Case Study 24
Complications of Diabetes
Jennifer Hubbard
Chelsea Guetherman
Andrew Middleton
Question #1 Define the following as they relate to diabetes:
1. Hyperglycemia- also high blood sugar; an excessive amount of glucose in the
blood
Chronic hyperglycemia in the fasting states indicates Diabetes mellitus
2. Retinopathy- damage to the retina that may cause blindness, one cause of
retinopathy is diabetes
3. Neuropathy-changes in the peripheral nervous system; nerve damage
caused by diabetes
4. Nephropathy- renal disease; may be caused by damage to blood vessels
induced by hyperglycemia
5. Nephrotic Syndrome- clinical condition of the kidneys with the following
symptoms:
Protein in the urine>3.5g/day, Hyperlipidemia, Low albumin <3.5 g/dL with
edema
Many times caused by diabetes induced glomerulosclerosis
6. Proteinuria- excess protein found in the urine
7. Angioplasty- procedure designed to open blocked or narrow
Coronary arteries and increase blood flow to the heart
8. Myocardial Infarction- necrosis of the myocardial cells as a result of oxygen
deprivation; heart attack; has shown to be more severe in diabetic patients
due to accelerated atherosclerosis
Question #2 Determine Mrs. M’s IBW and percent of IBW.
IBW or Ideal body weight can be estimated using Hamwi equation
100lbs for 5 foot+ 5lbs per inch over 5 feet
Mrs. M is 5’3 100+(5*3)= 115 lbs IBW
%IBW= (252*100)/115=219.13%
Question #3 Calculate Mrs. M’s BMI.
BMI is the preferred method of weight assessment
BMI
252/2.2=114 kg 5’3=1.4m
114.545/(1.600)^2=44.74kg/m^2
Question #4 Give the pathophysiology of the following:
Retinopathy
There are 2 stages of retinopathy. They include proliferative and non-proliferative.
Non- proliferative is the first to occur. An enlarging or blockage of blood vessels in
the eye is seen. Also hemorrhage of the retina may occur, all negatively affecting
eyesight. The second stage, proliferative retinopathy is the most advanced. New
blood vessels begin to grow in the retina and bleeding and scar tissue develops.
Macular edema, retinal detachment, glaucoma and cataracts may occur
concurrently.
Neuropathy
Neuropathy is characterized by progressive damage to nerve fiber function, most
commonly occurring in the feet. Symptoms can include tingling, numbness, burning
and pain.
In type 1 DM, “distal polyneuropathy” becomes symptomatic with years of chronic
hyperglycemia. Patients with type 2 DM present with “distal polyneuropathy after
only a few years of known poor glycemic control”
Other complications may include foot ulcers, falls, amputations, fractures, and death.
Nephrotic Syndrome
Inflammation of the glomeruli of the kidney causes the retention of salt and water.
The increased retention of salt and water is also called edema. Edema leads to
hypertension by increasing pressure in certain blood vessels near the kidneys and
the heart. This can prevent the proper elimination of fluid from the blood. In
Nephrotic syndrome eventually a reduction in kidney function occurs.
Question #5 Describe the following foods and include the amount of
carbohydrates per serving:
Plantains: relative low starch, low sugar. Member of the banana family- One serving
is equal to 1cup sliced-48g CHO
Yucca: root, similar to a potato, may be bitter or sweet- One serving is equal to ½
Cup raw-38.1g CHO
Chickpeas: garbanzo bean, edible legume-One serving is equal to ½ cup -22.5g CHO
Yams: tuber of a tropical vine, sweeter than a sweet potato- One serving is equal to
½ cup baked-18.8g CHO
Arroz con qui: Spanish style rice- One serving equal to 1/3 Cup-51g CHO
Question #6 Some of Mrs. M’s food choices are extremely poor for her medical
condition. Her intake is complicated by her obese son who cooks for her. The
meal plan she should be following is complex because of the multiple
problems she has. Each of Mrs. M’s problems is listed as a heading below.
Under each heading list the foods mentioned in the case study that Mrs. M
should avoid. Many foods may be listed more than once.
Foods to avoid or limit=X
Foods Obesity Diabetes Renal Cardiovascular
Fried X X X
plantains
Dried black X
beans
Chick peas X
Rice
Yams
French X X X
Fries
Chicken X
Pork X X X
Beef X X X
Fried X X X X
eggplant
Beets X
Greens X
Salt Pork X X X X
Ham X X X
Lard X X X X
Sugared X X X X
Coffee
Oil X X X
Orange juice X
Hamburgers X X X
Soda X X X X
Beer X X X X
Question #7 For the above mentioned foods that should be avoided, suggest an
appropriate substitute.
Substitutions
Fried Plantains- raw banana occasionally
French fries-baked potato/sweet potato
Fried vegetables-baked/steamed/roasted vegetables
Beer and Soda- water
Animal protein-tofu/soy proteins
Sugar-sugar substitute
Orange juice-an orange occasionally or vegetable juice
Hamburger-turkey burger
Question #8 While Mrs. M is hospitalized for DVT, the RD will have a chance to
work with her. Outline the steps that you, as the RD, would take to teach Mrs.
M her meal plan and the importance of following it.
The first step would be to find out Mrs. M’s current knowledge of her medical
conditions and implications thereof with diet. After this initial step, the next step
would be to fill in the blanks, so to speak, and address any knowledge gaps. Once
Mrs. M had a clear understanding of the “whys” of her necessary diet, the “hows” can
be addressed.
The RD would begin with discussing current eating behavior and assessing Mrs. M’s
readiness to change. Then proceed setting small goals to substitute better choices
for current ones. For instance, Mrs. M may be willing to cut back on her soda intake
and substitute water, as well as omit her hamburgers and French fries at bowling for
week one. Then as the RD, I would suggest for week 2, focusing on having her
vegetables prepared in ways other than frying. For example, I would suggest
roasting eggplant, and trying a baked sweet potato instead of yams.
The session would proceed in this manner until all needed changes were addressed
and documented so that Mrs. M would have a written agenda for her advancement
into a healthier lifestyle.
Question #9 Considering the lifestyle presented, what behavioral changes
would you suggest to Mrs. M to help her follow her meal plan?
In order to help Mrs. M follow her meal plan, it most important that her son
understands her condition and the impact that a proper diet has in slowing the
complications of Type 2 DM. Both she and her son must be fully committed in order
for change to successfully occur. For example, her son should limit the amount of
high cholesterol and high energy-dense foods that he is cooking for his mother
during the day. Removing heavily processed foods that are high in added fats and
sugars from her environment would be beneficial. In addition, Mrs. M, should avoid
snack foods at the bowling alley and try to eliminate them from her environment
unless they adhere to her meal plan.
Question #10 Mrs. M has hyperglycemia and nephrotic syndrome. How are
these conditions going to affect her lab values?
Hyperglycemia would increase blood glucose levels, triglyceride levels, and
osmolarity, and A1c
Nephrotic syndrome would decrease BUN and serum albumin levels. It would also
increase protein levels in urinalysis.
Question #11 Calculate Mrs. M’s adjusted body weight.
Standard BW = 115 lbs
Adjusted BW = (252-115)*.25+115
= 149.25 lbs
Question #12 Why would the MD order a protein restriction of .7g/kg of IBW?
Explain.
The MD would order a protein restriction of .7 g/kg of IBW instead of the normal
.8g/kg of IBW, because a low protein diet would slow the progression of nephrotic
syndrome and kidney failure. In nephrotic patients, a low protein diet reduces the
urinary albumin excretion rate and results in an overall reduction of protein
breakdown.
Question #13 Why use the IBW weight instead of the adjusted body weight? In
your answer, relate how this would affect her protein requirement.
Since the patient has been ordered a protein restriction, using the ABW would
exceed the patient’s recommended protein intake. Therefore, IBW should be used in
order for the patient to receive the exact amount of protein. Using the ABW would
almost double her protein intake (149.25 vs. 115 lbs).
Question #14 Why was it important for Mrs. M to receive potassium and
phosphorous I.V. along with insulin?
In treating a patient with Type 2 diabetes, the monitoring of serum potassium and
phosphorus is crucial. It is important for Mrs. M to receive potassium along with
insulin in order to prevent hypokalemia. Hypokalemia can lead to serious cardiac
dysrhythmia and complications. Also, Type 2 DM can lead to hypophosphatemia, or
a decrease in the levels of serum phosphate in the body. Phosphate is an essential
component of ATP, DNA, and RNA. Phosphate should be administered along with
insulin in order to increase serum phosphate levels.
Question #15 Define the following terms:
Ileus: decreased or absence of motility of the bowel and forward movement of
bowel contents
Venography: xray of the veins taken by injecting dye into veins or marrow
Ischemia: the inadequate supply of oxygen
Esophagogastroduodenoscopy: a diagnostic endoscopic procedure that visualizes
the upper GI tract (up to the duodenum)
Gastroparesis: the delayed emptying of the stomach
Gastrovasculitis: inflammation of gastric blood vessels
Question #16 Summarize what has happened to Mrs. M with this latest
complication of diabetes and explain what may have caused this.
Mrs. M experienced gastroparesis or slow gastric emptying. This is a common
consequence of diabetes (2). Chronic high blood glucose can lead to vascular and/or
nerve damage (2). Damage to the vagus nerve or to gastric vasculature can lead to
gastroparesis (2). Venography showed Mrs. M to have gastric ischemia, which was
causing gastroparesis (1). This was probably caused by chronically high blood
glucose and the resulting gastric vasculature damage.
Question #17 What is the action of Reglan, and what are its side effects?
Reglan is a metoclopramide, and is in a class of drugs known as prokinetic agents
(3). These function to speed the movement of food through the stomach and
intestines (3). Side effects include: drowsiness, excessive tiredness, weakness,
headache, dizziness, diarrhea, nausea, vomiting, breast enlargement or discharge,
missed menstrual period, decreased sexual ability, frequent urination, and inability
to control urination (3). Some side effects are more serious and the patient should
contact their doctor immediately if any of the following arise: tightening of the
muscles (especially in the jaw or neck), speech problems, thinking about harming or
killing yourself, fever, muscle stiffness, confusion, irregular heartbeat, sweating,
restlessness, nervousness or jitteriness, agitation, difficulty falling or staying asleep,
pacing, foot tapping, slow or stiff movements, blank facial expression, uncontrollable
shaking of a part of the body, difficulty keeping your balance, rash, hives, swelling,
sudden weight gain, difficulty breathing or swallowing, high-pitched sounds while
breathing, or vision problems (3).
Question #18 Describe the placement and purpose of a PEJ.
A PEJ, or percutaneous endoscopic jejunostomy, is the creation of a hole in the
jejunum, commonly accomplished by laparoscopy, in order to place a feeding tube
(4).
Question #19 Considering all of the problems Mrs. M has, what TF would you
recommend? Justify your answer.
I would recommend beginning with a continuous drip tube feeding, due to
proximity to surgery. Eventually I would move to an intermittent drip tube feeding.
This would allow Mrs. M to continue ambulatory exercises. In addition, her GI
function is stable enough to allow for the eventual transition to intermittent drip,
but not so soon after surgery. Bolus feedings are not recommended for PEJ patients
because the feeding tube is smaller and prone to clog.
Question #20 Describe the initial strength and flow rate you would use, the
progression to the final flow rate, and the total kcals and protein Mrs. M would
be receiving at the final flow rate (in total kcals and total grams and in kcals
and grams per kg of IBW).
The estimated daily energy requirement for Mrs. M is 1995 kcal or an approximately
2000 kcal/day diet. In addition, if the .7 g protein per kg IBW regimen is continued,
she has a protein need of 36.68 grams per day. Also, we selected a continuous drip
administration so these values will be calculated for an hourly basis.
If Suplena with carbsteady is used, she will need approximately 1.1L of formula per
day. This will result in a protein intake of 50g per day, which is a realistically close
value to the suggested limit of 37 grams per day. At the final flow rate, each hourly
feeding will consist of 46 milliliters of formula which translates to 83 kcal and 2
grams protein or 1.6 kcal/kg IBW and .04 grams protein/kg IBW.
The flow should start at 30 ml/hour and progress by 10 ml/hour up to the final flow
rate of 46 ml/hour.
Question #21: Compare 2-3 of the enteral nutrition supplements that would
be appropriate for someone with diabetes with Mrs. M’s complications
(Appendix E).
Product Producer Form Cal/ml Non- Pro g/L CHO/L Fat/L Na K mg mOsm/kg Vol to G of Free
pro mg water meet fiber/L H2O/L
cal/g RDA in ml
N in ml
Nepro with Abbott Oral/tube 1.8 121:1 81 144 203 1055 1055 745 944 13 172
carbsteady Nutrition
Suplena with Abbott Oral/tube 1.8 239:1 45 196 96 802 1139 780 944 13 175
carbsteady Nutrition
Glucerna 1.2 Abbott Oral/tube 1.2 100:1 60 114 60 1118 2025 720 102 192
Cal Nutrition
Jevity Abbott Oral/tube 1.2 10:1 56 222 122 1371 1857 450 1000 18 191
Nutrition
(5)
Question #22: Write two nutrition diagnoses for Mrs. M.
Obesity related to nutrition knowledge deficit as evidenced by poor food choices.
Delayed gastric emptying related to chronic hyperglycemia as evidenced by
ischemia.
References:
1. The case study itself.
2. http://digestive.niddk.nih.gov/ddiseases/pubs/gastroparesis/
3. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000821/
4. http://www.dukehealth.org/health_library/care_guides/cancer/treatment_i
nstructions/jejunostomy
5. http://www.abbottnutrition.com/products
References
Nelms MN. Nutrition Therapy & Pathophysiology, 2nd Ed.
Belmont, CA: Wadsworth, Cenage Learning; 2011, 2007
http://www.diabetes.org/livingwithdiabetes/complications/neuropathy/
http://en.wikipedia.org/wiki/Hyperglycemia
http://www.nhlbi.nih.gov/health/health-topics/topics/angioplasty/
http://www.mayoclinic.com/health/heart-attack/DS00094
http://circ.ahajournals.org/content/93/12/2089.full
http://www.mdcalc.com/ideal-body-weight
http://health.yahoo.net/adamcontent/diabetic-retinopathy
http://emedicine.medscape.com/article/1170337-overview
http://en.wikipedia.org/wiki/Nephritic_syndrome#Pathophysiology
http://grabemsnacks.com/what-is-a-plantain.html
http://homecooking.about.com/od/howtocookvegetables/a/sweetpotatodiff.htm
http://en.wikipedia.org/wiki/Chickpea
http://www.calorieking.com/
http://www.ehow.com/facts_5670095_foods-avoid-kidney-disease.html
http://www.drugs.com/cg/renal-failure-diet.html
http://www.medterms.com/script/main/art.asp?articlekey=3135
http://www.medicinenet.com/peripheral_vascular_disease/article.htm
http://www.globalrph.com/labinter.htm
http://www.nature.com/ki/journal/v60/n1/full/4492392a.html
http://emedicine.medscape.com/article/118361-treatment#a1156
http://emedicine.medscape.com/article/767955-overview#showall
http://www.carbs-information.com/carbs-in-food.htm
http://www.livestrong.com/article/70198-edema-related-hypertension/