A 56-year-old man comes to the office for follow-up of type 2 diabetes mellitus. He has an extensive family history of complicated type 2 diabetes, and multiple family members have required lower extremity amputations for nonhealing ulcers. The patient has tried multiple oral medications and his most recent hemoglobin A1c is 9.6%. He is now being considered for basal insulin therapy. After an extended discussion of injection technique, the patient tells the clinician that he does not want to initiate insulin. He says, "My diabetes is my own fault. My mother always said I was too fat and was going to get diabetes like my dad. Maybe if I stop eating too much, I wouldn't have to waste your time giving me insulin." Which of the following is the most appropriate response to this patient's statement?

Question

A 56-year-old man comes to the office for follow-up of type 2 diabetes mellitus.  He has an extensive family history of complicated type 2 diabetes, and multiple family members have required lower extremity amputations for nonhealing ulcers.  The patient has tried multiple oral medications and his most recent hemoglobin A1c is 9.6%.  He is now being considered for basal insulin therapy.  After an extended discussion of injection technique, the patient tells the clinician that he does not want to initiate insulin.  He says, "My diabetes is my own fault.  My mother always said I was too fat and was going to get diabetes like my dad.  Maybe if I stop eating too much, I wouldn't have to waste your time giving me insulin."  Which of the following is the most appropriate response to this patient's statement?

Quizplus · Accepted Answer

11ec160b_3688_0d96_9249_9180e798b349_MD0001_00 Failure of oral medications is common in long-standing type 2 diabetes mellitus due to progressive loss of pancreatic beta cell function. Basal insulin therapy is often necessary, especially when multiple agents have failed or when a patient has a hemoglobin A1c >9%. It is common for patients to have reservations about initiating insulin due to treatment complexity, risk of hypoglycemia, or injection pain. However, this patient is expressing concern that the failure of oral agents represents a personal inadequacy; in other words, he thinks that his diabetes is uncontrolled because he has failed to follow lifestyle recommendations (ie, diet). In counseling patients with treatment failure, especially those who have overpersonalized their medical condition, it is appropriate to review the natural history of the condition. In this case, the clinician should explain that type 2 diabetes is a progressive disorder and that escalating treatment regimens are often the norm. Lifestyle factors (eg, diet, weight loss) should not be neglected but should be discussed in a compassionate, nonjudgmental way, and self-blame should not be encouraged. (Choice A) Although the clinician should assist the patient in developing weight loss strategies, this patient's hesitation in initiating insulin is primarily related to guilt and self-worth. Once the psychosocial aspects of treatment are addressed, weight loss counseling is likely to be more fruitful. (Choice C) This patient's frustrations pertain to diabetes and insulin. Once that issue is addressed, if the patient has additional concerns or depressive symptoms in other domains, a more detailed depression assessment could be performed. (Choice D) This response conveys empathy but diverts attention from the patient to the provider. Such a statement might be appropriate as a cheerful end to the conversation but is not an effective way to initiate further discussion. (Choice E) This patient's feelings of guilt may be related to his family background, but his concerns focus specifically on his lifestyle habits and diabetic control rather than genetic factors in the etiology of diabetes. Educational objective: Failure of oral medications is common in long-standing type 2 diabetes mellitus due to progressive loss of pancreatic beta cell function. Patients should be counseled that because of the natural history of the condition, the need for supplemental insulin is common and does not represent a personal failure.

A 56-Year-Old Man Comes to the Office for Follow-Up of Type