Question

Mrs. Folley is a 51-year-old African American female who works as a bookkeeper for an insurance company. Her father and brother have type 2 diabetes mellitus, and have had severe complications because of poor control of blood glucose.  
She is 5' 4" tall and weighs 174 pounds with a medium frame. She has a history of obesity, hypertension, hypothyroidism, and frequent urinary tract infections, and is currently taking propranolol hydrochloride and synthroid.  
Mrs. Folley complains of constant fatigue over the past two months and has lost 8 pounds, although she is thirsty and hungry and eats all the time. She is concerned that she may have another urinary tract infection because she has frequent urination and pain in her lower abdomen. Her physician orders some fasting blood tests and the results show the following: glucose 380 mg/dL (normal 70-110 mg/dL), HbA1c 7.6% (normal < 6%), serum LDL cholesterol 270 mg/dL (normal <200 mg/dL), triglycerides 290 mg/dL (normal <200 mg/dL). She is diagnosed with type 2 diabetes, and started on a 1200kcal diet and glyburide. She is also scheduled to see the nurse, who is a Certified Diabeties Educator (CDE), at the end of the week for further counseling.

1. What symptoms of type 2 diabetes does Mrs. Folley manifest? Explain the pathophysiology of these symptoms.
2. What is the relationship between being overweight or obese and diabetes?
3. What is the HbA1c and how is it used to monitor diabetes?
4. In view of her other laboratory results, what other dietary counseling will Mrs. Folley need?
5. What is the difference between the two meal planning strategies, exchange lists and carbohydrate counting? Which strategy do you think the CDE will teach Mrs. Folley? Why?
6. Mrs. Folley's family members suffer from some of the complications of uncontrolled diabetes. What are some of the chronic complications that she is at risk for developing?
7. Why is a referral to a Certified Diabetes Educator important for this patient?

Answer 1

1.Symptoms of mrs. Folley

• Constant fatigue: The constant fatigue is due to lack of energy in the body. There is presence of sugar or glucose in the blood, but the cells are not able to take it and use it, hence the cells are in a constant state of energy deprivation .
• She is thirsty and hungry all the time: As stated above, the cells are in energy deprivation, hence it increases the stimuli to eat so as obtain energy. Now, there is lot of sugar in the blood and the kidneys work really hard to process these sugars, but after a point of time due to overload, kidneys do not function that efficiently, and eliminating these sugar through urine. This leads to washing out of fluids in the body, which leads to dehydration and polyuria at the same time. Hence she is hungry and thirsty all the time.
• Frequent urination and pain in her lower abdomen: Frequent urination is due to increased sugar levels in the blood, which after a point of time is excreted through urine. Now pain in the lower can be due to a potential UTI (urinary tract infection) due to frequent urination.

2. How obesity is linked to diabetes?

Obesity =======> High levels of free fatty acids in the body =======> effects insulin signalling =======> Decreases absorption and metabolising of glucose in the liver and skeletal muscle =======> insulin resistance =======> diabetes type 2

3. HbA1c or glycated hemoglobin is a type of hemoglobin that is chemically linked to sugar. By assessing the levels of HbA1c , clinicians are able to get an overall picture of the blood sugar levels over a period of weeks or months (average plasma glucose concentration). The normal level is below  42 mmol/mol. Above 48mmol/mol is called diabetic level. Between 43-47 mmol/mol it is called pre diabetic level.

4. Her lab reports show that her serum LDL cholesterol is 270 mg/dL and serum triglycerides is 290 mg/dL . Both of these values are above the normal levels. This shows that her lipid profile is not satisfactory and she needs restrictions on the diet. She needs to reduce her fat intake.

5. Carbohydrate counting is dietary tool that helps to keep a track of the carbohydrate intake throughout the day where as in exchange list there are food groups and within a food group one serving of each food item, contains the same amount of in that food group has the same amount of proteins, carbohydrates, fats and calories. CDE should suggest the exchange list method because along with carbohydrates, mrs folley needs to watch her fat intake too and exchange list will allow her to have a more balanced diet.

6. Chronic complications associated with diabetes are

• Hypertension : very common among diabetics
• Microvascular complications like nephropathy, retinopathy, neuropathy.
• Diabetic foot ( lower extremities gangrene)
• Accelerated arteriosclerosis : increased risk for MI and stroke.
• Infections of the skin.

7. It will help mrs. Folley to learn diabetes self- management education and she will be able to manage her die, reduced complications , reduce the cost related to hospital admissions etc.