Anticipating and Responding to Major Life Changes
Introduction
Diabetes is a lifelong condition. And, as with any chronic disease when circumstances change, modifications must be made. This chapter focuses on important transitions in diabetes management that frequently coincide with significant life changes. Being prepared for these transitions can help you and your patients be proactive and thereby avoid some of the pitfalls that might otherwise occur.
Case 1. Prediabetes and Diabetes Prevention
“I will worry about that when I get diabetes.”
A 32-year-old man presents to his primary care provider (PCP) complaining of foot pain. He reports pain in the arches of both feet when standing for long periods of time. It is particularly severe, he reports, when he first gets out of bed in the morning and when he stands after sitting for an extended length of time. The pain improves with walking in sneakers but is worse when he is barefoot. He bought gel insoles, but they have not helped. He has been using over-the-counter (OTC) naproxen for several weeks without improvement in his pain level.
He denies any chronic medical issues. He is not taking any prescribed medications.
Med HX: none
Medications: only OTC naproxen
Allergies: penicillin
Family Medical History: strong family history (FH) of type 2 diabetes; dad and P (paternal) uncle died from chronic kidney disease (CKD)
Social History: lives with his partner. No kids—they have been having trouble conceiving. No tobacco, alcohol, or recreational drugs.
Physical Exam: Ht. 5′9″, Wt. 257 lb, BMI 38, P 84, R 14, BP 142/86
GEN: obese man with truncal obesity in no distress
HEENT: normal including thyroid exam
CV: normal
RESP: normal
Extremities: the patient has flat arches and pain with dorsiflexion of toes, pain runs along the plantar fascia of both feet, and has maximal tenderness upon palpation at calcaneus insertion bilaterally
Labs: no recent labs
He was diagnosed with pes planus, plantar fasciitis, and obesity. He was asked to get fasting labs done and advised to check his BP at least 3 times per week.
CASE QUESTIONS1. What lab tests should be ordered and why?
View Answer
1. This is an obese man with a family history of diabetes and is at high risk for diabetes and should be screened for diabetes. He has a strong family history of renal disease and presents with elevated blood pressure. His renal function will need to be assessed. In addition, he should be screened for nonalcoholic fatty liver disease (NAFLD) as his blood pressure elevation and truncal obesity meet the metabolic syndrome criteria.
Lab orders should include a CMP (comprehensive metabolic panel) to screen for hyperglycemia, electrolyte abnormalities, renal function abnormalities, and transaminase elevation. A CBC (complete blood count) should also be included since a platelet count is necessary to calculate his FIB-4 score and determine his NAFLD risk. A lipid panel and A1c are important, too, as we suspect he may have metabolic syndrome. Finally, a urinary albumin/creatinine ratio (UACr) would be helpful to identify early kidney disease.
No specific labs are necessary for his plantar fasciitis. X-rays of his feet could be a consideration to assess for structural deformity and calcaneal spur formation.
Home blood pressure readings: 152/88, 148/92.
Fasting Lab Results:
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2. Does he have a diabetes-related diagnosis?
View Answer
2. He has an HbA1c in the prediabetes range and fasting glucose in the prediabetes range. He meets the criteria for prediabetes.
3. What are his other diagnoses?
View Answer
3. His systolic blood pressure, at 142 mm/Hg, meets the criteria for stage 2 hypertension. His serum creatinine and eGFR are normal. Thus, if a UACr repeat check is above 30 mg/G, he will meet the criteria for moderate albuminuria, which would qualify him for stage G1A2 CKD.1 This could be the result of his prediabetes, his hypertension, or both. Based on his BMI of 38 with other metabolic abnormalities, he should be diagnosed with medically complicated obesity. His elevated ALT suggests a diagnosis of NAFLD, although his FIB-4 score places him in the lower risk category for advancing to nonalcoholic steatohepatitis. As a reminder, one-third of people who develop type 2 diabetes present with a complication on the day they are diagnosed. Finally, we also diagnosed him with plantar fasciitis at the last visit.
4. What are the recommended treatments for people with prediabetes?
View Answer
4. There are a wide variety of treatments that have been shown to delay or prevent the diagnosis of type 2 diabetes. Treatment options include intensive lifestyle management, as demonstrated by the Diabetes Prevention Program, several medications, and metabolic surgery.
The Diabetes Prevention Program has demonstrated a 58% reduction of new-onset type 2 diabetes in those younger than 60 years and 71% in those older than 60 years. The program duration is 1 year and focuses on the achievement of 5% -7% weight loss via dietary modification and increased physical activity to at least 150 min/wk. It also involves coaching and group classes that can be offered in person or online. Increasingly, these programs are being covered by many insurance plans.
Medications that help prevent or delay the diagnosis of diabetes include metformin, the alpha-glucosidase inhibitor acarbose, thiazolidinediones, and the GLP-1RAs (glucagon-like peptide-1 receptor agonists).2,3,4,5 To date, no medication has been approved by the FDA (Food and Drug Administration) to treat prediabetes. Historically, metformin has been used most often in people felt to be at high risk for developing type 2 diabetes, especially if the HbA1c is greater than 6.0%.
In moderately obese persons with prediabetes, bariatric surgery (also known as metabolic surgery) has been shown to reduce the risk of progression to type 2 diabetes to a degree at least twice that of lifestyle interventions. It is worth noting that risk reduction persists for at least 10 years after surgery.6
The patient in this case study has multiple metabolic-related problems. It is important to inform him of the severity of his health risks while also letting him know that much can be done to stop or at least delay their progression.
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5. Is there a relationship between his foot pain and diabetes?
View Answer
5. Maybe. Plantar fasciitis often occurs in people who do not have diabetes. However, in people with diabetes who have sustained hyperglycemia, a condition termed “diabetic heiropathy” can arise. Classically, this affects the fingers, though, and is characterized by an inability to fully extend the metacarpophalangeal joints. This is related to the shortening of tendons and myofascial tissues from glycosylation and can lead to pain, injury, and chronic joint changes.7
ANSWERS AND EXPLANATIONS1. This is an obese man with a family history of diabetes and is at high risk for diabetes and should be screened for diabetes. He has a strong family history of renal disease and presents with elevated blood pressure. His renal function will need to be assessed. In addition, he should be screened for nonalcoholic fatty liver disease (NAFLD) as his blood pressure elevation and truncal obesity meet the metabolic syndrome criteria.
Lab orders should include a CMP (comprehensive metabolic panel) to screen for hyperglycemia, electrolyte abnormalities, renal function abnormalities, and transaminase elevation. A CBC (complete blood count) should also be included since a platelet count is necessary to calculate his FIB-4 score and determine his NAFLD risk. A lipid panel and A1c are important, too, as we suspect he may have metabolic syndrome. Finally, a urinary albumin/creatinine ratio (UACr) would be helpful to identify early kidney disease.
No specific labs are necessary for his plantar fasciitis. X-rays of his feet could be a consideration to assess for structural deformity and calcaneal spur formation.
Home blood pressure readings: 152/88, 148/92.
Fasting Lab Results:
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|
|
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2. He has an HbA1c in the prediabetes range and fasting glucose in the prediabetes range. He meets the criteria for prediabetes.
3. His systolic blood pressure, at 142 mm/Hg, meets the criteria for stage 2 hypertension. His serum creatinine and eGFR are normal. Thus, if a UACr repeat check is above 30 mg/G, he will meet the criteria for moderate albuminuria, which would qualify him for stage G1A2 CKD.1 This could be the result of his prediabetes, his hypertension, or both. Based on his BMI of 38 with other metabolic abnormalities, he should be diagnosed with medically complicated obesity. His elevated ALT suggests a diagnosis of NAFLD, although his FIB-4 score places him in the lower risk category for advancing to nonalcoholic steatohepatitis. As a reminder, one-third of people who develop type 2 diabetes present
with a complication on the day they are diagnosed. Finally, we also diagnosed him with plantar fasciitis at the last visit.
with a complication on the day they are diagnosed. Finally, we also diagnosed him with plantar fasciitis at the last visit.
4. There are a wide variety of treatments that have been shown to delay or prevent the diagnosis of type 2 diabetes. Treatment options include intensive lifestyle management, as demonstrated by the Diabetes Prevention Program, several medications, and metabolic surgery.
The Diabetes Prevention Program has demonstrated a 58% reduction of new-onset type 2 diabetes in those younger than 60 years and 71% in those older than 60 years. The program duration is 1 year and focuses on the achievement of 5% -7% weight loss via dietary modification and increased physical activity to at least 150 min/wk. It also involves coaching and group classes that can be offered in person or online. Increasingly, these programs are being covered by many insurance plans.
Medications that help prevent or delay the diagnosis of diabetes include metformin, the alpha-glucosidase inhibitor acarbose, thiazolidinediones, and the GLP-1RAs (glucagon-like peptide-1 receptor agonists).2,3,4,5 To date, no medication has been approved by the FDA (Food and Drug Administration) to treat prediabetes. Historically, metformin has been used most often in people felt to be at high risk for developing type 2 diabetes, especially if the HbA1c is greater than 6.0%.
In moderately obese persons with prediabetes, bariatric surgery (also known as metabolic surgery) has been shown to reduce the risk of progression to type 2 diabetes to a degree at least twice that of lifestyle interventions. It is worth noting that risk reduction persists for at least 10 years after surgery.6
The patient in this case study has multiple metabolic-related problems. It is important to inform him of the severity of his health risks while also letting him know that much can be done to stop or at least delay their progression.
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5. Maybe. Plantar fasciitis often occurs in people who do not have diabetes. However, in people with diabetes who have sustained hyperglycemia, a condition termed “diabetic heiropathy” can arise. Classically, this affects the fingers, though, and is characterized by an inability to fully extend the metacarpophalangeal joints. This
is related to the shortening of tendons and myofascial tissues from glycosylation and can lead to pain, injury, and chronic joint changes.7
is related to the shortening of tendons and myofascial tissues from glycosylation and can lead to pain, injury, and chronic joint changes.7
Case Follow-Up:
The patient was informed that, based on his lab results, he had multiple metabolic abnormalities that were obesity related. In addition, he was told that the presence of protein in his urine suggested he was at risk for progressive kidney disease. The lab results were shared in detail and his options were discussed. He was informed that his relative youth provided him an opportunity to choose any of the above treatments to help delay or prevent his progression to type 2 diabetes. In addition, he was advised that aggressive weight loss would also help address his elevated blood pressure and his liver abnormalities. An emphasis was placed on making proactive changes for “health protection,” reinforcing that, at present, his body’s systems were working well, and making effective changes now would help sustain his health in the future.
Despite this guidance, he responded that he would “wait and worry about this when and if I get diabetes.” He was not motivated to change his diet or increase his activity level. He attributed his elevated blood pressure to drinking too much coffee and subsequently planned to reduce his intake. He did agree to return in 1 month to recheck his blood pressure and repeat his urine albumin level.
Before you react to his response, take the patient’s perspective. He came in for foot pain and now he is being told he has multiple medical problems and is likely overwhelmed. It may be worthwhile to try to let him know you will help him to feel better and you want to develop a plan that he can help decide and implement to reduce his risk of these other problems.
Other patients may not be ready to engage. This is a good time to share that you are concerned for their well-being. Let them know that you can be a resource for information and support and when they are ready you will be there to help them. This allows the patient to see you as a partner in health.
Case Summary and Closing Points
Prediabetes affects one-third of all Americans. We know that type 2 diabetes can be largely prevented or delayed. However, doing so requires first that the condition be identified, and second that the affected individual responds proactively. Our role as clinician is to use effective screening strategies, communicate the significance of prediabetes to our patients, and enroll them in effective evidence-based risk-reduction programs such as the Diabetes Prevention Program or other evidence-based treatments.8
References
1. de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: A consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022;45(12):3075-3090. doi:10.2337/dci22-0027
2. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
3. STOP-NIDDM Trial Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet. 2002;359:2072-2077.
4. Defronzo RA, Tripathy D, Schwenke DC, et al. Pioglitazone for diabetes prevention in impaired glucose tolerance. N Engl J Med. 2011;364(12):1104-1115.
5. le Roux CW, Astrup A, Fujioka K, et al. 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial.. Lancet. 2017;389(10077):1399-1409. doi:10.1016/S0140-6736(17)30315-X
6. Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med. 2012;367:695-704.
7. Edrees A. Diabetic cherioarthropathy, a clue for uncontrolled diabetes: case report and review of the literature. Clin Med Rev Case Rep. 2020;7:327. doi:10.23937/2378-3656/1410327
8. Prevent T2D Curriculum. https://nationaldppcsc.cdc.gov/s/article/Introducing-the-Revised-PreventT2-Curriculum3
Case 2. Increasing Responsibility in Self-Care
“The diabetes police.”
A 30-year-old woman presents for her first diabetes-specific appointment. She is accompanied at today’s visit by her sister “Rose.” Shortly after introducing yourself, Rose informs you that she does not normally come to her sister’s appointments but needed to today because someone had to “tell on her.” Until recently the patient lived with their mother, but after their mother’s death 6 months ago, the patient moved in with Rose. Rose is concerned that her sister is not taking care of herself. She reports that her sister “eats sugars and does not watch her diet.” Apparently, their mother took on the greater responsibility for managing the patient’s diabetes. According to Rose, the mother prepared her meals, checked her blood sugars, and made sure that she took her medications. Rose does not have diabetes but has friends that do. They told her that diabetes should be controlled with a “eat nothing white” diet.
The patient, on the other hand, states that she has no problem taking care of herself, and that her sister does not understand diabetes. She does not just eat sugars and tries to pay attention to her diet. She likes to have eggs and toast for breakfast (or oatmeal). Lunch is usually a salad, and dinner is usually soup or salad with meat. She likes to eat rice, but it spikes her sugar too high, so when she eats it, she only eats about half of a cup. She is good about remembering to take her insulin and uses her mealtime insulin regularly. She admits she does not check her blood sugar as often as she should. She gets really frustrated when her glucose climbs for no apparent reason, so sometimes she will just stop checking. She enjoys eating and does not want to be hassled about what she is eating.
She did not bring her glucometer to the appointment, explaining that Rose rushed her out of the door so they would not be late. She promises to bring her meter next time. She feels like her glucose is all over the place, from 50 to 300 mg/dL in the same day. There is no regular pattern that she can identify. She can tell when her blood sugar gets low because she gets shaky and breaks out in a sweat. When she feels low, she drinks juice.
Med HX: type 1 diabetes (14 years), hypothyroidism (10 years)
Medications: insulin glargine 24 units at bedtime, insulin aspart 1:10 carb ratio plus 1:30 above 130 before each meal (often she will estimate the meal and correction)
Allergies: none
Family Medical History: thyroid disorders in mom and sister
Social History: lives with her sister, works in the public library, walks 30 min/d, no tobacco or EtOH.
Physical Exam: Ht. 5′7″, Wt. 137 lbs., BMI 21.5, P 84, R 14, BP 118/72
GEN: well adult in no distress
HEENT: normal including thyroid exam
CV: normal
RESP: normal
Extremities: normal pulses, normal sensation to monofilament, and vibration
Skin: no skin changes—injection sites with signs of infection or subcutaneous changes
Point-of-care labs:
Glucose: 248 mg/dL
HbA1c: 7.9%
CASE QUESTIONS1. What initial recommendations should be made for this patient?
View Answer
1. There is a lot to explore at a patient’s first diabetes visit. I often like to open the interview with, “Tell me your diabetes story.” This encourages the patient to share information in their own words and not worry about telling the physician what “they want to hear.” I encourage the patient to describe how they were diagnosed, what has traditionally worked for them, and what has not worked. Often the patient may also share the positive and negative influences in their life that affects their diabetes management. It is important not to interrupt the patient while they are “story-telling.” I follow this up by encouraging them to talk about their activities, interests, hobbies, etc., things they enjoy outside of dealing with their diabetes. Often people with diabetes say they think their diabetes defines them. Patients will be more trusting of caregivers who show an interest in them as individuals rather than diseases.
I also like to ask what their goals are for the visit. This allows me to prioritize those aspects of care that will best support the patient. I do not always make changes in a treatment regimen on the first visit, especially if I do not have data to support it. My priorities for the first visit are to build rapport with the patient and address their immediate needs. Most patients are more open to treatment changes once they have a sense that their clinician understands their current treatment and is familiar with their past experiences.
From here, I ask the patient about what has worked well in terms of glucose management and at what glucose levels they feel best. (Note that this is not always in the normal range.) Once I have a sense of where they feel best, I explore how often they drop low, what they feel during these lows, as well as how often they go high, and what this feels like. Identifying when and under what circumstances someone is doing their “best” in terms of diabetes management can provide critical information about the support systems that work best for this patient.
I would bring this patient back in a couple of weeks and request that she bring her glucose readings and detailed information about her daily schedule. These will provide critical information from which safe and effective treatment recommendations can be made. Her second visit is also a great time to introduce diabetes technology such as the use of a continuous glucose monitor (CGM) to help us understand her glucose course over the 24-hour period.
One additional factor in this case scenario must be addressed. Part of this patient’s “story” is that she has had a diabetes “chaperone” all her life. This is uncommon for someone her age and is likely impacting her ability to manage her condition as effectively as she could. This “chaperone” dynamic is more common in patients with type 1 diabetes, particularly in those patients first diagnosed at a very young age. In this case, it is not clear how or why this pattern of treatment behavior began. It may have been due to resistance among the entire family to adapt to the patient’s diabetes diagnosis. It may be related to the patient’s own reluctance to assume responsibility for her self-management. Regardless, the dynamic between the patient and her sister indicates that they could both benefit from a visit to a diabetes care and education specialist. The specialist can provide them with a unified set of information to learn from and help them work together more productively.
2. What advice, if any, should be given to the patient’s sister?
View Answer
2. Caring for patients with diabetes and managing their family members’ expectations at the same time can be challenging. This may be particularly difficult when the patient is an adult. I want to be able to interact with this patient in a manner that respects her autonomy. At the same time, it is important to acknowledge Rose’s concerns, with the understanding that her desire to be present at today’s visit is likely motivated by a sincere concern for her sister.
It is important for both sisters to understand that the patient’s needs are my priority. As mentioned earlier, this is her diabetes story to tell. In this case, I would ask the patient directly if she is comfortable letting me hear from her sister. This interaction should be brief. I would clearly acknowledge Rose’s concerns. At the same time, I would let Rose know that while I appreciate her input my primary focus will be on the patient. Balancing the patient’s needs with the family’s desires is important; we want everyone’s contribution to care to be positive and productive.
Having Rose know that her concerns have been heard and that I will help the patient with diabetes self-management may be a great relief for her. She could have assumed that the patient’s health and welfare were her responsibility. Furthermore, asking her to be part of her sister’s care team by asking her to participate in diabetes education (assuming this is OK with her sister) engenders trust. Letting her and the patient know I can be a resource for them is crucial.
3. What key information should a person with diabetes share with friends and family?
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