2 What is diabetes?Diabetes is a chronic disease associated with abnormally high blood glucose where the body does not produce sufficient amounts or properly use insulin.PrevalenceTwo types of diabetesType 1: develops when the immune system destroys pancreatic beta cells, the only source of insulinType 2: more common form with progressive loss of beta cells insulin deficiency or insulin resistance
3 What is diabetes? (continued) PathophysiologyBeta cell destruction leading to absolute insulin deficiencyNo insulin hyperglycemia no glucose to cells symptoms & complicationsDiagnostic criteria:Many symptoms are similar: hyperglycemia, polyuria, polydipsiaCan differentiate by: age of onset, etiology (autoimmune), risk factors (genetic, environmental), lab tests, ketoacidosis, significant weight lost, electrolyte disturbances,& comorbiditiesT1DM presents in three stages with different levels of symptoms, autoantibodies, & abnormal blood glucose (FBG, CPG, 2-h PG, HgA1C)There are two forms of Type 1: immune-mediated & idiopathic
4 summary of case study: Mg 32 year old Hispanic man admitted with acute uncontrolled hyperglycemiaDid not feel well, thirst and frequent urinationBG level of 610 mg/dLAdmitting Diagnosis was DKAPMH/FH: smoker 1ppd x10 yrs., father – MI, mother T2DMWt. 165 lbs. Ht. 5’11” BMI 23BP 78/100 Temp 99.6° Resp. 24HR 100
5 Interpretation: metabolic events & Pathophysiology Symptoms are consistent with admitting diagnosis of diabetic ketoacidosis.DKA is an acute, life-threatening complication especially common with Type 1.DKA is a complex disordered metabolic state involving hyperglycemia, ketoacidosis, and ketonuria.Treated in ER with insulin drip to regain glycemic control and reduce further complications.Without insulin the cells don’t have glucose to use as fuel, so the counterregulatory hormones try to get or make more glucose which worsens the hyperglycemiaPt. felt ill - may have had virus that might have been an environmental trigger .
6 Insulin: types and dosing Types: rapid, short, intermediate, long, & mixedPrescribed: Insulin drip. Eventual insulin regimen for discharge is total daily dose, TDD, of 30 units divided as 15 units from Glargine in the PM & 15 units from Novolog bolus prior to meals using ICR of 1:17TDD = Units x body weight = 0.4 units x 75 kg = 30 unitsHypoglycemia – need for glucose tablets, juiceGlargineNameOnsetPeak ActionDurationNovolog< 0.25 hr0.5 – 1.0 hr3 -5 hrGlargine2 - 4 hrPeak lesshr
7 Carb counting plan Suggested Foods Healthy carbohydrates: Whole grains 3.5 Servings CHO/meals, 1-2 snacksRecommended 240 – 270 grams of CHOICR = 1:17Breakfast = 75 g / 4 servings UnitsLunch = 75 g / 5 servings UnitsDinner = 75 g / 5 servings UnitsSnack = 30 g / 2 servings UnitsTotal CHOs = 255g / 16 servings UnitsHealthy carbohydrates: Whole grainsFiber rich foods: Vegetables, nuts, beans, peas, branFish: Salmon, tuna, sardines, and codGood fats: Avocados, pecans, olives, walnuts and almonds
8 pes statementsImpaired nutrient utilization (NC- 2.1) related to insufficient insulin level as evidenced by lab results ( BG 610mg/dl, A1C 10.2, C-peptide 0.09).Food and nutrition related knowledge deficit (NB-1.1) related to being newly diagnosed with Type 1 diabetes as evidenced by lack of awareness/knowledge of symptoms, disease, diet, glucose testing and self-monitoring.Excessive calorie intake or excessive carbohydrate intake (NI-5.8.2) related to uncontrolled type one diabetes as evidence by increased blood glucose and HgbA1C.
9 Nutrition care plan Monitoring Intervention Short Term Goals Monitor food and glucose levelExerciseNutrition educationUnderstand the complications and how to handle problemsTo achieve tight glycemic control by matching your carbohydrate to your insulin; timing and amountLong Term GoalsTo maintain blood glucose level and the AICTo improve MG’s health and also help reduce any risk of developing hypertension, stroke and CVDMonitoringCheck A1C testingSelf monitoring of blood glucoseBlood pressureKetonesCheck weight statusCheck lipid panel, TGsEvaluationKeep records of what MG eatsSee diabetic educator weeklyEvaluate for a pump in future
10 ReferencesAmerican Diabetes Association: Diagnosis and classification of diabetes mellitus, Diabetes Care 37(S1):S5, 2014a.Chiang JL, et al: Type 1 diabetes through the life span: a position statement of the American Diabetes Association, Diabetes Care 37:2034, 2014.Mahan, L. K., & Raymond, J. L. (2017). Krause's food & the nutrition care process (14th ed.) PagesAtkinson MA, Maclaren NK. The pathogenesis of insulin-dependent diabetes mellitus. N Engl J Med 1994; 331:1428.Quinn M, Fleischman A, Rosner B, et al. Characteristics at diagnosis of type 1 diabetes in children younger than 6 years. J Pediatr 2006; 148:366.Ziegler AG, Hillebrand B, Rabl W, et al. On the appearance of islet associated autoimmunity in offspring of diabetic mothers: a prospective study from birth. Diabetologia 1993; 36:402.Achenbach P, Koczwara K, Knopff A, et al. Mature high-affinity immune responses to (pro)insulin anticipate the autoimmune cascade that leads to type 1 diabetes. J Clin Invest 2004; 114:589.