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Jessica Pitzer
Case Study #16
11/18/14
KNH 411
Type 2 Diabetes Mellitus: Pediatric Obesity
Case Questions
I. Understanding the Diagnosis and Pathophysiology
1. What are the risk factors for developing type 2 DM as a child? What do the
current ADA standards of medical care recommend concerning screening at-
risk children?
Researchers don’t fully understand why some children develop type 2 diabetes and others
don’t, even if they have similar risk factors. However, it’s clear that certain factors
increase the risk, including weight, inactivity, family history, and race. Being overweight
is a primary risk factor for type 2 diabetes in children. The more fatty tissue a child has,
the more resistant his or her cells become to insulin. However, weight isn’t the only
factor in developing type 2 diabetes. The less active a child is the greater the risk they
have for type 2 diabetes. Being active helps to maintain a child’s weight, use glucose as
energy, and makes a child’s cells more reactive to insulin, making them less insulin
resistant. Family history plays a huge role in the development of type 2 diabetes. The
risk of type 2 diabetes is significantly increased if a parent or sibling has type 2 diabetes.
But it’s also difficult to tell if this is related to lifestyle, genetics or both. Although race
is an unclear risk factor, children of certain races, especially black, Hispanics, Native
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Americans, Asian Americans and Pacific Islanders are more likely to develop type 2
diabetes. (Mayo Clinic)
The recommendations include screening, diagnostic, and therapeutic actions that
are known or believed to favorably affect health outcomes of patients with diabetes. The
recommendation for testing to detect type 2 diabetes and prediabetes should be
considered in children and adolescents who are overweight and who have two or more
risk factors for diabetes. (American Diabetes Association)
(American Diabetes Association)
2. Evaluate Adane’s medical records. Identify which risk factors most likely
led to the routine screening for DM during her school physical.
There were many red flags and reasons that Adane was screened for DM during her
school physical. The first sign that she needed to be tested was her high BMI and her
high weight. Her BMI was recorded at 36.4 and is off the charts when looking at the
CDC body mass index percentile charts. Even for an adult, a BMI of 30 or higher is
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considered to be obese and at risk for health complications. Her general appearance is
described as “overweight”. Adane’s African American ethnicity also puts her at a higher
risk for developing type 2 diabetes. Both Adane’s mother and her grandmother have type
2 diabetes and her mother had gestational diabetes during pregnancy with Adane.
Adane’s physical findings and lab values also show questionable indications of diabetes.
Her skin was dry along with dry mucous membranes in the throat, which more than likely
make Adane feel very thirsty. And lastly many of the categories in her blood and urine
tests were abnormal. (CDD, Nelms).
3. What are the ADA standard diagnostic criteria for T2DM? Which are
included in Adane’s medical record?
There is set criteria for diagnosing type 2 diabetes. This criteria includes an A1C greater
than or equal to 6.5%, fasting plasma glucose greater than or equal to 126 mg/dL during
an oral glucose tolerance test, or a patient with classic symptoms of hyperglycemia.
Adane’s HbA1c was recorded at 6.9% and this is elevated from the normal level of 3.9-
5.2%. Adane’s glucose was above the normal range and classified her for type 2 diabetes
because they were above 126 on both days. On the day of admission her glucose was 171
mg/dL and on the second day her glucose was 151 mg/dL. She also tested positive for
glucose in her urinalysis.
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(American Diabetes Association)
4. Adane’s physician requested additional testing that included autoantibody
levels and C-peptide. Explain why these tests were done and what the results
indicate for Adane.
Diabetes- related autoantibody testing is primarily used to help distinguish
autoimmune type 1 diabetes from diabetes due to other causes. Determining which type
of diabetes is present allows for early treatment with the most appropriate therapy to
avoid complications from the disease. This test may be ordered when a person is newly
diagnosed with diabetes and the doctor want to distinguish between type 1 and type 2
diabetes. They also may be used when the diagnosis is unclear in diabetics who have
been diagnosed as type 2 but who have great difficulty in controlling their glucose levels
with treatments. From Adane’s EAG levels it is known that it is at an elevated level of
151. (Lab Tests Online)
A C-peptide test is not ordered to help diagnose diabetes, but when a person has been
newly diagnosed with diabetes, like Adane, it may be ordered by itself or along with an
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insulin level to help determine how much insulin a person’s pancreas is still producing.
Type 2 diabetes, the body is resistant to the effect of insulin and it compensates by
producing and releasing more insulin, which can also lead to beta cell damage. Type 2
diabetes usually is treated with oral drugs to stimulate their body to make more insulin
and/or to cause their cells to be more sensitive to the insulin that is already being made.
Eventually, because of the beta cell damage, type 2 diabetes may make very little insulin
and require injects. Any insulin that the body does make will be reflected in the C-
peptide level; therefor, the C-peptide test can be used to monitor beta cell activity and
capability over time and to help a doctor determine when to begin insulin treatment. The
C-peptide test measurements can also be used in conjunction with insulin and glucose
levels to help diagnose the cause of documented hypoglycemia and to monitor its
treatment. Symptoms of hypoglycemia may be caused by excessive supplementation of
insulin, alcohol consumption, inherited liver enzyme deficiencies, liver or kidney disease,
or by insulinomas. (Lab Test Online)
5. Insulin resistance is a major component of T2DM. Explain this
pathophysiology. How could you determine whether Adane is exhibiting
insulin resistance?
Individuals with T2DM produce insulin, but their tissues are insulin resistant. This
causes increased need for insulin, so the pancreas increases production. Eventually the
pancreas loses its ability to produce insulin. Although insulin resistance develops many
years before onset of diabetes in individuals with predisposition to T2DM, clinical onset
is correlated with the diminishing pancreatic release of insulin. Insulin resistance is
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caused by a cell-receptor defect resulting in the body’s inability to use insulin. When
cells cannot respond to insulin by trans locating glucose transporters to their outer
membrane, they are unable to take up glucose from the blood for fuel. Since insulin
normally serves to inhibit glycogenolysis and gluconeogenesis when blood glucose is
high, defective insulin secretory response results in excess production of glucose in the
lever. For T2DM to manifest, both defect must be present. At first, postprandial glucose
levels rise due to the inability of the cells to utilize glucose; subsequently, hepatic
gluconeogenesis steps up to compensate for this lack of glucose, resulting in fasting
hyperglycemia. Another condition related to insulin resistance is metabolic syndrome,
which shares some characteristics of T2DM. Central obesity and insulin resistance are
significant contributing features, along with atherosclerotic risk factors including
dyslipidemia and hypertension.
To determine if Adane is exhibiting insulin resistance a number of test could be
preformed. From the box 17.8 in Nelms, some of the criteria for this disease are outlined.
An A1C test, sometimes called hemoglobin A1c can be preformed and this reflects the
average blood glucose level over the past three months. This test is the most reliable test
for prediabetes, but it is not as sensitive as the other tests. A fasting plasma glucose test
measures blood glucose in people who have not eaten anything for at least 8 hours. This
test is most reliable when done in the morning. A blood glucose level between 140 and
19 mg/dl indicates prediabetes and anything above that is considered diabetic. The oral
glucose tolerance test measures blood glucose after people have not eaten for at least 8
hours and 2 hours after they drink a sweet liquid provided by a doctor of laboratory.
(Nelms 499)
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6. Children with T2DM are at high risk for early cardiovascular disease. Why
does this complication occur with diabetes? Evaluate Adane’s lipid profile.
How does this compare to the lipid goals for children with diabetes?
Adane is at a high risk for early onset of cardiovascular disease because of the
Many risk factors of diabetes also correlate with cardiovascular disease. Adane high
BMI is a huge concern for both her diabetes and her heart. Uncontrolled diabetes causes
damage to your body’s blood vessels making them more prone to damage from
atherosclerosis and hypertension. People with diabetes develop atherosclerosis at a
younger age and more severely than people without diabetes. Hypertension is more than
twice as common in people with diabetes as in people with normal blood glucose levels.
Diabetes can damage the blood vessels and over time this puts people with diabetes at far
greater risk of intermittent claudication’s and lower-limb amputation. Adane’s high
cholesterol level also puts her at risk for heart disease. Inactivity, being overweight, poor
diet, and poorly controlled glucose levels are all risk factors for cardiovascular disease
and diabetes. (World Heart Federation)
7. Adane’s grandmother asks about medication for treating high cholesterol as
her husband is on this medicine. What are the recommendations for the use
of statin drugs in children?
High cholesterol is on the rise in the pediatric population. Treatment of
dyslipidemia in children is similar to treatment in adults in that it involves both lifestyle
interventions as well as possible pharmacologic therapy. Cholesterol is an important
factor for growth and development in children. Although statins primarily use the liver
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for their site of action, a few statins are lipophilic in nature and cross the blood brain
barrier. Concerns exist utilizing statins for long-term therapy when it is unknown is the
child’s central nervous system; energy function, growth and sexual hormones could be
altered by statin use at such a young age. As young girls who are placed on statin therapy
will at some point become fertile, it is important for healthcare providers and caregivers
to recognize that birth control should be utilized in females. Statins should be
discontinued at once in any patient who becomes pregnant. But there are findings from
studies of statin use in children with this inherited condition are partly behind the
hypothesis that a child with elevated LDL levels would benefit from cholesterol-lowering
medications based on an analysis of the published evidence by the American Society of
Hospital-Pharmacists. The FDA approved them to be used with dietary modifications to
reduce LDL levels in the bloodstream. (ConsumerReport.org)
8. Adane’s urinalysis is positive for protein. What does this mean and how may
this be related to her diabetes?
Protein in the urine is known as proteinuria and is any excess amount of protein found in
a urine sample. Your kidneys filter waste products from your blood while retaining
components your body needs including protein. However, some diseases and conditions
can allow protein to pass through the filters of your kidneys, causing protein in urine.
Disease when untreated like diabetes can cause great damage to the kidneys because of
the high glucose levels in the blood. (The Global Diabetes Community)
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9. Should Adane and her family be taught about self-monitoring of blood
glucose (SMBG)? If so, what are the standard recommendations for daily
frequency of testing? What would be the appropriate fasting and
postprandial target glucose levels for Adane?
Self-monitoring of blood glucose is very important Adane and her family to learn. This
is recommended for people with diabetes and their health care professionals in order to
achieve a specific level of glycemic control and to prevent hypoglycemia. For patients
with type 2 diabetes, optimal SMBG frequency varies depending on pharmaceutical
regimen and whither patients are in an adjustment phase or at their target for glycemic
control. People with type 2 diabetes who use insulin should perform SMBG at least four
times per week, including at least two fasting and two postprandial values. Additional
measurements at bedtime and before meals can also be obtained. Thoughtful
interpretation of SMBG data will assist patients and health care providers in selecting
appropriate pharmaceutical and lifestyle regimens. According to the American Diabetes
Association an appropriate range for fasting glucose level for Adane would be 70-130
mg/dL. An appropriate postprandial target range for her would be about 180 mg/dL or
less. (Clinical Diabetes, American Diabetes Association)
II. Understanding the Nutrition Therapy
10. Outline the basic principles for Adane’s nutrition therapy to assist in control
of her T2DM.
Weight Management- overweight and obesity are strongly associated with
development of T2DM
o Moderate weight loss improves glycemic control and reduces CVD risks
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o Therapeutic lifestyle changes that include a reduction in energy intake and
increase in physical activity are recommended
Carbohydrates- monitoring total grams of carbohydrate by either the use of
exchanges or carbohydrate counting is strategic in achieving glycemic control
o Low carb diets are not suggested because carbs are a significant source of
energy, water soluble vitamins and minerals, and fiber
Protein- intake of dietary protein exceeding 20% of energy intake may be a risk
factor for development of nephropathy.
o Protein intake for individuals with diabetes who have nephropathy should
not exceed 0.8g/kg or less than 10% of calories.
Fat- fat intake should be the same for people with diabetes as people with
cardiovascular disease history
o Fat should not exceed 25%-35% of total kcals, and saturated fat intake
should not exceed 7%
Fiber- foods containing a mixture of fibers, but those foods have high amounts of
gums, beta-glucans, psyllium, resistant starches, and pectin appear to have the
biggest positive effect on serum glucose levels by slowing the absorption of
glucose from the small intestine
o U.S Dietary Guidelines recommend that men under 50 consume 38 grams
of fiber/day and women consume 25 grams of fiver/day
III. Nutrition Assessment
11. Using the charts on pg. 188-189, assess Adane’s ht/age; wt/age; ht/wt; and
BMI. What is her desirable weight?
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When referencing the growth charts given, Adane is in very high in all of her percentiles.
Adane's ht/age is categorized at 70th percentile; her wt/age is in the 100th percentile; her
ht/wt is at the 100th percentile; and lastly her BMI is also in the 100th percentile for being
9 years old. A desirable weight for Adane would be 75 pounds. This would put her at
about the 75th percentile for height and weight. At the age of 9, she should not lose all the
extra weight that she currently has. The best option is to change her lifestyle in healthier
ways and to grow into her current weight. (Nelms Case Study 187-189)
12. Identify any abnormal laboratory values measured upon her admission.
Explain how they may be related to her newly diagnosed T2DM.
Upon admission some of Adane’s lab values were not at the normal level. Her
cholesterol level should have been below 170mg/dL and it was 210mg/dL. Triglyceride
levels should have been below 150mg/dL and Adane's levels were 210mg/dL. When
testing her HbA1c Adane’s score was recorded at 6.9% and the normal range is 3.9-5.2%.
Her EAG score was elevated at 151. A normal C-peptide level is 0.51-2.72 ng/mL and
Adane’s was recorded at an elevated level of 2.75 ng/mL. In Adane’s urinalysis she
tested positive for protein, glucose, and Prot chk and these should all be negative.
When relating these high levels to Adane’s new diagnosis many things can be
assumed. The high HbA1c, glucose, and C-peptide in the urine analysis depict the insulin
resistance. When diabetes is not properly handled it can lead to kidney malfunction,
which can affect the protein levels in urine. The high triglyceride levels and cholesterol
could be signs of metabolic syndrome that is directly tied with diabetes.
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13. Determine Adane’s energy and protein requirements. Be sure to explain
what standards you used to make these estimations. Should weight loss be a
component of your estimation of energy requirements?
After looking at a few different methods of calculating protein and energy needs, I came
to the conclusion that the TEE equation for girls between the ages of 3-18 years old
would be the most accurate depiction of her needs.
ENERGY NEEDS:
TEE=389−41.2 × age+PA ×15.0 × weight (kg )+701.6 ×height (m)
TEE=389−41.2 ×9+1.0× 15.0× 63.6 (kg )+701.6× 1.32(m)
TEE=¿ 1,898 kcals
EER= 88.5-61.9 x age + PA x (10 x weight kg) + (934 x height meters)+ 20=
88.5-61.9 x 9 + 1.0 x (10 x 63.6kg) + (934x 1.32) + 20=
RDA= 70kcal/kg, 63.6kg x (69kcal-79kcal)=
WHO= 22.5 x wt + 499
22.5 x 63.6kg + 499=
A 1.0 PA factor was used because no activity was logged in her report and there was no
evidence that she is an active child.
PROTEIN NEEDS: A diabetic patients protein needs should never exceed 10% of their
total caloric intake.
Protein Needs=1,898 kcals× 0.1=189 kcals ¿ protein
189 kcals ¿ protein ÷ 4 kcalg
=47 grams of protein
Adane’s should not be losing weight, so it is not considered into her energy and
protein needs. She is at a young age and she is still developing. Cutting calories and
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weight loss may stunt this process. She will grow into her weight as she makes lifestyle
changes to improve the quality of her life.
14. Using Adane’s diet history, assess the approximate number of kilocalories
her intake provided, as well as the energy distribution of calories for protein,
carbohydrate, and fat, using the exchange system. Compare this to the
recommendations that you made in question #10.
Exchange List Analysis of Diet:
Food Calories Carbs Fat Protein
Fruit punch 1,800 0 0 0
Frosted flakes 200 35 1 6
Whole milk 120 12 5 8
Toast with
butter and jam
180 30 7 5
Cookies 400 75 10 1
Cheetos 150 15 10 0
Popsicles 50 0 0 0
4 pieces of
bread
320 60 4 12
Peanut butter 100 0 8 7
Mayo 45 0 5 0
Banana 60 15 0 0
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Pork chops 100 0 8 7
Green Beans 25 5 0 2
Corn Bread 80 15 1 3
Butter 45 0 5 0
Iced tea with
Sugar
150 0 0 0
Pizza Rolls 400 75 40 35
Coke 100 0 0 0
Chips 150 15 10 0
TOTALS 4,475 kcals 352g 114g 86g
FitDay.com Analysis of Diet:
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After calculating Adane’s intake in both fit day and the exchange list, it is very clear that
she is consuming a substantial amount more than she should be. In fit day she consumed
about 5,400kcals total. Adane is consuming 3,502 more calories than she should. She
consumes 146 grams of fat, 973 grams of carbohydrates, and 85 grams of protein from
fitday.com. When analyzing the exchange list she consumed 4,475 calories, 352 grams
of carbohydrates, 114 grams of fat, and 86 grams of protein. Both of these exceed the
0.8g/kg of protein. Fat exceeds 25-35% in both cases.
5,400-1,898= 3,502 kcals extra
Fit Day:
146g fat x 9= 1,314 kcals from fat
973 g carbs x 4= 3,892 kcals from carbs
85 g protein x 4= 340 kcals from protein
Exchange List:
352 g carbs x 4= 1,408 kcals from carbs
114 g fat x 9= 1,026 kcals from fat
86 g protein x 4= 344 kcals from protein
IV. Nutrition Diagnosis
15. Prioritize two nutrition problems and complete the PES statement for each.
1. Excessive energy intake of about 5,000 kcals related to poor diet choices as
evidence by 24-hour food recall.
2. Overweight related to high BMI of 36 as evidence by being in the 100th percentile
for age and BMI.
Excessive fat intake: NI-5.6.2
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Excessive energy intake: NI-1.3
Overweight: NC-3.3
Nutrition Intervention
16. Determine Adane’s initial nutrition therapy prescription using her diet
record from home as a guideline, as well as your assessment of her energy
requirements.
When starting out, especially with Adane being so young, the goals need to be
realistic and attainable. I would start out with reducing her consumption of sugary
high calorie beverages. By just cutting out the kool-aid, iced tea, and coke Adane
could cut out almost 2,000 calories. Next I would recommend that Adane and her
family replace the corn bread and white enriched bread with whole grains. I would
educate them on other cooking methods beside breaded and deep frying foods. I
would request that she replace one snack with a cup of fresh vegetables. And lastly I
would recommend that she do some form of physical activity starting with two days a
week for 30 minutes.
Two of the ideas described above can be incorporated into Adane's life ever week
until she implements them all. Once she has reached these steps in her life. The team
of health care providers can them work together to fine tune her diet and work to
make sure she is staying within the appropriate caloric intake.
17. Outline the initial steps you would use to teach Adane and her family about
nutrition and diabetes. What education materials could you use?
1. Pretest- This will allow me to assess what the family already knows and what I
should specifically focus on
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2. Handouts- Handouts will help them remember everything that I talked about if
they felt overwhelmed and couldn’t remember everything. These can also be
used for future reference when the family is at home, eating out, or at the grocery
store.
3. Technology education- In today’s education a lot of technology sources are used
especially with children. I would show them different apps, computer games, and
computer resources for nutrition education.
4. Plastic food models- By using plastic food models to show portion size, I can
educate the family on what proper portions of protein, carbs, and fat are. This is
especially important for Adane to control her diabetes.
5. Journal- The journal can be done from any of the online resources previously
educated on, or they can use paper and pencil. I would advise them to record
amounts, methods of cooking, and how they felt before and after the meal. We
could then use the food journals to establish goals, review diet, and ways to
implement the healthier lifestyle goal.
6. Summary folder- I would give both Adane and her family folders that they can
put there new resources in along with a sheet of paper they could write there
thoughts and future questions on for me in future meetings.
18. Considering that Adane will not be started on medication, is it necessary to
teach her and her family about hypoglycemia, sick-day rules, and exercise?
It is very important to teach Adane and her family about hypoglycemia, sick-day
rules, and exercise because if her family is uneducated it could lead to other health
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problems. Hypoglycemic symptoms are important clues that you have low blood
glucose. Each person’s reaction to hypoglycemia is different, so it’s important that you
learn your own signs and symptoms when your blood glucose is low. Some of these
signs may include shakiness, anxiety, irritability, confusion, fast heartbeat, dizziness,
hunger, sleepiness, blurred vision, numbness, headaches, weakness, anger, lack of
coordination, seizures, and unconsciousness. Snacks with 15-25 grams of carbohydrates
should always be on hand incase hypoglycemia takes place.
It is important to monitor sick-day rules because often times children will lie to
try to get out of school or important events they don’t particularly want to attend. But
when Adane may actually be sick they need to be ready and be prepared. Before
diabetes, the usual parent prescription for a cold or flue was rest, refreshment and reruns.
After a diabetes diagnosis, tending to a cold also includes managing blood glucose levels
that may be more difficult to control. A sick day note book should be created that
includes, a doctor’s guidelines when to call, diabetes care team daytime and after-hours
phone numbers, copy of your insurance card, sick-day meal plans, list of over-the-counter
medicines that do not interfere with blood glucose or insulin, a record of blood glucose
reading and carb counts of foods eaten, and lastly comics, poems, pictures or anything
else that may help the patient feel better. (American Diabetes Association)
Exercising is one of the best things that a person can do if they have diabetes. It
helps the body burn extra fat, lowers blood pressure, improves blood circulation, helps
your body use insulin and control blood sugar, and tames stress. Adane should start low
with walking and work her way up, as she feels better. If Adane starts to feel any of the
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hypoglycemia symptoms, she should stop exercising immediately and take the
precautions to treat the symptoms.
19. Adane’s mother is worried that none of the children will ever be able to have
birthday cake or other sweet treats. She feels that she cannot offer these to
the other children if Adane cannot have them. What would you tell her?
I would tell Adane and her mother that they do not have to take away all sweet treats
especially for other kids. It is important that Adane’s mother understand her disease and
everything that it entails. Desserts do not have to be permanently removed from the diet;
Adane just has to understand how to compensate with her insulin. It is also very
important to understand what an actual portion size is and that Adane just eat a small
amount of cake instead of a large piece like she normally would.
There are other healthier alternatives to sugary desserts. There are many diabetic
cookbooks that give really to recipes for low glycemic index desserts. Fruit, though it
does contain sugar, is a much better alternative. Many different desserts can be made
with fruit as the base that taste just as sweet as a cake. It is essentially that Adane does
not feel anymore different than she already does because of her situation.
Nutrition Monitoring and Evaluation
20. Write an ADIME note for your initial nutrition assessment.
Assessment-
Anthropometric data= 9 years old, height 52”, Weight 140lb, BMI= 36.4, Temp
98.6, BP 100/59, Pulse 72, African American, African Methodist Episcopal
Biomedical data= glucose of 171 on day one and 151 on day two, Cholesterol
elevated at 210 mg/dL, Triglyceride levels of 175 mg/dL, high HbA1c 6.9%, high
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EAG of 151, C-peptide levels of 2.75, positive protein, positive glucose, positive
prot chk
Clinical- frequent ear infections as infant and toddler, overweight/ obese, mother
and grandmother have type 2 diabetes, grandfather has high cholesterol and
hypertension
Diet history- current intake of about 5,200 kcals, estimated needs calculated at
1,898 kcals, 10-20% should be from protein, 30% from fat (less than 10% of fat
from saturated fat), 50% from carbohydrates
Diagnosis-
Excessive energy intake of about 5,000 kcals related to poor diet choices as
evidence by 24-hour food recall
Excessive fat intake of 146 grams related to poor food choices and healthy
cooking techniques as evidence by 24-hour recall and being overweight.
Overweight related to high BMI of 36 as evidence by being in the 100th percentile
for age and BMI.
Intervention-
Instructed client on a 1,900 calories
Incorporate fruits and vegetables starting with at least twice a day
Increase physical activity to walking at least 10,000 steps a day, gradually
increasing by 2,000 steps per week
Goals- increase fruits and vegetables, increase whole grains, increase lean meat,
decrease sugar sweetened high calorie beverages
Monitory/ Evaluation-
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Food journal with amount, type, food preparation, and feeling before and after
meals
Monitory lab values (test two weeks after first meeting with dietician)
Glucose level log
Physical activity journal- type, duration, and intensity
Weight
Review goals
21. Adane’s grandmother suggests that perhaps Adane should have “stomach
surgery” so that she will lose weight more quickly. What are the
recommendations for pediatric bariatric surgery?
There are many risk factors related with pediatric bariatric surgery. Many people think
that this is the best and easiest way to get a child’s health issues under control and this is
not always the case. When bariatric surgery is preformed there are large risks for mal
absorption. This is a huge problem stunting the growth of a growing young girl. Weight
loss surgery does not replace the long-term need for a healthy diet and regular physical
activity. This is why Adane should try all the new healthier lifestyle changes that the
dietician has recommended for her for at least 6 months to try and see improvement and
avoid surgery. Bariatric surgery should be a last resort option.
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Work Cited
American Diabetes Association. (n.d.). Retrieved November 18, 2014, from
http://care.diabetesjournals.org/content/37/Supplement_1/S14.ful
Clinical Diabetes. (n.d.). Retrieved November 18, 2014, from
http://clinical.diabetesjournals.org/content/20/1/45.full
C-peptide. (n.d.). Retrieved November 18, 2014, from
http://labtestsonline.org/understanding/analytes/c-peptide/tab/test
Defining Overweight and Obesity. (n.d.). CDC Retrieved November 18, 2014, from
http://www.cdc.gov/obesity/adult/defining.htm
Diabetes. (n.d.). World Heart Federation. Retrieved November 18, 2014, from
http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-
factors/diabetes/
Diabetes-related Autoantibodies. (n.d.). Lab Tests Online. Retrieved November 18, 2014,
from http://labtestsonline.org/understanding/analytes/diabetes-auto/tab/test/
Proteinuria (Albuminuria). (n.d.). The Global Diabetes Community. Retrieved November
18, 2014, from http://www.diabetes.co.uk/diabetes-complications/proteinuria.html
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Nelms, M., & Roth, S. (2014). Medical nutrition therapy: A case study approach (4nd
ed.). Belmont, CA: Wadsworth/Thomson Learning.
Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy and
pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.
Should children take statin drugs to lower their cholesterol? (n.d.). Consumer Report.org.
Retrieved November 18, 2014, from
http://www.consumerreports.org/cro/2012/05/should-children-take-statin-drugs-to-lower-
their-cholesterol/index.htm
Type 2 diabetes in children. (n.d.). Mayo Clinic. Retrieved November 18, 2014, from
http://www.mayoclinic.org/diseases-conditions/type-2-diabetes-in-children/basics/risk-
factors/con-20030124
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