Melanie Boney
NUTN 511
02/22/2010
Case Study # 3: Diabetes
ASSESSMENT:
Client History:
Mrs. Douglas is a mildly obese 71-year-old African American female admitted with high blood glucose
measured, an unhealed ulcer on her left foot, blurry vision, Stage 1 HTN, and elevated total cholesterol.
PMH: HTN
Family History: Sister was diagnosed with type 2 DM 10 years ago
Current Medications: Capoten, Cipro, and sliding scale Humulin
Biochemical Data:
Blood Glucose (mg/dL)
HbA1C (%)
Cholesterol (mg/dL)
LDL (mg/dL)
HDL (mg/dL)
HGB (g/dL)
HCT (%)
Admittance
325
8.5
300
140
35
9.9
30.4
Discharge
121
250
138
37
10.1
29.7
Anthropometrics:
Ht:
5’0”/1.52 m
Wt:
155 lb/ 70.5 kg
BMI: 30.3
Ideal Body Wt: 100 lb/ 45.5 kg
Adjusted Body Wt: 51.75 kg
Nutrition – Focused Physical Findings:
Physical Appearance: Obese, elderly female
Vitals: Temp: 99.2°F
BP: 150/97 mm Hg
Eyes: Mild retinopathy
Skin: Ulcer on lateral left foot
HR: 75 bpm
Food/Nutrition – Related History:
Current Diet Order: 1200 kcal ADA exchange diet
Interview: Mrs. Douglas lives and cares for her 80 – yo diabetic sister in a low-income housing
apartment on the third floor. Patient states “This cut on my foot happened over 2 months ago and has
not healed.” Patient complains of blurry vision, frequent bladder infections, and tingling and numbness
in her feet. Her and her sister avoid starchy foods and sweets; although they both have cake and ice
cream once a month at Senior Center birthday parties.
Usual Daily Intake: Egg fried in bacon fat, bacon, coffee, orange juice, lunchmeat sandwich, greens
cooked with fatback, new potatoes, cornbread with butter, beans with ham, and vanilla wafers.
DIAGNOSIS:
PES: Excessive energy intake related to food and nutrition related knowledge deficit as evidenced by self
reported dietary intake and BMI of 30.3.
INTERVENTIONS:
Nutrition Education: An initial session will be conducted with the patient for 60 minutes and then three 45
minute follow-up visits will be scheduled over 3 – 6 months. Counseling sessions will focus on reduced energy
and fat intake, consistent carbohydrate intake strategies, simplified meal plans, healthy food choices,
individualized meal planning strategies, exchange lists, and insulin-to-carbohydrate ratios.
CVD and Cardioprotective Nutrition Interventions: Cardioprotective nutrition interventions for prevention
and treatment of CVD include reduction in saturated and trans fats and dietary cholesterol, and interventions
to improve blood pressure. Studies in persons with diabetes utilizing these interventions report a reduction in
cardiovascular risk and improved cardiovascular outcomes.
Carbohydrate Intake Consistency: In persons on either MNT alone, glucose-lowering medications or fixed
insulin doses, meal and snack carbohydrate intake should be kept consistent on a day-to-day basis.
Consistency in carbohydrate intake results in improved glycemic control.
Daily intake pattern based on ADA Dietary Recommendations:
Estimated kcal needs for wt loss: 1200
Recommended kcal intake for wt loss: 1200
Protein: 103.5 grams (34%) [2 g/kg of ABW for wound healing]
Fat: 27 grams (20%) with less than 7% from saturated fat
Carbohydrate: 185 grams (46%) with at least half whole grains
Breakfast
55 grams
Lunch
55 grams
Dinner
55 grams
Snacks (2 per day)
<15 grams for each snack
Total = ~185 grams
Coordination of Care: The RD should implement MNT and coordinate care with an interdisciplinary team. An
interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall
management.
References:
American Dietetic Association Evidence Analysis Library. Diabetes Mellitus (DM) Type 1 and 2
Evidence-based Nutrition Practice Guideline for Adults
http://www.adaevidencelibrary.com/topic.cfm?cat=2651. Accessed February 19, 2010.
American Diabetes Association Position Statement: Standards of Medical Care in Diabetes—2010. Diabetes
Care; 33:1: pp. 11-61.
Escott-Stump, Sylvia and Mahan, Kathleen L.; Krause’s Food, Nutrition, & Diet Therapy 11th Edition. Elsevier,
USA, 2004.
Escott-Stump, Sylvia; Nutrition and Diagnosis-Related Care 6th Edition; Lippincott Williams & Wilkins, USA,
2008.
Wolever TMS, Hamad S, Chiasson JL, Josse RG, Leiter LA, Rodger NW, Ross SA, Ryan EA. Day-to-day
consistency in amount and source of carbohydrate intake associated with improved glucose control in type 1
diabetes. J Amer Coll Nutr. 1999;18:242-247.