Sydney Reichhardt
NUTR 425
Case Study #6: Nelms p. 281
Diabetes Mellitus
I. Understanding the Disease and Pathophysiology
1. What is the difference between type 1 DM and type 2 DM?
Type I DM is an autoimmune disorder that is characterized by a decreased ability by the body to produce insulin, while type 2 DM is related to decreased insulin sensitivity.
2. How would you clinically distinguish between type 1 and type 2 DM?
Previously, type 1 DM was considered childhood DM, and type 2 DM was considered adult onset. However, with the increasing prevalence of childhood obesity, type 2 DM is increasing in children. One distinguishing factor in clinical manifestations of DM is that type 1 DM usually has a sudden onset, while type 2 DM is generally characterized by a more gradual onset.
3. What are the risk factors for development of type 2 DM? What risk factors does Mrs. Douglas present with?
The risk factors for development of type 2 DM are obese BMI classification, central obesity, physical inactivity, family history, age, race, poor glucose metabolism, and a history of gestational diabetes. Mrs. Douglas has a BMI in the obese range (>30 kg/m2), a family history of DM (her sister has diabetes), is elderly (71 yo), and is African American, all which put her at a higher risk of developing type 2 DM.
4. What are the common complications associated with DM? Describe the pathophysiology associated with these complications, specifically addressing the role of chronic hyperglycemia.
Complication
Pathophysiology
Cardiovascular Disease
Hyperglycemia results in blood vessels being prone to endothelial damage, leading to thinking and changes in composition of the subendothelial layer.
Nephropathy
Hyperglycemia results in changes in the structure of the blood vessel of the glomerulus, the functioning unit of the kidney, which is comprised of a tuft of capillaries.
Retinopathy
Likely a result of damage to the blood vessels of the eye as a result of chronic hyperglycemia.
Peripheral neuropathy
The pathophysiology of neuropathy is not completely understood, but it is hypothesized that it is a result of continual oxidative stress and resulting nerve damage as a result of extended periods of hyperglycemia.
Autonomic neuropathy
5. Does Mrs. Douglas present with any complications of DM? If yes, which ones?
Yes, Mrs. Douglas likely has retinopathy (blurred vision), neuropathy (sensation to light tough mildly diminished in feet), and hyperglycemia.
6. Identify at least four features of the physician’s physical examination as well as her presenting signs and symptoms that are consistent with her admitting diagnosis. Describe the pathophysiology that might be responsible for each physical finding.
Physical Finding
Physiological Change/Etiology
Blurred vision
Retinopathy as a result of damage to the blood vessels of the eyes
Dry mucous membranes
Result of dehydration
Elevated blood pressure
Diabetes causes thickening of the artery walls and atherosclerosis requiring increased blood pressure to transport blood through the body.
Diminished sensation to light touch in feet
Result of neuropathy due to decreased circulation in feet
2-3 cm ulcer on left foot
High susceptibility to illness as a result of DM
7. Prior to admission, Mrs. Douglas had not been diagnosed with DM. How could she present with complications?
Mrs. Douglas likely has been developing Type 2 DM for quite some time. Individuals with Type 2 DM can be asymptomatic for up to ten years, but present with complications associated with diabetes as a result of increased insulin resistance and frequency of hyperglycemic states.
8. Briefly describe hyperglycemic hyperosmolar nonketotic syndrome (HHNS). How is this syndrome different from ketoacidosis?
HHNS is a complication of type 2 DM that usually develops after a period of hyperglycemia combined with inadequate fluid intake. HHNS is characterized by an individual that has adequate insulin to prevent lipolysis and ketogenesis, but inadequate insulin to maintain normal glycemic levels. It is more common in the elderly. HHNS differs from ketoacidosis in that it’s onset is generally prolonged, plasma glucose levels are >600 mg/dL, compared to the diagnostic criteria of diabetic ketoacidosis of >250 mg/dL, and there are only small amounts of urine and serum ketones present in HHNS, whereas presence of ketones in these locations is a defining characteristic of ketoacidosis.
9. What are the symptoms of HHNS?
· Undiagnosed diabetes
· Progresses slowly (over days and weeks)
· Polyuria
· Polydipsia
· Progressive decline in level of consciousness
· Fever (due to underlying infection)
· Volume depletion
10. What factors may lead to HHNS? Is Mrs. Douglas at risk?
Poor hydration, extended periods of hyperglycemia, and poor blood glucose monitoring can lead to HHNS. HHNS is more likely to occur in elderly patients. Because of Mrs. Douglas’s age, her new diagnosis which may create challenges in blood glucose monitoring, and her lack of fluid consumption put her at risk of developing HHNS.
11. What is the immediate aim of treatment for HHNS? If HHNS is not treated, how would you expect the condition of HHNS to progress?
Immediate aim of treatment for HHNS is slow rehydration and treatment of any underlying medical problems that may be exasperating the syndrome. Sometimes insulin is also necessary in treatment. If HHNS is not treated, it will likely be fatal.
II. Nutrition Assessment A. Evaluation of Weight/Body Composition 12. Calculate Mrs. Douglas’s BMI.
155 lb= 70.45 kg
60”= 1.52 m
BMI= 30.50 kg/m2
13. What are the health implications for a BMI in this range?
Mrs. Douglas’s BMI is in the obese range. A BMI in this range put Mrs. Douglas at a higher risk of developing Type 2 DM. Also, obesity is an independent risk factor for the leading causes of death in individuals with diabetes: hypertension, dislipidemia, and cardiovascular disease.
B. Calculation of Nutrient Requirements 14. Calculate Mrs. Douglas’s energy needs using the Mifflin-St. Jeor equation. Should Mrs. Douglas’s weight be adjusted for obesity?
According to the AND, Mifflin St. Jeor is the most accurate calculation of RMR for overweight and obese individuals. However, Mrs. Douglas’s weight should be adjusted for obesity, because weight loss is recommended in patients with diabetes with a BMI of over 25 kg/m2, because moderate weight loss is improves glycemic control and reduces the risk of cardiovascular complications.
RMR=161+10(W)+6.25(H)-5(A)
RMR=161+10(70.45)+6.25(152)-5(71)= 1310 kcals
(1310 kcals) (1.12 AF)=~1470 kcals/day
If Mrs. Douglas wants to maintain her current body weight, she would need to consume about 1470 kcals per day. However, a calorie deficit of 250 kcals would promote about a half a pound of weight loss per week. Taking this into consideration, Mrs. Douglas should aim to consume about 1200 kcals per day.
15. Calculate Mrs. Douglas’s protein needs.
0.8 g of protein per kg of body weight
0.8 g (70.45 kg)= 56.4 g of protein per day
16. Is the diet order of 1,200 kcal appropriate?
Yes.
17. If yes, explain why it is appropriate. If no, what would you recommend? Justify your answer.
As stated above in answer 14, If Mrs. Douglas wants to maintain her current body weight, she would need to consume about 1470 kcals per day. However, a calorie deficit of 250 kcals would promote about a half a pound of weight loss per week. Taking this into consideration, Mrs. Douglas should aim to consume about 1200 kcals per day.
C. Intake Domain 18. Does Mrs. Douglas’s “usual” dietary intake meet the USDA Food Guide/MyPyramid (MyPlate) guidelines? Is she deficient in any food groups? If so, which ones?
Mrs. Douglas’s diet is lacking in fruits and vegetables. With the exception of the turnip greens, which were cooked in fat, she did not consume any fruits or vegetables. Also, Mrs. Douglas’s diet is lacking in full grains, and therefore, does not meet the MyPlate guideline of “Make half of your grains whole.”
19. Using a computer dietary analysis program or food composition table, calculate the kcalories, protein, fat, CHO, fiber, cholesterol, and NA content of Mrs. Douglas’s diet.
Kcalories: 1224 kcals
Protein: 51 g or 17% of total kcals
Fat: 52 g or 35% of total kcals
CHO: 141 g or 46% of total kcals
Fiber: 16 g
Sodium: 3897 mg
20. How would you compare Mrs. Douglas’s “usual” dietary intake to her current nutrient needs?
Mrs. Douglas is obtaining the proper amount of kcalories in her usual dietary intake, and her macronutrient distributions are within the normal ranges. However, her fat intake is on the high end of the normal range, and giving her present condition it would be desirable to have that lowered. It is important to look at the source of fat, and currently saturate fat is making up 14% of Mrs. Douglas’s daily kcalories; she should aim to cut this percentage in half. Also, Mrs. Douglas should aim to increase her fiber intake and decrease her sodium intake to aid in her diabetes’ management. It is also very important that Mrs. Douglas be educated on staying hydrated, and incorporating water intake into her daily life.
D. Clinical Domain 21. Compare the patient’s laboratory values that were out of range on admission with normal values. How would you interpret this patient’s labs? Make sure explanations are pertinent to this situation.
Parameter
Normal Value
Patient’s Value
Reason for Abnormality
Nutritional Implications
Glucose (mg/dL)
70-110
325
Type 2 DM-insulin resistance
Detects risk of glucose intolerance, diabetes mellitus, and hypoglycemia; helps to monitor diabetes treatment
HbA1C (%)
3.9-5.2
8.5
Type 2 DM-insulin resistance-extended period of hyperglycemia
Used to monitor long term blood glucose control (~1-3 months prior)
Cholesterol (mg/dL)
120-199
300
Type 2 DM; Excessive intake of foods high in animal fat, especially saturated fats
Puts the patient at risk for developing atherosclerosis
LDL-cholesterol (mg/dL)
<130
140
Type 2 DM; Excessive intake of foods high in fat, especially saturated fats
Leads to plaque build up on the artery walls and can result in cardiovascular disease
HDL-cholesterol (mg/dL)
>55
35
Type 2 DM; Excessive intake of foods high in fat, especially saturated fats
Decreases the patient’s ability to effectively transport triglycerides
Triglycerides (mg/dL)
35-135
400
Type 2 DM; Excessive intake of foods high in fat, especially saturated fats
Very high triglyceride level, increase cardiovascular stress; component of metabolic syndrome diagnosis
22. Identify two lab values that should be monitored regularly.
Mrs. Douglas’s glucose levels and HbA1C levels should be monitored regularly. Her blood glucose needs to be monitored regularly several times a day to help her manage her DM, while her HbA1C levels should be measured every 90-120 days by a medical professional to determine her average blood glucose levels over an extended period of time.
23. Why wasn’t HbA1C measured at discharge?
HbA1C levels were not measured at discharge because this lab value is representative of what her blood glucose levels have been over the life cycle of her red blood cells. Because red blood cells have an average lifespan of 120 days, it is only beneficial to measure them every 90-120 days.
24. Why is regular insulin used to correct hyperglycemia in patients with HHNS?
Regular insulin is used to treat patients with hyperglycemia, because it is challenging to predict the strength and action of insulin administered subcutaneously or intramuscularly due to dehydration and the severe state of hyperglycemia.
25. When HHNS is treated, the initial target serum blood glucose level is typically set at the 250 mg/dL range instead of normal blood glucose level. Why?
The initial blood glucose target is set at 250 mg/dL to avoid cerebral edema. When a significant shift in cellular fluid occurs, it can result in water on the brain, or cerebral edema, if it is not monitored at done slowly.
26. Compare the pharmacologic differences among the oral hypoglycemic agents.
Class
Brand Names
(Generic Name)
Mechanism of Action
Efficacy (measured as A1C % reduction)
Effect on Plasma Insulin Levels
Effect on Body Weight
Effect on Plasma Lipids
Side Effects & Contraindications
Adult Daily Maintenance Dose (mg)
Number of Daily Doses
a-Glucosidase inhibitors
Precose, Glyset, Volix
(Acarbose, Migitol, Voglibose)
Delays intestinal absorption of glucose
0.5-1.0%
Increase
No effect
No effect
Flatulence, diarrhea
Contraindicated in individuals with intestinal disaease, must take with meals 3x/day
25-100 mg
3
Biguanides
Metformin
(Glucophage)
Decreases hepatic glucose production and increases insulin sensitivity/uptake, especially in muscles
1.5-2.0%
No effect/ Decrease in states of hyperinsulimia
No effect
Decrease
Transient diarrhea, nausea, bloating, anorexia, flatulence, lactic acidosis (rare)
Contraindicated in individuals with renal insufficiency, liver failure, of treated CHF
500-1000 mg
3
Meglitinides
Prandin, Starlix
(Repaglinide, Nateglinide)
Stimulated insulin secretion in presence of glucose, short-acting
1.0-2.0%
Increase
Weight gain
No effect
Hypoglycemia, frequent dosing, expensive
120 mg
3
Sulfonylureas
(First generation)
Dymelor, Diabinese, Tolinase, Orinase
(Acetohexamide, Chlorpropamide, Tolazamide, Tolbutamide)
Stimulates insulin production
1.0-2.0%
Increase
Weight gain
No effect
Hypoglycemia
Contraindicated in individuals with renal insufficiency
100-250 mg
1
Sulfonylureas
(Second generation)
Glucotrol, Clucotrol XL, DiaBeta, Micronase, PresTab, Glynase
(Glipizide, Glipizide-GITS, Glyburide)
Stimulate insulin secretion from the beta cells
1.0-2.0%
Increase
Weight gain
No effect
Hypoglycemia
Contraindicated in individuals with renal insufficiency
~8-20 mg
1-2
Thiainedioneszolid
Actos, Avandia
(Pioglitazone, Rosiglitazone)
Decreases insulin resistance
1.0-2.0%
No effect
Weight gain
Increase
Weight gain, edema, worsened CHF, most expensive, slow onset of action
Contraindicated in individuals with CHF
*No longer sold per FDA, November 2011
15-45 mg
1
27. Avandia is often used to help control blood glucose levels. Describe the (medication) action of Avandia.
Avandia is in the thiazolidinediones class of diabetes medications. As of November 2011, no new patients are being prescribed avandia due to the high risk of water retention, which greatly increases the risk of congestive heart failure. However, when Avandia is prescribes it works by increasing the body’s natural sensitivity to insulin.
28. The goal for healthy elderly patients with diabetes should be near-normal, fasting plasma glucose levels without hypoglycemia. Although acceptable glucose control must be carefully individualized, the elderly tend to be predisposed to hypoglycemia. List five factors that predispose elderly patients to hypoglycemia.
1. Decreased metabolism (especially hepatic and renal)
2. Presence of co-morbid conditions
3. Lack of transportation, resources, education, etc. that allow the elderly to seek early treatment for hypoglycemia
4. Alterations in mental status (i.e. dementia) that impair the individual’s ability to recognize and evaluate hypoglycemia
5. Poor nutritional intake as a result of decreased hunger or interest in eating, lack of resources, etc.
E. Behavioral-Environmental Domain 29. Identify at least three factors that may interfere with Mrs. Douglas’s compliance and success with her diabetes treatment.
· Low-income- Mrs. Douglas could have difficulty affording her prescription medications and supplies and purchasing food to help her in management of her diabetes
· Blurry vision-Could make it difficult for Mrs. Douglas to read labels and to document her self-monitoring blood glucose levels
· Caring for her elder sister- Mrs. Douglas may have other priorities and difficulties with the care for her sister that make it difficult for her to manage her own health
III. Nutrition Diagnosis 30. Select two high-priority nutrition problems and complete the PES statement for each.
(1) Inappropriate intake of types of carbohydrates related to new type 2 DM diagnosis and high consumption of simple carbohydrates as evidenced by usual diet recall and blood glucose level of 325 mg/dL at admittance.
(2) Food and nutrition knowledge deficit related to 10th grade education achievement and new diagnosis of type 2 DM as evidenced by management of sister’s diabetes, thought that all starch must be eliminated from the diet, and food recall.
IV. Nutrition Intervention 31. What was the most important nutritional concern when the patient was originally admitted to the hospital (time of Dx)?
The most important nutritional concern was to normalize Mrs. Douglas’s blood glucose levels.
32. What additional information does the dietitian need to collect before he or she can mutually develop clinical and behavioral outcomes with the patient and health care team?
The dietitian should assess the patient’s willingness to change, the resources currently available to Mrs. Douglas, the current understanding of diabetes that Mrs. Douglas has, and any outside supports that Mrs. Douglas may be able to rely on for assistance in her diabetes management.
33. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).
PES Statement
Ideal Goal
Appropriate Intervention
(1) Inappropriate intake of types of carbohydrates related to new type 2 DM diagnosis and high consumption of simple carbohydrates as evidenced by usual diet recall and blood glucose level of 325 mg/dL at admittance.
-Increase Mrs. Douglas’s consumption of whole grain carbohydrates
-Decrease Mrs. Douglas’s blood glucose levels to 250 mg/dL
-Educate Mrs. Douglas on what foods contain whole grains and how they can be incorporated into foods that she enjoys cooking and eating.
(2) Food and nutrition knowledge deficit related to 10th grade education achievement and new diagnosis of type 2 DM as evidenced by management of sister’s diabetes, thought that all starch must be eliminated from the diet, and food recall.
-Increase efficiency and appropriateness that Mrs. Douglas is managing her diabetes.
-Educate Mrs. Douglas on appropriate management of type 2 DM, through label reading, carbohydrate counting, etc.
V. Monitoring 34. Mrs. Douglas was d/c with instructions for a non-kilocaloric-restricted, low-fat (<30% total kcal), high-CHO (>50% total kcal) diet, in combination with a walking program, and a prescription for captopril to control her HTN. Glucose levels were well controlled for 6 months, but she became unable to afford the necessary supplies to check her BG or urine acetone levels. After 6 months, she was readmitted with a BG of 905 mg/dL, a slight temperature, BP of 68/100 mm Hg, tachycardia, and shallow, tachypenic breathing (Kussmal respirations). She was diagnosed with pneumonia, dehydration, and HHS. What is the MNT for HHNS?
The medical nutrition therapy for HHNS involves increasing the patient’s hydration status gradually, generally in a hospital setting. Sometimes insulin is appropriate in the treatment of HHNS. Electrolyte imbalances resulting from the HHNS/ dehydration should be addressed and corrected.
NUTR 425
Case Study #6: Nelms p. 281
Diabetes Mellitus
I. Understanding the Disease and Pathophysiology
1. What is the difference between type 1 DM and type 2 DM?
Type I DM is an autoimmune disorder that is characterized by a decreased ability by the body to produce insulin, while type 2 DM is related to decreased insulin sensitivity.
2. How would you clinically distinguish between type 1 and type 2 DM?
Previously, type 1 DM was considered childhood DM, and type 2 DM was considered adult onset. However, with the increasing prevalence of childhood obesity, type 2 DM is increasing in children. One distinguishing factor in clinical manifestations of DM is that type 1 DM usually has a sudden onset, while type 2 DM is generally characterized by a more gradual onset.
3. What are the risk factors for development of type 2 DM? What risk factors does Mrs. Douglas present with?
The risk factors for development of type 2 DM are obese BMI classification, central obesity, physical inactivity, family history, age, race, poor glucose metabolism, and a history of gestational diabetes. Mrs. Douglas has a BMI in the obese range (>30 kg/m2), a family history of DM (her sister has diabetes), is elderly (71 yo), and is African American, all which put her at a higher risk of developing type 2 DM.
4. What are the common complications associated with DM? Describe the pathophysiology associated with these complications, specifically addressing the role of chronic hyperglycemia.
Complication
Pathophysiology
Cardiovascular Disease
Hyperglycemia results in blood vessels being prone to endothelial damage, leading to thinking and changes in composition of the subendothelial layer.
Nephropathy
Hyperglycemia results in changes in the structure of the blood vessel of the glomerulus, the functioning unit of the kidney, which is comprised of a tuft of capillaries.
Retinopathy
Likely a result of damage to the blood vessels of the eye as a result of chronic hyperglycemia.
Peripheral neuropathy
The pathophysiology of neuropathy is not completely understood, but it is hypothesized that it is a result of continual oxidative stress and resulting nerve damage as a result of extended periods of hyperglycemia.
Autonomic neuropathy
5. Does Mrs. Douglas present with any complications of DM? If yes, which ones?
Yes, Mrs. Douglas likely has retinopathy (blurred vision), neuropathy (sensation to light tough mildly diminished in feet), and hyperglycemia.
6. Identify at least four features of the physician’s physical examination as well as her presenting signs and symptoms that are consistent with her admitting diagnosis. Describe the pathophysiology that might be responsible for each physical finding.
Physical Finding
Physiological Change/Etiology
Blurred vision
Retinopathy as a result of damage to the blood vessels of the eyes
Dry mucous membranes
Result of dehydration
Elevated blood pressure
Diabetes causes thickening of the artery walls and atherosclerosis requiring increased blood pressure to transport blood through the body.
Diminished sensation to light touch in feet
Result of neuropathy due to decreased circulation in feet
2-3 cm ulcer on left foot
High susceptibility to illness as a result of DM
7. Prior to admission, Mrs. Douglas had not been diagnosed with DM. How could she present with complications?
Mrs. Douglas likely has been developing Type 2 DM for quite some time. Individuals with Type 2 DM can be asymptomatic for up to ten years, but present with complications associated with diabetes as a result of increased insulin resistance and frequency of hyperglycemic states.
8. Briefly describe hyperglycemic hyperosmolar nonketotic syndrome (HHNS). How is this syndrome different from ketoacidosis?
HHNS is a complication of type 2 DM that usually develops after a period of hyperglycemia combined with inadequate fluid intake. HHNS is characterized by an individual that has adequate insulin to prevent lipolysis and ketogenesis, but inadequate insulin to maintain normal glycemic levels. It is more common in the elderly. HHNS differs from ketoacidosis in that it’s onset is generally prolonged, plasma glucose levels are >600 mg/dL, compared to the diagnostic criteria of diabetic ketoacidosis of >250 mg/dL, and there are only small amounts of urine and serum ketones present in HHNS, whereas presence of ketones in these locations is a defining characteristic of ketoacidosis.
9. What are the symptoms of HHNS?
· Undiagnosed diabetes
· Progresses slowly (over days and weeks)
· Polyuria
· Polydipsia
· Progressive decline in level of consciousness
· Fever (due to underlying infection)
· Volume depletion
10. What factors may lead to HHNS? Is Mrs. Douglas at risk?
Poor hydration, extended periods of hyperglycemia, and poor blood glucose monitoring can lead to HHNS. HHNS is more likely to occur in elderly patients. Because of Mrs. Douglas’s age, her new diagnosis which may create challenges in blood glucose monitoring, and her lack of fluid consumption put her at risk of developing HHNS.
11. What is the immediate aim of treatment for HHNS? If HHNS is not treated, how would you expect the condition of HHNS to progress?
Immediate aim of treatment for HHNS is slow rehydration and treatment of any underlying medical problems that may be exasperating the syndrome. Sometimes insulin is also necessary in treatment. If HHNS is not treated, it will likely be fatal.
II. Nutrition Assessment A. Evaluation of Weight/Body Composition 12. Calculate Mrs. Douglas’s BMI.
155 lb= 70.45 kg
60”= 1.52 m
BMI= 30.50 kg/m2
13. What are the health implications for a BMI in this range?
Mrs. Douglas’s BMI is in the obese range. A BMI in this range put Mrs. Douglas at a higher risk of developing Type 2 DM. Also, obesity is an independent risk factor for the leading causes of death in individuals with diabetes: hypertension, dislipidemia, and cardiovascular disease.
B. Calculation of Nutrient Requirements 14. Calculate Mrs. Douglas’s energy needs using the Mifflin-St. Jeor equation. Should Mrs. Douglas’s weight be adjusted for obesity?
According to the AND, Mifflin St. Jeor is the most accurate calculation of RMR for overweight and obese individuals. However, Mrs. Douglas’s weight should be adjusted for obesity, because weight loss is recommended in patients with diabetes with a BMI of over 25 kg/m2, because moderate weight loss is improves glycemic control and reduces the risk of cardiovascular complications.
RMR=161+10(W)+6.25(H)-5(A)
RMR=161+10(70.45)+6.25(152)-5(71)= 1310 kcals
(1310 kcals) (1.12 AF)=~1470 kcals/day
If Mrs. Douglas wants to maintain her current body weight, she would need to consume about 1470 kcals per day. However, a calorie deficit of 250 kcals would promote about a half a pound of weight loss per week. Taking this into consideration, Mrs. Douglas should aim to consume about 1200 kcals per day.
15. Calculate Mrs. Douglas’s protein needs.
0.8 g of protein per kg of body weight
0.8 g (70.45 kg)= 56.4 g of protein per day
16. Is the diet order of 1,200 kcal appropriate?
Yes.
17. If yes, explain why it is appropriate. If no, what would you recommend? Justify your answer.
As stated above in answer 14, If Mrs. Douglas wants to maintain her current body weight, she would need to consume about 1470 kcals per day. However, a calorie deficit of 250 kcals would promote about a half a pound of weight loss per week. Taking this into consideration, Mrs. Douglas should aim to consume about 1200 kcals per day.
C. Intake Domain 18. Does Mrs. Douglas’s “usual” dietary intake meet the USDA Food Guide/MyPyramid (MyPlate) guidelines? Is she deficient in any food groups? If so, which ones?
Mrs. Douglas’s diet is lacking in fruits and vegetables. With the exception of the turnip greens, which were cooked in fat, she did not consume any fruits or vegetables. Also, Mrs. Douglas’s diet is lacking in full grains, and therefore, does not meet the MyPlate guideline of “Make half of your grains whole.”
19. Using a computer dietary analysis program or food composition table, calculate the kcalories, protein, fat, CHO, fiber, cholesterol, and NA content of Mrs. Douglas’s diet.
Kcalories: 1224 kcals
Protein: 51 g or 17% of total kcals
Fat: 52 g or 35% of total kcals
CHO: 141 g or 46% of total kcals
Fiber: 16 g
Sodium: 3897 mg
20. How would you compare Mrs. Douglas’s “usual” dietary intake to her current nutrient needs?
Mrs. Douglas is obtaining the proper amount of kcalories in her usual dietary intake, and her macronutrient distributions are within the normal ranges. However, her fat intake is on the high end of the normal range, and giving her present condition it would be desirable to have that lowered. It is important to look at the source of fat, and currently saturate fat is making up 14% of Mrs. Douglas’s daily kcalories; she should aim to cut this percentage in half. Also, Mrs. Douglas should aim to increase her fiber intake and decrease her sodium intake to aid in her diabetes’ management. It is also very important that Mrs. Douglas be educated on staying hydrated, and incorporating water intake into her daily life.
D. Clinical Domain 21. Compare the patient’s laboratory values that were out of range on admission with normal values. How would you interpret this patient’s labs? Make sure explanations are pertinent to this situation.
Parameter
Normal Value
Patient’s Value
Reason for Abnormality
Nutritional Implications
Glucose (mg/dL)
70-110
325
Type 2 DM-insulin resistance
Detects risk of glucose intolerance, diabetes mellitus, and hypoglycemia; helps to monitor diabetes treatment
HbA1C (%)
3.9-5.2
8.5
Type 2 DM-insulin resistance-extended period of hyperglycemia
Used to monitor long term blood glucose control (~1-3 months prior)
Cholesterol (mg/dL)
120-199
300
Type 2 DM; Excessive intake of foods high in animal fat, especially saturated fats
Puts the patient at risk for developing atherosclerosis
LDL-cholesterol (mg/dL)
<130
140
Type 2 DM; Excessive intake of foods high in fat, especially saturated fats
Leads to plaque build up on the artery walls and can result in cardiovascular disease
HDL-cholesterol (mg/dL)
>55
35
Type 2 DM; Excessive intake of foods high in fat, especially saturated fats
Decreases the patient’s ability to effectively transport triglycerides
Triglycerides (mg/dL)
35-135
400
Type 2 DM; Excessive intake of foods high in fat, especially saturated fats
Very high triglyceride level, increase cardiovascular stress; component of metabolic syndrome diagnosis
22. Identify two lab values that should be monitored regularly.
Mrs. Douglas’s glucose levels and HbA1C levels should be monitored regularly. Her blood glucose needs to be monitored regularly several times a day to help her manage her DM, while her HbA1C levels should be measured every 90-120 days by a medical professional to determine her average blood glucose levels over an extended period of time.
23. Why wasn’t HbA1C measured at discharge?
HbA1C levels were not measured at discharge because this lab value is representative of what her blood glucose levels have been over the life cycle of her red blood cells. Because red blood cells have an average lifespan of 120 days, it is only beneficial to measure them every 90-120 days.
24. Why is regular insulin used to correct hyperglycemia in patients with HHNS?
Regular insulin is used to treat patients with hyperglycemia, because it is challenging to predict the strength and action of insulin administered subcutaneously or intramuscularly due to dehydration and the severe state of hyperglycemia.
25. When HHNS is treated, the initial target serum blood glucose level is typically set at the 250 mg/dL range instead of normal blood glucose level. Why?
The initial blood glucose target is set at 250 mg/dL to avoid cerebral edema. When a significant shift in cellular fluid occurs, it can result in water on the brain, or cerebral edema, if it is not monitored at done slowly.
26. Compare the pharmacologic differences among the oral hypoglycemic agents.
Class
Brand Names
(Generic Name)
Mechanism of Action
Efficacy (measured as A1C % reduction)
Effect on Plasma Insulin Levels
Effect on Body Weight
Effect on Plasma Lipids
Side Effects & Contraindications
Adult Daily Maintenance Dose (mg)
Number of Daily Doses
a-Glucosidase inhibitors
Precose, Glyset, Volix
(Acarbose, Migitol, Voglibose)
Delays intestinal absorption of glucose
0.5-1.0%
Increase
No effect
No effect
Flatulence, diarrhea
Contraindicated in individuals with intestinal disaease, must take with meals 3x/day
25-100 mg
3
Biguanides
Metformin
(Glucophage)
Decreases hepatic glucose production and increases insulin sensitivity/uptake, especially in muscles
1.5-2.0%
No effect/ Decrease in states of hyperinsulimia
No effect
Decrease
Transient diarrhea, nausea, bloating, anorexia, flatulence, lactic acidosis (rare)
Contraindicated in individuals with renal insufficiency, liver failure, of treated CHF
500-1000 mg
3
Meglitinides
Prandin, Starlix
(Repaglinide, Nateglinide)
Stimulated insulin secretion in presence of glucose, short-acting
1.0-2.0%
Increase
Weight gain
No effect
Hypoglycemia, frequent dosing, expensive
120 mg
3
Sulfonylureas
(First generation)
Dymelor, Diabinese, Tolinase, Orinase
(Acetohexamide, Chlorpropamide, Tolazamide, Tolbutamide)
Stimulates insulin production
1.0-2.0%
Increase
Weight gain
No effect
Hypoglycemia
Contraindicated in individuals with renal insufficiency
100-250 mg
1
Sulfonylureas
(Second generation)
Glucotrol, Clucotrol XL, DiaBeta, Micronase, PresTab, Glynase
(Glipizide, Glipizide-GITS, Glyburide)
Stimulate insulin secretion from the beta cells
1.0-2.0%
Increase
Weight gain
No effect
Hypoglycemia
Contraindicated in individuals with renal insufficiency
~8-20 mg
1-2
Thiainedioneszolid
Actos, Avandia
(Pioglitazone, Rosiglitazone)
Decreases insulin resistance
1.0-2.0%
No effect
Weight gain
Increase
Weight gain, edema, worsened CHF, most expensive, slow onset of action
Contraindicated in individuals with CHF
*No longer sold per FDA, November 2011
15-45 mg
1
27. Avandia is often used to help control blood glucose levels. Describe the (medication) action of Avandia.
Avandia is in the thiazolidinediones class of diabetes medications. As of November 2011, no new patients are being prescribed avandia due to the high risk of water retention, which greatly increases the risk of congestive heart failure. However, when Avandia is prescribes it works by increasing the body’s natural sensitivity to insulin.
28. The goal for healthy elderly patients with diabetes should be near-normal, fasting plasma glucose levels without hypoglycemia. Although acceptable glucose control must be carefully individualized, the elderly tend to be predisposed to hypoglycemia. List five factors that predispose elderly patients to hypoglycemia.
1. Decreased metabolism (especially hepatic and renal)
2. Presence of co-morbid conditions
3. Lack of transportation, resources, education, etc. that allow the elderly to seek early treatment for hypoglycemia
4. Alterations in mental status (i.e. dementia) that impair the individual’s ability to recognize and evaluate hypoglycemia
5. Poor nutritional intake as a result of decreased hunger or interest in eating, lack of resources, etc.
E. Behavioral-Environmental Domain 29. Identify at least three factors that may interfere with Mrs. Douglas’s compliance and success with her diabetes treatment.
· Low-income- Mrs. Douglas could have difficulty affording her prescription medications and supplies and purchasing food to help her in management of her diabetes
· Blurry vision-Could make it difficult for Mrs. Douglas to read labels and to document her self-monitoring blood glucose levels
· Caring for her elder sister- Mrs. Douglas may have other priorities and difficulties with the care for her sister that make it difficult for her to manage her own health
III. Nutrition Diagnosis 30. Select two high-priority nutrition problems and complete the PES statement for each.
(1) Inappropriate intake of types of carbohydrates related to new type 2 DM diagnosis and high consumption of simple carbohydrates as evidenced by usual diet recall and blood glucose level of 325 mg/dL at admittance.
(2) Food and nutrition knowledge deficit related to 10th grade education achievement and new diagnosis of type 2 DM as evidenced by management of sister’s diabetes, thought that all starch must be eliminated from the diet, and food recall.
IV. Nutrition Intervention 31. What was the most important nutritional concern when the patient was originally admitted to the hospital (time of Dx)?
The most important nutritional concern was to normalize Mrs. Douglas’s blood glucose levels.
32. What additional information does the dietitian need to collect before he or she can mutually develop clinical and behavioral outcomes with the patient and health care team?
The dietitian should assess the patient’s willingness to change, the resources currently available to Mrs. Douglas, the current understanding of diabetes that Mrs. Douglas has, and any outside supports that Mrs. Douglas may be able to rely on for assistance in her diabetes management.
33. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).
PES Statement
Ideal Goal
Appropriate Intervention
(1) Inappropriate intake of types of carbohydrates related to new type 2 DM diagnosis and high consumption of simple carbohydrates as evidenced by usual diet recall and blood glucose level of 325 mg/dL at admittance.
-Increase Mrs. Douglas’s consumption of whole grain carbohydrates
-Decrease Mrs. Douglas’s blood glucose levels to 250 mg/dL
-Educate Mrs. Douglas on what foods contain whole grains and how they can be incorporated into foods that she enjoys cooking and eating.
(2) Food and nutrition knowledge deficit related to 10th grade education achievement and new diagnosis of type 2 DM as evidenced by management of sister’s diabetes, thought that all starch must be eliminated from the diet, and food recall.
-Increase efficiency and appropriateness that Mrs. Douglas is managing her diabetes.
-Educate Mrs. Douglas on appropriate management of type 2 DM, through label reading, carbohydrate counting, etc.
V. Monitoring 34. Mrs. Douglas was d/c with instructions for a non-kilocaloric-restricted, low-fat (<30% total kcal), high-CHO (>50% total kcal) diet, in combination with a walking program, and a prescription for captopril to control her HTN. Glucose levels were well controlled for 6 months, but she became unable to afford the necessary supplies to check her BG or urine acetone levels. After 6 months, she was readmitted with a BG of 905 mg/dL, a slight temperature, BP of 68/100 mm Hg, tachycardia, and shallow, tachypenic breathing (Kussmal respirations). She was diagnosed with pneumonia, dehydration, and HHS. What is the MNT for HHNS?
The medical nutrition therapy for HHNS involves increasing the patient’s hydration status gradually, generally in a hospital setting. Sometimes insulin is appropriate in the treatment of HHNS. Electrolyte imbalances resulting from the HHNS/ dehydration should be addressed and corrected.