Running head: RA TYPE 2 DIABETES MELLITUS 1

Type 2 Diabetes Mellitus: A Case Study for Patient RA

Ericha M. Grace and Amanda J. Tome

NTD 414-02 Medical Nutrition Therapy II

April 27, 2016

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Disease Information

Type 2 diabetes mellitus (T2DM) is a disease of the endocrine system characterized by

the body’s inability to properly utilize insulin. This type of diabetes was once called “adult on-

set” diabetes because of its common diagnosis in later stages of life, but the prevalence among

younger populations and children has grown over the years with increased rates of childhood

obesity. In a normal, healthy body, insulin is released by the beta cells of the pancreas in

response to raised blood glucose levels, and the insulin helps to shuttle glucose into the cells for

energy metabolism. In T2DM, the beta cells are initially producing sufficient insulin, but the

tissues have become insulin resistant and the body cannot properly utilize this hormone. As a

result of insulin resistance, blood glucose levels continue to rise, leading to hyperglycemia. In

response to the high blood glucose levels, the beta cells continue to secrete insulin, although it is

not able to effectively lower these levels. This may lead to hyperinsulinemia, which is high

levels of insulin in the blood. After the beta cells have excessively secreted insulin for a

prolonged period of time, they eventually become damaged, fail, and can no longer produce

insulin (Roth, 2011). Normally, the secretion of insulin would inhibit gluconeogenesis and

glycogenolysis, since the body would be adequately using glucose for energy. However, because

glucose is not entering the tissues, the liver responds with gluconeogenesis, the formation of

glucose from non-carbohydrate sources, resulting in hyperglycemia even in a fasting state

(Inzaucchi et al., 2012). Consistent hyperglycemia may lead to several complications, such as

nephropathy, retinopathy, gastroparesis, cardiovascular disease, hyperglycemic hyperosmolar

syndrome, and ultimately death.

There are numerous factors that lead to the development of T2DM. T2DM has an

autosomal dominant heredity, which means if one parent possesses the gene, the child will have
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the gene as well, but it may not be expressed. Obesity and physical inactivity are also two

primary causes for T2DM, due to increased central body fat. Increased central body adiposity

increases the degree of insulin resistance, resulting in the body’s inability to properly utilize

glucose carried by insulin (Roth, 2011). Physical activity increases insulin sensitivity in the body

and increases the uptake of glucose into tissues. Those who are physically inactive, therefore, are

more likely to develop T2DM (Francesconi, Lackinger, Weitgasser, Haber, & Neibauer, 2016).

Contrary to popular belief, diabetes is not caused solely by overconsumption of sugar. Other

causes include low birth weight, poor development of the pancreas in utero, and other stress on

the pancreas that may cause dysfunction of the Islet cells. Older age, body mass index, certain

ethnicity (African American, Latino, Native American, Asian American, and Pacific Islander),

previous gestational diabetes, polycystic ovarian syndrome, and impaired glucose tolerance also

increase the risk for developing T2DM (Roth, 2011).

There are no direct signs and symptoms related to T2DM. However, those who have this

condition may experience symptoms associated with hyperglycemia, such as increased thirst,

hunger, and urination, blurred vision, weight loss, fatigue, irritability, and slow wound-healing.

Such symptoms and factors such as physical inactivity, having a first-degree relative with

diabetes, elevated blood pressure, impaired glucose tolerance or impaired fasting glucose, and/or

elevated triglycerides may warrant testing for T2DM (Roth, 2011). There are several tests to

evaluate blood glucose levels, such as fasting plasma glucose, casual plasma glucose, and two-

hour plasma glucose. Fasting plasma glucose is measured by taking a sample of the patient’s

blood after they have fasted for at least 8-10 hours. If this measurement is 126 mg/dL or greater,

the patient is considered diabetic. Casual plasma glucose is taken during any time of the day,

whether the patient has been fasting or not; the patient is considered diabetic if this number is
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200 mg/dL or greater, combined with symptoms. A two-hour plasma glucose test is conducted

by administering an oral solution containing 75 grams of glucose to the patient and testing the

patient’s plasma glucose level after two hours. If it is greater than or equal to 200 mg/dL, the

patient is considered diabetic. Hemoglobin A1c over 6% is also considered a diagnostic criterion

for diabetes. These numbers in conjunction with the aforementioned factors lead to a diagnosis

of T2DM (Roden, 2016).

T2DM is a chronic disease with many nutritional implications. As previously discussed,

overweight and obesity, especially central obesity, are strong nutritional risk factors for T2DM

because obesity increases insulin resistance; however, weight loss is common in cases of

undiagnosed or poorly managed diabetes because of the body’s reliance on lipolysis for energy

(Roth, 2011). Carbohydrates have the largest impact on blood glucose levels; therefore,

adherence to a carbohydrate consistent diet is recommended to avoid fluctuating blood glucose

levels and maintain glycemic control. The body metabolizes macronutrients differently, so it is

beneficial for individuals with diabetes to consume all three macronutrients (protein, fat, and

carbohydrate) at each snack or meal for optimal glycemic control (Evert et al., 2013). Overeating

or consuming a large meal can also cause a spike in blood glucose levels, so eating four to six

small meals per day rather than three large meals is often recommended (Cleveland Clinic, n.d.).

Nutrition therapy also focuses on weight management and controlling blood pressure and lipid

levels by emphasizing portion control, nutrient-dense foods, high fiber foods, and essential fatty

acids and limiting processed food, sodium, sugar-sweetened beverages, alcohol, saturated fat,

and trans fats (Evert et al., 2013; Franz, Boucher & Evert, 2014).

Poorly managed T2DM is associated with complications such as hypoglycemia,

hyperglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar syndrome

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(HHS). Hypoglycemia, low blood glucose levels, is often caused by skipping meals, fasting,

prolonged or intense exercise, or administration of excessive insulin or oral glucose lowering

medications. Hypoglycemia requires the immediate intake of simple sugars to raise the blood

glucose back to a normal range. DKA and HHS are both severe forms of hyperglycemia which

cause fluid and electrolyte imbalances, and possibly acidosis that must be treated with insulin,

fluids, and electrolytes. Chronic hyperglycemia damages blood vessels, which contributes to

developing atherosclerosis, gastroparesis, nephropathy, and retinopathy. Development of one or

more of these complications will affect and be affected by nutrition. Cardiovascular disease

requires following a heart-healthy diet, free of trans fats, low in saturated fat, fat and sodium, and

high in fiber. Small, frequent meals low in fat and fiber are often recommended for patients with

gastroparesis and patients with pre-dialysis kidney disease must follow a low-protein diet (Roth,

2011). Diabetes is also associated with dyslipidemia because the increased lipolysis increases

circulating triglycerides and LDL cholesterol and decreases HDL cholesterol (Muačević-Katanec

& Reiner, 2011).

Patient Description

RA is a 55-year-old, college-educated, African American female diagnosed with T2DM

five years ago. She is married with two children and works in business, usually from 9 am until 6

pm. RA’s past medical history only includes the T2DM diagnosis, and a family medical history

is not provided. She is 5 feet 7 inches tall and currently weighs 205 pounds. Her usual body

weight is 195 pounds, which she weighed one year ago. Her ideal body weight is 135 pounds and

she is 151.9% of her ideal body weight. Her current body mass index (BMI) is 32.1 kg/m2, and

she has experienced a 5.1% weight gain in the past year.

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RA was prescribed 2.5 mg. glyburide to be taken once per day in the morning, but RA

admitted that she discontinued the medication because she experienced side effects such as

dizziness, sweating, and mild agitation in the late afternoon. Glyburide is a second generation

sulfonylurea, an oral hypoglycemic agent,that reduces blood glucose levels by stimulating

pancreatic beta cells to produce more insulin (NLM, n.d.; Pronsky, Elbe, & Ayoob, 2015). RA

also reported erratic shifts in blood glucose levels, foot pain and recent weight gain, and inability

to lose weight despite an increase in physical activity during the past six months. RA’s physical

examination was unremarkable except for abnormal blood pressure, 135/90 mmHg, which could

indicate stage 1 hypertension (NHLBI, n.d.). RA’s foot pain may indicate neuropathy caused by

chronic hyperglycemia from uncontrolled diabetes. Diabetic neuropathy often presents as

tingling, burning or stinging pain and/or weakness and results from chronic hyperglycemia

damaging nerve fibers and capillaries that normally supply nutrients and oxygen to nerves,

thereby diminishing nerve function (ADA, n.d.; Mayo Clinic, 2015). Diabetes is a risk factor for

hypertension because hyperglycemia damages small blood vessels, which can lead to kidney

dysfunction and therefore disrupt blood pressure regulation (Sowers & Epstein, 1995).

RA and her husband share responsibility for purchasing and preparing meals, and they

typically dine out at a local diner or chain restaurant once or twice per week. RA denies any

known food allergies, and she received nutrition education on a “diabetic diet” five years ago but

does not currently follow any prescribed nutrition recommendations other than avoiding high

sugar foods, which she has replaced with sugar-free snack foods like pudding and cookies. The

prescribed diet order is an 1,800-calorie, carbohydrate-consistent diet.

Laboratory Findings
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Laboratory Normal Patient’s Reason for Nutritional Implications

Test Value Value Abnormality
Glucose 70-110 196 mg/dL Hyperglycemia A balanced, healthy CHO
mg/dL (elevated) from uncontrolled consistent diet with 50% of
T2DM total calories from CHO
HbA1c 4.6-5.8% 8.8% Hyperglycemia A balanced, healthy CHO
(elevated) from uncontrolled consistent diet with 50% of
T2DM total calories from CHO
HDL-C >55 46 mg/dL Diabetic A balanced, heart healthy
mg/dL (low) dyslipidemia from diet with 50% of total
uncontrolled T2DM calories from CHO, 25-35%
of total calories from fat,
less than 7% saturated fat,
and minimal trans fat
Triglycerides < 150 158 mg/dL Diabetic A balanced, heart healthy
mg/dL (elevated) dyslipidemia from diet with 50% of total
uncontrolled T2DM calories from CHO, 25-35%
of total calories from fat,
less than 7% saturated fat,
and minimal trans fat
Osmolality 285-295 298 Hyperglycemia A balanced, healthy CHO
mmol/kg/ mmol/kg/H2O from uncontrolled consistent diet with 50% of
H2O (elevated) T2DM total calories from CHO

Elevated blood glucose and HbA1c levels are indicative of hyperglycemia and confirm the

diagnosis of uncontrolled T2DM and RA’s self-report of poor glycemic control marked by

erratic blood sugar levels. Normal fasting blood glucose levels are between 70 and 100 mg/dL;

however, fasting blood glucose levels between 70 – 130 mg/dL and non-fasting blood glucose

levels under 180 mg/dL indicate tight glycemic control and are recommended for individuals

with diabetes. HbA1c measures the average blood glucose level for the preceding three months

with a normal level below 5.5%, although a level below 7% is recommended for tight glycemic

control in individuals with diabetes (ADA, 2013; Roth, 2011). Hyperglycemia can elevate

osmolality because the excess glucose creates a higher solute concentration (Roth, 2011).

Insulin resistance deprives cells of energy, thus triggering increased lipolysis for energy, which
RA TYPE 2 DIABETES MELLITUS 8

results in increased triglycerides and decreased HDL cholesterol circulating in the blood

(Muačević-Katanec & Reiner, 2011).

Analysis of Diet

After entering RA’s 24-hour recall into ESHA, it is clear that she is over-consuming

calories and protein. As estimated by her 24-hour recall, RA is consuming approximately 2,940

calories and 112 grams of protein per day. She is also consuming about 362 grams of

carbohydrates per day (see Appendix A). All of these factors could be contributing to her recent

weight gain within the past year as well as her increased blood glucose levels. She has tried to

increase her physical activity but did not have success in losing weight. Her level of physical

activity apparently was not enough to balance her intake of nearly 3,000 calories per day. Based

on RA’s given anthropometrics, her recommended energy, protein, and fluid are calculated

below.

 BMI: (205/672) x 703 = 32  Obese  %IBW: 205/135 = 151.9%

 IBW:100 + 5(7) = 135#/2.2 = 61.4kg

 EER = (9.99 x 93.2 kg) + (6.25 x 170.2 cm) – (4.92 x 55 years) – 161 = 1563.2 x 1.2

(activity level) = 1875.8 – 500 (for weight loss) = 1375.8. This would be too restrictive,

so only 250 was subtracted for weight loss: 1875.8 – 250 = 1625.8

 Shortcut: 16-20 kcal/kg = 16x93.2 = 1491.2 | 20 x 93.2 = 1864. Range: 1491–1864kcal

The amount of recommended energy calculated by the Mifflin-St. Jeor equation falls into

the range calculated by the shortcut method. This confirms that the amount of calories RA should

be consuming would fall within this range, and a daily recommendation of 1625.8 calories is

appropriate to promote weight loss while not being too restrictive for someone of RA’s age,

weight, height, and activity level.

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 Protein: For BMI > 27, 1.5-2 g/kg IBW = 1.5 x 61.4 = 92.1 g protein | 2 x 61.4 = 122.8 g

protein. Range: 92.1 – 122.8 g protein.

The higher end of this range would provide entirely too much protein for RA, especially

since she is not physically active and does not have any sort of current metabolic stress. Using

our clinical judgment, the lower end of this range still seems excessive. When calculating normal

protein with her actual body weight (0.8 g/kg x 93.2 g = 74.6 = ~75 g), this amount seems more

appropriate for RA. For this reason, we will prescribe RA a daily recommendation of 75 grams

of protein per day, which falls between 15-20% of total kcals, as opposed to 92.1 – 122.8 grams.

 Fluid: For ages 22-55 years of age, 35 mL/kg IBW = 35 x 61.4 = 2,149 mL

Based on RA’s 24-hour recall for beverages, she only consumed about 1680 mL of fluids,

as opposed to the recommended 2,149 mL. However, she should not increase this with beverages

she is currently drinking, like soda and juice. She should increase her water consumption to

assure proper hydration without potentially spiking blood glucose levels or adding unnecessary

calories.

RA has aspects of her diet that could be improved, but there are also positive parts of it.

RA stated that she tries to avoid high-sugar foods, which is admirable for someone with T2DM.

She also has positive intentions by purchasing sugar-free foods, but it is important that she be

cautious about other ingredients in the food to replace the sugar and how much she eats of that

food. In her 24-hour recall, RA reports eating oatmeal and whole wheat bread. These are both

excellent choices because of the fiber content and complex carbohydrates. Foods that are higher

in fiber and complex carbohydrates take more time for the body to digest and do not spike blood

glucose levels. RA has a fairly appropriate portion size for her chicken thigh and choosing to

bake it is a healthy alternative when compared to other cooking methods. She consumes some
RA TYPE 2 DIABETES MELLITUS 10

vegetables, but these could be increased. RA does have some flaws within her diet. RA and her

husband eat out once or twice a week, which often leads to uncontrolled portion sizes and

excessive consumption of calories. She also consumes calories as liquid from orange juice and

milk. Orange juice and milk contain unnecessary calories and sugar that RA could be saving for

whole foods, while these sugars may also spike blood sugar (especially from juice). RA’s

consumption of doughnuts and potato chips also increases her calorie intake and are additional

carbohydrates. She also uses condiments like mayonnaise and margarine that are high in fat.

RA would benefit from dietary instruction that teaches her about an overall healthier diet,

especially heart healthy, as well as a carbohydrate-controlled diet. Some specific

recommendations for RA include replacing the potato chips at lunch with a salad, which would

increase her vegetable intake while also providing a more balanced lunch. In patients with

diabetes, it is important to have meals that are balanced in the food groups to decrease the risk of

spikes in blood glucose levels. She should also replace her high-sugar, high-calorie doughnut at

breakfast with a piece of fruit to increase fiber. She should decrease her consumption of fruit

juice. Although natural, the sugars in these beverages may be high, and it would be better for to

consume the whole fruit to get the added benefits of fiber. RA may also benefit from replacing

her potato at dinner with a controlled portion of whole-wheat pasta. These carbohydrates are

more complex than those from a potato and supply more fiber. She might also want to choose a

leaner cut of meat at dinner. Thigh meat is predominantly dark and higher in fat, while chicken

or turkey breast is much lower in fat. It is important that RA consume a diet that is not only

carbohydrate-controlled but also heart healthy overall. Insulin helps store triglycerides as fat, and

because insulin is not being utilized correctly in her body, blood concentration of triglycerides

rises. According to her labs and vital signs, RA already has altered triglyceride levels and
RA TYPE 2 DIABETES MELLITUS 11

hypertension, respectively; to reduce these numbers and prevent future cardiovascular

complications, she should make changes for a heart healthy, carbohydrate-controlled diet.

Carbohydrate counting is a vital part of the diabetic diet. Carbohydrates are necessary for

energy metabolism and should not be eliminated but appropriately controlled. Counting the

number of carbohydrates in foods can be beneficial for those with diabetes to better control their

blood glucose levels while still eating the foods they enjoy. It is recommended that people with

diabetes consume about 50% of their calories from carbohydrates. If RA is advised to consume

about 1600 calories per day, this would include 800 calories from carbohydrates (1600/2 = 800).

There are 4 kilocalories per gram of carbohydrates, so RA should consume 200 grams of

carbohydrates per day (800/4 = 200). Based on the diet analysis of her 24-hour recall, RA

consumed about 362 grams of carbohydrates, which is much greater than the recommended

amount. A “choice” of a carbohydrate is about 15 grams of carbohydrate, giving RA about 13

“choices” per day (200/15 = 13.333). If RA consumes three meals and a snack per day, she can

have about 3 “choices” at breakfast, lunch, and snack, with 4 “choices” at dinner (3 + 3 + 3 + 4 =

13). These choices could be distributed differently throughout the day, but it is important that

carbohydrates are spread evenly from meal to meal to avoid hyperglycemia. Nutrition education

about portion sizes and what a “choice” is will provide RA with the necessary tools to change

her diet to better control her blood glucose levels and lose weight.

Nutrition Care Process

PES Statements

 Excessive energy intake related to recent increased appetite, lack of nutrition education,

frequent dining out, and poor dietary choices as evidenced by 10-pound weight gain over

the past year, BMI, 24-hour recall, and patient interview.

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 Excessive carbohydrate intake related to recent increased appetite, lack of diabetes

education, frequent dining out, poor dietary choices as evidenced by labs (low HDL and

elevated blood glucose, HbA1c, osmolality, and triglycerides), 10-pound weight gain,

BMI, 24-hour recall, and patient interview.

 Food and nutrition-related knowledge deficit related to lack of education at time of initial

diagnosis of T2DM as evidenced by labs (low HDL and elevated blood glucose, HbA1c,

osmolality, and triglycerides), patient interview, and diagnosis of uncontrolled T2DM.

Interventions

 Energy and carbohydrate-modified diet of 1600 kcal per day, 75 g protein/day,

carbohydrate-consistent (200 g/day).

 Nutrition education on carbohydrate counting, carbohydrate-consistent diet, heart-healthy

diet, self-monitoring of blood glucose, medications, portion control, “diabetic snack

food,” label reading, adequate fluid intake, and general diabetes information.

Goals

1. Adherence to prescribed diet of 1600 kcal, 75 g protein, 200 g CHO per day at least 6

days per week for the next two weeks, then gradual progression to 7 days per week.

2. Blood glucose <180 mg/dL 90% of the time.

3. Demonstration of diabetes education by next visit.

4. Weight loss of 1 pounds per week to promote better diabetes control.

Nutrition Prescription

Carbohydrate consistent heart-healthy diet of 1600 kcal, 75g protein, 200 g CHO, and

2,150 mL fluid and a maximum of 2,300 mg sodium per day.

RA TYPE 2 DIABETES MELLITUS 13

References

American Diabetes Association. (n.d.). Complications. Retrieved April 20, 2016 from

http://www.diabetes.org/living-with-diabetes/complications/?referrer=https://www.

google.com/

American Diabetes Association. (2013, June 7). Tight diabetes control. Retrieved April 20, 2016

from http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-

control/tight-diabetes-control.html

Cleveland Clinic. (n.d.). Diabetes and the foods you Eat. Retrieved April 20, 2016 from

https://my.clevelandclinic.org/health/diseases_conditions/hic_Diabetes_Basics/hic_Diet_

and_Diabetes/hic_Diabetes_and_the_Foods_You_Eat

Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., Mayer-Davis, E. J., . . .

Yancy, W. S. (2013). Nutrition therapy recommendations for the management of adults

with diabetes. Diabetes Care, 37(Supplement 1). doi:10.2337/dc14-s120

Francesconi, C., Lackinger, C., Weitgasser, R., Haber, P., & Niebauer, J. (2016). Physical

activity and exercise training in prevention and therapy of type 2 diabetes mellitus. Wien

Klin Wochenschr.

Franz, M., Boucher, J. L., & Evert, A. B. (2014). Evidence-based diabetes nutrition therapy

recommendations are effective: The key is individualization. Diabetes, Metabolic

Syndrome and Obesity: Targets and Therapy DMSO, 65. doi:10.2147/dmso.s45140

Inzucchi, S., Bergenstal, R., Buse, J., Diamant, M., Ferrannini, E., Nauck, M., . . . Matthews, D.

(2013). Management of hyperglycemia in type 2 diabetes: A patient-centered approach.

Position statement of the American Diabetes Association (ADA) and the European
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Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364-1379.

Diabetes Care, 36(2), 490-490.

Mayo Clinic. (2015, February 24). Diabetic neuropathy. Retrieved April 20, 2016 from

http://www.mayoclinic.org/diseases-conditions/diabetic-neuropathy/basics/causes/con-

20033336

Muačević-Katanec, D., & Reiner, Ž. (2011). Diabetic dyslipidemia or ‘diabetes lipidus’? Expert

Review of Cardiovascular Therapy, 9(3), 341-348. doi:10.1586/erc.11.17

National Heart, Lung, and Blood Institute. (n.d.). Description of High Blood Pressure. Retrieved

April 20, 2016, from http://www.nhlbi.nih.gov/health/health-topics/topics/hbp.

National Library of Medicine. (n.d.). LiverTox drug record: Second generation sulfonylureas.

Retrieved April 20, 2016, from http://livertox.nih.gov/SecondGenerationSulfonylureas

.htm

Pronsky, Z. M., Elbe, D., & Ayoob, K. (2015). Food medication interactions (18th ed.).

Birchrunville, Penn.: Food-Medication Interactions.

Roth, S. L. (2011). Diseases of the endocrine system. In Nutrition therapy & pathophysiology

(2nd ed., pp. 482-506). Belmont, CA: Cengage Learning.

Roden, M. (2016). Diabetes mellitus: Definition, classification, and diagnosis. Wien Klin

Wochenschr, 128.

Sowers, J. R., & Epstein, M. (1995). Diabetes mellitus and associated hypertension, vascular

disease, and nephropathy: An update. Hypertension, 26(6), 869-879.

doi:10.1161/01.HYP.26.6.869
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Appendix A

ESHA Nutrient Analysis of RA’s 24-hour Food Recall

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