A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. 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. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon. A.B. also 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.

During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” to improve his diabetes control. He stopped these supplements when he did not see any positive results. He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies. During the past year,

A.B. has gained 22 lb. 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).

A.B.’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 prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” 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 A.B. 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. A.B. 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.

Physical Exam A physical examination reveals the following: • Weight: 178 lb; height: 5’2″; b Body mass index (BMI): 32.6 kg/m2 • Fasting capillary glucose: 166 mg/dl • Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg • Pulse: 88 bpm; respirations 20 per minute • Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriovenous nicking, no retinopathy • Thyroid: nonpalpable • Lungs: clear to auscultation • Heart: Rate and rhythm regular, no murmurs or gallops • Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally • Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes- Weinstein) felt only above the ankle

Lab Results Results of laboratory tests (drawn 5 days before the office visit) are as follows: • Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl) • Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl) • Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl) • Sodium: 141 mg/dl (normal range: 135–146 mg/dl) • Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl) • Lipid panel • Total cholesterol: 162 mg/dl (normal:

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