Case study

Diabetes + hypertension + Dyslipidemia + Obesity

Patient Background
• 58-year old male
• Clerk from Cairo
• Diagnosed with Type 2 diabetes 2 years ago
• 1.75 meters tall & weighs 97 kg
• No apparent complications of diabetes
• He starts on glimepiride 4 mg/day for 1 year
• Then, He was shifted to NPH insulin for 1 year (60 U before breakfast)
• During this 2 years, he has gained 3 kg in weight
Lifestyle
• He smokes 15 cigarettes a day for 35 years
• He has abdominal obesity and does very little exercise

Family history
• His father has hypertension
• his mother is obese, with Type 2 diabetes
Nutritional history
• At diagnosis, he was told to cut down on the amount of processed
foods
• He reduced his intake of take-aways and desserts
• Yet his diet is still fairly high in other fatty foods and sauces.
Nutritional habits
• Breakfast: toast with butter and a glass of orange juice
• Lunchtime and evening: red meat or chicken with sauce and potatoes
or rice at lunchtime
• Drinks 4 cups of black coffee with sugar a day
• BP: 155/108 mmHg
Amin’s HbA1C and FPG results
• HbA1C : 7.6%

• FPG: 236 mg/dl

• Total cholesterol: 211 mg/dl

• HDL-cholesterol: 27 mg/dl

• LDL-cholesterol: 144 mg/dl

• Triglycerides: 251 mg/dl

What do you want to do now?
• What is his BMI?

• Is he Hypertensive?
• Comment on his HbA1C and FPG results? Do his FPG and glycated haemoglobin
level indicate that his glycaemic control is adequate on his current treatment
regimen?

• Comments on his blood test results? Is his lipid profile within the desired range?

• What are the further investigations?

• What are the problems list that need to be addressed? Make a treatment
decision?
• What lifestyle modifications should be discussed?
• immediate cessation of smoking, exercise and dietary modifications
• What other issues would you like to discuss?
• Blood glucose self-monitoring
• Education about the concept of chronic disease
• The risk of developing of complications

• control of diabetes; empowerment leads to behavioral change

• certain eating patterns affect blood glucose profile, self-monitoring
will enable this
• risks of developing complications if he maintains his current lifestyle
• How would you treat his hypertension?
• How would you change his treatment regimen?
• Immediate goal of therapy: lower FPG level
• Metformin + thiazolidinedione appropriate treatment:
• Unassociated with hypoglycaemic episodes
• Metformin reduces triglyceride and LDL-cholesterol level
• Metformin and thiazolidinediones are insulin-sparing, thus good
glycaemic control with a reduced dose of insulin
• Weight gain and hypoglycemia with insulin treatment will be reduced
OR
• Switch to modern basal insulin (Detemir):
• Once daily
• Better glycaemic control
• Less incidence of hypoglycaemias
• No weight gain
• Better HBA1c control
• He returned for follow-up after 6 months. He has been taking a
combination of:
• metformin
• Rosiglitazone
• reduced dose of insulin
• ACE inhibitor
• He has taken up jogging once a week, and now walks more, rather
than using the car.
• His weight has gone down to 91 kg.
• He feels much happier and more in control of his diabetes because
of his weight loss
• He has learned to self-monitor his blood glucose levels
• He finds it somewhat inconvenient to do this after his lunchtime meal,
which he eats with his colleagues
• He has not stopped smoking but has cut down to 10 cigarettes per
day.
• Failed to follow meal plan suggestions
• But he reduced portion sizes and substituted artificial sweeteners for
sugar in his coffee.
Follow-up
• FPG: 184 mg/dl
• HbA1c: 6.4%
• Total cholesterol: 207 mg/dl
• HDL-cholesterol: 31 mg/dl
• LDL-cholesterol: 130 mg/dl
• Triglycerides: 234 mg/dl
• BP: 135/95 mmHg
Further plan:
• Stopping smoking completely
• Reducing the amount of red meat in his diet
• Eating more fresh fruit and vegetables
• Reminder of the importance of spacing meals and snacks, and having
evening meal at an earlier hour

• A follow-up appointment for Amin should be arranged for 3 months'

time
Any Questions?