By Melinda Young
A man in his 40s had recently received a diabetes diagnosis. It was tough news to hear because he was a single father of three children, and he worked full-time.
“He had severe fatigue, and his kids ranged from seven to 15,” says Megan Adelman, PharmD, a clinical pharmacy specialist with the department of family medicine and an assistant professor at the West Virginia University (WVU) School of Pharmacy. “He wanted to be a part of his kids’ lives, but was having a hard time keeping up with them,” she adds.
WVU School of Medicine helped form an intensive diabetes clinic, designed to help the highest-risk patients with diabetes improve their health and habits. The man started coming to the clinic for focused attention.
The patient’s life had taken a stressful turn recently when his wife left him and the children. The father was not surprised by the diabetes diagnosis because his family had a history of problems with the disease. Diabetes had led to kidney disease and multiple skin infections for some of his relatives.
“He said, ‘With everything going on in my life, I knew this was inevitable,’” Adelman recalls. “He wanted to start insulin, and he wanted a quick turnaround.”
The diabetes team worked with him to lower his glucose levels and improve his health habits. Insulin helped, as did the team’s focus on his stress levels and self-care motivation, she notes. “He felt empowered and wanted to be there for his kids,” Adelman says. “When we were talking about goal setting, he said, ‘I have to take care of these kids, and I want to live to see grandkids.’”
The patient needed to improve his diet, even as he faced the obstacle of having three children to feed. “His diet was focused on what his family could eat, so he began to teach his children healthy lifestyle choices. He told them that he was trying to get healthier so he could be healthy for them,” Adelman says.
The easy part was increasing his physical activity because his children were very active, she adds. “There was a lot of chasing them around, going on hikes, kicking the ball around,” she says.
Within six months, the patient’s A1c level decreased from greater than 10 to single digits. He lost weight every week, Adelman says.
In another case, a pizza shop owner, who had spent much of his time eating his own pizzas and other Italian food, developed diabetes and chronic kidney disease. The man was adamant about not receiving insulin, even though his A1c level was between 11 and 12, Adelman says.
The team listened to him and came up with an alternative strategy to lower his blood glucose levels. It required great discipline. “This case highlights how we’re not a compliant-driven or physician-oriented clinic; we’re a holistic clinic, where the goals of patients drive our care,” Adelman explains. “It would have been easy to say, ‘You’re going on insulin,’ but we said, ‘If your A1c doesn’t come down, then we feel like you’ll have to go on insulin to make sure you’re not hurting your organs.’ We started him on oral medications that are appropriate to start if you have kidney disease, and we asked about what other lifestyle changes he could do,” Adelman says. “He was active in self-care and goal-setting. He didn’t want to go on insulin because he bought into the lifestyle changes.”
The patient changed his diet. He still ate at his restaurant, but stuck to salads and consumed far less pizza. He also set realistic exercise goals, including walking three times a week for 20 minutes. Later, he increased to walking five times a week.
“These small, incremental changes helped to make it sustainable,” Adelman says. “We started slow, so he could have self-confidence.”
The patient’s kidney disease was a baseline comorbidity, and no one expected it to improve. But the diabetes treatment helped prevent it from becoming worse, she adds. The man lost weight and reduced his A1c to 5.8, a level that put him into nondiabetic category.
When a follow-up check-up showed that the patient’s A1c level remained low, the diabetes team decided to stop one of his oral diabetes medications. Eventually, if his improvements hold, he could be taken off diabetes medication entirely, Adelman says.
“These are the kind of stories that motivate us,” she adds.
West Virginia University's team case management approach to diabetes management has led to positive outcomes with patients.
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