Emma Craig

Professor Matuszak

KNH 411

18 November 2014

Case Study 16

Type 2 Diabetes Mellitus- Pediatric Obesity

I. Understanding the Diagnosis and Pathophysiology

1. What are the risk factors for developing type 2 DM as a child? What do the current ADA standards of medical care recommend concerning screening at risk children?

T2DM is distributed equally among genders, but the risk of developing T2DM increase with age. Additionally, family history, obesity, history of gestational DM, race, impaired glucose metabolism and physical inactivity are risk factors for T2DM. The current standards from the ADA are for children ten years old or at the onset of puberty and are as follows:

· The child must be obese (BMI >85th percentile for age and gender or weight for weight, or weight >120% of ideal for height)

· Plus any two of these following risk factors

· Family history of T2DM in first- or second-degree relative

· Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)

· Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia or polycystic ovarian syndrome)

This fasting plasma glucose test is generally done every two years (Nelms, 498-499).

2. Evaluate Adane’s medical record. Identify which risk factors most likely led to the routine screening for DM during her school physical.

Adane has many risk factors that led to the routine screening for DM during her school physical. To begin, she has a strong family history of diabetes. Her mother had gestational diabetes during pregnancy and her mother and grandmother also have type 2 DM. She is also African American which puts her at a higher risk for type 2 DM. With a BMI of 36.4 kg/m2 Adane is considered obese, another major risk factor.

3. What are the ADA standard diagnostic criteria for T2DM? Which are included in Adane’s medical record?

The ADA standard diagnostic criteria for T2DM is as follows:

· A1C greater than or equal to 6.5%

· OR

· FGP greater than or equal to 126 mg/dl

· OR

· Two-hour or random PG greater than or equal to 200mg/dL

Adane’s A1C was 6.9% which is greater than 6.5% and her EAG was 151 mg/dL which is greater than the 126 mg/dL. Her glucose measures were also 155 mg/dL and 171 mg/dL which are also in the high range.

Diabetes Care. (n.d.). Retrieved November 6, 2014, from http://care.diabetesjournals.org/content/37/Supplement_1/S14/T2.expansion.html

4. Adane’s physician requested additional testing that included autoantibody levels and C-peptide. Explain why these tests were done and what the results indicated for Adane.

Autoantibody testing is used to distinguish type one diabetes from diabetes due to other causes. In Adane’s case, this would have been used to distinguish type 1 diabetes from type 2 diabetes. The four most common autoantibodies that are tested are: islet cell cytoplasmic autoantibodies, glutamic acid decarboxylase autoantibodies, insuinoma-soosiacted-2 autoantibodies and insulin antiautobodies. If ICA, GADA and/or Ia-2A are present in the person, type 1 diabetes is the cause. If none of these are present, it is unlikely the diabetes is type 1.

C-Peptide is measured to tell the difference between the insulin injected in the body and insulin produced by the body. When the pancreas produces insulin a large molecule is produced and it splits in two pieces: insulin and c-peptide. The C-peptide level is measured in patients with diabetes to see if any insulin is being produced in the body. A low level of C-peptide indicates the body is producing little to no insulin. People with type 2 diabetes may have a high C-peptide level that is normal for their degree of insulin resistance.

Based on Adane’s medical results, she has type 2 diabetes as her results for ICA, GADA, Ia-2A, IAA and tTG were negative. Based on Adane’s c-peptide level it is clear she has insulin resistance.

Diabetes-related Autoantibodies. (n.d.). Retrieved November 9, 2014, from http://labtestsonline.org/understanding/analytes/diabetes-auto/tab/test/

Insulin C-peptide test: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved November 9, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/003701.htm

5. Insulin resistance is a major component of T2DM. Explain this pathophysiology. How could you determine whether Adane is exhibiting insulin resistance?

Individuals with T2DM produce insulin, but their tissues are insulin resistant. This causes an increased need for insulin, so the pancreas increases production, eventually causing the pancreas to lose its ability to produce insulin. T2DM is typified by peripheral insulin resistance and the insulin defect varies in severity. When there is a cell-receptor defect, cells cannot respond to insulin by translocating glucose to the outer membrane, thus they are unable to take up glucose to use for fuel. Insulin generally inhibits glycogenolysis and gluconeogenesis, but defective insulin secretory responses result in excess glucose production in the liver.

Fasting blood glucose level could be used to test for insulin resistance. The A1C tests as well as C-peptide could test for insulin resistance as well (Nelms, 499).

6. Children with T2DM are at high risk for early cardiovascular disease. Why does this complication occur with diabetes? Evaluate Adane’s lipid profile. How does this compare to the lipid goals for children with diabetes?

Although diabetes is manageable, children with T2DM are at high risk for cardiovascular disease because they often have other risk factors. For example, high blood pressure could result from diabetes and is also major risk factor for cardiovascular disease. Obesity is also linked to diabetes and is a risk factor for cardiovascular disease. Obesity is usually caused by lack of physical activity, which is another risk factor. Two other risk factors are abnormal cholesterol and high triglycerides (dyslipidemia) as well as poorly controlled blood sugar out of normal range.

Lipid goals for children include: an LDL cholesterol of <100 mg/dL, normal triglyceride <150 mg/dL and total cholesterol levels <170 mg/dL. Adane had a high triglyceride level of 175 mg/dL and total cholesterol level of 210 mg/dL, both higher than what is recommended. Adanes hould also have limited trans fat, less than 7% saturated fat and her diet should contain no more than 25% to 35% total fat.

Diabetes Care. (n.d.). Retrieved November 6, 2014, from http://care.diabetesjournals.org/content/37/Supplement_1/S14/T2.expansion.html

7. Adane’s grandmother asks about medications for treating high cholesterol as her husband is on this medication. What are the recommendations for the use of statin drugs in children?

There has been no long-term safety or cardiovascular outcome efficacy established in children. In recent studies, there has been lowering of HDL cholesterol levels as well as improvement of endothelial function. No statin is approved for children under the age of 10 years and statins should not be used in children with type 2 diabetes. This would not be recommended for Adane, especially because she is nine years old. After the age of ten years, the addition of a statin can be occur if after MNT and lifestyle changes, if the child has an LDL cholesterol >160 mg/dL or LDL cholesterol >130 mg/dl and one or more CVD risk factors.

Standards of Medical Care in Diabetes-2013. (n.d.). Retrieved November 10, 2014, from http://care.diabetesjournals.org/content/36/Supplement_1/S11.full

8. Adane’s urinalysis is positive for protein. What does this mean and how may this be related to her diabetes?

Small amounts of protein may indicate that Adane is suffering from kidney damage. Having small amounts of protein in the urine is called microalbuminuria. Diabetes can damage the filtering system of the kidney. High levels of blood sugar make the kidneys filter too much blood. After many years, the filters start to leak and useful protein is lost in the urine. This could lead to chronic kidney disease.

Kidney Disease (Nephropathy). (n.d.). Retrieved November 10, 2014, from http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.html

9. Should Adane and her family be taught about self-monitoring of blood glucose (SMBG)? If so, what are the standard recommendations for daily frequency of testing? What would be the appropriate fasting and post prandial and target glucose levels for Adane?

Adane and her family should be taught about self-monitoring blood glucose. Her parents should also be educated as Adane is so young and will need help properly monitoring her blood glucose. This is a useful tool in identifying patterns and ways in which food, exercise and other factors effect Adane’s blood glucose levels. It is recommended Adane test her blood glucose three or more times a day. When Adane is first starting out, it may be helpful to check her blood glucose all throughout the day including before and after meals to see the ways in which food can alter her blood glucose levels. The appropriate fasting and post prandial target glucose levels for Adane are as following (Nelms, 494-495):

Normal

Goal

Pre prandial Glucose

<100 mg/dL

70-130 mg/dL

Post Prandial Glucose

<140 mg/dL

<180 mg/dL

II. Understanding the Nutrition Therapy

10. Outline the basic principles for Adane’s nutrition therapy to assist in control of her T2DM.

Adane’s nutrition therapy will have many different factors contributing to it. Adane will have to consistently monitor her blood glucose using SMBG. In order to control her blood glucose, Adane will need to watch her weight and make sure she does not gain any more pounds. She will also need to watch what she is eating and when she is eating it. Due to her young age, it will not be recommended she focus on losing weight through calorie restriction a she is still developing. Adane will also need to have at least 130 grams of carbohydrates which are strictly monitored as they are the major contributor to glycemic response. She should also have less than 10% of protein from her diet. This is based on her urinalysis testing positive for protein. This indicates her kidneys are not functioning properly and protein should be limited. Adane’s fat intake should nto exceed 25% to 35% of total kcal and her saturated fat should not exceed 7%. Her intake of trans fat should be little to none. Adane will also need to consume approximately 25g of fiber per day, which will increase her whole grain, fruits and vegetable intake (Nelms, 505-506).

Although not nutrition based, Adane will be prescribed some sort of exercise regimen of 30 to 40 minutes of moderate physical activity three to four times a week. This may help Adane lose weight as well as improve glycemic control. Also, Adane may be put on glucose-lowering medications if glycemic control can not be achieved. This would be a worst-case scenario type situation (Nelms, 500).

III. Nutrition Assessment

11. Using the charts on pp. 188-189, assess Adane’s ht/age; wt/age; ht/wt and BMI. What is her desirable weight?

Ht/age (52’,9)

49th percentile

Wt/age (140lbs, 9)

>97th percentile

Ht/wt (52”, 140lbs)

>97th percentile

BMI (36.4)

>97th percentile

Besides Adane’s height for age, all her values are extremely high for her age. An ideal weight for Adane would put her in the 50th percentile, which would be around the area of 60-70lbs. Weight loss would not be the first priority at the moment, as Adane is still developing.

12. Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T2DM.

The abnormal lab values are as follows:

Ref. Range

Adane’s Value

Glucose (mg/dL)

70-110

171

Cholesterol (mg/dL)

<170

210

Triglycerides (mg/dL)

<150

175

HbA1c (%)

3.9-5.2

6.9

EAG

------

151

C-peptide (ng/mL)

.51-2.72

2.75

Urinalysis

Protein (mg/dL)

Neg

+

Glucose (mg/dL)

Neg

+

Prot chk

Neg

+

The glucose, HbA1c, EAG and C-peptide levels are all consistent with her diagnosis of T2DM. These values are in the diabetic range. The high glucose indicates her body is not producing enough insulin to allow the cells to use glucose. The HbA1c indicates blood glucose levels over the past three months. Her C-peptide level indicates insulin resistance. Her cholesterol and triglycerides are high most likely due to her diet, which is one of the risk factors of diabetes. Based on her diet history, it is clear she eats a lot of fatty foods. Based on her urinalysis, it is clear her kidneys are not functioning properly as protein, glucose and prot chk were found in her urine.

13. Determine Adane’s energy and protein requirements. Be sure to explain what standards you used to make these estimations. Should weight loss be a component of your estimation of energy requirements?

I chose to use the TEE calculation for overweight females aged 3 through 18 years. Weight loss should not be a component of the estimation of energy requirements as Adane is so young and is still developing. Limiting calories could limit her growth due to lack of nutrients (Nelms, 243).

TEE: 389-41.2xage + PA x 15.0 x weight + 701.6x height

PA: 1.00

Weight: 140lbs/2.2 kg=63.6

Height: 52inx2.54cm=132/100=1.32m

389-41.2 (9) + 1.00 x 15.0 x 63.6 + 701.6x 1.32=1898kcal

Due to Adane having improper kidney function, I would recommend no more than 10% of her total diet be protein.

1900kcalx.10=190kcal

190kcal/4kcal/gprotein=48g protein

14. Using Adane’s diet history, assess the approximate number of kilocalories her intake provided, as well as the energy distribution of calories for protein, carbohydrate, and fat, using the exchange system. Compare this to the recommendations that you made in question #10.

Exchange

CHO

PRO

FAT

kcal

Breakfast

Fruit Punch (1 cup)

2 carbohydrates

30

0

0

120

Frosted Flakes (2 cup)

4 starches

60

4

12

320

Whole Milk (1 cup)

1 milk

12

8

8

150

Mid Morning Snacks

2 slices toast

2 starches

30

0

0

120

Butter

1 fat

0

0

5

45

Jam

1 carbohydrate

15

0

0

60

Chocolate Chip Cookies (multiple)

2 carbohydrate

2 fat

30

0

10

210

2 bags cheetos

2 carbohydrates

4 fats

30

0

20

300

Fruit Punch (multiple)

4 carbohydrates

30

0

0

240

Popsicles (2)

2 starch

30

0

0

120

Lunch

Bread (4 slices)

4 starches

60

4

12

240

Peanut Butter (4 tbsp)

4 protein (high meat)

0

32

28

400

Mayo (2 tbsp)

2 fat

0

0

10

180

Banana (1)

2 fruits

30

0

0

120

Fruit Punch (2 cup)

4 carbohydrates

60

0

0

240

Chips

1 carbohydrate

2 fat

15

0

10

150

Dinner

Fried Pork Chop

3 oz meat

0

21

24

300

Greens

1 vegetable

5

2

0

25

Potatoes

1 starches

30

0

0

120

Cornbread

1 starch

1 fat

15

3

6

125

Butter

2 fat

0

0

10

90

Iced Tea (sugar)

1 sugar-15g carbs

15

0

0

60

Bedtime Snack

Pizza Rolls

1 meat

2 fat

3 starch

45

7

28

460

Coke

2 carbohydrate

30

0

0

120

Total

572

81

183

4215

572x4=2288/4215=54.3%CHO

81x4-324/4215=7.7% PRO

183x9=1674/4215=39.1% FAT

Based on the carbohydrate counting system, Adane consumes 54% CHO, 7.7% PRO and 39.1% FAT. It would be important to decrease her total fat intake to no higher than 25 %to 35% of her diet. I would also try and increase her protein to 9%. Her total carbohydrate should also be decreased by a small percentage. Adane should be consuming around 2000kcal and she is almost double that at the moment. By cutting her kcal to what it is supposed to be, many of these values will fall into the accurate range.

IV. Nutrition Diagnosis

15. Prioritize two nutrition problems and complete the PES statement for each.

-Obesity (NC-3.3) related to diabetes and excessive energy intake as evidenced by a BMI of 36.4 kg/m2, ht/wt and ht/age above the 97th percentile and food recall.

-Excessive energy take (NI-1.3) related to high caloric food intake as evidenced by food recall of 4000 kcal of high caloric foods.

V. Nutrition Intervention

16. Determine Adane’s initial nutrition therapy prescription using her diet record from home as a guideline, as well as your assessment of her energy requirements.

To begin Adane’s nutrition therapy prescription, I would first require Adane to consume 1800-1900 kcal per day. This will be a big change in calories for Adane but I believe it will be necessary for her to be healthy. I would not cut down the calories any lower because she is still growing and developing. Of this 1800-1900 kcal, I would want no more than 10%(48g) of her diet from protein. This is due to her kidney function. I would want no more than 25% to 35% of her diet from fats, with less than 7% saturated fat and 0% trans fat. This would leave approximately 55% to 65% of her diet to be from carbohydrates. Of these carbohydrates, I would recommend Adane’s family to limit the amount of sugar and increase the amount of whole grains in her diet. This could be a whole-wheat roll instead of cornbread, or whole wheat toast instead of white bread. Also, she currently she drinks a lot of fruit punch and soda. I would recommend to the family to completely cut this out of her diet, but if she insists on having either of this drinks, to make them diet. This will cut down the total amount of sugar. I would also suggest the family cut out the amount of fried food and processed food Adane as in her diet. I would recommend instead of fried pork chops, just a regular pork chop and instead of potatoes, perhaps a more green vegetable such as broccoli.

I would also stress the need for Adane to get in some sort of physical activity. This will help aid in her weight loss. I would recommend she join some sort of team that means at least four times a week for an hour. This way she can meet children her age and also become more active.

17. Outline the initial steps you would use to teach Adane and her family about nutrition and diabetes. What education materials could you use?

The first thing I would teach Adane’s family is just the basics of diabetes. Although they may have heard of diabetes, they might not know the specifics of what it is and how it works in the body. It would be important to teach the whole family about this as she is so young, she will need her family’s support. For this stage of education, I would use informational pamphlets and brochures aimed toward a younger population such as Adane. I would then educate Adane and the family of how Adane should test her blood glucose. I would have her show me how she pricks her finger to make sure she is doing it accurately. The next thing I would educate Adane on is carb counting. I would use food models during this stage of education. This way Adane can visually see the different amounts of food contain 15g of carbohydrate. I would also give the family sample menus that the whole family could eat. This way, the parents do not have to make a separate meal. This will prevent Adane from feeling left out as well. After this stage of nutrition based education, I would go into further detail of the importance of physical activity. I would recommend Adane join some sort of team to get her physically active. This will also allow her to socialize with more children her age.

18. Considering that Adane will not be started on medication, is it necessary to teach her and her family about hypoglycemia, sick-day rules and exercise?

Yes, it is necessary to teach Adane’s family about hypoglycemia, sick-day rules and exercise. Exercise will help Adane to reach a normal weight for her age. She will also need to be cautious of her blood sugar before and after exercise. Sick-day rules will also be important because being sick can cause blood sugar levels to go very high. In this case, Adane should make a sick day plan for when she knows or feels like she is going to get sick. It would also be important to teach her about hypoglycemia, low blood sugar, because if untreated, Adane go into a coma or have seizures.

When You're Sick. (n.d.). Retrieved November 11, 2014, from http://www.diabetes.org/living-with-diabetes/treatment-and-care/whos-on-your-health-care-team/when-youre-sick.html

19. Adane’s mom is worried that none of the children will ever be able to have birthday cake or other sweet treats. She feels she cannot offer these to the other children if Adane cannot have them. What would you tell her?

I would tell Adane’s mom that moderation is key, even though Adane has diabetes. Adane is allowed to have a sweet treat every so often as long as it is small and she is aware of how it affects her blood glucose levels. Adane does not need to be completely sugar free in order to stay healthy. If Adane were at a birthday party, it would be beneficial for her to get a smaller piece of cake rather than a larger piece. She should always look to have smaller amounts of sugar than she did previously. Also, I would recommend she look to reward Adane with other items other than food if she has been doing it in the past. This way, Adane does not see sweet treats as something she automatically gets after doing something good, but rather a treat on a special occasion.

VI. Nutrition Monitoring and Evaluation

20. Write an ADIME note for your initial nutrition assessment.

A

-Adane, 9 y/o African American, family history of diabetes as well as hypertension and high cholesterol, 52 inches, 140 lbs, BMI of 36.4 kg/m2

- High glucose (171 mg/dL), cholesterol (210 mg/dL), triglycerides (175 mg/dL), HbA1c (6.9), EAG (151), C-Peptide (2.75), tested positive for protein and glucose in urine—Diagnosed with type 2 diabetes mellitus

-Consuming 4000 kcal per day, 54% carbohydrate, 7% protein, 39% fat

D

Obesity (NC-3.3) related to diabetes and excessive energy intake as evidenced by a BMI of 36.4 kg/m2, ht/wt and ht/age above the 97th percentile and food recall.

Excessive energy take (NI-1.3) related to high caloric food intake as evidenced by food recall of 4000 kcal of high caloric foods.

I

-Meet with Adane and family and educate about diabetes and ways to cope with diabetes: food models, carb counting, sbmg

-consume 1800-1900 kcal per day

-broken down to: less than 10% protein, 25% to 35% fat (0% trans fat and less than 7% saturated fat) , 55%-65% carbohydrate

-do some sort of physical activity at least 4x a week

M/E

-Have Adane food log with the help of her family to make sure she is eating properly as well as with the food log have her log her blood glucose (when she is measuring it and what the value is)

-Give Adane and family my phone number in case they have any questions about monitoring

-Watch weight to make sure she is losing weight in a healthy way

-Get Adane’s labs done in a month to check her levels, including a urinalysis- (A1c in three months)

- Ask the mom how the adjustment is going in two weeks

21. Adane’s grandmother suggests that perhaps Adane should have “stomach surgery” so that she will lose weight more quickly. What are the recommendations for pediatric bariatric surgery?

According to the EAL, bariatric is not recommended for adolescents unless they are severely obese and have not lost weight using less invasive methods. The child that qualifies for this surgery must be severely obese and have other comorbities that will be resolved with weight loss. The child must also have attained almost full skeletal maturity. I would not recommend that Adane get this surgery. She will be able to lose weight with the calories I have allowed her as well as becoming physically active.

EAL. (n.d.). Retrieved November 13, 2014, from http://www.andeal.org/template.cfm?template=guide_summary&key=1383&highlight=pwm&home=1

References

EAL. (n.d.). Retrieved October 13, 2014, from http://www.andeal.org/template.cfm?template=guide_summary&key=1383&highlight=pwm&home=1

Diabetes Care. (n.d.). Retrieved November 6, 2014, from http://care.diabetesjournals.org/content/37/Supplement_1/S14/T2.expansion.html

Diabetes-related Autoantibodies. (n.d.). Retrieved November 9, 2014, from http://labtestsonline.org/understanding/analytes/diabetes-auto/tab/test/

Insulin C-peptide test: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved November 9, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/003701.htm

Kidney Disease (Nephropathy). (n.d.). Retrieved November 10, 2014, from http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.html

Standards of Medical Care in Diabetes-2013. (n.d.). Retrieved November 10, 2014, from http://care.diabetesjournals.org/content/36/Supplement_1/S11.full

When You're Sick. (n.d.). Retrieved November 11, 2014, from http://www.diabetes.org/living-with-diabetes/treatment-and-care/whos-on-your-health-care-team/when-youre-sick.html