Diabetes Case Study
YELENA TKACHENKO
FARIN FARAHZADI
LILYAN VOSGHANIAN
QUNDEEL “Q” KHATTAK
TATIANA KIESEWETTER
1.) Mrs. R’s IBW and % IBW :
2.) Calculate Mrs. R’s BMI and Interpret the results:
 Hamwi Method for Females: 100lb for 5ft + lb/inch over or under 5ft.
 a.) IBW: 100 lbs + ( 5 lb /inch x 6 inch= 30) → 100lb + 30 lb= IBW is
130 lbs
 b.)% IBW= Current Weight/ Ideal Body Weight x 100%
210 lb/130 lb = 1.62 x 100% = % IBW is 161.5
 BMI = weight (kg) / height in (m)2
95.4 kg/ 167.64 cm →
95.5 kg /( 1.68 m)₂ → BMI = 33.82
Her BMI of 34 is an indicator that she is morbidly obese
3.)
Calculate Mrs. R’s LDL in Table 3:
Mrs. R Lab Results:
Total
Cholesterol
300 mg/dl
Formula for LDL (mg/dl) = TC- (HDL + 0.2 TG)
300 mg/dl – (30mEq/L + 0.2 x 350 mg/dl) →
HDL
30mEq/L
TG
350 mg/dl
300mg/dl – ( 30mEq/L + 70 mg/dl)→
300 mg/dl – (100 mg/dl) = LDL is 200 mg/dl
4.) is the HbA1c and how is it used in diabetes?
 HbA1c is a form of hemoglobin that has been gylcated. It is
used to measure how much glucose is circulating in the
bloodstream because of how HbA1c and glucose interact. If
glucose levels are high, the glucose will slowly and
irreversibly attach to proteins in plasma. It is a valuable
long term indicator to investigate the last 2-3 months of an
individual’s average blood glucose level. It is particularly
valuable because short term factors such as food intake,
exercise or stress will not affect the level of glycated HbA1.

American Diabetes Association. Symptoms. Retrieved from http://www.diabetes.org/diabetes-basics/symptoms/
5.) List the Symptoms of Type 2 Diabetes that are
manifested in Mrs. R:
 Polyphagia
 Polyuria
 Polydipsia
 Fatigue
 Vision has become blurred
 Frequent bladder infections
6.) Explain the pathophysiology
of these symptoms:
Polyuria: Occurs due to high amounts of solutes within the renal tubule cause a passive
osmotic diuresis (solute diuresis) and thus an increase in urine volume. An example of this
process is the glucose-induced osmotic diuresis in uncontrolled diabetes mellitus, when
high urinary glucose levels (> 250 mg/dL) exceed tubular reabsorption capacity, leading to
high glucose levels in the renal tubules; water follows passively, resulting in glucosuria and
increased urine volume.
(Merks Manual for Health Care Professional, 2012)
Polydipsia: Dehydration results from osmotic diuresis then leads to decreased circulation
blood volume and decreased blood pressure. The fall in blood pressure triggers
homeostatic mechanisms for maintaining blood pressure , including secretion of ADH,
thirst that causes constant drinking (polydipsia) and cardiovascular compensations.
Sillverthorn U., Dee.(2009) Human Physiology: Metabolism and Energy Balance(4th ed.) San Francisco:
CA Person Benjamin Cummings. pg 736
Polyphagia: The
metabolism of the brain is not insulin dependent , however, neurons in
the brains’ satiety center are insulin sensitive . Thus, the absence of insulin , the satiety
center is unable to take up plasma glucose. The center unable to take up glucose perceives
itself as experiencing starvation and allows the feeding center to increase food intake.
Sillverthorn U., Dee.(2009) Human Physiology: Metabolism and Energy Balance(4th ed.) San Francisco:
CA Person Benjamin Cummings. pg 736
6.) Continued
 Fatigue: Many factors can contribute to this. They include dehydration
from increased urination and body's insulin resistance and inability to
function properly and perform metabolism and lowered plasma volume
produces weakness and fatigue.
Sillverthorn U., Dee.(2009) Human Physiology: Metabolism and Energy Balance(4th ed.) San Francisco:
CA Person Benjamin Cummings. pg 737
 Blurred Vision : Blurred vision develops as the lens and retina are
exposed to higher osmolar fluids. Lowered plasma volume produces
weakness and fatigue.
Mattson, Carol .Essentials of Pathophysiology: Concepts of Altered Health States: 3rd ed. Wolters Kluwer
Company Philadelphia: PA pg 811
 Frequent Bladder Infections: Incomplete bladder emptying
caused by autonomic neuropathy permits urinary colonization of some
microorganisms in the presence of high glucose concentration.
Aubert, Ronald. (1995) Diabetes in America 2nd ed. Diane Publishing Company pg 485-487
7.) Define these terms:
 Polydipsia: Excessive thirst
Cohen, Barbara (2011) Medical Terminology 6th ed. Wolters Kluwer Health Philadelphia: PA pg 287
 Polyphagia: Excessive or voracious eating
Cohen, Barbara (2011) Medical Terminology 6th ed. Wolters Kluwer Health. Philadelphia: PA pg 287
 Polyuria: Elimination of large amounts of urine, as in diabetes
mellitus
Cohen, Barbara (2011) Medical Terminology 6th ed. Wolters Kluwer Health. Philadelphia: PA pg 287
8.) What evidence did the MD have that suggested
that Mrs. R was dehydrated?
 Increased values for serum sodium, albumin, blood urea nitrogen
(BUN), and creatinine are good indications of dehydration.
 Increased output of urine can lead to dehydration.
9.) What labs may be elevated due to dehydration?
 Dehydration causes everything in the body to rise superficially.
 Other labs that may be elevated are serum protein, Hgb, Albumin, Hct,
Mg, and Na.
10.) On what basis did the MD decide that Mrs. R
was anemic?
 Anemia is characterized by Hgb values below 95% of total blood volume
 Hydration problems can mask nutritional anemia
 Hgb levels are mid range
 MCV, MCH, and MCHC values are below conventional levels
 We can determine that Mrs. R has microcytic anemia, associated with
Fe deficiency. (Table 1.14)
11.) After Mrs. R’s BS is corrected, what changes in
other blood values would you expect? Explain.
 A1c values ↓
 Total cholesterol, LDL, and TG and B.P. ↓
 HDL values will ↑
 When blood sugar is maintained in the system, then carbohydrate, protein and
fat metabolism will be restored.
 When insulin is sufficient,” it activates the transport system of glucose into
muscle and adipose tissue; lowers blood amino acids in parallel with blood
glucose levels; activates lipoprotein lipase, facilitating transport of triglycerides
into adipose tissue.” (Mahan, 2012)
 “Promotes storage and facilitates conversion of glucose to glycogen for storage
in muscle and liver; stimulates protein synthesis; facilitates conversion of
pyruvate to FFA, stimulating lipogenesis.” (Mahan, 2012)
 “Insulin prevents the breakdown and release of glycogen from liver; inhibits
protein degradation, diminishes gluconeogenesis; inhibits lipolysis, prevents
excessive production of ketones and ketoacidosis.” (Mahan, 2012)
12.) What is considered to be good control for BS for
someone with diabetes and what is considered poor
control?
 Good control is fasting blood glucose at 70-130 mg/dL; post meal <180
mg/dL.
 Anything below the fasting blood glucose means hypoglycemic, and
anything above post meal means hyperglycemic.
13.) Why should the physician be concerned about the
abnormal lipid profile of a person with diabetes who is
out of control like Mrs. R?
 Long-term complications associated with diabetes are
macrovascular disease (disease of large blood vessels), ex: CHD,
and microvascular disease (disease of small blood vessels), which
includes nephropathy, retinopathy, and diabetic neuropathy
which is a nerve damage.
 People with type II DM typically have smaller, denser LDL
particles, which increase athrogenicity (clogged arteries).
 Combination of these diseases will lead to metabolic syndrome:
obesity, dyslipedimia, hypertension, and glucose intolerance.
14.) Describe the function of glipizide and list any
nutritional complications?
 Glipizide (Glucotrol) is in a class of medications called sulfonylureas.
 This medication promotes insulin secretion by the beta cells of the
pancreas.
 Disadvantages may include weight gain, and potential to cause
hypoglycemia.
 No nutritional complications found.
15.)Describe the function of pravastatin sodium and list
any nutritional complications. Why did the physician tell
Mrs. R to take it at bedtime?
Medication prescribed for lowering high cholesterol and triglycerides

Inhibits production of cholesterol by liver by inhibiting enzyme HMG-CoA reductase
Drug/Drug Interactions
Colchicine: The risk of myopathy/rhabdomyolysis is increased with simultaneous
administration of colchicine
 Fibrates: Because it is known that the risk of myopathy during treatment with HMG-CoA
reductase inhibitors is increased with concurrent administration of other fibrates,
 Niacin: The risk of skeletal muscle effects may be enhanced when pravastatin is used in
combination with niacin; a reduction in Pravachol dosage should be considered in this
setting

Alcohol



Alcohol can interact with certain medicines.
In the case of Pravastatin sodium:
There are no known interactions between alcohol and Pravastatin sodium
Diet



Medicines can interact with certain foods.
In the case of Pravastatin sodium:
There are no specific foods that you must exclude from your diet when taking Pravastatin
sodium
(C. Song, personal communication, October 12, 2012) confirmed information above.
15.) Continued

Study:

Increased toxicity when fibrates and statins are administered in combination--a
metabolomics approach with rats.

fatal side-effects like rhabdomyolysis followed by acute renal necrosis sometimes occur

doses of 100 mg/kg fenofibrate, 50mg/kg clofibrate, 70 mg/kg atorvastatin and 200 mg/kg
pravastatin as well as combinations thereof were administered to rats for 4 weeks

Plasma metabolome profile was measured on study days 7, 14 and 28

Upon study termination, clinical pathology parameters were measured

Lowering of blood lipid levels as well as toxicological effects, like liver cell degradation (statins) and
anemia (fibrates) and distinct blood metabolite level alterations were observed in monotherapy

When fibrates and statins were co-administered metabolite profile interactions were generally under
additive – fibrates and statins did not act on the body in the same way

However, more metabolite levels were significantly altered during combination therapy.

New effects on the antioxidant status and the cardiovascular system were found which may be related
to a development of rhabdomyolysis
16.) Mrs. R’s BP was 150/88. What is the current
recommended BP for Mrs. R?
 150/180 = Stage I Hypertension
 Recommended BP for Mrs. R would be the normal recommendation =>
120/80
Blood Pressure
Category
Systolic mm Hg
(upper #)
Diastolic mm Hg
(lower #)
Normal
Less than 120
and
Less than 80
Pre-hypertension
120-139
or
80-89
Hypertension Stage
I
140-159
or
90-99
Hypertension Stage
II
160 or higher
or
100 or higher
Hypertensive Crisis
Higher than 180
or
Higher than 110
17.) What is metabolic syndrome and what symptoms of
metabolic syndrome does Mrs. R demonstrate?
 Metabolic syndrome is a combination of metabolic risk factors such
as:
 Central or abdominal obesity (measured by waist circumference):


Men - Greater than 40 inches
Women - Greater than 35 inches
 Fasting blood triglycerides greater than or equal to 150 milligrams
per deciliter of blood (mg/dL)
 Blood HDL cholesterol:
 Men - Less than 40 mg/dL
 Women - Less than 50 mg/dL
 Blood pressure greater than or equal to 130/85 millimeters of
mercury (mmHg)
 Fasting glucose greater than or equal to 100 mg/dL meaning there’s
insulin resistance or intolerance
 Mrs. R demonstrates all!
18.) Describe the relationship between obesity, diabetes,
and metabolic syndrome.
 Metabolic syndrome is a combination of metabolic risk
factors, which includes obesity, high LDL levels, low HDL
levels, high blood pressure, and insulin resistance or
intolerance. A patient is said to have metabolic syndrome, if
they demonstrate two or more of these risk factors. In the case
of Mrs. R, she demonstrates all complications mentioned
above; therefore, if she loses weight, she will reduce her total
cholesterol thus increasing her HDL, and maximize her
insulin efficiency ultimately ridding her of metabolic
syndrome.
19.) Prepare a NCP note and write PES statement for
Mrs. R up to this point.
 Obesity with Type II Diabetes (P) is related to family
history, physical inactivity, and consumption of lownutrient dense foods (E) as evidenced by high intake of
processed foods, sweets, foods high in saturated fats and
sodium, as well as little to no dairy intake (S).
20.) Approximate Mrs. R’s energy needs for weight
reduction.
 Female
 Height = 5’6” = 167.64cm
 Age = 48 years
 IBW = 100 + 5(6) = 130lbs/2.2= 59.1kg
 Harris Benedict (Women)
655 + (9.6 x wt in kg) + (1.8 x ht in cm) – (4.7 x age in yrs) x AF
655 + (9.6 x 59.1kg) + (1.8 x 167.64 cm) – (4.7 x 48yrs) x 1.4
655 + 567.36 + 301.75 – 225.6 x 1.4
1,817.9kcal = TEE
21.) Would you prescribe a 1000 kcal diet? Why or why
not?
 No, prescribe an 1,800 kcal diet instead (based on the HB formula).
 Mrs. R’s condition is serious; she continues to gain weight – needs to
make a drastic change in terms of weight loss and caloric intake to help
control her blood sugar; however, 1,000 would be too drastic.
 1,800 kcal will also benefit her as she becomes more physically active.
22.) What recommendations for dietary intervention
would you give Mrs. R? Carbohydrate Counting method
or the standard Exchange Lists for Meal Planning?
 Encourage Mrs. R to implement lifestyle modifications that reduce intakes
of energy, saturated fats, cholesterol, and sodium and to increase physical
activity
 Plasma glucose monitoring can be used to determine whether adjustments
in foods and meals will be sufficient to achieve blood glucose goals or if
medication(s) needs to be combined with MNT
 Implement a dietary pattern that includes carbohydrate from fruits,
vegetables, whole grains, legumes, and low-fat milk
 Monitor carbohydrate, whether by carbohydrate counting or exchanges
 Limit intake of saturated fats and cholesterol
 Increase consumption of protein – will aid in weight loss
22.) Continued
 Recommend standard Exchange Lists for Meal
Planning:
 Advantages






Offers variety and versatility to the person with diabetes
It provides a framework to group foods with similar carbohydrate,
protein, fat, and calorie contents
It emphasizes important management concepts, such as carbohydrate
amounts, fat modification, calorie control, and awareness of highsodium foods
By making food choices from each of the different lists a variety of
healthful food choices can be assured
It provides a system that allows individuals to be accountable for
what they eat
Accurate and convenient
23.) The guidelines for meal plans for people with diabetes allows for a limited amount of sugar
to be incorporated into the meal plan. Think about how you would persuade Mrs. R to limit her
sugar intake and describe how you would teach her to use sugar in her meal plan. Include in
your discussion any possible pitfalls of allowing sugar in the meal plan.
Ways to Persuade to
Reduce Her Sugar
Intake
Ways to Teach How to
Use Sugar in Her Meal
Planning
Pitfalls of Allowing
Sugar in the Meal Plan
Measure out amount of actual
sugar in junk foods she consumes
Bake at home and use sugar
substitutes
Create a daily meal plan that
includes balanced meals to
ultimately reduce her sweet
cravings
Offer recipes with fewer calories
and carbohydrates
Overusing and overeating of sugar
will wipe out the calorie and
carbohydrate savings resulting in
weight gain and increase in blood
glucose levels
To satisfy sweet cravings, suggest a
piece of fresh or dried fruit or a
fruit salad
Educate ways to use her calories
wisely by setting a “budget control”
for sweets
Save sweets and desserts for special
occasions
Keep portions small when
including a treat in the meal
Demonstrate the practice of portion
control
Teach her how to read nutrition
facts labels and identify serving
sizes, total carbohydrates and
carb-containing foods in her meals
24.)Describe the Native-American foods, fry bread and
wojapi.
 Fry bread is flat dough fried or deep fried in oil, shortening, or lard. It
is leavened by yeast or baking powder, and can be eaten alone, or with
toppings such as honey, or ground beef, tomatoes, cheese, onions, and
lettuce.
 Wojapi is a thick berry dish, with a consistency of pudding. It is made
with flour or cornstarch, sugar, and berries.
25.)What nutritional deficiencies are likely to result
from following the diet Mrs. R described? Explain.
 Deficiency in B Vitamins, especially B12, due to lack of meat
consumption.
 Deficiency in Vitamin A, Vitamin D and Calcium due to lack of milk
consumption.
 Iron, Folate, Potassium, Vitamin A, Vitamin C and Fiber deficiencies
due to limited variety of fresh vegetables and fruits.
26.)What behavioral changes would you recommend to
Mrs. R to help her keep her dietary and treatment goals?
 Keep a daily food log to track her caloric and carbohydrate intake
 Visualize her plate
 Follow a special meal plan that includes a variety of foods containing a




mixture of carbohydrate, protein and fat.
Monitor her BP on a weekly basis and BS levels on daily basis.
Eat snacks that will 1) keep her full and 2) blunt the effects of certain foods
on blood glucose. Ex: adding a tablespoon of peanut butter to an apple will
tame the apple’s effect on blood glucose level.
Strongly encourage her to loose weight – begin a walking/jogging
program, 4 to 5 times a week.
Lower her blood pressure


Lower her intake of sodium
Continue to work in the garden but incorporate yoga/meditation in her routine
 Stay consistent with her medications to insure stable lab results and
controlled BS and BP levels.
 Be compliant and visit the CDE dietitian, nurse and physician on a weekly
basis.
27.) Prepare a Meal Plan using Exchange Method
and Carbohydrate Counting
 Type II DM Exchange List
 MNT for Type II DM: Step II Diet is recommended
Based on a 1800 Kcal/day Meal Plan
CHO = 55% Total Calories= 990 kcal/4 kcal = 248grams
PRO = 15% Total Calories, (20% for Mrs. R) = 360 kcal/4kcal = 90 grams
FAT= <30% total Calories, (25% for Mrs. R) = 450kcal/ 9kcal= 50grams
27.) Continued
Group Listz
Serving
Size
CHO
(g)
PRO (g)
Fat (g)
Kcal
Starch
8
120
24
8
640
Fruit
6
90
--------
-------
360
Vegetables
8
40
16
-------
200
56
8
280
30
270
CHO group
Milk
Total CHO
250g
Meat Substitutes
Total Protein
8
Fat Group
6
Total Fat
Total Kcal
-------
96 g
-------
-------
46 g
1750 kcal
27.) Continued
Breakfast:
1 tortilla (6 inch) = 15 grams
1 banana (small) = 15 grams
1 peach (small) = 15 grams
½ cup cooked squash = 5 grams
Total CHO: 50 grams
Morning Snack:
1 apple = 15 grams
1 cup raw carrot = 5 grams
1 cup raw celery = 5 gram
Total CHO: 25 grams
Lunch:
1/3 cup brown rice = 15 grams
1/2 cup beans = 15 grams
1/2 cup mashed potato = 15 grams
1 cup of green = 5 grams
I cup peppers = 5 grams
1 tbsp salad dressing, fat-free = 5 grams
Total CHO: 60 grams
Afternoon Snack:
2-5 whole wheat crackers= 15 grams
1 small orange= 5 grams
I cup sugar snap peas = 5 grams
Total CHO: 25 grams
Dinner:
1/2 cup corn = 15 grams
1/2 cup cooked lentils = 15 grams
1/2 cup cooked pasta = 15 grams
1 ¼ cup watermelon, cubes= 15 grams
1/2 cup red peppers = 5 grams
1/2 cup cooked spinach= 5 grams
Total CHO: 70 grams
Midnight Snack:
Sugar-Free Candy = 5 grams
3 medium prunes = 15 grams
Total CHO = 20 grams
Total CHO count for the entire day: 250 grams
28.) Determine Mrs. R’s LDL levels in Tables 4 and 5
 LDL (mg/dl )= TC-(HDL+ 0.2 TG)
Table 4: Results after 3 months
224 mg/dl – (*35 mg/dl + 0.2 x 185 mg/dl) = 152 mg/dl
Table 5: Results after 6 months
200 mg/dl – (**38 mg/dl + 0.2 x 150 mg/dl) = 132 mg/dl
*1) 35mEq/L x (1.0mmol per L/40 mEq per L) = 0.9mmol/L
2) 0.9 mmol/L x (130 mg per dl/3.4 mmol per L) = 34.4 or 35 mg/dl
** 1) 40 mEq/L x(1.0 mmol per L/40 mEq per L) =1.0 mmol/L
2) 1.0 mmol x(130 mg per L/3.4 mmol per L) = 38.2 or 38 mg/dl
29.) Define Humulin N and R Insulin
 Humulin (insulin human recombinant) is synthesized in a special non-
disease-producing laboratory strain of E. coli bacteria that has been
genetically altered to produce human insulin. The concentration is 100
units/mL (U-100).
 Humulin N: crystalline suspension of human insulin with protamine
and zinc, provides an intermediate-acting insulin with a slower onset of
action (2-4 hrs), peak action (4 -10 hrs) and a longer duration of activity
(up to 16-24 hrs). Very individualized. Only SQ (subcutaneous).
 Humulin R: sterile, clear, aqueous, and colorless solution that contains
human insulin (rDNA origin) 100 units/mL, glycerin 16 mg/mL and
metacresol 2.5 mg/mL, endogenous zinc (approximately 0.015 mg/100
units) and water for injection. Short-acting insulin with fast onset (0.5-1
hr), peak action (2-4 hrs) and shorter duration (3-6 hrs). Requires to be
injected 30 to 60 min before meals. May be used in combination with oral
antihyperglycemic agents or longer-acting insulin products. SQ/IV.
 Drug/food interactions: alcohol (causes hypoglycemia/hyperglycemia)
30.) Research the insulin Lantus and describe how it
may help Mrs. R.
 Study: Lantus by Sanofi-Aventis U.S. LLC
 Controlled clinical trials in adults (n=3890) and in pediatric patients (n=349)
 Production organism is E. Coli. Insulin glargine differs from human insulin in
that the amino acid asparagine at position A21 is replaced by glycine and two
arginines are added to the C-terminus of the B-chain.
30.) Continued
 Insulin glargine is a human insulin analog that has been designed to have low
aqueous solubility at neutral pH. At pH 4, as in the LANTUS injection solution,
it is completely soluble. After injection into the subcutaneous tissue, the acidic
solution is neutralized, leading to formation of microprecipitates from which
small amounts of insulin glargine are slowly released, resulting in a constant
concentration/time profile over 24 hours with no pronounced peak.
30.) Continued

Mrs. R’s worsening overtime condition was due to her refusal to
follow specialized meal plans and not taking her medications in a
timely and proper manner plus her low economic status.
Mrs. R and benefits of Lantus:
 Once a day dose, SQ only, usually HS (at bedtime).
 Recommended (DM type 2) 10 units,
with monitoring and adjustments
 Slow dissolution at the injection site with a
constant and peakless delivery over 24 hrs
31.) What is the action of Precose and what are its side
effects?
Mechanism of action: works in the small
intestine as a competitive inhibitor of intestinal
brush-border alpha-glucosides required for
breakdown of carbohydrates, thereby delaying
carbohydrate absorption and lowering
postprandial (after a meal) glycemia.
Side effects: Flatulence, diarrhea, cramping,
abdominal pain
Interactions: drug/drug (activated charcoal,
digestive enzyme products: amylase, pancreatin),
metoprolol. No food interaction.
Precose (acarbose tablets): oral alpha-glucosidase inhibitor for use in the management of type 2 diabetes
mellitus. Acarbose is an oligosaccharide which is obtained from fermentation processes of a
microorganism, Actinoplanes utahensis.
32.) Describe fully the process of insulin resistance.
Insulin resistance (or metabolic syndrome)
is a condition in which the cells of the body
become resistant to the effects of insulin. One
of insulin's responsibility is to get body cells to
"open up" to take in glucose (or to store the
glucose as fat). When cells don’t open, the body
puts out more insulin to stabilize blood glucose.
Overtime cells become insulin resistant due to
their trying to protect themselves from the toxic
effects of high insulin. They down-regulate their
receptor activity and number of receptors so
that they don't have to be subjected to all that
stimuli all the time. Since the pancreas can't
always keep up that high level of insulin
production forever, the production of insulin
starts slowing down, or the resistance goes up,
then blood sugar goes up and the person
becomes a diabetic.
33.) List the aspects of Mrs. R’s case that indicate
insulin resistance.
 Waist circumference 42” (normal <35”)
 Genetics (Native American)
 High-fat diet (fried bread, wojapi, potato chips, etc.)
 Obesity (BMI 35)
 Elevated BP (150/88)
 Glucose intolerance (353 mg/d : 3 times more than normal)
34.) What is the action of Glucophage and what are its
side effects?
Mechanism of action:
• Metformin activates AMPK, the cellular energy sensor.
Activation of AMPK leads to suppression of many of the
processes highly dependent on ATP, such as
gluconeogenesis (formation of glucose, especially by the
liver, from non-carbohydrate sources, such as amino acids
by pathways mainly involving the citric acid cycle and
glycolysis), protein, fatty acid, and cholesterol biosynthesis.
• It inhibits transcription of gluconeogenesis genes in the
liver and ↑ glucose uptake in skeletal muscle. Thus ↓ the
levels of circulating glucose, ↑ insulin sensitivity and ↑
peripheral glucose uptake, and ↓ the hyperinsulinemia
associated with insulin resistance. It also improves lipid
levels.
Side effects: GI distress (nausea, abdominal
pain, & diarrhea) and Lactic acidosis (low pH,
lactate buildup, fatal)
Food/drug interactions: ↓ Vitamin B12 ,
Ca, Folic Acid, Cr.
Metformin: antihyperglycemic agent, class
biguanides (insulin sensitizer), molecular
formula of C4H11N5 • HCl , requires the
presence of insulin, Unlike sulfonylureas,
metformin does not produce hypoglycemia.
35.) This has been a long ordeal for Mrs. R. with many opportunities for her to
become discouraged. Try to imagine what it would be like to be her dietician and
to be counseling her through this ordeal. What advice would you give Mrs. R?
 Nutrition assessment, diagnosis, monitoring and evaluation:
 1st) Theoretical Basis/ transtheoretical model
o
o
o
o
o
Precontemplation: reflection on patients attitude (be understanding)
Contemplation: no intention for change for next 6 months (discuss barriers)
Preparation: intends to take an action in next 6 months (set specific goals)
Action: intends to take action within next 30 days (eliminate triggers, use self-help)
Maintenance: changes for more than 6 months (encouragement, reinforcement)
 2nd) Health Belief model
o
Intervention, education, motivation and reinforcement to take health-related actions
 Detailed explanation of food-planning approaches:
o
o
o
Diabetes nutrition guidelines
Carbohydrate counting
Exchange lists
 Healthcare programs information (Medical, Medicare, Food stamps)
 Family/friends support
Final PES Statement
 Mrs. R has excessive caloric intake of
nutrient lack food and reduced intake of
nutrient dense food as related to her high fat,
carbohydrate, high sodium in processed food
convenience foods and absence of dairy,
fruit, and low protein as evidenced by her
high BMI (obese) and fasting GLU levels of
353 mg/dl and lack of physical exercise.
References
American Diabetes Association. (2012). Baking with sugar substitutes: Tips and recipes. Retrieved from
http://forecast.diabetes.org/baking-oct2012?loc=footer1_forecast-baking-sugar-substitutes_oct2012
American Diabetes Association. (2012). Symptoms. Retrieved from http://www.diabetes.org/diabetesbasics/symptoms/
American Heart Association. (2011, August 24). Metabolic Syndrome. Retrieved from
http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/Symptoms-and-Diagnosisof-Metabolic-Syndrome_UCM_301925_Article.jsp
Cohen, Barbara (2011) Medical Terminology 6th ed. (PP 287) . Wolters Kluwer Health. Philadelphia: PA
Franz, M. (2008) MNT from Diabetes Mellitus and hypoglycemia of nondiabetic origin. In Mahan, K.,
Escott-Stump, S. Krause’s Food and Nutrition Therapy (pp.764- 800). St. Louis: Saunders Elsevier
Press.
Insulin Glargine (n.d.). Retrieved October 10, 2012 from US National Library of Medicine website:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a600027.html
Insulin Injection (n.d.) Retrieved October 10, 2012 from US National Library of Medicine website:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682611.html
Mahan, L.K., Escott-Stump, S. (2012). Krause’s Food and the Nutrition Care Process.
Philadelphia, PA: W.B. Saunders Company.
Mattson, Carol .Essentials of Pathophysiology: Concepts of Altered Health States: 3rd ed. Wolters Kluwer
Company Philadelphia: PA pg 811
Metformin. (n.d.). Retrieved October 10, 2012 from US National Library of Medicine website:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a696005.html
References
Metformin. (n.d.). Retrieved October 10, 2012 from US National Library of Medicine website:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a696005.html
Mihesuah, D.A. (2012). Traditional Indigenous recipes. Retrieved from
http://www.aihd.ku.edu/recipes/wojapi.html
Polyuria (n.d). Retrieved October 9, 2012. from the Merk Manual for Health Care Professionals website:
http://www.merckmanuals.com/professional/genitourinary_disorders/symptoms_of_genitourinary_d
isorders/polyuria.html
Pub med Health. (July 15, 2011). Glipizide. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000834/
Sanofi-Aventis U.S. LLC (2007). Lantus (insulin glargine) injection. (2007). Retrieved October 10, 2012
from Sanofi- Aventis Archived Drug-Label website:
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=3517#section-4
Sillverthorn U., Dee. (2009) Human Physiology: Metabolism and Energy Balance(4th Ed.).(PP 736). San
Francisco: CA Person Benjamin Cummings.
Strauss, V., Mellert, W., Wiemer, J., Leibold, E., Kamp, H., Walk, T., . . . van Ravenzwaay, B. (2012).
Increased toxicity when fibrates and statins are administered in combination--a metabolomics approach
with rats. Experimental Toxicology and Ecology, 211(2), 187-200.
Theoretical Basis. (2012). In Academy of Nutrition and Dietetics (4th Ed.), Pocket guide for international
dietetics and nutrition terminology (IDNT) reference manual. (PP.316-328). Chicago: Academy of
Nutrition and Dietetics Press.
U.S. Food and Drug Administration. (2012, February). Safety - Pravachol (pravastatin sodium) Tablets.
Retrieved from http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm295627.htm