ANSWERS AND EXPLANATIONS
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:
Comprehensive Metabolic Panel
Carbon dioxide (CO2)
Urea nitrogen, blood (BUN)
eGFR (estimated glomerular filtration rate)
>60 mL/min/1.73 m2
Comprehensive Metabolic Panel
>40 mg/dL men; >50 women
White blood cell count
Red blood cell count
MCV (mean corpuscular volume)
MCH (mean corpuscular hemoglobin)
MCHC (mean corpuscular hemoglobin concentration)
RDW (red cell distribution width)
Urine albumin/creatinine ratio (UACr)
<1.3 (low risk for advanced fibrosis)
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.
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
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.
Reduction in Risk of T2D
31% (P < .001)
25% (P = .0015)
72% (P < .001)
Weight loss interventions
75% (P < .001)
(P value vs placebo)
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
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.