USNEWS：哪些医生能帮我治疗糖尿病？

IN JULY 2017, THE Centers for Disease Control and Prevention reported that 30.3 million adults, or 9.4 percent of the U.S. population, have diabetes. “Another 84.1 million have prediabetes, a condition that if not treated often leads to Type 2 diabetes within five years,” according to the agency.

These figures are alarming because diabetes is a progressive disease that takes a massive toll on patients, their families and the U.S. economy. A 2018 report from the American Diabetes Association found that “the total costs of diagnosed diabetes have risen to $327 billion in 2017 from $245 billion in 2012, when the cost was last examined.” In addition, the report noted that more than 300 million work days are lost to the economy because of diabetes and a quarter of all health care dollars spent in 2017 went toward care of diabetic patients.

Much of this cost is related to the progressive nature of the disease and the fact that often, it takes a whole team of doctors to appropriately manage the health of a diabetic patient with complications. “Diabetes progresses over time,” says Dr. Kathleen Wyne, associate professor in endocrinology at The Ohio State University Wexner Medical Center. “We put them on a medication, but eventually at some point it’s going to progress and we’re going to have to add a second medicine and a third or eventually insulin. That’s just what diabetes does.”

So what is diabetes? “Diabetes is a group of diseases all characterized by elevated blood glucose levels,” says Dr. Kathleen Dungan, an endocrinologist also at the Wexner. There are two primary types of diabetes – Type 1, also sometimes called juvenile diabetes because it tends to occur more often in younger people, is an autoimmune disorder in which “the body’s immune system attacks the pancreas, the organ that makes insulin that helps the body use glucose, the primary fuel source required by the body. In Type 1 diabetes, there’s absolutely no insulin or very little insulin. Those patients are dependent upon (injecting) insulin for their life,” Dungan says.

Type 2 diabetes is a chronic disease that’s related to obesity and typically starts as prediabetes, also known as insulin resistance. With Type 2 diabetes, the pancreas isn’t producing enough insulin or the patient’s organs aren’t able to use the insulin properly, requiring bigger doses of insulin to have an effect. “Type 2 diabetes can often be treated with pills or other medications and sometimes with diet alone,” Dungan says, and it typically occurs in older, overweight patients with a strong family history of diabetes.

Who Can Help Me With Diabetes?

While many cases of diabetes are diagnosed by the patient’s primary care provider, “the diagnosis could come from a lot of places,” Dungan says. Because diabetes affects virtually every system in the body, symptoms can show up in seemingly unrelated places, such as the eyes, which are harmed by high blood sugars. Therefore, an ophthalmologist or optometrist conducting a routine eye exam may spot evidence of diabetes before other symptoms have developed.

Once you’ve been diagnosed, your primary care provider will likely take the lead on managing your disease, but you may need to work with several other doctors as your diabetes advances, including:

Endocrinologist

While your diabetes journey likely will begin with a primary care provider, you may need to see an endocrinologist early on for a more precise diagnosis, or later as the disease progresses. “The vast majority of the time, the primary care provider handles the initial diagnosis and management,” Dungan says. “There may be situations where the patient has an unclear type of diabetes or presents with some severe findings like diabetic ketoacidosis (dangerously low levels of insulin that cause the body to produce ketones, acidic bodies that can be life-threatening) that requires hospitalization. In those cases, the endocrinologist might be involved from the beginning.”

Endocrinologists are specialist experts in hormones and glands. Subspecialists in this field may focus specifically on treating diabetes or even a particular type of diabetes, and their vast knowledge about the disease and how it changes over time can be critical to treating patients appropriately.

“Unfortunately, there are not enough endocrinologists to take care of all the patients with diabetes,” Dungan says, noting that “typically patients are referred to endocrinologists when they are failing initial therapies from their primary care providers. The endocrinologist typically takes care of more complex patients or patients who have advanced technologies like insulin pumps and patients who have more complications like hypoglycemia (low blood sugars) or require hospitalizations or other end-organ problems,” such as kidney or heart disease.

“Endocrinologists often get involved when there are one or more complications, particularly if the glucose levels, the blood sugar levels, aren’t well controlled,” Dungan says. Endocrinologists often work closely with a patient’s primary care provider to help coordinate all the health maintenance activities needed in these situations.

Podiatrist

These feet specialists can help diabetics manage foot health, which is a common problem. Patients with poorly controlled blood sugar levels are more likely to develop a condition called diabetic neuropathy that disrupts how the nerves in the feet and lower legs communicate with the brain. This means you could step on a piece of glass and never feel it. If infection sets it, it is less likely to heal properly because of the high blood sugars, and in extreme cases, some diabetics need to have toes, feet or lower limbs amputated because of diabetic neuropathy. Regular visits to a podiatrist can help identify problems, such as sores or ulcers, early before a more serious infection sets in and prevent you from having to take such drastic measures.

Dietitian or Nutritionist

Controlling your diet is a major component of effectively managing diabetes, and for that reason, you may need to work with a dietitian or nutritionist to make sure you’re getting the right balance of nutrients while tightly controlling your blood sugar levels.

Ophthalmologist

Eye care becomes critical for diabetic patients because over time, elevated blood sugar levels can damage the retina and other delicate structures in the eye. Dr. Stephanie Marioneaux, an ophthalmologist in private practice in Chesapeake, Virginia, and clinical spokesperson for the American Academy of Ophthalmology, says seeing an ophthalmologist is an important component of maintaining your vision. When you’re first diagnosed with diabetes, you may be sent to an ophthalmologist for a baseline evaluation to look for holes or tears in the retina – a thin film of light-sensitive cells at the back of the eyeball – that could be a sign of diabetic retinopathy or other complications of diabetes, Marioneaux says. Detached retinas are another common complication of diabetes that an ophthalmologist can perform surgery to correct.

In addition, “ophthalmologists are among the earliest people to diagnose diabetes in patients,” Marioneaux says. Because they are trained to look for tell-tale signs of a problem, an annual visit to the eye doctor could result in a suspicion of diabetes that will be further investigated by your primary care provider or an endocrinologist.

Nephrologist

Nephrologists care for the kidneys, two bean-shaped organs in the mid-back that remove toxins from the blood. Diabetes is a major risk factor for developing kidney disease. Dr. Maria Bermudez, a nephrologist at Geisingerin Danville, Pennsylvania recommends that “kidney function be checked regularly,” as part of routine lab work conducted in diabetics because the kidneys are sensitive to fluctuations in blood sugar levels and likely to suffer negative consequences from diabetes as the disease progresses. If evidence of kidney disease is found, you may be referred to a nephrologist for further testing and treatment.

Cardiologist

Because they share so many risk factors, heart disease and diabetes often go hand-in-hand, and as a result, many diabetics end up seeing a cardiologist, or heart specialist, at some point during the course of their treatment. A cardiologist can help counsel you on how to keep your heart as healthy as possible despite a diabetes diagnosis.

Neurologist

Dungan says people with diabetes are much more likely to suffer strokes, and if such occurs, you’ll likely need to work with a neurologist to address the issue and prevent future strokes. Neurologists are experts in nerves, and some may focus on the brain while others may center their practices on other aspects of the nervous system. They can also help diabetics manage nerve damage in the extremities, also called peripheral neuropathy. According to the National Institute of Diabetes and Digestive and Kidney Diseases “research suggests that up to one-half of people with diabetes have peripheral neuropathy.” The NIDDK also notes that about 30 percent of diabetics have autonomic neuropathy, a type of nerve damage that affects the internal organs. A neurologist can help you manage these issues.

Physiatrist or Physical Medicine and Rehabilitation Physician

Physiatrists, also called physical medicine and rehabilitation physicians, can help diabetics who need rehabilitative care get back to better health. This may become particularly important if the diabetic has had a stroke and needs to regain the capacity to walk or speak. It may also be an important aspect of post-surgical recovery, such as after an amputation necessitated by diabetic neuropathy. You may also work with a physical or occupational therapist to regain full function after a trauma such as surgery or a stroke.

Mental Health Professionals, Pharmacists and Other Clinicians

In addition to the above-named doctors, you may come into contact with many other health care providers over the course of your care. Pharmacists fill the prescriptions you need and alert the team to potentially dangerous drug interactions. A social worker, psychologist or psychiatrist can help you manage the emotional side of dealing with a chronic illness. You may also come in contact with a host of physician assistants and nurse practitionersalong the way who all contribute their expertise towards keeping you healthy.

Managing Care

That’s a lot of specialists and subspecialists you may end up dealing with at some point during your diabetes journey, and they’ll all need to communicate with each other about your progress. Electronic health records can help keep everyone apprised of a patient’s progress, but even so, in most cases, your primary care provider or family doctor will be tasked with coordinating your care and communicating with the team to make sure you’re on target to meet your treatment goals.

Dungan says that though an endocrinologist is often involved in helping manage a diabetic’s care, “the primary care provider remains an integral part of the team, ensuring that all of the health maintenance and screening tests are completed.” This provider acts “as a central coordination hub” that helps all the other specialists provide high-quality, comprehensive intervention.

Preventing Complications

As with anything, preventing a problem before it starts leads to better outcomes. Dungan says tight control of blood sugars can prevent complications and keep you healthier longer, despite the progressive nature of the disease. “There are a number of screening and preventive measures to help prevent these complications, so that’s going to be job number one – to try to identify them early and/or prevent them from occurring in the first place.” Your primary care provider will likely take the lead on these preventive and screening activities, but other specialists may be involved too, such as in the case of an annual eye exam by an ophthalmologist, regular foot checks by a podiatrist and regular blood work, urinalysis and other lab tests to look for kidney disease and other problems that can occur with the internal organs. Talk with your primary care provider to make sure that all of the ongoing health maintenance tests you need are being completed on schedule.

In addition to working with your PCP, you should also advocate for yourself with each doctor you see. Speak up if you don’t understand something a doctor is telling you or if it conflicts with what another provider has told you. Take notes during your appointment or bring a loved one to jot down important information.

Dungan recommends bringing all of your medications with you to every appointment you go to be sure that each doctor knows the full scope of your condition and treatment program. Keeping a regular log of your blood sugars is also critical, and there are now several online options for tracking your various metrics, such as blood sugars and hemoglobin A1C (a longer-range average of blood sugars). You may also want to work with a certified diabetes educator to help you manage the day-to-day process of following your treatment plan.

All of this tracking and logging might seem a little overwhelming at first, “but it’s critical to provide the best, most efficient care and you can help facilitate that communication by making sure that all the offices have your records,” Dungan says. “You should bring (all your records) to every visit no matter who the provider is because the more touch points you have to make sure that you’re being managed effectively, the better.”

Lastly, Dungan recommends writing down a list of questions and talking points you want to address prior to each appointment. “That’s your time, so you should take advantage of it.” Focus on discussing your treatment goals, whether they’re being met and what to do if they’re not.

Diabetes isn’t curable, but it is manageable with the help of a team of providers and some diligence.