Male, 66 years of age, type 2 diabetes, class III obesity, peripheral neuropathy, multiple toe amputations, hypertension, hyperlipidemia and, most importantly, a 2-year-old granddaughter. Patient taking 100 units long-acting insulin, sulfonylurea, metformin, beta blocker, and statin. Checks glucose once in a while; in the 200 to 270 range when checks. A1C 9.3%.
Patient had no interest in changing lifestyle, had really given up hope, except for the fact he adored his granddaughter. Her picture was the wallpaper of his phone. A picture of the two of them.
Discussed simple eating changes for him, including decreasing his carbohydrate intake. He had no interest. Informed him some of his meds were most likely making him hungry and there are medications that can decrease his appetite and also help his blood sugar. His eyes and ears perked up. He was interested.
Knowing we had a lot to do and his glucose was so elevated, together we discussed changing his pill from a sulfonylurea to an SGLT-2 inhibitor. In time if/when his glucose started getting lower we could look at decreasing his insulin. Talked candidly with him about his reason to make some changes…for him it was the granddaughter.
A week later, check in on patient. He said he started the new pill, had been urinating a lot more, which we warned him he might, but he had not been checking his blood sugar. I reminded him that insulin can increase his hunger, but the only way we could consider decreasing it was if he checked his blood glucose regularly. We can’t adjust without having numbers. I reminded him he’s doing it for his granddaughter. He said he would do it.
The next part of the plan is to add a GLP-1 agonist, which hopefully will decrease his appetite and his glucose and allow him to decrease his insulin. One step at a time.
- Find out what is important in a person’s life.
- Use that reason to help motivate patients.
- What motivates a person to change is very personal and should be taken in consideration when making treatment choices. Remind each patient of what they said motivates them to change.
- Certain medications that lower glucose can increase weight and hunger. People who are hungry won’t choose to eat less, at least for very long.
- When working with people who have type 2 diabetes, overweight or obesity, choose medications that not only lower glucose but also have the “side effect” of lowering appetite and weight.
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