Case study

Question 1

Gary's main disease is Type 2 diabetes (T2D), which is a condition categorized by metabolic

abnormalities, such as persistent high blood sugar levels, arises due to insulin resistance and

insufficient production of insulin (Fritschi & Quinn, 2010). In the case of T2D, the body displays

resistance towards the impact of insulin, a hormone responsible for controlling glucose levels,

while the pancreas might fail to generate an adequate amount of insulin to counteract this

resistance (Fletcher et al., 2002). As a consequence, heightened blood glucose levels arise,

posing potential harm to numerous organ systems if not effectively controlled. This situation

engenders various adverse impacts, affecting the normal functioning of multiple bodily systems

(Apostolopoulos et al., 2016; Cho et al., 2018). The symptoms Gary is experiencing, such as

chronic fatigue, polydipsia (excessive thirst), frequent nocturia (waking up at night to pass

urine), and his elevated plasma glucose level and HbA1c, are consistent with the clinical

manifestations of T2D.

The main causes of T2D include genetic factors, sedentary lifestyle, poor dietary habits, and

obesity (Shaw et al., 2010; Wild et al., 2004). In Gary's case, his sedentary lifestyle as a software

engineer, poor dietary habits including frequent consumption of fast food and sugary drinks, and

significant weight gain contribute to his increased risk for developing T2D.

Chronic fatigue is a frequently reported symptom among individuals with diabetes, significantly

affecting their quality of life and ability to manage the condition (Martin, 2021). It can be

influenced by various factors, such as glycemic control, lifestyle, medical conditions,

psychological factors, and endocrine imbalances. However, studies focused specifically on

fatigue in diabetes are limited. Managing diabetes-related fatigue involves addressing the

underlying causes, including optimizing glycemic control, managing comorbid conditions,

improving sleep quality, and adopting a healthy lifestyle (Balch, 2006; Midhet et al., 2010;

Mukhtar et al., 2020).

Excessive thirst, known as polydipsia, is a well-known symptom of diabetes, particularly when

accompanied by high blood sugar levels (Moses & Olenik, 2019). As blood sugar levels rise, the

body responds by intensifying urine production in an effort to expel the surplus glucose. This

process can lead to dehydration and instigate a pronounced sensation of thirst. Managing

polydipsia in diabetes involves ensuring proper hydration and maintaining stable blood sugar

levels through medication, dietary adjustments, and lifestyle changes (Weiss, 2012).

Frequent nocturnal urination, or nocturia, can be associated with diabetes, although it can have

other causes as well. In diabetes, nocturia may be linked to factors such as polyuria (excessive

urine production) and obstructive sleep apnea (OSA). OSA is a common comorbidity in diabetes

and can contribute to nocturia. Effective management of nocturia in diabetes involves optimizing

blood sugar control, addressing OSA if present, and considering lifestyle modifications like

reducing fluid intake before bedtime (Umlauf & Chasens, 2003; Weiss, 2012).

While specific supplements or treatment methods for these symptoms in diabetes should be

determined in consultation with healthcare professionals, some studies have suggested potential

benefits of certain supplements in managing fatigue associated with chronic conditions.

Coenzyme Q10 (CoQ10) and nicotinamide adenine dinucleotide (NADH) have shown promise

in reducing fatigue levels and improving symptoms in chronic fatigue syndrome (Wood, 2022).

However, research specifically on their utility for diabetes-related fatigue is limited,

necessitating further investigation to establish their effectiveness.

To address the nutritional issues of Gary, it is important to develop a comprehensive nutrition

plan that focuses on managing blood glucose levels, promoting weight loss, and improving

overall dietary quality. Extensive research investigations have consistently demonstrated the

paramount importance of dietary and nutritional strategies in both averting and effectively

handling Type 2 diabetes. These approaches serve as pivotal factors in thwarting the onset of the

condition as well as effectively overseeing its management (Pradhan, 2007; Rubin & Peyrot,

1999; Swift et al., 2018; Wang & Hu, 2018). These studies emphasize the importance of

adopting a healthy dietary pattern, which includes:

 Embrace a balanced diet abundant in whole grains, fruits, vegetables, and legumes.

 Limit the intake of refined grains, red/processed meats, and sugary beverages.

 Reducing energy intake to promote weight loss and improve insulin sensitivity.

 Incorporating regular physical activity to support weight management and glucose

control.

 Monitoring carbohydrate intake and distributing it evenly throughout the day to avoid

large fluctuations in blood glucose levels.

Additionally, nutrition education and counseling can be beneficial for Gary to enhance his

understanding of healthy eating, portion control, and meal planning. Such interventions have

been shown to improve dietary feeding practices and lifestyle factors in individuals with Type 2

diabetes (Paschalides et al., 2004).

To assess the nutritional status and nutrient requirements of the patient, we will calculate the

BMI, Basal Energy Expenditure (BEE) using the Harris-Benedict equation, Resting Energy

Expenditure (REE), protein requirement, and Acceptable Macronutrient Distribution Range

(AMDR).
BMI Calculation:

Body Mass Index (BMI) is a metric utilized to assess the amount of adipose tissue in relation to

height and weight. It is determined by dividing the weight in kilograms by the height in meters

squared (Ogden et al., 2008). The formula for BMI is as follows:

BMI = weight (kg) / (height (m))^2

Using the given data for Gary, who weighs 115 kg and has a height of 1.75 m, we can calculate

his BMI as follows:

BMI = 115 / (1.75^2) = 37.55 kg/m^2

Gary's BMI is 37.55 kg/m^2. As per the guidelines of the World Health Organization (WHO),

individuals with a BMI equal to or surpassing 30 kg/m^2 are classified as having obesity (Seo et

al., 2019). Therefore, Gary falls under the category of obesity according to WHO standards.

Basal Energy Expenditure (BEE) Calculation:

BEE represents the energy expenditure at rest. The Harris-Benedict equation is commonly used

to estimate BEE (Frankenfield et al., 1998). The equation varies based on gender and age. The

formula is as follows:

For men:

BEE = 66.5 + (13.75 × weight in kg) + (5.003 × height in cm) - (6.755 × age in years)

Using the given data for Gary, who is a 53-year-old man weighing 115 kg and measuring 1.75 m

in height, we can calculate his BEE as follows:

 BEE = 66.5 + (13.75 × 115) + (5.003 × 175) - (6.755 × 53) = 66.5 + 1581.25 + 875.525 -

358.915 = 2164.36 kcal/day

Gary's BEE is approximately 2164.36 kcal/day.

Resting Energy Expenditure (REE) Calculation:

The REE accounts for about two-thirds of the total energy expenditure. It can be calculated by

multiplying the BEE by an activity factor that reflects the individual's activity level (Fraipont &

Preiser, 2013).

Since Gary has a sedentary lifestyle and works as a software engineer, we can use an activity

factor of 1.2 (sedentary/light activity) to estimate his REE.

REE = BEE * Activity Factor

REE = 2164.36 * 1.2 = 2597.23 kcal/day

Gary's estimated REE is approximately 2597.23 kcal/day.

Protein Requirement:

The protein necessity fluctuates depending on variables such as individual's age, gender, and

level of physical activity. The Recommended Dietary Allowance (RDA) for protein in adults is

0.8 grams per kilogram of body weight on a daily basis (Gaffney‐Stomberg et al., 2009).

However, individuals with specific conditions or goals may have different protein needs.

To calculate Gary's protein requirement, we will use the RDA for protein and his weight.

Protein Requirement = 0.8 grams/kg/day * weight (kg)

Protein Requirement = 0.8 * 115 = 92 grams/day

Gary's protein requirement is approximately 92 grams/day.

Acceptable Macronutrient Distribution Range (AMDR):

The AMDR provides a range of macronutrient intake percentages that are considered

nutritionally adequate (Murphy et al., 2022). The AMDR for adults is generally as follows:

 Carbohydrates should make up 55-60% of the total calorie intake.

 Protein should constitute 15-20% of the total calorie consumption.

 Fat should account for 25-30% of the total calorie intake.

CHO: 55%

CHO = 55/100 x 2597

CHO = 1428

CHO= 1428/4

CHO = 357 g/day

PRO = 20/100 x 2597

PRO = 519

PRO = 519/4

PRO = 129 g/day

FAT =. 25/100 x 2597

FAT = 649

FAT = 649/9

FAT = 72 g/day

Converting grams to servings:

CHO: 357/15 = 23 servings/day

PRO: 129/7 = 18 servings/ day

FAT: 72/5 = 14 servings/day

Question 2

To manage type 2 diabetes, it is important for Gary to make dietary and lifestyle changes. Here

are evidence-based recommendations and strategies that can be implemented:

Dietary Changes:

a. Follow an evidence-based Eating Pattern: To optimize his dietary choices, it is advised that

Gary embraces a scientifically supported eating plan centered around whole, unprocessed food

sources. Several recommended dietary patterns to consider are the Mediterranean diet, the

Dietary Approaches to Stop Hypertension (DASH) diet, and the plant-based diet, all of which are

backed by substantial evidence (Miller et al., 2021).

b. Carbohydrate Intake: Gary should choose carbohydrates that have a lower glycemic index,

as they have a lesser impact on blood sugar levels. This includes consuming whole grains,
legumes, vegetables, and fruits, while limiting the intake of refined grains, sugary foods, and

beverages.

c. Portion Control: Gary should pay attention to portion sizes and avoid overeating. Controlling

portion sizes can help manage blood sugar levels and support weight management.

d. Healthy Fats: To promote a balanced diet, Gary should incorporate nutritious sources of

beneficial fats into his meals. These can include options like avocados, nuts, seeds, and olive oil,

which provide valuable dietary fat. These can help improve insulin sensitivity and promote heart

health (Balch, 2006).

Lifestyle Changes:

a. Physical Activity: Gary should aim for regular physical activity, including both aerobic

exercises and strength training. Active participation in physical activity plays a pivotal role in

enhancing the body's response to insulin, assisting in weight control, and fostering holistic well-

being. He can start with moderate-intensity activities and gradually increase the duration and

intensity.

b. Sedentary Behavior: Given Gary's sedentary job, it is crucial to reduce prolonged sitting.

Encourage him to take frequent breaks, stretch, and incorporate movement throughout the day.

Standing desks or walking meetings can also be beneficial (Swift et al., 2018).

c. Weight Management: Gary's weight is a contributing factor to his diabetes. The management

of diabetes necessitates the attainment and sustenance of a healthy body weight. It is advisable to

adopt a gradual and sustainable weight loss strategy, which entails creating a calorie deficit by

implementing a blend of dietary modifications and enhanced physical activity.

d. Stress Management: Chronic stress can affect blood sugar levels. Encourage Gary to find

stress-reducing techniques such as mindfulness, meditation, yoga, or engaging in hobbies he

enjoys (Martin, 2021).

Short-term Management Strategy (EEN - Very Low-Calorie Diet):

Gary can consider a short-term intervention known as an "extremely low-calorie diet" (ELCD) or

an "energy-enforced low-calorie diet" (EEN). This approach involves consuming around 800

calories per day in the form of nutritionally complete meal replacements for a period of 8 to 12

weeks. EEN has shown to induce weight loss, improve glycemic control, and promote diabetes

remission (Reintam Blaser et al., 2017).

Long-term Management Strategy:

a. Continuous Support: Gary should have ongoing support from healthcare professionals, such

as registered dietitians, diabetes educators, and physicians, to monitor his progress, provide

education, and make necessary adjustments to his treatment plan.

b. Diabetes Self-Management Education and Support (DSMES): DSMES programs offer

comprehensive instruction on self-care practices, encompassing areas such as nourishing dietary

choices, engaging in regular exercise, effectively managing medications, and monitoring blood

sugar levels. Gary should consider participating in a DSMES program to enhance his knowledge

and skills for long-term diabetes management (Moses & Olenik, 2019).

c. Regular Monitoring: Regular monitoring of blood sugar levels, blood pressure, and weight is

crucial for managing diabetes. Gary should work with his healthcare team to establish a

monitoring schedule and set target ranges for these parameters.

Question 3

The following meal choices offer Gary a well-balanced and nutrient-rich eating plan that

emphasizes the consumption of unprocessed food items, lean sources of protein, carbohydrates

rich in fiber, and beneficial fats. These options encompass a diverse array of fruits, vegetables,

whole grains, and lean protein sources. The meals aim to promote a moderate caloric intake,

considering Gary's weight management goals.

Question 4

Gary's sedentary lifestyle, poor dietary habits, and excessive weight gain have likely contributed

to the development of type 2 diabetes. Multiple research studies provide evidence for the role of

lifestyle and dietary factors in the pathogenesis of type 2 diabetes.

Sedentary Lifestyle:

Gary's job as a software engineer requires long hours of sitting in front of a computer, indicating

a sedentary lifestyle. Extended periods of sitting and a sedentary lifestyle have been linked to a

heightened likelihood of developing type 2 diabetes. Insufficient engagement in regular physical

activity diminishes the body's sensitivity to insulin, hampers the metabolism of glucose, and

fosters weight gain, all of which are factors that contribute to the risk of diabetes. Multiple

studies have underscored the adverse consequences of a sedentary lifestyle on glucose

metabolism and the body's responsiveness to insulin (Fletcher et al., 2002; Hawley, 2004).

Consistently participating in physical activities, including aerobic exercises and resistance

training, can enhance the body's sensitivity to insulin and facilitate the process of shedding

excess weight. By doing so, the risk of developing type 2 diabetes can be effectively reduced.
Poor Dietary Habits:

Gary's frequent consumption of fast food and sugary drinks is indicative of a poor diet. These

eating patterns frequently contain an abundance of calories, detrimental fats, excessive amounts

of added sugars, and a deficiency of vital nutrients. Consuming an excess of calories, particularly

from unhealthy fats and added sugars, contributes to the accumulation of body weight and the

onset of obesity, both of which are strongly associated with the emergence of insulin resistance

and type 2 diabetes. Furthermore, the consumption of sugary beverages, in particular, has been

linked to an elevated likelihood of developing type 2 diabetes (Odegaard et al., 2010). Several

research studies have emphasized the importance of adopting a healthy and balanced diet for the

prevention and management of type 2 diabetes. Nourishing the body with a plethora of fruits,

vegetables, whole grains, lean sources of protein, and beneficial fats can significantly enhance

glycemic control and lower the potential for complications related to diabetes (McMacken &

Shah, 2017). Dietary interventions may also include reducing the consumption of processed

foods, sugary drinks, and foods high in saturated and trans fats.

Weight Gain and Obesity:

Gary's weight of 115 kg and height of 1.75 m indicate a high body mass index (BMI) and

obesity. Obesity is a major risk factor for T2D, as excess adipose tissue, especially in the

abdominal region, promotes insulin resistance and impairs insulin secretion. Adipose tissue

produces pro-inflammatory cytokines and adipokines, which contribute to chronic low-grade

inflammation, further worsening insulin resistance and promoting the progression to diabetes.

Multiple research studies have demonstrated the strong association between obesity and the

development of type 2 diabetes (Apostolopoulos et al., 2016). For individuals with T2D,

achieving weight loss by implementing dietary modifications and engaging in consistent physical
activity plays a critical role in enhancing the body's response to insulin and effectively managing

blood sugar levels (Alsairafi et al., 2016).

HbA1c Level:

The HbA1c result of 58 mmol/mol or 7.5% suggests that Gary's average blood glucose control

over the past few months has been higher than the target range. In general, for individuals with

diabetes, an ideal HbA1c level is 48 mmol/mol (6.5%) or below (Hughes et al., 2014). When

HbA1c levels are elevated, it signifies inadequate management of blood sugar levels and a

heightened susceptibility to complications associated with diabetes. It is important for Gary to

work towards lowering his HbA1c levels through lifestyle modifications and, if necessary,

medical interventions.

In terms of treatment options, Gary would benefit from comprehensive lifestyle modifications

and medical interventions, if necessary. Lifestyle modifications should include regular physical

activity, such as aerobic exercises and resistance training, to improve insulin sensitivity and

promote weight loss. To effectively manage blood sugar levels, it is recommended to embrace a

nourishing and well-balanced eating plan that prioritizes the consumption of unprocessed food

sources, such as fruits, vegetables, whole grains, lean protein options, and beneficial fats.

Additionally, dietary interventions may involve limiting the intake of processed foods, sugary

beverages, and foods that are high in saturated and trans fats (Gulati & Misra, 2017).

If lifestyle modifications alone are not sufficient to manage Gary's diabetes, medical

interventions may be necessary. This can include oral antidiabetic medications, such as

metformin, which improve insulin sensitivity and reduce hepatic glucose production. On certain

occasions, healthcare providers may recommend the utilization of injectable medications, such as
GLP-1 receptor agonists or insulin, to enhance the regulation of blood glucose levels. These

medications are prescribed to effectively manage and stabilize blood sugar levels (Abd El Aziz et

al., 2017).
Question 4:
Table 1: Calories, carbs, protein and fat level in day 1 meal plan
Figure 1: Micronutrients analysis of day 1 meal plan
Table 2: Calories, carbs, protein and fat level in day 2 meal plan
Figure 2: Micronutrients analysis of day 2 meal plan
Table 3: Calories, carbs, protein and fat level in day 3 meal plan

Figure 3: Micronutrients analysis of day 3 meal plan

Conclusion

In conclusion, Gary's sedentary lifestyle, poor dietary habits, and excessive weight gain have

likely contributed to the development of type 2 diabetes. Implementing evidence-based lifestyle

modifications, including regular physical activity and a healthy diet, along with appropriate

medical interventions, can help manage his condition and improve his overall health.

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