1. Type 2 DM - Case Study Jean Kerver, MS, RD, CDE kerverje@pilot.msu.edu 2/18/00

2. DR is a 45 y.o. male; Ht: 5’9”; Wt: 215 lbs Present complaint: polydipsia, polyuria, fatigue. Past med hx: Type 2 DM x 5 yrs. Meds: None; NKDA. Labs: No SBGM; serum glucose=285 mg/dL 1 hr ppd; HbA1C=9.2% urinary glucose=2+; temp=98.8 F.

3. 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 out—fast food or deli type; dinner at home —cooks or orders take-out food; seldom snacks.

4. 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 fruit380 kcals 2 fruit120 kcals 1 high fat milk150 kcals 2 fruit120 kcals 4 med-fat meat300 kcals 1 high-fat meat100 kcals 2 starch160 kcals 1 vege, 1 fat 70 kcals 2 fat 90 kcals 1 starch, 1 fat125 kcals 150 kcals

5. Dinner (24-hr recall, cont’d) 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 2 beer 300 kcals 2 fruit 120 kcals Total Kcals: 3360

6. How Many kcals Should He Have? Ht: 5’9”; 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

7. 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

8. ADA Exchanges Food GpCHO (g)PRO (g)FAT (g)Kcals Starch153-80 Meat-73-855-100 Vege52-25 Fruit15--60 Milk1280-890-150 Fat--545

9. 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.

10. 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 -

11. 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

12. Convert FAT (67 g) No. of Exchange s 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

13. 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

14. Increased Insulin Sensitivity Increased peripheral glucose uptake Lower Blood Glucose Decreased Plasma Insulin Lipolysis Metabolic Effects of Exercise in Type 2 DM

15. Meal Planning and Physical Activity Monotherapy Oral Agents: Sulfonylureas, Metformin, Troglitazones, etc. Combinations of Oral Agents: Metformin + Sulfonylureas, etc. Add Bedtime NPH to Orals When Therapy Changes NPH + Humalog BID Multiple Dose Regimen

16. Diabetes Education Tell patient what to expect Individualize-always give choices Be systematic-prioritize Discuss coping strategies Special situations

17. 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