Case Study 1: Diabetes Mellitus

Please list any resources that you used along with your response to each question (5 points).
Professor Randalls presentation may be cited as a resource.

Example:
The recommended level of saturated fat intake for this population is 10% of total energy. (EAL)

If you use any scientific journal articles, please list the full citation (using whatever citation style
you prefer).

Answer the following case study questions, thinking in terms of this patient being your
actual patient, and also complete an initial assessment note and follow-up progress note.

Mrs. Robinson is a 48 y/o Caucasian in Tulsa, OK. She is married, has three children, and works
as a teacher in the local high school.

Mrs. Robinson has a pronounced family history of Type 2 diabetes mellitus. Her mother and her
brother have both had severe complications because of poor control of blood glucose. Mrs.
Robinson is well aware of the problems in her familys past, but this has not motivated her to
take steps to prevent diabetes for herself. She is 56 and weighs 210 lbs with a waist
circumference of 42. She is not very active but does work in her vegetable garden a
lot. Occasionally she goes for long walks in her neighborhood in the evenings. On several
occasions she has been treated for UTIs and has frequent colds. She does not have a history of
any major illness. She is not currently taking any medications.

During the past month, Mrs. Robinson noticed some significant changes in the way she
feels. She becomes fatigued easily and has to urinate more frequently, even during the
night. She is thirsty and hungry all the time. She is eating more but she lost 20 lbs. in the last six
weeks and her vision has become blurred. Her blood pressure was 150/88 and her HgA1c was
14%. The physician obtained a CBC, BMP and lipid profile (all fasting) and found the following:

Date: 01/10/2016
Result Reference Range

Glu 353 mg/dl (H) 70-110 mg/dl

BUN 28 mg/dl (H) 6-20 mg/dl
Cr 1.1 mg/dl 0.6-1.1 mg/dl
Ca 9.1 mg/dl 8.8-10.0 mg/dl
Alb 3.7 mg/dl 3.5-4.8 mg/dl
Na 148 mEq/L (H) 136-145 mEq/L
K 5.3 mEq/L (H) 3.5-5.2 mEq/L
Cl 104 mEq/L 96-106 mEq/L
Mg 2.0 mEq/L 1.8-2.6 mEq/L
P 3.1 mEq/L 2.7-4.5 mEq/L

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 Chol 300 mg/dl (H) 140-199 mg/dl
TG 350 mg/dl (H) <150 mg/dl
HDL 30 mg/dl (L) 40-85 mg/dl

1. Calculate Mrs. Robinsons BMI. How do her BMI and waist circumference factor into her
overall health risks? (2 points)
Mrs. Robinsons BMI is 33.9 classifying her as obese, her waist circumference is also greater
than 40 inches which is a risk factor for heart disease and metabolic syndrome. (NIH)

2. What is HbA1C and how does it relate to diabetes? What is a normal value for an individual
without diabetes? (3 points)
HbA1C is the measure of glycated hemoglobin in an individual, and provides information on
blood glucose level averages over the course of three months. This value can provide a snapshot
of an individuals blood glucose over three months. A normal HbA1C value should be below
5.7% according to the National Institute of Diabetes and Digestive and Kidney Diseases.

3. List the signs and symptoms of Type 2 diabetes that are manifested in Mrs. Robinson.
Explain the pathology for each of these symptoms.(4 points)
Fatigue- due to the inability to absorb glucose, which is a primary energy source.
Polyuria- due to the bodys desire to rid the body of excess glucose.
Polydipsia- due to the polyuria.
Polyphagia- due to starving cells- glucose is not being absorbed, so the body is being starved of
glucose.
Unexplained weight loss- inability to absorb energy, shift to fat stores for energy.
Blurry vision- due to fluctuations in blood glucose levels, fluid drawn from lens of eyes may occur.
UTI- due to hyperglycemia, infection is common due to excess glucose along with delayed healing.

4. Define the following terms: polydipsia, polyphagia and polyuria. (3 points)

Polydipsia- abnormal increased thirst. Polyphagia- excessive hunger. Polyuria- frequent,
excessive urination.

5. What is considered to be good control for blood glucose, lipid, and blood pressure in patients
with diabetes and what is considered poor control? (2 points)

Good blood glucose values for patients with diabetes would be 80-130 pre-meal and <180 two
hours postprandial, blood pressure should be <140/90, and an LDL <100, HDL >50 and
triglycerides <150 according to the ADA. According to the NIDDK guidelines, an A1C of >9
which equals an average blood glucose value of 215 is considered poorly controlled diabetes.
Poor control of lipids and blood pressure, according to the Eighth Joint National Committee
2014 guidelines are any values above the range listed for good control. However, it is
important to note goals are meant to be individualized as much as possible based on life
expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular
complications. (NCM)

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6. Why should the physician be concerned about the abnormal lipid profile of a person with
diabetes who is out of control like Mrs. Robinson? (2 points)
Yes, an elevated lipid panel in a patient with poorly controlled diabetes can lead to increased
tissue and organ damage. Furthermore, according to the American Heart Association, a common
condition found with diabetes is diabetic dyslipidemia, categorized by high levels of triglycerides
and low levels of HDL. Furthermore, diabetes, high triglycerides and low HDL are all factors of
metabolic syndrome, which is a cluster of risk factors for heart disease and stroke.

7. Describe the function of metformin and list any nutritional implications/side effects. (2
points)
Metformin is an oral medication that works to lower blood sugar by blocking the endogenous
production of glucose in the liver. In turn, this halts the production of excess glucose, which may
aid in the absorption of excess blood glucose by the body. Side effects can be lactic acidosis,
weight loss, diarrhea, nausea, asthenia, and decreased serum B12.

8. Describe the function of pravastatin sodium and list any nutritional implications and side
effects. Why did the physician tell Mrs. Robinson to take it at bedtime? (3 points)
Pravastatin sodium is a statin with the primary objective of lowering LDL and triglycerides, and
increasing HDL. Pravastatin sodium may cause muscle pain, nausea, diarrhea, or headaches.
This drug is commonly prescribed to be taken before bed because the cholesterol forming
enzyme is more active at night.

9. The MD told Mrs. Robinson that weight loss may help control her diabetes. Describe the
relationship between obesity and diabetes. (2 points)
Obesity is related to insulin resistance which is the primary characteristic of diabetes. Excessive
weight and in particular abdominal adiposity are huge risk factors for developing diabetes and
metabolic syndrome. It is hypothesized that increased abdominal fat causes the release of pro-
inflammatory chemicals, which weakens the bodys insulin response. (Global Diabetes
Community)Weight reduction can also improve her blood pressure and lipid profile which
reduces her risk factors for diabetes related complications.

10. The MD encouraged Mrs. Robinson to start a walking routine. Describe how
walking/increased exercise can help with the management of DM. (2 points)
Regular physical activity can facilitate weight loss, which will improve blood pressure, blood
lipids and glycemic control. Increased energy expenditure can encourage the body to use the
excess sugar in her blood for fuel. Exercise will also improve blood flow, mood, and may help
Mrs. Robinson sleep better. The NIDDK lists improved cholesterol and reduced risk of sleep
apnea among the benefits of physical activity on diabetes.

The RDN (you) interviewed Mrs. Robinson and discovered that she consumed a high-fat, low-
protein, high-carbohydrate diet. She liked fried chicken and consumed a large amount of regular
soda, candy, cookies, potato chips, and corn chips. The sodium content of her diet was
high. She did not drink milk and ate cheese and yogurt very infrequently. There were very few
fruit and vegetables in her diet, and she did not eat meat often. She was used to eating a snack

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before going to bed at night. She usually got up early in the morning to avoid the heat and had a
light snack before working in the yard for a couple of hours. She then came in and ate breakfast;
lunch was around 1 PM, and the evening meal was at about 6 PM. Sometimes she would take a
walk after supper but not specifically for the purpose of getting exercise.

11. How many visits for MNT are recommended: number and length of both initial and follow-
up encounters? When should MNT begin? (3 points)
Per the EAL, three to six MNT visits are recommended during the initial six months of
diagnosis. Furthermore, follow up encounters should be at least annually. The visits should last
around 45-90 minutes.

12. Calculate Mrs. Robinsons estimated energy needs. Indicate which equation you used to
estimate her needs and why. Show your work. How many kcal/kg does this translate into? (4
points)
According to the NCM, the Mifflin St. Jeor equation is the most appropriate for estimating RMR
in obese patients. Using this equation, I found Mrs. Robinsons caloric needs to be 1600 calories,
which equals around 17 kcal/kg. For protein, I would estimate Mrs. Robinsons needs at
approximately 0.8g/kg due to the fact that she is without kidney impairment. This places her
protein needs at around 76g/day. For fluid recommendations, I would advise 1mL/kcal.

10 x 95 (kg) + 6.25 x 167.64 (cm) 5 x 48 (y) 161.

13. What level of caloric intake would you recommend for weight reduction? Explain your
answer. (2 points)

Per the NCM, calorie requirements of 20 kcal/kg are advised for obese or very inactive
individuals. This puts Mrs. Robinson at around 1900 calories per day. I would recommend Mrs.
Robinson begins with a goal of 5-10% weight loss, with around 1-2 pounds of weight loss a
week. This would place her at a weight range of 189-199 pounds. This could be achieved by
establishing a caloric deficit of around 500-1000kcal per week, which would put her caloric
needs at 1700-1800 calories.

14. What nutrient deficiencies could possibly result from following the diet Mrs.
Robinson described? Explain your answers. (4 points)
Mrs. Robinsons diet was void in fruits in vegetables, which are main providers of micronutrients
and fiber. Furthermore, avoidance of milk, cheese and yogurt could cause hypocalcemia, or B12
deficiency. Her diet was also very low in protein- due to her lack of meat consumption and meat
alternatives.

15. What initial education would you provide for Mrs. Robinson? What behaviors would you
target in your dietary intervention? Explain your rationale. (10 points)

I would educate Mrs. Robinson on the macronutrient composition of foods, I would see what
knowledge she has on carbohydrates. I would additionally, highlight the high levels of sodium,

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simple sugars and saturated fat in her diet. I would offer substitutions for saturated/trans fat and
educate Mrs. Robinson on heart healthy options like monounsaturated and polyunsaturated fats. I
would also present Mrs. Robinson with examples of common items high in sodium and sugar to
avoid. I would be applaud Mrs. Robinsons nightly walk and encourage her to establish a more
routine exercise schedule. However, my primary focus would be to teach her about the
importance of meal timing with diabetes and portion sizes. I would advise Mrs. Robinson to have
a consistent meal every 4-5 hours of the waking day. I would provide Mrs. Robinson with
handouts on how an ideal diabetes plate should look- with emphasis on lean protein, non-
starchy vegetables, and a controlled portion of carbohydrates. Furthermore, it would be
important to educate Mrs. Robinson on what to do if she experiences a low blood sugar, and to
provide the ideal times she should be measuring her glucose along with what values to look for.
My rationale behind this is based on the NCM guidelines for diabetes therapy goals, which state
their primary objective as creating lifestyle changes to improve clinical outcomes and prevent
complications. This is consistent with the ADA guidelines for nutrition therapy for individuals
with diabetes, which states therapy goals of establishing an eating pattern designed to lower
glucose, blood pressure, and alter lipid profiles.

At this point in the case study, please complete and attach an ADIME note for your initial
visit with Mrs. Robinson. (20 points)

Mrs. Robinson took her medication and followed your nutrition advice as best she could but
many of her symptoms continued. She had not worked in her yard or walked as much as usual
because she still did not feel very well. She returned to the doctor for regular checkups and saw
the RDN for the prescribed number of visits. Three months later, her weight had decreased by 10
lbs to 200. Her doctor was happy to see that her glucose went down but he explained that if did
not lower it further then she may need to start on insulin. Her labs were as follows:

Date: 04/12/2016
Result Reference Range
Chol 224 mg/dl (H) 140-199 mg/dl
HDL 35 md/dl (L) 40-85 mEq/L
TG 185 mg/dl (H) <150 md/dl
Glu 255 mg/dl (H) 70-110 mg/dl
HbA1C 10.0% (H) 5.5-8.5%

16. Compare these labs to her initial labs during her visit three months ago. Describe any
changes. (2 points)
Cholesterol has declined along with triglycerides, glucose and A1C have also declined. HDL has
increased.

The physician made adjustments in her medications. She was supposed to be coming to the clinic
weekly to see the RDN and nurse, but was non-adherent. The physician encouraged her to come
weekly and to show them her daily log of blood glucose levels from her finger sticks. Over the

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next several months, Mrs. Robinson continued to report to her doctor with little success. Her
weight stayed about the same with slight changes in her glucose and HbA1C. Her lipid profile
continued to be worrisome. The physician continued to increase her Metformin until she was at
two doses of 1000 mg each. On her last visit her labs were as follows:

Date: 10/10/2016
Result Reference Range
Chol 200 mg/dl (H) 140-199 mg/dl
HDL 40 mg/dl 40-85 mg/dl
LDL 130 mg/dl <130 mg/dl
TG 150 mg/dl (H) <150 md/dl
Gluc 180 mg/dl (H) 70-110 mg/dl
HbA1C 9.1% (H) 5.5-8.5%

After increasing her metformin, her weight decreased to 193 lbs. Still, with this slow rate of
improvement, the physician decided to start her on insulin. Mrs. Robinson had to learn how to
give herself insulin but did not like it at all. The physician told her that if she got her glucose
under control and lost weight, she may not need the insulin. This motivated her to go back to see
the RDN and start her walking routine.

17. How would your nutrition education/counseling/intervention at this follow-up visit differ
from that provided at the initial visit? Explain your answer. (5 points)
Yes, in the initial visit I would focus on explanation of what diabetes is, and focus on
carbohydrate identification and food group education. The primary objective would be to
establish habits in Mrs. Robinson that would improve glycemic control. In this follow-up visit, I
would focus more on weight reduction through diet and physical activity. The NCM
recommends 90 to 150 minutes of moderate-intensity aerobic physical activity a week as well as
resistance/strength training three times per week. I would suggest the possibility of Mrs.
Robinson beginning a food and/or exercise journal, in order to facilitate self-monitoring
practices. Another suggestion could be for Mrs. Robinson to purchase a pedometer in order to
track her steps. Furthermore, I would work more specifically to identify any barriers Mrs.
Robinson is having, and look to decipher what information she retained from the initial visit.

At this point in the case study, please complete and attach an ADIME note for your follow-
up visit with Mrs. Robinson. (20 points)

Mrs. Robinson finally had favorable results with her new regimen but only after she began to
follow her meal plan, finally started a walking program, and took her meds as prescribed. The
blood glucose levels were coming down along with her HbA1C. Triglycerides, total cholesterol,
LDL and HDL all stayed in an appropriate range.

Adapted from: Billon W. Clinical Nutrition: Case Studies (4 th Edition). Belmont, CA: Thomson Wadsworth, 2006.

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 Assessment 1/10
Client history:
Age: 48 years
Sex: female
Patient health history: family history of T2DM in mother and brother, frequent UTIs,
frequent seasonal colds.
Height: 66
Current weight: 210 lbs
Weight loss: patient reported unintentional 20# significant 8.6% weight loss in six
weeks. BMI of 33 is indicative of obesity.
Biochemical:
Elevated Cholesterol, TG, and low HDL based on ATP III guidelines. Glucose value of
353mg/dl and A1C of 14% consistent with T2DM. Albumin within normal limits.
Elevated BUN, K and N possibly related to dehydration secondary to polyuria.
Nutrition-focused physical findings:
Patient reports increased fatigue, urination, nocturia, polyphagia, polydipsia, and blurred
vision.
Food/nutrition related history:
Typical daily intake:
Meals: Fried chicken
Beverages: soda
Snacks: candy, cookies, potato chips, corn chips
Meal pattern: typically consuming 2 meals/day at 1 PM and 6 PM
Comparative standards: 1900 kcal based on 20kcal/kg, 76g protein with protein factor of
0.8/kg, fluids of 1900mL based off of 1ml/kcal
Goal of weight loss of 1-2#/week towards a reduction of 5-10% body weight 189-199#
Goal blood glucose: downward trending towards goal value of fasting glucose <130, and A1C
near 7%.
Diagnosis
Excessive carbohydrate intake (NI-53.2) related to dietary habits as evidenced by 24 hour
recall, A1C of 14, Glucose of 353mg/dl.
Excessive energy intake (NI-1.3) related to high-fat, low-protein, high-carbohydrate diet as
evidenced by BMI of 33, waist circumference of 42, dietary recall.
Involuntary weight loss (NC-3.2) related to undiagnosed type 2 diabetes as evidenced by A1C
of 14, glucose of 353mg/dl, polyuria, polydipsia, polyphagia, unintential 20# weight loss in six
weeks.
Intervention
Nutrition prescription: Consistent Carbohydrate Diet ND-1.2.4.1 1700-1800kcal/day to
establish a deficit of 500-1000kcal, 76g protein, 1900-2000mL fluid.

Modification of distribution, type, or amount of food and nutrients within meals or at

specified time (ND-1.2)

Recommended going no greater than 4-5 hours between meals during the waking hours of the
day, educated patient on meal timing and diabetes and importance of consistency of meals.

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Provided hand-out on ideal diabetic plate, along with lists of foods with their food groups and
portion sizes.
Comprehensive nutrition education (E-2.1)
Educated the patient on carbohydrate identification, low carbohydrate food options, healthy
portion sizes.
Educated patient on impact of dietary fats on lipid profile, connection with diabetes and heart
healthy substitutions.
Educated patient on ideal blood glucose ranges and how to treat hypoglycemia.
Monitoring and evaluation:
Weight: AD-1.1.2 will be taken at next appointment goal is controlled weight loss of
approximately 1-2#/week.
Labs: BD-1.5.1 fasting blood glucose averages <130mg/dl and A1C near 7%.

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Assessment- Follow Up
Client history:
Age: 48 years
Sex: Female
Patient health history: family history of T2DM
Height: 66
Current weight: 193 lbs
Weight loss: 7# insignificant (3.5%) weight loss in 7mo. Goal weight reduction
Biochemical:
Elevated Cholesterol per ATP III guidelines, LDL of 130mg/dl and TG of 150mg/dl are
within the acceptable range, but still concerning. HDL at 40mg/dl is low and at the cut off
range for recommended ATP III guidelines. Fasting blood glucose value is elevated at
180mg/dl with recommended range of 70-110. A1C value of 9.1% is elevated with
recommended value for diabetes dx <10 years being 7-8%.
Nutrition-focused physical findings:
Patient reports increased physical activity
Comparative standards, estimated energy needs: Remains unchanged from note (1/10)
Goal weight loss (1/10 remains relevant)
Diagnosis
Obesity (NC-3.3) related to insufficient physical activity as evidenced by BMI of 31.
Intervention
Nutrition prescription: Continue with carbohydrate controlled diet.
Strategy: Self-Monitoring (C-2.3), Strategy: Problem Solving (C-2.4)
Suggested patient self-monitoring of exercise through use of an exercise journal and pedometer.
Suggest patient self-monitoring of food intake via food journal.
Goal: Log at least 7 days worth of exercise and food intake before next appointment.
Monitoring and evaluation:
Weight AD-1.1.2 Criteria: loss of 1-2lb/week between today and next appointment.
Activity: Establish baseline activity through food log review and increase accordingly to reach
long term goal of 150min/week.