Managing Diabetes - Poor Glycaemic control and Low BMI.

Introduction

Meet John*, a dedicated 57-year-old taxi driver, who has been navigating the challenges of type 2 diabetes since his diagnosis in 2016. Faced with deteriorating glycaemic control, John embarked on a transformative journey to regain control over his health.

This LinkedIn post explores John's path, highlighting the tailored strategies working alongside a dietitian that has helped him achieve remarkable improvements.

The Challenge: Managing Worsening Diabetes

In early 2023, John's HbA1c levels were fluctuating between 57-65 mmol/mol. By mid-April, they had surged to 79 mmol/mol, indicating poor glycaemic control. Despite maintaining a relatively low BMI of 21.6 kg/m² and a weight of 71 kg, his blood glucose levels were persistently high.

His presentation was atypical for type 2 diabetes, which is often associated with obesity, older age, or certain minority ethnic groups.

John was then referred to our PCN dietitian.

Initial Treatment and Assessment

John was initially managed with Metformin and Sitagliptin. However, Sitagliptin was discontinued due to rapid HbA1c reduction, posing a risk of retinal damage. Consequently, Gliclazide was introduced and titrated slowly alongside daily capillary blood glucose monitoring.

Despite eating a balanced diet and being mindful of carbohydrate intake, John's occupation as a taxi driver often meant consuming meals on the go, complicating his diabetes management. His capillary blood glucose tests showed concerning levels: 14.1-15.5 mmol/l before breakfast and 8.8-11.6 mmol/l before dinner.

Setting Goals and Crafting a Care Plan

John's current background:

• 57 years old
• Weight = 71kg
• BMI = 21.6kg/m2

It is important to note that John's BMI is 21.6kg/m2, which is considered normal.

Disclaimer! Use BMI with caution - i t is a simplistic measure to determine health, and does not take into account muscle mass.

John had two clear goals: regain his weight to 75 kg and avoid starting insulin therapy, which was impractical due to his job. Together, we developed a comprehensive care plan aimed at optimising glycaemic control and promoting healthy weight gain.

Goals:

• Optimise glycaemic control
• Promote weight gain within a healthy BMI range

Care Plan:

1. Carbohydrate Management: Aim for 30-40g of carbohydrates per meal, totaling 150g per day. Balance meals with higher protein and unsaturated fats to lower the glycaemic index (GI).
2. Snacking Smart: Opt for low-carb, high-calorie snacks like full-fat yoghurts, cheese, nuts, and peanut butter on oatcakes.
3. Increase Calories: Fortify meals by adding olive oil dressings to salads and cheese to sandwiches.
4. Boost Protein Intake: Double the protein portion at dinner (two palm-sized portions).

John was also encouraged to monitor his blood glucose levels twice a day and provided with resources such as the ‘Diabetes UK Low-carb meal plan’ and the NDR leaflet on ‘Carbohydrate and blood glucose.’ He also started using MyFitnessPal to track his nutritional intake.

Progress and Outcomes

Four weeks later, John returned for a review. He had diligently tracked his dietary intake, aiming for approximately 2500 calories and 150g of carbohydrates daily. He followed the dietary advice, incorporating controlled portions of carbohydrates at each meal and increasing his intake of protein and healthy fats. High-calorie, low-carb snacks like peanuts, full-fat Greek yoghurt, cheese, and fruit with cream became staples in his diet.

Positive Changes:

• Blood Glucose Levels: Improved to 9.5-13 mmol/l before breakfast and 3.8-8.6 mmol/l before dinner.
• Weight: Increased by 1 kg.
• Well-being: John felt more confident in his food choices and reassured by the reduction in blood glucose levels, decreasing the likelihood of needing insulin therapy.

Conclusion

John's journey exemplifies the power of individualised diabetes management. Through tailored dietary advice, consistent monitoring, and dedicated effort, he achieved significant health improvements tailored to his goals. John's story is a testament to the impact of education and support in managing chronic conditions, empowering individuals to lead healthier, more fulfilling lives.

To find out more about dietitians, visit our website www.primarycaredietitians.co.uk or drop us an email at info@primarycaredietitians.co.uk!

*Name changed for anonymity.