Case Study 15Type 1 Diabetes

MellitusMollie Gallagher and Mary Allison

Geibel

TYPE 1 vs. TYPE 2

TYPE 1 DIABETES● Body is unable to synthesize enough

insulin in pancreas to allow for glucose absorption

● Cells “starve” without enough glucose for energy

● Pancreatic beta cells are destroyed by autoimmune disease

● Common in children and teenagers● 5% of people with diabetes have T1

TYPE 2 DIABETES● Body produces insulin, but become

insensitive to insulin, building up glucose in blood

● Less insulin receptors/defective● Lifestyle and nutrition related● Most prevalent form of diabetes

(adult onset)● Common with overweight/obese,

starting to develop in younger ages

Mechanisms

EtiologyGenetic FactorsChildren whose mother has type 1 DM have a 2-3% risk of developing the disease, whereas those whose father has the disease have a 5-6% risk. When both parents are diabetic, the risk rises to almost 30%.

EthnicityType 1 DM is most prevalent in Caucasians than African-Americans and Hispanic-Americans. Chinese people have a lower risk of developing type 1, as do people in South America, more common in northern climates

Environmental FactorsT cells can attack beta cells, triggered by viruses and antibodies such as German measles, mumps, rotavirus, and exposure to a protein in cows milk young in life

Signs and Symptoms

● Frequent urination

● Extreme hunger

● Unintended weight loss

● Irritability and other mood changes

● Fatigue and weakness

● Blurred vision

● Increased thirst

● Slow healing cuts and bruises

● Hypo/hyperglycemia-high and low glucose levels in the blood● Diabetic Ketoacidosis-overproduction of acetyl-CoA, FA converted to

ketones (acidic)● Diabetic Neuropathy-increased glucose in nerve cells, degradation● Polyuria-excessive passage of urine (3+ liters/day)● Polydipsia-excessive thirst, mouth dryness● Polyphagia-excessive hunger

Potential T1DM Complications

DetectionType 1 and Type 2● Symptoms of Diabetes plus casual plasma glucose >200 mg/dL (11.1

mmol/L)● Fasting Plasma Glucose Test>126 mg/dL (7.0mmol/L)● 2-Hour Postprandial Glucose Test >200 mg/dL during an OGTT● 75-gram Oral Glucose Tolerance Test● Hemoglobin A1c value of ≥ 6.5%

LADA● Presence of circulating islet antibodies (including ICA, GADA, protein

tyrosine phosphatase antibody)-also in T1DM● Age ≥ 30 years● Insulin independent for at least 6 months after being diagnosed

Patient Summary● Armando Gutierrez, 32 year old, male● Divorced● 16 years of education, speaks English/Spanish● Computer software engineer, works 8-7 M-F and some weekends● Hispanic and Catholic● Smoker 1ppd x 10 years, daily alcohol use● Father-MI, mother-ovarian cancer and T2DM

Previous Nutrition IntakeBreakfast Toast, jelly, coffee, and scrambled egg

Lunch Subway sandwich, chips, diet soda

Dinner Pasta, rice, vegetables, some kind of meat (eats out 3-4 times/week)

Total kcal intake 1995 kcal

Protein 87.1 grams

Fat 74.4 grams

Carbohydrate 243.6 grams

Fiber 16.3 grams

● 99.6 F temperature● Pulse 100● Resp rate 24● BP 78/100● Height 5’11”● Weight 165 lbs

Anthropometric Data

height: 5’11” = (71 in)(2.54 cm/in)(1m/100cm) = 1.8 m

weight: (165 lbs)(1 lb/2.2kg) = 75 kgBMI (kg/m^2) = (75 kg)/(1.8m)^2 = 23.1

kg/m^2

Vital Signs● Groggy and nearly unconscious, admitted to ER● Admitted with serum glucose 610 mg/dL● Tachycardia (fast heart rate)● Tense abdomen with guarding● Cloudy, amber urine● Pale, diaphoretic, and clammy skin

[Diagnosed with T2DM 1 year ago, improper use of metformin medication]

Medical Orders● Regular insulin 1 unit/mL NS 40 mEq Kcl/L @ 300 mL/hr

begin infusion @ 0.1 unit/kg/hr and increase to 5 units/hr● Laboratory analysis, urinalysis, hematology

Nutritional Orders● NPO except ice chips and meds for 12 hrs, switch to clear liquids (if stable)● Consistent Carb diet: 70-80 g breakfast + lunch, 85-95 g dinner, 30 g PM snack● 2200 mL fluid requirement

Medical Dx/Treatment #1

Laboratory ResultsLaboratory Value Normal Range Armando’s Value

Sodium (mEq/L) 136-145 130

CO2 (mEq/L) 23-30 31

Glucose (mg/dL) 70-110 683

Phosphate (mg/dL) 2.3-4.7 2.1

Osmolality (mmol/kg/H20)

285-295 306

Cholesterol (mg/dL) 120-199 210

Triglycerides (mg/dL)

40-160 175

HbA1c (%) 3.9-5.2 12.5

C-peptide (ng/mL) 0.51-2.72 0.09

Laboratory ResultsLaboratory Value Normal Range Armando’s Value

ICA - +

GADA - +

IAA - +

pH (urinalysis) 5-7 4.9

Protein (mg/dL) - +1

Glucose (mg/dL) - +3

Ketones - +4

Prot chk - tr

pH (ABGs) 7.35-7.45 7.31

HCO3 (mEq/L) 24-28 22

Three months later reevaluated condition...[Diagnosed with T1DM based on +ICA, GADA, IAA, (-) C-peptide levels]

Medical Orders● Change IVF to D5.45NS, 40 mEq K@ 135 mL/hr● Begin Novolog 0.5 units/2 hrs until glucose is 150-200 mg/dL● Begin Glargine 15 units @ 9PM● Progress Novolog using ICR 1:15● Check glucose hourly, notify if >200 or <80 mg/dL

Medical Dx/Treatment #2

1) Altered nutrition-related laboratory values (NC-2.2) related to poor management of DM and improper medication use as evidenced by elevated serum glucose level of 610 mg/dL.

2) Food- and nutrition-related knowledge deficit (NB-1.1) related to lack of knowledge of T1DM after being diagnosed as evidenced by symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss.

Nutrition Diagnosis

ENERGY REQUIREMENTSREE= 10 x wt (kg) + 6.25 x ht (cm) - 5 x age (yrs) + 5

REE = 10 x 75 + 6.25 x 180 - 5 x 32 + 5 = 1,720 kcalTEE= 1720 x 1.0 = 1720 kcal (resting) to 1720 x 1.4 = 2408 kcal

(sedentary)

PROTEIN REQUIREMENTSPro = 0.8g/kg

Pro = 0.8(75)= 60g of protein/day Pro = 60g x 4 kcal = 240 kcal/day

Energy & Protein Requirements

Nutrition Intervention

Energy Intake 2400 kcal/day, 4-5 small frequent meals

Fatconsume less cholesterol/saturated fat, lower lipid profiles

Protein 60 g/day

Carbohydrate 70-80 g breakfast + lunch, 85-95 g dinner, and 30 g PM snack

Fiberincrease through fruits, vegetables, legumes, whole grains

● Carbohydrate Counting/Glycemic Index● Decrease alcohol intake to 4 days/wk (2

drink max)● Introduce light exercise (30 min/day)● Monitor BG 3+ times/day, before exercise● 2200 mL fluid requirement

Goal Lab LevelsA1C <7%BP < 140/80 mmHgLDL< 100 mg/dLTG < 150 mg/dLHDL> 40 mg/dLpreprandial glucose of 70-130 mg/dL postprandial glucose of <180 mg/dL

Sample Diabetic MenuBreakfast 1 cup 1% milk, 1 orange, 1.5 cups

Cheerios cereal

Snack 1.5 cups cantaloupe, ⅔ cups low fat/sodium cottage cheese

Lunch Lentil salad, salmon, 1 large whole-wheat pita, ⅔ cups nonfat strawberry frozen yogurt

Snack 4 tbsp. prepared hummus, 4 oz carrot sticks

Dinner ¾ cups cooked brown rice, 1 cup steamed spinach, grilled steak with beets & radicchio, pineapple-raspberry parfait

*Based on 2000 kcal diet

Blood Glucose Monitoring

Physical Activity-BG 100+ mg/dL prior-eat before activity-keep carb/sugar source on hand

Carb Counting-glycemic index/load-increase whole grain, fruit, and veg consumption-set max carb intake for each meal

Insulin Pump-dosage based on ICR-regular or rapid acting insulin-0.5-0.7 units/kg-CSII, MDI, or mixed dose

Self Monitoring-3+ times/day-used to alter meal and medications-maintain glycemic control

● Lab values- blood glucose, ketones, lipids, protein, HbA1c, C-peptide, urinalysis, micronutrients

● Food and exercise journal● Analyze adherence to diet and glycemic response

● Have you felt comfortable about self monitoring your glucose levels?● Are there alterations needed in your diet to keep you blood glucose levels

more stable?● Are you able to exercise without your blood glucose levels decreasing

rapidly?● Have you felt dizzy, nauseous, or lethargic at any times during the day?● Do you need extra guidance to plan your meals to meet your nutrition goals?● Have you been able to count carbohydrates to keep your glucose levels

adequate?● Have you been selecting high fiber foods and controlling your fat intake?● Has the insulin schedule been easy to follow and does it effectively lower

your glucose?

Follow Up Evaluation

TreatmentPrognosis

● More than 60% of patients with T1DM do not experience future complications

● Serious complications may includeo Blindnesso ESRD - End Stage Renal Diseaseo Early death

● Outcomes also depend on the patient’s:o Educationo Awarenesso Motivation

● Management of blood glucose, hemoglobin A1c, lipids, blood pressure, and weight greatly affect the outcome of the patient

ResourcesAutoantibody Markers (2014). Diapedia. Retrieved on 16 Nov 2014 from http://www.diapedia.org/type-1-diabetes-mellitus/autoantibody-markers. doi: http://dx.doi.org/10.14496/dia.21040851461.17

Avoiding Low Blood Glucose Levels During Exercise. One Touch. Retrieved on 17 Nov 2014 from http://www.onetouch.com/articles/lowbloodglucoselevels

Diabetes Signs. Diabetes.co.uk. Retrieved on 16 Nov 2014 from http://www.diabetes.co.uk/The-big-three-diabetes-signs-and-symptoms.html

Higdon, J. PhD. Glycemic Index and Glycemic Load. (2005). Linus Pauling Institute Micronutrient Information. Retrieved on 17 Nov 2014 from http://lpi.oregonstate.edu/infoce neter/foods/grains/gigl.html

Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.

NovoLog® is designed to mimic the normal physiologic insulin profile. Novolog. Retrieved on 17 Nov 2014 from https://www.novologpro.com/pharmacology/mechanism-of- action.html

Polyuria-Frequent Urination. Diabetes.co.uk. Retrieved on 16 Nov 2014 from http://www.diabetes.co.uk/symptoms/polyuria.html

Stenstrom, G., Gottsater, A., Bakhtadze, E., Berger, B., Sundkvist, G. Latent Autoimmune Diabetes in Adults (2005). American Diabetes Association 54 (S68-S62). Retrieved on 16 Nov 2014 from http://diabetes.diabetesjournals.org/content/54/suppl_2/S68.full. doi:10.2337/diabetes.54.suppl_2.S68

Unexplained Weight Loss. Diabetes.co.uk. Retrieved on 16 Nov 2014 from http://www.diabetes.co.uk/symptoms/unexplained-weight-loss.html

What is Type 1/2 Diabetes? Diabetes Research Institute Foundation. Retrieved on 16 Nov from http://www.diabetesresearch.org/what-is-type-one-diabetes