TYPE 1 DIABETES Chandler Ray, Dietetic Intern

University of Maryland College Park January 31, 2014

Outline• Type 1 Diabetes

• Nutrition and Type 1 Diabetes

• Case Study: Outpatient Center for Endocrinology & Diabetes Initial Assessment

Type 1 Diabetes• Formally called “Insulin dependent, IDDM”• A chronic autoimmune disease in which the beta cells in the pancreas produce little or no insulin

• Insulin is a hormone that it needed to move blood sugar (glucose) into cells to store and use later for energy

• Results in glucose building up in the bloodstream (hyperglycemia)

• The body is unable to use the glucose for energy

Google Images Labeled for Re-use: http://upload.wikimedia.org/wikipedia/commons/8/8c/Pancreas_insulin_beta_cells.png

Type 1 Diabetes • Characteristics of DM I

• 5-10% of all DM cases • Usually diagnosed <30 y/o • Onset not associated with diet or lifestyle • Requires insulin treatment for life

• Risk factors • Autoimmune (viral infections) • Genetic • Environmental (toxins)

Type 1 Diabetes • Prior diagnosis: symptomatic hyperglycemia (wt loss) and/or

DKA • Criteria for diagnosis

• A1C > 6.5% or • FPG > 126 mg/dL (7.0 mml/L) or • 2-h plasma glucose > 200 mg/dL (11.1 mmol/L) during an OGTT or• In a patient with classic symptoms of hyperglycemia, a random plasma

glucose > 200 mg/dL (11.1 mmol/L)

Google Images Labeled for Re-use:http://pixabay.com/static/uploads/photo/2014/11/11/22/19/nurse-527615_640.jpg

Signs/symptoms: Hyperglycemia: >126 mg/dL

- Polyuria - Polydipsia

- Polyphagia - Unintentional weight loss

- Fatigue/weakness - Blurred vision

Diabetic Ketoacidosis: ketones in the urine - Deep, rapid breathing - Nausea or vomiting

- Dry skin + mouth - Flushed face- Fruity breath - Stomach pain

Hypoglycemia <70 mg/dL- Shaking/sweating - Dizzines

- Fast heartbeat - Hunger

- Fatigue/weakness - Anxious/irritable

Treatment: Exogenous Insulin • Types:

• Rapid-acting (insulin lispro [Humalog], insulin aspart [Novolog], and insulin glulisine [Apidra])

• Short-acting (insulin regular)• Intermediate-acting (insulin NPH)• Long-acting (insulin glargine [Lantus], insulin detemir [Levemir])

• Regimens • Classic Basal/Bolus *• Modified Basal/Bolus • NPH/Regular • 70/30 Mixture

Nutrition and Type 1 Diabetes • Carbohydrates: Individualized for each patient/client

• Adjust food pattern in accordance with insulin requirement prescription

• Adjust insulin for physical activity • Intense therapy-counting CHO, adjusted for multiple injections

• Protein: typically recommend 1 serving with each meal

• Fat: ~30% of total kcals

CHO Counting • Basic Carbohydrate Counting (poster)

• Identify CHO choices, learn choice groups• Using food labels • Design Meal Plan

• Advanced Carbohydrate Counting • Food record keeping • Monitor blood glucose patterns • Identify insulin: CHO ratio to become more flexible and develop

strategies to adjust medication, exercise, CHO intake

Case Study

Outpatient Nutrition Questionnaire

Patient Name: JC Age: 16 years-old Sex*: Male Race*: Caucasian

Reason for Visit: overweight/ uncontrolled type 1 diabetes

Activity: On high school cheerleading team (seasonal)

• Outpatient visit to Diabetes Clinic 1/21/15: Recent issues with diabetes management include difficulty with consistent blood sugar checks, missed insulin injections, and skipped meals. Previously seen on 11/7/2014 with a HbA1c of over 14%.

• Patient Goal: JC is interested in getting a drivers license, and therefore, is motivated to improve his glucose control and his monitoring frequency

Background • PMH: Type 1 diabetes diagnosed in September 2011, Graves’ disease diagnosed at age 5, asthma, elevated blood pressure, microalbuminuria, bipolar disorder, depression, and anxiety.

• Birth history: 35 week ex-preemie, 2 weeks in NUCI for lung problems. Pregnancy complicated by Gestational DM in mother.

• Family history: Diabetes in maternal great-grandmother and maternal great-grandfather

• Social history: Admits to smoking cigarettes

Mental Health • Depression• Bipolar Disorder• Anxiety• Binge Eating Disorder

• History of binging and purging

• Self-injury • Cutting on arms and legs • Suicide attempt

• Irregular sleep patterns

Assessment • Nutrition Risk Level: Overweight/ uncontrolled type 1

diabetes/ binge eating disorder • Diet Order: Carbohydrate Controlled Diet + CHO counting

• Classic Basal Bolus Therapy: getting Lantus at a dose of 55 units at bedtime

• Carb ratio is 1:5 with a correction factor of 25.

Diet History • Upon examination, pt presents with poor glucose control,

though A1c is slightly better than before

• Pt and mother report a “typical” day:• Breakfast is usually skipped because pt sleeps in late • Pt often forgets to pack a lunch so will grab something “on-the-go”

for lunch (i.e.: granola bar) • Skipped meals tend to lead to extreme hunger later on, as pt

reports excessive food intake throughout the evening hours while grazing late at night

• Claims to carbohydrate count at every meal

Labs

Lab Normal Reference Range (no diabetes)

Target (diabetes)

1/21/15

Hemoglobin A1c <5.7% <7% 13.8%

14-day Average Blood Sugars

Less than 140 mg/dL(7.8 mmol/L)

150 Breakfast 303, lunch 397, dinner 287, bedtime 310

Blood Pressure Less than 120/80 mmHg

<120/80 125/75 mmHg

Medications Medicine Function Possible-Nutrition Related Side

Effect

Novolog (insulin aspart) Fast-acting mealtime insulin Hypoglycemia (excessive hunger, nausea), hyperglycemia (increased thirst, weight loss), hypokalemia (dry mouth, increased thirst)

Lantus (insulin glargine)

 

Long-acting basal insulin Hypoglycemia, hyperglycemia, hypokalemia

Lisinopril ACE inhibitor Abdominal pain, diarrhea, nausea, vomiting, sore throat, loss of appetite

Levothyroxine 

Thyroid hormone replacement Difficulty with swallowing, nausea, swelling of lips, throat, or tongue, diarrhea,  

Lamictal 

Anticonvulsant/ mood stabilizer   Bloody stools, painful mouth sores, sore throat, trouble breathing, loss of appetite, or weight loss, dry mouth  

Weight for Age • Weight: 84.9 kg (187.2 lb)• 95th %ile• Z-score: 1.62

Rate of Weight Change

Date of Measurement Weight Rate of weight change

January 29, 2014 86.8 kg --

February 14, 2014 85.5 kg -1.3 kg

April 16, 2014 88.3 kg +2.8 kg

May 20, 2014 87.0 kg -1.3 kg

July 23, 2014 83.9 kg -3.1 kg

November 22, 2014 84.0 kg +0.1

November 26, 2014 86.3 kg +2.3 kg

January 21, 2015 84.9 kg -1.3 kg

Height for Age • Height: 180 cm (5’9’’ in)• 79 %ile• Z-score= 0.81

BMI for Age • BMI: 26.2 kg/m2• 92%ile • Z-score= 1.40

Source: http://nccd.cdc.gov/dnpabmi/Calculator.aspx?CalculatorType=Metric

PES Statement • NI-5.2.8 Excessive carbohydrate intake related to lack of

willingness/failure to modify carbohydrate intake as evidenced by average blood sugars 303, 397, 387, 310; Hemoglobin A1c 13.8%

Estimated Requirements • Energy needs (kcals/kg): 2,500 Kcals per day (29.4 kcals/kg/day)

• Based on Mifflin St. Jeor (MSJ) using Actual Body Weight (ABW)

• Protein needs (Grams Protein/kg): 72.2 g PRO per day (0.85 grams protein/kg) • Based on DRI for Boys 14-18 years old

• Maintenance fluid needs (mL/day): 2,971.5 - 3396 ml (35-40 ml/kg)• Based on recommendations from Clinical Nutrition Pocket Guide for

Young Active 16-35 yo

Recommendations • Continue carbohydrate counting • Recommend a normal eating schedule

• Pack a breakfast for on-the-go and pack lunch at night• Setting an alarm to take Levothyroxine in AM

• Limit consumption of sugary and carbohydrate-rich foods, especially late at night • Snacking on vegetables during the evening

• Monitor blood sugar checks (4x/day) and insulin injections • Reasonable weight loss goal

• 50-84%ile = 61.9kg (134lb)- 74.3kg (164lb) or • 75-84%ile given ED history = 70 (154lb)- 74.3kg (164lb)

Plan/Goals

1) Use phone and mom as reminders for dinnertime insulin shots

2) Check blood sugar at breakfast, lunch, dinner, and nighttime

3) Eat 3 meals daily

References • American Diabetes Asociation. Medical Management of Type 1 Diabetes. Alexandria, VA, American Diabetes Association, 2008. Web. 22 Jan. 2015.

• Appel, Lawrence J., Michael W. Brands, Njeri Karanja, Patricia J. Elmer, Frank M. Sacs. Dietary Approaches to Prevent and Treat Hypertension: A Scientific Statement From the American Heart Association.

• Barlow, S. E. "Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report." Pediatrics 120.Supplement (2007): S164-192. 22 Jan. 2015.

• "Bipolar Disorder | Anxiety and Depression Association of America, ADAA." ADAA, n.d. Web. 28 Jan. 2015.

• BMI Percentile Calculator for Child and Teen Metric Version. CDC, n.d. Web. 30 Jan. 2015. <http://nccd.cdc.gov/dnpabmi/Calculator.aspx?CalculatorType=Metric>.

• Board, A.D.A.M. Editorial. Graves Disease. U.S. National Library of Medicine, 10 May 2014. Web. 26 Jan. 2015.

• Clinical Nutrition Pocket Guide- MedStar Square Medical Center/ MedStar Harbor Hospital

• Diabetes - type 1 | University of Maryland Medical Center http://umm.edu/health/medical/reports/articles/diabetes-type-1#ixzz3PyIU7HcE

• Glucometer. Google Images Labeled for Re-use: http://pixabay.com/static/uploads/photo/2014/11/11/22/19/nurse-527615_640.jpg

• KDIGO. Chapter 1: Definition and classification of CKD. Kidney Int Suppl 2013; 3:19. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf 26 Jan. 2015.

• Lowry, Adam W., Kushal Y. Bhakta, and Pratip K. Nag. Texas Children's Hospital Handbook of Pediatrics and Neonatology. New York: McGraw-Hill, 2011. Print.

• Mahan, L. Kathleen., Sylvia Escott-Stump, and Janice L. Raymond. Krause's Food & the Nutrition Care Process. St. Louis (Miss.): Saunders, 2012. Print.

• Michigan Diabetes Research and Training Center. Diabetes Research, n.d. Web. 28 Jan. 2015. <http://www.med.umich.edu/borc/cores/ChemCore/hemoa1c.htm>.

 • "Standards of Medical Care in Diabetes--2012." Diabetes Care35.Supplement_1 (2011): S11-63. Web. 22 Jan. 2015.

• Type 1 diabetes. Google Images Labeled for Re-use: http://upload.wikimedia.org/wikipedia/commons/8/8c/Pancreas_insulin_beta_cells.png

• Wu, Patricia, MD, FACE, FRCP. "Thyroid Disease and Diabetes." Thyroid Disease and Diabetes 18.I (2000): n. pag. Thyroid Disease and Diabetes. Web. 28 Jan. 2015.