because you’re trying to lose weight or it isn’t convenient. No wonder so many of us have stomach problems or experience lack of energy.

I’m sure I explained already that to lose weight you eat small amounts more frequently. You don’t miss meals. Our meals also need to be balanced with sufficient veges, peas and beans and fibre and less of the rice, flour, meat and sweets.

Do you drink sufficient water? Many people don’t. 6-8 glasses a day is a rough estimate. You may require more but not much less. Many people do not like to or do not make the time to drink enough water but our bodies are made up mainly of water and all systems need it to function efficiently.

What about sleep? That’s my Achilles’ heel. I literally started to feel that there weren’t enough hours in the day to get a proper rest, 7-9 hours, and do everything I wanted to do.

But that’s the quickest way for your body to be run down, for you to be less alert, less focused. You make more mistakes without a good night’s sleep, have more memory lapses and are more irritable. It also feeds both anxiety and depression. We need to plan our days so that we get the essential sleep.

You don’t need a doctor to tell you to eat right and sleep right. You need to know the importance for yourself. There is no medication that can replace these things. As I say, basic.

Being active. Many of us lead sedentary lifestyles. A family doctor may sit at a desk for hours with little breaks in between. The office worker, the computer geek, often does the same. The little old lady will sit on the comfy chair all day. The housewife may whip up her chores early in the morning then relax all day. These are common but unfortunately unhealthy scenarios. We must keep moving throughout the day. Obesity is so rampant because we do not do this.

Exercise is something you need to add to that active lifestyle. It increases your heart rate, breathing and the energy you expend. But we don’t like to exercise!!! It takes up our time, and certainly takes effort. It even hurts sometimes. The exercise buff is the exception rather than the rule. But we all know we need to exercise. It’s no secret. Exercise has a long lists of benefits. You lack energy? …Well exercise.

Lastly, let’s talk about stress baby. It is a relatively new buzz term isn’t it? But it’s so real. It incorporates worry, anxieties, fears, depression, all sorts of negative emotions we allow to play on our minds and disturb our psyche. Stress is not the situation or person that is affecting you, but your response to them. Two persons can have completely different responses in identical situations. If we are stressed we cannot function properly.

We often blame others for our problems. But if we do that, we can never solve them because we cannot change the other person. We need to change our attitude to acceptance and move on.

We cannot be dwelling on our past. Those monsters can only hurt us if we bring them into the present. And worrying about the future does not help either. I tell that to clients who insist on worrying about their children and grandchildren as a duty.

We often find inadequacies in ourselves. But we should not dwell on these. Sure, we all have faults, but there are so many wonderful things in each of us that we can be grateful for and focus on instead.

I ask my patients, when last did you have a vacation, or a break? Do you have any me time, especially those wives and mothers. I’ve come across miserable housewives caring for husbands, children, parents and/or in-laws with no time for themselves and feeling unappreciated by those they care for.

For me, I know, I need a time everyday to feel like I am me. Not a doctor, daughter, sister, friend, just me. Just to exist for a few moments. Nothing to rush and do next.

So, please people. These tips I am giving here are worth thousands. Take care of yourself. Do what is necessary. Avoid unnecessary doctor visits. He cannot do for you what you ought to do for yourself. Eat right, sleep well, a little exercise wouldn’t kill, in fact it prolongs lives. And deal with the stressors.

And if you do break these rules know that you will suffer and who will put humpty dumpty back together again? …  Take care. Dr. Louella.

Hypertension 10 – Summary

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Hi folks! It’s Dr. Louella and we’ve reached the grand finale of our discussions on hypertension. Yeeaaah!!!!

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This one you should definitely keep for your records because I’ll be reiterating and reminding you of all the important points, having already explained the mechanics of this disorder in detail.

Firstly blood pressure is derived from the pumping action of the heart as it forces blood into large blood vessels. This causes the blood to circulate around our bodies. The force with which  the blood flows is called the blood pressure.

Just as we are unable to feel the blood circulating around our bodies, we are unable to feel our blood pressure. It is a common myth in Trinidad and Tobago that high blood pressure causes neck pain.

95% of high blood pressure cases are caused by the kidneys by an unknown mechanism. The other 5% have an identifiable cause, usually in younger individuals.

Certain emotional states, such as anger, pain and anxiety, as well as increased physical activity, can cause a temporary rise in blood pressure. This is not hypertension, which is a chronic condition. For this reason, not just one, but a few blood pressure readings need to be taken before a person is diagnosed as hypertensive.

Factors which predispose to the disease include a family history of hypertension, increasing age and certain ethnicities such as Afro-American or Afro-Caribbean.

Dietary associations of hypertension include a high sodium intake (salt, not fresh seasonings), low potassium intake, heavy consumption of alcohol and obesity. Increased oats and fruits in the diet help to reduce blood pressure. Physical inactivity is also associated with a higher blood pressure.

General guidelines for hypertension are that a reading of 120/80 or less is normal and ideal; a target of less than 140/90 is used for those on treatment; less than 150/90 is now used for those over 60 and 130/80 or less for those with certain diseases such as diabetes and heart disease.

Complications of hypertension are the dreaded stroke, heart failure, heart attack, kidney failure, aortic aneurysm and eye disease. Hypertension damages the inner lining of blood vessels allowing cholesterol to enter the wall and form a plaque that partially blocks blood flow.

If it a blood clot forms at the site it seals up the blockage long enough for no blood to flow and permanently damage brain or heart cells. The person then gets a stroke or heart attack.

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The DASH diet has been shown to help lower blood pressure. It includes less salt, alcohol, red meat, fat and sweets including sweetened drinks.

But it also includes more fruits, vegetables and high fibre foods (whole grain products such as whole wheat/meal bread, bran, oats, as well as more peas, beans and nuts).

Weight loss for the overweight and obese is important in controlling hypertension. This can be achieved by a combination of dietary control and exercise. To lose weight you need to eat less and have a lower calorie intake but frequent little meals, and not starvation, is the key.

Exercise is beneficial in lowering blood pressure on its own, even in those of normal weight. Aerobic exercise can take many forms including running, skipping and dancing.

Some people can have their hypertension controlled through diet and exercise alone but most will still need the assistance of medication. Medication is varied but it must be stressed that it needs to be taken everyday, as prescribed by the doctor, unless the person is experiencing ill effects, which he must inform his doctor about.

So there! We’re done. That’s the end of hypertension. I’ve taught you almost everything I know. Feel free if you have questions or comments. See you next week. Dr. Louella is out!!!

Hypertension 8 – Prevention/Treatment 2

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Hi. This is Dr Louella saying sorry for the late post. It was a hectic weekend! But we need to continue our discussion on prevention and treatment of hypertension. Previously we talked about how your diet can help lower blood pressure so now we go on to weight loss and exercise.

Yes, I know you’ve heard a lot on these topics before, but not like this…

Now weight loss and exercise are not the same thing.There are so many health benefits to exercise that everybody needs to exercise (including  the skinny, the fat and the in-between; toddlers and grandmas) but not everyone needs to lose weight. I have frequently heard the retort, “What you have to lose?” when people hear that I exercise.

But I love to provoke my elderly patients by asking them if they’re exercising because they should be. It would help unstiffen those joints, reduce their pains, strengthen their bodies and lift their depression among other things.

Now if there is one thing you need to know about exercise is that it makes you live longer. Exercise increases your longevity! Did you know that? It’s been proven!.

It has been also been found to lower blood pressure about 1 to 3 months after engaging in it, as long as the person continues to exercise. It strengthens heart muscle reducing the force needed to pump the blood around the body.

Exercise is recommended for everyone for the prevention and/or control of hypertension. 30 min of moderate exercise, 5 days a week is the basic requirement for health or, if its vigorous exercise, 15 min for 5 days will do.

Now don’t get scared. It isn’t as hard as you think. Get yourself a pair of sneakers and pants, as well as a safe environment, and you’re almost there. I tell my patients these things because I am saddened to find out that many of them don’t exercise even though they know better.

I was a gym freak once, but not anymore. I’m well aware that not everyone can toil away for hours at the gym… timing, cost, distance, shyness, whatever, prohibits that. But that does not rule you out.

Remember, anything aerobic will do – brisk walking, jumping, jogging, dancing, aerobics, active sports, swimming, cycling, skipping, climbing etc. You can use a video, gym instructor, exercise equipment, a friend or do it by yourself. You can be in the house, around the house, on the street, in the park, in the gym.

Weight training is not as good for blood pressure as it may increase it. But your housework (scrubbing, mowing the lawn etc) may count, once it increases your heart rate and breathing. It has been found that physically strenuous jobs are associated with lower life expectancy because of the stress associated with them.

If you’re new to exercise 5 min may be enough and you gradually work your way up. Don’t try to overdo it. The body has to get accustomed. If you injure yourself you’ll never want to go back. Warm up first before you stretch. Never stretch a cold body but always stretch those muscles after use. Please drink sufficient water. Hydration is important.

Now, I’m going to burst some people’s bubble here. I’m going to make it clear that exercise alone  is not enough. You cannot lead a sedentary lifestyle, sit for most of the day, and think that 30 min of exercise is going to be sufficient to counteract that.

There is something called non-exercise physical activity that we must also engage in. This simply means being active throughout the day, doing the little stuff. Excessive sitting is unhealthy. If you reduce it to less than 3 hours a day it can help extend your lifespan by 2 years.

A generally active daily life is associated with cardiovascular health and longevity in older adults. So get the old people moving and get yourself active: stairs instead of elevator, walk instead of drive, manual tools instead of automatic, do it yourself instead of outsourcing, walk the dog, do the dishes, wash on hand and so on… They all add up.

Our populations are getting fatter so hypertension is rising. Remember obesity is linked to hypertension. So many of us need to lose the weight, for this and other reasons (helps lower cholesterol, blood sugar etc).

No one said it would be easy but it will be worth it. You know the drill. Weight loss entails diet and exercise. Even when you take weight loss pills you need some kind of diet.

You don’t need to get down to your ideal weight, a BMI of 18.5 to 24.9. That would be lovely, but for some it is extremely difficult. It is said that losing as little as 5% of your weight may make a difference to your blood pressure, 10% is better and more even better, if you are obese.

What I discussed previously with regards hypertension was a healthy diet but not a weight loss diet. I will mention the main features of this.

You should know by now that you must eat less (or take in less calories) in order to lose weight. Watch the content of the food: less sugar, flour and fatty/oily items. Decrease your portion size, but I stress, gradually. You don’t want to feel hungry. Use more protein, especially beans and peas, and your veggies. Increase your number of meals to 4-6 a day. You use calories more efficiently this way.

Make your dietary changes healthy and palatable and never entertain long periods without meals. In this way the diet will be easier for you to incorporate into your lifestyle and not be just a passing fad. You would not continue to lose weight indefinitely but eventually settle.

While the majority of weight loss would be achieved through the diet, exercise is also very important as it increases your calorie output, increases the efficiency with which you lose the weight, tones the body, etc. I normally explain to my patients that 30 min of exercise, 5 days a week is the basic requirement for health so if you’re looking to lose weight you may need to go beyond that.

So I have told you about exercise and the weight reducing diet, why they are needed and how to achieve them to prevent/control hypertension.  But it’s been another long day. I’m tired. But I really enjoy doing these blogs so come back for more when we talk a bit about drug treatment of hypertension. Later! Dr. Louella is out.