Living with Diabetes

 In GIM clinic last week, I saw a patient in his mid-40s for management of recently diagnosed diabetes mellitus. I was reminded of the impact that this illness has on patients and gained insight into the difficult transition that our patient experienced with this diagnosis.

He was a previous healthy individual who had developed symptoms of polyuria, polydipsia, and fatigue over the last several weeks. As he had a significant family history of both Type 1 and Type 2 diabetes, he checked his blood glucose at home which read 33 mmol/L. He went to the emergency department and was admitted with his first presentation of diabetes. During his hospital stay, he was initiated on metformin and insulin, received counselling from a diabetes nurse educator and dietician, and was referred to our GIM clinic for follow-up.

When I spoke with him, he expressed feeling anxious about not knowing which type of diabetes he had. At this time, his anti-islet cell and anti-GAD antibodies were pending and it was unclear whether he had Type 1 or Type 2 diabetes. This led to uncertainty as to whether he would require insulin therapy permanently. Additionally, he disclosed a sense of self-guilt if he were to have Type 2 diabetes, as he felt that it could have been prevented if he had a healthier diet and lifestyle. I empathized with him and counselled him that Type 2 diabetes has a strong hereditary component and that it is often not the fault of the individual. The patient was grateful upon hearing this and I was glad that I could comfort him during a difficult time.

Our patient was motivated to make lifestyle changes. We reinforced the importance of a balanced diet, ensured that he was eating 3 meals per day, and limiting foods with saturated and trans fats, cholesterol, and sodium. We also discussed the importance of exercise and working towards a goal of 150 minutes of moderate to vigourous aerobic activity each week. As the patient primarily had a sedentary lifestyle, we came up with a plan to progressively increase the intensity and duration of his exercise schedule to set goals that were feasible and attainable.

He was also becoming more accustomed to checking his blood glucose multiple times per day and injecting insulin into his abdomen. He was currently taking basal bolus insulin therapy with Lantus 20 U qHS and Novorapid 5 U before breakfast, lunch, and dinner. Upon reviewing his glucose readings, we noticed that his morning glucose levels fluctuated between 11-14 mmol/L and his pre-meal readings ranged from 18-24 mmol/L. Based on this, we recommended that he increase his Lantus to 25 U qHS and Novorapid to 7 U before each meal. With these recommendations, we also counselled him on the risk of hypoglycemic episodes including potential symptoms (tremors, palpitations, diaphoresis, confusion) and management with a fast-acting carbohydrate.

I really appreciated participating in this patient's care. As a medical student, diabetes was one of the most common comorbidities that I encountered when caring for patients on the wards. However, seeing this illness in an ambulatory setting helped me better understand the day-to-day challenges that come with this diagnosis, including the lifestyle changes, new information for patients to learn, and also the added stress, anxiety, and feelings of guilt that can be associated with diabetes. I will be mindful of these lessons as I progress in my medical training.

-CB