Answer: C. After detecting the patient’s albuminuria, improved glycemic control, ongoing efforts at keeping his blood pressure under control, and tactics for eating healthy and losing weight were reviewed. Adherence to a high-protein diet would not be beneficial for this patient.

The patient’s HbA1c of 7.7% was improved from 8.1% at his previous visit but there was still room for improvement. Recommendations for this patient were to continue Lantus insulin 40 unit once daily with adjustment to his Humalog insulin doses at mealtimes (increasing from 12 units to 14 units with his noon meal) in an effort to maintain a blood sugar goal of 100 to 140 mg/dL.

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The patient was referred to a diabetes educator to review principles of insulin dose adjustment. He will continue on his current blood pressure regimen, which includes an ACE inhibitor, lisinopril. He was also referred to a dietitian to review a carbohydrate-consistent diet that will assist in weight loss and improve glycemic control. The dietitian can also help the patient to better assess the amounts of protein he is consuming. Several studies suggest that following a lower-protein diet can be beneficial in managing kidney disease. The patient also agreed to work on limiting snacking at bedtime. The patient has a follow-up appointment in 3 months to assess the efficacy of these interventions with repeat HbA1c and fasting glucose evaluation.

Jennifer A. Grenell, APRN, CNP, practices at the Mayo Clinic department of endocrinology, specializing in diabetes management.