Diabetes
Type 2 diabetes is a disease that GPs are seeing more and more of, and recent research suggests that treatment will use £16.9 billion of the NHS budget, as the number of diabetics rises from 3.8 million to 6.25 million by 2035. This has fuelled scaremongering in the media, with talk of diabetes bankrupting the NHS within a generation.
Unlike other diseases, discussion about type 2 diabetes often results in debate about who is to blame. The head of diabetes UK states that the NHS needs to improve its care of diabetics. Other commentators recommend that the government should be blamed for not taxing sugar-rich food, while others suggest that supermarkets are responsible because of the cheap, unhealthy foods they push. The other obvious villains in the piece are the diabetics themselves, who are usually portrayed as unrepentant fatties who cant stop shovelling down the doughnuts. Im not convinced that looking to blame any one group, especially those who have the condition, serves any purpose other than demonising the disease and alienating the sufferers.
Firstly, its important to state that type 2 diabetes isnt solely caused by obesity. Age and genetics play a significant role, too. Nevertheless, it is true that appropriate improvements in diet and lifestyle would cause incidence of the disease to plummet and would also significantly reduce complication rates for those who already have the condition.
Part of my job is to encourage an improvement in the lifestyle of my patients, but the more bullish I am about the advice I give, the more defensive and unresponsive my patients usually become. Early on in my career I remember having a hugely overweight patient who insisted that she only ate lettuce. When I suggested this couldnt be true, the ensuing debate escalated to a full-blown row. We got nowhere and on top of this, she disengaged from any of the support services available and completely failed to gain control of either her weight or her diabetes.
The longer Im a doctor, the more I realise that patriarchal-style education rarely works with regard to encouraging lifestyle changes. As with any addiction, the addict needs to admit the problem to themselves before he or she can accept any help and change behaviour. Deep down, most of us have issues with food at some level and I am no exception.
I spend a lot of my time explaining the perils of excess sugar to my patients and so this particular week I had decided to practise what I preach. I completely banned myself from eating any sugar during my working day. How hard could it be? It was going well on Monday until one of my morning patients brought me a Twix bar. It sat on my desk goading me for half an hour, but then temptation got the better of me. The shiny gold wrapper poked out of the bin mocking my poor willpower for the rest of the morning. The afternoon was going well until our nurse brought in some home-baked chocolate brownies to celebrate her birthday. It seemed rude not try one and they looked so much more appetising than the pot of sunflower seeds I had optimistically brought in to stave off the predictable mid-afternoon sugar craving
Changing diet and lifestyle habits that we have held for all of our lives is hard. Our brains are trained to respond positively to the reward of a sugary treat; well, mine is anyway.
Fortunately for my diabetic patients, we have a fantastic new community diabetes team. The nurses who run it are enthusiastic and welcoming and offer clear non-judgmental advice and support on everything related to diabetes. They dont preach or lecture but just allow patients to come and ask questions, meet each other, dispel myths and hopefully feel motivated to make the changes they need to control their disease.
Right now Im slim, young and active, but Im certainly not immune to getting diabetes one day. For those of you feeling holier than thou, who can live on a diet of porridge oats and celery, I salute you, but for the rest of us mere mortals lets look at some more practical ways of helping fight diabetes rather than solely looking to vilify the victims of the disease. I mentioned how brilliant our community diabetes team is, but I really wish we had a similar service to help overweight patients before they develop the disease. Practical, simple, non-judgmental support would be a real investment and potentially pay for itself many times over if it successfully reduced diabetes.
We do need to work hard together to effectively prevent and treat type 2 diabetes, but ultimately, if the NHS collapses it will do so because of underfunding and government privatisation. Lets not blame type 2 diabetics who already have enough on their plate (pun intended).
Tarig I
Tarig poked his tongue out at me and it was covered in a white fur.
Its sore every time I eat, he told me.
Its a fungal infection on your tongue.
Is it because of my disease?
Yes, the HIV is affecting your immune system.
He shrugged and went to stand up and leave.
Still not going to consider taking any medications for it?
No, Doctor. You know that my fate is Gods will, not yours or mine.
It was now my turn to shrug. I nearly let him leave, but as a doctor it is so hard to watch a dying man walk away, knowing that he could be treated and effectively cured.
Its not too late to change your mind, Tarig. On medication you could live a long and normal life.
Tarig was a Coptic Christian from Egypt. He was a strictly religious man, but he slept with a prostitute while on a business trip to the Sudan and contracted HIV. Rather than accept treatment, he decided that the HIV was a punishment from God that he must suffer, even if this meant a painful, premature death.
As a teenager I used to get drawn into long religious debates with Jehovahs Witnesses who came knocking at the door. I was convinced that I would enlighten them as to what I believed to be the flaws in their religious convictions. They of course felt they could do the same for me. You wont be surprised to hear that after many wasted hours of debate on my doorstep, I had failed to convert a single Jehovahs Witness to atheism. As Ive got older, my atheist ideas have remained, but now I wouldnt dream of challenging anyone else about their religious views, especially my patients. My job is to treat them within their cultural beliefs rather than inflict my own upon them, but this can be difficult when their viewpoint is affecting their physical health. I just couldnt bring myself to let go of Tarig.
Tarig, when youre about to cross a busy road, do you look left and right first?
Yes, of course.
But surely if a car hits you that would be Gods will too?
Yes, God will decide my fate, but he wants me to take some responsibility too. He wanted me to resist temptation when he sent the whore to cross my path, but I failed him and I must accept the consequences of my sin. I must suffer for my redemption.
Yes, God will decide my fate, but he wants me to take some responsibility too. He wanted me to resist temptation when he sent the whore to cross my path, but I failed him and I must accept the consequences of my sin. I must suffer for my redemption.
I felt a bit like the teenage me arguing in vain with the Jehovahs Witnesses. As a GP Ive witnessed some of the enormous good religion can achieve. Some of my patients have given up drugs and crime in order to embrace the love of the Lord. Some of our local religious communities offer amazing support for members of their flock who are taken ill both physically and mentally. Faith can also help people overcome enormous personal suffering and help them move on and find meaning in their lives. I wasnt trying to convert Tarig to atheism; I simply wanted him to agree to take life-saving medications that were freely available at our local HIV clinic.
The last time I witnessed someone die of AIDS was 2002. He was a young man, barely out of his teens, and he was lying helplessly in filthy sheets in a Mozambique hospital. I can still picture the painful-looking sores eating into his lips and the skin cancers that had spread all over his body. Pneumonia was taking over his lungs, meaning he was gasping for breath. His broad shoulders showed how muscular he had once been, but now he was hunched over with his muscles all but completely wasted away. We gave him antibiotics to try to fight the infection but the HIV virus had completely destroyed his immune system. Each day on the ward round I saw him fade further away until he was almost a skeleton. Everyone was surprised how long he lasted. Finally, during my last week there, he gasped his last breath in front of my eyes.
Times have changed and now HIV is brilliantly managed by our local clinic. People living with HIV today can look forward to a normal life expectancy on treatment. Without treatment the condition is unpredictable and dangerous. I feel woefully out of my depth with Tarig, but while he continues to refuse to take treatment or be seen by the specialist, he is stuck with me, and I with him.
Look, Tarig, let me at least treat the thrush on your tongue. I can give you some drops that will clear it. And can you let me do some blood tests so that we know at what stage your disease is?
Tarig reluctantly agreed.
I documented again very carefully Tarigs decision to decline a referral to the HIV team and that he was of sound enough mind to make this choice. If he was genuinely going to die of this disease, I needed to make sure that I was able to protect myself medico-legally from any potential fallout.
Is the quality of NHS care really declining?
Late one evening 30 years ago, the senior partner at my surgery visited a six-year-old boy at home with a fever. He diagnosed a viral illness and advised paracetamol. By the next morning, the young lad was dead from meningitis. Mortified to hear of his mistake he visited the grieving family to apologise, but rather than being met with anger and legal proceedings, he was thanked by the tearful parents for his help and efforts the previous night and he continued to be the familys GP for years to come.