Diabetes and the 12-perogy predicament (and why it takes a whole team to change it)
“I’m an addict.” Quite a stark revelation from Don Kupina as he sits in a fast food outlet, sipping coffee and telling his health care story. He is forthright. Inquisitive. Sharp as a tack.
Don’s gaze captures the attention of everyone around the table as he speaks eloquently about the journey he has been on. Now that his listeners are fixed on the eyes of this engaging 67-year-old, Don reveals the twinkle in his eye and then, a smile. “Yes, I am an addict,” he grins. “But not to drugs or alcohol or gambling.”
“It’s food. I love it. Can’t quit. It’s part of my culture.” He blames his Polish-Ukrainian heritage. “Boy, do we eat good.”
Food. Family. Celebrations. Traditions. Comfort. Don is acutely aware that food has had a huge impact on his life.
And his waistline.
He speaks fondly of perogy, or pyrohy in Polish, which is pronounced as “pedaheh” by Canadian Ukrainians who have long perfected the fast rolled-r sound. “You could eat six pyrohy, but why not eat 12?” he recalls of his many years of feasting. “You work hard on the farm and you work it off, so it doesn’t really matter how many you eat.” Until, he says, you “get a nice job with the government and you’re sitting at a desk and then you start getting old and your metabolism slows down and then you can’t eat 12 pyrohy anymore.”
But you do eat 12, because it is part of your culture. And besides, everyone else is eating 12.
Don recalls his years working on the farm before launching a career as a provincial researcher and air quality analyst. Too much desk work and too little hard labour led to weight gain and a diagnosis of “prediabetes” more than a decade ago. With his strong family history of diabetes, Don realized he’d better keep an eye on his health. “Back then, doctors told you to ‘watch your weight’ and that was about it.
So instead of eight slices of bread at a meal, I cut back to four.” It wasn’t quite enough, though, and soon Don was diagnosed with type II diabetes.
After struggling with diabetes for years, in 2007 Don’s family physician, Dr. Narpinder Hans, referred him to the multidisciplinary care team within the Edmonton Southside Primary Care Network. The care team includes nurses, educators and dietitians who work closely with patients on every aspect of their diabetes management program. From regular blood sugar monitoring and medication management to nutrition advice and patient support groups, the goal is to give patients the support and education they need to manage their chronic disease – and take primary responsibility for their own health.
The first step was monitoring Don’s blood sugar levels more closely, so he was put on a strict regimen of lab tests, medication reviews and more lab tests. Every 90 days, without fail, he was checked again. And every time he presented for a medical check-up, Dr. Hans had that week’s blood work and medication summary on-hand so she could see, at a glance, the trending. “It was all so well organized and laid out,” reports Don, “that it always took the doctor a lot less time to do her work.”
Next came teaching and self-management support. PCN nurse Cheryl Barabash explains that physicians often have too heavy a patient schedule to invest sufficient time in patient education. Nurses, on the other hand, are usually available to spend the extra time with patients in areas such as diabetes education and medication monitoring. In Don’s case, this means he not only gets the hands-on support he needs, it also ensures Dr. Hans’ time is focused on the more complex aspects of his care.
“The nurses really do excellent work in areas such as patient education, monitoring care against guidelines, and medication management.” says Dr. Hans. “It is amazing how responsible patients become when there is an entire team involved -- the care team is able to pay so much more attention to their care.”
Dr. Hans says hospital care has always been team-based, and the concept is slowly making its way into primary care. Craig Beaton, a PCN nurse who worked for years in urgent care settings, says family practice and urgent care nursing are worlds apart. “The differences are astronomical. In urgent care, the focus is on vital signs and physical needs, whereas in primary care, the focus is more on the patient’s emotional and spiritual needs.” Craig is thoughtful as he explains, “In primary care we actually get to experience the patient’s journey and help them bring about change from within, whereas in acute care we’re really not concerned with whether the patient is ready to make changes.”
With his medication regimen well established and his blood sugar regularly monitored, the next step in Don’s journey was giving his perogy addiction a run for its money. At the diet and nutrition classes – free to patients within the PCN who are referred by a physician -- the first thing Don learned was portion sizes. “That’s a portion size,” he demonstrates as he holds up a clenched fist, and then, happily, “I have big farmer hands so I get to eat more than most people.”
Another thing Don and his wife, Bonnie, learned was portion control (“We didn’t realize that a serving of meat is the size of a deck of cards!”) as well as the importance of meal and snack timing (“Eat smaller portions, more frequently.”). And that you can’t eat a whole loaf of white bread in one sitting.
“This GI (glycemic index) was a big thing – a gigantic learning curve for us,” says Bonnie. “And the information you learn from others in the classes – what works for others, and what they’re struggling with. You get great tips all the time.” Finally, Don added exercise to his regimen. “I would walk around West Edmonton Mall while Bonnie shopped,” he explains. “Man, can she shop. My feet were killing me!”
Aside from the newfound knowledge about diet and lifestyle, both Don and Bonnie are in awe of the personalized care they have received from so many within the PCN. Bonnie gushes about the calibre of people. “All I can say is ‘Wow’.” Don concurs. “They invest so much of their time . . . their personal stories . . . they connect in ways we never imagined. They take such a personal interest in my problem, and I find that very gratifying.”
In spite of the tremendous gains Don has made over the past 18 months, he was recently told he needed to start taking insulin. He was stunned, but he knew the day would come eventually. “Every morning I watched the trend of my A1Cs,” says the admitted information junkie, who maintains a personal file of his medical records, “and every morning they were high.”
It was a sad day for him. “Here I am, a fat old man and I am going to die of diabetes. And now they want me to go onto a needle. I was very, very apprehensive about going on a needle. I’m taking more drugs than a drug addict.”
Nurse Debbie Hartlieb had a critical role to play in alleviating Don’s fears. “I provided him with information on the pathophysiology of diabetes,” explains Debbie, “and the fact that the insulin he’s injecting isn’t a foreign substance. It’s a natural product within the body.” Don was okay with this, and upon reflection, now realizes his initial fears were unfounded. “There’s nothing to it. I was hearing from the nurses every second day – they were very intent on making sure nothing goes haywire. And sure enough, everything is going in the direction it’s supposed to.”
And so Don will continue with the lifestyle changes he committed to, and he will stay on insulin for as long as he needs to. He doesn’t see the insulin as a failure, but rather as an inevitability that he likely delayed for several years as a result of his dietary and lifestyle changes. While Dr. Hans won’t speculate on the course Don’s diabetes might have taken if he hadn’t started making lifestyle changes, she points out that Don’s situation mirrors the natural course of diabetes. “It does get worse over time and at some point, insulin needs to be added,” she explains, “but we do know from studies that tighter control at the beginning (of treatment) leads to a reduction in mortality and morbidity. And that is what we’re
trying to achieve.”
Don is pretty sure he never would have changed his eating habits without the support of the care team. "Developing a new discipline around eating is one of the more difficult things I’ve ever had to do in my life,” he admits. “But I did it, and it’s mostly due to my respect for the nurse clinicians, and how much they’re cheering me on, and the fact that I didn’t want to disappoint them. They are so enthusiastic about making this work, and their attitude is insurmountable. I really didn’t want to mess this up.”
Don ends his story on a hopeful note that seems inconsistent with his initial critique about the health care system, its waiting lists and all of its other shortcomings: “I predict a very good future for society if we can continue with programs like the ones at the Edmonton Southside PCN.”