Issue 174 Item 8 Patient Education Succeeds Even in Diabetes Capital of the U.S.

Everyone in health care needs to get fired up about educating people on diabetes care.”

“In Sunflower County, Miss., where I practice, we have the dubious honor of having the highest incidence of diabetes in the country,” said the Cleveland, Miss., family physician. “One in five people has diabetes. I see about 120 patients a week, and 25% are diabetic.” He added that 10.3% of the total population of the state of Mississippi is diabetic.

The rural South is a difficult setting in which to try and manage diabetes. For one, there are very few physicians per capita, meaning that each doctor must do a tremendous amount of work in short periods of time. Sixty percent of the population in Dr. Nelson’s area is on public assistance; 50% live below the poverty line.

“There’s a real lack of insight into the complications of diabetes and the driving factors. Unfortunately many people only start to worry about their health when they end up in the emergency room with a rotten leg, a heart attack, or a coma.”

Trying to manage type 2 diabetes in this context is clearly a Herculean challenge, but one that Dr. Nelson has taken on with unbridled enthusiasm. Speaking at a press briefing on diabetes sponsored by the New York Academy of Sciences, he shared his experiences and his success stories.

Patient education, early insulin therapy, and innovative use of inexpensive, low-tech, sometimes surprising adjuncts are key, Dr. Nelson said.

“Patients have got to take an active role, and it requires a team approach. You have to have other health care providers teaching patients about their disease and how to manage it,” he said.

Anyone in the health care field could play a role in patient education and support, he added. “Everyone in health care needs to get fired up about educating people on diabetes care.”

Boston’s Joslin Diabetes Center is fired up, and will be collaborating with the University of Mississippi’s Diabetes Education and Research Center, the Bolivar Medical Center, and other Mississippi clinics to develop patient education programs aimed at improving self-care among rural populations with limited access to care.

In Dr. Nelson’s experience, hemoglobin A1c monitoring is the most patient-friendly diabetes management tool in years. “It is not the be-all, end-all, but it is a better, more effective way to teach patients about their diabetes than fasting blood glucose levels.”

Most patients, even those with limited education, can relate the number 7 as a target for therapy. “I tell them to write down a big number 7, put it on their refrigerator door, and look at it every day. They should try as best they can to keep their A1c at ‘lucky’ 7 or below. It gives patients a much better picture of their glucose control.”

Dr. Nelson has urged his colleagues to consider their own resistance to starting insulin therapy early. “It is something a lot of doctors suffer from. But the new forms of insulin are easy to use, painless, and really not bad at all.”

In working with his patients, he has also discovered an unlikely but useful tool: the Polaroid camera. For patients who live far from medical clinics, the camera can be an important link to the health care system.

Dr. Nelson routinely gives diabetic patients with foot and leg ulcers an inexpensive Polaroid camera that they can use to take weekly or monthly photographs of their legs. They send these to their practitioners for evaluation. The pictures allow the physicians to monitor who is at risk for amputation. Since the ulcers often improve if the patients are managing their diabetes well, they provide an inexpensive way of monitoring patient self-care without requiring patients to drive long distances for office visits.

“We’ve had a 90% reduction in amputations, and lots of healing ulcers since we started doing this,” he said.

He cited a number of success stories, including the case of a man in his 50s with a history of diabetic coma, whose HbA1c went from close to 9% down to 6.3% after only 6 months of therapy with slow-acting insulin.

“If we can do this in the Mississippi Delta, you can do it anywhere else. It is possible to get the A1c down and get these patients under control,” Dr. Nelson said.

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