A 46-year-old man comes to the office to discuss type 2 diabetes mellitus and obesity. The patient has poorly controlled diabetes despite multiple oral medications and previous attempts at dietary change. He reports that his endocrinologist has recommended insulin therapy, but he has declined because he wishes to avoid injected medications. The patient says, "I found a new diet on the Internet that I am thinking of trying. I know my weight is bad for me, but if I can get the weight off, maybe I won't have to go on insulin." Which of the following is the most appropriate response to this patient's statement?

Question

A 46-year-old man comes to the office to discuss type 2 diabetes mellitus and obesity.  The patient has poorly controlled diabetes despite multiple oral medications and previous attempts at dietary change.  He reports that his endocrinologist has recommended insulin therapy, but he has declined because he wishes to avoid injected medications.  The patient says, "I found a new diet on the Internet that I am thinking of trying.  I know my weight is bad for me, but if I can get the weight off, maybe I won't have to go on insulin."  Which of the following is the most appropriate response to this patient's statement?

Quizplus · Accepted Answer

11ec25c8_d0c6_347e_bc81_ef0025d203dc_MD0003_00 This patient with uncontrolled type 2 diabetes mellitus wishes to avoid insulin therapy and is considering lifestyle interventions to achieve weight loss and better diabetic control. He has not yet committed to any specific intervention but acknowledges his need to change and is actively searching for information regarding options. When counseling patients on lifestyle modification, it is often helpful to consider their readiness using a stages of change model. This patient is in the contemplation phase; that is, he understands the need to modify his diet and is considering options but is not yet ready to commit to a specific dietary plan. In this situation, the patient will benefit from the clinician's medical expertise so that he can make an informed choice regarding dietary modifications. The clinician should probe the patient's current understanding of diabetic diet requirements, as well as the specifics of the diet he is considering, and provide a scientifically valid assessment of the pros and cons of the proposed diet. Once the clinician and patient agree on a general intervention, they can begin discussing implementation and appropriate follow-up. (Choice A) Although many diets can facilitate weight loss, not all are appropriate for every patient. This patient needs reliable advice from the physician to make an informed decision. (Choice B) Initiating insulin can help this patient achieve better glycemic control. In addition, many patients find that, after maintaining tight control for an extended period, they are able to reduce their insulin doses, especially if they have instituted lifestyle changes in the interim. However, insulin induces weight gain in most patients. (Choice D) Once the patient decides on a specific dietary plan for weight loss, the clinician can advise on realistic interim goals. However, this step would be premature for this patient, who has not committed to a specific diet. (Choice E) Although obesity is associated with insulin resistance, this statement does not provide the patient with any new information he will need to make an informed decision about diet. Educational objective: Provider counseling that reflects patient readiness can increase the likelihood of successful lifestyle change. One such approach is the stages of change model. In the contemplation phase (ie, the patient understands the need for change but has not committed to a specific plan), the clinician should probe the patient's level of understanding and provide a scientifically valid assessment of the pros and cons of the proposed change.

A 46-Year-Old Man Comes to the Office to Discuss Type