Question

The patient is a 73 years old man diagnosed one year ago with type 2 diabetes mellitus. He has a history of coronary heart disease s\p angioplasty 5 years prior, hypertension, retinopathy, and left foot neuropathy. He makes every attempt to follow a healthy diet, and has been avoiding table sugar for the past year on his physician’s advice. He comes to see the registered dietitian due to a persistently elevated hemoglobin A1c and hypoglycemia during the night.

His weight is 99.79 kg (240 lbs), height is 187.96 cm. He weighed 108.86 kg (30 lbs) 5 years ago, and lost 13.60 (10 lbs) after his angioplasty by adopting a lower fat diet. He has since regained 4.53 kg.

• Biochemical data:

Parameter	Value
Glucose (mid- morning fingerstick)	223 mg\dl
Fasting glucose	140 mg\dl
Hemoglobin A1C	9.2%
Total cholesterol	160 mg\dl
LDL cholesterol	97 mg\dl
HDL cholesterol	55 mg\dl
Triglyceride	87 mg\dl

His blood pressure 130\80 mm Hg.

• Client history

o Family history

Paternal history is positive for heart disease and type 2 diabetes. He lives with his wife who does most of the cooking and shopping. He does not smoke. He gets little physical activity.

• Medications

o He is on insulin: Humulin R (short acting insulin) and Lantus (long acting insulin)

• Total daily insulin 50 units\d

o 18 units as basal insulin at bedtime (long acting insulin)

o 10 units in the morning before breakfast (short acting insulin)

o 10 units for lunch

o 10 units for diner

o 2 units for snack

o He doesn’t take any vitamins or supplements

• The following represent his usual intake

Meal	Description
Breakfast	Cold cereal (raisin bran), 2oz Nonfat milk, 1 cup Cranberry juice, 1 cup 2 slices rye toast with 2 tbs (tablespoon) fruit spread coffee with 2 tbs fat-free hazelnut creamer
Lunch	Turkey club sandwich: 3 oz turkey 1 tbs reduced fat mayonnaise lettuce and tomato 1\4 sliced avocado 2 slices turkey bacon 2 slices white bread, toasted fresh fruit, 1 piece tea with 1 tbs honey
Snack	4 fat free fig cookies 1\2 cup apple cider
Dinner	6 oz of fish or chicken, baked or broiled 1\2 cup cooked white rice or potato 1\2 cup cooked vegetables (carrots and green beans) 1 oz rool with 1 tbs stanol-ester enriched margarine green salad with 1 tbs olive oil and 1 tbs vingar plain seltzer water, 12 oz
Evening snack	6 oz nonfat vanilla yogurt ¼ cup mixed nuts

write pes statement and calculate insulin to carb ratio

Answer 1

PES Statement Components

The PES statement describes the nutrition problem, its root cause and evidence for the diagnosis.

The format of the PES statement is: Problem (the nutrition diagnosis) related to Etiology (factors contributing to the nutrition diagnosis) as evidenced by Signs and Symptoms (findings from the nutrition assessment that determine the nutrition diagnosis).

The Problem

The problem, or nutrition diagnosis, is based on the most urgent issue, with verbiage taken directly from the Nutrition Diagnostic Terminology Sheet (1).

Frequently used nutrition diagnoses include:

Inadequate energy intake

Inadequate oral intake

Swallowing difficulty

Altered nutrition-related laboratory values

Altered GI function

Malnutrition (specify mild, moderate or severe and context)

Food/nutrition-related knowledge deficit

Depending on which nutrition diagnosis you use, you must be able to resolve or improve it.

The Etiology

The etiology is the cause or contributing risk factors of the nutrition diagnosis. It connects to the nutrition diagnosis by the words related to.

It tells you what type of intervention you need to either treat the nutrition diagnosis or lessen the signs and symptoms.

The Signs and Symptoms

The signs and symptoms are the evidence that supports your nutrition diagnosis. It connects the etiology by the words as evidenced by.

Commonly used signs and symptoms may include lab values, intake history, nutrition knowledge, anthropometric data or findings from the nutrition focused physical exam.

TYPE 2 DIABETES ADULT OUTPATIENT INSULIN GUIDELINES

If post-meal glucose levels > 180: ADD PRANDIAL INSULIN6,7,8

Note: If patient unable to do multiple daily injections, consider switching to MIXED INSULIN instead of adding prandial

insulin. (Mixed insulin is more likely to cause hypoglycemia8,19 and generally requires a fixed meal schedule8

)

TITRATE:

Teach patient to self titrate ↑ by 2 units every 2-3 days until average fasting glucose < 130*6,7,8,13,14,30,32

(*Inform patient to hold titration until further evaluation if develops any hypoglycemia)

or

Titrate 1-2 times per week such as per table below until average fasting glucose < 1306,19

Fasting glucose > 200 ↑ 4 units

Fasting glucose 131-200 ↑ 2 units

Fasting glucose 70-130 No change in dose

Fasting glucose < 70 ↓ 2-4 units or by 10%

STARTING DOSE:

Start dose: 10 units6,7,8,11,12,13,14,16,19,20,21,22,25

Consider using a lower starting dose (such as 0.1 units/kg/day32) especially if

patient is thin or has a fasting glucose only minimally above goal.17,19

GENERAL RECOMMENDATIONS

 Start insulin if A1C and glucose levels are above goal despite optimal use of other diabetes

medications. (Consider insulin as initial therapy if A1C very high, such as > 10.0%) 6,7,8

 Start with BASAL INSULIN for most patients 6,7,8

 Consider the following goals1,6

ADA A1C Goals: A1C < 7.0 for most patients

A1C > 7.0 (consider 7.0-7.9) for higher risk patients

1. History of severe hypoglycemia 2. Multiple co-morbid conditions

3. Long standing diabetes 4. Limited life expectancy

5. Advanced complications or 6. Difficult to control despite use of insulin

ADA Glucose Goals*: Fasting and premeal glucose < 130

Peak post-meal glucose (1-2 hours after meal) < 180

Difference between premeal and post-meal glucose < 50

*for higher risk patients individualize glucose goals in order to avoid hypoglycemia

BASAL INSULIN

Intermediate-acting:

NPH Note: NPH insulin has elevated risk of hypoglycemia so use with extra

caution6,8,15,17,25,32

Long-acting:

Glargine (Lantus®)

Detemir (Levemir®)

 Basal insulin is best starting insulin choice for most patients (if fasting glucose above goal). 6,7,8

 Start one of the intermediate-acting or long-acting insulins listed above. 6,7 Start insulin at night. 8

 When starting basal insulin: Continue secretagogues. Continue metformin. 7,8,20,29

 Note: if NPH causes nocturnal hypoglycemia, consider switching NPH to long-acting

STARTING DOSE:

Start dose: 10 units6,7,8,11,12,13,14,16,19,20,21,22,25

Consider using a lower starting dose (such as 0.1 units/kg/day32) especially if

patient is thin or has a fasting glucose only minimally above goal.17,19

TITRATE:

Teach patient to self titrate ↑ by 2 units every 2-3 days until average fasting glucose < 130*6,7,8,13,14,30,32

(*Inform patient to hold titration until further evaluation if develops any hypoglycemia)

or

Titrate 1-2 times per week such as per table below until average fasting glucose < 1306,19

Fasting glucose > 200 ↑ 4 units

Fasting glucose 131-200 ↑ 2 units

Fasting glucose 70-130 No change in dose

Fasting glucose < 70 ↓ 2-4 units or by 10%

Once fasting

glucose at goal,

evaluate post-meal

glucose pattern6,7,

If post meals glucose levels > 180: ADD PRANDIAL INSULIN6,7,8

Note: If patient unable to do multiple daily injections, consider switching to MIXED INSULIN instead of adding prandial

insulin. (Mixed insulin is more likely to cause hypoglycemia8,19 and generally requires a fixed meal schedule8).