Monday, October 22, 2012

Treating Insulin deficiency is a game that allows you to be less than perfect and still win

Diabetes is just a game of numbers.  

                   It is a game that allows you to be less than perfect and still win

Todays post is a continuation of post from 10/17 and 10/19. On 10/17 I discussed the idea above and on 10/19 reviewed the  effects of doubling the dose of Crestor on his LDL. Today the discussion will center overall management of this problem.

Case review
I have a friend who shared his recent laboratory results with me . He has had a coronary bypass and was diagnosed with diabetes at the time of surgery. He currently is taking Lantus insulin ? dose, Novolog about once daily if his sugar is high before a meal, and Januvia. His glucose test result are higher than usual , he does not feel well and has lost weight without trying.
Lab test results
      FBS 321  mg/dl
      A1c 10.4
     Cholesterol 271       mg/dl
     LDL Cholesterol 160 mg/dl
     Triglycerides 383    mg/dl
      HDL  34
He does not like the idea of multiple injection and will be starting Bydureon if it is approved by his insurance company and his doctor doubled his dose of *Crestor.
He and his wife are concerned about his test results, especially the LDL of 160 mg/dl while taking Crestor.

Insulin deficiency is the  primary problem for people with type 2 diabetes

 - Doubling the dose of Crestor  and trying Bydureon will be of some benefit but it will not fix the  primary problem ,insulin deficiency. In the absence of any other occult medical problem such as infection , he  needs to take enough insulin to meet his daily needs.  
- He demonstrates the typical progressive loss of  adequate insulin production and this  has to be corrected before an accurate evaluation of his cholesterol and triglyceride can be made.

 - Adequate insulin is needed to effectively use and store glucose and triglycerides as fuel for our bodies . Without enough insulin both glucose and triglycerides will back up in the blood. 

 -You may remember, one fifth of Triglycerides is cholesterol. With a little math , Triglyceride 383/5 = 76.6 mg of cholesterol, we can move his total cholesterol to over 300 mg/dl.

- This man has severe insulin deficiency and this deficiency must be corrected before anything else can be  effectively managed.

Management ideas
#1 Physical exam and lab to rule out reasons other than insulin deficiency as a cause
     for his elevated glucose levels

#2 reevaluate his life style and move towards a vegetarian style of eating . The Dash
     diet is a good place to start .I have attached my thoughts on the Dash diet below.
      He can start applying the basic food management ideas needed to control his blood
               Chapter 5 page 21 of Diabetes office visit   and

           a) recognize foods that contain carbohydrates , fruits, grains , milk and 
           b ) control portion size and start counting carbohydrates
           c ) work on being consistent with daily carbohydrate intake.

 #3 Start thinking about insulin / carbohydrate ratios 

 #4 make the mental decision to do what ever is necessary to control and just do it

Tomorrow---- injectable options

Have fun be smart and remember , applying the basic ideas of glucose control really does work
David Calder, MD

A few previous post to review
My favorite diet ideas including the DASH diet

Dash Diet, Simple Ideas That Work


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Your comments and questions are appreciated. David Calder,MD