Maria P is a 65 year old, non-smoker Hispanic female who is coming to see you for management of her Type 2 diabetes. Her blood glucose levels are uncontrolled as evidenced by an A1C .10, and she complains of increasing numbness in her feet and occasionally in her fingers, and frequent urination during the day and overnight. From interviewing her and reviewing her health record, you learn the following about her: Education: Did not complete high school, attended through middle school. Occupation: Not employed outside the home, babysits infant grandchild on a daily basis Household Members: Lives with her husband and with one of her four adult children. Ethnic Background: Latin American, born in Mexico, emigrated to US in 1980 Religious Affiliation: Catholic Language: Native Spanish, speaks English – has difficulty reading English Patient History: Weighed more than 9 lb at birth. Maria was diagnosed with T2DM, 10 or 15 years ago and her diabetes management history is as follows: Type of Treatment: Nutrition therapy plus oral diabetes medication and long-acting insulin at bedtime (HS) Medications: Meds: glargine 80 units at HS, metformin XR 1000 mg BID, enalapril 10 mg daily, simvastatin 40 mg daily, levothyroxine 75 mcg daily Family history: Mother had type 2 diabetes, 12 year old grandson recently diagnosed with prediabetes Medical History: type 2 diabetes, hypertension, hyperlipidemia, hypothyroidism, episodic migraines (last occurrence 2012) Physical exam shows the following: Weight: 201 lbs. Height: 5’2” inches, Temp: 98.6 F BP: 143/88 mm Hg Heart rate; 80 bpm Labs: A1C 9.8%, TSH 8, FT4 0.3; Total cholesterol 144 mg/dL, LDL 116 mg/ dL, HDL 54 mg/dL; Triglycerides 545 mg/dL, BUN 14 Self-monitoring of blood glucose record shows: Aggregate mean: 218 mg/dL, Standard deviation: 48 (n 5 68) over last 30 days Frequency – 2 x/day Fasting (6 AM): 173 mg/dL, Standard deviation: 35 (n 5 21) Prebreakfast (9 AM): 248 mg/dL, Standard deviation: 30 (n 5 6) Prelunch: (1 PM): 193 mg/dL, Standard deviation: 47 (n 5 17) Predinner (6 PM): 195 mg/dL, Standard deviation: 33 (n 5 11) Bedtime (n 5 9): 260 mg/dL, Standard deviation 34 (n 5 13) Range: 69 mg/dL to 304 mg/dL
Nutrition History:
General: Good appetite, with wide consumption of foods and beverages native to the region in Mexico where she was born. She plans and prepares meals for the household. Performed a 24-hour diet recall. Breakfast: coffee with milk and sugar (several spoons) 1 sweet bread 3 to 4 pieces Lunch: chicken and vegetable soup 1 corn tortillas (4-6), home-prepared fruit juice (1-2 x 16 ounce glass)
Dinner: Largest meal – chicken/beef, rice (,2 cups) and beans (1½ - 2 cups), 1 corn tortillas (4-6), home-prepared fruit juice (1-2 x 16 ounce glass) Afternoon snack: 1 can “natural” cola 1 3 to 4 sugar-free cookies HS snack: cereal 1 milk Food allergies/intolerances/aversions: None Previous nutrition therapy: Several years ago when diagnosed Vitamin/supplement intake: Vitamin D3 – 2000 IU per day, One A Day vitamin supplement
Tx Plan:
1. Referral to RDN, CDE for instruction on carbohydrate counting for use with a basal-bolus insulin plan.
2. Physician prescribed:
a. rapid-acting insulin analog lispro. Premeal dose breakfast 10 units, lunch 15 units, dinner 20 units Correction insulin (insulin sensitivity factor) 1 unit to drop blood glucose level 50 mg/dL when premeal blood glucose . 150 mg/dL
b. Increased self-monitoring of blood glucose premeal (breakfast, lunch and dinner) and 2 hour postprandial blood glucose after dinner.
Nutrition Care Questions
1) Why did Maria’s physician prescribe mealtime insulin? Would another medication have been more effective at this stage of her disease?
2) What is a potential problem of the current mealtime insulin plan using “set” or “fixed” doses of premeal insulin?
3) Will the long-acting insulin need to be adjusted? If so, why?
4) What is the proposed mechanism of action of metformin? Why did her physician leave Maria on this medication after the insulin was initiated?
5) Identify at least two reasons why regular physical activity such as walking would be beneficial for Maria?
6) What is causing the numbness and tingling in Maria’s feet and occasionally in her fingers?
Nutrition Assessment
7) Determine Maria’s nutrition requirements
a) Identify two methods for determination of Maria’s energy requirements.
b) Calculate body mass index, percent usual body weight (UBW), percent ideal body weight?
8) Intake Domain:
a) Dietary factors associated with increase of overweight/obesity and hyperglycemia are large portions of food, no regular physical activity, and increased consumption of sugar-sweetened beverages. Identify foods in Maria’s diet history that fit these criteria.
b) Increased vegetable and fruit intake is associated with a reduced risk of overweight. Using Maria’s usual intake, is her vegetable and fruit intake adequate?
c) Using the carbohydrate counting Eating Plan approach with 3 to 4 carbohydrate choices per meal (Breakfast/Lunch and Dinner) and 1 carbohydrate choice at HS, plan a 1 day menu for Maria.
9) Clinical Domain:
a) Why does Maria’s physician order pre- and 2 hour postmeal blood glucose monitoring?
b) What are the pre/postmeal glucose targets?
10) Behavioral-Environmental Domain:
a) What behaviors might be contributing to Maria’s overweight and obesity?
b) Identify one specific physical activity recommendation for Maria that she could do during the day when she is caring for her grandchild.
Nutrition Diagnostic Statements
Select two of Maria’s nutrition problems and complete PES statements for each one. PES Statements:
1) Food and nutrition-related knowledge deficit related to lack of previous diabetes nutrition education as evidenced by patient’s nutrition history.
2) Limited adherence to nutrition-related recommendations related to poor understanding as evidenced by elevated hemoglobin A1C and food records that indicate that patient is consuming excessive amounts of carbohydrate and calories.
3) Altered blood glucose levels related to inability to match insulin to carbohydrate intake as evidenced by patient’s nutrition history and glucose monitoring download data report.
For each of the two PES statements, write a goal, based on signs and symptoms.
5) For the two goals, write 2 to 3 nutrition interventions, based on the etiology that would be appropriate for Maria. NOTE: In a real face-to-face appointment between an RDN/CDE and Maria, they would collaboratively develop Maria’s goals together.
Nutrition Evaluation and Monitoring
a) When should the next nutrition counseling session be scheduled for Maria?
b) What would you assess at the follow-up visit based on the nutrition goals and interventions developed at the initial appointment?