Download Type of Insulin - Dietetic Portfolio

KNH 411
Erin Baas
Case Study 22: Type 1 Diabetes Mellitus
Case Questions
I. Understanding the Disease and Pathophysiology
1. Define insulin. Describe its major functions within normal metabolism
a. Insulin is a hormone that regulates blood glucose along with promoting uptake,
utilization, and storage of nutrients. It is produced in the pancreas by Beta cells and
controls the metabolic fate of carbohydrates, proteins, and lipids. Insulin secretion is
stimulated by an increased level of blood glucose, and when secreted, promotes the
uptake of glucose into hepatic muscle, and adipose cells. All tissues in the body, except
the cells of the brain, liver, and working muscles, depend on insulin for transportation
of glucose from the bloodstream into cells to be used for energy. Insulin also promotes
protein synthesis within cells through aiding in the transport of amino acids from the
blood into muscle and other tissues. This protein metabolism also produces a positive
nitrogen balance. A negative nitrogen balance, and a loss of protein, will occur when
insulin is deficient. This is why the presence of insulin is important for tissue growth.
(Nutrition Therapy and Pathophysiology, pages 478-479)
2. What are the current options regarding the etiology of type 1 diabetes mellitus (DM)?
a. Type 1 diabetes can either be immune mediated or idiopathic. Immune mediated type 1
diabetes results from the destruction of beta cells in the pancreas. This destruction of
beta cells can be either fast or slow depending on the individual. Faster destruction is
seen in infants and children, while slower destruction is seen more in adults. There is
no clear understand of what causes the autoimmune destruction of beta cells, however,
there are genetic predispositions and unidentified environmental factors that appear to
contribute to development of type 1 diabetes. Idiopathic type 1 diabetes has no known
cause. Individuals with idiopathic diabetes do not produce insulin. Very few
individuals have this type of type 1 diabetes, and those that do are most of African or
Asian decent.
(Nutrition Therapy and Pathophysiology, page 483)
3. What genes have been identified that indicate susceptibility to type 1 diabetes mellitus?
a. ***Autoantibody testing can be valuable to those who may be more at risk for
develping type 1 diabetes. Tests used to measure diabetes related autoantibodies
include glutamic acid decarboxylase antibodies (GADA), islet cell cytoplasmic
autoantibodies (ICA), and insulin autoantibodies (IAA). GADA are more prevalent in
older children and have been found in 70-90% of people with type 1 diabetes. The ICA
test measures a group of islet cell autoantibodies. The more of these islet
autoantibodies an individual has present, the greater their risk is for developing type 1
diabetes. IAA are primarily found in young children developing type 1 diabetes. The
presence of IAA shows that there has been continuous destruction of the beta cells.
(Nutrition Therapy and Pathophysiology, page 485)
4. After examining Susan’s medical history, can you identify any risk factors for type 1 DM?
a. Susan has a family history of diabetes, which is seen in her grandmother.
5. What are the established diagnostic criteria for type 1 DM? How can the physicians
distinguish between type 1 and type 2 DM?
a. Diagnosis of type 1 diabetes can be made by looking at plasma glucose levels. If they
are greater than or equal to 200 mg/dL, than the individual has type 1 diabetes. Other
symptoms such as unexplained weight loss, polydipsia, polyuria, or fasting blood
glucose above 126 mg/dL, should be taken into account and are characteristics of those
with type 1 diabetes. Physicians can distinguish between type 1 and type 2 diabetes by
looking at whether or not the individual is insulin resistant (type 2), or insulinopenic
due to beta cell destruction/failure (type 1).
(Nutrition Therapy and Pathophysiology, page 485)
6. Describe the metabolic events that led to Susan’s symptoms (polyuria, polydipsia, polyphagia,
weight loss, and fatigue) and integrate these with the pathophysiology of the disease.
a. In type 1 diabetes, glucose is unable to enter cells. This causes cells to starve along
with plasma glucose levels to rise(hyperglycemia). Excess glucose is lost in the urine
to compensate for the hyperglycemia due to the fact the kidneys can only filter so
much glucose from the blood. This causes polyuria, which is frequent urination. This
frequent urination and excessive loss of fluid leads to polydipsia, or frequent thirst.
Because cells are dependent on glucose for energy, and now have none available, the
body responds through polyphagia, which is the promotion of hunger. Weight loss and
fatigue occur from hypovolemia, which is the decreased fluid volume in the body
caused by the loss of total body water, along with the loss of potassium, sodium,
magnesium, and phosphorus.
(Nutrition Therapy and Pathophysiology, page 483)
7. List the microvascular and neurologic complications associated with type 1 diabetes.
a. Microvascular complications include nephropathy and retinopathy. Nephropathy is the
leading cause of chronic kidney disease and occurs in 20-40% of individuals with
diabetes. Retinopathy is strongly associated with diabetes and is the most frequent
cause of new cases of blindness in adults. The damage to the eyes is directly related to
damage to the blood vessels caused by hyperglycemia. Neurologic complications can
occur with neuroglycopenia, which is the inadequate supply of glucose to the brain.
(Nutrition Therapy and Pathophysiology, pages 472, 497)
8. When Susan’s blood glucose level is tested at 2 am, she is hypoglycemic. In addition, her
plasma ketones are elevated. When she is tested early in the morning before breakfast, she is
hyperglycemic. Describe the dawn phenomenon. Is Susan likely to be experiencing this? How
might this be prevented?
a. The dawn phenomenon is an increase in blood glucose in the early morning, most
likely due to increased glucose production in the liver after an overnight fast. If she had
too little food the night before, this could explain both the hyperglycemia and the
hypoglycemia. The hypoglycemia could have also been cause from inappropriate
timing of medication consumption. This dawn phenomenon can be prevented by
proper blood glucose monitoring and coordinating timing of medications and food
correctly.
(Nutrition Therapy and Pathophysiology, pages 472, 486)
9. What precipitating factors may lead to the complication of diabetic ketoacidosis? List these
factors and describe the metabolic events that result in the signs and symptoms associated with
DKA.
a. Ketoacidosis is one of the most acute complications of type 1 diabetes and usually
develops from an inadequate intake of insulin. This inadequate insulin intake causes an
increased dependence on lipids as the body’s primary source of energy, which in turn
increases the rate of lipolysis. This can result in the production of ketones, which are
acids that lower serum pH. These ketone bodies are excreted by the kidneys in the
urine. This results in increased hydrogen ion levels and causes metabolic acidosis. As
the pH lowers, increased amounts of sodium, potassium, and ammonia are excreted in
the urine. Ketoacidosis needs to be treated promptly and correctly to prevent coma and
death. Treatment includes providing insulin, fluids, and electrolytes.
(Nutrition Therapy and Pathophysiology, page 145)
II. Nutrition Assessment
A. Evaluation of Weight/Body Composition
10. Determine Susan’s stature for age and weight for age percentiles.
a. Weight for age = 15th Percentile
Stature for age = 24th percentile
(www.cdc.gov/growthcharts/data/set1clinical/cj41l022.pdf)
11. Interpret these values using the appropriate growth chart.
a. When stating that Susan’s weight for age is in the 15th percentile, it means her weight
is either greater than or equal to 17% of the reference population, and less than 85% of
that reference population. When stating her stature for age is in the 24th percentile, this
means Susan’s height is greater than or equal to 24% of the reference populations
height, but shorter than 77% of the reference population at the age of 15.
B. Calculation of Nutrient Requirements
12. Estimate Susan’s daily energy and protein needs. Be sure to consider Susan’s age.
a. Daily Energy Needs (Harris-Benedict Equation):
655.1 + 9.6 (45.5 kg) + 1.9 (157.5 cm) - 4.7 (15) = 1320.65 kcals
1320.65 kcals x PAL (1.6) = 2,113.04 kcals or between 2,100-2,200 kcals/day
Daily Protein Needs:
20% of daily kcals (2,000-2,500 kcals/day) = 400-500 kcals/day from protein, or
100-125 g protein/day
13. What would the clinician monitor in order to determine whether or not the prescribed energy
level is adequate.
a. Since Susan has been losing weight, the clinician would need to be monitoring whether
or not she is gaining back the weight she lost. Once she gains back that weight, the
clinician will need to make sure Susan is maintaining that healthy and not losing or
gaining weight. The clinician should also always be making sure Susan feels like she
has enough energy throughout the day/during volleyball practices.
C. Intake Domain
14. Using a computer dietary analysis program for food composition table, calculate the
kcalories, protein, fat (saturated, polyunsaturated, and monounsaturated), CHO, fiber, and
cholesterol content of Susan’s typical diet.
a. Kcals = 4,622
Fat = 190.3 g
Saturated = 76.1 g
Monounsaturated = 74.2
Polyunsaturated = 40.0 g
Carbs = 626.3 g
Protein = 134.7 g
Cholesterol = 380.5 mg
Fiber = 45 g
15. What dietary assessment tools can Susan use to coordinate her eating patterns with her
insulin and physical activity.
a. There are a few different assessment tools Susan can use to coordinate her eating
patterns with her insulin and physical activity. One of these tools is Self-Monitoring of
Blood Glucose (SMBG). This requires pricking the finger to acquire a drop of blood,
and is recommended three or more times daily for most individuals with type 1
diabetes. With this tool, Susan could see what her glucose level is at the very moment
the measurement is taken. The information given by the SMBG can assist in adjusting
daily eating patterns and medications as necessary to maintain glycemic control.
SMBG could also help Susan to see patterns in the ways in which food, exercise, or
other factors affect glycemic control. Another assessment tool Susan could use is
Continuous Glucose Monitoring, which uses a device that places a sensor right under
the skin. The sensor transmits the blood glucose reading to a receiver device worn
around the waist. This device gives readings of blood glucose levels every five
minutes.
(Nutrition Therapy and Pathophysiology, pages 493, 494)
16. Dietitians must obtain and use information from all components of a nutrition assessment to
develop appropriate interventions and goals that are achievable for the patient. This
assessment is ongoing and continuously modified and updated throughout the nutrition
therapy process. For each of the following components of an initial nutrition, list at least
three assessments you would perform for each component.
Component
Assessments You Would Perform
Clinical data
1. Hematological assessment: hemoglobin, hematocrit,
MCV, MCHC, MCH, TIBC
1. Lipid assessment: total cholesterol, HDL, LDL,
triglyceride levels
2. Renal assessment: BUN, creatine, creatinine
clearance, spot urinalysis for albumin: creatinine
ration, glomerular filtration rate
Nutrition history
1. Nausea, vomiting
2. Symptoms interfering with ability to ingest normal
diet
3. Food allergies, preferences, or intolerances
Weight history
1. Current heigh/weight
2. Weight history
3. Reference weight (BMI)
Physical activity history
1. Type of activities, if any
2. Frequency of activities
3. Length of time participating in activities
Monitoring
1. Blood sugar
2. CHO intake
3. Weight
Psychological/economic history
1. Socioeconomic status of family
2. Does family have health insurance
3. Does susan have any friends/family
members/counselors to talk to/to help make her
more comfortable about the disease
Knowledge and skills level
1. How much nutrition education does she have
2. Does she know how to check her blood sugar
3. How does she feel about checking her blood sugar
by herself
Expectations and readiness to change
1. Is she following her diabetic regimen
2. Is she taking her insulin shots
3. Is she willing to learn and make lifestyle/dietary
changes
D. Clinical Domain
17. Does Susan have any laboratory results that support her diagnosis?
a. Susan has a number of laboratory results that support her diagnosis. Her pre-albumin
levels were at 40 mg/dL, and the normal range is between 16-35 mg/dL. Her
osmolality level was high at 304 mmol/kg/H2O, and the normal range is between 285295 mmol/kg/H2O. Susan had increased glucose levels at 250 mg/dL, when the normal
range is between 70-110 mg/dL. Her BUN level was increased from the normal value
between 8-18 mg/dL at 20 mg/dL. Susan’s HbA1c level was also high at 7.95%, and
the normal range is usually between 3.9-5.2%.
18. Why did Dr. Green order a lipid profile?
a. Dr. Green ordered a lipid profile so he can asses her total cholesterol, HDL levels, LDL
levels, and triglyceride levels. He will be checking to see where these levels are at
compared to where they should be. Total cholesterol should be less than 200 mg/dL,
LDL should be less than 70 mg/dL, HDL should be greater than 50 mg/dL, and
triglycerides should be less than 150 mg/dL.
(Nutrition Therapy and Pathophysiology, page 495)
19. Evaluate Susan’s laboratory values.
Chemistry
Normal Value
Susan’s Value
Reason for
Abnormality
Nutritional
Implications
Osmolality
285-295
mmol/kg/H2O
304 mmol/kg/H2O
Hyperglycemia,
diabetes
Dehydrated
Glucose
70-110 mg/dL
250 mg/dL
hyperglycemia
Will cause hunger
BUN
8-18 mg/dL
20 mg/dL
Kidneys aren’t
functioning properly
GI tract
complications,
kidney failure
Total Cholesterol
120-199 mg/dL
169 mg/dL
Normal
Can increase risk for
CVD and other
diseases if levels
are too high
LDL Cholesterol
<130 mg/dL
109 mg/dL
Normal
Can increase risk for
CVD and other
diseases if levels
are too high
HbA1c
3.9-5.2%
7.95%
Diabetes
Polyuria, polydipsia
(http://www.nlm.nih.gov/medlineplus/)
20. Compare the pharmacological differences in insulins:
Type of Insulin
Brand Name
Onset of Action
Peak of Action
Duration of Action
lispro
Humalog
5-15 min
30-90 Hours
3-5 hours
aspart
NovoLog
5-15 min
30-90 Hours
3-5 hours
glulisine
Apidra
5-15 min
30-90 Hours
3-5 hours
NPH
Humulin N, Novolin
N
2-4 hours
4-10 hours
10-16 hours
glargine
Lantus
2-4 hours
Peak-less
20-24 hours
Type of Insulin
Brand Name
Onset of Action
Peak of Action
Duration of Action
detemir
Levemir
2-4 hours
6-14 hours
16-20 hours
70/30 premix
Humulin
30-60 min
Dual
12-20 hours
50/50 premix
Humulin
30-60 min
Varies
10-16 hours
60/40 premix
Novolin
30-60 min
2-8 hours
18-24 hours
(Nutrition Therapy and Pathophysiology, page 488)
(http://www.mayoclinic.com/health/insulin/DA00091)
(http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/insert_C.aspx)
(http://chealth.canoe.ca/drug_info_details.asp?brand_name_id=1255&rot=4)
21. Once Susan’s blood glucose levels were under control, Dr. Green prescribed the following
insulin regimen: 24 units of glargine in pm with the other 24 units as lispro divided between
meals and snacks. How did Dr. Green arrive at this dosage?
a. To determine this dosage, Dr. Green multiplied a daily insulin dose of 0.5 units, as it is
a common starting dosage for insulin in individuals who are 120% of their IBW, by
Susan’s body weight in kilograms. 0.5 x 45.5 kg = 23 units/kg insulin. Since Susan is
very physically active with volleyball, he added another unit of insulin to come up with
24 units/kg.
(Nutrition Therapy and Pathophysiology, pages 487-488)
E. Behavioral-Environmental Domain
22. Identify at least three specific potential nutrition problems within this domain that will need
to be addressed for Susan and her family
a. 1.) Inappropriate intake of types of carbohydrates
2.) Food and nutrition related knowledge deficit
3.) Undesirable food choices
23. Just before Susan is discharged, her mother asks you, “my friend who owns a health food
store told me that Susan should use stevia instead of artificial sweeteners or sugar. What do
you think?” What will you tell Susan and her mother?
a. I would first give Susan and her mother a bit of background information on stevia in
saying that it is a novel sweetener and is approved by the FDA. Novel sweeteners are
those that are combinations of different types of sweeteners, which is turn makes they
hard to place in one particular category of sweeteners. I would tell them to make sure
the stevia they choose to use is highly refined, as this is the type of stevia the FDA has
approved. Stevia, along with other artificial sweeteners are good alternatives to sugar
for those with diabetes since they lack carbohydrates and therefore do not raise blood
sugar levels. I would also make sure to tell Susan and her mother to not use stevia or
any other artificial sweetener in excess, as this could potentially be harmful to the
body.
(http://www.mayoclinic.com/health/artificial-sweeteners/MY00073)
F. Nutrition Diagnosis
24. Select two high-priority nutrition problems and complete the PES statement for each.
1. Increased glucose levels related to diet and type 1 diabetes as evidenced by usual
dietary intake and lab values.
2. Excessive energy intake related to diet as evidenced by usual dietary intake.
III. Nutrition Intervention
25. For each of the PES statements that you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).
a. 1.) The ideal goal would be for Susan to keep her glucose levels as normal as possible
through using tools such as SMBG or continuous glucose monitoring.
2.) The ideal goal would be for Susan to decrease her energy/total kcal intake to between
2,100-2,200 kcals/day.
For both of these, the proper intervention would include diabetes self-management
education (DMSE). This would include learning to manage school work/schedule, eating
patterns, physical activity, social environment and personality, cultural issues, other
medical conditions, and the presence of any complications.
(Nutrition Therapy and Pathophysiology, page 485)
26. Does the current diet order meet Susan’s overall nutritional needs? If yes, explain why it is
appropriate. If no, what would you recommend? Justify your answer.
a. I think since Susan still needs to get back to a healthy weight, and is currently very
physically active with volleyball, 2,400 kcals/per day is a good amount. However,
because of her regular involvement in volleyball, I do think Susan should be taking in
more protein, around 120 g/day, instead of only 55-65 g/day. This would be increasing
her protein intake from 10% of her daily kcals to 20% of her daily kcals. I think 300 g
of CHO is a good amount, as it is 50% of her daily kcals, along with 80 g of lipid, as it
is 30% of her daily kcals.
IV. Nutrition Monitoring and Evaluation
27. Susan is discharged Friday morning. She and her family have received information on insulin
administration, SMBG, urine ketones, record keeping, exercise, signs, symptoms, and Tx of
hypo-/hyperglycemia, meal planning (CHO counting), and contraception. Susan and her
parents verbalize understanding of the instructions and have no further questions at this time.
They are instructed to return in 2 weeks for appointments with the outpatient dietitian and
CDE. When you come in to work Monday morning, you see that Susan was admitted through
the ER Saturday night after her discharge on Friday. She tested her blood glucose before
going to the party, and it measured 95 mg/dL. She took 2 units of insulin and knew she
needed to have a snack that contained approximately 15 grams of CHO, so she drank one
beer when she arrived at the party. She remembers getting lightheaded and then woke up in
the ER. What happened to Susan physiologically?
a. What happened to Susan physiologically was that she went into a fasting hypoglycemic
state, which can result from too much insulin or insulin-like substances such as
alcohol. However, blood glucose levels are not affected by moderate alcohol use if
diabetes is well controlled, and should be taken into consideration when adding kcals
to food/meals. Alcohol should also not be substituted for food, which is what occurred
in Susan’s case. She said she knew she needed a snack, and chose to have that snack be
a beer. Susan should have instead eaten a snack, and then proceeded to not drink any
alcohol seeing as she is not yet 21 years of age.
(Nutrition Therapy and Pathophysiology, pages 491, 507)
28. What kind of educational information will you give her before this discharge? Keep in mind
that she is underage for legal consumption of alcohol.
a. I would educate Susan on the information addressed above, but I would also advise her
not to consume alcohol. I would empathize with her in knowing what it is like to try to
fit in and give in to peer pressure, but remind her that not only is she not of drinking
age yet, but her diabetes is not to a well controlled state just yet. I would also remind
her her place on the volleyball team, and that drinking and/or doing any other drugs at
her age will only decrease any future improvements she has the chance of making in
the sport.