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Diabetes Mellitus Type 2

This case presents the story of Alvin Floyd, a 53-year-old African American who presented with symptoms of uncontrolled mellitus, and traces the 9 months following diagnosis.

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History of Present Illness

He had been in good health until about two months ago when he started to feel weak and tired more rapidly than usual. On questioning, he admitted to getting up two or three times a night to urinate. He also is often thirsty at those times and drinks a glass of water each time.

His weight had been average through high school, where he had been on the football team. After leaving school, he had gradually gained weight over the years. His appetite remained excellent but he now was losing weight and becoming weak.

The pain in his feet was worse at night and sometimes kept him awake. It was burning in character and sometimes his toes felt numb. The tingling and numbness in his fingers was causing him problems at his work as an auto mechanic because he frequently drops small parts or has difficulty making fine manual adjustments to engines.

His vision was blurry at times, especially in the afternoon.

All other symptoms were negative.

Physical Examination

Wt. 217 lbs., ht. 5′ 11″ (BMI 30), P 76, regular, BP 142/78
Head and neck-mild bleeding of gums reported with tooth brushing.
Chest, abdomen and genital examination normal.
Feet: skin dry with calluses on the medial side of the big toes.
Nails normal.
Pulses strong and equal.
Sensation: normal to 10g monofilament.
Laboratory Tests

Urinalysis: 4+ glucose, negative for ketones and protein.
Random blood glucose: 456 mg/dL.
Glycohemoglobin (HbA1c) 16.4%.
Total cholesterol 243 mg/dL, HDL 20 mg/dL, triglycerides 416 mg/dL.

Primary Care Physician

Dr. Emmett told Alvin that he had diabetes based on his elevated random glucose and the presence of symptoms. The American Diabetes Association standard for diagnosing diabetes is a fasting blood glucose above 125 mg/dL or a random blood glucose of 200 mg/dL or above with symptoms of diabetes, either criteria repeated on a second day. The elevated HbA1c result indicated that Alvin’s average blood glucose for the prior two to three months was in excess of 400 mg/dL. This level of blood glucose accounted for the increase in urination and the weight loss that Alvin had experienced. The four classic symptoms of diabetes are:

* polyuria (excessive urination),
* polyphagia (excessive hunger),
* polydipsia (excessive thirst) and
* unexplained weight loss.

Common symptoms are fatigue, blurred vision, frequent infections, poor wound healing, dry, itchy skin and numbness and tingling in hands, legs and feet. Of the common symptoms, Alvin had the numbness in his fingertips, a burning sensation in his feet and blurred vision. His blurred vision was often worse after lunch on workdays, caused by his drinking a “Big Gulp” regular soda with his lunch, and thus increasing his glucose load in the afternoons.

Dr. Emmett gave Alvin a referral for a dilated eye exam in his health plan’s eye care center. He also suggested that Alvin make an appointment with a dentist to be assessed for periodontal disease, another common problem for patients with diabetes.

Dr. Emmett performed a Carville foot exam on Alvin, checking for both microvascular and neuropathic problems. The exam was normal, except for calluses on his big toes. Dr. Emmett advised to wear shoes with larger toe boxes. Alvin did discuss his fears with Dr. Emmett about diabetes leading to amputations, since this had been a major problem in his mother’s condition.

Dr. Emmett used the opportunity to discuss blood glucose management through monitoring, medical nutrition therapy, and medication. He instructed Alvin to contact the Diabetes Center to sign up for classes on diabetes self-management, which were a benefit of Alvin’s health plan. In addition, he gave Alvin two prescriptions: one for a blood glucose meter, instructing Alvin to check his blood sugar before meals, and one for an oral diabetes agent.

In Alvin’s case, Dr. Emmett prescribed Amaryl® (glimepiride), 4 mg. a day. Amaryl® is in the class of drugs called sulfonureas, which stimulate the islet cells in the pancreas to produce more insulin. Other classes of oral diabetes agents are:

* Biguanides:  decrease the release of glucose by the liver, and makes other cells more sensitive to insulin.
* Thiazolidinediones (TZDs):  increase cellular sensitivity to insulin and decreases the release of glucose by the liver.
* Meglitinides:  stimulate the pancreas to release insulin over a shorter period of time (after meals).
* Alpha glucosidase inhibitors:  slow the absorption of carbohydrates in the intestine.

These oral diabetes agents can be given singly or in combinations.

Dr. Emmett scheduled Alvin back for a visit in one month.

Progress and Monitoring

When Alvin and his wife returned for their second class in two weeks, Alvin reviewed his blood sugar testing records with Nurse Ireland. His records showed that he had been testing 3 — 4 times daily and that greater than 75% of the results were in target range. At class, Alvin’s test result was 93 mg/dl, and his technique was good.

Since the first class, Alvin had had an appointment with Dr. Emmett. Based on his blood sugar records, Dr. Emmett had decreased the dose of Amaryl® from 4 mg. to 2 mg. daily. Alvin had also noticed that the burning in his feet was gone and the numbness and tingling in his fingers was much better. He stated that Dr. Emmett had said this was because his diabetes was better. Nurse Ireland praised Alvin for his success and encouraged him to keep up the good work. She also pointed out that his weight had stabilized another sign that his diabetes was better controlled. His wife smiled broadly.

The class learned about low blood sugar and high blood sugar, the causes of both and what actions to take if either occurred. Alvin learned that he should carry some form of fast-acting carbohydrate on him at all times, to treat a low blood sugar, and should wear some type of medical identification.

The class reviewed their food and activity records with Ms. May. They asked questions about various foods and the effects that they noticed on blood sugars. Alvin was surprised to learn that the sugar-free cookies he had at lunch one day still contained a significant amount of carbohydrate, and were the reason his blood sugar was high before dinner. Ms. May reviewed food label reading, and told the class to be especially watchful on foods labeled low-fat or sugar-free, since these foods may still contain carbohydrates.

She then moved on to discuss other nutrition issues, such as the recommendation to eat 6 oz. protein daily, and to try to limit fat intake to 30% or less of total daily calories.

Ms. May also discussed alcohol consumption in diabetes. She told the class that persons with controlled diabetes could drink alcohol, but men should limit themselves to two drinks per day, and women to one. Persons with diabetes should never drink on an empty stomach, since alcohol can lower blood sugar levels, leading to hypoglycemia. She also reminded the class to be sure and “count” any carbohydrate in the drink itself (like beer), or in the mixer, such as fruit juice or milk.

Ms. May and Nurse Ireland talked with the class about setting personal goals for their own management of their diabetes. Alvin was happy to report that he and his wife had taken a walk after dinner several times in the past week, and that he had enjoyed the time to talk. He set a goal to walk at least 5 times per week, and to purchase a medical identification medallion.

The class was instructed to continue their blood glucose testing schedule, and to bring their record books to the next class in 2.5 months.

By the time Alvin returned for his 3 month class, 100% of his tests were in target range, and his average blood sugar, calculated by his glucose monitor, was 111. He had lost 4.4 lbs. He had seen Dr. Emmett again, who again cut his dose of Amaryl®, down to 0.5 mg qd.

He had also seen the eye doctor. His blurry vision was resolved, and his eye exam was normal.

Alvin was most proud to report that his HbA1c was down to 8.3%. At the third class, he and his wife learned about the necessity for maintaining normal blood pressure, what to do on sick days, and how to check and care for his feet.

They also learned how to estimate portion sizes, like a piece of meat the size of a deck of cards is about 3 oz. and a serving of potatoes about the size of a tennis ball is one carbohydrate choice or 15 grams. The class discussed strategies for dining out and reviewed how they were doing on their goals.

The fourth and final class was six months after Alvin started at the Diabetes Center. His weight had stabilized at 199 lbs. And he had taken in his belt by an inch. He was no longer taking Amaryl®, and his blood glucose tests remained 100% in range. He was walking/jogging 5 — 6 times per week for at least 30 minutes. Most impressively, his HbA1c was down to 6.8%.

In class, pattern control of blood glucose readings was discussed, and what to do if more than 50% of tests were out of target range. The role of stress and stress management were emphasized. The natural progression of diabetes was discussed, along with the need to maintain blood glucose testing for a lifetime.

Necessary routine medical care such as frequent blood pressure checks, an annual eye exam, an annual foot exam, periodic laboratory tests, and an annual flu shot were outlined. The session included a review of the food pyramid and healthy eating habits. Goal setting and community resources for ongoing education and support topped off the class.

A complete report of Alvin’s progress in class was sent to Dr. Emmett. A few months later, Dr. Emmett shared back with the Diabetes Center that Alvin’s nine-month HbA1c was 6.9% and his weight remained stable. He continued off of medication, and his glucose control was excellent.

Medical Nutrition Therapy & Activity

“Diets” are temporary. The goal of “medical nutrition therapy” is to promote healthy eating habits and to decrease obesity. There is no specific “diabetic diet;” it is the same as the “prudent diet” promoted for cardiac health.

Caloric control is the keystone. A negative caloric balance will reduce blood glucose levels before any reduction in weight is seen. It is unnecessary and impractical to aim for an “ideal body weight.” A reduction of 5–10% of body weight often is sufficient to reduce blood glucose levels into the normal range. Note that the goal is not to lose weight but to lose fat. Improved glucose control and increased activity can increase muscle weight and results may only be evident in a smaller waist. An extreme reduction in calories can not be maintained. A modest decrease in calories can and, if continued, will have a better long-term effect.

People with diabetes mellitus are at high risk for cardiovascular disease. They often have hyperlipidemia. Their meal plan should aim for 30% or less of calories derived from fat and 10% or less saturated fats. Monounsaturated fats, like those found in olive oil, are best.

It is not necessary to join a gymnasium or a high-impact aerobics class. Any increase in activity will improve insulin sensitivity of the muscles. Aerobic activities also will improve cardiovascular fitness and walking further on a regular basis is an excellent choice. Long sessions are not required; three ten-minute sessions are as effective as one thirty-minute period.

Exercise improves the body’s response to insulin, lowers the risk of heart and blood vessel disease, burns calories, and reduces stress and tension.

Standards of Care

Early detection of complications is extremely important because appropriate therapy can prevent progression.

Eyes: A dilated eye examination every year.

Feet: Check for lesions, vascular status and neurologic integrity at least annually if normal. For any abnormality, check at each visit.

Kidneys: Urinalysis for microalbuminuria every year.

Lipids: Fasting lipid profile every year if not yet on therapy.

Choice of Initial Therapy

This depends upon the severity of symptoms and associated clinical factors.

If the patient is asymptomatic, a trial of just a meal plan and increased activity is appropriate. With a negative caloric balance, glucose levels come down before any change in weight is seen. In a very obese person, metformin may be useful because it is the only antidiabetic medication that does not cause weight gain.

In a symptomatic patient, relative insulin deficiency predominates and either a sulfonylurea or insulin should be used. Metformin can be added. Initial therapy with metformin or a thiazolidinedione alone can take several weeks to develop a full effect.

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