1st READ THE CASE Patient History Albert is a retired 54-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 2018, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 120–130 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia (wake up during the night to urinate) associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lbs.”), but no action was taken. Referred by his family physician to the diabetes specialty clinic, Albert presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. Albert takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control, though he has heard of FreeStyle Libre. Thinks that would be too painful. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.” Albert states that he has “never been sick a day in my life.” He recently sold his business (independent bookstore) and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years, Mable, and has two married children (Stephen (42) and Christine (39). Although both his mother and father had type 2 diabetes, Albert has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. During the past year, Albert has gained 22 lbs. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). Albert’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.” The medical documents that Albert brings to this appointment indicate that his hemoglobin A1c(A1C) has never been

1st READ THE CASE Patient History Albert is a retired 54-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 2018, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 120–130 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia (wake up during the night to urinate) associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lbs.”), but no action was taken. Referred by his family physician to the diabetes specialty clinic, Albert presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. Albert takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control, though he has heard of FreeStyle Libre. Thinks that would be too painful. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.” Albert states that he has “never been sick a day in my life.” He recently sold his business (independent bookstore) and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years, Mable, and has two married children (Stephen (42) and Christine (39). Although both his mother and father had type 2 diabetes, Albert has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. During the past year, Albert has gained 22 lbs. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). Albert’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.” The medical documents that Albert brings to this appointment indicate that his hemoglobin A1c(A1C) has never been. 1st READ THE CASE
 
Patient History
Albert is a retired 54-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 2018, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 120–130 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia (wake up during the night to urinate) associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lbs.”), but no action was taken.
 
Referred by his family physician to the diabetes specialty clinic, Albert presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. Albert takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule.
 
He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control, though he has heard of FreeStyle Libre. Thinks that would be too painful. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.” Albert states that he has “never been sick a day in my life.” He recently sold his business (independent bookstore) and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years, Mable, and has two married children (Stephen (42) and Christine (39). Although both his mother and father had type 2 diabetes, Albert has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar.
 
During the past year, Albert has gained 22 lbs. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).
Albert’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”
 
The medical documents that Albert brings to this appointment indicate that his hemoglobin A1c(A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health.
 
Albert has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.
2nd ANSWER THE QUESTIONS IN DETALIES
 
Questions

  1. What questions would you ask Albert and/or Mable? List 8 questions at least.
  2. How do you educate the couple regarding sugars? What do you think is/are the best method(s) of monitoring his glucose and why?
  3. What dietary recommendations would you make for Albert? Are there preparation methods that can be incorporated here and if so, what?
  4. What physical activity recommendations would you make for Albert and Mable?
  5. What questions and/or recommendations would you have for Stephen and Christine (the children)?
  6. If Albert does not change his diet, what health risks may he suffer in the near future and why?
  7. What is the importance of knowing Albert’s family history of type 2 diabetes? What impact does this have on your education of Albert, Mable, Stephen, and Christine?
  8. What physical examinations would perform on Albert and why?
  9. What lab tests would you get from Albert and why?
  10. Briefly, how would you educate a senior population regarding type 2 diabetes management and prevention?
  11. What are some possible difficulties that you might encounter when implementing such education for this population? How would you address these difficulties?

 

1st READ THE CASE Patient History Albert is a retired 54-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 2018, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 120–130 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia (wake up during the night to urinate) associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lbs.”), but no action was taken. Referred by his family physician to the diabetes specialty clinic, Albert presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. Albert takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control, though he has heard of FreeStyle Libre. Thinks that would be too painful. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.” Albert states that he has “never been sick a day in my life.” He recently sold his business (independent bookstore) and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years, Mable, and has two married children (Stephen (42) and Christine (39). Although both his mother and father had type 2 diabetes, Albert has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. During the past year, Albert has gained 22 lbs. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). Albert’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.” The medical documents that Albert brings to this appointment indicate that his hemoglobin A1c(A1C) has never been