Michelle Koch
MNT 1
12/8/15
Pediatric Type 1 Diabetes Mellitus
1. What are the current thoughts regarding the etiology of type 1 diabetes mellitus (T1DM)?
No one else in Rachel’s family has diabetes – is this usual? Are there any other findings
in her family medical history that would be important to note?
Type 1 Diabetes Mellitus (T1DM) is an idiopathic disease that is characterized by
the circulation of auto-antibodies that destroy β-cell. The etiology of T1DM is currently
unknown, but thought to be a combination of genetics, autoimmune, and environmental
factors.
Though no one in Rachel’s family also has diabetes, her mother and sister both
have autoimmune disorders of hypothyroidism and celiac disease, which could be genetic
predispositions for her T1DM. It would not be unusual for no one in Rachel’s family to
also have diabetes.
2. What are the standard diagnostic criteria for T1DM? Which are found in Rachel’s
medical record?
Type 1 Diabetes Mellitus is diagnosed through the use of at least one of three
tests: A1C, fasting plasma glucose, or 2-hour plasma glucose. Diabetes is determined
through an A1C ≥ 6.5%, Two day FPG ≥ 126 mg/dL, or a 2-hour PG ≥ 200 mg/dL, and
the presence of auto-antibodies that destroy β-cells. In patients with classic symptoms of
hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL can be
used to diagnose diabetes.
Rachel arrived at the hospital with a FBG of 724mg/dL and 683mg/dL when labs
were drawn, a hemoglobin A1C of 14.6%, and the presence of ICA, GADA, and IAA
antibodies. The presence of ketones in Rachel’s urine identifies that her body is not
properly using carbohydrates for energy and is instead breaking down fat for energy.
3. Using the information from Rachel’s medical record, identify the factors that would
allow the physician to distinguish between T1DM and T2DM.
The peak onset of T1DM is 10-12 years of age in girls. Rachel, being 12 years of
age falls into the peak onset category of T1DM. The presence of ICA, GADA, and IAA
antibodies, which promote β-cell destruction, in Rachel’s blood work indicate an
autoimmune association of T1DM.
People with T1DM are often lean and experience excessive thirst, frequent
urination, and weight loss. All of which occur in Rachel’s medical history.
4. Describe the metabolic events that led to Rachel’s symptoms and subsequent admission
to the ER (polyuria, polydipsia, polyphagia, fatigue, and weight loss), integrating the
pathophysiology of T1DM into your discussion.
The lack of glucose in cells leads to the increased breakdown of fat and protein
for energy. The glucose that is not found in the cells in excessive in the blood causing
hyperglycemia. This concentrated blood is then diluted by the body, causing excess water
in the blood that is excreted in the urine.
The excess glucose from the blood is also excreted in the urine, known as
glucosuria. Glucosuria and excess water lead to polyuria, which in turn causes
dehydration, polydipsia (excessive thirst), and fatigue.
The breakdown of protein and fat for energy leads to an increased weight loss and
the production of ketone bodies. Ketones are circulated in the blood causing ketoacidosis
and then excreted in the urine. The increased need for energy leads to polyphagia.
5. Describe the metabolic events that result in the signs and symptoms associated with
DKA. Was Rachel in this state when she was admitted? What precipitating factors may
lead to DKA?
Diabetic ketoacidosis (DKA) is the result of inadequate insulin for glucose use.
As a result, the body relies on fat for energy and ketones are formed. Acidosis results
from the increased production and decreased use of acetoacetic acid and 3-βhydroxybutyric acid from fatty acids.
DKA is characterized by elevated blood glucose levels (greater than 250mg/dL
but less than 600mg/dL) and ketones in the urine. Symptoms include polyuria,
polydipsia, hyperventilation, dehydration, the fruity odor of ketone, and fatigue.
Rachel was suffering from DKA when she was admitted to the hospital. Her
inability to breakdown and use glucose properly forced her body to rely on fat for energy
and causing hyperglycemia. The breakdown of fat lead to ketones in the urine, her
increased thirst and increased urinations. The lack of treatment for her DKA lead to
Rachel fainting.
Rachel’s recent strep throat infection could have been a precipitating factor for
DKA. Her increased need for energy in order to heal her body would have brought an
increased breakdown of fat, flooding the kidneys with ketone bodies.
6. Rachel will be started on a combination of Apidra prior to meals and snacks with glargine
given in the a.m. and p.m. Describe the onset, peak, and duration for each of these types
of insulin. Her discharge dosages are as follows: 7 u glargine with Apidra prior to each
meal or snack – 1:15 insulin:carbohydrate ratio. Rachel’s parents want to know why she
cannot take oral medications for her diabetes like some of their friends do. What would
you tell them?
Onset
Peak
Duration
Apidra
Less than 15 minutes
1-2 hours
3-5 hours
Glargine
2-4 hours
Peakless
20-24 hours
T1DM may only be treated with insulin injections, T2DM may be treated with
oral insulin. Oral insulin is broken down through metabolism, rendering it unusable.
Rachel, who suffers from T1DM cannot produce insulin on her own due to the
destruction of pancreatic β-cells. For this reason, she is prescribed insulin injections that
will circulate in the blood unchanged.
7. Rachel’s physician explains to Rachel and her parents that Rachel’s insulin dose may
change due to something called a honeymoon phase. Explain what this is and how it
might affect her insulin requirements.
Honeymoon phase is the recovery of hyperglycemia, metabolic acidosis,
ketoacidosis, and endogenous insulin secretion after diagnosis. Insulin requirements can
be decreased for up to a year or longer and metabolic control may be easily reached.
However, the increased need for insulin replacement is inevitable. Once the honeymoon
phase has ended, Rachel will require a larger dose of insulin at meals.
8. How does physical activity affect blood glucose levels? Rachel is a soccer player and
usually plays daily. What recommendations would you make to Rachel to assist with
managing her glucose during exercise and athletics events?
Physical activity improves insulin sensitivity within cells, reduce cardiovascular
risk factors, control weight, and improve well-being in individuals with diabetes. In
patients with T1DM, the glycemic response to exercise varies depending on diabetes
control, plasma glucose, and insulin levels upon the start of exercise.
During physical activity more glucose is needed to provide energy to the muscles.
Hypoglycemia can occur due to insulin-enhanced muscle glucose uptake by the
exercising muscles. It is important that Rachel monitors her blood glucose before, during,
and after exercise. If her blood glucose is low before exercising, I would recommend that
she has a pre-exercise snack so she can raise her blood glucose, and take insulin in order
for her body to use that glucose during soccer. It is important to keep snacks on hand
during practice and games to ensure that her blood glucose levels remain stable. 15 grams
of carbohydrates are required for every 30-60 minutes of intense activity.
9. Rachel’s blood glucose records indicate that her levels have been consistently high when
she wakes up in the morning before breakfast. Describe the dawn phenomenon. Is Rachel
experiencing this? How might it be prevented?
The dawn phenomenon is the increased need for insulin at dawn that causes a
rise in fasting blood glucose. This is common when insulin levels decline between
predawn and dawn or if overnight hepatic glucose output becomes excessive, as in
T2DM.
In order to identify the dawn phenomenon, blood glucose levels are monitored at
bedtime and at 2-3:00 am. It is treated with metformin for patients with T2DM and longacting insulin for patients with T1DM.
Nurses were required to check Rachel’s blood glucose levels hourly throughout
the night. It is noted that her blood glucose levels are consistently high when she wakes
up. For this reason, Rachel is experiencing the dawn phenomenon.
In order to decrease the dawn phenomenon occurring in the morning for Rachel,
apidra should not be administered before or during bed because it peaks in 1-2 hours.
Glargine should be administered before bed to provide a peakless and consistent release
of insulin.
10. The MD ordered a consistent carbohydrate-controlled diet when Rachel begins to eat.
Explain the rationale for monitoring carbohydrate in diabetes nutrition therapy.
Consistency in the amount of carbohydrate eaten at meals improves glycemic
control. The American Diabetes Association states that keeping track of the amount of
carbohydrate intake and setting a limit for the amount of carbohydrates eaten will help
manage blood glucose levels within a desirable range.
Carbohydrate counting is a meal planning technique for managing blood glucose
levels. Carbohydrate counting helps to keep track of how much carbohydrate is being
eaten. By monitoring carbohydrate intake, an individual can determine the amount of
insulin required for that meal.
11. Outline the basic principles for Rachel’s nutrition therapy to assist in control of her
T1DM.
To begin, Rachel’s energy requirements will reflect her weight loss. Initial meal
plans must be based on adequate calories to restore body weight. After approximately 4-6
weeks, caloric requirements will be modified to meet caloric needs that promote growth
and development.
Rachel will need to learn how to monitor her blood glucose and inject insulin.
This should be integrated into her preferred eating and physical activity schedule and
provide consistency in timing and amount of carbohydrate. She needs to learn her insulinto-carbohydrate ratio, what it means, and how to implement it correctly.
Doctors should recheck Rachel’s A1C, lipids, blood pressure, ketones, weight and
growth at every visit. Prior to discharge, Rachel should attend a self-management
educational lecture.
12. Assess Rachel’s ht/age; wt/age; ht/wt; and BMI. What is her desirable weight?
Height
60 in x 2.54
152.4 cm
Weight
82 lb / 2.2
37.3 kg
BMI
37.3 kg / (1.52 m)2
16.1
DBW
Between 5th and 95th percentiles for age
68-134 lb
Rachel’s height is around the 60th percentile. Her weight is around the 30th
percentile. And her BMI is around the 20th percentile. (See growth charts) These put
Rachel at a healthy weight, height, and BMI for age (between 5th and 95th percentiles).
Rachel’s usual body weight of 90 lb falls in the 50th percentile for her age.
Rachel’s usual body weight would be a desirable body weight for her height and age.
13. Identify any abnormal laboratory values measured upon her admission. Explain how they
may be related to her newly diagnosed T1DM.
Lab
Value
High/Low
T1DM Relation
Sodium (mEq/L)
126
Low
Hyperglycemia (osmotic flux), dehydration
Glucose (mg/dL)
683
High
Hyperglycemia, insulin resistance
Phosphate, inorganic (mg/dL)
1.9
Low
Dehydration, hyperglycemia
Osmolality (mmol/kg/H2O)
295.3
High
Dehydration
HbA1C (%)
14.6
High
Hyperglycemia, insulin resistance
C-peptide (ng/mL)
0.10
Low
β-cell destruction
ICA
+
High
Autoimmune response
GADA
+
High
Autoimmune response
IAA
+
High
Autoimmune response
Specific gravity
1.035
High
Dehydration
pH
4.9
Low
Dehydration, ketoacidosis
Protein (mg/dL)
100
High
Increased protein breakdown, kidney failure
Glucose (mg/dL)
+
High
Hyperglycemia, dehydration, kidney failure
Ketones
+
High
Ketoacidosis, Fat breakdown
Prot Chk
+
High
Protein in urine, protein breakdown,
Urinalysis
improper kidney function
14. Determine Rachel’s energy and protein requirements. Be sure to explain what standards
you used to make this estimation.
Energy
135.3 – 30.8 x 12yrs + 1.56 x (10 x 37.3kg + 934 x 1.523m) + 25 =
135.3 – 30.8 x 12yrs + 1.56 x (373 + 1401) + 25 =
135.3 – 369.6 + 2767.44 + 25 = 2558.14
2558 kcal
Protein
.95-1.00g/kg x 37.3kg = 35.435
35-37g protein
EER for a girl age 9-18 within the 5th-85th percentile for BMI was used to asses
nutritional requirements. Rachel plays sports and suffers from an autoimmune disorder.
For these reasons, the physical activity factor of very active was used and a range was
used to estimate her increased protein requirement.
16. Determine Rachel’s initial nutrition prescription using her diet record from home as a
guideline, as well as your assessment of her energy requirements.
Calories
From question 14
2558 kcal
CHO Calories
2558kcal x 45-65%
1151-1663 kcal
CHO grams
1151-1663kcal / 4
287.75-415.75 g CHO
CHO Choices
287.75-415.75g / 15
19-28 CHO Choices per day
Rachel can enjoy 19-28 carbohydrate choices per day. Because she only eats three
meals a day, approximately 2 snacks, and is allowed a free carbohydrate choice with
soccer, she is free to enjoy 5-6 carbohydrate choices at each meal, and 3-4 carbohydrate
choices at snacks.
Rachel’s CHO Prescription:
C
P
F
Kcal
12 Starches
180
0-36
0-12
960
3 Reduced Fat Milk
36
24
15
360
75-90
-
-
300-360
30
12
-
150
5-6 Lean Meat
-
35-42
0-18
275-330
4 Fat
-
-
20
180
321-336g
71-114g
35-65g
=2225-2340kcal
1344kcal
456kcal
585kcal
=2385kcal
56%
19%
25%
5-6 Fruit
6 Vegetables
Total Grams
Sample Menu (Based on Rachel’s History)
Breakfast
Snack
3 Starches – 2 Pop
1 Starch + 1 Milk –
3 Starches – 2
3 Starches – 2
3 Starches – 1-1 ½
Tart
1 yogurt
slices bread, 2 oz
granola bars
cup rice
1-2 Milk – 1-2 cups 2 Fruit – 1 apple, 1
oven fries
1 Fruit – 1 cup
3 Vegetables –
1 Fruit – 1 banana
1 Fruit – 1 peach
raspberries
approximately 2
cup strawberries
Lunch
Snack/Soccer
Dinner
2-3 Vegetables – 1-
cups tomato and
2 cups carrots
broccoli salad
2 Meat – 1 oz
4 Meat – 4 oz
turkey, 1 oz cheese
chicken or fish
2 Fat – 2 tbsp
2 Fat – 2 tbsp
dressing
dressing
17. What is an insulin:CHO ratio (ICR)? Rachel’s physician ordered her ICR to start at 1:15.
If her usual breakfast is 2 Pop-Tarts and 8 oz skim milk, how much Apidra should she
take to cover the carbohydrate in this meal?
An insulin-to-carbohydrate ratio is the adjustment of mealtime insulin doses to
match carbohydrate intake.
According to Kellogg’s, 2 Pop-Tarts are 5 carbohydrate exchanges, with 75 grams
of carbohydrates. 1 cup of skim milk is one carbohydrate exchange with 12 grams of
carbohydrates. Total, Rachel consumes 87 grams of carbohydrate.
1 / 15 = x / 87 = 87g / 15 = 5.8
Rachel requires 5 ½ to 6 units of Apidra for her breakfast.
18. Dr. Cho set Rachel’s fasting blood glucose goal at 90-180 mg/dL. If her total daily
insulin dose is 33 u and her fasting a.m. blood glucose is 240 mg/dL, what would her
correction dose be?
1700 / 33 = 51.5
240 – 52 = 188
Correction factor is determined using the “1700 rule.” One unit of insulin should
lower Rachel’s blood glucose by 52 mg/dL. One unit brings Rachel’s blood glucose level
just above goal range. Her correction dose would be 1-2 units. With two units, Rachel’s
blood glucose would be around 137 mg/dL.
20. When Rachel comes back to the clinic, she brings the following food and blood glucose
record with her.
a. Determine the amount of carbohydrates she is consuming at each meal.
b. Determine whether she is taking adequate amounts of Apidra for each meal
according to her record.
c. Calculate a correction dose for her to use.
Time
Diet
Grams
Exercise
BG (mg/dL)
Insulin Taken
Adequate?
CHO
7:30 am
Insulin
Correction
2 Pop-Tarts
75
(Pre) 150
5 u Apidra
1 banana
+15
8.27
16 oz skim milk with
+24
8-8.5 u
Ovaltine (2 tbsp)
+10
No
124 / 15 =
124
12 noon
2 slices pepperoni
60
pizza
(based on
2 chocoalte chip
frozen
cookies
pizza)
Water
+15
75
(Pre) 180
6 u Apidra
Too many
5u
2 p.m
Granola bar
22.5
PE class –
No
1.5 u
(Pre) 110
No
2u
(Pre) 140
No
2u
No
114 / 15 =
30 minutes
4:30 pm
5-6:30 pm
Apple
15
6 saltines
+15
2 tbsp peanut butter
30
16 oz Gatorade
30
Soccer
practice –
1.5 hours
6:30 pm
Chicken and broccoli
(Pre) 80
5 u Apidra
stir-fry
7.6
(1 c fried rice, 2 oz
45
chicken, ½ c broccoli)
+15
Egg roll – 1
+30
2 c skim milk
+24
7.5-8 u
114
8:30 pm
2c ice cream
2 tbsp peanuts
10:30 pm
Bed
60
(Pre) 150
4 u Apidra
Yes
4u