Mrs. Jones presented to my office approximately six months ago having been told that she had type 2 diabetes two years ago. Her HbA1c was 8.2. This is a measurement of how well glucose has been controlled for the previous three months. Normal is under 5.7 and anything over 7 is typically considered too high. Her number correlated with an average blood glucose of 186 and we know it needs to be under 120 to avoid serious diabetic complications. Since her previous primary care doctor had not been able to adequately help her, I sent her to an endocrinologist. She returned to my office six months later and was proud to point out her HbA1C which was down to 6.2. She said to me, “I read my records from my previous doctor. She told me to diet and exercise. That’s all she ever said. She never told me why it applied to my diabetes. Now I understand how increased weight and lack of exercise affects insulin. Why didn’t she tell me those things?” I thought about it. Why didn’t I tell her? I assumed that the physiology and treatment of her condition had been well explained to her and that she was just ignoring her doctor’s advice. Diet and exercise alone as words are not powerful enough for people to understand their importance. Education is more than advice. It includes understanding the significance of the recommendations.
How many times am I guilty of the same poor communication technique? Doctor comes from the latin docere, to teach. It is part of my job and I hope my patients feel comfortable enough to say, “Hey, I don’t understand that” when I am unclear. Only by working together can we hope to improve the “outcomes of chronic disease”. And more importantly, my patients will feel better and live longer.
In follow up to an ER visit for a new onset migraine headache, my patient casually asks if caffeine could be playing a part in his headache and blood pressure issue. As we reflected on that possibility he admitted to drinking at least 64 ounces of diet, caffeine-containing sodas daily. WHAT?!?!? Not only can caffeine raise both blood pressure and pulse but if one already has hypertension, caffeine may elevate it even more than in a normal person. When he presented to the ER with an excruciating headache and extremely high blood pressure he underwent a head CT scan that was normal and it was theorized that the blood pressure was due to the headache, perhaps a migraine. The problem I had with the diagnosis is that people do not typically present with their first migraine headache in their mid-40s. The ER started him back on blood pressure medication (he had been able to stop it about a year ago with diet and exercise) and sent him back to me for followup. So in my office we began to explore the biggest question: was the pressure causing the headache or the pain from the headache causing the blood pressure? In the time between the ER and our office visit he realized that he got a headache if he went a few hours without caffeine. We developed a plan for slowly stopping all caffeine products before ordering any more expensive tests. Since his pressure was still elevated, his blood pressure medication was increased.
Over the course of a month he brought his exercise level back to 2012 levels (before he let work take over his schedule) . He reduced and came off the caffeine with the exception of one cup of green tea in the morning. He took the bigger medication dose just one day but it made him dizzy. Soon he found the 1/2 dose too much. By the time I saw him one month later his weight was down, his blood pressure was normal and he was completely off medication.
Moral of the story? First of all, caffeine can be beneficial as can working hard. However–all things in moderation. Secondly, what you put in your mouth (or don’t) and how much you exercise you do can sometimes work as well as a pill. And there are no side effects!
1. Hypertension Risk Status and Effect of Caffeine on Blood Pressure. Hartley, Terry R., et al. Hypertension.2000; 36: 137-141. http://hyper.ahajournals.org/content/36/1/137.full