Upload
ldfrench
View
5.915
Download
3
Embed Size (px)
Citation preview
Case Study #3 Diabetes Mellitus:
Type 1
Lindsey French, Andrea Meiring, Katherine Mykytka, Jessica Oakley
October 30, 2009
Diabetes Mellitus: Type 1Type 1 Diabetes Mellitus results from a deficiency
in insulin production and insulin action causing hyperglycemia.
Immune meditated or Idiopathic
Deficiencies caused by the cellular mediated destruction of pancreatic beta cells
Results in cells being unable to use glucose for energyPlasma glucose levels rise (Hyperglycemia) and cells
starve Glycosuria, Polyuria, Dehydration, Poydipsia, Polyphagia,
Fatigue and Electrolyte Imbalanace
Diabetes Mellitus: Type 1Commonly diagnosed in children and
adolescentsJuvenile Diabetes
Some cases develop later in lifeLatent Autoimmune Diabetes of Adulthood (LADA)
Long term complicationsCardiovascular Disease, Nephropathy, Retinopathy,
Autonomic Neuropathy
The Patient Susan Cheng
Asian American
15 years old, HS student
Active: Starter for the girls’ volleyball teamPractices four nights a week and has games two nights a
week
Lives with her parents, older sister,
and younger brotherAll are in excellent health
Uneventful medical history, no significant illness until recently
Has recent complaints of polydipsia, polyuria, polyphagia, weight loss and fatigue.
Chief Complaint“I’ve been so thirsty and hungry. I haven’t slept
through the night for 2 weeks. I have to get up several times a night to go to the bathroom. It’s a real pain. I’ve also noticed that my clothes are getting loose. My mom and dad think I must be losing weight.”
Physical Exam General Appearance: Tired-appearing adolescent female
Vitals: Temp 98.6 F, BP 124/70 mm Hg, HR 85 bpm, RR 18 bpm
Heart: Regular Rate and rhythm, heart sounds normal
HEENT: Noncontributory
Genitalia: Normal adolescent female
Neurologic: Alert and oriented
Extremities: Noncontributory
Skin: Smooth, warm, and dry; excellent turgor; no edema
Chest/lungs: Lungs are clear
Peripheral vascular: Pulse 4+ bilaterally, warm, no edema
Abdomen: Nontender, no guarding
Chemistry Normal Value Susan’s ValueReason for
AbnormalityNutritional
Implications
Albumin 3.5-5 g/dL 4.2 g/dL Normal -
Total Protein 6-8 g/dL 7.5 g/dL Normal -
Prealbumin 16-35 mg/dL 40 mg/dLDecreased fluid
volume in the bodyDehydration
Sodium 136/145 mEq/L 140 mEq/L Normal -
Potassium 3.5-5.5 mEq/L 4.5 mEq/L Normal -
Chloride 95-105 mEq/L 98 mEq/L Normal -
PO4 2.3-4.7 mg/dL 3.7 mg/dL Normal -
Magnesium 1.8-3 mg/dL 2.1 mg/dL Normal -
Osmolality285-295
mmol/kg/H2O304 H
mmol/kg/H2ODecreased fluid
volume in the bodyWeight loss, dehydration
Glucose 70-110 mg/dL 250 H mg/dL
High blood sugar due to diabetes, in
ability to use glucose due to
insulin deficiency
Hyperglycemia, frequent thirst,
urination, hunger, drop in pH,
ketoacidosis
BUN 8-18 mg/dL 20 HIncreased glucose
levelsDehydration
Creatinine 0.6-1.2 mg/dL 0.9 mg/dL Normal -
Calcium 9-11 mg/dL 9.5 mg/dL Normal -
CHOL 120-199 mg/dL 169 mg/dL Normal -
LDL <130 mg/dL 109 mg/dL Normal -
HbA1C 3.9-5.2% 7.95%Increase in glucose
binding to hemoglobin
Diabetes complications, eye
disease, heart disease, kidney disease, nerve damage, stroke
Admission Diagnosis:Type 1 diabetes
mellitus
Risk Factors and EtiologyMember of high risk ethnic group
Asian American
Stressful lifestyle
Maternal grandmother had diabetes (but not first-degree relative)
EtiologyGenetics
HLA markersEnvironment
High birth weight, viral infection, dietary factors
TreatmentAchieve glycemic control
Evaluate serum lipid levels
Monitor blood glucose levels
Initiate self-management training for patient and parents on insulin administration, nutrition prescription, meal planning, signs/symptoms and Tx oc hypo-/hyperglycemia, monitoring instructions (SBGM, urine ketones, and use of record system), exercise
Baseline visual examination
Contraception education
Insulin
Types of Insulin
Brand Name
Onset of Action
Peak of Action (Hours)
Duration of Action (Hours)
Lispro Humalog 10-20 min 1-3 3-5
Aspart NovoLog 10-20 min 1-3 3-5
Glulisine Apidra 10-20 min 1-3 3-5
NPH Humulin NNovolin N
1-3 hours 8 20
Glargine Lantus 1 hour None 24
Detemir Levemir Same as above
70/30 premix MixtardHumulin 70/30
30-60min Dual 10-16
50/50 premix Humuli 50/50 30-60 min Dual 10-16
60/40 premix Mixtard 40 30 min 2-8 24
•Most patients with T1DM require approximately 0.6 units of insulin per kilogram of body weight per day•Dosage adjusted according to blood glucose levels
Pharmacological Differences:
AnthropometricsHeight: 5’2”
Weight: 100 lbs
BMI:45.45kg/(1.6m)2= 17.75
Susan is at a normal weight for her age and height and falls just below the 25th percentile on the CDC growth chart.
Nutrition HistoryMother describes Susan’s appetite as good.
Meals are somewhat irregular due to Susan’s volleyball practice/game schedule. She is a starter on the girls’ volleyball team,
practices four evenings per week, and participates in approximately two games per week, some of which are away games.
Susan eats lunch in the school cafeteria.
Food Serving Calories CHO (g) Protein (g)
Fat (g)
Kellogg’s Frosted Flakes Dry Cereal
1 ½ cup 215 kcal 53.15g 2.54g 0.123g
2% Milk 1 cup 122 kcal 11.71g 8.05g 6.044g
Orange Juice
1 cup 112 kcal 25.79g 1.74g 0.248g
Total 449 kcal
90.65 12.33g 6.415g
Breakfast
LunchFood Serving Calories CHO (g) Protein
(g)Fat (g)
Pizza 6 inch, pepperoni
770 kcal 69g 35g 16g
Mixed Salad
1 cup 17 kcal 3.35g 1.3g 0.049g
Thousand Island Salad Dressing
¼ cup 178 kcal 7.03g 0.52g 14.973g
Snickers 1 candy bar
280 kcal 35.06g 0.26g 11.376g
Total 1245 kcal
114.44g 37.08g 42.378g
SnackFood Serving Calories CHO (g) Protein
(g)Fat (g)
Peanut Butter
2 tbsp 188 kcal 25.79g 7.7g 15.181g
Grape Jelly
1 tbsp 50 kcal 13g 0g 0g
White Bread
2 slices 133 kcal 25.3g 3.82g 1.377g
Coke 1 12oz can
136 kcal 35.18g 0.26g 0g
Total 507 kcal
99.27g 11.78g 16.558g
DinnerFood Serving Calories CHO (g) Protein
(g)Fat (g)
Spaghetti
2 cups noodles
442 kcal 25.79g 16.24g 1.753g
Spaghetti Sauce
½ cup 111 kcal 17.61g 2.28g 3.165g
Ground Beef
1 oz 77 kcal 0g 7.24g 4.628g
Steamed Brocolli Stalks with salt
3 stalks 147 kcal 30.15 10g 1.215g
2% Milk 2 cups 244 kcal 23.42g 16.1g 11.667g
Total 1021 kcal
96.97g 52.04g 22.428g
HS SnackFood Serving Calories CHO (g) Protein
(g)Fat (g)
Ice cream
2 cups, chocolate
572 kcal 89.6g 10g 28g
Coke 1 12oz can
136 kcal 35.18g 0.26g 0g
Total 708 kcal
124.78g 10.26g 28g
Estimated Energy and Protein Requirements
EER for females 9 through 18 Years=
135.3-30.8(15 years)+1.56(10(45.5kg)+934(1.6m))+25=
2,739 kcals/day
Physical activity coefficient: 1.56 for very active
Protein
RDA for 14-18 year old female= 46g/day
Diet Plan ComparisonTotal Daily Patient Intake
Recommended Diet Plan Intake
% of Recommended Intake
Kcal 3643 kcal 2800 kcal 130%
CHO 473.73g 300g 157.9%
Protein 118.33g 55-65g 182% - 215.4%
Fat 95.15g 80g 118.9%
Nutrition Care ProcessStep 1: Assessmento Appropriate and reliable data were collected
to determine the existence of specific nutrition problems
Step 2: Diagnosis o Food and nutrition-related knowledge deficit o Self-monitoring deficit
Nutrition DiagnosesPES Statements
Food and nutrition-related knowledge deficit (P) related to newly diagnosed Type 1 DM (E) as evidenced by HbA1c of 7.95% and diet hx notable for inappropriate intake of carbohydrate (S).
Self-monitoring deficit (P) related to lack of knowledge regarding appropriate alcohol intake (E) as evidenced by fluctuating blood glucose levels and belief that beer can be considered a carbohydrate exchange (S).
Achieve HbA1c <5.2%Educate both patient and family about…
Role of nutrition in diabetes managementCarbohydrates and diabetesHow certain foods effect blood glucosePreventing hyperglycemiaFood purchasing/preparation
Decrease Frequency of Poor Carbohydrate Choices
Nutrition Education/Counseling:
Outpatient appointmentsMeal planningPractice skills
Carb counting, blood glucose monitoring
Reviewing logs of meals, snacks, blood glucose readings, insulin administrations
Psycho/social statusEffects of alcohol consumption
Effects of AlcoholSusan is admitted to the ER the night after she is
discharged. She had a BG of 50 mg/dL. She was invited to a party Saturday night and tested her blood glucose before leaving. It measured 95 mg/dL so she took 2 units of insulin. She knew she needed to have a snack that contained 15g CHO so she drank a beer when she arrived at the party. She remembers getting lightheaded then woke up in the ER.
Effects of AlcoholOnce Susan administered the insulin, her blood
glucose was going to drop
Normally, liver will begin changing stored CHO into glucose
The glucose then sent to blood to slow down low blood glucose reaction
When alcohol ingested, liver wants to clear it as quickly as possible
Alcohol must be completely metabolized
If blood glucose is low, alcohol can lead to passing out
Effects of AlcoholAlcohol may be consumed occasionally WITH
FOOD
Do not count alcohol
as a carbohydrate
Hypoglycemia can
occur easily, especially
with nocturnal intake
Underage consumption
What about Stevia? Native to Central and South America
Grown for its sweet leaves - ~200-300x sweeter than sugar
Not approved in the US as a food additive or sweetener- only as a “dietary supplement”
Banned in several countries as food additive, approved as dietary supplement in others
Has been shown to lower blood glucose by increasing insulin secretion in lab studies
May want to focus more on Reb A extract of stevia “Rebiana”
Truvia and PureViaContain Reb A “Rebiana”
Extracted from stevia leaf, erythritol, and other natural flavors
Received GRAS recognition in US
Questions?