Case Study #3 Diabetes Mellitus:

Type 1

Lindsey French, Andrea Meiring, Katherine Mykytka, Jessica Oakley

October 30, 2009

Diabetes Mellitus: Type 1Type 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 energyPlasma glucose levels rise (Hyperglycemia) and cells

starve Glycosuria, Polyuria, Dehydration, Poydipsia, Polyphagia,

Fatigue and Electrolyte Imbalanace

Diabetes Mellitus: Type 1Commonly diagnosed in children and

adolescentsJuvenile Diabetes

Some cases develop later in lifeLatent Autoimmune Diabetes of Adulthood (LADA)

Long term complicationsCardiovascular Disease, Nephropathy, Retinopathy,

Autonomic Neuropathy

The Patient Susan Cheng

Asian American

15 years old, HS student

Active: Starter for the girls’ volleyball teamPractices four nights a week and has games two nights a

week

Lives with her parents, older sister,

and younger brotherAll 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 ValueReason for

AbnormalityNutritional

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/dLDecreased fluid

volume in the bodyDehydration

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 -

Osmolality285-295

mmol/kg/H2O304 H

mmol/kg/H2ODecreased fluid

volume in the bodyWeight loss, dehydration

Glucose 70-110 mg/dL 250 H mg/dL

High blood sugar due to diabetes, in

ability to use glucose due to

insulin deficiency

Hyperglycemia, frequent thirst,

urination, hunger, drop in pH,

ketoacidosis

BUN 8-18 mg/dL 20 HIncreased glucose

levelsDehydration

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

binding to hemoglobin

Diabetes complications, eye

disease, heart disease, kidney disease, nerve damage, stroke

Admission Diagnosis:Type 1 diabetes

mellitus

Risk Factors and EtiologyMember of high risk ethnic group

Asian American

Stressful lifestyle

Maternal grandmother had diabetes (but not first-degree relative)

EtiologyGenetics

HLA markersEnvironment

High birth weight, viral infection, dietary factors

TreatmentAchieve 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

Types of Insulin

Brand Name

Onset of Action

Peak of Action (Hours)

Duration of Action (Hours)

Lispro Humalog 10-20 min 1-3 3-5

Aspart NovoLog 10-20 min 1-3 3-5

Glulisine Apidra 10-20 min 1-3 3-5

NPH Humulin NNovolin N

1-3 hours 8 20

Glargine Lantus 1 hour None 24

Detemir Levemir Same as above

70/30 premix MixtardHumulin 70/30

30-60min Dual 10-16

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

Pharmacological Differences:

AnthropometricsHeight: 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 HistoryMother 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.

Food Serving Calories CHO (g) Protein (g)

Fat (g)

Kellogg’s Frosted Flakes Dry Cereal

1 ½ cup 215 kcal 53.15g 2.54g 0.123g

2% Milk 1 cup 122 kcal 11.71g 8.05g 6.044g

Orange Juice

1 cup 112 kcal 25.79g 1.74g 0.248g

Total 449 kcal

90.65 12.33g 6.415g

Breakfast

LunchFood Serving Calories CHO (g) Protein

(g)Fat (g)

Pizza 6 inch, pepperoni

770 kcal 69g 35g 16g

Mixed Salad

1 cup 17 kcal 3.35g 1.3g 0.049g

Thousand Island Salad Dressing

¼ cup 178 kcal 7.03g 0.52g 14.973g

Snickers 1 candy bar

280 kcal 35.06g 0.26g 11.376g

Total 1245 kcal

114.44g 37.08g 42.378g

SnackFood Serving Calories CHO (g) Protein

(g)Fat (g)

Peanut Butter

2 tbsp 188 kcal 25.79g 7.7g 15.181g

Grape Jelly

1 tbsp 50 kcal 13g 0g 0g

White Bread

2 slices 133 kcal 25.3g 3.82g 1.377g

Coke 1 12oz can

136 kcal 35.18g 0.26g 0g

Total 507 kcal

99.27g 11.78g 16.558g

DinnerFood Serving Calories CHO (g) Protein

(g)Fat (g)

Spaghetti

2 cups noodles

442 kcal 25.79g 16.24g 1.753g

Spaghetti Sauce

½ cup 111 kcal 17.61g 2.28g 3.165g

Ground Beef

1 oz 77 kcal 0g 7.24g 4.628g

Steamed Brocolli Stalks with salt

3 stalks 147 kcal 30.15 10g 1.215g

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

Total 1021 kcal

96.97g 52.04g 22.428g

HS SnackFood Serving Calories CHO (g) Protein

(g)Fat (g)

Ice cream

2 cups, chocolate

560 kcal 68g 8g 28g

Coke 1 12oz can

136 kcal 35.18g 0.26g 0g

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 ComparisonTotal Daily Patient Intake

Recommended Diet Plan Intake

% of Recommended 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 ProcessStep 1: Assessmento 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 DiagnosesPES 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 managementCarbohydrates and diabetesHow certain foods effect blood glucosePreventing hyperglycemiaFood purchasing/preparation

Decrease Frequency of Poor Carbohydrate Choices

Nutrition Education/Counseling:

Outpatient appointmentsMeal planningPractice skills

Carb counting, blood glucose monitoring

Reviewing logs of meals, snacks, blood glucose readings, insulin administrations

Psycho/social statusEffects of alcohol consumption

Effects of AlcoholSusan 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 AlcoholOnce 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 AlcoholAlcohol 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 PureViaContain Reb A “Rebiana”

Extracted from stevia leaf, erythritol, and other natural flavors

Received GRAS recognition in US

Questions?