1. Medical Nutrition Therapy
Diabetes Mellitus
Stephanie Bachmann
Dietetic Intern
Purdue University Coordinated Program in Dietetics

2. Objectives
 To demonstrate the effects uncontrolled diabetes mellitus
can have on patients.
 To discuss the Nutrition Care Process by presenting a
diabetes mellitus case study.
 To provide education on carbohydrate counting for
healthcare providers to better assist patients in managing
diabetes mellitus.

3. Outline
 Overview of patient
 Diabetes Mellitus
 Current research
 Nutrition Care Process
 Carbohydrate Counting
 Suggestions for similar cases

4. Patient Information
 Adult female presented to the ED with complaint of right foot pain
 Piece of glass in patient’s foot
 Past medical history
 Type 2 diabetes
 Diabetic neuropathy and retinopathy
 Amputation of fourth metatarsal head
 CKD stage 3
 Anemia
 Hypertension

5. Patient Diagnosis
 Patient was diagnosed with diabetic foot infection and
uncontrolled type 2 diabetes mellitus
 Patient selection
 Demonstrate effects of uncontrolled diabetes
 Patient education
 Barriers to good nutrition

6. Diabetes Mellitus
 In pancreas Islet of Langerhans
contain
 beta cells that release insulin
when glucose levels are
elevated in the blood
 Insulin binds to receptors and
glucose travels into the cell
 Glucose is used by the cell for
energy
http://www.westfalia-separator.com.sg/v2/applications/chemical-
pharmaceutical-technology/pharmaceutical-
biotechnology/hormones.html
Diabetes Mellitus (DM). The Merck Manual Web site.
http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/diabetes_mellitus_and_di
sorders_of_carbohydrate_metabolism/diabetes_mellitus_dm.html?qt=type%202%20diabetes%20mellitus&alt=s
h Updated June 2014. Accessed March 1, 2015.

7. Diabetes Mellitus (cont.)
 In diabetes
 Pancreas does not produce any
insulin or does not produce
enough insulin
 Pancreas makes sufficient
amount of insulin but cells are
resistant to insulin
 Glucose accumulates in blood
 Cells are unable to utilize
glucose for energy
http://prediabetescenters.com/prediabetes-101/insulin-
resistance-and-prediabetes/
Diabetes Mellitus (DM). The Merck Manual Web site.
http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/diabetes_mellitus_and_
disorders_of_carbohydrate_metabolism/diabetes_mellitus_dm.html?qt=type%202%20diabetes%20mellitus&a
lt=sh Updated June 2014. Accessed March 1, 2015.

8. Implications of Diabetes
 Hyperglycemia
 Weight gain
 Hypoglycemia
 Diabetic coma
 Increased risk for infections and amputations
 Damage to blood vessels
 CKD
 Retinopathy
 Neuropathy
 Cardiovascular disease
Diabetes Mellitus (DM). The Merck Manual Web site.
http://www.merckmanuals.com/professional/endocrine_and_metabolic_disorders/diabetes_mellitus_and_disorders_of_
carbohydrate_metabolism/diabetes_mellitus_dm.html?qt=type%202%20diabetes%20mellitus&alt=sh Updated June 2014.
Accessed March 1, 2015.

9. American Diabetes Association (ADA)
Recommended Goals
 Self-management
 Hemoglobin A1c: <7%
 Blood Pressure: 140/80mmHg
 LDL: <100mg/dL
 HDL: >40mg/dL (men), >50mg/dL (women)
 Maintain body weight goals
 Postponing and preventing complications associated with DM
Evert A, Boucher J, Cypress M. Nutrition Therapy Recommendations for the Management of Adults
with Diabetes. Diabetes Care. 2014; 37: S120-S143.

10. Carbohydrate Counting in Patients with
Type 2 Diabetes
 Martins et al. researched adherence to carbohydrate counting in
patients with type
2 diabetes and the effect on blood glucose control
 21 participants
 16 female
 5 male
 Provided three patient education classes
Martins M, Ambrosio A, Nery M, Aquino R, Queiroz M. Assessment Guidance of Carbohydrate Counting
Method in Patients with Type 2 Diabetes Mellitus. Primary Care Diabetes. 2014; 8: 39-42.

11. Carbohydrate Counting in Patients with
Type 2 Diabetes (cont.)
 Hemoglobin A1c taken before education (8.42 + 0.02%)
 Patients were asked opinion of carbohydrate counting
 66% said difficult but possible
 34% said practical because food selection is made by
patient
66%
34%
PATIENT OPINION OF
CARBOHYDRATE
COUNTING
Difficult Practical
Martins M, Ambrosio A, Nery M, Aquino R, Queiroz M. Assessment Guidance of Carbohydrate Counting
Method in Patients with Type 2 Diabetes Mellitus. Primary Care Diabetes. 2014; 8: 39-42.

12. Carbohydrate Counting in Patients with
Type 2 Diabetes (cont.)
 Patient education class topics
 Glucose and insulin metabolism
 Diabetes treatment
 Target goals
 Healthy eating
 Food groups
 Serving sizes
 Carbohydrate counting method
 Application of material presented
Martins M, Ambrosio A, Nery M, Aquino R, Queiroz M. Assessment Guidance of Carbohydrate Counting
Method in Patients with Type 2 Diabetes Mellitus. Primary Care Diabetes. 2014; 8: 39-42.

13. Carbohydrate Counting in Patients with
Type 2 Diabetes (cont.)
 Follow up 1 year later
 Martins et al. found patients were able to apply
carbohydrate counting
 Improvement in blood glucose levels
 Improvement in Hemoglobin A1c
 7.66 + 0.01%
Martins M, Ambrosio A, Nery M, Aquino R, Queiroz M. Assessment Guidance of Carbohydrate Counting
Method in Patients with Type 2 Diabetes Mellitus. Primary Care Diabetes. 2014; 8: 39-42.

14. Nutrition Care Process
 Entry of patient into NCP
 Nutrition Screen
http://ada.portalxm.com/eal/ncp/

15. Nutrition Care Process (Cont.)
 Nutrition screen identified
 Complex wound on patient’s foot
 Increased protein needs to promote wound healing
 Diabetes education
Hemoglobin A1c was >9%
 Diabetes was uncontrolled over last 3 months

16. Nutrition Assessment
 BMI: 52kg/m2
 Extreme obesity class 3
 Elevated glucose, hemoglobin A1c, WBC
 Due to uncontrolled DM and infection
 Medical history
 Type 2 diabetes
 Diabetic neuropathy and retinopathy
 Amputation of fourth metatarsal head
 CKD stage 3
 Anemia
 Hypertension
Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk.
National Heart, Lung, and Blood Institute Web site.
http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_dis.htm Accessed February 26, 2015.

17. Nutrition Assessment (cont.)
 On Metformin, Humalog, and Insulin NPH
 Patient was on 3 carbohydrate diet then advanced
to 6 carbohydrate diet
 Patient did not carbohydrate count at home
 Financial constraints at home
 Decreased appetite
Type 2. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5517&lv2=18469&ncm_
toc_id=18469&ncm_heading=Nutrition%20Care Accessed February 26, 2015.

18. Nutrition Assessment (cont.)
 Energy needs (20kcal/kg – 500 kcal): 2600kcal/day
 To promote weight loss
 Protein needs (1.3-2g/kg ideal body weight): 83-127g/day
 To promote wound healing

19. Nutrition Diagnosis
 Increased nutrient needs related to need to promote
wound healing as evidenced by wound on the patient’s
right plantar aspect of foot.
 Limited access to food related to lack of financial
resources to purchase a sufficient quantity of healthful
foods as evidenced by limited supply of food in the home.

20. Nutrition Diagnosis (cont.)
 Food-and nutrition-related knowledge deficit related to
lack of prior nutrition-related education as evidenced by
no prior knowledge of need for food- and nutrition-related
recommendations.

21. Nutrition Intervention
 Meals
 Snacks
 Referral to social worker
 Food assistance programs
 Patient education from the Nutrition Care Manual
 Carbohydrate counting
 Label reading
 Meal planning

22. Carbohydrate Counting Education
 Carbohydrates metabolize into sugar and elevate blood glucose levels
 Breads, pasta, beans, fruit, starchy vegetables, milk, cookies
 1 carbohydrate choice = 15g carbohydrates
 1 piece of bread
 1/3 cup pasta (cooked)
 ½ cup beans or starchy vegetable (corn, peas, potatoes)
 1 small fresh fruit
 1 cup fat-free milk
 2 small cookies (2/3 oz)
Carbohydrate Counting for People with Diabetes. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=123 Accessed March 10, 2015.
http://www.weightlossforall.com/carbohydrates.htm

23. Carbohydrate Counting Education
(cont.)
 Patient on 6 carbohydrate diet = 90g
carbohydrates
90g carbohydrates at each meal
 To keep blood glucose levels consistent
throughout the day
Carbohydrate Counting for People with Diabetes. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=123 Accessed March 10, 2015.

24. Carbohydrate Counting Education
(cont.)
 If meals are 4 hours or more apart have a 1
carbohydrate (15g) snack between meals
 If more than 4 hours or greater between last meal
and going to sleep have a 1 carbohydrate (15g)
snack before bed
 To prevent hypoglycemia
Carbohydrate Counting for People with Diabetes. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=123Accessed March 10, 2015.

25. Carbohydrate Counting Education (cont.)
 When reading a nutrition facts label focus on
 Serving size
 Total carbohydrates
 DON’T focus on grams of sugar
https://www.nutritioncaremanual.org/client_ed.cfm?nc
m_client_ed_id=125
Carbohydrate Counting for People with Diabetes. Nutrition Care Manual. Available at:
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=123 Accessed March 10, 2015.

26. Sample Menu
Breakfast Lunch Dinner HS Snack
1 English Muffin
2 1oz sausage links
1 small orange
2 pancakes
½ cup oatmeal
1 over easy egg
1 cup coffee
6 carbohydrate
choices (90g)
Turkey sandwich
2 pieces of whole
grain wheat bread
½ large baked
potato
2 Tbsp. sour cream
1 oz cheese
½ cup canned
peaches
1 oz peanuts
1 cup fat-free milk
6 carbohydrate
choices (90g)
3 oz meatloaf
½ cup corn
4 oz cinnamon
glazed apple cubes
1 dinner roll
1/3 cup white rice
1 cup fat-free milk
1 ¼” square
brownie
6 carbohydrate
choices (90g)
3 oz grapes
¼ cup cottage
cheese
1 carbohydrate
choice (15g)

27. Nutrition Monitoring and Evaluation
 Patient’s oral intake was monitored
Improved oral intake
Met >45% of estimated energy needs
Met >65% of protein needs
 Social worker spoke with patient
Provided patient with information about
Meals on Wheels

28. Nutrition Monitoring and Evaluation
(cont.)
 Patient understanding of education
Able to list foods that were 1 carbohydrate
choice
Verbalized carbohydrate choices of foods in
example menu
Verbalized how to read a food label
Compliance expected to be fair to good with
more practice

29. Summary
 DM involves a problem with insulin
 Production
 Resistance
 Uncontrolled DM can lead to complications of
several body systems
 Entered NCP through nutrition screen

30. Summary (cont.)
 Nutrition Assessment
 Extreme obesity class 3
 Elevated labs due to uncontrolled DM and infection
 Metformin, Humalog, and Insulin NPH
 6 carbohydrate diet
 Energy needs: 2600kcal/day
 Protein needs: 83-127g/day

31. Summary (cont.)
 Nutrition diagnosis
 Pt had increased nutrition needs
 Limited access to food
 Food-and nutrition-related knowledge deficit
 Interventions
 Meals
 Snacks
 Referral to social worker
 Patient education

32. Summary (cont.)
 Monitoring and evaluation
 Improved oral intake
 Provided information about Meals on Wheels
 Compliance of carbohydrate counting expected to be
fair to good with more practice

33. Summary (cont.)
 Carbohydrates metabolize to sugars
 Carbohydrate counting
 1 carbohydrate choice = 15g carbohydrates
 6 carbohydrate diet = 90g carbohydrates at each meal
 Snacks between meals and before bed to prevent
hypoglycemia
 Label reading
 Serving size
 Total carbohydrates

34. Summary (cont.)
 ADA recommended goals emphasize self-management
 Martins et al. researched effects on carbohydrate
counting and blood glucose control on patients with type 2
DM
 Three classes
 Follow up 1 year later
 Martins et al. found that carbohydrate counting
 Decreased hemoglobin A1c
 Better blood glucose control

35. Other Suggestions for Similar Cases
 For patients on a carbohydrate controlled diet explain
what diet consist of upon initiation of diet
 Provide inpatient education on carbohydrate counting and
schedule outpatient education
 Obtain information on foods and beverages patient drinks
at home
 Obtain information on regular meal times to determine
appropriate meal plans for patients

36. Objectives
 To demonstrate the effects uncontrolled diabetes mellitus
can have on patients.
 To discuss the Nutrition Care Process by presenting a
diabetes mellitus case study.
 To provide education on carbohydrate counting for
healthcare providers to better assist patient’s in managing
diabetes mellitus.

37. Questions?