This patient is a 55-year-old woman with type 2 diabetes, obesity, and hypertension who has been under a physician's care for diabetes for 2 years. Her HA1c is 8.1% indicating poorly controlled diabetes. She takes medications for her conditions. Her diet recall revealed foods high in saturated fat, sodium, and added sugars. The nutrition assessment found her nutritional intake and status to be poor. The nutrition diagnosis is a food and nutrient-related knowledge deficit. Goals include educating the patient on saturated fats, sodium, carbohydrates, and energy balance to better manage her conditions. The intervention method involves nutrition education and monitoring.

1. Part I: Assignment Instructions
FSHN 450
Type 2 Diabetes Case Study
Fall 2014
Mrs. DM is a 55-year-old woman with type 2 diabetes, obesity, and hypertension whom has been
under a physicians care for diabetes for the past 2 years. She has no history of
microalbuminuria,retinopathy, or neuropathy. She has never had a cardiovascular event and
reports no cardiac symptoms. She has a positive family history of cardiovascular disease. In the
past, she has successfully lost weight (from 5 to 12 kg) on various diets but each time has
regained all of the weight she lost. She tries to walk 30 minutes each day. She monitors her
fasting glucose levels three times weekly using a personal glucometer, and her morning fasting
glucose levels have ranged between 110 and 140 mg per deciliter and she does not test during the
day.
Medications:
She has been receiving metformin (1000 mg twice a day) and glipizide (10 mg twice daily). She
has hypertension which is treated with hydrochlorothiazide (25 mg daily) and lisinopril (20
mgdaily). She takes aspirin (81 mg daily) and lovastatin (20 mg daily). She notes that she
consistently takes her medications.
Anthropometric and biochemical Measurements:
Her body-mass index is 31Kg/M2.
Her blood pressure is 128/78 mm Hg. Her general assessment,
including cardiorespiratory, abdominal and neurologic examinations, are normal. Her HA1c
level is 8.1%, and her creatinine 0.9 mg per deciliter. She has no microalbuminuria, and liver
function studies are normal.
Treatment:
Physician wants to add insulin but the patient wants to try diet changes first.
Her 24 hour dietary recall revealed a typical day:
AM 1 cup orange juice, 4 strips bacon, 2 fried eggs and 2 slices of toast with strawberry jam
(about 1TBSP), coffee with sugar substitute and ¼ cup 1% milk.
NOON½ Dominos pizza with pepperoni and cheese (or MacDonald’s Big Mac, with medium
fries) and a large diet Coke.
2PM 1 Diet coke and 1 piece chocolate cake (about 1/10 of an 8” round cake with icing)
5:30 PM 2 chicken breasts, 1 cup broccoli, 1 cup mashed potatoes with ¼ cup gravy, 4 Oreo
cookies and ½ cup vanilla ice cream
7:30 PM 2 cups popcorn with butter
HS 1 cup 1% milk and 4 Oreo cookies
Assess the patient’s laboratory data and provide an interpretation in table format.
Patients Value Normal Range Explanation

2. Assess drug:nutrient interactions. When reporting these interactions, report only those
interactions which pertain to this patient
Assess the patient’s nutritional intake and nutritional status and report in short paragraph form.
Use the ADIME format to communicate the patient’s nutritional needs and provide an
appropriate nutrition diagnosis and PES statement and intervention, goals and follow-up.
Describe the diabetes intervention method that you would use to help her achieve her dietary
goals. What self-care activities would you suggest for this patient?
Provide a recent reference from the literature to support your intervention (Remember that the
recommendations from AHA changed this year!!!)
Part II: My Work on Assignment
Type 2 DM Case Study
Molly Carroll
10/17/14

3. Lab values
Test Patient’s value Normal range Explanation
Blood pressure 128/78 < 120/80 Slightly high from
hypertension
HA1c 8.1% 4.0-6.0% Poorly controlled DM
Creatinine 0.9 mg/dL 0.4-1.2 mg/dL Within normal limits
Fasting blood glucose 110-140 mg/dL 70-99 mg/dL DM
Liver function &
microalbuminuria
normal
Drug-nutrient interactions
 Metformin (antihyperglycemic drug)- should consume with a diabetic diet including
decreased calories if weight loss is needed (patient does not appear to be consuming a
diabetic diet as her diet is high in non-nutrient-dense carbohydrates, added sugars, and
kcalories), this drug decreases folate and vitamin B12 absorption
 Glipizide (hypoglycemic drug, also called: glucotrol or glucotrol XL)- drug should be
consumed with diabetic diet (the patient is not consuming a diabetic diet as her diet is
high in non-nutrient-dense carbohydrates, added sugars, and kcalories), this drug can
cause increased appetite and weight gain (this may be the reason the patient is consuming
so many calories and gains weight after she loses it)
 Hydrochlorothiazide (antihypertensive diuretic)- may need decreased sodium, decreased
kcals with this drug (patient is consuming high kcals and appears to be consuming high
amounts of sodium with bacon, pizza, big macs, and fries), may need increased
potassium and increased magnesium with this drug, should use caution with this drug and
diabetes as it can increase glucose (could be the reason the patient has high glucose
levels)
 Lisinopril (antihypertensive drug, also called: Prinivil/Prinzide and Zestril/Zestoretic)-
should be sure to drink adequate fluids (patient does not appear to be consuming adequate
fluids with only 1 1/4 cups of milk, 1 coke, and 1 cup of orange juice), decreased sodium
and kcal intake may be suggested (patient appears to be consuming high amounts of
sodium with pizza, fries, big mac, bacon, and high kcals with these high fat foods and
foods with added sugars)
 Aspirin (to prevent myocardial infarction/heart attack)- be sure to consume adequate
fluids (patient is not consuming adequate fluids), increase foods high in Vit C and folate
with long term & high dose (patient’s dose is not very high but she could increase her
vegetable/fruit intake to get adequate amounts of these vitamins), avoid or limit natural
products that affect coagulation (garlic, ginger, gingko, ginseng or horse chestnut), limit
caffeine with this drug (patient may need to limit caffeine more as she consumed a large
diet coke and coffee)

4.  Lovastatin (antihyperlipidemic to decrease risk of CV events and slow progression of
atherosclerosis)- take with decreased fat and cholesterol and decreased calories if needed,
grapefruit/related citrus fruits (Seville oranges and certain exotic oranges) should be
avoided with this drug (patient consumed orange juice and should avoid this), high-fiber
food consumption should be separated from drug consumption by 1 hour as this can
decrease this drug’s absorption
Assessment
 General: 55-year-old female
 Medical hx: Type 2 DM, obesity, and hypertension, no history of microalbuminuria,
retinopathy, neuropathy, cardiovascular events or symptoms, does have a family history
of cardiovascular disease
 Treatment hx: under physician’s care for diabetes, has been on diets and lost 5-12kg body
weight, but regains it, walks 30 min/day, monitors fasting glucose three times/week and
has levels of 110-140 mg/dL, physician wants to add insulin and patient wants to change
diet first
 Rx: 1000 mg metformin twice daily, 10 mg glipizide twice daily, 25 mg
hydrochlorothiazide daily and 20 mg lisinopril daily for hypertension, 81 mg aspirin daily,
20 mg lovastatin daily, consistent with all medications
 Anthropometric measurements:
o Height- 5 ft (60 in.)= 1.52 m
 60 in. x 2.54 cm/1 in. x 1 m/102
cm= 1.52 m
o Weight- 71.6 kg
 31 kg/m2
= x kg/1.52 m2
, x=71.6 kg
o BMI- 31 kg/m2
– obese
o General assessment – cardio-respiratory, neurologic, abdominal – normal
 Biochemical and physical lab values: high fasting blood glucose, high HA1c levels,
slightly high systolic blood pressure (see table above)
 Current issues: Regains weight lost and fasting glucose levels high, poor diet
 Nutritional intake and status:
o Protein needs: 2.0 g/kg body weight per day for Class I obesity- 2.0 x 71.6=143 g
protein/day
o Kcal needs: Resting energy expenditure + physical activity (=REE x .15) +
thermic effect of food (REE x .10)= 2,734 kcal/day
 (Mifflin equation) Resting energy expenditure: 9.99(71.6 kg) + 6.25(152
cm) – 4.92(55 years – 161)= 2,187 kcal/day
 Physical activity (minimal-moderate): 2,187 x .15=328 kcal
 Thermic effect of food: 2,187 x .10=219 kcal
o The patient’s nutritional intake is high in saturated fat, added sugars, and
kilocalories. The patient consumes foods high in saturated fat, such as pizza, big

5. macs, fries, buttered popcorn, ice cream, and bacon and consumes 1% milk. In
addition, the patient consumes foods high in added sugars, such as oreos, ice
cream, and chocolate cake. The patient not only consumes foods high in saturated
fat and added sugars, but consumes large portions of these foods, such as half a
Domino’s pizza, or a big mac, which contains two burgers. The patient also
consumed, for example, two chicken breasts at dinner instead of one, and had
dessert four times throughout the day. Many of the foods consumed by the
patient are high in sodium as well, such as the pizza or big mac with fries, and
bacon. The nutritional status of the patient is poor. Consumption of high
amounts of added sugars is not beneficial in the management of diabetes, and
consumption of foods high in saturated fats and excess kilocalories (the patient
should only be consuming 2,734 kcals per day as calculated above) do not help
with weight loss and management in an obese patient. Weight loss and
maintenance could help with the management of the patient’s diabetes. High
sodium consumption is not beneficial for the patient’s management of
hypertension, and high sodium consumption paired with a high consumption of
saturated fats could put this patient at an even greater risk for cardiovascular
disease, as the patient is already at risk with obesity and a family history of
cardiovascular disease.
Diagnosis
PES statement: Food and nutrient-related knowledge deficit (NB-1.1) related to obesity
and poorly managed diabetes as evidenced by diet recall.
Intervention
Excessive consumption of saturated fats, sodium, added sugars, and kilocalories as seen in the
patient’s diet contribute to the development of health problems and disease. All of these factors
work together to increase disease, and monitoring each of them can help better manage the
diseases the patient already has (Type 2 diabetes, obesity, and hypertension) and help prevent the
development of more diseases, such as cardiovascular disease. As stated in one journal article,
“To effectively and equitably address the chronic disease burden, public health and health-care
systems need to deploy integrated approaches that bundle strategies and interventions, address
many risk factors and conditions simultaneously” (1).
Goal 1: Educate patient about the risk of continuing obesity and development of cardiovascular
disease with high consumption of saturated fats in her diet. Define saturated fats and help patient
understand what they are. Encourage patient to lower consumption of saturated fats to better
help with weight loss and maintenance and decrease the risk of developing cardiovascular
disease.

6. Goal 2: Educate patient about the effects of sodium on hypertension and the role hypertension
plays in increasing the risk for cardiovascular disease. Define sodium, hypertension, and
cardiovascular disease and make sure patient understands how they connect. Encourage patient
to lower sodium levels by 1,000 mg increments until levels are at or below 1,500 mg/day.
Goal 3: Educate patient about how carbohydrates and added sugars contribute to blood sugar.
Define carbohydrates, educate patient about what nutrient-dense and low-glycemic index
carbohydrates are, and encourage lowering added sugars and increasing nutrient-dense and low-
glycemic carbohydrates to better manage blood sugar.
Goal 4: Educate patient about energy intake and energy expenditure and the process of balancing
the two to maintain weight that is lost.
Source:
1. Bauer UE, Briss PA, Goodman RA, et al. Prevention of chronic disease in the 21st
century: elimination of the leading preventable causes of premature death and disability
in the USA. Lancet. 2014;384(9937):45-52.
Abstract:
“With non-communicable conditions accounting for nearly two-thirds of deaths worldwide, the
emergence of chronic diseases as the predominant challenge to global health is undisputed. In
the USA, chronic diseases are the main causes of poor health, disability, and death, and account
for most of health-care expenditures. The chronic disease burden in the USA largely results
from a short list of risk factors--including tobacco use, poor diet and physical inactivity (both
strongly associated with obesity), excessive alcohol consumption, uncontrolled high blood
pressure, and hyperlipidaemia—that can be effectively addressed for individuals and populations.
Increases in the burden of chronic diseases are attributable to incidence and prevalence of
leading chronic conditions and risk factors (which occur individually and in combination), and
population demographics, including ageing and health disparities. To effectively and equitably
address the chronic disease burden, public health and health-care systems need to deploy
integrated approaches that bundle strategies and interventions, address many risk factors and
conditions simultaneously, create population-wide changes, help the population subgroups most
affected, and rely on implementation by many sectors, including public--private partnerships and
involvement from all stakeholders. To help to meet the chronic disease burden, the US Centers
for Disease Control and Prevention (CDC) uses four cross-cutting strategies: (1) epidemiology
and surveillance to monitor trends and inform programmes; (2) environmental approaches that
promote health and support healthy behaviours; (3) health system interventions to improve the
effective use of clinical and other preventive services; and (4) community resources linked to
clinical services that sustain improved management of chronic conditions. Establishment of
community conditions to support healthy behaviours and promote effective management of
chronic conditions will deliver healthier students to schools, healthier workers to employers and

7. businesses, and a healthier population to the health-care system. Collectively, these four
strategies will prevent the occurrence of chronic diseases, foster early detection and slow
disease progression in people with chronic conditions, reduce complications, support an
improved quality of life, and reduce demand on the health-care system. Of crucial importance,
with strengthened collaboration between the public health and health-care sectors, the health-care
system better uses prevention and early detection services, and population health is improved and
sustained by solidifying collaborations between communities and health-care providers. This
collaborative approach will improve health equity by building communities that promote health
rather than disease, have more accessible and direct care, and focus the health-care system on
improving population health.”
Monitoring/Evaluation
Continue to have appointments with the patient and assess whether the patient has decreased
consumption of saturated fat, sodium, and added sugars, and whether she is balancing
kilocalories from her diet recalls. Ask patient which foods in her diet do or do not contain higher
amounts of saturated fat, sodium, and added sugars, and determine whether she seems capable of
managing these factors and energy intake in her diet. If not, continue education and help patient
develop strategies to manage saturated fat, sodium, added sugars, and kilocalories. Monitor
blood sugar levels and blood pressure.
Diabetes Intervention Method
As stated above, the diabetes intervention method for this patient is education about what
carbohydrates are and their effects on blood glucose levels, including an explanation of low-
glycemic index and nutrient-dense carbohydrates and their benefits in managing blood glucose.
Education also includes lowering saturated fats, sodium, and balancing kilocalories to better
manage weight and decrease risk for additional diseases – overall management of health will
help better manage the patient’s diabetes (1). Continuing intervention/monitoring includes
helping the patient develop strategies to include nutrient-dense and low-glycemic index
carbohydrates in her diet, and decrease saturated fats, sodium, added sugars, and balance
kilocalories in her diet. For self-care, the patient should initially record what she eats throughout
the day and make sure it follows these recommendations. Educational materials should be
provided to help the patient find ways to implement these recommendations.