1. Mrs. DM’s laboratory data and interpretation:
Patients Value Normal Range Explanation
Morning fasting
glucose levels
120-140 mg/dl 70-99 mg/dl Diabetes
Weight 145 lbs 117-156 lbs Normal
BMI 24.2 Kg/M^2 18.5-25.0 Kg/^2 Normal
Blood pressure 148/95 mm Hg <130/80 Hypertension
HA1c 8.1% 5-5.2% or <7% Poorly controlledDM
Creatinine 0.9 mg/dl 0.4-1.2 mg/dl Normal
BUN 27 8-23 mg/dl Diabetes
Hgb 12.1 12.1-15.6 g/dl Normal
Hct 37% 34-54% Normal
Urine albumin 4+ (>300 mg/dl) <30 mg/24 hour Diabetic Nephropathy
Assess drug: nutrient interactions:
Mrs. DM is currently taking hydrochlorothiazide (25 mg) daily. This drug is
recommended to be taken in the morning with food or milk, as well as maintaining a
diet low in sodium and calcium and high in potassium and magnesium. Sodium
consumption for Mrs. DM needs to be addressed based off of her 24-hourdietary
recall. Foods consumed that are high in sodium are as follows: Processed foods or
take out (pepperoni and cheese pizza or a McDonalds Big mac with medium fries),
gravy, butter and salted popcorn. Other adjustments that should be made are Mrs.
DM’s fat consumption such as butter, pizza and fast food, chocolate chip cake, gravy,
vanilla ice cream and Oreo cookies.
Lisinopril in a prescription Mrs. DM is taking for hypertension, which also
recommends a diet low in sodium and calcium, but with adequate hydration. She is
currently taking 20 mg daily and this should be taken on an empty stomach 1 hour
before a meal.
Mrs DM takes about 81 mg of aspirin each day. This should be taken after meals and
with mill or water. Because hydrochlorothiazine and lisinopro both recommended a
diet low in calcium, water is recommended over milk. Because most orange juice is
fortified with calcium, Mrs. DM should consume non-fortified milk or other juices
high in vitamin C. Her caffeine intake should be limited or monitored while taking
aspirin.

2. ADIME:
Assessment:
35 y/o female. Ht: 5’5’’ Wt: 145# (65.9 kg). BMI 24.2. BP: 148/195 mm Hg.
Nutrition Dx: Type 1 Diabetes. Moderate Albuminuria. Outpatient nutrition consult was
ordered. BMI and body weight within normal range.
Nutritional Needs: Intake of daily calories (~1900 calories), protein (53 – 67g), and
fluid intake (1977 mL/day). DM needs a higher consumption of fruits and vegetables and
decreased sodium, fat and sugar consumption.
Medical Hx: Type 1 Diabetes. Moderate Albuminuria. Poorly controlled HTN. Under
physicians care for diabetes for 20 yrs. No history of retinopathy or neuropathy. No
cardiovascular event and reports no cardiac symptoms.
Family Hx: CVD
Social: N/A
Mrs. DM had been under physicians care with type 1 diabetes for 20 years and is
here due to poorly controlled hypertension and moderate albuminuria. Mrs. DM
claims to monitor her fasting glucose levels three times a day via personal
glucometer. Mrs. DM is currently taking hyperchlorothiazide (25 mg daily, for
hypertension), Lisinopro (20 mg daily, for hypertension), aspirn (81 mg daily), 30
units of NPH (20 U in the am and 10 U at bedtime) and uses 30 U of Lispro at meals
(10 U at lunch and dinner). Mrs. DM claims that she takes her medication
consistently and she had no prior history of a cardiovascular episode and reports no
cardiac symptoms. Cardiorespiratory, abdominal, and neurological examination
assessments are normal but an outpatient nutrition consult was ordered. BMI and
body weight are within normal range, therefore a daily consumption of 1900 kcals
and 53-67 grams of protein are recommended. Due to diabetic nephropathy, less
protein in recommended, so closer to 53 grams than to 67 grams.
Kcal Recommendations (Harris Benedict):
655+9.6(65.9 kg)+1.7(65 cm)-4.7(35 yr)= 1888.64
=~1900 kcals/day
Protein recommendation for acute kidney failure:
0.8-1.0 g protein/kg/day
0.8x65.9 kg=~53 f of protein/day
1.0x65.9 kg=~67 g of protein/day
=53-67 grams of protein/day

3. Fluid recommendation:
30 mL/kg/day
30 mLx 65.9 kg=1977 mL/day
=~1977 mL/day
Nutritional Diagnosis:
Excessive mineral intake (NI-5.10.2) of sodium (10736) R/T high intake of high sodium
processed foods AEB poorly controlled hypertension.
Intervention/Monitoring and Evaluation:
1.) Regarding Mrs. DM’s 24-hour recall and lab reports, decreased sodium
consumption is recommended. A DASH or Mediterranean diet, whichever is
more appealing to her, will be assigned along with a diet of <2000mg of
sodium/day. Mrs. DM will be educated on these diets, how to properly read
labels, what to shop for at the grocery store and how to cook using less
sodium and more fruits and vegetables. Fast food and processed foods, such
as Big Mac’s and pizza, are encouraged to be eliminated from her diet and
replaced with more fruits and vegetables and foods low in sodium and fat. A
cooking class is held here once a week at the hospital and Mrs. DM is
encouraged to attend to help her learn how to cook nutritious meals using
the DASH or Mediterranean diet. This will be monitored by her keeping a
food journal of what she eats and additional comments, such as if she liked it
and what her insulin levels where after consumption. We will evaluate her
diet from her journal entries as well as from lab reports. Because this goal is
intended to lowering hypertension, blood pressure will be monitored and
urine albumin tests will be assessed weekly because kidney failure has few
signs. From Mrs. DM’s food journal and lab results, further adjustments, if
any, can be made to her diet.
2.) Carbohydrate counting will be required to better monitor CHO consumption
and insulin. It is important for Mrs. DM to focus on the same amount to CHO
at each meal (“constant CHO”), to establish customary eating patterns,
determine the amount of CHO at each time, coordinate time of meal/snack
with insulin and to calculate the “exchanges” for CHO consumed. Mrs. DM will
be educated on how to properly read food labels and to divide the amount of
CHO by 15 to get #CHO choices. The plate theory will also be shown to her to
help her visualize the correct amount of macronutrients as well as what each
are categorized as (PRO, CHO, FATS, fruit’s/veggies). This will be monitored
by keeping this in her food journal so we can see how much CHO she is
consuming, and if she is properly counting CHO’s and reading labels. Insulin
levels should also be recorded as well as time of consumption, grams and
exchanges.
3.) Due to Mrs. DM’s diabetic nephropathy, a diet low in protein is
recommended. Because the kidneys are already compromised, breaking
down protein will cause them to over-work, eventually causing liver failure.

4. As previously mentioned, a diet of 53-67 grams of protein was calculated,
however, I would like to start Mrs. DM off at 53 grams/day. From the 24-hour
diet recall, she is consuming enough protein through Big Mac, pepperoni
pizza, hard boiled eggs and chicken breast. Since Big Macs, pizza and other
processed and fast foods are to be eliminated from her diet, a substitution of
healthy foods that contain a good source of protein is recommended. For
example, 1 cup of cooked red quinoa contains 8 grams of a compete protein,
and ½ cup of bean sprouts, lentils and peas contains 13.1 grams of proteins.
Legumes are to be closely monitored for their high CHO content. Mrs. DM will
meet with a dietician to be educated on healthy foods high in protein and
how to break up protein consumption for each meal. For example, if Mrs. DM
has three meals and two snacks, have her consume 10-15 grams of protein/
meal and 3-5 grams of protein at each snack. Like CHO counting and low
sodium goals, this too should be recorded in the same food journal so we can
see what she is consuming and what adjustment need to be made. Like CHO
counting, a weekly urine albumin test will be assessed to monitor levels and
kidney functions. Tests will be lessened once levels begin to decrease.
Describe the diabetes education which you would provide to this patient to help her
achieve her dietary goals. What self-care activities would you suggest for this
patient?
Although Mrs. Has had DM for 20 years and monitors her blood glucose
levels three times a day, it’s possible that maybe she doesn’t fully understand that
these numbers mean. If she knew what these numbers meant for her health she
would be more conscious of what she ate. I would help her understand what insulin
is, how her body is affected by it and exactly what the numbers mean is comparison
to what she ate. This will help her with CHO counting and portion sizes. Also, I
would suggest Mrs. DM having a self-blood pressure monitor available. Again, if Mrs.
DM can visual her blood pressure and successfully compare that to the foods she ate
the and physical activity she has done, or needs to do, this might help her become
more conscious and motivated to eat healthier and control her hypertension more
efficiently. Physical activity is highly suggested. According to the Journal of Nutrition
and Dietetics, physical activity is recognized to produce multiple general and
diabetes-specific health benefits. Even though body weight and BMI are within
normal range, reducing fats stores can be healthy for her liver, kidney and overall
health. Mrs. DM should meet with a trainer, but participation in at least 30 min of
moderate-intensity dynamic aerobic exercise (walking, jogging, cycling or
swimming) on 5 to 7 days a week is recommended. If physical activity is increased
then her body weight needs to be monitored because some weight loss is desirable
but too much is not. In this case, kcal recommendations per day needs to be adjusted
accordingly.

5. Reference from the Journal of Nutrition and Dietetics:
Role of Physical Activity in Diabetes
Management and Prevention
Charlotte Hayes, MMSc, MS, RD and Andrea Kriska, PhD
Accepted December 13, 2007
Abstract:
During recent years, evidence supporting the vital role of physical activity in the prevention and
treatment of diabetes has been accumulating. Physical activity is recognized to produce multiple general
and diabetes-specific health benefits. Yet despite the multitude of benefits, many people are physically
inactive. As the prevalence of overweight and obesity, prediabetes, and type 2 diabetes has continued
to rise at an alarming rate, physical inactivity has become an urgent public health concern. The purpose
of this article is to review the physical activity/exercise research in diabetes and summarize the current
exercise recommendations. This information can be used by clinicians to make safe and effective
recommendations for integrating physical activity/exercise into self-management plans for individuals
with diabetes or at risk for its development.