Man, 76 years of age, type 2 diabetes, obesity, SP right total hip replacement one year out. When preparing for hip surgery, was on basal and bolus insulin, metformin. Had been on a GLP-1 but had diarrhea so he stopped. Was able to, for the most part, follow a lower carbohydrate meal plan but was not active. When he first started coming to us for weight loss to prepare for his surgery, his weight was 304 pounds, BMI 45, A1c 9.9%, Cr 1.87, eGFR 34. We decreased his metformin from 2,000mg/day to 1,000mg day and referred to nephrology. With this change and being motivated for surgery, he lost weight and in 6 months went into surgery having lost 25 pounds with an A1c of 6.9%. Note, due to eating less carbs, he could take less insulin, which seemed to help his appetite. Surgery was performed and he did well.
Patient moved out of town, contacted me 6 months later to tell me he’d like to come back. “I gained my weight back and my hip really hurts.” When he visited, he was no longer on metformin, only basal bolus insulin, which he did not always take regularly. His A1C was 10.6, off metformin, and he regained his weight. He was back to his old ways of eating-high carb and large portions-appetite back with a vengeance.. And…his hip pain was back.
We reviewed his plan. He is now seeing a nephrologist. I discussed his being off the metformin now, perhaps his side effects will be less with the GLP-1 and no metformin. Weight loss being so important for him, I want to make sure he has something to combat his appetite and weight gain from his higher doses of insulin.
Patient was started on a GLP-1. Told me his appetite is improved, back to sharing dinners with his wife rather than each of them having a full meal. Glucose back in his target levels. Time will tell on his A1C and weight. Going to see him tomorrow.
- Many patients will change their habits when they have an event they are looking forward to, such as the birth of the baby, a wedding or a surgical procedure. We often see these patients go back to their old behaviors once the event is over.
- Behavior change is not easy. We as health care providers need to understand this, be nonjudgmental and offer help before, during, and after the event for the lifelong behavior changes that promote health. In the case of diabetes and obesity, when choosing medications, be aware of how certain glucose-lowering meds affect one’s appetite and weight. Offer medications to people that can treat diabetes, appetite and weight even if it takes more than one class, which it usually will. And don’t forget to consider and discuss surgery, procedures, and devices. We have these tools. Let’s use them!
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