Introduction
Patient has a history of diabetes mellitus since 1993. Patients diabetes has been poorly controlled which has led to other medical conditions, such as acute renal failure. Diabetic patients are also at higher risk for pressure ulcers and impaired wound healing. Case study will focus on how the low-carbohydrate diet may help control type II diabetes and prevent further renal failure.
Patient ProfilePsych/Social/Economic
Occupation- Special Education Teacher
Home life- Lives with her husband
Patient Profile
Medical History
Patient has an extensive history of uncontrolled diabetes and diagnosed in 1993. Pressure ulcers to left posterior hip and right plantar foot. Pneumonia with septic shock Hypertension Acute Renal Failure
Patient Profile
Family Medical History
Mother died of methicillin-resistant staphylococcus aureus (MRSA) infection at age 70
Father is living at age 80. He suffers from diabetes mellitus, heart disease, and arthritis.
Substance abuse- ETOH was a problem in the past, but not current.
GI system- GI system has not been a problem until recently.
Patient Profile
Pathophysiology Inflammatory condition involving the lungs, which include the visceral pleura, connective tissue, airways, alveoli, and vascular structures. Typical symptoms associated with pneumonia include cough, chest pain, fever, shortness of breath, loss of appetite, and nausea or vomiting.
Pulmonary function and weight status is related to respiratory muscle weakness and immunodeficiency.
Diaphragm and intercostal muscle mass decreases with weight loss leading to a decrease in inspiratory and expiratory muscle strength and a reduction in vital capacity Symptoms and clinical manifestations- nonproductive cough, weakness, rigors, sweats, and chills. Patient had nausea and vomiting.
Patient Profile
Etiology- The most common causes of infectious pneumonia are bacteria and viruses. Less common causes of infectious pneumonia are fungi and parasites. Treatment-Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. Extremely sick individuals require intensive care treatment which include intubation and artificial ventilation. Prevent weight loss and malnutrition. Nutrition intervention- Preventing weight loss, small frequent meals, easy to swallow and digest foods, supplements and nutrient dense nourishments, whole grain cooked and soft vegetables and fruit.
Patient Profile
Symptoms- decreased motility, dehydration, and comorbid conditions such diabetes, renal failure, thyroid disease, exposure of skin to urinary and fecal incontinence, steroids or other drugs that interfere with wound healing, unintentional weight loss
Patient Profile
Etiology- It is more likely to occur with those who are confined to a chair or bed and older adult. Other causes or diseases that affect blood flow such as diabetes, fragile skin, urinary/bowel incontinence and malnourishment. Treatment- wound team, topical medicine such as Bactroban and Silvadene, special gauze dressings, and avoid further friction to the area and relieve pressure with pillow. Vitamin A, C, and zinc need to be monitored. Mineral and vitamin wound care guidelines are in the appendix.
Nutrition intervention- protein and kcal needs are increased to aid in wound healing, snack, supplements, and small frequent meals.
Patient Profile
Pathophysiology- characterized by sudden reduction in glomelur filtration rate and an alternation in the ability of the kidney to excrete metabolic waste. Symptoms and clinical manifestations- rapid decrease in urine output, acidosis, electrolyte imbalances, fluid disturbances, impaired glucose utilization, protein catabolism, and accumulation of metabolic waste products.
Patient Profile
Etiology- hypertension, diabetes mellitus, toxic drug exposure, and progressive glomerulonephritis Treatment Medical management- depends on the stage of kidney failure but common treatments are IV fluids, medications such as Kayexalate, PO4 or K+ binders, and meds to help restore blood calcium. If severe, treat with dialysis, and electrolyte management (K+, PO4, Na).
Nutrition intervention-
Renal diets which limit K+ and PO4. Diets usually high in kcal and protein intake depends on the stage of failure Protein recommendations vary depend on the severity of renal failure from 62.0g/kg, potassium 2-3gm a day, and sodium restriction (less 100mg per serving). Avoid fat soluble and choose water soluble vitamins, because fat soluble vitamins rather than water soluble vitamins deposit in the body and cause complications.
Patient Profile
Patient Profile
Abnormal pattern of insulin secretion and action. Decreased cellular uptake of glucose and increased postprandial glucose, and increased release of glucose by liver in early morning hours. Patients are insulin-resistant to predominately deficient in insulin secretion.
Symptoms and clinical manifestations- excessive thirst, hyperglycemia, frequent urination, polyphagia, excessive thirst, and weight loss. Etiology- genetic facets, older age, obesity, physical inactivity, family history, prior history of gestational diabetes, impaired glucose homeostasis, excessive calories, and environmental factors.
Patient Profile
Treatment Medical management- Physical activity is the cornerstone of management of type 2 diabetes. The progressive nature of type 2 diabetes usually requires use of one or more glucoselowering medications and eventually insulin, along with MNT and physical activity. A few common glucose lowering medications are insulin, sulfonylureas, biguanides, and a-glycosidase
Nutrition intervention- Nutrition education such as better food choices, caloric restriction to promote weight loss, and spreading carbohydrate nutrient intake throughout the day (consistent carb diet). Also, research indicates low-carb diets have the excellent results in preventing progression of impaired glucose tolerance to diabetes.
Diabetes diet aims at evenly distributing meals with increase intake of vegetables, dietary fiber, whole-grain bread, and other whole-grain cereal products, and fruits and berries, and decrease intake of total fat. Popular diets are exchange lists and carb counting. Carb counting is a meal planning technique for managing your blood glucose levels.
American Diabetes Association. January 2008. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care, Volume 31: S61-S78.
Pathophysiology LC Biochemistry
Pancreas to dietary carbohydrate
Insulin related to glucose in the bloodstream and effects fatty acid metabolism and storage. Insulin fatty acid (acetyl-coA) and triglycerol synthesis (lipoprotein lipase liver). Fatty acid storage is favored as insulin inhibits the release of fatty acids from the cell through activation of the hormone-sensitive lipase. Insulin increases the carb metabolism which helps affects appetite and reduce fat storage.
Hite AH, Berkowitz VG, Berkowitz K. Nutr Clin Pract. 2011 Jun;26(3):300-8.
Jonsson Study
Randomized crossover pilot study assessed 13 subjects with T2DM on Paleo diet compared to diabetes diet. Blinded study with two consecutive 3-month periods. Randomized controlled study of 29 men with IHD and T2DM on 12 week Paleo diet. Results of diabetes diet v. Paleo diet resulted:
significant lower mean of hemoglobin A1C weight and BMI triglycerides improved insulin sensitivity diastolic blood pressure and systolic blood pressure lower glycemic load
Jnsson T, Granfeldt Y, Ahrn B, Branell UC, Plsson G, Hansson A, Sderstrm M, Lindeberg S. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009; 8:35
Kitava Study
Epidemiological study with traditional Pacific Islanders of Kitava, Papua New Guinea. Pacific Islanders of Kitava consumed a traditional diet (paleo) and population had no signs of metabolic syndrome.
David C. Klonoff The Beneficial Effects of a Paleolithic Diet on Type 2 Diabetes and Other Risk Factors for Cardiovascular Disease J Diabetes Sci Technol. 2009 November; 3(6): 1229 1232.
Gulbrand Study
Low carb diet v. low fat on glycemic control, non blinded study, randomized parallel trial, n=61. Outcomes reduction in HbA1c for LCD patients and weight variance wasnt significant but insulin doses were reduced more for the LCD patients.
Guldbrand H, Dizdar B, Bunjaku B, Lindstrm T, Bachrach-Lindstrm M, Fredrikson M, Ostgren CJ, Nystrom FH. In type 2 diabetes, randomisation to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss. Diabetologia. 2012 Aug;55(8):2118-27. doi: 10.1007/s00125-012-2567-4. Epub 2012 May 6.
Hussain Study
Randomized controlled study comparing low-carb ketogenic to low-calorie diet in improving glycaemia. Three hundred and sixty three obese and diabetic participants could choose LCD or LCKD and study lasted 24 weeks. Conclusion- LCKD had significant positive effects on body weight, waist measurement, triaglycerol, and glycemic control. HgbA1c improvement was remarkable and the antidiabetic medications had been decreased substantial in participants using LCKD.
Hussain TA, Mathew TC, Dashti AA, Asfar S, Al-Zaid N, Dashti HM. Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. Nutrition. 2012 Oct;28(10):1016-21. doi: 10.1016/j.nut.2012.01.016. Epub 2012 Jun 5.
Meta-Analysis Study
20 randomized controlled trials, n=3073, >/=6 compared LC, vegan, vegetarian, GI, high fiber, Mediterranean with control diets low fat, high GI, ADA, EASD, and low protein diets. Conclusion LC, low-GI, Mediterranean, and high protein diets all led to greater improvement in glycemic control and improve glucose management and largest effect in Mediterranean diet.
LC and Mediterranean led to the greatest weight loss and increase in HDL which were seen in all diets except high protein
Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013 Mar;97(3):505-16.
LC Controversies
Argument Expensive Kidney adverse effect
Counter Medical bills are $$$$$ DRI- 10-35% protein and LC intake doesnt imply HP
Fiber intake
Dietary fiber in US is potatoes and white flour. A shift to leafy greens will give more nutritive value
Depends on SF and HbA1c elevated linked to CVD
Saturated fat
Hite AH, Berkowitz VG, Berkowitz K. Nutr Clin Pract. 2011 Jun;26(3):300-8.
Application to Patient
Initial Diagnosis- Pressure ulcer but after lab results diagnosis changed to Acute Kidney Failure. Duration and intensity- She had the right plantar pressure ulcer since 7/23/2013 and she was recently seen on 11/01/2013 for a pressure ulcer on left hip Patient understands disease and treatments, but behavior modification is not occurring and poorly controlled diabetes is lead to other multi organ dysfunctions.
Current Diagnosis
Acute Renal Failure Metabolic Acidosis Hyperkalemia
Treatments
Surgical- N/A
Therapies- Rehydration Medications with potential drug nutrient interactions
Potassium binder - Kayexalate Sliding Scale Insulin to stabilize sugars Lisinopril- kidney protection from CKF Vitamin C 500mg BID Multivitamin
Lack of compliance or inconsistent compliance with plan related to kidney and endocrine dysfunction as evidenced by variable PO intake and elevated BGs and HgbA1C.
Multivitamin daily
Refer patient to Diabetic Outpatient clinic
Nutrition Intervention
Advance from a renal diet/consistent carb diet to a low-carb diet when discharged Refer patient to Diabetic Outpatient Clinic for education Offer Nepro supplement if less than 75% PO intake
Key Points
Patient has uncontrolled diabetes that has led to acute renal failure. If patient adheres to the low-carb diet after discharged, HgbA1c, weight, BMI, fasting plasma insulin can be lowered. Patient can benefit from a low-carb diet that may improve blood glucose , HgbA1C , lipid profile, and promote weight loss and reduce the possibility of other adverse events.
Summary/Conclusion
Patient has poorly controlled diabetes and a low-fat diet may prevent further kidney disease and improve endocrine functions. Research shows that a low-fat diet compared to the conventional diabetes diet has better outcomes on risk factors and prevention.
References
Mahan LK & Escott-Stump S : Krause's Food, Nutrition and Diet Therapy, 11th ed, Elsevier, Philadelphia, PA, 2004. Hite AH, Berkowitz VG, Berkowitz K. Nutr Clin Pract. 2011 Jun;26(3):300-8. Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013 Mar;97(3):505-16. David C. Klonoff The Beneficial Effects of a Paleolithic Diet on Type 2 Diabetes and Other Risk Factors for Cardiovascular Disease J Diabetes Sci Technol. 2009 November; 3(6): 12291232. Guldbrand H, Dizdar B, Bunjaku B, Lindstrm T, Bachrach-Lindstrm M, Fredrikson M, Ostgren CJ, Nystrom FH. In type 2 diabetes, randomisation to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss. Diabetologia. 2012 Aug;55(8):2118-27. doi: 10.1007/s00125-012-2567-4. Epub 2012 May 6. American Diabetes Association. January 2008. Nutrition Recommendations and Interventions for Diabetes. Diabetes Care, Volume 31: S61-S78. Jnsson T, Granfeldt Y, Ahrn B, Branell UC, Plsson G, Hansson A, Sderstrm M, Lindeberg S. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009; 8:35 Hussain TA, Mathew TC, Dashti AA, Asfar S, Al-Zaid N, Dashti HM. Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. Nutrition. 2012 Oct;28(10):1016-21. doi: 10.1016/j.nut.2012.01.016. Epub 2012 Jun 5.