CASE STUDY #3 - NUT 116AL

Type I Diabetes Mellitus

DUE Wednesday 12/7 by 4:00 pm in Meyer 3135 (Nutrition Dept. office).

Instructions:
Read all questions before starting on the case study as many are related to
each other.
Review the pts medical record below. Answer each question and show your
calculations (if necessary) for each. You may include your calculations in the
answer box and, if needed, attach as a separate, hand-written sheet. Use the
following conversion factors: 1=2.54 cm and 1 kg=2.2#.
Reference all calculation formulas with the text and page number from the
Pocket Resource (i.e., PG p. ___). Only use the PG for all calculations. You may
use lecture notes and the textbook for all other questions. Cite lecture notes as
116AL CVD Lecture, slide#.
After you have EXHAUSTED your sxearch for answers to your CS questions and
you are still unable to find the answer, you may use outside resources as long
as they are credible resources. e.g.: Mayo Clinic, medline plus, research
articles, etc., NOT wikipedia. Remember to conduct a thorough search of the
resources available to you prior to using outside references to avoid losing
points.
In your citation, please include the resource name (i.e.: Mayo Clinic), title
of page/article, & exact URL link.
You must type your answers! If not, questions will not be graded and you will
receive 0 points.
To familiarize yourself with medical terminology, utilize an online dictionary such
as: http://www.medilexicon.com/medicaldictionary.php
CS #3 is worth 50 pts.
____________________________________________________________________________________

Cxxxxxx, Oxxxx Male 33 yo

Allergies: NKA Code: FULL Isolation: NONE
Pt. Location: RM 1307 Physician: J. Robinson Admit Date: 12/02/16

Pt Summary: O.C. is a 33 yo male admitted through the ED with c/o excessive

thirst and frequent urination of 2 wk duration, in addition to increased appetite and
weight loss of 12 pounds in 3 weeks.

PMH: pt was product of normal pregnancy and delivery; had varicella at age 6,
and an appendectomy at age 15. No Medications. NKA.

FH: Parents L&W. Paternal uncle has Type 1 DM; Maternal grandfather died of CVD
2 to Type 2 DM. Other grandparents L&W. Has 1 sibling, a younger brother, L&W.

Social Hx: 33 yo male, post-doc at UC Davis. Pt used to play soccer three times a
week, but says he now tires easily so he has not played in 3 weeks.

ROS:
1
GI: No hx of N/V, or diarrhea
GU: No hx of urgency, frequency, or burning urination except for
present complaint of polyuria
CNS: Alert and oriented, no hx of impaired LOC, convulsions, or
difficulty walking

PE:
General: Slightly underweight, tired appearing male; wt: 170#
ht: 73
Vitals: T 98.2F; P 120; R 27 with fruity odor; BP 110/70 mm
Hg
Lungs: Clear to percussion and auscultation
Heart: Normal sinus rhythm, no murmurs
HEENT: Non-contributory
Abdomen: Flat, non-tender, no liver enlargement
Genitalia: Nl
Extremities: Non-contributory
CNS: Normal gait and deep tendon reflexes
Skin: Smooth, warm, dry, no edema
Peripheral Pulse +4 bilaterally
Vascular:

Laboratory Results
Ref. Range 12/02/16 1210
(non-fasting)
Chemistry
Sodium (mEq/L) 136-145 129 !
Potassium (mEq/L) 3.5-5.5 3.6
Chloride (mEq/L) 95-105 101
Carbon dioxide (CO2, 23-30 32 !
mEq/L)
BUN (mg/dL) 8-18 17
Creatinine serum 0.6-1.2 1.1
(mg/dL)
Glucose (mg/dL) 70-110 372 !
Phosphate, inorganic 2.3-4.7 2.0 !
(mg/dL)
Magnesium (mg/dL) 1.8-3 1.9
Calcium (mg/dL) 9-11 10
Osmolality 285-295 303 !
(mmol/kg/H2O)
Bilirubin total (mg/dL) 1.5 0.2
Bilirubin, direct (mg/dL) <0.3 0.01
Protein, total (g/dL) 6-8 6.9

2
Albumin (g/dL) 3.5-5 3.2 !
Prealbumin (mg/dL) 16-35 14 !
Ammonia (NH3, umol/L) 9-33 9
Alkaline phosphatae 30-120 110
(U/L)
ALT (U/L) 4-36 6.2
AST (U/L) 0-35 21
CPK (U/L) 30-135 F; 55- 61
170 M
Lactate dehydrogenase 208-378 229
(U/L)
Cholesterol (mg/dL) 120-199 180
Triglycerides (mg/dL) 35-135 F; 40- 150
160 M
T4 (ug/dL) 4-12 8
T3 (ug/dL) 75-98 81
HbA1C (%) 3.9-5.2 8.55 !
C-peptide (ng/mL) 0.51-2.72 0.52
ICA - + !
GADA - + !
IA-2A - -
IAA - + !
tTG - -
Hematology
WBC (x 103/mm3) 4.8-11.8 10.6
RBC (x 106/mm3) 4.2-5.4 F; 4.5- 5.8
6.2 M
Urinalysis
Collection method - Clean catch
Color - Yellow
Appearance - clear
Specific Gravity 1.003-1.030 1.008
pH 5-7 4.8 !
Protein (mg/dL) Neg +1 !
Glucose (mg/dL) Neg +4 !
Ketones Neg +4 !
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.1 Neg
Leukocyte esterase N+eg Neg
Protein check Neg tr !
WBCs (/HPF) 0-5 0

3
RBCs (/HPF) 0-5 0
Bacteria 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 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 DSM training; nutrition consult for
hospital and home diet planning and pt. education.

You are the in-patient RD.

You meet with O.C. 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. O.C. 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. O.C. is Muslim and follows Islamic dietary laws.

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 instead of the cereal)

Lunch (eaten at the CoHo/Silo on weekdays):

2 slices of cheese pizza with a small salad or
Grilled cheese and French fries or
Meal from Shahs Halal Food cart Gyro or Rice Plate (lamb/chicken)
16 oz of sweetened iced tea
dessert such as 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:
~6 oz. meat (chicken/lamb/beef, occasionally fish)
1 cup of rice
Vegetables in season (will eat w/ salt & butter)
12 ounces of 2% milk
or
4
A vegetarian sandwich and chips and soda if he does not have time to cook

HS:
O.C. 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

Name: Erina Hayashi

1. Compare O.C.s admission laboratory values with normal values. What does
each value indicate, based on the hospitals lab value reference ranges above? Use
your texts for non-fasting BG values. (5 pts)
Test nl Values O.C.s Values Compariso What do O.C.s lab values suggest
n: about his metabolic state?
</=/> nl
values
BG 70- 372 mg/dL n/a (non- Non-fasting BG in DM is
110mg/d fasting) =/>200mg/dL (NTP p. 486), O.C.s
L value of 372 >200mg/dL. He has
DM and hyperglycemia.
Urinary negative +4 >nl values Glucose not entering cells,
glucose glycosuria resulting from
hyperglycemia. Possibly having
osmotic diuresis. (NTP p. 482)
Urinary negative +4 >nl values With low urine pH, urine ketones
ketones indicates fatty acids being
metabolized as alternative energy
source; ketosis (NTP p. 481)
PreAlb 16- 14mg/dL < nl values Malnourished, low protein status
35mg/dL
HbA1C 3.9-5.2% 8.55% > nl values Indicate prolonged hyperglycemia;
insulin deficient & cell starvation.

2. What is HbA1C and what does HbA1C measure? (1 pt)

HbA1C refers to percentage of glycated hemoglobin in the blood, which is used to
measure the average level of blood glucose in the previous two to three months.
NTP p. 503

5
3. List the following HbA1C ranges. (2 pts)
Normal non-diabetic: N/A

Pt w/ controlled 5.7- 6.4%

diabetes:
Pt w/ fair to poorly >6.5%
controlled diabetes:
116A Diabetes Lecture slide 12

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

vascular complications of diabetes. (2 pts)
HbA1C indicates blood glucose control in the patient, and high blood glucose
levels or poorly managed diabetes (high HbA1c) in turn are related to increased
risk for CVD, nephropathy, retinopathy and neuropathy.
High blood glucose in diabetes lead to changes in the small blood vessels, altering
function in highly vascularized tissues such as the eyes and kidneys. It also leads
to endothelial damage and stiffening of the blood vessels, contributing to
hypertension and atherosclerotic plaques in larger arteries resulting in CVD. Large
amounts of glycated proteins can cause cellular damage, leading to nephropathy
and associated symptoms such as pain and loss of sensation in the limbs.
NTP p.507-8

5. What are three metabolic reasons for O.C.s weight loss (number each for full
credit). (2 pts)
He is experiencing insulin deficiency, which leads to the following:
1. Glucose and amino acid uptake by cells is decreased, which leads to
hyperglycemia and gluconeogenesis by the liver. This in turn increases
blood osmolality, resulting in polyuria as the body attempts to get rid of
excess glucose. The water loss from frequent urination contributes to weight
loss.
2. Protein degradation increases and produces amino acids into blood, which
leads to muscle wasting and therefore weight loss.
3. Hormones that stimulate lipolysis such as catecholamines and glucagon are
released, breaking down fat stores in adipose tissue and leading to weight
loss.
NTP p. 481-2

6. Describe and explain Islamic dietary laws and any dietary restrictions you would
need to consider when counseling O.C. (2 pts)
Pork and pork-byproducts are prohibited, including gelatin, certain emulsifiers
and enzymes of mixed sources. Animals must be slaughtered according to
halal regulations, and cannot include some birds and reptiles. Foods containing

6
alcohol and blood are also against Islamic dietary law. I should remember to
not recommend these foods to O.C when counseling, and respect fasting
practices during Ramadan, the fasting month observed in Islam.

Nour El-Zibdeh, RD. Todays Dietitian. 2009. Vol. 11 No. 8 P. 56

7. Based on O.C.s diet history information and what you know about MNT
management of Type 1 DM, name 3 nutrition-related topics that are important to
discuss in educating O.C. as he prepares to head home from the hospital. (3 pts)
1. Discuss Self-Monitoring of Blood glucose to confirm hypo- and hyperglycemia in
relation to the diet and to help with glycemic control.
2. Explain how to use carbohydrate counting using the exchange list, and to
coordinate it with insulin injections to achieve glycemic control.
3. Discuss importance of healthy diet patterns along with exercise for reducing
risk of long-term complications, along with explaining how to treat hypoglycemia if
it occurs.
NUT 116A Diabetes Pt 2 Lecture Slide 24-27

8. You determine that O.C. needs 3000-3300 kcals/day based on EER calculations
and the fact that O.C. 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 O.C.s diet. (15 pts)
Food group Number of CHO Protein Fat grams
Exchanges grams grams
Breakfast
Starch/CHO 2 30 6 2
Fruit 2 30 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1 12 8 5
Protein (lean, med- or high-fat) 2 0 14 10
Fats 2 0 0 10
Morning Snack
None
Lunch
Starch/CHO 6 90 18 11
Fruit
Milk & Subs.(skim, 1%, 2%, or
whole) 1 12 8 5
Non-starchy vegetables 1 5 2 0
Protein (lean, med- or high-fat) 4 0 28 20
Fats

7
 Afternoon Snack
Starch/CHO 2 31 11 0
Milk (2%)
Fat
Dinner
Starch/CHO 4 60 12 4
Fruit 1 15 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1.5 18 12 7.5
Non-starchy vegetables 3 15 6 0
Protein (lean, med- or high-fat) 6 0 42 12
Fats 2 0 0 10
HS Snack
Milk (2%) 1 12 8 5
Starch/CHO 2 30 0 10
Fats
Total grams 360 175 111.5
X4 X4 X9
kcal from each macronutrient 1440 700 1003.5
TOTAL KCAL: 3,143.5 46% 22% 32%

9. O.C. is taught about his diet, insulin injections, SMBG, and other self-care issues
prior to discharge. He is discharged on a basal injection of Levemir, with bolus
injections of Novolog regular insulin at mealtimes. Provide the generic name and
indication of each medication and its effects. 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 FMI text. (3 pts)
Levemir
Generic name: Insulin detemir
Classification: Anti-diabetic, hypoglycemic
Onset of Action: 1-3 hours
Peak: 6-8 hours
Duration: 18-22
FMI p. 179, NTP p. 491
Novolog
Generic name: Aspart
Classification: Anti-diabetic, hypoglycemic
Onset of Action: 5-15 minutes
Peak: 30-90 minutes
Duration: 3-5

8
FMI p. 179, NTP p. 491
Levemir & Novolog
Indication: Hyperglycemia, DMT1
Diet: Diabetic meal plan, must coordinate meal timings with insulin.
Possible FMI: Caution with alcohol, since it increases hypoglycemic effect
when taken with insulin. Levemir: do not mix with other insulin
Potential Increased weight with Novolog. Lower blood/serum glucose,
Nut/Oral/GI Side K,Mg, P. Could cause hypoglycemia.
Effects:
FMI p. 179

10. Write an ADIME note for O.C., 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. (8
pts)
A:
Patient Hx: 33yo M admitted through ED c/o symptoms of T1DM, eg. Polyuria &
fatigue. Dx new onset T1DM. Family hx T1DM (paternal uncle). Noted MD consult
for hospital/home diet planning & pt education.

MD Diet order: Regular

Anthropometrics:
Ht: 185.4cm
CBW: 77.3kg
IBW: 83.6kg
%IBW: 92%
BMI: 22.5kg/m2 (normal)
Weight Hx: Pt reports wt loss 5.45kg w/ increased appetite; -6.5% in 3 wks
(significant loss).

Nut. Focused physical finding:

BP 110/70, breath w/ fruity odor

Biomedical data/labs:
Blood: Glucose 372mg/dL non-fasting (high), HbA1c 8.55% (high), Osm.
303mmol/kg (high), Albumin 3.3g/dL (low), Na 129mEq/L (low), CO2 32mEq/L

9
(high)
Urine: Glucose, Ketones, Protein present. pH 4.8 (low)
ICA, GADA, IAA positive (distinguish T1DM from T2DM). C-peptide (Low nl)
(NTP p.487)

Medications Upon Discharge:

Insulin Levemir (basal), Novolog (bolus)

Estimated Nut. Needs (based on CBW 77.3kg)

Energy: 2658~3101kcal/d (average activity)
Protein: 155~193g/d (2-2.5g/d, catabolic pt)
Fluid: 2657~3100mL/d (1ml/kcal)
Food and Nut. Hx:
Pt reports quantity of food eaten much > usual intake due to increased hunger. Pt
follows Islamic dietary laws (avoiding pork products, etc). NKFA. Pt is a university
post-doc, plays soccer 3x/wk but could not play in past 3wks due to fatigue.
Based on 24-hour recall analysis, pt consumed 3003Kcals, 330g CHO (44%), 172g
protein (23%), 110.5g fat (33%). Fluids obtained from milk, juice, sweetened tea,
coffee drinks.

D:
Unintended weight loss (NC-3.2) r/t new onset T1DM AEB pt report of 12# wt loss
over 3 wks (-6.5%) and increased food intake.

Physical inactivity (NB-2.1) r/t fatigue from uncontrolled T1DM AEB pt report of
abstaining from regular soccer practice.
PG p. 58

I:
MNT Goal: Prevent further wt loss and achieve optimal glycemic self-control.

Recommendations: Continue current diet, aim for 3000-3300kcal/d to achieve

UBW. CHO need to be counted each meal to match insulin bolus. Recd increase
high-fiber foods to promote satiety and help with BG control. Aim for fat 30-40%
kcals & protein 20% kcals.
Nutrition education/Diet Instruction:
Explain importance of good glycemic control in minimizing complications,
discussed spreading out exchange food groups.
Explain how to use carbohydrate counting, SMBG, & correction dose calculations
for self-care.
Gave Exchange List Booklet & Meal plan with 3000-3300kcal/d. Expect low

10
barriers d/t high education level.
Expected Compliance: Good

PG p. 58

M/E
Monitoring:
Bring BG monitor & food diary to RD visit in 1 week. Monitor HbA1C, urine
ketone/glucose.
Follow-up planned in the next week in-person.

PG. p58

11. O.C. 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 soccer. 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 O.C. about carbohydrate counting. Describe briefly how this will differ
from the exchange-based diet plan that he was using. (1 pt)
The exchange-based diet plan is based on the patients usual intake with
modifications as needed, and is meant to be a guide to keep daily meal patterns
consistent. Therefore, there are prescribed doses of insulin. With the exchange-
based plan, hypoglycemia could be an issue if there was unplanned physical
activity. However, by using an insulin pump and intensive therapy method, there
will be more injections of insulin administered through his pump. OCs schedule
with meals and insulin can be more flexible; insulin dosage can be easily adjusted
according to changes in carbohydrate intake and exercise.

NTP p. 492

12. O.C. brings his SMBG record in for review when he comes for nutrition
counseling. The pre-prandial BG goal is 70-130 mg/dl. Several pre-meal entries are
listed below.
Day Breakfast Lunch Dinner HS Snack
1 94 152 110 100
2 90 106 97 69
3 142 108 95 102

a. Circle/highlight the values that are outside the desirable range. (1 pt)

11
b. What adjustment(s) should O.C. make if the values are above the desirable
range? (1 pt)
For BG less than 150mg/dL, he would not need extra insulin. However, for BG
levels 151mg/dL to 200mg/dL, he should add 1 unit of insulin to his normal dose
calculated from the insulin-carbohydrate ratio. Should he ever find that his BG is
between 201 to 250mg/dL, he should add 2 units of insulin.
NTP p. 502

c. What adjustment(s) should O.C. make if the values are below the desirable
range? (1 pt)
O.C. can consume a 15-20g dose of quick-acting sugars, such as hard candy, fruit
juice, table sugar or soft drink, and wait 15 minutes to test BG again. If BG is still
low, he can consume another dose of sugar and recheck, repeating the process as
needed until BG is normalized.
NTP p. 505

13. What adjustments should O.C. make on the days when he plays soccer? (1 pt)
He needs to check his BG before and after exercise. If the soccer session is less
than half an hour, he probably does not need adjustments to his food or insulin
intake. However, if his pre-practice BG is <100mg/dL and if the session is before
breakfast, later in the afternoon before dinner, or lasts longer than 30 minutes, he
should consume 15g of carbohydrate snack before practice. If it is planned to be a
strenuous practice lasting an hour, he should consume 30g of carbohydrate snack
before practice. He may also need to reduce insulin dosage on the day of exercise,
compared to the other 4 days of the week he does not play soccer, to avoid
hypoglycemia. (NTP p.505)

14. O.C. has caught a cold and has a fever of 102 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 diet 7-up). What advice would you
give him and why? (2 pts)
Since colds and fever can interfere with glycemic control and there is a risk for
developing hyperglycemia, I would advise that he should continue taking usual
insulin and keep checking his blood glucose. In addition, he should administer
additional insulin if his blood glucose is above 240mg/dL.
He should also try to keep his blood sugar constant by eating small amounts of
the chicken noodle soup or other soft, well-tolerated carbohydrate sources every
3-4 hours, and keep hydrated by drinking water, tea or clear broth every hour. I
would not recommend that he drinks diet soda to get his carbohydrates because it
does not supply carbohydrates. Finally, he should call his PCP if he cannot eat for
over a day or if he notices symptoms of ketoacidosis.

12
NTP p. 507

13