A 48-year-old woman comes to the office for follow-up of type 2 diabetes mellitus. She has had diabetes for 10 years with gradually worsening glycemic control despite taking multiple oral antidiabetic agents. Three months ago, the patient discontinued her oral medications (except for metformin) and started a daily injection of insulin glargine; she has had multiple visits with the diabetes educator since then to review injection technique and titrate up the dose. However, the patient reports a 4.5-kg (10-lb) weight gain since starting insulin. She says, "I feel like I need to eat more. If that's how insulin is going to be, then I don't want to continue it." Which of the following is the most appropriate response to this patient's statement?

Question

A 48-year-old woman comes to the office for follow-up of type 2 diabetes mellitus.  She has had diabetes for 10 years with gradually worsening glycemic control despite taking multiple oral antidiabetic agents.  Three months ago, the patient discontinued her oral medications (except for metformin) and started a daily injection of insulin glargine; she has had multiple visits with the diabetes educator since then to review injection technique and titrate up the dose.  However, the patient reports a 4.5-kg (10-lb) weight gain since starting insulin.  She says, "I feel like I need to eat more.  If that's how insulin is going to be, then I don't want to continue it."  Which of the following is the most appropriate response to this patient's statement?

Quizplus · Accepted Answer

11ec160b_3bc3_78ac_9249_bb7b58ad3588_MD0001_00 Insulin therapy for diabetes mellitus commonly causes weight gain due to increased peripheral glucose uptake, increased adipose lipid deposition, and reduced renal glucose loss (due to normalization of blood glucose, which reduces the filtered glucose load). Behavioral factors, including snacking and less rigorous adherence to dietary recommendations, can also contribute. Weight gain is especially pronounced in patients with type 2 diabetes who typically have high circulating levels of insulin and preexisting obesity. This patient has experienced weight gain after initiating a long-acting insulin analogue (ie, insulin glargine). Insulin normally suppresses appetite, but this patient reports increased need to eat, which suggests that the weight gain may not be simply due to the metabolic effects of insulin. Specifically, this patient may be eating more to suppress feelings of hypoglycemia. To address this patient's insulin-induced weight gain, the clinician should obtain additional history to elicit the patient's perspective on appetite, recent changes in dietary patterns, and associated hypoglycemic symptoms. Once the causes are better understood, several strategies, including dietary modification and changes to the insulin regimen, can mitigate insulin-induced weight gain. (Choice A) Periodic review of exercise habits is recommended for patients with diabetes. However, this patient has already stated that appetite is her primary concern, so this should be explored first. (Choice C) Patients can gain weight due to a variety of factors. In addition to physiologic factors, stress often alters diet and exercise habits, leading to weight gain. However, this patient's weight gain is temporally associated with the initiation and titration of insulin, which makes insulin the most reasonable culprit. If the issue is not resolved after addressing the patient's insulin regimen, other factors can be explored. (Choice D) Although the benefits of improved glycemic control with insulin generally outweigh the negative effects of weight gain, this statement does not address the patient's concerns and could miss an opportunity to improve the insulin program. Educational objective: Insulin can cause weight gain due to physiologic (eg, increased peripheral glucose uptake, reduced renal loss of glucose) and behavioral (eg, increased snacking in response to hypoglycemia, less rigorous attention to diet) factors. Counseling should elicit the patient's perspective on appetite, changes in dietary patterns, and hypoglycemic symptoms. __________ References: Insulin-associated weight gain in obese type 2 diabetes mellitus patients: what can be done? (http://www.ncbi.nlm.nih.gov/pubmed/28509408)

A 48-Year-Old Woman Comes to the Office for Follow-Up of Type