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Nicole Azurin, Nicole Karetov, Maria Pavlova, Babak Maknoon
Case Study #17
1. What are the standard diagnostic criteria for T2DM? which are found in Mitch’s medical
record?
The standard diagnostic criteria for type 2 diabetes mellitus include hyperglycemia, glycosuria,
polyuria, polydipisia, weight loss, polyphagia, lipemia, and ketosis. Diagnostic criteria for
hyperglycemia is classified as casual plasma glucose of ≥200 mg/dL, or a fasting plasma glucose
of ≥126 mg/dL, or a 2-hour post-prandial glucose of ≥200 mg/dL during an oral glucose
tolerance test. Physical symptoms include fatigue, increased hunger and/or thirst, frequent
urination, blurred vision, tingling in the hands and feet. According to his medical record, Mr.
Fagan shows high plasma glucose levels (1524 mg/dL on 4/12 and 475 mg/dL on 4/13 [nl=70110]). His high levels of glucose in his urine are indicative of glycosuria. Mr. Fagan has
symptoms of polyuria, as shown by his net intake/output of +2,140 mL/kg. He has some
symptoms of polydipisia, including dry mucous membranes of the throat, poor turgor of the skin,
cloudy/amber-colored urine, high urine specific gravity, and elevated pulse. He has symptoms of
polyphagia, including high protein levels in his urine. Mr. Fagan has high levels of ketones in his
urine, which is a sign of ketosis. He also has a high A1C (15.2%), which is not usually used for
initial diagnosis but is a useful indicator of the average glucose concentration for the previous
two to three months in people with known diabetes.
2. What types of medication are Metformin and Glyburide? Describe their mechanism as well as
their potential side effects/drug-nutrient interactions.
Both metformin and glyburide are oral medications used for type 2 diabetics. Metformin is a type
of biguanide, which decreases hepatic glucose production and increases insulin uptake in
muscles. It does not result in weight gain or create a risk of hypoglycemia. Taking metformin
may cause side effects such as gas, stomach pain, bloating, diarrhea, indigestion, heartburn, and
headache. In rare and extreme cases, lactic acidosis may also occur.
Glyburide is a type of sulfonylurea agent. It stimulates pancreatic insulin secretion, which can
lower blood glucose levels. Unlike metformin, this drug has the potential to cause a high risk of
hypoglycemia and weight gain. Other side effects may include nausea, upper abdominal fullness,
heartburn or rash.
5. Discuss HHS and DKA, describe the information in Mitch’s chart that supports the diagnosis
of HHS.
Nicole Azurin, Nicole Karetov, Maria Pavlova, Babak Maknoon
HHS stands for hyperosmolar hyperglycemic state, which is a complication of diabetes
that can be a life-threatening emergency. It typically develops after a combination of inadequate
fluid intake and a prolonged period of hyperglycemia. As a result, there is gradual, but steady
fluid losses and rising blood glucose levels that will eventually lead to severe dehydration. Other
causes of HHS include undiagnosed diabetes, substance abuse, certain medications and a
coexisting disease. HHS is marked by elevated blood glucose levels, hyperosmolarity, and little
or no ketosis.
DKA stands for diabetic ketoacidosis, another serious condition that may result in a
diabetic coma or even death. It is a severe form of hyperglycemia that may be caused during
illness, infection, emotional stress or omission of insulin. DKA occurs when ketones and glucose
build up in the bloodstream, a result of lipolysis to prevent the body from starvation. Once this
happens, osmotic diuresis can occur and eventually cause dehydration and electrolyte
imbalances. As the patient loses fluid, the blood will become increasingly concentrated, which
will result in the hyperglycemia. Nausea and/or vomiting, stomach pain, fruity or acetone breath,
Kussmaul respirations (abnormally slow, deep breathing) and changes in mental status are
possible symptoms of DKA.
The symptoms of HHS are similar to hyperglycemia/DKA: polyuria, polydipsia,
polyphagia, weight loss, fever, volume depletion, and progressive decline in the level of
consciousness. Unlike HHS, DKA develops rapidly and has a high increase in serum ketones,
while there may be only a slight increase of ketones HHS, which develops over time. HHS also
has a plasma glucose of >600 mg/dL and a serum osmolality of >320 mg/dL, while DKA has a
glucose level of >250 mg/dL and variable serum osmolality.
Mitch’s charts show elevated blood glucose levels (1524 mg/dL) and hyperosmolarity
(360 mg/dL), indicative of HHS.
9) Describe the insulin therapy that was started for mitch. What is Lispro? What is Glargine?
Initially, the MD ordered 1 unit/kg/h of insulin in Mitch’s normal saline IV to immediately
reduce his blood glucose. Mitch was then started on a standard, mixed insulin therapy consisting
of Lispro and Glargine. Mitch was started on Lispro every 2 hours. Lispro is a rapid acting
(bolus) insulin that begins acting within 5-15 minutes, and peaks at 30-90 minutes after injection.
It has a duration of 3-5 hours. Lispro was used to immediately lower his blood glucose to normal
ranges (150-200mg/dL) and to control his blood glucose around mealtimes. He was then started
with Glargine at 9pm. Glargine is a long-acting (background/basal) insulin. It takes 2-4 hours to
Nicole Azurin, Nicole Karetov, Maria Pavlova, Babak Maknoon
work, but it does not have a peak and continues working for 20-24 hours. Glargine allows for
maintenance of Mitch’s blood glucose levels during sleep and throughout the next day.
11) Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM?
To control type 2 diabetes through nutrition therapy, the main principles are: to promote
weight loss, increase physical activity, give nutrition education to show better food choices, and
to spread carbohydrate intake throughout the day.
In more detail, it is important to restrict and stabilize calories, distribute carbohydrates
throughout the day, adjust the amount of carbohydrate to glucose tolerance, modify fat intake (to
decrease saturated and trans fat), introduce simple carbohydrates into meal plans, provide
nutrition counseling based on the patient’s age and literacy level, and finally encourage physical
activity.
12) Assess Mitch’s weight and BMI. What would be a healthy range for Mitch?
97 kg/(1.74)^2 = 31.69 BMI, 214 lbs. His BMI indicates that he is obese. A safe and realistic
goal for Mitch would be for him to lose 10% of this body weight over a 6 month period. He
would have to lose 1-2 lbs in order to achieve this, so in 6 months he would weigh around 192
lbs. A 10% reduction in weight would result in a BMI of 28.5, meaning he would still be
overweight but not obese.
13) Identify and discuss any abnormal laboratory values measured upon his admission. How did
they change after hydration and initial treatment for HHS?
When Mitch was hospitalized, he had high BUN (31mg/dL), high creatinine serum levels
(1.9mg/dL), and elevated hematocrit (57%), which are all clinical indicators of dehydration. His
BUN and creatinine levels dropped after he was hydrated, but were still elevated (20mg/dL and
1.3mg/dL, respectively). His initial sodium level was slightly low (132mEq/L), which could
indicate hyperosmolar body fluids. This level rose to 134mEq/L on his second laboratory
assessment.
Mitch’s blood glucose was 1524 mg/dL and his serum osmolality was 360mmol/kg/H2O,
indicative of HHS. Both levels dropped after initial treatment, to 475 mg/dL and
Nicole Azurin, Nicole Karetov, Maria Pavlova, Babak Maknoon
304mmol/kg/H2O, respectively. These levels are no longer in the danger zone for HHS (glucose
>600mg/dL and serum osmolality>320mOsm/kg).
Mitch also had high HbA1c (15.2), which could indicate that he has had hyperglycemia for the
last couple months.
14) Determine Mitch’s energy and protein requirements for weight maintenance. What energy
and protein intakes would you recommend to assist with weight loss?
(Use IBW because patient is obese, 106 + (9x6) = 160 lb = 73kg )
REE = 66.5 + (13.8 x 73) + (5 x 175 cm) – (6.8 x 53) = 1588.5 kcal
TEE = 1588.5 kcal x 1.2 =
1588.5 kcal x 1.3 =
Daily Energy Requirements: ~1,906 - 2,064 kcals
Protein Requirements *use 0.8 grams per kilo due to the fact that he does not suffer from a
disease that takes a significant amount of energy. 10-20% of Mitch’s calories should be from
protein.
0.8g x 73kg = 58.4g Protein per day
2,064 x 0.10 = 206 kcal
2,064 x 0.20 = 413 kcal
*The maximum amount of kcal from protein Mitch should have is 206 - 413 kcal.
What energy and protein intakes would you recommend to assist with weight loss?
In Mitch’s case, he should set a goal of initial weight loss at about 10% of his body
weight over a 6 month period, at a rate of losing 1-2 pounds per week. His weight is currently
214 lbs, so his weight loss goal would be to lose about 22 lbs, which would make him 192 lbs.
To do this, it would be appropriate to reduce his energy intake by 500-1000 kcal per day. In
terms of protein intake, Mitch’s protein intake should be 10-20% of his caloric intake throughout
the day.
15) Prioritize 2 nutrition problems and complete the PES statement for each.
Nicole Azurin, Nicole Karetov, Maria Pavlova, Babak Maknoon
1. Inadequate fluid intake related to HHS, as evidenced by polyuria, elevated blood glucose, and
hyperosmolality.
2. Food and nutrition-related knowledge deficit related to lack of diabetes-teaching as evidenced
by self reported diet history of meals consisting of high glycemic foods.
16) Determine Mitch’s initial CHO prescription using his diet history as well as your assessment
of his energy requirements
total energy needs = 2065 kcals *CHO intake should be 50-60% of kcal
2065 kcal x .50 = ~1033 kcal
2065 kcal x .60 = ~1239 kcal
~1033 kcal - 1239 kcal of CHO requirements or (divide by 4) = ~258g - 310g CHO
258g/15g = 17
310g/15g = 21
17-21 CHO choices per day
CHO needs: 1,033 kcal - 1,239 kcal
Mitch’s initial carbohydrate prescription would be to spread out his carbohydrate servings
throughout the day. To keep blood sugars consistent, there is an addition of a mid-afternoon
snack. The total choices of carbohydrates per day will range from 17-21 choices. For example:
AM: 4 - 5 choices
Midmorning: 3 choices
Lunch: 4 - 5 choices
Afternoon: 2 - 3 choices
Dinner: 4 - 5 choices
17) Identify two initial nutrition goals to assist with weight loss.
One main initial nutrition goal that will assist with weight loss is to reduce energy intake
(500 calories less than his TEE). In addition, his dietary fat intake should not exceed 25-35% of
total kcal, which amounts to less than 80g per day. His saturated fat intake should be less than
7% of total kcal, which amounts to less than 16g per day.
Another goal we could incorporate would be to consume low-energy dense foods (foods
that are low in kcal relative to one’s weight)--this will keep satiety while controlling energy
Nicole Azurin, Nicole Karetov, Maria Pavlova, Babak Maknoon
intake. Foods like high-water vegetables and fruits, whole grains, and broths are examples of
low-energy dense foods.