Type 2 DM - Case Study

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Type 2 DM - Case Study
2/18/00

• Jean Kerver, MS, RD, CDE
• kerverje_at_pilot.msu.edu

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• DR is a 45 y.o. male Ht 59 Wt 215 lbs
• Present complaint polydipsia, polyuria, fatigue.
• Past med hx Type 2 DM x 5 yrs.
• Meds None NKDA.
• Labs No SBGM
• serum glucose285 mg/dL 1 hr ppd
• HbA1C9.2
• urinary glucose2
• temp98.8 F.

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• Family med hx Grandma type 2 DM at age 60 yrs
• Social hx architect lives alone nonsmoker no
  regular physical activity.
• Diet hx no known food allergies
• no supplements (vit/min or other)
• no special diet
• drinks 2 beers qd after work
• brkfst at home
• lunch outfast food or deli type
• dinner at home cooks or orders take-out food
• seldom snacks.

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Breakfast (24-hr recall) 2 cups raisin bran 1
lg banana 1 cup whole milk 8 oz orange
juice Lunch 4 oz corned beef 1 oz swiss
cheese 2 slices rye bread ½ cup cole slaw 2
tbsp russian dressing 1 small bag potato
chips 12 oz juice cocktail
4 starch, 1 fruit 380 kcals 2 fruit 120 kcals 1
high fat milk 150 kcals 2 fruit 120 kcals 4
med-fat meat 300 kcals 1 high-fat meat 100
kcals 2 starch 160 kcals 1 vege, 1 fat 70
kcals 2 fat 90 kcals 1 starch, 1 fat 125
kcals 150 kcals
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Dinner (24-hr recall, contd) 1 cup fried rice
4 oz Hunan chicken (fried) 4 oz shrimp and
cashews 2 bottles beer 1 lg orange Total
kcals 3411 Protein 14 Fat 40 Carb 46
3 starch, 3 fat 375 kcals 4 high fat meat
400 kcals 4 high fat meat 400 kcals 2
beer 300 kcals 2 fruit 120
kcals Total Kcals 3360
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How Many kcals Should He Have?

• Ht 59 Wt 215 lbs
• IBW 106 lbs (9 x 6 lbs) 160 lbs
• IBW 215 lbs /160 lbs 134
• AdjBW 0.25 (215-160) 160 174 lbs (79 kg)
• 25 kcals/kg 25 x 79 1975 kcals/d
• 24-hr 3411 kcals 500 kcals 2900 kcals

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Calculation of Initial Dietary Pattern

• Total kcals 2000
• 50 CHO 0.50 x kcal 0.50 x 2000 250 g CHO
• 4 kcal/g CHO 4
• 20 PRO 0.20 x kcal 0.20 x 2000 100 g PRO
• 4 kcal/g PRO 4
• 30 FAT 0.30 x kcal 0.30 x 2000 67 g FAT
• 9 kcal/g FAT 9

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ADA Exchanges
Food Gp CHO (g) PRO (g) FAT (g) Kcals
Starch 15 3 - 80
Meat - 7 3-8 55-100
Vege 5 2 - 25
Fruit 15 - - 60
Milk 12 8 0-8 90-150
Fat - - 5 45

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Negotiate, Then Convert Into Exchanges

• First, determine how many servings of milk,
  fruit, and vegetables the patient is willing to
  eat each day.
• Next, add up the CHO from the milk, fruit, and
  vegetable groups and subtract that amount of CHO
  from the total amount of CHO needed.
• Then divide the remaining amount of CHO into
  starch exchanges.
• Do the same for PRO and FAT.

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Negotiate, then Convert CHO (250 g)
No. of Exchanges CHO (g) PRO (g) FAT (g)
Milk 2 (12) 24 (8) 16 (5 - 2) 10
Vege 3 (5) 15 (2) 6 -
Fruit 4 (15) 60 - -
Starch 10 (15) 150 (3) 30 -
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Convert PRO (100 g)
No. of Exchanges CHO (g) PRO (g) FAT (g)
Milk 2 (12) 24 (8) 16 (5 - 2) 10
Vege 3 (5) 15 (2) 6 -
Starch 10 (15) 150 (3) 30 -
Meat 7 - (7) 49 (5) 35
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Convert FAT (67 g)
No. of Exchanges CHO (g) PRO (g) FAT (g)
Milk 2 (12) 24 (8) 16 (5 - 2) 10
Meat 7 - (7) 49 (5) 35
Fat 4 - - (5) 20
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Diet Pattern
Food Group No. of Exchanges CHO (g) PRO (g) FAT (g)
Starch 10 (15) 150 (3) 30 -
Meat 7 - (7) 49 (5) 35
Vege 3 (5) 15 (2) 6 -
Fruit 4 (15) 60 - -
Milk 2 (12) 24 (8) 16 (5 - 2) 10
Fat 4 - - (5) 20
Totals 249 101 65 Rx Totals
250 100
67

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Metabolic Effects of Exercise in Type 2 DM
Lipolysis
Decreased Plasma Insulin
Lower Blood Glucose
Increased peripheral glucose uptake
Increased Insulin Sensitivity
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Multiple Dose Regimen
When Therapy Changes
NPH Humalog BID
Add Bedtime NPH to Orals
Combinations of Oral Agents Metformin
Sulfonylureas, etc.
Monotherapy Oral Agents Sulfonylureas, Metformin
, Troglitazones, etc.
Meal Planning and Physical Activity
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Diabetes Education

• Tell patient what to expect
• Individualize-always give choices
• Be systematic-prioritize
• Discuss coping strategies
• Special situations

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Evaluating Outcomes in DM Treatment
Outcomes Can Be Clinical
Economic Quality
of Life Glycemic Control length/stay
Participation in care HbA1c
-ER visits - SMBG Blood lipids
-costs to - keeps appts.
Weight/BMI health plan - Rx
refills Blood pressure
Complications Better work Q of
Life survey
attendance