Disasters Averted

Male, 21 years of age has class III obesity, binge eating disorder, fatty liver, and asthma, and was recently diagnosed with type 2 diabetes. It is his freshman year at a college away from home. He eats in the cafeteria, and has no refrigerator or stove in his room. He visits today after not taking metformin or GLP-1 agonist since at starting school. He is under a lot of stress and states the food at school is terrible, unhealthy, and not diabetes-friendly at all. Note, he has been taught a lower carb meal plan. He says he is not taking Glucophage or Victoza; each of them at low doses gives him terrible diarrhea. He states he checks his glucose twice a week, with fastings in the 90-100 range. He is up 10 pounds since our last visit in September.

I work in obesity medicine. As many of us know, losing weight isn't the problem for most, but weight regain is. As the saying goes for many, you can't be rich enough or thin enough. Many of our patients come in with unrealistic goals regarding their weight loss, and don't give themselves enough credit for the weight they have lost. Many, for many reasons, regain.

Many of our patients have intolerable GI side effects from metformin. We use ER to try to decrease these, but that doesn’t always work. If they have these symptoms, I recommend they take it slow and take it after they eat. If they still have problems, I recommend they break the tablet to 250mg, even though the label may say one shouldn’t break the tablet.

It’s never too early to start talking about the holidays with our patients. For some, it’s a holiday almost every night. Man, 76 years of age, visits with his wife for obesity and type 2 diabetes management. Despite diabetes education, including medical nutritional therapy and medication, he was not losing weight nor were his glucose levels improving…especially his bedtime glucose levels.

Female, 76 years of age, type 2 diabetes, well managed, A1C 6%, on metformin 500mg daily. Patient also has well-managed hypertension, hyperlipidemia, and osteoporosis. She lives alone. Wants tighter diabetes control. Was having hypoglycemia when on 500mg twice daily. Requests, almost begs me, to increase her medication. States she’s afraid she’s going to have kidney problems.

Woman, 64 years of age. History of Class II Obesity and hyperlipidemia. While she had obesity, her glucose levels were elevated. A1C 8.2%. She followed a lower carb meal plan, was active, took metformin and a GLP-1, a statin and an ACE-I. She lost 22% total body weight. A1C then remained in the 6-6.5% range for 3 years on this treatment plan. Over the past 8 months, due to insurance and her statement of denial that she ever really had diabetes, she stopped taking her glucose-lowering medication, statin, and ACE-I, wasn’t as strict with meal plan or activity, and stopped checking her glucose, but did not gain back her weight.

I am a diabetes educator and certified foot care nurse. Through the years, I’ve learned that most topics we teach people who have diabetes are really topics every person should know about. I teach patients how to care for their feet, how to prevent foot problems, and how to treat them if they should have problems.

I received a call from a physician’s office regarding a patient who needed education as soon as possible. Her A1C had risen to 7.5 and at 64 years old, the patient needed to make changes. The only problem: the patient was blind. The patient lived alone with her Seeing Eye dog and was assisted by her brother. She lived a relatively normal life despite her blindness, working a clerical job and visiting the gym 2 days per week. As an educator, I had never dealt with a truly sightless individual and was feeling ill-equipped to take on this challenge. The majority of the diabetes patients in our small rural clinic have sight enough to manage their disease. I started to think of all the things we take for granted when teaching our patients, such as lancing their fingers, reading a label, even simply putting the correct amount of food on their plate. All that was thrown out the window. How did I help this patient to see her diabetes care?

College student, type 1 diabetes, wears a pump and CGM. She has good family support. Several of her family members get her CGM readings on their phone. She received a call from her mother about 2:45 am waking her up. She told her to treat her low blood glucose, which patient reported to be 41.

Female 43 years of age. Type 1 diabetes/insulin resistant, hyperglycemia, increasing insulin to manage glucose, but not covering well. Increasing appetite and gaining weight. GLP-1 (Victoza) added at 1/2 recommended start dose for people who have type 2 diabetes, which is 0.6mg, so patient started at 0.3mg daily. Patient started having hypoglycemic reactions, most often postprandially and nocturnally.