July 27, 2003
Daily Care
Question from Sacramento, California, USA:
My 42 year old fiancee was diagnosed with type 2 diabetes about four months ago, and he is taking 500 mg of Glucophage [metformin] daily. He has been getting all of his diet/medication instructions from two nurses and a dietitian at the diabetes clinic for his medical group where he goes monthly. He weighed 355 pounds when diagnosed, and is now about 320 pounds.
The meal plan they laid out for him consists of 60-90 grams of carb per meal and two snacks each containing 15 grams of carb, but if he eats this many carbs, his blood sugar sky-rockets, and he feels awful. As a result, he has been limiting himself to around 45 grams of carb per meal, with protein and fats only for snacks, and he has had excellent readings overall. The problem is that he is eating far too much protein and fat, is constantly hungry, and will occasionally binge.
For instance, this weekend for our one night a week meal out, he ignored my suggestions and he ate four slices of bread, a medium sized bowl of minestrone soup (with beans and pasta), and an entire huge plate of spaghetti (more than three cups). He left two bites of noodles and later insisted that he had only eaten half the plate. He was miserable afterwards, but refused to test because he knew he would be high and didn’t want the high number on his meter the next time he went in. It’s not always the night out, either. At home, he will eat a huge bowl of granola (35 grams of carb per half cup, and he eats more than two cups, in addition to the milk), an entire bunch of grapes, or he’ll bring home a burger with a super sized fries, and eat them all.
We both think that his Glucophage dose needs to be adjusted so that he can eat the correct amount of carb in his meals. This might help with the bingeing too. However, he has discussed this several times with the nurses even shown them elevated post-meal tests from when he had eaten their recommended 60 grams of carb. They insist that since his A1c has been good, and the majority of his self testing numbers are all in healthy ranges, he is fine on the current dose. We even measured out 60 grams of carb worth of cereal one day, and tested every 30 minutes for two hours afterwards. His blood glucose peaked at 165 mg/dl [9.2 mmol/L], and they said “occasional peaks to that level shouldn’t hurt, and a range of 80-120 mg/dl [4.4-6.7 mmol/L] is just a guideline”. Which I guess would be true, except that if he ate normally it wouldn’t just be occasional peaks.
It seems a shame that he would have to make himself sick for several months, in addition to causing further organ damage, by eating what they tell him, so they can have the proof they need (an elevated A1c) to change his medication. He has even asked to be referred to an endocrinologist, and they have refused, because his numbers are good. Is this normal? Should we try to find a different diabetes clinic?
How bad is this sort of bingeing for him in the long run? I obviously can’t make him eat or not eat anything since he’s an adult and in the end, responsible for himself, but I worry about the effect that this kind of eating will have on him long term, even with normal A1cs. Also, he is an enormous grump and very difficult to deal with when his blood glucoses get high. He eats like this maybe once a week or so. Obviously, it is not often enough to elevate his A1cs to dangerous levels, but does that make it okay to have a blood glucose over 250 mg/dl [13.9 mmol/L] (that’s just my guess since he never will test after he binges), even if it is only once a week?
Answer:
I think you need to give your boyfriend a little slack! Even though I agree that he perhaps has morbid obesity, a weight loss of two pounds per week is manageable and healthy, and he should be commended for doing such a great job. A two-hour postprandial blood sugar of 165 mg/dl [9.2 mmol/L] is really pretty good (the American Diabetes Association guideline is 140 mg/dl [7.8 mmol/L].), especially if your boyfriend’s hemoglobin A1c is less than 7%.
I think that “bingeing” is something all of us do — especially on weekends! If your boyfriend continues to lose weight at this rate, I would encourage his efforts, and let him “go off track” once in a while.
SS
Additional comments from Dr. Donough O’Brien:
I think your fiance’s real problem is his body weight and your report suggests that he may have reached the point that gastric surgery should be considered. At a time when human studies of the hormone PYY and of ghrelin receptor antagonists in obesity are promising but nowhere near the point of FDA approval he should perhaps talk to his doctor about getting a second opinion on this.
DOB
Additional comments from Jane Seley, diabetes nurse specialist:
You are right about the carbohydrate portions per meal. 45 grams per meal would be better to help your fiance lose weight and balance his blood sugar. 500 mg of Glucophage [metformin] is a starting dose and should be gradually increased to a therapeutic level by his health care provider. Your fiance should also consider gastric bypass surgery. He would not be able to tolerate bingeing if he had the surgery. You really should encourage him to see an endocrinologist as soon as possible.
JS
