Rachel Gilwit St Barnabas Hospital February 13, 2013 Rise of obesity Close to home Requires dietary and lifestyle changes My future career goal Discussion of the Disease Medical Nutrition Therapy Patient Presentation Critical Reflection Summary Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older Obesity (BMI 30 kg/m 2 ) Diabetes No Data 45 years SedentaryEthnicity Waist BMI Impaired Glucose Tolerance Exocrine Function Ducts secrete hormones to break down lipids, carbohydrates and protein Endocrine Function Islets secrete hormones with specific functions Bolus from the mouth PolyuriaPolydipsiaPolyphagiaWeight loss Acetone breath Blurred visionLethargyHead aches >126mg/dl twice Fasting Glucose >6.5% HgbA1c + Urinalysis Ketones >200mg/dl Glucose Tolerance Test Blood glucose 200mg/dl Causes uncontrolled diabetes non compliance excessive carbohydrate intake Symptoms polyphagia polydipsia, polyuria, weakness, blurred vision Treatment insulin or oral hypoglycemic Criteria Glucose >250mg/dl pH Bicarbonate Urine Ketones + Serum Ketones Anion Gap >11mEq/L Lack of Alertness Symptoms Kussmals Respirations Nausea Vomiting Abdominal Pain Tachycardia Seizures Coma -> Death The leading cause of blindness Elevated glucose levels damage the microscopic blood vessels supplying the eyes Occurs in some degree in 60% of people with diabetes Damaged nerve endings loss of sensation amputations diabetic gastroparesis Microalbuminuria ->CKD -> ESRD Indicators renal hypertrophy hyperfiltration urine creatinine Dietary and lifestyle changes Low cholesterol/fat diet Consistent carbohydrate intake (complex, fiber) Lean protein intake Low sodium diet Exercise MedicationExampleLevel of Action BiguanidesMetforminLiver SulfonylureasGlyburide Pancreas MeglitinidesPrandinPancreas TZDsActosInsulin sensitivity DPP-4 InhibitorsJanuviaLiver A-glucosidase Inhibitors PrecoseBloodstream Bile Acid SequestrantsWelcholHypoglycemic Combination PillsRepaglinide + Metformin Combines the action TypeOnsetPeakDuration Rapid Acting5 minutes1 hour2-4 hours Regular/Short30 minutes2-3 hours3-6 hours Intermediate2-4 hours4-12 hours12-18 hours Long Acting6-10 hoursNo peak20-24 hours Daily injections Vary in their onset, peak and duration Determined by endocrinologist Anthropometrics Physical Appearance Body Composition Food Intake Biochemical Data Social History Medical History Vitamins, Minerals and Supplements *indirect calorimetry is the gold standard Harris Benedict M: (kg) + 5(cm) 6.7(yrs) F: (kg) + 1.8(cm) 4.7(yrs) x activity factor Mifflin St-JeorM 9.99(kg) (cm) (yrs) + 5 F 9.99(kg) (cm) 4.92(yrs) 161 Ireton JonesIf patient is spontaneously breathing: EEE(s) = 629 11(A) + 25(W) 609(O) Vent Dependent Patients: EEE(v) = 1784 11(A) + 5(W) + 244(S) + 239(T) + 804(B) *For current weight 35-40kcal/kg repletion 25-30kcal/kg maintenance 20-25kcal/kg weight loss ProteinGrams/kg: g/kg FluidBased on weight, age, energy, fluid balance *edema Fiber14g per 1000kcal intake Fat admitted to 3 rd tier ICU Impression of hypertriglyceridemia induced severe pancreatitis triggering DKA Endocrinology consult ordered DKA CriteriaER Admission (11/7) Glucose >250mg/dl388 mg/dl pH (moderate)7.08 bicarbonate 11 mEq/L22 mEq/L AlertnessLethargic 31 y/o M Mexican Bronx, NY Wife Unemployed Purchases and prepares food Regular diet No past medical history Father with diabetes Height: 59 Stated weight: 260lbs Actual weight: 277lbs Usual Weight: 260lb IBW: 160lb %IBW: 173% BMI 40.9 (MO) ABW: 86kg (189lb) Shrimp allergy NPO; high nutritional risk Nutritional Needs using ABW 86kg: Calories: kcal (25-30kcal/kg) Protein 69-86gm ( g/kg) Fluid: 3010ml (35+ml/kg) 11/711/8 CO26 LL11 L Chloride110 H120 H Glucose388 H224 H Lactic Acid4.2 HH1.3 Albumin L KetonemoderateN/A Lipase1078 H1272 H Phosphorus0.4 L8.7 H, 0.7 L PrescriptionIndication Acetaminophen (TYLONEL)Pain Famotidine (PEPCID)GERD HeparinPrevent blood clots Insulin DripHypoglycemic Metoclopramide IVPB (REGLAN)Nausea and vomiting Potassium PhosphateIV fluids Gemfibrozil (LOPID)Hyperlipidemia Magnesium SulfateIV fluids Potassium ChlorideIV fluids Glucose 388mg/dl on admission and CBGs mg/dl on insulin drip DKA and new onset Type 2 Diabetes As evidence by Altered nutrition-related lab values (NC-2.2) Related to Intervention Education 2200kcal diabetic diet Request HgbA1c Goals 1-2lb weight loss per week until 160lb (+/- 10%) reached PO intake and tolerance at least 75% Electrolytes WNL Adequate hydration BG >80 and Full liquids Type 2 Diabetes Complex vs Simple Carbohydrates Fiber Skipping Meals Low Cholesterol Diet Portion Sizes Exercise Weight Loss Hyperglycemia Hypoglycemia Education 11/811/911/10 HDL37 L32 L LDLLIP Chol495 HH395 H358 H TGLIP>400 H Lipase1272H80 HN/A CO211 L16 L17 L Potassium3.73 LL2.9 LL Chloride120 H114 H107 Albumin2.7 L2.5 LN/A Glucose244 H210 H195 H Phosphorus0.7 L1.5N/A Sodium L Assessment 75% PO intake Weight change Estimated Needs (88kg): kcal (25-30kcal) 70-88gm pro ( g/kg) 2625ml fluid (30ml/kg) 11/711/811/911/1011/1111/1211/1311/1411/ Glucose/CBGs mg/dl on regular insulin and sliding scale insulin Newly diagnosed Type 2 Diabetes as evidence by Altered nutrition related lab values related to Intervention 2200kcal diabetic 2gmNa 250mgChol diet + NCS No HS snack Request HgbA1c Outpatient Referral Goals PO intake and tolerance >75% 1-2lb weight loss per week BG >80 and