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

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.

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

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

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

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

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

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

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!

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

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

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 Kcl/L @ 300 mL/hr begin infusion @ 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: 70-80 g breakfast + lunch, 85-95 g dinner, 30 g PM snack 2200 mL fluid requirement Mollie Nutrition orders nothing by mouth except ice chips and meds for 12 hours

Laboratory Results Laboratory Value Normal Range Armando’s Value Sodium (mEq/L) 136-145 130 CO2 (mEq/L) 23-30 31 Glucose (mg/dL) 70-110 683 Phosphate (mg/dL) 2.3-4.7 2.1 Osmolality (mmol/kg/H20) 285-295 306 Cholesterol (mg/dL) 120-199 210 Triglycerides (mg/dL) 40-160 175 HbA1c (%) 3.9-5.2 12.5 C-peptide (ng/mL) 0.51-2.72 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)

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) 7.35-7.45 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

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 K@ 135 mL/hr Begin Novolog 0.5 units/2 hrs until glucose is 150-200 mg/dL Begin Glargine 15 units @ 9PM Progress Novolog using ICR 1:15 Check glucose hourly, notify if >200 or <80 mg/dL MA

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

Energy & Protein Requirements ENERGY REQUIREMENTS REE= 10 x wt (kg) + 6.25 x ht (cm) - 5 x age (yrs) + 5 REE = 10 x 75 + 6.25 x 180 - 5 x 32 + 5 = 1,720 kcal TEE= 1720 x 1.0 = 1720 kcal (resting) to 1720 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

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, 85-95 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 70-130 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

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

Blood Glucose Monitoring Insulin Pump -dosage based on ICR -regular or rapid acting insulin -0.5-0.7 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 10-15 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

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?

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 10-20 years after being diagnosed, their probability for managing T1DM greatly increases

Resources Autoantibody Markers (2014). Diapedia. Retrieved on 16 Nov 2014 from http://www.diapedia.org/type-1-diabetes-mellitus/autoantibody-markers. doi: http://dx.doi.org/10.14496/dia.21040851461.17 Avoiding Low Blood Glucose Levels During Exercise. One Touch. Retrieved on 17 Nov 2014 from http://www.onetouch.com/articles/lowbloodglucoselevels Diabetes Signs. Diabetes.co.uk. Retrieved on 16 Nov 2014 from http://www.diabetes.co.uk/The-big-three-diabetes-signs-and-symptoms.html Higdon, J. PhD. Glycemic Index and Glycemic Load. (2005). Linus Pauling Institute Micronutrient Information. Retrieved on 17 Nov 2014 from http://lpi.oregonstate.edu/infoce 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 https://www.novologpro.com/pharmacology/mechanism-of- action.html Polyuria-Frequent Urination. Diabetes.co.uk. Retrieved on 16 Nov 2014 from http://www.diabetes.co.uk/symptoms/polyuria.html 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 http://diabetes.diabetesjournals.org/content/54/suppl_2/S68.full. doi:10.2337/diabetes.54.suppl_2.S68 Unexplained Weight Loss. Diabetes.co.uk. Retrieved on 16 Nov 2014 from http://www.diabetes.co.uk/symptoms/unexplained-weight-loss.html What is Type 1/2 Diabetes? Diabetes Research Institute Foundation. Retrieved on 16 Nov from http://www.diabetesresearch.org/what-is-type-one-diabetes