CASE STUDY #23



Kramer Ahrens

Dr. McCullough

Medical Nutrition Therapy

28 October 2014

Case Study 2: Diabetes

CASE STUDY #2:

TYPE 2 DIABETES MELLITUS AND METABOLIC SYNDROME

Case Study #2: Diabetes

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This is a typical account of obesity contributing to diabetes. It is also an introduction to some of the cultural practices of Native Americans, although their eating habits have been greatly influenced by those of the general population. The highest recorded incidence of diabetes in the United States is 40 percent seen in the Pima Indiana in Arizona of age 45 or older. Mrs. R. is our patient.

Medications:

Become familiar with the following medications before reading the case study. Note the diet-drug interactions, dosages and methods of administration, gastrointestinal tract reactions, etc. 1. Glucotrol (glipizide); 2. Insulin: Humulin, Regular (see your text), and Lantus insulin: 3. Precose (acarbose); 4. Glucophage (metformin); 5. Pravachol (pravastatin). Attach to your case study answers.

Glucotrol: Take 30 minutes before first meal of the day. Do not chew, crush, or cut- swallow whole. The starting dose is 5mg and adjustments should be made in increments of 2.5-5mg. The maximum dose is 15mg. Take in adjunction to prescribed diabetic diet and exercise. Glucotrol may increase or decrease appetite, cause weight gain, dyspepsia, nausea, diarrhea, and constipation. Avoid with the consumption of alcohol. Caution should be taken in geriatric or malnourished patients and pregnant women. Other side effects include: dizziness, headache, drowsiness, blurred vision and skin reactions.

Precose: Precose is an Alpha-glucosidase Inhibitor. Take with first bite of each meal and titrate dose to decrease GI side effects. There us no fixed dosage but, 100mg is the maximum limit. The recommended starting dose is 25mg TID. Do not take with digestive enzymes such as amylase or pancreatin. Medication delays absorption of dietary disaccharides and complex CHO. Side effects include: abdominal pain, diarrhea, flatulence and borborygmus. Limit alcohol; do not take while lactating, caution with moderate decrease renal function, not with diabetic ketoacidosis and IBS.

Glucophage: Metformin is an anti-hyperglycemic agent. Take with meals to decrease GI distress and swallow whole with evening meal. The maximum amount for adults is 2550mg and 2000mg for pediatrics. May cause weight loss, anorexia and decrease in Fol and VitB12 absorption. GI side effects include: metallic taste, dyspepsia, N/V, bloating, diarrhea, flatulence and constipation. Avoid alcohol, lactating, caution with low hepatic function and severe cardiac disease. Other side effects include: headache, fatigue, muscle pain, dyspnea, rash, increase swelling, chills, flushing, chest discomfort, palpitation, dizziness, asthenia and rarely lactic acidosis.

Pravachol: Pravastatin is a HMG-CoA Reductase Inhibitor used to decrease total and LDL cholesterol. Take in regard to food. Take single dose HS and swallow whole. The recommended dose for adults is 40 mg. No or minor interaction with grapefruit/citrus. Do not take with high dose niacin and separate fiber, pectin or oat bran from drug several hours. GI side effects include: nausea, dyspepsia, abdominal pain, constipation, diarrhea and flatulence. Avoid substantial alcohol and lactation. Other side effects include: myopathy, back pain, weakness, headache, rash, dizziness, chest pain, insomnia, bronchitis and decrease in bone resorption.

Lantus insulin: Timing of injection or pump bolus in relation to food varies with insulin form. Lantus insulin is long-acting and may cause weight gain in some individuals. Exercise, stress, illness, pregnancy, heavy smoking or large weight gain increases insulin needs.

PART I: INITIAL TREATMENT

Mrs. R is a 48 y/o Native American F living on a reservation. She has lived there with her family all of her life, is a housewife and has three children. Her husband works in a nearby factory. All of Mrs. R’s children have finished high school but one still lives at home and is unemployed. The income for Mrs. R’s family is meager and they depend on home-grown vegetables and wild game to supplement their food supply. Government commodities contribute a small amount.

Mrs. R has a pronounced family history of Type 2 diabetes mellitus. Several family members have had severe complications because of poor control of blood glucose. Mrs. R is well aware of the problems in her family’s past, but this has not stopped her from eating whatever she wants. She is 5’6” and weighs 210 lbs with a medium frame and a waist of 42”. She is not very active but does work in her vegetable garden a lot. Occasionally she goes for long walks on her reservation in the evenings. She has graduated from high school and reads and writes adequately. On several occasions she has been treated for UTI’s and has frequent colds. She does not have a history of any major illness. During the past month, Mrs. R. noticed some significant changes in the way she feels. She becomes fatigued easily and has to go to the bathroom more frequently, even during the night. She is hungry all the time and is eating more but she lost 10 lbs in the last six weeks and her vision has become blurred. Mrs. R went to the doctor because she developed another bladder infection. She can always tell when she has a bladder infection by the pain in her lower abdomen and frequency of her urination. She decided to go to the doctor for the infection and while there explained the other problems she was having. Her BP was 150/88. The physician obtained some fasting blood tests and found the following:

TABLE 1

|CBC |

|TEST |RESULT |REFERENCE UNITS |TEST |RESULT |REFERENCE UNITS |

| | |Conventional SI | | |Conventional SI |

|Hgb |

|TEST |RESULT |REFERENCE UNITS |TEST |RESULT |REFERENCE UNIT |

| | |Conventional SI | | |Conventional SI |

|Glu |

|TEST |RESULT |REFERENCE UNITS |TEST |RESULT |REFERENCE UNITS |

| | |Conventional SI | | |Conventional SI |

|Chol |

| |

| |

| |

| |

|D: |

| |

| |

| |

|I: |

| |

| |

| |

| |

|M&E: |

| |

| |

| |

34. On a separate sheet of paper, use the kcal levels and the proportions of each major nutrient you recommended and prepare a meal pattern and meal plan for Mrs. R based on food availability using both the exchange method and the carbohydrate method. Remember to adjust her meal plan to meet her usual eating habits as much as possible. For example, incorporate a reasonable amount of sweets into Mrs. R’s meal plan. In your meal plan, regardless of the method, Mrs. R will benefit from a consistent intake of grams of carbohydrate at each meal and snack. You also have to remember to take into account activity and when her medications are taken.

Mrs. R’s Diabetic Diet Plan

Goal:

~1800 kcal for obtainable weight loss

~2 ½ cups vegetables

~ 1 ½ cups fruit

~ 5oz protein

~ 3 cups (or equivalent) milk

~ 6oz grains

~ < 5 Tbs. oils

~ 2.9 L of fluids

1500-2000 mg Na

45-65% carbohydrates

10-35% protein

20-35% fat

Breakfast-

Medications: Glucotrol (30 minutes before meal) and Precose with first bite of meal. Lantus insulin once a day at the same time every day

• 1 slice sourdough toast- 15g CHO, 3g PRO, 1g FAT

• ¾ cup blueberries- 15g CHO

• 2/3 cup fat free yogurt- 12g CHO, 8g PRO, 5g FAT

• 2 scrambled egg whites- 0 CHO, 7g PRO, 2g FAT

• 1 cup hot tea w/ Splenda- FREE

• 2 slices turkey bacon- 0 CHO, 7g PRO, 5g FAT

• 2 tsp. SF grape jelly- FREE

• 1 Tbsp. lower-fat margarine spread- 5g FAT

Snack #1-

• 1 cup celery sticks- 5 CHO, 2g PRO, 0g FAT

• 1 Tbsp. peanut butter- 0 CHO, 7g PRO, 8g FAT

• 1 small apple- 15g CHO

• 8 oz. diet coke- FREE

Lunch-

Medications: Glucotrol and Precose

• 1 oz. lean buffalo burger- 7g CHO, g PRO, 2g FAT

• 1 hamburger bun- 30g CHO, 6g PRO, 2g FAT

• ½ cup fresh steamed green beans- 5g CHO, 2g PRO

• ¾ cup canned mandarin oranges- 15g CHO

• ½ cup light ice-cream- 15g CHO, 5g FAT

• Lettuce leaf- FREE

• Tomato slice- FREE

• Onion slice- FREE

• 1 tsp. ketchup- FREE

• 2 cups ice water- FREE

Snack #2-

• 1 cup fat free cottage cheese- 0 CHO, 28g PRO, 0g FAT

• ¾ oz. backed potato chips- 15g CHO, 3g PRO, 1g FAT

• 1 cup baby carrots- 5g CHO, 2g PRO, 0 FAT

• 2 cups ice water- FREE

Dinner-

• 2 oz. chicken breast (marinated in 1tsp olive oil, garlic and oregano)- 0 CHO, 14g PRO, 10g FAT

• ½ cup black beans (drained and rinsed)- 15g CHO, 7g PRO

• 1/2 cup vegetable medley (peppers and squash) – 5g CHO, 2g PRO

• 1/3 cup brown rice- 15g CHO, 3g PRO, 1g FAT

• 5 vanilla wafers- 15g CHO, 5g FAT

• 2 cups ice water- FREE

• 1 cup black coffee- FREE

*Mrs. R should take her walk in between dinner and her last snack. She will be using more glucose during exercise so caution needs to be taken. Her snack can be eaten immediately if she feels weak or fatigued.*

Snack #3-

• 2 slices Swiss cheese- 0 CHO, 7g PRO, 8g FAT

• 6 saltine crackers- 15g CHO, 3g PRO, 1g FAT

• 1 cup SF lemonade- FREE

• 3 small gingersnap cookies- 15g CHO

• Tomato slice- FREE

Bedtime w/ Precose-

• SF jello- FREE

• 2 cups water- FREE

• Carb Counting-

15 carbohydrate choices, 3-4 per meal, snacks 1-2 carbohydrates

225 grams carbohydrates total

|Daily Calories |Daily Carb Allowance |

|1800 kcal |15 |

|Breakfast |Snack |Lunch |Snack |Dinner |

|Milk/milk equivalent |3 cups |36g |24g |8g |

|Vegetables |4 servings |20g |6g |- |

|Fruit |3 servings |45g |- |- |

|Starch |8 servings |120g |24g |8g |

|Meat |5 servings |- |35g |19g |

|Fat |5 servings |- |- |25g |

|TOTAL: | |221g |89g |60g |

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