Two faces of type 2 diabetes

A woman came to the clinic proudly carrying her blood glucose diary with several weeks worth of fasting, pre- and post-prandial values. She had also kept a fairly good diary of her food intake. I was a bit surprised by her enthusiasm because the HbA1c value obtained three days before the clinic visit has held steady at 9%.

She proudly displayed her fasting values, 70% of which were 120 mg/dL or lower with only a few >150 mg/dL. For her that was a big improvement and not really in keeping with the unchanging HbA1c. Then she showed me her post-prandials, with most of the evening meal values > 400 and a few >500. “It’s the ice cream, doctor! I must have some before I go to bed or I will have trouble falling asleep.“ She carefully checks her capillary blood glucose before supper, waits an hour, has her ice cream and checks the capillary blood glucose 30 to 40 minutes later.

When patients are so wrong with their application of instructions given in the office the initial responsibility must lie with me in that I didn’t foresee all possibilities and/or gave instructions without carefully checking the patient’s understanding. I tried again this time but I have little hope that the ice cream will disappear from her diet. I did recommend a small dose of rapid acting insulin pre-ice cream but that suggestion was not well received. At 76 years old it’s tough for her to give up any of life’s pleasures but it is just as tough for me to repeat the litany of the slowly progressive consequences of her actions. I will rely on twice monthly clinic visits for the next little while but I am not confident of forward progress.

Another patient had a very different story. At age 70 he has had enough of multiple oral therapies and did not take kindly to multiple injections. Six months ago he requested a trial of therapy with an insulin pump and he took to that like a duck to water. His HbA1c went from 8.9% to 6.4%. Perfection — almost!

A month ago he was asked to return to his former employment as a forklift driver in a lumber yard. The extra workforce would be needed for only four to six weeks. One big problem — he was to work the night shift and he had carefully tuned his pump settings for his daytime activities and a good night’s sleep. It wasn’t too long before he experienced some minor symptoms of hypoglycemia with his lowest recorded meter reading of 63 mg/dL. I can think of few things more dangerous in the workplace than hypoglycemia while steering a forklift. He had worked very hard to learn the intricacies of pump therapy for his usual lifestyle but we had not prepared him for this change. With two weeks left on this job before settling back to retirement I opted not to retrain him on the pump but gave advice about increasing his food intake while burning up calories at work. For two weeks I think it is safer for him and his coworkers if he is mildly hyperglycemic all the time than hypoglycemic any time.

There is no cookbook recipe for management of type 2 diabetes and no individualized program works for all circumstances.