Part I: Assignment Instructions

FSHN 450

Type 2 Diabetes Case Study

Fall 2014

Mrs. DM is a 55-year-old woman with type 2 diabetes, obesity, and hypertension whom has been

under a physicians care for diabetes for the past 2 years. She has no history of

microalbuminuria,retinopathy, or neuropathy. She has never had a cardiovascular event and

reports no cardiac symptoms. She has a positive family history of cardiovascular disease. In the

past, she has successfully lost weight (from 5 to 12 kg) on various diets but each time has

regained all of the weight she lost. She tries to walk 30 minutes each day. She monitors her

fasting glucose levels three times weekly using a personal glucometer, and her morning fasting

glucose levels have ranged between 110 and 140 mg per deciliter and she does not test during the

day.

Medications:

She has been receiving metformin (1000 mg twice a day) and glipizide (10 mg twice daily). She

has hypertension which is treated with hydrochlorothiazide (25 mg daily) and lisinopril (20

mgdaily). She takes aspirin (81 mg daily) and lovastatin (20 mg daily). She notes that she

consistently takes her medications.

Anthropometric and biochemical Measurements:

Her body-mass index is 31Kg/M2.

Her blood pressure is 128/78 mm Hg. Her general assessment,

including cardiorespiratory, abdominal and neurologic examinations, are normal. Her HA1c

level is 8.1%, and her creatinine 0.9 mg per deciliter. She has no microalbuminuria, and liver

function studies are normal.

Treatment:

Physician wants to add insulin but the patient wants to try diet changes first.

Her 24 hour dietary recall revealed a typical day:

AM 1 cup orange juice, 4 strips bacon, 2 fried eggs and 2 slices of toast with strawberry jam

(about 1TBSP), coffee with sugar substitute and ¼ cup 1% milk.

NOON ½ Dominos pizza with pepperoni and cheese (or MacDonald’s Big Mac, with medium

fries) and a large diet Coke.

2PM 1 Diet coke and 1 piece chocolate cake (about 1/10 of an 8” round cake with icing)

5:30 PM 2 chicken breasts, 1 cup broccoli, 1 cup mashed potatoes with ¼ cup gravy, 4 Oreo

cookies and ½ cup vanilla ice cream

7:30 PM 2 cups popcorn with butter

HS 1 cup 1% milk and 4 Oreo cookies

Assess the patient’s laboratory data and provide an interpretation in table format.

Patients Value Normal Range Explanation

Assess drug:nutrient interactions. When reporting these interactions, report only those

interactions which pertain to this patient

Assess the patient’s nutritional intake and nutritional status and report in short paragraph form.

Use the ADIME format to communicate the patient’s nutritional needs and provide an

appropriate nutrition diagnosis and PES statement and intervention, goals and follow-up.

Describe the diabetes intervention method that you would use to help her achieve her dietary

goals. What self-care activities would you suggest for this patient?

Provide a recent reference from the literature to support your intervention (Remember that the

recommendations from AHA changed this year!!!)

Part II: My Work on Assignment

Type 2 DM Case Study

Molly Carroll

10/17/14

Lab values

Test Patient’s value Normal range Explanation

Blood pressure 128/78 < 120/80 Slightly high from

hypertension

HA1c 8.1% 4.0-6.0% Poorly controlled DM

Creatinine 0.9 mg/dL 0.4-1.2 mg/dL Within normal limits

Fasting blood glucose 110-140 mg/dL 70-99 mg/dL DM

Liver function &

microalbuminuria

normal

Drug-nutrient interactions

Metformin (antihyperglycemic drug)- should consume with a diabetic diet including

decreased calories if weight loss is needed (patient does not appear to be consuming a

diabetic diet as her diet is high in non-nutrient-dense carbohydrates, added sugars, and

kcalories), this drug decreases folate and vitamin B12 absorption

Glipizide (hypoglycemic drug, also called: glucotrol or glucotrol XL)- drug should be

consumed with diabetic diet (the patient is not consuming a diabetic diet as her diet is

high in non-nutrient-dense carbohydrates, added sugars, and kcalories), this drug can

cause increased appetite and weight gain (this may be the reason the patient is consuming

so many calories and gains weight after she loses it)

Hydrochlorothiazide (antihypertensive diuretic)- may need decreased sodium, decreased

kcals with this drug (patient is consuming high kcals and appears to be consuming high

amounts of sodium with bacon, pizza, big macs, and fries), may need increased

potassium and increased magnesium with this drug, should use caution with this drug and

diabetes as it can increase glucose (could be the reason the patient has high glucose

levels)

Lisinopril (antihypertensive drug, also called: Prinivil/Prinzide and Zestril/Zestoretic)-

should be sure to drink adequate fluids (patient does not appear to be consuming adequate

fluids with only 1 1/4 cups of milk, 1 coke, and 1 cup of orange juice), decreased sodium

and kcal intake may be suggested (patient appears to be consuming high amounts of

sodium with pizza, fries, big mac, bacon, and high kcals with these high fat foods and

foods with added sugars)

Aspirin (to prevent myocardial infarction/heart attack)- be sure to consume adequate

fluids (patient is not consuming adequate fluids), increase foods high in Vit C and folate

with long term & high dose (patient’s dose is not very high but she could increase her

vegetable/fruit intake to get adequate amounts of these vitamins), avoid or limit natural

products that affect coagulation (garlic, ginger, gingko, ginseng or horse chestnut), limit

caffeine with this drug (patient may need to limit caffeine more as she consumed a large

diet coke and coffee)

Lovastatin (antihyperlipidemic to decrease risk of CV events and slow progression of

atherosclerosis)- take with decreased fat and cholesterol and decreased calories if needed,

grapefruit/related citrus fruits (Seville oranges and certain exotic oranges) should be

avoided with this drug (patient consumed orange juice and should avoid this), high-fiber

food consumption should be separated from drug consumption by 1 hour as this can

decrease this drug’s absorption

Assessment

General: 55-year-old female

Medical hx: Type 2 DM, obesity, and hypertension, no history of microalbuminuria,

retinopathy, neuropathy, cardiovascular events or symptoms, does have a family history

of cardiovascular disease

Treatment hx: under physician’s care for diabetes, has been on diets and lost 5-12kg body

weight, but regains it, walks 30 min/day, monitors fasting glucose three times/week and

has levels of 110-140 mg/dL, physician wants to add insulin and patient wants to change

diet first

Rx: 1000 mg metformin twice daily, 10 mg glipizide twice daily, 25 mg

hydrochlorothiazide daily and 20 mg lisinopril daily for hypertension, 81 mg aspirin daily,

20 mg lovastatin daily, consistent with all medications

Anthropometric measurements:

o Height- 5 ft (60 in.)= 1.52 m

60 in. x 2.54 cm/1 in. x 1 m/102 cm= 1.52 m

o Weight- 71.6 kg

31 kg/m2= x kg/1.52 m

2, x=71.6 kg

o BMI- 31 kg/m2 – obese

o General assessment – cardio-respiratory, neurologic, abdominal – normal

Biochemical and physical lab values: high fasting blood glucose, high HA1c levels,

slightly high systolic blood pressure (see table above)

Current issues: Regains weight lost and fasting glucose levels high, poor diet

Nutritional intake and status:

o Protein needs: 2.0 g/kg body weight per day for Class I obesity- 2.0 x 71.6=143 g

protein/day

o Kcal needs: Resting energy expenditure + physical activity (=REE x .15) +

thermic effect of food (REE x .10)= 2,734 kcal/day

(Mifflin equation) Resting energy expenditure: 9.99(71.6 kg) + 6.25(152

cm) – 4.92(55 years – 161)= 2,187 kcal/day

Physical activity (minimal-moderate): 2,187 x .15=328 kcal

Thermic effect of food: 2,187 x .10=219 kcal

o The patient’s nutritional intake is high in saturated fat, added sugars, and

kilocalories. The patient consumes foods high in saturated fat, such as pizza, big

macs, fries, buttered popcorn, ice cream, and bacon and consumes 1% milk. In

addition, the patient consumes foods high in added sugars, such as oreos, ice

cream, and chocolate cake. The patient not only consumes foods high in saturated

fat and added sugars, but consumes large portions of these foods, such as half a

Domino’s pizza, or a big mac, which contains two burgers. The patient also

consumed, for example, two chicken breasts at dinner instead of one, and had

dessert four times throughout the day. Many of the foods consumed by the

patient are high in sodium as well, such as the pizza or big mac with fries, and

bacon. The nutritional status of the patient is poor. Consumption of high

amounts of added sugars is not beneficial in the management of diabetes, and

consumption of foods high in saturated fats and excess kilocalories (the patient

should only be consuming 2,734 kcals per day as calculated above) do not help

with weight loss and management in an obese patient. Weight loss and

maintenance could help with the management of the patient’s diabetes. High

sodium consumption is not beneficial for the patient’s management of

hypertension, and high sodium consumption paired with a high consumption of

saturated fats could put this patient at an even greater risk for cardiovascular

disease, as the patient is already at risk with obesity and a family history of

cardiovascular disease.

Diagnosis

PES statement: Food and nutrient-related knowledge deficit (NB-1.1) related to obesity

and poorly managed diabetes as evidenced by diet recall.

Intervention

Excessive consumption of saturated fats, sodium, added sugars, and kilocalories as seen in the

patient’s diet contribute to the development of health problems and disease. All of these factors

work together to increase disease, and monitoring each of them can help better manage the

diseases the patient already has (Type 2 diabetes, obesity, and hypertension) and help prevent the

development of more diseases, such as cardiovascular disease. As stated in one journal article,

“To effectively and equitably address the chronic disease burden, public health and health-care

systems need to deploy integrated approaches that bundle strategies and interventions, address

many risk factors and conditions simultaneously” (1).

Goal 1: Educate patient about the risk of continuing obesity and development of cardiovascular

disease with high consumption of saturated fats in her diet. Define saturated fats and help patient

understand what they are. Encourage patient to lower consumption of saturated fats to better

help with weight loss and maintenance and decrease the risk of developing cardiovascular

disease.

Goal 2: Educate patient about the effects of sodium on hypertension and the role hypertension

plays in increasing the risk for cardiovascular disease. Define sodium, hypertension, and

cardiovascular disease and make sure patient understands how they connect. Encourage patient

to lower sodium levels by 1,000 mg increments until levels are at or below 1,500 mg/day.

Goal 3: Educate patient about how carbohydrates and added sugars contribute to blood sugar.

Define carbohydrates, educate patient about what nutrient-dense and low-glycemic index

carbohydrates are, and encourage lowering added sugars and increasing nutrient-dense and low-

glycemic carbohydrates to better manage blood sugar.

Goal 4: Educate patient about energy intake and energy expenditure and the process of balancing

the two to maintain weight that is lost.

Source:

1. Bauer UE, Briss PA, Goodman RA, et al. Prevention of chronic disease in the 21st

century: elimination of the leading preventable causes of premature death and disability

in the USA. Lancet. 2014;384(9937):45-52.

Abstract:

“With non-communicable conditions accounting for nearly two-thirds of deaths worldwide, the

emergence of chronic diseases as the predominant challenge to global health is undisputed. In

the USA, chronic diseases are the main causes of poor health, disability, and death, and account

for most of health-care expenditures. The chronic disease burden in the USA largely results

from a short list of risk factors--including tobacco use, poor diet and physical inactivity (both

strongly associated with obesity), excessive alcohol consumption, uncontrolled high blood

pressure, and hyperlipidaemia—that can be effectively addressed for individuals and populations.

Increases in the burden of chronic diseases are attributable to incidence and prevalence of

leading chronic conditions and risk factors (which occur individually and in combination), and

population demographics, including ageing and health disparities. To effectively and equitably

address the chronic disease burden, public health and health-care systems need to deploy

integrated approaches that bundle strategies and interventions, address many risk factors and

conditions simultaneously, create population-wide changes, help the population subgroups most

affected, and rely on implementation by many sectors, including public--private partnerships and

involvement from all stakeholders. To help to meet the chronic disease burden, the US Centers

for Disease Control and Prevention (CDC) uses four cross-cutting strategies: (1) epidemiology

and surveillance to monitor trends and inform programmes; (2) environmental approaches that

promote health and support healthy behaviours; (3) health system interventions to improve the

effective use of clinical and other preventive services; and (4) community resources linked to

clinical services that sustain improved management of chronic conditions. Establishment of

community conditions to support healthy behaviours and promote effective management of

chronic conditions will deliver healthier students to schools, healthier workers to employers and

businesses, and a healthier population to the health-care system. Collectively, these four

strategies will prevent the occurrence of chronic diseases, foster early detection and slow

disease progression in people with chronic conditions, reduce complications, support an

improved quality of life, and reduce demand on the health-care system. Of crucial importance,

with strengthened collaboration between the public health and health-care sectors, the health-care

system better uses prevention and early detection services, and population health is improved and

sustained by solidifying collaborations between communities and health-care providers. This

collaborative approach will improve health equity by building communities that promote health

rather than disease, have more accessible and direct care, and focus the health-care system on

improving population health.”

Monitoring/Evaluation

Continue to have appointments with the patient and assess whether the patient has decreased

consumption of saturated fat, sodium, and added sugars, and whether she is balancing

kilocalories from her diet recalls. Ask patient which foods in her diet do or do not contain higher

amounts of saturated fat, sodium, and added sugars, and determine whether she seems capable of

managing these factors and energy intake in her diet. If not, continue education and help patient

develop strategies to manage saturated fat, sodium, added sugars, and kilocalories. Monitor

blood sugar levels and blood pressure.

Diabetes Intervention Method

As stated above, the diabetes intervention method for this patient is education about what

carbohydrates are and their effects on blood glucose levels, including an explanation of low-

glycemic index and nutrient-dense carbohydrates and their benefits in managing blood glucose.

Education also includes lowering saturated fats, sodium, and balancing kilocalories to better

manage weight and decrease risk for additional diseases – overall management of health will

help better manage the patient’s diabetes (1). Continuing intervention/monitoring includes

helping the patient develop strategies to include nutrient-dense and low-glycemic index

carbohydrates in her diet, and decrease saturated fats, sodium, added sugars, and balance

kilocalories in her diet. For self-care, the patient should initially record what she eats throughout

the day and make sure it follows these recommendations. Educational materials should be

provided to help the patient find ways to implement these recommendations.