The results of four questionnaire surveys performed every 10 years since 1982 were compared to examine the changes in nutritional education for diabetics in the last 30 years. The fiscal year (FY) 2012 survey included answers from 915 of 1,961 medical facilities that specialize in diabetes treatment around Japan. Employment for national registered dieticians or dieticians and individual teaching for diabetics have increased over the last 30 years. The employment rate for a Certified Diabetes Educator of Japan (CDEJ) has increased to 62.9 % from 52.1 %, the rate when the CDEJ system was established 10 years ago. The percentage of facilities that considered an "explanation of the Food Exchange List (Japan Diabetes Society)" to be time-consuming decreased to 28.0 %, compared to 37.6 %, 58.8 %, and 75.0 % in the surveys performed 10, 20, and 30 years ago, respectively. This result shows that knowledge and motivation among national registered dieticians or dieticians have improved with the establishment of the CDEJ system, resulting in greater awareness of the importance of nutritional education in diabetes treatment.

The case involves a 95-year-old woman who has been receiving oral treatment since the onset of diabetes and hypertension in 1995. In 2015, she developed acute heart failure but is in remission. Following the heart failure episode, her diabetes had been managed with repaglinide at a dose of 1.5 mg/day. In March 2016, the patient was referred to us due to symptoms of general fatigue and dyspnea. We confirmed a casual blood glucose level of 501 mg/dL and HbA1c level of 11.1 % and observed worsening heart failure. In the acute stage, we used diuretics and treated the hyperglycemia and heart failure with insulin. After remission of the heart failure, we temporarily discontinued the diabetes drug in favor of continuous glucose monitoring (CGM). One week later, we administered subcutaneous injections of dulaglutide (0.75 mg/week), while continuing the CGM. The mean blood glucose±standard deviation declined at each reading, from before the injection and at 1, 2, and 3 weeks after: 233±61 mg/dL, 220±54 mg/dL, 190±47 mg/dL, and 173±42 mg/dL, respectively. At this point, we determined that sufficient glycemic control had been achieved for this particular patient and transferred her to home care, having instructed the family about the administration of the injections. This case shows the effectiveness of weekly administration of a glucagon-like peptide-1 analog in very elderly diabetic patients.

A 58-year-old woman who had been diagnosed with diabetes mellitus in 1991 was administered an oral hypoglycemic agent. Her HbA1c levels were approximately 6 %, which were lower than the randomly measured plasma glucose levels of 200-300 mg/dL. Glycated albumin (GA) levels were high at 25 %-26 %, and the GA/HbA1c ratio was markedly high at 4.0-4.5 (reference value: 2.0-3.4). Mild normocytic normochromic anemia, elevated indirect bilirubin levels, and positivity for urinary urobilinogen were observed. However, her haptoglobin levels and reticulocyte count were within the normal range. Hence, this case did not meet the diagnostic criteria for hemolytic anemia. The red blood cell lifespan, measured using ⁵¹Cr, was found to be shortened at 17.8 days (reference value: 26-40 days), which suggested the presence of hemolysis. On the basis of a negative Coombs test result and the observation of red blood cell morphology using a scanning electron microscope, the cause of hemolysis was thought to be stomatocytosis. To our knowledge, this is the first case of a patient with stomatocytosis in which falsely low HbA1c values were noted due to latent hemolysis.