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E-case #17-B Richard Ludwig, M.D. October 8-12, 2001 Self Management Goal Setting WF is a 69 yo man who presented after a long absence to have a lesion removed from his face. It was an obviously benign lesion that was eventually removed. He was found to have a blood pressure of 200/140. He lives alone and admitted to drinking daily with his friends at the Elks, usually 5 to 6 drinks in an evening. Two months later he was found to have a HgbA1C of 11.9. He was advised that the drinking was a factor in his blood pressure and his diabetes and that he should quit. He discussed diet with a nutritionist. He agreed to discontinue drinking and alter his diet to conform to the recommendations of the nutritionist. On 5/17/00 his weight was 220 lbs. It is now 178. Blood pressure was controlled initially with lisinopril 20, atenolol 50, and HCTZ 25. Atenolol has been reduced to 25 and his recent BP was 130/70. Last HgbA1C was 5.5. Metformin was reduced to 500 mg a day. MA is a 41 yo woman who presented with classic symptoms of DM. Her weight was 300 lbs on 10/25/00. HgbA1C was 13.8. She was a smoker. She was asked what she felt she could tackle first and was given several areas to consider working on. She said she wanted to quit smoking. She plays bingo all day on the computer, and heard through the bingo chat room that Zyban really worked. She was given a prescription for Zyban with the usual instructions. When she returned for her next visit her weight had gone up 12 lbs. She did not try the Zyban because it was too expensive. WS is a 79 yo man with CAD and DM, lumbar stenosis and DJD of the knees. Because of his renal insufficiency he cannot have another angiogram. He had angina. He walks with canes because of his knee pain. He was encouraged to think about an exercise program and asked what he thought he could do. He likes to get into the pool. He decided to go to the pool three times a week and do three specific exercises, working up to 40 minutes per session. He began a swimming program and lost 6 lbs over three months. More importantly, his back pain is improved, his angina is gone, and his sense of well being is much better. Discussion What is obvious to us as clinicians has recently been "proven" in two studies related to diabetes. A recent headline in the morning paper reviewed an article on the prevention of type two diabetes, showing that life style changes, primarily diet and exercise, reduced the risk of developing type 2 diabetes. The NEJM article below demonstrated that 91 percent of the women who developed diabetes in this cohort had high-risk life style issues (primarily obesity), implying that with life style changes their diabetes would improve or disappear. What to do? The food industry produces 50% more calories daily than are needed by the US population. Sedentary lives are the norm. In the past we have advised or admonished our patients to do better, lose weight, exercise more, but with little effect. More recent research has demonstrated that we can make a difference in this area with more directed interventions. For instance, we must:
Attached are some tools to use for diabetics. I think they are self-explanatory. You can create similar tools for other chronic diseases entities such as hypertension etc. References
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