Samantha Jamieson

MNT 1 Diabetes/Obesity Case Study 1 2017

Objectives:
Use the Nutrition Care Process to make decisions, to identify nutrition-related problems and
determine and evaluate nutrition interventions, including medical nutrition therapy, disease
prevention and health promotion.
Demonstrate an understanding between food, nutrition and pharmacology.
Use current information technologies to locate and apply evidence-based guidelines and
protocols, such as the AND Evidence Analysis Library.

Mrs. M, a 69 y/o female from Burleson, TX, was admitted to the hospital due to weakness, confusion,
dehydration and hyperglycemia. Pt has a history of Type 2 DM (unmedicated & diet controlled per pt) &
hypercholesterolemia.

Medical Hx: Type 2 DM diagnosed 4 years ago, hypercholesterolemia diagnosed 9 years ago

Social Hx: Non-drinker, non-smoker, denies illicit drug use. Lives at home with her husband who is
disabled due to CVA 2 years ago. She has 2 daughters who live about 30 minutes away.

Symptoms: hyperglycemia, weakness, joint and muscle pain, anxiety, c/o headaches

Medications: lovastatin (Mevacor) 15 mg daily

Supplements: St. Johns wort for mild anxiety, Centrum Silver Multivitamin

Ht: 54; Wt: 178#

Labs:
Test Result Reference Test Result Reference Value
Value
Glucose 276 mg/dL 70-110 mg/dL Na 146 mEq/L 136-145 mEq/L
BUN 25 mg/dL 10-20 mg/dL K 5.2 mEq/L 3.5-5.0 mEq/L
Cr 1.8 mg/dL 0.6-1.2 mg/dL Cl 110 mEq/L 98-106 mEq/L
Ca 10 mg/dL 9.0-10.5 mg/dL HbA1C 8% 3.9-%-5.2%
(glycosylated
hemoglobin)
Serum Albumin 5.4 g/dL 3.5-5.0 g/dL

You received a consult to assess Mrs. M due to elevated blood glucose level. While visiting with pt, she
explains that normally she controls her blood glucose level with her diet. Reports checking BG once or
twice weekly, states her FBG runs around 140-160 mg/dL and when she checks her postprandial BG, 2-3
hours after a meal it is 175-190 mg/dL. Denies N/V/C. However, she states that she has frequent
diarrhea. Pt states that she is unable to get much exercise because she cares for her husband. However,
pt reports that she does have a stationary bike at her home that she has considered beginning to use.
She has had no formal nutrition education for her DM. She believes that her usual body weight last year
was about 172#. She states she does not want to gain any more wt and would like to start losing wt.
Mrs. M reports that she no longer has a PCP. Her doctor retired within the last couple of months and
since then no one has been following her DM.
You obtain a diet hx from Mrs. M she reports that her intake PTA was as follows:

Breakfast
I cup coffee with 2 Tbsp sugar-free vanilla creamer
grapefruit with Splenda
2 English muffin halves with 2tbsp. peanut butter and 2 tsp no sugar added jelly

Lunch:
1 piece of fried chicken (2oz)
1 cups of mashed potatoes with 1Tbsp butter added
1 small white roll
1 tsp butter
16oz diet soft drink

Snack:
1 large banana
5 Vanilla Wafers

Dinner:
2 slices (1/4 of 14) pepperoni pizza (hand-tossed crust)
1 cup salad with 2 Tbsp. Ranch dressing
2 pieces of sugar free chocolate candy
16oz diet soft drink

Snack:
4 pieces of sugar free chocolate candy

*Drinks: 3 cans diet soft drinks throughout the day.

ASSESSMENT

1. Calculate Pts BMI, %IBW, %UBW, and % weight gain

BMI 30.6 Obese IBW 120 %IBW 67%

UBW 172 %UBW 96.6% % wt change 3.5%

Is this cause for concern? Why or why not?

Her obese BMI is a cause for concern and the fact that she is 50+ pounds over her IBW. She has not
gained a ton of weight but she was obese before she gained 6 pounds so her weight does need to be
brought down.
2. Thoroughly evaluate the abnormal lab values. Investigate potential causes and discuss the
causes that are applicable to this patient.

High glucose and HbA1c means that her sugars are not being controlled. She needs to get in
to see a new doctor to get insulin and other medicine to control her diabetes.
Her high BUN and Cr could indicate that she is having some sort of kidney failure or disease
because they are not getting filtered out of her blood. High potassium levels also related to
kidney failure or improper kidney function. Referring Mrs. M to a kidney doctor would
probably be a first step for her.
Her high albumin levels could indicate malnutrition and dehydration. The high sodium and
chloride levels could also help verify that she is dehydrated.

3. Investigate Ms medications and supplements using the following chart detailing: drug generic &
brand name, drug function/classification, nutrition-related symptoms, food/nutrient
interactions and any other considerations that are applicable to this patient.
Drug Function Nutr-related sx Food/Drug intx Other NB info/SE

Lovastatin Controls Nausea, Take with meals Lowers cholesterol

(metacor) cholesterol dyspepsia,
headache
St. Johns Wort Anti- Insomnia, Up intake of Not FDA approved
depressant/ restlessness, tyramine foods
anti-anxiety headache,
fatigue
Multivitamin

4. Evaluate Mrs. Ms intake. Estimate Mrs. Ms caloric, CHO, and protein intake based upon her
food recall. Evaluate by food groups-kcals/pro/CHO per group using appendix K in your Nelms
text. Add lines as needed.

food exchange # exchange kcals Pro g CHO g

grapefruit fruit 1 60 0 15
with Splenda
1 full English Starch/br 2 160 6 30
muffin ead
2 tbsp Peanut High fat 2 200 16 0
Butter meat
 2 oz fried High fat 2 200 16 0
chicken meat
1.5 cups Starchy 3 240 9 45
mashed vegetable
potatoes s
1 tbsp butter Sat fat 3 300 21 0
(high)
1 white roll Bread 1 80 3 15
1 tsp butter Sat fat 1 100 7 0
(high)
1 banana Fruit 2 60 0 15
5. D5 vanilla wafers 1 starch, 1 280 17 15
e 2 fat
t
2 slices of Medium 1 medium 235 13 30
e
pepperoni pizza fat, fat, 2
r
starches starches
m
1 cup salad Vegetabl 1 25 0 5
i
e
n
2 tbsp ranch Unsatura 6 330 42 0
e
ted fat
(high)
M
2 tsp sugar free vegetable 1 25 0 5
r
jelly
s
.
Totals 2295 150 175
Ms kcal, protein and fluid requirements. Calculate pt needs based upon her need/desire to
lose wt. Show your calculations.

a. Kcals:_______________ 1670__________________________Use quick and easy formula

Calculations
21 x 79.5kg= 1670

Why did you use this number?

The pt is obese so the number 21 is used.

b. Protein:__64 _________g

Calculations
0.8 x 79.5= 63.5
Why did you use these factors?

The recommended amount of protein is 0.8g per kg of body weight.

 c. Fluid:__79.5_________ml

Calculations

79.5 x 1= 79.5

Why did you use these factors?

The recommendation for water is 1 mL per kg

6. Compare Mrs. Ms current intake to her estimated needs (from question 5. What percent of
her kcal, protein needs is she meeting based upon her 24 hour recall

Values/calcs %
Kcal Estimated intake: 2295 kcal 1.37%
Recommended intake: 1670 kcal
Pro Estimated intake: 150 2.34%
Recommended: 64
Fluid Estimated intake: 36oz .45%
Recommended: 79.5%

7. Is the pts dietary intake of vitamins and minerals adequate? What macronutrients &
vitamins/minerals do you suspect are lacking or are in excess based on food groups? Explain.

The patients intake of vitamins and minerals are not adequate. She had 1 serving of real
vegetables and 2 servings of real fruit. All of the bread she had was white and processed and
not whole grain. She also had no intake of water throughout her food diary. She is most likely
lacking vitamin A, vitamin D, and most other vegetables because she did not incorporate them
into her diet.

8. Discuss the problems/ issues that you have identified for Mrs. M. Include all including those
from her history as well as those that you have identified answering the previous questions.
 Add more rows if needed. Highlight those that you think are the most important to address.
DIAGNOSIS- HINT- Use these in your ADIME note to follow

social Takes care of husband who had a stroke.

education Has no education on nutrition and diabetes education.

Medical care Does not see a current doctor for her diabetes so her diabetes is not
under control

Diet hx Does not have nutrition education so does not have a good diet history

lifestyle Sedentary but willing to change

Anthropometrics/changes Gained 6#

meds On a cholesterol lowering drug, an herbal supplement for anxiety, and a

multivitamin.

labs Has labs indicating dehydration, kidney failure, and diabetes. Needs to
see a doctor about these.

9. Prioritize the problems from question 8. Choose the top three and write a PES statement for
each one. Brainstorm one or more intervention for each nutrition diagnosis. Use the NCP
standardized language and list your interventions under each nutrition diagnosis. Use the NCP
standardized language and list the Monitoring/Evaluation criteria that you will use to measure,
monitor and evaluate progress.

Nutr dx 1 No nutritional education

Intervention FND

NE/NC Needs a nutrition counseling and education session on eating healthy

and diabetes.
CC

M/E Have pt teach back what she is told and also bring back a food diary
proving that she has taken her nutrition education and put it to use.
 Nutr dx 2 High lab values for glucose, creatinine, Na, Cl, K, HbA1c, and BUN.

Intervention FND Increase water intake and control blood sugar with insulin.

NE/NC

CC

M/E Have pt come back after a month and evaluate lab values.

Nutr dx 3 No medicine or doctor for Diabetes

Intervention FND Get pt insulin to control blood sugar.

NE/NC Refer to doctor to control diabetes

CC

M/E Refer pt to a doctor to get diabetes under control and have pt check
back in a month to see progress.

INTERVENTION
10. For the nutrition interventions you listed above that require nutrition education (NE), provide
an outline of the information that will be discussed the patient. Do not write a paragraph
The pt needs education on how to eat healthy and also how to control her diabetes. Simple
information on glucose and insulin would be helpful for the pt. Also how to incorporate more
fruits and vegetables and also how to swap out wheat for white bread would be helpful.

DOCUMENTATION
11. Write a chart note in the ADIME format. Hint- Refer back to questions 8, 9, 10. Use the PES
template as a guide if you wish.
 Assessment
Pt is 69 y/o female; ht is 54; wt is 178#; type 2 diabetes
Medication: Lovastatin, st johns wort, and multivitamin
Current calorie intake: 2295
Recommended calorie intake: 1670
Diet related behavior: takes care of sick husband. Does not work out but wants to start. Wants
to lose weight. Severely lacks nutrition education

Diagnosis
Excessive energy intake due to lack of nutritional education.

Intervention
Nutrition education session and prescribed nutritional counseling to get diabetes and energy
intake under control.

Goals:
Pt will increase water intake to at least 70 oz per day
Pt will see a doctor to control her diabetes within the next week
Pt will do some sort of exercise for 30 minutes a day 3 times a week

Monitoring and Evaluation

Pt will return in 1 month to get lab levels checked, wt checked, and have pt bring another food
recall with her.

ADA EVIDENCE ANALYSIS LIBRARY (EAL)

12. Mrs. M has read some information about an Atkins style (high protein) diet and how it can lead
to weight loss. She asks you if you think that this diet would be appropriate for her. Using the
Academy EAL, investigate the influence of protein intake on glycemic control. What does the
research show? What is the overall strength of the statement according to the EAL?
Higher protein and lower carbs lowers the glycemic rate but does not substain energy.

What is the overall strength of the statement according to the EAL? What does the strength
mean?
Medium

What is your response to her question? What do you generally recommend for her?

I would recommend eating a well balanced diet with carbohydrates and proteins.