Case Study 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin

Transcription

1 1 Case Study 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin DFM 484: Medical Nutrition Therapy I San Francisco State University Professor Julie Matel MS, RD, CDE Fall 2013 By Alma Hernandez & Josephine Middleton

2 2 Case Study 17 Adult Type 2 Diabetes-Mellitus (T2DM): Transition to Insulin I. Understanding the Diagnosis and Pathophysiology: 1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch s medical record? Standard diagnostic criteria for T2DM: casual plasma glucose concentration equal or greater than 200 mg/dl or fasting plasma glucose concentration equal or greater than 126 mg/dl, or 2-hour postprandial glucose equal or greater than 200 mg/dl during an OGTT (oral glucose tolerance test). Mr. Fagan s casual glucose are 1524 mg/dl (4/12) and 425 md/dl (4/13). 2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his medications. What types of medications are metformin and glyburide? Describe their mechanisms as well as their potential side effects/drug-nutrient interactions. Metformin is non-insulin, oral diabetes medication that decreases hepatic glucose production and increases insulin uptake in muscles may decrease chances of cardiovascular disease due to ability to lower triglyceride level and LDL level. Metformin has a low risk of putting patient in hypoglycemia, and does not cause weight gain. Adverse effects: temporary diarrhea, n/v, frequent flatulence, anorexia, lactate acidosis (rare occurrence), contraindicated in patients with impaired kidneys, liver failure or CHF. Metformin decreases absorption of folate and vitamin B 12. Individual must avoid alcohol when taking this medication, and must be taken with meals to reduce gastrointestinal distress. Glyburide is another non-insulin, diabetes medication that stimulates insulin secretion. This medication does put the patient in a high risk of hypoglycemia and cause weight gain. This medication is contraindicated in patients with renal insufficiency. However, Glyburide is inexpensive and long history of effectiveness. Most diabetes patients may oy need to take once daily. Individual taking this medication must avoid alcohol because it may cause stress on liver. 5. HHS and DKA are the common metabolic complications associated with diabetes. Discuss each of these clinical emergencies. Describe the information in Mitch s chart that supports the diagnosis of HHS. HHS (hyperosmolar hypeglycemic syndrome) is when the diabetes patient has an abnormally high plasma glucose level (greater than 600 md/dl) due to inadequate amounts of insulin to maintain normoglycemia. HHS is very common amongst T2DM older adults, and tends to have

3 3 cases of dehydration due to reduced thirst recognition causes older adults to be slightly confused. This happens when T2DM is uncontrolled for a long time. Symptoms may include poluyuria and polydipsia. Patient must be hospitalized. DKA (diabetic ketoacisdosis), a metabolic acidosis, happens to be more common amongst T1DM and rarely in T2DM. Other DKA descriptions are high levels of ketones in urine and high levels of glucose in blood (hyperglycemia; greater than 250mg/dL). Also, the patient s arterial ph is below Symptoms include polyuria, polydipsia, weight loss, abdominal pain, vomiting, and Kussmaul respirations (deep/labored breathing). Information that supports Fagan s HHS diagnosis at admittance: glucose is 1524 mg/dl ( is mg/dl); serum osmolality is 360 mmol/kg/h 2 O ( is mmol/kg/h 2 O). Fagan also reported excessive vomiting, and irregular with taking diabetes medications. Mild confusion and dry mucous membranes show signs of dehydration. 9. Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine? How likely is it that Mitch will need to continue insulin therapy? The insulin therapy started for Mitch is Lispro and Glarine (both are administered via injection). Lispro is a rapid acting insulin that acts 5 to 15 minutes after injecting the medication, and peak of action is 30 to 90 minutes with a duration of 3 to 5 hours. Lispro can be used in pump therapy. Glargine differs from Lispro because this is an extended long-acting analog, which means it is peak-less and has duration of 20 to 24 hours. Glargine sets 2 to 4 hours after administering the injection. Glargine cannot be mixed with other insulins. II. Understanding the Nutrition Therapy: 11. Outline the basic principles for Mitch s nutrition therapy to assist in control of his DM. Basic principles for nutrition therapy to control T2DM: - Restriction and maintaining a stable calorie intake. - Allow an even distribution of carbohydrate foods throughout the day. - Make adjustments for carbohydrate to glucose tolerance. - Reduce eating foods that are high in saturated fat and/or trans fat. - Integrate simple sugars/carbohydrates such as fruits, milk, and vegetables. - Continuous nutrition counseling and motivation to promote behavior change to make better food choices and exercise.

4 4 III. Nutrition Assessment: 12. Assess Mitch s weight and BMI. What would be a healthy weight range for Mitch? Weight: 97.3 kg; Height: ; BMI = 97kg/1.75m 2 = 32 kg/m 2 which means Mitch is obese (class 1). Healthy weight or IBW for Mitch is 142 lbs or 64.5 kg. 13. Identify and discuss any abnormal laboratory values measured upon his admission. How did they change after hydration and initial treatment of his HHS? Abnormal laboratory values upon admission and how did they change after hydration and initial tx of his HHS? Ref. Range 4/12 4/12 Post-hydration and tx of HHS BUN (mg/dl) Lowered and is now near the range Glucose (mg/dl) Decreased 1049 mg/dl. However, still high and not within the range Osmolality (mmol/kg/h 2 O) Decreased 56 mmol/kg/h 2 O. However, still not in range. HbA 1c (%) Returned back to Hematocrit M 57 Returned back to Specific gravity Returned back to ph Returned back to

5 5 Ketones (urine) Neg (-) + Returned back to Glucose (urine) Neg (-) + Returned back to Color (urine) - Yellow Returned back to 14. Determine Mitch s energy and protein requirements for weight maintenance. What energy and protein intakes would you recommend to assist with weight loss? Energy requirements using Harris-Benedict eqtn for male: (72kg) (175cm) 6.8 (53 y/o) = 1574 kcal 1574 (1.0) = 1574 kcal 1574 (1.2) = 1889 kcal.: kcal/day Used Mitch s IBW to calculate his estimated energy requirements because he is obese (class 1). Used an activity factor of because he is sedentary and does not do much physical activity. Protein requirements: 0.8 g/72 kg = 57.6 g of PRO/day. Used IBW to calculate PRO requirements because he is obese g is 14% of daily calories, which is within the recommended amount (10-20%). Energy and protein intake recommendations to assist with loss: Carbohydrates: recommended 50-60% of calories per day. Food items like starch (bread), fruits, milk, non-starchy vegetables/fiber, and sweets/desserts/other carbohydrates will vary from 5 g to 15 g of carbohydrates. These items do include about 3 to 8 g of PRO and kcal per serving. There are three main types of carbohydrates: starches, sugars and fiber. Protein: recommended % of calories per day. Other PRO sources are meat and meat substitutes that has about 7 g of PRO and ranges from 45 to 100 kcal per serving. Fats: recommended is 25-35% of calories per day, with less than 7% of saturated fat and minimal trans fat. One serving or portion size has 45 kcal. Alcohol: Since Mitch is on insulin therapy, he should limit his alcohol intake to less than 2 drinks per day. One serving of beer (12 oz) has 100 kcal. IV. Nutrition Diagnosis: 15. Prioritize two nutrition problems and complete the PES statement for each.

6 6 Nutrition Dx 1: Overweight/obesity related to poor eating habits, unhealthy dietary choices, excessive caloric intake as evidenced by BMI of 32 kg/m 2, 34% over IBW of 64.5 kg. Nutrition Dx 2: Inadequate fluid intake related to decreased thirst recognition, high plasma glucose content as evidence by plasma glucose level of 1524 mg/dl, osmolality level of 360 mmol/kg/h 2 O, positive glucose in urine, and urine specific gravity of V. Nutrition Intervention: 16. Determine Mitch s initial CHO prescription using his diet history as well as your assessment of his energy requirements. Because Mitch is has T2DM, he has to distribute his carbohydrate intake throughout the day. Mitch should be eating carbohydrates 50 to 60 % of calories per day. Mitch has to take in kcal per day to maintain life. Therefore, his CHO intake should total to about 1250 kcal to 1500 kcal per day. Food items Serving size/no. Total CHO (g) CHO Kcal Total Kcal of Ex Bagel 1 oz (4 oz bagel) Cream cheese 1 tbsp Diet soda Fast-food sandwich 2 CHO + 2 medfat fat Chips Grilled chicken/beef Salad Potatoes/rice Different ethnic Varies Varies Varies Varies foods Half and half 2 tbsp Estimated daily total CHO: 255 g Estimated daily CHO kcal: 1020 Estimated daily kcal: 1315

7 7 Mitch s diet hx show that his CHO intake is 68% of his total daily kcal. He consumes most of his CHO in the afternoon. What he can do is eat 1/3 of his CHO kcal in the morning, another 1/3 at noon, and 1/3 around dinnertime. 17. Identify two initial nutrition goals to assist with weight loss. Nutrition goal for weight loss 1: Increase fruits, vegetables, and whole grain intake especially for the first meal of the day, lower intake of high-calorie dense foods like fast-food sandwiches and chips. Reduce calorie intake to kcal per day, it may help to count calories and count carbohydrates. Healthy weight loss of 1-2 lbs per week is suggested. Nutrition goal for weight loss 2: Increase physical activity, and increase eating home-cooked meals with healthier cooking techniques. Refer to exercise physiologist. Also, continue nutrition counseling with RD for behavior changes motivation and dietary education.