Case Study #3 Diabetes Mellitus: Type I

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.”

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.

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 in the body Dehydration

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/H2ODecreased fluid volume

in the bodyWeight loss, dehydration

Glucose 70-110 mg/dL 250 H mg/dLHigh 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 H Increased glucose levels Dehydration

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 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

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.

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

Diet Plan Comparison

Total Daily Patient Intake

Recommended Diet Plan Intake

% of Recommended Intake

Kcal 3643 kcal 2400 kcal 151.7%

CHO 473.73g 300g 157.9%

Protein 118.33g 55-65g 182% - 215.4%

Fat 95.15g 80g 118.9%

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

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:

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/dayPhysical activity coefficient: 1.56 for very active

• ProteinRDA for 14-18 year old female= 46g/day

Nutrition Care Process

• Step 1: Assessmento Appropriate and reliable data was collected to determine

the existence of specific nutrition problems

• Step 2: Diagnosis o Food and nutrition-related knowledge deficit o Undesirable food choices

Diagnosis

• PES Statements– Food and nutrition-related knowledge deficit (P) related to newly

diagnosed Type 1 DM (E) as evidenced by no prior knowledge of disease related nutrition therapy and self management (S).

– Undesirable food choices (P) related to nutrition-related knowledge deficit and physical environment (E) as evidenced by usual dietary intake exceeding fat and CHO recommendations, poor food purchase/preparation by parents, and irregular meals due to volleyball schedule (S).

Intervention

Nutrition Education:Educate both patient and family about…– Role of nutrition in diabetes management– Carbohydrates and diabetes– How certain foods effect blood sugar– Avoiding hypo/hyperglycemia• Signs/symptoms of both

– Food purchasing/preparation– Alcohol consumption

Intervention

Nutrition 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

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 sugar was going

to drop, therefore she needed the CHO snack• Normally when blood sugar levels start to drop, the liver will

begin changing stored CHO into glucose• The glucose would then be sent into the blood to slow down the

low blood sugar reaction• When Susan drank the alcohol, her liver wanted to clear it as

quickly as possible since it was a “poison”• The liver would not put out glucose again until the alcohol was

completely metabolized• Since her blood sugar level was falling she reached a very low

blood sugar level, extremely quickly, thus causing her to pass 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