CASE — A patient calls for an early appointment on the advice of a clinician in a nearby emergency department after being treated for hypoglycemia.
The patient, whom you have followed for several years, is a 61-year-old male with a 17-year history of type 2 diabetes. He has been treated with insulin for the last eight years. He checks his fingerstick glucose level only three times per week and only before breakfast. At his most recent office visit seven weeks ago, the fasting glucose values in his diary were in the range of 95 to 154 mg/dL (5.3 to 8.6 mmol/L) and the glycated hemoglobin (A1C) was 7.3 percent.
He was treated with NPH insulin 44 units before breakfast, regular insulin 14 units before supper, and NPH insulin 16 units at bedtime. He was also taking lisinopril 30 mg every morning, atorvastatin 20 mg at bedtime, and aspirin 81 mg per day. He usually avoided concentrated sweets but did not count carbohydrates or follow a specified diabetes nutritional regimen. The patient had been referred to a registered dietitian but had not kept the appointment. At his last visit, his body mass index (BMI) was 34 kg/m2, and he was noted to have nonproliferative retinopathy, distal sensory neuropathy, and modest microalbuminuria.
Yesterday, the patient became confused and combative. His wife called 911. The emergency medical technician noted a fingerstick glucose level of 29 mg/dL (1.6 mmol/L), gave 25 cc of D5W (5 percent dextrose in water) intravenously, and transported him to the emergency department. His mental status returned rapidly to normal. The doctor on duty learned from the patient that he had been having insulin reactions for approximately 10 days at various times of day. The clinician advised him to reduce all insulin doses by half and advised him to call you. You agree to see him the next day.
At the office visit, you review the patient's interval history. His daughter had urged him to follow the South Beach Diet to lose weight and given him the book by that name. He immediately started Phase 1 of the diet, in which he eliminated bread, rice, potatoes, pasta, baked goods, and fruit. He did not adjust his insulin regimen. The insulin reactions began two days later. You explain to the patient the relationship between his very low-carbohydrate diet and the marked fall in insulin requirement he has experienced. He is motivated to improve his diet but requests your advice.
What dietary approach do you recommend? (More than one choice is acceptable.)
●You advise him to resume his previous diet and previous insulin doses based upon the fact that his A1C is 7.3 percent, to check his blood glucose values three to four times per day before meals and at bedtime, and to return in five weeks for a regularly scheduled visit. (See "Interactive diabetes case 18: A 61-year-old patient with type 2 diabetes and a recent change in diet (medical nutrition therapy) - A1".)
●You advise him to continue Phase 1 of the South Beach Diet, to continue his reduced doses of insulin, and to return in five weeks for his regularly scheduled visit. (See "Interactive diabetes case 18: A 61-year-old patient with type 2 diabetes and a recent change in diet (medical nutrition therapy) - A2".)
●You advise him to go immediately to Phase 2 of the South Beach Diet, which involves the reintroduction of certain "healthy" carbohydrates that were excluded in the earlier phase such as fruit, whole-grain bread, whole-grain rice, whole-wheat pasta, and sweet potatoes. You advise him to reduce his insulin doses by approximately 20 percent compared with his doses at the time of his most recent office visit, ie, to use NPH 35 units before breakfast, regular insulin 11 units before supper, and NPH 13 units at bedtime. You instruct the patient not to use the Phase 1 diet, even occasionally. You refer him to a registered dietitian to learn to count carbohydrates, anticipating a later change from fixed doses of regular insulin to the use of prandial and correction doses of a short- or very short-acting insulin. You advise him to return in five weeks for his regularly scheduled visit. (See "Interactive diabetes case 18: A 61-year-old patient with type 2 diabetes and a recent change in diet (medical nutrition therapy) - A3".)
●You advise him to start the Atkins Diet, to continue the reduced insulin doses advised by the emergency department clinician, and to monitor his urine ketones until they are positive. (See "Interactive diabetes case 18: A 61-year-old patient with type 2 diabetes and a recent change in diet (medical nutrition therapy) - A4".)
●You advise him to follow a program of lifestyle change. This includes a consistent intake of carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk; limitation of refined sugars; a low intake of saturated fats (<7 percent of total calories) with an emphasis on mono- and polyunsaturated fats; cholesterol intake <200 mg per day (which necessarily excludes egg yolks); two or more servings of fish per week; varied sources of good-quality protein, including meat, poultry, and fish; an increase in dietary fiber; and a 2000 mg/day intake of sodium. This also includes moderate exercise, such as walking for 30 to 35 minutes at least five days a week. You refer him to a registered dietitian for education and support and to learn to count carbohydrates. (See "Interactive diabetes case 18: A 61-year-old patient with type 2 diabetes and a recent change in diet (medical nutrition therapy) - A5".)
