18. Type 2 diabetes mellitus
What are the risk factors for type 2 diabetes mellitus (DM)? What are the diagnostic criteria for type 2 DM? How do type 1 and type 2 DM differ in terms of prevalence, aetiology, prevention and management? What are the aims of treatment? How is this condition managed medically? What are the target blood glucose levels? How are patients with this condition monitored? How frequently should monitoring be conducted? Justify this frequency and the need for monitoring. What is the National Institute for Health and Care Excellence (NICE) guidance on monitoring? How can patients monitor themselves? What short and long term complications are associated with poor diabetic control? Describe possible mechanisms. What does HbA1c stand for? Why is it important to monitor this in diabetes? The units for HbA1c have recently changed. What are the current units? How do you convert % values to these new units? Give the target value in both units. What is metabolic syndrome? What are the diagnostic criteria? Why is this a serious health issue for affected individuals and society? Using the available information, can any of the following clients be diagnosed with metabolic syndrome?
Case study 1 Sema Jethwa Mrs Desai is a 63-year-old retired widow. She lives alone but her son, daughter in law and grandchildren live nearby. She came to the UK from East Africa in 1970. She is a Hindu and Gujarati is her main language (spoken and written) but she can converse in English. She was diagnosed with type 2 DM 15 years ago. Her mother died from a heart attack at 65 years of age. She was referred by the diabetes nurse for dietetic review as she often feels dizzy during the day. Her most recent HbA1c was 55 mmol/mol. She presented in clinic feeling dizzy and her blood glucose when tested was 5.7 mmol. She is currently taking metformin 500 mg tds and gliclazide 160 mg bd. Her current BMI is 23.9 kg/m2 and she has lost 6 kg since her husband died a year ago. She walks 5–10 minutes/day to collect her grandchildren from school; her son and his wife
have a busy legal practice. Mrs Desai used to travel on the bus but is now less confident as her eyesight has deteriorated. She often feels lonely.
How would you assess Mrs Desai using the ABCDE format? What dietary restrictions are associated with Hinduism? What is a likely cause of her dizzy spells associated with her diet and condition? What dietary advice can you give her to help with this problem? What is the dietetic diagnosis? What is the dietetic intervention? Describe both short and long term aims. What dietary advice would you give her about the type of carbohydrate in her diet? Calculate her dietary energy requirements. How can she monitor her diabetes herself? What are her target blood glucose levels? What are the possible barriers to change? How can you support her to make these changes? What can you suggest to help her feel less lonely? Mrs Desai wears dentures. How may this affect her diet? What advice can you give her to encourage her to have an adequate intake of fruit and vegetables?
Case study 2 Sunita Wallia Mrs Singh, a 47-year-old Sikh woman, has been living in Scotland for the past 15 years with her son’s family. Her daughter in law is her main carer. She does not speak any English. She communicates well in Punjabi but is illiterate. Her carer understands limited English. She was diagnosed with type 2 DM 17 years ago and had a myocardial infarction 4 years ago. The diabetes specialist nurse requested a joint visit with her mainly due to the language barrier. Currently her BMI is 31 kg/m2 and her waist circumference is 112 cm. Mrs Singh is dependent on friends and relatives visiting her and enjoys savoury matthies (a savoury snack made from white flour dough, rolled and deep fried), biscuits or small piece of Asian sweet during visits. Her physical activity is limited to 10 minutes of walking three times a week and minimal domestic chores. Her most recent biochemistry results were HbA1c 8.7 mmol/mol, total cholesterol 5.2 mmol/L and high density lipoprotein (HDL) 0.8 mmol/L. Her medication is as follows: Omeprazole 10 mg od Atorvastatin 40 mg od Amlodipine 15 mg od Amitriptyline 25 mg bd
Ferrous sulphate bd Aspirin 75 mg Insulin mixtard 30 (22 units AM, 14 units PM, and currently being monitored for insulin adjustment) How would you assess Mrs Singh using the ABCDE format? What is the dietetic diagnosis? What dietary restrictions are associated with Sikhism? What is the dietetic intervention? Her daughter in law uses a lot of ghee and sugar in her cooking and fries a lot of food. How would you impart advice to her about Mrs Singh’s diet? Why do you think Mrs Singh is being prescribed ferrous sulphate? How does her diet affect this? What dietary advice can you give to help this condition? What other biochemistry test would you like to request from her GP? What are the barriers to change? How can you assist Mrs Singh in overcoming them? Given the language and literacy difficulties, what teaching style can you adopt? What lifestyle and social changes could you suggest? What are the short and long terms aims and how will you monitor them?
Case study 3 Tahira Bashir Mr Yusuf is a 65-year-old Muslim businessman. He came to the UK at the age of 17 years with his parents and is married with three children. He can speak English but is more confident speaking in Urdu or Punjabi and would prefer to communicate in his mother tongue. His BMI is 26 kg/m2 and he has a waist circumference of 105 cm. He was diagnosed with type 2 DM and hypertension 7 years ago and a stomach ulcer 3 years ago. His mother had type 2 DM and is now deceased. His brother also has type 2 DM. His HbA1c has gradually deteriorated over the last 18 months and is currently 57 mmol/mol. He takes Glucophage (metformin) 500 mg bd to control his diabetes. His blood pressure was 160/64 mmHg in clinic and his lipid profile was: TC 5.8 mmol/L LDL 4.5 mmol/L HDL 1.2 mmol/L TG 2.7 mmol/L
How would you assess Mr Yusuf using the ABCDE format? What is the dietetic diagnosis? What dietary restrictions are associated with Islam?
What risk factors does he have for cardiovascular disease? What tools could you use to predict someone’s 5-year risk of cardiovascular disease? What role does genetics play in this risk? Use the diagram in Figure 5.5.1 to draw a pedigree for Mr Yusuf. What is the dietetic intervention? Describe the dietary advice you would give Mr Yusuf. Who should you discuss shopping and cooking with? Why? How important is the sodium content of his diet? Describe the DASH diet and its rationale. What are the barriers to change? How can you help him overcome these barriers?
Case study 4 Thomina Mirza Mr Hussain is a 56-year-old married man living with his wife and two daughters in social accommodation. He is a retired restaurant manager and is currently unemployed. He speaks Sylheti Bengali and some English. Mr Hussain is not an observant Muslim but is quite strict about Islamic food laws, and whenever possible will only eat halal foods. He has type 2 DM, hypertension, hyperlipidaemia, liver disease and depression. The last HbA1c test result was 68 mmol/mol. His medication is: Metformin 850 mg tds Gliclazide 160 mg bd Pioglitazone 45 mg od Simvastatin 40 mg od Lisinopril 20 mg od Amitriptyline 50 mg od Calcichew D3 Thiamine
How would you assess Mr Hussain using the ABCDE format? What is the period of fasting associated with Islam? Describe the dietary rituals associated with Ramadan? How may this affect a person with diabetes? What is the dietetic diagnosis? Why do you think Mr Hussain is taking calcichew D3? How would you advise him to change his diet to help this condition? What type of liver disease is associated with type 2 DM? Describe the possible mechanisms for this.
Why do you think he is prescribed thiamine? What type of liver disease does Mr Hussain have? What is the dietary intervention? What is the dietetic priority? What lifestyle advice should you give him? What are the barriers to change? How can you help him overcome them? How will you evaluate the success of your intervention? Given his social circumstances, what advice about referral to other agencies can you offer?
Case study 5 Ruth Kander Mrs Cohen is a 33-year-old housewife. She lives with her husband and six children. She was born in the UK but her parents and grandparents came from Europe to escape the Second World War. She speaks English and Yiddish at home. She is an ultra orthodox Jew and follows strict kashrut laws, observes the Shabbat and festivals, along with all the other laws. She has type 2 DM. Her random blood glucose in clinic was 15 mmol/L and her total cholesterol was 6 mmol/L. She is currently taking metformin 500 mg bd. Her current weight is 95 kg, height 1.60 m, BMI 37 kg/m2 and waist circumference 90 cm.
What are the dietary laws associated with being an ultra orthodox Jew? How would you assess Mrs Cohen using the ABCDE format? Describe the traditional foods that Mrs Cohen would cook and eat. Comment on the fat, carbohydrate and energy content of these traditional foods. What are the comorbidities associated with her degree of obesity? Calculate the energy content of the recommended diet for Mrs Cohen? What level of energy restriction would you recommend? Why? What is the recommended macronutrient content of a diet for someone of her age and size? What is the dietary intervention? What are the aims and objectoves? How can she reduce the sugar and fat content of her diet while adhering to a strict kosher regimen? What advice can you give her to cope with festivals including Shavuot, which is associated with dairy foods? What medication can she be prescribed to reduce her cholesterol if dietary measures are not entirely effective?
Mrs Cohen is a busy housewife. Does she need to increase her physical activity level and if so, how can she fit this into a busy lifestyle? What are the barriers to change? How can you help her make the necessary changes? How would you evaluate her progress?
Case study 6 Christina Merryfield Mr Al-Sayer is a 65-year-old Muslim man originally from Kuwait who now lives in the UK with his wife and four children. He speaks limited English but his children are able to translate and speak, read and write good English. At least one of his children and wife are able to accompany him to his appointments. He was diagnosed with type 2 diabetes 6 months ago. His wife and both his sons also have diabetes. His fasting blood sugar level was 12 mmol/L and HbA1c 69 mmol/mol. His current weight is 100 kg (usual weight 97 kg), height 1.70 m, BMI 35 kg/m2 and waist circumference 104 cm. He takes metformin 500 mg tds and antihypertensive agents.
How would you assess Mr Al-Sayer using the ABCDE format? Why is waist circumference reported? What are the gender appropriate cut-offs for Middle Eastern men and women? What other ethnically appropriate cut-offs are available? Why do the associated health risks vary with ethnicity? Comment on Mr Al-Sayer’s waist circumference. What foods would you associate with a Middle Eastern diet? What is the dietetic diagnosis? What is the dietetic intervention? What are the aims and objectives? Mr Al-Sayer enjoys dates as a snack several times a day and does not understand why this is not ‘good for him’ as he considers this part of his 5 A DAY. How can you help him understand? He also enjoys Arabic sweetmeats such as baklava. What alternative foods could he snack on during the day? As his wife and two of his sons are also diabetic, what changes can you help the family with to improve their glycaemic control? Is this appropriate in a consultation aimed at Mr Al-Sayer? How can Mr Al-Sayer reduce his waist circumference? What is the energy prescription so that he can reduce weight? He and his family are very sociable and frequently entertain family and friends; a spread of dishes is served rather than individual portions. Does this affect his ability to adhere to a prescribed energy reducing diet? How can you advise him appropriately? What are the barriers to change? How can these barriers be overcome?
What outcome measures would you use to monitor and evaluate the intervention? Are they SMART?
Case study 7 Nardos Yemane Mrs Ahmed is from Somalia and has lived in the UK for over 10 years. She is 43 years old and was diagnosed with type 2 DM soon after arriving in the UK. She is known to the diabetes specialist dietitian in the diabetes centre as she has been referred previously to improve her diet to help manage her diabetes. She also has hypercholesterolaemia and hypertension. She lives with her three sons and daughter, aged between 17 and 24 years old. She does not work. She does not speak English and in the past has attended her appointments with the dietitian with a Somalian interpreter. One of her sons has attended one of her appointments with her but often her family are too busy to accompany her. She is a Muslim and prefers Halal meat. Prior to commencing on insulin treatment in 2002 in addition to her oral therapy, she used to observe Ramadan. She has developed diabetic complications including background retinopathy and neuropathy. Her current antidiabetic agents are: Lantus 28 units at night Novorapid 6 + 10 + 14 units with each meal Metformin 1000 mg tid Her last HbA1c was 107 mmol/mol and her current weight is 95.8 kg, height 1.68 m and BMI 33.9 kg/m2.
How would you assess Mrs Ahmed using the ABCDE format? What are the difficulties when assessing someone’s diet when using an interpreter? Are the difficulties the same if a family member is used for this purpose? What is the dietetic diagnosis? Mrs Ahmed’s carbohydrate intake varies in amount during the day and between days. How will this affect her diabetic control? What is the dietetic intervention? Is it SMART? Her carbohydrate intake is usually refined, e.g. white bread and pasta. How will this affect her blood glucose levels? What types of carbohydrates do you advise? What level of glycaemic load should she be aiming for? Define glycaemic index (GI) and glycaemic load. How are they measured? Give examples of low, medium and high GI foods. Glycaemic index can be a difficult concept to understand. What teaching methods could be helpful?
Mrs Ahmed has frequent hypoglycaemic blood levels. How can these be avoided? How should they be treated? How can you sensitively explore any cultural beliefs and myths about diabetes and losing weight? Why is overweight valued in some societies? Describe how you would evaluate and monitor Mrs Ahmed’s progress.
Case study 8 Elzbieta (Ela) Szymula Mrs Kowalska is a 45-year-old Polish woman who lives with her husband and two children. She works part time work as an accountant and looks after the family for the rest of the time. They have lived in the UK for 12 years and she speaks fluent English. She enjoys cooking and tries to be adventurous with food. Her current weight is 93 kg, height 1.70 m and BMI 32 kg/m2 with a waist circumference of 101 cm. She has gradually put on approximately 15 kg in the past 10 years. She was recently diagnosed with type 2 DM and hypercholesterolaemia. The relevant biochemistry results are: FBG 8 mmol/L HbA1c 62 mmol/mol TC 5.6 mmol/L LDL 3.8 mmol/L HDL 0.85 mmol/L TG 2.3 mmol/L This is her first appointment with a dietitian.
How would you assess Mrs Kowalska using the ABCDE format? What is the dietetic diagnosis? What are the priorities? Discuss the availability of traditional Polish foods and their nutrition content. Mrs Kowalska is daunted by the diagnoses. How will this affect her ability to listen and understand your advice? What is the dietetic intervention? She has a busy life and does not always prioritise herself, often missing meals. How can she make the necessary changes to facilitate success? Mr and Mrs Kowalska have a busy social life and she enjoys wine, beer, rum and vodka cocktails; her alcohol intake is 20 units/week. What are the government recommendations on alcohol intake for women? How much energy does she consume as alcohol?
She has tried to make some changes while waiting for her appointment with you and has started having honey rather than sugar in her tea and coffee. Is this advisable? Her physical actively level is 1.4. Calculate her energy requirements using appropriate prediction equations. What are the barriers to change? What advice can you give her to help overcome these barriers? How would you evaluate and monitor her progress?
Case study 9 Christiana Pavlides Mr Michaelides is a 61-year-old semi retired tailor who lives with his wife and youngest son. He has another three children who all live locally and six grandchildren. His cooking skills are very basic as his wife is an excellent cook. The immediate family eat together on a regular basis. Eating out with friends and family is a key part of their social life. He has lived in the UK since 1969. He understands English very well and can read and write. He is a Greek orthodox. Following his brother’s recent myocardial infarction he attended his GP who diagnosed type 2 DM. He was likely to have had this diagnosis for several months as he reports a history of thirst, tiredness and polyuria; this is consistent with his glycated haemoglobin. His GP has referred him for dietary advice and education. His relevant and recent biochemistry results are: TC 6.8 mmol/L LDL 4.3 mmol/L TG 2.17 mmol/L HDL 1.5 mmol/L FBG 9.8 mmol/L HbA1c 88 mmol/mol His GP has prescribed metformin 500 mg bd. However, he has refused to take it as he feels ‘tablets are for sick people’ and wants to try lifestyle changes first. His current weight is 96 kg (before he retired it was 85 kg) and height is 1.68 m.
What dietary rules are associated with being Greek orthodox? What foods would you expect to be included in the diet of a Greek person living in the UK? Comment on the fat and sugar content. How you would assess Mr Michaelides using the ABCDE format? What is his BMI? What is the dietetic diagnosis? What is his target weight and BMI?
Why is it important to do a full lipid profile on this man? Describe the metabolism of the different lipids and how they relate to diet. What is the dietetic intervention? What are the priorities? How can the different lipids be modified by diet? Mr Michaelides is confused as he has read that the Mediterranean diet is healthy, particularly as it is rich in olive oil. What is the Mediterranean diet? Why is it considered healthy? How do you think his diet and lifestyle differ from this type of diet? Is he being realistic about not taking medication? How would you assess his willingness to change? Describe a model of change. He attended the appointment alone. Why does this present problems with making the necessary changes? What changes can he make to his lifestyle? Which and what levels of physical activity do you recommend? What are the barriers to change? How would you evaluate and monitor his overall progress?
Case study 10 Arit Ana Mr Effiong is a 55-year-old Nigerian man who lives with his wife and three teenage children in a three bedroom council flat. He works a 12-hour shift as a security guard in a local warehouse from 8 AM to 8 PM, 6 days a week. He was diagnosed with type 2 DM on presenting with extreme tiredness and other symptoms of hyperglycaemia, which he attributed to his long working hours and irregular and unhealthy diet. He had been managing his symptoms by himself at home for 6 months until his wife insisted that he saw a doctor. His current weight is 85 kg, height 1.64 m and waist circumference 99 cm. His blood pressure was 166/88 mmHg and the relevant biochemistry results were: Random glucose 7 mmol/ HbA1c 54 mmol/mol TC 4.2 mmol/ HDL 1.1 mmol/L LDL 2.2 mmol/L TG 0.7 mmol/L
How would you assess Mr Effiong using the ABCDE format? Calculate his BMI and waist to hip ratio, and comment on these. What normal ranges would you use? Why?
What symptoms would you associate with hyperglycaemia? Calculate his TC:HDL ratio. Comment on his biochemistry results. What Nigerian foods would you expect Mr Effiong to include in his diet? What is the dietetic diagnosis? What is the dietetic intervention? What is his target weight and BMI? What is the recommended rate of weight loss? What is the recommended energy and macronutrient intake for his present and target weights? How could you advise him to have a healthy eating pattern while he is working this shift pattern? What types of carbohydrate would you recommend to help him maintain normal glycaemia throughout the day? Mr Effiong is taking metformin bd. Would you expect him to experience hypoglycaemic episodes? Justify your answer. He has a sedentary job. How could he increase his physical activity levels? Mr Effiong is taking herbal remedies. How could you assess what has been taken? How can you give him culturally specific advice about complementary therapy? He only counts the main meal he eats at home as food; other foods are seen as snacks and not food. How could you help him understand what is meant by regular meals and snacks? What healthier snacks can you recommend? He often has fast food and bottles of sugar sweetened drinks while he is on shift. What alternatives would you advise? What are the barriers to change? How could you help him overcome these barriers? How would you evaluate and monitor his progress?