Disasters Averted

I have a patient who has type 2 diabetes. He was started on long-acting insulin 8 months ago. Before adding the insulin, he was taking a daily GLP-1. He had experienced diabetic ketoacidosis (DKA) while on a SGLT-2, and did not tolerate metformin due to GI side effects. Therefore, these …

As we know, the holidays are very tough for many of our patients who have diabetes and/or obesity. They may have made some changes -- big changes -- in their eating habits, only to get in trouble over the long holiday season, then have a very difficult time getting back on track. The long holiday season can be a disaster to their health. I have found that for most, having leftovers at home wreaks havoc.

Young woman, 15 years of age, presented with class II obesity (BMI 37), irregular periods, hirsutism, and continuing to gain weight. Her first visit was with her mother. We met and discussed the possibility of her having polycystic ovarian syndrome because of her symptoms. We confirmed with labs.

Man, 32 years of age, of Asian Indian descent, family history of type 2 diabetes, BMI-28,  blood pressure 142/84, WC-92cm visited for annual physical. Although the patient has not at this time been diagnosed with type 2 diabetes, the numbers and history were revealing that he is at increased risk. Not just because of his family history but also his BMI and WC. We discussed the importance of this person’s weight with him. In discussing this, we talked about making some changes in his meal plan and increasing his activity.

Man, 69 years of age, of Italian descent, “a numbers guy,” has type 2 diabetes, A1C 8.9%, taking a GLP-1 daily, and metformin 1,000mg twice daily. Blood pressure was managed, in target range of ~110-120/70-80, HR 76-82, weight-BMI 25.3. Had been on an SGLT-2, but developed DKA, so he can no longer take SGLT-2’s nor did he want to. Checked fasting glucose some mornings a week but not every day because he did not like to stick his finger. He really didn’t want to deal with his diabetes. Due to his recent illness, he was willing to try something new and different, especially since I told him it’s about numbers and he would not have to regularly stick his fingers.

It’s not unusual for people who have excess weight or obesity to have many barriers to overcome in managing their weight. In my experience, the holiday season can be a big barrier. For much of the world, holidays are associated with food; not just food but an overabundance of food. And for many, the weather is cold at this time of the year, which doesn’t help with being active.

A 60-year-old woman with type 2 diabetes and no serious health complications began an exercise program as part of a research study. It involved doing an hour of moderate aerobic exercise three days per week in a supervised setting (at a local Y). She showed up to all the training sessions, stating about a month into the 12-week training program that she was so happy to be active again, that she felt so much better physically and mentally and felt like she had “found herself” again.

Male, 68 years of age, type 2 diabetes, Italian, on long-acting insulin and GLP-1. Basal glucose levels are within target as are most post-prandials except every night after dinner. We have talked several times about lowering carbs, which he has done during the daytime, but has difficulty cutting back on dinner meal. We had in the past discussed taking rapid-acting insulin for meals, but he refused. After two weeks, patient sent me his CGM results. Even he started getting concerned about his evening post-prandial levels. Rapid-acting insulin added before dinner and post-prandials are now in target range. He has not once complained about taking the rapid-acting insulin before dinner.

I received a call and glucose numbers from patient who has type 2 diabetes, usually with hyperglycemia, never hypoglycemia. I noticed there was at least a 12-hour span since the last glucose reading. His glucose levels after the over-12-hour lag showed hypoglycemia during the  night when the numbers start showing. His glucose averaged 53 during that time, but it has been running 150 and over, and we have been slowly increasing his insulin.

Patient is male, 48 years of age, type 2 diabetes with hyperglycemia for eight years, class III obesity,  and very symptomatic GERD. Patient planned to have laparoscopic sleeve gastrectomy. I asked him why he chose that particular surgery. He said, "Because it's less invasive." I asked if his surgeon told him the sleeve gastrectomy could increase his GERD, and is not as effective for the treatment of type 2 diabetes nor for weight loss as is a bypass. He said, "No, the surgeon just left it to my choice. I said I wanted the sleeve and he was good with that."