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Theodore Mitchell

CASE STUDY III Type I Diabetes Mellitus


______________________________________________________________________________
Kxxxxx, Dxxxxx
Male
22 yo
Allergies: NKA
Code: FULL
Isolation: NONE
Pt. Location: RM 1202
Physician: C. Johnston
Admit Date: 12/02/15
______________________________________________________________________________
Pt Summary: D.K. is a 22 yo male admitted through the ED who c/o excessive thirst and frequent
urination of 2 wk duration, in addition to increased appetite and weight loss of 9 pounds in 3 weeks.
PMH: pt was product of normal pregnancy and delivery; had varicella at age 6, and an appendectomy at
age15. No Medications. NKA.
FH: Parents L&W. Maternal aunt has Type 1 DM; Paternal grandfather died of CVD 2 to Type 2 DM.
Other grandparents L&W. Has 2 siblings, one older brother, one younger sister; both L&W.
Social Hx: 22 yo male, undergraduate student at UC Davis. Pt used to play ultimate frisbee three times a
week, but says he now tires easily so he has not played in 2 weeks.
ROS:
GI:
GU:
CNS:
PE:
General:
Vitals:
Lungs:
Heart:
HEENT:
Abdomen:
Genitalia:
Extremities:
CNS:
Skin:
Peripheral Vascular:

No hx of N/V, or diarrhea
No hx of urgency, frequency, or burning urination except for present complaint
of polyuria
Alert and oriented, no hx of impaired LOC, convulsions, or difficulty walking
Slightly underweight, tired appearing male; wt: 145# ht: 71
T 98.2F; P 120; R 27 with fruity odor; BP 110/70 mm Hg
Clear to percussion and auscultation
Normal sinus rhythm, no murmurs
Non-contributory
Flat, non-tender, no liver enlargement
Nl
Non-contributory
Normal gait and deep tendon reflexes
Smooth, warm, dry, no edema
Pulse +4 bilaterally

Laboratory Results (non-fasting)


Chemistry
Sodium (mEq/L)
Potassium (mEq/L)
Chloride (mEq/L)
Carbon dioxide (CO2, mEq/L)
BUN (mg/dL)
Creatinine serum (mg/dL)
Glucose (mg/dL)
Phosphate, inorganic (mg/dL)
Magnesium (mg/dL)
Calcium (mg/dL)
Osmolality (mmol/kg/H2O)
Bilirubin total (mg/dL)

Ref. Range

12/02/15 1950

136-145
3.5-5.5
95/105
23-30
8-18
0.6-1.2
70-110
2.3-4.7
1.8-3
9-11
285-295
1.5

130 !
3.6
101
31 !
18
1.1
382 !
2.1 !
1.9
10
306 !
0.2
1

Bilirubin, direct (mg/dL)


Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
Ammonia (NH3, umol/L)
Alkaline phosphatae (U/L)
ALT (U/L)
AST (U/L)
CPK (U/L)
Lactate dehydrogenase (U/L)
Cholesterol (mg/dL)
Triglycerides (mg/dL)
T4 (ug/dL)
T3 (ug/dL)
HbA1C (%)
C-peptide (ng/mL)
ICA
GADA
IA-2A
IAA
tTG
Hematology
WBC (x 103/mm3)
RBC (x 106/mm3)
Urinalysis
Collection method
Color
Appearance
Specific Gravity
pH
Protein (mg/dL)
Glucose (mg/dL)
Ketones
Blood
Bilirubin
Nitrites
Urobilinogen (EU/dL)
Leukocyte esterase
Protein check
WBCs (/HPF)
RBCs (/HPF)
Bacteria
Mucus
Crys
Casts (/LPF)
Yeast

<0.3
6-8
3.5-5
16-35
9-33
30-120
4-36
0-35
30-135 F; 55-170 M
208-378
120-199
35-135 F; 40-160 M
4-12
75-98
3.9-5.2
0.51-2.72
-

0.01
6.9
3.2
15
9
110
6.2
21
61
229
180
150
8
81
8.12 !
0.52
+ !
+ !
+ !
-

4.8-11.8
4.2-5.4 F; 4.5-6.2 M

10.6
5.8

1.003-1.030
5-7
Neg
Neg
Neg
Neg
Neg
Neg
<1.1
Neg
Neg
0-5
0-5
0
0
0
0
0

Clean catch
Yellow
Clear
1.008
4.9 !
+1 !
+4 !
+4 !
Neg
Neg
Neg
Neg
Neg
tr !
0
0
0
0
0
0
0

Dx: New Onset Type 1 Diabetes Mellitus


MDs Plan: Admit, achieve glycemic control with Regular Insulin then adjust to daily therapy with
mixed insulin therapy; initiate diabetes SBGM training; nutrition consult for hospital and home diet
planning and pt. education.
2

You are the in-patient RD.

1. What are three metabolic reasons for D.K.s weight loss (number each for full credit). (3 points)
1. Lack of insulin function, as evidenced by ICA, GADA, IAA and resultant high blood sugar levels,
leads to subsequent loss of glucose absorption.
2. The degradation of muscle and fat stores to supply energy for the body.
3. Due to high amounts of sugar in blood and plasma increasing osmolality Water and mineral loss from
excessive urination and loss of water loss at the cellular and interstitial fluid level increases.
Source
NTP; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management
www.mayoclinicallaborotories.com/test-catalog/clinical+and+interpertive/82080
2. Compare D.K.s admission laboratory values with normal values. What does each value indicate,
based on the hospitals lab value reference ranges above?
Test
Nl Values
D.Ks Values
Comparison
What do D.K.s lab values
(+/-)
suggest about his metabolic
state?
BG mg/dl
70-100 mg/dl
382 mg/dl
+
Insulin
deficiency
and
hyperglycemia
Urinary
Negative
+4
+
High circulating blood glucose
glucose
leading to excess sugar filtration
from body. ADH released RAS
(renin-angiotensinsystem)
activated.
Urinary
Negative
+4
+
Lipolysis, abnormal fatty acid
ketones
metabolism body using ketones
for energy; ketosis; ketoacidosis
Alb g/dl
3.5-5 g/dl
3.2 g/dl
Low protein intake, or loss from
catabolism for metabolic use.
Pre-Alb. mg/dl 16-32 mg/dl
15 mg/dl
Marker of nutritional status and
low protein intake.
3.9-5.2 %
8.12%
+
High amount of sugar in the
HbA1c
blood binding to Hb. Cell signal
disruption, gene expression,
inflammation and metabolic
change
Source- Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

3. List the following HbA1C ranges. (2 points)


Normal non-diabetic:
4-6
Pt w/ controlled diabetes:
< or = to 7
Pt w/ fair to poorly
controlled diabetes:

>7

Source- Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

4. What is HbA1C and what does HbA1C measure? (1 point)


Glycosolated hemoglobin. It measures the level of sugar in the blood over a three month period of time as
the blood cell lives for 120 days which indicates the efficiency of the bodys glucose absorption and
usage system
Source-Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116 MNT for Diabetes Lecture
and Art and Science of Diabetes Management

5. Explain the role/relationship of HbA1C in the development of micro- and macro-vascular


complications of diabetes.
High HbA1Ccan lead to the formation of AGE advance glycosylation end products. These cause changes
in cell signaling and genetic expression resulting in inflammation, altered metabolism and other long term
complications like vascular damage.
These AGEs and their effects on physiology can lead to macrovascular conditions live CVD (HCD and
stroke), HTN and atherosclerosis, and micro-vascular issues as well leading to poor nutrient delivery and
gas exchange.
HTN can result from the above factors and also changes in osmolality and activation of RAS.
Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

You meet with D.K. to do a nutrition assessment and begin a general introduction to dietary management
of diabetes. You take a diet history (listed below) as part of your assessment. D.K. states that these are
the types of foods that he usually eats, but the quantity is much greater than usual because he has felt so
hungry lately.
Breakfast (eaten at home):
1 c. oatmeal with brown sugar and cup of 2% milk
1 c. juice (orange, apple, or cranberry)
Toast (2 slices or English muffin) w/ butter & jelly
Coffee with sugar and 2% milk
(occasionally 2 scrambled eggs and 2 strips of bacon instead of the cereal)
Lunch (eaten at the CoHo on weekdays):
2 slices of pepperoni pizza with a small salad or
Cheeseburger and French fries or
Spinach Crepe
16 oz of sweetened iced tea
dessert such a cookies or a brownie
(sometimes 8 oz of 2% milk instead of the iced tea)
Mid afternoon:
medium mocha or latte,
A cookie or a piece of fruit
Dinner:
Spaghetti w/ meat sauce (about 2 c. cooked noodles)
2 pieces of garlic bread
Salad w/ fat free dressing
12 ounces of 2% milk
or
~6 oz. meat (chicken or beef, only occasionally fish)
1 cup of rice or large baked potato w/ butter
Vegetables in season (will eat w/ salt & butter but prefers cheese or bechamel sauce)
12 ounces of 2% milk
or
A deli sandwich and chips and soda if he does not have time to cook
HS:
D.K. eats one of the following:
Bag of microwave popcorn w/ 1-12 oz can of regular soda
2 scoops of ice cream
1 c 2% milk and 4-5 cookies
2 oz. cheese and 12 Wheat Thin crackers
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6. Based on the diet history information above and what you know about MNT management of Type 1
Diabetes Mellitus, name 3 nutrition-related topics that are important to discuss in educating D.K. as
he prepares to head home from the hospital.
1. Carbohydrate counting and insulin dosing
2. Basic nutrition knowledge around metabolism and physiologic use of macronutrient and micronutrient
needs for patient with DM
3. Decreasing saturated fatty acid intake and increasing intake PUFAs
Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

7. You determine that D.K. needs 2736.1 kcals/day based on your calculations and the fact that D.K.
needs to gain weight to achieve his normal weight. You want to follow his normal eating pattern as
much as possible while still meeting his protein requirements and keeping the kcal from fat at 30-40%
of total kcals. Using the Exchange Lists, develop a pattern for D.K.s diet.
EER= Based on MSJ with Activity of factor of 1.3 and Injury factor of 1.1- with IBW used since DK
underweight.
MSJ for men (10 * wt. [kg]) + (6.25 * Ht. [cm]) (5 * age) + 5
= (10 * 78.181818 18kg) + (6.25 * 180.34 cm) - (5 * 22 yrs.) + 5= 1803.941182 * 1.5 (activity factor)
= 2705.911773; (1803.941182 * 1.1)* 1.4 (1.4 average activity factor cause patient is young and
physically active and injury factor for protein and fat loss from catabolic state)=
2778.006942=2778.01 or 2778.0 kcal actual kcal based on diet pattern
MNT Pocket Guide

Column1

Column2

Column
4
Protein
grams

Column
5
Fat
grams

Column6

Number of
Exchanges

Column
3
CHO
grams

Food group

Breakfast
Starch

2- Starch

30 g

6g

2g

Fruit-

1-fruit

15 g

0g

0g

Milk & Subs.(circle skim,


1%, 2%, or whole)
Protein (circle lean, med- or
high-fat)

1svg.- 2%

12 g

8g

5g

oats, brown rice,


whole grain
dried cranberry cup
2% milk

2 medium fat

0g

21 g

12 g

Turkey sausage

Fats

1 non saturated

0g

0g

5g

pumpkin seeds

Fat unsaturated

0g

0g

510g

brazil nuts

Non Starchy V-egetable


Fruit

1
1 fruit

5g
15 g

2g
0g

0g
0g

1/2 cup broccoli


Grapes

1/2 muffin

2 CHO 1.25 fat

30 g

0g

6.25 g

bran blueberry

Lunch
Starch

30 g

6g

2g

whole grain pasta,


millet, quinoa

Sample food

Morning Snack
(write in Food Group below)

Fruit

15 g

0g

0g

Kiwi

Milk & Subs.(circle skim,


1%, 2%, or whole) 1%
Vegetables

10 g

4g

0g

green beans

Protein (circle lean, med- or


high-fat)

2 medium fat

0g

14 g

10 g

Turkey, roast beef

Fat

2 unsaturated
fats

0g

0g

10 g

olive oil

Fats

0g

0g

15 g

Avocado

free food
Protein (circle lean, med- or
high-fat)
Dinner
Starch

1
2 medium fat
protein

0g
0g

0g
14 g

0g
10 g

salad greens
Chicken thigh

30 g

6g

2g

1 cup yogurt

2 CHO2 fat

30 g

1g

10 g

grits, buckwheat,
whole grain etc.
Yogurt

Milk & Subs.(circle skim,


1%, 2%, or whole)
Vegetables

10 g

4g

0g

spinach or DGLV

14 g

4g

Fish

Afternoon Snack
(write in Food Group below)

Protein (circle lean, med- or


high-fat)
Fats
HS Snack
(write in Food Group below)
shake medium

2 lean

Olive oil

~5.5 milk
substitute CHO
and ~4 fat

50 g

40 g

25.5 g

~282g

~140g

~125g

X4
1128
kcal

X4
560 kcal

X9
1125
kcal

Whole fruit
smoothie with
almond coconut
blend

Total grams
kcal from each macronutrient
TOTAL KCAL

2813.0 kcal

40%
20%
40%
Choose Your Foods Booklet- American Diabetes association
8. D.K. is taught about his diet, insulin injections, SBGM, and other self-care issues prior to discharge.
He will be discharged on a basal injection of Lantus, with bolus injections of Humalog insulin at
mealtimes. Provide the information below. Also note any dietary recommendations,
contraindications/precautions, and interactions. What effect will these medications have on his
nutritional care? Refer to the medication information in the Food-Medication Interactions text. (3
points)
Lantus

Generic name:

Insulin glargine

Classification:

Anti-Diabetic, hyperglycemic Medication


7

Onset of Action:

1.1 Hour

Peak:

No peak

Duration:

Long lasting all day 20-24 hours

Food Medication Interactions TM pp. 179-180

9. Humalog

Generic name:

Insulin lispro

Classification:

Anti-Diabetic hyperglycemic medication

Onset of Action:

5-30 min

Peak:

0.5-2.5 hours

Duration:

3-6.5 hours

Food Medication Interactions TM pp. 179-180

10. Lantus & Humalog

Indication:

Uncontrolled DM or for tightly controlled glucose monitoring on MNT

Diet:

Diabetic meal plan to balance CHO insulin intake

Possible FoodMedication Interactions:

alcohol, inadequate CHO intake, nopal cactus*, aloe vera tea*

Potential
Nutrition/Oral/GI Side
Effects:

Mau increase weight, may see no weight increase in DM 1. Improper dose


food interaction can result in low blood sugar hypoglycemia or
hyperglycemia. Oral and GI side effects rare

Food Medication Interactions TM pp. 179-180

11. Write an ADIME note for D.K., using the information that you have obtained up until this point. Base
your note on the pertinent information given in the presentation data, diet history, and questions
above. Write the ADIME note below and attach a separate sheet with all calculations. Include two
PES statements.
A:
22 y/o male admitted through the ED with excessive thirst and frequent urination. 2 week duration.
Increased appetite and weight loss of 9 pounds in 3 weeks. MDx- Recent onset Type 1 diabetes mellitus
Family history both parents L&W, history of Type 1 DM in maternal aunt, paternal grandfather passes
from CVD secondary to type 2 DM. Other grandparents L&W, siblings L&W

Social History- Undergraduate university student, plays ultimate Frisbee three times a week
Anthropometrics
Wt.: 145 lb./2.2 kg=65.9 kg H.t: 71 in x 0.254= 180.3 cm BMI=wt.[kg]/ht.[m]2=65.9/1.8032= 20.27 (low
normal) IBW= 106 lb. + 6 lb. for every lb. over 5ft.= 106lb. + 66lbs= 172 lb./2.2= 78.18 kg % IBW=
(ABW/IBW)*100= (145lb./172lb.) * 100 = 84% patient underweight based on % IBW and low range
BMI
UBW 154 lb. % UBW= UBW/CBW * 100% 145/154 * 100% = 94.15%
% WEIGHT CHANGE = 100- % UBW= 100 94.15= 5.85%in less three weeks is evidence of
nutritional risk.
Labs- Na-130and P-2.1 (levels low); Glucose-382 (levels high); HbA1C -8.12(high); 306 Osmolality
(high, cellular dehydration)
ICA, GADA, IAA (all present)- (related to Type 1 diabetes dx; insulin deficiency and nutrient absorption
lost);
Albumin and Pre-albumin levels within normal range
8

Glucose, Proteins and Ketones in urine (abnormal metabolism, ketosis, body in catabolic state);
Urinary pH (high) & CO2 (high) (body in acidic state may have altered metabolism of food or drugs)
Diet order- food logs and journal see below for full history.
Weight History- in past three weeks patient has lost 5.85% body weight.
Medications- Lantus; Humalog both for management of Diabetes Mellitus Type 1 with goal of tight
glucose regulation MNT
Estimated Nutrient Needs
EER= 2778.0 kcal actual kcal based on diet pattern
Based on MSJ with Activity of factor of 1.3 and Injury factor of 1.1- with IBW used since DK
underweight. MSJ for men (10 * wt. [kg]) + (6.25 * Ht. [cm]) (5 * age) + 5 = (10 * 78.181818
18kg) + (6.25 * 180.34 cm) - (5 * 22 yrs.) + 5= 1803.941182 * 1.1 (injury factor because patient is
underweight)= 1954.3353 * 1.4 (activity factor cause patient is young and physically active)=
2778.006942=2778.01 or 1.5 * 1803.941182= 2705.911773 2705.91[kcal]- 27778.01 [kacl]
Protein Needs=132.9[g/d]-140.7[g/d]
Physiologically/metabolically stressed factor 1.7 * 71.18181818 kg= 132.9 kg to 1.8 * 71.18181818 *
1.8= 140.72 so between
Fluid Needs average adult 2.35 [l] 2.74 [1]
30-35ml/kg= 30 * 78.1818181818= 2345.5454545/1000=2.345454545 35 * 78.18181818= 2736.363636
Food/Nutrition/Diet HistoryBreakfast (eaten at home):
1 c. oatmeal with brown sugar and cup of 2% milk
1 c. juice (orange, apple, or cranberry)
Toast (2 slices or English muffin) w/ butter & jelly
Coffee with sugar and 2% milk
(occasionally 2 scrambled eggs and 2 strips of bacon instead of the cereal)
Lunch (eaten at the CoHo on weekdays):
2 slices of pepperoni pizza with a small salad or Cheeseburger and French fries or Spinach Crepe
16 oz. of sweetened iced tea
dessert such a cookies or a brownie
(sometimes 8 oz. of 2% milk instead of the iced tea)
Mid afternoon:
medium mocha or latte,
A cookie or a piece of fruit
Dinner:
Spaghetti w/ meat sauce (about 2 c. cooked noodles); 2 pieces of garlic bread; Salad w/ fat free dressing
12 ounces of 2% milk or ~6 oz. meat (chicken or beef, only occasionally fish), 1 cup of rice or large
baked potato w/ butter; Vegetables in season (will eat w/ salt & butter but prefers cheese or bechamel
sauce); 12 ounces of 2% milk or A deli sandwich and chips and soda if he does not have time to cook
HS:
D.K. eats one of the following:
Bag of microwave popcorn w/ 1-12 oz. can of regular soda
2 scoops of ice cream
MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

wei
D:
Unintended weight loss (NC 3.2) /t Mx of DM1 related catabolic process aeb pt. reported weight loss and
% IBW and % UBW.TIDM
9

Impaired nutrient utilization (NC 2.1) r/t MX of T1DM aeb urinary glucose, ketones, and protein
I:
Overall MNT goal for DK is to attain and maintain optimal metabolic outcomes. Prevent chronic
Complications and improve health through healthful food choices and physical activity.
1. Patient education around need for general healthful diet (ND-1.1) and the nutrition relationship with
health/disease (B-1.4) and need to increase and maintain energy intake with desirable food choices.
2. Discuss incorporated a low carbohydrate type dietary pattern with focus on source of carbohydrate and
fat food groups and potion sizes (FH1.5.3.6, FH-1.5.3.7)
3. Discuss carbohydrate counting and insulin usage: dietary exchange 15g- 1 serving CHO- 1 unit of
insulin, the importance of an ideal CHO insulin ratios at meals, to decrease spikes or drops in blood
sugar.
4. Discuss possible lifestyle changes and need for social support and family involvement.
4. Discuss increasing consumption of F/V; PUFAs and plant sterols
5. Provided handouts related to the all items and label reading discussed for further reading; provided
composition pad for the following, blood sugar record, PA log & Food Journal
M/E:
Monitor blood sugar regularly via patient records, and glucometer
PO intake with food journal, PA with PA log
Monitor weight weekly and check urine and other lab values HgbA1C, BG, lipid panel in addition to pre
albumin
Scheduled return visit for <1 week weeks with reassurance that counsel and assistance is available
anytime of day.
Theodore Mitchell -TRM
B. Sci. Clinical Nutrition
12/8/15
MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

12. D.K. does well over the next few months in learning to manage his diabetes. However, he is finding
it difficult to keep his activity and intake constant due to the fact that his schedule is variable and he
wants to resume playing ultimate frisbee. He and the health care team agree to use an insulin pump
with intensive therapy in order to make his self-care more flexible and achieve tighter glucose
control. You begin teaching D.K. about carbohydrate counting.
a. Assume that his kcal needs have remained the same. How many CHO points or servings are in
his daily diet from question 7?
277.8 g CHO/15g CHO/CHO serving = 18.52 or 19 CHO servings
b. Describe briefly how this will differ from his exchange-based diet plan that he was using.
Is slightly less than current intake but the composition of that would be much different. Possibly
incorporating more whole grain high fiber and vegetable options. This will provide a different
carbohydrate and fat composition that will be more anti-inflammatory and friendly to the body.
13. D.K. brings his SBGM record in for review when he comes for nutrition counseling. The pre-prandial
BG goal is 80-120 mg/dl. Several pre-meal entries are listed below.
BG mg/dl
Day
Breakfast
Lunch
Dinner
HS Snack
1
94
145X
110
100
2
90
106
97
72X
3
158X
108
95
102
a. Circle the values that are outside the desirable range. bolded with X
b. What adjustment(s) should D.K. make if the values are above the desirable range?
Time of last meal before bed and the amount of insulin taken with that meal relative to need. The amount
of insulin taken with breakfast may be insufficient; and there may be a problem with CHO counting so
10

further education should be provided.


Lecture The Art and Science and Diabetes Management; MNT for Diabetes.
c. What adjustment(s) should D.K. make if the values are below the desirable range?
(1 point)
Eat within the desired CHO/insulin ratio with adequate fat protein and other options to ensure
micronutrient intake is adequate.
14. What adjustments should D.K. make on the days when he plays ultimate frisbee?
DK should ensure adequate kcal intake, electrolyte balance, can decrease and monitor insulin levels
before after and throughout duration of activity. If using pump can lower intake during session to avoid
low BS. Recommend DK keep protein snacks and a liquid with CHO and electrolytes, maybe dried or
fresh fruits and seeds and nuts .
MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

15. D.K. has caught a cold and has a fever of 101 F. He feels miserable and is not eating much. He
calls you to ask if he should reduce his insulin dose since his diet is just a few foods (chicken noodle
soup and low kcal Jello and diet 7-up). What advice would you give him and why?
Patient may have to increase insulin intake in order to ensure blood sugar level regularity, eat same
amount of food as normal may have to use meal replacement drinks. CHO and maintain protein intake. 5g
CHO every three hours, drink plenty of fluids and ensure electrolyte balance. Chicken soup Jello and 7 up
are okay choices but ensure protein intake with shake, meal replacement bar etc.
www.nim.nih.gov/medlineplus/ency/patientinstructions/000079.htm Diabetes When You are Sick
www.diabetesforecast.org Erika Gebel Ph. D Common cold remedies. Your guide to over the
counter medicine and diabetes care
www.diabetes.org American Diabetes Association When Youre Sick
NTP: MNT Pocket Guide; Insulin Signaling and Glucose Homeostasis; Diabetes Mellitus Parts 1 & 2 116
MNT for Diabetes Lecture and Art and Science of Diabetes Management

11