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 for type 2 diabetes-

• Loss of weight
• Frequent urination (polyuria)
• Increased thirst (polydipsia)
• Increased hunger (polyphasia)
• Lower abdomen pain
• Fatigue

Due to impaired glucose uptake in body excess glucose reaches the kidney. When kidney reaches its threshold glucose is excreted in urine (glucosuria). This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss.

The lost body fluids are replaced from water in cells and otger fluid compartments leading to dehydration. This leads to increased thirst.

Body cells are not able to utilize the glucose and produce energy. This leads to easy fatigue.

2. A high prevalence of diabetes is seen inpatients with obesity. In overweight people, nonesterified fatty acids, glycerol, hormones, cytokines, proinflammatory markers, and other substances involved in the development of insulin resistance increases. In diabetes the ?-islet cells of the pancreas are impaired, causing a lack of control of blood glucose. The development of diabetes becomes more inevitable if the failure of ?-islet cells of the pancreas is accompanied by insulin resistance.

3. HbA1c is known smas glycaled haemoglobin. It is measured to give 3 month average of plasma glucose concentration. Higher level HbA1c indicates poor control of blood glucose. Higher levels of HbA_1c are found in people with persistently elevated blood sugar. A diabetic with good glucose control has a HbA_1c level within the reference range.

4. Mrs Folley have high LDL and triglyceride which suggests hyperlipidemia. Her diet modificatiins should include low fat food, low intake of fatty and oily food and sodium. She also needs to incorporate some exercises in her routine.

5. Exchange meal : food is divide into six categories — starch, fruit, milk, vegetable, meat, and fat. A defined serving or "exchange" of each food item in one of these categories has the same calories, grams of fat, protein, and carbohydrate in it as every other food item in that category.

Carbohydrate counting : patient is defined number of grams of carbohydrate to eat in each meal to keep a check on blood glucose.

Exchange meals are used in chronic diabetic patients. Mrs Folley can go for carbohydrate counting.

6. Complications include blood vessel disease, cardiovascular disease, diabetic retinopathy, nephropathy, chronic kidney disease, diabetic neuropathy.

7. Certified Diabetic Educator will help her to understand about diabetes and related disorders better. It will help her to know about its causes, symptoms and risk factors. It will help her to understand the management of DM. It will also help her to know about the associated complications and prevention. Educator will educate about dietary and lifestyle modifications