Type I Diabetes Mellitus in the Adult

A Case Study
Erin Norton, Dana Omari, Louise Peery, Emily Smith, Olivia Wooliver November 6th, 2013

Introduction

Introduction to the Patient

S 32 year old male, Armando Gutirrez, diagnosed with

T2DM last year

S Has now presented in the ER with grogginess and near

unconsciousness after being found in his apartment by a friend

S Now suspected that patient has T1DM, specifically Latent

Autoimmune Diabetes of Adults (LADA), instead of original T2DM diagnosis

T1 vs T2 Diabetes Mellitus
T1DM & LADA
S S S S S S

T2DM
S S S

Autoimmune disease Genetic component Body does not synthesize adequate insulin Insulin-dependent Usually diagnosed before the age of 30

Strongly related to lifestyle and weight Can have a genetic component Body produces adequate insulin, but cells are resistant to it; over time insulin production can decrease

S Can develop and be diagnosed at any LADA is diagnosed after age 30, age progresses slowly, and the insulin-secreting cells stay functional longer S Can be improved with lifestyle

modification

Pathophysiology of T1DM
S Autoimmune attack on beta cells of the pancreas, which produce

insulinthis leads to inadequate insulin production

S Glucose circulating in the blood cannot get into cells, leading to

hyperglycemia
S Hyperglycemia puts extra stress on the kidneys to excrete the

glucose
S In doing so, excess water is excreted via the urine (polyuria) S Leaves the patients body dehydrated and they experience thirst

(polydipsia)

Pathophysiology of T1DM
S Body must utilize other sources of energy since it

cannot use carbohydrate

S Hydrolysis of triglycerides in fat cells to long chain fatty acids

and glycerol (convert to acetyl-coA molecules to produce energy via TCA) S Catabolism of lean tissue to fuel gluconeogenesis S Leads to weight loss and also exacerbates hyperglycemia because both of these pathways add carbohydrate to the blood

T1DM and Diabetic Ketoacidosis

S Diabetic Ketoacidosis (DKA) can also result when the

body is overwhelmed by acetyl-CoA

S Body begins converting acetyl-CoA to ketone bodies,

which can be used for energy but also acidify the blood impaired brain function, coma

Nutrition Assessment

Client History
S Personal history: S 32 year old Hispanic male S Occupationcomputer software engineer S Marital statusdivorced S Tobacco use: smokes 1 PPD x 10 years S Alcohol intake: daily S Medical & Health history: S Endocrine/metabolism: Mother suffers from T2DM; patient was diagnosed with T2DM one year ago S Cardiovascular: father suffered MI S Hematology/oncology: Mother diagnosed with ovarian cancer

Client History
S Medical treatment/therapy: S Prescribed metformin for T2DM diagnosis, but does not feel medication is necessary, so doesnt take it regularly S Chief complaint upon todays admission:
Patient is distressed, lethargiccomplaint taken from friend S Friend states that Armando had not been feeling well the previous day at work; thought he was fighting a virus S Patient did not show up to work this morning, and his friend found him groggy and nearly unconscious in his apartment, friend called 911 and patient was transported to University Hospital via ambulance
S

Anthropometric Measurements

S Weight: 165 lbs S Height: 511 S BMI: 23.1 kg/m2

S Within the healthy weight range of 18.5 24.9 kg/m2

Biochemical Data, Medical Tests, and Procedures

Laboratory Tests Sodium (mEq/L) CO2 (mEq/L) Glucose (mg/dL) Phosphate (mg/dL) Osmolality (mmol/kg/H2O)

Reference Range 136-145 23-30 70-110 2.3-4.7 285-295

Patient Result 130 (L) 31 (H) 683 (H) 2.1 (L) 306 (H)

Cholesterol (mg/dL)
Triglycerides (mg/dL) Hemoglobin A1c (%) C-peptide (ng/mL)

120-199
40-160 3.9-5.2 0.51-2.72

210 (H)
175 (H) 12.5 (H) 0.09 (L)

Biochemical Data, Medical Tests, and Procedures

Laboratory Test Islet Cell Autoantibody Glutamic Acid Decarboxylase Autoantibody (GADA) Islet Autoantibodies

Reference Range -----

Patient Result + +

---

Urine pH
Urine Protein (mg/dL) Urine Glucose (mg/dL) Urine Ketones

5-7
neg neg neg

4.9 (L)
+1 (H) +3 (H) +4 (H)

Arterial Blood Gases pH

ABG Bicarbonate (mEq/L)

7.35-7.45
24-28

7.31 (L)
22 (L)

Food and Nutrition-Related History: Food & Nutrient Intake

Meal Breakfast

Usual Meal Intake (past few months)

2 slices toast butter 2 tbsp jelly 2 scrambled eggs 1 cup orange juice coffee Subway sandwich chips diet soda Usually cooks: pasta/rice vegetables some type of meat

Approximate Carbohydrate Intake 86 grams ~ 6 choices

Lunch

75 grams ~ 5 choices

Dinner

80 grams ~ 6 choices

Food and Nutrition Related History

S Current diet order

modified diet

S NPO then progress to clear liquids for 12 hours S Then progress to consistent carbohydrate controlled diet: 70-80g

breakfast and lunch, 85-95g dinner, 30g snack pm and HS S Considering estimated carbohydrate intake from each meal from the previous slide, his carb intake at breakfast is too high and that at lunch and dinner is a bit low. Also does not report consuming snacks and will need to begin to

Food and Nutrition-Related History

S Food and Nutrient Administration:
S Eats out 3-4 x per week for dinner

S Medication and Herbal Supplement Use:

S Prescribed Metformin after T2DM diagnosis, but does not take

regularly S Metformin is an oral drug for the treatment of T2DM only suppresses gluconeogenesis by the liver (targets hyperglycemia)
S No other medications in the home

Food and Nutrition Related History

S Medication and Herbal Supplement Use upon admission:
S Initial insulin drip: Regular insulin 1 unit/mL NS 40 mEq KCl/liter @

300 mL/hr S 50 mL flush of insulin drip solution prior to connecting patient S Next day change IVF to D5 45NS with 40 MEq K @ 135 mL/hr S Begin Novolog 0.5 u every 2 hours until glucose is 150-200 mg/dL; progress Novolog using ICR 1:15
S

Novolog is a fast-acting insulin injection used to cover mealtime insulin needs Glargine is a long-acting insulin infusion used to cover ones insulin needs over the entire day, aside from additional needs at mealtimes, etc

S Begin glargine 15 u at 9pm

S

Food and Nutrition Related History

S Knowledge/Beliefs/Attitudes: S Expresses concern over mothers T2DM (complications include vision problems and burning in her feet) and his own health S Poor control of newly diagnosed T1DM; does not know much about it S Physical Activity and Function: S Plays tennis several times per week and bicycles twice a week over 20 miles at a time S Has not been very active in the past couple weeks because he was not feeling well

Nutrition-Focused Physical Findings

S

Overall appearance: slim, in obvious distress

S
S S S S

Abdomen: active bowel sounds, nondistended

Neurologic: lethargic but able to arouse, follows commands appropriately; Glasglow Coma Scale score 13 Head, eyes, ears, nose, throat: dry mucous membranes without exudates or lesions Skin: warm & dry Vital signs:
S

S
S S

Temperature 99.6F Blood Pressure: 78/100 Pulse: 100 Tachycardia Respiration rate: 24 respirations are rapid, clear to auscultation and percussion

Comparative Standards

S Weight recommendations: healthy BMI range 18.5 24.9

(according the CDC)

S Armandos BMI fits is within this range

Comparative Standards

SEnergy needs (using Mifflin St. Jeor):

REE = (10 x 74.84kg) + (6.25 x 180.34cm) (5 x 32) + 5

= 1,720 kcal/day TEE based on activity factor of 1.2 (he is currently bed-bound) TEE = 1,720 x 1.2 = 2,065 kcal/day
SNo information on typical daily energy intake, but patient should

maintain this recommended intake in order to remain at his current healthy weight

Comparative Standards
S Macronutrient needs S No specific macronutrient distribution recommended for diabetes S Carbohydrate requirements for general population are 45-65% of daily kcal recommended 232-336 grams of carbohydrate daily S Nutrition plan states that he will progress to a consistent carb-

controlled diet with 70-80g of carb allowed for breakfast

S His typical breakfast usually consists of 86g of carbohydrate, so he will

need to better monitor his carbohydrate intake S Other meals will also need adjustment, & will need to incorporate snacks S Recommended fluid requirements: 30-35 mL/kg body weight = 2,250-

2,625 mL daily
S Doctors orders state 2,200 mL requirement, so he may need additional

fluids

Nutrition Diagnosis

Diagnoses

S (P) Altered nutrition-related laboratory values (glucose,

HbA1C) (NC- 2.2) related to (E) uncontrolled DM as evidenced by (S) serum glucose level of 610 mg/dL and HBA1C level of 12.5%.
S (P) Food and nutrition-related knowledge deficit (NB- 1.1)

related to (E) lack of education regarding newly diagnosed T1DM diagnosis as evidenced by (S) confusion and numerous questions regarding diet, physical activity, and hypoglycemia.

Nutrition Intervention

Nutrition Intervention
S PES #1: (P) Altered nutrition-related laboratory values (glucose,

HbA1C) (NC- 2.2) related to (E) uncontrolled DM as evidenced by (S) serum glucose level of 610 mg/dL and HBA1C level of 12.5%.
S Nutrition Prescription: Follow consistent and controlled diet so that

nutrition-related laboratory values will normalize.

S Nutrition Intervention: Modify composition of eating bouts, specifically a

carbohydrate-modified diet (ND-1.2) in order to control the amount of carbohydrate consumed and ensure the adequacy of prescribed insulin therapy. This includes following a consistent carbohydrate-controlled diet, consuming breakfast and lunch with 70-80g carbohydrate each, dinner with 85-95g carbohydrate, and an afternoon and bedtime snack each with 30g carbohydrate. Total daily carbohydrate intake should be between 232 and 336 grams.

Carb Counting Resources

to ensure a consistent, carb-controlled diet

Carb Counting Resources

to ensure a consistent, carb-controlled diet

Each food on the food list (above) equals 15g carbs, or 1 carb choice Try to incorporate a variety of foods Protein and fat do no directly affect blood glucose

Sample Daily Meal Regimen

Mealtime
Breakfast8:00AM

Time to take insulin

7:30-7:45AM

Carb choices
5-6 (70-80g) 5-6 (70-80g) 2 (30g) 6-7 (85-95g)

Units of Novolog
5-6 5-6 2 6-7

Lunch- 12:00PM 11:30-11:45AM Snack- 3:00PM Dinner- 6:00PM 2:30-2:45PM 5:30-5:45PM

Snack- 910:00PM

8:30-8:45 or 9:30-9:45
TOTAL:

2 (30g)
20-22 or 232336g

2
20-22

Nutrition Intervention
S

PES #2: (P) Food and nutrition-related knowledge deficit (NB- 1.1) related to (E) lack of education regarding newly diagnosed T1DM diagnosis as evidenced by (S) confusion and numerous questions regarding diet, physical activity, and hypoglycemia.
S

Nutrition Prescription: Provide nutritional education regarding new T1DM diagnosis so as to enhance patient ability to consume a controlled yet adequate diet necessary for improvement of current condition. S Nutrition Intervention: Provide nutrition-related education to the patient regarding priority modifications to the diet (E-1.2) and nutrition relationship to health/disease (E-1.4), in order to ensure he has the needed information to control his disease via his diet. Continue to provide application-centered education, in which result interpretation (E-2.1) and skill development (E-2.2) are assessed to ensure the patient is fully competent in managing his T1DM. This includes ensuring patient is capable of calculating carbohydrate content of foods, understanding glycemic index, making healthful dietary choices in order to meet carbohydrate goals, and staying within daily recommendations for carbohydrate intake. Also that the patient understands physical activity interaction with blood glucose levels.

Carb-counting/Insulin Management Resources

S Along with the aforesaid resources, make sure Armando is

aware of the following..

S How blood glucose is affected by physical activity S Know the signs of hypo/hyperglycemia S Glycemic index and how different carb sources have different GI

levels & will therefore affect blood glucose differently

S S S

High GI foods: white potatoes, white bread, bagels Medium GI foods: table sugar, white rice, coca cola, ice cream Low GI foods: brown rice, oatmeal, apples, pears, skim milk

Nutrition Monitoring and Evaluation

Monitoring and Evaluation

S Appropriate fasting and postprandial target glucose levels for

Armando The ADA suggests these targets for most adults with diabetes:
S Fasting (preprandial) plasma glucose: 70-130 mg/dL (3.9-7.2

mmol/L)
S Postprandial plasma glucose (1-2 hours after beginning of

meal): less than 180 mg/dL (<10.0 mmol/L)

Monitoring and Evaluation

S Dietary control of T1DM: S Monitor serum glucose and Hg-A1c levels over time (endocrine profileBD-1.5). S Return to normal ranges and maintain
S Knowledge deficit regarding T1DM: S Continue nutrition education sessions to monitor patients understanding of T1DM (FH-4.1). Do this until knowledge proficiency is evident and patient is able to take necessary steps in controlling his disease on his own. S Monitor client-reported dietary intake to ensure adherence to recommendations (FH-5.1).

Monitoring and Evaluation

S Knowledge deficit regarding T1DM:

S Monitor for perceived importance of compliance to

medications (FH-3.1.3).
S Monitor BMI to ensure body weight is being maintained

(CS-5.1.1).

Recheck

S Two weeks after his discharge, Armando returns for a

follow-up visit. He reports hes been playing tennis 3-4 times a week, and cycling 20+ miles twice a week.
S Increasing activity:
S S

REE: (10 x 75 kg) + (6.25 x 71 cm) (5 x 32) + 5 = 1,720 (MSJE) TEE: 1,720 x 2.0 AF = 3,440 kcal/day

Documentation

ADIME
S Assessment:
Client is a 32 year old Hispanic male originally diagnosed with T2DM one year ago. Consumes toast, jelly, coffee, orange juice, scrambled eggs and coffee for breakfast; Subway sandwich, chips and diet coke for lunch; and cooked pasta, rice, vegetables and some type of meat for dinner. Also eats out 3-4 times per week for dinner (FH-2.1.3.1). Reports not being physically active lately due to bed rest but likes to exercise regularly and enjoys long distance cycling, which he plans to start again (FH-7.3.1). Was not compliant with Metformin medication after T2DM diagnosis (FH-3.1.3). Mother has history of T2DM, and client expresses concern over his mothers and his own conditions. S Anthropometric data: 511, 165 lbs. BMI of 23.1 S Biochemical data: Elevated blood glucose level of 683 mg/dL and elevated HbA1c level at 12.5% (BD-1.5), elevated cholesterol level of 210 mg/dL, elevated trigylcerides level of 175 mg/dL, and low C-peptide level of 0.09 ng/dL (BD-1.7), low sodium level of 130 mg/dL, low phosphate level of 2.1 mg/dL (BD-1.13). S Nutrition-focused physical findings: Temp. 99.5, resp. rate 25, pulse 82, BP 101/78, dry mucous membranes, lethargic, able to arouse, Glasglow Coma Scale score 13

ADIME

SDiagnoses:

(P) Altered nutrition-related laboratory values (NC- 2.2) related to (E) uncontrolled DM as evidenced by (S) serum glucose level of 610 mg/dL and HBA1C level of 12.5%. (P) Food and nutrition-related knowledge deficit (NB- 1.1) related to (E) lack of education regarding newly diagnosed T1DM diagnosis as evidenced by (S) confusion and numerous questions regarding diet, physical activity, and hypoglycemia.

ADIME
S Intervention:
S

Nutrition Prescription: Follow consistent and controlled diet so that nutrition-related laboratory values will normalize.

S Nutrition Intervention: Modify composition of eating bouts,

specifically a carbohydrate-modified diet (ND-1.2) in order to control the amount of carbohydrate consumed and ensure the adequacy of prescribed insulin therapy. This includes following a consistent carbohydrate-controlled diet, consuming breakfast and lunch with 70-80g carbohydrate each, dinner with 85-95g carbohydrate, and an afternoon and bedtime snack each with 30g carbohydrate. Total daily carbohydrate intake should be between 232 and 336 grams.

ADIME
S Intervention
S Nutrition Prescription: Provide nutritional education regarding new T1DM

diagnosis so as to enhance patient ability to consume a controlled yet adequate diet necessary for improvement of current condition. S Nutrition Intervention: Provide nutrition-related education to the patient regarding priority modifications to the diet (E-1.2) and nutrition relationship to health/disease (E-1.4), in order to ensure he has the needed information to control his disease via his diet. Continue to provide application-centered education, in which result interpretation (E-2.1) and skill development (E-2.2) are assessed to ensure the patient is fully competent in managing his T1DM. This includes ensuring patient is capable of calculating carbohydrate content of foods, understanding glycemic index, making healthful dietary choices in order to meet carbohydrate goals, and staying within daily recommendations for carbohydrate intake. Also that the patient understands physical activity interaction with blood glucose levels.

ADIME
S Monitoring & Evaluation:
S Client self-monitor preprandial and postprandial plasma glucose to meet S S

S S

target T1DM goals for these values per AND (FH-5.1.4). Monitor serum glucose and Hg-A1c levels over time (BD-1.5) compared to normal ranges, to evaluate dietary control of T1DM. Continue nutrition education sessions to monitor patients understanding of T1DM (FH-4.1) until knowledge proficiency is evident and patient is able to take necessary steps in controlling his disease on his own (FH4.2.8). Monitor for perceived importance of compliance to medications (FH-3.1.3). Monitor client-reported dietary intake to ensure adherence to carbohydrate intake recommendations for T1DM (FH-5.1). Monitor BMI to ensure body weight is being maintained (CS-5.1.1).

References
S Diabetes Care and Education Dietetic Practice Group, the Academy of Nutrition and Dietetics. Ready,

Set, Start Counting: Carbhohydrates Countinga Tool to Help Manage Your Blood Glucose. http://dbcms.s3.amazonaws.com/media/files/84fbc534-f57f-4c01-9ebfa65b207ae2e0/ADA_Carbohydrate%20counting_FINAL.pdf

S The Academy of Nutrition and Dietetics. Nutrition Assessment and Monitoring and Evaluation

Terminology. http://www.adancp.com/vault/editor/Docs/IDNT%20e3%20NA-NMETerms-NCM.pdf
S The Academy of Nutrition and Dietetics. Nutrition Care Manual. S The Academy of Nutrition and Dietetics. Nutrition Diagnostic Terminology.

http://www.adancp.com/vault/editor/Docs/02.0%20Nutrition%20Diagnostic%20Terminology.pdf
S The Academy of Nutrition and Dietetics. Nutrition Intervention Terminology.

http://www.adancp.com/vault/editor/Docs/03.0%20Nutrition%20Intervention%20Terminology.pdf