Complex, Extended Case - 34 Months
Thomas: age 7.9, Grade 2, NDD Presence Score: 28 (Possible NDD = 12+ )
Pregnancy – Morning sickness 3 wk. - 2 mo., only nausea; bed rest at 2 mo.; emotional stress; Rh negative; placenta previa diagnosed at 13 wk.
Delivery – contractions 21/2 min. for three hours, no dilation; no response to pitocin, 3x; fetal distress; emergency caesarian. Had to be resuscitated at birth; signs of brain damage at birth; jaundiced, under lights; cried 24 hours a day, tactily defensive.
Significant history – Never slept more than 45 min. at a time; allergic to milk; failure to thrive, marked improvement after eliminating gluten – weight gain.
Family History -
Seizure 15 mo. - MMR given with other immunizations
speech began at 27 mo.; skipped crawling, toe walking at 9 mo.; conversation at 4 yr.; headaches from reading; wanted to read but vision therapy results would regress when stopped, therapy very uncomfortable; hypersensitive to light, sound, tactile, taste; speech and coordination deteriorated with fatigue; became fatigued with preschool; resisted fine motor activities and printing.
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W.G. is a 41-year-old white man who was diagnosed with diabetes 15 months ago. He is now beginning diabetes education and medical nutrition therapy (MNT) to gain weight upon referral from his primary care physician. His most recent hemoglobin A1c (A1C) was 5.0%. His current diabetes medication is metformin (Glucophage), 500 mg with breakfast, and he was started on pioglitazone (Actos) 2 weeks ago. He takes no other medications; denies smoking, alcohol, and drug use; and knows of no health problems other than diabetes.
His history revealed a blood glucose level >500 mg/dl at the time of diagnosis, with negative ketones. He checked ketones occasionally in the first year of diabetes, and all tests were negative. His mother had diabetes and was on insulin. He reports that he was on glimepiride (Amaryl) during the first year of diabetes, but that it was discontinued when he was started on metformin.
He complains of frequent urination, hunger, and thirst, which leads to drinking more than 1 gallon of water daily. He is very concerned because he is often agitated, anxious, and impatient to the point that it is affecting his family and work life. He was employed as a technician but is on leave until he feels better. His physician prescribed alprazolam (Xanax) for anxiety, but he did not fill the prescription.
Physical assessment reveals a height of 74 inches, weight of 174 lb, and body mass index of 22 kg/m2. He reports a 35-lb weight loss over the past 15 months of diabetes, including a recent 10-lb weight loss resulting in the referral for MNT.
W.G. reports that his doctor has prescribed a 2,500-calorie daily meal plan. He includes no fruits and no sweets in his diet and has small snacks between meals. He eats a moderate breakfast and lunch and a bigger dinner before his exercise in the evening. He reports that he is not currently able to maintain his usual 1.5 hours per day of lifting weights and playing basketball because of fatigue and lack of energy. Instead, he is exercising in short intervals as he can tolerate. He also reports symptoms of hypoglycemia but has not checked his blood glucose.
Why is this patient losing weight?
Does this patient have type 1 or type 2 diabetes, and does it make a difference in his treatment?
Are other interventions needed considering his symptoms and most recent A1C?
Nutrition assessment revealed that W.G. was eating ∼1,800 calories daily rather than 2,500 calories, as prescribed. He had a good appetite but appeared to be controlling his blood glucose by exercising and eating less than his energy requirement. An 1,800-calorie meal plan would result in weight loss of 1 lb per week for a man of his height, weight, and activity level.
W.G.’s records from self-monitoring of blood glucose (SMBG) showed an average fasting blood glucose of 118 mg/dl, which is consistent with his A1C result of 5.0%. Previous A1Cs were 5.1 and 5.6%.
His classic diabetes symptoms of polyuria, polyphagia, and polydipsia indicated that diabetes education and MNT were not adequate diabetes care for this patient. His physician readily provided a referral to an endocrinologist/diabetologist. A new treatment plan would need to address nutrition, exercise, and medications.
MNT for W.G. began with an increase to 3,000 calories daily to gain weight and to observe the effect of adequate calories on his blood glucose before his appointment with the diabetologist. He was willing to increase his calories but needed education on meal planning. He was educated about calorie points for a 3,000-calorie daily meal plan. One calorie point equals 75 calories, so his 40 daily calorie points were distributed into meals and snacks and based on healthy eating guidelines for diabetes. The meal plan was individualized based on his usual food and eating habits.1 His SMBG results with the 3,000-calorie meal plan showed a postprandial glucose average of 150 mg/dl and a fasting glucose average of 135 mg/dl.
Medication options included increasing the dosages of his current medications, adding new oral medications, or using a combination of oral agents and insulin. W.G. was quite willing to start insulin. Because of his marked symptoms and in light of this willingness, the diabetologist at his first visit discontinued his oral medications and initiated insulin therapy. Insulin was adjusted daily during the first week, and the regimen that allowed for normal blood glucose without hypoglycemia was 10 units of glargine (Lantus) at 10:00 p.m. daily and 4 units of aspart (Novolog) with each meal.
W.G.’s education also included exercise recommendations, including safety issues such as how to recognize and treat hypoglycemia.
Laboratory tests were ordered during his first visit to the diabetologist. Because abnormal thyroid function can affect weight and anxiety, a thyroid-stimulating hormone reading TSH was ordered, with results in the normal range. A fructosamine measurement, which reflects glycemic control over the previous 3–4 weeks, was also in the normal range. Fasting C-peptide, which is a measure of insulin secretion, was 2.5 ng/ml (normal: 1.1–4.0 ng/ml) and islet cell antibodies were 10 JDF units (normal: 0–4.9 JDF units). The basic metabolic profile results were within normal range.
At a follow-up visit 4 months after insulin initiation, W.G. had gained 5 lb, felt more energetic and less anxious, was exercising, and had A1C results of 6.1%. Based on his SMBG results showing occasional hyperglycemia, his insulin was increased to 11 units of glargine at 10:00 p.m. daily and 5 units of aspart with each meal, which is 1/3 unit/kg of body weight. He was advised to continue following a 3,000-calorie daily meal plan, adjusted with exercise.
Recent research has identified a slowly progressive autoimmune diabetes in adult patients. Known as latent autoimmune diabetes of adulthood (LADA) or type 1.5 diabetes,2 it is a slowly progressive form of type 1 diabetes.3 After months to years, affected individuals become increasingly insulin-dependent. This type of diabetes could be the explanation for W.G.’s symptoms and progression of disease. He may have been preventing more severe hyperglycemia by exercising and restricting calories, but this also resulted in weight loss. His A1C and fructosamine results may have been surprisingly low because of his frequent hypoglycemic episodes.
Diabetes management should be based on more than A1C results if the results do not fit with the rest of the clinical picture. In this case, symptoms were the clue to the patient’s actual condition and indicated the need for treatment.
In the presence of frequent hypoglycemia, A1C levels may not accurately reflect the level of hyperglycemia present.
Nutrition, medications, and exercise must each be assessed and addressed individually in diabetes management.
Insulin initiation may be more acceptable to patients than some health professionals believe.4
Judy Friesen, RD, LD, FADA, CDE, is a diabetes educator at the Diabetes Treatment and Research Center of Via Christi Regional Medical Center in Wichita, Kans.
- American Diabetes Association