Ramtin Navabzadeh
Amber Huizar
DFM 484
MNT Case Study #17
(1, 2, 5, 9, 11, 12, 13, 14, 15, 16, & 17)
1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s
medical record?
The diagnostic criteria for type 2 diabetes mellitus, is insulin resistance, with possible
insulin deficiency. Type 2 diabetes mellitus accounts for 90 to 95% of diagnosed cases, which
may go undiagnosed for several years. Unlike type 1 diabetes mellitus, type 2 doesn't require
exogenous insulin for survival.
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 an oral diabetes medicine for people with type 2 diabetes, which helps them
control blood sugar levels. The drug is in the biguanides class of drugs, which does not result in
weight gain or risk of hypoglycemia. Metformin acts by reducing LDL cholesterol and
triglyceride levels. Common adverse effects of Metformin include gastrointestinal distress,
diarrhea, cramps, vomiting, and increased flatulence. The most severe side effect is lactic
acidosis, due to metformin inhibiting gluconeogenesis. An increased lactate production may be
present in the small intestine. Since gluconeogeneis is inhibited, glucose won't be generated
from non-glucose substrates, such as pyruvate, lactate, glycerol, and amino acids.
Glyburide is an oral anti-diabetic drug for people with type 2 diabetes. Glyburide falls in
the drug class of sulfonylurea agents, which are drugs to stimulate pancreatic insulin secretion,
and may result in a high risk of hypoglycemia. Glyburide acts lower blood sugar levels by
causing the body's own insulin to be released, whereas metformin acts to lower blood sugar
levels by allowing the body to use insulin more effectively. Both of these drugs work well
together to achieve better blood glucose control. Those with a glucose-6-phosphate
dehydrogenase deficiency and take glyburide, may develop hemolytic anemia. Another major
side effect caused by glyburide is cholestasis, which is a condition where bile cannot flow from
the liver to the duodenum.
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.
The Hyperosmolar hyperglycemic state occurs when elevated blood sugar levels cause
severe dehydration and an increased osmolarity. HHS can be diagnosed with blood tests. With
HHS, plasma glucose levels are relatively high, being above 600 mg/dL. HHS can cause an
altered mental status, motor impairments, polydipsia, and possible death if untreated. In Mitch's
chart, HHS can be diagnosed from his blood glucose level being 1524 mg/dL, and serum
osmolality being 360 mmol/kg/h2o.
Diabetic ketoacidosis occurs more often in patients with type 1 diabetes, but may also
occur in those with type 2 diabetes. DKA is a result of decreased insulin, in which the body acts
to burn fatty acids and produce ketone bodies. Through blood and urine tests DKA can be
diagnosed. Hyperglycemia is common with DKA, as well as nausea, vomiting, thirst, increase
urine production, and severe abdominal pain. DKA can be diagnosed as mild with a pH of 7.257.3, moderate with a pH of 7-7.25, and severe with a pH below 7. If gone untreated, coma and
death may be results.
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 started for Mitch includes a rapid acting and extended long acting
form of insulin. Lispro is the rapid acting insulin, which is taken right before a meal to deliver
immediate insulin. Glargine is an extended long acting insulin, which delivers slow releasing
insulin to help control blood glucose levels. Glargine lasts from 18 to 26 hours without peaking.
Since Mitch is diagnosed with type 2 diabetes, insulin therapy would last until his blood glucose
levels remain in the range of 150-200 mg/dL.
11. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM.
Nutrition therapy for Mitch would include to promote weight loss, and spread out
carbohydrate intake throughout the day. Lispro would be needed right before eating a meal.
Between 50 to 60% of Mitch's calories should be carbohydrates, primarily simple carbohydrates,
10-20% being protein, and fats being 25-35%. Each meal should contain no more than 45-60
grams of carbohydrates. Saturated fats should be less than 7% , and trans fat to be strictly
limited. Fiber is suggested between 20 and 35g per day, and sodium should be less than 3000
mg/day. Since Mitch is on insulin, alcohol should be under 2 drinks per day.
12. Assess Mitch’s weight and BMI. What would be a healthy weight range for Mitch?
Mitch's weight = 214 lbs. Mitch's height = 5'9" = 69 inches or 175 cm
BMI = 703 x (lbs/in2) = 703 x (214/4761) = 31.6
BMI = 32
Mitch's BMI indicates him as obese. A normal BMI range is from 18.5 to 24.9, so a
healthy weight range for Mitch would be 125 to 168 lbs. Dropping just 6-8 pounds within
several months would be a SMART goal for Mitch in controlling his diabetes.
13. Identify and discuss any abnormal laboratory values measured upon his admission.
How did they change after hydration and initial treatment of his HHS?
Abnormal values in Mitch's laboratory values were BUN being 31 mg/dL, creatinine
serum being 1.9 mg/dL, glucose being 1524 mg/dL, inorganic phosphate being 1.8 mg/dL,
osmolality of 360 mmol/kg/h2o, triglycerides of 185 mg/dL, HbA1C of 15%, increased white
blood cells, positive protein balance in urine being 10, and presence of glucose and ketones in
urine. The increase lab results are due to Mitch's uncontrolled type 2 diabetes. BUN is
extremely high as Mitch is dehydrated. Blood glucose levels are extremely high, which leads to
an extremely high value for HbA1C. White blood cell count is elevated due to infection and type
2 diabetes. After hydrating and HHS treatment, BUN dropped to 20 mg/dL, blood glucose
dropped to 475 mg/dL, and osmolality dropped to 304 mmol/kg/h2o.
14. Determine Mitch’s energy and protein requirements for weight maintenance. What
energy and protein intakes would you recommend to assist with weight loss?
Harris-Benedict: M: 66.5 + 13.8W + 5H - 6.8A
Mitch's weight = 214 lbs. = 97 kg Mitch's height = 5'9" = 69 inches or 175 cm Mitch's Age = 53
IBW = 160 lbs = 73 kg
Calories = 66.5 + 13.8(73) + 5(175) - 6.8(53) = 66.5 + 1007.4 + 875 - 360.4
Calories = 1589 x factor (1.3) = 2066
Protein = 0.8g/kg/day = 58grams
Mitch's ideal body weight is being used to calculate kcals and protein, as he is obese and
we want to assist him with weight loss. A factor of 1.3 is also used as white blood cells are
elevated, and that activity will be accounted for. We recommend Mitch to consume around 2066
calories, and about 58 grams of protein each day to assist him with weight loss.
15. Prioritize two nutrition problems and complete the PES statement for each.
A nutrition problem would be the limited access to healthy food choices, and a preference
for fast foods high in carbohydrates. A PES statement would be - Elevated blood glucose levels
related to limited access to healthy food opposed to preferred access to fast foods as evidenced
by blood glucose levels of 1524 mg/dL.
Another nutrition problem is the excess of calories consumed, which surpasses the
needed amount of calories per day. A PES statement would be - Increased energy intake related
to abundance of carbohydrate consumption during lunch and dinner as evidenced by BMI of 32
categorized as obese.
16. Determine Mitch’s initial CHO prescription using his diet history as well as your
assessment of his energy requirements.
Noted in Mitch's usual diet intake is an abundant amount of carbohydrates consumed at a
given time. During lunch, Mitch consumes a fast-food sandwich, with a bag of chips. Both of
these foods results in over 45-60 grams of carbohydrates, which is the ideal amount of
carbohydrates per meal. During dinner, Mitch consumes a meal with potatoes or rice, or dines
out for ethnic foods, which are commonly high and above 45-60 grams of carbohydrates per
meal. In assessing Mitch's calories per day, 50-60% should be carbohydrates. Given the 2066
calories, around 1033 to 1240 calories should be carbohydrates.
17. Identify two initial nutrition goals to assist with weight loss.
A SMART goal for Mitch to assist with his weight loss would be to eat frequent small
meals throughout the day. If Mitch would be to consume 45-60 grams of carbohydrates per
meal, that would be 180 to 240 calories. Diving meals throughout the day and eating 5 to 6
meals a day can help Mitch reach his carbohydrate limit. Another SMART goal for Mitch can be
to increase activity. Recommended by the CDC is 2 hours and 30 minutes of activity each week
along with 2 days of muscle strengthening workouts. With extremely high or low blood sugar
levels, exercise should be avoided, but continued when the levels are stabilized.