Emily Greco, BS DIE 3246 - Nutrition Therapy II Zhiping Yu, PhD RDN January 20, 2014

CASE STUDY #1: TYPE 2 DIABETES IN AN ELDERLY MAN

The client is a 73-year old man diagnosed one year ago with Type 2 Diabetes mellitus. He has a history of coronary heart disease s/p angioplasty 5 years prior, hypertension, retinopathy, and left foot neuropathy. He makes every attempt to follow a healthy diet, and has been avoiding table sugar for the past year on his physicians advice. He comes to see the RD d/t a persistently elevated hemoglobin A1c. Height: 62 Weight: 220 lbs Weighed 240 lbs 5 years, and lost 30 pounds after his angioplasty by adopting a lower fat diet. He has since regained 10 lbs. Glucose: 223 mg/dL Hemoglobin A1C: 7.8% Total cholesterol: 160 mg/dL LDL cholesterol: 97 mg/dL HDL cholesterol: 55 mg /dL Triglycerides: 87 mg/dL Blood pressure: 130/80 mm Hg Family Hx: Paternal history is positive for heart disease and type 2 diabetes. He lives with his wife who does most of the cooking and shopping. He does not smoke and drinks alcohol socially. He gets little physical activity. Medications: Lipitor, Prevacid, ACTOplus met, and Januvia; no supplements. Food/Nutrition-Related Hx: Breakfast: 2 oz raisin bran, 1 c non fat milk, 1 c cranberry juice, 2 slices rye toast w/ 2 tbs fruit spread, Coffee w/ 2 tbs fat-free hazelnut creamer. Lunch: Turkey club sandwich: 3 oz turkey, 1 tbs reduced fat mayo, lettuce, tomato, sliced avocado, 2 slices turkey bacon, 2 slices white bread toasted. 1 piece of fresh fruit, tea w/ 1 tbs honey. Snack: 2 fat-free fig cookies, c apple cider Dinner: 6 oz fish or chicken baked or broiled, c cooked white rice or potato, c cooked vegetable (carrots or green beans), 1 oz roll w/ 1 tbs stanol-ester enriched margarine, green salad w/ 2 tbs olive oil and 1 tbs vinegar, plain seltzer water, 12 oz. Snack: 6 oz nonfat vanilla yogurt, c mixed nuts.

(WNL) (WNL) (WNL) (WNL)

1. What is his IBW, % IBW, and BMI? Estimate caloric requirements to promote an optimal weight. IBW: Hamwi equation: 106 lbs for the first five feet, +6 lbs for every inch over +/- 10% (106 lbs * 5) + (6 * 14) = 190 lbs %IBW: (Current weight / IBW) x 100 (220/190) x 100 = 116% BMI: Weight (kg) / (height m)2 (220 lbs/2.2) = 100 kg (74 in * 2.54) = 187.96 cm = 1.8796 m (100 kg) / (1.8796)2 = 28.31 kg/m2 Caloric requirements: Mifflin St. Jeor Equation: (9.99 x weight kg) + (6.25 x height cm) (4.92 x age) + 5 (9.99 x 100 kg) + (6.25 x 187.96) (4.92 x 73) + 5 999 + 1174.75 359.16 + 5 = 1820 kcal x 1.2 PAL = 2185 kcal *All references from this section came from reference #1. Did not use exponent citations because of math equations.* 2. Suggest an appropriate diet for him. What percent of his diet should come from carbohydrate? How many grams of carbohydrate should he have in a day? How should the carbohydrate be spread out over the day? An appropriate diet for him would be approximately 2100-2200 kcal per day. About 50% of his diet should come from carbohydrates (approximately 1100 kcal), 20% from protein (approximately 440 kcal), and 30% from fat (approximately 650 kcal).6 This means he should have approximately 275 g carbohydrates, 110 g protein, and 73 g of fat per day. His carbohydrate intake should remain even and consistent throughout the day: 4-5 CHO servings for breakfast, lunch, and dinner, and 1-2 CHO servings per snack (PM and HS).6,10 3. How does his current intake compare to his needs? Analyze his current intake and show your work. Approximately how many grams of carbohydrate is he currently consuming at 2

each meal and snack? How do you think his low-fat diet has influenced his carbohydrate intake? Software:9

Exchange List System:6,8 Food Group Starch Fruit Milk Veg Meat Fats CHO Choices 6 4 2 3 4 B 2.5 2.4 1 2 6 3 2 2 1 L 2 1 S 3 1 1 D 2 S Total Svg/day 9.5 4.4 2 2 10 7 16 X4 = 970 kcal X4 = 474 kcal X9 = 868.5 3 CHO (g) 142.5 66 24 10 16 4 70 50 35 2 Pro (g) 28.5 Fat (g) 9.5

kcal %cal = 42% Total Calories: 2,312.5 The two systems (software and exchange lists) came up with two very different calorie counts (2856 vs. 2312). I believe the reason behind this is it is not possible to find exact matches to the foods listed by the client in the software so it seemed to overestimate the number of calories. His needs are approximately 2,200 kcal so he is going over this number by a bit. He is consuming approximately 6 CHO (90 g) at breakfast, 3 CHO (45 g) at lunch, 4 CHO (60 g) for a snack, 2 CHO (30 g) at dinner, and 1 CHO (15 g) for his evening snack. While he may be paying attention to eating low-fat or fat free foods, he has not paid much attention to the carbohydrate spacing or carbohydrate exchanges per meal. Low fat and fat free foods do not necessarily make them low in sugar or carbs. He mentioned that he has avoided consuming table sugar for the past year, but he has continued to eat sugar-rich foods rather than foods with artificial sweeteners for replacements. For example, the fat-free fig cookies he eats contain 23 g of carbs per cookie this means for his midday snack he is consuming 3 CHO rather than the recommended 1-2 CHO (he also drinks sugar-rich apple cider counting for 1 CHO, making a total of 4 CHO for his midday snack).6,10 Men should consume between four or five carbohydrate servings per meal and one to two servings per snack.6 He is consuming a very unsteady amount of carbs throughout the day; he starts out high and progressively decreases the amount of CHO per meal. Consistency in the amount of carbohydrates eaten per meal and snacks is reported to improve glycemic control, especially in people on medical nutrition therapy alone, glucose lowering medications, or fixed insulin regimens.6 His unsteady spacing could be contributing to his high A1C level readings. 4. How do hemoglobin A1C levels correlate with blood sugar (mean plasma glucose) levels? Calculate his estimated average glucose based on his hemoglobin A1c levels. What factor(s) in his diet might be leading to his inability to further reduce his hemoglobin A1c, and what can you do to help him? Hemoglobin A1C levels correlate with blood glucose levels by showing the percent of hemoglobin that is glycated (glucose bound to hemoglobin protein via addition of glucose molecules to amino acid side-chains).3,7 This measures chronic glycemia because red blood cells have a lifespan of 120 days therefore the test measures long term glycemia by showing the average glucose concentration for the previous two to three months.3 Short term control would not affect the number, making this a great measure for the long term effects of diabetes.3 Mean Blood Glucose (MBG) mg/dl = (HbA1c% x 33.3) 86 (7.8% x 33.3) 86 = 174 mg/dl
11

%cal = %cal = 20% 38%

His inconsistency with carbohydrates at each meal is contributing to his high hemoglobin A1c value because his blood glucose levels are so variable throughout the day.3,6 I could help him create a meal 4

plan that would evenly space out his carbohydrates per meal (4-5 CHO per meal and 1-2 CHO per snack).6,10 He would need to self monitor his blood glucose levels throughout the day and keep a log to make sure that the meal plan is working for him, as diabetes is a very individualized disease.3,6 We would check his A1c value again in three months. 5. Explain the pathophysiology of type 2 diabetes. What risk factors does this client have for developing this condition? People with Type 2 Diabetes produce insulin; however their tissues have become insulin resistant. This increases insulin demand thus the pancreas increases production. The pancreas eventually loses its ability to produce insulin from being so overworked. Insulin resistance results from a cellreceptor defect which in turn causes the body to become unable to use insulin. If the cells cannot respond to insulin by translocating glucose transporters to their outer membrane, then the body cannot use glucose for fuel. Insulin also inhibits glycogenolysis and gluconeogenesis when blood glucose is high, but when insulin is not being responded to, the liver produces excess glucose that the body cannot handle resulting in hyperglycemia.3 This clients risk factors for T2DM are his older age, being overweight, family history of T2DM, and physical inactivity.3 6. What are the complications of type 2 diabetes? Which complications is he already experiencing? How can the dietitian assist in the management of type 2 diabetes and its associated problems? Complications of type 2 diabetes include cardiovascular disease, nephropathy, retinopathy, and nervous system diseases.3 He is already experiencing retinopathy and left foot neuropathy. The dietitian can help assist in the management of type 2 diabetes and its problems by using motivational interviewing, helping create diet plans with adequate amounts of carbohydrates, protein, fat, and fiber (using exchange system, carbohydrate counting, and glycemic control), encouraging physical activity and self-monitoring behaviors, educating the patient about normal range glucose levels, lipid and lipoprotein levels, and blood pressure.3,4 7. Make a chart of common classes of oral medications for type 2 diabetes and how they are intended to work. Which ones is this client taking? DPP-4 Inhibitors prevent the breakdown of a naturally occurring compound in the body called GLP-1 (reduces blood glucose levels in the body). By preventing the breakdown of GLP-1, this class of drugs allows it to remain active in the body for a longer period of time, which helps to lower blood glucose levels only when they are elevated.5 Thiazolidinediones help insulin to work more efficiently in the muscle and fat and reduce glucose production in the liver; effective in reducing A1C.5 Sulfonylureas stimulate pancreas beta cells to release more insulin.5 Biguanides mainly lower blood glucose levels by decreasing the amount of glucose produced by the liver; also helps to lower blood glucose levels by making muscle tissue more sensitive to insulin so that glucose is able to be absorbed.5 Meglitinides stimulate pancreas beta cells to release insulin.5 SGLT2 Inhibitors Sodium-glucose transporter 2 (SGLT2) reabsorbs glucose in the kidneys; these inhibitors block this action and cause excess glucose to be excreted in urine.5 Alpha-glucosidase inhibitors help lower blood glucose levels by blocking the breakdown of starches and also slow the breakdown of certain sugars such as sucrose. This slows the elevation of blood glucose after meals.5 5

Bile Acid Sequestrants cholesterol-lowering medication that also reduces blood glucose levels.5

The client is taking ACTOplus met, a thiazolidinedione, and Januvia, a DPP-4 Inhibitor. 8. Identify an appropriate nutrition diagnosis and write a PES statement based on the available nutritional assessment data. Inconsistent carbohydrate intake related to food- and nutrition-related knowledge deficit concerning appropriate timing of carbohydrate intake as evidenced by high blood glucose levels, high HbA1c%, retinopathy, and left foot neuropathy.12 9. What are your goals for this client? How will you help him to achieve those goals, and what outcome measure(s) will you monitor to see that your intervention is working? It may be beneficial for this client to lose some weight, but since he is 73 years old his BMI of 28 is not startling. According to Gulistan et al., the optimal range of BMI for American elderly people is suggested as 2429 kg/m2 by the 1989 report of the American Committee on Diet and Health. However, in regard of these findings the upper cut-off level of BMI for elderly functional independency may be put forward as 30 kg/m2, if not higher.2 I would definitely not want to see any weight gain because of his diabetes, but he does not need to lose a substantial amount of weight due to his age. I would definitely suggest that this client be more physically active, so if this caused some weight loss that would be okay as long as it wasnt more than 5-10 lbs. Physical activity helps people with diabetes improve insulin sensitivity, reduce cardiovascular risk factors, control weight, and improve well being.6 Structured exercise regimens of at least eight weeks have been shown to lower A1C values as well.6 He needs to be made aware of the risk for hypo or hyperglycemia during exercise and monitor his blood glucose levels until he gets a feel of how exercise will affect him.3 I would like to see this client monitor his blood glucose levels throughout the day before and after eating so that we can monitor whether the specific meal plan with consistent carbohydrate intake (4-5 CHO per meal, 1-2 CHO per snack) is working for him. We will discuss a meal plan that includes adequate spacing of carbs and what foods would be good to eat (ex: yogurt made with artificial sweetener vs. sucrose, cutting down on fruit juice, eating whole grains, sugar free cookies vs. fat free cookies, artificial sweeteners vs. honey). If he becomes very ill or very stressed out, we should test his urine for ketones because glucose levels are likely to be very high.3We will also monitor his blood pressure since he has hypertension. Blood pressure should be measured at every diabetes visit.6 Lowering his intake of sodium would also be beneficial <2300 mg/day is appropriate for people with diabetes, but since he is already hypertensive, an even lower amount could have additional benefits.13 We will also continually monitor his blood lipid and lipoprotein profile, even though it was WNL, because it reduces the risk for macrovascular disease.3 Consuming adequate fiber (14 g/1000kcal) is also something we will discuss because it is important for people with diabetes.13 The American Diabetes Association recommends lifestyle modifications based on reduction of saturated fat, trans fat, and cholesterol intake; increase of omega-3 fatty acids, viscous fiber and plant stanols/sterols; weight loss; and increased physical activity.13 The main takeaway from our session would be that monitoring hyperglycemia is of utmost importance at this point. Since his A1C has been higher than what we want to see, and he is 6

experiencing detrimental long-term side effects (neuropathy and retinopathy), we will monitor his A1C level quarterly.3 His goal should be <7% A1C level.1 10. Write a note that documents your interaction with the patient using the SOAP or ADIME format. S (Subjective): Meal/snack pattern: Client eats three meals per day plus two snacks. Client says hes been avoiding table sugar for the past year on his physicians advice. Food intake: Includes many fat free or reduced fat foods, high in sugar foods and drinks. Alcohol intake: Limited to social occasions. Beliefs and Attitudes: Client comes to see me today for persistently elevated hemoglobin A1c; client seems ready to make changes. Weight change: Client states he lost 30# after his angioplasty 5 years ago by adopting a lower fat diet; he has since regained 10#. Physical activity history: He gets little physical activity. Personal history: 73 yr old, male, family hx includes type 2 diabetes and heart disease (paternal). He has a personal hx of coronary heart disease s/p angioplasty (5 years ago), hypertension, retinopathy, and left foot neuropathy. O (Objective): Ht. 62 Current weight 220#; BMI 28.3 Glucose: 223 mg/dL Hemoglobin A1C: 7.8% Total cholesterol: 160 mg/dL LDL cholesterol: 97 mg/dL HDL cholesterol: 55 mg /dL Triglycerides: 87 mg/dL A (Assessment): Energy intake: Intake of approximately 2300-2500 calories/d. Readiness to change: 7

Ready to change; client has been able to stick to a low fat diet for five years; wants to learn how to prevent further diabetic complications. Estimated energy needs: Calorie intake is approximately 200 kcal/day more than estimated needs of 2,200 kcal. Mifflin-St Jeor Equation with activity factor of 1.2. Nutrition Diagnosis: Inconsistent carbohydrate intake related to food- and nutrition-related knowledge deficit concerning appropriate timing of carbohydrate intake as evidenced by high blood glucose level, high HbA1c, retinopathy, and left foot neuropathy.12 P (Plan) Nutrition prescription: 2200 kcal, 73g Fat (30% energy), 110 g PRO (20% energy), 30 g dietary fiber, 275 g CHO (50% energy), 1500 mg Na. Conducted Motivational interviewing:4 Client desires to learn about exchange system and carbohydrate spacing. His wife does the cooking and shopping so he would like her to learn the information as well. Goals: Increase physical activity to 3 days per week, learn exchange system and how to space out carbohydrates during the day (form meal plan 4-5 CHO per meal, 1-2 CHO per snack), increase food related knowledge (artificial sweeteners, sugar free foods, whole grains, fiber, sodium), lower sodium intake, increase fiber intake, self-monitor blood glucose levels up to 8 times per day and keep records, see lower hemoglobin A1c level when checked in three months. 3,6,13

References 1. Emery EZ. In: Goldberg S, Bloom AL, Sekerak R, eds. Clinical Case Studies for the Nutrition Care Process. Burlington, MA: Jones & Bartlett Learning; 2012. 2. Gulistan B, Fatih T, Mehmet Akif K, et al. Which body mass index (BMI) is better in the elderly for functional status? Archives Of Gerontology And Geriatrics. 2011;54:78-81. 3. Nelms MN, Sucher K, Lacey K, et al. In: Cossio Y, Williams P, Feldman E, et al. Nutrition Therapy and Pathophysiology Second Edition. Belmont CA: Wadsworth Cengage Learning; 2011. 4. Chen, SM, Creedy, D, Lin, H-S, & Wollin, J. (2011). Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: A randomized controlled trial. International Journal Of Nursing Studies. 49(2012): 637-644. 5. What Are My Options? American Diabetes Association (ADA) Website. http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/oralmedications/what-are-my-options.html. Accessed January 19, 2014. 6. Mahan LK, Escott-Stump S, Raymond JL. In: Alexopoulos Y, Frazier DM, eds. Krauses Food and the Nutrition Care Process Thirteenth Edition. St. Louis, MO: Elsevier Saunders; 2012. 7. Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine R. Translating the A1c assay into estimated average glucose values. Diabetes Care. 2008; 31(1):1-6. 8. The Exchange List System for Diabetic Meal Planning. University of Arkansas Division of Agriculture Cooperative Extension Service Website. http://www.uaex.edu/Other_Areas/publications/PDF/FSHED-86.pdf. Accessed January 20, 2014. 9. Eatracker.ca Web Site. www.eatracker.ca. Accessed January 20, 2014. 10. Ready, Set, Start Counting! Diabetes Care and Education Dietetic Practice Group. http://www.wheatoniowa.org/webres/File/Diabetes%20Education/ADA_Carbohydrate% 20counting_WFH.pdf. Accessed January 20, 2014. 11. Nathan Formula to Calculate the Average Blood Glucose Level Ehow website. http://www.ehow.com/way_5600975_nathan-average-blood-glucose-level.html. Accessed January 20, 2014. 12. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutriton Care Process, 4th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013. 13. Standards of Medical Care in Diabetes--2014. Diabetes Care. January 2, 2014;37(S1):S14S40. Accessed January 20, 2014.