Patient, type 2 diabetes and obesity, on basal/bolus insulin with an A1C of 10.7%. He was not following any particular meal plan, and was, for the most part, consuming a high carb diet.
Diabetes education was provided, including how carbohydrates affect glucose levels, lowering his carbs, and ideal target glucose levels. We told him we did not expect him to reach these levels right away, in fact we wanted to see how he adjusted to the change in diet without low glucose levels, so we recommended he decrease both his basal and bolus insulin, with clear instructions on how much insulin to take.
Upon his return visit in two weeks, we found out that for the first week his glucose levels were much improved, fastings in the 110-130 range and post prandials in the 130-140 range. There was one post prandial glucose level of 182mg/dL. Then, he started having lows. When I asked him if he had skipped meals or why he thought his blood glucose levels were low, he said he increased his prandial insulin doses. We instructed on the importance of not adjusting insulin due to a one-time number.
His weight was down 2 pounds. He thought he should have lost more than the 2 pounds. We informed him that many times, with improved glucose levels, a weight gain is not unusual and why. In his case the fact he lost 2 pounds was showing he was responding well to treatment using a weight-centric approach.
We commended him on the great work he had done thus far and recommended he follow the insulin recommendations we originally ordered. We asked him not to make changes without checking with us first. He agreed.
- When teaching glucose targets/goals, teach it may take time to reach these levels.
- When assessing glucose levels, and changing treatments, assess patterns (pattern management) rather than a one-time numbers
- Although we do teach patients how/when to titrate, make sure to clearly teach what to do, if anything, to treat a one-time high
- A weight-centric approach to diabetes management includes treatment modalities to improve glucose levels without weight gain, and in time hopefully a weight loss.