In the wee hours of a summer night in 2017, Ann Marshall’s eyes fluttered open. She was on the floor of a bedroom she’d turned into an office in her Aurora home. She was woozy, her head hurting from hitting a file cabinet when she fell after passing out.
What caused the blackout? Marshall, now 62, didn’t know. But a short trip to the Emergency Department at UCHealth University of Colorado Hospital on the Anschutz Medical Campus for treatment put her on a long road to recovery from issues that are all too common in the United States and take a powerful toll on the health care system.
Too little air, too much sugar
Providers at UCH found that the blow to Marshall’s head was the least of her problems. She was severely hypoxic – oxygen starved – the result of extra body weight that compressed her lungs and led to the bedroom tumble. She went from the ED to an inpatient unit and left the hospital with an oxygen tank that delivered three liters to her laboring lungs 24 hours a day.
Marshall’s troubles were to worsen. She’d been diagnosed with Type 2 diabetes in 2015, about a year after her husband died, and by her own admission she’d done a poor job of managing her diet for a long time. The problem wasn’t how much she was eating; it was what she chose to eat.
“You wouldn’t believe the amount of fast food I ate,” she said. “It was a really unbelievably unhealthy lifestyle I was leading.”
During her hospitalization, her A1C levels, a key measure of blood glucose, hovered around 7 percent – borderline high. But when she visited her endocrinologist at UCH in December 2017, she got another shock. Her A1C was 10 percent, well above the danger line established by the American Diabetes Association. Marshall went home with a prescription for insulin and the prospect of injecting it every day – as she maintained her oxygen around the clock.
Her response? “I was told I’d be on oxygen the rest of my life. Same with insulin too,” Marshall recalled. “I said, ‘Nope, that’s not happening.’”
Flipping the script
Mission accomplished. Today, Marshall no longer lugs the oxygen tank around, and she’s off insulin. She owes that to spiritual belief, lifestyle changes and a helping hand from her medical providers, especially UCH pulmonologist Dr. Jeff Sippel and his team.
There was no magic formula for the success. Marshall shed 62 pounds, mostly by drastically cutting her fast-food and carbohydrate intake in favor of proteins and vegetables and increasing her activity on a stationary bike. Sippel prescribed a CPAP (continuous positive airway pressure) machine to treat the obstructive sleep apnea that was a big contributor to both her low oxygen and high blood sugar levels as well as, unsurprisingly, fatigue that became so severe that she frequently fell asleep during the day.
Thanks to the CPAP, Marshall said she now sleeps through the night, is alert all day and maintains healthy blood oxygen levels consistently. That’s earned her freedom from the oxygen tank – a considerable relief.
“I had to pull the hose and tank all over the place. It was a huge hindrance and I hated it,” Marshall said. “Now I’m off it. I didn’t want to be on it and I knew I had to find a way.”
The CPAP machine’s role in improving oxygen flow is no surprise, but how did it help Marshall manage her blood sugar? Sippel explained that in some patients, untreated sleep apnea contributes to high levels of two hormones, adrenaline and cortisol, that promote weight gain and can make it harder to lose weight. Cortisol, he added, triggers the liver to produce blood sugar and resist insulin. That combined with genetics, body type, and lifestyle, makes the hormone a risk factor for diabetes.
The gains from change
Three months after beginning to wear the CPAP machine and taking her insulin regularly, Marshall said she lowered her dangerously high A1C level to a manageable 6.9 percent. She stopped taking insulin early last summer and her last A1C reading stood at a very healthy 5.9 percent. But Marshall takes nothing for granted. She said she checks her blood sugar three times a day.
“So long as I can keep track of it during the day, it hasn’t gotten away from me,” she said, adding that thanks to Sippel and his team, she knows that keeping her blood oxygen saturation at 90 percent or above will also help keep her blood sugar in check.
Sippel believes that while Ann Marshall’s story is not the stuff of front-page medical news, it is vitally important – precisely because her health care struggles are so common.
“A lot of people are overweight with sleep apnea,” he said. “The fact that she got to victory underscores the opportunity for many other people to get to victory. She paid attention to her symptoms, admitted she didn’t feel well and adhered to the recommendations for improving her health. Those are the nuts and bolts, the blocking and tackling of health care.”
Marshall’s example illustrates the benefits both patients and society at large reap from that effort, Sippel added. Reducing reliance on oxygen produces direct savings for patients and the system as a whole, he said. Patients who manage their sleep apnea are more productive and less likely to miss work, while those like Marshall who have diabetes are better able to manage their disease and avoid complications – another potential source of enormous cost savings.
In addition, Sippel said, some patients with sleep apnea end up with congestive heart failure, leading to emergency department visits and hospitalizations that could in many cases be avoided with effective and comparatively inexpensive treatment.
There are no shortcuts to these improvements. Sippel said he and his team spend considerable clinic time educating patients, but he sees the encounters as a dialogue, not a lecture from on high.
“It really means talking to patients about what is this diagnosis and what does it mean, how may it affect [your] life?” he said. “I feel that if we can empower patients with that knowledge, they will ultimately be able to make the best recommendations and decisions for themselves.”
An important element to that approach is motivational interviewing techniques that Sippel said he gleaned from his own efforts and from the hospital’s tobacco treatment specialists, notably Kathleen Moreira. The idea is to work with patients to identify their own reasons for changing their behaviors.
“We say, ‘Let’s find something of value that could be improved on if you adhere to this therapy,’” Sippel said.
He readily admitted the extended discussions lengthen the standard clinic visit. “It’s a matter of balancing out how efficiently or inefficiently we might spend our time,” he said. “But if our goals are lifestyle and behavioral changes, it’s worth spending some time with patients trying to understand that.”
Marshall credits Sippel for being honest with her and “not sugar-coating” information about her condition. “I got my tests quickly, and my questions were answered. Things were explained well,” she said. At the same time, she advises other people with conditions similar to hers to take an active role in their own care and find intrinsic motivations for improving.
“I’d also say, don’t sit back and listen only to your doctors,” Marshall added. “Find out for yourself. Investigate it, research it, and figure it out. My diet is going to be a lot different than somebody else’s because my metabolism is different.” She also stresses that her reliance on God played a big role in her recovery.
One year after her health cratered, Marshall said she’s made a 180-degree turnaround. “Last year I was pulling along an oxygen tank. I was tired. I felt really bad. Now I don’t,” she said.
With her weight down to 195 pounds, Marshall said she’s plateaued, at least for now. She’d like to lose more but is concentrating on maintaining the improvements she’s made.
“If I don’t lose more weight, it’s not the end of the world,” Marshall said. “I can move around really well, I can breathe and bend over and not pass out. That’s really good.”
Marshall’s story and others like it are “not necessarily made for TV,” Sippel acknowledged. “Dramatic, exciting cases are awesome. This one, on one hand, is not dramatic or exciting. But it is incredibly successful and meaningful.”