DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
Case Study # 17: Adult Type 2 Diabetes Mellitus Transition to insulin
Patient Summary: Mitchell Fagan is a 53-year old male with type 2 diabetes mellitus who has a
long history of noncompliance. He was admitted through the ER with severe hyperglycemia and
dehydration.
1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical
record?
The standard diagnostic criteria for T2DM include:
a. Casual plasma glucose: Concentration > 200 mg/dL
Or
b. Fasting plasma glucose > 126 mg/dL
Or
c. 2-hour post prandial glucose > 200 mg/dL during an oral glucose tolerance test.
Plus
d. Symptoms of Diabetes:
 Hyperglycemia – an excess of glucose in the bloodstream

Glycosuria - a condition characterized by an excess of sugar in the urine

Polyuria -production of abnormally large volumes of dilute urine

Weight loss associated with diabetes – In individuals with diabetes, insufficient insulin
prevents the body from getting glucose from the blood into the body's cells to use as
energy. When this occurs, the body starts burning fat and muscle for energy, causing a
reduction in overall body weight.

Polyphasia - excessive hunger and abnormally large intake of solids by mouth.

Lipemia – the presence of an abnormally high concentration of emulsified fat in the
blood.

Ketosis – a condition characterized by raised levels of ketone bodies in the body,
associated with abnormal fat metabolism and diabetes mellitus.

Diabetic Coma – a life-threatening diabetes complication that causes unconsciousness.
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
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 and glyburide are glucose-lowering medications if glycemic control cannot be
achieved with nutrition therapy and regular physical activity.
Metformin is a biguanide, which is a class of oral medicine that reduces the body’s need for
insulin. Biguanides lower blood glucose levels primarily by reducing the amount of glucose
produced by the liver and by making muscle tissue more sensitive to insulin so glucose can be
absorbed. Metformin does not cause the pancreas to produce more insulin. It should not cause
low blood sugar or weight gain, unless it is taken in combination with medicines that do. Some
people may lose weight when starting this medicine. Side effects of metformin include diarrhea,
nausea, bloating, anorexia, flatulence, loss of appetite, lactic acidosis (rapid breathing, excessive
sweating, cool and clammy skin, sweet-smelling breath, belly pain, nausea or vomiting, and/or
confusion); contraindicated in individuals with renal insuffiency, liver failure, or treated chronic
heart failure (CHF). In addition, intake of metformin decreases folate and vitamin B12
absorption. Alcohol consumption should be avoided. Also, it is recommended to take metformin
with meals to decrease GI distress.
Glyburide is a sulfonylurea agent that lowers blood glucose and help control blood sugar
levels by stimulating the beta cells of the pancreas to release more insulin and by helping the
body better use the insulin it makes to help the body use glucose for energy. The medicine is
helpful for people who cannot make enough insulin or who have become resistant to the insulin
the body makes. Common side effects of this medicine include hypoglycemia (sweating, feeling
nervous, dizziness, and/or confusion, hunger, and weight gain. It is contraindicated in individuals
with renal insufficiency.
5. HHS and DKA are the common metabolic complications associated with diabetes. Discuss
each of these clinical emergencies. Describe the information in Mitch’s chart that supports
the diagnosis of HHS.
Hyperglycemic hyperosmolar Syndrome (HHS) is a metabolic complication of type 2 diabetes
characterized by extremely high blood glucose levels (< 600 mg/dL). Due to the high blood
glucose levels the kidneys try to accommodate by allowing extra glucose to exit the body
through urine. If inadequate amounts of fluids are consumed, the kidneys are unable to continue
to rid the body of the excess glucose. Blood sugar levels become very high, and the blood
becomes thick and sticky ( hyperosmolarity). HHS is characterized by high salt and glucose
concentrations in the blood, which causes a filtering process that result in a massive loss of
bodily fluids, including loss of water to the brain. Immediate medical treatment is imperative
since blood glucose levels and dehydration can continue to rise and can eventually lead to death.
HHS is more common in type 2 diabetes and characterized by a greater severity of
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
hyperglycemia, a significant increase of plasma osmolality, absent to mild ketosis, and mental
confusion.
HHS Symptoms: Progresses slowly, hyperglycemia, polyuria, polydipsia, sleepiness, confusion,
fever, vomiting, and volume depletion.
Diabetic ketoacidosis (DKA) is a life-threatening emergency that affects individuals with
diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no
insulin or not enough insulin. Fat is used for fuel instead. When fat breaks down, waste products
called ketones build up in the body. As fat is broken down, ketones build up in the blood and
urine. In high levels, ketones are poisonous. DKA is often the first sign of type 1 diabetes in
people who do not yet have other symptoms. It can also occur in someone who has already been
diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin shots,
or surgery foods can lead to DKA in individuals with type 1 diabetes. Those with type 2 diabetes
can also develop DKA, but it is less common. It is usually triggered by uncontrolled blood sugar
or a severe illness. Patients with DKA present with hyperglycemia, ketosis, and metabolic
acidosis secondary due to insulin deficiencies.
DKA Symptoms: Develops rapidly, polyuria, polydipsia, weight loss, nausea, vomiting,
abdominal pain, dehydration, loss of skin turgor, dry skin, dry mucus membranes, tachycardia,
acetone breath, deep and rapid respirations, mental cloudiness, flushing, and headache.
Mr. Fagan’s chart states that he did not show up for work or answer his phone and his coworkers
became concerned and went to check on him. When they found him he was drowsy and confused
and they took him to the ER. Confusion and sleepiness are symptoms of HHS. He also presented
at the ER with serum glucose of 1524 mg/dL. The result of his HbA1c was 15.2. Mr. Fagan’s
medical history states that he was diagnosed one year ago with Type 2 diabetes mellitus and was
prescribed glyburide and metformin to control his blood glucose levels, but he admits that he
does not take the medications regularly. His diabetes is being poorly controlled and this can
result in HHS.
Many of Mr. Fagan’s symptoms and abnormal laboratory results are common in both HHS and
DKA. His history of type 2 diabetes, severe hyperglycemia (1524 mg/dL), HbA1c of 15.2,
significantly high plasma osmolality, mild ketosis, and mental confusion support Mr. Fagan’s
diagnosis of HHS. The HbA1c represents an average free blood glucose level over a three-month
period of time. Mr. Fagan’s HbA1c of 15.2 indicates that over a period of three months his blood
glucose levels have been very high. HHS develops slowly and DKA develops quickly, therefore
this is important information in his chart that supports the diagnosis of HHS.
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 that was started for Mitch began with 0.5 units of Lispro for every two
hours until his glucose is 150-200 mg/dL and took 19 units of Glargine in the evening at 9 pm.
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
Then, Lispro was progressed using ICR 1:15. His bedside glucose was checked hourly, and his
doctor was notified if his blood glucose >200 or <80.
Lispro is a rapid-acting insulin. On average, Lispro insulin starts to lower blood glucose
within five minutes after injection. It has its strongest effect thirthy minutes to one hour after
injection but keeps working for three hours after injection. Glargine is an extended long-acting
insulin. On average, Glargine insulin starts to lower blood glucose levels within one hour after
injection and keeps working evenly for 24 hours after injection.
Since he was diagnosed with type 2 diabetes one year ago he has not taken his medications
(glyburide and metformin) regularly. He was sent to the ER for acute hyperglycemia (1524
mg/dL). Hence, it is very likely that Mitch will need to continue insulin therapy to control his
blood glucose within 150-200 mg/dL, and it is important that he takes his medications (glyburide
and metformin) along with a consistent-carbohydrate diet.
11. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM.
Mr. Fagan stated that the only education for diabetes that he has received occurred when he was
first diagnosed with type 2 diabetes a year ago from his doctor. Mr. Fagan lacks that knowledge
to control his diabetes through his food choices or the importance of taking his diabetes
medications as prescribed by his physician.

The basic principles for Mitch’s nutrition therapy will be to teach him to identify
carbohydrate sources and be able to track his carbohydrate intake throughout the day to
achieve and maintain his blood glucose in the normal range. He will also receive
instruction on coordinating his prescribed medication schedule to his eating schedule.

He will be taught that a healthy dietary pattern supports optimal health and includes
carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat dairy products.

The basic nutrition principles will also be to assist Mitch in achieving and maintaining
glucose, lipids, and blood pressure goals by encouraging him to choose a variety of fibercontaining foods such as legumes, fiber-rich cereals and breads (≥5 g fiber/serving),
fruits, vegetables, and whole grain products because they provide vitamins, minerals, and
other substances important for good health. Research suggests that consuming a highfiber diet can help control glucose levels and can assist in the prevention of
cardiovascular disease.

Nutrition therapy interventions that are used will meet his individual goals and lifestyle.
They must also include changes that he can and is willing to implement.
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
12. Assess Mitch’s weight and BMI. What would be a healthy weight range for Mitch?
The patient weighs 214 lbs (97.3 kg) and he is 5’9” (175.3 cm) tall. This patient’s BMI is 31.7,
which categorizes him as Class I obese.
IBW: M: 106 lbs + 6 lbs (for every inch over 5 feet)
=106+ 6(9)
= 160 lbs (72.7 kg) +/- 10%
A healthy weight range for Mitch is 144 -176 lbs.
13. Identify and discuss any abnormal laboratory values measured upon his admission. How
did they change after hydration and initial treatment of his HHS?
Mr. Fagan’s abnormal laboratory values upon his admission.
Test
Sodium
Normal
Value
136-145
Abnormal Value
Value at after
Admission Initial
Treatment
At admission Mr. Fagan’s sodium level was
132˅
134˅
BUN
8-18
31˄
20˄
Creatinine
0.6-1.2
1.9˄
1.3˄
Glucose
70-100
1524˄
475˄
low. Sodium levels increase with dehydration
but decrease with vomiting and over
hydration. His low sodium level is most likely
due to vomiting. Electrolytes follow free
water and are therefore also are lost in the
urine. After receiving IV fluids Mr. Fagan’s
sodium level increased.
BUN and Creatinine levels increase during
periods of dehydration. After receiving fluids
Mr. Fagan’s BUN level decreased, although it
is still not at optimal level.
Creatinine and BUN levels increase during
periods of dehydration. After receiving fluids
Mr. Fagan’s Creatinine level decreased,
although it is still not at optimal level.
Indicates Type 2 DM-insulin resistance. Used
to indentify risk of glucose intolerance,
diabetes mellitus, and hypoglycemia; and
helps to monitor diabetes treatment. Mr.
Fagan’s blood glucose level decreased from
the administration of insulin. It is important
that his high blood glucose is decreased
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
HbA1c
3.9-5.2
15.2˄
Cholesterol
120-199
205˄
Triglycerides F 35-135
M 40-160
185˄
WBC
4.8-11.8
13.5˄
Hematocrit
40-54
57˄
Phosphate
Inorganic
2.3-4.7
1.8˅
2.1˅
Osmolality
285-295
360˄
304˄
slowly to prevent a rapid fall in blood glucose
which can result in hypoglycemia. When
blood glucose levels are returning to almost
normal a dextrose infusion will need to be
used to prevent this.
Indicates Type 2 DM-insulin resistanceextended period of hyperglycemia. Used to
monitor long term blood glucose control (~13 months prior). Mr. Fagan’s HbA1c of 15.2 is
a good indication that he has HHS. Since an
HbA1c is an average percent of blood glucose
levels over a ~1- 3 month period it is too soon
to re-evaluate
Mr. Fagan’s cholesterol level of 205 indicates
that he is classified as borderline high and
puts him at risk for CVD. . Mr. Fagan states
that he tries to avoid fatty foods, high sugar
desserts but does not follow a strict diet. Due
to his lack of knowledge of the diabetic diet
he may not know which foods fall in which
category. It is too soon to re-evaluate and to
know if he is responding to treatment.
Type 2 DM can increase Triglycerides since
excessive intake of carbohydrates and foods
high in fat, especially saturated fats can lead
to elevated Triglycerides Very high
triglyceride levels increase cardiovascular
stress and are components of metabolic
syndrome. It was too soon to re-evaluate and
to know if he is responding to treatment.
Elevated WBC is usually due to stress &
dehydration. There were no recent lab values
for WBC count to assess if Mr. Fagan’s WBC
count is responding to treatment of his HHS.
Mr. Fagan’s hematocrit is elevated due to
hemoconcentration. As he is rehydrated and
his blood glucose levels are decreased his
hematocrit levels should return to normal the
range. There was not a current level to assess
if he is responding to treatment.
Mr. Fagan’s Phosphate inorganic level is
responding to treatment. It was 1.8 at
admission and after treatment it rose to 2.1.
Although the level is not as high as it should
be.
Osmolality measures solute concentration
and increases in dehydration and
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
Specific
Gravity
1.0031.030
1.045˄
pH
5-7
5.0˅
Protein
Neg
10˄
Glucose
Neg
+˄
Ketones
Neg
+˄
Prot chk
Neg
+˄
hyperglycemia. Mr. Fagan’s osmolality value
was very high at admission (360) and after he
was given fluids to alleviate dehydration and
insulin to decrease his high blood glucose
level his osmolality levels decreased to 304
which is still high, but it shows that he is
responding to treatment.
Specific gravity is directly proportional to
urine osmolality, measures urine density, or
the ability of the kidney to concentrate or
dilute the urine over that of plasma. Since
Mr. Fagan is dehydrated his SG is high. It was
too soon to re-evaluate and to know if he is
responding to treatment, but since his
osmolality level decreased it may be safe to
assume that his SG has also decreased.
In HHS blood pH may be > 7.30. Mr. Fagan’s
pH 5.0 which is at the very low end of normal
pH levels. Acidosis is absent. There were no
recent lab values for pH level to assess if Mr.
Fagan’s is responding to treatment of his
HHS.
During long periods of uncontrolled blood
glucose levels protein leaks into the urine. If
no significant damage has occurred Mr.
Fagan should respond to treatment and the
protein may no longer leak into his urine.
When the body is experiencing very high
hyperglycemic levels, excess sugar passes
from the blood into the urine it triggers a
filtering process that draws tremendous
amounts of fluid from the body. There were
no recent labs to compare Mr. Fagan’s
admission glucose urine levels to or to access
if treatment is working.
In type 2 diabetes there is usually just enough
insulin produced by the pancreas to keep fat
in fat cells and prevent ketone formation, so
ketone levels are normal or only slightly
elevated in HHS. Mr. Fagan’s urine ketone
levels are slightly elevated but there are no
recent labs to access if his ketone level is
responding to treatment.
There may be a trace of Prot chk when an
individual is experiencing severe dehydration.
There is not a recent lab value for Mr. Fagan’s
Prot chk, but it should improve as he is
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
rehydrated.
14. Determine Mitch’s energy and protein requirements for weight maintenance. What
energy and protein intakes would you recommend to assist with weight loss?
a. energy requirement
Weight: 214 lbs = 97.3 kg
Height: 5’9” = 69”= 175.3 cm
BMI: 31.7 (Class I obese)
IBW: M: 106 lbs + 6 lbs (for every inch over 5 feet)
=106+ 6(9)
= 160 lbs= 72.7 kg
Male: 66.5+ 13.8W+ 5H-6.8A

REE=66.5 + 13.8 (72.7 kg) + 5 (175.3 cm)-6.8 (53 y.o.)
=66.5 + 1003.26 + 876.5-360.4
=1585.86
1585.86 X 1.2= 1903 kcal/d

To lose weight:
1903-250= 1653
1903-500=1403
= 1403-1653 kcal/d
b. protein requirement
IBW X 0.8-1.0g/kg
=72.7 kg X 0.8g/kg
=58.2-72.7 g/d
To assist with weight loss, his recommended energy intake is 50-60% of his daily calories
and that would be about 702-992 kcals of CHO or 176-248 grams to assist with weight loss.
There are three main types of carbohydrates: starches, sugars and fiber. Carbohydrate foods like
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Polly Peru
Rachelle Sebastian
10/27/14
whole grains, fruits, vegetables and non-fat and low fat milk are important components to a
healthy diet. Limit to two drinks/day for adult men.
1403 X 0.5 and 0.6= 702-841.8 kcal/4 calories=176 g
1653 X 0.5 and 0.6= 826.5-991.8 kcal/4 calories=248 g
His recommended protein intake is 10-20% of his daily calories at 140-331 kcal of protein or
35-83 grams to assist with weight loss.
1403 X 0.1 and 0.2 =140.3-280.6 kcal/4 calories=35 g
1653 X 0.1 and 0.2=165.3-330.6 kcal/4 calories = 83 g
15. Prioritize two nutrition problems and complete the PES statement for each.
1. Deficit of food and diabetic medication utilization knowledge related to lack of prior nutrition
education related to information on Type 2 Diabetes as evidenced by new diagnosis of
Hyperglycemic Hyperosmolar Syndrome.
2. Abnormal lab values related to type 2 diabetes mellitus as evidenced by an HbA1c of 15.2%.
16. Determine Mitch’s initial CHO prescription using his diet history as well as your
assessment of his energy requirements.
Based on his diet history,
Morning: Coffee with half and half
Snack: Bagel with cream cheese and 2-3 cups of coffee
Lunch: Goes to a restaurant (Jimmy Johns) or a fast-food sandwich, chips, and a diet soda.
Dinner: Sometimes he cooks grilled chicken or beef, salad, and potatoes or rice at home. He
meets his friends for dinner at restaurants a lot. He loves ethnic foods such as Chinese, Mexican,
Indian, and Thai.
Food items
Coffee
Half and half
Serving size or #
of exchanges
0
2 tbsp
Total CHO (g)
0
1g
CHO kcal
0
0
Total Kcal
0
40 kcal
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
Bagel
1 large
70.2g
354 kcal
1g
70.2x4kcal=281
kcal
1g x4= 4kcal
Philadelphia
cream cheese,
original
Coffee
Half and half
Coffee
Half and half
Coffee
Half and half
Applebee's Honey
BBQ Chicken
Sandwich, without
sides
Baked Lays chips
Diet soda
Grilled chicken
2 tbsp
0
2 tbsp
0
2 tbsp
0
2 tbsp
1 each
0
1g
0
1g
0
1g
88g
0
0
0
0
0
0
88x4=352kcal
0
40 kcal
0
40 kcal
0
40 kcal
1,010 kcal
2 bags
0
3 oz
46g
0
0
46x4=184kcal
0
0
130 kcal
0
90 kcal
Mixed salad
greens, tossed
without dressing
Ranch salad
dressing
Mashed potato
(1/2 cup)
4 cups
29.12g
29.12x4=117kcal
160kcal
2 tbsp
2g
2x4= 8kcal
146kcal
2 cups
60g
60x4=240 kcal
420 kcal
Estimated total
CHO/d:
300.32g/d
Estimated CHO
kcal/d:
1186 kcal/d
Estimated
kcal/d:
2570 kcal/d
100 kcal
Mitch’s initial carbohydrate (CHO) prescription would be to spread out his carbohydrate
servings throughout the day. His energy requirement for weight maintenance is 1903 kcal/d but
to lose weight 1403-1653 kcal/d. One carbohydrate exchange equals 15 grams of carbohydrate.
To assist with weight loss, his recommended energy intake is 50-60% of his daily calories and
that would be about 702-992 kcals/d of CHO or 176-248 grams/d.
If I use his energy requirement for weight maintenance:
His total energy needs = 1903 kcals
1903 X 0.5=951.5 kcal of CHO/4 calories per gram CHO=238/15 g=16
1903 X 0.6=1141.8 kcal of CHO/4 calories per gram CHO=285/15g=19
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
16-19 CHO exchanges/d
To control his blood sugar levels, snacks are recommended. The total exchanges of
carbohydrates per day will range from 16-19 choices for weight maintenance.
For example:
AM: 3-4 choices
Snack: 1-2 choice(s)
Lunch: 3-4choices
Snack: 1-2 choices(s)
Dinner: 3-4 choices
Snack: 1-2 choice(s)
If I use his energy requirement for weight loss:
His total energy needs= 1403-1653 kcals
1403 X 0.5 and 0.6= 702-841.8 kcal/4 calories per gram CHO=176 g/15g=12
1653 X 0.5 and 0.6= 826.5-991.8 kcal/4 calories per gram CHO=248 g/15g=17
12-17 CHO exchanges/d
To control his blood sugar levels, snacks are recommended. The total exchanges of
carbohydrates per day will range from 12-17 choices for weight loss.
For example:
AM: 3-4 choices
Snack: 1 choice
Lunch: 3-4choices
Snack: 1 choice
Dinner: 3-4 choices
Snack: 1 choice
DFM 484
Polly Peru
Rachelle Sebastian
10/27/14
17. Identify two initial nutrition goals to assist weight loss.
Current body weight: 214 lbs
Ideal body weight: 160 lbs
BMI: 31.5
Goal 1: Learn how to manage Type 2 Diabetes and to take diabetic medications as prescribed.
Nutrition educations to teach how to achieve glycemic control, self monitor glucose levels. Learn
how to self manage insulin administration. Learn how to count carbohydrates and follow a CHOconsistent meal plan.
Goal 2: To consume 4-5 smaller meals during the day.
Eating every 3-4 hours helps to control hunger and avoid blood glucose spikes. Consume
nutritionally balanced portion controlled meals that includes all food groups, recommended fluid
intake and not exceed daily total energy goals.