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Managing Clinical Problems in Diabetes, Case Study #20: Insulin Fears and a Lack of Education

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mr. AT self-referred to the diabetes center for advice when he was told he needed insulin by his GP. “I have type 2 diabetes which is reasonably controlled on DiaBeta (glibenclamide) but the dose has been gradually increased and the doctor told me I need insulin. I do not want to take insulin. I started on the Atkins diet 4 weeks ago. It is very difficult to stick to but I have lost some weight and my blood glucose now averages about 126mg/dL. (7 mmol/L.) I stopped DiaBeta because I had dizzy spells. I want to know whether 80 g of carbohydrate a day is enough?”…

Dietitian

Although some people lose weight and have improved blood glucose control on the Atkins diet and other low-carbohydrate diets, reducing carbohydrates to less than 130 g/day is not the standard of care that is recommended for people with diabetes. The long-term consequences are not clear (Sheard et al.2004) and it is very difficult to sustain.

Diabetes educator

Mr. AT needs a careful explanation about the progressive nature of type 2 diabetes and the eventual need for insulin. The issue needs to be approached with sensitivity — it is very difficult to argue with his personal successful experience (weight loss and reduction in his blood glucose). Sustaining the Atkins program in the long term may be more difficult. It is important to explore the reasons why he does not want to commence insulin, so that his concerns can be addressed. 

The dizzy spells were possibly hypoglycemia associated with the reduction in carbohydrate. His medicines should be reviewed and he needs advice about how to recognize and manage hypoglycemia. If he has also commenced an exercise program he will need advice about avoiding hypoglycemia during and after exercise.

It is important that he continues to monitor his blood glucose.

Nutritional management and physical activity

Key points
  • Good nutrition and appropriate physical activity are essential to good health and diabetes management.
  • Nutrition and physical activity are still essential when oral glucose-lowering agents and/or insulin is required.
  • Malnutrition is common despite obesity, especially in older people.
  • People’s food beliefs and the social and cultural aspects of food need to be considered.
  • People who present with other comorbidities such as disordered eating, renal or gastrointestinal diseases require assessment by a dietitian.
  • Changing people’s eating behavior is difficult — behavioral approaches, motivational interviewing, goal setting, and lifestyle counseling are essential to dietary change.
References

American Diabetes Association (2006) Nutrition recommendations and interventions for diabetes – 2006. A position statement. Diabetes Care 29(9): 2140–2157.

Baines S, Roberts D (2001) Undernutrition in the community. Australian Prescriber 24(5): 113–115.

Bouchard L, Drapeau V, Provencher V et al. (2004) Neuromedin beta: a strong candidate gene linking eating behaviours and susceptibility to obesity. American Journal of Clinical Nutrition 80(6): 1478–1486.

Brand-Miller J, Foster-Powell K, Colagiuri S et al. (1998) The GI Factor. Hodder, Sydney.

Chagnon YC, Perusse L, Weisnagel SJ et al. (2000) The human obesity gene map: the 1999 update. Obesity Research 8: 89–117.

Conn V, Hafdahl A (2007) Metabolic effects of interventions to increase exercise in adults with type 2 diabetes. Diabetologia 50: 913–921.

Egger G (2007) An interview with Professor Gary Egger. Part 1. Weight Management in Review 5: 1–4.

Howe M (2007) Weighty issue. Australian Doctor 16 March: 43. International Diabetes Federation (IDF) (2006) Incidence of diabetes. Diabetes Atlas 2 (www.eatlas.idf.org/Incidence/).

Knowler WC, Barrett-Connor E, Fowler SE et al. (Diabetes Prevention Program Research Group) (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention and metformin. New England Journal of Medicine 346: 393–403.

Lindström J, Louheranta A, Mannelin M et al. (Finnish Diabetes Prevention Study) (2003) Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 26(12): 3230–3236.

Marks S (2000) Obesity management. Current Therapeutics 41: 6.

Mooradian A, Failla M, Hoogwerf B et al. (1994) Selected vitamins and minerals in diabetes care. Diabetes Care 17: 464–479.

Moyad M (2007) Fad diets and obesity. Part 1: measuring weight in a clinical setting. Urology Nursing 24(2): 114–119. National Health and Medical Research Council (NHMRC) (1999)

Dietary Guidelines for Older Australians. NHMRC, Canberra. 

Recommended reading

Apelqvist J, Bakker K, Van Houtum W et al. (2000) The international consensus and practical American Diabetes Association (2006) Nutrition recommendations and interventions for diabetes – 2006. A position statement. Diabetes Care 29(9): 2140–2157.

British Diabetic Association Report (1992) Dietary recommendations for people with diabetes. Diabetic Medicines 9: 189–202. Dietary Guidelines for all Australians (2003) Australian Government Publications, Canberra.

National Health and Medical Research Council (NHMRC) (2003) Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents. NHMRC, Canberra.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion #21

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath