Case Study #1: Diabetes Mellitus

Objective: To provide evidence-based Medical Nutrition Therapy for a 48 y/o woman diagnosed
with Type 2 diabetes mellitus.
Primary Resources to be used: (you will need to use other resources from the Resource List in
Appendix B of the Course Syllabus). Please list the resources that you used (using
abbreviations below) at the end of your answers to the questions that are shown in red.
Academy of Nutrition and Dietetics Evidence Analysis Library (EAL) at
http://andevidencelibrary.com/default.cfm?auth=1
Academy of Nutrition and Dietetics Nutrition Care Manual (NCM) at
http://nutritioncaremanual.org/auth.cfm?p=%2Findex%2Ecfm%3F&err=NotLoggedIn
Cochrane Library of Systematic Reviews (CLSR)
http://www.thecochranelibrary.com/details/browseReviews/685223/Type-2.html?page=1

Instructions: Answer the following case study questions, thinking in terms of this patient being
your actual patient, and then complete the initial assessment note and follow-up progress note.

Mrs. Robinson is a 48 y/o Caucasian in Tulsa, OK. She has lived there with her family all of her
life and has three children. She has never worked outside the home. Her husband worked at a
local automobile plant, but has been laid off for the past 6 months. All of Mrs. Robinsons
children have finished high school but one still lives at home and is unemployed. The family
income is just high enough that they do not qualify for any food assistance programs.
Mrs. Robinson has a pronounced family history of Type 2 diabetes mellitus. Her mother and her
brother have both had severe complications because of poor control of blood glucose. Mrs.
Robinson is well aware of the problems in her familys past, but this has not stopped her from
eating whatever she wants. She is 56 (167.6 cm) and weighs 210 lbs (95.4 kg) with a medium
frame with a waist circumference of 42. She is not very active but does work in her vegetable
garden a lot. Occasionally she goes for long walks in her neighborhood in the evenings. She
graduated from high school and reads and writes at a 12th grade level. On several occasions she
has been treated for UTIs and has frequent colds. She does not have a history of any major
illness. She is not currently taking any medications.
During the past month, Mrs. Robinson noticed some significant changes in the way she feels.
She becomes fatigued easily and has to urinate more frequently, even during the night. She is
thirsty and hungry all the time. She is eating more but she lost 10 lbs (4.5 kg) in the last six
weeks and her vision has become blurred. Her blood pressure was 150/88. The physician
obtained a CBC, BMP and lipid profile and found the following:

Date: 02/10/2015
Result

BMP
(Basic
Metabolic
Panel)

Lipid
Profile

Reference Range

Glu
BUN
Cr
Ca
Alb
Na
K
Cl
Mg
P

353 mg/dl
28 mg/dl
1.1 mg/dl
9.1 mg/dl
3.7 mg/dl
148 mEq/L
5.3 mEq/L
104 mEq/L
2.0 mEq/L
3.1 mEq/L

(H)
(H)

Chol
TG
HDL
LDL

300 mg/dl
350 mg/dl
30 mg/dl
? mg/dl

(H)
(H)
(L)

(H)
(H)

70-110 mg/dl
6-20 mg/dl
0.6-1.1 mg/dl
8.8-10.0 mg/dl
3.5-4.8 mg/dl
136-145 mEq/L
3.5-5.2 mEq/L
96-106 mEq/L
1.8-2.6 mEq/L
2.7-4.5 mEq/L

140-199 mg/dl
<150 mg/dl
40-85 mg/dl
<130 mg/dl

1. Calculate Mrs. Robinsons BMI. How does her BMI and waist circumference factor into her
overall health risks? (2 points)
BMI = weight (kg)/ height (m)2
BMI = 95.4kg/ 1.676m2 = 2.81
BMI = 33.95 ~ 34
This places her in the obesity category (class 1 obesity). Her waist circumference is greater
than 35 inches. A value greater than 35 inches for women, along with her BMI of 34,
indicates a very high risk of the onset of weight-associated diseases (NHLBI).

Specifically, a waist circumference greater than 35 inches may indicate metabolic syndrome.
Metabolic syndrome is based on criteria such as abdominal obesity (defined by waist
circumference greater than 35 inches for women and greater than 40 inches for men) high
blood pressure, high TG, low HDL, and high fasting blood sugar. An individual is said to
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have metabolic syndrome when they have at least three of the five criteria above. Therefore,
Mrs. Robinson has metabolic syndrome because she has a waist circumference of greater
than 35 inches, low HDL, high TG, and high blood pressure.
2. Calculate Mrs. Robinsons LDL using the Friedewald Equation:
LDL = Total cholesterol HDL (TG/5) (2 points)
LDL = 300 mg/dl 30 mg/dl - (350 mg/dl /5)
LDL = 200 mg/dl
Healthy value = <130 mg/dl

3. What is the goal for LDL in a patient with diabetes? (2 points) (NCM) (ATP III)
The ATPIII guidelines regard diabetes as a CHD risk equivalent. Thus, a patient with
diabetes may have a modified LDL cholesterol goal, taking into account their other risk
factors as well. Specifically, for Mrs. Robinson, her LDL goal is modified by the fact that she
is hypertensive with a BP of 150/88 mmHg and has low HDL cholesterol of 30 mg/dl. With
this criteria, her LDL goal would be < 130 mg/dl. However, presumably, she will also be
diagnosed with diabetes. Since diabetes is a CHD risk equivalent, her LDL goal is < 100
mg/dl. Further, the Nutrition Care Manual suggests that statin therapy be added to lifestyle
therapy, regardless of baseline lipid values, for patients with diabetes who are older than 40
years of age and have one or more CVD risk factors. In Mrs. Robinsons case, she is older
than 40 years of age and has both low HDL and hypertension. Thus, her LDL goal is < 100
mg/dl.

4. What is HbA1C and how is it used in diabetes education? (2 points) (NCM)

HbA1C is glycosylated hemoglobinglucose that is attached to a hemoglobin protein. It is a
marker of glycemic control and is a target of MNT for diabetes since it defines a diagnosis of
DM. When a patient is first thought to be at risk of having diabetes, HbA1c is evaluated. If a
patient has an A1C level between 5.7-6.4%, then they are said to have prediabetes and they
should be referred to a support program with emphasis on weight loss and increasing
physical activity. If a patient has an A1C level greater than 6.5%, they are then diagnosed
3

with diabetes. HBA1c is used in diabetes education as an indication of effectiveness of MNT.

Patients are taught that A1C levels reflect glycemic control. For MNT, patients are given
intervention goals involving carbohydrate counting, healthy food choices, physical activity,
meal plans, lowered energy and fat intake, and behavioral strategies to support these goals.
A1C levels are checked again post-intervention to assess the effectiveness of treatment. They
glycemic goal for non-pregnant adults with diabetes is an A1C <7%. A patient is taught that
if their glycemic goal, as defined by A1C, cannot be met after diet and lifestyle changes, then
they will need more aggressive therapy with medications such as metformin.

5. List the symptoms of Type 2 diabetes that are manifested in Mrs. Robinson. (2 points)
Mrs. Robinson is experiencing symptoms of type 2 diabetes including fatigue, frequent
urination, constant hunger and thirst, blurry vision, and weight loss despite her appetite and
dietary consumption.

6. Explain the pathophysiology of these symptoms. (2 points)

Fatigue: blood sugar is not properly getting into cells to be used for fuel so body feels like it
does not have much energy to run on
Frequent urination: excess blood sugar is being filtered out via the kidneys at a high rate,
increasing urination
Increased hunger: because the body is deprived of proper utilization of glucose, it thinks that
it is not being fed thus feelings of hunger intensify
Increased thirst: increased urination leads to increased thirst mechanism
Blurry vision: high glucose levels alter the shape of the eye
Weight loss: without proper glucose utilization, the body is using fat for metabolism

The MD diagnosed Mrs. Robinson with dehydration and obesity with Type 2 diabetes. He based
his decision on her family history, lab values, anthropometric measurements, elevated BP, and
the symptoms he described as polydipsia, polyuria, polyphagia, hyperglycemia, and fatigue. He
prescribed a 1,000 kcal diet, Glucophage (metformin), 500 mg BID 30 minutes before breakfast,
Pravachol (pravastatin sodium), 40 mg per day at bedtime, and referred her to the clinics RDN
(you). He also wanted her to start an exercise program, but he wanted her to get her blood
glucose down first. He told her it would be alright if she started walking a small amount, even if
it was just a block a day, and increase her distance as she was able. He told her she had to lose
weight and if she did, she may be able to stop taking her medication and be free of the symptoms
of diabetes, or at least lessen them.
7. Define the following terms: polydipsia, polyphagia and polyuria. (2 points)
Polydipsia: abnormal increased sensation of thirst
Polyphagia: abnormal increased sensation of hungry
Polyuria: abnormally frequent urination

8. What evidence did the MD have that suggested that Mrs. Robinson was dehydrated? (2 points)
MD based Mrs. Robinsons diagnosis of dehydration on her subjective symptoms of frequent
urination and increased thirst while also taking into account her high Na level. Hypernatremia is
caused by water losses greater than water intake. Although Mrs. Robinson may be drinking a lot
to combat her thirst, she is frequently urinating since her kidneys are excreting the excess
glucose out of her body. Mrs. Robinson also has an elevated BUN level which may be associated
with dehydration. Additionally, her potassium level is high; dehydration most likely caused this.

9. What is considered to be good control for blood glucose, lipid, and blood pressure in
patients with diabetes and what is considered poor control? (2 points) (NCM)
The NCM recommends certain targets for glycemic goals, lipid goals, and blood pressure goals.
A1C should be less than 7%, preprandial capillary plasma glucose should be between 70-130
mg/dL, and peak postprandial capillary plasma glucose should be less than 180 mg/dl. Adults
with hypertension and diabetes, as is the case with Mrs. Robinson, should works toward reaching
a systolic blood pressure of less than 140 mmHg and a diastolic blood pressure of less than 80
mmHg. As for lipid management, LDL cholesterol should be less than 100 mg/dL in patients
with diabetes without overt CVD or less than 70 mg/dl if the patient with diabetes has CVD.
Both patients with and without CVD however should take stains along with therapeutic lifestyle
changes to reduce lipids. Further, triglycerides should be less than 150 mg/dL and HDL should
be greater than 40 mg/dl in men and greater than 50 mg/dl in women. These MNT goals should
be reached through healthful eating patterns with an emphasis on portion control and nutrient
density. It is important to note that all MNT goals should be individualized, taking into account
the patients duration of diabetes, age/life expectancy, comorbid conditions, CVD or advanced
microvascular complications, hypoglycemia unawareness, and individual patient considerations.
Poor control for blood glucose, lipid, and blood pressure in patients with diabetes is values
outside these target ranges.

10. Why should the physician be concerned about the abnormal lipid profile of a person
with diabetes who is out of control like Mrs. Robinson? (2 points) (EAL)
The physician should be concerned about the abnormal lipid profile of a person with DM
because the ATP III defines DM as a CHD risk equivalent. Also, according to the EAL, diabetes
is associated with an increased risk of CVD complications; specifically diabetic patients are at a
three-to fourfold increase. Mrs. Robinson is already at risk for CVD complications because she
has high cholesterol independent of her DM. Diabetes can lead to both microvascular (diabetic
neuropathy, retinopathy, and nephropathy) and macrovascular complications (stroke, CAD, and
peripheral arterial disease). A diabetic patient with an abnormal lipid profile may advance more
quickly to having stroke, CAD, or peripheral arterial disease.

11. Describe the function of metformin and list any nutritional implications/side effects.
(4 points)
Metformin, also known as glucophage, is part of the biguanide class of medications. It acts on
the liver to decrease hepatic glucose production and help to reduce insulin resistance.
Noteworthy side effects include nausea, vomiting, diarrhea, and gas. These side effects may be
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lessened by taking the drug with a meal and by slowly increasing its dose. Metformin is the first
medication used to treat type 2 DM in addition to MNT and lifestyle changes
Metformin: preferred initial pharmacological agent for type 2 DM either in addition to MNT and
support for weight loss and physical activity or when lifestyle efforts alone havent achieved or
maintained glycemic goals. If use of metformin still does not allow the patient to reach their
glycemic goals, metformin may be used in combination with glucagon-like peptide 1 receptor
agent as a form of more aggressive therapy.

12. Describe the function of pravastatin sodium and list any nutritional implications and side
effects. Why did the physician tell Mrs. Robinson to take it at bedtime? (4 points)
Pravastatin sodium is a statin to help lower lipid values by reducing cholesterol biosynthesis via
HMG-CoA reductase inhibitors. It is used along with diet therapy to reduce the risk of MI;
reduce elevated cholesterol, LDL, and TG; and, raise HDL. Adverse side effects and nutritional
implications include musculoskeletal pain, nausea and vomiting, upper respiratory infection,
diarrhea, and headaches. The MD told Mrs. Robinson to take pravastatin sodium at bedtime
because most of the bodys cholesterol is made at night during sleep. The medication will be
most effective taken right before bedtime then.

13. The MD told Mrs. Robinson that if she lost weight, she might not need the medication
and could be free of her symptoms. Describe the relationship between obesity and diabetes.
(2 points) (EAL) (Leong KS, Wilding JP. Obesity and diabetes. Clinical Endocrinology &
Metabolism. 1999; 13(2): 221-237)
Obesity is closely related to the development of diabetes. According to Leong and Wilding in
Obesity and diabetes, elevations in plasma leptin, TNF-, and non-esterified fatty acid levels
are integral in causing insulin resistance. Thus, the EAL suggests the RDN to development a
plan for the patient with diabetes focusing on education, reduced fat and energy intake, and
regular physical activity. Emphasis is placed on long term weight reduction but as far as diabetes
management is concerned, glycemic control is the primary focus rather than immediate weight
loss. Weight loss may improve glycemic control but weight loss alone may not be enough to
reach target glycemic levels. The EAL notes that as diabetes progresses and insulin deficiency
worsens, diabetic medications will most likely need to be combined with MNT to achieve proper
glycemic control. Further, weight reduction drugs, such as orlistat, have shown to have
consistent improvement in A1C in a number of studies.

14. The MD encouraged Mrs. Robinson to start a walking routine. Describe how
walking/increased exercise can help with the management of DM. (2 points) (NCM)
Walking/increased exercise on a regular basis can help with the management of DM by
increasing energy expenditure and helping with weight loss, improving insulin sensitivity,
reducing the risk of CVD, and improving by glycemic and lipid levels. To benefit from exercise,
Mrs. Robinson should perform 90-150 minutes of moderate-high intensity aerobic physical
activity per week. This amount should be broken down into 20-30 minutes of physical activity
per day. Additionally, Mrs. Robinson should partake in resistance/strength training at least three
6

times per week. It is important to note that Mrs. Robinson should begin her exercise regimen
gradually as to not injure herselfshe may have a lower VO2max and require starting slowly. If
she is already walking around outside and working in her garden, I would recommend to increase
the frequency and length of her walks and then work in more intense aerobic exercise and
strength training with body weight initially. To begin, Mrs. Robinson should work towards being
physical active 20 minutes and work up to 30 minutes per day which will help improve fitness
(she can even start with ten minute intervals and accumulate 30 minutes throughout the day). She
would need to increase this amount when ready to 60-90 minutes per day to maintain weight
loss.

The RDN (you) interviewed Mrs. Robinson and discovered that she consumed a high-fat, lowprotein, high-carbohydrate diet. She liked fried chicken and consumed a large amount of soda,
candy, cookies, potato chips, and corn chips. The sodium content of her diet was high. She did
not drink milk and ate cheese and yogurt very infrequently. There were very few fruit and
vegetables in her diet, and she did not eat meat often. She was used to eating a snack before
going to bed at night. She usually got up early in the morning to avoid the heat and had a light
snack before working in the yard for a couple of hours. She then came in and ate breakfast;
lunch was around 1 PM, and the evening meal was at about 6 PM. Sometimes she would take a
walk after supper but not specifically for the purpose of getting exercise.

15. How many visits for MNT are recommended: number and length of both initial and
follow-up encounters? When should MNT begin? (4 points) (NCM)
According to the NCM, 3-4 visits are recommended as part of an initial series of consultations
between patient with diabetes and an RDN. These first 3-4 visits should last 45-90 minutes in
length. This series should begin within 3 to 6 months of when a patient is given the diagnosis
of having diabetes or is referred to an RDN for MNT for diabetes. The RDN should then
determine whether additional assessment visits are needed. At least one follow-up visit is
recommended per year to evaluate and monitor therapy goals and to assess changes in MNT,
lifestyle, or medications. A follow-up visit should last around 45-90 minutes as well. Besides the
one follow-up visit per year, the RDN can suggest meeting with the patient more often, if
needed.

16. A. Calculate Mrs. Robinsons estimated energy needs. Indicate which equation you
used to estimate her needs and why. Show your work. (2 points) (NCM, EAL)
The EAL suggests using the Mifflin St. Jeor equation is estimate resting metabolic rate of
overweight/obese patients. For women, the Mifflin St. Jeor equation is:
10 (weight in kg) + 6.25 (height in cm) 5 (age) 161
Mrs. Robinsons estimated energy needs:
10 (95.4kg) + 6.25 (167.6cm) 5(48) 161 =
954 + 1047.5 240 161 = 1600 kcal/d

Because 1600 kcal/d is only the pts RMR, an activity factor needs to be considered for
total energy requirement. I am choosing an activity factor of 1.3 which indicates a
sedentary lifestyle since Mrs. Robinson has stated she is not very active. An injury factor
does not need to be added at this time.
1600 (1.3) = 2000 kcal/d
However, because Mrs. Robinson is obese, she should maintain a caloric deficit to lose
weight. To reach a caloric deficit, she should consume 70% of her needs and try to lose
around a pound/week. This equates to reducing energy intake by 500 kcal per week.
Thus, Mrs. Robinsons estimated energy needs are more around 1500 kcal/d. The NCM
recommends an approximate energy intake of 1200-1500 kcal/d for weight loss. To start,
Mrs. Robinson should try to consume 1500 kcal/d as a realistic goal for weight loss.
For protein, patients with diabetes with normal renal function should consume the usual
amount of protein around 15-20% of daily energy intake. The NCM states that although
protein has an acute effect on insulin secretion, 15-20% of protein intake in long-term
studies has had minimal effect on glucose, lipid, and insulin concentrations. 15-20% of
protein equates to 225-300 kcal of protein/d.
Her protein needs can also be calculated using her weight in kg. Mrs. Robinsons
desirable body weight (DBW), based on the Hamwi formula, is 130 lbs or 59.1kg. She is
currently 95.4kg. This makes her 161% over her DBW. Thus, for protein needs using kg,
her adjusted body weight (ABW) should be calculated. Her ABW is 68.2 kg
ABW = (actual weight DBW).25 + DBW
ABW = (95.4-59.1).25 + 59.1 = 68.175kg
Usual protein needs = 0.8g/kg body weight
0.8(68.2) = 54.56 ~ 55g
Thus, I am going to provide Mrs. Robinson a range of protein intake between 55-70 g
(55g pro x 4kcal/g pro = 220 kcal) This checks with the above 225-300
(70 g pro x 4kcal/g pro = 280 kcal)
I am suggesting up to 70 g pro/d because lean proteins are healthful food choices that fit
into a meal plan emphasizing weight loss.
For fluid needs, average adults need 25-30mL/kg of body weight.
25mL(68.2kg) = 1705 mL
30mL(68.2kg) = 2046mL
Thus, I would suggest 1700-2000mL or per MD recommendation.
B. How many kcal/kg does this translate into? (2 points)
1500 kcal/ 95.4 kg = 15.7 kcal/kg

17. What level of caloric intake would you recommend for weight reduction? (2 points)
(NCM)
For weight reduction, I would recommend between 1200-1500 kcal/d. I would first start
recommend 1500 kcal/d since this value has taken into account a 500 kcal deficit from
Mrs. Robinsons estimated energy needs of 2000 kcal/d (activity factor included)
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calculated with the Mifflin St. Jeor equation. If Mrs. Robinson adheres to a 1500 kcal/d
diet and does not achieve desirable weight loss results, she may need to further cut back
on kcal if she is not willing to increase her physical activity level. The NCM recommends
approximately 1200-1500 kcal/d for weight loss.

18. Would you prescribe a 1,000 kcal diet? Why or why not? (2 points)
I would not prescribe a 1000 kcal diet. This amount of kcal is too low and unrealistic to
achieve for a long period of time. If Mrs. Robinson was able to adhere to this low of oral
intake for a number of weeks, she would in fact lose weight. However, it is very probable
she wouldnt be able to maintain this level of kcal and would end up regaining the weight
she lost. She should start off with a more realistic goal then re-evaluate to see what type
of therapy she will need to maintain long term weight losseither increased physical
activity, continued deficit in kcal, or a combination of both. If Mrs. Robinson does not eat
enough, she may become hypoglycemic.

19. What recommendations for dietary intervention and nutrition education would you use
with Mrs. Robinson? Explain your answer. (4 points) (NCM)
I would provide Carbohydrate Counting for People with Diabetes and Type 2
Diabetes Nutrition Therapy handouts from NCM to Mrs. Robinson. With these
handouts, I would explain the importance of not only carbohydrate counting but also
consuming carbohydrates consistently, complex carbohydrates, fiber, healthy fats, fruit
and vegetable consumption, and a low salt diet.
First, I would educate Mrs. Robinson on what a carbohydrate is. I would do this by going
through the different food groups; carbohydrates are found in grains (pasta, rice, bread,
crackers, cereals), starchy vegetables (potatoes, corn, peas), fruits, beans and legumes,
dairy (milk, soy milk, yogurt, cheese) and sweets (ice creams, cakes, cookies, jams).
Then, I would explain to her how to count carbohydrates. For most adults with diabetes,
3-5 servings of carbohydrates are appropriate for each meal if consuming three meals/
day. 1-2 servings of carbohydrates are appropriate for each snack if consuming two
snacks/day. 1 serving of carbohydrate = 15 grams of carbohydrate. For example, 3
servings of carbohydrates in her breakfast would equate to 75 g of carbohydrate in that
meal. Most of Mrs. Robinsons carbohydrates in her meals should come from fruits,
starchy vegetables, beans, legumes, and dairy products. She should aim for at least 6
servings of fruits and vegetables per day, at least 6 servings of grains (at least 3 servings
whole grains) and legumes per day, and at least 2 servings of dairy products per day. She
should aim to consume the same number of carbohydrates at each meal to keep blood
glucose levels consistent.
As for protein and fat consumption, Mrs. Robinson should focus on low-fat/lean sources
of protein such as fish, chicken, lean cuts of beef/pork, tofu, or beans and legumes. Mrs.
Robinson should avoid all trans fats, consume very little saturated fats (those found in
butter, fatty meats, and cream) and instead choose heart healthy fats such as olive oil,
flaxseed oil, canola oil, and nuts.

I would show Mrs. Robinson how to look for total fat content, grams of protein, and
grams of carbohydrate on a food label.
The diet she described contained a lot of salt. To lower her salt intake, I would advise her
to be wary of all bagged, boxed, or canned items and other processed foods. I would also
recommend for her to follow a 2 gram sodium diet.

20. Describe the effects of the following on metabolic outcomes and possible mechanisms.
(2 points each)
a. percent of total calories from CHO (Cochrane)
A study looking at the effects of various dietary carbohydrate intakes on carbohydrate
and lipid metabolism in patients with type 2 DM used 60% of total kcal from CHO and
40% of total kcal from CHO (diet 1: 20% protein, 20% fat, 60% CHO; diet 2: 20%
protein, 40% fat, 40% CHO). PFG and insulin concentrations were similar in both diets
but incremental glucose and insulin responses were higher in response to the 60% of total
kcal from CHO diet. Further, TG were increased and HLD was reduced. These results
indicate that a low fat, high CHO diet may produce detrimental metabolic effects in
patients with type 2 DM. Another study using a diet of 20% CHO, 30% protein, and 50%
fat in adults with type 2 diabetes found lowered fasting blood glucose and HbA1c
compared to the control diet group (60% CHO, 15% protein, 25% fat).
b. dietary sucrose (EAL, Cochrane)
The EAL states that if individuals with diabetes choose to substitute sucrose containing
foods with other carbohydrate foods, no negative effect on glycemic or lipid responses is
seen. However, this is only when the person consumes sucrose as 10-35% of total energy
intake and if substitution for other carbohydrate foods is made isocalorically. While
sucrose does not have an effect on glycemic response when consuming appropriate
intakes, substitution with fructose may lower the acute and chronic glycemic responses.
Fructose increases glucose uptake and utilization in the liver
c. alternative sweeteners (EAL)
In the majority of studies, alternative sweeteners, such as saccharin, aspartame,
acesulfame-K, sucralose, and neotame, have not been found to have an effect on changes
in glycemic response or blood lipid profiles in people with diabetes. One study by Grotz
did find decreased glycosylated hemoglobin level and fasting plasma glucose levels in
adults with diabetes from baseline after consuming sucralose for three months. Another
study found significantly higher HbA1c levels in adults with diabetes who drank 1 or
more diet sodas per day compared to those with did not drink diet soda. It is important to
note that the energy and carbohydrate amount of alternative sweeteners needs to be taken
into account. Also, patients using alternative sweeteners are advised to not exceed the
ADI.
d. soluble dietary fiber (EAL, Cochrane, NCM)
Soluble fiber is able to lower cholesterol by binding to micelles thus preventing reabsorption. Soluble fiber also touts a reduction in glycemic response causing a lowered
insulin stimulation of hepatic cholesterol synthesis. A study assessing the effect of
soluble fiber on lipid profile in diabetic patients showed that 12 g of soluble fiber per day
resulted in a significant decrease in plasma total cholesterol, TG, and LDL. Another study
looking at the effect of 10 g of soluble fiber on glycemic response in overweight
10

individuals with type 2 DM showed that this amount of soluble fiber significantly
reduced peak glucose response at 30 min. The EAL notes that 24 g of soluble fiber daily
has not shown to have any beneficial effects and that recommendations for soluble fiber
should be kept similar to those of general public:14 g per 1000 kcal. Specifically, 7-13 g
soluble fiber has been shown to help reduce total cholesterol by 2-3% and LDL by 7%.
e. cinnamon supplements (cochrane)
A meta-analysis of studies examining the effect of cinnamon in 1 to 6 gram doses on
HbA1c found a significant decrease in mean HbA1c and mean fasting plasma glucose.
Researchers attribute the decrease in HbA1c (by .09%) and FPG (by 0.84mmol/l) to
cinnamons ability to mimic the effect of insulin; cinnamon is able to increase glucose
uptake in adipocytes and skeletal muscles.

21. What nutrient deficiencies could possibly result from following the diet Mrs. Robinson
described? Explain. (4 points)
Mrs. Robinson consumes a high-fat, low-protein, high-carbohydrate diet. She enjoys fried
chicken, soda, candy, cookies, potato chips, and corn chips. She does not consume dairy products
regularly. She eats very little fruits and vegetables and does not like much meat. The diet she has
described lacks protein due to her infrequent meat consumption thus she may be deficient in
certain amino acids with essential amino acids a primary concern. Her diet also lacks complex
carbohydrates and fiber (soluble and insoluble). Little intake of fruits and vegetables may lead to
deficient levels of antioxidants such as vitamin A, vitamin C, vitamin E, and beta-carotene. Her
diet also lacks calcium since she does not consume dairy products regularly.

At this point in the case study, complete and attach the

MNT Initial Assessment Note
that is used in your hospital.
(20 points)

11

12

13

Mrs. Robinson took her medication and stayed on her meal plan as best she could but many of
her symptoms continued. She had not worked in her yard or walked as much as usual because
she still did not feel very well. She returned to the doctor for regular checkups and saw the RDN
for the prescribed number of visits. Three months later, her weight had decreased by 10 lbs
(4.5kg) to 200 (90.9kg). Her labs were as follows:
Date: 05/12/2015
Chol
HDL
LDL
TG
Glu
HbA1C

Result
224 mg/dl
35 md/dl
? mg/dl
185 mg/dl
255 mg/dl
10.0%

(H)
(L)
(H)
(H)
(H)

Reference Range
140-199 mg/dl
40-85 mEq/L
<130 mg/dl
<150 md/dl
70-110 mg/dl
5.5-8.5%

22. Calculate Mrs. Robinsons LDL using the Friedewald Equation. (2 points)
LDL = Total cholesterol HDL (TG/5)
LDL = 224 35 (185/5)
LDL = 152 mg/dl

23. Compare these labs to her initial labs during her visit three months ago. Describe any
changes. (2 points)
Initial lab
Current lab
Reference range
Total cholesterol
300 mg/dl
224 mg/dl
140-199 mg/dl
HDL
30 mg/dl
35 mg/dl
40-85mg/dl
LDL
200 mg/dl
152 mg/dl
<130 mg/dl
TG
350 mg/dl
185 mg/dl
<150 mg/dl
Mrs. Robinsons total cholesterol, LDL, and TG levels were reduced while her HDL cholesterol
raised 5 mg/dl. However, her total cholesterol, LDL, and TG levels are all still above the healthy
range while her HDL cholesterol is still below the healthy range.

24. What kinds of behavioral interventions would be the MOST likely to help her attain
her goals related to glycemic control and weight loss? (4 points) (EAL)
A study done by Laitinen et al. noted in the EAL (details in table below) showed that an
intervention focused on diabetic diet; intake of fat, carbohydrates, and fiber; use of sweeteners;
and, food preparation practice was able to significantly lower HbA1C by 0.6% compared to the
control group.
Author,
year

Rating Study Intervention

type

Focus of intervention

Duration of

Population

Outcomes

intervention

14

Laitinen A, +

86 obese

Between 3 and 15

et al,

RCT

Conventional group (follow- Education was focused on

up every 2-3 months for

principles of the diabetic

15 months

subjects

months, the change in

1993

usual education) or

diet, fat, carbohydrates and

with type 2

fasting blood glucose and

intervention group (clinic

fiber, use of sweeteners,

diabetes

HbA1c were significantly

every 2 months, for a total

advantages and

lower in the intervention

of 6 times, for education by disadvantages of special

group, compared to the

the physician, diabetes

products for diabetic

conventional group (-7.2

nurse and clinical

patients, behavior

vs. 0.0mg/dl and -0.6%

nutritionist). Visit duration

modification and food

vs. -0.3%, respectively).

not mentioned.

preparation practice

As learned from Professor Randall and supplemental readings, self-monitoring blood glucose
practices may not be the most effective to attain glycemic control and weight loss. Further,
physical activity also is not the most effect to attain glycemic control and weight loss. If physical
activity is used in combination with a diabetic diet and diabetic and/or weight loss medications
then it is more effective. Therefore, behavioral strategies that focus on diet are the most effective.
These include carbohydrate counting, reductions in energy and fat intake, and individualized
meal planning with healthy food choices. Nutrition education should be paired with these
behavioral strategies for intervention. Additionally, the RDN should assess the patients
willingness and ability to change.

The physician made adjustments in her medications and strongly encouraged Mrs. Robinson to
start a walking program. She was supposed to be coming to the clinic weekly to see the RDN
and nurse, but was non-adherent. The physician encouraged her to come weekly and to show
them her daily log of blood glucose levels from her finger sticks. Over the next several months,
Mrs. Robinson continued to report to her doctor with little success. Her weight stayed about the
same with slight changes in her glucose and HbA1C. Her lipid profile continued to be
worrisome. The physician continued to increase her Metformin until she was at two doses of
1000 mg each. On her last visit her labs were as follows:

Date: 11/10/2015
Chol
HDL
LDL
TG
Gluc
HbA1C

Result
200 mg/dl
40 mg/dl
130 mg/dl
150 mg/dl
225 mg/dl
9.1%

(H)

(H)
(H)
(H)

Reference Range
140-199 mg/dl
40-85 mg/dl
<130 mg/dl
<150 md/dl
70-110 mg/dl
5.5-8.5%

After increasing her metformin, her weight decreased to 193 lbs (87.7kg). Still, with this slow
rate of improvement, the physician decided to start her on insulin.

15

Mrs. Robinson had to learn how to give herself insulin but did not like it at all. The physician
told her that if she got her glucose under control and lost weight, she may not need the insulin.
This motivated her to follow her meal plan and her walking routine. Mrs. Robinson finally had
favorable results with her new regimen but only after she began to follow her meal plan, finally
started a walking program, and took her meds as prescribed. The blood glucose levels were
coming down along with her HbA1C. Triglycerides, total cholesterol, LDL and HDL all stayed
in an appropriate range.

At this point in the case study, complete and attach the

MNT Follow-up Assessment Note
that is used in your hospital.
(10 points)

Adapted from: Billon W. Clinical Nutrition: Case Studies (4th Edition). Belmont, CA: Thomson Wadsworth, 2006.

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