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Case Study 18

By
Jessika Berryessa
Cansu Colbay
Michael Hoyt
Madeline McAndrew
DFM 484 MNT I
November 2, 2016

1) The standard diagnostic criteria for T2DM are: Hgb A1C greater than 6.5%, fasting blood
glucose greater 126, casual plasma glucose greater than 200gm/dL, or 2 hour postprandial
greater than 200 OGTT. Mitchell Fagan laboratory results come back as having a Hgb A1C of
11.5% and blood glucose concentration of 855 mg/dL on 4/12 and 475 mg/dL on 4/13 after
medication treatment.
2) Metformin and glyburide are antihyperglycemic agents taken orally. Metformin, which is
from the biguanide family, decreases hepatic glucose production. Decreasing hepatic glucose
production leads to a decrease in hepatic energy triggering the AMP which phosphorylates and
activates protein kinase. This leads to a decrease amount of hepatic glucose that is generated in
the liver. Metformin side effects are stomach pain, nausea, vomiting, dizziness, diarrhea, chest
pain, rash, yellowing of skin or eyes, light-colored stools, dark urine. Although Metformin has
many negative side effects, it may also improve ovarian function in polycystic ovary syndrome,
reduce fatty liver, may treat cancer and gestational diabetes. Metformin has shown to deplete
vitamin B12 and folate. This happens because of an interference with a dependent-calcium
mechanism. It is recommended to take a vitamin B12 and folate supplement.
4) Mitch was admitted to the emergency room due to his acute hyperglycemia. He was found
drowsy and confused by a coworker and was taken to the emergency room where his serum
glucose was 1524 mg/dL (highly uncontrolled- HHS). The metabolic events which led to Mitchs
state of health was his inability to uptake glucose with insulin and an extreme lack of water
(dehydration). When the blood glucose level is too high it is because the body is not properly
using or does not make the hormone insulin. In order to use the glucose, the body needs insulin
which helps transport glucose into the cells, in particular the muscle cells. High blood sugar can
happen if one misses taking their diabetes medicine, eats too much, or does not get enough
exercise. People with diabetes may become hyperglycemic if they do not keep their blood
glucose level under control by using insulin, medications, and appropriate meal planning. Mitch
was not monitoring or controlling his blood sugar through diet, exercise, or medication. He was
also severely dehydrated (from HHS) which led to him feeling confused and drowsy and
needing to be taken to the emergency room.
8) The insulin therapy that was started for Mr. Fagan is to take 0.5 u Lispro every 2 hours until
glucose is 150-200 mg/dL and then begin Glargine 19 u at 9 pm. It was recommended to
progress Lispro using ICR 1:15. His bedside glucose also needs to be checked hourly. His MD
needs to be notified if blood glucose is less than 80 or higher than 200.
Lispro is a rapid-acting insulin that begins to work 15 minutes after injection, it peaks in an
hour and works for 2 to 4 hours. Lispro is used to control blood sugar level in adults and children
with diabetes. It is used to treat type 2 diabetes in adults and type 1 diabetes in adults and
children who are three years old and up.
Glargine is a long-acting insulin, which starts working after several hours of injection. It
works evenly throughout 24 hours. Unlike lispro, glargine is used to treat type 1 diabetes in adult
and children who are six years or older. It is also used for type 2 diabetes treatment.
According to Mitchs health history, he was diagnosed with type 2 diabetes a year ago,
however he has not taken his medications, metformin and glyburide regularly. Therefore he was
diagnosed with hyperglycemia at the ER. This shows that Mitch will most likely continue the
insulin therapy to control his blood glucose within the range. It is also necessary for Mitch to

take his medications regularly and have a balanced diet and even carbohydrate distribution
throughout the day.
10) The basic principles to help manage Mitchs DM are: avoid sugar sweetened beverages,
spread CHO intake throughout the day, promote weight loss, modify fat intake(decrease
saturated and trans fat), provide nutrition counseling (Mitchell stated he has never seen anyone
for diabetes teaching other than a physician), physical activity, and emphasis on complex
carbohydrates and low fat dairy. Other principles to follow include: a diet of 45% of kCal from
carbohydrates, less than 30% of kCal from fat (fat quality may be more important that fat
quantity), and adjustment of CHO amount according to glucose tolerance.
11) Weight: 214 lbs (97 kg) (214/2.2)
Height: 59 (5x12+9=69 in x 2.54=175 cm = 1.75 m)
BMI: (97/1.75^2)= 31.7 (Obese= BMI is equal to or over 30)
Healthy weight: Ideal Body Weight= 100 + 5(9)= 145 lbs.
Healthy weight range: 193-203 lbs or 88-92 kg based on the information below
A healthy weight loss would be 5-10% of his body weight: 10.7 lbs- 21.4 lbs of
weight loss. You want to prevent yoyo dieting, which is when an individual
begins a cycle of first losing a lot of weight and then gaining a lot of weight after.
This is not healthy because it interferes with homeostasis in the metabolism. If a
person loses too much weight in a small period of time, this can lead to nutrient
deficiency and they may become dehydrated (rocks in the river). Michael has
hyperglycemia and HHS. HHS causes severe dehydration because kidneys try to
excrete the extra glucose in the urine and uses water to drive out the glucose.
Also when an individual is at a state of dehydration, electrolytes and glucose
levels are elevated in the blood and draws out water. Mitchell would be at a high
risk to lose even more weight than he should because of the water and electrolytes
being exerted out of his body. These are a few reason why a healthy weight loss is
very important and necessary for Mitchell who has HHS.
12) The abnormal laboratory values measured upon his admission were: serum glucose of 855
mg/dL on 4/12, serum osmolality of 322.6 mmol/kg/H_2O, and a BUN of 31 mg/dL. Reference
range for serum glucose is 70-99 mg/dL, serum osmolality of 275-295 mmol/kg/H_2O, and a
BUN of 6-20 mg/dL. All of these laboratory results show elevated levels above normal and are
of high concern toward the patients health. After hydration
13) The abnormal laboratory values measured upon Mitchs admission are listed in the table. The
changes after hydration and treatment of his HHS are observed and recorded.
Reference
Range

4/12
1780

4/13
1522

After Hydration and Treatment of


HHS

BUN (mg/dL)

8-18

31

20

Decreased and is now close to the


normal range

Glucose (mg/dL)

70-110

1524

475

Decreased by 1049, but is still too


high and is not close to the normal
range.

Osmolality
(mmol/kg/H2O)

285-295

360

HbA1C

3.9-5.2

15.2

Returned to normal

Ketones (urine)

Negative

Returned to normal

Glucose (mg/dL)
(urine)

Negative

Returned to normal

Color (urine)

____

Yellow

Returned to normal

14)

304

Decrease by 56, but is still too high.


It is close to the normal range.

a) Obesity related to lack of nutritional education as evidenced by high BMI of 32.


b) Elevated glucose levels of 855 mg/dL related to type 2 diabetes mellitus as evidence
by lack of nutritional knowledge pertaining to managing patients condition.

15) Mitchells initial CHO prescription based on his diet history and diabetes mellitus would be
to distribute his carbohydrate intake evenly in each meal. He currently was not eating any
carbohydrates in the AM when he enjoys his first cup of coffee. 50-60% of his caloric intake
would be CHOs out of 2000 kCal, therefore 1000-1200 kCal should be his goal throughout the
day. Instead of three meals Mitchell should eat smaller but more frequent meals to prevent a
sudden glucose spike in his blood concentration. If he were to enjoy 5 meals in one day, at each
of those meals he should focus on eating about 200-200 kCal per meal. 250-300 grams of
carbohydrates is his daily goal of CHOs, thus his target at each meal should be 50-60 grams per
meal. Since he dines out frequently he can use either calculation to aide him to reach his
recommendation of carbohydrates.
16) Identify two nutritional goals to assist in weight loss:
Goal 1 A diet of 45% kCal of CHO and substitute low fat dairy. Mitchell can reduce the
amount of his dietary carbohydrates by replacing his morning bagel with eggs with vegetables
(cooked to his liking). Mitchell currently uses half & half in his morning coffee and cream
cheese on a bagel. He can switch to 2% milk and work toward non-fat milk eventually while also
using a reduced fat cream cheese for his bagel.
Goal 2 A balanced diet is recommended for Mitchell to lose weight. He does not consume any
fruits or vegetables that are mentioned, besides what could be present in his dinner salad and
food selections when at restaurants. Eating 2.5 cups of variety vegetables and 2 cups of fruits a
day is ideal to lose weight. It is also necessary to reduce the consumption of processed and fast
foods. Mitchell should start incorporating fruits and vegetables into his homemade meals and
dining options more often rather than chips with his fast-food sandwich.