Case 18 Adult Type 2 Diabetes Mellitus: Transition to Insulin

Jazzmin Hardaway
Jessica Manner
Sydney Maxfield
Tina Nguyen
Ezekiel Nwaigwe

NUTR 484: Medical Nutrition Therapy

San Francisco State University
November 6, 2019
CASE 18: Adult Type II Diabetes Mellitus

I. Understanding the Diagnosis and Pathophysiology

1. What are the standard diagnostic criteria for T2DM? Identify those found in Mitch’s medical
record.

Standard criteria is FPG​>​126 mg/dL 2-h PG​>​200mg/dL A1C​>​6.5% (48mmol/mol),

hyperglycemia or hyperglycemic crisis, a random plasma glucose​>​200mg/dL (11.1mmol/L)

Mitch is in his 50s and appears to be obese, He’s currently suffering from ​hyperglycemic
hyperosmolar syndrome (HHS), hypertension (HTN), hyperlipidemia, and his ​lab results came
in as HbA1c 11.5% glucose levels 855mg/dL, and 475mg/dL. These lab values are high and
have him meeting the criteria for a diabetes diagnosis.

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 and glyburide are oral antihyperglycemic medications that alleviate high
blood sugar in T2DM through glucose regulation. Patients taking these medications are
advised to refrain from alcohol consumption. They differ in classification as Metformin is a
biguanide drug whereas glyburide is a second-generation sulfonylurea drug. Another difference
is that glyburide increases a patient’s susceptibility to hypoglycemia whereas metformin does
not. Metformin should be taken with meals to decrease the risk of GI discomfort.

Metformin reduces hepatic glucose production and fat accumulation via decreased
gastrointestinal glucose absorption. Insulin sensitivity is improved insulin uptake is increased
in the muscles. This medication increases risk of lactic acidosis. In terms of micronutrients, the
body’s absorption of vitamin B12 and folic acid are reduced. Testosterone production is also
decreased. The symptoms may include: nausea, fullness, vomiting, bloating, anorexia, diarrhea,
and flatulence.
CASE 18: Adult Type II Diabetes Mellitus

Glyburide lowers blood glucose concentration through stimulating pancreatic insulin

release. Risk of hypoglycemia and weight gain are increased. Relating to micronutrients, this
medication impairs the uptake and release of iodine.

4. Describe the metabolic events that led to Mitch’s symptoms and subsequent admission to the
ER with the diagnosis of uncontrolled T2DM with HHS (be sure to include the information in
Mitch’s chart that supports his diagnosis. Compare and contrast HHS with the other common
clinical emergency condition of diabetes—diabetic ketoacidosis (DKA).

The metabolic effect of T2DM begins with the body becoming insulin resistant and
compensating by increasing pancreatic insulin production. Increased insulin production
stresses the pancreas, leading to it’s loss in effectively producing insulin. Decreased insulin
production and sensitivity in the body leads to hyperglycemia due to the body’s inability to
process blood sugar. Symptoms he experienced which indicate HHS were his dehydration,
drowsiness, and confusion. His T2DM was reflected in his glucose and HbA​1C​ lab values -
which displayed acute hyperglycemia as well as prolonged hyperglycemia. His diagnosis of
HHS, hyperglycemic hyperosmolar state, was reflected in his low sodium level, low phosphate
inorganic level, high osmolality, cloudy amber urine, and recurring vomiting - all values define
his dehydration.

Symptoms HHS shared with DKA include polyuria, polydipsia, and polyphagia. HHS is
similar to DKA because they both indicate inadequate pancreatic insulin production. However,
HHS is characterized by dehydration, prolonged hyperglycemia, hyperosmolality, and the
absence of significant ketoacidosis. Whereas, DKA commonly occurs in T1DM. It induces
metabolic acidosis and ketogenesis. Characteristics include acetone breath due to high ketones
and labored breathing due to increased lipolysis. Symptoms include: weight loss, vomiting,
abdominal pain, dehydration, acetone breath, and Kussmaul respirations. While his urinalysis
reveals a small amount of ketones are present and he is experiencing mental change as well as
CASE 18: Adult Type II Diabetes Mellitus

vomiting, he does not exhibit other symptoms of DKA such as: unexplained weight loss, acetone
breath, labored breathing, and acidic pH in his urine.

8. 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’s new insulin plan utilizes Lispro (Humalog) rapid-acting to lower glucose levels after a
meal, and Glargine (Lantus) basal insulin analogs, which is extended long-acting to control his
levels between meals. The plan starts immediately to lower his blood glucose levels with
Lispro 0.5 u every 2 hours until glucose is at 150–200 mg/dL then glargine 19 u at 9 pm to
sustain him through the night. Mitch didn’t like his original diabetes medication because of his
experience with the nausea side effect, Lispro (Humalog) similarly has a side effect of nausea.
If Mitch experiences this he is not likely to continue taking it and may need a new rapid-acting
insulin.

II. Understanding the Nutrition Therapy

10. Outline the basic principles for Mitch’s nutrition therapy to assist in the control of his DM.

Mitch’s MNT plan to control his DM should focus on a healthy decline in weight and the
utilization of motivational interviewing to come up with a diet plan that maintains the pleasure
of eating with non-judgemental comments on food choices while also implementing carb
counting and limiting triglyceride intake while giving nutrition education on blood glucose
regulation. And encouraging physical activity.

III. Nutrition Assessment

11. Assess Mitch’s weight and BMI. What would be a healthy weight range for Mitch?

Weight: 214 lbs = 97.2 kg

Height: 5’9 = 175.2 cm

BMI: 31.6
CASE 18: Adult Type II Diabetes Mellitus

IBW: 106 + 6 x 9 = 160 lbs

Mitch's BMI is considered to be Class I Obese. His ideal body weight would be around 160
lbs. His healthy weight range would be between 130-165 lbs.

12. Identify and discuss any abnormal laboratory values measured upon his admission. How
did they change after hydration and initial treatment of his HHS?

Chemistry Ref. 4/12 1780 4/13 1522 Discussion

Range

Sodium 136–145 132 ! ↓ 135 ! ↓ Low sodium indicates impaired

(mEq/L) kidney functioning, polyuria, and
dehydration. This is in line with
his excessive vomiting and his
cloudy amber urine. His sodium
level is low but improved with
treatment.

Glucose 70–99 855 !↑ 475 !↑ His high glucose level defines

(mg/dL) acute hyperglycemia. This
reflects his T2DM because he
has insulin resistance and
decreased insulin production.
His glucose level decreased
dramatically with treatment.

Phosphate, 2.2–4.6 1.8 ! ↓ 2.1 ! ↓ This level indicated electrolyte

inorganic imbalance and dehydration. His
(mg/dL) level improved after hydration
treatment.
CASE 18: Adult Type II Diabetes Mellitus

Osmolality 275–295 322.6 !↑ 303.5 !↑ His high osmolality reflects high

(mmol/kg/H2O) solute concentration and is the
result of hyperglycemia and
dehydration. This level improved
and decreased after insulin and
hydration treatments.

HbA​1C​ (%) <5.7 11.5 !↑ This level reflects prolonged

hyperglycemia which is in line
with his lack of adherence to his
T2DM medications.

Hematology Ref. 4/12 1780 4/13 1522 Discussion

Range

Hematocrit 41–51 M 57 !↑ This level reflects his

(Hct, %) dehydration and is expected to
improve after treatment.

Urinalysis Ref. 4/12 1780 4/13 1522 Discussion

Range

Protein Neg 10 !↑ High amounts of protein in urine

indicate kidney damage or
disease. This is most likely due
to damage via polyuria.

Ketones Neg 1 !↑ Small amounts of ketones

present indicates the body’s
minor lipolysis for energy. This
reflects his body’s poor response
to and utilization of glucose.
CASE 18: Adult Type II Diabetes Mellitus

His laboratory values improved because his body positively responded to insulin and hydration
treatments. As shown, his glucose and osmolality improved from the insulin treatment.
Hydration alleviated his low sodium, low phosphate inorganic, and high osmolality. It is too
soon to assess whether the treatments have improved his HbA​1C​ , hematocrit, protein, and
ketones. These values were included to support his diagnosis of acute hyperglycemia and
dehydration.

13. Determine Mitch’s energy and protein requirements for weight maintenance. What
energy and protein intakes would you recommend to assist with weight loss?

Weight Management:

Mitches MSJ for his current body weight is roughly 2,293 calories. His current protein
requirements for weight management would be 77.7 g of protein.

MSJ:

RMR=(10 x 97.2 kg)+ (6.25x 175.2) - (5x53)+5= 1797 calories

1797* activity factor of 1.2= 2,156.4 calories

72.2 kg (IBW) x 1.2g/kg (obese)= 86.64​ g protein

Weight Loss:

For weight loss, his MSJ would be based on his ideal body weight which is roughly 2,087
calories. His protein intake would be 58.2g of protein for weight loss and is based off of his
ideal body weight.

IBW: 106+6x9=160 lbs or 72.2 kg

MSJ: (10x72.2)+(6.25x175.2)+ (5x53)+5= 2,087 calories

72.7x 0.8= 58.2 g protein

CASE 18: Adult Type II Diabetes Mellitus

14. Prioritize two nutrition problems and complete the PES statement for each.

- Excess carbohydrate intake as related to limited changes in diet secondary to type

2 diabetes mellitus as evidenced by severe hyperglycemia.

- Excess saturated fat intake as related to frequent consumption of high fat, fast
food meals as evidenced by elevated cholesterol levels.

V. Nutrition Intervention

15. Determine Mitch’s initial CHO prescription using his diet history as well as your
assessment of his energy requirements.

As a male diabetic on the consistent-carbohydrate controlled diet, carbs should be limited to

130 grams per day, or about 60-75 grams per meal, with 4 to 5 carb choices per meal.
(D'Arrigo, 2019). Based on Mr. Mitchell’s estimated calorie needs of 2,293 calories per day,
and his diet history.

16. Identify two initial nutrition goals to assist with weight loss.

- Pack a lunch daily by preparing a homemade salad with cooked beef or chicken and a
room temperature potato instead of fast food sandwich and chips to increase protein
intake while reducing excess sugar and sodium intake.

- Stick to protein and vegetable dishes without heavy sauces when going out to eat with
friends to increase protein intake while reducing excess sugar and sodium intake.

Additional Questions: ​as it pertains to this patient in the case study.

*What other healthcare professionals may be involved in this patient’s care? What are their
roles? Consider both inpatient and outpatient encounters.
Other healthcare professionals include a dentist, podiatrist, nurse, pharmacist, optometrist,
audiologist, primary care physician, and psychologist.
Dentist​: to monitor dental health due to decreased blood supply to the gums.
CASE 18: Adult Type II Diabetes Mellitus

Podiatrist​: to monitor the patient’s foot health due to decreased sensitivity in extremities
and daily foot vulnerabilities.
Nurse​: to monitor his stability while in the hospital setting.
Pharmacist​: to relay his medications in proper doses.
Optometrist​: to monitor eyes as elevated blood glucose levels can cause damaged tissues
and blood vessel damage in the eyes and lead to diseases such as glaucoma, cataracts,
diabetic retinotherapy, and diabetic macular edema (National Institute of Diabetes and
Digestive and Kidney Diseases, 2017).
Audiologist​: to monitor hearing and potential loss of hearing since diabetes is more
common among people that have normal blood glucose levels.
Psychologist​: to help him with coping and motivation for the life changes he must make.
Primary Care Physician​: to monitor general symptoms and refer to a specialist if needed.

*Discuss in 5 sentences or less, the impact of healthcare policy and different healthcare delivery
systems on this patient’s care.
According to the Centers for Disease Control and Prevention, the Affordable Care Act
(ACA) currently only covers preventative services that include type 2 diabetes screening, diet
counseling, and blood pressure screening. Because Mr. Mitchell already has type 2 diabetes, he
would not qualify for services related to his diabetes. However, there are incoming provisions
that would be financially beneficial to Mr. Mitchell depending on his income. Generally, such
plans include the “metallic” plans that involve the sharing of costs between insurers and the
insured. If Mr. Mitchell significantly falls below the federal poverty level, additional discounts
will be available to him (Burge & Schade, 2014).
CASE 18: Adult Type II Diabetes Mellitus

Reference

Burge, M. R., & Schade, D. S. (2014, July). Diabetes and the Affordable Care Act. Retrieved
October 23, 2019, from ​https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4074744/​.

Jimmy John's Menu. (n.d.). Retrieved from​ ​https://www.jimmyjohns.com/menu/#/​.

D'Arrigo, T. (2019). Manage Your Diabetes Head2Toe. WebMD. Retrieved from

https://www.webmd.com/diabetes/head2toe-15/diabetes-counting-carbs

National Institute of Diabetes and Digestive and Kidney Diseases. (2017, May 1). Retrieved
from
https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/di
abetic-eye-disease#affect​.

Nelms, M. (2017). ​Medical Nutrition Therapy: A Case Study Approach​ (5th ed.). Boston, MA:
Cengage Learning.
Nelms, M. N., Sucher, K., Lacey, K., Habash, D., Nelms, G. R., Hansen-Petrik, M., … Wong, J.
(2016). ​Nutrition Therapy and Pathophysiology​ (4th ed.). Boston, MA: Cengage
Learning.
CASE 18: Adult Type II Diabetes Mellitus