Christina Pascual & Hoang-Kim (Kimmy) Nguyen

November 2, 2016
DFM 484
Julie Matel
Case Study 17:
Adult Type 2 Diabetes Mellitus: Transition to Insulin
1. What are the standard diagnostic criteria for T2D<? Which are found in Mitchs medical
record?
The standard diagnostic criteria are a HbA1C over 6.5% (3.9-5.2) using standardized
laboratory, a fasting plasma glucose of over 126 mg/dL (7.0 mmol/L), diabetic symptoms
including a random plasma glucose concentration of over 200 mg/dL (11.1 mmol/L), or a
2-hour post-prandial glucose of over 200 mg/dL (11.1 mmol/L) during an oral glucose
tolerance test.
According to his medical record, Mitch has a fasting plasma glucose of 1524 mg/dL and
a HbA1C of 15.2.
2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his
medications. What types of medications are metformin and glyburide? Describe their
mechanisms as well as their potential side effects/drug-nutrient interactions.
Metformin is classified as a biguanide medication. The medication decreases hepatic
glucose production and increases uptake in muscles. The advantages to taking this
medication is weight control, no risk of hypoglycemia, and could contribute
cardiovascular assistance. There are, however, disadvantages such as diarrhea, nausea,
bloating, anorexia, flatulence, and lactic acidosis in rare cases. This drug should not be
used in patients with renal inefficiency or liver or heart failure.
Glyburide is a sulfonylurea agent. This increases insulin secretin, but there is an increased
risk of the individual experiencing hypoglycemia, especially with this drug. The
advantages of using this drug is that it is cheap, has a long record of effectiveness, and is
only need one daily for most patients. A side effect of this medication is weight gain. This
drug should not be taken by patients with renal inefficiency.
5. HHS and DKA are the common metabolic complications associated with diabetes.
Discuss each of these clinical emergencies. Describe the information in Mitchs chart that
supports the diagnosis of HHS.
HHS is hyperglycemic hyperosmolar syndrome which occurs in a combination of
prolonged hyperglycemia, inadequate intake of fluid, and excessive loss of fluid.
Symptoms include polyuria, polydipsia, decreased consciousness, fever, and volume

depletion. The prolonged hyperglycemia is due to increased blood glucose and lack of
daily adherence to diabetes medication. Persistent low intake of fluid and excess loss of
fluid can be seen in low intake of water and nutrients and occurrence of vomiting
respectively. Patient is also experiencing lack of consciousness. Lab values indicating
HHS increased osmolality and an increased urine specific gravity. Increased WBC count
may indicate a fever or infection.
DKA is diabetic ketoacidosis, which only occurs under severe stress such as in HHS and
is a life-threatening condition. Symptoms of DKA are nausea and/or vomiting, stomach
pain, acetone breath, heavy breathing, and mental disorientation. Causes are lack of
glucose monitoring, severe illness or infection, insulin omission, and increased insulin
requirements. Lab values indicating DKA include increased serum glucose, increased
serum osmolality, lowered urine pH, and presence of glucose and ketones in the urine.

9. Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine?
How likely is it that Mitch will need to continue insulin therapy?
Mitch will be put on an insulin therapy plan that requires him to take Lispro 0.5 u every 2
hours until glucose levels are 150-200 mg/dL and glargine 19 u daily starting at 9:00 pm.
Lispro is a rapid acting insulin that is activated within 5-15 minutes and can last for 3-5
hours. This can be administered via pump therapy. Glargine is an extended long acting
drug that is taken once daily. This drug works within 2-4 and has no peak of action as it
works for 20-24 hours.
It is likely that Mitch will need to continue insulin therapy post discharge as he is not
educated in diabetes management and is not aware of carbohydrate counting tools. A
diabetes class in combination with a carbohydrate monitored diet and exercise would
lessen insulin therapy requirements.
11. Outline the basic principles for Mitchs nutrition therapy to assist in control of his DM.
a. Restrict and maintain calorie amounts
b. Distribute carbohydrates evenly throughout the day
c. Adjust amount of carbohydrate intake to individuals glucose tolerance and
monitor glucose levels
d. Modify fat intake by decreasing saturated and trans fats
e. Incorporate simple carbohydrates into meal plans
f. Provide nutrition counseling based on patients age and literacy levels to promote
nutrition knowledge and skill, increasing self-efficacy
g. Encourage physical activity to increase insulin sensitivity
12. Assess Mitchs weight and BMI. What would be a healthy weight range for Mitch?
Mitchs height and weight is 59 and 214 lbs respectively. His BMI is 31.6, classifying
Mitch as mildly obese. A healthy weight (IBW) for Mitch would be 160 lbs.

13. Identify and discuss any abnormal laboratory values measured upon his admission. How
did they change after hydration and initial treatment of his HHS?
Upon admission Mitchs sodiums lab value is low at 132. His BUN was high at
21. His creatinine serum is high at 1.9. Glucose levels were high at 1524. Phosphate
levels were low at 1.8. Osmolality levels were high at 360. Mitchs low sodium lab values
may be due to his vomiting and losing of electrolytes, along with not eating much in the
last 24 hours. His high BUN lab values and creatinine phosphate may be due to kidney
failure. The kidneys are responsible for filtering the blood, including urea and creatinine.
BUN levels also increase with dehydration, which may be caused by the vomiting.
Diabetic ketoacidosis is a reason the phosphate levels are low. The last lab result that was
abnormal was osmolality levels, leaning towards the hyperosmolality. Hyperosmolality
may be caused of increased blood glucose. An increased blood glucose would send
signals to the kidney to release ADH, therefor increasing the blood osmolality.
After hydration and initial treatment of HHS, all levels returned closer to a normal
range besides sodium and phosphate. The biggest difference was in blood glucose which
dramatically decreased to 475 mg/dL. Because of a better maintenance of blood glucose,
it had a positive effect on other lab values as well as rehydration
14. Determine Mitchs energy and protein requirements for weight maintenance. What energy
and protein intakes would you recommend to assist in weight loss?
66.5 + 13.8(72.48 kg) +5(165.6 cm) - 6.8(53) = 1,534.32 x (1.3) = 1,994.62 Kcal
0.8g * 72.48 kg= 58.0 g
15. Prioritize two nutrition problems and complete the PES statement for each.
Two nutrition problems: hyperglycemia because of altered nutrition related lab values,
blood glucose and high blood ketones
High blood glucose levels due to inadequate knowledge of how to maintain a healthy
blood glucose outside of PCP and not taking diabetic medications regularly as shown by
the high glucose lab value of 1524.
High blood ketones due to poor management of diabetes as shown by a lab value of 15.2
micrograms/dL.
16. Determine Mitchs initial CHO prescription using his diet history as well as your
assessment of his energy requirements.
-NPO them progress to clear liquids and then consistent carbohydrates-controlled diet
with a fluid requirement of 2000-2500 mL after rehydration
-1,994.62 Kcal *.45= 897.58 kCal from CHO
17. Identify two initial nutrition goals to assist with weight loss.
Lose 10.7 lbs (5%) within 6 months by decreasing overall calorie intake and increasing
physical activity.

Increase fiber intake by 2 servings of fruits or vegetables to increase satiety, lower

cholesterol, and slower absorption of nutrients.