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

 Reason for Nutritional
Chemistry Normal Value Susan’s Value
Abnormality Implications
Albumin 3.5-5 g/dL 4.2 g/dL Normal -
Total Protein 6-8 g/dL 7.5 g/dL Normal -
Decreased fluid
Prealbumin 16-35 mg/dL 40 mg/dL Dehydration
volume 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 -
285-295 Decreased fluid Weight loss,
Osmolality 304 H mmol/kg/H2O
mmol/kg/H2O volume in the body dehydration
Hyperglycemia,
High blood sugar due
frequent thirst,
to diabetes, in ability
Glucose 70-110 mg/dL 250 H mg/dL urination, hunger,
to use glucose due to
drop in pH,
insulin deficiency
ketoacidosis
Increased glucose
BUN 8-18 mg/dL 20 H 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 -
Diabetes
complications, eye
Increase in glucose
HbA1C disease, heart
3.9-5.2% 7.95% binding to
disease, kidney
hemoglobin
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 Name Onset of Peak of Duration of
Insulin Action Action Action
(Hours) (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 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
Cereal
2% Milk 1 cup 122 kcal 11.71g 8.05g 6.044g

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 kcal 114.44g 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 3 stalks 147 kcal 30.15 10g 1.215g
Brocolli
Stalks with
salt

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

Total 1021 kcal 96.97g 52.04g 22.428g
 HS Snack
Food Serving Calories CHO (g) Protein Fat (g)
(g)

Ice cream 2 cups, 572 kcal 89.6g 10g 28g

chocolate
Coke 1 12oz 136 kcal 35.18g 0.26g 0g
can
Total 708 kcal 124.78g 10.26g 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 Recommended
Intake 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?