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Managing Clinical Problems in Diabetes, Case Study #26: Avoiding Insulin Weight Gain

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

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Mr. XYZ was referred by his GP.

“I saw Mr. XYZ today for a routine checkup. He is basically well but is complaining of putting on a lot of weight since you started him on insulin 6 months ago. He said about 15.5 lbs (7 kg.) He is trying with his diet and exercise, and his glucose control is reasonable. Can you please advise him what to do?”

Diabetes educator

The UK Prospective Diabetes Study (UKPDS) showed that every 1% reduction in HbA1c reduced the risk of microvascular complications by 30% but increased the risk of hypoglycemia by 25% and was associated with an average weight gain of approximately 4.5lbs (2 kg/)1% reduction in HbA1c (UKPDS 1998). Putting on weight is one of the reasons many people with type 2 diabetes do not want to start insulin. Some weight gain occurs initially when the blood glucose control improves and the glucose that was previously excreted in the urine begins entering the cells. This could account for the weight increase Mr. XYZ describes.

Sulphonylureas and thiazolidinediones also increase weight, and consideration could be given to stopping these medicines if he is still taking them. Another possibility that needs to be considered is that he might be having hypoglycemia associated with his exercise and eating more food to treat it, which in turn contributes to weight gain. If that is the case, his insulin regime may need to be adjusted and education about exercising safely provided.

I would check whether he is also taking other medicines that contribute to weight gain such as some atypical antipsychotic medicines, and check his thyroid status.

I would refer him to a dietitian for dietary advice and suggest exercise strategies such as wearing a pedometer, with the aim of gradually increasing his exercise level, and educate him about caring for his feet during exercise.

Health assessment, management targets, and deciding on a management plan

Key points

Individualized holistic assessment is essential to planning appropriate care for people with diabetes.

  • Mental, spiritual, and general health status should be monitored as assiduously as diabetes status.
  • The individual must be involved in planning and monitoring his or her care.
  • Collaborative, structured multidisciplinary team care is essential to achieving optimal outcomes and continuity of care.
References

Borch-Johnsen K, Wenzel H, Vibert G et al. (1993) Is screening and intervention for microalbuminuria worthwhile in patients with IDDM? British Medical Journal 306: 1722–1725.

Boulware LE, Marinopoulos S, Phillips KA et al. (2007) Systematic review. The value of the periodic health examination. Annals of Internal Medicine 146: 289–300.

Cohen M (1996) Diabetes: A Handbook of Management. International Diabetes Institute, Melbourne.

Del Prato S (2002) In search of normoglycaemia in diabetes: controlling postprandial glucose. International Journal of Obesity 26:s 9–17.

Del Prato S, Tiengo A (2001) The importance of first-phase insulin secretion: implications for the therapy of type 2 diabetes. DiabetesMetabolism Research Review 17: 164–174.

Guo JJ, Keck PE Jr, Corey-Lisle PK et al. (2006) Risk of diabetes mellitus associated with atypical antipsychotic use among patients with bipolar disorder: a retrospective, population-based case-control study. Journal of Clinical Psychiatry 67: 1055.

Hanefeld M, Fischer S, Julius U et al. (1996) The DIS-Group: risk factors for myocardial infarction and death in newly diagnosed NIDDM: the diabetes intervention study, 11-year follow-up. Diabetologia 29: 2072–2077.

Hedman C, Lindstrom T, Arnqvist H (2001) Direct comparison of insulin aspart and insulin lispro in patients with type 1 diabetes. Diabetes Care 24: 1120–1121.

Jenkinson C, McGee H (1998) Health Status Measurement: A Brief But Critical Introduction. Radcliffe Medical Press, Oxford, pp 61–63.

Natrass M (2002) Improving results from home blood-glucose monitoring: accuracy and reliability require greater patient education as well as improved technology. Clinical Chemistry 48: 979–980.

Oates D, Berlowitz D, Glickman M et al. (2007) Blood pressure survival in the oldest old. Journal of the American Geriatrics Society

 
Recommended reading

Abrahamson M (2004) Optimal glycaemic control in type 2 diabetes mellitus. Fasting postprandial context. Archives of Internal Medicine 164: 486–491.

Australian Medicines Handbook (2006) National Prescribing Service, Adelaide.

Bergenstal RM, Gavin JR (2005) The role of blood glucose self-monitoring in the care of people with diabetes: report of a global consensus conference. American Journal of Medicine 118(9a): 1S–6S.British Diabetes Association (1999) Guidelines for Practice for Residents with Diabetes in Care Homes. Diabetes UK, London. Diabetes Control and Complications Trial (DCCT) Research Group (1993) Effects of intensive insulin therapy on the development and progression of long-term complications of IDDM. New England Journal of Medicine 329: 977–986.

Dunning T (2003) Care of People with Diabetes: A Manual of Nursing Practice. Blackwell Publishing, Oxford.

Dunning T (2005) Nursing Care of Older People with Diabetes. Blackwell Publishing, Oxford.

 

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 #27

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