Medical Nutrition Therapy CLNS 321

Practice 5
Type 2 Diabetes Mellitus

Student Names:

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 Case Questions:

I. Nutrition Assessment

Organize the assessment data in the table below

Food/ Nutrition Anthropometric Biochemical Data, Nutrition Client

Related History Measurements Medical Tests, and -Focused Physical History
Procedures Findings
Because her sister Weight= 70kg HbA1c= 8.5% general appearance: Mrs.Douglas is a
has sugar Height= 152 cm Glucose= 325mg/dl overweight, eldrly 71 y/o African
Mrs.Douglas does BMI=30.29 sodium= 140 mEq/L vitals: American female
not buy candies, chloride= 103 mEq/L Temp=99.2 F who lives with
PO4= 3.6 mg/dl BP=150/97mmHg
cake or other her sister whom
magnesium= 2.1 mg/dl
deserts. She HR=75 bpm she cares for. She
Lipids profile:
avoids all starchy RR=12 bpm has an unhealed
HDL= 35 mg/dl
food as her sister LDL= 140 mg/dl mild retinopathy wound and blurry
does. Once a T-G= 400 mg/dl vision.
month she and her cholesterol= 300 mg/dl Douglas has
sister have cake kidney function : frequent bladder
and ice cream at BUN= 26 mg/dl infection, tingling
the senior center's albumin= 4 g/dl and numbness in
birthday party. creatinine= 1.2 mg/dl her feet.
She diagnosed with
DM type2
family Hx: DM in
her sister

II. Understanding the Disease and Pathophysiology

1. What are the risk factors does Mrs. Douglas present with for development of type 2 diabetes mellitus?
Risk factors for type 2 diabetes mellitus include environmental and genetic risk factors, includes
a family history of diabetes -her sister- with DM, a prior history of gestational diabetes, physical
inactivity also, inactivity and she is presently overweight.

2. Does Mrs. Douglas present with any complications of diabetes mellitus? If yes, which ones?

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Yes, Mrs. Douglas Suffers from hypertension BP 150/97, blurry vision Maybe in the early stage
of diabetic retinopathy. she is also Suffers numbness and tingling in her feet suggesting she is
experiencing peripheral neuropathy, Nephropathy and HHNS (Hyperosmolar
Hyperglycemic Nonketotic Syndrome)

II. Nutrition Assessment

A. Evaluation of Weight/Body Composition

3. Calculate Mrs. Douglas’s body mass index (BMI).

BMI= 70/(152/100)^2= 30.2

4. What are the health implications for a BMI in this range?

Mrs. Douglas’s BMI is 30.3 which is considered obese.therefore, she has a higher risk of
developing diseases such as HTN, CVD, and DM.

B. Calculation of Nutrient Requirements

5. Calculate Mrs. Douglas’s energy needs using the Mifflin-St. Jeor equation. Should Mrs. Douglas’s weight
be adjusted for obesity?

Females: 10(W) + 6.25(Ht) - 5(Age) - 161

(10 x 70.3) + (6.25 x 152) - (5 x 71) - 161

703 + 950 - 348.3 - 161 = 1,144 kcal

TEE = REE x (AF) x (IF)

Activity factor = 1.5 (daily activities), Injury factor = 1.2 (infection)

TEE = 1144 x 1.5 = 572

TEE = 1144 x 1.2 = 229

TEE = 1144 + 572 + 229 = 1945 kcal

Mifflin-St. Jeor equation is a precise and an accurate tool for individuals who are obese or
overweight according to AND. For this reason, her weight doesn’t need to be adjusted.
6. Calculate Mrs. Douglas’s protein needs.

Since she is older than 50 years (71 years) = 0.8-0.1g/kg/day, & her weight is 70.3 kg:
0.8 x 70.3 =56g
1.0 x 70.3 =70.g (wound healing)

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Protein needs = 56g-70g / day
7. Is the diet order of 1,200 kcal appropriate?
No, it is not appropriate.

8. If yes, explain why it is appropriate. If no, what would you recommend? Justify your answer.

It is not appropriate, she needs higher calories and protein, so that her wound could heal.
and after her infection clears up her TEE would decrease because losing weight can help lower
her lipid panel and may help control her diabetes.

C. Intake Domain

9. Using a computer dietary analysis program or food composition table, calculate the kcalories, protein,
fat, CHO, fiber, cholesterol, and Na content of Mrs. Douglas’s diet.

Calories Protein Fat CHO Fiber Cholesterol Sodium

Total 1224 51g 52g 141g 16g 327mg 3897mg

10. How would you compare Mrs. Douglas’s “usual” dietary intake to her current nutritional needs?

Mrs.Douglas usual diet don't meet her nutritional need, it is lower than her need. She needs more
calories and protein to help heal her wound.

D. Clinical Domain

11. Compare the patient’s laboratory values that were out of range on admission with normal values. How
would you interpret this patient’s labs? Make sure explanations are pertinent to this situation.

Parameter Normal Patient’s Reason for Abnormality Nutritional

Value Value Implications
Glucose (mg/dL) 70-110 325 mg/dL Elevated blood glucose -Monitor CHO
(Hyperglycemia). intake
- reduce fat intake
- monitor serving
sizes

HbA1c (%) 3.9-5.2 8.50% Chronic hyperglycemia due to -Monitor CHO

insulin resistance. intake
- reduce fat intake
- monitor serving
sizes

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 Cholesterol 120-199 300 mg/dL High consumption of fat in her Reduce saturated &
(mg/dL) diet. trans fat intake,
increase fiber,
choose lean protein,
omega-3 fats,
MUFA & whole
grains, fruits rich in
pectin

LDL-cholesterol <130 140 mg/dL High consumption of fat in her Reduce saturated &
(mg/dL) diet. trans fat intake,
increase fiber,
choose lean protein,
omega-3 fats,
MUFA & whole
grains, fruits rich in
pectin

HDL-cholesterol >55 35 mg/dL Obesity and physical Limit refined CHO,

(mg/dL) inactivity. saturated fat intake,
avoid trans fat

Triglycerides 35-135 400 mg/dL Obesity and physical Limit refined CHO,
(mg/dL) inactivity. saturated fat intake,
avoid trans fat

12. Identify two lab values that should be monitored regularly.

HbA1c, urine, and SMBG.
13. Avandia is often used to help control blood glucose levels. Describe the (medication) action of Avandia.

Mechanism of Action: Rosiglitazone (Avandia), a member of the thiazolidinedione class of

antidiabetic agents, improves glycemic control by improving insulin sensitivity. Rosiglitazone is
a highly selective and potent agonist for the peroxisome proliferator-activated receptor-gamma
(PPARγ). In humans, PPAR receptors are found in key target tissues for insulin action such as
adipose tissue, skeletal muscle, and liver. Activation of PPARγ nuclear receptors regulates the
transcription of insulin-responsive genes involved in the control of glucose production, transport,
and utilization. In addition, PPARγ-responsive genes also participate in the regulation of fatty
acid metabolism. (fda.gov)

E. Behavioral–Environmental Domain

14. Identify at least three factors that may interfere with Mrs. Douglas’s compliance and success with her
diabetes treatment.

1&2: Her willingness to exercise and to change her diet.

3: Her income.

III. Nutrition Diagnosis

15. Select two high-priority nutrition problems and complete the PES statement for each.

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PES1:
Impaired nutrient utilization related to diagnosis of type 1 DM as evidenced by admit lab results
of high HbA1c level (8.5%), high blood glucose level (325 mg/dL), blurred vision, edema,
frequent infections in the bladder, numbness and delayed wound healing in feet.

PES2:
Inappropriate intake of types of carbohydrates related to food, nutrition, and nutrition-related
knowledge deficit as evidenced by high consumption of simple CHO, admit lab results of high
blood glucose level (325 mg/dL), high HbA1c level (8.5%), high TG level (400 mg/dL), low HDL
level (35 mg/dL), and borderline high LDL level (140 mg/dL).

IV. Nutrition Intervention

16. For each of the PES statements that you have written, establish an ideal goal (based on the signs and
symptoms) and an appropriate intervention (based on the etiology).

PES1:
Goal: self-monitoring, reducing her blood glucose to at least 200 mg/dL.
Intervention: to control and monitor the blood glucose, must provide the patient with knowledge
and education about DM type 2.

PES2:
Goal: self-monitoring, reducing her blood glucose to at least 200 mg/dL.
Intervention: to control and monitor the blood glucose, must provide the patient with knowledge
about DM type 2, also about the proper carbohydrate counting and fat intake and portion sizes,
increase her physical activity, and increase whole grain CHO.

17. Design One day menu plan for Mrs. Douglas, considering her diagnosis.

Breakfast: 1 cup milk low fat, One poached egg and half a small avocado spread on one slice of
bread, one orange.
Lunch: a one-third cup brown rice with fish, two-thirds cup home-made baked beans, 1 cup
chopped spinach, a quarter cup chopped tomatoes, a quarter cup bell peppers, 1.5 oz cheese,
1 tbsp salsa as a sauce.milk low fat
Snack: 20 10-gram baby carrots with 2 tbsp hummus. one banana
Dinner: 1 cup cooked lentil penne pasta, 1.5 cups veggie tomato sauce (cook garlic, mushrooms,
greens, zucchini, broccoli, and eggplant into it), with olive oil
Snack: 1 cup cucumber, 2 tsp tahini. 1\2 cup yogurt

V. Monitoring

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18. Mrs. Douglas was d/c with instructions for a non–kilocaloric-restricted, low-
fat (≤ 30% total kcal), high-CHO ( 50% total kcal) diet, in combination with a
walking program, and a prescription for captopril to control her HTN. Glucose
levels were well controlled for 6 months, but she became unable to afford the
necessary supplies to check her BG or urine acetone levels. After 6 months, she
was readmitted with a BG of 905 mg/dL, a slight temperature, BP of 68/100 mm Hg,
tachycardia, and shallow, tachypneic breathing (Kussmaul respirations). She was Dx with
pneumonia, dehydration, and hyperglycemic hyperosmolar nonketotic syndrome (HHNS). What is the
MNT for patients with HHNS?

Mrs. Douglas Need to make sure she understands how to lower fats and eat healthy balanced
meals and rehydrate the patient, involves administering intravenous fluids like electrolyte
solutions to restore fluid balance, combined with insulin to slowly bring down the blood
glucose level also, monitor her lipid levels, BP and weight.