Mrs. Anonymous (Mrs. A) had a hemoglobin A1C (HbA1C) of 13.8, up from 13.4 three months ago. She had been struggling with type 2 diabetes mellitus for years now after being diagnosed while establishing care with her primary care physician. With an A1C greater than 14 at the time, who knows how long it had been. As of late, her legs had been feeling like she was stepping on pins and needles. For a while now, she felt like her vision was getting worse: “I probably just need new glasses.”
As Thanksgiving, Christmas, then the New Year passed, Mrs. A had run out of her metformin and her sulfonylurea. At the time of her diagnosis, she did not want to start insulin. She wanted to try oral medications and lifestyle modifications prior to anything she needed to inject. For the past two months, she had been running low on her metformin. She began to space out her dosing: 500 mg twice a day became 500 mg every day became 500 mg every other day. Then she ran out. Over the holidays, she did not have any left to ease the blow of American tradition.
“I knew I was going to let myself go, so I figured why try?”
“Did you keep a glucose log?”
“No. I knew it would be bad anyway. I just stopped checking when I finally ran out of metformin.”
“Did you run out due to financial issues or trouble accessing your medications?”
“No. I was just being lazy.”
We talked about her legs and about her eyes. We discussed how when sugar falls in love with the proteins in one’s blood vessels, it slowly wears away at them until there is nothing left, until the blood supply is gone, until all that is left is numbness in the wake of strangulated circulation. She became tearful. “I know it is my fault. If I just ate right, none of this would have happened.” She was unaware of the interplay between genes and environment in type 2 diabetes: She did not know how one loads the gun before the other pulls the trigger.
Mrs. Anonymous’s husband, her only support aside from her son, would say, “Just diet and exercise. You do not have to be on all of those pills if you just do the right things.” Trying to do the “right things” became harder and harder. Birthdays and holidays passed. Glucose is rising. Why try?
Mrs. A also had a history of depression. She was of a generation in which you do not speak of it. After years of pushing it down, the apathy, the guilt, the withdrawal from social support turned into bigger pieces of the literal and figurative pie. She had not realized how much her mental health was keeping her from managing her physical health. As the depression led to the diabetes led to the poorly controlled diabetes, she began to have feelings of never being able to overcome her struggles with her health. She felt alone.
Mrs. A did not have the barriers to health care that I normally think of. She had primary care, stable housing and a good job with the right funds. What she lacked was specific information about her diabetes and how to control it as well as the social support and a sense of empowerment to manage her disease. Generations of stigmatization of mental health was also a hindrance to her care making it difficult to manage her medications due to depression. Given how common diabetes is, she was also faced with feelings that it was something that one can live with without very tight control. She knew that high blood sugar was bad, but she was not sure why or that there were other means of preventing it outside of diet and exercise.
Mrs. A helped me further understand the importance of patient education and a support system in chronic disease. She also helped me understand that challenges in health care are not limited to access or other issues I think about when I think of non-adherence. Sometimes all patients need is a little help and someone to believe in them.
Medical Student Contributing Writer
University of South Carolina School of Medicine Greenville
Madeleine Mendelow is a third-year medical student at the University of South Carolina School of Medicine Greenville. She received her BA in Romance Languages and Literatures and International Studies from the University of Michigan and practiced as a licensed esthetician prior to medical school. She hopes to pursue OBGYN and incorporate her love of psychiatry into her practice.
