Sample Case Study Diabetes Type 2

"The new information prescriptions developed by Diabetes UK are simple, clear and easy to understand. They are an additional resource that will allow the person with diabetes to monitor their progress, whilst supporting them to take more responsibility for their condition."

Gail Pasquall, Diabetes Clinical Nurse Specialist

Information Prescriptionsare a simple and practical one page document, which can be tailored to your patients. They contain the crucial information your patients need on how to better manage their diabetes and an action planning section  that they agree with you, their healthcare professional. The document can be printed off and taken away by the patient.

Read the case studies below from healthcare professionals who have used the Information Prescriptions with patients. The case studies highlight:

  • the ease of using the Information Prescriptions in short consultations and the benefits of goal setting.
  • how Information Prescriptions change the nature of the conversation you have with patients, and
  • how  Information Prescriptions can be used as a tool to improve adherence and self management.

Dr Farooq Ahmad, GP, South London

A 57-year-old Asian man who has had diabetes for eight years came to see me for a minor illness. After dealing with this I saw the pop up icon on the right of the screen suggesting I could print an information prescription about his diabetes and the fact that his diabetes control was not optimum. After setting some goals himself and handing over the printed personalised sheet to him, he was really grateful and commented that in his time as a diabetic patient this was the first time anyone did some goal setting with him and gave him a personalised plan for his health. Since then this patient has greatly improved his diabetes control and become more focused about his health.


Dr Stephen Lawrence, GP, Medway

A 56-year-old woman with a six year history of Type 2 diabetes with reasonable glycaemic control but sub-optimal lipid profile and blood pressure levels. It is fair to say that over the six years since her diagnosis I, together with many other healthcare professionals, had contributed to her education regarding cardiovascular risk factors. However, it was is sobering revelation to me that, on issuing her with information prescriptions relating to her blood pressure and lipid profile to personalised interventions, she revealed to me that it was the first time that anyone had explained her results. Perhaps more accurately it was the first time that her results have been presented in the way that she could understand. I would highly recommend this tool to healthcare professionals seeking to optimise the care of their patients with diabetes.


Sandi Kendall, Practice Nurse, South London

A 42 year-old man with Type 2 diabetes diagnosed for about five years. He works night shifts at a packing factory and is currently living with his mother due to not being able to afford his own accommodation.

He has a history of poor compliance in taking his medication as he reports that he has adverse side effects with most of the medication he has been prescribed. He also finds it difficult to remember to take his medication, particularly since he has been doing night shift work.

His attendance at his six month reviews is unpredictable as he normally tends to be asleep during the day because of his job. It is difficult to contact him in order to invite to these reviews. He has a love for fizzy drinks and consumes large amounts even though he has been advised to cut down.

In the first three years of his diabetes he was treated with oral medication. Due to his rising HbA1c he agreed to start a mixed insulin to take twice daily. Due to poor compliance with the insulin regime this was discontinued after two months.

When he attended his review I gave him a copy of his Information Prescription. He was able to see in black and white how his blood glucose levels have risen over the last year. We focused on the need to comply with medication and on how keeping to a healthy diet and weight can effect blood glucose levels and cholesterol. The fact that he could actually make his own goals and write them down gave him something concrete and structured to aim for. This had more impact than just being given verbal advice. He was also able to take this home and have a reminder of the goals he had made.

This patient has started to make these small changes which have had an overall effect in improving his diabetes management, resulting in a reduction in his HbA1c from 82mmols to 65 mmols.

When people are enabled to be in the driving seat of their care they invariably make decisions that are right for them and enjoy better personal and health outcomes. Diabetes UK have developed some promising, desktop-accessible Information Prescriptions. When these are used as part of a caring therapeutic relationship, they will help promote shared decision making, goal setting and support self-management. They are likely to be a welcome tool to help people have more confidence, knowledge, understanding and skills to collaborate in their diabetes care”  

Graham Kramer, GP and The Scottish Government's Clinical Lead for Self Management and Health Literacy

CLINICAL DIABETES
VOL. 17 NO. 3 1999


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CASE STUDIES


Case Study: A 52-Year-Old Woman With Obesity, Poorly Controlled Type 2 Diabetes, and Symptoms of Depression

Marjorie Cypress, MS, C-ANP, CDE


Presentation

A 52-year-old woman with obesity and a 9year history of type 2 diabetes presents with complaints of fatigue, difficulty losing weight, and no motivation. She denies polyuria, polydipsia, polyphagia, blurred vision, or vaginal infections.

She notes a marked decrease in her energy level, particularly in the afternoons. She is tearful and states that she was diagnosed with depression and prescribed an antidepressant that she chose not to take.

She states that she has gained an enormnous amount of weight since being placed on insulin 6 years ago. Her weight has continued to increase over the past 5 years, and she is presently at the highest weight she has ever been. She states that every time she tries to cut down on her eating she has symptoms of shakiness, diaphoresis, and increased hunger. She does not follow any specific diet and has been so fearful of hypoglycemia that she often eats extra snacks.

Her health care practitioners have repeatedly advised weight loss and exercise to improve her health status. She complains that the pain in her knees and ankles makes it difficult to do any exercise.

Her blood glucose values on capillary blood glucose testing have been 170–200 mg/d1 before breakfast. Before supper and bedtime values range from 150 mg/dl to >300 mg/dl. Her current insulin regimen is 45 U of NPH plus 10 U of regular insulin before breakfast and 35 U of NPH plus 20 U of regular before supper. This dose was recently increased after her HbA1c, was found to be 8.9% (normal <6.1 %).

Past medical history is remarkable for hypertension, hypertfiglyceridemia, and arthritis. Current medications include only insulin, lisinopril (Prinivil), and hydrochlorthiazide (Dyazide) with triarnterene.

On physical exam, her height is 5' 1 1/2" and her weight is 265 lb. Her blood pressure is 160/88 mmHg. The remainder of the physical exam is unremarkable.

On laboratory testing, chemistries, BUN, creatinine, and liver function tests are normal. Thyroid function tests and urine microalburnin are also normal.

After an explanation that the increasing insulin doses were contributing to her weight gain and that she would need to decrease her insulin dose along with her food intake to prevent hypoglycemia, the patient agreed to follow a restricted-calorie diet and to decrease her insulin to 30 U of NPH and 10 U of regular insulin twice daily. As she had no contraindications to metformin (Glucophage), she was also started on 500 mg orally twice daily.

She returned to clinic 3 months later, still on the same dose of insulin. She was feeling a little less depressed. She continued to complain of fear of hypoglycemia in the middle of the night and was overeating at night. Despite this she had lost 7 lb. Her blood glucose values were still elevated in a range of 120–275 mg/dl before meals.

She was reassured that further insulin reduction would prevent hypoglycemia. Her insulin dosage was decreased to 25 U of NPH and 5 U of regular insulin twice daily and metformin was increased to 500 mg three times daily. Two months later, she returned to the clinic with an average blood glucose level of 160 mg/dl. Her weight was now 246 lb, and her HbA1c was 7.5%. She was feeling much more energetic, no longer felt depressed, and was able to start a walking program.

Questions

1. Can individuals on high insulin doses successfully lose weight?
2. How does fear of hypoglycernia contribute to uncontrolled diabetes?
3. Does this patient have depression or symptomatic hyperglycernia?
4. What is a possible approach to obese patients with insulintreated, poorly controlled type 2 diabetes?

Commentary

This is a common case that illustrates several issues: high insulin doses contributing to weight gain, fear of hypoglycemia, the similarity of symptoms of depression and hyperglycemia, and the use of combination therapy in type 2 diabetes.

Patients do not often communicate their fear of hypoglycernia and subsequent overeating to their health care providers. When they present with poorly controlled diabetes, practitioners usually increase the insulin dose and advise them to lose weight and exercise. The continual increase in insulin doses to correct hyperglycernia can cause weight gain from cessation of glycosuria, fluid retention, and increased synthesis of fat. When the patient tries to decrease calories, the mismatch of insulin to food intake will result in low blood glucose levels and symptoms of hypoglycemia. The perception of and fear of hypoglycemia is a major problem for individuals treated with insulin, and it is often unrecognized by health care providers.

If insulin doses are not lowered in conjunction with caloric restriction, a cycle begins of hypoglycemia, overeating, further hyperglycernia, increasing insulin requirements, and subsequent weight gain. Even with the use of metformin, which will usually lower insulin requirements, fear of hypoglycemia may persist with increased eating and high blood glucose levels.

The cycle continues as the individual feels exhausted, experiences polyuria, polydipisia, and polyphagia and feels helpless and hopeless. These symptoms can escalate into symptoms of poor selfimage, low self-esteem, low energy, difficulty concentrating, and poor selfcare. Whether these symptoms represent depression or are a result of severe hyperglycernia is confusing and difficult to determine. There is a high incidence of depression in individuals with diabetes, and uncontrolled diabetes can contribute to or exacerbate symptoms of depression.

Once this woman was convinced that lowering her insulin dose would prevent hypoglycemia and that this would enable her to decrease calories and lose weight, she was much more adherent to her treatment regimen. The use of metformin may have helped decrease her hunger and insulin requirements and thus assisted in her weight loss. In this case, the patient's symptoms of depression improved with improved blood glucose control, which resulted in increased energy. She was then able to exercise, further reducing her insulin requirements and leading to successful weight loss.

Clinical Pearls

1. When recommending caloric restriction to obese, insulin-treated patients, decrease insulin doses at the same time. When assessing obese, insulin-treated patients with diabetes, ask about symptoms of hypoglycemia and overeating.
2.  When accessing obese, insulin-treated patients, decrease insulin doses at the same time.
3.  Adding metformin to insulin can help decrease insulin requirements and assist with weight loss.
4. Treating hyperglycernia can alleviate symptoms of depression.


SUGGESTED READINGS

Korzon-Burakowska A, Hopkins D, Matyka K, Lomas J, Pernet A, MacDonald I, Amiel S: Effects of glycemic control on protective responses against hypoglycemia in type 2 diabetes. Diabetes Care 21:283–90, 1998.

Van der Does FEE, De Neeling JND, Snoek FJ, Kostense PJ, Grootenhuis PA, Bouter LM, Heine RJ: Symptoms and well-being in relation to glycemic control in type 11 diabetes. Diabetes Care 19:204–10,1996.

Lustman PJ, Clouse RE: Identifying depression in adults with diabetes. Clinical Diabetes 15:78–81, 1997.

Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson JM, Aponte JE, Schwartz C: Assessment of diabetes-related distress. Diabetes Care 18:754–60,1995.

U.K. Prospective Diabetes Study Group: Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854–65, 1998.


Marjorie Cypress, MS, C-ANP, CDE, is a nurse practitioner in the Lovelace Regional Diabetes Program at Lovelace Health Systems in Albuquerque, N. Mex.


Copyright � 1999 American Diabetes Association
Updated7/99
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