2/18/00

Type 2 DM - Case Study

Jean Kerver, MS, RD, CDE
kerverje@pilot.msu.edu
DR is a 45 y.o. male; Ht: 5’9”; Wt: 215 lbs
Present complaint: polydipsia, polyuria,
fatigue.
Past med hx: Type 2 DM x 5 yrs.
Meds: None; NKDA.
Labs: No SBGM;
serum glucose=285 mg/dL 1 hr ppd;
HbA1C=9.2%
urinary glucose=2+;
temp=98.8 F.
Family med hx: Grandma type 2 DM at age
60 yrs
Social hx: architect; lives alone; nonsmoker;
no regular physical activity.
Diet hx: no known food allergies;
no supplements (vit/min or other);
no special diet;
drinks 2 beers qd after work;
brkfst at home;
lunch out—fast food or deli type;
dinner at home —cooks or orders take-out
food;
seldom snacks.
Breakfast (24-hr recall)
2 cups raisin bran 4 starch, 1 fruit 380 kcals
1 lg banana 2 fruit 120 kcals
1 cup whole milk 1 high fat milk 150 kcals
8 oz orange juice 2 fruit 120 kcals
Lunch
4 oz corned beef 4 med-fat meat 300 kcals
1 oz swiss cheese 1 high-fat meat 100 kcals
2 slices rye bread 2 starch 160 kcals
½ cup cole slaw 1 vege, 1 fat 70 kcals
2 tbsp russian dressing 2 fat 90 kcals
1 small bag potato chips 1 starch, 1 fat 125 kcals
12 oz juice cocktail 150 kcals
Dinner (24-hr recall, cont’d)
1 cup fried rice 3 starch, 3 fat 375 kcals
4 oz Hunan chicken (fried) 4 high fat meat 400 kcals
4 oz shrimp and cashews 4 high fat meat 400 kcals
2 bottles beer 2 beer 300 kcals
1 lg orange 2 fruit 120 kcals

Total kcals: 3411

Total Kcals: 3360
Protein: 14%
Fat: 40%
Carb: 46%
How Many kcals Should He Have?
Ht: 5’9”; Wt: 215 lbs
IBW: 106 lbs + (9” x 6 lbs) = 160 lbs
% IBW = 215 lbs /160 lbs = 134%
AdjBW = 0.25 (215-160) + 160 = 174 lbs (79
kg)

25 kcals/kg = 25 x 79 = 1975 kcals/d

24-hr = 3411 kcals – 500 kcals= 2900 kcals
 Calculation of Initial Dietary Pattern

Total kcals = 2000

50% CHO = 0.50 x kcal = 0.50 x 2000 = 250 g CHO

4 kcal/g CHO 4

20% PRO = 0.20 x kcal = 0.20 x 2000 = 100 g PRO

4 kcal/g PRO 4

30% FAT = 0.30 x kcal = 0.30 x 2000 = 67 g FAT

9 kcal/g FAT 9
 ADA Exchanges
Food Gp CHO (g) PRO (g) FAT (g) Kcals
Starch 15 3 - 80
Meat - 7 3-8 55-100
Vege 5 2 - 25
Fruit 15 - - 60
Milk 12 8 0-8 90-150
Fat - - 5 45
Negotiate, Then Convert Into Exchanges
First, determine how many servings of milk,
fruit, and vegetables the patient is willing to
eat each day.
Next, add up the CHO from the milk, fruit,
and vegetable groups and subtract that
amount of CHO from the total amount of CHO
needed.
Then divide the remaining amount of CHO
into starch exchanges.
Do the same for PRO and FAT.
Negotiate, then Convert CHO (250 g)
No. of CHO (g) PRO (g) FAT (g)
Exchanges
Milk (12) (8) (5 - 2%)

2 24 16 10
Vege (5) (2) -

3 15 6
Fruit (15) - -

4 60

Starch (15) (3) -

10 150 30
 Convert PRO (100 g)
No. of CHO (g) PRO (g) FAT (g)
Exchanges
Milk (12) (8) (5 - 2%)

2 24 16 10
Vege (5) (2) -

3 15 6
Starch (15) (3) -

10 150 30

Meat - (7) (5)

7 49 35
 Convert FAT (67 g)
No. of CHO (g) PRO (g) FAT (g)
Exchange
s
Milk (12) (8) (5 - 2%)

2 24 16 10
Meat - (7) (5)

7 49 35

Fat - - (5)

4 20
 Diet Pattern
Food No. of CHO (g) PRO (g) FAT (g)
Group Exchanges
Starch (15) (3) -

10 150 30
Meat - (7) (5)

7 49 35
Vege (5) (2) -

3 15 6
Fruit (15) - -

4 60
Milk (12) (8) (5 - 2%)

2 24 16 10
Fat - - (5)

4 20
Totals: 249 101 65
Rx Totals: 250 100 67
Metabolic Effects of Exercise in Type 2 DM

Lipolysis

Decreased Plasma
Insulin

Lower Blood Glucose

Increased peripheral glucose uptake

Increased Insulin Sensitivity

 Multiple
When Therapy Changes Dose
Regimen
NPH + Humalog
BID

Add Bedtime NPH

to Orals

Combinations of Oral Agents:

Metformin + Sulfonylureas, etc.

Monotherapy Oral Agents: Sulfonylureas,

Metformin, Troglitazones, etc.

Meal Planning and Physical Activity

 Diabetes Education
Tell patient what to expect
Individualize-always give choices
Be systematic-prioritize
Discuss coping strategies
Special situations
 Evaluating Outcomes in DM Treatment

Outcomes Can Be:

Clinical Economic Quality of

Life

Glycemic Control length/stay Participation in

care
HbA1c -ER visits - SMBG
Blood lipids -costs to - keeps appts.
Weight/BMI health plan - Rx refills
Blood pressure
Complications Better work Q of Life survey
attendance