Case Study-Adult Type 2 Diabetes Mellitus: Transition to Insulin

1. What are the standard diagnostic criteria for T2DM? Which are
found in Mitchs medical record?

Casual plasma glucose concentration equal or greater than 200mg/dL, or

fasting plasma glucose concentration equal or greater than 125mg/dL, or 2-
hour postprandial glucose equal or greater than 200mg/dL during an oral
glucose tolerance test (OGTT), or an A1C1 of 6.5 or higher. The pts. casual
glucose results were 1524mg/dL on 4/12, and 425mg/dL on 4/13.

2. Mitch was previously diagnosed with T2DM. He admits that he

often does not take his medications. What types of medications are
metformin and glyburide? Describe their mechanisms as well as
their potential side effects/drug-nutrient interactions.

Metformin is a non-insulin, antihyperglycemic oral medication that decreases

hepatic glucose production and enhances the effects of insulin. It may also
lower triglycerides and LDL in ones body. There is a risk of putting a pt. into
hypoglycemia when not used as a single agent. Adverse effects include:
diarrhea, nausea/vomiting (N/V), bloating, anorexia, sweating, chills, in rare
cases lactic acidosis. It should be avoided in pts. with impaired kidney
function, liver failure, or CHF. Alcohol should be avoided while taking the
medication. This medication also decreases absorption of folate and vitamin
B12. May be taken with meals to decrease gastrointestinal (GI) distress.

Glyburide (sulfonylureas) is a non-insulin, oral hypoglycemic medication that

stimulates insulin secretion. This medication puts the pt. at risk for
hypoglycemia, dizziness, headaches, drowsiness, and blurred vision. It
should be avoided in pts. with decreased kidney or decreased liver function.
Alcohol should be avoided in order to reduce strain on the liver. No specific
drug-nutrient interactions noted.
3. What other medications does Mitch take? List their mechanisms
and potential side effects/drug-nutrient interactions.

Dyazide is an antihypertensive and diuretic. Potential side effects include:

changes in taste, N/V, diarrhea, and decreased renal function. May need to
decrease sodium, decrease calcium, increase potassium, and increase
magnesium intake.

Lipitor is an antihyperlipidemic used to prevent cardiovascular events and

slow atherosclerosis. May cause nausea, dyspepsia, abdominal pain,
constipation, diarrhea, and flatulence. Alcohol should be avoided while taking
this medication.

4. Describe the metabolic events that led to Mitchs symptoms and

subsequent admission to the ER with the diagnosis of uncontrolled
T2DM with HHS.

Mitch has done a poor job controlling his diabetes. This led to an episode in
which he had very high levels of glucose in his blood. When blood glucose
levels are too high, the kidneys correct this by excreting the extra glucose
through the urine. The pt. was also dehydrated, which causes the kidneys to
not function properly reducing their ability to excrete the extra glucose. The
high levels of glucose create hyperosmolarity, which in turn creates more
dehydration by pulling water from other parts of the body.

5. HHS and DKA are the common metabolic complications associated

with diabetes. Discuss each of these clinical emergencies. Describe
the information in Mitchs chart that supports the diagnosis of HHS.

HHS (hyperglycemia hyperosmolar syndrome) involves very high levels of

blood sugar without the presence of ketones, which is due to inadequate
insulin to maintain normoglycemia. This often causes severe dehydration due
to the sugar in the blood making the blood hyperosmolar. This results in the
blood pulling fluids from other parts of the body. This can result from long
time uncontrolled T2DM. Symptoms can include polyuria and polydipsia. In
older adults, this is a higher risk due to reduced thirst recognition. The pt.
had decreased consciousness, fever, a plasma glucose of 1524mg/dL, and
serum osmolality of 360mmol/kg/H2O.

DKA (diabetic ketoacidosis) is a condition in which levels of ketones in the

blood and levels of blood glucose are high. Also, a pts. blood pH falls below
normal (7.0-7.3). Ketones can be measured in the urine. This condition is
seen more commonly in pts. with T1DM, and is rare is T2DM. The ketones are
created when there is not enough insulin present which leads to the body
breaking down fat stores for energy. Without the presence of carbohydrates,
the triglycerides are improperly broken down creating ketone bodies.
Symptoms of this condition include polyuria, polydipsia, weight loss,
abdominal pain, vomiting, and labored breathing. The pt. reported excessive
vomiting, dry mucous membranes and signs of dehydration.

6. HHS is often associated with dehydration. After reading Mitchs

chart, list the data that are consistent with dehydration. What
factors in Mitchs history may have contributed to his dehydration?

Data consistent with dehydration include: dry mucous membranes in the

throat, vomiting, warm skin with poor turgor, drowsiness, increased pulse
and respiration rates, cloudy urine and pale skin. Lab results supporting
dehydration include increased BUN and creatinine. Extremely high blood
glucose levels and lack of water intake during the past 24 hours both
probably caused the pts. dehydration.

7. Assess Mitchs intake/output record for the first 24 hours of his

admission. What does this tell you? Assuming Mitch tells you that
his usual weight is 228lbs, can you estimate the volume of his
dehydration?
The pts. estimated fluid needs based on his weight are 2400ml to 2900ml.
The chart says he took in 4335ml, and the output was only 2195ml. This
shows the body retained a large portion of the fluid. Based on a 14# weight
loss at about 500ml per pound, the pt. is dehydrated by 6-7L. This shows the
pt. is severely dehydrated.

8. 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 HHS?

The normal saline solution with potassium will help hydrate and replenish the
pts. electrolytes. Potassium is added because insulin can cause an
intracellular shift in potassium. The insulin drip is used in order to stabilize
blood glucose levels.

9. Describe the insulin therapy that was started for Mitch. What is
Lispro? What is glargine? How likely is it that Mitch will need to
continue insulin therapy?

The insulin therapy plan started for the pt. was 0.5 u injections of Lispro until
blood glucose is 150-200mg/dL. Then proceed to an injection of Glargine at
19 u at nighttime to help stabilize blood glucose levels during the night.
Lispro injections will then be given at a normal rate of 1:15. Lispro is an
insulin that acts within 5-15 minutes after injection, peak is 30-90 minutes
with a duration of 3 to 5 hours. This rapid insulin is good for the pt. because
he has very elevated levels of glucose in his blood. Glargine is an extended
longer-lasting insulin. This type of insulin has no peak and a duration of 20-
24 hours. The pt. will most likely need to continue insulin therapy because he
has not been able to control his diabetes/blood glucose up to that point.
10. Mitch was NPO when admitted to the hospital. What does this
mean? What are the signs that will alert the RD and physicians that
Mitch may be ready to eat?

NPO means nothing by mouth (or Nil per os-I learned some Latin!). Some
signs that show the pt. will be ready to eat are glucose levels returning to
normal and his fluid levels stabilizing. Since the pt. had excessive vomiting,
food should be administered as tolerated.

11. Outline the basic principles for Mitchs nutrition therapy to assist
in control of his DM.

Basic principles for the pts. MNT therapy of his DM include:

restricting/maintaining a stable caloric intake, strive for even distribution of
carbohydrate intake throughout the day not just one large carbohydrate
containing meal, adjust carbohydrate intake to glucose tolerance, reduce
intake of foods high in saturated fat, incorporate simple carbohydrates such
as fruits, milk and vegetables. The pt. should also be given further nutrition
education to ensure he understands the dangers of not managing his DM
properly.

12. Assess Mitchs weight and BMI. What would be a healthy weight
range for Mitch?

Weight= about 97kg Height= 175.26 cm BMI= 97kg/1.75m2= 32kg/m2

This classifies the pt. as obese. A healthy weight (DBW) range is 160 +/- 10%
(144#-176#).

13. Identify and discuss any abnormal laboratory values measures

upon his admission. How did they change after hydration and initial
treatment of his HHS?

Sodium- 132 mEq/L-Low due to hyperglycemia causing a shift of water from

intracellular to extracellular space. Remained low after therapy but closer to
normal.
BUN- 31 mg/dL- High due to dehydration and high stress on kidneys.
Decreased greatly after therapy, still slightly high, but much closer to
normal.

Creatinine serum- 1.9mg/dL-High due to diabetes and dehydration.

Decreased to near normal range after therapy

Glucose-1524mg/dL-Very high due to lack of insulin. Decreased greatly after

therapy but still very high compared to normal range.

Phosphate-1.8mg/dL-Low due to electrolyte levels dropping during

dehydration. Increased following therapy but still below normal.

Osmolality-360mmol/kg/H2O-High, blood is thicker due to high

concentrations of glucose and lack of water. Decreased following therapy but
still above normal.

Cholesterol-205mg/dL-High, may be due to diabetes, dehydration and other

conditions. No follow-up lab values to compare to.

Triglycerides-185mg/dL-High, may be due to diabetes, dehydration, and

other conditions. No follow-up lab values to compare to.

HbA1c-15.2%-High due to diabetes and large amount of glucose in the blood.

No follow-lab values to compare to.

WBC-13.5x10^3/mm^3-High probably due to obesity. No follow-lab values to

compare to.

Hematocrit-57%-High, dehydration can cause a false high hematocrit value.

No follow-lab values to compare to.

Specific Gravity-1.045-High due to dehydration. No follow-lab values to

compare to.

pH-5-Low, ketones in blood lower blood pH. If ketones are present, then DKA
is suspected.
Protein-10mg/dL-High due to dehydration. No follow-lab values to compare
to.

Glucose-Positive due to diabetes and high levels of glucose in the blood, the
kidneys are trying to excrete the extra through the urine. No follow-lab
values to compare to.

Ketones-Positive due to improper breakdown of fats in absence of

carbohydrates, complication of DM, usually type 1. Points to DKA. No follow-
lab values to compare to.

Prot chk-Positive due to dehydration. No follow-lab values to compare to.

14. Determine Mitchs energy and protein requirements for weight

maintenance. What energy and protein intakes would you
recommend to assist with weight loss?

DBW = 160# +/- 10% Current wt-214#

%DBW = 133% = must adjust for obesity

(214-160#) *.38+160=180# = 82kg adjusted

82kg *(25-30) = 2050-2460kcals Goal=2400kcals

Pro req. = 82*1.1= 90g/day

For weight loss- Energy req. = 2400kcals (300-500 kcals/day) = 1900-

2100kcals/day Goal= 2000kcals/day

Pro req. = 2000kcals * (15%) = 300 kcals/4kcals/g=75g PRO

15. Prioritize two nutrition problems and complete the PES

statement for each. *I know this was crossed out but I wanted to attempt
the question anyways, feedback is appreciated for this answer.

Nutrition Dx: Overweight/obesity related excessive energy intake with limited

physical activity as evidence by a BMI of 32 and 33% above IBW.
Nutrition Dx: Inadequate fluid intake related to decreased thirst recognition,
poor and dry skin turgor, high plasma glucose content as evidence by
positive glucose in the urine, plasma glucose level of 1524mg/dL, osmolality
of 360mmol/kg/H2O, and specific gravity of 1.045.

*Skin turgor was reported as poor upon admission, but also reported as
good by the nursing assessment. This is most likely due to an error either
in reporting, or assessment.

16. Determine Mitchs initial CHO prescription using his diet history
as well as your assessment of his energy requirements.

Energy req. = 2400kcals/day * (50%) = 1200kcals /4= about 300g CHO/day

= 300g/15g per exchange = 20 exchanges per day. In order to maintain a
steady blood glucose, the pt. should spread carbohydrate intake evenly
throughout the day.

This could be broken up into 4 exchanges for breakfast, lunch and dinner,
and 3 exchanges for 2 snacks during the day. If the pt. really wants to stick to
4 meals per day (as his history shows he usually eats in this pattern), a
sample breakdown could be 5 exchanges for breakfast, lunch and dinner,
and 5 exchanges for a snack (basically 4 even CHO containing meals).

17. Identify two initial nutrition goals to assist with weight loss.

Goal 1: Focusing on an even intake of carbohydrate throughout the day will

really help keep blood glucose levels more stable. The pt. reports not having
a real breakfast, this could be a point of emphasis to start, making sure he
eats a balanced breakfast to start his day. Also, increasing from 3 to possibly
4 or 5 smaller meals per day, compared to 1 small meal followed by 2 large
meals will help maintain BG.

Goal 2: Increasing intake of fruits, vegetables and whole grains, while

reducing intake of high energy dense foods (e.g. fast-food sandwiches, chips
and Chinese takeout). Also, reducing energy intake to a range that promotes
weight loss. Education on the use of exchange list can help the pt.
understand the content of his food better and provide simple structure for
maintaining a healthier carbohydrate intake.

18. Mitch also has hypertension and high cholesterol levels.

Describe how your nutrition interventions for diabetes can include
nutrition therapy for his other conditions.

By decreasing his weight, making healthier food choices and maintaining an

even intake of carbohydrates throughout the day, these factors can help
lower stress on the body which may lower blood pressure. These therapies
can also aid in lowering cholesterol by reducing intake of higher fat foods and
promote proper breakdown of fats in the body. Exercise should also be
mentioned as it not only promotes better circulation and can decrease blood
pressure, but it also can increase the bodies sensitivity to insulin extremely
important in pts. with DM.