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Diabetes Mellitus 2 Case Study

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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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care.1

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses.3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues.4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes,5 in specialized diabetes foot care programs,6 in the management of diabetes in pregnancy,7 and in the care of pediatric type 1 diabetic patients and their parents.8,9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients.10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

Case Presentation

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health.11

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

  • Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m2

  • Fasting capillary glucose: 166 mg/dl

  • Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

  • Pulse: 88 bpm; respirations 20 per minute

  • Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

  • Thyroid: nonpalpable

  • Lungs: clear to auscultation

  • Heart: Rate and rhythm regular, no murmurs or gallops

  • Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

  • Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

  • Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

  • Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

  • Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

  • Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

  • Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

  • Lipid panel

        • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

        • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

        • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

        • Triglycerides: 177 mg/dl (normal: <150 mg/dl)

        • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

  • AST: 14 IU/l (normal: 0–40 IU/l)

  • ALT: 19 IU/l (normal: 5–40 IU/l)

  • Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

  • A1C: 8.1% (normal: 4–6%)

  • Urine microalbumin: 45 mg (normal: <30 mg)

Assessment

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

  • Uncontrolled type 2 diabetes (A1C >7%)

  • Obesity (BMI 32.4 kg/m2)

  • Hyperlipidemia (controlled with atorvastatin)

  • Peripheral neuropathy (distal and symmetrical by exam)

  • Hypertension (by previous chart data and exam)

  • Elevated urine microalbumin level

  • Self-care management/lifestyle deficits

        • Limited exercise

        • High carbohydrate intake

        • No SMBG program

  • Poor understanding of diabetes

Discussion

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain.12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain.12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%.13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy.14

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test.11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Summary

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes.15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Footnotes

  • Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

  • Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

  • American Diabetes Association

References

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