Meal Planning for Type II Diabetes Mellitus
As the Diabetes Education Centre dietitian, you must provide SG with dietary guidance.
- Based on the information presented develop a nutrition diagnosis for SG. Write this as a PES statement.
- Patient’s uncontrolled glucose and hyperglycemia is related to type 2 diabetes as evidenced by high fat and carbohydrates intake and abnormal laboratory results of Hb-A1C.
- At the risk of cardiovascular and hypertension related to excessive consumption of saturated fat and trans-fatty acid food and pre-packaged products as evidenced by high lipid profile including high total cholesterol, LDL-C and triglyceride level in laboratory results and 24h food recall record.
- Lack of food-nutrition knowledge related to lack of prior nutrition education as evidenced by patient unable to appropriately verbalize food choices.
- Identify the social issues in SGs presentation that you will need to consider.
SG is working as a taxi driver with relatively lower and unstable wages. Without health insurance, he must continue working full-time in order to gain financial support for his treatment. If the complication of diabetes jeopardize his work, he will not be able to afford his rent, food, health supplies, children, etc. with a part-time job. Since his wife passed away, SG started to encounter difficulties in life due to lacking of cooking skills which caused he and his son’s regular intake of pre-packaged foods and snacks. This bad eating habits could worsen his disease in addition to the risk of family diabetes history. SG’s sister can only help him out with meals from time to time, so do his neighbours. However, there is no indication that the neighbours are willing to prepare meals for his family. SG is worrying that his son might suffer from stress due to his wife’s death and his diagnosis with diabetes. His working schedule might have influence on his unhealthy eating habits. He often eats high-fat, high–calories take-out fast foods and soda drinks.
- Use the information provided to assess his current diabetes status.
Age: 49 years old
BMI: 31.2 Kg/m2 (obesity)
Height: 180 cm
Ideal body weight (IBW): 71.28 (calculated with normal BMI=22)
Many factors could lead to SG’s diagnosis of type 2 diabetes, which also have influence on his diabetic status:
SG has a family history of T2DM, and himself has obesity and prediabetes. Research has proved that these are the high risks factors of suffering diabetes (Clearinghouse, 2014).
SG has suffered from bladder infection, which indicates a particular problem for diabetes patients as sugar in the urine makes for a fertile breeding ground for bacteria. Visual impairment is also a common complication of diabetes due to diabetic retinopathy, which occurs when blood vessels in the retina are damaged (Klein et al., 1984). Other symptoms such as short of breath, feeling fatigued and light-headed are also indications for hypoglycemia. In combination of these factors plus the first laboratory result show that SG’s bad control over glucose level.
SG’s BMI is 31.2 Kg/m2, which means obesity. Therefore, a diet control was suggested to lower his weight which he did not follow. Obesity can raise the risk of getting T2DM. What makes it worse could be the bad dietary behaviors such as high-calorie fast food intake, excessive refined sugar intake, high fat and carbohydrates, sodium (from processed food) intake (24h recall) can increase his insulin resistance and lipid profile. Study has found that when patients participated in an exercise program, the experienced weight loss shows a significant drop in fasting blood glucose level and reductions in the use of hypoglycemic medications (Heath et al., 1991). In combination of these conditions lead to his current uncontrollable T2DM.
His unexplained weight loss is also a symptom of diabetes which caused by increased insulin resistance that decrease the malfunction of cell glucose absorption (Sjöström et al., 1999). The decreased function cause the energy consumption of proteins and fat in body which leads to weight loss.
- Provide an assessment of his current dietary habits.
- First result
- Glucose tolerance test
The first results indicate that SG might suffer from the complications of unmanaged diabetes. For example, the condition of bladder infection could be worsen due to the impaired renal function from unmanaged diabetes. The unmanaged diabetes might further cause renal failure which is a common complication of diabetes (high level of BUN and creatinine). Moreover, an infection might affect its liver function which presented a higher level of ALT. The Na+ laboratory result was high because of the bladder infection has affected its renal function.
The high lipid profile indicates bad eating habits, unbalanced diet and wrong choice of oil. It results the high level of TG, total cholesterol and low HDL.
- After Nutrition Intervention
SG’s uncontrolled glucose level shows a bad condition of his diabetes status. A bad glucose level control can develop into several complications of diabetes. Moreover, plus his family history of this disease, bladder infection and hypoglycemia syndromes, these will increase his risk of suffering diabetes long-term complication such as:
- Foot problems
- Regular hypoglycemia or hyperglycemia symptoms: the status of hyperglycemia can be monitored from patient’s impaired fasting glucose. Its symptoms include thirst, increased urination, increased hunger and weight loss (“WHO | About diabetes,” n.d.). SG also need to be aware of hypoglycemia symptoms such as sweat, tremble, feeling hungry and anxious (Fanelli et al., 1998).
- Cardiovascular disease:
CVD is the major cause of morbidity and mortality in patients with DM. The pathophysiology of CVD in diabetes including hypertension, dyslipidemia, genetic factors, hyperglycemia, metabolic abnormalities, oxidative stress and inflammation (Yamagishi & Imaizumi, 2005). Specific vascular, myopathic and neuropathic alternations are suggested to be responsible for the disease development into coronary heart disease (CHD) and congestive heart disease (Candido, Srivastava, Cooper, & Burrell, 2003).
- Microvascular disease:
Diabetic retinopathy can lead to visual impairment (Klein et al., 1984). Diabetic nephropathy leads to kidney diseases such as kidney failure which will lead to fluid filtration deficits of kidney function (Al‐Khoury et al., 2007). There is an increase in blood pressure (hypertension) and fluid retention in the body plus a reduced plasma oncotic pressure, which causes edema.
- Develop a meal management plan for SG that fits with his needs and abilities.
- Age: 49 years old
- BMI: 31.2 Kg/m2 (obesity)
- Height: 180 cm
- Current body weight: 101 kg
- Ideal body weight (IBW): 71.28 (calculated with normal BMI=22)
- Calories in need per day (Harris-Benedict Formula):
66.5 + (13.75 * weight in kg) + (5.003 * height in cm) – (6.775 * age in years) = 66.5+ (13.75 * 101) + (5.003 * 180) – (6.775 * 49) = 2023.28 kcal/day
A weight loss for SG is suggested. Therefore, we consider a reduction of 500 kcal per day which makes a total calorie around 1500 kcal per day. If continue a daily calorie reduction of 500 kcal, it is expected that SG can lose 1 kg in every one month.
- The dietary recommendation:
CHO: 45% - 60%
Energy requirement from CHO = 675 - 900 kcal
Total grams of CHO= 168.8 – 225 gm.
I pick around 200g of CHO (53%) per day for better calculation
Protein: 15 – 20%
Energy requirement from protein = 225 – 300 kcal
Total grams of protein= 56.25 – 75 gm.
I pick around 62 g of protein (17%) a day for better calculation. A restricted protein intake can help to control renal failure as one of diabetes complication
Energy requirement from fat < 525 kcal
Total grams of fat= 58.4 gm.
I pick around 50 g of fat (30%) per day for better calculation
The recommendation of Canada Food Guide Servings per Day for Adult from 19-50Y:
Therapeutic Lifestyle Changes Diet (TLC Diet)
TLC diet is endorsed by the American Heart Association (AHA) as a heart-healthy regimen that can reduce the risk of CVD. It is suggested that SG should consider the guidelines of TLC diet which can help to lower LDL-C level (Ernst & Cleeman, 2002).
- It is suggested that SG should do physical activities for 30min per day. But must be aware of glucose level before and during the exercise in order to prevent hypoglycemia symptoms.
- It is planned to get the carbohydrates from the whole grain product.
- It is planned to use olive oil as cooking oil
- It is suggested to use both water and oil while sauté the vegetables or corns
- It is suggested to choose lean protein meat such as chicken, turkey, salmon, lean beef over beef, ground beef or pork chop
- The choice of snack must avoid high glycemic index food and with sweetener substitute of sugar
- Indicate how you will communicate your plan to SG and how you will follow his progress.
- Firstly, I want to clarify with SG that this dietary plan is made through the discussion of both patient and dietitian. It is not entirely an order from dietitian but an adjustment of dietary lifestyle that is feasible to be done by SG. The evaluation from time to time is meant for adjusting the dietary plan in order to achieve an effective dietary treatment.
- SG need to fully understand the condition of his health status and the development of diabetes complication in the future.
- It is important to educate SG to measure the portion of foods by tools, hands and size. This helps him to control the dietary intake portions.
- When doing physical activities, it is suggested to test glucose level in order to know the physical condition. Accompanying of friends of family (his son) during exercise is strongly recommended due to the risk of hypoglycemia. Avoid aggressive physical activities such as running and choose aerobic physical activities such as walking, yoga or swimming.
- His son need to fully understand the disease. But should be reminded that diabetes is controllable with a positive dietary habits and plans. His son would also be suggested for a dietary adjustment due to the high risk of family T2DM history.
- Learn how to select health snacks that doesn’t contain high fat and carbohydrates
- Choose fresh food, vegetables, meat over processed or pre-packaged food. This helps him to prevent hypertension from limiting the sodium intake.
- Educate several simple cooking skills to improve his self-cooking abilities. For example, baked, sauté with little oil (water can be added later on) and boiling.
- Give one page of paper that lists all the guidelines of diabetes self-management.
- A list of recipe or simple food exchange list with healthy food
- Give tips on saving money when dining out and follow health diets
- Follow up- It is suggested that he should record his 24h recall in order to calculate his dietary intake. If possible, with the utilization of mobile technology devices, he can chat with dietitian via mobile phone or email about his dietary inquiry or dietary report.
- Monitor his glucose level every day and record the results for a week.
- Monitor the physical activities and type of the physical activities. Report any uncomfortableness occurred during or before exercise.
- Monitor his A1C every 3 months.
- Monitor his lipid profile annually.
- Monitor his renal function by following up the BUN and creatinine level every 3 months.
Al‐Khoury, S., Afzali, B., Shah, N., Thomas, S., Gusbeth‐Tatomir, P., Goldsmith, D., & Covic, A. (2007). Diabetes, kidney disease and anaemia: time to tackle a troublesome triad?. International journal of clinical practice, 61(2), 281-289.
Candido, R., Srivastava, P., Cooper, M. E., & Burrell, L. M. (2003). Diabetes mellitus: a cardiovascular disease. Current Opinion in Investigational Drugs (London, England: 2000), 4(9), 1088–1094.
Clearinghouse, T. N. N. D. I. (n.d.). Am I at Risk for Type 2 Diabetes? Taking Steps to Lower Your Risk of Getting Diabetes. text. Retrieved March 24, 2014, from http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/
Fanelli, C. G., Paramore, D. S., Hershey, T., Terkamp, C., Ovalle, F., Craft, S., & Cryer, P. E. (1998). Impact of nocturnal hypoglycemia on hypoglycemic cognitive dysfunction in type 1 diabetes. Diabetes, 47(12), 1920–1927.
Heath, G. W., Wilson, R. H., Smith, J., & Leonard, B. E. (1991). Community-based exercise and weight control: diabetes risk reduction and glycemic control in Zuni Indians. The American Journal of Clinical Nutrition, 53(6), 1642S–1646S.
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WHO | About diabetes. (n.d.). WHO. Retrieved March 25, 2014, from http://www.who.int/diabetes/action_online/basics/en/