Download Claire Millonig KNH 411 Case Study 18 November 2014 Diabetes

Claire Millonig
KNH 411
Case Study
18 November 2014
Diabetes Mellitus
I.
Understanding the Diagnosis and Pathophysiology
1. 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?
Children are at a risk for type 2 diabetes based on genetic factors and environmental
factors. Genetics can play a role on type 2 diabetes in children but their influence also
play a huge part. Children typically have the same habits as their parents, such as
eating habits and exercise. The ADA recommends “testing to detect type 2 diabetes
and pre-diabetes should be considered in children and adolescents who are
overweight and who have two or more additional risk factors for diabetes” (ADA).
These additional risk factors must include 2 or more of the following: “have a family
history of type 2 diabetes in first or second degree relative, race/ethnicity (Native
American, African American, Latino, Asian American, Pacific Islander), Signs of
insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-forgestational-age birth weight), and maternal history of diabetes or GDM during the
child’s gestation” (ADA).
http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html
http://care.diabetesjournals.org/content/37/Supplement_1/S14.full#sec-10
2. Evaluate Adane’s medical record. Identify which risk factors most likely led to the
routine screening for DM during her school physical.
In her medical history it states that her mother had gestational diabetes while pregnant
with Adane. She was born with a birth weight of 10 lbs. and 4 ounces. Her mother
and grandmother both are type 2 diabetics and her grandfather has high cholesterol
and hypertension. The indication of a family history of diabetes and her mother
having gestational diabetes led to the routine screening for type 2 diabetes during her
school physicals.
3. What are the ADA standard diagnostic criteria for T2DM? Which are included in
Adane’s medical record?
Diagnosis of type 2 diabetes is mainly based on blood glucose levels. A series of tests
are conducted testing fasting plasma glucose (FPG) or 2-h plasma glucose (2-h PG)
levels after 75 g oral glucose tolerance test (OGTT). Recently the A1C test has been
added as a third diagnostic test. The A1C results of ≥6.5%, FPG ≥ 126 mg/dL, and 2h PG ≥ 200 mg/dL are indicators of diabetes. Adane’s medical tests show glucose
levels of 171 mg/dL the first day and 155 mg/dL on the second day and her A1C level
was 6.9% when tested.
http://care.diabetesjournals.org/content/37/Supplement_1/S14.full#sec-26
4. Adanes’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.
“C-peptide is a substance produced by the beta cells in the pancreas when proinsulin
splits apart and forms one molecule of C-peptide and one molecule of insulin”
(AACC). This is normally tested while determining if a patient is diabetic because c-
peptide and insulin are normally produced at the same rate. In type 2 diabetes, the
body is resistant to the effects of insulin and produces excess amounts. So testing cpeptide can indicate levels of insulin and help diagnosis diabetes. It has been found
that in type 1 diabetics, their bodies produce autoantibodies. These antibodies are
directed at the insulin produced by the pancreas. Typically this test is one of the main
indicators of type 1 diabetes.
http://labtestsonline.org/understanding/analytes/c-peptide/tab/test/
http://diabetes.diabetesjournals.org/content/54/suppl_2/S52.full
5. Insulin resistance is a major component of T2DM. Explain this pathophysiology.
How could you determine whether Adane is exhibiting insulin resistance?
In type 2 diabetes, your body doesn’t process and use the insulin correctly. Your cells
feel starved for energy and in return the pancreas produces excess insulin because the
body is not registering the amounts of insulin in your system. Over time, your
pancreas is not about to make enough insulin to properly regulate blood glucose
levels. Adane has high blood glucose levels, which could be an indicator of insulin
resistance.
http://www.diabetes.org/diabetes-basics/type-2/facts-about-type-2.html
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 does this
compare to the lipid goals for children with diabetes?
Elevated levels of glucose in the blood are a precursor for diabetes, but also a risk
factor for cardiovascular disease. People with type 2 diabetes typically have
unhealthy diets and exercise habit, which also puts them at risk for cardiovascular
disease with hypertension, high LDL cholesterol and triglycerides, and low HDL
levels. “50% of people with diabetes die of cardiovascular disease (primarily heart
disease and stroke) (World Health Organization). Adane’s cholesterol level was 210
mg/dL, which is way over the normal of less than 170 mg/dL. Her triglyceride levels
were also high. Her results indicated 175 mg/dL, when a normal result is less than
150 mg/dL. LDL levels for children who have diabetes are to be kept at 100 mg/dL or
below (ADA).
http://www.who.int/mediacentre/factsheets/fs312/en/
http://www.diabetes.org/newsroom/press-releases/2014/are-the-new-acc-ahaguidelines-for-lipids-appropriate-for-people-with-diabetes.html
7. 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?
Although statin drugs are administered for adults, they should be avoided for
children. Nutrition therapy and exercise interventions should be the first resource in
lowering a child’s cholesterol. Medication would only be considered in children of 10
years or older only after 6 months to a year of regular exercise and a healthy diet that
revealed no improvements (Eiland).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018249/
8. Adane’s urinalysis is positive for protein. What does this mean and how may this be
related to her diabetes?
A positive test for protein in Adane’s urinalysis indicates that her kidneys are not
filtering her urine properly. In type two diabetics this presents itself as an indicator of
kidney disease, more specifically diabetic kidney disease. Certain medications and
uncontrolled blood sugar levels in diabetics can cause diabetic kidney disease.
Without treatment, the damage of the kidneys can worsen and eventually result in
kidney failure.
http://www.webmd.com/diabetes/diabetes-urine-tests
9. 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?
Yes, Adane and her family should learn how to self-monitor her blood glucose
because in order to improve her blood glucose levels she must monitor them. SMBG
is especially helpful to determine what foods are best to be consumed and which
should be avoided. Blood glucose levels should be tested as necessary to establish
glycemic goals. This normally includes before and after meals, before and after
exercise and any other time you feel necessary. During illness, blood sugar levels
should be tested more frequently. Adane’s target glucose levels should be (Nelms):
Glycemic Indicator
Normal
Goal
Preprandial glucose
< 100mg/dL
70-130mg/dL
Postprandial glucose
<140mg/dL
<180mg/dL
http://www.diabetes.co.uk/blood-glucose/blood-glucose-testing-times.html
II.
Understanding the Nutrition Therapy
10. Outline the basic principles for Adane’s nutrition therapy to assist in control of her
T2DM.
Type 2 diabetics are advised to decrease their weight by monitoring caloric intake and
glucose levels. Lifestyle changes and behavior modifications can be done within
nutrition therapy and physical activity plans to improve their metabolic control level.
Overweight and obesity put the patient at risk for hypertension, dyslipidemia and
cardiovascular disease as well. Glycemic control is a very important factor that needs
to be monitored. Monitoring total grams of carbohydrates using the exchange system
or other carb counting method should be used to control glycemic intake. Protein
intake should not exceed 20% of the persons total calories for the day while fat
should remain around 25% - 35% as normal. However, saturated fat needs to be
monitored more closely and not exceed 7% of the total intake. Fiber rich foods such
as legumes and fortified cereals are recommended. The U.S dietary Guidelines
recommend 14 g of fiber for every 1000 kcal consumed (Nelms).
III.
Nutrition Assessment
11. Using the charts on pp. 188-189, assess Adane’s ht/age; wt/age; ht/wt; and BMI.
What is her desirable weight?
Adane is categorized in the 50th percentile for her age of 9 and her height of 52
inches. When evaluating her weight to age she is above the 97th percentile, along with
evaluating her BMI, she also falls above the 97th percentile. To fall into the 50th
percentile, Adane should weight between 58 and 65 lbs.
12. Identify any abnormal laboratory values measured upon her admission. Explain how
they may be related to her newly diagnosed T2DM.
Adane’s lab reports when admitted are as follows:
Glucose
Cholesterol
Triglycerides
HbA1c
EAG
C-peptide
Protein
Glucose
Prot chk
Reference Range
70-110mg/dL
< 170 mg/dL
< 150 mg/dL
3.9-5.2
-0.51-2.72 ng/mL
Neg
Neg
Neg
Actual
171 mg/dL
210 mg/dL
175 mg/dL
6.9
151
2.75 ng/mL
Tr
+
+
Adane’s high cholesterol and triglycerides are associated with her high BMI of 36.4.
her HbA1c level of 6.9 indicates that her blood glucose levels have been high the past
3 months. The glucose level of 171 mg/dL indicates that her body is not properly
producing and using insulin. C-peptide levels are tested because they are produced
alongside with insulin, so testing these levels can result in an approximate
measurement of insulin being produced as well. In Adane’s urinalysis she tested
positive for proteins and glucose. Protein in her urine indicates that her kidneys are
not functioning properly anymore.
13. Determine Adane’s energy and protein requirements. Be sure to explain what
standard you used to make these estimations. Should weight loss be a component of
your estimation of energy requirements?
140 lbs. / 2.2 kg = 63.6 kg
Mifflin-St. Jeor equation: 10 x 63.6 kg + 6.25 x 132.08 cm – 5 x 9 -161 = 1,255 kcals
1,255 x 1.2 = 1,506 kcals per day to maintain current weight
.8 g x 63.6 kg = 51 g of protein/day
Weight loss for pediatric patients is not recommended because they are still growing
and developing. The goal is to have them eating the right portions and types of foods
combined with physical activity to improve their health. After calculating the
estimated amount of calories, I multiplied by an activity factor of 1.2 because Adane
is currently not active. As she incorporates physical activity into her daily routine, her
caloric needs can increase.
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
1 C fruit punch
2 c. frosted
flakes
1 C Whole Milk
2 slices toast
with butter and
jam
Snacks
4 choc. Chip
cookies
2 small bags of
Cheetos
3, 8 oz. glasses
of fruit punch
2 popsicles
4 T Peanut
Butter
2 T mayo
1 banana
2 C. fruit punch
Chips
Fried pork chop
(5 oz. approx.)
Greens (1 cup
approx.)
Calories (kcal)
120
320
Carbohydrates (g)
30
60
Fat (g)
0
4
Protein (g)
0
12
150
280
12
22
8
12
8
6
1,000
320
163
60
39
4
12
0
170
30
12
6
360
90
0
0
60
200
15
0
0
16
0
14
270
60
240
85
500
0
15
60
15
0
30
0
0
6
40
0
0
0
3
35
50
10
0
4
Potatoes (1 cup
approx.)
Cornbread with
butter
Iced tea made
with sugar
Pizza roles and
coke
Total
160
30
2
6
125
15
6
3
120
30
0
0
490
89
10
7
4,960 kcals
746 g
189 g
116 g
When totaling the amount of calories Adane had eaten in the past 24 hours, we see
that she eats an excessive amount of calories. She should be taking in no more than
20% from protein, 25%-35% from fat, no more than 7% of that from saturated fat and
45% - 55% from carbohydrates. In her 24 hour recall she ate: 60% carbs, 34% fats,
and 24% protein. Therefore, she is eating a high percentage of carbs, higher fats, and
is over on protein percentage. Also, the foods she is eating are higher in saturated fat
and would be higher than 7% of her total calories.
http://glycemic.com/DiabeticExchange/The%20Diabetic%20Exchange%20List.pdf
IV.
Nutrition Diagnosis
15. Prioritize two nutrition problems and complete the PES statement for each.
Excessive energy intake (NI-1.3) related to consumption of high calorie diet as
evidence by 24-hour recall.
Obese, pediatric, (NC-3.3.2) related to high caloric intake as evidence by BMI of 36.4
and diagnosis of type 2 diabetes.
V.
Nutrition Intervention
16. 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.
I would prescribe Adane a 1,500 kcal diet based on previous calculations of energy
needs. As her activity level increased I would increase her caloric needs as well.
Within the 1,500 initial calories; 20% from protein, 25%-35% from fats (no more
than 7% coming from saturated fat), and 45%-55% from carbohydrates. I would
recommend taking out the high fat and calorie dense foods in her diet such as fried
meats, pizza rolls, and whole milk. Switching to fruits and vegetables for her daily
snacks will eliminate some of these high fat foods. Also, I recommend switching to a
low fat or skim milk and drinking water or 100% fruit juice rather than sugary drinks.
17. Outline the initial steps you would use to teach Adane and her family about nutrition
and diabetes. What education materials could you use?
To start out with, I would emphasize the importance of the whole family improving
their overall health. One person can make these changes easier when their family is
making the same changes. Then I would instruct them with some informational
handouts from the American Diabetes Association. Using these resources I would
instruct them on how to use the exchange system to monitor carbohydrate intake
especially along with overall calorie consumption. Emphasizing the difference
between refined carbs and whole grain carbs is important in controlling their blood
glucose levels. Another tool I would refer them to is using SuperTracker online. This
may be easier for them to navigate and understand. I would also provide them with
ways that they can become more active as a family, such as taking a walk after
dinner.
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?
Yes, it is still necessary to educate Adane and her family about hypoglycemia, sickday rules and exercise. Managing type 2 diabetes is necessary whether the patient is
on medication or not. Monitoring blood glucose levels is important, especially before
and after meals to watch for hypo- and hyperglycemia. Physical activity can help
improve insulin sensitivity, therefore improving blood glucose levels (Nelms). During
illness it is recommended that a patient checks their blood glucose level every 4-6
hours to monitor properly (Nelms).
19. 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 it is ok to give your child a treat every once in a while.
Having a piece of birthday cake would be acceptable but be cautious of the portion.
Larger portions will have higher amounts of sugar and carbohydrates, so it is best to
consume a small portion. It is also important to monitor blood glucose levels if she is
going to eat something sweet. Another option would be to research low sugar recipes
and serve one of those in place of a store bought cake.
VI.
Nutrition Monitoring and Evaluation
20. Write an ADIME note for your initial nutrition assessment.
Assessment:

Adane Ross is a 9 year old female diagnosed with T2DM during her school
physical.

Full term infant with a birth weight of 10 lbs. 4 oz.  her mother had
gestational diabetes

Family history of type 2 diabetes (mother and grandmother) and high
cholesterol and hypertension (grandfather).

Height: 52”; weight: 140 lbs.; BMI: 36.4

Labs:
Glucose
Cholesterol
Triglycerides
HbA1c
EAG
C-peptide
Protein
Glucose
Prot chk
Reference Range
70-110mg/dL
< 170 mg/dL
< 150 mg/dL
3.9-5.2
-0.51-2.72 ng/mL
Neg
Neg
Neg
Actual
171 mg/dL
210 mg/dL
175 mg/dL
6.9
151
2.75 ng/mL
Tr
+
+
Diagnosis:
Excessive energy intake (NI-1.3) related to consumption of high calorie diet as
evidence by 24-hour recall.
Obese, pediatric, (NC-3.3.2) related to high caloric intake as evidence by BMI of 36.4
and diagnosis of type 2 diabetes.
Intervention:

Educate Adane and her family on managing type 2 diabetes

Recommend a minimum of 30 minutes of physical activity per day

Provide lists of foods for healthier options for meals and snacks to meet her
caloric needs of approximately 1,500 kcals per day
Monitor/Evaluation:

At next appointment evaluate weight and BMI

Request a food journal to make sure patient is making necessary dietary changes

Re-evaluate Adane’s labs especially the ones that were abnormal at initial
appointment
21. Adane’s grandmother suggest that perhaps Adane should have “stomach surgery” so
that she will lose weight more quickly. What are the recommendations for pediatric
bariatric surgery?
For an adolescent to be considered for bariatric surgery they must be considered
morbidly obese (BMI ≤40) and have previous tried for six months or more to lose
weight through nutrition therapy (Inge). Also, they must have achieved skeletal
maturity, which is typically around age 13 for girls and 15 for boys (Inge). Bariatric
surgery is typically not performed on children because they are still growing.
Therefore, the considerations and qualifications for a child to have bariatric surgery
are only for extreme cases.
http://pediatrics.aappublications.org/content/114/1/217.abstract
Bibliography
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http://www.diabetes.co.uk/blood-glucose/blood-glucose-testing-times.html
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http://labtestsonline.org/understanding/analytes/c-peptide/tab/test/
Diabetes. (2014, November 1). Retrieved November 18, 2014, from
http://www.who.int/mediacentre/factsheets/fs312/en/
Diabetic Exchange List. (n.d.). Retrieved November 18, 2014, from
http://glycemic.com/DiabeticExchange/The Diabetic Exchange List.pdf
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Eiland, L. (2010, July 1). Use of Statins for Dyslipidemia in the Pediatric Population.
Retrieved November 18, 2014, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018249/
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Inge, T. (2003, November 10). Bariatric Surgery for Severely Overweight Adolescents:
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http://www.diabetes.org/newsroom/press-releases/2014/are-the-new-acc-ahaguidelines-for-lipids-appropriate-for-people-with-diabetes.html
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from http://care.diabetesjournals.org/content/37/Supplement_1/S14.full#sec-26