Interactive diabetes case 6: Poorly managed diabetes in a 64-year-old patient treated with insulin – B4

ANSWER — 

Correct.

The patient tells the registered dietitian that she and her husband have been having lunch at restaurants three or four times a week since her retirement two years ago. She has not been counting carbohydrates at those meals, which she views as holidays from her diabetes routine. She says she "guestimates" her carbohydrate intake at these times. The dietitian's assessment reveals a carbohydrate intake of 30 to 50 g at breakfast, 15 to 90 g at lunch, 0 to 30 g at an afternoon snack, and 60 to 90 g at supper. The variability in carbohydrate intake is identified as a major source of the variability of the blood glucose values. The marked variability in carbohydrate intake at lunch and at the afternoon snack account for the variable glucose readings before supper. The patient is taught to count carbohydrates and is given goals for consistent carbohydrate intake at meals and snacks as follows: 40 to 50 g for breakfast, 50 to 60 g for lunch, 20 to 30 g for afternoon snack, and 75 to 85 g for supper.

At the patient's next visit with you, she tells you that she has been exercising vigorously on an elliptical cross-trainer three to five times a week for approximately 45 minutes each time, usually but not always in the mid-afternoon, and not always on the days she eats out. You reinforce the advice of the registered dietitian. You advise the patient to count carbohydrates at lunch as well as at other times. You advise her to exercise at the same time each day and to indicate each workout in her diabetes diary. Also, you add a dose of aspart insulin before lunch using the same sensitivity and correction factors to provide a more intensive insulin regimen.

At the next visit, the patient states that she is counting carbohydrates more consistently, including those consumed at lunch. She is exercising on a more regular routine, usually in the mid-afternoon. The glucose diary reveals that the glucose values are less variable than in the past, especially before supper, when they fluctuate between 66 and 146 mg/dL (3.7 to 8.1 mmol/L) but usually within the middle of this range. Over the next six months, the glycated hemoglobin (A1C) value falls to 7.2 percent.

For additional information, see the comment at the end of this sequence. (See "Interactive diabetes case 6: Poorly managed diabetes in a 64-year-old patient treated with insulin – Comment".)