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Adrienne GroganKNH 411Gretchen MatuszakNovember 2014Case Study #16 DiabetesI. Understanding the Diagnosis and Pathophysiology1. 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?There are many risk factors for developing type 2 DM as a child. According to Nelms, these include:Obesity, meaning above the 85th percentile for age and gender or weight for heightA family history of Type 2 DM in a first or second degree relativeBeing of a specific race including Native American, African-American, Latino, Asian American, or Pacific IslanderExperiencing signs of insulin resistance such as acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovarian syndromeChildren should be tested if they are obese and have 2 risk factors mentioned above. Tests should be performed every 2 years via a fasting plasma glucose. Nelms, M. (2011).?Nutrition therapy and pathophysiology?(2nd ed., pp. 498-499). Belmont, CA: Wadsworth, Cengage Learning.2. Evaluate Adane’s medical record. Identify which risk factors most likely led to the routine screening for DM during her school physical.There were many risk factors in Adane’s medical record, which most likely led to a screening of DM at her school physical. Adane’s mother and grandmother both had type 2 DM. She is 52’, 140lbs, and has a BMI of 36.4 which puts her in the obese weight category. Additionally she is of African American decent, and it is known that African Americans are more likely to have diabetes than other ethnicities. 3. What are the ADA standard diagnostic criteria for T2DM? What are included in Adane’s medical record?The ADA standard diagnostic criteria for T2DM include one of the following:Fasting plasma glucose > 126 mg/dL Casual plasma glucose > 200 mg/dL with diabetes symptoms including increased urination, increased thirst and unexplained weight lossOral glucose tolerance test (OGTT) of >200 mg/dL According to Adane’s medical record, her blood glucose was 171 mg/dL on her first visit and 155 mg/dL the next day. Additionally, her urinalysis was positive for glucose. Lastly her HbA1c level was high, at 6.9%, while the recommended range is 3.9-5.2%. This means that her blood sugar levels have been high for a significant amount of time. American Diabetes Association Recommendations. (n.d.). Retrieved November 10, 2014, from . Adane’s physician requested additional testing that included autoantibody levels and C-peptide. Explain why these tests were done and what the results indicate for Adane. Autoantibody levels are used to determine if a patient has type 1 or type 2 diabetes. If autoantibodies are present, than it is indicative of a Type 1 or autoimmune diabetes, whereas type 2 diabetes is not an autoimmune disease, it is associated with insulin resistance. Adane’s results for autoantibodies were negative, meaning the cause of her diabetes diagnosis is not type 1 or autoimmune-related. C-peptide test was ordered to see how much insulin Adane’s pancreas is still producing. Adane’s C-peptide levels were high at 2.75ng/mL, showing she does have insulin resistance. Diabetes-related Autoantibodies. (2014, May 9). Retrieved November 12, 2014, from . Insulin resistance is a major component of T2DM. Explain this pathophysiology. How could you determine whether Adane is exhibiting insulin resistance?Insulin resistance is a condition in type 2 diabetes patients, when the body produces insulin and does not use it properly. Instead of the body using the insulin to absorb glucose floating in the blood, it does not, meaning there is an excess amount of glucose. The body needs higher concentrations of insulin to help glucose go into the cells, which is why insulin injections are required for most patients with type 2 DM. To determine whether Adane is exhibiting insulin resistance a fasting blood glucose level would be taken, and if the level is high on more than one account, it would be concluded that she indeed is. Additionally, Adane could have other symptoms that often are seen with insulin resistance such as high blood pressure, high LDL, and the darkening of certain areas of skin. Nelms, M. (2011).?Nutrition therapy and pathophysiology?(2nd ed., pp. 498-499). Belmont, CA: Wadsworth, Cengage Learning.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 hoes this compare to the lipid goals for children with diabetes?T2DM and early cardiovascular disease in children are often seen hand in hand. This is because oftentimes diabetes patients have conditions that will increase their risk for developing CVD. These conditions include high blood pressure, dyslipidemia, obesity, physical inactivity, and a poorly controlled diet. The American Heart Association reports that if a person has insulin resistance or diabetes along with one of the risk factors mentioned above, they are at a much higher risk of developing CVD. Adane’s lipid profile showed that she was above the reference range for both total cholesterol and triglycerides. Lab ValueReference RangeAdane’s RangeTotal cholesterol (mg/dL)<170210Triglycerides (mg/dL)<150175Cardiovascular Disease & Diabetes. (2012, July 5). Retrieved November 12, 2014, from . Adane’s grandmother asks about medication for treating high cholesterol as her husband is on this medicine. What are the recommendations for the use of statin drugs in children?According to 2014 ADA guidelines, the use of statin drugs are allowed and recommended for treatment of high cholesterol in children. However, there are guidelines to the use of these drugs. Children should at least be 10 years old and the first line of treatment should be lifestyle changes and MNT. If lifestyle and nutritional changes are not enough, then statins could be added, however not all statins are FDA approved for children, so the type of statin used needs to be carefully chosen by a medical provider. Diabetes Management Guidelines. (2014, March 13). Retrieved November 12, 2014, from . Adane’s urinalysis is positive for protein. What does this mean and how may this be related to her diabetes? The scientific name for protein in the urine is proteinuria. A small amount of protein in the urine is normal, however moderate to high levels are a sign of chronic kidney disease. Chronic Kidney disease can occur when blood proteins leak into urine due to damage of the kidney. It is common in people with diabetes and hypertension. Albumin in the urine is one of the first signs of deteriorating kidney function in both type 1 and type 2 diabetes. Adane’s lab results showed trace amounts of protein in the urine, which is an early sign of kidney disease. Proteinuria. (2014, April 2). Retrieved November 12, 2014, from . 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 postprandial target glucose levels for Adane? Adane and her family need to be properly educated about self-monitoring of blood glucose (SMBG), as it will assist in adjusting daily eating patterns and insulin injections needed to maintain a healthy blood glucose level. Frequency of SMBG testing is determined by the needs and goals of the patient carefully thought out by the medical team. For a Type 2 DM patient, testing should be done around mealtimes, before and after physical activity and anytime the patient feels low or high. For Adane, target fasting glucose levels would be 70-130mg/dL as the normal range is <100mg/dL. Target postprandial glucose levels would be <180mg/dL, as the normal level is <140mg/dL. Nelms, M. (2011).?Nutrition therapy and pathophysiology?(2nd ed., pp. 493-494). Belmont, CA: Wadsworth, Cengage Learning. II. Understanding the Nutrition Therapy10. Outline the basic principles for Adane’s nutrition therapy to assist in control of her T2DM.To assist Adane in her control and management of T2DM, there are many principles of nutrition therapy that she should be following. These include:Increase physical activity regime Monitor total grams of carbohydrate by using exchange lists or carb countingMonitor protein intake and keep between 10-20% of daily intake. Intake should not exceed 20% as it is a contributor to nephropathy.Achieving a fat intake of 25-35%Saturated fat intake of <7%Minimal to no trans fat intakeIncrease fiber intake by consuming fiber rich cereals, legumes, fruits, vegetables, and whole grain products. For every 1000 kcal it is recommended that 14g of fiber is taken in. Nelms, M. (2011).?Nutrition therapy and pathophysiology?(2nd ed., pp. 505-506). Belmont, CA: Wadsworth, Cengage Learning.III. Nutrition Assessment11. 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: 45th percentileWt/age: 99th percentileHt/wt: 99th percentileBMI: 36.412. Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T2DM.Lab ValueReference Range8/3Glucose (mg/dL)70-110171Cholesterol (mg/dL)<170210Triglycerides (mg/dL)<150175Protein (mg/dL)NegTrGlucose (mg/dL)Neg +Prot chkNeg+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?Wt: 140lbs/2.2lb/kg= 63.6kgHt: 52in x .0254m/in= 1.32 mTotal Energy Expenditure for Overweight Girls Ages 3-18TEE= 389- (41.2 x age (y)) + PA x (15.0 x weight (kg) + 701.6 x height (m))TEE= 389-(41.2 x 9) + 1.18 x (15.0 x 63.6kg + 701.6 x 1.32m)TEE=389- 371 + 2218TEE= 2,236 kcalProtein Requirements 0.8g/kg0.8g x 63.6kg= 51g ProteinAdane is only 9 years old and still growing, therefore she should not be put on a calorie-restricted diet. Instead, it would be suggested that she increases her physical activity, and adheres to the recommended calories for her age group and she might gradually begin to see some weight loss. Nelms, M. (2011).?Nutrition therapy and pathophysiology?(2nd ed., p. 243 Belmont, CA: Wadsworth, Cengage Learning.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. Food ItemExchangeCarbohydrateFatProteinCaloriesBreakfast1 C fruit punch2 starches30g0g0g120 kcal2 C frosted flakes4 starches60g4g12g240 kcal1 C whole milk1 milk12g8g8g150 kcalMidmorning Snack2 slices toast2 starches30g2g6g160 kcalButter 1 fat0g5g0g45 kcalJam1 starch15g0g060 kcalSnacksChocolate chip cookies2 starches & 2 fat30g12g6g252 kcal2 bags Cheetos2 starches & 2 fat30g12g6g252 kcalFruit punch2 starches30g0g0g120 kcal2 popsicles2 starch30g0g0g 120 kcalLunch4 slices bread4 starches60g4g12g380 kcal4 tbsp. peanut butter (2 per sandwich)4 protein0g32g28g400 kcal2 tbsp. mayo6 fat0g30g0g270 kcal1 banana2 fruits30g0g0g120 kcal2 Cups fruit punch4 starches60g0g0g240 kcalChips1 starch & 1 fat15g5g3g125 kcalDinnerFried pork chip3 meat0g24g21g300 kcalGreens1 vegetable5g 0g2g25 kcalPotatoes2 starches30g0g6g160 kcalCornbread1 starch & 1 fat15g6g3g125 kcalButter1 fat0g5g0g45 kcalIced tea + sugar1 starch15g0g0g60 kcalBedtime SnackPizza Rolls3 starch, 3 fat45g18g9g 378 kcalCoke2 starch30g0g0g120 kcalTotal572g167g122g4267 kcalTotals:Calories: 4267 kcalCarbohydrate: 572g x 4kcal/g=2,288 kcal from carb= 54% carbohydrateFat: 167g x 9cal/g= 1,503 kcal from fat= 35 % fatProtein: 122g x 4kcal/g= 488 kcal from protein= 11% proteinAfter calculating nutrient totals from Adane’s 24 hour recall, it was found that she is not following a diet similar to what is recommended for her age, size, and diabetes diagnosis. She is consuming about 2000 calories more than what is recommended for her height, weight, and age, which is a major contributor to her obese weight classification. When her nutrient totals were broken down, she is within the normal percentages, however I would suggest lowering her fat intake to closer to 25% and increasing her protein intake by 5%. Additionally, she needs should increase her fruit, vegetable, and fiber consumption as she is not eating enough from those food groups and eats a lot of junky, highly processed, convenience foods. IV. Nutrition Diagnosis15. Prioritize two nutrition problems and complete the PES statement for each.PES 1:Excessive energy intake related to food preferences of high caloric and high fat foods as evidenced by 24 hour recall of over 4,000kcal a day. PES 2:Obesity related to type 2 DM diagnosis and excessive energy intake as evidenced by BMI of 36.4 and weight per age classification of 99th percentile. V. Nutrition Intervention16. 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. For Adane’s initial nutrition therapy prescription, I would recommend a daily caloric allowance of 2,200 kcal. Of this amount, she should be following the guidelines for a type 2 DM patient, meaning she needs to monitor the percentages of foods she is getting from each food category. Her carbohydrate intake should be 55-65%, her protein intake should be 10-20%, her fat intake should be 25-35%, and no more than 7% of her total calories should come from saturated fat. From her 24-hour recall, it was concluded that she does not eat many fruits, or vegetables and that she is eating well above the portion sizes that she should be for each food item. I would want to see her eating less processed foods, and more produce, especially when snacking. Additionally, she and her parents need to be educated on correct portion sizes (for example, she should not be eating two sandwiches for lunch, 2 cups of cereal for breakfast, and a bag of pizza rolls as a before bedtime snack). Adane’s consumed a lot of high fat foods and additives in her diet, and if she could cut out or modify these, than a great chunk of her calories would be decreased. Some examples include substituting skim milk for whole milk, peanut butter sandwiches for turkey sandwiches, baked meat instead of fried, and water or 100% fruit juices instead of fruit punch and soda. Aside from making modifications to her diet, I would advise that her parents incorporate some sort of physical activity into her daily routine. This start off as simple as taking a 30 minute walk after school, going on a bike ride, or playing games outside with friends. She should be getting at least 30-60 minutes of physical activity daily in order to help her maintain her weight. 17. Outline the initial steps you would use to teach Adane and her family about nutrition and diabetes. What education materials could you use? It is important that Adane and her family are taught about nutrition and diabetes, as proper diet and lifestyle choices are key in keeping diabetes under control. Some steps I would take would be as follows:Educating the family on what diabetes is, and how it can be controlled with proper adherence to diet and medications. Teach family and Adane about proper blood glucose levels and SMBG.Teach family and Adane how to properly count carbohydrates, provide the exchange list, and give examples.Write out and plan sample menus that would be good for Adane to follow using foods she likes. Explain and provide examples of slow acting vs. fast acting carbohydrates.Set goals on SMBG, physical activity, and diet. Some materials I would use would include the exchange lists, food models, etc.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?Although Adane will not be started on medication, I still think it is important to educate her and her family on hypoglycemia, sick-day rules, and exercise. When sick, your blood sugar levels can spike, due to an imbalance of hormones, and insulin often cannot work as it is supposed to. It become very difficult to keep your blood sugar in your target range when ill, which can lead to serious conditions, and could cause a diabetic coma. When Adane does get sick, her parents need to contact her medical team and will need to monitor her blood sugar levels very closely. It will be important for Adane to exercise, as it is very useful in lowering blood glucose and will be vital to maintaining and not gaining any further weight. Although people with type 1 diabetes are more prone to hypoglycemia during physical activity, it still can occur in type 2 diabetes patients. If it occurs during or after exercising it is important to immediately treat it with 15g of a fast acting carbohydrate and then rechecking your blood glucose. Adane and her family need to know all of this information because she is a child, she needs daily exercise, and it is likely that she will get sick a few times a year. If she is properly educated on these topics, than it is likely that her blood sugar will stay under control and she will not need any further medical treatment. When You're Sick. (2014, April 1). Retrieved November 17, 2014, from . Adane’s mom is worried that none of the children will ever be able to have birthday cake or other sweet treats. She feels that 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 a diagnosis of type 2 diabetes does not mean that her daughter will have to give up sweets all together and miss out on important childhood memories such as eating her own birthday cake. It is true that Adane should not be eating these types of foods regularly, however every once in a while is alright, just make sure portion sizes are correct and her blood sugar is tested before and after. Additionally, I would suggest that her mother buy a diabetic cookbook and try altering some of her recipes to accommodate Adane’s special needs. VI. Nutrition Monitoring and Evaluation20. Write an ADIME note for your initial nutrition assessment.A9 y.o. femaleAfrican AmericanHt: 52”Wt: 140lbsBMI: 36.4 kg/m2BP: 100/59Temp: 98.6Family Hx of type 2 DM, high cholesterol, hypertensionNo current medicationsDietary recall revealed daily intake of 4000+ kcal, large portions, high intake of high fat foods, and insufficient intake of fruits, vegetables and whole grainsAbnormal laboratory results:\sDPES 1:Excessive energy intake related to food preferences of high caloric and high fat foods as evidenced by 24 hour recall of over 4,000kcal a day. PES 2:Obesity related to type 2 DM diagnosis and excessive energy intake as evidenced by BMI of 36.4 and weight per age classification of 99th percentile. IPatient will being a 2200 daily calorie diet, increase whole grain, fruit and vegetable consumption, and decrease fat consumption. 55-65% of diet will be from carbohydrates, 10-20% protein, and 25% fat. Education will be provided to patient and family on SMBG, carbohydrate counting, carbohydrate exchanges. Patient will be advised to participate in at least 30 minutes of physical activity 5 days of the week. M/EPatient will keep a daily food and activity log, to be evaluated by dietitian and medical team every 2 weeks to ensure a proper diet and exercise routine is being followed.At check up, abnormal laboratory results will be reevaluated (glucose, cholesterol, triglycerides, urinanalysis) to make sure progress is being made in the right direction. Weight will also be taken to make sure patient is maintaining, and not gaining any weight. 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? Gastric bypass surgery is a complicated and risky procedure for the pediatric population. The following criteria would make a child a candidate:A history of obesity for at least 3 yearsTried weight loss problems without successBMI greater than 40Have attained physiologic or skeletal maturity (typically age 13)According to this information, Adane is not a candidate for gastric bypass surgery. She is only 9 years old and has not met skeletal maturity. Her BMI is currently 36.4, which is less than 40. Adane currently is obese, but if she complies with her new diet and physical activity regime then she should be able to maintain and not gain any additional weight without needing bariatric surgery. Bariatric Surgery | Obesity Institute | Children's National | Washington, DC. (n.d.). Retrieved October 10, 2014, from Diabetes Association Recommendations. (n.d.). Retrieved November 10, 2014, from Surgery | Obesity Institute | Children's National | Washington, DC. (n.d.). Retrieved October 10, 2014, from Disease & Diabetes. (2012, July 5). Retrieved November 12, 2014, from Autoantibodies. (2014, May 9). Retrieved November 12, 2014, from Management Guidelines. (2014, March 13). Retrieved November 12, 2014, from , M. (2011).?Nutrition therapy and pathophysiology?(2nd ed., pp. 498-499). Belmont, CA: Wadsworth, Cengage Learning.Proteinuria. (2014, April 2). Retrieved November 12, 2014, from You're Sick. (2014, April 1). Retrieved November 17, 2014, from ................
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