Karla Moreno
913583065
484
Case #17
Adult Type 2 Diabetes Mellitus: Transition to Insulin
Understanding the Diagnosis and Pathophysiology
1. What are the standard diagnostic criteria for T2DM? Which are found in
Mitch’s medical record?
The Criteria for Diagnostic Diabetes is the following:
Symptoms of diabetes plus casual plasma glucose concentration

200 mg/dL
Or Fasting Plasma Glucose concentration

126mg/dL or 2-hour post-prandial glucose

200 ml/dL during an oral glucose tolerance test
Considering diagnosis criteria in Mitch’s medical record we can see that the reason for admittance to the hospital is hyperglycemia (1,524 mg/dL), despite that he also shows the following diagnose criteria to assume that this is T2DM instead of T1DM:
- Genetic correlation (mother T2DM)
- BMI 31.77 Obese
- Previous Diagnose of T2DM (patient admits to do not take pills)
- Vascular Disease Hiperlipidemias
- Dehydration (Caused by Poliuria)
- HHS Hyperosmolar Hyperglycemic State
- Deep gasping breathing
2. Mitch was previously diagnoses 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 drug in the biguanides class that suppresses glucose production by the liver and increase insulin uptake in muscle. Metformin is the most common oral drug to treat T2DM. The side effects that have been found by taking this drug are primarily related with GI alteration: diarrhea, stomach pain, gas, indigestion, bloating, nausea, heartburn, constipation, metallic taste in mouth and

Karla Moreno
913583065
484 headache. Is very uncommon found more serious side effects such as rash, chest pain or lactic acidosis; Metformin did not cause hypoglycemia and helps to weight control and may be CV benefits. Metformin is contraindicated in renal and liver failure.
Glyburide: it’s a Sulfonylurea agent that stimulates insulin secretion; it is inexpensive and has a long history of effectiveness, only needs to be take one time a day. As a disadvantage, can cause hypoglycemia, weight gain and it is also contraindicated in renal insufficiency.
3. HHS and DKA are the common metabolic complications associated with diabetes. Discuss each of these clinical emergencies.
De scribe the information in Mitch’s chart that supports the diagnosis of HHS.
HHS, Hyperosmolar Hyperglycemic State, is a very common complication in T2DM, where sever sugar concentration in blood can cause severe dehydration and due that increase osmolarity developing high-risk complication: coma and dead.
Some of the symptoms related with HHS are mental and neurologic alterations and polydipsia.
DKA , Diabetic Ketoacidosis, is a result of an excessive production of ketones bodies as an energy source. DKA may be the first way to diagnose diabetes, and is more common on T1DM than on type 2. Some of the common symptoms are vomiting, dehydration, deep gasping breathing, confusion and occasionally coma.
Both of these are serious complications of Diabetes, but the major difference between them is that in HHS, serum glucose levels are extremely high, usually greater than 40-50 mmol/L but a metabolic acidosis is absent or mild. Mental alteration is more common in HHS than in DKA.

Karla Moreno
913583065
484
In Mitch presents mental alteration, dehydration and his serum levels are high:
BUN
Creatinine Serum
Glucose
Osmolarity
Normal
8-18
0.6-1.2
70-110
285-295
Mitch Labs when admission
31

1.9

1,524

360

4. Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine?
Mitch’s insulin therapy begin with Lispro 0.5 unites every 2 hours until glucose is between 150 -200 mg/dL. Glargine: 19 units and nighttime.
Lispro: using ICR means 1:15 every 15gr of Carbohydrates 1 unit of Lispro
(Insulin Carbs
Ratio)
Lispro: is a Rapid- Acting Insulin Analog, and works by replacing insulin that is usually in the body. It also helps to lower glucose production in liver. It should be administered between 5-15 minutes before meals; the peak of action is 30-90 minutes after provision and acts during 3-5 hours.
Glargine: is an Extended Long-Acting Analog, it should be administered between 2-4 hour before desire effect, this insulin type is peak less and the duration of action is between 20-24 hours. It cannot be mixed with other insulins
5.
Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM.
Mitch will start insulin shots as a part of the medical therapy to control his diabetes.
For this nutrition therapy is very important and a diet must be followed carefully in order to administered insulin. We have same priority to prevent hyperglycemia as same as hypoglycemia. Carbohydrates must be distributed in different intakes through the day

Karla Moreno
913583065
484
Mitch must follow and hypo caloric diet with the following macrodistribution:
- Carbohydrates: 50%
- Protein: 30%
- Fat: 20 %
6. Assess Mitch’s weight and BMI. What would be a healthy weight range for
Mitch?
To place Mitch in a healthy weight, his weight must be between 125.3
– 169.3 pounds base on the recommendations of a healthy BMI weight.
If we use Robinson Formula, Mitch’s IBW is 152.3 pounds.
H : 5’9” 175.26 cm
W: 214 Lb 97.3 kg
BMI: 31.77
If I consider that Mitch is a mildly obese 53 years men, we can set as and ideal weight 170 pounds being this the most realistic and approachable weight.
7. Identify and discuss any abnormal laboratory values measured upon his admission. How did they change after hydration and initial treatment of his
HHS?
Sodium, BUN, Creatinine Serum, Glucose, Phosphate inorganic and osmolality are altered in lab results. All this is known as an HHS Hyperosmolar Hyperglycemic
State, this is as a result of hyperglycemia in blood causing severe dehydration in the patient.
Once hydration and insulin therapy is started we can see some modification in the results. Blood is becoming less sticky because sugar is being normalized and hydration in being correct also which facilitated transportation of nutrients. Even that lab results still show a disorder; some of them such as BUN, Creatinine Serum,
Phosphate inorganic and Osmolality are almost reaching normal ranges as we can see in the following table:

Karla Moreno
913583065
484
Chemistry
Sodium (mEq/L)
Ref. Range
136-145
BUN (mg/dL) 8-18
Creatinine Serum (mg/dL) 0.6-1.2
4/12
132
31
1.9
Glucose mg/dL) 70-110
Osmolality (mmol/kg2/h2o) 285-295
1,525
360
4/13
134
20
1.3
475
304
Besides the HHS we can notice that patient presents Hyperlipidemia (cholesterol and triglycerides higher levels), some protein, keton bodies and glucose are being excreted by urine.
8. 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
REE: 66.47 + (13.75 x w kg) + (5.003 x H cm) – (6.755 x Y)
66.47 + (13.75 x 77) + (5.003 x 175) – (6.755 x 53)
REE: 1, 643 x 1.08
TEE: 1, 774 kcal – 300 weight loss = 1,474 kcal

Karla Moreno
913583065
484
9. Prioritize two nutrition problems and complete the PES statement for each
1. Inadequate energy intake related to a lack of nutritional education and lack of healthy choices (restaurant eating) as evidence by a BMI of 31.7 Obesity range
2. Inconsistent carbohydrates intake and distribution related to a lack of education or nutrition knowledge evidence by food frequency in medical record
10.
Determine Mitch’s initial CHO prescription using his diet history as well as your assessment on his energy requirements

Karla Moreno
913583065
484
11. Identify two initial nutrition goals to assist with weight loss
1. Limit Calorie Intake to 1,450 kcal per day 324 less kcal per day
2. Initiation of a Physical Activity Program. At least 30-45 min 3-4 times per week in order to promote weight loss and insulin dose