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No hx of N/V, or diarrhea
No hx of urgency, frequency, or burning urination except for present complaint
of polyuria
Alert and oriented, no hx of impaired LOC, convulsions, or difficulty walking
Slightly underweight, tired appearing male; wt: 145# ht: 71
T 98.2F; P 120; R 27 with fruity odor; BP 110/70 mm Hg
Clear to percussion and auscultation
Normal sinus rhythm, no murmurs
Non-contributory
Flat, non-tender, no liver enlargement
Nl
Non-contributory
Normal gait and deep tendon reflexes
Smooth, warm, dry, no edema
Pulse +4 bilaterally
Ref. Range
12/02/15 1950
136-145
3.5-5.5
95/105
23-30
8-18
0.6-1.2
70-110
2.3-4.7
1.8-3
9-11
285-295
1.5
130 !
3.6
101
31 !
18
1.1
382 !
2.1 !
1.9
10
306 !
0.2
1
<0.3
6-8
3.5-5
16-35
9-33
30-120
4-36
0-35
30-135 F; 55-170 M
208-378
120-199
35-135 F; 40-160 M
4-12
75-98
3.9-5.2
0.51-2.72
-
0.01
6.9
3.2
15
9
110
6.2
21
61
229
180
150
8
81
8.12 !
0.52
+ !
+ !
+ !
-
4.8-11.8
4.2-5.4 F; 4.5-6.2 M
10.6
5.8
1.003-1.030
5-7
Neg
Neg
Neg
Neg
Neg
Neg
<1.1
Neg
Neg
0-5
0-5
0
0
0
0
0
Clean catch
Yellow
Clear
1.008
4.9 !
+1 !
+4 !
+4 !
Neg
Neg
Neg
Neg
Neg
tr !
0
0
0
0
0
0
0
1. What are three metabolic reasons for D.K.s weight loss (number each for full credit). (3 points)
1. Lack of insulin function, as evidenced by ICA, GADA, IAA and resultant high blood sugar levels,
leads to subsequent loss of glucose absorption.
2. The degradation of muscle and fat stores to supply energy for the body.
3. Due to high amounts of sugar in blood and plasma increasing osmolality Water and mineral loss from
excessive urination and loss of water loss at the cellular and interstitial fluid level increases.
Source
NTP; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
www.mayoclinicallaborotories.com/test-catalog/clinical+and+interpertive/82080
2. Compare D.K.s admission laboratory values with normal values. What does each value indicate,
based on the hospitals lab value reference ranges above?
Test
Nl Values
D.Ks Values
Comparison
What do D.K.s lab values
(+/-)
suggest about his metabolic
state?
BG mg/dl
70-100 mg/dl
382 mg/dl
+
Insulin
deficiency
and
hyperglycemia
Urinary
Negative
+4
+
High circulating blood glucose
glucose
leading to excess sugar filtration
from body. ADH released RAS
(renin-angiotensinsystem)
activated.
Urinary
Negative
+4
+
Lipolysis, abnormal fatty acid
ketones
metabolism body using ketones
for energy; ketosis; ketoacidosis
Alb g/dl
3.5-5 g/dl
3.2 g/dl
Low protein intake, or loss from
catabolism for metabolic use.
Pre-Alb. mg/dl 16-32 mg/dl
15 mg/dl
Marker of nutritional status and
low protein intake.
3.9-5.2 %
8.12%
+
High amount of sugar in the
HbA1c
blood binding to Hb. Cell signal
disruption, gene expression,
inflammation and metabolic
change
Source- Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
>7
Source- Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
You meet with D.K. to do a nutrition assessment and begin a general introduction to dietary management
of diabetes. You take a diet history (listed below) as part of your assessment. D.K. states that these are
the types of foods that he usually eats, but the quantity is much greater than usual because he has felt so
hungry lately.
Breakfast (eaten at home):
1 c. oatmeal with brown sugar and cup of 2% milk
1 c. juice (orange, apple, or cranberry)
Toast (2 slices or English muffin) w/ butter & jelly
Coffee with sugar and 2% milk
(occasionally 2 scrambled eggs and 2 strips of bacon instead of the cereal)
Lunch (eaten at the CoHo on weekdays):
2 slices of pepperoni pizza with a small salad or
Cheeseburger and French fries or
Spinach Crepe
16 oz of sweetened iced tea
dessert such a cookies or a brownie
(sometimes 8 oz of 2% milk instead of the iced tea)
Mid afternoon:
medium mocha or latte,
A cookie or a piece of fruit
Dinner:
Spaghetti w/ meat sauce (about 2 c. cooked noodles)
2 pieces of garlic bread
Salad w/ fat free dressing
12 ounces of 2% milk
or
~6 oz. meat (chicken or beef, only occasionally fish)
1 cup of rice or large baked potato w/ butter
Vegetables in season (will eat w/ salt & butter but prefers cheese or bechamel sauce)
12 ounces of 2% milk
or
A deli sandwich and chips and soda if he does not have time to cook
HS:
D.K. eats one of the following:
Bag of microwave popcorn w/ 1-12 oz can of regular soda
2 scoops of ice cream
1 c 2% milk and 4-5 cookies
2 oz. cheese and 12 Wheat Thin crackers
5
6. Based on the diet history information above and what you know about MNT management of Type 1
Diabetes Mellitus, name 3 nutrition-related topics that are important to discuss in educating D.K. as
he prepares to head home from the hospital.
1. Carbohydrate counting and insulin dosing
2. Basic nutrition knowledge around metabolism and physiologic use of macronutrient and micronutrient
needs for patient with DM
3. Decreasing saturated fatty acid intake and increasing intake PUFAs
Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
7. You determine that D.K. needs 2736.1 kcals/day based on your calculations and the fact that D.K.
needs to gain weight to achieve his normal weight. You want to follow his normal eating pattern as
much as possible while still meeting his protein requirements and keeping the kcal from fat at 30-40%
of total kcals. Using the Exchange Lists, develop a pattern for D.K.s diet.
EER= Based on MSJ with Activity of factor of 1.3 and Injury factor of 1.1- with IBW used since DK
underweight.
MSJ for men (10 * wt. [kg]) + (6.25 * Ht. [cm]) (5 * age) + 5
= (10 * 78.181818 18kg) + (6.25 * 180.34 cm) - (5 * 22 yrs.) + 5= 1803.941182 * 1.5 (activity factor)
= 2705.911773; (1803.941182 * 1.1)* 1.4 (1.4 average activity factor cause patient is young and
physically active and injury factor for protein and fat loss from catabolic state)=
2778.006942=2778.01 or 2778.0 kcal actual kcal based on diet pattern
MNT Pocket Guide
Column1
Column2
Column
4
Protein
grams
Column
5
Fat
grams
Column6
Number of
Exchanges
Column
3
CHO
grams
Food group
Breakfast
Starch
2- Starch
30 g
6g
2g
Fruit-
1-fruit
15 g
0g
0g
1svg.- 2%
12 g
8g
5g
2 medium fat
0g
21 g
12 g
Turkey sausage
Fats
1 non saturated
0g
0g
5g
pumpkin seeds
Fat unsaturated
0g
0g
510g
brazil nuts
1
1 fruit
5g
15 g
2g
0g
0g
0g
1/2 muffin
30 g
0g
6.25 g
bran blueberry
Lunch
Starch
30 g
6g
2g
Sample food
Morning Snack
(write in Food Group below)
Fruit
15 g
0g
0g
Kiwi
10 g
4g
0g
green beans
2 medium fat
0g
14 g
10 g
Fat
2 unsaturated
fats
0g
0g
10 g
olive oil
Fats
0g
0g
15 g
Avocado
free food
Protein (circle lean, med- or
high-fat)
Dinner
Starch
1
2 medium fat
protein
0g
0g
0g
14 g
0g
10 g
salad greens
Chicken thigh
30 g
6g
2g
1 cup yogurt
2 CHO2 fat
30 g
1g
10 g
grits, buckwheat,
whole grain etc.
Yogurt
10 g
4g
0g
spinach or DGLV
14 g
4g
Fish
Afternoon Snack
(write in Food Group below)
2 lean
Olive oil
~5.5 milk
substitute CHO
and ~4 fat
50 g
40 g
25.5 g
~282g
~140g
~125g
X4
1128
kcal
X4
560 kcal
X9
1125
kcal
Whole fruit
smoothie with
almond coconut
blend
Total grams
kcal from each macronutrient
TOTAL KCAL
2813.0 kcal
40%
20%
40%
Choose Your Foods Booklet- American Diabetes association
8. D.K. is taught about his diet, insulin injections, SBGM, and other self-care issues prior to discharge.
He will be discharged on a basal injection of Lantus, with bolus injections of Humalog insulin at
mealtimes. Provide the information below. Also note any dietary recommendations,
contraindications/precautions, and interactions. What effect will these medications have on his
nutritional care? Refer to the medication information in the Food-Medication Interactions text. (3
points)
Lantus
Generic name:
Insulin glargine
Classification:
Onset of Action:
1.1 Hour
Peak:
No peak
Duration:
9. Humalog
Generic name:
Insulin lispro
Classification:
Onset of Action:
5-30 min
Peak:
0.5-2.5 hours
Duration:
3-6.5 hours
Indication:
Diet:
Potential
Nutrition/Oral/GI Side
Effects:
11. Write an ADIME note for D.K., using the information that you have obtained up until this point. Base
your note on the pertinent information given in the presentation data, diet history, and questions
above. Write the ADIME note below and attach a separate sheet with all calculations. Include two
PES statements.
A:
22 y/o male admitted through the ED with excessive thirst and frequent urination. 2 week duration.
Increased appetite and weight loss of 9 pounds in 3 weeks. MDx- Recent onset Type 1 diabetes mellitus
Family history both parents L&W, history of Type 1 DM in maternal aunt, paternal grandfather passes
from CVD secondary to type 2 DM. Other grandparents L&W, siblings L&W
Social History- Undergraduate university student, plays ultimate Frisbee three times a week
Anthropometrics
Wt.: 145 lb./2.2 kg=65.9 kg H.t: 71 in x 0.254= 180.3 cm BMI=wt.[kg]/ht.[m]2=65.9/1.8032= 20.27 (low
normal) IBW= 106 lb. + 6 lb. for every lb. over 5ft.= 106lb. + 66lbs= 172 lb./2.2= 78.18 kg % IBW=
(ABW/IBW)*100= (145lb./172lb.) * 100 = 84% patient underweight based on % IBW and low range
BMI
UBW 154 lb. % UBW= UBW/CBW * 100% 145/154 * 100% = 94.15%
% WEIGHT CHANGE = 100- % UBW= 100 94.15= 5.85%in less three weeks is evidence of
nutritional risk.
Labs- Na-130and P-2.1 (levels low); Glucose-382 (levels high); HbA1C -8.12(high); 306 Osmolality
(high, cellular dehydration)
ICA, GADA, IAA (all present)- (related to Type 1 diabetes dx; insulin deficiency and nutrient absorption
lost);
Albumin and Pre-albumin levels within normal range
8
Glucose, Proteins and Ketones in urine (abnormal metabolism, ketosis, body in catabolic state);
Urinary pH (high) & CO2 (high) (body in acidic state may have altered metabolism of food or drugs)
Diet order- food logs and journal see below for full history.
Weight History- in past three weeks patient has lost 5.85% body weight.
Medications- Lantus; Humalog both for management of Diabetes Mellitus Type 1 with goal of tight
glucose regulation MNT
Estimated Nutrient Needs
EER= 2778.0 kcal actual kcal based on diet pattern
Based on MSJ with Activity of factor of 1.3 and Injury factor of 1.1- with IBW used since DK
underweight. MSJ for men (10 * wt. [kg]) + (6.25 * Ht. [cm]) (5 * age) + 5 = (10 * 78.181818
18kg) + (6.25 * 180.34 cm) - (5 * 22 yrs.) + 5= 1803.941182 * 1.1 (injury factor because patient is
underweight)= 1954.3353 * 1.4 (activity factor cause patient is young and physically active)=
2778.006942=2778.01 or 1.5 * 1803.941182= 2705.911773 2705.91[kcal]- 27778.01 [kacl]
Protein Needs=132.9[g/d]-140.7[g/d]
Physiologically/metabolically stressed factor 1.7 * 71.18181818 kg= 132.9 kg to 1.8 * 71.18181818 *
1.8= 140.72 so between
Fluid Needs average adult 2.35 [l] 2.74 [1]
30-35ml/kg= 30 * 78.1818181818= 2345.5454545/1000=2.345454545 35 * 78.18181818= 2736.363636
Food/Nutrition/Diet HistoryBreakfast (eaten at home):
1 c. oatmeal with brown sugar and cup of 2% milk
1 c. juice (orange, apple, or cranberry)
Toast (2 slices or English muffin) w/ butter & jelly
Coffee with sugar and 2% milk
(occasionally 2 scrambled eggs and 2 strips of bacon instead of the cereal)
Lunch (eaten at the CoHo on weekdays):
2 slices of pepperoni pizza with a small salad or Cheeseburger and French fries or Spinach Crepe
16 oz. of sweetened iced tea
dessert such a cookies or a brownie
(sometimes 8 oz. of 2% milk instead of the iced tea)
Mid afternoon:
medium mocha or latte,
A cookie or a piece of fruit
Dinner:
Spaghetti w/ meat sauce (about 2 c. cooked noodles); 2 pieces of garlic bread; Salad w/ fat free dressing
12 ounces of 2% milk or ~6 oz. meat (chicken or beef, only occasionally fish), 1 cup of rice or large
baked potato w/ butter; Vegetables in season (will eat w/ salt & butter but prefers cheese or bechamel
sauce); 12 ounces of 2% milk or A deli sandwich and chips and soda if he does not have time to cook
HS:
D.K. eats one of the following:
Bag of microwave popcorn w/ 1-12 oz. can of regular soda
2 scoops of ice cream
MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
wei
D:
Unintended weight loss (NC 3.2) /t Mx of DM1 related catabolic process aeb pt. reported weight loss and
% IBW and % UBW.TIDM
9
Impaired nutrient utilization (NC 2.1) r/t MX of T1DM aeb urinary glucose, ketones, and protein
I:
Overall MNT goal for DK is to attain and maintain optimal metabolic outcomes. Prevent chronic
Complications and improve health through healthful food choices and physical activity.
1. Patient education around need for general healthful diet (ND-1.1) and the nutrition relationship with
health/disease (B-1.4) and need to increase and maintain energy intake with desirable food choices.
2. Discuss incorporated a low carbohydrate type dietary pattern with focus on source of carbohydrate and
fat food groups and potion sizes (FH1.5.3.6, FH-1.5.3.7)
3. Discuss carbohydrate counting and insulin usage: dietary exchange 15g- 1 serving CHO- 1 unit of
insulin, the importance of an ideal CHO insulin ratios at meals, to decrease spikes or drops in blood
sugar.
4. Discuss possible lifestyle changes and need for social support and family involvement.
4. Discuss increasing consumption of F/V; PUFAs and plant sterols
5. Provided handouts related to the all items and label reading discussed for further reading; provided
composition pad for the following, blood sugar record, PA log & Food Journal
M/E:
Monitor blood sugar regularly via patient records, and glucometer
PO intake with food journal, PA with PA log
Monitor weight weekly and check urine and other lab values HgbA1C, BG, lipid panel in addition to pre
albumin
Scheduled return visit for <1 week weeks with reassurance that counsel and assistance is available
anytime of day.
Theodore Mitchell -TRM
B. Sci. Clinical Nutrition
12/8/15
MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
12. D.K. does well over the next few months in learning to manage his diabetes. However, he is finding
it difficult to keep his activity and intake constant due to the fact that his schedule is variable and he
wants to resume playing ultimate frisbee. He and the health care team agree to use an insulin pump
with intensive therapy in order to make his self-care more flexible and achieve tighter glucose
control. You begin teaching D.K. about carbohydrate counting.
a. Assume that his kcal needs have remained the same. How many CHO points or servings are in
his daily diet from question 7?
277.8 g CHO/15g CHO/CHO serving = 18.52 or 19 CHO servings
b. Describe briefly how this will differ from his exchange-based diet plan that he was using.
Is slightly less than current intake but the composition of that would be much different. Possibly
incorporating more whole grain high fiber and vegetable options. This will provide a different
carbohydrate and fat composition that will be more anti-inflammatory and friendly to the body.
13. D.K. brings his SBGM record in for review when he comes for nutrition counseling. The pre-prandial
BG goal is 80-120 mg/dl. Several pre-meal entries are listed below.
BG mg/dl
Day
Breakfast
Lunch
Dinner
HS Snack
1
94
145X
110
100
2
90
106
97
72X
3
158X
108
95
102
a. Circle the values that are outside the desirable range. bolded with X
b. What adjustment(s) should D.K. make if the values are above the desirable range?
Time of last meal before bed and the amount of insulin taken with that meal relative to need. The amount
of insulin taken with breakfast may be insufficient; and there may be a problem with CHO counting so
10
15. D.K. has caught a cold and has a fever of 101 F. He feels miserable and is not eating much. He
calls you to ask if he should reduce his insulin dose since his diet is just a few foods (chicken noodle
soup and low kcal Jello and diet 7-up). What advice would you give him and why?
Patient may have to increase insulin intake in order to ensure blood sugar level regularity, eat same
amount of food as normal may have to use meal replacement drinks. CHO and maintain protein intake. 5g
CHO every three hours, drink plenty of fluids and ensure electrolyte balance. Chicken soup Jello and 7 up
are okay choices but ensure protein intake with shake, meal replacement bar etc.
www.nim.nih.gov/medlineplus/ency/patientinstructions/000079.htm Diabetes When You are Sick
www.diabetesforecast.org Erika Gebel Ph. D Common cold remedies. Your guide to over the
counter medicine and diabetes care
www.diabetes.org American Diabetes Association When Youre Sick
NTP: MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
11