Case Report of Lifestyle Management of a Complex Patient With Type 2 Diabetes Mellitus, Hypertension, and Multiple Co-Morbidities

Abstract

Objective: This case report depicts the application of lifestyle medicine to an adult, non-Hispanic, African American patient in their late 40s, with poorly controlled hypertension and associated co-morbidities of obesity, Type 2 diabetes mellitus (T2DM), depression and multiple degenerative joint disease (DJD). The patient was managed via telehealth for 1 year. Background: Chronic diseases are major risks to population health. Among these, diabetes, obesity, and hypertension are the most prevalent. United States (U.S.) prevalence estimates 34.2 million (10.5%) people of all ages are diagnosed diabetes cases and 7.3 million (2.8%) adults met diagnostic criteria but are but are not formally diagnosed. As such, diabetes ranked eighth for U.S all-cause mortality. The incidence of diabetes varied across the country from 1.2 to 46.2 per 1000 persons in 2016. Among these, 89.0% were overweight or obese, 38.0% were physically inactive and 68.4% were reported with a blood pressure of 140/90 mmHg or above. In 2017, the total cost of diagnosed diabetes was calculated at 327 billion dollars. In 2019, Hypertension (HTN) was reported as a primary or contributing cause in more than half a million deaths in the U.S. In the U.S. the HTN prevalence is 47%, or 116 million. Blood pressure (BP) control is higher among non-Hispanic white adults (32%) than non-Hispanic black adults (25%), non-Hispanic Asian adults (19%), or Hispanic adults (25%). Obesity is a modifiable risk factor for cardiometabolic disease. This especially appears true with less active to non-active lifestyles of this modern century where people tend to eat more easily accessible, unhealthy and processed food. Pandemic isolation has further enhanced people’s sedentary lifestyle. An answer for many of these issues is behavioral lifestyle modification. Lifestyle management is a flexible and a multi-focused approach program based on detecting individual health risks, barriers, and goal development through motivational interviewing and clinical coaching.

“The epidemic of diabetes and obesity and its association with other chronic diseases highlights the need to focus on prevention and lifestyle modification along with acute care management.”

Method

A 47-year-old, non-Hispanic,^1,2 African American female presented to lifestyle medicine clinic to explore lifestyle modifications to improve her cardiometabolic health.^1,2 The patient endorsed her main problems as high blood pressure,^1,2,3 “borderline diabetes” and chronic pain due to arthritis, ¹ systemic lupus erythematosus, and fibromyalgia. ¹ Her self-stated goal was to lose weight to improve her blood pressure and chronic pain.

In addition to her above chronic conditions, her past medical history (PMH) was also significant for gastroesophageal reflux disease, depression (Becks Depression Index (BDI II:42), history of steroid use, and hearing loss. Her surgical history was positive for bilateral shoulder arthroscopy and left rotator cuff repair. She also had significant family history of cardiometabolic disease including type 2 diabetes mellitus (T2DM) and myocardial infarction (MI) in both parents as well as HTN and kidney disease in her father. The initial lifestyle medicine evaluation focused on the 6 pillars of lifestyle medicine with concentration on nutrition, physical activity, stress management, and sleep health. She was followed over a period of 15 months. The frequency of follow-up was guided by her behavioral stage of change and progress toward goal achievement. Of note, the patient did have multiple cancellations and missed appointments during treatment. Social screening revealed that she lived over an hour away. As such, she was offered telehealth services. She would also serve as caretaker for her young grandchildren which would affect her ability to participate in telehealth visits. Her self-reported memory issues also led to missed appointments. She did receive text and email reminders related to visits. There were no other social barriers identified. Motivational interviewing techniques were utilized at each session.

Case Presentation

As the initial visit was conducted via telehealth methods due to pandemic restrictions, vital signs were not collected. However, review of electronic health record (EHR) data yielded most recent findings:

• Blood pressure (BP): 138/73 mmHg.

• Heart rate (HR): 88 beats per minute.

• Weight: 213 pounds.

• Body mass index (BMI): 42.25, Class III Obesity.

Her physical exam was limited due to telehealth methodology but was grossly negative for any significant abnormality except self-reported elevated blood pressure, obesity and tenderness of multiple joints. Her lab work including complete blood count, comprehensive metabolic panel, and thyroid tests were all normal. Her erythrocyte sedimentation rate was elevated (range 31-33) with a positive anti-nuclear antibody (ANA) speckled pattern. Lumbar spine imaging supported chronic multilevel degenerative disc and facet changes.

She was on multiple classes of medication for chronic disease management.

• Anti-hypertensive: calcium-channel blocker and angiotensin receptor blocker.

• Cholesterol lowering: statin.

• Anti-hyperglycemics: biguanide, insulin lispro, and glargine.

• Anti-depressant: serotonin-norepinephrine reuptake inhibitor.

• Immunomodulators: disease modifying anti-rheumatics, anti-malarial.

• Analgesics: oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants and opioid agonist.

Nutrition Assessment

• Breakfast: She indicated that she often skipped breakfast. However, when consumed, she endorsed having 4 pieces of sausage, 2 eggs, and 4 slices of toast.

• Lunch and Dinner: She endorsed having similar foods for both lunch and dinner which included items such as baked chicken or chicken salad.

• Snacks: She reported choosing both salty and sweet snacks including chips and pre-packed snack cakes.

• Beverages: Her main beverages included water, regular soda (24 ounces), and occasionally juice.

Physical Activity Assessment

Physical Activity Vital Signs (PAVS) screening indicated no current aerobic or resistance training. Of note, the patient had just completed physical therapy.

Stress Assessment

The patient was already under the care of psychiatric providers for depression management. Her Beck Depression Index II score was 42, and she was receiving cognitive behavioral therapy (CBT) related to chronic pain and insomnia.

Sleep Assessment

The patient endorsed poor quality sleep related to chronic pain and was undergoing psychological counseling to address this. She also endorsed a history of obstructive sleep apnea (OSA) but was not routinely utilizing continuous positive airway pressure (CPAP) therapy.

Lifestyle prescriptions were developed as a patient-provider team prioritizing patient perspective and comfort level where we served as coach and supporter. An action plan was set with a weight loss goal of 5% total body weight (TBW) over 2-3 months. Additional goals related to reduction in blood pressure and blood glucose to near normal levels while continuing pharmaceutical therapy with also set. This was reinforced with an ultimate goal of a normal BP and glucose while minimizing polypharmacy. Recommendations offered were reductions in added sugar and sugar-sweetened beverages, saturated fat and cholesterol. Special emphasis was placed on choosing whole-food based sources of nutrient dense items over highly palatable convenience items. Patient initially succeeded in reducing processed snack intake to 1-2 servings on alternate days. Eventually, she self-decided to avoid purchasing these items from the store and initiated a reduction of sugar-sweetened beverage intake.

Patient was counseled about sleep hygiene and CPAP utilization for her chronic OSA during follow-up visits. The importance of self-monitoring of blood glucose (SMBG) was reinforced as a strategy for targeting lifestyle interventions at each visit. As the patient was already connected with behavioral health services, our task was to further support and improve patient compliance with psychiatric medication management and CBT.

Result

Self-monitored and lab-tested glucose levels showed an average reduction in blood glucose of 8.6 grams/deciliter (g/dl) with a much narrower glycemic range. In addition, reduction in systolic and diastolic blood pressures from patient baseline occurred. More specially, the patient achieved an average reduction of 7.6 and 5.5 points in systolic and diastolic pressures, respectively. While the patient only had minimal weight loss of .5 pounds, the previous trend of year over year weight gain was halted. These results are presented in Table 1.

Table 1.

Biometric Outcomes.

	Pre-Lifestyle Medicine	Post-Lifestyle Medicine
Systolic blood pressure	Range: 132-158 mmHg	Range: 123-146 mmHg
	Average: 143.9 mmHg	Average: 136.6 mmHg
Diastolic blood pressure	Range: 73-93 mmHg	Range: 67-84 mmHg
	Average: 79.1 mmHg	Average: 73.6 mmHg
Blood glucose	Range: 99-180 g/dL	Range: 129-135 g/dL
	Average: 140.3 g/dL	Average: 131.7 g/dL
Yearly weight change	19 pound gain	.5 pound loss

Discussion

The diabetes epidemic has been associated with increased risk of cardiovascular disease ⁴ and requires appropriate management of modifiable risk factors. ¹ However, this goal is often not fully met despite being on optimal pharmacological treatment in the era of health care advancement. ⁴ With increased incidence and prevalence of diabetes and HTN, a recommendation of a low-fat whole-food plant-based (WFPB) diet in conjunction with other lifestyle modifications cannot only prevent HTN and T2DM but can also change the disease course and optimize blood sugar and BP naturally with no known adverse effects. ¹

“The American College of Lifestyle Medicine defines lifestyle medicine as the use of evidence-based lifestyle therapeutic intervention including a whole-food, plant-predominant eating pattern, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection as a primary modality, delivered by clinicians trained and certified in this specialty, to prevent, treat, and often reverse chronic diseases.” ⁵

Many of these chronic diseases are preventable and can be approached via lifestyle pillars either as lifestyle only or lifestyle-plus pharmacologic interventions at both the primary care and cardiovascular specialist level. The main goal is to refocus on improving quality of life and appropriate medication reduction by open discussions that redirects focus towards a change in patterns of lifestyle while strengthening the patient-provider relationship. Discussion with patients about potential side effects of hypoglycemic drugs, as well as alternative options including education on how to eat a WFPB diet and its’ relevant benefits may make patients more receptive to lifestyle changes. Per literature, 89% of patients reported being unaware of using a plant-based diet for the prevention and management of T2D and others reported low self- confidence in adopting a WFPB diet pattern. Thus, the above approach may increase long-term adherence with ad libitum intake of low-fat, WFPB foods. This may lead to sustained beneficial outcome via a natural reduction in total calories ⁵ especially for those who feel hunger as a barrier to diet compliance. ⁵

Thus, it is time for practical implementation of a constructive collaboration between the public, health care providers, academic institutions, health insurance companies, and policymakers for model reform to support individual and population health progress. However, patient collaboration through motivational interviewing is needed for an effective sustainable outcome. ⁶

Study Limitations

• • The main limitation of our project is that it utilized a case report design. However, this has added real-world positive evidence to the growing field of lifestyle medicine. The authors have plans to expand into case series designs next.

• • In our study non-availability of in-person interaction secondary to pandemic isolation protocol via telehealth has clinical limitations including lack of real-time biometric data. The video aspect of telehealth interaction further helped in improving the rapport and communication. Additionally, this further supports the case that lifestyle medicine can be successfully delivered via a telehealth platform.

• • We used food journal records for food intake, weight and sleep, based mainly on patient’s self-reporting. This can lead to recall bias. However, biometric data from other collaborative clinics were collected and reviewed for an objective review of clinical progress.

• • Patient missed several appointments and no repeat hemoglobin A1c or lipid analysis was available. However, patient self-reporting for home glucose levels and correlation with documented labs from other care provider notes reduced this limitation.

• • Patient had co-morbid conditions including DJD and depression making study result less generalized to a population without these characteristics.

Conclusion

The epidemic of diabetes and obesity and its association with other chronic diseases highlights the need to focus on prevention and lifestyle modification along with acute care management. The population health curve towards betterment cannot be moved by acute management only. Primordial prevention for elevated glucose levels and controlling high blood pressure at early stages are far more efficient and cost-effective than dealing with diabetic ketoacidosis, MI or acute stroke in the emergency room.

In our case, we applied a multifaceted lifestyle patient selected approach for poorly controlled HTN and T2DM with decreased motivation and depression secondary to her chronic pain and multiple co-morbidities. Our approach involved assessment of health barriers and customized counseling supported with lifestyle pillars. Our patient showed improvement in glucose levels. Additionally, a positive change in mood, confidence, and energy was recorded subjectively as above. Thus, we strongly believe that our case will support lifestyle strategies for the early detection, prevention, and management of chronic disease. We also think that our case will encourage primary care providers and specialists in the practical implementation of lifestyle management and behavior modification counseling for chronic disease and provides further evidence for future studies in this area.

Learning Points

• • Significant clinical outcomes can be achieved via evidence-based prescribed LM interventions in practice for HTN and T2DM. (Table 1).

• • The main challenge was pain secondary to DJD which limited patient’s physical activity, affected sleep and led to poor diet and decreased motivation.

• • Negotiation rather than dictation plays an effective role in behavior modification.

• • Identifying patient barriers helps to customize lifestyle-based counseling which leads to improved motivation and subsequent improved outcome.

ORCID iD

Iram Aman https://orcid.org/0000-0002-0661-4789