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Running Head: Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Mona Hossain
Queens College
2Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
I. Understanding the Disease and Pathophysiology
1. What are the standard diagnostic criteria for T2DM? Cite the ADA Standards of Medical Care – 2014.
Which are found in Mitch’s medical record? (5)
There are four measures associated with the diagnostic criteria for T2DM. One of the criteria would be the
presence of symptoms of diabetes (hyperglycemia) along with a casual or random plasma glucose ≥ 200 mg/dl
(11.1 mmol/L). Another criteria would be a fasting plasma glucose (FPG) ≥ 126 mg/dl (7.0 mmol/L) following
an 8 hour period without caloric intake. A 2 hour post prandial glucose ≥ 200 mg/dl during an oral glucose
tolerance test (OGTT) consisting of 75g of anhydrous glucose load dissolved in water serves as another
measure. An A1C ≥ 6.5% may also serves as an indicator for diagnosis as it reflects average blood glucose
levels of 2-3 month periods. All of the measures have been determined by the first Expert Committee on the
Diagnosis and Classification of Diabetes Mellitus as the level when there is prevalence of retinopathy
(American Diabetes Association, 2014).
In Mitch’s medical records, he was presented to the ER with noted hyperglycemia with a serum glucose of
1524 mg/dL. Additionally, his HbA1C was found to be 15.2% which is well above the normal limit as well as
above ≥ 6.5% .
2. Mitch was previously diagnosed with T2DM. His admits that he often does not take his medications.
For each of his diabetes pills, metformin and glyburide, state the class of medication and mechanism of
action; list potential drug side effects (i.e nausea, etc) and drug-nutrient interactions (i.e. foods or nutrients
to be added or avoided) for each drug. (6)
Metformin is a generic form of oral glucose lowering medication in the class of medications known as
Biguanides. The mechanism by which this class of medication works is by decreasing the hepatic production of
glucose and increasing insulin uptake in the muscles. Potential side effects include nausea, vomiting, bloating,
diarrhea, flatulence, dyspepsia, lactic acidosis (rare) and more (Pronsky and Crowe 2012, p210). Possible drug-
nutrient interactions may occur resulting in decreased absorption of vitamin B12 and folate and must be
monitored. Additionally, alcohol must be avoided.
Glyburide is a generic oral glucose lowering medication belonging in the class of medication known as
Sulfonylureas. This class of drug functions as an insulin secretagogue as it stimulates insulin production from
3Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
the beta cells of the pancreas (Krause 2012). Potential side effects include dyspepsia, nausea, diarrhea,
constipation. Possible drug-nutrient interactions may occur with alcohol use and must be avoided.
3. Mitch also takes other medications, Dyazide and Lipitor. List their mechanisms, potential side effects and
drug-nutrient interactions.
Lipitor is a HMG-CoA reductase inhibitor also known as “statins”. They decrease production of cholesterol
by inhibiting HMG-CoA reductase responsible in the hepatic production of cholesterol (Krause 2012, p215-
216). Potential side effects include nausea, dyspepsia, abdominal pain, constipation, diarrhea and flatulence
(Pronsky and Crowe 2012, p164). Possible drug-nutrient interactions exist with grapefruit and citrus related
fruits and substantial alcohol consumption must be avoided. Additionally, the drug reduces Coenzyme Q10
levels and may need to be supplemented.
Dyazide is an antihypertensive medication and diuretic used to treat fluid retention and high blood pressure.
It is composed of a thiazide diuretic (hydrochlorothiazide) and a potassium sparing diuretic (triamterene)
(Ogbru and Marks, 2014). Hydrochlorothiazide works my preventing reabsorption of sodium and water in the
kidneys which results in eliminating water retention and uptake of too much sodium in the body. When there
are increased amounts of sodium and water in the kidney tubules for excretion as urine, the kidney tries to
reabsorb more sodium and water for the body by taking potassium out of the blood and exchanging it with
sodium in the tubules causing potassium levels to fall. (Ogbru and Marks, 2014) Triamterene works by
preventing the reabsorption of sodium in exchange for potassium functioning as a potassium sparing diuretic.
Therefore, the combinations of these two types of diuretics eliminate sodium and water reabsorption without
loss of potassium which is necessary in controlling blood pressure. Thus, dyazide functions as both
antihypertensive agent and diuretic.
Potential side effects of dyazide include abdominal pain, nausea, vomiting, rash, headache, dizziness,
constipation, low blood pressure, and possible electrolyte imbalances (such as increase in potassium levels)
(Ogbru and Marks, 2014). Increased/excessive potassium levels may result as a concern of drug- nutrient
interaction.
He is beginning insulin. For insulin, state type; time of onset, peak, duration; potential side-effect. (5)
Name Type of
Insulin
Onset Peak Duration Potential Side Effects
4Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Lispro Rapid-
Acting
<15 min 1-2 hrs 3-5 hrs Hypoglycemia, redness and irritation is
injected, skin thickness around injection,
weight gain, constipation.(National Institutes of
Health 2014)
Glargine Long-
Acting
2-4 hr peakless 20-24 hrs Hypoglycemia, redness, swelling, pain, or
itching at the injection site, changes in the feel
of your skin, skin thickening (fat build-up), or a
little depression in the skin (fat breakdown),
swelling of the hands or feet, weight gain,
constipation (National Institutes of Health
2014)
*(Krause 2012, p692)
4. Mitch experienced symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM
with HHS.
Describe what led to his severe hyperglycemia.
Mitch admitted that he was not taking his medicine for diabetes regularly therefore poor management of his
diabetes led to his severe hyperglycemia.
State Mitch’s signs and symptoms of dehydration.
In his chief complaint, Mitch said that he had a lot of vomiting and his throat had dry mucus membranes.
He reports only having sips of water after vomiting for 12-24 hrs. Additionally, skin was reported to be warm
and dry and have poor turgor which would indicate dehydration. Additionally, his diet history reflects a lot of
coffee consumption which functions as a diuretic.
Define HHS, its etiology and symptoms.
Hyperglycemic hyperosmolar state (HHS) is defined by high blood glucose levels ranging in 400 to 2800
mg/dL (22.2-155.6 mmol/L0 without presence of ketones (Krause 2012, p699). Hyperosmolarity results when
the blood becomes concentrated with high levels of sodium, glucose or other substances that causes water to be
drawn out of vital organs and into the bloodstream (Topiwala 2012). In the case of hyperglycemic hyperosmolar
state, there is a high concentration of glucose in the blood therefore it results in extremely elevated blood
5Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
glucose levels in addition to causing dehydration as water is drawn out. It is usually prevalent in older age
patient with type 2 diabetes; other factors contributing to its onset may be due to other illness such as stroke and
heart attack, medications that reduce glucose tolerance or increase fluid loss in those who normally don’t get
enough fluid intake and, poor management of diabetes or stopping medications designed to lower glucose levels
such as insulin (Topiwala 2012). Symptoms include dehydration/ excessive thirst, altered mental state such as
confusion, hallucination, coma, increased urination, weakness, lethargy, and weight loss. MNT includes
monitoring of blood glucose and rehydration.
State Mitch’s signs and symptoms of HHS. (8)
Mitch was admitted to the ER with a serum glucose of 1524 mg/dl which is within the range of 400 to 2800
mg/dL as indication of HHS. Additionally, he claimed that he was not taking his medication for diabetes
consistently so poor management of his diabetes contributed to this severe hyperglycemia as indication of HHS.
Moreover, Mitch was found in a confused mental state before arriving in the ER which is also a symptom of
HHS. Dehydration is a symptom is another symptom of HHS; in his chief complaint, Mitch said that he had a
lot of vomiting and his throat had dry mucus membranes, and warm dry skin with poor skin turgor which is an
indication of dehydration. This is confirmed by his altered lab values for hydration status such as sodium (↓!),
BUN(↑!), Osmolality(↑!), urine specific gravity(↑!).
5. HHS and DKA are metabolic complications associated with diabetes. Define DKA, its precipitating factors
and signs /symptoms. What characteristics of Mitch’s condition indicate HHS as opposed to DKA? (5)
Diabetic Ketoacidosis (DKA) is a condition marked by hyperglycemia (blood glucose levels > 250mg/dL
and usually < mg/dL) and presence of ketones in the blood and urine (Krause 2012, p703). It occurs when the
body begins to breakdown fat in an attempt to avoid starvation and forms ketones due to body’s inability to use
glucose for energy since there is no insulin being produced. As the glucose (since it can’t be used as insulin is
not available) and ketones build up, it becomes concentrated in the blood and urine. It is usually seen in patients
with type 1 diabetes but may also be seen in those with type 2 diabetes due poor blood sugar management or
severe illness (Wisse 2013). Other precipitating factors include infections, cerebrovascular accident, substance
abuse, pancreatitis, pulmonary embolism, myocardial infarction, and trauma, psychological stress, and drugs
such as corticosteroids, thiazides, sympathomimetic agents, and pentamidine (Umpierrez et al 2002). Symptoms
of DKA are polyuria, polydipsia, hyperventilation, dehydration, the fruity odor of ketone and fatigue (Krause
2012, p703). Treatment includes self monitoring of blood glucose and checking ketone levels (Nelms 2011).
Mitch’s condition would however indicate HHS as opposed to DKA since his serum glucose was found to
be 1524 mg/dL (in diagnosis of DKA, the serum glucose levels are usually above 250 mg/dL and below
6Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
600mg/dL). Additionally, Mitch had a previously altered mental status (confusion) which is a symptom of HHS
as opposed to DKA where mental status is usually more alert (Umpierrez et al 2002). Classic signs of
ketoacidosis such as fruit breath and abnormal breathing are not presented symptoms in Mitch’s condition
therefore HHS would be a better suited diagnosis than DKA. Moreover, serum osmolality is a diagnostic criteria
often used to asses DKA and HHS; a level >320 mOsm/kg indicates HHS (Umpierrez et al 2002). Mitch’s
osmolality was found to be 360 mmol/kg.
6. Mitch was started on normal saline with potassium as well as an insulin drip. Why are these fluids a
component of his rehydration and correction of the HHS? (3)
During a hyperglycemic crisis as in the case of HHS, fluid volume in the body decreases and the kidneys
ability to perfuse becomes abnormal or inactive. The use of normal saline (0.09% saline) is a form of fluid therapy
used to increase intravascular, interstitial, and intercellular volume and restore renal perfusion (Kitabchi et al. 2009).
Additionally, it is used to bring the body out of hyperosmolar/hypertonic state with the isotonic saline for balancing
since fluid moves out of the cell in a hypertonic state resulting in dehydration. Moreover, potassium is used in
solution since as dehydration results from total body water decreases (vomiting, frequent urination), potassium along
with other electrolytes (sodium, chloride, magnesium) is lost as well. Furthermore, insulin drip is used to decrease
serum glucose levels and bring the body out of a hyperglycemic states. Because these components (normal saline
with potassium, insulin drip) are components that act on the symptoms of HHS (hyperglycemia, hyperosmolarity,
dehydration) they are used for rehydration and correction of HHS.
Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
7. Describe the insulin therapy that was started for Mitch. When would a patient be started on insulin, based on
the recommendations of the ADA? How likely is it that Mitch will need to continue insulin therapy? (3)
Mitch’s insulin therapy consists of 0.5 units of Lipro (rapid-acting insulin) being administered every 2
hours until serum glucose reaches between 150-200 mg/dL. The rapid acting insulin is considered a bolus or
mealtime insulin which is given 30- 60 minutes before meals (Krause 2012, p691-692). Then, in the
evening/night time Mitch is to begin taking 19 units of Glargine (long acting insulin) which works in the
background over a 20-24 hour period to prevent excessive hepatic output of glucose and lipolysis (Krause 2012,
p693). Then he is to progress Lispro to an insulin-to-carbohydrate ratio of 1:15 or 1 unit of insulin for every 15
grams of carbohydrate.
A patient would be started on insulin when oral antidiabetes medications have failed (possibly due to
noncompliance in taking the pills) (Davidson 2005). Additionally, people with type 2 diabetes overtime may
have very little to no insulin production and have to begin taking their insulin to manage their blood glucose
7Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
especially during time of stress of illness (ADA 2004). Also, oral medications also may not be effective (once
possible cause being poorly controlled diabetes) in getting A1C levels within normal limit and may need to
initiate insulin therapy (Henske et al. 2009).
Mitch will most likely need to continue insulin therapy because he doesn’t take his oral glucose lowering
medications since he doesn’t like how they make him feel. Without insulin, his blood glucose will still be
elevated if it is poorly managed and could possibly lead to other complications of diabetes such as diabetic
nephropathy.
II. Nutrition Assessment
8. Assess Mitch’s desirable body weight and BMI. What would be a healthy weight range for Mitch? (3)
DBW BMI
Hamwi-Males- 106 for 5 ft +6 for every inch above 5 ft
Mitch= 5ft 9 in
DBW=106+ 6(9)= 106 + 54= 160 lbs
DBW= 160 lbs
BMI = weight (lb) / height (in2) x 703
Mitch weight= 214 lbs height= 69 in
BMI= 214 (lbs)/ 69 (in2) x 703
BMI= (214/ 4761) x 703
BMI= (0.045)x 703
BMI= 31.6 (Obese-Class I)
A healthy weight is between the BMI range of 18.5- 24.9 (CDC 2011). Therefore, if Mitch were to be within a BMI
range of 18.5-24.9, his healthy weight range would have to be between 125 lbs-168lbs. However given that Mitch’s
current weight falls within the obese category, he would have to lose a severe amount of weight to reach 125lbs.
Thus, I would recommend aiming for the upper limit of his range (168lbs) or his ideal/desirable body weight (as
calculated to be 160lbs) as a starting point for reaching a healthy weight (between 160-168 lbs) once he is no longer
in the hospital.
9. For each lab value, state its abnormal value upon admission and what the value means / indicates.
How did glucose, sodium, phosphate and osmolality change - state the changed value and why it changed.
(16)
8Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Initial lab values:
Abnormal Value Indication
Glucose 1524!↑ mg/dL
(Ref range- 70-110 mg/dL)
Too much glucose in the blood-Hyperglycemia;
indication of DM
Creatinine 1.9!↑ mg/dL
(Ref range- 0.6-1.2 mg/dL)
May indicate muscle damage or renal disease, may
also be elevated to due dehydration (Dugdale 2013).
Sodium 132!↓ mEq/L
(Ref range- 136-145 mEq/L)
lower than normal levels may be due dehydration,
vomiting, ketonuria, use of diuretic pills (Mitch takes
Dyazide which is functions as a potassium sparing
diuretic) (Dugdale 2011).
Phosphate 1.8!↓ mg/dL
(Ref range- 2.3-4.7 mg/dL)
Lower than normal values may be due to vomiting,
alcohol abuse, or poor dietary intake, or renal failure
(Dugdale 2011).
Cholesterol 205!↑ mg/dL
(Ref range- 120-199 mg/dL)
Elevated value is possible due to excessive dietary
intake of cholesterol and saturated fat
HbA1c 15.2!↑ %
(Ref range- 3.9-5.2 mg/dL)
Elevated level indicates poorly managed blood
glucose over a 2-3 month period or uncontrolled
diabetes
C-peptide 1.10 ng/mL
(Ref range- 0.51-2.72 ng/mL)
Within normal limit; indicates that insulin is still being
produced in the body (Topiwala 2012).
Osmolality 360!↑ mmol/kg/H20
(Ref range- 285-295
mmol/kg/H20)
Serves as an indicator of fluid status; higher than
normal levels is due to dehydration and
hyperglycemia in Mitch’s case.
Specific
gravity
1.045!↑
(Ref range- 1.003-1.030)
Elevated value is due to dehydration( fluid losses and
vomiting) and presence of glucose in the urine
(Dugdale 2013).
BUN 31!↑ mg/dL
(Ref range- 8-18 mg/dL)
Serves as an indication of hydration status; elevated
value are indicative of hypovolemia/dehydration as
well as possible renal complications such as renal
disease or renal failure. (Dugdale 2013)
Glucose in
urine
+!↑
(Ref range- Neg)
+ value indicates that the kidney are spilling glucose
into the urine (renal glycosuria) (Nelms 2011)
Protein in 10!↑ mg/dL Protein in the urine may indicate renal complications
9Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
urine (Ref range- Neg) as the kidney is supposed to facilitate protein to stay in
the blood- may indicate diabetic nephropathy; it may
be caused by dehydration as well (Dugdale 2013).
Changed values:
Changed Value Reason for Change
Glucose 475 ↑ mg/dL
(Prev. value: 1524 !↑ mg/dl)
(Ref range- 70-110 mg/dL)
Lowered serum glucose due administration of
insulin(insulin drip) and rehydration using normal
saline and possible increase in renal perfusion
Osmolality 304 ↑ mmol/kg/H20
(Prev. value: 360!↑ mmol/kg/H20)
(Ref range- 285-295 mmol/kg/H20)
Closer to normal range, changed due to rehydration
with normal saline
Sodium 134 ↓ mEq/L
(Prev value:132! mEq/L)
(Ref range- 136-145 mEq/L)
Closer to normal range; changed due to rehydration
with normal saline
Phosphate 2.1↓ mg/dL
(Prev value: 1.8!↓ mg/dL)
(Ref range- 2.3-4.7 mg/dL)
Closer to normal range, improvement may be due to
increased renal perfusion
10. Determine Mitch’s energy requirements for weight maintenance using Mifflin St. Jeor equation.
Mifflin St.Jeor
Mifflin-St Jeor= 10 (wt kg) + 6.25 (ht cm) – 5 (age) +5
Mifflin-St Jeor= 10 (97) + 6.25 (175.26) – 5 (53) + 5
Mifflin-St Jeor= 970 + 1095.375 – 265 + 5
Mifflin-St Jeor= 2065.375 – 260
= 1805.375 ≈ 1805
RMR= 1805
RMR x Activity Factor x Stress factor
Activity factor= 1.0-1.2 stress factor= 1.1 (medical stress factor)
1805 x 1.0 x 1.1= 1985.5 ≈ 1986
10Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
1805 x 1.2 x 1.1= 2382.6 ≈ 2382
Energy requirements for weight maintenance= 1986-2382 kcal/d
I chose an activity factor 1.0-1.2 because Mitch is in the hospital although has some degree of
functionality for light activity and is not completely bedridden. I chose a medical stress factor of 1.1 due to his
HHS.
Although weight loss is not recommended while being hospitalized, I would recommend Mitch to stay
within the lower range of his energy requirements to maintain his weight because his current weight puts him at
the obese category and puts him at risk of other serious illness such as heart disease.
Determine Mitch’s protein requirements.
Estimated Protein Requirements
Method: .0.8-1.0 g/kg for normal maintenance of protein needs for hospitalized patient
Mitch’s IBW: 160 lbs = 72.7 kg ≈ 73 kg
73 kg x 1.0 g/kg= 73 g
73 kg x 1.2 g/kg= 87.6 g ≈ 87g
Due to the fact that Mitch’s weight is currently puts him at the obese category, his protein requirements were
calculated by using his ideal or desirable body weight found to be 160lbs based on the Hamwi equation. I used a
protein range of 1.0-1.2g/ kg BW because Mitch is currently in the hospital due to his acute hyperglycemia and
would need atleast 1.0g/kg for maintenance. People with type 2 diabetes and moderate hyperglycemia may have
increased protein need due protein turnover (American Diabetes Association 2004). This is evidenced by
presence of protein in urinalysis. Therefore I chose to increase his protein needs to 1.2g/kg BW. The estimated
protein requirements yield a range of 73g-87 of protein per day or 292-348 kcals from protein per day. Protein
should supply no more than 15-20% of calories in persons with diabetes (Krause 2012, p686).
What daily energy intake would you recommend for an appropriate rate of weight loss? Justify your
recommendation. (3)
Daily energy intake requirements are about 500-1000 calories lower than the amount needed to maintain
weight as an appropriate rate of weight loss (American Diabetes Association 2004). Therefore Mitch’s daily
11Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
energy intake requirement for weight loss would be about 1486-1882 kcal/day based on a rate of deducting 500
kcal from the amount needed for weight maintenance (calculated to be 1986-2382 kcal/day based on Mifflin-
St.Jeor). I chose the lower rate (500 kcal/d as opposed to the 1000 kcal/d) deduction due to the fact that Mitch
was just hospitalized and severe weight loss during time of stress or physical injury is not recommended. Once
he is discharged, he could begin at this rate and possibly gradually adjust an increase in the rate to reach a long
term goal of 5-7% weight loss from his starting weight (American Diabetes Association 2004).
III. Understanding the Nutrition Therapy
11. Mitch was NPO when admitted to the hospital. Why? What does this mean? When will Mitch be ready to eat?
What foods would be recommended immediately following NPO, before initiating a diet for diabetes? (4)
NPO is the medical abbreviation for the latin word nil per os and means nothing by mouth. He was NPO
when admitted because of altered GI functionality as he reports vomiting a lot (emesis is also reported on his
fluid intake/output report). Additionally, his serum glucose was excessively high (1524 mg/dL); food intake
may cause the blood glucose to increase and contribute more his hyperglycemia. Moreover, NPO diet ensures
more accurate results when doing medical testing such as blood tests. He will be ready to eat when his condition
stabilizes (he stops vomiting and his hyperglycemia is controlled or resolves). Immediately following NPO, he
will be recommended clear liquid foods such as clear broths and fruit juices and possibly liquid nutritional
supplements before initiating a diet for diabetes to allow energy intake and minimal stimulation of the GI tract
(Nelms 2011, p68).
12. Mitch was prescribed and initial ICR 1:15. Explain what this means.
ICR or insulin to carbohydrate ratio represents the ratio of how many units of insulin is needed to
metabolize a certain amount of carbohydrate intake. Therefore an ICR of 1:15 represents a 1 unit dosage of
insulin (rapid acting insulin/bolus/meal time insulin) to cover every 15g of carbohydrate intake (Nelms 2011,
p493)
Outline the general principles for nutrition therapy, to assist in control of DM, for: meals and snacks,
carbohydrate, sugar substitutes, fats and weight reduction. Cite the ADA’s Clinical Practice
Recommendations for Medical Nutrition Therapy – 2014. (5)
According to the American Diabetic Associations’s general principles for 2014, these are the
recommendations for the following (Evert et al. 2014):
Carbohydrates :
12Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
o There is no significant evidence to establish percentages for carbohydrate recommendation for
all diabetics. Individualized plans must be made to determine need based on assessment and
goals. Insulin to carbohydrate ratios play a part in determination of needs as well.
o For well-being, carbohydrate sources from fruit, vegetables, whole grains, legumes and dairy
products are best for consumption. Sources from sugary drinks and fast food should be
avoided.
o Fiber should be consumed based on recommendations for the general public.
o Glycemic control should be maintained by methods such as carbohydrate counting. Lower
glycemic index foods are better than higher glycemic index food for controlling blood sugar.
Fats:
o There is no conclusive evidence to determine percentage or amount of fat to be consumed by
diabetics. However according to IOM, AMDR was established for total fat to be 20-35%
energy intake with no upper limit
o Monounsaturated fats as emphasized on the Mediterranean diet is beneficial for controlling
blood sugar and may substitute the typical low-fat, high-carb diet
o Omega-3 should be emphasized because of its effect on lipoproteins, preventing heart disease,
e and general health benefits it provides as recommended for the general public.
o Same recommendations apply for saturated fat (<10%), cholesterol (<300 mg) and trans fat
(to be limited as much as possible0 as the general public.
Sugar substitutes:
o May help to reduce caloric intake if substituted for calorie based sugars and no additional
caloric intake is taken to make up for the reduced amount through other foods
Weight reduction:
o Overweight and obese individuals with diabetes need to decrease energy intake and maintain
a healthful diet for weight loss
o Modest amounts of weight loss have been shown improvement in blood glucose, blood
pressure and lipid profile
o Intensive lifestyle interventions are needed to achieve weight reduction. physical activity, and
regular contact with an RD can be an intervention which can result in weight loss of 7-8.5%
of starting body weight (Evert et al, 2014)
13Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
IV. Nutrition Diagnosis
13. Write 2 priority nutrition diagnoses, each in PES format. (6)
1. NI-5.8.4- Inconsistent carbohydrate intake related to poor management of diabetes evidenced by diet
history revealing inconsistency of carbohydrate intake, uncontrolled serum glucose level of 1524 mg/dL,
HgbA1c of 15.2% and patient reporting noncompliance with taking oral diabetes medications consistently.
2. NC-3.2- Overweight/ obesity related to poor dietary choices such as frequent fast food consumption as
evidenced by BMI of 31.6 (class 1 obese), 134% desirable body weight, elevated triglyceride level of 185
mg/dl and elevated cholesterol level of 205mg/dL
V. Nutrition Intervention
14. Determine Mitch’s initial CHO prescription using his diet history as well as your assessment of his energy
requirements for weight loss: State daily kcal intake, percent kcal from CHO, g CHO, number of CHO
choices per day; Suggest the number of CHO choices you would recommend for 3 meals and 2 snacks based
on his diet history. (5)
Meal/
FOOD AM Midmorning Lunch dinner Total
servings
/day
CHO
(g)
CHO
KCAL
PRO
(g)
PRO
kcal
FAT
(g)
FAT
kcal
Starches -
- 4 11 1 16
15
240960
3
48192
1
16
144
fruit -
-
-
-
-
-
-
-
-
-
15
-
-
-
-
-
-
-
-
-
-
-
milk
1
-
-
-
-
-
- 1
12
1248
8
832
1
1
9
vegetables -
-
-
-
-
- 1 1
5
520
2
28
-
-
-
-
Meats
/substitutes
-
-
-
- 1 1 2
-
00
7
1456
5
10
90
fats - 1 1 - 2 - - - - 5 90
14Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
- - 0 0 - - 10
Mitch’s
CHO
choices/d 1 5 13 3
Estimated
Totals
22
servings257g
1,028
kcal72g 288
kcal37g
333
kcal
Total %
kcal CHO62%
It appears that Mitch’s diet history reveals Mitch has approximately 22 carbohydrate choices in a 24 hour period and
it is mostly concentrated around lunch time. His energy requirements were calculated to be 1986-2382 kcal/day for
weight maintenance and 1486-1882kcal/d for weight loss after subtracting 500. About 45 to 65% of calories should
come from carbohydrates. If I were to choose 55% of calories from CHO for Mitch then 817-847 kcal should come
from carbohydrates or 204g-211g of CHO which would result in13-14 carbohydrate choices for Mitch to be
consumed though out the day based on recommendations for weight loss. For 3 meals such as breakfast I would
recommend 3-4carbohydrate choices, for lunch 3- carbohydrate choices and 3 carbohydrate choices for dinner and 2
and 2 carbohydrate choices for snacks to balance it out throughout the day.
15. Identify two initial nutrition goals to assist with weight-loss. (4)
1. Pt will learn to replace fast-food options with healthier alternatives to consume during lunch in to achieve
cholesterol and triglyceride levels within normal limit resulting in weight loss.
2. Pt will learn to self monitor their glucose levels in order to reduce serum glucose within normal limit by taking in
appropriate amounts of carbohydrate throughout the day along with their glucose lowering medications.
16. Mitch also has hypertension and high cholesterol levels. State the recommendations for the lipid profile,
LDL, HDL, Cholesterol and Triglycerides for people with diabetes. (4)
Recommendations for people with diabetes for LDL, HDL, Cholesterol and Triglycerides are as follows
(American Diabetes Association 2014):
LDL <100 mg/dL (without overt CVD)
HDL >40 mg/dL in men
Cholesterol <200 mg/dL
Total daily kcal= 1,649
15Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Triglycerides <150 mg/dL
Lipid profile- fasting lipid profiles should be measured at least once every year and lipid assessments
should be conducted every 2 years.
Describe nutrition recommendations for fiber, types of fat and sodium for Mitch and why.
Fiber recommendations for diabetics are the same as for the general population. 14g for every 1000kcal are
recommended by the US Dietary Guidelines (Nelms 2011, p506). Usually 25-30g of fiber with about 7-3g of
soluble fibers can promote cardiovascular health (Krause 2012 p686). Additionally soluble fibers such as gums
and pectins can improve glucose levels by slowing the absorption of glucose from the small intestines (Nelms
2011, p506). Food sources such as whole grains, fruits, vegetables, and legumes can contribute a significant
amount of fiber to the diet if consumed in appropriate amounts. Therefore, Mitch should get about 25-30g of
fiber which can add bulk to his diet and lower his cholesterol levels in addition to promoting cardiovascular
health.
Since Mufa’s are known to have beneficial effects on glycemic control and promote cardiovascular health,
Mitch should include them in the diet instead of saturated fats. Omega-3s should also be increased in his diet
because of its positive effects on cardiovascular health, lipoproteins and general health (American Diabetes
Association 2014). Omega-3 may be found in fatty fish which Mitch can consume 2-3 times per week in
exchange of his lunch or dinner meat option. Saturated fat should be limited to less than 7% of energy intake
while total fat should not exceed 25-35% of caloric intake (Nelms 2011,p505). Additionally, it is best to
minimize or eliminate transfats consumption as it contributes to increases cholesterol and cardiovascular
disease.
The general recommendation for sodium is 2300 mg which is appropriate for people with diabetes
(American Diabetes Association 2014). However, since Mitch has diabetes and has hypertension, he should
reduce it further to improve blood pressure. Additionally, his diet history seems to reflect frequent consumption
of fast foods which has a lot of sodium. Therefore, due to his condition 1500 mg may be appropriate (Evert et al
2014)
VI. Nutrition Monitoring and Evaluation
17. Write an ADIME/SOAP note for your initial nutrition assessment.
Use form provided below: SEE BELOW (10
16Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
A - Assessment
S - Subjective
Chief Complaint: “I had a lot of vomiting that I thought at first was food poisoning but I just kept getting worse.” When questioned
about medications, patient admits that he has not taken medications for diabetes regularly—“I hate how they make me feel but I
almost always take my other medications for blood pressure and cholesterol”
UBW: 228
Weight change: loss; 6%
Appetite: poor
Chewing / swallowing problem / sore mouth: none
Nausea / vomiting / diarrhea / constipation: vomiting
Food intolerance / allergies:
Diet prior to admit:
Nutritional supplement:
Vitamins / herbs:
Food preparation: self preparation
Factors affecting food intake: dines out frequently- fast food;
ethnic food
Social / cultural / religious / financial
Other:
O - Objective
Current Diet Order: NPO then progress to clear liquids and then consistent carbohydrate-controlled diet
Medical Diagnosis: Type 2 DM uncontrolled with HHS Pertinent Medical History:
Type 2 DM x 1 year; HTN; hyperlipidemia; gout
Nutrition Focused Physical Signs & Symptoms:
Drowsy with mild confusion, emesis x 12-24 hours, dry mucus membranes, obese
Age: 53 Gender: Male
Ht:
5’9’’
Wt: Admit 214
lbs
DBW: 160 BMI: 31.6
17Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
% UBW: 93.9% % wt : 6% % DBW: 134% Other:
Nutritionally Relevant Laboratory Data:
Glucose 1524↑ mg/dL BUN 31↑ mg/dl Cholesterol 205↑ mg/dL
HbA1C 15.2↑ Creatinine 1.9 ↑ mg/dl triglyceride 185↑ mg/dL
Osmolality 360↑ mmol/kgH20
Sodium 132↓ mEq/L
Specific gravity 1.045↑
Drug Nutrient Interaction:
Dyazide-↑ potassium
Lipitor- caution w/ grapefruit/ citrus fruit; avoid alcohol
Metformin- ↓ Folate, ↓B12
Glyburide- avoid alcohol
Estimated Energy Need:
_1986-2382___ kcal / day
Based on: Mifflin-St.Jeor activity factor 1.0-
1.2; stress factor 1.1
Estimated Protein Need:
____73-87______ g/day
Based on: 1.0-1.2g/kg IBW (73kg)
Estimated Fluid Need:
______1986-2382___ ml / day
Based on: 1ml/kcal
Nutrition Diagnosis (D)
A - Assessment (A)
State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis Terminology sheet
ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :
1. NC-3.2- Overweight/ obesity related to poor dietary choices such as frequent fast food consumption as evidenced by BMI of 31.6
(class 1 obese), 134% desirable body weight, elevated triglyceride level of 185 mg/dl and elevated cholesterol level of 205mg/dL
1. NI-5.8.4- Inconsistent carbohydrate intake related to poor management of diabetes evidenced by diet history revealing
inconsistency of carbohydrate intake throughout the day, uncontrolled serum glucose level of 1524 mg/dL, HgbA1c of 15.2% and
patient reporting noncompliance with taking oral diabetes medications consistently to lower glucose levels.
18Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
Nutrition Intervention (I)
P - Plan
List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems
(diagnoses).
1. E-1.4- Nutrition Related to health/disease
Pt will be educated on effect of obesity as a contributing factor to complications of diabetes; pt will be educated on making
healthier choices for eating out in order to reduce consumption of excessive amounts of fat from fast food which contributes to
cholesterol and triglyceride levels.
2. C-2.3- Self monitoring
Pt will self-monitor their blood glucose to adjust carbohydrate intake along with antidiabetic medications to keep blood glucose
within normal levels.
Goal(s):
1. Pt will learn to replace fast-food options with healthier alternatives to consume during lunch in to achieve cholesterol and
triglyceride levels within normal limit resulting in weight loss.
2. Pt will learn to self monitor their glucose levels in order to reduce serum glucose within normal limit by taking in appropriate
amounts of carbohydrate throughout the day along with their glucose lowering medications.
Plan for Monitoring and Evaluation (M E)
List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the
plan for monitoring would indicate if interventions are addressing the problems).
1. AD-1.1.2-Weight, BD-1.7.1- Cholesterol, BD-1.7.7- Triglycerides
2. FH-5.1.4- Self monitoring as agreed upon rate, BD-1.5.3- HgbA1C,
Mona Hossain 4/29/2014
Signature: Date:
19Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin
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