Mrs. DM’s laboratory data and interpretation:

Patients Value Normal Range ExplanationMorning fasting glucose levels

120-140 mg/dl 70-99 mg/dl Diabetes

Weight 145 lbs 117-156 lbs NormalBMI 24.2 Kg/M^2 18.5-25.0 Kg/^2 NormalBlood pressure 148/95 mm Hg <130/80 HypertensionHA1c 8.1% 5-5.2% or <7% Poorly controlled DMCreatinine 0.9 mg/dl 0.4-1.2 mg/dl NormalBUN 27 8-23 mg/dl DiabetesHgb 12.1 12.1-15.6 g/dl NormalHct 37% 34-54% NormalUrine albumin 4+ (>300 mg/dl) <30 mg/24 hour Diabetic Nephropathy

Assess drug: nutrient interactions:Mrs. DM is currently taking hydrochlorothiazide (25 mg) daily. This drug is recommended to be taken in the morning with food or milk, as well as maintaining a diet low in sodium and calcium and high in potassium and magnesium. Sodium consumption for Mrs. DM needs to be addressed based off of her 24-hour dietary recall. Foods consumed that are high in sodium are as follows: Processed foods or take out (pepperoni and cheese pizza or a McDonalds Big mac with medium fries), gravy, butter and salted popcorn. Other adjustments that should be made are Mrs. DM’s fat consumption such as butter, pizza and fast food, chocolate chip cake, gravy, vanilla ice cream and Oreo cookies.Lisinopril in a prescription Mrs. DM is taking for hypertension, which also recommends a diet low in sodium and calcium, but with adequate hydration. She is currently taking 20 mg daily and this should be taken on an empty stomach 1 hour before a meal.Mrs DM takes about 81 mg of aspirin each day. This should be taken after meals and with mill or water. Because hydrochlorothiazine and lisinopro both recommended a diet low in calcium, water is recommended over milk. Because most orange juice is fortified with calcium, Mrs. DM should consume non-fortified milk or other juices high in vitamin C. Her caffeine intake should be limited or monitored while taking aspirin.

ADIME:Assessment:

35 y/o female. Ht: 5’5’’ Wt: 145# (65.9 kg). BMI 24.2. BP: 148/195 mm Hg.

Nutrition Dx: Type 1 Diabetes. Moderate Albuminuria. Outpatient nutrition consult was ordered. BMI and body weight within normal range.

Nutritional Needs: Intake of daily calories (~1900 calories), protein (53 – 67g), and fluid intake (1977 mL/day). DM needs a higher consumption of fruits and vegetables and decreased sodium, fat and sugar consumption.

Medical Hx: Type 1 Diabetes. Moderate Albuminuria. Poorly controlled HTN. Under physicians care for diabetes for 20 yrs. No history of retinopathy or neuropathy. No cardiovascular event and reports no cardiac symptoms.

Family Hx: CVD

Social: N/A

Mrs. DM had been under physicians care with type 1 diabetes for 20 years and is here due to poorly controlled hypertension and moderate albuminuria. Mrs. DM claims to monitor her fasting glucose levels three times a day via personal glucometer. Mrs. DM is currently taking hyperchlorothiazide (25 mg daily, for hypertension), Lisinopro (20 mg daily, for hypertension), aspirn (81 mg daily), 30 units of NPH (20 U in the am and 10 U at bedtime) and uses 30 U of Lispro at meals (10 U at lunch and dinner). Mrs. DM claims that she takes her medication consistently and she had no prior history of a cardiovascular episode and reports no cardiac symptoms. Cardiorespiratory, abdominal, and neurological examination assessments are normal but an outpatient nutrition consult was ordered. BMI and body weight are within normal range, therefore a daily consumption of 1900 kcals and 53-67 grams of protein are recommended. Due to diabetic nephropathy, less protein in recommended, so closer to 53 grams than to 67 grams.

Kcal Recommendations (Harris Benedict):655+9.6(65.9 kg)+1.7(65 cm)-4.7(35 yr)= 1888.64

=~1900 kcals/day

Protein recommendation for acute kidney failure:0.8-1.0 g protein/kg/day0.8x65.9 kg=~53 f of protein/day1.0x65.9 kg=~67 g of protein/day

=53-67 grams of protein/day

Fluid recommendation:30 mL/kg/day30 mLx 65.9 kg=1977 mL/day

=~1977 mL/day

Nutritional Diagnosis:

Excessive mineral intake (NI-5.10.2) of sodium (10736) R/T high intake of high sodium processed foods AEB poorly controlled hypertension.

Intervention/Monitoring and Evaluation:1.) Regarding Mrs. DM’s 24-hour recall and lab reports, decreased sodium

consumption is recommended. A DASH or Mediterranean diet, whichever is more appealing to her, will be assigned along with a diet of <2000mg of sodium/day. Mrs. DM will be educated on these diets, how to properly read labels, what to shop for at the grocery store and how to cook using less sodium and more fruits and vegetables. Fast food and processed foods, such as Big Mac’s and pizza, are encouraged to be eliminated from her diet and replaced with more fruits and vegetables and foods low in sodium and fat. A cooking class is held here once a week at the hospital and Mrs. DM is encouraged to attend to help her learn how to cook nutritious meals using the DASH or Mediterranean diet. This will be monitored by her keeping a food journal of what she eats and additional comments, such as if she liked it and what her insulin levels where after consumption. We will evaluate her diet from her journal entries as well as from lab reports. Because this goal is intended to lowering hypertension, blood pressure will be monitored and urine albumin tests will be assessed weekly because kidney failure has few signs. From Mrs. DM’s food journal and lab results, further adjustments, if any, can be made to her diet.

2.) Carbohydrate counting will be required to better monitor CHO consumption and insulin. It is important for Mrs. DM to focus on the same amount to CHO at each meal (“constant CHO”), to establish customary eating patterns, determine the amount of CHO at each time, coordinate time of meal/snack with insulin and to calculate the “exchanges” for CHO consumed. Mrs. DM will be educated on how to properly read food labels and to divide the amount of CHO by 15 to get #CHO choices. The plate theory will also be shown to her to help her visualize the correct amount of macronutrients as well as what each are categorized as (PRO, CHO, FATS, fruit’s/veggies). This will be monitored by keeping this in her food journal so we can see how much CHO she is consuming, and if she is properly counting CHO’s and reading labels. Insulin levels should also be recorded as well as time of consumption, grams and exchanges.

3.) Due to Mrs. DM’s diabetic nephropathy, a diet low in protein is recommended. Because the kidneys are already compromised, breaking down protein will cause them to over-work, eventually causing liver failure.

As previously mentioned, a diet of 53-67 grams of protein was calculated, however, I would like to start Mrs. DM off at 53 grams/day. From the 24-hour diet recall, she is consuming enough protein through Big Mac, pepperoni pizza, hard boiled eggs and chicken breast. Since Big Macs, pizza and other processed and fast foods are to be eliminated from her diet, a substitution of healthy foods that contain a good source of protein is recommended. For example, 1 cup of cooked red quinoa contains 8 grams of a compete protein, and ½ cup of bean sprouts, lentils and peas contains 13.1 grams of proteins. Legumes are to be closely monitored for their high CHO content. Mrs. DM will meet with a dietician to be educated on healthy foods high in protein and how to break up protein consumption for each meal. For example, if Mrs. DM has three meals and two snacks, have her consume 10-15 grams of protein/ meal and 3-5 grams of protein at each snack. Like CHO counting and low sodium goals, this too should be recorded in the same food journal so we can see what she is consuming and what adjustment need to be made. Like CHO counting, a weekly urine albumin test will be assessed to monitor levels and kidney functions. Tests will be lessened once levels begin to decrease.

Describe the diabetes education which you would provide to this patient to help her achieve her dietary goals. What self-care activities would you suggest for this patient?

Although Mrs. Has had DM for 20 years and monitors her blood glucose levels three times a day, it’s possible that maybe she doesn’t fully understand that these numbers mean. If she knew what these numbers meant for her health she would be more conscious of what she ate. I would help her understand what insulin is, how her body is affected by it and exactly what the numbers mean is comparison to what she ate. This will help her with CHO counting and portion sizes. Also, I would suggest Mrs. DM having a self-blood pressure monitor available. Again, if Mrs. DM can visual her blood pressure and successfully compare that to the foods she ate the and physical activity she has done, or needs to do, this might help her become more conscious and motivated to eat healthier and control her hypertension more efficiently. Physical activity is highly suggested. According to the Journal of Nutrition and Dietetics, physical activity is recognized to produce multiple general and diabetes-specific health benefits. Even though body weight and BMI are within normal range, reducing fats stores can be healthy for her liver, kidney and overall health. Mrs. DM should meet with a trainer, but participation in at least 30 min of moderate-intensity dynamic aerobic exercise (walking, jogging, cycling or swimming) on 5 to 7 days a week is recommended. If physical activity is increased then her body weight needs to be monitored because some weight loss is desirable but too much is not. In this case, kcal recommendations per day needs to be adjusted accordingly.

Reference from the Journal of Nutrition and Dietetics:

Role of Physical Activity in Diabetes Management and PreventionCharlotte Hayes, MMSc, MS, RD and Andrea Kriska, PhD

Accepted December 13, 2007

Abstract:

During recent years, evidence supporting the vital role of physical activity in the prevention and treatment of diabetes has been accumulating. Physical activity is recognized to produce multiple general and diabetes-specific health benefits. Yet despite the multitude of benefits, many people are physically inactive. As the prevalence of overweight and obesity, prediabetes, and type 2 diabetes has continued to rise at an alarming rate, physical inactivity has become an urgent public health concern. The purpose of this article is to review the physical activity/exercise research in diabetes and summarize the current exercise recommendations. This information can be used by clinicians to make safe and effective recommendations for integrating physical activity/exercise into self-management plans for individuals with diabetes or at risk for its development.