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Case Study #15Type 1 Diabetes Mellitus in the AdultLynne RollerNovember 20, 2013Understanding the Diagnosis and PathophysiologyWhat are the differences among T1DM, T2DM, and LADA?Type 1 diabetes mellitus is the result of a cellular-mediated autoimmune destruction of beta cells in the pancreas. This destruction leads to little to no insulin production. Most patients with T1DM are diagnosed before they turn 30. Type 2 diabetes is not an autoimmune disease, instead it the body resists effects of insulin or cannot produce enough insulin to control one’s blood sugar levels. In patients with latent autoimmune diabetes in adults (LADA), the body cannot produce insulin because of beta cell destruction, however, this disease is a slow progression and is seen later in one’s adult life (Nelms 482).What are the standard diagnostic criteria for each of these diagnoses?The diagnosis of T1DM is made on the basis of a normal plasma glucose ≥200 mg/dL paired with symptoms of either unexplained weight loss, polydipsia, or polyuria. It can also be diagnosed based on a fasting plasma glucose of ≥ 126 mg/dL. A Glycated hemoglobin (A1C) test can be run to diagnose someone with Type 2 diabetes. A test with blood sugar levels of 6.5 percent or higher on two separate tests indicates diabetes (Mayoclinic). Why do you think he was originally diagnosed with T2DM? Why does the MD now suspect he may actually have T1DM or LADA?A family history of disease is a leading risk factor for developing that condition. Since Armando’s mother has T2DM, it would be more likely that he could also have T2DM. It is also more likely to develop T2DM later in adulthood, and T1DM in children and adolescents. Since Armando is 32, is would be more likely that his symptoms are related to T2DM. Describe the metabolic events that led to Armando’s symptoms and subsequent admission to the ER (polyuria, polydipsia, polyphagia, fatigue, and weight loss), integrating the Pathophysiology of T1DM into your discussion. Armando is insulin deficient, which is a result of increased hepatic glucose output and decreased glucose uptake. This state is called hyperglycemia. Armando’s hyperglycemia caused osmotic diuresis leading to polyuria. This excessive urination can cause dehydration, resulting in polydipsia. Armando also has a high amount of fatty acids in his blood forcing his body to use stored fat as energy. This process could have led to his symptoms of polyphagia. Having high amounts of amino acids in the blood could have increased the rate of protein degradation leading to muscle wasting, fatigue, and possible weight loss. Describe the metabolic events that result in the signs and symptoms associated with DKA. Was Armando in this state when he was admitted? What precipitating factors may lead to DKA? The metabolic events that occur in patients with Diabetic Ketoacidosis are high blood sugar levels and high ketone levels in the urine. These signs can lead to excessive thirst, nausea, abdominal pain, weakness, shortness of breath and confusion (Diabetic). Armando will be started on a combination of Novolog 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. The onset of Novolog is 15 minutes with a peak of 30-90 minutes, and duration of 3-5 hours. The onset of glargine is one hour and does not have a peak. The duration of glargine is 20-26 hours (Types). Using his current weight of 165lbs, determine the discharge dose of glargine as well as an appropriate ICR for Armando to start with. 0.6 units of glargine per kg of body weight.75kg X 0.6 = 45 units of glargineICR= 500/45 units= 11.1 g of carbohydrates per unit of insulin Intensive insulin therapy requires frequent blood glucose self-monitoring. What are some of the barriers to success for patients who begin this type of therapy? Give suggestions on how you might work wit Armando to support his compliance. Self-monitoring of blood glucose (SMBG) is a way to monitor an individual’s glucose levels at home. This test is user-dependent and is only accurate if the individual know how to perform this test properly. Starting SMBG requires the individual to be responsible in checking levels frequently and consistently, which is a major lifestyle change for some. It might be useful to talk with Armando’s friends and family about keeping him accountable in taking this test, as well as have someone assess his ability to perform the test accurately (Nelms 494). Armando tells you that he is very frightened of having his blood sugar drop too low. What is hypoglycemia? What are the symptoms? What information would you give to Armando to make sure he is well prepared to prevent or treat hypoglycemia? Hypoglycemia is a condition when one’s blood sugar drops too low. Symptoms of hypoglycemia include: trembling, nervousness, trouble concentrating, anxiety, blurred vision, sweating, irritability, rapid heart rate, inability to think clearly, tingling in extremities, dizziness, hunger, nausea, fatigue, weakness, and headaches (Nelms 486). It would be important to inform Armando on the proper timing and amounts of medications and insulin. He should be encouraged to eat meals on time and maintain adequate energy intake. Since Armando drinks alcohol daily, it is important that he eats every time he drinks (Nelms 486). Armando’s mother has T2DM. She is currently having problems with vision and burning in her feet. What is she most likely experiencing? Describe the Pathophysiology of these complications. You can tell that he is worried not only about his mother but also about his own health. Explain using the foundation research of the Diabetes Control and Complications Trial (DCCT) as well as any other pertinent research data, how he can prevent these complications. His mother is experiencing complications from not maintaining close to normal blood glucose levels. When diabetes is not controlled, it can begin to affect the major organs of the body, specifically the heart, blood vessels, eyes, nerves, and kidneys. The Diabetes Control and Complications Trial was a study that showed maintaining close to normal blood glucose levels will help reduce these complications. Understanding the Nutrition TherapyOutline the basic principles for Armando’s nutrition therapy to assist in control of his DM. Armando needs to maintain glucose levels in a normal range and increase healthy food choices and physical activity. It is important to count carbohydrates and monitor insulin-to-carbohydrate ratios (Nelms 492). Nutrition AssessmentAssess Armando’s height and weight. Calculate his BMIHeight: 5’11” (180cm, 1.8m) Weight: 165lb (75kg)BMI = 75kg/3.24 = 23Identify any abnormal laboratory values measured upon his admission. Explain how they may be related to his newly diagnosed DM.Armando’s glucose levels were 683mg/dL (normal range 70-110) because the glucose is not being absorbed to the cells from the blood due to a lack of insulin production.Phosphate levels of 2.1 (normal range 2.3-4.7mg/dL)Osmolality levels of 306 mmol/kg/H20 (normal range 285-295) due to dehydration. Cholesterol levels of 210 (normal range 120-199mg/dL)Triglyceride levels of 175 mg/dL (normal range 40-160mg/dL)HbA1c of 12.5% (normal range 3.9-5.2%) because of glucose in the blood stream. C-peptide levels of 0.09 (normal range 0.51-2.72ng/mL)Determine Armando’s energy and protein requirements. Be sure to explain what standards you used to make this estimation. Would you recommend that he either gain or lose weight in the future? Energy requirements: EER for males 19 and older= 662-9.53 X age + PA X (15.91 X weight + 539.6 X height)PA= 1.11 for low active662 – 9.52 X 32 + 1.11 X (15.91 X 75 + 539.6 X 1.8)= 2,760 kcal/dayPrioritize two nutrition problems and complete the PES statement for each.Impaired nutrient utilization (NC-2.1) related to physical symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss as evidence by laboratory values.Food and nutrition related knowledge deficient (NB-1.1) related to lack of past education when diagnosed as evidence by diagnosis of Type 1 Diabetes and symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss. Determine Armando’s initial CHO prescription using his diet record from home as a guideline, as well as your assessment of his energy requirements. What nutrition education material would you use to teach Armando CHO counting? Energy requirements: 2,760 kcal/day X 0.5 = 1.380/4g= 345/3 meals= 115g Carbohydrates per mealIt is important to distribute carbohydrates evenly between meals in order to better balance his blood glucose levels. Armando’s usual breakfast consists of 2 slices of toast, butter, 2 tbsp jelly, 2 scrambled eggs, and orange juice (~1c). Using the ICR that you calculated in question #7, how much Novolog should he take to cover the carbohydrate in this meal? Toast: 30g, Jelly: 15g, Orange Juice: 30g = 75g Carbohydrates= 6.8 units of NovologUsing the ADA guidelines, what would be appropriate fasting and postprandial target glucose levels for Armando?Fasting glucose levels: 70-100 mg/dLPostprandial glucose target level <180 mg/dL. Write an ADIME note for your initial nutrition assessmentAssessment:Weight: 165lb. Height: 5’11” BMI: 23Energy requirements: 2,760 kcal/day Biochemical: Glucose levels of 683mg/dL (normal range 70-110) Phosphate levels of 2.1 (normal range 2.3-4.7mg/dL)Osmolality levels of 306 mmol/kg/H20 (normal range 285-295) Cholesterol levels of 210 (normal range 120-199mg/dL)Triglyceride levels of 175 mg/dL (normal range 40-160mg/dL)HbA1c of 12.5% (normal range 3.9-5.2%) C-peptide levels of 0.09 (normal range 0.51-2.72ng/mL)Nutrition related history: Mother with T2DM, previously diagnosed with T2DMDiagnosis: Impaired nutrient utilization (NC-2.1) related to physical symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss as evidence by laboratory values.Food and nutrition related knowledge deficient (NB-1.1) related to lack of past education when diagnosed as evidence by diagnosis of Type 1 Diabetes and symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss. Intervention: Maintain normal blood glucose levels by managing insulin and nutrition. Educate him on healthy nutrition and exercise habits, specifically how to balance carbohydrates and insulin intake.Monitoring/Evaluation:Monitor patients blood glucose levels Evaluate physical symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss. Monitor weightArmando comes back to the clinic 2 weeks after his diagnosis. List the important questions you will ask him in order to plan the next steps for providing the additional education that he might need.It would be important to ask him how the self-monitoring glucose level tests are going to make sure he is paying attention to his blood glucose levels. It would also be necessary to ask if he is managing his carbohydrate intake and taking his insulin at the appropriate times. I would also ask if he is partaking in physical activity. Armando states that he would like to start exercising again as he is feeling better. He is used to playing tennis several times per week as well as cycling at least 2 days per week for over 20 miles each time. Again, he expresses his concern regarding low blood sugar. How would you counsel Armando regard physical activity, his diet, and his blood glucose monitoring?It is important to include physical activity in his lifestyle. However, it is crucial to consume appropriate amounts of carbohydrates before and possibly during exercise in order to ensure that his blood glucose levels do not drop too low. Armando states that one of his friends has talked about using the glycemic index as a way to manage his diabetes. He says that he has also seen some nutrition programs advertise their food products as being “low glycemic index” on TV. Explain glycemic index, glycemic load, and how he might use this information within his nutrition therapy plans. Glycemic index and glycemic load show how a specific food might affect one’s blood glucose levels. The lower these numbers are, the less that food will affect one’s blood sugar or insulin levels. Armando might use this information to monitor the foods that he consumes in order that his blood glucose levels maintain around normal (Glycemic)Works Cited “Diabetic Ketoacidosis.” MayoClinic. Oct. 23, 2012.. “Glycemic Index and glycemic load.” Hardvard Health Publications. . Nelms, Marcia; Sucher, Kathryn; Lacey, Karen; Roth, Sara Long. “Nutrition Therapy & Pathophysiology.” 2/e. “Tests and Diagnosis.” Mayoclinic. Jan 25, 2013. . “Types of Insulin.” National Diabetes Information clearinghouse (NDIC). February 16, 2012.. ................
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