Yajie Zhang
KNH 411
Oct. 29, 2012
Case 22
Type 1 Diabetes Mellitus
i.
Understanding the Diesease and Pathophysiology
1. Define insulin. Describe its major functions within normal metabolism.
Insulin is a hormone produced by the β cells of the Islets of Langerhans in
the pancreas to regulate blood glucose; it promotes uptake, utilization, and storage
of nutrients (472). The major functions of insulin within normal metabolism are
regulating glucose metabolism, stimulating lipogenesis, diminishing lipolysis, and
increasing amino acid transport into cells (473).
2. What are the current opinions regarding the etiology of type 1 diabetes
mellitus (DM)?
One current opinion regarding the etiology of type 1 diabetes mellitus is that
it results from a cellular-medicated autoimmune destruction of β-cells of the
pancreas. Also, multiple genetic predispositions and unidentified environmental
factors appear to contribute to T1DM. Moreover, research has identified the
coxsackie virus, cow’s milk proteins, and rubella as potential triggers (482-483).
3. What genes have been identified that indicate susceptibility to type 1 diabetes
mellitus?
 IDDM2: the insulin gene
 HLA-DR/DQ: encode immune response proteins
 CTLA4: plays a regulatory role in immune response (“Genetics of
Diabetes”)
4. After examining Susan’s medical history, can you identify any risk factors
for type 1 DM?
The main risk factor for Susan to develop T1DM is that her grandmother on
her mother’s side had diabetes so that she has a chance of carrying the gene of
DM.
5. What are the established diagnostic criteria for type 1 DM? How can the
physicians distinguish between type 1 and type 2 DM?
 Established diagnostic criteria for T1DM:
 Symptoms of diabetes plus casual plasma glucose concentration
≥ 200 mg/dL (11.1 mmol/L) in addition to certain symptoms
(unexplained weight loss, polydipsia, polyuria), OR
 Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L) (483)
 Distinguishes between T1 and T2 DM:
 T1: complete lack of insulin, beta cells cannot produce insulin the
pancreas
 T2: insufficient amount of insulin produced by beta cells, or weaker
ability of the insulin to regulate glucose level
6. Describe the metabolic events that led to Susan’s symptoms (polyuria,
polydipsia, polyphagia, weight loss, and fatigue) and integrate these with the
pathophysiology of the disease.
 Susan’s insulin deficiency is caused by increase hepatic glucose output,
decreased glucose uptake by cells, deceased triglyceride synthesis, increased
lipolysis, decreased amino acid uptake by cells, and increased protein
degradation.
 The increase hepatic glucose output and decreased glucose uptake by cells,
caused hyperglycemia. The hyperglycemia caused glycosuria, which caused
osmotic diuresis causing her symptom of polyuria. The polyuria caused
dehydration, which caused her next symptom of polydipsia.
 Decreased triglyceride synthesis and increased lipolysis caused increased
blood fatty acids. This caused the body to use fat as an alternative energy
source, which produce ketones, and caused her symptoms of fatigue,
polydipsia, polyuria, and polyphagia.
 Decreased amino acid uptake by cells and increased protein degradation
cause the increased blood amino acids. Increased blood amino acids increased
the activity of gluconeogenesis, which caused an aggravation of
hyperglycemia. This leads back to all the symptoms caused by hyperglycemia.
Increased protein degradation also caused muscle wasting which lead to her
weight loss (483).
7. List the microvascular and neurologic complications associated with type 1
diabetes.
 Microvascular complications

Retinopathy

Nephropathy
 Neurological complications

Peripheral neuropathy

Cardiovascular autonomic neuropathy

Genitourinary autonomic neuropathy

Gastro paresis autonomic neuropathy (487)
8. When Susan’s blood glucose level is tested at 2 AM, she is hypoglycemic. In
addition, her plasma ketones are elevated. When she is tested early in the
morning before breakfast, she is hyperglycemic. Describe the dawn
phenomenon. Is Susan likely to be experiencing this? How might this be
prevented?
The dawn phenomenon is hyperglycemia that occurs early in the morning
between 4 and 8 am, most likely due to increased glucose production in the liver
after fasting overnight. Since Susan is hyperglycemic early in the morning before
eating anything, she might experience the dawn phenomenon. Conventional
therapies can be used to control dawn phenomenon. Option one would be that
short- or rapid-acting insulin mixed with intermediate-acting insulins given before
breakfast and before evening meal. In the other way, combine short- and
intermediate-acting insulins before breakfast, short-acting insulin before evening
meals, and intermediate-acting insulin at bedtime (487-489).
9. What precipitating factors may lead to the complication of diabetic
ketoacidosis? List these factors and describe the metabolic events that result
in the signs and symptoms associated with DKA.
Factors: illness, infection, emotional stress, and omission of insulin.
When adequate insulin is not available, glucose production via gluconeogenesis
and lipolysis is stimulated by counter-regulatory hormones in an effort to avoid
starvation. One of the by-products of lipolysis is the generation of ketones. As
glucose and ketones accumulate in the bloodstream, osmotic diuresis occurs,
resulting in dehydration and electrolyte imbalances. As fluid is lost, the blood
becomes concentrated, resulting in hyperglycemia (496).
ii.
Nutrition Assessment
A. Evaluation of Weight/Body Composition
10. Determine Susan’s stature for age and weight for age percentiles.
 Stature for age: 23th percentile
 Weight for age: 17th percentile
(Center for Disease Control)
11. Interpret these values using the appropriate growth chart.
Both of Susan’s values are above 5th and below 95th, which indicates that Susan is
in a normal and healthy condition.
B. Calculation of Nutrient Requirements
12. Estimate Susan’s daily energy and protein needs. Be sure to consider Susan’s age.
Ht = 5 feet 2 inch = 157 cm
Age = 15
Wt = 100lb = 45.5 kg
PAL = 1.9 (in volleyball team)
REE (Harris Benedict Method) = 655 + (9.56 x 45.5) + (1.85 x 157) – (4.68 x 15)
= 1310.23 kcal
TEE = REE x PAL = 1310.23 kcal x 1.9 = 2489. 44 kcal
EER for Female (9-18) = 135.3-30.8 x age (15) + PA (1.56) x (10.0 x wt-45.5 +
934 x ht-1.57) +25 = 2695 kcal
20% calories from protein = 20% x 2695 kcal = 539 kcal
Gram of protein needs = 539 kcal / (4kcal/gram) = 134.8 g
13. What would the clinician monitor in order to determine whether or not the
prescribed energy level is adequate?
The clinician would monitor Susan’s weight to determine whether or not the
prescribed energy level is adequate. Since she has lost weight the first goal will be
to gain back what she has lost in order to get her to a healthy weight, then the
clinician will monitor this weight to make sure she does not lose or gain too much
weight.
C. Intake Domain
14. Using a computer dietary analysis program or food composition table,
calculate the kcalories, protein, fat (saturated, polyunsaturated, and
monounsaturated), CHO, fiber, and cholesterol content of Susan’s typical
diet.
(FitDay.com)
 Total Kcal: 4,003
 Kcal from protein: 491 (124.2 g)
 Kcal from fat: 1,317 (148.7 g)
- Saturated: 531 (59.4 g)
- Polyunsaturated: 260 (29.6 g)
- Monounsaturated: 417 (47.2 g)
 Kcal from CHO: 2,247 (564.7 g)
 Fiber: 28.4 g
 Cholesterol: 393 mg
15. What dietary assessment tools can Susan use to coordinate her eating
patterns with her insulin and physical activity?
a. Susan could do a self-monitoring of blood glucose (SMBG) which indicates
a person’s blood glucose the very moment the measurement is taken. This
test includes a drop of blood obtained via a finger prick that is applied to a
chemically treated reagent strip (493).
b. A continuous glucose monitoring devise could be placed under the skin and
would allow for constant reading of blood glucose levels every five minutes.
This is not meant to replace SMBG but to provide a more detailed picture of
blood glucose fluctuations (494).
c. Susan can also test for ketones in her urine which should be done regularly
during periods of illness or stressful situations when glucose levels are likely
to be elevated (495).
16. Dietitians must obtain and use information from all components of a
nutrition assessment to develop appropriate interventions and goals that are
achievable for the patient. This assessment is ongoing and continuously
modified and updated throughout the nutrition therapy process. For each of
the following components of an initial nutrition assessment, list at least three
assessments you would perform for each component:
Component
Clinical data
Nutrition history
Weight history
Assessment You Would Perform
- Lipid assessment: total cholesterol,
HDL, LDL, & TG
- Renal assessment: BUN, creatine,
creatine clearance, spot urinalysis for
albumin: creatine ratio, & GFR
- Hematological assessment: hemoglobin,
hematocrit, MCV, MCHC, MCH, &
TIBC
- Nausea, vomiting
- Food allergies, preferences, or
intolerances
- Ethnic, cultural and religious influences
- Highest adolescent weight
- Usual body weight
- Recent weight changes
Physical history
Monitoring
Psychosocial/economic
Knowledge and skills level
Expectations and readiness to change
- Determine activity type
- Determine activity frequency
- Consider the length of the activity
- Blood sugar
- Weight
- Blood pressure
- Health insurance
- Ensure parents are able to afford
medical care for their child
- Learn if Susan has any friends with
diabetes to help her cope
- Check what previous nutrition
education she has received
- Check how comfortable she is with
sticking herself
- Check knowledge gained after session
with the RD
- Willingness to learn about disease state
- Cooperation with clinical team
- Check labs on a regular basis to ensure
she is taking her insulin shots
(491)
D. Clinical Domain
17. Does Susan have any laboratory results that support her diagnosis?
Yes, her Prealbumin was 40 mg/dL when admitted and then dropped to 39
mg/dL; this is high since the normal range is between 16-35 mg/dL. Her
osmolality was 304 mmol/kg/H2O when admitted and now 297 mmol/kg/H2O
which is high because normal ranges are between 285-295 mmol/kg/H2O. Her
glucose levels are also high since the normal ranges are between 70-110 mg/dL
and when admitted she was at 250mg/dL and now is at 120 mg/dL. Finally, her
HbA1C was 7.95% when admitted and it should be between 3.9-5.2%.
18. Why did Dr. Green order a lipid profile?
To check Susan’s cholesterol, triglyceride, HDL and LDL levels
19. Evaluate Susan’s laboratory values:
Chemistry
Osmolality
mmol/kg/H2O
Normal Value
Susan’s Value
285-295
Admit 304
d/c 297
Glucose mg/dL 70-110
Admit 250
d/c 120
BUN mg/dL
8-18
Admit 20
d/c 18
HbA1c %
3.9-5.2
Admit 7.95
Reason for
Abnormality
High levels of
glucose due to
dehydration
Glucose is not
being absorbed
into the cells
from the blood
stream because
she is not
producing insulin
Excessive protein
breakdown and
impaired kidney
function
Nutritional
Implications
Suggests a fluid
imbalance.
Patient needs
proper amounts
of carbohydrates
and added
insulin.
CHO-consistent
meal plan to control
glucose levels with
correct amount of
insulin
Due to
dehydration from
excessive
urination. Proper
intake of CHO
and insulin
needed to correct
Long-term
High blood
glucose in blood
glucose levels
stream is elevated over several
to about 200
months. Proper
mg/dL
intake of CHO
and insulin
needed to control
blood glucose level
(494)
20. Compare the pharmacological differences in insulins:
Type of
Insulins
Lispro
Aspart
Glulisine
NPH
Glargine
Detemir
70/30 premix
Brand Name
Humalog
Novolog
Apidra
Isophane
Lantus
Levemir
Humulin
Onset of
Action
5 – 15 min
5 – 15 min
5 – 15 min
2 – 4 hr
2 – 4 hr
2 – 4 hr
30 – 60 min
Peak of
Action
30 – 90
30 – 90
30 – 90
4 – 10
Peakless
6 – 14
Dual
Duration of
Action
3–5
3–5
3–5
10 – 16
20 – 24
16 – 20
10 – 16
50/50 premix
60/40 premix
(488)
Humulin
Novolin
30 – 60 min
30 – 60 min
Dual
2–8
10 – 16
18 – 24
21. Once Susan’s blood glucose levels were under control, Dr. Green prescribed
the following insulin regimen: 24 units of glargine in PM with the other 24
units as lispro divided between meals and snacks. How did Dr. Green arrive
at this dosage?
As diagnosed, Susan has T1DM that she needs to receive a daily dose of
insulin that is 0.6 units per kilogram of her actual body weight.
0.6 units/kg actual body wt
45.45 x 0.6 = 27.3
So, with concerns of other factor, Dr. Green slightly adjusted the dose from 27
units to 24 units for Susan.
E.
Behavioral-Environmental Domain
22. Identify at least three specific potential nutrition problems within this
domain that will need to be addressed for Susan and her family.
 Food- and nutrition-related knowledge deficit (NB-1.1)
 Not ready for diet/lifestyle change (NB-1.3)
 Undesirable food choices (NB-1.7)
23. Just before Susan is discharged, her mother asks you, “My friend who owns
a health food store told me that Susan should use stevia instead of artificial
sweeteners or sugar. What do you think?” what will you tell Susan and her
mother?
Though there had been some debates on this topic, stevia is now generally
recognized as safe by the U.S. Food and Drug Administration (FDA). This means
this product is proved to sweeten food items or beverages as artificial sweeteners
or sugar. Truvia (stevia-based sweetener) is a no-calorie sweetener and will not
have an effect on your blood glucose levels. This can be useful for people who
have diabetes. When used in excessive amounts, the carbs and calories in Truvia
can add up quickly. As with anything, do not go overboard when you use it. It is
new on the market, so hopefully more research will be available in the future
about its effects on blood glucose in people with diabetes. (ADA)
24. Select two high-priority nutrition problems and complete the PES statement
for each.
 Excessive energy intake related to high calorie intake as evidence by daily
calorie intake 60% in excess of estimated needs
 Involuntary weight loss related to impaired nutrient utilization as evidence by
lab results of 304 mmol/kg/H2O osmolality level, 250 mg/dL glucose level,
20 mg/dL BUN level and 7.95% HbA1c.
25. For each of the PES statements that you have written, establish an ideal goal
(based on the signs and symptoms) and an appropriate intervention (based
on the etiology).
Goals:
 Average daily caloric intake will be no more than 110% of estimated needs
about 2700 kcal, a reduction of about 1300 kcal/day.
 Blood glucose levels will be controlled as HbA1c below 7%, osmolality levels
between 285-295 mg/dL, glucose levels between 70-110 mg/dL, and BUN
levels between 8-18 mg/dL.
Interventions:
 Though the client is losing weight, she still needs to follow the EER to avoid
excessive energy intake which might affect her blood glucose level. Instruct
client on 2700 kcal diet and educate client with basic T1DM knowledge and
better food choices knowledge
 Educate client how to achieve glycemic control and monitor glucose levels;
how to self-manage insulin administration; how to count carbohydrates and
follow a CHO-consistent meal plan.
26. Does the current diet order meet Susan’s overall nutritional needs? If yes,
explain why it is appropriate. If no, what would you recommend? Justify
your answer.
No, I do not believe this diet order meets her nutritional needs. She should
be getting 15-20% of her kcal from protein which if she was following a 2695
kcal diet recommended here she should be getting anywhere from 101-135 g of
protein a day. Her carbohydrate recommendations will be calculated
specifically to her based on her eating habit, blood glucose goals, and lipid
goals but at least 130 g/day are recommended. Her total fat will be the same as
someone without diabetes which would mean that 30% of her kcal should come
from fat. This would mean she should get 91 g/day from fat (491-492).
iv.
Nutrition Monitoring and Evaluation
27. Susan is discharged Friday morning. She and her family have received
information on insulin administration, SMBG, urine ketones, recordkeeping,
exercise, signs, symptoms, and Tx of hypo-/hyperglycemia, meal planning (CHO
counting), and contraception. Susan and her parents verbalize understanding of
the instructions and have no further questions at this time. They are instructed to
return in 2 weeks for appointments with the outpatient dietitian and DCE. When
you come in to work Monday morning, you see that Susan was admitted through
the ER Saturday night with a BG of 50 mg/dL you see her when you make rounds
and review her chart. During an interview, Susan tells you she was invited to a
party Saturday night after her discharge on Friday. She tested her blood glucose
before going to the party, and it measured 95 mg/dL. She took 2 units of insulin
and knew she needed to have a snack that contained approximately 15 grams of
CHO, so she drank one beer when she arrived at the party. She remembers getting
lightheaded and then woke up in the ER. What happened to Susan
physiologically?
Susan went into a severe fasting hypoglycemic state. She took her insulin which
caused her blood glucose levels to drop because she did not consume any carbohydrates
to keep her blood glucose levels in check. When blood glucose levels fall too low,
glucagon releases stored hepatic glucose to raise blood glucose levels. Epinephrine is also
releases, causing the symptoms of weakness, fatigue, sweating, and tachycardia. (507)
28. What kind of educational information will you give her before this
discharge? Keep in mind that she is underage for legal consumption of
alcohol.
I would like to tell her the risks of alcohol in general and that it is illegal at her
age. I will also explain to her that alcohol can produce hypoglycemia in a fasting
state because the gluconeogenesis is blocked that it cannot be converted to
glucose. I may tell her that it also interferes with counter regulatory responses and
should be consumed with food. Insulin is not required when drinking alcohol
unless it is mixed with other carbohydrates such as a mixed shot. I might also tell
her that if her glucose is in good control, alcohol in moderation is ok. But since
she is underage, I would strongly advise her not to drink at all. At last, I would go
over her meal plan to make sure she understands what she needs to be eating and
what she’d better not to eat.
Reference:
Nelms, M., Sucher, K, P., Lacey, K., Roth, S. L. (2011). Nutrition Therapy &
Pathophysiology. (2 ed.). Belmont, CA: Wadsworth, Cengage Learning.
Genetics of Diabetes. (2012, May 13). Retrieved from http://www.diabetes.org/diabetesbasics/geneticcs-of-diabetes.html
Center for Disease Control. (2011, Sept. 22). Retrieved from
http://www.cdc.gov/growthcharts/data/set1clinical/Cj41cs022c.pdf
ADA. (2012, Mar. 24). Retrieved from http://www.diabetes.org/living-withdiabetes/treatment-and-care/ask-the-expert/ask-thedietitian/archives/index.jsp?page=6#is-the-sweetener-truvia-safe.html