Case Number: 17

Adult Type 2 Diabetes Mellitus: Transition to Insulin

Semester: Fall 2015

Class: MNT 438A

Section: 01

Group Member 1: Rachel Bertler

Signature_________________

Date 12/6/15

Group Member 2: Catherine Henderson

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Date 12/6/15

Group Member 3: Brianna Hudson

Signature_________________

Date 12/6/15

Group Member 4: Mona Lenihan-Costanzo

Signature_________________

Date 12/6/15

Group Member 5: Jenny Nguyen

Signature_________________

Date 12/6/15

Brief Description of the Case

Patient, MF, is a Caucasian, 53-year-old male who has been admitted to the Emergency Room (ER) with
severe hyperglycemia, dehydration, and complaints of vomiting. Patient was diagnosed with type II
diabetes mellitus (T2DM) 1 year ago, accompanied by hypertension (HTN), hyperlipidemia, and gout.
Patient has a family history of HTN, coronary artery disease (CAD), and T2DM. MF is currently taking
Glyburide, Metformin, Dyazide, and Lipitor but admits he does not take his medications for diabetes
mellitus (DM) on a regular basis. Patient has a long history of noncompliance and states he does not
follow strict diet guidelines; however, the patient avoids high cholesterol foods, high sugar desserts, and
does not add salt to food. No previous education for DM has been given. A new intervention will address
education on lifestyle changes, especially medical nutrition therapy (MNT) necessary for treatment of
DM, including consistent carbohydrate consumption and use of insulin at home.

Summary of the Disease Condition

Definition
Diabetes mellitus is a diverse group of disorders that share the primary symptoms of hyperglycemia
resulting from the defective production of insulin, insulin action, or both. Type II diabetes mellitus
(T2DM) is a combination of abnormal insulin secretion and insulin resistance (Nelms et al., 2016).
Epidemiology
The most prevalent form of diabetes, T2DM, occurs in the United States and worldwide, representing 9095% of all diagnosed cases of DM. Children are diagnosed more frequently now than before, but adults
are still diagnosed more often. The prevalence for both men and women is equal, but age and ethnicity
play a key role in increased prevalence. The incidence of T2DM based on ethnicity is as follows:
Caucasians - 10.2%, African Americans - 18.7%, Hispanic/Latinos - 11.8%, American Indians and
Alaskan Natives - 16.1%, and Asian Americans - 8.4% (Nelms et al., 2016). Worldwide, the areas that
have a high prevalence of T2DM are India, Latin America, the Caribbean the Middle East and China
(Nelms et al., 2016). Other contributing factors of the prevalence of T2DM include obesity, family
history, history of gestational DM, impaired glucose metabolism, and physical inactivity (Nelms et al.,
2016).
Etiology
The cause of T2DM is the abnormality of insulin secretion, which can be due to external factorsobesity,
poor nutrition, and physical inactivity (Nelms et al., 2016). Individuals with metabolic syndrome (MetS)
are at risk of developing T2DM (van der Pouw Kraan et al., 2015). Risk factors include visceral fat in the
abdominal area, dyslipidemia, high blood pressure, and elevated HbA1c (van der Pouw Kraan et al.,
2015). Physical inactivity can also increase risk for T2DM due to degradation of insulin sensitivity
(Nelms et al., 2016).
Pathophysiology
Development of T2DM occurs as production of insulin decreases and insulin resistance increases.
Elevated blood glucose will generate the release of insulin from the pancreas. Excessive glucose in the
bloodstream overtime can lead to the inability upkeep of the pancreas to produce insulin, which will cause
insulin deficiency (Nelms et al., 2016). Tissues become insulin resistant due to unresponsive cells when
communication is prevented with insulin and cell-receptors. Decreased insulin sensitivity and insulin
resistance decreases the cells ability to absorb glucose, leading to hyperglycemia (Nelms et al., 2016).
Specific Examinations including Lab Indicators and Medical Diagnosis:
A fasting blood glucose test is used to determine whether a patient has normal levels of glucose in the
blood, or if a patient is exhibiting prediabetes or diabetes. A fasting blood glucose level greater than 100
mg/dL indicates an impaired fasting glucose. More specifically, a level of 100 to 125 mg/dL indicates
prediabetes and a level of 126 mg/dL or greater indicates diabetes (Nelms et al., 2016). In addition, a
hemoglobin A1c test can be administered to determine a patients average blood glucose concentration for
the last two to three months. A result greater than or equal to 5.7% exhibits hyperglycemia. 5.7% to 6.4%
indicates prediabetes and 6.5% or greater indicates diabetes (Nelms et al., 2016). Oral glucose tolerance
tests (OGTTs) are administered to determine the bodys ability to utilize glucose. After an overnight fast
of 8-14 hours, a patient is given 75 grams of glucose dissolved in water. After two hours, the blood
glucose levels are tested. A blood glucose level between 140 and 199 mg/dL exhibits impaired glucose
tolerance or prediabetes. A glucose level of 200 mg/dL or greater is diagnostic for diabetes mellitus
(Nelms et al., 2016).

Medical Treatment
Treatment for T2DM involves a combination of medical nutrition therapy (MNT), physical activity,
medications or insulin therapy, and monitoring of blood glucose levels. The categories of medications
prescribed for T2DM are Biguanides, alpha-glucosidase inhibitors (AGI), sulfonylureas, meglitinides,
thiazolidinediones, DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors. The preferred
medication prescribed for T2DM is Metformin, a Biguanide that is also known as Glucophage or
Glutmeza. Metformin works to increase the body tissues sensitivity to insulin so insulin can be used
more effectively. It also lowers glucose production in the liver, but the drug alone will not significantly
lower blood sugar levels. AGIs compete with alpha glucosidase enzymes, which delay absorption of
glucose in the intestines. Sulfonylureas and meglitinides both work to help the body secrete more insulin;
however, meglitinides act faster and are not active in the body as long. Glyburide is an example of a
sulfonylurea medication. Thiazolidinediones increase tissue sensitivity to insulin so it can be used more
effectively. DPP-4 inhibitors and GLP-1 receptor agonists both help lower blood sugar levels; GLP-1
receptor agonists also slow digestion. SGLT2 inhibitors, the newest medications available for T2DM,
prevent the kidneys from reabsorbing sugar, instead, sugar is excreted out in the urine. Lastly, some
patients need insulin therapy. Insulin is injected, often once at night, either through a needle, syringe, or
pen injector. There are many different types of injectable insulin, each working in a different way (Nelms
et al., 2016).
Medical Nutrition Therapy
As outlined by the ADA, MNT for T2DM focuses on a collaborative team effort. This should consist of
3-4 sessions with a registered dietitian (RD) lasting 45-90 minutes and should begin upon diagnosis and
completed within 3-6 months. Whether additional follow-up visits are needed is at the discretion of the
RD. However, at least 1 follow-up is recommended per year to evaluate and monitor outcomes and
medications and for reinforcement of lifestyle changes (Evert et al., 2013).
The goal of MNT is to instill healthful eating patterns with reduced energy intake, encourage regular
physical activity if the patient is medically cleared, to improve cardiovascular health and promote weight
loss. Another factor, just as important, is teaching patients how to manage and self-monitor their
diagnosis. For many individuals, initiating pharmacotherapy, paired with a healthy diet is also needed to
prevent the onset of complications that often result from poor glycemic, lipid and blood pressure control.
The metabolic goals of patients with T2DM include having an HbA1c <7%, blood pressure <140/80
mmHg and LDL cholesterol <100 mg/dL; triglycerides <150 mg/dL; HDL cholesterol >50 mg/dL for
women and >40 mg/dL for men (Evert et al., 2013).
There is no specific diet designed for T2DM, but rather focuses on an individual approach to simple meal
planning consistent in intake and timing and includes a variety of nutrient-dense foods. Evidence is
inconclusive for determining an ideal amount of carbohydrates (CHOs); therefore, intake should be
individualized and, instead, focus on monitoring CHO intake by CHO counting or use of the exchange
system throughout the day. Staying within the general ADA guidelines of 45-65% of total kcal from
carbohydrate and <30% of total kcal from fat is a good starting point from which to adjust as necessary
based on further individual assessment of the patient. CHO intake for good health should be consumed
mainly from vegetables, fruits, whole grains, legumes and dairy products. It is recommended that <10%
of total kcal come from simple sugars. Selecting leaner protein sources and limiting sodium intake to
<2300 mg/day, and consuming at least 25g of fiber per day for women and 38g of fiber per day for men is
also recommended. Alcohol use can increase risk for hypoglycemia; therefore, it is best to limit alcohol
consumption to 1 drink/day for women and 2 drinks/day for men (Evert et al., 2013).

References Cited in This Summary

Evert, A.B., Boucher, J.L., Cypress, M., Dunbar, S.A., Franz, M.J., Mayer-Davis, E.J., Yancy Jr., W.S.
(2013).
Nutrition therapy recommendations for the management of adults with diabetes.
Diabetes Care, 36, 3821-3835. doi: 10.2337/dc13-2042.
Nelms, M., Sucher, K., & Lacey, K. (2016). Nutrition therapy and pathophysiology, third ed. Boston,
MA: Cengage Learning.
Van der Pouw Kraan, T. M., Chen, W. J., Bunck, M. M., van Raalte, D. H., van der Zijl, N. J., van
Genugten, R. E., & Horrevoets, A. G. (2015). Metabolic changes in type 2 diabetes are reflected
in peripheral blood cells, revealing aberrant cytotoxicity, a viral signature, and hypoxia inducible
factor activity. BMC Medical Genomics, 8(1), 1-16. doi:10.1186/s12920-015-0096-y.

To Apply the Nutrition Care Process

Part One: Nutrition Assessment
Food/Nutrition
Related History
Food and nutrient
intake,
medication/herbal
supplement intake,
knowledge, beliefs,
food and supplies
availability,
physical activity,
nutrition quality of
life

Biochemical data,
medical tests, and
procedures
Lab data (e.g.,
electrolytes,
glucose) and tests
(e.g. gastric
emptying time,
resting metabolic
rate)

Food and Nutrition History

Chief Complaint:
Usual Food and Nutrient Intake:

Diet Hx:
Tobacco Use:
Alcohol Use:
Medications at Home:
Physical Activity:

Anthropometric
Measurements

Nutrition-related
Physical Findings

Client History

Height, weight,
body mass
index(BMI),
growth pattern
indices/percentile
tanks, and weight
history

Physical
appearance,
muscle and fat
wasting, swallow
function, appetite,
and affect

Personal history,
medical/health/fam
ily history,
treatments and
complementary/alt
ernative medicine
use, and social
history

Diagnosed with T2DM; Pt is experiencing vomiting, not

adhering to T2DM treatment plan. Pt admitted for severe
hyperglycemia and dehydration.
AM: Coffee with half and half
Snack: Bagel with cream cheese, 2-3 c. coffee
Lunch: Jimmy Johns or fast food sandwich, chips, diet soda
Dinner: Grilled chicken or beef, salad, and potatoes or rice.
Food Preferences:
Pt eats out for lunch and dinner.
Typically enjoys ethnic foods
such as Chinese, Mexican, Indian, or Thai
Pt does not follow a strict diet, does not add salt, tries to avoid
high-cholesterol foods and high-sugar desserts; currently NPO
1 ppd x 20 years - now quit
3-4 drinks/week
Glyburide 20 mg daily; 500 mg metformin twice daily;
Dyazide once daily (25 mg hydrochlorothiazide and 37.5 mg
triamterene); Lipitor 20 mg daily
N/A
Nutrition Knowledge: MD has provided diet information for
patient; No previous formal diabetes education.
Family History:
Father: HTN, CAD; Mother: T2DM

Comparative Standards
Energy:
Mifflin St. Jeor: 10 x (97.27 kg) + 6.25 x (175.26 cm) - 5 x (53yrs) + 5 = 1808 kcal x 1.2 = 2170 kcal
For weight loss: 1670-1870 kcal (300-500 kcal deficit)
IBW: 106 + (6 x 9) = 160 lbs
Protein:
77.8-97.3 g PRO (0.8-1.0 g/kg)

20% PRO (ADA)

1670 (.20) = 334 kcal/4 kcal/g = 83.5g PRO
1870 (.20) = 374 kcal/4 kcal/g = 93.5g PRO
CHO, fiber (type, amount, distribution, if applicable):
45-65% CHO (AMDR). Start on low end, with 45-55% CHO and adjust as needed.
1670 kcal x .45 = 751.50 kcal/4 kcal/g = 188 g CHO
1670 kcal x .55 = 918.5 kcal/4 kcal/g = 230 g CHO
Spread CHO intake throughout the day, including 3 meals and 2 snacks.
Choose high fiber and low-glycemic index foods more often. For men, the recommended intake of fiber is
38 g/day (ADA).
Fat (type and amount, if applicable):
Total fat: 20-35% of total kcal (AMDR)
1670 (.20) = 334 kcal/9 kcal/g = 37g total fat
1670 (.35) = 584.50 kcal/9 kcal/g = 65g total fat
<10% of total kcal from SFAs
1670 (.10) = 167 kcal/9 kcal/g = 18.5g saturated fat
Vitamins and minerals, if applicable:
Sodium: 1500-2300 mg/day (ADA)
Cholesterol: <300 mg/day (DASH)
Potassium: 4700 mg/day (DASH)
Calcium: 1250 mg/day (DASH)
Magnesium: 500 mg/day (DASH)
Fluids: 2000-2500 mL/day (per diet order)
Please summarize the key dietary intake information (if available) in the table below
This pt/ client
Expected, normal, or reference value
Minimal intake of vegetables
At least 2 cups of vegetables/day
No fruit intake
Less than 2 cups of fruit/day
Low fiber intake
38 g fiber/day
Consumes mostly processed foods and dines
Less than 2300 mg sodium/day
Outside of home
Minimal potassium intake
4700 mg/day
High saturated fat intake
<10% of total kcal from saturated fats
Low in calcium
1250 mg/day
Interpretation and/or Comments:
Patient is not adhering to recommended strict diet plan. Breakfast at mid-morning is high in CHO and low
in protein. Meals do not consist of ideal nutrient-dense foods. They consist mainly of processed foods that
are high in saturated fat. Patients diet is lacking in healthy fats and is considered unhealthy, especially
since he has both T2DM and hypertension. Patient is lacking a healthy intake that should contain more
fruits, vegetables, fiber, whole grains, lean protein, nuts, fish, and healthy fats. Calculating the energy
needs for this patient was done by using MSJ, resulting in an approximate energy need of 2170 kcal/day;
this estimation should be reduced in order to achieve weight loss. Consuming a more healthful diet that is
carefully monitored in quantity (especially carbohydrates) and timing and restricts sodium intake would
be highly advantageous to improve this patients health and diabetic metabolic goals. Including a

reduction in caloric intake will also help the patient achieve recommended weight loss that may aide in
improving his glycemic, blood pressure, and lipid goals.
Anthropometric Measurements
This pt/client
Gender: Male
Height: 59
Weight: 214 lbs
BMI: 31.6 lb/in2

Expected or normal value

Weight: 160 lbs
BMI: 18.5-24.9 lb/in2

Interpretation and/or Comments:

Standing at 59 and weighing 214 lbs, male patient has a BMI of 31.6 lb/in2, classifying the patient as
obese, class I. Patients ideal body weight (IBW) is 160 lbs.
Biochemical, Laboratory, and Diagnostic Tests
This pt/client
BP: 129/92 mmHg

Expected or normal value

BP: 120/80 mmHg

Chemistry
Sodium: 134 mEq/L
BUN: 20 mg/dL
Creatinine serum: 1.3 mg/dL
Glucose: 475 mg/dL
Phosphate, inorganic: 2.1 mg/dL
Osmolality: 304 mmol/kg/H2O
Cholesterol: 205 mg/dL
Triglycerides: 185 mg/dL
HbA1c: 15.2%

Chemistry
Sodium: 136-145 mEq/L
BUN: 8-18 mg/dL
Creatinine serum: 0.6-1.2 mg/dL
Glucose: 70-110 mg/dL
Phosphate, inorganic: 2.3-4.7 mg/dL
Osmolality: 285-295 mmol/kg/H2O
Cholesterol: 120-199 mg/dL
Triglycerides: 40-160 mg/dL
HbA1c: 3.9-5.2%

Hematology
WBC: 13.5 x10^3/mm3
Hematocrit: 57%

Hematology
WBC: 4.8-11.8 x10^3/mm3
Hematocrit: 40-54%

Urinalysis
Urinalysis
Specific Gravity: 1.045
Specific Gravity: 1.003-1.030
pH: 5.0
pH: 5-7
Protein: 10
Protein: Neg
Glucose: +
Glucose: Ketones: +
Ketones: Prot chk: +
Prot chk: Interpretation and/or Comments:
Increased BUN and Creatinine may be due to dehydration and a result of the kidneys working hard to
remove the excess glucose; these levels have improved since admission. The patient has hyperglycemic
hyperosmolar syndrome (HHS); this causes high osmolality (hyperosmolality) due to extreme loss of
water (dehydration), making the blood more concentrated. As a result, glucose will accumulate in the
bloodstream, leading to high serum glucose levels (Wisse, 2015).

Nutrition-Focused Physical Findings

This pt/ client

Expected or normal

HEENT: Head: WNL

Eyes: PERRLA
Ears: Clear
Nose: Clear
Throat: Dry Mucous membranes
without exudates or lesions

Healthy, no excessive fat, no wasting

Clear, not sensitive to light
Clear
Clear
No hoarseness

Neurological: Alert, but previously drowsy with

mild confusion
Skin: Warm, dry, poor turgor

Alert
Smooth, warm, dry, no edema, no discoloration,
good musculature
Normal breathing sounds, not labored breathing

Chest/Lungs: Respirations are rapid, clear to

auscultation and percussion
Peripheral vascular: Pulse 4 + bilaterally, warm,
no edema
Abdomen: Active bowel sounds x 4: tender, non
distended.

Warm and no edema

Non tender, non distended

Interpretation and/or Comments:

Patient is currently alert after a state of drowsiness and mild confusion, indicating he is currently
improving neurologically. His skin has poor turgor, indicating an issue with hydration; this should be
addressed and the reason for dehydration is likely due to the vomiting patient experienced, but other
potential reasons should also be determined. The patients abdomen is tender, but not distended and
having active bowel sounds. Abdominal tenderness could be from the muscular tenderness that can occur
with vomiting, but it should be assessed to determine if there is other causes.
Client history
Client History

Implications on Nutrition Care

Personal: 53 yo Caucasian male

Patient is older, which is a risk factor of T2DM and

HTN.

Years Education: 16

Additional education regarding treatment for T2DM will

be required for this patient.

Social: Single, lives alone

Patient will have to shop for, prepare, and cook his own
meals. Education on how to do so will be required.

Tobacco use: 1 pack per day x 20 years;

now quit

Smoking is a risk factor for HTN and CAD.

Alcohol use: 3-4 drinks/week

Use of alcohol increases the risk of hypoglycemia in

diabetic individuals. The medications the patient is on
should not be mixed with alcohol, it can cause side
effects or can prevent medication from working.

Chief Complaint: Vomiting; Admitted to

the ER with severe hyperglycemia and

Patient not following dietary and/or pharmacological

recommendations for T2DM.

dehydration
Diagnosed 1 year ago w/ T2DM,
accompanied by HTN, hyperlipidemia,
and gout

Patient has been noncompliant with appropriate diet and

taking medications for T2DM. No previous diabetes
education has been given.

Occupation: Retired military; now works

as consultant for military equipment
company
Family History: Father has HTN and
CAD, mother has T2DM

Patient is genetically predisposed to T2DM, CAD, and

HTN

Physical activity: N/A

Physical inactivity is a risk factor for T2DM, HTN, and

hyperlipidemia. Patient is obese and physical activity and
weight loss could improve his conditions.

Medications: Glyburide 20 mg daily,

Metformin 500 mg twice daily, Dyazide
daily (25 mg hydrochlorothiazide and
37.5 mg triamterene), Lipitor 20 mg
daily

Glyburide - A sulfonylurea agent for T2DM that

stimulates insulin secretion. On this medication,
there is a high risk of hypoglycemia. Not
appropriate for individuals with renal
insufficiency.
Glucose, HbA1C, rare: AST, ALT,
LDH, alk phos, BUN, crea, Na,
dyscrasias
Can or appetite, may cause wt gain
Should avoid alcohol

Metformin - A biguanide agent for T2DM that

works to increase insulin uptake in the muscles,
while also decreasing glucose production in the
liver. Side effects include diarrhea, nausea,
bloating, anorexia, flatulence, lactic acidosis.
Not appropriate for individuals with renal
insufficiency or liver or heart failure.
Glucose, HbA1C, chol, LDL, TG,
HDL, Vit B12, homocysteine,
possible: Fol, anemia w/LT use
Should avoid alcohol

Dyazide - Used to treat fluid retention and high

blood pressure. The hydrochlorothiazide is a
thiazide diuretic that prevents the body from
absorbing too much salt. The triamterene is also
a diuretic that prevents the body from absorbing
too much salt but it also prevents potassium
levels from getting too low.
Hydrochlorothiazide - Na, chloride,
K, Mg, Zn, glucose, Ca,
dyscrasias, uric acid, bil, chol,

LDL, VLDL, TG, BUN, crea. Can

thirst, GI distress, limit alcohol
Triamterene - K, Mg, bicarb, uric
acid, Fol, rare: platelets, anemia,
BUN, crea, Na, Cl. Avoid excess K
intake

Lipitor - A statin (HMG CoA inhibitor) that

reduces levels of LDL cholesterol and
triglycerides, while increasing HDL levels.
Chol, LDL, TG, VLDL, apoB,
HDL, CRP, AST, ALT, alk phos,
Transient CPK, CoQ10, rare:
dyscrasias, myoglobin
Dietary fat and cholesterol, Ca if
needed, avoid citrus foods, avoid alcohol

Surgical history: ORIF R ulna; hernia

repair

Part Two: Nutrition Diagnosis

Intake
Too much or too little of a food
or nutrient compared to actual
or estimated needs

Clinical
Nutrition problems that relate to
medical or physical conditions

Behavioral-Environmental
Knowledge, attitude, beliefs,
physical environments, access to
food, or food safety

Analyze the assessment data collected in light of the patients admission medical diagnosis or reason
for referral. What was normal? What was not normal?
Normal: Patients physical examination indicated active bowel sounds, alertness, and normal
HEENT. Patients laboratory values (4/13) indicated normal levels of potassium, chloride,
carbon dioxide, magnesium, calcium, bilirubin, total protein, liver enzymes, HDL, LDL, thyroid
hormones, c-peptide, RBCs, and hemoglobin.
Abnormal: Patient reported vomiting for 12-24 hours. Patients physical examination indicated
drowsiness and confusion, elevated temperature (100 ), respiratory rate (26), and poor turgor
(skin). Patients laboratory values (4/13) indicated low levels of sodium (134 mEq/dL) and
inorganic phosphate (2.1 mg/dL). Values (4/13) also indicated elevated levels of BUN (20
mg/dL), creatinine (1.3 mg/dL), glucose (475 mg/dL), osmolality (304 mmol/kg/H2O),
cholesterol (205 mg/dL), triglycerides (185 mg/dL), HbA1c (15.2%), WBC (13.5 x 103/mm3),
and hematocrit (57%). Clients history indicated alcohol consumption of 3-4 drinks per week
and low compliance with treatment for type II diabetes mellitus.

Is this a well-nourished patient? Why or why not? This patient is not well-nourished. Assessment
data indicates the patient does not comply with his treatment plan for type II diabetes. He frequently
dines out, consuming foods high in fat and sodium. This puts the patient at a greater risk for other
diseases including CVD, neuropathy, retinopathy, etc. His dietary recall also indicates a low
consumption of fruits and vegetables. In addition, the patients laboratory values indicate elevated
cholesterol (205 mg/dL), HbA1c (15.2%), and triglycerides (185 mg/dL).
Is the patients current oral nutrient intake or nutrition support meeting his/her nutritional
needs? The patients current intake is not supporting his nutritional needs. According to his dietary
recall, he is consuming ~1792 total kcal, 19.2 kcal of saturated fat, and 3534 mg of sodium. In
addition, the patient is consuming an inadequate amount of fruits and vegetables, resulting in a low
intake of fiber (11 g).

Are there any other indications of nutrition problems? Other indications of nutrition problems
include obesity and HTN. A possible barrier for patient compliance may include living alone. In
addition, the patient did not report physical activity. Physical inactivity places the patient at greater
risk for complications and other diseases.

Problem:
Excessive carbohydrate intake
Intake of types of carbohydrates inconsistent with needs for T2DM
Obese, Class I
Inadequate energy intake
Inadequate fluid intake
Etiology:
Food and nutrition-related knowledge deficit
Not ready for diet/lifestyle change

Self-monitoring deficit
Limited adherence to nutrition-related recommendations
Undesirable food choices
Physical inactivity

Signs and symptoms:

Elevated blood glucose level of 1524 mg/dL (70-110 mg/dL)
Elevated cholesterol level of 205 mg/dL (120-199 mg/dL)
Elevated triglyceride level of 185 mg/dL (40-160 mg/dL)
Elevated HbA1C level of 15.2% (3.9-5.2%)
BMI of 31.6 lb/in2
Problem
Etiology
Sign and Symptoms

Problem
Etiology
Sign and Symptoms

PES Statement 1
Intake of types of carbohydrates inconsistent with needs for
T2DM
food and nutrition-related knowledge deficit

R/T
AEB

elevated blood glucose level of 1524 mg/dL at admission

vs. normal range of 70-110 mg/dL and elevated HbA1c
level of 15.2% vs. normal range of 3.9-5.2%.
PES Statement 2
Obese, Class I
undesirable food choices and self-monitoring deficit
intake of types of carbohydrates inconsistent with needs for
T2DM per 24 hour recall and BMI of 31lb/in2

R/T
AEB

Part Three: Nutrition Intervention

Nutrition Prescription (Nutrition Rx):
Specific diet (if applicable)

No specific diet; however, follow guidelines from

ADA, DASH, and TLC
1670-1870 kcal/day (300-500 Kcal deficit for
weight loss)
83.5 - 93.5 g/day

Energy goal (Kcal/day)

Protein goal (g/day)
If there is any specific goal or restrictions, please
list below
Add lean protein-rich foods (DASH)

Add colorful vegetables for different bioavailable

vitamins and minerals (DASH)
Minerals:
Decrease Na intake: 2,300 mg or less
(DASH)
Increase K intake: 4,700 mg (avoid
excessive K intake such as supplements may cause interference with Dyazide)
(DASH)
Increase Ca intake: 1,250 mg (DASH)
Increase Mg intake: 500 mg (DASH)
Reduce alcohol consumption to 1-2 drinks/week
(try to avoid alcohol overall due to drug
interference with Glyburide, Metformin, and
Lipitor) (DASH)

CHO 45% to start off and adjust if needed (ADA)

Consistency in day-to-day CHO intake
(ADA)
Increase fiber intake: 38 g (DASH)
<10% simple sugars (ADA)
CHO counting

FAT <30% to start off and adjust if needed (ADA)

<7% of saturated fats (TLC)
<1% of trans fat (TLC)
Choose nonfat/lowfat dairy products
(DASH)
Food sources rich in MUFAs and PUFAs
(DASH)

Strategic goals of nutrition intervention:

Strategic goals for individuals with T2DM through nutrition intervention are to:
Increase HDL cholesterol over 40 mg/dL
Decrease HbA1c under 7%
Decrease blood pressure under 140/80 mmHg
Decrease LDL cholesterol under 100 mg/dL
Decrease triglycerides under 150 mg/dL
These goals can be done through basic nutrition principles (Nelms et al., 2016). Other strategic nutrition
intervention goals for individuals with T2DM are to achieve/maintain body weight goals and delay or
prevent complications of diabetes by regulating insulin. Strategies used to attain this can be done through
motivational interviewing, goal setting, self-monitoring, problem solving, stress management, and relapse
prevention (Nelms et al., 2016).

Food and/or nutrient

delivery
An individualized
approach for
food/nutrient provision,
including meals and
snacks, enteral and
parenteral nutrition,
and supplements

Nutrition Education

Nutrition Counseling

A formal process to
instruct or train a
pt/client in a skill or to
impart knowledge to
help pts/clients
voluntarily manage or
modify food choices and
eating behavior to
maintain or improve
health

Coordination of
Nutrition Care
Consultation with,
referral to, or
coordination of
nutrition care with
other healthcare
providers, institutions,
or agencies that can
assist in treating or
managing nutritionrelated problems.

A supportive process,
characterized by a
collaborative
counselor-patient
relationship, to set
priorities, establish
goals, and create
individualized action
plans that acknowledge
and foster responsibility
for self-care to treat an
existing condition and
promote health
Consult the Academys Nutrition Care Manual, Evidence Analysis Library, the AHRQ or Cochrane
databases to locate evidence-based recommendations or guidelines for nutrition care.
Please summarize the relevant evidence regarding nutrition therapy of the disease conditions.
Please indicate the source of the evidence.

According to the EAL, the goals of nutrition therapy for patients with diabetes is to emphasize healthy
eating patterns that are individually customized since an optimal mix of macronutrients is inconclusive. A
treatment plan and consult with an RD should be timely and consist of at least 3-4 visits and 1 follow-up.
A team effort approach is best in that it will help in determining patient preferences, an optimal mix of
macronutrients, address and improve self-efficacy for proper self-management care, and include
important diabetes nutrition education (Evert et al., 2013).
Evidence does suggest that glycemic control is influenced by the amount of CHO intake and insulin and
therefore should be monitored carefully. The important factors are spreading the CHO intake throughout
the day and having consistent eating times. This, along with a diet that emphasizes an increase in colorful
vegetables and moderate fruit consumption, whole grains, fiber, lean poultry, nuts and fish, and that limits
unhealthy SFAs and trans fats, but is higher in MUFAs and PUFAs and Omega 3s is a healthy
nutritional mix. Evidence suggests that consuming a more healthful diet that limits sodium intake to <
2300 mg/day and is rich in important nutrients and minerals, coupled with weight loss from a moderate
decrease in energy and includes moderate physical activity if medically cleared is beneficial. These
modifications will improve his general ADA recommended diabetes metabolic goals for improving
glycemic, BP and lipid profile. These dietary and lifestyle modifications, along with his recommended
diabetes medications and insulin therapy, will also serve in decreasing the patients HTN and associated
risks of developing CVD (Evert et al., 2013).
Although EAL recommends a reduction of 500-1000 kcal for a weight loss of 1-2 pounds per week, it has
been shown clinically, that this is too drastic of a reduction for many patients to begin with initially and
can lead to patient noncompliance or result in ineffective long-term weight loss. Therefore, beginning
with a moderate reduction of 300-500 kcal from their usual dietary consumption and creating a diet plan
that is rich in nutrients and more healthful is the approach we chose, which is often a more realistic and
doable approach for most patients to begin with, which can be reevaluated and adjusted accordingly.

Describe the nutrition intervention using approved NCP terminology (eNCPT).

The Nutrition Intervention: Food and /or Nutrient Delivery (ND): Modify composition of meals and
snacks. (ND - 1.2)
It has been determined that the patient would benefit from a combination of a Mediterranean diet and a
modified DASH diet to help with his multiple health concerns of T2DM, hypertension, weight reduction,
hyperlipidaemia and gout. Previously the patient has had a high carbohydrate intake inconsistent with
needs for T2DM related to food and nutrition-related knowledge deficit as evidenced by elevated blood
glucose level of 1524 mg/dl at admission to the hospital vs. normal range of 70-110 mg/dl and elevated
HbA1c level of 15.2% vs normal range of 3.9-5.2%. A diet plan has been formulated to reduce the amount
of refined carbohydrates, added sugars to address the T2DM, sodium reduction from processed foods to
address his hypertension, and reduction of unhealthy fats to address his hyperlipidemia. The diet plan also
addresses gout by introducing foods and beverages that will help to alleviate gout issues such as cherries,
and other high vitamin C foods, proper hydration, reduction in the use of caffeine and avoiding alcohol
which is also contraindicated for the medications the pt. has been prescribed for his various diagnosis.
The diet provides options in a variety of ethnic foods that the pt. has expressed an appreciation for to
improve compliance. The increase in fruits and vegetables will increase potassium and other minerals.
Whole grains and non starchy carbohydrates will address the Obese, Type 1 as evidenced by undesirable
food choices and self-monitoring deficit related to intake of types of carbohydrates inconsistent with
needs for T2DM per 24 hour recall and BMI of 31.6 lb/in2
Nutrition Education (E): Nutrition relationship to health/disease (E-1.4)
Patient has been noncompliant in following the strict dietary guidelines for managing his disease as he
should. He also admits to not being consistent on taking his prescribed diabetic medications. Both of
these elements are critical in managing his T2DM, as well as the other complications that have arisen
such as his hyperlipidemia, HTN, gout and the need to begin insulin therapy.Therefore it is imperative
that as suggested by the ADA, that we continue to work as collaborative team to help this patient more
effectively manage is T2DM and understand the importance of compliance. In order to improve his
outcomes, we recommend that the patient begin meeting with an RD over the recommended course of 3-4
sessions for 45-90 minutes. During this time the general principles of T2DM nutrition management will
be discussed and reviewed. Topics that will be covered will include nutrition education on the importance
of consistency, timing and distribution of CHO throughout the day, learning CHO counting techniques, as
well as discussing easy, simplified meal plans that fit with his tastes, preferences and lifestyle. Discussing
the role of insulin therapy and its importance, as well as reviewing the role that exercise plays in
managing his disease are also important topics of discussion. Providing handouts and overcoming barriers
to change will also be beneficial. Whether additional follow-up visits are needed will be determined.
However, at least 1 follow-up is recommended after one year in order to evaluate and monitor outcomes
and for reinforcement of positive, lifestyle changes.
A Sample Menu for daily consumption on the new Diet Order is presented in Appendix B.

Part Four: Nutrition Monitoring and Evaluation

Food/NutritionRelated History
Outcomes
Food and nutrient
intake,
medication/herbal
supplement intake,
knowledge, beliefs, food
and supplies
availability, physical
activity, nutrition
quality of life

Biochemical Data,
Medical Tests, and
Procedure Outcomes
Lab data (e.g.
electrolytes, glucose)
and tests (e.g. gastric
emptying time, resting
metabolic rate)

Anthropometric
Measurement
Outcomes
Height, weight, body
mass index (BMI),
growth pattern
indices/percentile ranks,
and weight history

Nutrition-Focused
Physical Assessment
Outcomes
Physical appearance,
muscle and fat wasting,
swallow function,
appetite, and affect

Food/Nutrition-Related History Outcomes

M/E
1. Carbohydrate Intake

NCP Terminology
Total carbohydrate

2. Energy Intake

Total energy intake

3. Fat and Cholesterol

Intake

Saturated fat intake

Trans fatty acids

Additional Notes if Applicable

Recommended intake: 45% CHO (188230g/day) to start
Recommended intake: 1670-1870 Kcal/day for
weight loss
Recommended intake: <7% (<13-15 g/day)
Recommended intake: <1% (<2 g/day)

4. Fiber intake

Total fiber

Recommended intake: 38 g/day

5. Alcohol Intake

Frequency

Recommended intake: <2 drinks/day

6. Medication

Prescription medication
use
Misuse of medication

See if patient have been compliant with

prescribed medication intake:
Insulin dosage 3 times/day, 30 minutes
prior start of meals
Follow instructions and consume at
appropriate times to avoid GI distress

7. Food and nutrition

knowledge/skills

Areas and level of

knowledge skill

See if patients has been compliant with new

nutrition prescription

Biochemical Data, Medical Tests, and Procedure Outcomes

M/E
1

NCP Terminology
Glucose/Endocrine Profile

Lipid Profile

Additional Notes if Applicable

Glucose, fasting
HbA1c
Peak postprandial plasma glucose
Triglycerides, serum
Cholesterol, serum

Electrolyte/Renal Profile

Urine Profile

Acid-Base Balance

Vital Signs

Cholesterol, HDL
Cholesterol, LDL
BUN
Creatinine
Sodium
Potassium
Phosphorus
Color
Volume
Osmolality
Arterial pH
Venous pH
Blood Pressure
Temperature
Respiratory Rate
Pulse

Anthropometric Measurement Outcomes

M/E
1

NCP Terminology

Additional Notes if Applicable

Body composition/growth/weight history

1. Weight
2. Weight change
3. BMI

Nutrition-Focused Physical Assessment Outcomes

M/E
1
2
3

NCP Terminology
Overall Appearance
Body Language
Cardiovascular/Pulmonary

4
5
6
7
8
9

Extremities Muscles and bones

Digestive System (mouth to rectum)
Head and Eyes
Nerves and Cognition
Skin
Vital Signs

Additional Notes if Applicable

Skin, eyes, mouth/breath
Blood Pressure, Pulse. He has a family history of
CVD
Proper digestive function is important
PERRLA
Turgor - hydration
Particularly interested in his blood pressure

Nutrition Note Initial Session MF

4/13/15 1pm
A:
Client chief nutrition complaint: Vomiting; Admitted to the ER with severe hyperglycemia and dehydration
Diet Hx: Pt does not follow a strict diet, does not add salt, tries to avoid high-cholesterol foods and high-sugar desserts
Diet Order: Currently NPO
Food & Nutrient Intake (typical)/d: 13 oz. grains (0 whole), 1 3/4 c. vegetables 0 c. fruit, fats ~7 tsp., added sugars ~13
g, 3 oz protein
Macronutrient intake/d: ~1700-1900 kcal, 70-80 g pro, 65 g fat (~ 34 % of total kcal), less than 15 g fiber
Medications: Glyburide 20 mg daily, Metformin 500 mg twice daily, Dyazide daily (25 mg hydrochlorothiazide and 37.5
mg triamterene), Lipitor 20 mg daily
Personal Hx: 53 yo M Social Hx: Single, lives alone, Military background
Patient Medical History: T2DM x 1 yr, HTN, hyperlipidemia, gout
Body Composition: Ht 5'9", Wt 214#, IBW 160, %IBW 134%, BMI 31.6 lb/in2
Food + nutrition knowledge: Patient has history of noncompliance, no previous T2DM education given, admits to not
taking T2DM medications as prescribed
Physical Activity: N/A
Biochemical data: Glucose 1524 mg/dL (at admission), Osmolality: 360 mmol/kg/H2O (at admission), HbA1c 15.2%
Vital Signs: Temp 100.5, Pulse 105, Resp rate 26, BP 90/70
Comparative standards:

Calories: ~1670-1870 kcal/d (MSJ - 300-500 kcal) Protein: 83.5- 93.5 g ( 20% of kcal) (ADA)

CHO: 45-55% (ADA), 38 g fiber, FAT: 20-35% (AMDR), Fluid: 2000-2500 mL (per diet order)
D:
1. Intake of types of carbohydrates inconsistent with needs for T2DM R/T food and nutrition-related knowledge deficit
AEB elevated blood glucose levels of 1524 mg/dL at admission vs. normal range of 70-110 mg/dL and elevated HbA1c of
15.2% vs. normal range of 3.9-5.2%.
2. Obese, Class I R/T undesirable food choices and self-monitoring deficit AEB intake of types of carbohydrates
inconsistent with needs for T2DM per 24 hour recall and BMI of 31.6 lb/in2 .
I: Nutrition Rx: 1670-1870 Kcals, 83.5-93.5 g PRO, 45-55% CHO, 35% kcal fat, 38 g fiber, fluid 2000-2500 mL.
1. Modify Food & Nutrient Intake: Modify composition of meals to include consistent CHO intake including 3 meals
and 2 snacks. Calorie deficit included in meal plan for weight loss.
2. Nutrition Education: Provide education on T2DM and consistent and appropriate types of CHO intake along with
insulin use at home. Importance of consistent use of medication should be emphasized. At the end of the session, client
should be able to plan intake based on plans listed.
3. Coordination of Care: Referral to MD. Ask to check lab values for blood glucose, osmolality, sodium levels, and
HbA1c.
Goals:
1. Decrease intake of fast foods and increase amount of unrefined CHO including whole grains, fruits, and vegetables.
Patient will include approximately 40-43 g CHO at meals and 18-21 g CHO at each snack.
2. Patient will begin insulin use at home, 3 times per day and 30 min. prior to meals. Medication to be taken on a
consistent basis.
3. Loss of 1-2# per week to BMI within target range of 25 lb/in2
M/E: Carbohydrate intake: carbohydrate to insulin ratio; Food and Beverage Intake; Electrolyte and renal profile: sodium,
serum osmolality; Glucose/Endocrine profile: glucose, fasting, and HbA1c , any change in weight.
Goal: Patient will keep food log to be evaluated on the next visit. Patient will self monitor and follow guidelines for CHO
intake and insulin use at home. Lab values will be examined to determine decrease in blood glucose levels.
Rachel Bertler, Catherine Henderson, Brianna Hudson, Mona Lenihan-Costanzo, Jenny Nguyen, 4/12/1

References Cited in this Worksheet

Evert, A.B., Boucher, J.L., Cypress, M., Dunbar, S.A., Franz, M.J., Mayer-Davis, E.J., Yancy Jr., W.S.
(2013). Nutrition therapy recommendations for the management of adults with diabetes. Diabetes
Care, 36, 3821-3835. doi: 10.2337/dc13-2042.
Nelms, M., Sucher, K., & Lacey, K. (2016). Nutrition therapy and pathophysiology, third ed. Boston,
MA: Cengage Learning.
Wisse, B. (2015). Diabetic hyperglycemic hyperosmolar syndrome: MedlinePlus Medical Encyclopedia.
Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/000304.htm

Appendices
Appendix A. Intake analysis using Food Processor software (installed in FCS computer labs).
a. Spreadsheet - See attachments Nutrients Report 24 Hour Recall CS 2 and Meal
Summary Report 24 Hour Recall CS 2
b. Bar graphs: Macronutrient Intake Analysis

Bar Graph: Mineral Intake Analysis

c. Pie chart: Macronutrient Distribution of Intake

d. MyPlate recommendation:
6 oz grains, 2 1/2 c. vegetables, 2 c. fruits, 3 c. low fat dairy, 5 oz. proteins, 6 tsp. fats, less than
260 extra kcal (sugars + other fats), 45-65% CHO, 10-35% Protein, 20-35% Fat. Physical activity
should be 150 minutes a week.

Appendix B. Nutrition Intervention: sample menu for one-day.

A Sample Menu for daily consumption on the new Diet Order:
Breakfast
1 cup oatmeal, cooked

2 carb exchanges

tbsp almond butter

1 fat exchange

cup milk 1% fat (6 oz)

1 milk exchange

2 eggs, boiled

2 medium fat meat

3 cherries

.25 Fruit exchange

cup decaffeinated coffee (4

oz)

Free food

TBSP Coffee creamer

Free food

14 ounces Water
Snack
cup blueberries

Fruit exchanges

1 cup plain lowfat yogurt

1 Milk exchange

8 pistachios

.5 Fat exchange

8 ounces water

Free food

cup decaffeinated coffee (4

oz)

Free food

light coffee creamer

Free food

2 oz Poached Salmon

2 lean meat exchanges

cup Pasta, cooked

2.3 Carb Exchange

cup Red bell pepper cooked

1 Carb Exchange

1 cup Broccoli Florets, raw

1 Carb Exchange

Cup White Beans, cooked

.5 Plant Based Protein

Cup Diced portobello

Mushrooms, raw

.25 Carb Exchange

Lunch

2 teaspoon Olive oil

2 Fat Exchange

2 teaspoons Apple Cider

Vinegar

Free Food

1 teaspoon Basil

Free Food

teaspoon Oregano

Free Food

1 teaspoon Parsley

Free Food

1 teaspoon Raw garlic

Free Food

8 ounces of water

Free Food

1 cup MIlk 1% fat (8 oz.)

1 Milk Exchange

cup Spinach, raw

.5 Carb Exchange

cup Strawberries

.5 carb Exchange

3 Slices Banana

.25 Carb Exchange

Afternoon Snack

12 ounces of water
Dinner
cup Sweet Potato

1.5 Carb Exchange

1 Cup Chicken Broth

(homemade low sodium 8 oz.)

1 Carb Exchange

cup Onion

.5 exchange Non starchy

vegetables

1 ounce Lentils

.25 Exchange Carb and .25

exchange of Lean Meat

cup Tomatoes, cooked

1 Carb Exchange

cup lowfat Yogurt

.33 Milk Exchange

1 teaspoons Curry powder

Free Food

8 ounces of water

Appendix C. Analysis of the sample menu using Food Processor software.

a. Spreadsheet - See attachments Nutrients Report Sample Menu CS 2 and Meal
Summary Report Sample Menu CS 2
b. Bar graphs: Macronutrient Intervention Sample Daily Menu Analysis

Bar Graph: Mineral Analysis of Intervention Sample Daily Menu

c. Pie chart: Macronutrient Distribution of Intervention Sample Daily Menu

d. MyPlate recommendation:
5-6 oz grains, 2-2 1/2 c. vegetables, 1.5 c. fruits, 3 c. low fat dairy, 5 oz. proteins, 5 tsp. fats,
less than 160 extra kcal (sugars + other fats), 45-65% CHO, 10-35% Protein, 20-35% Fat.
Physical activity should be 150 minutes a week.