Diabetes: The tipping point to a metabolic meltdown

September 1, 2009

Follow the treatment and education of a newly diagnosed type 2 diabetes patient: taking a case history, making a diagnosis, and teaching the patient how to monitor and control blood sugar.

Note: The publications in Advanstar Communications' Life Sciences Group and its Web portal, http://ModernMedicine.com/, are collaborating in a coordinated, interdisciplinary initiative to address this major public health issue-cardiometabolic disorders and weight. To read the joint introductory articles in this series, visit the following links:

Cardiometabolic Disorders and Weight: Action for Outcomes

http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=621950

http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=621955

JON CHU, A DIVORCED MALE, AGE 54, is a booking agent for a local jazz club in a university town in the Midwest. He recently attended a local health fair and was found to have a fasting plasma glucose (FPG) level of 200 mg/dL. Upon questioning by the nurse, Jon said he didn't smoke; his blood pressure (BP), just measured, was 128/78 mm Hg; and he was unaware of his cholesterol level. The nurse noted he appeared to be overweight and asked if he had experienced any classic symptoms of diabetes, such as polyuria, polydipsia, polyphagia, or unexplained weight loss.1 He denied noticing any of these, but did comment that his older sister had type 2 diabetes. The nurse reinforced the need for Jon to find out if he also had type 2 diabetes, recognizing he had several risk factors. She explained that people with this disease may remain asymptomatic for years, but during that time, complications can begin to develop.1,2 He was advised to see his "regular" healthcare provider so a repeat FPG could be performed, one of the definitive criteria for the diagnosis of type 2 diabetes.2,3

A week later, Jon followed through with the nurse's recommendation. His FPG on this occasion was 147 mg/dL. His hemoglobin A1c-a measurement of blood glucose control for the previous three months-was elevated, at 8.7%.3 A fasting lipid profile (FLP) revealed the following: total cholesterol 198 mg/dL; low-density lipoprotein (LDL) 110 mg/dL; high-density lipoprotein (HDL) 36 mg/dL; and triglycerides 146 mg/dL. Serum chemistries, including liver function tests and creatinine, were all within normal limits, as was his albuminuria, and a calculated glomerular filtration rate was pending.1 His BP was 128/76 mm Hg, resting heart rate was 86 bpm, and he had a normal resting EKG. He denied any symptoms of overt cardiovascular disease (CVD), but said, "I think my sister takes medicine for heart pain." Other than that, he was unaware of any family history of CVD. His calculated body mass index (BMI) was 28, indicating he was overweight at 189 pounds on his 5'9" frame.4

He did not have any signs or symptoms of peripheral neuropathy and used reading glasses. He denied having any known allergies or ever having received a flu or pneumococcal vaccine.

Based on his two FPG readings and associated risk factors, he was diagnosed with having type 2 diabetes. Per current recommended guidelines, he was prescribed the following medications: metformin, a statin, and aspirin.1,2,3

ASSESSMENT As the senior registered nurse in the office, you are asked to meet with Jon to explain and arrange for the further components of his initial evaluation, and to assist in formulating an individualized plan to help him manage his diabetes. Before you can do this, however, you need to gather some more information about his background and lifestyle.1,3

You learn he dropped out of college after five semesters and does not work a "9-to-5" job; rather, he is "on the go" during most of his waking hours. He gets little exercise except for that attained during his regular daily activities-going up and down stairs, walking to his car, carrying out activities of daily living, etc. He doesn't smoke, but admits to drinking four to five beers per day, and three cups of coffee in the morning. He lives alone and eats most meals out and at irregular hours. He consumes primarily a Western diet, characterized by a high intake of red and/or processed meat, high-fat dairy products, and lots of sweets and desserts.1 He has a wide circle of friends and describes himself as "very social"; he's been divorced for 10 years and does not have children. He denies any history of depression or sexual dysfunction. He says that when he feels stressed, meeting with his buddies and "drinking some beers" usually helps, and that he sleeps about five to six hours per night. He admits he's never been good at taking pills and has not been successful in the past in maintaining a healthy level of physical activity due to his hectic schedule, but acknowledges he needs to lose weight. He has a high-deductable health insurance plan with limited copay and medication coverage, and admits to feeling a tad overwhelmed with his diagnosis, as he's aware of some of its associated complications. He says he doesn't know much else about type 2 diabetes and that he's never really been sick.

NURSING DIAGNOSIS5,6

DESIRED OUTCOMES/EVALUATION CRITERIA5,6

PLANNING AND IMPLEMENTATION5,6,7

EVALUATION Following the initial diagnosis and discussion with you, Jon did meet with a dietitian twice to begin education related to MNT, and he has another appointment with her in a few weeks. An ophthalmologist performed an initial dilated and comprehensive eye examination, which revealed the absence of retinopathy; an appointment with his dentist was scheduled for a future date. He had called once after his initial meeting to ask some questions regarding use of his glucometer and commented that he was "trying" to make the recommended lifestyle changes, especially in the area of adjusting his caloric intake.

He kept his three-month follow-up appointment with his primary healthcare provider, and you met with him again at that time. He was able to define type 2 diabetes, identify his risk factors, and explain in his own words why he was taking each medication. His BP was 128/78 mm Hg; A1c was measured at 7.5%; HDL 38 mg/dL; LDL 98 mg/dL; and he had lost 1.5 pounds. He said he was walking once a day for 10 minutes, sometimes longer; but hadn't yet "fit in" walking two times a day, nor had he incorporated any resistance-type exercise into his "routine." He had not reviewed the DVDs you had provided. He had cut back on his alcohol intake, but not to the recommended two drinks per day. Although he was able to describe why it was important, he said he didn't "get around" to checking his BG every day, but he had kept a record and was checking it at least once every other day. He was taking his medications as prescribed, and thus far he was able to afford them, but said as his income is dependent on getting the gig, he did have some anxiety about maintaining this expense. Jon said he had spoken several times with his sister about their shared diagnosis and that she was a valuable and useful source of information and support.

You praise and reinforce the positive changes Jon has made, and explain that his weight, lipids, and A1c are moving in the right direction, repeating again the goals for each of these parameters. You discuss strategies for increasing his activity and limiting his alcohol intake and explore potential barriers to meeting the predetermined goals. Throughout the meeting, you provide support by acknowledging that learning to live with diabetes and making multiple lifestyle changes is indeed challenging. You encourage him to continue to make appropriate choices regarding his health, repeating the vital need to stave away serious complications. You refer him to the office practice social worker in order to explore available resources to help pay for medications, and to subsidize participation in a medically monitored, structured exercise program. You explain that he needs to continue taking his current medications and that at his next three-month appointment, pending his A1c, a decision will be made regarding the need to add a second oral agent to help achieve and sustain BG goals. In the meantime, he can call anytime to ask questions or express concerns about his health.

Learning to live with diabetes requires patience and commitment from both the patient and the healthcare team to ensure that the disease management principles are met and sustained throughout life.

Morbidity involves both macro-and microvascular disease, so interventions to limit end organ damage are the focus of care for these patients. The major priority for diabetic patients, especially those with type 2, is prevention of CVD, which can be significantly reduced with aggressive control of the important risk factors-abstinence from smoking and management of hypertension and lipids. Glycemic control (A1c less than 7%) has been shown to significantly minimize risks for nephropathy, neuropathy, and retinopathy. Weight control, appropriate food choices, and participation in the recommended amount of exercise and physical activity will have a positive impact on minimizing the occurrence of the aforementioned complications, as well as improving overall insulin utilization.