When Charles Anderson felt the walls of the forklift closing in on him, he knew something was wrong. The job site in Jefferson City in front of him blurred, and as he stumbled out of the unloading machine, his line of sight narrowed until he saw nothing but darkness swallowing him from every side.
Anderson’s body hadn’t rebelled like this since 10 years ago, when his physician identified the cause of his constant fainting as Type 2 diabetes.
The paramedics arrived and measured his blood sugar at 534 mg/dl.
“They told me if it goes up to 600, you go into a coma,” Anderson said, chuckling, his hulky 230 pounds shaking beneath the blue sweats he wears when he relaxes in his Jefferson City apartment. “So I was pretty close to passing right out of here for good.”
Anderson wasn’t surprised when the paramedics checked him into the local hospital to pump him with insulin that evening five months ago. During his 10 years as a diabetic, he subsisted on take-out pizza and late-night fast-food runs, despite orders from his physician to lose weight and lower his blood sugar.
Now, even after his primary physician assigned him to an endocrinologist to push lifestyle changes to prevent more attacks and imminent complications like blindness or vascular disease, Anderson said he refuses to take his daily medication and insulin. He shrugs off physicians’ frustrated demands to diet and exercise.
Smiling with Santa Claus-red cheeks, Anderson, 54, shook his head, insisting that doctors don’t get why he prefers to keep his life comfortable.
“I just don’t like wasting my time fixing meals up, preparing ‘good nutritious meals’ and doing the walking thing,” he said, sitting up straight and pretending to fix a meal with dainty hand gestures. He fell back into his leather recliner, laughing.
“No, I hate that kind of life. I mean, put a bullet in your head, that’s no way to live.”
Anderson’s philosophy echoes in the voices of obstinate diabetics nationwide who insist on nursing their disease with biggie fries instead of medication, exercise and a nutritious diet.
Within 10 years of diagnosis, diabetics who fail to lower their LDL cholesterol, blood sugar and weight may lose their eyes, kidneys or lower limbs.
The number of Americans with diabetes, at 20.8 million, according to the American Diabetes Association, looms at an epidemic proportion, 95 percent of them affected with Type 2 diabetes, or adult-onset diabetes. Two principal causes of Type 2 diabetes are obesity and sedentary lifestyles, according to the American Diabetes Association.
Health concerns for nondiabetics, such as high cholesterol or smoking, turn into prominent risk factors for severe complications among diabetics.
Thus, ensuring a long life (or at least living to retirement age), often requires diabetics to pull a 180-degree reversal on their diets and physical activity. But in some cases, patients won’t.
Demands for managing diabetes include insulin shots before meals, exercising after meals and blood-sugar checks two or three times a day. Sedentary Type 2 diabetics find their lives shifting dramatically from inactivity to a daily juggle of constant self-regulation.
Like Anderson, some simply would rather not deal with the hassle. Type 1 and Type 2 diabetics typically don’t feel any worse physically when they continue to eat as they please without exercising to balance their blood sugar. Most who don’t change their lifestyles seal their fate by continuing a non-nutritious diet.
A doctor for diabetics
When things get bad, doctors send their patients to Alan Rauba.
After treating noncompliant diabetics for 11 years, the endocrinologist who specializes in diabetes at Jefferson City Medical Group knows where patients like Anderson are coming from. He also says he knows where they’re going — and quickly.
“I see a lot of patients in their 50s who’ve never exercised; they’ve always eaten what they want to eat,” he said. “They will not change their lifestyle; they will up the walls and battle me. I typically give these people a year.”
Diabetes end stages typically strike 10 to 15 years after diagnosis, and are the strongest signs a body can give that a diabetic needs to change his or her ways, or write a will. At that point, the diabetic is faced with clogged arteries, foot ulcers ripe for amputation and/or kidneys in need of dialysis or a transplant.
These and sometimes more extreme complications may seem to occur sooner among Type 2 diabetics, since most Type 2 diabetics don’t experience warning signs of diabetes that Type 1 diabetics do, like extreme thirst, and don’t get diagnosed for an average of five years.
Medication can stabilize some complications, but usually, only regulating lifestyle will prevent them from worsening once they develop.
“If you under-exercise and overeat, I can throw seven or eight drugs at you and nothing will get better,” Rauba said.
Anderson said living how he wants is worth any cost, even if that may one day include diabetes end stages or even death.
“I grew up tasting food and enjoying food,” he said. Eating what he likes gives him a reason to get up in the morning, Anderson said, and he wouldn’t know what to do if he changed his diet.
“I’m also an artist,” he said. “(Changing my diet) would be like cutting off my fingers and saying, ‘you can’t paint no more because you might die in 20 years.’”
Reasons for resistance
Anderson grew up on a farm in Jamestown, where he said no one in his family went to a doctor unless they “were dying or sawed something off.”
He’s just not a doctor person, he said.
So when Rauba told him to lower his blood pressure to 120 mg/dl by taking a handful of pills and an insulin shot twice a day, Anderson dismissed the instructions.
“I only take medications when I really need them,” he said, rolling his eyes and adding that the only person he ever knew who took pills every day was his grandmother. “If my blood sugar levels are over 200, I’ll take it. But if they’re around 130 or 140, I’m feeling great. As long I’m there, I don’t bother to take the shot.”
Someday he may follow Rauba’s suggestions to stop smoking, but more out of his frustration with the phlegm he coughs up during cold season than the fact that smoking enhances most diabetes complications. He relishes cigars on his way to work, on his way home, and even on the job site. A pack of 50 cigars lasts him two weeks.
As for the doctor’s pressure to lose weight, Anderson insists that his current routine leaves few options to change his diet. His evening job as a forklift operator starts at 2 p.m. and allows only two 20-minute breaks, just enough time to fight over a microwave with his co-workers, Anderson said. So fast food powers his life, starting with the cheeseburger he grabs for breakfast and ending with the pizza he orders to his apartment after work, when he crashes in front of the TV.
Anderson also says his social circles involve junk food: he compares the pressure to sample neighbors’ holiday treats to how his friends pushed him to drink when he was younger.
Most important, food relieves stress for Anderson. Nothing relieves his tired muscles, he said, like sinking his teeth into a steaming cheese pizza.
Rauba said most of his patients tell him similar stories.
“It’s very difficult to change a lifetime of bad habits,” Rauba said.
“When we put in people in a weight program and we take food away from them, we open up can of a worms,” Rauba said. “They don’t know how to react to situations or anxieties because their one stress reliever was food. Our task is teaching people not to reach for a bag of chips or go out for a fourth or fifth meal. Instead, we tell them, go out and walk. Find a hobby.”
Although some patients don’t like his candor, Rauba tells them what they’re doing wrong and why it’s important to care for diabetes on multiple levels.
“Ninety percent of what we deal with is something the patient can control,” he said. “It’s going to be about eating less fried food and exercising.”
Diabetics must also regulate their eating and exercise schedules to keep blood sugar at a normal level. The best time to go for a run, for instance, is right after a meal, to lower the sugars levels raised by the food.
Anderson considers the heavy lifting he does as a forklift operator plenty of exercise and can’t comprehend why Rauba doesn’t agree.
“All of a sudden I’ve got to be regimental about everything I do,” he complained of Rauba’s instructions. “I gotta get up at certain time, go eat a light breakfast and then take a run to eat it off? What’s the point of eating it if I’m going to run it off? To me, it’s just pointless.”
Every slight improvement, just as every lapse in responsibility, adds up, Rauba said, which he shows patients with statistics, often finding the best way to get through to them is by measuring out their imminent deaths.
Jogging a few days a week may lower blood pressure from 140/85 to 130/80, for instance, which decreases the likely risk of heart attack by 50 percent.
“I can scare them to death by saying, ‘This is the data,’” he said. “That’s realistic to patients.”
Rauba said the patients who end up in his office are the ones without someone to hold them accountable for their health decisions.
Pressured to see up to 50 patients a day, Rauba said, primary physicians lack time to monitor a diabetic’s progress or properly explain the necessary steps for improving the disease.
“Most doctors say, ‘You’ve got Type 2 diabetes, your sugars are too high, take this pill, check your sugars twice a week and I’ll see you in three months,’” he said.
Patients often choose not to take medications because they hear rumors of side effects, and many don’t see the point in eating nutritiously to prevent a problem they won’t experience for another 10 or 20 years, Rauba said.
Diabetics should seek out an endocrinologist immediately after diagnosis, Rauba said, instead of waiting to hear easy answers from their primary physicians.
“I’m in a disease-state management mode. We delve into the issues and hammer patients about lifestyle every time we see them,” he said. “I’m not here to blow sunshine at you and tell you you’re doing a great job if you’re not.”
If patients don’t want to hear it, he sends them back to their primary physicians.
The battle between doctor and patient may ease somewhat as technology and medication progress, however, Rauba said. More and more the difficulty of managing diabetes depends less on the whim of the patients. Doctors now prescribe pills to diabetics that were unheard of two years ago. While still controversial, Rauba said, the new medication may help the pancreas produce insulin longer among people with Type 2 diabetes, prolonging the need for insulin shots and the onset of end stages.
Diabetics who eat and inject insulin on a consistent daily schedule may also be eligible for an insulin pump. The size of an iPod, the pump contains a day’s worth of insulin, fed to a diabetic through a long piece of thin tubing with a needle at the end that inserts under the skin. Diabetics program the pump to deliver insulin constantly throughout the day at varying rates, and can wear it on or beneath their clothing.
Diabetics are responsible for filling the pump each day, but Rauba said experiments indicate that soon people will be able to surgically implant pumps to function as an artificial pancreas.
Anderson sees his future as a continuation of his current routine, though he doesn’t predict Rauba will be part of it for long.
“He’s just not my kind of doctor,” Anderson said. “He’s negative. Everything is wrong. Its like I’m seeing my father all over again.”
If the incident that landed Anderson in the hospital a few months ago indicates that he’s living his last days, he said, he would rather spend them chowing down on pizza than sucking on a steamed carrot. No one will convince him otherwise, he said.
“If doctors ask you to stop what you love,” he said, “what’s the point of being alive?”