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
1 lg banana
1 cup whole milk
8 oz orange juice
Lunch
4 oz corned beef
1 oz swiss cheese
2 slices rye bread
½ cup cole slaw
2 tbsp russian dressing
1 small bag potato chips
12 oz juice cocktail
4 starch, 1 fruit
380 kcals
2 fruit
120 kcals
1 high fat milk
150 kcals
2 fruit
120 kcals
4 med-fat meat
300 kcals
1 high-fat meat
100 kcals
2 starch
160 kcals
1 vege, 1 fat
70 kcals
2 fat
90 kcals
1 starch, 1 fat
125 kcals
150 kcals
Dinner (24-hr recall, cont’d)
1 cup fried rice
4 oz Hunan chicken (fried)
4 oz shrimp and cashews
2 bottles beer
1 lg orange
Total kcals:
Protein:
Fat:
Carb:
3411
14%
40%
46%
3 starch, 3 fat
375 kcals
4 high fat meat
400 kcals
4 high fat meat
400 kcals
2 beer
300 kcals
2 fruit
120 kcals
Total Kcals: 3360
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)
Starch
Kcals
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
Vege
Fruit
Starch
(12)
2
(8)
24
(5)
3
(2)
(15)
10
-
6
-
-
(3)
-
60
(15)
10
16
15
4
(5 - 2%)
150
30
Convert PRO (100 g)
No. of
CHO (g) PRO (g) FAT (g)
Exchanges
Milk
Vege
Starch
Meat
(12)
2
(8)
24
(5)
3
(2)
(15)
10
-
6
(3)
150
-
7
16
15
10
(5 - 2%)
-
30
(7)
(5)
49
35
Convert FAT (67 g)
No. of
CHO (g) PRO (g) FAT (g)
Exchange
s
Milk
Meat
Fat
(12)
2
(8)
24
-
16
(7)
7
10
(5)
49
-
4
(5 - 2%)
-
35
(5)
20
Diet Pattern
Food
Group
No. of
Exchanges
Starch
CHO (g)
PRO (g)
FAT (g)
(15)
(3)
-
10
Meat
150
-
30
(7)
7
Vege
49
(5)
3
Fruit
(2)
15
(15)
4
Milk
35
-
6
-
-
(8)
(5 - 2%)
60
(12)
2
Fat
(5)
24
-
16
-
10
(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
When Therapy Changes
Multiple
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
Life
Glycemic Control
care
HbA1c
Blood lipids
Weight/BMI
Blood pressure
Complications
Economic
length/stay
Quality of
Participation in
-ER visits
-costs to
health plan
- SMBG
- keeps appts.
- Rx refills
Better work
attendance
Q of Life survey