Knock, knock, the doctor opens the door to the exam room. "Hello, Mary, how are you today?"

"I'm here for you to tell me. Did you get the results of my lab work yet? I had my blood drawn on Monday?"

"Let's see here."

The doctor sits down on his stool and begins looking through the chart.

"Yes, your lab results are here. Let's see what it says."

After only a few seconds of studying them, the doctor looks up.

"Ms. Thompson, this shows that your fasting blood sugar on Monday was over 200. It was 212."

"So is that bad?"

"Well, it means you have diabetes, and that's not good. It's something you are going to have to take care of."

"Is 212 really high?"

"A normal fasting blood sugar level is less than 100 and you are 212, so yeah, you are up there."

"So what do I do?" Mary asks.

The doctor reaches into his pocket and pulls out a prescription pad. He then reaches over and takes a preprinted sheet out of a file folder attached to the wall. After briefly reviewing it he hands it to Mary.

"This is a 1500 calorie meal plan. I want you to try to follow this as much as possible until I see you again. Since you have too much sugar in your blood you need to really limit the amount of sugar or carbohydrates you eat. Following this meal plan should help a lot."

"I am also going to write you a prescription for metformin. I want you to take it twice a day with breakfast and with dinner."

The doctor tears the prescription from the prescription pad and hands it to Mary.

"This next one is for Januvia. Take this once a day in the morning only."

Again he rips the prescription from the pad, and gives it to the patient.

"This last prescription I am going to give you is for a blood glucose monitor. I want you to test your blood sugar first thing when you get up in the morning and before dinner.

Before breakfast your blood sugar should be less than 130 and if you check it 2 hours after dinner it should be less than 180."

"Do I get this at the pharmacy too?" the patient asks.

"Yeah, you get all of these from the pharmacy."

The doctor quits writing and spins himself around on his stool to directly face the patient.

"Lets' try this for 3 months and see how you do. Try to stick to that meal plan and that should help a lot. Ok?"

The doctor picks up the chart from the desk and gets up from the stool. He reaches out to shake Mary's hand and heads for the door. As the doctor reaches for the door, he turns toward Mary, and suggests, in what appears to be an after thought,

"Try to get more exercise, that's going to help too. Have a nice day."

On the way home, every time Mary pulls up to a red light, she picks up the 1500 calorie meal plan the doctor gave her and studies it to see what foods she has to eliminate and more importantly, what she can still eat. After 4-5 lights, Mary has seen enough. Now her attention turns to the idea of having o stick her finger twice a day. It's not a pleasant ride home.

Once home, she's greeted by her husband at the back door, "So what did the doctor say?"

"You are never going to believe this," Mary grumbles as she walks past her husband and heads to the living room.

Her husband follows her to see what it is he will never believe while hurriedly trying to gobble down the last several bites of mint chocolate chip ice cream he was enjoying before his visibly upset wife arrived home.

"Please don't eat that in front of me," she told her husband. "In fact, I want you to get rid of all of that," she told him implying she wanted him to empty the freezer of all the ice cream.

"Honey, what is going on? What is wrong? What did the doctor say?" He asked while hiding his bowl under the sofa skirt.

"The doctor said I have diabetes."

"Diabetes. I thought only old people got that. You're only forty-six. Why does he think you have diabetes?"

"Because my fasting blood sugar level was 212, and it is supposed to be under 100."

"So what are you supposed to do?"

"Well, because my blood sugar level is so high he wants me to follow this 1500 calorie meal plan. This stinks, I'm not going to be able to eat a lot of the stuff I was eating before."

"It may not be that bad," Mary's husband Bob says as he looks over the meal plan.

"Good, then you can do it with me."

What else did he say? "Are you going to have to take any medicine?"

"Yeah, that too. I have to take two of them. I can't pronounce them, but I have the prescriptions in my purse. And as if that is not enough I have to start testing my blood sugar every day, once when I first get up and then two hours after dinner."

"How do you do that?" Bob asks.

"I have to poke my finger and get it to bleed. Then somehow I use a little machine that measures the amount of sugar in my blood. You know how I hate needles; I don't know how I am going to do that."

"Did he say anything else?"

"No, I think that's it."

Mary gets off the couch and tells Bob that she is going to change her clothes. As she starts to leave the room, Bob reaches under the sofa skirt to retrieve his mostly melted ice cream. Little did Bob know that Mary was going to turn around to mention to him one last thing the doctor had said to her, almost as an after thought, the same way she was remembering to mention it to Bob now.

"The doctor did say that I should try to get more exercise. He said that would help."

Tale 2

Knock, knock, the doctor opens the door to the exam room. "Hello, Kristen, how are you today?"

"I'm here for you to tell me. Did you get the results of my lab work yet, I had my blood drawn on Monday?"

"Let's see here."

The doctor sits down on his stool and begins looking through the chart.

"Yes, your lab results are here. Let's see what it says."

After only a few seconds of studying them the doctor looks up.

"Kristen, this shows that your fasting blood sugar on Monday was over 200. It was 212."

"So is that bad?"

"Well, it means you have diabetes, and that's not good. It's something you are going to have to take care of."

"Is 212 really high?"

"A normal fasting blood sugar level is less than 100 and you are 212, so yeah, you are up there."

"So what do I do?" Kristen asks.

The doctor puts the cap on his pen, closes Kristen's chart, rests his right elbow on the table, crosses his legs, and now that he is comfortable, asks Kristen, "Kristen, how much exercise do you get. Do you get any regular exercise?"

"What do you mean by regular exercise? I mean I'm always doing something, housework, volunteering at the church; I take care of the lady next door who is very sick, every Wednesday. If you mean do I go for a walk or swim, or go to the gym every day, no I don't do that."

"I want you to. I want you to make time to get some regular exercise everyday. I'm glad you are up and around instead of sitting at a desk or computer all day but that is not enough. It is very important for your diabetes that you get some form of regular exercise nearly every day of the week. Do you think you can do that?"

"Well, yeah, but I'm pooped when I go to bed at night. I figured with all I was doing I was active enough."

"No, not really. A lot of people believe that, but it's not true. Everyone, regardless of having diabetes or not, needs regular exercise, but when you have type 2 diabetes which you do, exercise becomes even more important."

"OK well, if it is that important then I'll establish some kind of regular exercise program."

"Does it matter what I do? Is walking good enough? I heard swimming is better for you."

"It doesn't matter. You know what the best exercise is, the one you are willing to do."

"So the key is doing something on a regular basis."

"Right, and if you like to do a lot of different kinds of exercise then mix it up. That would be even better. Ideally you should aim for at least 150 minutes a week, but work up to it slowly. Once you can accomplish that comfortably, if you want to lose some weight gradually bump up the duration to 250 minutes per week."

"Can I split the time up anyway I want as long as I get 250 minutes in, in a week."

"Yes."

"Should I really push myself? My coaches in high school and college told me that if it didn't hurt I was wasting my time."

"No, forget what your coaches said. We have learned a lot more about exercise since then. Walk, jog, swim or whatever you choose to do at a comfortable pace. I want you to forget you ever heard the expression, "No pain, no gain."

"But I don't understand what exercise has to do with me having too much sugar in my blood," Kristen comments, sounding a bit confused.

"Kristen, the more exercise you get, the easier it is to get sugar out of your blood and into your muscle, fat and liver cells. Exercise may very likely be the most important thing most people can do to improve type 2 diabetes."

"OK, do you think you can do this?

"Yeah, yeah, I can. Will this totally take care of my diabetes? I mean is exercising more all I need to do?"

"In some cases, exercising more is all you need to do to control your diabetes as long as you are reasonably careful with what you are eating. For now what I would like to do is have you start testing your blood sugar first thing in the morning and two hours after dinner. If eating better, and what I mean by that is less carbohydrates, and getting more exercise don't improve your blood sugar levels enough, then we will try you on a small dose of metformin and go from there. Sound good?"

"Yep."

"Let me just write you a prescription for a blood glucose monitor and you will be on your way."

"Great."

"I want to see you again in 3 months and we will see how you are doing."

The doctor leans over and hands Kristen the prescription.

"Sounds good."

The doctor gets up, walks to the door, and opens it.

"Bye now."

The doctor walks off down the hall and Kristen leaves the office.

On Kristen's way home she's thinking about when she will be doing her exercise, how she is going to work it into her schedule, and what exercise she will be doing.

It occurs to her that her husband has been talking about getting more exercise. Maybe they could do something together; if not she might be able to talk her neighbor down the street into walking with her after dinner in the evenings.

As she gets closer to her home, she pays closer attention to the YMCA billboard encouraging people to join and participate in their many exercise programs. She pulls out an envelope from her purse and while sitting at a stoplight jots down the phone number of the YMCA listed on the billboard.

Once home, she pulls into the garage, careful to avoid the clutter, characteristic of most garages. But today, unlike any other day recently, as she inches her car into the garage she sees a bicycle, her bicycle. It has been there ever since her husband cleaned out the garage last time and she has seen it for the past 18 months, but today she SEES it.

As she opens the back door, she hears her husband call her, "Honey is that you?"

"It's me, I'm home."

Her husband walks in the room.

"What did the doctor say?"

"I'll tell you all about it in a minute. Listen, I need you to do something for me. Do you mind?"

"I'm not painting the house."

"No seriously, can you pull my bike out of the garage and take it to that bicycle shop around the corner. I haven't ridden it in forever and I'm sure it needs some new tires and probably an overall servicing."

"Are you going to start riding it again?"

"Yep, I'm going to start riding my bike and walking."

"That's great, but what prompted this?"

"The doctor said I have type 2 diabetes and if I start exercising regularly and eating more carefully that I might be able to keep my blood sugar levels normal without taking any medication. This weekend I want us to go to the YMCA and see what it would cost to join."

For most people with type 2 diabetes, unless they are eating very badly or living off of sodas, performing regular exercise, preferably a minimum of 150 minutes per week, is THE MOST IMPORTANT thing that they can do to improve their diabetes control.

In tale 1 the doctor mentioned it as he was walking out of the exam room, as though it were an afterthought. What impression does this leave on the patient?

In tale 2 the doctor sits and spends almost the entire visit discussing the importance of exercise as well as how long to do it, what she can do and how hard to push it.

What impression did this leave on the patient?

Exercise as well as how long to do it, what she can do, and how hard to push it. What impression does this leave on the patient?

Now, remember the last time you took a major exam. More than likely you had a question that asked you something like this:

Compare and contrast the impression left with the patient in Tale 1 and Tale 2. Discuss.

(This question is worth 98 points if you are a patient or a diabetes educator working with a patient with type 2 diabetes)

Milt Bedingfield is a certified diabetes educator and exercise physiologist. Milt received his graduate degree in exercise physiology from The University of South Florida in 1988. Milt has been teaching people with diabetes about the disease and how to care for it for the last 18 years.
Milt has a website at: http://www.TheExerciseDiabetesLink.com and Twitter account. His user name is: IKnosugar.
Milt's email address is: MBedingfield@yahoo.com

By Milt O Bedingfield