Case Study 15
Type 1 Diabetes Mellitus
Mollie 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
Etiology
Genetic Factors
Children 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%.
Ethnicity
Type 1 DM is most prevalent in Caucasians than African-Americans and HispanicAmericans. Chinese people have a lower risk of developing type 1, as do people in
South America, more common in northern climates
Environmental Factors
T 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
Potential T1DM Complications
● 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
Detection
Type 1 and Type 2
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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
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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
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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 Intake
Breakfast
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
Anthropometric Data
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99.6 F temperature
Pulse 100
Resp rate 24
BP 78/100
Height 5’11”
Weight 165 lbs
height: 5’11” = (71 in)(2.54 cm/in)(1m/100cm) = 1.8 m
weight: (165 lbs)(1 lb/2.2kg) = 75 kg
BMI (kg/m^2) = (75 kg)/(1.8m)^2 = 23.1 kg/m^2
Vital Signs
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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
Medical Dx/Treatment #1
[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
Laboratory Results
Laboratory 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 Results
Laboratory 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
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tr
pH (ABGs)
7.35-7.45
7.31
HCO3 (mEq/L)
24-28
22
Medical Dx/Treatment #2
Three months later reevaluated condition...
[Diagnosed with T1DM based on +ICA, GADA, IAA, (-) C-peptide levels]
Medical Orders
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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
Nutrition Diagnosis
1) Altered nutrition-related laboratory values (NC2.2) 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.
Energy & Protein Requirements
ENERGY REQUIREMENTS
REE= 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 kcal
TEE= 1720 x 1.0 = 1720 kcal (resting) to 1720 x 1.4 = 2408 kcal (sedentary)
PROTEIN REQUIREMENTS
Pro = 0.8g/kg
Pro = 0.8(75)= 60g of protein/day
Pro = 60g x 4 kcal = 240 kcal/day
Nutrition Intervention
2400 kcal/day, 4-5 small
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consume less
cholesterol/saturated fat, lower
lipid profiles
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Energy Intake frequent meals
Fat
Protein
60 g/day
70-80 g breakfast + lunch, 85-
Carbohydrate 95 g dinner, and 30 g PM snack
Fiber
increase 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 Levels
A1C <7%
BP < 140/80 mmHg
LDL< 100 mg/dL
TG < 150 mg/dL
HDL> 40 mg/dL
preprandial glucose of 70-130 mg/dL
postprandial glucose of <180 mg/dL
Sample Diabetic Menu
Breakfast
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
*Based on 2000 kcal diet
¾ cups cooked brown rice, 1 cup steamed
spinach, grilled steak with beets &
radicchio, pineapple-raspberry parfait
Blood Glucose Monitoring
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
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
Follow Up Evaluation
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Lab values- blood glucose, ketones, lipids, protein, HbA1c, C-peptide, urinalysis,
micronutrients
Food and exercise journal
Analyze adherence to diet and glycemic response
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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?
Treatment
Prognosis
● More than 60% of patients with T1DM do not experience future
complications
● Serious complications may include
o Blindness
o ESRD - End Stage Renal Disease
o Early death
● Outcomes also depend on the patient’s:
o Education
o Awareness
o Motivation
● Management of blood glucose, hemoglobin A1c, lipids, blood pressure, and
weight greatly affect the outcome of the patient
Resources
Autoantibody 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-ofaction.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