Developing Youngsters' Power in Diabetes Self-Care: Dr. DeLoach Talks about Campamento Diabetes Safari
Dr. Stan De Loach is a bicultural, trilingual, Certified Diabetes Educator (one of the first 13 in Mexico) and clinical psychologist, not to mention a pianist, composer, and writer. Born and educated in the U.S., he has been a resident of Mexico for decades, and his first love is the annual bilingual diabetes camp that he co-founded, the four-day Campamento Diabetes Safari in Mexico..
His journey to the camp began 41 years ago, when he developed type 1 diabetes at 21 years old, an age when many find it especially hard to accept. He didn't find it so, however, because the dietary advice at the time was so liberal with carbs that he didn't have to change his diet at all. "When you're told that you should lots of things like fruit and breads," he says, "it isn't difficult to adjust because you've been eating them all along." It was frustrating, however, because "even though you adapted, you had no results to show for it. There were no meters yet."
Dr. De Loach found his way to stable glycemic control partly on his own, by overeating at an upscale all-you-can-eat buffet in Chicago in 1980. He recalls, "There was a fancy hotel with a Sunday buffet. I decided that it would be ridiculous to eat mashed potatoes or bread because they're cheap and I could get them at home. So I would stuff myself on the crab, shrimp, prime rib, asparagus spears with butter, Caesar salad, and salmon, and then on the walk home I would be hypoglycemic. And I thought, ‘Something is weird here because I ate like a pig, yet my sugar is low.' Little by little, it dawned on me that it was the carbs that were causing the high blood sugars, not the proteins or fats or vegetables. So at that point, I began to modify my diet in an attempt at normoglycemia."
Years later, he discovered Dr. Richard Bernstein's book The Diabetes Solution, which made the influence of carbs "much clearer and more specific in terms of quantities. The precision really changed my life and my control enormously. Dr. Bernstein is a guide to me, a thinker who can provoke you to think, who uses real data rather than just theory or what people say. He presents his reasoning, and then you analyze it yourself. Just because professional organizations may say to eat 50 to 60 percent of your diet in carbs doesn't mean that it's valid. You have your measurements to go by, so you can see the results. Eat that way and check, and then don't eat that way and check, and you'll see a convincing difference."
"Explain to me," Dr. De Loach asks, "how a balanced diet can consist of 50 to 60 percent carbs, 20 percent protein, and 20 percent fat. How is that ‘balanced'? The commonly promoted balanced diet is really not balanced at all. A Spanish colleague of mine explains that what we want to promote is an unbalanced diet in order to produce balanced blood sugars." He adds, "Most people don't die of diabetes. They die of the effects of chronic diabetic hyperglycemia, the diabetic complications. Manage hyperglycemia, not diabetes. The hyperglycemia is manageable."
That Dr. Bernstein's ideas are controversial "is totally perplexing," says Dr. De Loach, "because, as I tell my clients, with any treatment that you are prescribed, how are you going to measure its success? You can gauge it by your blood sugars. If you're heading toward 200 mg/dL, you have to decide whether those doses of insulin, that food regimen, that activity level is effective treatment. Dr. Bernstein may be controversial in some quarters, but not among those who have tried his methods. Many people, however, are unwilling to try them."
Dr. De Loach believes that one powerful reason that people don't try low-carb methods of controlling blood sugars lies in the messages that they hear from the "theoretical authorities." "You get these messages," he says, "‘Oh, a high percentage of carbs in your diet is good for a person with diabetes.' There's no proven basis for believing that's true, but when you hear the message repeatedly, to change and do something different is going to cause anxiety because you think, ‘I'm doing the wrong thing. I'm going to kill myself by not eating so many carbs.' Using the blood glucose monitor helps with perspective and orientation."
Dr. De Loach is a convincing proponent of not relying on conventional wisdom when it comes to your own diabetes management. "If people who have diabetes think of themselves as passive recipients of infallible medical wisdom, they're not going to get optimal care. I can't tell anyone exactly how much insulin they need, for example. But you, by experience and measurement of your blood sugars, can learn that. It's just not to your advantage to be passive in your relationship with your physician. Basically, the responsibility lies with the person who has diabetes to handle these things, 24 hours a day. If a client with diabetes goes blind, how is that going to affect me? Maybe only emotionally, but it's going to affect that person quite a bit, physically, economically, and emotionally. The person who has the authority and responsibility for managing hyperglycemia is the person who has it."
"Glycemic control for the person with diabetes is complicated by the medicine that we all use daily and in greatest quantity: food. That's a medicine that requires more medicine (insulin) and that no one can dose except you. It has emotional ramifications that other over-the-counter medications don't have, and it exerts rapid and powerful physiological effects as well. Eating 200 grams of carbohydrate is going to affect your blood glucose right away, so it's a powerful medicine with psychological and social meanings. It complicates things."
The conviction that each individual holds the authority and responsibility for managing blood glucose guides the way Campamento Diabetes Safari is organized. "Who is capable of managing hyperglycemia?" asks Dr. De Loach "It's really the campers, to whom we say right off the bat, ‘You're not slaves here. It's not a question of obedience just because you're young and we're older. You have diabetes. Who's going to be in charge of managing your blood sugars for the rest of your life? It's you! It would be nice if daddy could do it, it'd be nice if I could, but we can't. You can, however.'"
"They catch on very quickly, and then we tell them that there is no battle, no force involved. We don't tell them to check their blood sugar. We don't order them to ‘not eat that or go do that.' Studies show that when young persons, or adults for that matter, have free access to the tools they need to manage their blood glucose, they do so. So the campers have their own meter and unlimited strips, thanks to Abbott Laboratories de México. They carry them and use them."
"Guidelines recommend checking blood sugars four times a day if you're using insulin, which really isn't enough in my experience," Dr. De Loach comments. "We don't say four or 12 times a day. It's whatever you think is best for you, with the suggestion that you do it whenever you don't know. If you know your blood sugar level, fine, you'll know what to do. If you don't know, it could be worthwhile checking." In fact, the campers decide to check their blood sugar an average of 11 times per day. The results of their self-directed learning are impressive. Dr. De Loach has published an article on the campers' blood glucose values, which indicated that their mean blood glucose was 209 mg/dl on arrival at the camp and 87 mg/dl when they departed.
"Campers also determine for themselves how much insulin to take before meals, which are all buffets from which they choose whatever they like. They are remarkably competent at calculating the dose of insulin needed to match their appetites. And they exercise as much as they decide to."
"We keep the educational focus on glycemic goals. If the campers do not learn to manage hyperglycemia in a diabetes camp, where we have professionals with tons of experience and knowledge, how will they learn at home, where the expertise may be unavailable? If they use the advice, the suggestions, the shared experience offered at camp, they can be expected to engineer normal blood sugars most of the time, if they wish. Sixty percent of the camp's staff members also have type 1 diabetes. By keeping their A1c to less than 5.2%, they model and confirm the possibility of normal values."
Dr. De Loach subscribes to Elliot Joslin's belief, voiced 85 years ago, that education is not just part of the treatment of diabetes, but rather the treatment itself. "This camp is designed to be educational, not recreational. Campers do go swimming, play, and recreate, but everything is turned to opportunities for learning about what everyday decisions and activities can mean in terms of how you control your blood sugar. Because education for type 1 diabetes has to be individualized, you can't give classes or just general information. Everything about type 1 treatment is individual. You might need five units of insulin, while I might need one. The question of the individual's authority and responsibility is related to this. In some diabetes camps, there is a cabin master or mistress who controls the number of strips, the test times, the meters, and the food intake, so the campers are not really in charge of the management of their own glycemia. But at Diabetes Safari, it's all on the camper, who sets the curriculum and asks for the support and consultation necessary for his or her self-directed learning."
As a clinical psychologist, Dr. De Loach brings expertise in system dynamics to the camp's design. He says, "We try to focus on the whole system. The entire staff and all campers meet twice a day in what are called plenary sessions, each lasting about an hour. There is really no assigned topic. You can say whatever you want to say or nothing at all, about anything going on in yourself or in the temporary social system that is the Campamento. I think the meetings are opportunities for campers to speak their mind, in a setting where it's permitted and respected, but not forced. Much of their inner resources finds voice at the plenary meetings, things that join them together."
The staff is available around-the-clock to accompany campers in their pursuit of whatever they need or wish to learn, but whether or not to implement the ideas or strategies that result from consulting with staff always remains the campers' decision and responsibility. Dr. De Loach emphasizes the importance of the public nature of staff's self-care behaviors. "Those of us with diabetes check our blood sugars and take insulins in public. The campers observe our meter readings. When they see staff who do not have type 1 diabetes check their blood sugar after a meal, they think, ‘Okay, these bigwigs have been saying that a normal blood glucose is 71 to 99 mg/dL, and this doctor without diabetes just got through eating and has 84 mg/dL, so maybe that really is a normal blood sugar.' They learn from the public nature of staff behaviors."
Dr. De Loach does not use a pump or continuous glucose monitor because he is satisfied with his results using injections of ultra-rapid and basal insulin analogs. "I ask myself the same question that I ask my clients. How can you tell if the treatment that you're using works or is good enough? The answer in my book is that if your blood glucose is between 71 and 99 mg/dL most or all of the time (that is, an A1c of 5% or less), then that's effective treatment. If not, I would consider adjusting or modifying treatment. If it isn't broken, don't fix it; but if it is broken, do fix it. Frankly, in my experience, if you can't get your blood sugar stable in a near-normal range with injections of insulin, you can't do it with a pump either. It's not a matter of how you're getting that insulin into you; it's knowing how much and what kind and at what time, and, of course, your food intake and activity level. Some campers are unhappy when I say that blood glucose management is a mathematical adventure, but I think it's true."
The clinical psychologist in Dr. De Loach comes to the fore when he discusses the feelings of depression that persons with diabetes may experience when they find themselves unable to manage their blood sugar levels, in spite of effort. He relates the painful feelings to others' easy acceptance of hyperglycemia simply because, after all, it's expected or "natural" when one has type 1 diabetes. "It's as if a person with diabetes has no right to expect to have a ‘normal' blood glucose level," he says. "Usually, the first treatment experience for a person with type 1 diabetes is of failure, because you will be told to do thus and so, and you will do it, and you will still have hyperglycemia or hypoglycemia most or all of the time. That experience of failure has to be modified by the realization that you can actually manage it. It is not rocket science, as Dr. Bernstein says, and you can learn how to do it."
Dr. De Loach adds, "Anguish is related to not knowing or not learning. Parents and healthcare professionals are not always aware of the anguish that children and adolescents feel when they experience abnormal blood sugars. They feel profound anguish because they know that chronic hyperglycemia is not normal or without negative consequence for them somewhere down the road. But they may feel impotent or be uncertain of what to do. When young people come to camp and learn strategies that allow successful control, they can alleviate the anguish and depression. They learn through experience by making food choices, figuring out insulin doses, and monitoring the results. Their exercise of authority is their power, and that power is the only real antidote to the anguish and depression. In the study mentioned previously, the campers' average three-day blood glucose value was 95 mg/dL. That's pretty darn normal. Staff didn't prescribe their insulin doses. The campers did. They made their choices, and the results are theirs."
Campamento Diabetes Safari is a nonprofit venture that charges only $225 per camper because it is partly supported by private donations and corporate contributions of supplies. To contribute or for registration details, see www.diabetes-safari.com. For more information, see the 2008 article on the DH website, "You Can't Push the River".Click Here To View Or Post Comments
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