Name: Marie Salvador

Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin

I. Understanding the Disease and Pathophysiology
1. What are the standard diagnostic criteria (not risk factors) for T2DM? Cite the ADA
Standards of Medical Care – 2016. Which are found in Mitch’s medical record? (5)
Standard diagnostic criteria for T2DM is having two of the following (ADA, 2016):
 Symptoms plus casual glucose >200mg/dl;
 Fasting plasma glucose (FPG)> 126mg/dl (fasting for at least 8 hours);
 2 hour plasma glucose (PG) >200mg/dl after a 75g glucose load; during oral
glucose tolerance test (OGTT).
 or A hemoglobin A1C (A1C) > 6.5%.

You can find on Mitch’s medical record that his plasma glucose was over 200
mg/dl; stated on chart on 4/12 it was measured to be at 1524 and the following
day at 475. Hemoglobin A1C was higher than 6.5 % and measured at 15.2%.
FPG was 475 mg/dL. Thus; Mitch has more than 2 of the criteria to diagnose
a pt with T2DM.
As per Krause (2012) risk factors for T2DM is having a BMI of over 25, physical
inactivity, first degree relative with diabetes, member of high-risk race/ethnicity, diagnosed
with gestational diabetes, hypertension of >140/90 mmHg, HDL cholesterol level <35 mg/dL
and or triglyceride level of >250mg/dl, women with polycystic ovary syndrome, other
clinical conditions associated with insulin resistance, history of CVD, older than 45 years of
age (ADA, table 2.2). You can find on Mitch’s medical record that he was at high risk as he
is 53 years old, his BMI is 31.6, mildly obese, previously dx with HTN, first degree family
member with T2DM, diagnosed with hyperglycemia.

2. Mitch was previously diagnosed with T2DM. His admits that he often does not take his
medications. For each of his diabetes pills, metformin and glyburide, state the class of
medication and mechanism of action; list potential drug side effects (i.e nausea, etc) and
drug-nutrient interactions (i.e. foods or nutrients to be added or avoided) for each drug.
(6)
 Metformin is in a class of drugs called binguanides which decreases hepatic glucose
production and increases insulin uptake by muscles. Potential drug side effects
include: GI problems, headaches, flushing, nail changes, muscle pain (Medline).
Drug-nutrient interactions may include: decreased folate, calcium and vitamin B
absorption (Jackson-Michel, 2013). Also alcohol should be avoided.
 Glyburide belongs to a class of medications labeled second generation sulfonylureas
which stimulates insulin secretion (Medline). Side effects can include:
Hypoglycemia, nausea, constipation, yellowing of skin/eyes, pain in stomach,
diarrhea, fever, and sore throat, swelling of eyes, lips, tongue or throat (Medline).
Drug-nutrient interactions should be noted and alcohol should be avoided.

3. Mitch also takes other medications, Dyazide and Lipitor. List their mechanisms,
potential side effects and drug-nutrient interactions.
He is beginning insulin. For his prescribed insulins, state type; time of onset, peak,
duration; potential side-effect. (5)
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
1. Dyazide: Mechanisms of action: Used for edema and HTN; prevents absorption of salt
to prevent fluid retention. Also acts as a diuretic limiting salt absorption and thus also
preventing fluid retention. Possible side effects: bradycardia, tachycardia, arrhythmia,
weight gain, anorexia, headaches weakness, abnormal potassium levels, nausea,
vomiting, bleeding, diarrhea, constipation, or other. Drug-Nutrient interactions:
alcohol should be avoided, potassium supplements should be prescribed, avoid of salt for
drug effectiveness (Medline).

2. Lipitor Mechanisms of action: Used for lowering lipids by rate-limit or reductase

inhibiting synthesis of cholesterol. Possible side effects: lethargy, weakness, memory
impairment, GI stress, abdominal pain, rash, difficult swallowing, myalgia, other. Drug-
Nutrient interactions: avoid grapefruit, citrus, may decrease Coenzyme Q10 (Medline).
INSULIN:
A. Lispro; time of onset: less than 15 min., peak: 1-2 hours, duration, 3-4 hours; potential
side-effect: ophthalmic refraction disorder, acute peripheral neuropathy, weight gain,
anxiety, confusion, seizures, fever, tachycardia, irritability, neurological symptoms,
allergic reactions, edema, other (Medline). .

B. Glargine: time of onset: 2- 4 hours, peak- none, duration: 20-24 hours; potential side-
effect-seizures, headaches, weakness, unconsciousness, tachycardia, irritability
(Medline).

4. Mitch experienced symptoms and subsequent admission to the ER with the diagnosis of
uncontrolled T2DM with HHS.
1. Describe what led to his severe hyperglycemia.
2. State Mitch’s signs and symptoms of dehydration.
3. Define HHS, its etiology and symptoms.
4. State Mitch’s signs and symptoms of HHS. (8)
1. Describe what led to his severe hyperglycemia.
This pt was previously diagnosed with T2DM; but states that does not take
medications regularly; thus, glucose/ insulin are not under control. In addition to not
taking his medications, he is not educated on nutrition for diabetes as he states that he
doesn’t follow any strict diet except for staying away from high sugar desserts, not
adding salt and avoiding high cholesterol foods. His diet recall also shows that his
ignorance of diet and diabetes led to his severe hyperglycemia. He states he eats
carbs in mid -morning, lunch, dinner and fat is not controlled either.
2. State Mitch’s signs and symptoms of dehydration.
Dark colored urine, hypotension: 90/70mm, dry mucous membranes, poor turgor,
decreased urine output, low sodium levels, his confusion/ change in mental state, high
specific gravity of urine, osmolality is also high at 360 mmol/kg/h2o and high
BUN/Creatine levels.
3. Define HHS, its etiology and symptoms.
HHS or Hyperglycemic Hyperosmolar state is a complication of T2DM, resulting in extreme
high blood sugar level above 600mg/dl without presence of ketones, osmolality greater than 320
mOsm/kg of water. Results of rise of glucose and then high osmolality in blood and ultimately
dehydration. Etiology is by high blood sugar levels, lack of hydration, and poor management of
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
diabetes, stopping insulin or other medicines that lower glucose levels. Symptoms may include:
fever higher than 100.4F, low systolic BP, increased thirst, feeling weak, nausea, weight loss, dry
mouth, fever, seizures, confusion, and/or coma (Medline).
4. State Mitch’s signs and symptoms of HHS.
Mitch’s medical record shows that he had symptoms of HHS; some which included that his
plasma glucose was extremely high at 1524mg/dl; osmolality of 360 mOsm/kg of water, Temp:
of 100.5F, confusion, and low systolic BP.

5. HHS and DKA are metabolic complications associated with diabetes. Define DKA, its
precipitating factors and signs /symptoms. What characteristics of Mitch’s condition
indicate HHS as opposed to DKA? (5)
DKA is diabetic ketoacidosis, problem that can occur in patients with diabetes and it is life
threathening. It happens when body cannot use glucose as a fuel source because there is not
enough insulin (Medline). Fat is used for fuel instead. When fat is broken down to fuel the
body, ketones build up (Medline). Symptoms may include: decreased alertness, deep rapid
breathing, flushing, frequent urination, fruity smelling breath, headache, muscle ache, nausea
and vomiting, stomach pain (medline).Mitch’s condition indicate it’s HHS as opposed to
DKA is the absence of complain of abdominal pain or fruity breath. Mitch’s symptoms
mostly match HHS rather than DKA due to dehydration symptoms high osmolality found in
labs.

6. Mitch was started on normal saline with potassium as well as an insulin drip. Why are
these fluids a component of his rehydration and correction of the HHS? (3)
These fluids are a component of his rehydration and correction of HHS because the saline with
potassium is aiming to correct pt’s electrolyte levels so osmolality goes back to normal levels in
the body and thus also correct all the complications that resulted from dehydration; thus, BP will
normalize as sodium and potassium normalize as well as other complications from HHS. Insulin
drip in the other hand will correct elevated glucose levels to also compliment for the
normalization of osmolality in the body resulted from HHS.

7. Describe the initial insulin therapy that was started for Mitch and his planned insulin
regimen. When would a patient be started on insulin, based on the recommendations of
the ADA? How likely is it that Mitch will need to continue insulin therapy? (3)
The initial insulin therapy started and planned regimen for Mitch was: Rehydration,
Lispro 0.5 u every 2 hours until glucose is 150-200 mg/dL. At night begin glargine 19 u.
Progress Lispro using ICR 1: 15. As per ADA (2016), if noninsulin therapy does not achieve
or maintain the A1C target over 3 months, then add a second oral agent a glucagon-like
peptide 1 receptor agonist, or basal insulin (ADA). Mitch is very likely to need continued
insulin therapy due; considering his current glucose levels and the fact that in the past he was
diagnosed with T2DM and failed to take medications. However, if patient is aggressive with
lifestyle changes it might help him a lot.
II. Nutrition Assessment

8. Assess Mitch’s desirable body weight and BMI. What would be a healthy weight range
for Mitch? (3)
Mitch is 214#, 53 year old male, 5’9 or 69inches in height.
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
BMI: (214 lb/ 69 𝑖𝑛2 ) x 703= 31.59 BMI indicates Obesity!

DBW using Hamwi: Males: 106# for 5 + 6# for each inch >60
DBW=106# + (6# x 9)= 160 lbs
DBW range 160+/- 10%= 144# to 176# would be a healthier weight range than current
weight

% DBW= (ABW/DBW) x 100

= (214lbs/160 lbs) x 100= 133.75%

9. For each lab value, state its abnormal value upon admission and what the value means /
indicates. How did glucose, sodium, phosphate and osmolality change - state the changed
value and why it changed. (16)
Initial lab values:
o Glucose: 1524 mg/dL at admission
 Means: Extremely high glucose indicates patient has severe hyperglycemia. No insulin or
very low insulin to clear glucose. Glucose is out of control and not properly used.

o Creatinine:1.9 mg/dL
 High creatinine means kidney is not functioning properly due to dehydration and
imbalance of solutes/ electrolytes.

o Sodium: 132 mEq/L

 Low sodium means patient is dehydrated, nonfunctional cellular mechanisms, loss of
fluids. High glucose causes a change in osmosis and water goes from intracellular to
extracellular and then losing sodium.
o Phosphate: 1.8 mg/dL
 Low phosphate means dehydration, renal system is not working properly due to the
change of osmosis in the body resulted from high glucose in system.
o Cholesterol: 205 mg/dL
 High cholesterol means there is an excess of fat, patient may be at risk for cardiovascular
problems.
o HbA1c: 15.2 %
 Very high values indicates poor control of glucose, chronic, very high amounts of
glucose in body.
o C-peptide: 1.10 ng/mL
 Within normal levels may indicate some insulin levels are still present

o Osmolality: 360 mmol/kg/H2O

 High levels means that there is high solutes in body and dehydration/ lack of water.
o Specific gravity: 1.045
 Slightly higher than normal limits indicates dehydration, higher solutes in urine than
water.
o BUN: 31 mg/dL
 High BUN indicates kidney is not functioning properly, kidneys are under stress.
o Glucose in urine: Positive
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
 This means kidneys are filtering excess glucose because body is not properly using
glucose, and the body is trying to find a way to get rid of excess glucose. Also means
lack of insulin to take care of the glucose in system
o Protein in urine: Possitive
 This means that kidney is not properly functioning, sign of dehydration.

Changed values:
A. Glucose: 475 mg/dL from 1524 mg/dL
Value decreased because md prescribed rapid-acting insulin to aid in the
hyperglycemia that pt presented at admission. Thus, rapid insulin is clearing glucose
of the body.

B. Osmolality: 304 mmol/kg/h2O from 360 mmol/kg/h2O

Osmolality decreased because hydration status is being corrected by the normal saline
with potassium being received intravenously. Electrolytes are going slowly back to
normal and therefore cellular function is getting better, balance between solutes and
water is returning to function.

C. Sodium: 134 mEq/L from 132 mEq/L

Sodium is increasing due to the the normal saline with potassium being received
intravenously for electrolyte correction, balance and rehydration.

D. Phosphate:2.1 mg/dL from 1.8 mg/dL

Phosphate is also increasing due to the the normal saline with potassium being
received intravenously for electrolyte correction, balance and rehydration.

10. Determine Mitch’s energy requirements for weight maintenance using Mifflin St. Jeor
equation; state why this equation is an appropriate choice; use AF and SF as
appropriate. Determine Mitch’s protein requirements justifying the use of DBW vs.
ABW and g protein / kg. What daily energy intake would you recommend for an
appropriate rate of weight loss? Justify your recommendation. (3)

Mitch is 214#/ 97.27kg in weight, 53 year old male, 5’9 or 69inches or 175.26 cm in height.
Mifflin st. Jeor: Male: kcal/d= 10(wg in Kg) + 6.25(ht in cm)-5 (age) +5
10(97.27 kg) + 6.25 (175.26) -5(53) +5
972.7+ 1095.4 – 265 +5
EER= 1,808 kcal/day
EER * 1.3 (Activity factor) =2,350 kcal/day is required for Mitch
 This equation is an appropriate choice for Mitch since it has previously shown less error
(~10%) when compared to HBE when used in Obese patient’s like Mitch.
 PRO: .8g * (ABW) 97.27kg= 77.818 g PRO for ABW
 PRO: .8 * (DBW) 75.57kg= 60.45g PRO for DBW
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
 2,350 kcal/ day - 500 kcal/ day= 1850 kcal/ day is recommended for Mitch if he is
willing to lose weight. As per ADA (2016), 500kcal / day is safe to abstain to
maintain energy requirements and aim to lose weight at the same time.

III. Understanding the Nutrition Therapy

11. Mitch was NPO when admitted to the hospital. Why? What does this mean? When will
Mitch be ready to eat? What foods would be recommended immediately following
NPO, before initiating a diet for diabetes? (4)
Mitch was NPO because when pt got admitted his glucose was out of control and he was
dangerously hyperglycemic. MD is now trying to regulate his health status by balancing his
body’s osmotic status via intravenous saline and insulin. The saline will balance out his
electrolytes for proper cellular function while the insulin will clear out the excess glucose in
his body; thus, the action of both solutions administered intravenously will help Mitch return
to homeostasis and then MD recommended to continue to clear liquids and finally to a
consistent CHO diet. Mitch will be ready to eat once his body’s glucose is under control and
his body reaches homeostatic balance. Immediately following NPO, it would be
recommended for pt to consume clear liquids and slowly introduce foods as so heavy foods
do not stress his GI system. And he should absolutely be educated of proper dieting by a
dietitian as soon as he is able to, otherwise if patient is not educated he is in danger of
harming himself again and possible death.

12. Mitch was prescribed an initial ICR 1:15. Explain what this means.
Outline the general principles for nutrition therapy, to assist in control of DM, for:
meals and snacks, carbohydrate, sugar substitutes, fats and weight reduction. Cite the
ADA’s Clinical Practice Recommendations for Medical Nutrition Therapy – 2016. (5)
An ICR 1:15 means that Mitch was prescribed with an insulin to carbohydrate ratio of 1 to 15
(ADA). Meaning that, 1 unit of insulin covers 15 grams of CHO. This is the ratio he has to use
to count his carbohydrate intake and so he is safe that insulin will clear the glucose in his intake.
 As per ADA recommendations, healthy eating is encouraged with 3 meals and
planned snacks, reducing portion size, encouraging water consumption and
reducing juice intake, increasing consumption of fruits and vegetables (ADA,
2016).
 Glycemic control can improve with knowledge of using CHO counting or
estimation to determine mealtime insulin (ADA, 2016). As there is no single
ideal distribution of kcal among macronutrients for people with diabetes,
macronutrient distribution should be individualized while keeping metabolic and
calorie goals in mind (ADA, 2016).
 Added sugars should be discouraged (ADA, 2016).
 Total ideal fat consumption is inconclusive, however should focus on eating fats
rich in monounsaturated fats to improve glucose metabolism and lower CVD risk
(ADA, 2016). Eating foods rich in long-chain omega-3 fatty acids recommended
(ADA, 2016). Distribution of fats should be 20 -35% of total EER (ADA, 2016).
 Insulin resistance may improve with weight reduction…(ADA, 2016). Reductions
in body weight has shown improvement of glycemic control (ADA, 2016).
Weight loss can be achieved with reducing 500- 750 kcal/day energy (ADA,
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
2016). Benefits can be seen with 5% weight loss, greater than 7% is optimal
(ADA, 2016).

IV. Nutrition Diagnosis

13. Write 2 priority nutrition diagnoses, each in PES format. Cite eNCPT. (6)
 Inadequate bioactive substance intake NI-4.1 related to high blood glucose levels as
evidenced by patient’s statement that he does not take diabetes medications regularly
regardless of being diagnosed with T2DM previously.

 Inadequate fluid intake NI-3.1 related to vomiting and T2DM as evidenced by patient’s
abnormal laboratory values of high bun, creatinine, glucose, osmolality, HbA1c, protein
and abnormally low values of sodium and phosphate.

V. Nutrition Intervention
14. Determine Mitch’s initial CHO prescription using his diet history as well as your
assessment of his energy requirements for weight loss: State daily kcal intake, percent
kcal from CHO, g CHO, number of CHO choices per day; Suggest the number of CHO
choices you would recommend for 3 meals and 2 snacks based on his diet history and
medication. Cite Choose Your Foods: Exchange Lists for Meal Planning/Food Choices.
(5)
1850 kcal/ day is recommended for Mitch if he is aiming to lose weight. As per
ADA (2016), 500kcal / day is safe to abstain to maintain energy requirements and
aim to lose weight at the same time.
 1850 kcal/day (55% CHO) = 1,017 kcal/day CHO
 1,017 kcal/day CHO / 4kcal/g= 254 grams of CHO
 254 grams of CHO/15grams= 17 choices of CHO Per Day.

 3 meals / 2 snacks I would recommend based on his previous diet and preference:

I. Morning meal: 3 choices of CHO

II. Lunch meal:5 choices of CHO
III. Dinner meal:5 choices of CHO
 Morning Snack: 2 choices of CHO
 Dinner snack :2 choices of CHO Total in a day= 17 choices CHO

15. Identify two initial nutrition goals to assist with weight-loss. (4)
 Increase vegetable and fruit intake: one per meal.
 Increase physical activity: to exercising at least 30 minutes 5 times a week.

16. Mitch also has hypertension and high cholesterol levels. State the recommendations for
the lipid profile, LDL, HDL, Cholesterol and Triglycerides for people with diabetes
Describe nutrition recommendations for fiber, types of fat and sodium for Mitch and
why. (4)
This pt’s other ailments of HTN and high cholesterol can be reduced with diet prescribed for
diabetes, since it requires pt to eat healthier and to maintain physical activity. Recommendations
for lipid profile include LDL of <130 mg/dL, HDL >40 mg/dL, cholesterol of <200 mg/dL,
 Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
triglycerides of < 150 mg/dL. Fiber: 14 grams fiber per 1000 kcal in intake w/ less than 5 grams
per serving. Sodium: <2,300 mg/day. However, lowering sodium intake to approximately
1,500 mg/day may benefit blood pressure sometimes and for some populations (ADA). Fats: 20-
35% total kcal of Fats, rich in monosaturated fats because it can improve glycemic control and
blood lipids (ADA, 2016). Trans fat should be avoided (ADA, 2016). Following nutritional
recommendations will aid Mitch control glycemic levels and maintain a healthier life.

VI. Nutrition Monitoring and Evaluation

17. Write an ADIME/SOAP note for your initial nutrition assessment. Remember to always
sign and date your note (5). Create a meal plan based on his glucose, weight loss and
lipid goals and his food preferences using exchanges (5). Use forms provided below:
(10)
A – Assessment
S - Subjective
Chief Complaint: Vomiting, states that has not taken his diabetes medications regularly
UBW: N/A Nutritional supplement: N/A
Weight change: gain / loss N/A
Vitamins / herbs: N/A
Appetite: No food intake past 12-24 hours, some
water only. Previous to symptoms normal appetite. Food preparation: Restaurant, sometimes cooks

Chewing / swallowing problem / sore mouth Factors affecting food intake: Past 12-24 hours
vomiting, T2DM, HTN, Cholesterol
Nausea / vomiting / diarrhea / constipation
Social / cultural / religious / financial: single; 16
Food intolerance / allergies: N/A years education, full time job, lives alone, N/A
religion
Diet prior to admit: normal, no added salt, tries to
limit high cholesterol foods and high sugar desserts. Other: Alcohol 3-4 drinks per week
O – Objective
Current Diet Order:
NPO, only ice chips and Rx. After 12 hrs clear liquids, if stable Then progress to consistent-
carbohydrate diet. Dietitian for consult.
Medical Diagnosis: T2DM uncontrolled, HHS Pertinent Medical History: T2DM 1 year dx,
HTN, hyperlipidemia, gout
Nutrition Focused Physical Signs & Symptoms: 4/12 Hyperglycemia, emesis, high temp: 100.5, BP: 90/70,
Pulse: 105, Rapid respiration rate: 26 ; dry mucous membranes, poor skin turgor, warm/dry skin,
Age: 53 Gender: Ht: Wt: Admit DBW: 160# BMI: 31.6 %
years Male  5’9  214# Range: 144# to 176#
old Female  Current 
% UBW: N/A % wt : N/A % DBW: 133.75% Other:

Nutritionally Relevant Laboratory Data: Glucose: 1524 mg/dL- high; Creatinine:1.9 mg/dL- high;
Sodium: 132 mEq/L- low; Phosphate: 1.8 mg/dL- low; Cholesterol: 205 mg/dL- high; HbA1c: 15.2 %-
high; C-peptide: 1.10 ng/mL-WNL; Osmolality: 360 mmol/kg/H2O-high; Specific gravity: 1.045- high;
BUN: 31 mg/dL- high; Glucose in urine: Positive- high; Protein in urine: Positive- high
 Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin

Drug Nutrient Interaction:

Estimated Energy Need: Estimated Protein Need: Estimated Fluid Need:

______________ kcal / day _______________ g/day _____________ ml / day

Based on: Based on: Based on:

Nutrition Diagnosis (D)

A - Assessment (A)
State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis
Terminology sheet
ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :

1. Inadequate bioactive substance intake NI-4.1 related to high blood glucose levels as evidenced by
patient’s statement that he does not take diabetes medications regularly regardless of being diagnosed
with T2DM previously.

2. Inadequate fluid intake NI-3.1 related to vomiting and T2DM as evidenced by patient’s abnormal
laboratory values of high bun, creatinine, glucose, osmolality, HbA1c, protein and abnormally low
values of sodium and phosphate.

Nutrition Intervention (I)

P - Plan

List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address
the problems (diagnoses).

Goal(s):

Plan for Monitoring and Evaluation (M E)

 Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets.
(Upon follow-up, the plan for monitoring would indicate if interventions are addressing the problems).

Signature: Maria Salvador

Date: 03/14/2017

EXCHANGE LISTS FOR MEAL PLANNING

Carbohydrate Protein Fat
______g ______g _____g
______ kcal ______ kcal ______ kcal Total Kcal______
% Carbohydrate ~____% % Protein ~____% % Fat ~____%
EXCHANGES Menu CHOg PROg FATg kcal
MORNING MEAL
____ CHO group
____ Starch ______________________________________________________
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
____ Fruit ______________________________________________________
____ Milk _____ ______________________________________________________
____ Meat group__ ______________________________________________________
____ Fat group ___ ______________________________________________________
MORNING SNACK
NOON MEAL
____ CHO group
____ Starch ______________________________________________________
____ Fruit ______________________________________________________
____ Milk _____ ______________________________________________________
____ Veg ______________________________________________________
____ Meat group__ ______________________________________________________
____ Fat group ___ ______________________________________________________
AFTERNOON SNACK
EVENING MEAL
____ CHO group
____ Starch ______________________________________________________
____ Fruit ______________________________________________________
____ Milk ______ ______________________________________________________
____ Veg ______________________________________________________
____ Meat group__ ______________________________________________________
____ Fat group ___ ______________________________________________________
BEDTIME SNACK

References

ADA (2016). Standards of Medical Care in Diabetes. (2016). Diabetes Care,37 (Supplement_1).
Retrieved from http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-
Standards-of-Care.pdf
Name: Marie Salvador
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
Jackson-Michel, N. D. (2013, October 09). Vitamin Interactions with Metformin. Retrieved March 18,
2017, from http://www.livestrong.com/article/144857-what-are-the-nutrient-drug-interactions-for-
metformin/

Mahan, L. K. (2012). Krause's Food the nutrition care process. Philadelphia: Saunders.

Medline. Retrieved March 18, 2017, from https://medlineplus.gov/druginfo/meds/a696005.html

Nelms, M. N., & Roth, S. L. (2013). Case 17: Adult Type 2 Diabetes Mellitus: Transition to Insulin.
Medical Nutrition Therapy: A Case Study Approach (4thEd). Belmont, CA: Cengage Learning.