Question

T2DM case study

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

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write pes statement

calculate insulin to carb ratio

Answer 1

1st Answer: A PES Statement helps to describe a nutrition problem, to root cause-analysis and the evidence collected as per the diagnosis.

P stands for Problem, E for Etiology and S for Signs and Symptoms while writing a PES statement. A PES statement helps in nutrition assessment and diagnosis.

The PES statement for this patient is;

Problem - He has Type 2 Diabetes so his carbohydrate intake should be monitored regularly so that his glucose levels do not rise or falll. He is supposed to have protein rich diet.

Etiology - This condition, he has acquired from his paternal history who are positive for heart disease and Type 2 diabetes. He has to maintain a controlled diet to maintain his glucose levels.

Signs and Symptoms - Whenever he has more carbohydrates in his diet or eats unhealthy fast food his glucose levels rise beyond normal range or even fall beyond normal range causing him to have hemoglobin A1c and hypoglycemia at night.

An healthy diet would help him solve this problem. He should follow a regular well balanced diet and have regular exercise to maintain his metabolism as well.

2nd Answer: Insulin to carb ratio can be explained as the treatment if insulin administer to patient for the carbohydrates that he/she consumes per day. In other words, insulin to carb ration means the unit of insulin that is required per gram of carbohydrate consumed by a patient. For instance, if the doctor prescribes a unit of insulin for 5 grams of carbohydrate then the patient's insulin to carb rato would be 1:5. For this patient we cannot determine the insulin ot carb ratio correctly as the carbohydrates units that he consumes is not clearly given. The doctor has already prescribed two insulins for him Human R and Lantus. This patient may have to reduce his dosage on Lantus based on his carbohydrates consumed so that he does not feel hypoglycemic at night.