Nutritional Management of

Diabetes Mellitus: Psychosocial

Health and Glucose Levels
Elmhurst Hospital, 1/18/2024
Joanna Fitzmorris
Queens College Dietetic Internship
Abstract:
Diabetes is a multifactorial disease that requires constant blood sugar monitoring,
medication use, and consistent carbohydrate intake to keep blood glucose levels within the
normal range. If left untreated, diabetes can affect multiple organ systems, leading to blindness,
loss of limbs, kidney failure, and death. The stress related to major lifestyle changes upon a new
Type 2 Diabetes (T2DM) diagnosis can inhibit a person’s ability to comply with their care plan.
Stressors such as major diet changes can lead to depression and social isolation if the patient
does not have appropriate support from their providers and their community. Additional factors
such as age, race, socioeconomic status, and stress levels affect a person’s ability to self-manage
their diabetes. In particular, Black individuals experience increased morbidity and mortality as a
result of lacking the proper psychosocial support needed to properly self-manage their diabetes.
Major life events such as the illness or death of a spouse can also have a major impact on a
person’s capacity and motivation to self-manage their condition. Patients who experience major
life stressors such as racism, financial instability, family conflict, or the loss of a loved one can
improve their health outcomes when provided with psychosocial support and a continuum of
care. This case study explores the nutritional management of a patient with T2DM, emphasizing
psychosocial factors influencing health outcomes.

Chronic Disease Description:

Etiology:
Type 2 Diabetes Mellitus (T2DM) is a metabolic disorder characterized by insulin
resistance and relative insulin deficiency. Genetic predisposition, coupled with environmental
factors such as a sedentary lifestyle, obesity, and poor dietary habits, plays a significant role in
the development of T2DM. Insulin resistance impairs the body's ability to utilize insulin
effectively, leading to elevated blood glucose levels. Diabetes develops when there is impaired
insulin secretion from pancreatic beta cells or insulin resistance in peripheral tissues. Factors that
increase a person's risk for diabetes include being overweight or obese, having a family history
of diabetes, using tobacco or alcohol in excess, previously having gestational diabetes, impaired
glucose intolerance, and physical inactivity. There is emerging evidence that shows that stress
may increase a person's risk for diabetes if stress-induced hyperglycemia goes untreated.

Signs/Symptoms:
Clinical signs and symptoms of T2DM may include polyuria (excessive urination),
polydipsia (excessive thirst), unexplained weight loss, fatigue, and blurred vision. Patients might
also experience slow wound healing and increased susceptibility to infections. Diabetic patients
may experience hyperglycemia, or high blood sugar, as well as hypoglycemia, or low blood
sugar. Signs and symptoms of hyperglycemia include increased thirst and dry mouth, frequent
urination, tiredness, blurred vision, and recurrent infections. Signs and symptoms of
hypoglycemia include fast heartbeat, shaking, sweating, anxiety, irritability or confusion,
dizziness, and hunger. Any signs and symptoms of hyperglycemia or hypoglycemia should be
addressed immediately and if the situation is emergent, the patient should call 911 and seek
medical attention.
Pathology:
The pathology of T2DM involves a complex interplay of insulin resistance in peripheral
tissues (muscle and adipose) and impaired insulin secretion from pancreatic beta cells. This
results in an inability of cells to efficiently take up glucose, leading to hyperglycemia. Chronic
hyperglycemia contributes to microvascular and macrovascular complications, affecting organs
such as the eyes, kidneys, nerves, and cardiovascular system.
A healthy pancreas efficiently regulates glucose levels through well-maintained islet
architecture, appropriate beta-cell response to elevated glucose, and balanced intra-islet
signaling. In type 2 diabetes (T2DM), pancreatic function is characterized by insulin resistance,
leading to compensatory hyperinsulinemia. Over time, beta-cell dysfunction develops, resulting
in reduced glucose-stimulated insulin secretion (GSIS). The altered architecture of pancreatic
islets, with decreased beta-cells and increased alpha-cells, disrupts intra-islet signaling and
impairs metabolic homeostasis.¹
If left unmanaged, T2DM can impact the entire body. Insulin resistance in peripheral
tissues, including skeletal muscles, leads to impaired glucose uptake, contributing to
hyperglycemia. In the bones, T2DM is associated with an increased risk of bone fractures and
reduced bone mineral density, potentially affecting bone health. Digestion and nutrient
absorption may be affected by gastrointestinal complications such as gastroparesis and altered
gut microbiota, which promotes proinflammatory cytokine release. Chronic hyperglycemia may
lead to skin complications, including increased susceptibility to infections and delayed wound
healing. Increased insulin resistance and hyperglycemia have been linked to non-alcoholic fatty
liver disease (NAFLD), which can progress to more severe liver conditions.¹ T2DM is a leading
cause of diabetic nephropathy, characterized by impaired kidney function and proteinuria.¹ The
effects of T2DM on the cardiovascular system significantly increase the risk of cardiovascular
diseases, including heart attacks and strokes, often exacerbated by hypertension and
dyslipidemia. T2DM may also impair immune function, leading to an increased susceptibility to
infections. The nervous system effects of T2DM are associated with peripheral neuropathy,
impacting sensory and motor functions, and may have implications for cognitive function.¹
Finally, adipose tissue dysfunction contributes to insulin resistance and metabolic disturbances in
T2DM.

Epidemiology:
T2DM has reached epidemic proportions globally, with a rising prevalence linked to
lifestyle changes, aging populations, and urbanization. The condition is more prevalent in adults
but is increasingly diagnosed in children and adolescents. According to the World Health
Organization (WHO), in 2022, approximately 422 million people worldwide were living with
diabetes, and this number is expected to rise.² Diabetes is the seventh leading cause of death
among Americans.² Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke,
and lower limb amputation. Seventy-five percent of people with diabetes live in low- and
middle-income countries. Alaska Native adults (13.6) and non-Hispanic Blacks (12.1%) have the
highest rates of diabetes in the US.² Currently, 8.7 million Americans are living with
undiagnosed diabetes, meaning that 22.8% of adults with diabetes are undiagnosed.²

Comorbidities:
Individuals with T2DM often present with a spectrum of comorbidities that exacerbate
the disease's impact on overall health. Common comorbidities include hypertension,
hyperlipidemia, retinopathy, nephropathy, and neuropathy. Elevated blood pressure, or
hypertension, is prevalent in individuals with T2DM, contributing to an increased risk of
cardiovascular complications. Hyperlipidemia, characterized by elevated levels of cholesterol
and triglycerides, is frequently observed in T2DM patients, further enhancing cardiovascular
risk. Diabetes can lead to retinal damage, affecting vision and potentially leading to blindness if
left untreated. Diabetes is a leading cause of kidney disease, marked by impaired kidney function
and proteinuria.³ Type 2 diabetes is the leading cause of dialysis in the United States and one in
three adults with diabetes suffers from kidney disease.³ Diabetes and Hypertension are the major
causes of kidney failure in the United States.³
Peripheral neuropathy can result in sensory and motor deficits, impacting daily
functioning. Chronic high blood sugar, as well as increased triglycerides in the blood from
diabetes, can cause nerve damage.³ Peripheral neuropathy affects the feet, legs, and sometimes
hands and arms. Nearly one-third to one-half of people with diabetes have peripheral
neuropathy.³ Autonomic neuropathy damages the nerves of internal organs, which can affect
heart rate, blood pressure, and the digestive system, as well as masking hypoglycemia symptoms.
Focal neuropathies typically damage a single nerve, such as in the hand, torso, or leg. The most
common focal neuropathy type experienced by adults with diabetes includes entrapment
syndromes such as carpal tunnel syndrome.³ Proximal neuropathy is rare but disabling, affecting
the hip, buttock, or thigh on one side of the body. This type of neuropathy typically does not
spread to both sides of the body and symptoms gradually improve over months or years.

Case Presentation:
Patient, age 68, presents with Type 2 Diabetes Mellitus. She was diagnosed 12 years ago
in her home country of Zimbabwe and arrived in the United States in 2018 with her husband and
5 adult children. Recently, her diabetes has become more uncontrolled. During the session, she
reported that her husband died of stomach cancer last year and that she lacks proper social
support. She also reports stress from being unable to bring her husband back to their home
country.
The major stressors described by the patient included family conflict over how she
handled her husband’s passing. She stated that she was unable to return to Zimbabwe for her
husband to pass peacefully due to financial constraints, as well as not being able to receive her
medications while there. This caused conflict not only with her 5 children but with her extended
family. She chose to cremate her husband’s body due to financial reasons, which caused her to
lose the relationship with two of her children. As evidenced by the patient’s recounting, she has
been struggling to self-monitor her glucose and follow a carbohydrate-consistent diet due to
stress and low mood as a result of her lack of psychosocial support during what she reported to
be the most stressful time of her life. A detailed timeline of patient encounters from 6/22/23 to
1/4/24, covering the patient's husband's illness, the patient’s medication changes,
hospitalizations, and his eventual passing can be seen below as follows:
6/22/23: The case worker reports the patient’s husband is sick. The patient cannot work
due to health issues. The patient requested assistance with securing food. She was
referred to Groceries to Go and enrolled in NYC Cares. She was referred to a social
worker. Currently, she is experiencing financial, food, and social barriers to care.
7/5/23: She was prescribed Ozempic but has not not taken it. She is waiting to confirm
her cancer history, specifically pancreatic cancer. She denies any history of pancreatitis.
Her husband is in the hospital. The patient reports not adhering to a carbohydrate-
consistent diet due to visiting him often. The doctor states there is not much more they
can do for him. At this time the patient is experiencing medical and social barriers to
care.
8/15/23: The patient arrived 1hr 20m late to apt, as she was coming from the hospital
visiting her husband. At this time the patient is experiencing social barriers to care.
8/17/23: There is a note for acute kidney injury (AKI). The patient reported stopping
Ozempic due to hypoglycemic intolerance. She is positive for nephropathy (eGFR 40),
proteinuria, and retinopathy. The husband was discharged from the hospital, went home
for 3 days, went into cardiac arrest, and was re-admitted.
8/22/23: The patient missed her scheduled nutrition appointment.
9/24: The patient reports that her husband passed away and she stated that she would like
to see a social worker.
9/28: Repeat referral to SW. The original referral was placed 06/2023.
10/3/23: The patient missed her scheduled nutrition appointment.
10/29/2023: The patient had a hypoglycemic event after her husband’s memorial service.
At three am, her blood glucose was 53 mg/dL and her daughter called 911. Paramedics
arrived and assisted in regulating the patient’s glucose levels but the patient was not taken
to the ER.
1/4/24: As of today the patient has still not seen a social worker.

NCP Assessment:
Client History:
Medical History:
Hypertension
Hyperlipidemia
Retinopathy
Anemia
Microalbuminuria
Susrgical History:
Cataract Removal surgery (2003, Zimbabwe)
Hysterectomy (2003, Zimbabwe)
Family History:
Mother (Deceased) Hypertension
Father (Deceased) No Known Problems
Sister Diabetes
Brother Diabetes
Paternal Grandfather Diabetes
Social History:
The patient reports a lack of social support post-husband’s death. She reports that her daughter
lives in Brooklyn and is supportive.
cultural: The patient is unable to return to her home country to bury her husband or practice any
cultural rites of passing.
financial: The patient requested financial assistance and assistance securing food.

Food/Nutrition Related History:

Diet recall:
Breakfast: cereal (bran flakes) milk, if sugar is low, add whole wheat bread with butter and
decaf tea or coffee
lunch: cornmeal or rice with relish (cabbage/green veggies) and meat
dinner: noodles with vegetables
snacks: fruit (apple or orange)
drinks: water

Current Medications, Usage, and Interactions:⁴

Medication Usage⁴ Instructions⁴ Drug/Nutrient Interaction⁴

1. atorvastatin HMG-CoA Take 1 tablet (40 mg) by avoid grapefruit, avoid alcohol⁴
(LIPITOR) 40 MG reductase mouth daily.
tablet inhibitor⁴

2. Empagliflozin SGLT-2 Take 1 tablet (10 mg avoid alcohol⁴

(JARDIANCE) 10MG inhibitors⁴ total) by mouth daily.
tablet

3. Ferrous sulfate Oral iron Take 1 tablet (325 take 1-2 hours before eating⁴
(FERATAB) 325(65 supplement⁴ mg total) by mouth
FE) MG tablet daily.

4. Insulin glargine Long-acting Inject 0.08 ml (8 Units avoid alcohol⁴

(LANTUS insulin⁴ total) under the
SOLOSTAR) 100 skin nightly.
UNIT/ML injection

6. Losartan (COZAAR) Angiotensin II Take 1 tablet (25 mg total) avoid potassium-containing salt
25 MG tablet receptor blockers by mouth substitutes⁴
(ARBs) nightly.

7. Metoprolol tartrate Beta blocker, take 0.5 tablets (12.5 mg) Take 2 hours apart from
(LOPRESSOR) 25 mg antiadrenergic, twice daily. multivitamin/multimineral, take
tablet antiarrhythmic⁴ with or immediately after food.
Beta-adrenergic receptor blocking
agents (aka beta-blockers) may alter
serum lipid profiles. Increases in
serum VLDL and LDL cholesterol
 and triglycerides, as well as
decreases in HDL cholesterol, have
been reported with some beta-
blockers. Patients with preexisting
hyperlipidemia may require closer
monitoring during beta-blocker
therapy, and adjustments⁴

8. NIFEdipine Calcium channel 1 tablet orally daily take 2 hours apart from
(ADALAT CC) 60 MG blocker⁴ multivitamin/multimineral, avoid
ER 24 hr tablet grapefruit juice, avoid alcohol⁴

9. Polyvinyl alcohol 1.4 Eye lubricant - Administer 1 drop (15 ml) n/a
% (LIQUIFILM ophthalmic to both eyes 4 (four) times
TEARS) 1.4 % a day.
ophthalmic solution

10. Sodium zirconium Calcium channel Take 1 packet (5 g total) take 2 hours apart from
cyclosilicate blocking agents⁴ and mix with 3 multivitamin/multimineral, avoid
(LOKELMA) 5 g packet tablespoons of water grapefruit juice, avoid alcohol⁴
and take by mouth
daily.

Supplements: none
Food and Supply Availability: The patient prepares her food. The patient requested assistance
with securing food. She was referred to Groceries to Go and enrolled in NYC Cares.

Nutrition-Focused Physical Findings:⁵

No nutrition-focused physical exam was performed at the time of the visit. The patient appeared
well nourished PD-1.1.1.⁵ The patient appeared slightly overweight but proportional NC-3.3.⁵
The patient’s skin was intact PD-1.1.8.⁵ The patient reports low appetite due to mood.

Anthropometrics:⁶
● Ht: 1.52 m (4’ 11.84”)
● Wt (current):71.2 kg (157 lb)
● BMI: 30.82 kg/m² (overweight)
● DBW: 45.5 kg
● % UBW: 101
● % wt Δ: -1.28
● % DBW: 156%

Labs:
Component Lab Value Etiology (if Normal Range⁴ Date
applicable)⁴

CREAT 1.27 (H) -may be 2/2 kidney Female: 0.4–1.1 10/04/2023

damage⁴ mg/dL⁴
 EGFR 46 (L) May be 2/2 chronic >60mL/min/1.73m²⁴ 10/04/2023
*note: not renal insufficiency/
determined to kidney damage⁴
be low as per
hospital
standards*

BUN 22.0 8–23 mg/dL⁴ 10/04/2023

Glucose 159 (H) - may be 2/2 74 - 110 mg/dl⁴ 10/04/2023

uncontrolled diabetes⁴

Glucose poc Capillary 80 70- 105 mg/dl⁴ 01 /04/2024

HGB 9.4 (L) May be 2/2 anemia⁴ Female: 12–16 g/dL⁴ 11/29/2023

HCT 31.4 (L) May be 2/2 anemia⁴ Females: 11/29/2023

35%–46%⁴

IRON 64 Female: 40–155 μg/dL⁴ 11/29/2023

Cholesterol 89 <100 ⁴ 10/04/2023

Very-High-Risk Patients (T2D
Plus >1 Major ASCVD Risk
or Established) ASCVD)

Triglyceride 39 <150⁴ 10/04/2023

Very-High-Risk Patients (T2D
Plus >1 Major ASCVD Risk
or Established) ASCVD)

HDL 48 <3.0⁴ 10/04/2023

Very-High-Risk Patients (T2D
Plus >1 Major ASCVD Risk
or Established) ASCVD)

LDL 33.2 <100⁴ 10/04/2023

Very-High-Risk Patients (T2D
Plus >1 Major ASCVD Risk
or Established) ASCVD)

HBA1C 10.0 (H) - may be 2/2 </=5.6%⁴ 01/04/2024

7.4 (H) uncontrolled diabetes⁴ 10/04/2023
7.0 (H) 09/07/2023
8.4 (H) 06/16/2023
9.1 (H) 04/26/2023
9.1 (H) 04/14/2023
8.7 (H) 09/14/2022
8.5 (H) 02/09/2022

Interpretation:
The patient’s elevated creatinine level (1.27 mg/dL) aligns with T2DM's impact on
kidney function. Chronic hyperglycemia in diabetes can lead to diabetic nephropathy,
contributing to impaired renal function and elevated creatinine levels. Reduced eGFR (46
mL/min/1.73m²) is consistent with diabetic nephropathy, indicating decreased kidney filtration
capacity. Persistent hyperglycemia damages the renal microvasculature, leading to impaired
glomerular filtration. Elevated BUN (22.0 mg/dL) is in line with impaired kidney function
associated with diabetic nephropathy. BUN levels rise as the kidneys struggle to excrete urea, a
waste product. The patient’s high glucose levels (159 mg/dL) are indicative of uncontrolled
diabetes. The patient's reported challenges in self-monitoring and dietary adherence,
compounded by emotional stress, likely contribute to poor glycemic control. Low hemoglobin
(9.4 g/dL) and hematocrit (31.4%) levels suggest the presence of anemia. Anemia is a common
complication of chronic diseases, including diabetes, and can result from a combination of
factors such as nutritional deficiencies and chronic inflammation. While the iron level is within
the normal range, it is important to monitor for changes as anemia management may require
attention to iron status. Anemia in diabetes can be multifactorial. The patient’s lipid profile
within the very-high-risk range indicates the need for cardiovascular risk management.
Individuals with diabetes often experience dyslipidemia, contributing to increased cardiovascular
risk. Despite being in the very-high-risk-range, her lab values are normal at the moment. For this
reason, her nutrition intervention and follow-up appointment will only address diabetes unless
her lab values change. Her elevated HBA1C levels (ranging from 7.4% to 14.0%) indicate
persistent hyperglycemia and uncontrolled diabetes. Emotional stress, as reported by the patient,
can further exacerbate glycemic fluctuations. These lab values underscore the effects of diabetes-
related complications on multiple organ systems, which further emphasizes the need for a
continuum of care that addresses not only glycemic control but also the patient's psychosocial
well-being and associated comorbidities.

Nutrition Needs:⁶
Estimated nutrition needs are based on the Hospital’s Standards of Care.⁶ Please see Appendix 2
for the full Standards of Care.

Calories 1424 kcal/day, based on 20 kcal/kg ABW

Protein 64 gm/day, based on 0.9 gm/kg ABW

Fluids 2136 mL/kg, based on 30 mL/kg ABW

NCP: Diagnosis:
1. Altered nutrition-related laboratory values NC-2.2 related to endocrine dysfunction as
evidenced by elevated HgbA1C 10%.⁷
2. Inability to manage self-care NB-2.3 related to spousal death as evidenced by
uncontrolled glucose levels and hypoglycemic event on 10/29/23.⁷

NCP: Intervention:
Medical:
Medical interventions for diabetes management include pharmacotherapy and creating a blood
glucose monitoring plan. The pharmacotherapy includes the patient continuing her regimen of
insulin glargine (LANTUS SOLOSTAR) and empagliflozin (JARDIANCE). Psychosocial
support can be applied in medication management to ensure that the patient understands how to
use her lancet device to properly monitor her blood sugar at home, as well as understanding
normal and abnormal blood glucose values. The Hospital protocol is that Outpatient Dietitians
counsel on the reason for referral. This patient was referred for diabetes education, therefore
hypertension management will be managed by the pharmacy.

Nutritional:
Food and/or nutrient delivery ND Meal and Snacks (1); Modify distribution, type, or
amount of food and nutrient ND-1.2⁸
The current diet order for this patient is a carbohydrate-consistent diet. Based on the patient’s
diet recall, she is consuming large quantities of carbohydrates at a time, as well as consuming
carbohydrates on their own, which both elevate blood sugar. The patient was educated on a
carbohydrate-consistent diet and how to measure carbohydrate portions using measuring cups.
She was instructed to read nutrition labels on food packages to understand how many
carbohydrates foods contain.

Education:
Nutrition Education–Content (1); Recommended modifications E-1.5⁸
During the session, the patient was educated on food groups and encouraged to include
foods from all food groups in her diet based on the MyPlate method. The patient was also
educated on how to prepare balanced meals including non-starchy vegetables, whole grains, lean
protein, and healthy fats. The education portion of the session addressed foods containing
carbohydrates and appropriate portion sizes. The patient was encouraged to increase her intake of
non-starchy vegetables and increase moderate-intensity physical activity as she is able. She was
also encouraged to consume adequate amounts of fiber and water. The patient verbalized
understanding and asked relevant questions. Education handouts were provided. The patient
stated that she wants to lower the blood sugar to the target range, and the patient wants to
improve her understanding and compliance with a carbohydrate-consistent diet, Patient
education completed.

Counseling:
Theoretical Basis/Approach (1); Health Belief Model C-1.2⁸
The Health Belief Model, as applied to diabetes, considers several key factors influencing
health-related behaviors. The patient's assessment of the severity of their diabetes can motivate
them to engage in preventive measures. Cues to action are triggers that prompt the patient to take
action, such as a doctor's visit or adopting healthier habits. Perceived benefits and barriers are
what the patient believes are the benefits and obstacles to managing their diabetes. Finally, self-
efficacy allows the provider to assess the patient's confidence in their ability to achieve their
goals.

Social Learning Theory C-1.3⁸

The Social Learning Theory proposes that individuals observe and learn behaviors from
their environment. The theory emphasizes the person's ability to actively shape their environment
to achieve behavioral goals. This means that individuals with diabetes can modify their
surroundings, such as creating a supportive social network, engaging in health-promoting
activities, and fostering an environment conducive to positive health behaviors, ultimately
contributing to effective diabetes self-management.
Other C-1.5: Motivational Interviewing⁸ ⁹
Motivational interviewing consists of four processes: engaging, focusing, evoking, and
planning. Motivational interviewing assumes that the patient is engaged and willing/ready to
learn by assessing the patient’s readiness for change. Motivational interviewing focuses on what
can be controlled, such as diet and medication for self-management of blood glucose levels. For
this patient, she can manage the amount of carbohydrates she consumes and her compliance with
her medication regimen. Asking open-ended questions evokes more information from the
patient, evidenced by the question “Has anything changed in the past year that could have
affected your appetite or stress levels?” to which the patient responded with her husband’s death
and recounting the experience pre-and post-mortem. In the planning stage of motivational
interviewing, the patient can set clear goals that can be reviewed in her next nutrition
appointment. The patient stated that her two main goals were improving her understanding of
and compliance with a carbohydrate-consistent diet, as well as lowering her blood sugar to the
target range. These goals can be assessed via a dietary recall and by reviewing her next HbA1c
and glucose labs.
In addition to the four processes in motivational interviewing, the spirit of motivational
interviewing provides a foundation for recognizing and affirming the dignity and humanity of
patients, regardless of their health status. The four aspects of the MI Spirit include partnership,
acceptance, compassion, and evocation.¹⁰ The partnership emphasizes that nutrition counseling
is a conversation between two experts, assuming that the patient is their own best advocate and
expert in their lived experience. Acceptance emphasizes the patient’s absolute worth, autonomy
and support, affirmation, and accurate empathy. A patient is more likely to be honest regarding
their issues if their situation, regardless of context, is understood and given respect.¹⁰ In
motivational interviewing, the patient’s autonomy must be accepted and it must be understood
that the patient is responsible for making behavior changes. This also includes respecting any
decisions to not change.¹⁰ Affirming the patient and identifying their strengths reinforces
positive behaviors that can help them understand their disease or make any necessary changes.
Finally, accurate empathy is a core skill of motivational interviewing and ensures that the
patient’s concerns are understood.¹⁰
The motivational interviewing processes and experience were especially
beneficial in this counseling session. The structured approach to engaging the patient, gathering
relevant information, and setting clear goals helped the patient navigate her complicated social
situation. While the behaviors of those around the patient could not be controlled, she understood
that she could control her behaviors such as compliance to her diet order and medication
regimen. This made the patient feel empowered in a chaotic situation and motivated her to keep
trying to lower her blood glucose levels to the target range. Perhaps in this situation, the MI spirit
was more beneficial than the process of motivational interviewing itself. After the patient
recounted her husband’s illness and passing, it did not seem appropriate to return to nutrition
education. For the last 5-10 minutes of the session, the patient received psychosocial support. It
was reflected to her that the stress she was experiencing was an incredible burden for one person
to carry and that it makes sense that she struggled to manage her health in the context of the past
five months. This seemed especially helpful because the patient entered the session appearing
helpless and confused, but stated that she was comforted by the support that she received from
the session and that she felt that she could make positive changes in her life. Motivational
interviewing provides a natural segue into providing psychosocial support for patients, which is
extremely important for patients who have a history of noncompliance with their care plan.

Strategies (2); Social support C-2.5⁸

Culture is the framework through which people perceive and interact with the world,
making it necessary for RDs to understand how culture affects food choices. Cultural awareness
and understanding of the client’s perspectives about their health are necessary to gain empathy
and establish rapport with the client. This can improve the quality of the communication, and
improve self-efficacy in goal setting. Clients who present with significant barriers to dietary
change or who return multiple times with low adherence may benefit from additional social
support, referral to outside agencies, or referral to counselors or psychologists for evaluation.¹¹

Stress management C-2.6⁸

Physical and emotional factors may also make it hard to change, especially for people
who hold multiple marginalized identities. Additionally, cortisol, the "stress hormone" affects
blood glucose levels, blood pressure, and inflammatory systems throughout the body. Managing
stress and providing support during major life events can help patients better manage their
health. Counseling and cognitive behavioral therapy, which can reduce perceived stress, may
also help control glycemic levels.¹¹

Rationale:
Several studies show that among older adults, spousal illness or death is associated with
poor health outcomes.¹² Some stress hormones, such as norepinephrine, epinephrine, cortisol, β-
endorphin, and growth hormone, can affect glucose homeostasis by interfering with various
metabolic functions, such as insulin release, glucose utilization, and hepatic glucose
production.¹² Divorce, separation, and widowed status are viewed as among the most stressful of
life events but have not been fully explored with diabetes mortality.¹² Several studies have shown
that divorced men often lose the social support of their spouses, who are also typically their
primary caregivers. Husbands’ illness or death might increase financial hardship, which often
leads to increased depressive symptoms for widows.¹² This is because Marriage promotes
healthful behaviors & reduces the risk of chronic disease.¹³ Some widowed men are more likely
to cope with the loss of a spouse by engaging in more dangerous activity leading to early
morbidity and mortality related to alcohol and drug use, accidents, homicide, and suicide.¹² For
women, a deterioration of the husband’s health of one step in a range from "very good" to "very
poor" is associated with a significant increase of 0.15 percentage points in HbA1c levels, and
losing a husband in very good health is associated with a significant increase in glycemic levels
of 0.76 percentage points. ¹²
Psychosocial care is particularly important for diabetic patients, as diabetic patients are
three times more likely to have depression than non-diabetic patients.¹³ In addition to stressors
related to type 2 diabetes, Black patients statistically become sicker and die from T2DM at
significantly higher rates than non-Black patients.¹³ Black patients are at a higher risk for stress
and depression due to poor adjustment to their diagnosis and lifestyle changes.¹³ This
maladjustment can be exacerbated by a lack of family, community, or professional support, such
as a lack of cultural relevance, social isolation due to diet changes, increased social barriers to
care, and medical racism.¹³ As a result of the increased difficulty in self-managing blood glucose
levels, Black patients are four times more likely to experience blindness, amputations, and renal
disease due to unmanaged diabetes and experience a 20% higher risk of fatality.¹³ Black patients
must be screened for non-diet factors that may affect their ability to self-manage their diabetes
such as income, financial barriers, social support, and cultural relevance of nutrition education
being provided.
Practitioners can incorporate social support strategies into patient care in many ways.
Empowering patients assists with self-management by improving self-efficacy. Cultural
competency, such as using the patient's native language and including cultural foods, can
promote self-care across populations. Using faith-based and community-based organizations that
are of value to specific cultural groups not only aids in diabetes management but can help
prevent diabetes in vulnerable populations by providing culturally appropriate education backed
by trusted community leaders.¹³

Continuum of Care:
Psychosocial care is defined as social support, psychological support, emotional support,
material resources, and education that help to manage glucose levels.¹³ Upon a new T2DM
diagnosis, patients experience major changes to their lives including but not limited to diet
changes, new medications, major lifestyle changes, social isolation, fatalism, and guilt or shame.
Psychosocial care is often overlooked when considering diabetes management and has been
proven effective in reducing stigma, promoting social functioning, and improving overall quality
of life.¹³ Providing a continuum of care such as referrals to social workers, specialist providers
such as nephrologists, and communicating with all providers about relevant findings ensures that
all of the patient’s needs, including emotional and psychological, are considered when treating
any patient. By providing a continuum of care, the patient will have the support needed to make
major life changes that otherwise may be too cumbersome to manage on their own.

NCP: Monitoring and Evaluation:

Food and Nutrient Administration (2); Diet order (2.1.1)¹⁴
Modified diet FH-2.1.1.2¹⁴
CHO consistent diet
At the next nutrition visit, the patient will speak with the dietitian regarding her diet changes and
whether she has been able to comply with the carbohydrate-consistent diet. She will review
portion sizes with the dietitian and set new goals for following the carbohydrate-consistent diet
based on her progress. Her HbA1c and at-home blood glucose log will provide insight into her
diet quality and whether she can consistently monitor her blood sugar through diet.

Medication and herbal supplement use (3); Medications FH-3.1.1¹⁴

Monitor the use of the following diabetes management medications:
● empagliflozin (JARDIANCE) 10MG tablet
● insulin glargine (LANTUS SOLOSTAR) 100 UNIT/ML injection
At the next nutrition visit, the patient will speak with the dietitian regarding her compliance with
her medications. If she is experiencing any adverse reactions she will be referred to her primary
care physician.

Biochemical Data, Medical Tests and PROCEDURES (BD)¹⁴

Will continue to monitor the following lab values:
Electrolyte and renal profile (1.2)
 Creatinine BD-1.2.2
BUN BD-1.2.1
Glucose/endocrine profile (1.5)
Glucose, fasting BD-1.5.1
HgbA1c BD-1.5.3
Preprandial capillary plasma glucose BD-1.5.4
Lipid profile (1.7)
Cholesterol, serum BD-1.7.1
Cholesterol, HDL BD-1.7.2
Cholesterol, LDL BD-1.7.3
Triglycerides, serum BD-1.7.7
Nutritional anemia profile (1.10)
Hemoglobin BD-1.10.1
Hematocrit BD-1.10.2
Iron, serum BD-1.10.11

Coordination of Other Care During Nutrition Care (1); Collaboration/referral to other

providers RC-1.3¹⁴
At the next nutrition visit, the dietitian can read notes regarding the patient’s encounters
with their primary doctor, nephrologist, and pharmacy to determine if any other interventions
need to be made. The dietitian can assess whether the client has received appropriate support
from other providers and if additional referrals are needed. The dietitian can also contact the
primary care physician and request another referral to a social worker if the patient has still not
been contacted. The dietitian can also determine if the patient’s hypertension requires nutrition
intervention or if the primary focus should remain on managing her diabetes, and speak with the
primary care provider as needed.

Future Exams:
02/24/2023 RETINOPATHY SCREEN
0/11/29/2023 PNEUMOCOCCAL 65+ YEARS VACCINE (3 - PPSV23 or PCV20)
04/04/2024 A 1 C (MANAGEMENT)
01/04/2024 NUTRITION FOLLOW UP
08/17/2024 NEPHROPATHY (eGFR, MICROALBUMIN)~
09/14/2024 MAMMOGRAM
10/04/2024 LIPID PANEL
08/07/2029 TDAP/TD VACCINE

Referral to community agencies/programs RC-1.4¹⁴

Although dietitians cannot refer to social work as per hospital protocol, but they can
message the provider to request a referral or follow up. At the patient’s follow-up appointment,
the dietitian will check the patient’s progress in being contacted by a social worker and request
another referral from the patient’s primary care physician if needed. Thus far, the patient has
been referred to Groceries to Go, NYC Cares, and has a community case worker through Health
Corps.
Conclusion:
Health educators and medical professionals should be aware of external factors that may
affect self-care. Vulnerable patients should be targeted for early detection and intervention and
referred to other providers as necessary. Using Motivational Interviewing techniques, dietitians
can affirm the patient's experiences and help them focus on the factors in their life that can be
changed, such as diet and medications. Counseling and cognitive behavioral therapy, which can
reduce perceived stress, may also help control glycemic levels.
In conclusion, nutrition counseling is a conversation between two experts; as previously
stated, the dietitian is the nutrition expert and the patient is the expert in their own experiences.
For patients to have the best health outcomes, there must be respect for a patient's autonomy and
an understanding of the patient's lived environment and barriers to health. Collaborative care and
psychosocial support help to identify the patient's strengths and resources. Dietitians must
function under the assumption that the patient wants to and is capable of change and help set
realistic goals with coordination of care as needed.
Appendix:
Appendix 1: Calculations estimating nutrient needs:
Calories 1775 kcal/day, based on 25 kcal/kg

Protein 57 gm/day, based on 0.9 gm/kg

Fluids 2130 mL/kg, based on 30 mL/kg

Appendix 2: Standards of Nutrition Care: Nutrient Need Calculations:
__Insert Hospital Name Here_ Standards of Nutrition Care 2022
 Patient Daily Kcal Needs Daily Daily Fluid Other Referen
Population Protein Needs Recommendations/Co ce
Needs mments
Adults 25-30 Kcal/kg 0.8-1.0 g/kg 1mL/kcal NCM1
(maintenance) (maintenanc OR ASPEN3
30-35 Kcal/kg (repletion) e) 25-35 mL/kg
BMI > 25: 20-25 kcal/kg 1.2-2.0 g/kg ABW
ABW (repletion)
BMI 30-40: 15-20 kcal/kg
ABW *May be
BMI > 40 use 11-15 kcal/kg 1.2-1.5 g restricted for
ABW pro/kg IBW medical
OR for BMI 30- condition
Mifflin-St Jeor (MSJ) + AF 40
as applicable 1.5-2.0 g
pro/kg IBW
for BMI > 40
Older adults 20-25 Kcal/kg 1.0-1.25 30-35 mL/kg NCM1
(maintenance) g/kg EAL2
25-30 Kcal/kg (repletion) 1.2-1.5 g/kg
OR (repletion)
MSJ

Burns IC if feasible 1.5-2.0 g/kg Parkland Daily MVI NCM1

25 kcal/kg + 40 kcal x Severe: Formula: Vitamin C: 500 mg/d ESPEN9
%TBSA >2.0g/kg 3-4ml/kg/ Vitamin A: 10,000 IU/D
For burns covering more %BSA/24 hrs
than 50% TBSA, use a (50% of total
maximum value of 50%. volume in the
first hours,
50% of total
Minor Burns: <15% BSA volume over
Moderate Burns: ~15-25% the next 16
BSA hrs)
Major Burns: >25% BSA

Urine Output
:
Goal: 0.3-0.5
ml/kg/hr
Critically ill Penn State 2003b (vented; 1.2-2.0 g/kg 1 ml/kcal *Typically used after NCM1
adults non-obese) Up to 2 g/kg the first week of JPEN3
Penn State 2010 (vented; IBW if BMI critical illness EAL2
obese)* 30-40 **Typically used ASPEN3
11-14 kcal/kg Up to 2.5 within the first week of AND2
ABW (vented; BMI 30- g/kg IBW if critical illness (7-10
50)** BMI >40 days)
22-25 kcal/kg IBW (vented;
BMI > 50)**
Monitor MAP
Monitor propofol rate
 12-25 kcal/kg** (per
ASPEN 2022 update, can
be used for all critical care
patients per clinical
judgement)
 HIV 30 -35 kcals/kg 1.0-1.5 g/kg 30 - 35 ml/kg NCM1
asymptomatic Asymptoma Asymptomati AND3
35-40 kcals/kg tic; c EAL2
symptomatic; weight loss 1.5 - 2.0 35 - 40 ml/kg
OR g/kg Symptomatic
MSJ Symptomati Fluid control
c; 2.0 -2.5 for those
g/kg CD 4 experiencing
<200, ESRD
presence of
AIDS
defining
condition
&/or
opportunisti
c infection
CHF 22-25 1.1 – 1.4 20-25 ml/kg Malnutrition is present NCM1
Kcal/kg(maintenance) g/kg actual (or as in 36-53% of CHF III-IV AND3
30-35 Kcal/kg BW indicated by EAL2
(repletion) (normally MD for fluid
20-22 Kcal/kg (weight nourished or restrictions) Maintain:
reduction) malnourishe Na+ ~140 mEq/dL
OR d) K+ 4-5 mEq/dL
MSJ/ Monitor:
HBE + 15-25% (minimal Zn, Mg, Ca, replete as
PA) needed
25-45%
(hypermetabolism)

Cerebrovascu 25-30 Kcal/kg Maintenanc 25-35 ml /kg NCM1

lar (maintenance) e needs
30-35 Kcal/kg (repletion) (unless
subsequent
condition):
0.8-1. g/kg
COPD 30 Kcal/kg (maintenance) 1-1.2 g/kg 25-35 ml /kg Monitor Vit D, Phos, EAL2
30-35 Kcal/kg(repletion) (maintenanc up to 40 replete as needed
20 – 22 Kcal/kg (weight e) ml /kg
reduction) 1.2-2 g/kg
(repletion)

Obstetrics 1st Trimester: 71 g/day 35-40ml/kg Supplement with pre- NCM1

25 – 30 kcal /kg pre- (RDI + pre- natal vitamin
pregnancy wt 25g/d) or pregnancy wt
Second Trimester: 1.1 g/kg pre-
25-30 kcal /kg pre- pregnancy DRIs for specific
pregnancy wt + 340 kcal / weight, micronutrients:
 day whichever is Ca: <18 yrs: 1300 mg
Third Trimester: greater. For 19+ yrs: 1000
25-30 kcal/kg + 452 some mg
kcal/day women with
Multiple Gestation: greater
EER + additional kcal energy Fe: 27 mg/d
per each trimester + needs,
500 kcal/day once it is protein
determined to be a needs may Folate: 600 mcg/d
multiple gestation need to be
pregnancy adjusted.
Lactation:
For gradual weight loss:
1st 6 months: +500 Teenagers:
kcal/day DRI +25 gm
2nd 6 months: +400 kcal

Multiple
Gestation:
96 g/day
(RDI + 50
g/d) starting
in the 2nd
trimester

Lactation:
1.3 g/kg
 Oncology 25-30 Kcal/kg (Non- 1 – 1.5 25-35 ml/kg NCM1
ambulatory or g/kg
Sedentary Adults) (non-
30-35 Kcal/kg (Slightly stressed
Hypermetabolic )
patients) 1.5-2.5 g/kg
35 Kcal/kg (hypermeta
(Hypermetabolic or bolic/stem
severely stressed cell
patients) transplant/p
rotein-losing
enteropathy
)

Pancreatitis Moderate to severe Moderate to 1 ml/kcal For patients with mild NCM1
pancreatitis: severe acute pancreatitis,
25-35 kcal/kg pancreatitis initiate nutrition
Chronic Pancreatitis: 35 1.2-1.5 g/kg support if unable to
kcal/kg Chronic advance to a PO diet
Pancreatitis: within 7 days
1-1.5 g/kg

For patients with

moderate to severe
pancreatitis, consider
starting trophic feeds
within 24 – 48 hrs

Standard enteral
formulations are
appropriate

Gastric or jejunal feeds

are appropriate

If EN is not feasible,
consider PN after 7
days from onset of
symptoms

Chronic Pancreatitis:
Consider addition of
PERT Enzyme

Hepatic 30-35kcal/kg 1.0-1.2g/ Maintenance Long-term oral NCM1

 Disease Or REE x 1.2-1.4 kg/day : supplementation of
(hepatitis) 25-30 mL/kg BCAA (0.25g/kg/day)
may be recommended
improved overall
1.0-1.5g/ If survival benefit and
kg/day ascites/edem quality of life
(cirrhosis) a present, (cirrhosis)
fluid Encephalopathy-Add
restriction is Thiamine
0.8g/kg/day only Check Ammonia, if
(severe indicated elevated consider
hepatic when serum Lactulose
encephalop Na+ < 125
athy for a mEq/Ld
short
duration)

Kidney 25-35 kcal/kg (include kcal 0.8-1.2g/kg 500 ml + UOP Sodium: 2.0-3.0 g/day NCM1
Disease: from continuous renal (non- AKI w/ CRRT Potassium: 2.0-3.0 EAL2
replacement therapy - catabolic, – no g/day
CRRT) without restriction Phosphorus: 8-15
Acute Renal dialysis) mg/kg
Failure

1.2-1.5g/kg
(catabolic
and/or
initiation of
dialysis/CRR
T)
Kidney CK 25-35 kcal/kg IBW 0.55-0.66 1 ml/kcal *Vegetable protein NCM1
Disease D g/kg/d diets may have EAL2
: (st (metabolical beneficial effects on
ag ly stable) (In CKD health by a variety of
e Stages 1-4, mechanisms but
1- fluids are insufficient evidence
5); 0.6-0.8 usually to definitively
no g/kg/d unlimited) recommend a
n- (diabetic) particular protein type.
dia
lysi
s OR Advise patients to
gradually reduce Pro
intake and/or
0.28-0.43 encourage occasional
g/kg/d with meatless meals
additional
keto acid
analogs
 (sufficient
energy
intake e.g.
>30kcal/kg
per day, pro
intake level
can be
safely
decreased
to 0.55 to
0.6g/kg/d)
 CK 25-35 kcal/kg IBW 1.0-1.2 1000 ml + Potassium and NCM1
D g/kg/d UOP Phosphorus should be K/DOQI4
5D (patients at (the fluid adjusted to maintain
on risk of recommenda serum levels within
Dia hyperglycem tion is to normal range (It is
lysi ia and/or ensure that reasonable to consider
s hypoglycemi overhydratio bioavailable of
a, higher n and phosphorus sources;
levels of underhydrati additives > animal >
dietary pro on are vegetable). Limit
intake may avoided: sodium intake to less
need to be target of UFR than 2.3 g/day.
considered) less than 13
ml/hour/kg)

Paraplegia/ Paraplegic: 28kcal/kg 0.8-1g/kg 25-35 ml/kg NCM1

Quadriplegia Quadriplegic: 23kcal/kg

BMI > 22 (Obese)

Paraplegic: subtract 5-10%
from IBW
Quadriplegic: subtract 10-
15% from IBW

Pressure 30-35kcal/kg (Stages I-IV, 1.25-1.5g/kg 30ml/kg Juven (Arginine and NPUAP7
ulcer DTI, Unstageable) (Stages I-IV, (Stages I-II) Glutamine) 1 packet NCM1
Unstageable 30-35ml/kg BID (Stages II-IV,
, DTI) (Stages III-IV, Unstageable, DTI).
DTI, Juven contains
Unstageable) Arginine, Glutamine,
HMB, C, E, and Zinc.
Consider d/c
additional zinc. TUL for
elemental zinc is 40
mg.
 Pediatrics 0-6 Months: 1-10kg: PNCM6
0-6 Months: 108kcal/kg 2.2g/kg 100ml/kg Texas
6-12 Months: 98kcal/kg 6-12 11-20kg: Children’
1-3 Years: 102kcal/kg Months: 100ml/kg + s8
4-6 Years: 90kcal/kg 1.6g/kg 50ml/kg
7-10 Years: 70kcal/kg 1-3 Years: above 10kg
1.2g/kg >20kg:
Males 4-6 Years: 1500ml +
11-14 Years: 55kcal/kg 1.2g/kg 20ml/kg
15-18 Years: 45kcal/kg 7-10 Years: above 20kg
1.0g/kg
Females
11-14 Years: 47kcal/kg Males
15-18 Years: 40kcal/kg 11-14
Years:
1.0g/kg
15-18
Years:
0.9g/kg

Females
11-14
Years:
1.0g/kg
15-18
Years:
0.8g/kg
**These are standard guidelines. Clinical judgement always prevails**

Ideal Body Weight (IBW) Calculation (Hamwi Formula):

Female: 100# for 60” tall, add 5# for every additional inch of height, subtract 2-3# for each inch under 60”
Male: 106# for 60” tall, add 6# for every additional inch of height, subtract 2-3# for each inch under 60”
Affected Limb Adjustment Percent
Hand 0.7%
Lower arm and hand 2.3-3.1%
Entire arm 5.0-6.5%
Foot 1.5-1.8%
Lower leg and foot 5.9%
Entire leg 16-18.5%

Adjusted Body Weight for Amputation Calculation:

Adj. BW = IBW – (IBW x % for affected limb)
Values for other disease states, macronutrients and micronutrients are calculated using appropriate reference
range standards from NCM or PNCM.
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