Presentation

S.D. is a 49-year-old white man who has had type 1 diabetes for 43 years. He has been on an intensive insulin regimen since 1982, when he began attending the diabetes clinic. At that time, his program consisted of ultralente twice daily and regular insulin before each meal. His total daily insulin dose was 45 units per day. He was testing his blood glucose four to six times daily with a home blood glucose monitor.

Presently, S.D. has background diabetic retinopathy. He has no other known diabetes complications. He has been on a statin medication since 2002 for hyperlipidemia. His total cholesterol was 219 mg/dl, LDL cholesterol was 139 mg/dl, and HDL cholesterol was 69 mg/dl when medication was initiated. For a period of time, he was treated with an antidepressant, but he has been off this medication since a job change. He no longer feels an antidepressant is needed.

Eight years ago, S.D.'s BMI was 28 kg/m²; his weight was 198 lb, and his height was 70.5 inches. Two years ago, his weight was 242 lb, and his BMI was 34 kg/m². With the intensification of his insulin regimen and lowering of his blood glucose and hemoglobin A_1c (A1C), he has progressively gained weight.

In 1996, S.D.'s regimen changed from ultralente and regular insulin to ultralente and lispro. This regimen change decreased his hypoglycemia, especially nocturnal hypoglycemia. His A1C ranged from 5.6 to 8.0% (normal range 2.9–7.1) during this 10-year period. He remained on this regimen until 2001, when he began subcutaneous insulin pump therapy to help prevent frequent hypoglycemia and improve his hypoglycemia awareness. He weighed 228 lb (BMI 32.2 kg/m²) when he began insulin pump therapy.

His A1C range while on the insulin pump was 6.9–7.8% (normal range 3.4–6.2). His total …