Case 23: Type 2 Diabetes Mellitus

Casey Flowers Vaishali Keshani Punam Patel Ruchi Patel

Introduction
Patient: Eileen Douglas is 71 years old African American female. Her chief complaint is a cut on her foot that happened over 2 months ago and has yet to heal. Sx: Unhealed wound, frequent bladder infections, slight tingling and numbness in her feet, retinopathy.

Nutrition Assessment

Domain 5: Client History

Age: 71 (DOB 7/27) Sex: Female Education: Less then high school (10th grade) Occupation: Homemaker Sister age 80 was Dx with T2DM 10 years ago. Non-smoker Frequent bladder infections and HTN (currently on medication).

Domain 1: Food and Nutrition Related History

Medications: Capoten (captopril), 50 mg PO bid
Tx of HTN Side effects: Dizziness, salty taste, cough, sore throat, fever, mouth sores, unusual bruising, fast heartbeat, excessive tiredness.

Analysis of Dietary Intake via Diet Recall

Kcalories 1274 kcal

Protein
Fat Carbohydrates Fiber Cholesterol Sodium

54.770 grams
48.191 grams 159.704 grams 24.893 grams 307 milligrams 3822 milligrams

Domain 1: Food and Nutrition Related History

Lifestyle
Knowledge/Beliefs/Attitudes
Believes her sister has sugar

Behaviors
Doesnt buy sweets Avoids all starchy foods

Factors Affecting Access

Low-income housing

Physical Activity
Not reported, likely to be sedentary

-No Nutrition-Related Patient/Client-Centered Measures************

Domain 1: Food and Nutrition Related History

Lifestyle cont..
-Nutrition-Related Patient/Client-Centered Measures
Acquainted with Diabetes from her sister. Believes she should avoid all starchy foods and sugars Has good intentions, but lacks knowledge to take appropriate measures.

Usual Dietary Intake

AM
1 egg, fried in bacon fat, two strips of bacon or sausage. 1 cup of coffee black, cup orange juice unsweetened.

Lunch
Lunch meat sandwich [2 slices of enriched white bread, 1 slice (1oz) bologna, 1 slice (1oz) American cheese, mustard], 1 glass (8oz) ice tea unsweetened.

PM
1 cup turnip greens, seasoned with 1oz fat back, salt and pepper; 2 small new potatoes, boiled, seasoned with salt and pepper; 2in square of cornbread w/teaspoon butter; 1 c beans and ham (~ c beans and c ham); 1 cup coffee black.

Snack
2 vanilla wafers.

Domain 2: Anthropometric Measurements

Ht 50 (152.4 cm) Wt 155lbs (70.5 kg) BMI 30.34 (Obese Class I) Weight Change N/A

Domain 3: Biochemical Data, Medical Tests, and Procedures***

Parameter Normal Value Patients Value

Glucose (mg/dL)

70-110

325

HbA1c(%)

3.9-5.2

8.5

Cholesterol (mg/dL)

120-199

300

Reason for Abnormality Hyperglycemia, having high blood glucose without sufficient insulin. High concentration of glucose in the blood, so more hemoglobin is glycated High intake of fatty foods, BMI 30.34, poorly controlled T2DM

Nutritional Implications 1. Monitor blood glucose 2. Insulin regiment 1. Long-term monitoring of blood glucose. 2. Monitor glycemic index 1. Control daily fat intake, specifically sat. fat and trans fat. 2. Increase physical activity.

Parameter

Normal Value

Patients Value

Reason for Abnormality High intake of saturated fats, cholesterol, and trans fats

Nutritional Implications Same as above

LDL-Cholesterol (mg/dL)

<130

140

HDL-Cholesterol

>55

35

Too much saturated fats and not sufficient amounts of polyunsaturated.

Same as above

Parameter

Normal Value

Patients Value

Reason for Abnormality

Nutritional Implications

Triglycerides

35-135

400

BUN (mg/dL)

8-18

26

HCT (%)

37-47

30.4

BMI of 30.34, plus Same as above poor control of T2DM. Poor kidney 1. Increase fluid function and intake. dehydration. 2. Control blood glucose levels. Anemia Bone marrow problems and kidney failure

Parameter

Normal Value

Patients Value

Reason for Abnormality

Nutritional Implications

Osmolality (mmols/kg/H2O)

285-295

315

HGB (g/dL)

12-15

9.9

Increase of solute to water molecules, i.e. Dehydration Poor kidney function, and possible vitamin deficiency anemia. Same as above

Increase fluid intake.

Iron supplementatio n. Same as above

HCT (%)

37-47

30.4

Domain 4: Nutrition-Focused Physical Findings

Physical Findings Overweight Mild Retinopathy Poor wound healing Diminished sensation in feet Physiological Change/Etiology High cholesterol, BMI Hyperglycemia, small vessel damage Hyperglycemia Hyperglycemia, nerve damage

Domain 6: Comparative Standards

According to the Mifflin-St. Jeor equation
Energy Needs: 1,367 calories/day for her sedentary lifestyle.

Protein Needs
56.36 grams/day.

Weight Recommendations
Decrease weight by 10lbs (4.5kgs) Optimal BMI 24.9 or 125lbs (56.8kgs)

Fluid Needs
2.5+L

Macronutrient Recommendations
Macronutrient Recommended Current diet Needs

Protein

10-35%

17%

Within recommended range

Fat
Carbohydrates

20-35%
45-65%

43%
45%

Decrease by 13% to 30%

Increase complex carbohydrates

Micronutrient Recommendations****
Micronutrient Recommended Why

Chromium

Vitamin B12

500mcg 3x daily

Correction of nerve function to help improve peripheral neuropathy.

Helps decrease sorbitol.

Vitamin C

1-3g daily.

Zinc

MyPlate

MyPlate

Recommendations

Current Diet

Fruits

1.5 cups

.5 cup of orange juice (Does not meet recommendations) 1 c turnip greens +2 new potatoes (Does meet recommendations) 2oz of enriched white bread + 2in sq. cornbread +2vanilla wafers (Does not meet recommendations) 1oz American cheese (Does not meet recommendations) 1 egg+2 strips bacon/sausage+1oz bologna+1oz ham+ 3/4c beans

Vegetables

1.5 cups

Grains

5 ounces

Dairy

2.5 cups

Protein

4 ounces

Nutrition Diagnosis

 PES 1
Excessive fat intake related to frequent consumption of high fat meals as evidenced by average daily intake of 48.2 grams of fat, HDL of 35 mg/dL, and LDL of 140 mg/dL.

PES 2
Food and nutrition related knowledge deficit related to excessive carbohydrate intake as evidenced by average daily intake of 159.7 grams of carbohydrate and blood glucose of 325 mg/dL.

PES 3

Nutrition Intervention

 PES 1
Goal is to get within recommended ranges of fat
HDL > 55 mg/dL LDL <130 mg/dL.

To do this, she must eat less high fat foods and eat more nutrient dense foods.

PES 2
Educate specifically about carbohydrate exchange, portion control, blood glucose testing, types of carbohydrates. Goal is to maintain her blood glucose to the normal range of 70-110 mg/dL by checking glucose frequently and decreasing carbohydrate intake. This can be done by eating less simple carbohydrates and more complex carbohydrates and nutrient dense foods.

Overall, bringing her BMI into normal range between 18.5-24.9 will help nutritional problems as well.

Monitoring and Evaluation

Doctors Recommendation
Tx plan
Debride wound Normalize blood glucose levels Begin self-management training on nutrition prescription, meal planning, signs/symptoms, and Tx of hypo-/hyperglycemia, SMBG, appropriate exercise, potential food-drug interaction. Initiate Lipitor 10 mg gd, continue 50 mg bid

Nutrition Recommendations
Mrs. Douglas was d/c with the following instructions:
Non-kilocaloric-restricted Low-fat (less than or equal to 30% total kcal) High-CHO (greater than or equal to 50% total kcal) diet Walking program Continue prescription for captopril to control her HTN.

Evaluation
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, tachypneic breathing (Kussmal respirations). She was Dx with pneumonia, dehydration, and hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The medical nutrition therapy for patients with HHNS is correcting high glucose levels via insulin therapy, replacing electrolytes through fluid therapy, and monitoring lab results frequently.

Evaluation continued
She was Dx with pneumonia, dehydration, and hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
The medical nutrition therapy for patients with HHNS
Correcting high glucose levels via insulin therapy Replacing electrolytes through fluid therapy Monitoring lab results frequently

ADIME
Assessment
BMI 30.34 Blood Glucose 325mg/dL, suggests T2DM Physical Findings
Unhealed wound Blurry vision Frequent bladder infections Slight tingling and numbness in feet High
Cholesterol HbA1C Osmolality BUN LDL HGB HCT HDL

Significant lab values

Low

Sedentary lifestyle Dietary Intake: Kcalories 1274

ADIME cont..
Diagnosis
T2DM HTN Excessive fat and carbohydrate intake

Intervention
Get fat intake and BMI within recommended range. Lower glucose levels

ADIME cont
Monitor
Normalize blood glucose levels Fat, CHO, and kcal intake Physical activity

Evaluation
Follow up with pt regarding previous recommendations Discuss better strategies to control blood glucose levels and prevent HHNS

Questions?