A 52-year-old woman with obesity and a 9-year history of type 2 diabetes present

Question

A 52-year-old woman with obesity and a 9-year history of type 2 diabetes presents with complaints of fatigue, difficulty losing weight, and no motivation. She denies polyuria, polydipsia, polyphagia, blurred vision.

She notes a marked decrease in her energy level, particularly in the afternoons. She is tearful and states that she was diagnosed with depression and prescribed an antidepressant that she chose not to take.

She states that she has gained an enormous amount of weight since being placed on insulin 6 years ago. Her weight has continued to increase over the past 5 years, and she is presently at the highest weight she has ever been. She states that every time she tries to cut down on her eating she has symptoms of shakiness, diaphoresis, and increased hunger. She does not follow any specific diet and has been so fearful of hypoglycemia that she often eats extra snacks.

Her health care practitioners have repeatedly advised weight loss and exercise to improve her health status. She complains that the pain in her knees and ankles makes it difficult to do any exercise.

Her blood glucose values on capillary blood glucose testing have been 170–200 mg/d1 before breakfast. Before supper and bedtime values range from 150 mg/dl to >300 mg/dl. Her current insulin regimen is 45 U of NPH plus 10 U of regular insulin before breakfast and 35 U of NPH plus 20 U of regular before supper. This dose was recently increased after her HbA1c, was found to be 8.9% (normal <6.1 %).

Past medical history is remarkable for hypertension, hypertriglyceridemia, and arthritis. Current medications include only insulin, lisinopril (Prinivil), and hydrochlorothiazide (Dyazide).

On physical exam, her height is 5' 1 1/2" and her weight is 265 lb. Her blood pressure is 160/88 mmHg.

After an explanation that the increasing insulin doses were contributing to her weight gain and that she would need to decrease her insulin dose along with her food intake to prevent hypoglycemia, the patient agreed to follow a restricted-calorie diet and to decrease her insulin to 30 U of NPH and 10 U of regular insulin twice daily. As she had no contraindications to metformin (Glucophage), she was also started on 500 mg orally twice daily.

She returned to clinic 3 months later, still on the same dose of insulin. She was feeling a little less depressed. She continued to complain of fear of hypoglycemia in the middle of the night and was overeating at night. Despite this she had lost 7 lb. Her blood glucose values were still elevated in a range of 120–275 mg/dl before meals.

She was reassured that further insulin reduction would prevent hypoglycemia. Her insulin dosage was decreased to 25 U of NPH and 5 U of regular insulin twice daily and metformin was increased to 500 mg three times daily. Two months later, she returned to the clinic with an average blood glucose level of 160 mg/dl. Her weight was now 246 lb., and her HbA1c was 7.5%. She was feeling much more energetic, no longer felt depressed, and was able to start a walking program.

Questions

Can individuals on high insulin doses successfully lose weight?

How does/ can fear of hypoglycemia contribute to uncontrolled diabetes?

What is a possible approach to treat obese patients that are insulin treated, and have poorly controlled type 2 diabetes?

As a new exercise physiologist assigned to treat this individual, how would you best treat her?

How might an intense exercise training session impact this individual?

Explanation / Answer

Individuals on high insulin dose do not lose weight since one of the functions of insulin is lipid synthesis. When insulin is high there is more lipid synthesis which results in weight gain by the individual. Another important function of insulin is absorbing blood glucose for energy so in diabetes high amount of insulin is required to neutralise the blood glucose which does not respond to the normal levels of insulin produced. This can consequently lead to weight gain.

Hypoglycemia is a condition of low blood sugar. When people fear hypoglycemia they will intake more energy foods to avoid that condition and in the process they will accumulate more glucose in blood that needs to be processed for energy. However the insulin levels produced by beta cells may not be sufficient to process the increased glucose level and this may lead to diabetes.

For type 2 diabetes, beta cells wear out and stop producing sufficient insulin hence insulin injection may be required to process the extra glucose. A regulated dose of insulin after careful observation of patient's medical history and metabolic requirement has to be taken into consideration before deciding the dose. For example, the early stages of onset of diabetes may lead to higher production of insulin by the body due to resistance followed by drop in the insulin level due to wearing out of beta cells hence the dose should be such that the insulin dose is proportional to the energy intake.

A normal exercise regime such as a 45 minute walk every morning will be a good place to start especially if the diabetic is going through the insulin resistant phase. This will help ensure they get the extra workout to burn the fat as well as blood circulation to get the blood glucose utilised. This will also reduce the insulin dose required to artificially induce glucose utilisation and will reduce the lipid storage and weight gain in the future of the treatment as well.

The normal timing of the exercise is so that patient is not pushed too hard which will increase stress and consequently blood glucose levels will be increased. Also some patients complain of fatigue during the onset of diabetes which can make it difficult for them to follow an intense exercise session. An intense exercise training may be counterproductive for the same reasons.

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