Case Presentation:   Following a referral from his family practice physician, a 58-year-old Caucasian man and his wife present for a visit to an endocrinology clinic for diabetes education.  Six months earlier, the patient was found to have a fasting glucose of 138 mg/dL at his annual physical exam.  A follow-up fasting lab test revealed a glucose level of 132 mg/dL and an A1C of 6.5%, confirming a diagnosis of type 2 diabetes.  The patient has a 15-year history of hypertension and hyperlipidemia, which are currently controlled with quinapril HCl 20 mg twice daily, nifedipine 60 mg daily, and simvastatin 40 mg daily.  His blood pressure at his physical was 118/76 mmHg and his lipid profile results were: Chol 190 mg/dL, TG 123 mg/dL, LDL 95 mg/dL, and HDL 43 mg/dL.  Kidney and liver function were normal.  He was diagnosed four years ago with obstructive sleep apnea and feels he is getting relief with use of a C-PAP machine while sleeping.  At the time of diagnosis, his weight was 227 pounds (BMI 30.8 kg/m²).

The patient admits he was shocked and in denial when his physician revealed 6 months ago that he had type 2 diabetes.  He admitted being a bit overweight, but said he did not feel unwell.  He and his wife were told by his doctor that diabetes is a progressive disease but that he could delay starting medication if he changed his diet and increased his activity level.  A referral to a diabetes self-management education (DSME) class was offered at that time but the patient refused, stating that he and his wife would educate themselves. 

His concerned wife immediately started restricting his food portions, avoiding all foods that contained sugar.  They walked together in the evenings for several months but stopped when the weather turned colder in winter.  The patient started to rebel against his restricted diet at home and started eating more during the day at work.  He would occasionally stop at a fast food restaurant on his way home from work for a burger and fries, which he rationalized as acceptable once in awhile, because his dinner would be low in calories.  At a follow-up visit with his primary care physician, he was surprised to learn that his A1C had increased to 6.9% and he had gained 8 pounds (BMI 31.8 kg/m²).  His blood pressure was 128/84 mmHg and his lipid profile reflected a small undesirable change in each measurement: Chol 202 mg/dL, TG 160 mg/dL, LDL 105 mg/dL and HDL 42 mg/dL.  He admitted he had not been doing self-monitoring of blood glucose (SMBG) at home. The patient recognized that his lack of attention to his condition was putting his health at risk and creating a strain on his marriage.  His physician again recommended he attend a DSME program and also suggested some individual sessions with a registered dietitian for medical nutrition therapy (MNT).  The physician acknowledged that making lifestyle changes can be difficult and success is enhanced when a patient works with a dietitian to come up with an individualized diet.  He was told that if he could not improve his glycemic control with lifestyle changes he would need to start medication to adequately treat his diabetes.  The patient agreed he was willing to give it a more concerted effort with lifestyle and would return for lab work in three months.   

Case Presentation:   A 36-year-old Caucasian woman presents for a visit 2 days after discovering she is pregnant through use of a home pregnancy test.  The patient was diagnosed 4 years ago with polycystic ovary syndrome (PCOS) when she and her husband sought medical evaluations after a year of infertility.  Three years ago she learned she had type 2 diabetes and was started on metformin treatment, with addition of glyburide 2 years ago.  There is no evidence of retinopathy or other known complications of diabetes.  She was diagnosed with mild hypertension last year and started on an ACE inhibitor (lisinopril).

Her pregnancy is confirmed with a serum pregnancy test. Based on the start date of her last menstruation, she is at 3 weeks’ gestation. Her current medications include metformin 1000 mg twice daily, glyburide 5 mg twice daily, lisinopril 10 mg daily, and folate 400 mcg daily.  Her fasting glucose this morning was 118 mg/dL.  At this visit, her A1C level is 6.7% and her blood pressure is 115/68 mmHg.  Her height is 62 inches; her weight of 206 lb (BMI 38 kg/m²) reflects a weight loss of 10 lb since her clinic visit 3 months earlier.  The patient states she has been seeing a dietitian to improve her diet and has been walking 1-2 miles daily to lose weight and improve her glycemic control.  She performs self-monitoring of blood glucose (SMBG) every morning before breakfast and occasionally 2 hours after eating.  She and her husband still yearn to have a child—she experienced a spontaneous abortion early in the first trimester 3 years ago and is highly motivated to do whatever is needed to improve her chances of having a healthy baby.   

Case Presentation:   A 17-year old white male with a 3-year history of type 1 diabetes presents for a clinic visit after experiencing in the previous month two severe hypoglycemic reactions that required assistance. The patient is an active high school junior who plays on the varsity basketball team; basketball season started 6 weeks ago.  At this visit, his height is 74 inches and he weighs 170 pounds (BMI 22 kg/m²).  He has been using an insulin pump, a continuous subcutaneous insulin infusion (CSII), to deliver his insulin for the previous two years.  His A1C is 7.3%.  The patient consistently monitors his blood glucose 4-6 times daily and results range from 62-190 mg/dL during the day.  His problem times for hypoglycemia are typically in the late evening and during the night, and usually occur following afternoon basketball practice or after a strenuous evening basketball game.

The patient currently takes a rapid-acting insulin and approximately 50% of his total daily insulin is administered as basal insulin.  He uses four basal rates (1.4 units/hour [midnight-4 am], 1.8 units/hour [4 am-7 am], 1.7 units/hour [7 am-3 pm] and1.5 units/hour [3 pm- midnight] and insulin boluses for meals.  The boluses are based on counting carbohydrates, where 1 unit of insulin is given for every 10 grams of carbohydrate consumed.  The insulin pump is detached during both practices and games (for approximately 2 hours each time), so insulin is not being infused during exercise.  Practices are less strenuous than games and occur in the afternoon immediately after school.  The patient finds that if he does not drink a sports drink that contains approximately 15 grams of carbohydrate during his practices, his blood glucose can drop into the 50-70 mg/dL range directly after exercise.  After playing a strenuous evening game, the patient often finds his blood glucose will increase to a range of 160-180 mg/dL, so he drinks only unsweetened beverages during and immediately after the game.  If his blood glucose is below 100 mg/dL before bed, he eats a snack that contains carbohydrate, usually a bowl of cereal or a granola bar, and does not bolus for these carbohydrates consumed.  Despite this, his blood glucose has been decreasing to levels as low as 40 mg/dL during the night while he is asleep.  His parents are waking him every 2-3 hours to check his blood glucose and have decided that he will have to stop playing basketball if his hypoglycemia does not improve, since they feel this is putting his health at risk and creating too much stress on the family.   

Case Presentation:   A 37-year-old Caucasian male with a 17-year history of type 1 diabetes presents for a follow-up appointment after a severe hypoglycemic reaction, for which he required assistance but not hospitalization.  He remains on the insulin regimen he was started on at the time of diagnosis: regular insulin prior to breakfast and supper (approximately 5 to 10 units depending on his blood sugar and planned carbohydrate intake) and two injections of NPH insulin (16 units pre-breakfast and 15 units pre-supper).  He has insisted on keeping this regimen, out of fear that making a change would increase his hypoglycemic reactions.  He has been experiencing regular mild hypoglycemic reactions around noon before lunch, but this recent severe reaction, in which his blood sugar dropped to 38 mg/dL, has him wondering if his insulin regimen could be improved.  The patient does not feel he is ready for an insulin pump, but he is not opposed to increasing the number of his daily injections if he can use an insulin pen.

Despite checking his blood sugars 4 to 6 times a day, the patient still experiences wide fluctuations in his daily blood sugar values (50 to 350 mg/dL).  He usually takes his insulin approximately 10 to 15 minutes before a meal but admits to sometimes taking it just before he starts to eat.  He follows a regular meal pattern, eating a small high-carbohydrate breakfast, a sandwich and soup for lunch, an afternoon snack of fruit or a candy bar, and a larger standard meal for supper.  The patient received diabetes education when he was diagnosed, but has never met with a dietitian.  Most of what he understands regarding carbohydrate intake and counting has come from what he has researched on the internet.  He works as a high school teacher but admits to little regular exercise outside of his job.  He is 72 inches tall and 91.3 kg (BMI 27 kg/m²). He has a history of hypertension, hyperlipidemia, and seasonal allergies.  In addition to his insulin, the patient takes aspirin 81 mg, dilatizem HCL 360 mg, and pravastatin sodium 40 mg daily.  His blood pressure and lipid levels are currently well controlled.  His A1C at this visit measures 8.3%.  The patient is concerned that his A1C has increased from 7.4% one year ago.   

Case Presentation:  A 25-year-old Hispanic woman with a 5-year history of type 2 diabetes presents for a routine follow-up visit.  Despite education, she has had difficulty making diet and lifestyle modifications and currently has a BMI of 45 kg/m².  Her treatment advanced from monotherapy with metformin at initial diagnosis, to her current regimen of metformin 2000 mg, glimepiride 8 mg, and sitagliptin 100mg daily.  She performs home blood glucose monitoring and her fasting blood glucose levels range between 120 and 150 mg/dL.  She experiences symptoms of hypoglycemia very rarely, only once every few months.  Her A1C level is 7.8% and a recent fasting c-peptide level was 6 ng/mL (normal range 0.78-1.89 ng/dL).  The patient is concerned that her medication is not working as well as it should.  Although her mother has type 2 diabetes, a nephew has type 1 diabetes, and she is wondering if she could have type 1 diabetes instead of type 2.   

Case Presentation:  A 47-year-old Caucasian woman presents for a routine follow-up visit.  She was diagnosed 10 months earlier with type 2 diabetes.  Her initial fasting glucose average was 155 mg/dL and her A1C was recorded at 7.4%.  At the time of diagnosis, her height was 64 inches and her weight was 210 pounds (BMI 36 kg /m²).  She received diabetes education in the first month after diagnosis from a dietitian and certified diabetes educator and learned ways to modify her diet and increase her activity level. She began an active walking program and walked over 3 miles daily 5-6 times a week.  Four months after diagnosis, her weight had decreased to 196 pounds.  Her A1C was 6.5% and her provider felt that her diabetes was well controlled without medication. 

At this visit 6 months later, her weight has increased to 202 pounds (BMI 35 kg /m²) and she admits to having a hard time maintaining the exercise goals she initially set for herself. She is still walking 3-4 times a week at approximately 2 miles each session and is doing her best to maintain healthy eating habits.  However, her A1C has now increased to 6.8%.  She is monitoring her blood sugars at home and reports they are usually between 110 and 130 mg/dL fasting, and vary greatly after eating, e.g. ranging from 175 to 230 mg/dL.  The patient is frustrated because she feels she is doing as well with her diet and exercise regimen as she possibly can, given her work and family schedule.  She is concerned about the slight increase in A1C, although she feels her fasting sugars have improved.  She is wondering about possible options to treat her diabetes. 

Case Presentation:  A 63-year-old African-American male has a 15-year history of hypertension controlled with medication (blood pressure of 128/76 on an ARB (Irbesartan 100 mg BID) and low dose chlorthalidone 25 mg daily).  He was diagnosed 3 months earlier with type 2 diabetes; at the time of diagnosis, his fasting glucose was 280 mg/dL and his A1C was 11.2%.  Based on the ADA/EASD algorithm, his primary care physician started him on metformin and lifestyle modification.  He was given education to improve his diet, which was high in carbohydrates, fat, and salt. His job is sedentary and he did little exercise at the time of diagnosis, but planned to start walking during his lunch hour. His metformin has been titrated up to 2000 mg daily. 

Despite taking his metformin regularly and making some lifestyle changes, his A1C at this visit is 10.4%.  His BMI is 37 kg/m² although he has lost 10 pounds in the past 3 months.  He performs home blood glucose monitoring each morning and knows his average fasting blood sugar of 230 mg/dL is still too high.  He is wondering if he needs additional medication. Given the insufficient reductions in A1C and average fasting blood sugar, his physician decides that more aggressive treatment is necessary.