Case Study: Symptoms in a Diabetes Client: Type 1, Type 2, or Type 1.5?

Abstract

Presentation W.G. is a 41-year-old white man who was diagnosed with diabetes 15 months ago. He is now beginning diabetes education and medical nutrition therapy (MNT) to gain weight upon referral from his primary care physician. His most recent hemoglobin A1c (A1C) was 5.0%. His current diabetes medication is metformin (Glucophage), 500 mg with breakfast, and he was started on piogli-tazone (Actos) 2 weeks ago. He takes no other medications; denies smoking, alcohol, and drug use; and knows of no health problems other than diabetes. His history revealed a blood glucose level >500 mg/dl at the time of diagnosis , with negative ketones. He checked ketones occasionally in the first year of diabetes, and all tests were negative. His mother had diabetes and was on insulin. He reports that he was on glimepiride (Amaryl) during the first year of diabetes , but that it was discontinued when he was started on metformin. He complains of frequent urination, hunger, and thirst, which leads to drinking more than 1 gallon of water daily. He is very concerned because he is often agitated, anxious, and impatient to the point that it is affecting his family and work life. He was employed as a technician but is on leave until he feels better. His physician prescribed alprazolam (Xanax) for anxiety, but he did not fill the prescription. Physical assessment reveals a height of 74 inches, weight of 174 lb, and body mass index of 22 kg/m 2. He reports a 35-lb weight loss over the past 15 months of diabetes, including a recent 10-lb weight loss resulting in the referral for MNT. 93 CLINICAL DIABETES • Volume 21, Number 2, 2003 W.G. reports that his doctor has prescribed a 2,500-calorie daily meal plan. He includes no fruits and no sweets in his diet and has small snacks between meals. He eats a moderate breakfast and lunch and a bigger dinner before his exercise in the evening. He reports that he is not currently able to maintain his usual 1.5 hours per day of lifting weights and playing basketball because of fatigue and lack of energy. Instead, he is exercising in short intervals as he can tolerate. He also reports symptoms of hypoglycemia but has not checked his blood glucose. Questions 1. Why is this patient losing weight? 2. Does this patient have type 1 or type 2 diabetes, and does it make a difference in his treatment? 3. Are other interventions needed considering his symptoms and most recent A1C? Commentary Nutrition assessment revealed that W.G. was eating ~1,800 calories daily rather than 2,500 calories, as prescribed. He had a good appetite but appeared to be controlling his blood glucose by exercising and eating less than his energy requirement. An 1,800-calorie meal plan would result in weight loss of 1 lb per week for a man of his height, weight, and activity level. W.G.'s records from self-monitoring of blood glucose (SMBG) showed an average fasting blood glucose of 118 mg/dl, which is consistent with his A1C result of 5.0%. Previous A1Cs were 5.1 and 5.6%. His classic diabetes symptoms of polyuria, polyphagia, and polydipsia indicated that diabetes education and MNT were not adequate diabetes care for this patient. His physician readily provided a referral to an endocrinolo-gist/diabetologist. A new treatment plan would need to address nutrition, exercise , and medications. MNT for W.G. began with an increase to 3,000 calories daily to gain weight and to observe the effect of adequate calories on his blood glucose before his appointment with the dia-betologist. He was willing to increase his calories but needed education on meal planning. He was educated about calorie points for a 3,000-calorie daily meal plan. One calorie point equals 75 calories , so his 40 daily calorie points were distributed into meals and snacks and based on healthy eating guidelines for diabetes. The meal plan was individualized based on his usual food and eating habits. 1 His SMBG results with the 3,000-calorie meal plan showed a post-prandial glucose average of 150 mg/dl and a fasting glucose average of 135 mg/dl. Medication options included increasing the dosages of his current medications , adding new oral medications, or using a combination of oral agents and insulin. W.G. was quite willing to start insulin. Because of his marked symptoms and in light of this willingness, the diabetologist at his first visit discontinued his oral medications and initiated insulin therapy. Insulin was adjusted daily during the first week, and the regimen that allowed for normal blood glucose without hypoglycemia was 10 units of