John is a 55 year-old Caucasian man with diabetes and asthma. He teaches math at a local high school in New York City. He was diagnosed with type 2 diabetes on blood tests performed when he applied for life insurance at age 51. At the time, he was obese, weighing 220 pounds at 5 feet, 10 inches height (BMI = 31.6).
He stopped smoking at age 46 and he does not consume alcohol.
John lost 20 pounds with a strict diet and daily exercise and started metformin, which was titrated up to 1000 mg twice-daily. His glucose levels improved and his A1c declined from 7.2% to 6.2% within 4 months.
At age 53 glimepiride (Amaryl®) was added at a dose of 2 mg daily due to a rise in A1c to 7.3%. His A1c rose to 6.6%, and he gained 5 pounds.
John controls his asthma with inhaled medications, including fluticasone propionate and salmeterol inhalation powder (Advair®) 250/50 mcg, and montelukast sodium (Singulair®) 10 mg daily.
Last year John’s asthma worsened. In addition to inhaled medications, he has intermittently required Prednisone in doses up to 40 mg daily. Exercise has been less regular and he has gained a further 10 pounds in weight. HbA1c has risen to 8.5%, corresponding to an overall average blood glucose of 220 mg/dL.
Weight: 215 lbs.
Height: 5’ 10"
Last A1C: 8.5% (overall
average 220 mg/dL)
Fasting: 94-135 mg/dL
Post-breakfast: 250-340 mg/dL
Pre-lunch: 200-300 mg/dL
Post-lunch: 220-310 mg/dL
Pre-dinner: 125-180 mg/dL
Bedtime: 164-234 mg/dL
Total: 194 mg/dL
LDL: 120 mg/dL
HDL: 31 mg/dL
Creatinine: 1.2 mg/dL
Normal: 135/90 mmHg
High cholesterol, low HDL, no history of chest pain or known CHD
Background diabetic retinopathy
Compliance with meal plan?
Less compliant with diabetes meal plan
than he used to be.
Compliance with exercise plan?
For blood glucose:
Metformin 1000 mg bid
Glimepiride 2 mg qd
For other conditions:
prednisone (Sterapred®) 40 mg qd
fluticasone propionate and salmeterol (Advair Diskus®) 250/50 mcg qd
montelukast sodium (Singulair®) 10 mg qd
What lifestyle changes could John make to improve his glucose levels?
a) Reduce the carbohydrate content in his meals
b) Exercise after breakfast
c) Skip dinner
d) a and b above
e) All of the above