By Erin DeLlamas

Introduction
Patient has a history of diabetes mellitus since 1993. Patients diabetes has been poorly controlled which has led to other medical conditions, such as acute renal failure. Diabetic patients are also at higher risk for pressure ulcers and impaired wound healing. Case study will focus on how the low-carbohydrate diet may help control type II diabetes and prevent further renal failure.

Patient Profile- Personal Data

Gender- Female Age- 60 years old Marital status- Married Ethnic/Religious background- LDS Admit/Discharge Date- 11.01.13 to 11.08.13

Patient ProfileAdmission Circumstances

Pressure wound on the left hip Frequent falls Fatigue, tired, nausea, vomit, diarrhea Poor appetite Visited local clinic because of above symptoms. Patient had lab work done and was asked to go to Dixie Regional Medical Center emergency to have labs repeated.

Patient ProfilePsych/Social/Economic
Occupation- Special Education Teacher
Home life- Lives with her husband

Education- Masters in Special Education

Patient Profile
Medical History
Patient has an extensive history of uncontrolled diabetes and diagnosed in 1993. Pressure ulcers to left posterior hip and right plantar foot. Pneumonia with septic shock Hypertension Acute Renal Failure

Patient Profile
Family Medical History
Mother died of methicillin-resistant staphylococcus aureus (MRSA) infection at age 70

Father is living at age 80. He suffers from diabetes mellitus, heart disease, and arthritis.

 Exercise- Patient has never exercised regularly.

Patient ProfileHealth History

Sleep- adequate sleep 7-8hrs a night

Appetite- Patient has a good appetite with a PO intake of 75100% x 1 and intermittent snacking throughout the day. Weight- Patient mentioned that her weight fluctuates from 102131kg, and she has always been overweight. Diet- Patient was a Herbal Life Distributor in 2008; per patient, this helped with exercise and BG control.

Substance abuse- ETOH was a problem in the past, but not current.
GI system- GI system has not been a problem until recently.

Patient Profile Disease background- HTN

Pathophysiology Systolic blood pressure (SBP) of 140 mm Hg or higher and diastolic blood pressure (DBP) of 90 mm Hg or higher or both. Blood pressure is a function of cardiac output by peripheral resistance (resistance in blood vessels to the flow of blood). Major regulators of the blood pressure are sympathetic nervous system (short term) and kidneys (long term). When regulators falter, HTN develops which can lead to congestive heart failure.

Patient Profile Disease background- HTN

Symptoms and clinical manifestations- patient manifested at least three of the etiologies below such as overweight, stress, and lack of exercise. Etiology- excess alcohol, overweight, lack of exercise, stress, low K+, Mg+, and Ca+. Electrolyte imbalance can cause hypertension. Nutrition intervention- Low-sodium diet

Patient Profile Disease background- HTN

Treatment Drug therapy- diuretics, beta blockers, vasodilators, ACE inhibitors, calcium, a-channel blockers, and a-1 receptor blockers. Nutrition intervention- low-sodium diet Lifestyle Modification weight loss if overweight limit alcohol intake increase aerobic activity 30-45 min daily 2-3cups of fruits and vegetables daily reduce sodium intake 2400mg and then to 1500mg reduce stress reduce saturated fat and cholesterol nutrition education on low sodium diet adequate calcium, magnesium, and potassium with balanced diet

Disease background- Pneumonia

Patient Profile

Pathophysiology Inflammatory condition involving the lungs, which include the visceral pleura, connective tissue, airways, alveoli, and vascular structures. Typical symptoms associated with pneumonia include cough, chest pain, fever, shortness of breath, loss of appetite, and nausea or vomiting.

Pulmonary function and weight status is related to respiratory muscle weakness and immunodeficiency.
Diaphragm and intercostal muscle mass decreases with weight loss leading to a decrease in inspiratory and expiratory muscle strength and a reduction in vital capacity Symptoms and clinical manifestations- nonproductive cough, weakness, rigors, sweats, and chills. Patient had nausea and vomiting.

Disease background- Pneumonia

Patient Profile

Etiology- The most common causes of infectious pneumonia are bacteria and viruses. Less common causes of infectious pneumonia are fungi and parasites. Treatment-Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. Extremely sick individuals require intensive care treatment which include intubation and artificial ventilation. Prevent weight loss and malnutrition. Nutrition intervention- Preventing weight loss, small frequent meals, easy to swallow and digest foods, supplements and nutrient dense nourishments, whole grain cooked and soft vegetables and fruit.

Disease background- Pressure Ulcer

Patient Profile

Disease background- Pressure ulcers

Pathophysiology- occur over a bony prominence as a result of continued pressure on tissue covering the bone. Staging systems exist that defines six categories of pressure ulcers.

Symptoms- decreased motility, dehydration, and comorbid conditions such diabetes, renal failure, thyroid disease, exposure of skin to urinary and fecal incontinence, steroids or other drugs that interfere with wound healing, unintentional weight loss

Pressure Ulcer Staging Guide

Disease background- Pressure Ulcer

Patient Profile

Etiology- It is more likely to occur with those who are confined to a chair or bed and older adult. Other causes or diseases that affect blood flow such as diabetes, fragile skin, urinary/bowel incontinence and malnourishment. Treatment- wound team, topical medicine such as Bactroban and Silvadene, special gauze dressings, and avoid further friction to the area and relieve pressure with pillow. Vitamin A, C, and zinc need to be monitored. Mineral and vitamin wound care guidelines are in the appendix.

Nutrition intervention- protein and kcal needs are increased to aid in wound healing, snack, supplements, and small frequent meals.

Disease background- ARF

Patient Profile

Pathophysiology- characterized by sudden reduction in glomelur filtration rate and an alternation in the ability of the kidney to excrete metabolic waste. Symptoms and clinical manifestations- rapid decrease in urine output, acidosis, electrolyte imbalances, fluid disturbances, impaired glucose utilization, protein catabolism, and accumulation of metabolic waste products.

Disease background- ARF

Patient Profile

Etiology- hypertension, diabetes mellitus, toxic drug exposure, and progressive glomerulonephritis Treatment Medical management- depends on the stage of kidney failure but common treatments are IV fluids, medications such as Kayexalate, PO4 or K+ binders, and meds to help restore blood calcium. If severe, treat with dialysis, and electrolyte management (K+, PO4, Na).

Nutrition intervention-

Renal diets which limit K+ and PO4. Diets usually high in kcal and protein intake depends on the stage of failure Protein recommendations vary depend on the severity of renal failure from 62.0g/kg, potassium 2-3gm a day, and sodium restriction (less 100mg per serving). Avoid fat soluble and choose water soluble vitamins, because fat soluble vitamins rather than water soluble vitamins deposit in the body and cause complications.

Disease background- Diabetes Type II

Patient Profile

Disease background- Diabetes Type II

Pathophysiology-

Patient Profile

Abnormal pattern of insulin secretion and action. Decreased cellular uptake of glucose and increased postprandial glucose, and increased release of glucose by liver in early morning hours. Patients are insulin-resistant to predominately deficient in insulin secretion.

Symptoms and clinical manifestations- excessive thirst, hyperglycemia, frequent urination, polyphagia, excessive thirst, and weight loss. Etiology- genetic facets, older age, obesity, physical inactivity, family history, prior history of gestational diabetes, impaired glucose homeostasis, excessive calories, and environmental factors.

Disease background- Diabetes Type II

Patient Profile

Treatment Medical management- Physical activity is the cornerstone of management of type 2 diabetes. The progressive nature of type 2 diabetes usually requires use of one or more glucoselowering medications and eventually insulin, along with MNT and physical activity. A few common glucose lowering medications are insulin, sulfonylureas, biguanides, and a-glycosidase

Nutrition intervention- Nutrition education such as better food choices, caloric restriction to promote weight loss, and spreading carbohydrate nutrient intake throughout the day (consistent carb diet). Also, research indicates low-carb diets have the excellent results in preventing progression of impaired glucose tolerance to diabetes.

Definition of Low-Carb Diet and Diabetes Diet

Low-carb diets are dietary programs that restrict carbohydrate consumption. Foods high in easily digestible carbohydrates such as pasta, bread, and sugar are limited or replaced with foods containing a higher percentage of fats and moderate protein. Foods on a low carb diet include lean meat, poultry, fish, shellfish, eggs, cheese, nuts, fruits, vegetables, and roots, and seeds.. Popular low-carb diets are South Beach, Mediterranean, Zone, Paleo, Food Addict Anonymous, Atkins, Medifast, etc

Diabetes diet aims at evenly distributing meals with increase intake of vegetables, dietary fiber, whole-grain bread, and other whole-grain cereal products, and fruits and berries, and decrease intake of total fat. Popular diets are exchange lists and carb counting. Carb counting is a meal planning technique for managing your blood glucose levels.

Low-Carb Diet and Diabetes Diet

American Diabetes Association & LC Diet

The ADA revised its Nutrition Recommendations and Interventions for Diabetes in 2008 to acknowledge lowcarbohydrate diets as a legitimate weight-loss plan. They also acknowledged the benefit for carbohydrate restriction for glycemic control.

American Diabetes Association. January 2008. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care, Volume 31: S61-S78.

Pathophysiology LC Biochemistry
Pancreas to dietary carbohydrate
Insulin related to glucose in the bloodstream and effects fatty acid metabolism and storage. Insulin fatty acid (acetyl-coA) and triglycerol synthesis (lipoprotein lipase liver). Fatty acid storage is favored as insulin inhibits the release of fatty acids from the cell through activation of the hormone-sensitive lipase. Insulin increases the carb metabolism which helps affects appetite and reduce fat storage.
Hite AH, Berkowitz VG, Berkowitz K. Nutr Clin Pract. 2011 Jun;26(3):300-8.

Benefits of Low-Carb Diet on Type II Diabetes

Lowers
Hemoglobin A1C Triglycerides Systolic Blood Pressure Weight BMI Waist Circumference Fasting Plasma Glucose Fasting Plasma Insulin AUC Glucose

Jonsson Study
Randomized crossover pilot study assessed 13 subjects with T2DM on Paleo diet compared to diabetes diet. Blinded study with two consecutive 3-month periods. Randomized controlled study of 29 men with IHD and T2DM on 12 week Paleo diet. Results of diabetes diet v. Paleo diet resulted:
significant lower mean of hemoglobin A1C weight and BMI triglycerides improved insulin sensitivity diastolic blood pressure and systolic blood pressure lower glycemic load

Jnsson T, Granfeldt Y, Ahrn B, Branell UC, Plsson G, Hansson A, Sderstrm M, Lindeberg S. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009; 8:35

Kitava Study
Epidemiological study with traditional Pacific Islanders of Kitava, Papua New Guinea. Pacific Islanders of Kitava consumed a traditional diet (paleo) and population had no signs of metabolic syndrome.

David C. Klonoff The Beneficial Effects of a Paleolithic Diet on Type 2 Diabetes and Other Risk Factors for Cardiovascular Disease J Diabetes Sci Technol. 2009 November; 3(6): 1229 1232.

Gulbrand Study
Low carb diet v. low fat on glycemic control, non blinded study, randomized parallel trial, n=61. Outcomes reduction in HbA1c for LCD patients and weight variance wasnt significant but insulin doses were reduced more for the LCD patients.

Guldbrand H, Dizdar B, Bunjaku B, Lindstrm T, Bachrach-Lindstrm M, Fredrikson M, Ostgren CJ, Nystrom FH. In type 2 diabetes, randomisation to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss. Diabetologia. 2012 Aug;55(8):2118-27. doi: 10.1007/s00125-012-2567-4. Epub 2012 May 6.

Hussain Study
Randomized controlled study comparing low-carb ketogenic to low-calorie diet in improving glycaemia. Three hundred and sixty three obese and diabetic participants could choose LCD or LCKD and study lasted 24 weeks. Conclusion- LCKD had significant positive effects on body weight, waist measurement, triaglycerol, and glycemic control. HgbA1c improvement was remarkable and the antidiabetic medications had been decreased substantial in participants using LCKD.
Hussain TA, Mathew TC, Dashti AA, Asfar S, Al-Zaid N, Dashti HM. Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. Nutrition. 2012 Oct;28(10):1016-21. doi: 10.1016/j.nut.2012.01.016. Epub 2012 Jun 5.

Meta-Analysis Study
20 randomized controlled trials, n=3073, >/=6 compared LC, vegan, vegetarian, GI, high fiber, Mediterranean with control diets low fat, high GI, ADA, EASD, and low protein diets. Conclusion LC, low-GI, Mediterranean, and high protein diets all led to greater improvement in glycemic control and improve glucose management and largest effect in Mediterranean diet.

LC and Mediterranean led to the greatest weight loss and increase in HDL which were seen in all diets except high protein

Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013 Mar;97(3):505-16.

LC Controversies
Argument Expensive Kidney adverse effect

Counter Medical bills are $$$$$ DRI- 10-35% protein and LC intake doesnt imply HP

Fiber intake

Dietary fiber in US is potatoes and white flour. A shift to leafy greens will give more nutritive value
Depends on SF and HbA1c elevated linked to CVD

Saturated fat

Hite AH, Berkowitz VG, Berkowitz K. Nutr Clin Pract. 2011 Jun;26(3):300-8.

Benefits of Low-Carb Diet on Type II Diabetes

Lowers
Hemoglobin A1C Triglycerides Systolic Blood Pressure Weight BMI Waist Circumference Fasting Plasma Glucose Fasting Plasma Insulin AUC Glucose

Application to Patient
Initial Diagnosis- Pressure ulcer but after lab results diagnosis changed to Acute Kidney Failure. Duration and intensity- She had the right plantar pressure ulcer since 7/23/2013 and she was recently seen on 11/01/2013 for a pressure ulcer on left hip Patient understands disease and treatments, but behavior modification is not occurring and poorly controlled diabetes is lead to other multi organ dysfunctions.

Initial Diagnosis Current Admission

Nausea and vomiting Diarrhea Pressure ulcer

Current Diagnosis
Acute Renal Failure Metabolic Acidosis Hyperkalemia

Diagnostic procedures with interpretation of results

HgbA1C is 10.7 uncontrolled diabetes with a glucose range of 114-301. Acute Renal Failure diagnosed with high creatinine, BUN, K+, and PO4 labs.

 Medical- IV fluids and daily fluid ins/outs

Treatments

Surgical- N/A
Therapies- Rehydration Medications with potential drug nutrient interactions
Potassium binder - Kayexalate Sliding Scale Insulin to stabilize sugars Lisinopril- kidney protection from CKF Vitamin C 500mg BID Multivitamin

Supplements with potential nutrient interaction

NCP- Nutrition Assessment Diet Order- Patient is on a Renal Diet

Anthropometrics- Height 62in Weight 118kg BMI 47.7 IBW 49.9kg Diet History- According to 24hr recall/food frequency, patient ate a yogurt for breakfast, bag of apples for lunch, beef and canned vegetables for dinner. Snacks include root beer, ice cream, cookies, and candy. She buys a lot of sweets because her husband loves them. They drink between 24-48oz of root beer a day.

NCP- Nutrition Assessment

Biochemical Labs
11/08/13 PO4 K+ BUN Creatinine HgbA1C Glu 172 H 4.1 WNL 41 H 2.82 H 11/05/13 6.1 H 3.4 L 57 H 5.3 H 10.7 H 301 H 114 H 11/01/13 6.9 H 6.8 H 64 H 5.1 H

NCP- Nutrition Assessment

Previous MNT, instruction, outcome, & compliance
Patient has at least 18 outpatient clinic reports from 2002-2013 with assessment of poorly controlled diabetes and high hgbA1C levels. 04/11/07-Patient complained about metformin and glyburide, but has been taking those drugs since 2007. 10/07/13- The doctor mentioned the patient would be a good candidate for Lantus or 70-30 insulin. She had been on Humulin-N 20 units bid. 07/01/2013- The doctor put her on lantus 20 units at bedtime and a sliding scale insulin. Patient mentioned to doctor that sugars are up and down and doctor noted all are elevated with none lower than 125 and only one higher than 200. Patient received counseling and consultations with each visit. It appears the patient has not been compliant with MNT, including a diet high in carbs which has led to the outcome of renal failure.

NCP- Nutrition Assessment

Evaluation of Data
Weight- Patient admit weight was 114kg with a 47.7 BMI. She now weighs 118kg which may be attributed to fluid status. Patients usual weight is 120kg.
Labs- BUN, Creatinine, PO4, and K+ are elevated, but improving. Daily blood glucose levels range from 104301. Hemoglobin A1C at 10.7, which indicates uncontrolled diabetes.

Diet- Patient is on Renal Diet with adequate PO intake 75-100% x 3 meals.

NCP- Nutrition Assessment

Assessment of level of nutritional compromise
Patient is moderate risk at a Level 2 due to diagnosis of ARF and Diabetes.

NCP- Nutrition Assessment

Macronutrient needs
Based on adjusted weight = 77kg
ABW = 50 + 0.4( 118 50 )

Kcal= 1925-2310kcal/kg Protein= 61-77gm/kg protein

NCP- Nutrition Diagnosis

Altered nutrition-related laboratory values related to kidney and endocrine dysfunction as evidenced by blood glucose range from 54-188 and HgbA1C 10.7. BUN and creatinine are high.

Lack of compliance or inconsistent compliance with plan related to kidney and endocrine dysfunction as evidenced by variable PO intake and elevated BGs and HgbA1C.

NCP- Nutrition Goal

Improve diabetes control with medical therapy, diet, and exercise Promote adequate PO intake (kcal & protein) Prevent further kidney damage Gradual weight loss to prevent further kidney damage Promote recovery from acute renal failure

NCP- Nutrition Recommendations

Provide Renal Diet and Consistent-Carb Medium Diet in hospital Advance diet to low-carb diet on discharged

Multivitamin daily
Refer patient to Diabetic Outpatient clinic

Nutrition Intervention
Advance from a renal diet/consistent carb diet to a low-carb diet when discharged Refer patient to Diabetic Outpatient Clinic for education Offer Nepro supplement if less than 75% PO intake

NCP- Monitor and Evaluation

Monitor BGs, BUN, K+, PO4+, and Creatinine labs PO intake Weight management Adherence to Renal and Consistent Carb Medium Diet

Key Points
Patient has uncontrolled diabetes that has led to acute renal failure. If patient adheres to the low-carb diet after discharged, HgbA1c, weight, BMI, fasting plasma insulin can be lowered. Patient can benefit from a low-carb diet that may improve blood glucose , HgbA1C , lipid profile, and promote weight loss and reduce the possibility of other adverse events.

Summary/Conclusion
Patient has poorly controlled diabetes and a low-fat diet may prevent further kidney disease and improve endocrine functions. Research shows that a low-fat diet compared to the conventional diabetes diet has better outcomes on risk factors and prevention.

References
Mahan LK & Escott-Stump S : Krause's Food, Nutrition and Diet Therapy, 11th ed, Elsevier, Philadelphia, PA, 2004. Hite AH, Berkowitz VG, Berkowitz K. Nutr Clin Pract. 2011 Jun;26(3):300-8. Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013 Mar;97(3):505-16. David C. Klonoff The Beneficial Effects of a Paleolithic Diet on Type 2 Diabetes and Other Risk Factors for Cardiovascular Disease J Diabetes Sci Technol. 2009 November; 3(6): 12291232. Guldbrand H, Dizdar B, Bunjaku B, Lindstrm T, Bachrach-Lindstrm M, Fredrikson M, Ostgren CJ, Nystrom FH. In type 2 diabetes, randomisation to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss. Diabetologia. 2012 Aug;55(8):2118-27. doi: 10.1007/s00125-012-2567-4. Epub 2012 May 6. American Diabetes Association. January 2008. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care, Volume 31: S61-S78. Jnsson T, Granfeldt Y, Ahrn B, Branell UC, Plsson G, Hansson A, Sderstrm M, Lindeberg S. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009; 8:35 Hussain TA, Mathew TC, Dashti AA, Asfar S, Al-Zaid N, Dashti HM. Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. Nutrition. 2012 Oct;28(10):1016-21. doi: 10.1016/j.nut.2012.01.016. Epub 2012 Jun 5.