One patient that came in recently initially presented with a Hb A1c of 15-something, and in three months lowered it to 6.8. (HgA1C is a percentage that represents the average blood glucose level over a three month period. For diabetics, it is considered "controlled" when the Hb A1c is less than 7.0. For people without diabetes, the normal range for the hemoglobin A1c test is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes.) He said that he started exercising more, stopped drinking soda and coffee entirely, and started eating more fruits and vegetables. His fiancee came with him and said that Natalia has been the only one who took time to explain how to count carbohydrates in a way that was understandable to him. She thanked her repeatedly and complimented her style of teaching.
With each patient that has come in after that (and believe me, they are not all success stories), I have been more tuned-in to how Natalia interacts with her patients. What I like most about Natalia's style of teaching is that she is able to adapt and change the way she explains things depending on how the patient reacts to her suggestions. No two counseling sessions have been the same, and as a result, I am learning how to interact with all types of patients.
For example, we tell patients that for one carbohydrate exchange, it is 15 grams of carbohydrates. Then we design meal plans around how many exchanges or how many grams they will be allowed to have in a day. Some patients easily understand that and are able to use labels to know how many grams of carbohydrate are in the packaged foods they eat every day. Like on the box of the granola bar I just ate, it said there were 24 g of carbohydrate. Because that is closer to 30 g (2 exchanges) than 15 g (1 exchange), I would count it as 2. So if I was a patient told I could have 5 exchanges at breakfast, I would know that I should eat 3 more.
Other patients have a hard time grasping the connection between grams of carbohydrate and exchanges, so we just tell them, "At lunch, you can have 5 exchanges." Every patient is given a booklet that states the portion size of common foods, and each one counts as one exchange. For example:
1 exchange of carbohydrates = 17 grapes = 1/2 c oatmeal = 1 slice of toast
...and so on. Based on my weight, diet history, and physical activity level, I would likely be given 200 g carbohydrates in a day. Based on that number, let's say the dietitian told me I could eat 3 exchanges for breakfast. Therefore, I could eat 17 grapes (1 exchange), 1/2 c oatmeal (1 exchange), and 1 slice of toast (1 exchange). Or I could eat 17 grapes (1 exchange) and 2 slices of toast (2 exchanges) and not eat any oatmeal. In other words, I can divide up the exchanges however I want to, as long as for every breakfast I always have 3 exchanges...not 1 or 5.
Clear as mud? Good! Consistency is key here. The more consistent the patient is when eating carbohydrates, the more likely they are to maintain control over their blood glucose...which is the main goal in the end! The biggest thing I can take away from this rotation is the importance of quick adaptations. All patients need things explained differently, so the worst thing I could do would be to go into the counseling session with the same attitude, the same "script", the same demonstrations, and hope that everyone understands things the same.
Can you tell I L-O-V-E this rotation? I really, really hope I can find a job in outpatient. If anyone hears of any job openings, you know who to call :)
