Case Study: Adult Type 2 Diabetes Melitus (T2DM): Transition to Insulin

Patient Summary: Mitchell Fagan is a 53- year old male admitted with acute hyperglycemia.
What are the standard diagnostic criteria for T2DM?
Hemoglobin A1c > 6.5%
Fasting plasma glucose >126 mg/dL
Casual plasma glucose >200 mg/dL
2 hour postprandial glucose >200 mg/dL, after OGTT
Mitchs medical record shows a high HbA1c percentage (15.2%) and a high casual plasma
glucose (1524 mg/dL and 475 mg/dL).
What types of medications are metformin and glyburide? Describe their mechanisms as
well as their potential side effects/drug-nutrient interactions
Metformin is a type of biguanide and glyburide is a type of sulfonylurea. Biguanides are
designed to increase insulin uptake in muscles and decrease hepatic glucose production. Their
inhibition of hepatic gluconeogenesis prevents the blood sugar from rising too high. Their
actions on enzymes aim to increase cell sensitivity to insulin to increase glucose; thereby keeping
blood sugar levels in a healthy range. They dont create a risk for hypoglycemia and they dont
induce weight gain.
Sulfonylureas work to stimulate pancreatic secretion of insulin. This increased insulin secretion
is aimed to lower blood sugar.
Discuss HHS and DKA. Describe the information in Mitchs chart that supports the
diagnosis of HHS.
DKA is most common in the Type I diabetic patient. It is an acute condition that results in
hyperglycemia with excessive urine output due to the high blood sugar levels and ketones that
are being filtered by the kidneys. This in turn can result in dehydration, electrolyte depletion and
acidosis.
HHS is seen more in the Type II diabetic. HHS presents with glucose levels above 600 mg/dl.
The outcome is similar as that of DKA, except that the Type II diabetic does have the ability to
produce some insulin, therefore acidosis produced by ketogenesis is not part of the causation of
HHS.
In Mr Fagans chart dehydration is indicated by hyperosmolality, increased BUN levels, low
sodium, dry mucous membranes, amber colored urine that is cloudy, as well as blood pressure
that is slightly low at 90/70.
Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine?
How likely is it htat Mitch will need to continue insulin therapy?

The physicians plan for Mitchell Fagan was to begin using insulin to reduce his blood sugar
levels. Glargine is an extended long acting insulin type and Lispro is fast acting. It is possible for
a Type II diabetic to control their blood sugar levels and stop insulin therapy. However, Mr.
Fagans inappropriate intake and his inconsistent use of the oral medications prescribed before
admission, indicate that he will need to continue insulin therapy.
Outline the basic principles for Mitchs nutrition therapy to assist in control of his DM
The basic principles of his therapy should include increased physical activity,
restricting/stabilizing calories, distributing carbohydrates (CHO) evenly throughout the day,
incorporating simple CHO into meal plan, adjust amount of CHO to glucose tolerance, and
closely monitoring his fat intake to ensure he is consuming minimal amounts of saturated fats
and trans fats. It is also important that he receives proper nutrition education given by a dietitian
since he indicated he had only received his nutrition-related info from his physician.
Asses Mitchs weight and BMI. What would be a healthy with range for Mitch?
Mr Fagans BMI is 31.3 and he weighs 97.3 kg, according to the BMI scale he is obese. A
healthy weight range for Mitchell would be about 150-165 lbs as he would be in the normal
range of the BMI at that weight. .
Identify and discuss any abnormal laboratory values measured upon his admission. How
did they change after hydration and initial treatment of HHS?
Upon admission, Mitch had just below normal sodium and phosphate levels, and above normal
BUN, creatinine serum, glucose, osmolality, cholesterol, triglycerides, HbA1c, WBC, and
hematocrit levels. His urinalysis results reported above normal specific gravity, protein, glucose,
and ketone levels, as well as a positive protein urine test, and below normal pH. The results also
indicate he was dehydrated upon admission, based on his sodium and osmolality levels. After
his HHS was treated with slow hydration, his sodium increased from 132 to 134 mEq/L and his
phosphate levels increased from 1.8 to 2.1 mg/dL; however, both remain below normal levels.
His BUN decreased from 31 to 20 mg/dL and creatinine serum decreased from 1.9 to 1.3 mg/dL,
both are above normal levels. His lab results show that he was hyperglycemic upon admission.
His glucose levels made a significant decrease from 1524 to 475 mg/dL, which is still above
normal blood glucose level. Mitchs osmolality decreased from 360 to 304 mmol/kg/H2O, which
is above the normal range.
The BUN and creatinine test results, and the presence of protein in his urine suggest his kidneys
are not functioning properly, ie unable to filter and excrete the excess blood glucose. Electrolyte
losses and dehydration are characteristic of HHS, and Mr. Fagans lab values reflected this.
HHS is often precipitated by an infection, which would explain his elevated WBC level.

Determine Mitchs energy and protein requirements for weight maintenance. What energy
and protein intakes would you recommend to assist with weight loss?
Due to his status as an obese patient the Hamwi Equation is used to determine his ideal weight
(IBW) when evaluating energy requirements; IBW= 151 lbs/ 69kg. There is no information in
regards to his physical activity, so the adjustment for his activity level is merely an estimate.
Energy requirement (Harris-Benedict formula)
=
66.5 + (13.8x69) + (5x172.5) -(6.8x53)
= 66.5 + (952) + (862.5) - (360.4)
=1520.6
1,520.6 x 1.3= 1,977 calories per day.
His protein requirement = 97.3kg/0.8= 121.6g
For weight loss, reducing his calorie intake by 250-500 calories per day would be result in -1
pound of weight loss per week. The recommended calorie intake would be 1,727-1,477 calories
per day, with emphasis on lean sources of protein. A loss of only 3-5% of body weight (6-10lbs)
will provide significant health benefits, especially if weight loss is maintained.
Prioritize two nutrition problems and complete the PES statement for each
Inappropriate intake of types of carbohydrates related to daily consumption of meals at fast food
restaurants as evidenced by the patients 24 hour diet recall.
Altered nutrition related lab values related to high blood glucose levels as evidenced by HbA1c
count at 15.2%
Determine Mitchs initial CHO prescription using his diet history as well as your
assessment of his energy requirements
Mr. Fagan has had limited education in regards to his carbohydrate requirements as a diabetic
patient. His energy requirements were calculated to be 1,977 calories per day. 45% of his energy
requirements, which totals 222.5 calories, should be met by carbohydrates, in particular complex
carbohydrates as opposed to simple sugars. Mr Fagans dietary recall is lacking in fruits, whole
grains, legumes and low fat dairy products that are sources of complex carbohydrates.
Identify two nutrition goals to assist with weight loss.
Aiming for less than 30% of calories from fat, and 45% of calories from carbohydrates- with
emphasis on fruits, vegetables, legumes, low-fat dairy products, and whole grains- will assist
with weight loss.