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 Normal Value Susan’s Value Reason for Abnormality Nutritional Implications

Albumin 3.5-5 g/dL 4.2 g/dL Normal -

Total Protein 6-8 g/dL 7.5 g/dL Normal -
Prealbumin 16-35 mg/dL 40 mg/dL Decreased fluid volume Dehydration
in the body
Sodium 136/145 mEq/L 140 mEq/L Normal -
Potassium 3.5-5.5 mEq/L 4.5 mEq/L Normal -
Chloride 95-105 mEq/L 98 mEq/L Normal -
PO4 2.3-4.7 mg/dL 3.7 mg/dL Normal -
Magnesium 1.8-3 mg/dL 2.1 mg/dL Normal -
Osmolality 285-295 mmol/kg/H2O 304 H mmol/kg/H2O Decreased fluid volume Weight loss,
in the body dehydration
Glucose 70-110 mg/dL 250 H mg/dL High blood sugar due to Hyperglycemia,
diabetes, in ability to frequent thirst,
use glucose due to urination, hunger, drop
insulin deficiency in pH, ketoacidosis
BUN 8-18 mg/dL 20 H Increased glucose Dehydration
levels
Creatinine 0.6-1.2 mg/dL 0.9 mg/dL Normal -
Calcium 9-11 mg/dL 9.5 mg/dL Normal -
CHOL 120-199 mg/dL 169 mg/dL Normal -
LDL <130 mg/dL 109 mg/dL Normal -
HbA1C 3.9-5.2% 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 first-
degree 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 Brand Onset of Peak of Duration of
Insulin
Lispro Name
Humalog Action
10-20 min Action
1-3 Action
3-5
Aspart NovoLog 10-20 min (Hours)
1-3 (Hours)
3-5
Glulisine Apidra 10-20 min 1-3 3-5
NPH Humulin N 1-3 hours 8 20
Novolin N
Glargine Lantus 1 hour None 24
Detemir Levemir Same as above
70/30 premix Mixtard 30-60min Dual 10-16
Humulin 70/30
50/50 premix Humuli 50/50 30-60 min Dual 10-16
60/40 premix Mixtard 40 30 min 2-8 24


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
practice/game schedule.
— She is a starter on the girls’ volleyball team, practices
four evenings per week, and participates in
approximately two games per week, some of which
are away games.

— Susan eats lunch in the school cafeteria.




 Breakfast
Food Serving Calories CHO (g) Protein Fat (g)
(g)
Kellogg’s 1 ½ cup 215 kcal 53.15g 2.54g 0.123g
Frosted
Flakes
Dry
2% Milk 1 cup 122 kcal 11.71g 8.05g 6.044g
Cereal
Orange 1 cup 112 kcal 25.79g 1.74g 0.248g
Juice
Total 449 kcal 90.65 12.33g 6.415g
 Lunch
Food Serving Calories CHO (g) Protein Fat (g)
(g)
Pizza 6 inch, 770 kcal 69g 35g 16g
pepperoni
Mixed 1 cup 17 kcal 3.35g 1.3g 0.049g
Salad
Thousand ¼ cup 178 kcal 7.03g 0.52g 14.973g
Island
Salad
Dressing
Snickers 1 candy 280 kcal 35.06g 0.26g 11.376g
bar
Total 1245 kcal114.44g 37.08g 42.378g
 Snack
Food Serving Calories CHO (g) Protein Fat (g)
(g)
Peanut 2 tbsp 188 kcal 25.79g 7.7g 15.181g
Butter
Grape 1 tbsp 50 kcal 13g 0g 0g
Jelly
White 2 slices 133 kcal 25.3g 3.82g 1.377g
Bread

Coke 1 12oz 136 kcal 35.18g 0.26g 0g

can
Total 507 kcal 99.27g 11.78g 16.558g
 Dinner
Food Serving Calories CHO (g) Protein Fat (g)
(g)
Spaghetti 2 cups 442 kcal 25.79g 16.24g 1.753g
noodles
Spaghetti ½ cup 111 kcal 17.61g 2.28g 3.165g
Sauce
Ground 1 oz 77 kcal 0g 7.24g 4.628g
Beef
Steamed
Brocolli Stalks
3 stalks 147 kcal 30.15 10g 1.215g
with salt

2% Milk 2 cups 244 kcal 23.42g 16.1g 11.667g

Total 1021 kcal96.97g 52.04g 22.428g
 HS Snack
Food Serving Calories CHO (g) Protein Fat (g)
(g)
Ice cream 2 cups, 560 kcal 68g 8g 28g
chocolate
Coke 1 12oz 136 kcal 35.18g 0.26g 0g
can
Total 696 kcal 103.18g 8.26g 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
Total Daily Recommended % of
Patient Intake Diet Plan Recommende
Intake d Intake
Kcal 3643 kcal 2800 kcal 130%

CHO 473.73g 300g 157.9%

Protein 118.33g 55-65g 182% -

215.4%
Fat 95.15g 80g 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
— When alcohol ingested, liver wants to clear it as quickly as
possible
— 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”

— Banned in several countries as food

additive, approved as dietary
supplement in others

— Has been shown to lower blood glucose by

increasing insulin secretion in lab
studies

— May want to focus more on Reb A extract of

stevia “Rebiana”
 Truvia and PureVia
— Contain Reb A “Rebiana”
— Extracted from stevia leaf,
erythritol, and other natural
flavors
— Received GRAS recognition in US
 Questions?