Mitch, a 53-year-old man with uncontrolled type 2 diabetes, was admitted to the ER with hyperglycemic hyperosmolar syndrome (HHS). His blood glucose was 1524 mg/dL and osmolality was 360 mmol/kg/water. He was started on insulin therapy with Lispro and glargine to control his blood sugar. As his diabetes was poorly controlled for an extended period, he is at high risk for chronic complications and will likely need to continue insulin. The nutrition consult will focus on diabetes self-management education and transitioning Mitch to a consistent carbohydrate diet.

1. Name(s):MarisaGutierrez,Laurie Hill,JessicaLeslie,AshleyMarsh
Date: 3/27/2014
Class period: TR 1:30-2:45
NTR 341
Due: On the date stated in your syllabus by 10:00 pm via Blackboard
Case Study #17 – Adult Type 2 Diabetes Mellitus: Transition to Insulin
Understanding the Disease and Pathophysiology
1. (3 points) What are the standard diagnostic criteria for T2DM? Which are found in
Mitch’s medical record?
The standard diagnostic criteria for T2DM are symptoms of diabetes which include
polyuria, polydipsia, polyphagia, and weight loss, weakness and fatigue. Neuropathyor
retinopathy may be present as complications in a patient with undiagnosed T2DM. Most
patients do not have symptoms indicating T2DM (1). Clinically the diagnostic will be one
of the following:
plasma glucose concentration ≥200 mg/dL
fasting plasma glucose ≥126 mg/dL
2-hour post-prandial glucose ≥200 mg/dL during an oral glucose test
(2 pg. 485).
Mitch’s serum glucose in the ER was 1524 mg/dL. The next day his glucose level was at
475. This is still elevated since normal limits are between 70-110 mg/dL and his HbA1c
was 15.2%, normal is between 3.9-5.2, indicating that his blood glucose has not been in
control the past few months (3 pg. 198-199). His osmolality was 360 the first day he was
in the hospital and then the 2nd day it was 304 which is improved but not within the
normal limits of 285-295 (3 pg. 198). His urinalysis showed protein, glucose, and ketones.
2. (3 points) What types of medications are metformin and glyburide? Describe their
mechanisms as well as their potential side effects/drug-nutrient interactions.
Metformin is in a category of drugs called biguanides and is used to treat Type 2
diabetes. It works to control the glucose in the blood by lowering the amount of glucose
that manufactured by the liver as well as that glucose the body would absorb from food
consumption. Metformin will help the body respond to insulin that is naturally produced
in the body. Some people may have side effects that include the following: diarrhea,
bloating, stomach pain, gas, indigestion, constipation, unpleasant metallic taste in
mouth, heartburn, headache, flushing of the skin, nail changes, muscle pain. More
serious complications such as chest pain or a rash may appear and need immediate
emergency treatment. Lactic acidosis may also occur. There may be other side effects
such a polyps in the uterus but have not been proven in humans (4). Metformin is known

2. to lower B12 absorption which if there is adequate intake of B12 in the diet, taking
metformin will not necessarily cause a problem. However, in some cases it can cause a
nutrient deficiency and the following are more at risk: older age, vegetarian diet, if the
drug is used in high doses or taken for more than 3 years. Correction of the deficiency
would be to supplement with 1000-2000 mcg on a daily basis (5).
Glyburide is in the sulfonylureas classification of drugs. This medication is used to
decrease blood sugar by stimulating the pancreas to produce insulin and assist in
productivelyutilizing the insulin. Some of the complications from this medication may
include nausea, upper abdominal fullness, heartburn, rash. More serious side effects
may include yellowing of the skin or eyes, light colored stools, dark urine, pain in the
upper right part of the stomach, unusual bruising or bleeding, diarrhea, fever, sore
throat, and swelling of the eyes, face, lips, tongue, or throat. Other symptoms may
appear as well (6).
3. (4 points ) Describe the metabolic events that led to Mitch’s symptoms and subsequent
admission to the ER with the diagnosis of uncontrolled T2DM with HHS. Make sure to define
HHS and relate this to the patients’ symptoms.
The metabolic events that led to Mitch’s symptoms and admission to the ER with T2DM
and HHS were caused by the body’s inability to use the insulin and his body breaking
down muscle and producing ketone bodies. This led to drowsiness and confusion which
was observed upon the arrival of the co-worker.
HHS is Hyperglycemic Hyperosmolar Syndrome which can occur in patients who have
T2DM with a blood glucose greater than 600 mg/dL. Mitch presented at the ER with a
glucose level of 1524 mg/dL. HHS also occurs when a patient’s serum osmolality is
greater than 320 mOsm/kg of water, Mitch had an osmolality level of 360 mmol/kg/water.
Patients with HHS will also not have a presence of ketoacidosis. HHS can be initiated by
both dehydration and infections (2 pg. 499). Mitch had been vomiting and due to his
physical state of being drowsy and confused upon his co-worker’s arrival, he was
hyperglycemic and dehydrated. He also had ketones present in his urine.
4. (4 points) HHS and DKA are the common metabolic complications associated with
diabetes. Discuss each of these clinical emergencies. Describe the information in Mitch’s chart
that supports the diagnosis of HHS.
HHS is Hyperglycemic Hyperosmolar Syndrome and many people with type 2 diabetes
can have this complication. HHS is initiated by an infection or severe illness which can
cause dehydration if vomiting or diarrhea are involved. There are three main factors that
contribute to HHS: 1. excessivelyhigh levels of blood glucose, >600 mg/dL 2.
dehydration from lack of fluid intake or excessive loss of fluid 3. decreased
consciousness. These symptoms do not occur all at once and are a result of lifestyle and
are not usually recognized until there is a problem (2 pg. 499). Other symptoms include

3. undiagnosed diabetes, polyuria, polydipsia, fever (due to infection), weight loss that is
unexplained. Laboratory tests include a plasma glucose >600 mg/dL, arterial pH >7.3,
serum bicarbonate >15 mEq/L, urine and plasma ketones will both be small, and serum
osmolality >320 mOsm/kg. These symptoms result in the need of hospital treatment for
re-hydration to occur at a slow rate, treat any underlying conditions such as an infection,
balance electrolytes, and possible use of insulin to bring the blood glucose back in
control (2 pg.503).
DKA is diabetic ketoacidosis and occurs in patients with type 1 diabetes and those who
have undiagnosed type 2 diabetes, are obese & do secrete insulin and use it efficiently.
There are many issues that can cause DKA such as infections, psychological stress, lack
of self-monitoring blood glucose, not using insulin or the need for more insulin due to
growth, pump malfunction, drug abuse, or severe illnesses which include CVA, MI,
pancreatitis, pulmonary embolism, alcohol or drug abuse. Symptoms of DKA include
polyuria, polydipsia, weight loss (unexplained), vomiting, abdominal pain, dehydration
indicated by loss of skin turgor and dry mucous membranes, tachycardia, hypotension,
patients may also have acetone breath which is a fruity breath, and kussmaul
respirations which is a deep labored breathing. Laboratory tests include a plasma
glucose >250 mg/dL, arterial pH <7.0 to 7.3, serum bicarbonate < 10 to 18 mEq/L, ketones
in both blood and urine will be positive and serum osmolality will be variable. Hospital
treatment is necessary for IV fluids to hydrate the patient as well as insulin, and
assessment of blood electrolytes (2 pg. 503).
Mitch’s arrival at the hospital he had dry mucous membranes in the throat, he was
drowsy and mildly confused, his skin was warm, dry and had poor turgor. His lab values
show a blood glucose of 1524 mg/dL, and osmolality of 360 mmol/kg/water. His urinalysis
had positive values for both glucose and ketones. These symptoms and lab values fit the
criteria for HHS.
5. (3 points) Describe the insulin therapy that was started for Mitch. What is Lispro? What
is glargine? How likely is it that Mitch will need to continue insulin therapy?
Mitch will begin Lispro, 0.5 units every2 hours until blood glucose levels reach 150-200
mg/dL. Mitch will also be given glargine, 19 units. Lispro is a short acting form of insulin
used to control the amount of glucose in the blood. Glargine is a long acting form of
insulin that will lower blood glucose levels at a constant rate over time. It is verylikely
that Mitch will continue insulin therapy after discharge from hospital. His poorly
controlled diabetes and poor diet cause him to be at an increased risk for recurring
episodes of HHS and possibly DKA.

4. 6. (5 points) What are the chronic complications associated with diabetes mellitus?
Describe the pathophysiology associated with these complications, specifically addressing the
role of chronic hyperglycemia.
Chronic complications of DM include neuropathy, renal complications, blindness,
amputations of the lower extremities, MI and CVA. The complications are related to the
changes in the blood vessels caused by DM. Chronic hyperglycemia caused by poorly
controlled DM causes inflammation within the vessels. The resulting inflammation by this
excess glucose in the bloodstream is cause for cardiovascular and cerebrovascular
complications. Risks include but are not limited to MI or CVA. The microvascular
changes due to inflammation also cause damage to nerves in the extremities (7). This
damage causes pain and numbness and in severe cases, complete loss of function and
ultimately amputation. Renal complications as they relate to chronic hyperglycemia and
vasculature include hardening of the microvessels, or glomeruli of the kidneys (7). This
progressive DM complication is referred to as glomerular sclerosis (8). Ophthalmic
complications are also included in the list of complications due to vascular and
microvascular changes associated with DM. Chronic hyperglycemia, or excessive
glucose circulating in the blood, will cause more rapid and extensive damage to the
vessels. Damage to these vessels will, in turn cause complications throughout the body
systems.
*Requirement - Please cite at least one review article from a peer reviewed medical/nutrition
journal that is no more than 10 years old. Your reference(s) must be properly cited, and a pdf
copy of the full article you used must uploaded separately when you submit your case study
online. *
Nutrition Assessment
7. (6 points) Identify any abnormal laboratory values measured upon his admission. Which
lab values changed after hydration and initial treatment of his HHS?

5. Biochemic
al Value
Patient’s
Value
(Indicate
high or
low)
Reason for
Abnormality
Nutrition
Implication
(nutrition
related
concern with
abnormality)
Did values
change?
Sodium
(mEq/L)
132, low Vomiting
Retaining
nutritional
and fluid
intake
no
significant
change
BUN
(mg/dL)
31, high
Altered kidney
function due
to Diabetes
Must alter
protein intake
moderate
decrease
in BUN
Creatinine
serum
(mg/dL)
1.9,
high
Dehydration,
kidney
problems
Must
increase fluid
intake
small
change
Glucose
(mg/dL)
1524!,
high
Mal-
absorption of
insulin as a
complication
of DM
Sugar and
CHO levels in
diet
Significant
change in
BS levels
after tx
Phosphate
, inorganic
(mg/dL)
1.8, low
increased
loss of
bicarbonate in
urine, caused
by altered
kidney
function in
relation to
poorly
controlled DM.
Poor nutrition,
vitamin D
deficiency
slight
increase
osmolality
(mmol/kg/
H2O)
360,
high
diet lower in
LDL, and
higher in HDL
slight
decrease
after tx
Cholesterol
205,
high
atherosclerosi
s as related to
DM
diet lower in
LDL, and
higher in HD
would not
change
after initial
tx
Triglycerides
(mg/dL)
185,
high
high blood
glucose levels
alter intake of
saturated fat
would not
change

6. creating fatty
acids
after initial
treatment
HbA1c (%)
15.2,
high
excess blood
sugar over 3
months due to
DM
uncontrolled
Dietary
control of
blood sugar
levels
no
immediate
change in
percentag
e after
initial
treatment
WBC’s
13.5,
high
inflammation
caused by DM
included
inflammation
reducing
foods
especially
those with
Omega-3’s
no
immediate
change
Hematocrit 57, high Dehydration
Rehydrate
patient
will
change
over time
8. (2 points) Determine Mitch’s energy and protein requirements.
Kcal Needs:
Pt weighs 214 lbs 214/2.2 = 97.3 kg
kcal: 25 - 30 kcal/kg/day
Range for pt: 25 x 97.3 = 2432 kcal/day up to 30 x 97.3= 2919 kcal/day
Protein Needs:
Normal = 0.8(97.27)kg = 77.82 g Protein
Minor illness = 1.2(97.27kg) = 116.72 g Protein
Protein needs for pt: 77.82 g/day - 116.72 g/day
Nutrition Monitoring and Evaluation
(20 points) Write your nutrition care from the standpoint of your initial nutrition consult. Please
also add education goals that you plan on addressing prior to this patient’s discharge from the
hospital.

7. Sun Devil Nutrition Care Form (Total = 20 Points)
Please record N/Aif data is unavailable
Please show all calculations used to determine kcal, protein and fluid needs
DATA & ASSESSMENT: 2 Points: (all or nothing here)
Subjective Data:
Mitchell is a single, 53 year old caucasian white male who lives alone. He is retired
military, currently working as a consultant to a military equipment company. Mr. Fagan
has smoked 1ppd for 20 years but has now quit, he also admits to 3 to 4 drinks per week.
Family history of HTN and type 2 DM. Does not take his medication for diabetes regularly
as he does not like how the side effects make him feel. Does take all other medications
as prescribed.
Patient is not currently following a strict diet but does avoid added salt, high cholesterol
foods, and high sugar desserts. Has not had any formal education for diabetes aside
from what his physician has provided.
Usual Intake:
AM: Coffee with half and half
Midmorning: Bagel with cream cheese, 2-3 c of coffee
Lunch: Out at restaurant - usually Jimmy John’s or fast-food sandwich,
chips, and diet soda
Dinner: Cooks sometimes at home - this would be grilled chicken or beef,
salad, and potatoes or rice. Often will meet friends for dinner -
likes all foods and especially likes to try different ethnic foods
such as Chinese, Mexican, Indian, or Thai
Age: 53 y.o Gender: Male Height: 5’9” (175.26cm) Weight: 214lbs (97.27kg)Weight History:
n/a
Medical Diagnosis: Type 2 DM uncontrolled with HHS
Reason for Consult:
Consult dietitian for advancement, total carbohydrate Rx, and distribution
Diabetes education for self-management training
Medications:
Glyburide 20 mg daily
Metformin 500 mg twice daily
Dyazide once daily (25 mg hydrochlorothiazide and 37.5 mg triamterene)
Lipitor 20 mg daily
Current Diet Order:
NPO except for ice chips and medications, after 12 hours clear liquids if stable.
Then, advance to consistent-carbohydrate diet

8. Past Medical/Surgical History:
Medical Hx:
Type 2 DM x 1 year
Hypertension
Hyperlipidemia
Gout
Surgical Hx:
ORIF R ulna
Hernia repair
1 Point:
Lab Values and Assessment:
Chemistry Ref. Range 4/12 @ 1780 4/13 @ 1522
Sodium(mEq/L) 136-145 132 ↓ 134 ↓
BUN (mg/dL) 8-18 31 ↑ 20 ↑
Creatine serum
(mg/dL)
0.6-1.2 1.9 ↑ 1.3 ↑
Glucose (mg/dL) 70-110 1524 ↑ 475 ↑
Phosphate,inorganic
(mg/dL)
2.3-4.7 1.8 ↓ 2.1 ↓
Calcium(mg/dL) 9-11 10 9.8
Osmolality
(mmol/kg/H2O)
285-295 360↑ 304↑
Cholesterol (mg/dL) 120-199 205↑
HbA1c (%) 3.9-5.2 15.2↑
C-peptide (ng/mL) 0.51-2.72 1.10
Urinalysis showed positive for protein, glucose, and ketones.
Upon admission patient showed an elevated serumglucose of 1524 mg/dL, after insulin
infusion levels dropped to 475 mg/dL which is still elevated but heading back into a
normal range. Patient’s HbA1c level was at 15.2% upon admission which displays that
his blood glucose levels have not been controlled overthe past 3 to 6 months.

9. 1 Point:
Weight Assessment (BMI and/or Hamwi Range - not just IBW):
BMI = weight (kg) / height (m2
) = 97.27kg/ (1.753m)2
= 31.6
Hamwi = 106 + (6 x 9)= 160 lbs
Hamwi range = 144 lbs - 176 lbs
Mr. Fagan’s ideal body weight would be 160 lbs. Based on patient’s BMI of 31.6 he is in
the obese category and according to the Hamwi equation he is 21% overweight (214
lbs/176 lbs).
1 Point:
Energy Needs:
25kcal (97.27kg) = 2,431.75 kcal
30kcal (97.27kg) = 2,918.10 kcal
To maintain his current weight he needs to consume 2,432-2,918 kcal according to the
kcal/kg method . It is recommended that Mr. Fagan consume between 1,932- 2,418 kcal to
promote weight loss.
1 Point:
Protein Needs: Protein requirements would range from 77.82g - 116.72g
Normal = 0.8(97.27)kg = 77.82 g Protein
Minor illness = 1.2(97.27kg) = 116.72 g Protein
1 Point:
Fluid Needs:
2000-2500 mL after rehydration
4 Points:
NUTRITION ASSESSMENT NARRATIVE - Be specific so your audience (MD, RN, staff RD,
etc) understands your assessment.
Patient has experienced an episode of diabetic ketoacidosis due to not eating for 12-24
hours. Patient suffers from Type 2 Diabetes but admits to not using his medication.
Patient also suffers from hypertension, hyperlipidemia and gout. Patient reports recently
quitting smoking 1 ppd. Patient also drinks alcohol 3-4 times per week. Based on
patients usual intake, his diet consists of a majority of fast food items and coffee. This
means that his diet is high in sugar (which cannot make it into his cells due to lack of
medication/insulin) saturated fat, caffeine, and sodium. It is also low in vitamins,
minerals, and water (drinks coffee instead).

10. 3 Points:
NUTRITION DIAGNOSIS:
Problem (Terminology):
Impaired nutrient utilization (NC- 2.1)
Related To
Food- and nutrition-related knowledge deficit (NB-1.1)
As Evidenced by
24 hour recall
2 Points:
NUTRITION INTERVENTIONNARRATIVE - Be specific so your audience (MD, RN, staff RD,
etc) understands your desired intervention, what it provides and why this needs to take place.
First and foremost, the patient needs to meet with a diabetes educator to understand his
condition and how to properlytake his medication regularly. He should learn how to
determine administration of insulin based on his carbohydrate intake. He should
understand that carbohydrates are necessary in his diet, but insulin is required with it.
The side effects of the medication should also be addressed in order to ensure
compliance. A journal on patient’s daily diet and administration of insulin would be
preferable to ensure patient understands keyconcepts.
As for his diet, the daily caloric intake should be reduced by 500 kcal/day and further
reduced as needed to promote weight loss. He should be educated on the DASH diet to
prevent future CAD or CVD. He should be instructed on how to properly substitute the
foods high in empty calories in his diet for nutrient dense foods (e.g. drink water or juice
instead of coffee).
For non-dietary goals, the patient should continue cessation of smoking and should
begin regular exercise.
1 Point:
Nutrition Intervention (Terminology):
Goals:
General/healthful diet (ND-1.1)
Nutrition Education- survival information (E-1.3)
Nutrition Counseling- Health Belief Model (C-1.2)
Goal Setting (C-2.2)
Relapse prevention (C-2.9)
Referral to RD with different expertise- CDE (RC-1.4)

11. 2 Points:
NUTRITION MONITORING NARRATIVE - Be specific so your audience (MD, RN, staff RD, etc)
understands your desired monitoring plans and why this needs to take place.
In one week, call patient to ensure compliance. Ask specific questions on the patients
diet and administration of insulin. If compliance low or patient cannot recall his
education, have him come in for re-education. If compliance is high, schedule for
appointment in one month. When he comes in, track weight loss, Hemoglobin A1C levels
and blood glucose levels. Continue checks ups as seen fit.
1 Point:
Nutrition Monitoring (Terminology):
Goals:
Modified diet (FH-1.1.1.2)
Meal/snack pattern (FH-1.3.2.3)
Total Carbohydrate Intake (FH-1.6.3.1)
Food and nutrition Knowledge (FH-3.1)
Motivation (FH-3.2.4)
Ability to recall nutrition goals (FH-4.1.3)
Self-management as agreed upon (FH-4.1.5)
Physical Activity (FH-6.3)
Weight (AD-1.1.2)
Glucose, fasting (BD-1.5.1)
Glucose, regular (BD-1.5.2)
HgbA1c (BD-1.5.3)
RD Signature:Marisa Gutierrez, Laurie Hill, Jessica Leslie, Ashley Marsh (students)Date: 3/27/2014

12. References
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2nd edition. Belmont, CA:Cengage Learning.
3. Nelms, M.N., & Roth, S.L. (2014). Medical Nutrition Therapy: A Case Study Approach
4th edition. Stamford, CT: Cengage Learning
4. Medline Plus. (2014). Metformin. Retrieved from:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a696005.html
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http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=&pm=5&p
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6. Medline Plus. (2014). Glyburide. Retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a684058.htm
7. Lau C.W. David, MD, PhD, FRCPC. (2014). Cardiovascular Complications of Diabetes.
Canadian Journal of Diabetes, 37 (5). Retrieved from
http://www.sciencedirect.com.ezproxy1.lib.asu.edu/science/article/pii/S14992671130120
94?via=ihub#
8. Min T.Z., Stephens M.W., Kumar P., Chudleigh R.A. (2012 September 7). Renal
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