Case Presentation

M.J. is a 50-year-old white man who has had type 1 diabetes since age 20. He also has known retinopathy that has required laser treatment. He has no microalbuminuria. Treatment for depression was initiated more than 1 year ago. He has erectile dysfunction.

M.J. presents for his routine quarterly follow-up appointment with a blood pressure of 142/92 mmHg. He is on a four-shot insulin regimen using glargine and aspart. On physical exam, he has noted peripheral neuropathy. His family history includes hypothyroidism in his mother and hypertension in his father.

Physical examination and laboratory assays yield the following data:

• Height: 72 inches

• Weight: 171 lb

• BMI: 23 kg/m²

• Random capillary blood glucose: 126 mg/dl

• Triglycerides: 105 mg/dl

• Total cholesterol: 170 mg/dl

• HDL cholesterol: 69 mg/dl

• LDL cholesterol: 95 mg/dl

• Creatinine: 1.2 mg/dl

• Hemoglobin A₁c: 7.5%

• Electrocardiogram: normal

• Stress thalium: normal

The patient’s current medications and supplements include:

• ramipril, 5 mg daily initially (renal protection)

• insulin: glargine, 16 units a.m. and 20 units p.m.; aspart, 2 units/15 g carbohydrate for breakfast and 1 unit/15 g carbohydrate for lunch, dinner, and snacks

• simvastatin, 40 mg daily

• aspirin, 325 mg daily

• sertraline hydrochloride, 100 mg daily

• alpha lipoic acid, 300 mg three times a day

M.J. does not have a regular physical activity program and eats most of his lunches in restaurants. He consumes one to four alcoholic beverages in the evening and does not smoke. Diet history reveals that the carbohydrate content of his lunches and dinners varies greatly from meal to meal. Snacks are usually from the vending machine at work. His diet is estimated to include a daily average of 2,400 calories made up of 35% total fat, 12% saturated fat, 13% protein, and 52% carbohydrate

He bases his insulin doses on a sliding scale and not …