Nutr 245: Medical Nutrition Therapy: A Case Study Approach 3rd ed.

Case 23 Type 2 Diabetes Mellitus Name: Kerianne Hofsiss

Instructions: This is not a group case study; it is an individual assignment Complete the !ollo"ing #uestions using the bac$ground in!ormation o! Case 23 %pages &'()*+. ,emember ,D-s are e.perts in researching evidence(based practice !or their patients so you can use other credible sources. ///0e sure to re!erence your ans"ers and provide a 1or$ Cited page at the end.///
I. 2nderstanding the Disease and 3athophysiology
1. What are the ris !actors !or de"elopment o! type 2 diabetes mellitus# What ris !actors does Mrs. $ou%las present &ith# Overweight, Fat distribution, Family History, Race, Age, Gestational Diabetes, HT ! "rs! Douglas #resents with the following ris$ factors% &"' ()!( *overweight+, she is over ,- *age+, African American *race+ and HT ! 2. What are the common acute complications associated &ith type 2 diabetes mellitus# What are the chronic complications# $escribe the pathophysiolo%y associated &ith the chronic complications' speci!ically addressin% the role o! chronic hyper%lycemia. The acute com#lications associated with ty#e . diabetes include% Hy#erglycemia hy#erosmolar state, Hy#oglycemia and diabetic coma! /hronic com#lications caused by chronic hy#erglycemia include ne#hro#athy, which is caused by blood vessels located in the glomerulus changing! This increases the #ermeability and decreases0 the filtering ability of the $idney! Another com#lication is retino#athy which often causes blindness due to hy#erglycemic damage to the blood vessels! Also the accumulation of sorbitol causes the blindness! Glaucoma and cataracts also result from chronic hy#erglycemia! Another chronic com#lication is neuro#athy which most often results in im#aired sensations in hands and feet, slowed digestion *gastro#aresis+, and car#el tunnel syndrome! Hy#erglycemia causes substances such as sorbitol and glycated #roteins to accumulate which cause cell damage! Other nervous system damage can result in consti#ation, diarrhea, bladder dysfunction, se1ual dysfunction, incontinence, #yelone#hritis and /A *cardiovascular autonomic neuro#athy+ /2D is also another chronic com#lication of D&"'', chronically elevated glucose levels in the blood causes damage to the vessel walls causing atherosclerosis! (. )ere are !our !eatures o! the physician*s physical e+amination as &ell as her presentin% si%ns and symptoms that are consistent &ith her admittin% dia%nosis. $escribe the pathophysiolo%y that mi%ht be responsible !or each physical !indin%. ,hysical -indin% 3nhealed ulcer on foot Fre4uent bladder infections Tingling 5 numbness in feet &lood glucose (.mg7d8 HT ,hysiolo%ical Chan%e./tiolo%y result of altered #rotein and li#id metabolism as a result of chronic hy#erglycemia Autonomic neuro#athy caused by chronic hy#erglycemia due #resence of sorbitol and glycated #roteins *resulting in cellular damage+ 6eri#heral neuro#athy caused by cellular damage as a result of chronic hy#erglycemia! 'nsulin deficiency as a result of diabetes mellitus '' resulting in hy#erglycemia 'ncreased blood #ressure due high inta$e of saturated and tans fats * High /holesterol, High 8D8, 8ow HD8, High triglycerides+

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,hysical -indin% Retino#athy

,hysiolo%ical Chan%e./tiolo%y Hy#erglycemic damage to the blood vessels as a result of change in the blood vessels and #resence of sorbitol

4.

0rie!ly describe hyper%lycemic hyperosmolar non etotic syndrome 1))NS2. )o& is this syndrome di!!erent !rom etoacidosis# HH ; is more commonly found in ty#e '' while DKA is more commonly found in ty#e '! HH ; is when blood glucose levels <=)) mg7d8, serum osmolality <(.)mOsm7$g of water and there is no $etoacidosis! 't is often caused by infection or dehydration! The sym#toms are similar to D$a and include #olyuria, #olydi#sia, #oly#hagia and wight loss! "ost commonly elderly #eo#le with ty#e '' who do not rehydrate themselves fall victim to HH ; and will re4uire hos#itali>ation and further treatment if caused by an infection! 5. What !actors may lead to ))NS# 3s Mrs. $ou%las at ris #

Factors leading to HH ; are an infection or dehydration while being ty#e '' diabetic! "rs! Douglas is at ris$ because she is ty#e '' diabetic and is currently suffering from an infection! 4. What is the immediate aim o! treatment !or ))NS# 3! ))NS is not treated' ho& &ould you e+pect the condition o! ))NS to pro%ress# The immediate aim of treatment of HH ; is to rehydrate the #atient slowly and to cure any underlying medical conditions such as infection! 'nsulin may be administered in order to reduce glucose levels! 'f not treated HH ; will lead to death!

II. 4utrition 5ssessment 5. 6valuation o! 1eight70ody Composition

5. Calculate Mrs. $ou%las*s body mass inde+ 10M32. What are the health implications !or a 0M3 in this ran%e# ()!( this #uts her in the obese category '

0. Calculation o! 4utrient ,e#uirements

6. Calculate Mrs. $ou%las*s ener%y needs usin% the Mi!!lin7St. 8eor e9uation. 1)3NT: use actual &ei%ht and an A- and an 3-2

:)*?)!,-+ @ =!.-*=)+9-*?:+9 :=: @AF*:!(+ 'F*:!:+A:.== $cal :. Calculate Mrs. $ou%las*s protein needs. 1)3NT: remember she has an in!ection and needs to heal a &ound2 6rotein needs% :!)g7$g ?)!,-*:!)+A?)g #rotein 1;. 3s the hospital diet order o! 1'2;; cal appropriate# /+plain &hy or &hy not# For now since she needs to fight off her infection and heal her ulcer yes it is a##ro#riate! However this diet order is to maintain her weight at her height and since she is in the obese category she should try and lose weight after her infection and wound are healed!

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C. Inta$e Domain
11. <sin% a computer dietary analysis pro%ram or !ood composition table' calculate the calories' protein' !at' C)=' !iber' cholesterol' and Na content o! Mrs. $ou%las*s diet. -ill7in the blan s. $cal A BBB89'):C com#ared to $cal needs of BB82;;:: *BB829BBD of needs+ #rotein A BB9*Bg and BB82BD $calC com#ared to #rotein needs of BBB&;BBg *BBBB22BBD of needs+ fat A BB&8:::g and B92BD $calC com#ared to fat needs of BBBB3;BBBBBBBD $cal ;aturated fat A B2*.<::g and B8*BBD $calC com#ared to ;FA needs of BBBBBBE?BBBBBD $cal /HO A BB8&8Bg and B9*BBD $calC com#ared to /HO needs of BB9;(*;BBD $cal Fhat about consistency of /HO at mealtimesG fiber A BB8'BBBgC com#ared to fiber needs of BB2*BBBBg *BBB&<BBBD of needs+ chol A BBB3*8::mgC com#ared to cholesterol needs of BBB=2;;BBBmg *B8&*BBD of needs+ aA BBB923*BBmgC com#ared to a needs of BB=2*;;BBmg *B8<'BBD of needs+ 12. -rom the in!ormation %athered &ithin the inta e domain' list ey nutrition problems usin% the dia%nostic term. 'nconsistent carb inta$e, H1cessive fat inta$e, H1cessive energy inta$e, 'nade4uate #rotein inta$e

D. Clinical Domain
1(. Compare the patient*s laboratory "alues that &ere out o! ran%e on admission &ith normal "alues. )o& &ould you interpret this patient*s labs# Ma e sure e+planations are pertinent to this situation. ,arameter Glucose (mg/dL) Normal >alue ?)9::) ,atient*s >alue (.-H ?eason !or Abnormality 'nsulin deficiency due to diabetes mellitus '' Nutritional 3mplications 'm#ortant to balance carbs throughout the day and administer insulin 'm#ortant to balance carbs throughout the day Hat less saturated fats 8ess fat in the diet T8/ diet is best Follow T8/ diet, increase activity level, decrease sat fat inta$e Decrease amount of fat in the diet

HbA1c (%)

(!I9-!.

J!-

Cholesterol (mg/dL) LDL-cholesterol (mg/dL) HDL-cholesterol (mg/dL)

:.)9:II E:() <--

()) :,) (-

Due to chronic hy#erglycemia as a result of D"&'' hemoglobin has an elevated amount of glucose molecules attached to it High cholesterol correlates with HT a ris$ factor D"&'' High due to diet high in fat *saturated+ ;edentary lifestyle, high fat diet

Triglycerides (-9:(,)) (mg/dL) 14. Why &asn*t )bA1c measured at dischar%e#

High fat diet

This test shows how your blood sugar was elevated over a #eriod of time *.9(months+ chec$ing it at discharge would be #ointless because there would be no change! 't is something that ha##ens over time!

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15. Compare the pharmacolo%ic di!!erences amon% the oral hypo%lycemic a%ents. Class 0rand Names 1@ Aeneric Names2 6recise Glyset 2oli1 Acarbose "igilitol voglibose "etformin Gluco#hage Mechanism o! Action Delays intestinal absor#tion of glucose Side /!!ects @ Contraindications Flatulence, diarrhea, less efficacy fre4uent dosing /ontraindications% individuals with intestinal disease Transient diarrhea, nausea, bloating, anore1ia, flatulence, lactic acidosis /ontraindications% individuals with renal insufficiency, liver failure or treated /HF /an cause hy#oglycemia, fre4uent dosing, e1#ensive

Glucosidase i hibitors

!igua ides

"egliti ides

Re#aglinide ateglinide 6randin ;tarli1 Acetohe1amide /hlor#ro#amide Tola>amide Tolbutamide Dymelor Diabinese Tolinase Orinase Gli#i>ide Gli#i>ide9G'T; Glyburide 6ioglita>one Rosiglita>one Actos Avandia

#ul$o ylureas %irst ge eratio

Decreases he#atic glucose #roduction, increases insulin u#ta$e in muscle ;timulates insulin secretion in #resence of glucose, short acting ;timulates insulin secretion

Hy#oglycemia, /ontraindicated in individuals with renal insufficiency, weight gain

#eco d ge eratio

;timulates insulin secretion Decreases insulin resistance

Hy#oglycemia, contraindicated in individuals with renal insufficiency ,weight gain Feight gain, edema, worsened /HF, very e1#ensive, slow onset of action, contraindicated in individuals with /HF

Thiai edio es&oli d

14. -rom the in!ormation %athered &ithin the clinical domain' list possible nutrition problems usin% the dia%nostic term. 'm#aired nutrient utili>ation, Altered nutrition9related laboratory values

6. 0ehavioral6nvironmental Domain
15. 3denti!y at least three !actors that may inter!ere &ith Mrs. $ou%las*s compliance and success &ith her diabetes treatment. Within this domain' list possible nutrition problems. ( Factors% Her education level, her age, her diet history Food and nutrition9related $nowledge deficit, self9 monitoring deficit, not ready for diet7lifestyle change

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III. 4utrition Diagnosis

16. Select t&o hi%h7priority nutrition problems and complete the ,/S statement !or each. 6H; K:% Altered nutrition9related laboratory values as a result of endocrine dysfunction *diabetes mellitus ''+ as evidenced by increased #lasma glucose and increased Hg&A/: levels 6H; K.% 'nconsistent carbohydrate inta$e as a result of food and nutrition related $nowledge deficit concerning a##ro#riate timing of carbohydrate inta$e as evidenced by conditions associated with diabetes mellitus *foot ulcer, retino#athy+

I>. 4utrition Intervention

1:. Write Nutrition ,rescription !or patient. 3nclude $iet type' cal le"el' and ey components !rom the C)= consistent diet. /HO diet9 :.)) $cal! ( meals a day , carbohydrate e1change at every meal with an H; snac$ consisting of . carbohydrate e1changes and one #rotein! 2;. -or each o! the ,/S statements that you ha"e &ritten' establish an ideal %oal 1based on the si%ns and symptoms2 and an appropriate inter"ention 1based on the etiolo%y2. <se 3$NT manual to label 3nter"ention domains and subclassesB and %i"e details o! e+actly &hat you are %oin% to do. 6H; K: o Goal% To regulate insulin levels of #atient as to not #rolong chronic hy#erglycemia! o 'ntervention% utrition related medication managementC #atient is to administer insulin in the morning and have a #lanned /HO meal #lan for each day! utrition educationC #riority modifications! /hanges must be made in diet in order for insulin administration to wor$! 6atient is to $ee# a diet Lournal following a /HO meal #lan administered by myself! Glucose levels are to be tested before and . hours after every meal for the ne1t wee$! 6H; K. o Goal% To educate #atient on ways to ma$e managing insulin levels easier through nutrition o 'ntervention% utrition HducationC 6riority modifications, nutrition relationshi# to disease! 6atient is to be informed on how carbohydrates, not sugar, are what effect glucose levels! ;he will learn how diet changes in carbohydrates will ma$e a greater difference Food and7or nutrient deliveryC meals and snac$sC carbohydrate9modified diet! 6atient is to be educated on /HO e1changes and how to s#read them throughout the day evenly to hel# maintain glucose levels! 6atient is to also incor#orate and H; snac$ before bed every day that includes half the amount of starch e1changes found in her meals! Diet Lournal is to be $e#t until ne1t visit 21. Write a concise A$3M/ note by pullin% the ey components !rom you ans&ers. Consider the admission data only 1not the ( and 4 month data2. )and in typed "ersion only.

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AD'"H note 6atient% Hileen Douglas :.7)=7:. 5% ?: y!o female =)in! &"'%()!( 8ab values% High glucose (.-, high cholesterol ()), high 8D89/ :,), 8ow HD89 / (-, High Triglycerides ,))! 6atient com#lains about a cut that will not heal on her foot *<. months+ and having trouble seeing! 6atient also suffers from fre4uent bladder infections, along with tingling7numbness in feet! "eds% ace inhibitorC /a#oten -)mg! 6atient did not graduate high school and lives with her sister who Mhas sugarN! Refers starchy foods as ca$es, candies and desserts! ;he #re#ares and #urchases food herself D% 'nconsistent carbohydrate inta$e as a result of food and nutrition related $nowledge deficit concerning a##ro#riate timing of carbohydrate inta$e as evidenced by conditions associated with diabetes mellitus *foot ulcer, retino#athy+ I% Hnteral utrition% utrition #rescri#tion% /HO diet9 :.)) $cal! ( meals a day , carbohydrate e1change at every meal with an H; snac$ consisting of . carbohydrate e1changes and one #rotein! Goal One% To educate #atient on ways to ma$e managing insulin levels through nutrition Goal two% /ontrol glucose levels cure her chronic hy#erglycemia utrition HducationC 6riority modifications, nutrition relationshi# to disease! 6atient is to be informed on how carbohydrates, not sugar, are what effect glucose levels! ;he will learn how diet changes in carbohydrates will ma$e a greater difference Food and7or nutrient deliveryC meals and snac$sC carbohydrate9modified diet! 6atient is to be educated on /HO e1changes and how to s#read them throughout the day evenly to hel# maintain glucose levels! 6atient is to also incor#orate and H; snac$ before bed every day that includes half the amount of starch e1changes found in her meals! Diet Lournal is to be $e#t until ne1t visit /oordination of care% 6atient may be referred to doctor for #rescri#tion medications to lower her insulin until diet #attern is set in #lace and being followed

M76: :!+ 6atient is too ta$e glucose levels every morning and two hours after eating for the ne1t ( wee$s0

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a!

Outcome% glucose levels are stabili>ed and #atient is neither hy#o or hy#erglycemic

.!+ Knowledge of carbohydrate e1changes% 6atient is to $ee# a diet Lournal and record the amount of carbohydrate e1changes she consumed and at what time a! Outcome% #atient follows set /HO diet meal #lan and is able to more easily regulate her glucose levels!

Kerianne Hofsiss, Registered Dietitian

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