Case Study. Diabetes/HTN. Amanda Sullivan

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1 Case Study Diabetes/HTN Amanda Sullivan

2 Sullivan 1 Assessment Patient History (CH) CH-1.1: 71-year-old African American female with 10 th grade education level admitted for unhealed ulcer of left foot. Pt denies history of tobacco and alcohol use. CH-2.1: Pt with past medical history of HTN, myopia, mild retinopathy, and bladder infections. Family medical history includes DM2 (sister). CH-2.2: Pt receiving surgical debridement of wound on left foot and treatment to normalize blood glucose levels. Meds reviewed, include: Humulin sliding scale, Ciprofloxacin, Captopril, Diet: 1200 calorie CH-2.3: Pt is widowed, lives with her 80-year-old sister in a low-income housing apartment and serves as her sister s caregiver. Anthropometric Measurements (AD) AD-1.1: Ht: 5 Wt: 70.5 kg IBW: kg, 155% IBW BMI: 30.3 kg/m 2 Biochemical Data (BD) BD-1.2: BUN 26; Crt 1.2; Na 145; Cl 100; K 4.5; Mg 1.8; Phos 3.2; BD-1.5: BG 325, 121; HgbA1c 8.5 BD-1.7: Chol 250; HDL 37; LDL 138; TG 300 BD-1.10: HCT 29.7; HGB 10.1 BD-1.11: Alb 4.1; PAB 24.5; Transferrin 305 Nutrition-Focused Physical Findings (PD) PD-1.1 Elderly pt with an overweight habitus. Pt wears glasses for myopia and mild retinopathy; complains of increased blurriness. Pt s blood pressure is 150/97 mmhg, which is above acceptable ranges; continue to monitor changes is blood pressure. Mild edema, tingling, and numbness present in extremities; left foot with 2 x 3 cm ulcer. Food/Nutrition Related History Usual Dietary Intake:

3 Sullivan 2 AM: One egg, fried in bacon fat, 2 strips of bacon or sausage, 1 c coffee, black, ½ c orange juice (unsweetened) Lunch: Lunchmeat sandwich: 2 slices enriched white bread, 1 slice (1 oz bologna, 1 slice (1 oz) American cheese, mustard, 1 glass (8 oz) iced tea unsweetened Dinner: 1 c turnip greens seasoned with fatback, salt, and pepper (simmered on stove top for at least 3 hours), 2 small new potatoes, boiled, seasoned with salt and pepper, 2-inch square of cornbread with 1 tsp butter, 1 c beans and ham (Great Northern beans cooked with ham)- approximately 3/4 c beans and ¼ c or 1 oz ham), 1 c coffee black Snack: 2 vanilla wafers Based on patient 24-hour diet recall, patient consuming approximately 1500 kcals, 70 gm protein, 149 gm carbohydrate, 22 gm fiber, 62.6 gm total fat, 22.6 gm saturated fat, 344 gm cholesterol per day. Comparative Standards Estimated Nutrition Needs: kcals per day and g protein per day Diagnosis Inconsistent carbohydrate intake (NI-5.8.4) related to food- and nutrition- related knowledge deficit as evidenced by self-reported dietary intake consistent with irregular carbohydrate consumption. Food- and nutrition-related knowledge deficit (NB-1.1) related to lack of prior exposure to accurate nutrition-related information as evidenced by reports of inaccurate information regarding a diabetic diet. Altered nutrition-related laboratory values (NC-2.2) related to endocrine dysfunction as evidenced by abnormal plasma glucose of 325 mg/dl and HgbA1c of 8.5%. Obesity (NC-3.3) related to food- and nutrition- related knowledge deficit as evidenced by BMI of 30.3 kg/m 2 and reports of overconsumption of high-fat and calorie-dense food. Excessive fat intake (NI-5.6.2) related to food- and nutrition-related knowledge deficit as evidenced by total cholesterol level of 300 mg/dl, LDL cholesterol level of 140 mg/dl, HDL cholesterol level of 35 mg/dl, triglyceride level of 400 mg/dl, and reports of food containing fat more that diet prescription. Intervention Nutrition education and counseling session s lead by a registered dietitian should be implemented to address the knowledge deficit related to the client s new diagnosis of diabetes. The sessions should be tailored to meet the patient s cognitive ability and take into consideration her education level. The initial education session will last 45 minutes

4 Sullivan 3 and will provide fundamental, survival nutrition/diabetes education information until patient is able to return for nutrition counseling sessions. At least 5 planned counseling sessions will be scheduled with the patient to last 30 minutes each. Develop long term, attainable goals of: Outcome Goals: Implement lifestyle strategies that will improve patient s glycemic control, blood pressure, and dyslipidemia. Action Goals: An initial nutrition education session will educate the patient about carbohydrates, consistently consuming carbohydrates, self-monitoring blood glucose levels (SMBG), and healthy food choices/preparation. Nutrition counseling will educate the patient about meal planning; considering protein and fat content in addition to carbohydrate. Nutrition counseling will educate the patient about balancing food intake and physical activity to reach an optimal body weight. Nutrition counseling will educate the patient about sodium and it s effect on our health. Monitoring/Evaluation Check patients understand and compliance with nutrition interventions after the 3 rd counseling session using food records and recorded blood glucose levels.

5 Sullivan 4 EAL Recommendation for DM: Assess Relative Importance of Weight Management The RD should assess the relative importance of weight management for persons with diabetes who are overweight or obese. While modest weight loss has been shown to improve insulin resistance in overweight and obese insulin-resistant individuals, research on sustained weight loss interventions lasting 1 year or longer reported inconsistent effects on A1C. American Diabetes Association Recommendation: Energy balance, overweight, and obesity -In overweight and obese insulin-resistant individuals, modest weight loss has been shown to reduce insulin resistance. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. -For weight loss, either low-carbohydrate, low fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years). -For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy) and adjust hypoglycemic therapy as needed. -Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. Based on this client s PMH, I think it would be most appropriate to apply both recommendations. Modest weight loss is stressed in both recommendations, but the ADA suggests losing the weight by incorporating physical activity in addition to diet modifications. Focusing on interventions that will address a multitude of health risks; including diabetes, hypertension and obesity, would be advantageous to the client s overall health. Although the ADA s recommendation to follow a low-carbohydrate diet seems straightforward and simple, due to the client s misconceived idea about all carbohydrates being harmful, I would use a different approach and vocabulary to ensure the client s understanding about suggested diet modifications. Dietary modifications that apply to this client would be lowering total fat intake, consistent carbohydrate eating and eating balanced meals, which focus on correct portion sizes. Weight loss suggestions would be appropriate for her existing conditions and in preventing further complications such as, heart disease, liver disease, stroke, and sleep apnea (mayoclinic.com, 2010). EAL Recommendation for DM: Macronutrients The RD should encourage consumption of macronutrients based on the Dietary Reference Intakes (DRI) for healthy adults. Research does not support any ideal percentage of energy from macronutrients for persons with diabetes. Although total carbohydrate content of meals and snacks is the first priority, macronutrient content and total energy intake cannot be ignored as excessive energy intake may lead to weight gain, even if glycemic control is maintained. Diets too low in carbohydrate eliminate many foods that are important sources of vitamins, minerals, fiber and energy.

6 Sullivan 5 Diets too low in protein and energy can lead to hypoalbuminemia, and both intake and albumin levels need to be monitored in persons with diabetic nephropathy who are restricting protein intake and may have a diminished appetite. American Diabetes Association Recommendation: macronutrients in diabetes management -The best mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes. -Monitoring carbohydrate, whether by carbohydrate counting, choices, or experiencebased estimation, remain a key strategy in achieving glycemic control. -For individuals with diabetes, the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone. -Saturated fat intake should be 7% of total calories. -Reducing intake of trans fat lowers LDL cholesterol and increases HDL cholesterol; therefore, intake of trans fat should be minimized. The EAL s idea that low carbohydrate diets eliminate many foods that are important sources of vitamins, minerals, fiber and energy, is of concern for this client because of her knowledge deficit related to proper carbohydrate consumption. Even though she tries to avoid all starchy foods, education should be implemented about her excessive intake of the other macronutrients that is causing her to maintain an unhealthy weight. The ADA gives a more in-depth plan on balancing macronutrients. The high trans and saturated fat intake is concerning because of the self reported usual dietary intake. Like other professional guidelines, the ADA recommends that saturated fat should be less than 7% of total calories. Mrs. Douglas saturated fat intake was approximately double the recommended amount at 13.56%. Establishing a thorough diet regiment that is low in total fat, should improve her abnormal lipid profile. EAL Recommendation: Carbohydrate DM: Carbohydrate Intake Consistency In persons receiving either MNT alone, glucose-lowering medications or fixed insulin doses, meal and snack carbohydrate intake should be kept consistent on a day-to-day basis. Consistency in carbohydrate intake results in improved glycemic control. DM: Carbohydrate Intake and Insulin Dose Adjustment In persons with type 1 or type 2 diabetes who adjust their mealtime insulin doses or who are on insulin pump therapy, insulin doses should be adjusted to match carbohydrate intake (insulin-to-carbohydrate ratio). This can be accomplished by comprehensive nutrition education and counseling on interpretation of blood glucose patterns, nutritionrelated medication management and collaboration with the healthcare team. Adjusting insulin dose based on planned carbohydrate intake improves glycemic control and quality of life without any adverse effects. JADA Recommendation: Carbohydrate Intake

7 Sullivan 6 In persons receiving either MNT alone, glucose-lowering medications, or fixed insulin doses, meal and snack carbohydrate intake should be consistently distributed throughout the day on a day-to-day basis, as consistency in carbohydrate intake has been shown to result in improved glycemic control. Diets too low in carbohydrate may eliminate too many foods that are important sources of vitamins, minerals, fiber, and energy. In persons with type 1 (or type 2) diabetes who adjust their mealtime insulin doses or who are on insulin pump therapy, insulin doses should be adjusted to match carbohydrate intake (insulin-to-carbohydrate ratios). This can be accomplished by comprehensive nutrition education and counseling on interpretation of blood glucose patterns, nutritionrelated medication management, and collaboration with the health care team. Adjusting insulin doses based on planned carbohydrate intake has been shown to improve glycemic control and quality of life without any adverse effects. However, protein and fat content (total energy intake) cannot be ignored as excessive energy intake may lead to weight gain. The EAL and JADA have identical recommendations on carbohydrate intake and distribution. Taking both sources into consideration, consistently distributing carbohydrates will be especially important due to the short-acting insulin therapy prescribed by the physician. Working with Mrs. Douglas to develop balanced meal plans that: meet the RDI (>50 yrs of age), maintains a specific time schedule in order to receive the greatest benefit from her humulin, and which addresses her coexisting health complications of HTN and dyslipidemia. In addition to meal planning, it would be well advised for her to have an understanding of carbohydrate counting. Carbohydrate counting was the most successful meal planning approach according to the Diabetes Control and Complications Trail (Anderson et al. 1993). EAL Recommendation: Protein and Diabetes DM: Protein Intake and Normal Renal Function In persons with type 1 or type 2 diabetes with normal renal function, the RD should advise that usual protein intake of approximately 15 to 20% of daily energy intake does not need to be changed. Although protein has an acute effect on insulin secretion, usual protein intake in long-term studies has minimal effects on glucose, lipids, and insulin concentrations. JADA Recommendation: Protein Intake In persons with type 1 or type 2 diabetes with normal renal function, RDs should advise that usual protein in-take of approximately 15% to 20% of daily energy intake does not need to be changed. Although protein intake has an acute effect on insulin secretion, usual protein intake in longer-term studies has minimal effects on glucose, lipid levels, and insulin concentrations. Exceptions for change in protein intake are in persons who consume excessive protein choices high in saturated fatty acids, in those who have a protein intake less than the Recommended Dietary Allowance, or in patients with diabetic nephropathy.

8 Sullivan 7 American Diabetes Association Protein intake for individuals with diabetes and early nephropathy should not exceed 0.8g/kg or 10% of total kcal. Reduction of protein intake may improve renal function. Comparing the recommendations for protein intake is relatively similar throughout. Although Mrs. Douglas did not exceed the EAL and JADA s recommendations for protein of 15-20% of her daily energy intake, her protein choices were high in saturated fat. Advising and educating Mrs. Douglas about healthier sources of protein and monounsaturated fats may help reduce her risk of nephropathy. Based on Mrs. Douglas lab results, her creatinine is in the upper tolerable limits. The ADA (2011) suggests measuring serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion. The serum creatinine should be used to determine if chronic kidney disease (CKD) is present. EAL Recommendation for Hypertension (HTN): Management of Blood Pressure Management of elevated blood pressure should be based on a comprehensive program including lifestyle modification (weight reduction, medical nutrition therapy and physical activity) and pharmacologic therapy. Research indicates that a comprehensive program can prevent target organ damage and improve cardiovascular outcomes. EAL Recommendation for DM: CVD CVD and Cardioprotective Nutrition Interventions Cardioprotective nutrition interventions for prevention and treatment of CVD include reduction in saturated and trans fats and dietary cholesterol, and interventions to improve blood pressure. Studies in persons with diabetes utilizing these interventions report a reduction in cardiovascular risk and improved cardiovascular outcomes. American Association of Clinical Endocrinologists Recommendation: Hypertension Management Aim for target blood pressure goals less than 130/80 mm Hg for management of hypertension in patients with diabetes mellitus. Use the following as first-line therapy for patients with diabetes mellitus: an angiotensinconverting enzyme inhibitor or angiotensin receptor blocker in combination with a lowdose diuretic, calcium channel blocker, and/or third generation β-adrenergic blocker in addition to lifestyle modification. The causes of hypertension are multifactorial and in her case include: excessive salt intake, advancing age, African American background, and obesity. Mrs. Douglas is currently in the stage one-hypertension category. Lowering her blood pressure to the recommended goal of less than 130/80 mmhg (pre-hypernsion stage) suggested by the American Association of Clinical Endocrinologists, would reduce a number of risk factors as well as being a realistic goal. To further reduce her risk of CVD, the EAL for diabetes suggests the reduction of saturated and trans fat which was discussed above.

9 Sullivan 8 The EAL for HTN suggests weight loss and physical activity as part of a healthy lifestyle to manage blood pressure. A collaboration of these three recommendations would be ideal for this client.

10 Sullivan 9 References ADA Diabetes Type 1 and 2 Evidence-based Nutrition Practice Guideline for Adults. (2008). ADA Evidence Library. Retrieved February 13, 2011, from Anderson, E. J., Delahanty, L., Richardson, M., Castle, G., Cerone, S., Lyon, R., Mueller, D., Snetselaar, L. Nutrition interventions for intensive therapy in diabetes control and complications trial. J Am Diet Assoc. 1993; 93: Executive summary: Standards of medical care in diabetes (2011). Diabetes Care, 34 Suppl 1, S4-10. Franz, M. J., Powers, M. A., Leontos, C., Holzmeister, L. A., Kulkarni, K., Monk, A., et al. (2010). The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. Journal of the American Dietetic Association, 110(12), Hypertension Evidence-based Nutrition Practice Guidelines. (2008). ADA Evidence Library. Retrieved February 13, 2011, from Obesity: Complications - MayoClinic.com. (2010). Mayo Clinic. Retrieved February 14, 2011, from Rodbard, H. W., Blonde, L., Braithwaite, S. S., Brett, E. M., Cobin, R. H., Handelsman, Y., et al. (2007). American association of clinical endocrinologists medical

11 Sullivan 10 guidelines for clinical practice for the management of diabetes mellitus. Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 13 Suppl 1, 1-68.

MNT Case Reports. Lipid Disorders. Amanda Sullivan

MNT Case Reports. Lipid Disorders. Amanda Sullivan MNT Case Reports Lipid Disorders Amanda Sullivan Sullivan 1 Assessment Client History 61 y.o. male with PMH of cholecystectomy, appendectomy, emphysema, and angina admitted for severe chest pain. Family