Name(s):Marisa Gutierrez, Laurie Hill, Jessica Leslie, Ashley MarshDate: 3/27/2014Class period: TR 1:30-2:45NTR 341Due: On the date stated in your syllabus by 10:00 pm via Blackboard

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

Understanding the Disease and Pathophysiology 1. (3 points) What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical record?

The standard diagnostic criteria for T2DM are symptoms of diabetes which include polyuria, polydipsia, polyphagia, and weight loss, weakness and fatigue. Neuropathy or retinopathy may be present as complications in a patient with undiagnosed T2DM. Most patients do not have symptoms indicating T2DM (1). Clinically the diagnostic will be one of the following:

plasma glucose concentration ≥200 mg/dLfasting plasma glucose ≥126 mg/dL2-hour post-prandial glucose ≥200 mg/dL during an oral glucose test

(2 pg. 485).

Mitch’s serum glucose in the ER was 1524 mg/dL. The next day his glucose level was at 475. This is still elevated since normal limits are between 70-110 mg/dL and his HbA1c was 15.2%, normal is between 3.9-5.2, indicating that his blood glucose has not been in control the past few months (3 pg. 198-199). His osmolality was 360 the first day he was in the hospital and then the 2nd day it was 304 which is improved but not within the normal limits of 285-295 (3 pg. 198). His urinalysis showed protein, glucose, and ketones. 2. (3 points) What types of medications are metformin and glyburide? Describe their mechanisms as well as their potential side effects/drug-nutrient interactions.

Metformin is in a category of drugs called biguanides and is used to treat Type 2 diabetes. It works to control the glucose in the blood by lowering the amount of glucose that manufactured by the liver as well as that glucose the body would absorb from food consumption. Metformin will help the body respond to insulin that is naturally produced in the body. Some people may have side effects that include the following: diarrhea, bloating, stomach pain, gas, indigestion, constipation, unpleasant metallic taste in mouth, heartburn, headache, flushing of the skin, nail changes, muscle pain. More serious complications such as chest pain or a rash may appear and need immediate emergency treatment. Lactic acidosis may also occur. There may be other side effects such a polyps in the uterus but have not been proven in humans (4). Metformin is known

to lower B12 absorption which if there is adequate intake of B12 in the diet, taking metformin will not necessarily cause a problem. However, in some cases it can cause a nutrient deficiency and the following are more at risk: older age, vegetarian diet, if the drug is used in high doses or taken for more than 3 years. Correction of the deficiency would be to supplement with 1000-2000 mcg on a daily basis (5).

Glyburide is in the sulfonylureas classification of drugs. This medication is used to decrease blood sugar by stimulating the pancreas to produce insulin and assist in productively utilizing the insulin. Some of the complications from this medication may include nausea, upper abdominal fullness, heartburn, rash. More serious side effects may include yellowing of the skin or eyes, light colored stools, dark urine, pain in the upper right part of the stomach, unusual bruising or bleeding, diarrhea, fever, sore throat, and swelling of the eyes, face, lips, tongue, or throat. Other symptoms may appear as well (6).

3. (4 points ) Describe the metabolic events that led to Mitch’s symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM with HHS. Make sure to define HHS and relate this to the patients’ symptoms.

The metabolic events that led to Mitch’s symptoms and admission to the ER with T2DM and HHS were caused by the body’s inability to use the insulin and his body breaking down muscle and producing ketone bodies. This led to drowsiness and confusion which was observed upon the arrival of the co-worker.

HHS is Hyperglycemic Hyperosmolar Syndrome which can occur in patients who have T2DM with a blood glucose greater than 600 mg/dL. Mitch presented at the ER with a glucose level of 1524 mg/dL. HHS also occurs when a patient’s serum osmolality is greater than 320 mOsm/kg of water, Mitch had an osmolality level of 360 mmol/kg/water. Patients with HHS will also not have a presence of ketoacidosis. HHS can be initiated by both dehydration and infections (2 pg. 499). Mitch had been vomiting and due to his physical state of being drowsy and confused upon his co-worker’s arrival, he was hyperglycemic and dehydrated. He also had ketones present in his urine.

4. (4 points) 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 is Hyperglycemic Hyperosmolar Syndrome and many people with type 2 diabetes can have this complication. HHS is initiated by an infection or severe illness which can cause dehydration if vomiting or diarrhea are involved. There are three main factors that contribute to HHS: 1. excessively high levels of blood glucose, >600 mg/dL 2. dehydration from lack of fluid intake or excessive loss of fluid 3. decreased consciousness. These symptoms do not occur all at once and are a result of lifestyle and are not usually recognized until there is a problem (2 pg. 499). Other symptoms include

undiagnosed diabetes, polyuria, polydipsia, fever (due to infection), weight loss that is unexplained. Laboratory tests include a plasma glucose >600 mg/dL, arterial pH >7.3, serum bicarbonate >15 mEq/L, urine and plasma ketones will both be small, and serum osmolality >320 mOsm/kg. These symptoms result in the need of hospital treatment for re-hydration to occur at a slow rate, treat any underlying conditions such as an infection, balance electrolytes, and possible use of insulin to bring the blood glucose back in control (2 pg.503).

DKA is diabetic ketoacidosis and occurs in patients with type 1 diabetes and those who have undiagnosed type 2 diabetes, are obese & do secrete insulin and use it efficiently. There are many issues that can cause DKA such as infections, psychological stress, lack of self-monitoring blood glucose, not using insulin or the need for more insulin due to growth, pump malfunction, drug abuse, or severe illnesses which include CVA, MI, pancreatitis, pulmonary embolism, alcohol or drug abuse. Symptoms of DKA include polyuria, polydipsia, weight loss (unexplained), vomiting, abdominal pain, dehydration indicated by loss of skin turgor and dry mucous membranes, tachycardia, hypotension, patients may also have acetone breath which is a fruity breath, and kussmaul respirations which is a deep labored breathing. Laboratory tests include a plasma glucose >250 mg/dL, arterial pH <7.0 to 7.3, serum bicarbonate < 10 to 18 mEq/L, ketones in both blood and urine will be positive and serum osmolality will be variable. Hospital treatment is necessary for IV fluids to hydrate the patient as well as insulin, and assessment of blood electrolytes (2 pg. 503).

Mitch’s arrival at the hospital he had dry mucous membranes in the throat, he was drowsy and mildly confused, his skin was warm, dry and had poor turgor. His lab values show a blood glucose of 1524 mg/dL, and osmolality of 360 mmol/kg/water. His urinalysis had positive values for both glucose and ketones. These symptoms and lab values fit the criteria for HHS.

5. (3 points) 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?

Mitch will begin Lispro, 0.5 units every 2 hours until blood glucose levels reach 150-200 mg/dL. Mitch will also be given glargine, 19 units. Lispro is a short acting form of insulin used to control the amount of glucose in the blood. Glargine is a long acting form of insulin that will lower blood glucose levels at a constant rate over time. It is very likely that Mitch will continue insulin therapy after discharge from hospital. His poorly controlled diabetes and poor diet cause him to be at an increased risk for recurring episodes of HHS and possibly DKA.

6. (5 points) What are the chronic complications associated with diabetes mellitus? Describe the pathophysiology associated with these complications, specifically addressing the role of chronic hyperglycemia.

Chronic complications of DM include neuropathy, renal complications, blindness, amputations of the lower extremities, MI and CVA. The complications are related to the changes in the blood vessels caused by DM. Chronic hyperglycemia caused by poorly controlled DM causes inflammation within the vessels. The resulting inflammation by this excess glucose in the bloodstream is cause for cardiovascular and cerebrovascular complications. Risks include but are not limited to MI or CVA. The microvascular changes due to inflammation also cause damage to nerves in the extremities (7). This damage causes pain and numbness and in severe cases, complete loss of function and ultimately amputation. Renal complications as they relate to chronic hyperglycemia and vasculature include hardening of the microvessels, or glomeruli of the kidneys (7). This progressive DM complication is referred to as glomerular sclerosis (8). Ophthalmic complications are also included in the list of complications due to vascular and microvascular changes associated with DM. Chronic hyperglycemia, or excessive glucose circulating in the blood, will cause more rapid and extensive damage to the vessels. Damage to these vessels will, in turn cause complications throughout the body systems.

*Requirement - Please cite at least one review article from a peer reviewed medical/nutrition journal that is no more than 10 years old. Your reference(s) must be properly cited, and a pdf copy of the full article you used must uploaded separately when you submit your case study online. *

Nutrition Assessment 7. (6 points) Identify any abnormal laboratory values measured upon his admission. Which

lab values changed after hydration and initial treatment of his HHS?

Biochemical Value

Patient’s Value(Indicate high or low)

Reason for Abnormality

Nutrition Implication(nutrition related concern with abnormality)

Did values change?

Sodium (mEq/L)

132, low Vomiting

Retaining nutritional and fluid intake

no significant change

BUN (mg/dL)

31, highAltered kidney function due to Diabetes

Must alter protein intake

moderate decrease in BUN

Creatinine serum (mg/dL)

1.9, high

Dehydration, kidney problems

Must increase fluid intake

small change

Glucose (mg/dL)

1524!, high

Mal-absorption of insulin as a complication of DM

Sugar and CHO levels in diet

Significant change in BS levels after tx

Phosphate, inorganic (mg/dL)

1.8, low

increased loss of bicarbonate in urine, caused by altered kidney function in relation to poorly controlled DM.

Poor nutrition, vitamin D deficiency

slight increase

osmolality (mmol/kg/H2O)

360, high

diet lower in LDL, and higher in HDL

slight decrease after tx

Cholesterol205, high

atherosclerosis as related to DM

diet lower in LDL, and higher in HD

would not change after initial tx

Triglycerides (mg/dL)

185, high

high blood glucose levels

alter intake of saturated fat

would not change

creating fatty acids

after initial treatment

HbA1c (%)15.2, high

excess blood sugar over 3 months due to DM uncontrolled

Dietary control of blood sugar levels

no immediate change in percentage after initial treatment

WBC’s 13.5, high

inflammation caused by DM

included inflammation reducing foods especially those with Omega-3’s

no immediate change

Hematocrit 57, high Dehydration Rehydrate patient

will change over time

8. (2 points) Determine Mitch’s energy and protein requirements.

Kcal Needs:Pt weighs 214 lbs 214/2.2 = 97.3 kg

kcal: 25 - 30 kcal/kg/dayRange for pt: 25 x 97.3 = 2432 kcal/day up to 30 x 97.3= 2919 kcal/day

Protein Needs: Normal = 0.8(97.27)kg = 77.82 g ProteinMinor illness = 1.2(97.27kg) = 116.72 g ProteinProtein needs for pt: 77.82 g/day - 116.72 g/day

Nutrition Monitoring and Evaluation (20 points) Write your nutrition care from the standpoint of your initial nutrition consult. Please also add education goals that you plan on addressing prior to this patient’s discharge from the hospital.

Sun Devil Nutrition Care Form (Total = 20 Points)Please record N/A if data is unavailable

Please show all calculations used to determine kcal, protein and fluid needsDATA & ASSESSMENT: 2 Points: (all or nothing here)Subjective Data: Mitchell is a single, 53 year old caucasian white male who lives alone. He is retired military, currently working as a consultant to a military equipment company. Mr. Fagan has smoked 1ppd for 20 years but has now quit, he also admits to 3 to 4 drinks per week. Family history of HTN and type 2 DM. Does not take his medication for diabetes regularly as he does not like how the side effects make him feel. Does take all other medications as prescribed.Patient is not currently following a strict diet but does avoid added salt, high cholesterol foods, and high sugar desserts. Has not had any formal education for diabetes aside from what his physician has provided.

Usual Intake:AM: Coffee with half and halfMidmorning: Bagel with cream cheese, 2-3 c of coffeeLunch: Out at restaurant - usually Jimmy John’s or fast-food sandwich,

chips, and diet sodaDinner: Cooks sometimes at home - this would be grilled chicken or beef,

salad, and potatoes or rice. Often will meet friends for dinner - likes all foods and especially likes to try different ethnic foodssuch as Chinese, Mexican, Indian, or Thai

Age: 53 y.o Gender: Male Height: 5’9” (175.26cm) Weight: 214lbs (97.27kg)Weight History: n/a

Medical Diagnosis: Type 2 DM uncontrolled with HHSReason for Consult: Consult dietitian for advancement, total carbohydrate Rx, and distributionDiabetes education for self-management training

Medications: Glyburide 20 mg dailyMetformin 500 mg twice dailyDyazide once daily (25 mg hydrochlorothiazide and 37.5 mg triamterene)Lipitor 20 mg daily

Current Diet Order:NPO except for ice chips and medications, after 12 hours clear liquids if stable. Then, advance to consistent-carbohydrate diet

Past Medical/Surgical History:Medical Hx:Type 2 DM x 1 yearHypertensionHyperlipidemiaGoutSurgical Hx:ORIF R ulnaHernia repair

1 Point:Lab Values and Assessment:

Chemistry Ref. Range 4/12 @ 1780 4/13 @ 1522

Sodium (mEq/L) 136-145 132 ↓ 134 ↓

BUN (mg/dL) 8-18 31 ↑ 20 ↑

Creatine serum (mg/dL)

0.6-1.2 1.9 ↑ 1.3 ↑

Glucose (mg/dL) 70-110 1524 ↑ 475 ↑

Phosphate, inorganic (mg/dL)

2.3-4.7 1.8 ↓ 2.1 ↓

Calcium (mg/dL) 9-11 10 9.8

Osmolality (mmol/kg/H2O)

285-295 360↑ 304↑

Cholesterol (mg/dL) 120-199 205↑

HbA1c (%) 3.9-5.2 15.2↑

C-peptide (ng/mL) 0.51-2.72 1.10

Urinalysis showed positive for protein, glucose, and ketones. Upon admission patient showed an elevated serum glucose of 1524 mg/dL, after insulin infusion levels dropped to 475 mg/dL which is still elevated but heading back into a normal range. Patient’s HbA1c level was at 15.2% upon admission which displays that his blood glucose levels have not been controlled over the past 3 to 6 months.

1 Point:

Weight Assessment (BMI and/or Hamwi Range - not just IBW):

BMI = weight (kg) / height (m2) = 97.27kg/ (1.753m)2 = 31.6 Hamwi = 106 + (6 x 9)= 160 lbsHamwi range = 144 lbs - 176 lbs

Mr. Fagan’s ideal body weight would be 160 lbs. Based on patient’s BMI of 31.6 he is in the obese category and according to the Hamwi equation he is 21% overweight (214 lbs/176 lbs).

1 Point:Energy Needs: 25kcal (97.27kg) = 2,431.75 kcal30kcal (97.27kg) = 2,918.10 kcal

To maintain his current weight he needs to consume 2,432-2,918 kcal according to the kcal/kg method . It is recommended that Mr. Fagan consume between 1,932- 2,418 kcal to promote weight loss.

1 Point:Protein Needs: Protein requirements would range from 77.82g - 116.72g Normal = 0.8(97.27)kg = 77.82 g ProteinMinor illness = 1.2(97.27kg) = 116.72 g Protein

1 Point:Fluid Needs:2000-2500 mL after rehydration

4 Points:NUTRITION ASSESSMENT NARRATIVE - Be specific so your audience (MD, RN, staff RD, etc) understands your assessment.

Patient has experienced an episode of diabetic ketoacidosis due to not eating for 12-24 hours. Patient suffers from Type 2 Diabetes but admits to not using his medication. Patient also suffers from hypertension, hyperlipidemia and gout. Patient reports recently quitting smoking 1 ppd. Patient also drinks alcohol 3-4 times per week. Based on patients usual intake, his diet consists of a majority of fast food items and coffee. This means that his diet is high in sugar (which cannot make it into his cells due to lack of medication/insulin) saturated fat, caffeine, and sodium. It is also low in vitamins, minerals, and water (drinks coffee instead).

3 Points:

NUTRITION DIAGNOSIS:Problem (Terminology):Impaired nutrient utilization (NC- 2.1)Related To Food- and nutrition-related knowledge deficit (NB-1.1)As Evidenced by24 hour recall

2 Points:NUTRITION INTERVENTION NARRATIVE - Be specific so your audience (MD, RN, staff RD, etc) understands your desired intervention, what it provides and why this needs to take place.

First and foremost, the patient needs to meet with a diabetes educator to understand his condition and how to properly take his medication regularly. He should learn how to determine administration of insulin based on his carbohydrate intake. He should understand that carbohydrates are necessary in his diet, but insulin is required with it. The side effects of the medication should also be addressed in order to ensure compliance. A journal on patient’s daily diet and administration of insulin would be preferable to ensure patient understands key concepts.As for his diet, the daily caloric intake should be reduced by 500 kcal/day and further reduced as needed to promote weight loss. He should be educated on the DASH diet to prevent future CAD or CVD. He should be instructed on how to properly substitute the foods high in empty calories in his diet for nutrient dense foods (e.g. drink water or juice instead of coffee).For non-dietary goals, the patient should continue cessation of smoking and should begin regular exercise.

1 Point:Nutrition Intervention (Terminology): Goals:General/healthful diet (ND-1.1)Nutrition Education- survival information (E-1.3)Nutrition Counseling- Health Belief Model (C-1.2)Goal Setting (C-2.2)Relapse prevention (C-2.9)Referral to RD with different expertise- CDE (RC-1.4)

2 Points:

NUTRITION MONITORING NARRATIVE - Be specific so your audience (MD, RN, staff RD, etc) understands your desired monitoring plans and why this needs to take place. In one week, call patient to ensure compliance. Ask specific questions on the patients diet and administration of insulin. If compliance low or patient cannot recall his education, have him come in for re-education. If compliance is high, schedule for appointment in one month. When he comes in, track weight loss, Hemoglobin A1C levels and blood glucose levels. Continue checks ups as seen fit. 1 Point: Nutrition Monitoring (Terminology):Goals:Modified diet (FH-1.1.1.2)Meal/snack pattern (FH-1.3.2.3)Total Carbohydrate Intake (FH-1.6.3.1)Food and nutrition Knowledge (FH-3.1)Motivation (FH-3.2.4)Ability to recall nutrition goals (FH-4.1.3)Self-management as agreed upon (FH-4.1.5)Physical Activity (FH-6.3)Weight (AD-1.1.2)Glucose, fasting (BD-1.5.1)Glucose, regular (BD-1.5.2)HgbA1c (BD-1.5.3)

RD Signature:Marisa Gutierrez, Laurie Hill, Jessica Leslie, Ashley Marsh (students)Date: 3/27/2014

References

1. Virtual Health Care Team. (2013). Diabetes mellitus type 2. Retrieved from http://shp.missouri.edu/vhct/case2600/symptoms.htm

2. Nelms M., Sucher K.P., Lacey K., Roth SL (2011). Nutrition Therapy & Pathophysiology 2nd edition. Belmont, CA:Cengage Learning.

3. Nelms, M.N., & Roth, S.L. (2014). Medical Nutrition Therapy: A Case Study Approach 4th edition. Stamford, CT: Cengage Learning

4. Medline Plus. (2014). Metformin. Retrieved from: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a696005.html

5. Therapeutic Research Faculty. (2014). Drug-induced nutrient depletion. Retrieved from http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=&pm=5&pc=11-108&AspxAutoDetectCookieSupport=1

6. Medline Plus. (2014). Glyburide. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a684058.htm

7. Lau C.W. David, MD, PhD, FRCPC. (2014). Cardiovascular Complications of Diabetes. Canadian Journal of Diabetes, 37 (5). Retrieved from http://www.sciencedirect.com.ezproxy1.lib.asu.edu/science/article/pii/S1499267113012094?via=ihub#

8. Min T.Z., Stephens M.W., Kumar P., Chudleigh R.A. (2012 September 7). Renal Complications of Diabetes. British Medical Bulletin., 104 (1). Retrieved from http://bmb.oxfordjournals.org.ezproxy1.lib.asu.edu/content/104/1/113