Sunday, April 10, 2005

Role Reversal

My mother is 76 years old, educated with a master's degree in early childhood education, a teacher for over thirty five years and an accomplished pianist. She has raised two children, a physician and a professional opera singer, and took care of her mother during her battle with Alzheimer's. So what makes this straight forward, smart woman turn into a skulking, deceptive, pilfering sneak at the sight of chocolate cake, pie or candy?

Let's back up here. She also has a lot of physical problems. She has had a stent put in for coronary artery disease and still has occasional angina. She suffers with arthritis and fibromyalgia. She has had a hip replaced and a shoulder redone because of degenerative changes and probably some secondary effects of a car accident and a fall. She has had type II diabetes for some years, we really don't know how long but once when she was on prednisone for her fibromyalgia her blood glucose was almost 500. She has hypertension and last year discovered that the combination of high blood pressure, diabetes, and non-steroidal anti-inflammatory medication had worked a number on her kidneys. Further deterioration in kidney function could lead to dialysis.

I moved in with them in June and watched for about three weeks. She only checked her blood glucose once a day, didn't eat the right things and was trying to lose weight with no luck. She barely did anything, was too weak to stand and walk across the room, rarely got out of bed before noon and did not go out of the house for weeks at a time, except to go to the doctor. Finally, after compiling all this observational data, I read more about the treatment for diabetes and the diet and decided it was time to take over from my dad. I am after all a medical doctor; true, a pathologist so all of the bodies I see are already dead and I haven't had to keep up with the treatment side of things, but in medical school I trained under Leonard Madison MD, the "silver fox" and all-knowing guru of diabetes so I can treat a diabetic ketoacidosis in my sleep.

First I made her start checking her glucose four times a day...."But the strips are expensive and the doctor only wrote the prescription for enough for once a day!" This was not true. Mom had enough strips put up to check four times a day, the doctor actually wanted her to check that often and Medicare will pay for them. As I told her, it is cheaper for Medicare to pay for diabetes testing strips than for the dialysis that will result due to the kidney damage in uncontrolled diabetes. Testing four times a day, what did we find? WIDE UNCONTROLLED SWINGS in blood sugar....fasting 85, 2 hrs post breakfast 250, 2 hours after supper 320. Some mornings (if you can call noon morning) fasting of 75, next morning fasting 125. All over the chart. Chart....I love charts...I love Excel.....therefore....spreadsheet with charts for daily blood sugars....YES!!!!

Plan of action:
1. Get up in morning before noon.....this is easier said than done, requires badgering at first.
2. Choose a food plan. I usually don't say anything about other doctors and thank goodness the endocrinologist she went to for "diabetes control" had discharged her before I got here so that I never had to meet him at one of her visits, because he did absolutely squat about her diabetes. He didn't make it clear how often she should check, he sent her to a dietitian who went over the standard substitution diabetic diet (I don't see how anyone can follow that, very confusing, not practical), took one hemaglobin A1c test and pronounced that she was in control. NOT!!!!! I read and decided the easiest to adhere to is the "glycemic index" tool. I started choosing low glycemic index foods for her, completely omitted high glycemic index foods and cooked them appropriately.
3. I will cook the food, choose the food, and put the portions on the plate. Dad tries very hard but he can't get the proportions down. He gave her too much. Bless his heart, he gives in. Smaller meals, more often with a sensible snack in between. Choices based on what the previous 2 hour postprandial sugar was.
4. No rice, potatoes, bread, cakes, candy, cookies, breaded meats, watermelon, bananas, corn, none, at all.
5. I will make the rounds of, kidney, heart... to see what is really going on.

OK...plan in hand. At first she complained not that she didn't have enough to eat but that she was too weak to hold her head up to eat and felt nauseous. She was anemic, the kind you get with kidney disease and diabetes and she was on so much blood pressure medicine that her pressure was often too low, thus the weakness, feeling faint, nauseous, etc.

I made the rounds, talked to all the doctors, asked about Procrit for her anemia and decreasing a few of the blood pressure meds. I cooked for her, fed her, reminded her to check her sugar, charted the results and showed her the graphs. We set goals for a week...."This week we will try and keep the glucose under 180", "This week we are trying for a limit of 160."

It was slow. But as she got up earlier, ate smaller meals, ate more often than twice a day, rode her recumbent bike for fifteen minutes (slowly) a few times a week, and checked her glucose closely the wide swings began to lessen. Amazingly, at least to her, she began to lose weight. As the weight came off we decreased the blood pressure medication and when we started to see morning fasting glucoses that were too low (she sees spots when it is too low) we started decreasing the diabetic medication too.

Positives of the last ten months:
1. Blood sugars rarely below 80 and rarely above 140.
2. Cut one diabetic medication from 12 mg per day down to 2 mg per day.
3. Cut one blood pressure medication from three times a day to once a day.
4. Split medications so that the blood pressure stays more even with fewer low blood pressure moments.
5. Started and titrated Procrit so that anemia is under control and energy level is higher.
6. BUN and Creatinine have decreased significantly indicating better kidney function...less on the edge of dialysis.
7. Gets up earlier
8. Rides recumbent bike several times a week.
9. Started knitting again.
10. Started her Bible study again.
11. Started going back to church again.
12. Just has more interest in life.
13. Has lost just under 60 pounds.

So why do I call her a sneak? Because in spite of all of my best efforts and in spite of the good results she has had by following what I told her....she still stoops to sneaking forbidden food. Then when I catch her, and I ALWAYS catch her, she out and out lies about it.

Take today. She made a chocolate cake for us. We didn't want it, didn't ask for it, she just made it. Then she cut two pieces and iced them for us. When we were cleaning up after lunch, she started icing the other part of the cake. I went into the dining room after putting the last of the dishes in and saw her with a thin strip of chocolate cake in her hand. She had her lips tightly closed, but I saw a very tiny bit of white icing on her lower lip. I asked her if she had eaten a piece of the cake and icing and she shook her head "NO", didn't open her mouth. "You were going to eat that piece in your had weren't you?", I asked. She forgot herself and opened her mouth to say "NO" and I saw the cake she was trying to swallow in her mouth. She had already eaten a piece and she was planning to eat the other piece in her hand. In fact, after I left the room pretty disgusted she DID EAT the cake. Then I heard myself saying a phrase I used to use on my daughter when she was little..."If your two hour blood sugar is high you are GOING TO BE IN BIG TIME TROUBLE!!!!!!!" Dad asked the obvious question, "What are you going to do to her?" I am at a loss. I can't spank her or send her to her room (she would just go to bed and like that) nor can I make her stand in a corner. I'm not sure my threat of "if you lose any more kidney function because you can't control your diabetes you will have to start dialysis" will even work at this point. "I don't know what I'll do but it will be BIG TIME", I replied.

OK Nyssa, go ahead and say it......Mom, you have become your mother.

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