1. Case Study 15 Type 1 Diabetes Mellitus
Mollie Gallagher and Mary Allison Geibel

2. TYPE 1 vs. TYPE 2 TYPE 1 DIABETES TYPE 2 DIABETES
Body is unable to synthesize enough insulin in pancreas to allow for glucose absorption
Cells “starve” without enough glucose for energy
Pancreatic beta cells are destroyed by autoimmune disease
Common in children and teenagers
5% of people with diabetes have T1
TYPE 2 DIABETES
Body produces insulin, but become insensitive to insulin, building up glucose in blood
Less insulin receptors/defective
Lifestyle and nutrition related
Most prevalent form of diabetes (adult onset)
Common with overweight/obese, starting to develop in younger ages
Mollie
Type 1
Type 1 DM, or “juvenile” diabetes, is defined as the body’s inability to to synthesize enough insulin in the pancreas to properly function.
Autoimmune disease causes the immune system to attack part of the body’s pancreas for unknown reasons.
The insulin-producing cells, called beta cells are not recognized by the immune system and therefore destroys them
T1DM is most common in children and teenagers, although, it can develop at any age
Insulin’s function is to allow glucose into the cells throughout the body to be used for energy.
If insulin is not functioning properly, glucose builds up in the blood causing the cells to ‘starve’ from insufficient levels of glucose.
Type 2
Type 2 DM, also known as “adult onset” diabetes, is the most prevalent form of diabetes.
On average, most individuals develop type 2 DM around age 35, although it can develop at any age.
Individuals are able to produce insulin, however, it is not enough.
Overtime, the body’s cells also become insensitive to insulin, preventing insulin from bringing glucose into the cell.
T1DM is most commonly described as an autoimmune disease, whereas T2DM is described as a lifestyle and nutrition related disease.
Type 2 DM is typically is seen in individuals who are overweight or obese.

3. Mechanisms Mollie Type 1
Beta cells are not recognized by the immune system and therefore destroys them
Insulin cannot be produced
glucose cannot enter the cells
Cells must rely on glycogen from breakdown of muscle and tissue to get energy
Type 2
High levels of glucose in the blood
Cells produce insulin, but it is not enough
Cells become resistant to insulin overtime and prevent glucose from entering

4. Etiology Genetic Factors Ethnicity Environmental Factors
Children whose mother has type 1 DM have a 2-3% risk of developing the disease, whereas those whose father has the disease have a 5-6% risk. When both parents are diabetic, the risk rises to almost 30%.
Ethnicity
Type 1 DM is most prevalent in Caucasians than African-Americans and Hispanic-Americans. Chinese people have a lower risk of developing type 1, as do people in South America, more common in northern climates
Environmental Factors
T cells can attack beta cells, triggered by viruses and antibodies such as German measles, mumps, rotavirus, and exposure to a protein in cows milk young in life MA
Aren’t a lot of known causes of T1D, harder than T2D because not diet/lifestyle based

5. Signs and Symptoms Frequent urination Extreme hunger
Unintended weight loss
Irritability and other mood changes
Fatigue and weakness
Blurred vision
Increased thirst
Slow healing cuts and bruises MA

6. Potential T1DM Complications
Hypo/hyperglycemia-high and low glucose levels in the blood
Diabetic Ketoacidosis-overproduction of acetyl-CoA, FA converted to ketones (acidic)
Diabetic Neuropathy-increased glucose in nerve cells, degradation
Polyuria-excessive passage of urine (3+ liters/day)
Polydipsia-excessive thirst, mouth dryness
Polyphagia-excessive hunger MA
ketoacidosis can cause hyperglycemia, hyperketonemia, and metabolic acidosis. Symptoms are nausea, vomiting, abdominal pain. Can lead to edema, coma, and death.
hypoglycemia can cause weakness, fatigue, sweating, and tachycardia
diabetic neuropathy can cause pain in extremities, vision problems and loss of control of BP, heart rate, and digestion
polyuria happens because excess sugar is excreted into urine, draws out more water
polyphagia happens because body cant convert food you eat into energy

7. Detection Type 1 and Type 2 LADA
Symptoms of Diabetes plus casual plasma glucose >200 mg/dL (11.1 mmol/L)
Fasting Plasma Glucose Test>126 mg/dL (7.0mmol/L)
2-Hour Postprandial Glucose Test >200 mg/dL during an OGTT
75-gram Oral Glucose Tolerance Test
Hemoglobin A1c value of ≥ 6.5%
LADA
Presence of circulating islet antibodies (including ICA, GADA, protein tyrosine phosphatase antibody)-also in T1DM
Age ≥ 30 years
Insulin independent for at least 6 months after being diagnosed
Mollie
Casual plasma glucose
During the test, blood sugar is tested without regard to the time since the person's last meal.
Fasting Plasma Glucose Test
It measures blood glucose levels after a period of fasting, usually at least eight hours without food or liquid (except water).
2-hour postprandial glucose test
Within two hours of eating, your insulin and blood glucose levels should return to normal.
If your blood glucose levels remain high, you may have diabetes.
how your body responds to sugar and starch after you eat a meal.
75-gram oral glucose tolerance test
fasts overnight (at least 8 hours)
The next morning, the fasting plasma glucose is tested.
the person receives a dose of oral glucose
Blood samples are taken up to four times at different time points after consumption
Hemoglobin A1c
Well controlled diabetes <7
8 > poorly controlled
result reflects your average blood sugar level
Blood drawn or finger prick

8. Patient Summary Armando Gutierrez, 32 year old, male Divorced
16 years of education, speaks English/Spanish
Computer software engineer, works 8-7 M-F and some weekends
Hispanic and Catholic
Smoker 1ppd x 10 years, daily alcohol use
Father-MI, mother-ovarian cancer and T2DM
Mollie

9. Previous Nutrition Intake
Breakfast
Toast, jelly, coffee, and scrambled egg
Lunch
Subway sandwich, chips, diet soda
Dinner
Pasta, rice, vegetables, some kind of meat (eats out 3-4 times/week)
Total kcal intake
1995 kcal
Protein
87.1 grams
Fat
74.4 grams
Carbohydrate
243.6 grams
Fiber
16.3 grams MA
Comments: slightly low E intake for needs, not enough meals in a day, drinks alcohol every day!

10. Anthropometric Data 99.6 F temperature Pulse 100 Resp rate 24
BP 78/100
Height 5’11”
Weight 165 lbs
height: 5’11” = (71 in)(2.54 cm/in)(1m/100cm) = 1.8 m
weight: (165 lbs)(1 lb/2.2kg) = 75 kg
BMI (kg/m^2) = (75 kg)/(1.8m)^2 = 23.1 kg/m^2 MA
BMI is within the normal range, diastolic BP is too high, high respiratory rate

11. Vital Signs Groggy and nearly unconscious, admitted to ER
Admitted with serum glucose 610 mg/dL
Tachycardia (fast heart rate)
Tense abdomen with guarding
Cloudy, amber urine
Pale, diaphoretic, and clammy skin MA
Friend found Armando nearly unconscious and very groggy, admitted to ER

12. Medical Dx/Treatment #1
[Diagnosed with T2DM 1 year ago, improper use of metformin medication]
Medical Orders
Regular insulin 1 unit/mL NS 40 mEq 300 mL/hr
begin 0.1 unit/kg/hr and increase to 5 units/hr
Laboratory analysis, urinalysis, hematology
Nutritional Orders
NPO except ice chips and meds for 12 hrs, switch to clear liquids (if stable)
Consistent Carb diet: g breakfast + lunch, g dinner, 30 g PM snack
2200 mL fluid requirement
Mollie
Nutrition orders nothing by mouth except ice chips and meds for 12 hours

13. Laboratory Results Laboratory Value Normal Range Armando’s Value
Sodium (mEq/L)
130
CO2 (mEq/L)
23-30 31
Glucose (mg/dL)
70-110
683
Phosphate (mg/dL)
2.1
Osmolality (mmol/kg/H20)
306
Cholesterol (mg/dL)
210
Triglycerides (mg/dL)
40-160
175
HbA1c (%)
12.5
C-peptide (ng/mL)
0.09
Mollie
High Blood Glucose-
inability to produce insulin to bring glucose into the cells
HbA1c (%)
shows the average level of blood sugar (glucose) over the previous 3 months.
6.5% or higher
C-peptide (ng/mL)
a blood test that measures the amount of C-peptide
a breakdown product that is created when the hormone insulin is produced and released.
Cholesterol (mg/dL)
Diet
Triglycerides (mg/dL)

14. Laboratory Results Laboratory Value Normal Range Armando’s Value ICA -+
GADA
IAA
pH (urinalysis)
5-7
4.9
Protein (mg/dL) +1
Glucose (mg/dL) +3
Ketones +4
Prot chk tr
pH (ABGs)
7.31
HCO3 (mEq/L)
24-28 22 MA
ICA,GADA,IAA-autoantibodies that indicate T1DM (insulin resistance)
low urine pH-Diabetic Ketoacidosis produces acidic ketones, makes pH drop
Protein, Glucose, Ketones in urine-kidney damage and hyperglycemia

15. Medical Dx/Treatment #2
Three months later reevaluated condition...
[Diagnosed with T1DM based on +ICA, GADA, IAA, (-) C-peptide levels]
Medical Orders
Change IVF to D5.45NS, 40 mEq 135 mL/hr
Begin Novolog 0.5 units/2 hrs until glucose is mg/dL
Begin Glargine 15 9PM
Progress Novolog using ICR 1:15
Check glucose hourly, notify if >200 or <80 mg/dL MA

16. Nutrition Diagnosis
Altered nutrition-related laboratory values (NC-2.2) related to poor management of DM and improper medication use as evidenced by elevated serum glucose level of 610 mg/dL.
Food- and nutrition-related knowledge deficit (NB-1.1) related to lack of knowledge of T1DM after being diagnosed as evidenced by symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss.
Mollie

17. Energy & Protein Requirements
ENERGY REQUIREMENTS
REE= 10 x wt (kg) x ht (cm) - 5 x age (yrs) + 5
REE = 10 x x x = 1,720 kcal
TEE= 1720 x 1.0 = 1720 kcal (resting) to x 1.4 = 2408 kcal (sedentary)
PROTEIN REQUIREMENTS
Pro = 0.8g/kg
Pro = 0.8(75)= 60g of protein/day
Pro = 60g x 4 kcal = 240 kcal/day
Mollie
Resting energy expenditure = 1720 kcal / day
Total energy expenditure = 2,408 kcal / day
Protein requirement = 60 g or 240 kcal / day

18. Nutrition Intervention
Energy Intake
2400 kcal/day, 4-5 small frequent meals
Fat
consume less cholesterol/saturated fat, lower lipid profiles
Protein
60 g/day
Carbohydrate
70-80 g breakfast + lunch, g dinner, and 30 g PM snack
Fiber
increase through fruits, vegetables, legumes, whole grains
Carbohydrate Counting/Glycemic Index
Decrease alcohol intake to 4 days/wk (2 drink max)
Introduce light exercise (30 min/day)
Monitor BG 3+ times/day, before exercise
2200 mL fluid requirement
Goal Lab Levels
A1C <7%
BP < 140/80 mmHg
LDL< 100 mg/dL
TG < 150 mg/dL
HDL> 40 mg/dL
preprandial glucose of mg/dL
postprandial glucose of <180 mg/dL MA
Alterations to current diet: substitute whole grain bread for sandwiches, eat less processed foods, take in more fluids (not diet coke)-fruit juices, tea, low fat milk
carbohydrates can be adjusted based on his glucose levels (choose low glycemic index

19. Sample Diabetic Menu Breakfast Snack Lunch Dinner
1 cup 1% milk, 1 orange, 1.5 cups Cheerios cereal
Snack
1.5 cups cantaloupe, ⅔ cups low fat/sodium cottage cheese
Lunch
Lentil salad, salmon, 1 large whole-wheat pita, ⅔ cups nonfat strawberry frozen yogurt
4 tbsp. prepared hummus, 4 oz carrot sticks
Dinner
¾ cups cooked brown rice, 1 cup steamed spinach, grilled steak with beets & radicchio, pineapple-raspberry parfait MA
His current diet could easily be altered but if he needed further suggestions we would offer sample diabetic menus
*Based on 2000 kcal diet

20. Blood Glucose Monitoring
Insulin Pump
-dosage based on ICR
-regular or rapid acting insulin
units/kg
-CSII, MDI, or mixed dose
Self Monitoring
-3+ times/day
-used to alter meal and medications
-maintain glycemic control
Physical Activity
-BG 100+ mg/dL prior
-eat before activity
-keep carb/sugar source on hand
Carb Counting
-glycemic index/load
-increase whole grain, fruit, and veg consumption
-set max carb intake for each meal
INSULIN-insulin to carb ratio- usually grams carb covered by 1 unit insulin. CSII: Continuous subcutaneous insulin infusion (basal rapid/short acting insulin pumped continuously). MDI: Multiple Daily Injections (intermediate insulin 2x/day,, rapid insulin prior to meals)-MORE FLEXIBILITY IN MEAL TIMING. Mixed: combination therapies with short and rapid acting insulin
PHYSICAL ACTIVITY-can establish glycemic control, improve insulin sensitivity, and increase glucose absorption in muscles BUT drops blood glucose levels. Need to prevent hypoglycemia (<70 mg/dL)
CARB COUNTING-glycemic index compares foods containing the same amount of carbohydrate and their potential to raise blood glucose levels. Glycemic load quantifies the effect the amount of carbohydrate has on blood glucose levels (summarizes quality and quantity of a carb). Low glycemic index foods can improve blood glucose control

21. Follow Up Evaluation
Lab values- blood glucose, ketones, lipids, protein, HbA1c, C-peptide, urinalysis, micronutrients
Food and exercise journal
Analyze adherence to diet and glycemic response
Have you felt comfortable about self monitoring your glucose levels?
Are there alterations needed in your diet to keep you blood glucose levels more stable?
Are you able to exercise without your blood glucose levels decreasing rapidly?
Have you felt dizzy, nauseous, or lethargic at any times during the day?
Do you need extra guidance to plan your meals to meet your nutrition goals?
Have you been able to count carbohydrates to keep your glucose levels adequate?
Have you been selecting high fiber foods and controlling your fat intake?
Has the insulin schedule been easy to follow and does it effectively lower your glucose?
Mollie
Have you felt comfortable about self monitoring your glucose levels?
Have you felt dizzy, nauseous, or lethargic at any times during the day?

22. Treatment
Prognosis
More than 60% of patients with T1DM do not experience future complications
Serious complications may include
Blindness
ESRD - End Stage Renal Disease
Early death
Outcomes also depend on the patient’s:
Education
Awareness
Motivation
Management of blood glucose, hemoglobin A1c, lipids, blood pressure, and weight greatly affect the outcome of the patient
Mollie
If patients do not experience complications years after being diagnosed, their probability for managing T1DM greatly increases

23. Resources
Autoantibody Markers (2014). Diapedia. Retrieved on 16 Nov 2014 from doi:
Avoiding Low Blood Glucose Levels During Exercise. One Touch. Retrieved on 17 Nov 2014 from
Diabetes Signs. Diabetes.co.uk. Retrieved on 16 Nov 2014 from
Higdon, J. PhD. Glycemic Index and Glycemic Load. (2005). Linus Pauling Institute Micronutrient Information. Retrieved on 17 Nov 2014 from neter/foods/grains/gigl.html
Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
NovoLog® is designed to mimic the normal physiologic insulin profile. Novolog. Retrieved on 17 Nov 2014 from action.html
Polyuria-Frequent Urination. Diabetes.co.uk. Retrieved on 16 Nov 2014 from
Stenstrom, G., Gottsater, A., Bakhtadze, E., Berger, B., Sundkvist, G. Latent Autoimmune Diabetes in Adults (2005). American Diabetes Association 54 (S68-S62). Retrieved on 16 Nov 2014 from doi: /diabetes.54.suppl_2.S68
Unexplained Weight Loss. Diabetes.co.uk. Retrieved on 16 Nov 2014 from
What is Type 1/2 Diabetes? Diabetes Research Institute Foundation. Retrieved on 16 Nov from