monahossain.weebly.com · Web viewInsulin to carbohydrate ratios play a part in determination of needs as well. For well-being, carbohydrate sources from fruit, vegetables, whole

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Running Head: Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin

Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin

Mona Hossain

Queens College

2Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin


I. Understanding the Disease and Pathophysiology

1. What are the standard diagnostic criteria for T2DM? Cite the ADA Standards of Medical Care – 2014.

Which are found in Mitch’s medical record? (5)

There are four measures associated with the diagnostic criteria for T2DM. One of the criteria would be the

presence of symptoms of diabetes (hyperglycemia) along with a casual or random plasma glucose ≥ 200 mg/dl

(11.1 mmol/L). Another criteria would be a fasting plasma glucose (FPG) ≥ 126 mg/dl (7.0 mmol/L) following

an 8 hour period without caloric intake. A 2 hour post prandial glucose ≥ 200 mg/dl during an oral glucose

tolerance test (OGTT) consisting of 75g of anhydrous glucose load dissolved in water serves as another

measure. An A1C ≥ 6.5% may also serves as an indicator for diagnosis as it reflects average blood glucose

levels of 2-3 month periods. All of the measures have been determined by the first Expert Committee on the

Diagnosis and Classification of Diabetes Mellitus as the level when there is prevalence of retinopathy

(American Diabetes Association, 2014).

In Mitch’s medical records, he was presented to the ER with noted hyperglycemia with a serum glucose of

1524 mg/dL. Additionally, his HbA1C was found to be 15.2% which is well above the normal limit as well as

above ≥ 6.5% .

2. Mitch was previously diagnosed with T2DM. His admits that he often does not take his medications.

For each of his diabetes pills, metformin and glyburide, state the class of medication and mechanism of

action; list potential drug side effects (i.e nausea, etc) and drug-nutrient interactions (i.e. foods or nutrients

to be added or avoided) for each drug. (6)

Metformin is a generic form of oral glucose lowering medication in the class of medications known as

Biguanides. The mechanism by which this class of medication works is by decreasing the hepatic production of

glucose and increasing insulin uptake in the muscles. Potential side effects include nausea, vomiting, bloating,

diarrhea, flatulence, dyspepsia, lactic acidosis (rare) and more (Pronsky and Crowe 2012, p210). Possible drug-

nutrient interactions may occur resulting in decreased absorption of vitamin B12 and folate and must be

monitored. Additionally, alcohol must be avoided.

Glyburide is a generic oral glucose lowering medication belonging in the class of medication known as

Sulfonylureas. This class of drug functions as an insulin secretagogue as it stimulates insulin production from


the beta cells of the pancreas (Krause 2012). Potential side effects include dyspepsia, nausea, diarrhea,

constipation. Possible drug-nutrient interactions may occur with alcohol use and must be avoided.

3. Mitch also takes other medications, Dyazide and Lipitor. List their mechanisms, potential side effects and

drug-nutrient interactions.

Lipitor is a HMG-CoA reductase inhibitor also known as “statins”. They decrease production of cholesterol

by inhibiting HMG-CoA reductase responsible in the hepatic production of cholesterol (Krause 2012, p215-

216). Potential side effects include nausea, dyspepsia, abdominal pain, constipation, diarrhea and flatulence

(Pronsky and Crowe 2012, p164). Possible drug-nutrient interactions exist with grapefruit and citrus related

fruits and substantial alcohol consumption must be avoided. Additionally, the drug reduces Coenzyme Q10

levels and may need to be supplemented.

Dyazide is an antihypertensive medication and diuretic used to treat fluid retention and high blood pressure.

It is composed of a thiazide diuretic (hydrochlorothiazide) and a potassium sparing diuretic (triamterene)

(Ogbru and Marks, 2014). Hydrochlorothiazide works my preventing reabsorption of sodium and water in the

kidneys which results in eliminating water retention and uptake of too much sodium in the body. When there

are increased amounts of sodium and water in the kidney tubules for excretion as urine, the kidney tries to

reabsorb more sodium and water for the body by taking potassium out of the blood and exchanging it with

sodium in the tubules causing potassium levels to fall. (Ogbru and Marks, 2014) Triamterene works by

preventing the reabsorption of sodium in exchange for potassium functioning as a potassium sparing diuretic.

Therefore, the combinations of these two types of diuretics eliminate sodium and water reabsorption without

loss of potassium which is necessary in controlling blood pressure. Thus, dyazide functions as both

antihypertensive agent and diuretic.

Potential side effects of dyazide include abdominal pain, nausea, vomiting, rash, headache, dizziness,

constipation, low blood pressure, and possible electrolyte imbalances (such as increase in potassium levels)

(Ogbru and Marks, 2014). Increased/excessive potassium levels may result as a concern of drug- nutrient

interaction.

He is beginning insulin. For insulin, state type; time of onset, peak, duration; potential side-effect. (5)

Name Type of

Insulin

Onset Peak Duration Potential Side Effects


Lispro Rapid-

Acting

<15 min 1-2 hrs 3-5 hrs Hypoglycemia, redness and irritation is

injected, skin thickness around injection,

weight gain, constipation.(National Institutes of

Health 2014)

Glargine Long-

Acting

2-4 hr peakless 20-24 hrs Hypoglycemia, redness, swelling, pain, or

itching at the injection site, changes in the feel

of your skin, skin thickening (fat build-up), or a

little depression in the skin (fat breakdown),

swelling of the hands or feet, weight gain,

constipation (National Institutes of Health

2014)

*(Krause 2012, p692)

4. Mitch experienced symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM

with HHS.

Describe what led to his severe hyperglycemia.

Mitch admitted that he was not taking his medicine for diabetes regularly therefore poor management of his

diabetes led to his severe hyperglycemia.

State Mitch’s signs and symptoms of dehydration.

In his chief complaint, Mitch said that he had a lot of vomiting and his throat had dry mucus membranes.

He reports only having sips of water after vomiting for 12-24 hrs. Additionally, skin was reported to be warm

and dry and have poor turgor which would indicate dehydration. Additionally, his diet history reflects a lot of

coffee consumption which functions as a diuretic.

Define HHS, its etiology and symptoms.

Hyperglycemic hyperosmolar state (HHS) is defined by high blood glucose levels ranging in 400 to 2800

mg/dL (22.2-155.6 mmol/L0 without presence of ketones (Krause 2012, p699). Hyperosmolarity results when

the blood becomes concentrated with high levels of sodium, glucose or other substances that causes water to be

drawn out of vital organs and into the bloodstream (Topiwala 2012). In the case of hyperglycemic hyperosmolar

state, there is a high concentration of glucose in the blood therefore it results in extremely elevated blood


glucose levels in addition to causing dehydration as water is drawn out. It is usually prevalent in older age

patient with type 2 diabetes; other factors contributing to its onset may be due to other illness such as stroke and

heart attack, medications that reduce glucose tolerance or increase fluid loss in those who normally don’t get

enough fluid intake and, poor management of diabetes or stopping medications designed to lower glucose levels

such as insulin (Topiwala 2012). Symptoms include dehydration/ excessive thirst, altered mental state such as

confusion, hallucination, coma, increased urination, weakness, lethargy, and weight loss. MNT includes

monitoring of blood glucose and rehydration.

State Mitch’s signs and symptoms of HHS. (8)

Mitch was admitted to the ER with a serum glucose of 1524 mg/dl which is within the range of 400 to 2800

mg/dL as indication of HHS. Additionally, he claimed that he was not taking his medication for diabetes

consistently so poor management of his diabetes contributed to this severe hyperglycemia as indication of HHS.

Moreover, Mitch was found in a confused mental state before arriving in the ER which is also a symptom of

HHS. Dehydration is a symptom is another symptom of HHS; in his chief complaint, Mitch said that he had a

lot of vomiting and his throat had dry mucus membranes, and warm dry skin with poor skin turgor which is an

indication of dehydration. This is confirmed by his altered lab values for hydration status such as sodium (↓!),

BUN(↑!), Osmolality(↑!), urine specific gravity(↑!).

5. HHS and DKA are metabolic complications associated with diabetes. Define DKA, its precipitating factors

and signs /symptoms. What characteristics of Mitch’s condition indicate HHS as opposed to DKA? (5)

Diabetic Ketoacidosis (DKA) is a condition marked by hyperglycemia (blood glucose levels > 250mg/dL

and usually < mg/dL) and presence of ketones in the blood and urine (Krause 2012, p703). It occurs when the

body begins to breakdown fat in an attempt to avoid starvation and forms ketones due to body’s inability to use

glucose for energy since there is no insulin being produced. As the glucose (since it can’t be used as insulin is

not available) and ketones build up, it becomes concentrated in the blood and urine. It is usually seen in patients

with type 1 diabetes but may also be seen in those with type 2 diabetes due poor blood sugar management or

severe illness (Wisse 2013). Other precipitating factors include infections, cerebrovascular accident, substance

abuse, pancreatitis, pulmonary embolism, myocardial infarction, and trauma, psychological stress, and drugs

such as corticosteroids, thiazides, sympathomimetic agents, and pentamidine (Umpierrez et al 2002). Symptoms

of DKA are polyuria, polydipsia, hyperventilation, dehydration, the fruity odor of ketone and fatigue (Krause

2012, p703). Treatment includes self monitoring of blood glucose and checking ketone levels (Nelms 2011).

Mitch’s condition would however indicate HHS as opposed to DKA since his serum glucose was found to

be 1524 mg/dL (in diagnosis of DKA, the serum glucose levels are usually above 250 mg/dL and below

http://spectrum.diabetesjournals.org/content/15/1/28.full#T1


600mg/dL). Additionally, Mitch had a previously altered mental status (confusion) which is a symptom of HHS

as opposed to DKA where mental status is usually more alert (Umpierrez et al 2002). Classic signs of

ketoacidosis such as fruit breath and abnormal breathing are not presented symptoms in Mitch’s condition

therefore HHS would be a better suited diagnosis than DKA. Moreover, serum osmolality is a diagnostic criteria

often used to asses DKA and HHS; a level >320 mOsm/kg indicates HHS (Umpierrez et al 2002). Mitch’s

osmolality was found to be 360 mmol/kg.

6. Mitch was started on normal saline with potassium as well as an insulin drip. Why are these fluids a

component of his rehydration and correction of the HHS? (3)

During a hyperglycemic crisis as in the case of HHS, fluid volume in the body decreases and the kidneys

ability to perfuse becomes abnormal or inactive. The use of normal saline (0.09% saline) is a form of fluid therapy

used to increase intravascular, interstitial, and intercellular volume and restore renal perfusion (Kitabchi et al. 2009).

Additionally, it is used to bring the body out of hyperosmolar/hypertonic state with the isotonic saline for balancing

since fluid moves out of the cell in a hypertonic state resulting in dehydration. Moreover, potassium is used in

solution since as dehydration results from total body water decreases (vomiting, frequent urination), potassium along

with other electrolytes (sodium, chloride, magnesium) is lost as well. Furthermore, insulin drip is used to decrease

serum glucose levels and bring the body out of a hyperglycemic states. Because these components (normal saline

with potassium, insulin drip) are components that act on the symptoms of HHS (hyperglycemia, hyperosmolarity,

dehydration) they are used for rehydration and correction of HHS.


7. Describe the insulin therapy that was started for Mitch. When would a patient be started on insulin, based on

the recommendations of the ADA? How likely is it that Mitch will need to continue insulin therapy? (3)

Mitch’s insulin therapy consists of 0.5 units of Lipro (rapid-acting insulin) being administered every 2

hours until serum glucose reaches between 150-200 mg/dL. The rapid acting insulin is considered a bolus or

mealtime insulin which is given 30- 60 minutes before meals (Krause 2012, p691-692). Then, in the

evening/night time Mitch is to begin taking 19 units of Glargine (long acting insulin) which works in the

background over a 20-24 hour period to prevent excessive hepatic output of glucose and lipolysis (Krause 2012,

p693). Then he is to progress Lispro to an insulin-to-carbohydrate ratio of 1:15 or 1 unit of insulin for every 15

grams of carbohydrate.

A patient would be started on insulin when oral antidiabetes medications have failed (possibly due to

noncompliance in taking the pills) (Davidson 2005). Additionally, people with type 2 diabetes overtime may

have very little to no insulin production and have to begin taking their insulin to manage their blood glucose




especially during time of stress of illness (ADA 2004). Also, oral medications also may not be effective (once

possible cause being poorly controlled diabetes) in getting A1C levels within normal limit and may need to

initiate insulin therapy (Henske et al. 2009).

Mitch will most likely need to continue insulin therapy because he doesn’t take his oral glucose lowering

medications since he doesn’t like how they make him feel. Without insulin, his blood glucose will still be

elevated if it is poorly managed and could possibly lead to other complications of diabetes such as diabetic

nephropathy.

II. Nutrition Assessment

8. Assess Mitch’s desirable body weight and BMI. What would be a healthy weight range for Mitch? (3)

DBW BMI

Hamwi-Males- 106 for 5 ft +6 for every inch above 5 ft

Mitch= 5ft 9 in

DBW=106+ 6(9)= 106 + 54= 160 lbs

DBW= 160 lbs

BMI = weight (lb) / height (in2) x 703

Mitch weight= 214 lbs height= 69 in

BMI= 214 (lbs)/ 69 (in2) x 703

BMI= (214/ 4761) x 703

BMI= (0.045)x 703

BMI= 31.6 (Obese-Class I)

A healthy weight is between the BMI range of 18.5- 24.9 (CDC 2011). Therefore, if Mitch were to be within a BMI

range of 18.5-24.9, his healthy weight range would have to be between 125 lbs-168lbs. However given that Mitch’s

current weight falls within the obese category, he would have to lose a severe amount of weight to reach 125lbs.

Thus, I would recommend aiming for the upper limit of his range (168lbs) or his ideal/desirable body weight (as

calculated to be 160lbs) as a starting point for reaching a healthy weight (between 160-168 lbs) once he is no longer

in the hospital.

9. For each lab value, state its abnormal value upon admission and what the value means / indicates.

How did glucose, sodium, phosphate and osmolality change - state the changed value and why it changed.

(16)

http://www.cdc.gov/healthyweight/assessing/Index.html


Initial lab values:

Abnormal Value Indication

Glucose 1524!↑ mg/dL

(Ref range- 70-110 mg/dL)

Too much glucose in the blood-Hyperglycemia;

indication of DM

Creatinine 1.9!↑ mg/dL

(Ref range- 0.6-1.2 mg/dL)

May indicate muscle damage or renal disease, may

also be elevated to due dehydration (Dugdale 2013).

Sodium 132!↓ mEq/L

(Ref range- 136-145 mEq/L)

lower than normal levels may be due dehydration,

vomiting, ketonuria, use of diuretic pills (Mitch takes

Dyazide which is functions as a potassium sparing

diuretic) (Dugdale 2011).

Phosphate 1.8!↓ mg/dL


Lower than normal values may be due to vomiting,

alcohol abuse, or poor dietary intake, or renal failure

(Dugdale 2011).

Cholesterol 205!↑ mg/dL


Elevated value is possible due to excessive dietary

intake of cholesterol and saturated fat

HbA1c 15.2!↑ %


Elevated level indicates poorly managed blood

glucose over a 2-3 month period or uncontrolled

diabetes

C-peptide 1.10 ng/mL

(Ref range- 0.51-2.72 ng/mL)

Within normal limit; indicates that insulin is still being

produced in the body (Topiwala 2012).

Osmolality 360!↑ mmol/kg/H20

(Ref range- 285-295

mmol/kg/H20)

Serves as an indicator of fluid status; higher than

normal levels is due to dehydration and

hyperglycemia in Mitch’s case.

Specific

gravity

1.045!↑

(Ref range- 1.003-1.030)

Elevated value is due to dehydration( fluid losses and

vomiting) and presence of glucose in the urine

(Dugdale 2013).

BUN 31!↑ mg/dL


Serves as an indication of hydration status; elevated

value are indicative of hypovolemia/dehydration as

well as possible renal complications such as renal

disease or renal failure. (Dugdale 2013)

Glucose in

urine

+!↑

(Ref range- Neg)

+ value indicates that the kidney are spilling glucose

into the urine (renal glycosuria) (Nelms 2011)

Protein in 10!↑ mg/dL Protein in the urine may indicate renal complications

http://www.nlm.nih.gov/medlineplus/ency/article/003587.htm


urine (Ref range- Neg) as the kidney is supposed to facilitate protein to stay in

the blood- may indicate diabetic nephropathy; it may

be caused by dehydration as well (Dugdale 2013).

Changed values:

Changed Value Reason for Change

Glucose 475 ↑ mg/dL

(Prev. value: 1524 !↑ mg/dl)


Lowered serum glucose due administration of

insulin(insulin drip) and rehydration using normal

saline and possible increase in renal perfusion

Osmolality 304 ↑ mmol/kg/H20

(Prev. value: 360!↑ mmol/kg/H20)

(Ref range- 285-295 mmol/kg/H20)

Closer to normal range, changed due to rehydration

with normal saline

Sodium 134 ↓ mEq/L

(Prev value:132! mEq/L)

(Ref range- 136-145 mEq/L)

Closer to normal range; changed due to rehydration

with normal saline

Phosphate 2.1↓ mg/dL

(Prev value: 1.8!↓ mg/dL)


Closer to normal range, improvement may be due to

increased renal perfusion

10. Determine Mitch’s energy requirements for weight maintenance using Mifflin St. Jeor equation.

Mifflin St.Jeor

Mifflin-St Jeor= 10 (wt kg) + 6.25 (ht cm) – 5 (age) +5

Mifflin-St Jeor= 10 (97) + 6.25 (175.26) – 5 (53) + 5

Mifflin-St Jeor= 970 + 1095.375 – 265 + 5

Mifflin-St Jeor= 2065.375 – 260

= 1805.375 ≈ 1805

RMR= 1805

RMR x Activity Factor x Stress factor

Activity factor= 1.0-1.2 stress factor= 1.1 (medical stress factor)

1805 x 1.0 x 1.1= 1985.5 ≈ 1986


1805 x 1.2 x 1.1= 2382.6 ≈ 2382

Energy requirements for weight maintenance= 1986-2382 kcal/d

I chose an activity factor 1.0-1.2 because Mitch is in the hospital although has some degree of

functionality for light activity and is not completely bedridden. I chose a medical stress factor of 1.1 due to his

HHS.

Although weight loss is not recommended while being hospitalized, I would recommend Mitch to stay

within the lower range of his energy requirements to maintain his weight because his current weight puts him at

the obese category and puts him at risk of other serious illness such as heart disease.

Determine Mitch’s protein requirements.

Estimated Protein Requirements

Method: .0.8-1.0 g/kg for normal maintenance of protein needs for hospitalized patient

Mitch’s IBW: 160 lbs = 72.7 kg ≈ 73 kg

73 kg x 1.0 g/kg= 73 g

73 kg x 1.2 g/kg= 87.6 g ≈ 87g

Due to the fact that Mitch’s weight is currently puts him at the obese category, his protein requirements were

calculated by using his ideal or desirable body weight found to be 160lbs based on the Hamwi equation. I used a

protein range of 1.0-1.2g/ kg BW because Mitch is currently in the hospital due to his acute hyperglycemia and

would need atleast 1.0g/kg for maintenance. People with type 2 diabetes and moderate hyperglycemia may have

increased protein need due protein turnover (American Diabetes Association 2004). This is evidenced by

presence of protein in urinalysis. Therefore I chose to increase his protein needs to 1.2g/kg BW. The estimated

protein requirements yield a range of 73g-87 of protein per day or 292-348 kcals from protein per day. Protein

should supply no more than 15-20% of calories in persons with diabetes (Krause 2012, p686).

What daily energy intake would you recommend for an appropriate rate of weight loss? Justify your

recommendation. (3)

Daily energy intake requirements are about 500-1000 calories lower than the amount needed to maintain

weight as an appropriate rate of weight loss (American Diabetes Association 2004). Therefore Mitch’s daily

http://care.diabetesjournals.org/content/27/suppl_1/s36.full



energy intake requirement for weight loss would be about 1486-1882 kcal/day based on a rate of deducting 500

kcal from the amount needed for weight maintenance (calculated to be 1986-2382 kcal/day based on Mifflin-

St.Jeor). I chose the lower rate (500 kcal/d as opposed to the 1000 kcal/d) deduction due to the fact that Mitch

was just hospitalized and severe weight loss during time of stress or physical injury is not recommended. Once

he is discharged, he could begin at this rate and possibly gradually adjust an increase in the rate to reach a long

term goal of 5-7% weight loss from his starting weight (American Diabetes Association 2004).

III. Understanding the Nutrition Therapy

11. Mitch was NPO when admitted to the hospital. Why? What does this mean? When will Mitch be ready to eat?

What foods would be recommended immediately following NPO, before initiating a diet for diabetes? (4)

NPO is the medical abbreviation for the latin word nil per os and means nothing by mouth. He was NPO

when admitted because of altered GI functionality as he reports vomiting a lot (emesis is also reported on his

fluid intake/output report). Additionally, his serum glucose was excessively high (1524 mg/dL); food intake

may cause the blood glucose to increase and contribute more his hyperglycemia. Moreover, NPO diet ensures

more accurate results when doing medical testing such as blood tests. He will be ready to eat when his condition

stabilizes (he stops vomiting and his hyperglycemia is controlled or resolves). Immediately following NPO, he

will be recommended clear liquid foods such as clear broths and fruit juices and possibly liquid nutritional

supplements before initiating a diet for diabetes to allow energy intake and minimal stimulation of the GI tract

(Nelms 2011, p68).

12. Mitch was prescribed and initial ICR 1:15. Explain what this means.

ICR or insulin to carbohydrate ratio represents the ratio of how many units of insulin is needed to

metabolize a certain amount of carbohydrate intake. Therefore an ICR of 1:15 represents a 1 unit dosage of

insulin (rapid acting insulin/bolus/meal time insulin) to cover every 15g of carbohydrate intake (Nelms 2011,

p493)

Outline the general principles for nutrition therapy, to assist in control of DM, for: meals and snacks,

carbohydrate, sugar substitutes, fats and weight reduction. Cite the ADA’s Clinical Practice

Recommendations for Medical Nutrition Therapy – 2014. (5)

According to the American Diabetic Associations’s general principles for 2014, these are the

recommendations for the following (Evert et al. 2014):

Carbohydrates :



o There is no significant evidence to establish percentages for carbohydrate recommendation for

all diabetics. Individualized plans must be made to determine need based on assessment and

goals. Insulin to carbohydrate ratios play a part in determination of needs as well.

o For well-being, carbohydrate sources from fruit, vegetables, whole grains, legumes and dairy

products are best for consumption. Sources from sugary drinks and fast food should be

avoided.

o Fiber should be consumed based on recommendations for the general public.

o Glycemic control should be maintained by methods such as carbohydrate counting. Lower

glycemic index foods are better than higher glycemic index food for controlling blood sugar.

Fats:

o There is no conclusive evidence to determine percentage or amount of fat to be consumed by

diabetics. However according to IOM, AMDR was established for total fat to be 20-35%

energy intake with no upper limit

o Monounsaturated fats as emphasized on the Mediterranean diet is beneficial for controlling

blood sugar and may substitute the typical low-fat, high-carb diet

o Omega-3 should be emphasized because of its effect on lipoproteins, preventing heart disease,

e and general health benefits it provides as recommended for the general public.

o Same recommendations apply for saturated fat (<10%), cholesterol (<300 mg) and trans fat

(to be limited as much as possible0 as the general public.

Sugar substitutes:

o May help to reduce caloric intake if substituted for calorie based sugars and no additional

caloric intake is taken to make up for the reduced amount through other foods

Weight reduction:

o Overweight and obese individuals with diabetes need to decrease energy intake and maintain

a healthful diet for weight loss

o Modest amounts of weight loss have been shown improvement in blood glucose, blood

pressure and lipid profile

o Intensive lifestyle interventions are needed to achieve weight reduction. physical activity, and

regular contact with an RD can be an intervention which can result in weight loss of 7-8.5%

of starting body weight (Evert et al, 2014)


IV. Nutrition Diagnosis

13. Write 2 priority nutrition diagnoses, each in PES format. (6)

1. NI-5.8.4- Inconsistent carbohydrate intake related to poor management of diabetes evidenced by diet

history revealing inconsistency of carbohydrate intake, uncontrolled serum glucose level of 1524 mg/dL,

HgbA1c of 15.2% and patient reporting noncompliance with taking oral diabetes medications consistently.

2. NC-3.2- Overweight/ obesity related to poor dietary choices such as frequent fast food consumption as

evidenced by BMI of 31.6 (class 1 obese), 134% desirable body weight, elevated triglyceride level of 185

mg/dl and elevated cholesterol level of 205mg/dL

V. Nutrition Intervention

14. Determine Mitch’s initial CHO prescription using his diet history as well as your assessment of his energy

requirements for weight loss: State daily kcal intake, percent kcal from CHO, g CHO, number of CHO

choices per day; Suggest the number of CHO choices you would recommend for 3 meals and 2 snacks based

on his diet history. (5)

Meal/

FOOD AM Midmorning Lunch dinner Total

servings

/day

CHO

(g)

CHO

KCAL

PRO

(g)

PRO

kcal

FAT

(g)

FAT

kcal

Starches -

- 4 11 1 16

15

240960

3

48192

1

16

144

fruit -

-

-

-

-

-

-

-

-

-

15

-

-

-

-

-

-

-

-

-

-

-

milk

1

-

-

-

-

-

- 1

12

1248

8

832

1

1

9

vegetables -

-

-

-

-

- 1 1

5

520

2

28

-

-

-

-

Meats

/substitutes

-

-

-

- 1 1 2

-

00

7

1456

5

10

90

fats - 1 1 - 2 - - - - 5 90


- - 0 0 - - 10

Mitch’s

CHO

choices/d 1 5 13 3

Estimated

Totals

22

servings257g

1,028

kcal72g 288

kcal37g

333

kcal

Total %

kcal CHO62%

It appears that Mitch’s diet history reveals Mitch has approximately 22 carbohydrate choices in a 24 hour period and

it is mostly concentrated around lunch time. His energy requirements were calculated to be 1986-2382 kcal/day for

weight maintenance and 1486-1882kcal/d for weight loss after subtracting 500. About 45 to 65% of calories should

come from carbohydrates. If I were to choose 55% of calories from CHO for Mitch then 817-847 kcal should come

from carbohydrates or 204g-211g of CHO which would result in13-14 carbohydrate choices for Mitch to be

consumed though out the day based on recommendations for weight loss. For 3 meals such as breakfast I would

recommend 3-4carbohydrate choices, for lunch 3- carbohydrate choices and 3 carbohydrate choices for dinner and 2

and 2 carbohydrate choices for snacks to balance it out throughout the day.

15. Identify two initial nutrition goals to assist with weight-loss. (4)

1. Pt will learn to replace fast-food options with healthier alternatives to consume during lunch in to achieve

cholesterol and triglyceride levels within normal limit resulting in weight loss.

2. Pt will learn to self monitor their glucose levels in order to reduce serum glucose within normal limit by taking in

appropriate amounts of carbohydrate throughout the day along with their glucose lowering medications.

16. Mitch also has hypertension and high cholesterol levels. State the recommendations for the lipid profile,

LDL, HDL, Cholesterol and Triglycerides for people with diabetes. (4)

Recommendations for people with diabetes for LDL, HDL, Cholesterol and Triglycerides are as follows

(American Diabetes Association 2014):

LDL <100 mg/dL (without overt CVD)

HDL >40 mg/dL in men

Cholesterol <200 mg/dL

Total daily kcal= 1,649


Triglycerides <150 mg/dL

Lipid profile- fasting lipid profiles should be measured at least once every year and lipid assessments

should be conducted every 2 years.

Describe nutrition recommendations for fiber, types of fat and sodium for Mitch and why.

Fiber recommendations for diabetics are the same as for the general population. 14g for every 1000kcal are

recommended by the US Dietary Guidelines (Nelms 2011, p506). Usually 25-30g of fiber with about 7-3g of

soluble fibers can promote cardiovascular health (Krause 2012 p686). Additionally soluble fibers such as gums

and pectins can improve glucose levels by slowing the absorption of glucose from the small intestines (Nelms

2011, p506). Food sources such as whole grains, fruits, vegetables, and legumes can contribute a significant

amount of fiber to the diet if consumed in appropriate amounts. Therefore, Mitch should get about 25-30g of

fiber which can add bulk to his diet and lower his cholesterol levels in addition to promoting cardiovascular

health.

Since Mufa’s are known to have beneficial effects on glycemic control and promote cardiovascular health,

Mitch should include them in the diet instead of saturated fats. Omega-3s should also be increased in his diet

because of its positive effects on cardiovascular health, lipoproteins and general health (American Diabetes

Association 2014). Omega-3 may be found in fatty fish which Mitch can consume 2-3 times per week in

exchange of his lunch or dinner meat option. Saturated fat should be limited to less than 7% of energy intake

while total fat should not exceed 25-35% of caloric intake (Nelms 2011,p505). Additionally, it is best to

minimize or eliminate transfats consumption as it contributes to increases cholesterol and cardiovascular

disease.

The general recommendation for sodium is 2300 mg which is appropriate for people with diabetes

(American Diabetes Association 2014). However, since Mitch has diabetes and has hypertension, he should

reduce it further to improve blood pressure. Additionally, his diet history seems to reflect frequent consumption

of fast foods which has a lot of sodium. Therefore, due to his condition 1500 mg may be appropriate (Evert et al

2014)

VI. Nutrition Monitoring and Evaluation

17. Write an ADIME/SOAP note for your initial nutrition assessment.

Use form provided below: SEE BELOW (10


A - Assessment

S - Subjective

Chief Complaint: “I had a lot of vomiting that I thought at first was food poisoning but I just kept getting worse.” When questioned

about medications, patient admits that he has not taken medications for diabetes regularly—“I hate how they make me feel but I

almost always take my other medications for blood pressure and cholesterol”

UBW: 228

Weight change: loss; 6%

Appetite: poor

Chewing / swallowing problem / sore mouth: none

Nausea / vomiting / diarrhea / constipation: vomiting

Food intolerance / allergies:

Diet prior to admit:

Nutritional supplement:

Vitamins / herbs:

Food preparation: self preparation

Factors affecting food intake: dines out frequently- fast food;

ethnic food

Social / cultural / religious / financial

Other:

O - Objective

Current Diet Order: NPO then progress to clear liquids and then consistent carbohydrate-controlled diet

Medical Diagnosis: Type 2 DM uncontrolled with HHS Pertinent Medical History:

Type 2 DM x 1 year; HTN; hyperlipidemia; gout

Nutrition Focused Physical Signs & Symptoms:

Drowsy with mild confusion, emesis x 12-24 hours, dry mucus membranes, obese

Age: 53 Gender: Male

Ht:

5’9’’

Wt: Admit 214

lbs

DBW: 160 BMI: 31.6


% UBW: 93.9% % wt : 6% % DBW: 134% Other:

Nutritionally Relevant Laboratory Data:

Glucose 1524↑ mg/dL BUN 31↑ mg/dl Cholesterol 205↑ mg/dL

HbA1C 15.2↑ Creatinine 1.9 ↑ mg/dl triglyceride 185↑ mg/dL

Osmolality 360↑ mmol/kgH20

Sodium 132↓ mEq/L

Specific gravity 1.045↑

Drug Nutrient Interaction:

Dyazide-↑ potassium

Lipitor- caution w/ grapefruit/ citrus fruit; avoid alcohol

Metformin- ↓ Folate, ↓B12

Glyburide- avoid alcohol

Estimated Energy Need:

_1986-2382___ kcal / day

Based on: Mifflin-St.Jeor activity factor 1.0-

1.2; stress factor 1.1

Estimated Protein Need:

____73-87______ g/day

Based on: 1.0-1.2g/kg IBW (73kg)

Estimated Fluid Need:

______1986-2382___ ml / day

Based on: 1ml/kcal

Nutrition Diagnosis (D)

A - Assessment (A)

State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis Terminology sheet

ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :

1. NC-3.2- Overweight/ obesity related to poor dietary choices such as frequent fast food consumption as evidenced by BMI of 31.6

(class 1 obese), 134% desirable body weight, elevated triglyceride level of 185 mg/dl and elevated cholesterol level of 205mg/dL

1. NI-5.8.4- Inconsistent carbohydrate intake related to poor management of diabetes evidenced by diet history revealing

inconsistency of carbohydrate intake throughout the day, uncontrolled serum glucose level of 1524 mg/dL, HgbA1c of 15.2% and

patient reporting noncompliance with taking oral diabetes medications consistently to lower glucose levels.


Nutrition Intervention (I)

P - Plan

List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems

(diagnoses).

1. E-1.4- Nutrition Related to health/disease

Pt will be educated on effect of obesity as a contributing factor to complications of diabetes; pt will be educated on making

healthier choices for eating out in order to reduce consumption of excessive amounts of fat from fast food which contributes to

cholesterol and triglyceride levels.

2. C-2.3- Self monitoring

Pt will self-monitor their blood glucose to adjust carbohydrate intake along with antidiabetic medications to keep blood glucose

within normal levels.

Goal(s):

1. Pt will learn to replace fast-food options with healthier alternatives to consume during lunch in to achieve cholesterol and

triglyceride levels within normal limit resulting in weight loss.

2. Pt will learn to self monitor their glucose levels in order to reduce serum glucose within normal limit by taking in appropriate

amounts of carbohydrate throughout the day along with their glucose lowering medications.

Plan for Monitoring and Evaluation (M E)

List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the

plan for monitoring would indicate if interventions are addressing the problems).

1. AD-1.1.2-Weight, BD-1.7.1- Cholesterol, BD-1.7.7- Triglycerides

2. FH-5.1.4- Self monitoring as agreed upon rate, BD-1.5.3- HgbA1C,

Mona Hossain 4/29/2014

Signature: Date:


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APA formatting by BibMe.org.

monahossain.weebly.com · Web viewInsulin to carbohydrate ratios play a part in determination of needs as well. For well-being, carbohydrate sources from fruit, vegetables, whole

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