Case Study #3 Diabetes Mellitus: Type 1

Lindsey French, Andrea Meiring, Katherine Mykytka, Jessica Oakley October 30, 2009

Diabetes Mellitus: Type 1
— Type 1 Diabetes Mellitus results from a deficiency in
insulin production and insulin action causing hyperglycemia.
—Immune meditated or Idiopathic

— Deficiencies caused by the cellular mediated
destruction of pancreatic beta cells
—Results in cells being unable to use glucose for energy —Plasma glucose levels rise (Hyperglycemia) and cells
starve — Glycosuria, Polyuria, Dehydration, Poydipsia,
Polyphagia, Fatigue and Electrolyte Imbalanace

Diabetes Mellitus: Type 1
— Commonly diagnosed in children and adolescents
—Juvenile Diabetes

— Some cases develop later in life
—Latent Autoimmune Diabetes of Adulthood (LADA)

— Long term complications
—Cardiovascular Disease, Nephropathy, Retinopathy,
Autonomic Neuropathy

The Patient
— Susan Cheng — Asian American — 15 years old, HS student — Active: Starter for the girls’ volleyball team — Practices four nights a week and has games two nights a
week

— Lives with her parents, older sister,

and younger brother — All are in excellent health

— Uneventful medical history, no significant illness until recently — Has recent complaints of polydipsia, polyuria, polyphagia, weight loss
and fatigue.

—

Chief Complaint

“I’ve been so thirsty and hungry. I haven’t slept through the night for 2 weeks. I have to get up several times a night to go to the bathroom. It’s a real pain. I’ve also noticed that my clothes are getting loose. My mom and dad think I must be losing weight.”

Physical Exam
— General Appearance: Tired-appearing adolescent female — Vitals: Temp 98.6 F, BP 124/70 mm Hg, HR 85 bpm, RR 18 bpm — Heart: Regular Rate and rhythm, heart sounds normal — HEENT: Noncontributory — Genitalia: Normal adolescent female — Neurologic: Alert and oriented — Extremities: Noncontributory — Skin: Smooth, warm, and dry; excellent turgor; no edema — Chest/lungs: Lungs are clear — Peripheral vascular: Pulse 4+ bilaterally, warm, no edema — Abdomen: Nontender, no guarding

Chemistry Albumin Total Protein Prealbumin Sodium Potassium Chloride PO4 Magnesium Osmolality Glucose

Normal Value 3.5-5 g/dL 6-8 g/dL 16-35 mg/dL 136/145 mEq/L 3.5-5.5 mEq/L 95-105 mEq/L 2.3-4.7 mg/dL 1.8-3 mg/dL

Susan’s Value 4.2 g/dL 7.5 g/dL 40 mg/dL 140 mEq/L 4.5 mEq/L 98 mEq/L 3.7 mg/dL 2.1 mg/dL

Reason for Abnormality Nutritional Implications Normal Normal -

Decreased fluid volume Dehydration in the body Normal Normal Normal Normal Normal -

285-295 mmol/kg/H2O 304 H mmol/kg/H2O 70-110 mg/dL 250 H mg/dL

Decreased fluid volume Weight loss, in the body dehydration High blood sugar due to Hyperglycemia, diabetes, in ability to frequent thirst, use glucose due to urination, hunger, drop insulin deficiency in pH, ketoacidosis Increased glucose levels Normal Normal Normal Normal Dehydration -

BUN Creatinine Calcium CHOL LDL HbA1C

8-18 mg/dL 0.6-1.2 mg/dL 9-11 mg/dL 120-199 mg/dL <130 mg/dL 3.9-5.2%

20 H 0.9 mg/dL 9.5 mg/dL 169 mg/dL 109 mg/dL 7.95%

Increase in glucose Diabetes binding to hemoglobin complications, eye disease, heart disease, kidney disease, nerve damage, stroke

Admission Diagnosis: Type 1 diabetes mellitus

Risk Factors and Etiology
— Member of high risk ethnic group
— Asian American

— Stressful lifestyle — Maternal grandmother had diabetes (but not firstdegree relative)

— Etiology
— Genetics
—HLA markers — Environment —High birth weight, viral infection, dietary factors

—

Treatment
— Achieve glycemic control — Evaluate serum lipid levels — Monitor blood glucose levels — Initiate self-management training for patient and parents
on insulin administration, nutrition prescription, meal planning, signs/symptoms and Tx oc hypo-/hyperglycemia, monitoring instructions (SBGM, urine ketones, and use of record system), exercise

— Baseline visual examination — Contraception education

Insulin
Pharmacological Differences:

Types of Lispro Insulin
Aspart Glulisine NPH

Brand Humalog Name
NovoLog Apidra Humulin N Novolin N

Onset of 10-20 min Action
10-20 min 10-20 min 1-3 hours

Peak of 1-3 Action 1-3 (Hours)
1-3 8

Duration of 3-5 Action 3-5 (Hours)
3-5 20

Glargine
Detemir 70/30 premix 50/50 premix 60/40 premix

Lantus

1 hour
Same as above 30-60min 30-60 min 30 min

None
Dual Dual 2-8

24
10-16 10-16 24

Levemir Mixtard Humulin 70/30 Humuli 50/50 Mixtard 40

 Most patients with T1DM require approximately 0.6 units of insulin per kilogram of body weight per day Dosage adjusted according to blood glucose levels

Anthropometrics
— Height: 5’2” — Weight: 100 lbs — BMI:

45.45kg/(1.6m)2= 17.75 —Susan is at a normal weight for her age and height
and falls just below the 25th percentile on the CDC growth chart.

Nutrition History
— Mother describes Susan’s appetite as good. — Meals are somewhat irregular due to Susan’s volleyball
four evenings per week, and participates in approximately two games per week, some of which are away games.

practice/game schedule. — She is a starter on the girls’ volleyball team, practices

— Susan eats lunch in the school cafeteria.

Breakfast
Food Serving Calories CHO (g) Protein (g) Kellogg’s 1 ½ cup 215 kcal 53.15g 2.54g Frosted Flakes Dry Milk 1 cup 2% 122 kcal 11.71g 8.05g Cereal Orange Juice Total 1 cup 112 kcal 25.79g 449 kcal 90.65 1.74g 12.33g Fat (g) 0.123g

6.044g 0.248g 6.415g

Lunch
Food Pizza Serving Calories CHO (g) Protein (g) 6 inch, 770 kcal 69g 35g pepperoni 1 cup 17 kcal 3.35g 1.3g Fat (g) 16g 0.049g 14.973g

Mixed Salad Thousand ¼ cup 178 kcal 7.03g 0.52g Island Salad Dressing 1 candy 280 kcal 35.06g 0.26g Snickers bar Total 1245 kcal114.44g 37.08g

11.376g 42.378g

Snack
Food Peanut Butter Grape Jelly White Bread Coke Total Serving Calories CHO (g) Protein (g) 2 tbsp 188 kcal 25.79g 7.7g 1 tbsp 2 slices 1 12oz can 50 kcal 13g 0g 3.82g 0.26g 11.78g Fat (g) 15.181g 0g 1.377g 0g 16.558g

133 kcal 25.3g 136 kcal 35.18g 507 kcal 99.27g

Dinner
Food Serving Calories CHO (g) Protein (g) Spaghetti 2 cups 442 kcal 25.79g 16.24g noodles Spaghetti ½ cup 111 kcal 17.61g 2.28g Sauce Ground 1 oz 77 kcal 0g 7.24g Beef Steamed 3 stalks 147 kcal 30.15 10g Brocolli Stalks
with salt

Fat (g) 1.753g 3.165g 4.628g 1.215g

2% Milk 2 cups Total

244 kcal 23.42g 1021 kcal96.97g

16.1g 52.04g

11.667g 22.428g

HS Snack
Food Serving Calories CHO (g) Protein (g) Ice cream 2 cups, 560 kcal 68g 8g chocolate Coke 1 12oz 136 kcal 35.18g 0.26g can Total 696 kcal 103.18g 8.26g Fat (g) 28g 0g 28g

Estimated Energy and Protein Requirements
—EER for females 9 through 18 Years=

135.3-30.8(15 years)+1.56(10(45.5kg)+934(1.6m))+25= 2,739 kcals/day
Physical activity coefficient: 1.56 for very active

—Protein

RDA for 14-18 year old female= 46g/day

Diet Plan Comparison
Kcal CHO Protein Fat Total Daily Recommended % of Patient Intake Diet Plan Recommende Intake d Intake 3643 kcal 2800 kcal 130% 473.73g 118.33g 95.15g 300g 55-65g 80g 157.9% 182% 215.4% 118.9%

Nutrition Care Process
— Step 1: Assessment
o Appropriate and reliable data were collected to determine the existence of specific nutrition problems

— Step 2: Diagnosis
o Food and nutrition-related knowledge deficit o Self-monitoring deficit

Nutrition Diagnoses
— PES Statements
— — Food and nutrition-related knowledge deficit (P) related to
newly diagnosed Type 1 DM (E) as evidenced by HbA1c of 7.95% and diet hx notable for inappropriate intake of carbohydrate (S).

— — — Self-monitoring deficit (P) related to lack of knowledge

regarding appropriate alcohol intake (E) as evidenced by fluctuating blood glucose levels and belief that beer can be considered a carbohydrate exchange (S).

— —

Achieve HbA1c <5.2%

Educate both patient and family about… — Role of nutrition in diabetes management — Carbohydrates and diabetes — How certain foods effect blood glucose — Preventing hyperglycemia — Food purchasing/preparation

Decrease Frequency of Poor Carbohydrate Choices

Nutrition Education/Counseling:

— Outpatient appointments
— Meal planning —Practice skills
—Carb counting, blood glucose monitoring

—Reviewing logs of meals, snacks, blood glucose
readings, insulin administrations —Psycho/social status —Effects of alcohol consumption

Effects of Alcohol

Susan is admitted to the ER the night after she is discharged. She had a BG of 50 mg/dL. She was invited to a party Saturday night and tested her blood glucose before leaving. It measured 95 mg/dL so she took 2 units of insulin. She knew she needed to have a snack that contained 15g CHO so she drank a beer when she arrived at the party. She remembers getting lightheaded then woke up in the ER.

Effects of Alcohol
— Once Susan administered the insulin, her blood glucose was
going to drop

— Normally, liver will begin changing stored CHO into glucose — The glucose then sent to blood to slow down low blood
glucose reaction possible

— When alcohol ingested, liver wants to clear it as quickly as — Alcohol must be completely metabolized — If blood glucose is low, alcohol can lead to passing out

Effects of Alcohol
—Alcohol may be consumed occasionally WITH FOOD —Do not count alcohol

as a carbohydrate

—Hypoglycemia can

occur easily, especially with nocturnal intake

—Underage consumption

What about Stevia?
— Native to Central and South America — Grown for its sweet leaves - ~200-300x
sweeter than sugar

— Not approved in the US as a food additive
or sweetener- only as a “dietary supplement” additive, approved as dietary supplement in others

— Banned in several countries as food

— Has been shown to lower blood glucose by
increasing insulin secretion in lab studies stevia “Rebiana”

— May want to focus more on Reb A extract of

Truvia and PureVia
— Contain Reb A “Rebiana” — Extracted from stevia leaf,
erythritol, and other natural flavors

— Received GRAS recognition in US

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