Jessica Pitzer

Case Study #16

11/18/14

KNH 411

Type 2 Diabetes Mellitus: Pediatric Obesity

Case Questions

I. Understanding the Diagnosis and Pathophysiology

1. What are the risk factors for developing type 2 DM as a child? What do the

current ADA standards of medical care recommend concerning screening at-

risk children?

Researchers don’t fully understand why some children develop type 2 diabetes and others

don’t, even if they have similar risk factors. However, it’s clear that certain factors

increase the risk, including weight, inactivity, family history, and race. Being overweight

is a primary risk factor for type 2 diabetes in children. The more fatty tissue a child has,

the more resistant his or her cells become to insulin. However, weight isn’t the only

factor in developing type 2 diabetes. The less active a child is the greater the risk they

have for type 2 diabetes. Being active helps to maintain a child’s weight, use glucose as

energy, and makes a child’s cells more reactive to insulin, making them less insulin

resistant. Family history plays a huge role in the development of type 2 diabetes. The

risk of type 2 diabetes is significantly increased if a parent or sibling has type 2 diabetes.

But it’s also difficult to tell if this is related to lifestyle, genetics or both. Although race

is an unclear risk factor, children of certain races, especially black, Hispanics, Native

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Americans, Asian Americans and Pacific Islanders are more likely to develop type 2

diabetes. (Mayo Clinic)

The recommendations include screening, diagnostic, and therapeutic actions that

are known or believed to favorably affect health outcomes of patients with diabetes. The

recommendation for testing to detect type 2 diabetes and prediabetes should be

considered in children and adolescents who are overweight and who have two or more

risk factors for diabetes. (American Diabetes Association)

(American Diabetes Association)

2. Evaluate Adane’s medical records. Identify which risk factors most likely

led to the routine screening for DM during her school physical.

There were many red flags and reasons that Adane was screened for DM during her

school physical. The first sign that she needed to be tested was her high BMI and her

high weight. Her BMI was recorded at 36.4 and is off the charts when looking at the

CDC body mass index percentile charts. Even for an adult, a BMI of 30 or higher is

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considered to be obese and at risk for health complications. Her general appearance is

described as “overweight”. Adane’s African American ethnicity also puts her at a higher

risk for developing type 2 diabetes. Both Adane’s mother and her grandmother have type

2 diabetes and her mother had gestational diabetes during pregnancy with Adane.

Adane’s physical findings and lab values also show questionable indications of diabetes.

Her skin was dry along with dry mucous membranes in the throat, which more than likely

make Adane feel very thirsty. And lastly many of the categories in her blood and urine

tests were abnormal. (CDD, Nelms).

3. What are the ADA standard diagnostic criteria for T2DM? Which are

included in Adane’s medical record?

There is set criteria for diagnosing type 2 diabetes. This criteria includes an A1C greater

than or equal to 6.5%, fasting plasma glucose greater than or equal to 126 mg/dL during

an oral glucose tolerance test, or a patient with classic symptoms of hyperglycemia.

Adane’s HbA1c was recorded at 6.9% and this is elevated from the normal level of 3.9-

5.2%. Adane’s glucose was above the normal range and classified her for type 2 diabetes

because they were above 126 on both days. On the day of admission her glucose was 171

mg/dL and on the second day her glucose was 151 mg/dL. She also tested positive for

glucose in her urinalysis.

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(American Diabetes Association)

4. Adane’s physician requested additional testing that included autoantibody

levels and C-peptide. Explain why these tests were done and what the results

indicate for Adane.

Diabetes- related autoantibody testing is primarily used to help distinguish

autoimmune type 1 diabetes from diabetes due to other causes. Determining which type

of diabetes is present allows for early treatment with the most appropriate therapy to

avoid complications from the disease. This test may be ordered when a person is newly

diagnosed with diabetes and the doctor want to distinguish between type 1 and type 2

diabetes. They also may be used when the diagnosis is unclear in diabetics who have

been diagnosed as type 2 but who have great difficulty in controlling their glucose levels

with treatments. From Adane’s EAG levels it is known that it is at an elevated level of

151. (Lab Tests Online)

A C-peptide test is not ordered to help diagnose diabetes, but when a person has been

newly diagnosed with diabetes, like Adane, it may be ordered by itself or along with an

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insulin level to help determine how much insulin a person’s pancreas is still producing.

Type 2 diabetes, the body is resistant to the effect of insulin and it compensates by

producing and releasing more insulin, which can also lead to beta cell damage. Type 2

diabetes usually is treated with oral drugs to stimulate their body to make more insulin

and/or to cause their cells to be more sensitive to the insulin that is already being made.

Eventually, because of the beta cell damage, type 2 diabetes may make very little insulin

and require injects. Any insulin that the body does make will be reflected in the C-

peptide level; therefor, the C-peptide test can be used to monitor beta cell activity and

capability over time and to help a doctor determine when to begin insulin treatment. The

C-peptide test measurements can also be used in conjunction with insulin and glucose

levels to help diagnose the cause of documented hypoglycemia and to monitor its

treatment. Symptoms of hypoglycemia may be caused by excessive supplementation of

insulin, alcohol consumption, inherited liver enzyme deficiencies, liver or kidney disease,

or by insulinomas. (Lab Test Online)

5. Insulin resistance is a major component of T2DM. Explain this

pathophysiology. How could you determine whether Adane is exhibiting

insulin resistance?

Individuals with T2DM produce insulin, but their tissues are insulin resistant. This

causes increased need for insulin, so the pancreas increases production. Eventually the

pancreas loses its ability to produce insulin. Although insulin resistance develops many

years before onset of diabetes in individuals with predisposition to T2DM, clinical onset

is correlated with the diminishing pancreatic release of insulin. Insulin resistance is

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caused by a cell-receptor defect resulting in the body’s inability to use insulin. When

cells cannot respond to insulin by trans locating glucose transporters to their outer

membrane, they are unable to take up glucose from the blood for fuel. Since insulin

normally serves to inhibit glycogenolysis and gluconeogenesis when blood glucose is

high, defective insulin secretory response results in excess production of glucose in the

lever. For T2DM to manifest, both defect must be present. At first, postprandial glucose

levels rise due to the inability of the cells to utilize glucose; subsequently, hepatic

gluconeogenesis steps up to compensate for this lack of glucose, resulting in fasting

hyperglycemia. Another condition related to insulin resistance is metabolic syndrome,

which shares some characteristics of T2DM. Central obesity and insulin resistance are

significant contributing features, along with atherosclerotic risk factors including

dyslipidemia and hypertension.

To determine if Adane is exhibiting insulin resistance a number of test could be

preformed. From the box 17.8 in Nelms, some of the criteria for this disease are outlined.

An A1C test, sometimes called hemoglobin A1c can be preformed and this reflects the

average blood glucose level over the past three months. This test is the most reliable test

for prediabetes, but it is not as sensitive as the other tests. A fasting plasma glucose test

measures blood glucose in people who have not eaten anything for at least 8 hours. This

test is most reliable when done in the morning. A blood glucose level between 140 and

19 mg/dl indicates prediabetes and anything above that is considered diabetic. The oral

glucose tolerance test measures blood glucose after people have not eaten for at least 8

hours and 2 hours after they drink a sweet liquid provided by a doctor of laboratory.

(Nelms 499)

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6. Children with T2DM are at high risk for early cardiovascular disease. Why

does this complication occur with diabetes? Evaluate Adane’s lipid profile.

How does this compare to the lipid goals for children with diabetes?

Adane is at a high risk for early onset of cardiovascular disease because of the

Many risk factors of diabetes also correlate with cardiovascular disease. Adane high

BMI is a huge concern for both her diabetes and her heart. Uncontrolled diabetes causes

damage to your body’s blood vessels making them more prone to damage from

atherosclerosis and hypertension. People with diabetes develop atherosclerosis at a

younger age and more severely than people without diabetes. Hypertension is more than

twice as common in people with diabetes as in people with normal blood glucose levels.

Diabetes can damage the blood vessels and over time this puts people with diabetes at far

greater risk of intermittent claudication’s and lower-limb amputation. Adane’s high

cholesterol level also puts her at risk for heart disease. Inactivity, being overweight, poor

diet, and poorly controlled glucose levels are all risk factors for cardiovascular disease

and diabetes. (World Heart Federation)

7. Adane’s grandmother asks about medication for treating high cholesterol as

her husband is on this medicine. What are the recommendations for the use

of statin drugs in children?

High cholesterol is on the rise in the pediatric population. Treatment of

dyslipidemia in children is similar to treatment in adults in that it involves both lifestyle

interventions as well as possible pharmacologic therapy. Cholesterol is an important

factor for growth and development in children. Although statins primarily use the liver

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for their site of action, a few statins are lipophilic in nature and cross the blood brain

barrier. Concerns exist utilizing statins for long-term therapy when it is unknown is the

child’s central nervous system; energy function, growth and sexual hormones could be

altered by statin use at such a young age. As young girls who are placed on statin therapy

will at some point become fertile, it is important for healthcare providers and caregivers

to recognize that birth control should be utilized in females. Statins should be

discontinued at once in any patient who becomes pregnant. But there are findings from

studies of statin use in children with this inherited condition are partly behind the

hypothesis that a child with elevated LDL levels would benefit from cholesterol-lowering

medications based on an analysis of the published evidence by the American Society of

Hospital-Pharmacists. The FDA approved them to be used with dietary modifications to

reduce LDL levels in the bloodstream. (ConsumerReport.org)

8. Adane’s urinalysis is positive for protein. What does this mean and how may

this be related to her diabetes?

Protein in the urine is known as proteinuria and is any excess amount of protein found in

a urine sample. Your kidneys filter waste products from your blood while retaining

components your body needs including protein. However, some diseases and conditions

can allow protein to pass through the filters of your kidneys, causing protein in urine.

Disease when untreated like diabetes can cause great damage to the kidneys because of

the high glucose levels in the blood. (The Global Diabetes Community)

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9. Should Adane and her family be taught about self-monitoring of blood

glucose (SMBG)? If so, what are the standard recommendations for daily

frequency of testing? What would be the appropriate fasting and

postprandial target glucose levels for Adane?

Self-monitoring of blood glucose is very important Adane and her family to learn. This

is recommended for people with diabetes and their health care professionals in order to

achieve a specific level of glycemic control and to prevent hypoglycemia. For patients

with type 2 diabetes, optimal SMBG frequency varies depending on pharmaceutical

regimen and whither patients are in an adjustment phase or at their target for glycemic

control. People with type 2 diabetes who use insulin should perform SMBG at least four

times per week, including at least two fasting and two postprandial values. Additional

measurements at bedtime and before meals can also be obtained. Thoughtful

interpretation of SMBG data will assist patients and health care providers in selecting

appropriate pharmaceutical and lifestyle regimens. According to the American Diabetes

Association an appropriate range for fasting glucose level for Adane would be 70-130

mg/dL. An appropriate postprandial target range for her would be about 180 mg/dL or

less. (Clinical Diabetes, American Diabetes Association)

II. Understanding the Nutrition Therapy

10. Outline the basic principles for Adane’s nutrition therapy to assist in control

of her T2DM.

Weight Management- overweight and obesity are strongly associated with

development of T2DM

o Moderate weight loss improves glycemic control and reduces CVD risks

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o Therapeutic lifestyle changes that include a reduction in energy intake and

increase in physical activity are recommended

Carbohydrates- monitoring total grams of carbohydrate by either the use of

exchanges or carbohydrate counting is strategic in achieving glycemic control

o Low carb diets are not suggested because carbs are a significant source of

energy, water soluble vitamins and minerals, and fiber

Protein- intake of dietary protein exceeding 20% of energy intake may be a risk

factor for development of nephropathy.

o Protein intake for individuals with diabetes who have nephropathy should

not exceed 0.8g/kg or less than 10% of calories.

Fat- fat intake should be the same for people with diabetes as people with

cardiovascular disease history

o Fat should not exceed 25%-35% of total kcals, and saturated fat intake

should not exceed 7%

Fiber- foods containing a mixture of fibers, but those foods have high amounts of

gums, beta-glucans, psyllium, resistant starches, and pectin appear to have the

biggest positive effect on serum glucose levels by slowing the absorption of

glucose from the small intestine

o U.S Dietary Guidelines recommend that men under 50 consume 38 grams

of fiber/day and women consume 25 grams of fiver/day

III. Nutrition Assessment

11. Using the charts on pg. 188-189, assess Adane’s ht/age; wt/age; ht/wt; and

BMI. What is her desirable weight?

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When referencing the growth charts given, Adane is in very high in all of her percentiles.

Adane's ht/age is categorized at 70th percentile; her wt/age is in the 100th percentile; her

ht/wt is at the 100th percentile; and lastly her BMI is also in the 100th percentile for being

9 years old. A desirable weight for Adane would be 75 pounds. This would put her at

about the 75th percentile for height and weight. At the age of 9, she should not lose all the

extra weight that she currently has. The best option is to change her lifestyle in healthier

ways and to grow into her current weight. (Nelms Case Study 187-189)

12. Identify any abnormal laboratory values measured upon her admission.

Explain how they may be related to her newly diagnosed T2DM.

Upon admission some of Adane’s lab values were not at the normal level. Her

cholesterol level should have been below 170mg/dL and it was 210mg/dL. Triglyceride

levels should have been below 150mg/dL and Adane's levels were 210mg/dL. When

testing her HbA1c Adane’s score was recorded at 6.9% and the normal range is 3.9-5.2%.

Her EAG score was elevated at 151. A normal C-peptide level is 0.51-2.72 ng/mL and

Adane’s was recorded at an elevated level of 2.75 ng/mL. In Adane’s urinalysis she

tested positive for protein, glucose, and Prot chk and these should all be negative.

When relating these high levels to Adane’s new diagnosis many things can be

assumed. The high HbA1c, glucose, and C-peptide in the urine analysis depict the insulin

resistance. When diabetes is not properly handled it can lead to kidney malfunction,

which can affect the protein levels in urine. The high triglyceride levels and cholesterol

could be signs of metabolic syndrome that is directly tied with diabetes.

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13. Determine Adane’s energy and protein requirements. Be sure to explain

what standards you used to make these estimations. Should weight loss be a

component of your estimation of energy requirements?

After looking at a few different methods of calculating protein and energy needs, I came

to the conclusion that the TEE equation for girls between the ages of 3-18 years old

would be the most accurate depiction of her needs.

ENERGY NEEDS:

TEE=389−41.2 × age+PA ×15.0 × weight (kg )+701.6 ×height (m)

TEE=389−41.2 ×9+1.0× 15.0× 63.6 (kg )+701.6× 1.32(m)

TEE=¿ 1,898 kcals

EER= 88.5-61.9 x age + PA x (10 x weight kg) + (934 x height meters)+ 20=

88.5-61.9 x 9 + 1.0 x (10 x 63.6kg) + (934x 1.32) + 20=

RDA= 70kcal/kg, 63.6kg x (69kcal-79kcal)=

WHO= 22.5 x wt + 499

22.5 x 63.6kg + 499=

A 1.0 PA factor was used because no activity was logged in her report and there was no

evidence that she is an active child.

PROTEIN NEEDS: A diabetic patients protein needs should never exceed 10% of their

total caloric intake.

Protein Needs=1,898 kcals× 0.1=189 kcals ¿ protein

189 kcals ¿ protein ÷ 4 kcalg

=47 grams of protein

Adane’s should not be losing weight, so it is not considered into her energy and

protein needs. She is at a young age and she is still developing. Cutting calories and

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weight loss may stunt this process. She will grow into her weight as she makes lifestyle

changes to improve the quality of her life.

14. Using Adane’s diet history, assess the approximate number of kilocalories

her intake provided, as well as the energy distribution of calories for protein,

carbohydrate, and fat, using the exchange system. Compare this to the

recommendations that you made in question #10.

Exchange List Analysis of Diet:

Food Calories Carbs Fat Protein

Fruit punch 1,800 0 0 0

Frosted flakes 200 35 1 6

Whole milk 120 12 5 8

Toast with

butter and jam

180 30 7 5

Cookies 400 75 10 1

Cheetos 150 15 10 0

Popsicles 50 0 0 0

4 pieces of

bread

320 60 4 12

Peanut butter 100 0 8 7

Mayo 45 0 5 0

Banana 60 15 0 0

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Pork chops 100 0 8 7

Green Beans 25 5 0 2

Corn Bread 80 15 1 3

Butter 45 0 5 0

Iced tea with

Sugar

150 0 0 0

Pizza Rolls 400 75 40 35

Coke 100 0 0 0

Chips 150 15 10 0

TOTALS 4,475 kcals 352g 114g 86g

FitDay.com Analysis of Diet:

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After calculating Adane’s intake in both fit day and the exchange list, it is very clear that

she is consuming a substantial amount more than she should be. In fit day she consumed

about 5,400kcals total. Adane is consuming 3,502 more calories than she should. She

consumes 146 grams of fat, 973 grams of carbohydrates, and 85 grams of protein from

fitday.com. When analyzing the exchange list she consumed 4,475 calories, 352 grams

of carbohydrates, 114 grams of fat, and 86 grams of protein. Both of these exceed the

0.8g/kg of protein. Fat exceeds 25-35% in both cases.

5,400-1,898= 3,502 kcals extra

Fit Day:

146g fat x 9= 1,314 kcals from fat

973 g carbs x 4= 3,892 kcals from carbs

85 g protein x 4= 340 kcals from protein

Exchange List:

352 g carbs x 4= 1,408 kcals from carbs

114 g fat x 9= 1,026 kcals from fat

86 g protein x 4= 344 kcals from protein

IV. Nutrition Diagnosis

15. Prioritize two nutrition problems and complete the PES statement for each.

1. Excessive energy intake of about 5,000 kcals related to poor diet choices as

evidence by 24-hour food recall.

2. Overweight related to high BMI of 36 as evidence by being in the 100th percentile

for age and BMI.

Excessive fat intake: NI-5.6.2

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Excessive energy intake: NI-1.3

Overweight: NC-3.3

Nutrition Intervention

16. Determine Adane’s initial nutrition therapy prescription using her diet

record from home as a guideline, as well as your assessment of her energy

requirements.

When starting out, especially with Adane being so young, the goals need to be

realistic and attainable. I would start out with reducing her consumption of sugary

high calorie beverages. By just cutting out the kool-aid, iced tea, and coke Adane

could cut out almost 2,000 calories. Next I would recommend that Adane and her

family replace the corn bread and white enriched bread with whole grains. I would

educate them on other cooking methods beside breaded and deep frying foods. I

would request that she replace one snack with a cup of fresh vegetables. And lastly I

would recommend that she do some form of physical activity starting with two days a

week for 30 minutes.

Two of the ideas described above can be incorporated into Adane's life ever week

until she implements them all. Once she has reached these steps in her life. The team

of health care providers can them work together to fine tune her diet and work to

make sure she is staying within the appropriate caloric intake.

17. Outline the initial steps you would use to teach Adane and her family about

nutrition and diabetes. What education materials could you use?

1. Pretest- This will allow me to assess what the family already knows and what I

should specifically focus on

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2. Handouts- Handouts will help them remember everything that I talked about if

they felt overwhelmed and couldn’t remember everything. These can also be

used for future reference when the family is at home, eating out, or at the grocery

store.

3. Technology education- In today’s education a lot of technology sources are used

especially with children. I would show them different apps, computer games, and

computer resources for nutrition education.

4. Plastic food models- By using plastic food models to show portion size, I can

educate the family on what proper portions of protein, carbs, and fat are. This is

especially important for Adane to control her diabetes.

5. Journal- The journal can be done from any of the online resources previously

educated on, or they can use paper and pencil. I would advise them to record

amounts, methods of cooking, and how they felt before and after the meal. We

could then use the food journals to establish goals, review diet, and ways to

implement the healthier lifestyle goal.

6. Summary folder- I would give both Adane and her family folders that they can

put there new resources in along with a sheet of paper they could write there

thoughts and future questions on for me in future meetings.

18. Considering that Adane will not be started on medication, is it necessary to

teach her and her family about hypoglycemia, sick-day rules, and exercise?

It is very important to teach Adane and her family about hypoglycemia, sick-day

rules, and exercise because if her family is uneducated it could lead to other health

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problems. Hypoglycemic symptoms are important clues that you have low blood

glucose. Each person’s reaction to hypoglycemia is different, so it’s important that you

learn your own signs and symptoms when your blood glucose is low. Some of these

signs may include shakiness, anxiety, irritability, confusion, fast heartbeat, dizziness,

hunger, sleepiness, blurred vision, numbness, headaches, weakness, anger, lack of

coordination, seizures, and unconsciousness. Snacks with 15-25 grams of carbohydrates

should always be on hand incase hypoglycemia takes place.

It is important to monitor sick-day rules because often times children will lie to

try to get out of school or important events they don’t particularly want to attend. But

when Adane may actually be sick they need to be ready and be prepared. Before

diabetes, the usual parent prescription for a cold or flue was rest, refreshment and reruns.

After a diabetes diagnosis, tending to a cold also includes managing blood glucose levels

that may be more difficult to control. A sick day note book should be created that

includes, a doctor’s guidelines when to call, diabetes care team daytime and after-hours

phone numbers, copy of your insurance card, sick-day meal plans, list of over-the-counter

medicines that do not interfere with blood glucose or insulin, a record of blood glucose

reading and carb counts of foods eaten, and lastly comics, poems, pictures or anything

else that may help the patient feel better. (American Diabetes Association)

Exercising is one of the best things that a person can do if they have diabetes. It

helps the body burn extra fat, lowers blood pressure, improves blood circulation, helps

your body use insulin and control blood sugar, and tames stress. Adane should start low

with walking and work her way up, as she feels better. If Adane starts to feel any of the

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hypoglycemia symptoms, she should stop exercising immediately and take the

precautions to treat the symptoms.

19. Adane’s mother is worried that none of the children will ever be able to have

birthday cake or other sweet treats. She feels that she cannot offer these to

the other children if Adane cannot have them. What would you tell her?

I would tell Adane and her mother that they do not have to take away all sweet treats

especially for other kids. It is important that Adane’s mother understand her disease and

everything that it entails. Desserts do not have to be permanently removed from the diet;

Adane just has to understand how to compensate with her insulin. It is also very

important to understand what an actual portion size is and that Adane just eat a small

amount of cake instead of a large piece like she normally would.

There are other healthier alternatives to sugary desserts. There are many diabetic

cookbooks that give really to recipes for low glycemic index desserts. Fruit, though it

does contain sugar, is a much better alternative. Many different desserts can be made

with fruit as the base that taste just as sweet as a cake. It is essentially that Adane does

not feel anymore different than she already does because of her situation.

Nutrition Monitoring and Evaluation

20. Write an ADIME note for your initial nutrition assessment.

Assessment-

Anthropometric data= 9 years old, height 52”, Weight 140lb, BMI= 36.4, Temp

98.6, BP 100/59, Pulse 72, African American, African Methodist Episcopal

Biomedical data= glucose of 171 on day one and 151 on day two, Cholesterol

elevated at 210 mg/dL, Triglyceride levels of 175 mg/dL, high HbA1c 6.9%, high

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EAG of 151, C-peptide levels of 2.75, positive protein, positive glucose, positive

prot chk

Clinical- frequent ear infections as infant and toddler, overweight/ obese, mother

and grandmother have type 2 diabetes, grandfather has high cholesterol and

hypertension

Diet history- current intake of about 5,200 kcals, estimated needs calculated at

1,898 kcals, 10-20% should be from protein, 30% from fat (less than 10% of fat

from saturated fat), 50% from carbohydrates

Diagnosis-

Excessive energy intake of about 5,000 kcals related to poor diet choices as

evidence by 24-hour food recall

Excessive fat intake of 146 grams related to poor food choices and healthy

cooking techniques as evidence by 24-hour recall and being overweight.

Overweight related to high BMI of 36 as evidence by being in the 100th percentile

for age and BMI.

Intervention-

Instructed client on a 1,900 calories

Incorporate fruits and vegetables starting with at least twice a day

Increase physical activity to walking at least 10,000 steps a day, gradually

increasing by 2,000 steps per week

Goals- increase fruits and vegetables, increase whole grains, increase lean meat,

decrease sugar sweetened high calorie beverages

Monitory/ Evaluation-

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Food journal with amount, type, food preparation, and feeling before and after

meals

Monitory lab values (test two weeks after first meeting with dietician)

Glucose level log

Physical activity journal- type, duration, and intensity

Weight

Review goals

21. Adane’s grandmother suggests that perhaps Adane should have “stomach

surgery” so that she will lose weight more quickly. What are the

recommendations for pediatric bariatric surgery?

There are many risk factors related with pediatric bariatric surgery. Many people think

that this is the best and easiest way to get a child’s health issues under control and this is

not always the case. When bariatric surgery is preformed there are large risks for mal

absorption. This is a huge problem stunting the growth of a growing young girl. Weight

loss surgery does not replace the long-term need for a healthy diet and regular physical

activity. This is why Adane should try all the new healthier lifestyle changes that the

dietician has recommended for her for at least 6 months to try and see improvement and

avoid surgery. Bariatric surgery should be a last resort option.

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Work Cited

American Diabetes Association. (n.d.). Retrieved November 18, 2014, from

http://care.diabetesjournals.org/content/37/Supplement_1/S14.ful

Clinical Diabetes. (n.d.). Retrieved November 18, 2014, from

http://clinical.diabetesjournals.org/content/20/1/45.full

C-peptide. (n.d.). Retrieved November 18, 2014, from

http://labtestsonline.org/understanding/analytes/c-peptide/tab/test

Defining Overweight and Obesity. (n.d.). CDC Retrieved November 18, 2014, from

http://www.cdc.gov/obesity/adult/defining.htm

Diabetes. (n.d.). World Heart Federation. Retrieved November 18, 2014, from

http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-

factors/diabetes/

Diabetes-related Autoantibodies. (n.d.). Lab Tests Online. Retrieved November 18, 2014,

from http://labtestsonline.org/understanding/analytes/diabetes-auto/tab/test/

Proteinuria (Albuminuria). (n.d.). The Global Diabetes Community. Retrieved November

18, 2014, from http://www.diabetes.co.uk/diabetes-complications/proteinuria.html

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Nelms, M., & Roth, S. (2014). Medical nutrition therapy: A case study approach (4nd

ed.). Belmont, CA: Wadsworth/Thomson Learning.

Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy and

pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.

Should children take statin drugs to lower their cholesterol? (n.d.). Consumer Report.org.

Retrieved November 18, 2014, from

http://www.consumerreports.org/cro/2012/05/should-children-take-statin-drugs-to-lower-

their-cholesterol/index.htm

Type 2 diabetes in children. (n.d.). Mayo Clinic. Retrieved November 18, 2014, from

http://www.mayoclinic.org/diseases-conditions/type-2-diabetes-in-children/basics/risk-

factors/con-20030124

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