BIOL4355 FA2021 – FINAL EXAM CASE D

CASE D – The Expanding Waistline

41 marks
Part I – Johnny and His Fast Metabolism
Johnny had been way too skinny for as long as he could remember. He’d had a growth spurt
early in high school but in spite of stopping at 6´2˝ he was teased unmercifully by his friends
and family for being a twig, weighing 160 lb. Although he didn’t realize it at the time, his lean
physique contributed to his achievement of the highest vertical leap of all the athletes in his
high school district and he was extremely well coordinated. Johnny made the varsity basketball
team as a freshman in high school and was a starter all 4 years, making first-team all-
conference his junior and senior year.
In spite of his athletic success, mostly he just heard the name calling and jokes about being so
thin, and he packed in as many calories as he possibly could. In fact, all through high school
Johnny chose his foods based on the amount of carbohydrates they contained. He had at least
four large energy drinks per day, ate a large pizza and a box of donuts for lunch, snacked on one
or two family-size bags of potato chips, and his nightly routine consisted of chocolate milk and
Oreo cookies. While he was the all-star basketball player in high school, he received a few
scholarship offers from smaller schools and junior colleges. However, Johnny’s ultimate dream
was to become a surgeon, so he chose to turn down all the scholarship offers and attend a large
university with an excellent pre-med program.
A few years later…
“Mom! You’re washing my jeans in hot water and they’re getting too tight!” said Johnny as he
was preparing to return to college after spring break. Johnny’s mom replied, “Nope, the water
heater is broken. I’m afraid you’ve gained some weight.”
When Johnny began college, he soon realized it would be the best time of his life. While he lost
interest in playing sports, he thoroughly enjoyed attending university sporting events. His
favorite activity was tailgating at football games. Over lunch with his best friend Ashlyn at the
dining hall, Johnny sat down with his usual pizza, potato chips, Coke, and ice cream. Ashlyn
sighed and said, “Johnny, do you ever eat anything green? You know, food with nutrient
value…” Johnny replied, “HA! I hate anything green, all healthy food tastes horrible.”
Ashlyn looked at him disturbed. “Johnny, I’m concerned about your eating habits because
you’ve gained quite a bit of weight since we met the first week of school.” Johnny looked at his
plate and sighed; he suddenly started to feel anxious.
The following summer, Johnny had a check-up with his family doctor. Dr. Wilson noticed that
Johnny’s weight had increased to 203 lb and questioned Johnny’s weight gain and lifestyle.
After evaluating Johnny’s diet, she decided that he would need to return the next day at
8:00AM to complete blood tests. Dr. Wilson informed him that he had to fast before the test
and could neither eat nor drink anything but water after midnight to take a blood test for
Hemoglobin A1C and Fasting Plasma Glucose (FPG).

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BIOL4355 FA2021 – FINAL EXAM CASE D

Once Dr. Wilson reviewed Johnny’s lab results, she approached Johnny with serious concerns
about his health.

Questions (12 marks):

1. Predict Johnny’s A1C and FPG values as an inactive college student and explain your
reasoning for these values and what category Johnny would be placed in
(Normal/Prediabetes/Diabetes) (2 marks).
2. What is hemoglobin A1C (HbA1c) and why is it important in diagnosing diabetes mellitus
(3 marks)?
3. What is the difference between type I and type II diabetes in terms of insulin (4 marks)?
4. What type of diabetes do you think Johnny is at risk of developing (1 mark)? Why (2
marks)?

Part II – Type II Diabetes

Twenty-Five Years Later: Johnny graduated college, got married, and had 2 kids. He now taught
high school biology and coached basketball. His lifestyle had not changed since college. He still
refused to eat his greens and consumed large amounts of pop and potato chips. Johnny was
required to have blood tests every 1-2 years since college.
“Hello Johnny! According to your chart, you have gained some weight since your last visit” Dr.
Wilson stated. “Yeah, I’m still struggling with this dieting thing” Johnny said. “I just love the
food I eat so much.” Dr. Wilson asked how often he exercised. Johnny replied, “Dr. Wilson, I
couldn’t tell you the last time I participated in any exercise. I’m tired every day and don’t have
the energy to keep up with my kids.” Dr. Wilson asked, “and you have been experiencing aches
all over your body and loss of sensation in your feet?” “Yes doctor; I didn’t even feel the giant
splinter in my foot and my entire body just seems to ache every day.”

Dr. Wilson looked at Johnny’s fasting blood results (see below). A urinalysis that was also taken
prior to the appointment also showed glucose, protein, and ketones in the urine.

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BIOL4355 FA2021 – FINAL EXAM CASE D

Table 2. Fasting Chem-Screen Panel for Johnny

These blood results were followed up by a Glucose Tolerance Test. During the Glucose
Tolerance Test, Johnny’s blood was drawn at intervals to measure plasma C-peptide
concentrations. Plasma C-peptide concentration normally matches plasma insulin
concentration and is an indicator of how much insulin is produced by the pancreas. The results
of Johnny’s glucose tolerance test and plasma C-peptide levels are shown below.

Table 3 – Johnny’s test results from glucose tolerance test and plasma C-peptide levels.

Questions (15 marks):

5. Why were the first blood results followed up by a glucose tolerance test (2 marks)?
What does a glucose tolerance test measure (1 mark)?
6. Based on the results of the Glucose Tolerance Test, what can you infer about Johnny’s
insulin levels (1 mark)?

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BIOL4355 FA2021 – FINAL EXAM CASE D

7. Based on the Glucose Tolerance Test results, would you suspect type 1 or type 2
diabetes (1 mark)? Why (2 marks)?
8. Using terminology of the kidney (filtration, reabsorption, secretion, excretion), explain
how glucose (1 mark) and protein (1 mark) are each processed in the normal kidney.
9. What might glucose in the urine indicate about blood glucose levels (1 mark)? Explain
this using terminology of the kidney (filtration, reabsorption, secretion, excretion) (3
marks).
10. What might occur in the kidney that would cause the presence of protein in the urine (2
marks)?

Part III – Living with Type II Diabetes

Dr. Wilson sighed and continued, “Johnny, according to your results this morning, you have
officially developed type II diabetes. Now, we need to consider disease management options.
You must start paying attention to your diet, stay away from fast foods and processed
carbohydrates. You need to exercise for at least 30 minutes every day. We should also consider
the use of metformin, a diabetic medication that will assist in lowering your blood glucose
levels, or insulin injections.”

Questions (14 marks):

11. During the early stages of insulin resistance in college, Johnny did not need insulin
injections. However, Dr. Wilson explains that at this point in Johnny’s diagnosis, insulin
injections may be necessary for his health. Why do you think Johnny did not need insulin
injections when he was insulin resistant, but now that he has type II diabetes he does (2
marks)?
12. What does the loss of sensation in Johnny’s feet indicate (1 mark)? Briefly explain what
causes this (2 marks).
13. Would Johnny be more susceptible to Diabetic Ketoacidosis or Hyperosmolar
Hyperglycemic Nonketotic syndrome (HHNKS) (1 mark)? Explain what each syndrome is
(4 marks) and your reasoning why (1 mark).
14. If you were working in a lab that studied insulin resistance and type II diabetes and
needed to develop a drug to help treat type II diabetes, where would it be useful for it
to interact and why would a drug with this mechanism of action would be helpful (3
marks)?

Adapted from: A.R. Wilson, A.E. Rhodes, and E.G. Rozzell. NCCSTS , University at Buffalo,
State University of New York

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