1. Hilary Peace
Questions for Medical Nutrition Therapy: A Case Study Approach 5th ed.
Case 18 – Adult Type 2 Diabetes Mellitus: Transition to Insulin
Instructions: Answer the questions below and upload to your SharePoint folder.
1. What are the standard diagnostic criteria for T2DM? Identify those found in
Mitch’s medical record.
 A1C 6.5% or higher using standard measures OR;
 Fasting plasma glucose 126 mg/dl or higher (7.0 mmol/L) OR;
 Symptoms of diabetes + random glucose concentration 200 mg/dl or higher (11.1
mmol/L) OR;
 Glucose 200 mg/dl or higher (11.1 mmol/L) two hours post-prandial using an oral
glucose test (Nelms M., Sucher, K., Lacey, K., 2016, pp. 481).
Those found in Mitch’s record are A1C at 11.5% and plasma glucose at 855 mg/dL on
4/12 and 475 on 4/13. 70-99 is considered the normal range and he is well above that.
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.
Medication Mechanism Side effects/drug-nutrient
interactions
Metformin – biguanide,
glucose-lowering drug
Inhibits hepatic glucose
production by activating
AMP-activated protein
kinase, which decreases
blood glucose
concentration.
Take with food and avoid
alcohol. Possible increase of
hypoglycemic activity when
taken with glyburide.
Possible side effects are
allergic reactions, blurred
vision, tachycardia,
sweating, increased hunger,
and confusion.
Glyburide – sulfonylurea,
glucose-lowering drug
Triggers insulin release
from pancreas to lower
glucose levels.
Take half an hour to an hour
before breakfast and avoid
alcohol. Possible increase of
hypoglycemic activity when
taken with metformin.
Possible side effects are
allergic reactions, blurred
vision, tachycardia,
sweating, increased hunger,
and confusion.

2. Hilary Peace
(Drug Bank, n.d.)
(National Center for Biotechnology information [NCBI], 2016, October)
3. What other medications does Mitch take? List their mechanisms and potential side
effects/drug-nutrient interactions.
Medication Mechanism Side effects/drug-
nutrient
interactions
Dyazide 1 x daily -
(combination of 25 mg
hydrochlorothiazide and
37.5 mg triamterene)–
diuretics and anti-
hypertensives
It is a diuretic used to treat
edema, HTN, diabetes and
hypoparathyroidism.
Triamterene inhibits sodium
reabsorption, which
decreases osmotic gradient
needed for water
reabsorption. Has a
potassium-sparing effect,
which inhibits excretion.
Hydrochlorothiazide
increases water and
electrolyte secretion and
inhibits renal reabsorption.
Avoid alcohol, limit
sodium, avoid
licorice, avoid
taking calcium,
magnesium, iron or
aluminum
supplements within
2 hours of taking
medicine, increase
potassium intake,
take with a meal.
Lipitor – 20 mg daily – anti-
hyperlipidemia, statin, used
as secondary approach to
prevent CHD
Blocks enzyme (HMG-CoA)
required to form cholesterol,
which reduces serum
cholesterol.
Avoid drastic diet
changes, alcohol,
and grapefruit or
grapefruit juice;
take conjunctively
with a low-fat meal.
(Drug Bank, n.d.)
3. 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).
 He was confused, dehydrated and drowsy, not taking his medicine or following
diet recommendations for DM, which led to dx of HHS.

3. Hilary Peace
 Decrease effectiveness of insulin and increased levels of counteractive hormones
contributed to hyperglycemia (serum glucose upon admission was 855 mg/dL);
 Hyperglycemia caused glycosuria (pt’s urinalysis indicated +3 concentration of
glucose)
 Polyuria occurs because of osmotic diuresis and hepatic glucose is unable to be
reabsorbed, which will cause dehydration (pt had cloudy amber urine, decreased
serum sodium, increased osmolality, and poor skin turgor),
 Vomiting contributed to dehydration.
(Nelms et al, 2016, pp. 481-482, 506)
HHS and DKA similarities:
 Both are characterized by a reduced concentration of insulin;
 Severity of ketosis, metabolic acidosis and dehydration are main differences;
DKA:
 Occurs mostly in T1DM but can occur in T2DM if pt is metabolically stressed or
insulin deficient;
 Characteristics are hyperglycemia, increased ketone concentration and metabolic
acidosis and reduced effectiveness of insulin;
 Caused by inadequate serum insulin, pregnancy, abusing drugs, illnesses or
infections;
 Symptoms include an increase in urination and thirst, N/V, pain in the abdomen,
dehydration, acetone breath, deep and labored breathing, lethargy and/or cerebral
edema;
 Lab values are serum glucose 600-1200 mg/dL, arterial pH 6.8-7.3, serum
bicarbonate less than 15 mEq/L, positive urine and serum ketones, and serum
osmolality between 300 and 320 mOsm/kg;
 Lipid, protein and carbohydrate metabolism is altered due to body breaking down
stores of glycogen, breaking down of triglycerides, and amino acids being
mobilized for production of glucose and ketone bodies;
 Hyperglycemia results because of increased glycogenolysis and gluconeogenesis
as well as decreased glucose utilization, causing osmotic diuresis resulting in
dehydration;
 Further increase in concentration of glucose contributes more to hyperglycemia;
 Treatment involves supplemental insulin, administration of IV fluids, electrolyte
control;
 And most cases are resolved.
(Nelms et al, 2016, pp 505-506)
HHS:

4. Hilary Peace
 Most commonly seen in pts with T2DM and those over 55 y/o;
 Ketoacidosis not present and is condition is precipitated by infection and
dehydration;
 Caused by either prolonged hyperglycemia due to ineffective insulin action along
with increased counter-regulatory hormones causing an increase in glucose
production and inhibited utilization in tissues and/OR dehydration resulting from
excessive fluid loss or inadequate fluid intake;
 Symptoms that develop gradually include increases in urination and thirst, weight
loss, decrease in level of consciousness, fever, and depletion of volume;
 Lab values are a plasma glucose greater than 250-600 mg/dL, arterial pH lower
than 7.3, normal to slightly lower serum bicarbonate levels, small urine and serum
ketones, serum osmolality higher than 320 mOsm/kg;
 Treatment consists of rehydrating slowly and treating underlying medical
conditions;
 Insulin may/may not be required;
 And HHS has a higher mortality rate than DKA.
(Nelms et al, 2016, pp. 506)
5. HHS is often associated with dehydration. After reading Mitch’s chart, list the data that
are consistent with dehydration. What factors in Mitch’s history may have contributed to
his dehydration?
Data that are consistent with dehydration are as follows:
 Elevated specific gravity and osmolality (National Institute of Health [NIH], n.d.)
 Diaphoretic skin (Wolfson, A., Hendley, G., & Ling, L., 2009, pp. 86)
 Decreased sodium
 Elevate BUN and creatinine
 Dry mucous membranes
 Rapid respiration
 Poor skin turgor
 Low blood pressure
 Elevated body temperature
 Rapid heartbeat
 Cloudy, amber urine
(Mayo Clinic, 2014)
His frequent vomiting, use of diuretics, and having only “sips of water” in the last 12-24
hours could have contributed to his dehydration.
(Mayo Clinic, 2014)

5. Hilary Peace
6. Assess Mitch’s intake/output record for the first 24 hours of his admission. What does
this tell you? Assuming that Mitch tells you that his usual weight is 228 lbs., can you
estimate the volume of his dehydration?
He took in 4,335 mL/kg of fluid and only put out 2,195 mL/kg, which makes his net I/O
2,140. This would suggest he was very dehydrated as input and output are normally
equal.
 228#s-214#s = 14#s
 (14#/228#) *100% = 6.1% weight loss
 (228#s)(2.2kg/1#) = 103.64 kg
 6.1% * 103.64 kg = 6.32 kg or 6.32L is volume of his dehydration
7. Mitch was started on normal saline with potassium as well as an insulin drip. Why are
these fluids a component of his rehydration and correction of the HHS?
The saline with potassium is used to rehydrate the patient rapidly and normalize
electrolytes. Insulin is used to decrease serum glucose and lessen the hyperglycemia,
which will assist in inhibiting further dehydration.
(McNaughten, C., Wesley, S., Slovis, C., 2011)
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?
The insulin therapy that was started for Mitch was to begin Lispro .5 u every 2 hours until
glucose is between 150 and 200 mg/dL, progressing to an insulin-to-carbohydrate ratio
(ICR) to 1:15. At 9 p.m. that night he was to begin glargine at 19 u. Glucose is to be
checked hourly and MD should be notified if glucose is above 200 or below 80.
Lispro is a combo of a fast-and intermediate-acting type of insulin that is used to control
blood glucose. Glargine is a long-acting type of insulin that works over the course of
about 24 hours to help control blood glucose (NCBI, 2016, October).
It is likely insulin therapy will be needed as he has shown to be non-compliant in regard
to taking his medication and has not complied with the dietary recommendations his
physician gave him.
9. Mitch was NPO when admitted to the hospital. What does this mean? What are the
signs that will alert the RD and physician that Mitch may be ready to eat?
NPO means nothing per mouth. Once the vomiting ceases and electrolytes and osmolality
normalize, Mitch could progress to a clear liquid diet.
10. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his
DM.

6. Hilary Peace
 Build his nutrition-related knowledge and continue nutrition education on
carbohydrate timing and which carbohydrates are ideal for his condition;
 Achieve and maintain 5-10% weight loss;
 Determine macronutrient distribution after individually assessing Mitch and his
preferences and needs;
 Encourage at least 150 minutes of physical activity per week.
(Nelms et al, 2016, pp. 495-504)
11. Assess Mitch’s weight and BMI. What would be a healthy weight range for Mitch?
 5’9” = (69 inches)2 = 4,761
 (214/4,761)*703 = 31.6 (obese)
 An initial, reasonable goal of 10% weight loss would put him at 200#s.
12. Identify and discuss any abnormal laboratory values measured upon his admission.
How did they change after hydration and initial treatment of his HHS?
 Low sodium (132 on 4/12, 135 on 4/13 – still low but improved on 4/13)
 Low phosphate (1.8 on 4/12, 2.1 on 4/13 – still low but improved on 4/13)
 Low anion gap (6.0 on 4/12 and 11.0 on 4/13 – in reference range on 4/13)
 Elevated BUN (31 on 4/12 and 20 on 4/13 – in reference range on 4/13)
 Elevated creatinine (1.9 on 4/12 and 1.3 on 4/13 – in reference range on 4/13)
 Elevated glucose (855 on 4/12 and 475 on 4/13 – still elevated but improved on
4/13)
 Elevated osmolality (322.6 on 4/12 and 303.5 on 4/13 – still elevated on 4/13 but
improved)
 Low glomerular filtration rate (39 on 4/12 and 62 on 4/13 – normal on 4/13)
 There were abnormal findings with his lipid panel but those were not re-evaluated
on 4/13.
13. Determine Mitch’s energy and protein requirements for weight maintenance. What
energy and protein intakes would you recommend to assist with weight loss?
Energy
 RMR = 10(W) + 6.25 (H) – 5(A) + 5
 228/2.2 = 104 kg, 69 inches * 2.54 =175.3 cm
 10 (104) + 6.25 (175.3) - 5(53) + 5
 973 + 1,095.6 – 265 + 5 = 1,876 * AF 1.2 = 2,251 kcal
 Mitch would more than likely have better compliancy and success at losing 1# per
week, which puts his daily calorie goal at 2,251 – 500 = 1,751 kcal/day.

7. Hilary Peace
Protein
 Since protein intake for pts with T2DM does not appear to increase glucose
concentration, the American Diabetes Association [ADA] recommends 15-20%
of caloric intake to go to PRO.
 1,751 * .15 = 263 kcal/ 4 g/PRO/kcal = 66 g PRO
 1,751 * .20 = 350 kcal/ 4 g/PRO/kcal = 88 g PRO
 66 – 88 g PRO/day
14. Prioritize two nutrition problems and complete the PES statement for each.
 Altered nutrition-related lab values related to severe dehydration and HHS as
evidenced by glucose >200 mg/dL (855 mg/dL) and osmolality of 322.6 mOsm..
 Food- and nutrition-related knowledge deficit related to lack of prior diabetes
management education as evidenced by patient verbalizing incomplete
information.
15. Determine Mitch’s initial CHO prescription using his diet history as well as your
assessment of his energy requirements.
Using ICR of 15 g carbs to 1 unit of insulin, 238 g carbs / 15g = 16 carb choices for the
day.
 Using his diet history as a reference, Mitch should aim to eat consistent amounts
of carbohydrates throughout the day.
 4-5 carbs for breakfast: 1 bagel, or small bagel with cream cheese (light), coffee
w/ half-and-half (free)
 1-2 carbs for a snack: piece of fruit, small- to medium-sized banana or apple
 5-6 carbs for lunch: 12" subway sandwich, turkey with veggies, light on sauce if
any (no chips)
 5-6 carbs for dinner: 1 cup of rice, salad, grilled chicken, and 8 oz of fruit juice
16. Identify two initial nutrition goals to assist with weight-loss.
1. Restrict calories by 500 kcal a day or eat close to 1900 kcal each day.
 Limit foods high in trans fatty acids (education necessary on which foods these
are).
2. Aim to incorporate at least 150 minutes of moderate physical activity each week.
17. Mitch also has hypertension and high cholesterol levels. Describe how your nutrition
interventions for diabetes can include nutrition therapy for his other conditions.

8. Hilary Peace
 The HTN and high cholesterol will be improved as well by selecting nutrient-
dense foods with vitamins, minerals and fiber over highly processed foods with
sodium, added sugar and fats.
 By cooking at home, he can control the amount of sodium, sugar and fat is added
to his meal, improving all three conditions.
 Educating Mitch on how to manage diabetes would assist as well because he
would know what foods to limit, which would improve his HTN and
hypercholesterolemia.
 Losing 5-10% weight through diet modifications and physical activity would also
improve all three conditions as evidence shows weight loss improves HTN
(NCBI, 2014) and hypercholesterolemia (American Heart Association [AHA],
2015).
18. Write an ADIME note for your initial nutrition assessment.
Assessment:
 53 y/o Caucasian male dx with T2DM uncontrolled with HHS, HTN,
hyperlipidemia, gout
 Height: 5’9”, wt: 214#s, BMI: 31.6
 Primary language: English
 Vomiting for approximately 12-24 hours
 RMR: 2,170, EPR: 63-84 g
 Medications: glyburide, dyazide, Lipitor, metformin
 Poor skin turgor, rapid respirations, abdominal tenderness, dry mucous
membranes, elevated body temperature, cloudy, amber urine, diaphoretic skin
temperature
 Abnormal sodium (132 mEq/L), phosphate (1.8 mg/dL), BUN, creatinine, GFR,
glucose (855 mg/dL), anion gap, osmolality (322.6 mOsm), cholesterol, VLDL,
triglycerides, A1C (11.5%), WBC, C-peptide (1.10), specific gravity, and
urinalysis indicating elevated protein, glucose and ketones
Diagnosis:
 Altered nutrition-related lab values related to severe dehydration and HHS as
evidenced by glucose >200 mg/dL (855 mg/dL) and osmolality of 322.6 mOsm..
 Food- and nutrition-related knowledge deficit related to lack of prior diabetes
management education as evidenced by patient verbalizing incomplete
information.
Intervention:
 T2DM management education (carbohydrate-controlled diet, exchange method,
carbohydrate counting and distribution).
 Lose 5-10% of weight.

9. Hilary Peace
 Begin exercising 150 minutes per week.
 Counseling on checking glucose levels before and after exercise to determine
carbohydrate need.
 Counseling on importance of taking medication consistently and how to check
glucose levels daily.
 Counseling on importance of hydration and encourage 2000-2500 mL of fluid
daily.
Monitoring/Evaluating:
 Monitor A1C every 3 months to check compliancy to changes in lifestyle.
 Monitor electrolyte levels and weight changes every other month.

10. Hilary Peace
Reference List
American Diabetes Association (n.d). Nutrition Principles and Recommendations in
Diabetes. Retrieved October 20, 2016 from
http://care.diabetesjournals.org/content/27/suppl_1/s36
American Heart Association. (2015). Hyperlipidemia. Retrieved October 20, 2016
from
http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholester
ol/Hyperlipidemia_UCM_434965_Article.jsp#.WAphASMrIU0
Mayo Clinic (2014). Dehydration symptoms and causes. Retrieved October 18, 2016
from http://www.mayoclinic.org/diseases-
conditions/dehydration/basics/symptoms/con-20030056
Mcnaughton, C. D., Self, W. H., & Slovis, C. (2011). Diabetes in the Emergency
Department: Acute Care of Diabetes Patients. Clinical Diabetes, 29(2), 51-59.
doi:10.2337/diaclin.29.2.51
National Center for Biotechnology Information. (2014, August). Can losing weight lower
high blood pressure? Retrieved October 20, 2016 from
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072415/
National Center for Biotechnology Information. (2016, October 1) Glyburide. Retrieved
October 18, 2016 from
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0010485/?report=details#side
_effects
National Institute of Health. Urine specific gravity test: MedlinePlus Medical
Encyclopedia. (n.d.). Retrieved October 20, 2016, from
https://medlineplus.gov/ency/article/003587.htm
Nelms, M., Sucher, K. P., Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition therapy & pathophysiology. Belmont, CA: Cengage Learning.
The Metabolomics Innovation Centre (TMIC): Drug Bank. Accessed October 18, 2016
from http://www.drugbank.ca/
Wolfson, A., Hendley, G., & Ling, L. (2009, September 23). Section III: High-Risk Chief
Complaints. In Harwood-Nuss' clinical practice of emergency medicine. 5th ed.
(pg. 86) Lippincott Williams & Wilkins.