Caitlin Mazurek
KNH 411
11/3/11
Case 22: Type 1 Diabetes Mellitus
1. Define insulin. Describe its major functions within normal metabolism.
Insulin is a hormone produced by the Beta cells of the Islets of Langerhans in the
pancreas to regulate blood glucose and it promotes uptake of glucose into muscle and
cells, utilization, and storage of nutrients. Insulin is an anabolic hormone as it controls
the metabolic fate of carbohydrate, protein and lipid. pg 472, 478
2. What are the current opinions regarding the etiology of type 1 diabetes mellitus?
Diabetes mellitus, by far the most common of all endocrine disorders, is one of the
foremost public health concerns confronting the world today. Over 23 million
individuals or 8% of the US population have diabetes. However, nearly one fourth of
these people are unaware of their disease. Immune-mediated type 1 diabetes mellitus
results from a cellular-mediated autoimmune destruction of B-cells of the pancreas. pg
482
3. What genes have been identified that indicate susceptibility to type 1 diabetes mellitus?
Type 1 diabetes can develop in people who have a particular human leukocyte antigen
or HLA complex. The antigens function is to trigger an immune response in the body.
The genetic marker for type 1 diabetes is on chromosome 6. There are several HLA
complexes associated with type 1 diabetes, and if one or more is present there is a
higher risk of developing diabetes. (www.endocrineweb.com)
4. After examining Susan’s medical history, can you identify any risk factors for type 1
DM?
There are few risk factors for type 1 diabetes mellitus, however Susan does have family
history of diabetes by her maternal grandmother. Her ethnicity is Asian American and
that actually puts her at a lower risk for developing type 1 diabetes.
5. What are the established diagnostic criteria for type 1 DM? How can the physicians
distinguish between type 1 and type 2 DM?
There are three ways to diagnose diabetes. Use of glycosylated hemoglobin or A1C is
now used to diagnose type 2 diabetes. Type 1 diabetes can be made on the basis of a
casual plasma glucose greater than or equal to 200 mg/dL in addition to certain
symptoms such as unexplained weight loss, polydipsia, polyruia, polyphagia or having a
fasting plasma glucose greater than or equal to 126 mg/dL. Another way to diagnose
DM is through oral glucose tolerance tests. These are rarely needed to diagnose,
however, due to the sudden onset of symptoms accompanied by hyperglycemia. Pg. 483
6. Describe the metabolic events that led to Susan’s symptoms (polyuria, poydipsia,
polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of
the disease.
These are all symptoms that are involved in patients that have untreated diabetes. They
occur when the blood glucose levels rise fast and the insulin levels drop, these
symptoms are caused. When glucose can not enter the cells, plasma glucose levels rise
and cells starve. There fore excess glucose is lost in the urine because the kidneys can
filter onlys o much glucose from the blood. Loss of the fluid increases thirst and leads to
polydipisa.
7. List the microvascular and neurologic complications associated with type 1 diabetes.
The microvascular complications associated with type 1 diabetes include nephropathy
and retinopathy. The neurologic complications associated with type 1 diabetes include
peripheral neuropathy and autonomic neuropathy. Pg. 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 when there is an abnormal increase in blood glucose
between 2 AM and 8 AM. This is due to the natural release of hormones in the night that
in turn increase insulin resistance, or it could be due to the fact that she was given
incorrect amounts of insulin the night before. Since Susan has not been given any
insulin yet, the dawn phenomenon is most likely due to the former. Susan is likely to be
experiencing this. The dawn phenomenon may be prevented by adjusting future insulin
dosage pre bedtime, not eating carbohydrates close to bedtime, or changing type of
insulin all together. Pg. 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.
Ketoacidosis is the acid-base imbalance caused by an increase in concentration of
ketones in the blood. Symptoms of ketoacidosis include nausea and/or vomiting,
stomach pain, fruity breath, heavy breathing, and mental status change. The causes of
ketoacidosis are lack of blood glucose self-monitoring, severe illness or infection,
insulin is omitted, there is a growth spurt resulting in increased insulin needs, or the
insulin is stored inappropriately. Ketoacidosis can lead to a diabetic coma if left
untreated or treated incorrectly. It occurs when the body does not have enough glucose
to use as energy and begins burning fat for energy producing ketones. Pg. 472, 486
10. Determine Susan’s stature for age and weight for age percentiles.
Age: 15 yrs
BMI = 45.5 / (1.57)2 = 18.5 kg/m2
th
Susan is in the 25 percentile for her height, weight, and age based off of the CDC
growth charts. (www.cdc.gov)
11. Interpret these values using the appropriate growth chart.
These values prove that she is currently underweight for her current age in comparison
to the other girls within this age.
12. Estimate Susan’s daily energy and protein needs. Be sure to consider Susan’s age.
Using the Mifflin for females 9-18: EER = 135.3 – 30.8 x age – PAL x (10 x kg + 934 x cm)
+ 25
EER = 135.3 – 30.8 x 15 – 1.31 x (10 x 45.5 + 934 x 157) + 25 = 2219
Therefore her daily energy caloric needs is between 2200 and 2300 kcals/day.
Her protein requirements are 20% of this or divide 2250 by .8 to get 1800 kcals or
(1800/4 kcal/g) 450 grams of protein a day.
13. What would the clinician monitor in order to determine whether or not the prescribed
energy level is adequate?
The clinician would make sure to monitor Susan’s weight, blood glucose, and urine for
ketones. This would let the clinician know how the energy level is as well as how her
body is reacting to therapy.
14. Using a computer dieatary 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.
Susan was eating approximately 4,064 calories a day. Of that 483 kcal or 124 g of it is
protein, 1,360 kcal or 154 g is fat. In the fat category 531 kcal or 60 g is saturated, 280
kcal or 32 g is polyunsaturated and 443 kcal or 50 g is monounsaturated fat. 2,253
calories or 567 g comes from carbohydrates and she does consume about 26 g of fiber
daily. Susan’s total cholesterol intake coming from her usual dietary intake is 285 mg.
15. What dietary assessment tools can Susan use to coordinate her eating patterns with her
insulin and physical activity?
Susan can use many different dietary assessment tools to coordinate her eating
patterns with her insulin and physical activity. Susan can start by writing a food log and
insulin log of everything that she is eating throughout the day. She can also utilize the
carbohydrate counting method so she can keep track of how many units of insulin to
give herself. She will eventually be able to plan out her meals around her physical
activity and carbohydrate counting will become second nature.
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
Assessments You Would Perform
Clinical Data
14. Blood glucose levels
15. Look for ketones in urine sample
16. Temperature
Nutrition History
1. 24-hour dietary recall
2. 7-day dietary recall if possible
3. How food is obtained i.e. self, parents,
schools
Weight History
1. Examine current weight
2. Compare weight to height ratio/
calculate BMI
3. Look at CDC height- weight charts if
under 20
Physical Activity History
1. See what sports or activity is done daily
2. Ask to see what exercise is received
through physical education class in
school if any
3. Compare food intake with physical
activity and see if she is meeting her EER
Monitoring
1. Show how to use the glucose monitor
and how to use the strips, needles
2. Show parents how to use it as well and
the precautionary measures to take at
3.
Psychosocial/economic
1.
2.
3.
Knowledge and skills level
1.
2.
3.
Expectations and readiness to change
1.
2.
3.
home such as having a medical waste
container for the needles
Check blood glucose levels on a set
schedule at least three times daily for the
first few weeks or as often as insurance
will allow
Check insurance history as well as
insurance guidelines on monitor and
strips
Continue to tell the patient how common
type 1 diabetes is and that she is not
alone and can still do all the things she
used to do
Inform them that counseling services are
available if needed and give them
information regarding a psychologist’s
number
Check to see that the family understands
what carbohydrate counting is by asking
questions
Ask Susan to plan out her diet for the
next 2 meals and ask her about how
many carbohydrates it would be
Inform the patient and her family about
different resources that are available to
aid in this process
Ask Susan questions about how she is
feeling
Have goals ready for Susan and her
family
Check in with the family while Susan is in
the hospital and have them come back 2
weeks after she is released
17. Does Susan have any laboratory results that support her diagnosis?
Susan’s lab results show that her glucose levels are at 250 where 70 – 110 is within
normal limits. Anything above 200 is usually resulting in type 1 diabetes. Her A1C is
also abnormally high at 7.95 where 3.9 – 5.2 is normal. This is usually not the indicator
for type 1 as much as it is for type 2 diabetes.
18. Why did Dr. Green order a lipid profile?
Dr. Green ordered a lipid profile, because this would show whether Susan’s body is
using the glucose in her body to suppler her cells with energy or not. The lipid profile
indicates when the body uses up fat tissue stores as energy rather than glucose.
19. Evaluate Susan’s laboratory values:
Chemistry Normal Value Susan’s Value
Prealbumin
16 – 35
40
Reason for
Abnormality
Dietary intake
Osmolality
285 – 295
304
Type 1 Diabetes
Glucose
70 – 110
250
Type 1 Diabetes
BUN
8 – 18
20
Dietary intake
Calcium
9 – 11
9.5
n/a
HbA1C
3.9 – 5.2
7.95
Diabetes Mellitus
Nutritional
Implications
The food that is eaten
is causing her
prealbumin to increase
slightly
Blood glucose levels
are high causing other
levels in the blood to
also be incorrect.
Not getting correct
insulin to take care of
the amount of
carbohydrates that she
is eating
BUN levels increase
with the amount of
protein that is eaten.
Her calcium intake is
sufficient for a female
her age, height and
weight.
The glucose is not
being used
appropriately and
therefore her blood
levels are not within
normal ranges
20. Compare the pharmacological differences in insulins:
Type of Insulin Brand Name Onset of Action Peak of Action
Lispro
Humalog
5 – 15 min
30 – 90 min
Aspart
Novolog
5 – 15 min
30 – 90 min
Glulisine
Apidra
5 – 15 min
30 – 90 min
NPH
Novolin N
2 – 4 hours
4 – 10 hours
Glargine
Lantus
2 – 4 hours
None
Detemir
Levemir
2 – 4 hours
6 – 14 hours
70/30 premix
Humuliin
30 – 60 min
2 – 4 hours (dual)
50/50 premix
Humulin
30 – 60 min
2 – 5 hours (dual)
60/40 premix
Humulin
30 min
2 – 5 hours (dual)
Duration of Action
3 – 5 hours
3 – 5 hours
3 – 5 hours
10 – 16 hours
20 – 24 hours
16 – 20 hours
10 – 16 hours
10 – 16 hours
18 – 24 hours
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?
Dr. Green is using a conventional therapy where there is a split or mixed dose of insulin
used. The lispro is an insulin used to help keep blood glucose levels regulated around
meals and exercise. This is a short- or rapid- acting insulin. Glargine is an intermediateacting insulin taken at bedtime to help control her dawn phenomenon. Dosage is
determined by giving about 0.6 units/kg of actual body weight. Since Susan is 100
pounds this equals 45.5 kg. By taking 45.5 x 0.6 you get 27.3. Rounding this down to 24
allows Susan to exercise and adjust her insulin when needed. Pg. 488
22. Identify at least three specific potential nutrition problems within this domain that will
need to be addressed for Susan and her family.
Susan and her family will need to be taught how to count carbohydrates. They should
also be instructed how to read nutrition labels on all foods and understand that foods
without labels still have nutrition information. Lastly, Susan and her family should also
be addressed about why keeping a food log is so important and how keeping track of
the food that is eaten will help everyone know what is happening as time goes on.
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 artifical sweeteners or sugar.
What do you think?” What will you tell Susan and her mother?
Stevia is an herb native to South America. The leaf contains the sweetness that is said to
be 30 times more sweet than sugar. Since this is a relatively new found product in the
United States, there is still much research being done on stevia. The FDA has not
approved stevia extracts as food additives yet, because of the concerns of the effects on
blood sugar control, kidneys, and the cardiovascular system. At this time, I would not
recommend stevia as it is still being tested. Diabetes management is not necessarily
concerning all of the sugar in the food as much as it is the carbohydrates in the foods.
There are some sugar free foods that still have carbohydrates in them and there fore
would have to be accounted for when taking in insulin. (www.mayoclinic.com)
24. Select two high-priority nutrition problems and complete the PES statement for each.
P: Susan has a very high caloric intake
E: related to her excessive food intake
S: as evidenced by her usual dietary intake presented at the hospital of over 4,000
calories
P: Susan’s inability to count carbohydrates in a meal
E: related to her excessive amount of carbohydrates eaten each meal and snack
S: as evidenced by her usual dietary intake presented at the hospital and the
conversation about carbohydrate counting with herself and her parents.
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).
- In order to lessen the amount of calories that are eaten daily, Susan should start to
eliminate regular soda and either switch to diet or preferably water. The more
specific goal is for the first week lessen the number of sodas down to only 2 cans per
day and then the following week cut out one more can leaving it at only one can of
soda per day. Within a month, the goal is to cut out regular soda all together.
- So that Susan can start to count carbohydrates in each meal, it is important for her
to get nutrition education on the topic of carbohydrates. Susan and her family
should be instructed on how to read nutrition labels as well as learn what foods
have carbohydrates in them such as fruits, dairies, grains and sugary foods.
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.
The current diet order for Susan requires 2400 kcal where 300 g are carbohydrates, 5565 g are protein and 80 g are lipids. As stated from the Mifflin equation earlier, the
amount of calories is approximately correct. This is a little high, but generally okay. 300
g of carbohydrates is half of the total calories per day which is good and the protein is
within normal ranges as well. Lastly, lipids are 30% of the total kcal, which is within the
recommended amount according to the USDA. All in all, the current diet order is correct
for Susan and her health.
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 for the instructions and have no further
questions at this time. They are instructed to return in two weeks for appointments
with the outpatient dietitian and CDE. 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 out the party, and it measured 95 mg/dL. She took 2
units of insulin and knew she needed to have a snack that contained 15 grams 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?
Alcohol consumption when diagnosed with diabetes is a struggle to figure out at the
beginning of a diagnosis. It is seen that drinking alcohol as a diabetic can cause
hypoglycemia because the body is more likely to produce and need more insulin.
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 first give her the alcohol talk and how drinking alcohol is against the law and
she could be cited for underage consumption if she is in the ER again. I would also
inform her that a beer is not a 15 g carbohydrate. When her blood glucose was as low as
95 mg/dL it is important to eat a snack that will bring her blood glucose up quickly such
as drinking a pure fruit juice or eating 15 g of carbohydrate worth of glucose tablets. I
would then follow up with more alcohol consumption do’s and don’ts. I would strongly
discourage her to drink due to her underage, but would also inform her of how drinking
safely can be done such as drinking while eating food or alternating an alcoholic
beverage with a non alcoholic beverage.
References
Nelms, Marcia Nahikian. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA:
Wadsworth, 2011. Print.
Zeller, Patrick. "Type 1 Diabetes." Endocrine Diseases: Thyroid, Parathyroid Adrenal and
Diabetes - EndocrineWeb. Vertical Health LLC, 13 Oct. 2010. Web. 01 Nov. 2011.
<http://www.endocrineweb.com/>.
Zeratsky, Katherine. "Stevia." Mayo Clinic Nutrition and Healthy Eating. Mayo Foundation
for Medical Education and Research, 2 Aug. 2011. Web. 1 Nov. 2011.
<www.mayoclinic.com>.