By Neelam Vashi (Class of 2008, Feinberg School of Medicine)
Edited by Peter Lu (Class of 2010, Feinberg School of Medicine)

The Patient:
The patient is a 63 year old male with a history of hyperlipidemia and hypertension who presented for further evaluation of new-onset diabetes.

In early May, he had an annual physical in which he was found to have a fasting glucose of 180. At the end of May, one week before today's visit, he had a fasting glucose of 175. He reported minimal exercise and a diet consisting mostly of meats (beef, chicken, pork) and snack-type items (crackers, cookies, sweets). The majority of his meals were ate at restaurants, and he drank 3 cans of regular Pepsi per day. The patient had no family history of cardiovascular disease, heart disease, or obesity.

Upon evaluation, he was found to be obese with a BMI of 33.3. He had signs of underlying disease with a velvety hyperpigmentation of the skin in the posterior folds of the neck, evidence of acanthosis nigricans. Through physical exam and laboratory tests, he was found to have no microvascular complications (retinopathy, nephropathy, neuropathy) of diabetic disease.

Although worried and motivated to improve his glucose, he adamantly refused any type of medical treatment and expressed interest in controlling his disease with dietary changes. So what should he do?

The Plan:

• Discussion with patient concerning diabetes, its complications, and control without pharmacotherapy
• Recommend consultation with a registered dietitian for counseling on low calorie/low fat diet
• Suggested recommendations until meeting with dietitian:
  Eat less calories, eat smaller portions, eat more vegetables, increase fiber, increase water consumption, switch to diet beverages, space out meals, eat less fat. See Educational Tool.
• Tips from the American Diabetes Association:
  Choose whole grain foods (ex. brown rice, whole wheat bread), include dried beans and lentils, eat fish 2-3 times a week, choose lean meats, remove skin from chicken/turkey, choose liquid oils for cooking
• Increase exercise, take short walks after meals, work towards a moderate weight reduction of 5-10% of current weight
• Other recommendations:
  - Refer to ophthalmologist for yearly eye exams
  - Check hemoglobin A1 C tests to assess level of diabetes
  - Check U/A to assess for microalbuminuria
  - Home monitoring with glucose checks
• Return to clinic for follow up in 3 months

Educational Tool:
Controlling Diabetes With Diet - A helpful handout with a brief overview of diabetes and key nutrition strategies for diabetes control

References:
Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ. Beneficial Effects of High Dietary Fiber Intake in Patients with Type 2 Diabetes Mellitus. N Engl J Med. 2000 May; 342:1392-1398.

Ma Y, Olendzki BC, Hafner AR, Chiriboga DE, Culver AL, Andersen VA, Merriam PA, Pagoto SL. Low-carbohydrate and high-fat intake among adult patients with poorly controlled type 2 diabetes mellitus. Nutrition. 2006 Nov-Dec; 22(11-12):1129-1136.

Nathan DM. Initial Management of Glycemia in Type 2 Diabetes Mellitus. N Engl J Med. 2002 Oct; 347:1342-1349.

Rendell M. Dietary Treatment of Diabetes Mellitus. N Engl J Med. 2000 May; 342:1440-1441.

The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-986.