One of the principal challenges of diabetes management is the degree of planning, discipline, and commitment it demands of those living with the condition. At NYU Langone’s Center for Diabetes and Metabolic Health, an intensified multidisciplinary approach—combined with a focus on treating the whole person—helps patients do better at helping themselves.
A Nonhierarchical Model
In diabetes care, a team approach has long been recommended in practice guidelines. Often, however, the endocrinologist remains the patient’s main caregiver, with clinicians and healthcare professionals from other fields called in as necessary—for example, to establish a dietary regimen or treat comorbidities and complications. Under the leadership of Lauren H. Golden, MD, clinical associate professor in the Department of Medicine, the Center for Diabetes and Metabolic Health is working to make multidisciplinary collaboration central to each patient’s treatment plan.
“Our mission is to provide individualized care that adapts constantly to a patient’s changing needs and circumstances,” explains Dr. Golden, a nationally recognized clinician, who joined NYU Langone in September 2018. “People who have diabetes often face challenges that make it difficult to manage the disease over time, requiring different types of reinforcement to keep them on track. Evidence shows patients can benefit from having a variety of experts helping them find tools that work at a particular juncture of their lives.”
For this reason, Dr. Golden embraces an intensified multidisciplinary approach. “After patients meet with me to lay out an overall care map,” she says, “they have their initial consultation with a nutritionist or a diabetes educator. We then continue to alternate visits with different team members over the entire course of treatment, allowing us to continually adapt our treatment plan to the patient’s evolving needs. It’s a nonhierarchical model of care—very different from the formula of ‘follow these instructions, then come back and see the doctor in three months.’”
As with some other chronic conditions, Dr. Golden observes, the obstacles to successful diabetes management—whether for type 1 or type 2—are frequently practical and psychological rather than pharmacological and technological. Thus, in their interactions with patients, team members are encouraged to probe beyond conventional therapeutic questions. “Our emphasis is on getting to know patients very well on multiple levels,” Dr. Golden says. “What stresses are they under? Can they afford the healthy foods that we’re suggesting they eat? Are they working the night shift? Are they trying to get pregnant? If we don’t understand them as human beings, it’s very difficult to guide them in how best to keep their blood sugars under control.”
Marshaling Diverse Resources for Complex Cases
This emphasis on treating the whole patient extends to those referred by other departments in cases in which diabetes must be brought under control before a crucial procedure can take place. In other instances, diabetes presents as a complication of another disease or its treatment.
For example, the center collaborates with NYU Langone’s Transplant Institute to fast-track interventions for patients with diabetes who are preparing to receive a new organ, as well as for those experiencing post-transplant hyperglycemia—a common adverse effect for patients with or without a history of the disease. Dr. Golden has implemented a similar arrangement with the Division of Hematology and Medical Oncology for patients with diabetes induced by chemotherapy or pancreatectomy. “These people need to get started on insulin quickly,” Dr. Golden observes, “but they also need support in complying with their treatment regimen while dealing with cancer.”
Clinicians from the center work with colleagues from the Division of Gastroenterology and Hepatology to treat people who have nonalcoholic fatty liver disease (NAFLD)—a frequent comorbidity of diabetes, and one that can both exacerbate and be exacerbated by that disorder. “If we can get these patients early and manage their diabetes, we can help them stave off cirrhosis and liver failure,” explains Dr. Golden.
Because weight loss is the most effective approach to reversing the course of NAFLD in obese patients, Dr. Golden has built a team with specialization in liver disease, diabetes, and weight loss. She leads this effort in partnership with Ira M. Jacobson, MD, professor of medicine, director of hepatology, and a leading expert in fatty liver disease; and Holly Lofton, MD, assistant professor of surgery and medicine, and clinical lead of NYU Langone’s Weight Management Program.
“Our goal in all these efforts is to prevent the end-stage complications of diabetes, whether they affect the liver, kidneys, eyes, nerves, or vascular system,” Dr. Golden notes. “The resources and expertise available at NYU Langone, along with an extraordinary culture of collaboration, enable us to take an aggressive and proactive approach across a wide range of disciplines.”