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Jillian O’NeilKNH 41111/19/13Case Study #16 – Type 2 Diabetes Mellitus – Pediatric Obesity 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?When a child develops type 2 DM at a young age, he or she is at an increase risk for an unhealthy future. Currently, their bodies will not respond normal to the insulin it produces making glucose less able to enter cells and supply energy – know as insulin resistance. This ultimately causes a rise in blood sugar, which makes the pancreas work overtime. This can cause the pancreas to wear out and ultimately lead to a decrease in insulin production. In addition, developing type 2 DM at a young age puts the child at a greater risk for developing cardiovascular disease. Since both categories of African Americans and kids in puberty are at an increased risk for developing type 2 DM, the hormone levels can increase the insulin resistance levels. Lastly, when at an increased risk for metabolic syndrome, the child is also at an increased risk for developing hypertension, high cholesterol, stroke, vision impairment, and kidney disease. These concerns can lead to damage in the blood vessels, nerves, and gums. If DM hasn’t been controlled over the years of further age development, these concerns will be particularly common. The current ADA standards of medical care recommendations for at-risk children include: testing “children and adolescents who are overweight and who have two or more addition risk factors for diabetes.”(Dowshen, American Diabetes Association)Evaluate Adane’s medical record. Identify which risk factors most likely lead to the routine screening for DM during her school physical. Reviewing Adane’s medical record, numerous risk factors would play a part in the DM screening. First, her mother suffered from gestational diabetes during her pregnancy. Next, she has a strong family history; both her mother and grandmother suffers from type 2 diabetes where her grandfather suffers form high cholesterol and hypertension. In addition, her ethnicity of African-American puts her at an 1.8x increase risk of diabetes than non-Hispanic whites. Lastly, Adane is overweight with a BMI 36.4, has an unhealthy diet history, has a dry throat as well as dry skin, abnormal lab values and protein in urine. These factors would most likely lead to the routine screening for DM. (American Diabetes Association, Nelms)What are the ADA standard diagnostic criteria for T2DM? Which are included in Adane’s medical record?The ADA standard diagnostic criteria for Type 2 Diabetes includes: results from a progressive insulin secretory defect on the background of insulin resistance. In addition, the standard diagnostic criteria includes: an A1C greater than or equal to 6.5%, Fasting Plasma Glucose greater or equal to 126 mg/dL (7.0 mmol/L) during an Oral Glucose Tolerance Test, or a patient with classic symptoms of hyperglycemia or hyperglycemic crisis (a random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L). In regards to Adane’s medical record, her HbA1C was 6.9% (a greater value than 6.5%). In addition her glucose was 171mg/dL upon admission and 155mg/dl on the second day – both values indicate a glucose level greater than 126mg/dL.(Standards of Medical Care in Diabetes)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.Antibody tests are often requested to find the specific antibodies that attack the red blood cells. If the testing displays a presence of autoantibodies to a minimum of one of the autoantigens, an autoimmune pathogen is present and killing the beta-cells. Beta-cell loss over time is positively correlated with the onset of Type 2 Diabetes. When T-cell tests show the absence of the cells, it indicated a genetic risk and the onset of Type 1 Diabetes. In addition, the autoantibody levels may show prognostic data about the onset of Type 2 Diabetes in youths and adults. Autoantibody tests are for helping to diagnose autoimmune disorders – by determining the severity of the condition, monitoring the activity of the disease and assessing the effectiveness of treatments. In addition, it shows the estimated average glucose – making a correlation between this test and diabetes. Adane’s EAG was high – a value of 151. The Insulin C-Peptide blood test was requested because it measure the amount of C-Peptide, which is the result of the production of insulin. The test measures the difference between insulin injected into the body versus the amount of insulin that the body produces. It is often measured for patients with Type 2 Diabetes to determine if the body still produces insulin. While normal results would include a value of 0.5 to 2.0 ng/mL, an abnormal value indicates that the body is producing abnormal amounts of insulin – high or low. Adane’s C-Peptide value of 2.75 indicates a high value, the body is producing a large amount of insulin. In addition, the value reflects a level of high blood sugar in her body. (Autoantibodies, WebMD, Pihoker)Insulin resistance is a major component of T2DM. Explain this pathophysiology. How could you determine whether Adane is exhibiting insulin resistance?Those with Type 2 Diabetes produce insulin while their tissues are insulin resistant – thus causing an increased need for insulin. The pancreas then has to work harder to produce the amount needed. Ultimately, the pancreas will lose its ability to produce insulin. Peripheral insulin resistance with an insulin secretory defect that varies in severity is how T2DM is typified. While those cells are unable to respond to the insulin by translocating glucose transporters to the outer membrane, they are also unable to obtain energy from the glucose taken up. The defective insulin secretory response causes the liver to produce excess glucose. Initially, the inability of the cells to use glucose causes the postprandial glucose levels to increase. Then, the lack of glucose causes hepatic gluconeogenesis to take over and ultimately leading to fasting hyperglycemia. In addition, metabolic syndrome is correlated with insulin resistance. Obesity, insulin resistance, dyslipidemia, and hypertension are key factors of this condition. Diagnosis methods of metabolic syndrome may include may include: excessive energy, fat and sodium intake; inadequate calcium, fiber, potassium or magnesium intake; overweight/obesesity; food and nutrition related knowledge deficient; physical inactivity. In addition, displaying three of the five risk factors classifies a patient with metabolic syndrome – abdominal obesity, triglycerides, HDH cholesterol, blood pressure, and insulin resistance. It can be determined if Adane is exhibiting insulin resistance though the testing procedures for children: obesity (>85th percentile of weight for height) in addition to two of the following risk factors (family history, race/ethnicity, or signs of insulin resistance or conditions associated with insulin resistance). Based on these testing procedures, Adane would exhibit insulin resistance because she is at the 100th percentile of her weight for her height, she has a first degree relative with type 2 diabetes, and she is of the African-American population. (Nelms 292, 302, 499) 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?Patients with diabetes are at an increased risk for cardiovascular disease because they often have the conditions in which cause or contribute to cardiovascular disease – such as high blood pressure, abnormal cholesterol and high triglycerides, obesity, lack of physical activity, poorly controlled blood sugars and smoking. When insulin resistance is present in combination with any of the risk factors, the patient is at an increased risk for cardiovascular disease. Although controlling the concerns are beneficial, they also don’t decrease the risk. Adane’s lipid profile includes 210mg/dL of cholesterol and 175 mg/dL of triglycerides. According to the American Heart Association, cholesterol levels in children and adolescents from ages 2 to 19 years old should have less than 170mg/dL to have an ideal value. Borderline values include 170-199 mg/dL and high is greater than 200 mg/dL. Therefore, Adane’s cholesterol levels is considered “high.” (American Heart Disease; Nelms 302, 499)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?Statin drugs are a class of medications used often to lower blood cholesterol levels. This particular drug blocks the chemical action in the liver, which is important for making cholesterol. Statins inhibit HMG-CoA reductase – the enzyme that controls cholesterol production. The process is slowed down because the drug acts as the enzyme and replaces it in the liver. The average statin consumer has an average of 5mmol/l or 25-35% decrease in cholesterol levels. Even when the target cholesterol level is obtained, statin treatment remains to maintain the laboratory values and aid in the prevention of further atherosclerosis damage. Research from the American Heart Association has shown that when children have an inherited high level of cholesterol, statins can be used to lower cholesterol levels and reduce risk of coronary heart disease at a greater level than if parents are affected with disease. Research has shown that if statin therapy began during the patient’s childhood, there is “a reduced risk of disease and death from heart disease” and they did not suffer from “cardiovascular complaints.” Initially, lifestyle behavior changes are encouraged for children and adolescents; although, statins are encouraged wen lifestyle behavior changes aren’t effective. (Garfield, Danser)Adane’s urinalysis is positive for protein. What does this mean and how may this be related to her diabetes?Abnormally high protein amounts in urine is also known as “protein in urine” or proteinuria/microalbuminuria. While the kidneys filter waste products and retain protein, some disease states let the protein to flow into the urine without being filtered by the kidneys. A sign of diabetic kidney damage is correlated with high protein urine levels. Inadequate glucose control can increase diabetic kidney disease. Recently diagnosed with diabetes, the correlation with Adane’s urinalysis is that the lab values state an elevated level of protein in the urine. The disease has caused her kidneys to filter waste product but release the protein as well. (“Protein in Urine”)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 should absolutely be taught about self-monitoring of blood glucose. When a patient is diagnosed with diabetes, it is important to education him/her about controlling the disease. In this case, it is important to educate both the patient and the family because she is at such a young age – only 9 years old. Therefore, she will need the aid of her family to monitor and control the disease. According to the American Diabetes Association, the standard recommendations for daily frequency of testing include: testing prior to meals and snacks, occasionally postprandialy, at bedtime, prior to exercise, when suspecting low blood glucose, after treating blood glucose, and prior to critical tasks (such as driving). Although, the optimal frequency for the patients of SMBG on nonintensive regimens (for example, T2DM), is not known, studies have shown that the fasting SMBG levels are a titration of the basal insulin dose. The appropriate fasting target glucose level for Adane is less than 100mg/dL for a healthy child or 126mg/dL with a child of diabetes. The appropriate postpradialy target glucose level for Adane is 200mg/dl or more after two hours for diabetes; or, 140 to 199mg/dL for children with prediabetes. (American Diabetes Association)Outline the basic principles for Adane’s nutrition therapy to assist in control of her T2DM.The basic principles for Adane’s nutrition therapy:Treatment goals and lifestyle changes – nutrition intervention to support and facilitate lifestyle and behavior modifications, resulting in an improved metabolic controlWeight management – maintain her weight; as her age increases, she can “grow” into her current weight. Weight loss would only be encouraged if the physician suggested in the future. Carbohydrate – monitor carbohydrates with carb counting, exchange systemProtein – not to exceed 10% of total kcal to prevent nephropathy Fat –total fat not to exceed 25-35% of total kcal, saturated fat not exceed 7%, trans fat at a minimal. Fiber – encourage high fiber foods (such as legumes, enriched cereals, fruits, vegetables, whole-grain products); foods with a mixture of fibers are most effective for the serum glucose levels (they slow absorption of glucose form small intestine); encouraged to consume 14g of fiber per 1000 kcal. (Nelms 505, 506)Using the charts on pp. 188-189, assess Adane’s ht/age; wt/age; ht/wt; and BMI. What is her desirable weight?Referencing the charts in the “Case Study Approach” manual, Adane’s ht/age (132cm, 9yo) puts her at the 65th percentile; her wt/age (63.6kg, 9yo) is at the 100th percentile; her ht/wt (132cm, 63.6kg) is at the 100th percentile; her BMI (of 36.4 kg/m2) is also at the 100th percentile for her age of 9 years. Age = 9 years oldHT = 52” * 2.54 = 132cm / 100 = 1.32mWT = 140# / 2.2 = 63.6kgBMI = 36.4 kg/m2Her desirable weight for an age of 9 years and height of 52” would be at the 85th percentile or below – estimated about 73 pounds. She doesn’t need to lose the 67 pounds at this point; as she ages, she will slowly grow into the weight or may lose a little amount of that weight. (A Case Study Approach 188, 189)Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T2DM. Upon her admission, Adane’s laboratory values showed an increased glucose value of 171mg/dl (normal range: 70-119mg/dl), cholesterol value of 210 mg/dl (normal range: <70mg/dl), triglycerides of 175mg/dl (normal range: <150mg/dl), HbA1C value of 6.9% (normal range: 3.9-5.2%), estimated average glucose value of 151, and C-Peptide value of 2.75ng/mL (normal range: 0.51-2.72 ng/mL). In addition, her urine reflected an increased amount of protein, glucose and protein check (normal range: negative). In relation to her newly diagnosed T2DM, her increased HbA1c, glucose, c-peptide and urine analysis reflects the insulin resistance. The cholesterol and triglyceride values are indications of metabolic disease, which has a overlap of risks with diabetes. When insulin resistance is present, there is an increased risk of metabolic disease. Inadequate diabetic control can lead to a kidney malfunction, which ultimately can affect the protein in her urine. Lastly, the C-Peptide value of 2.75 indicates that the body is producing a large amount of inulin. (American Diabetes Association, Nelms)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 used the TEE for Overweight females aged 3 through 18 years old because Adane is currently considered overweight. I chose a PA value of 1.00 for sedentary because her medical history does not state any activity. Her Totally energy expenditure with a sedentary physical activity level for Adane is 1,898 calories with a caloric range of 1,800 to 1,900. TEE=389 – 41.2 * age + PA * 15.0 * weight + 701.6 * heightTEE=389 – 41.2 * 9 + 1.0 * 15.0 * 63.6 + 701.6 * 1.32TEE=389 – 370.8 + 954 + 926.112TEE = 1,898 calories (energy requirements)As stated in question 10, her protein should not exceed 10% of her energy requirements. Since we would still encourage a healthy and balanced diet, I would use the 10% protein for her recommended protein requirements of 48g. 1,898 * .10 = 189.8 calories from Protein / 4 = 48g protein. Weight loss is not a component of my estimation of energy requirements. Since Adane is at a young age, it is discouraged to encourage weight loss. Instead, it is encouraged to have the child “grow” into her current weight as she ages. Her lifestyle behavior changes may cause a slight decrease in weight but it is not an encouraged requirement. (Nelms 243, A Case Study Approach 182)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. Using , Adane consumed approximately 4,963 kcalories, 187.2g fat, 738.0 g carbohydrates and 104.7g of protein. Her diet consisted of 59% protein, 33% fats, and 8% protein. When comparing to the exchange system, she consumed 54 carbohydrates, 31 fats and 10 protein servings. See chart for detailed ratios of the exchange system. The recommended energy intake range for Adane (from question #10) is 1,898 calories. She consumed an excess 3,065 calories than what her body would require in reality. To put these values to scale, she consumed 261.5% of her recommended energy intake. 4963-1898 = 3065 calories in excess4963/1898 = 2.61486 * 100 = 261.5% PRIVATE "<INPUT NAME=\"oi75_oi11\" TYPE=\"submit\" VALUE=\"Cancel\">" MACROBUTTON HTMLDirect Food NameCalsFat (g)Carbs (g)Prot (g)Exchange System4,963187.2738.0104.7(Fat, Carb, Pro) HYPERLINK "" KRAFT, KOOL-AID SPLASH Soft Drink Grape Berry Punch, ready-t...1040.027.70.02 carb PRIVATE "<INPUT NAME=\"oi4_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Frosted corn flakes2940.472.22.65 carb HYPERLINK "" Milk, whole22011.916.511.8 PRIVATE "<INPUT NAME=\"oi10_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 1.5 carb1 protein1 fat HYPERLINK "" Bread1602.030.44.6 PRIVATE "<INPUT NAME=\"oi13_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 2 carb HYPERLINK "" Butter10211.50.00.11 fat PRIVATE "<INPUT NAME=\"oi16_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Jams and preserves390.09.60.1----- PRIVATE "<INPUT NAME=\"oi19_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Cookie, chocolate chip24412.432.02.85 carb5 fat PRIVATE "<INPUT NAME=\"oi22_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Snacks, corn-based, extruded, puffs or twists, cheese-flavor...31620.330.73.32 carb4 fats PRIVATE "<INPUT NAME=\"oi25_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Fruit punch juice drink, frozen concentrate, prepared with w...4962.0121.01.08 carb HYPERLINK "" Frozen novelties, juice type, POPSICLE SCRIBBLERS1380.433.50.0 PRIVATE "<INPUT NAME=\"oi31_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 2 carb HYPERLINK "" Bread3193.960.79.24 carb1 protein PRIVATE "<INPUT NAME=\"oi34_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Peanut butter37632.212.516.11 carb6 fat PRIVATE "<INPUT NAME=\"oi37_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Mayonnaise, regular19821.61.10.32 fat PRIVATE "<INPUT NAME=\"oi40_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Banana, raw1050.427.01.3 PRIVATE "<INPUT NAME=\"oi43_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 2 carb HYPERLINK "" Fruit punch drink, frozen concentrate, prepared with water2270.057.60.3 PRIVATE "<INPUT NAME=\"oi46_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 4 carb HYPERLINK "" Snacks, potato chips, cheese-flavor28115.432.74.8 PRIVATE "<INPUT NAME=\"oi49_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 2 carb3 fat HYPERLINK "" Pork chop, fried22615.00.021.4 PRIVATE "<INPUT NAME=\"oi52_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 3 fat3 pro HYPERLINK "" Greens, cooked342.03.61.3 PRIVATE "<INPUT NAME=\"oi55_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 1 carb HYPERLINK "" Potatoes, baked, flesh, with salt1130.126.32.4 PRIVATE "<INPUT NAME=\"oi58_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 3 carb HYPERLINK "" Cornbread, prepared from mix1404.520.93.71.5 carb1 fat PRIVATE "<INPUT NAME=\"oi61_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Butter10211.50.00.11 fat PRIVATE "<INPUT NAME=\"oi64_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Tea, ready-to-drink, LIPTON BRISK iced tea, with lemon flavo...1720.043.20.03 carb PRIVATE "<INPUT NAME=\"oi67_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect HYPERLINK "" Pizza rolls42019.543.117.4 PRIVATE "<INPUT NAME=\"oi70_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 3 carb4 fat2.5 pro HYPERLINK "" Soft drink, cola-type1380.135.60.32 carb PRIVATE "<INPUT NAME=\"oi73_oi11\" TYPE=\"submit\" VALUE=\" \">" MACROBUTTON HTMLDirect 4,963187.2738.0104.7TOTAL:54 carb31 fat10 pro (, Kulkarni)Prioritize two nutrition problems and complete the PES statement for each. Adane’s Nutrition problems:Excessive energy intake NI-1.3Excessive fat intake NI-5.6.2Excessive mineral intake NI-5.10.2 Sodium(7) 10736Overweight NC-3.3(Academy of Nutrition and Dietetics)Excessive Calorie IntakeExcessive caloric intake of 4,963 calories as related to lifestyle-diet choices as evidence by a BMI of 36.4 and weight history of 140 pounds. Excessive Fat IntakeExcessive fat intake of 187.2g as related to lack of nutrition knowledge as evidence by diet history. (A Case Study Approach 182)(Academy of Nutrition and Dietetics, A Case Study Approach 182) 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. Her initial nutrition therapy prescription would include the following list. Since this is only her initial prescription, it would be simple with realistic goals. Her future nutrition counseling sessions would include additional goals or lifestyle behavior changes. Replace sweetened beverages (ie. Fruit punch, Kool-Aid, soda, iced tea, and coke) with either water or maximum of two servings of 100% fruit juice/dayReplace snack items with a serving of fruit and/or low-fat yogurtIncrease physical activity – walk for 20 mins, 3x/weekThe three initial nutrition therapy prescription goals/lifestyle behavior changes would ultimately cause a decrease in calorie intake. A caloric goal may be difficult for the initial weeks of her lifestyle changes, which is why a caloric goal of 1800 to 1900 calories wasn’t listed. After feeling comfortable with these initial lifestyle changes, she will feel more confident to make the larger goals in the future (such as a decrease in caloric/energy intake). (Nelms 505, 506)Outline the initial steps you would use to teach Adane and her family about nutrition and diabetes. What education materials could you use?Materials: “Portion pals” – to show proper portion sizes “Take home” sheets to reinforce material discussed during counseling sessionJournal – recording daily energy intakeFood demonstrations about healthier cooking (if applicable during first session, otherwise during future sessions)Initial StepsOverview about diabetes; Importance of healthy nutrition to control diabetesShow calculations of body weight, ideal body weight for her ageReview 24-hour recall and diet history – indicate which choices were “good” and which could “use improvement”Provide log for client/parents to keep track of nutrition intake; review portion sizes – if comfortable, encourage online database (such as SparkPeople) to record food (will be helpful to evaluate exact nutritional analysis) – if understanding, can use carbohydrate counting with the exchange systemReview goals and how to implement them into dietSummary + distribute take home sheets/packets; encourage family to make healthy lifestyle changes with Adane; schedule next counseling sessionConsidering that Adane will not be started on medication, is it necessary to teach her and her family about hypoglycemia, sick-day rules, and exercise?It is necessary to teach Adane and her family about possible health risks that medication could normally fix. Mild hypoglycemia can be identified – through trembling, nervousness, trouble concentrating, anxiety, blurred vision, sweating, irritability, rapid heart rate, inability to think clearly, dizziness, hunger, nausea, fatigue, weakness or headaches – with too little food or carbohydrate levels, a missed or delayed meal, increased activity, side effects form non-diabetic medication, and variability of insulin absorption and rates of digestion of food. Severe hypoglycemia is associated with mental confusion, lethargy, and unconsciousness; it is with extremely low glucose levels. To aid in hypoglycemia concerns, appropriate amounts of insulin for correction should be used in addition to consuming meals on time with appropriate ratios and keeping 15-30g of carbohydrate snacks available for emergency use. In regards to sick days, a healthy individual would need sugar that can be used for energy to aid in the healing process of illness. When the patient feels too sick to eat, their body will retrieve energy from releasing blood sugar from the stored energy supplies in the liver. This causes an increase in blood sugar. Thus, this shows the importance of monitoring blood glucose levels. Testing blood sugars more often would be a good idea to ensure that the glucose levels are under control. If the blood sugar spikes drastically, stomach pains are present, excess fatigue, repetitive vomiting, repetitive diarrhea or an infection is present, it is very important to contact the doctor as soon as possible. Testing and monitoring for ketones is also important when sick because if the harmful waste builds up, diabetic ketoacidosis will occur. During this process, insulin isn’t available (in the needed amount) to break down the glucose so the body breaks down only fat. Ketones are formed while the fat is broken down, causing high levels in the blood. With exercise, hypoglycemia may be induced due to the increased activity. It is important to increase her food intake or reduce insulin levels. (Nelms 486, Diabetes Learning Center)Adane’s mom is worried that non 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 her that it is important for Adane to understand her condition. Although she may not be able to consume the sweet treats of other children, she still can have “desserts.” It would be of their best interest to not overcompensate for her condition because in her future, she will be faced with situations in which she cannot consume the products. At a young age, it may be beneficial to have the entire family participate in small lifestyle behavior changes. Then, I would suggest various ideas for her mom about birthday cake substitutes. She can make a “fruit cake” consisting of a big watermelon as the base, cantaloupe as middle layer, honeydew melon as top, and decorate with strawberry slices and blueberries (toothpicked into sides of melons). The candles will easily slide into the melon. Another option would be to make a healthy cake without added sugars and using only raw ingredients. A sample recipe can be found using the following link:. An alternative to cake, she can make a healthy smoothie and place the candle in the straw for a minute while singing the birthday song. My last suggestion would be to have a fruit and yogurt “bar.” The birthday guests can make a parfait with homemade/healthy granola. Greek yogurt is certainly thick enough to help keep the birthday candle upright. Write an ADIME note for your initial nutrition assessment.AA –52”, 140#, BMI = 36.4 kg/m2, African AmericanB – Glucose value of 171mg/dl, cholesterol value of 210 mg/dl, triglycerides of 175mg/dl, HbA1C value of 6.9%, estimated average glucose value of 151, C-Peptide value of 2.75ng/mL; urine: increased amount of protein, glucose and protein check C – 9 years old, female, obese; 1st degree family history, Type 2 Diabetes MellitusD – Prescribed: Lower-calorie energy intake (1,800 to 1,900 kcal); 48 g protein/day Current values: 4963 calories (261.5% of needed intake)DPES Statement:Excessive caloric intake of 4,963 calories as related to lifestyle-diet choices as evidence by a BMI of 36.4 and weight history of 140 pounds. Excessive fat intake of 187.2g as related to lack of nutrition knowledge as evidence by diet history. IPrescribed: 1,800 to 1,900 kcal diet with 48g proteinGoals:Replace sweetened beverages with either water or max. of 2 servings of 100% fruit juice/dayReplace snack items with a serving of fruit and/or low-fat yogurtIncrease physical activity – walk for 20 mins, 3x/weekNutrition Education (initial session with mother/family):Diabetes overview, important nutrition to control diabetesBody weight, ideal body weightDiet history: education on better choices for diabetic childPortion control review, food demonstrationSet GoalsM/EProvide journal to record daily energy intake and exercise; introduce to SparkPeople website to record food if possible“Take home” sheets to reinforce material discussed during counseling sessionJournal – recording daily energy intakeProvide number to contact in case of problem or questions/concerns (203-521-7885)Following counseling sessions:Monitor: weight, review diet history, assess continued compliance with regimen, diabetes/blood glucose; lab valuesSet new goals (if applicable)After sessions are complete: self-evaluation of counseling session and perceived progress of clientAdane’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?I do not encourage pediatric bariatric surgery at this time and would only recommended it as the last resort if the physician suggested the procedure. Although Adane is currently obese and at a high risk for developing other health concerns in addition to her Type 2 Diabetes, I would encourage to make lifestyle behavior changes initially. If these new techniques didn’t work, I would encourage her to make changes in the goals. Using surgery may be beneficial for her future but complications are always an issue. According to the University of San Francisco, they make every possible effort to achieve weight loss through non-surgical procedures. If these procedures do not work, the medical team can evaluate the child and the pediatric surgeon will then discuss surgical options. Ultimately, it is strongly encouraged for both the child and family to accept the responsibility to make lifestyle changes and commit to the strict program of healthy eating and exercise prior to surgery. (University of San Francisco)ReferencesAcademy of Nutrition and Dietetics (2013).?International dietetics and nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, IL: Academy of Nutrition and Dietetics."Antibody Tests." WebMD. WebMD, 27 May 2010. Web. 16 Nov. 2013. <;."Autoantibodies." Lab Tests. N.p., 26 Sept. 2013. Web. 19 Nov. 2013. <;."Cardiovascular Disease & Diabetes." American Heart Association. National Health Council, 31 Jan. 2013. Web. 17 Nov. 2013. <, AH Jan, Antoinette MaassenVanDenBrink, and Catharina AM van Kesteren. "69th Scientific Sessions Of The American Heart Association." Expert Opinion on Investigational Drugs 6.1 (2013): 87-90. American Heart Association. Web. 9 Nov. 2013.Dowshen, Steven. "KidsHealth." Type 2 Diabetes: What Is It?. N.p., n.d. Web. 17 Nov. 2013. <, Frances B.. "What About The Statins?." American Psychologist 56.4 (2001): 365-366. Print.Kulkarni, K. D.. "Carbohydrate Counting: A Practical Meal-Planning Option For People With Diabetes."?Clinical Diabetes23.3 (2005): 120-122. Print."Living with Diabetes." African Americans & Complications. American Diabetes Association, n.d. Web. 17 Nov. 2013. <, Marcia.?Medical nutrition therapy: a case study approach. 4th ed. Stamford, Connecticut: Cengage Learning, 2013. Print.Nelms, Marcia Nahikian.?Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print."Obesity Surgery." Pediatric Surgery. University of San Francisco, n.d. Web. 16 Nov. 2013. <, C., L. K. Gilliam, C. S. Hampe, and A. Lernmark. "Autoantibodies In Diabetes." Diabetes 54.suppl_2 (2005): S52-S61. Print."Protein in Urine."?Mayo Clinic. Mayo Foundation for Medical Education and Research, 21 May 2011. Web. 16 Nov. 2013. <;."Sick Days and Diabetes."?Diabetes Learning Center. BD Diabetes Education Center, n.d. Web. 16 Nov. 2013. <;."Standards of Medical Care in Diabetes—2013." American Diabetes Association. Version 36. N.p., n.d. Web. 16 Nov. 2013. <;. ................
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