Case Study #22 Type I Diabetes Mellitus

KNH 411
Brooke Bryant
Gretchen Matuszak
11-17-15

I.
Understanding the Disease Pathophysiology
1. Define Insulin. Describe its major functions with normal metabolism.
Insulin is the hormone that lowers the level of glucose in the blood. It is made by beta cells in the
pancreas and released into the blood when glucose levels are elevated after eating. Insulin helps
glucose enter the bodys cells where it is used for energy or stored for future use. Insulin helps
regulate normal metabolism by helping the body know when to release energy for normal body
functions and when to store it for future use in the body (KidsHealth, 2015).
2. What are the current opinions regarding the etiology of type I diabetes mellitus
(DM)?
Type I Diabetes is an autoimmune disease that causes the damaging and destruction of beta-cells
in the pancreas that result in the inability to create insulin and regulate glucose throughout the
body. The autoimmune disease is the only predominant factor for the cause of type I Diabetes
but may not be its primary cause of the disease. Type I diabetes precipitates in genetically
susceptible people that may be triggered by an environmental factor. Some of the genes that are
more susceptible to Type I diabetes are: HLA, insulin, PTPN22, IL2RA, and CTLA4. Other
studies have found that it is triggered by enteroviruses (NCBI, 2011).
3. What genes have been identified that indicate susceptibility to type I Diabetes
Mellitus?
The genes that have been identified that indicate susceptibility to type I Diabetes are : HLA,
insulin, PTPN22, IL2RA, and CTLA4 (NCBI,2011).

4. After examining Susans medical history, can you identify any risk factors for type I
DM.
No, there are no risk factors for Susan getting type I Diabetes because it is an autoimmune
disease. She has no previous medical history of complications with being able to regulate her
blood sugar. Her family has no medical history of type I diabetes and her family has no major
health issues that relate to type I diabetes. Susan is very active but does consume large amounts
of sugar and sugary drinks but this is not related to the onset of type I Diabetes. She takes no
vitamins and has no known allergies to any medications or food. The risk factors of eating the
sugary foods and drinks she consumes daily would be directly linked to type II Diabetes but not
type I which is the disease Susan has been diagnosed with.

5. What are the established diagnostic criteria for type I DM? How can the physicians
distinguish between type I and type II Diabetes?
The established diagnostic criteria for type I diabetes is the destruction of beta-cells and the
inability to create insulin. Physicians distinguish between type I and type II diabetes by seeing if
beta-cells are being destroyed, if this is the problem it is type I due to an autoimmune disease.
Type II is not caused by an autoimmune disease or the destruction of beta-cells. It is caused from
insulin resistance in the body often times caused by genetic disorders of insulin resistance but
can be caused by getting older, obesity and becoming more sedentary. There are some cases
where adults have autoimmune problems resulting in beta-cell destruction but certain tests have
to be done to find the underlying cause of the problem (Shane, 2003).

6. Describe the metabolic events that led to Susans symptoms (polyuria, polydipsia,
polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of
the disease.
The destruction of pancreatic beta-cells causes insulin deficiency, making it to where the glucose
cannot be used for energy which results in fatigue. The result of glucose not being able to be
used causes the glucose to rise and for cells to starve. To counteract the glucose raising the body
starts to create urine which causes polyuria where ketones are released into the urine. The loss of
fluids causes thirst from dehydration (polydipsia). The cells in the body that are dependent on
glucose have no response to the body which causes the polyphagia and the body having to use
what energy is taken in because it cannot use the energy that is being stored results in weight loss
(Healthline, 2014).
7. List the microvascular and neurological complications associated with type I
diabetes.
Retinopathy is one of the complications associated with type I diabetes due to the hyperglycemic
damage to the blood vessels. This results in blindness in some cases. Hypertension is also related
to the retinopathy. Neuropathy is also a complication associated with type I diabetes and this can
turn into complications with the kidneys and the onset of kidney disease. Diabetics that are
hyperglycemic cause damage and deformation of blood cells that cause the problems with the
kidneys. Neurological disorders are often the cause of hyperglycemia that affect diabetics and
this affects their heart rate and other bodily functions (Haykal,2015).
8. When Susans blood glucose level is tested at 2am, 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?
The Dawn phenomenon is a surge of hormones the body produces around 4am-5am this in
people with type I diabetes causes the fasting glucose to go up. Susan is most likely experiencing
this because her body wont have enough insulin to counteract the rise in glucose due to the
hormones in her body that cause the increase at this time of night. This can be prevented by
Susan eating dinner earlier in the evening or her exercising after dinner to help lower the amount
of glucose she has stored in her body to help it from elevating in the middle of the night (ADA,
2013).
9. What precipitating factors may lead to the complication of diabetic ketoacidosis?
Lis these factors and describe the metabolic events that result in the signs and
symptoms associated with DKA.
DKA is when the body produces large amounts of ketones that are a result from lack of insulin
being produced. The lack of insulin starts to have the body break down fat for energy which
results in acid build up or ketones in the blood stream. Complications that may lead to this is by a
diabetic not taking care of themselves by checking their glucose level and not injecting enough
insulin to counter act the glucose in their body being made. Illness, stress, and in women
changing of hormones can cause complications with DKA.The increase of glucose in the body
will result in fatigue and frequent thirst because of increased urination for the body to excrete the
amount of ketones in the body. Another symptom is fruity or sweet smelling breath due to the
increased amount of ketones in the body. Vomiting, stomach pain and nausea are all symptoms of
DKA.

II.
Nutrition Assessment
10. Determine Susans stature for age and weight for age percentiles.
Susan is 15 years old 5^2 and weighs 100lb. Her height in inches is 62 and her BMI will be
found through these calculations: 45.45/(1.57^2)= 18.4 BMI. Susan is underweight for her age
and height and should be at least 115 pounds to be at a normal BMI.
11. Interpret these values using the appropriate growth chart.
According to the CDCs growth chart Susan is underweight for her age and height and she is
within the 25percentile. This is determined by her BMI in question 10 and her height, weight and
age on the CDCs growth chart (CDC, 2009).
B. Calculation of Nutrient Requirements
12. Estimate Susans daily energy and protein needs. Be sure to consider Susans age.
135.3 (30.815) + 1.31 [(1045.45) + (9341.57)] + 25 = 2320
I chose a PAL of 1.31 because she is active in volleyball at her school so she burns more calories
than that of a sedentary adolescent.
2320

calories x 0.15 = 348/4 = 87 grams

13. What would the clinician monitor in order to determine whether or not the
prescribed energy level is adequate?
The Clinician would need to monitor her weight every week to make sure Susan is
gaining back the weight she needs to get to a normal BMI. The clinician should have
Susan keep a food log to log what she is taking in to make sure she is meeting all of her

energy requirements and macronutrient requirements each day. This will help ensure she
will get back to a normal BMI. This will also help with learning how different foods
affect her blood sugar and to know how much insulin to take with each meal.
C. Intake Domain
14. Using a computer dietary analysis program or food composition table, calculate
the kcalories, protein, fat (unsaturated, polyunsaturated, and monounsaturated),
CHO, fiber and cholesterol content of Susans typical diet.

Calories
3,312

Protein
91g

Sat.
57g

Poly.
24g

Mono.
41.5

CHO
443g

Fiber
17.7

Chol.
294.4mg

15. What dietary assessment tools can Susan use to coordinate her eating patterns
with her insulin and physical activity?
Susan can use super tracker to track what she eats every day and it will give a full
nutrient analysis of what she is taking in each day. This will help her stay within her goals
each day by showing it on a graph that she can understand. She can also keep a diary of
how her sugar reacts to different foods and how much physical activity she gets and how
much it affects her sugar so she knows how much insulin to take during different times of
day. My fitness pal is another dietary assessment Susan can use to keep track and it has
more food options than super tracker does so it better depicts what she is taking in.
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 assessment, list at least three assessments you would perform for
each component.

Component

Assessments You would Perform

Obtain height, weight, BMI, waist/hip
ratio
Determine reasonable body weight
Estimate daily energy needs

Clinical data
Evaluate who prepares food and shops for
food
Determine what kind of choices are made
when eating out
Evaluate energy intake and macronutrient
Nutrition History
Weight History

Obtain weight history, recent weight

changes and weight goals
Determine activity types and frequency
Estimate energy expenditure

Physical Activity
History
Monitoring

Assess ability to become more physically

active
Assess target blood glucose ranges.
Asses blood glucose frequency of testing
Asses Weight gain/loss if any changes
need to be made in diet make the

adjustments
Assess level of stress
Assess level of family and social support
Assess living situation, finances and
educational background
Psychosocial/Economic
Knowledge/skill level

Asses knowledge of the disease, determine

things they do not understand and educate

Expectations/readiness
to change

Evaluate what the family plans to do to

help the client, See if they know
expectations of lifestyle change, educate
them on risk factors if life style changes
do not occur.

17. Does Susan have any laboratory results that support her diagnosis?
Susans A1c is high at 7.95 and anything that is above 6 is considered diabetic. Susass blood
glucose is elevated showing that her body is not making enough insulin to lower the amount of
glucose in her blood. Her BUN is high which is showing how much urea and nitrogen is in her
blood this shows if ketones are present and being expended through urination. Osmolality is also
high which indicates that Susans kidneys are reabsorbing water which is also a sign of diabetes
because of the ADH that is released during this process (Mayoclinic, 2015).

18. Why did Dr. Green order a lipid profile?

Dr. Green ordered a lipid profile to make sure the diagnosis of Type I Diabetes is accurate
because type II diabetics tend to have much higher elevated lipid profiles and type I diabetics
generally have about the same as a normal person without type I diabetes. Dr. Green also ordered
a lipid profile also to check and make sure that the symptoms Susan is experiencing is not from
elevated lipid levels because some symptoms can be caused by abnormal lipid levels.
19. Evaluate Susans laboratory values:

Chemistry

Normal
Value

Susans
value

Abnormal
Reason

Albumin

3.55g/dL

4.2g/dL

normal

Total
Protein

6-8 g/dL

7.5g/dL

normal

Prealbumin

16-35
mg/dL

40 mg/dL

Decreased
fluid

Sodium

136-145
mEq/L

140mEq/L

normal

Potassium

3.505.5
mEq/L

4.5 mEq/L

normal

Chloride

95-105
mEq/L

98 mEq/L

normal

PO4

2.3-4.7
mg/dL

3.7 mg/dL

normal

Magnesium

1.8-3 mg/
dL

2.1 mg/dL

normal

Osmolality

285-295
mmol/kg

304
mmol/kg

Decreased
fluid
volume

Weight loss,
dehydration

Glucose

70-110

250 mg/dL

High blood

Hyperglycemia,

Nutrition Intake

Dehydration

mg/dL

sugar,
Inability to
produce
insulin

BUN

8-18
mg/dL

20 mg/dL

Increased
glucose
levels

Creatinine

.6-1.2
mg/dL

.9 mg/dL

normal

Calcium

9-11
mg/dL

9.5 mg/dL

normal

CHOL

120-199
mg/dL

169 mg/dL

normal

LDL

<130
mg/dL

109 mg/dL

normal

7.95%

Increase in
glucose
binding to
hemoglobin

HbAlc

3.9-5.2%

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
minutes

30-90
hr.

3-5 hr.

Aspart

Novolog

5-15
minutes

30-90
hr.

3-5 hr.

Glulisine

Apidra

5-15
minutes

30-90
hr.

3-5 hr.

2-4 hr.

4-10
hr.

10-16 hr.

Humulin
N
Novalin
N
NPH

frequent thirst,
urination,
hunger,
ketoacidosis

Diabetes

Glargine

Lantus

2-4 hr.

peak
less

20-24 hr.

Detemir

Levemir

2-4 hr.

6-14
hr.

16-20 hr.

70/30
premix

Humulin
70/30

30-60
minutes

dual

10-16 hr.

50/50
premix

Humilin
Mix
50/50

30-60
minutes

dual

10-16 hr.

60/40
premix

Mixture
40

30-60
minutes

2-4 hr.

24 hr.

This chart was found and organized by (Goldfine, 2011).

21. Once Susans 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
lisprodivided between meals and snacks. How did Dr. Green arrive at this dosage?
According to the chart above Dr. Green does 24 units of Glargine in the PM because the duration
of how it acts is 20-24hr. So this would cover Susans insulin throughout the night so she wont
have to get up in the middle of the night every 3 hours to take more insulin. The 24 units of
lisprodivided will be given between meals in snacks because its duration is only 3hr. and she will
be able to take more insulin throughout the day when needed (Goldfine,2011).
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.
One potential nutrition problem that will have to be addressed to Susan and her family is the
amount of carbohydrates Susan takes in per day. She needs to lower this intake because of the

increase of glucose in her body each time she ingests different types of carbohydrates. This
means her family will have to prepare meals lower in carbohydrates and that are higher in protein
for Susan. Another nutrition problem is the amount of Coke and sugary snacks Susan intakes
throughout the day. This means Susans parents will have to start buying snacks that are sugar
free or contain less sugar in them for Susan to eat and to buy different drinks like flavored water
or all natural juices for Susan to drink. Susan will need to change to drinking more water instead
of the sugary processed drinks she has been drinking. Another potential nutrition problem that
should be monitored is Susans exercise, she needs to make sure she is getting the adequate
amount of exercise and monitor her sugar before, during and after her workout to make sure she
does not go low or go to high during this process. The family will need to remind her and keep
snacks on hand while she is exercising.
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 Susans mother?
Stevia would be fine for Susan to use instead of artificial sweeteners or sugar because it is a zero
calorie sweetener that is proven to lower blood glucose because it enhances the secretion of
insulin. It tastes sweeter than other artificial sweeteners and it is not artificial. It is a natural plant
that is from Paraguay in South America that has been used to sweeten bitter drinks and foods
(Stevia, 2009).
F. Nutrition Diagnosis
24. Select two high-priority nutrition problems and complete the PES statement for each.

Lack of nutrition knowledge as related to newly diagnosed type I Diabetes as evidence by

A1c of 7.95%.
Increase weight loss as related to newly diagnosed type I Diabetes as evidence by a BMI

of 18.4.
Inappropriate intake of carbohydrates as related to newly diagnosed type I Diabetes as
evidence by a glucose lab value of 250.

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).
The goal for the first PES statement is to educate Susan and her family about what diabetes is
and how to maintain a healthy A1c and how to keep Susans blood sugar level at a healthy
fasting level of 80-130. The family will be educated on how to carb count and how much insulin
Susan will need before and after each meal and after working out. Another goal is to increase
Susans weight since her BMI is at the underweight range. Susan will keep a food log to keep
track of her calories per day so that she is not going under and is eating enough for her activity
level. Keeping a food log will also keep track of her carbohydrate intake that needs to be lowered
to not have Susans blood glucose going up to high. Educating her family on how carbohydrates
affect glucose levels will also help in reaching the goal of a healthy A1c and a healthy blood
sugar between 80-130.
26. Does the current diet order meet Susans overall nutritional needs? If yes, explain why
it is appropriate. If no, what would you recommend? Justify your answer.

Yes, her diet order meets Susans overall nutritional needs because it will help her maintain her
glucose levels. All of Susans macronutrients are met on this diet order and her calorie intake
may need to be increased depending on how much exercise she gets per day so she can get her
weight back up to a normal BMI instead of being underweight. Her CHO needs are met and this
will help maintain her blood sugar levels.
IV. Nutrition Monitoring and Evaluation
27. Susan is discharged Friday morning. She and her family have received information on
insulin administration, SMBG, urine ketones, recordkeeping, 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 95mg/dL. She took 2 units of
insulin and knew shed needed to have a snack that contained approximately 15grams 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?
Susans glucose dropped from taking too much insulin and not taking in enough food to create
the amount of glucose she needed to keep her sugar at a normal range. Susans sugar dropping
lower than a normal level caused her to get light headed and to pass out. If Susan would have
actually ate a snack before going to the party instead of exchanging her snack from food to a beer
then her blood sugar would not have dropped to a dangerous level. When blood glucose goes

lower than what it is supposed to be it causes neurological problems and for the brain to shut
down as it did when Susan passed out(Mayo Clinic,2015), .
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.
The education I would give Susan before her discharge is to inform her how different alcohols
can affect blood glucose. Even though she is underage she is going to get older and be come of
age to consume alcohol and she needs to know how it will affect her body and how her body will
react differently because of her type I Diabetes. I will discourage her from drinking since she is
underage but I will give her education on this subject. I will inform Susan on how mixed drinks
are higher in carbohydrates so it will cause her glucose to increase and how taking too much
insulin and not eating and just drinking her calories can cause her sugar to drop to an unsafe
level. I will inform her how much insulin she will need for different types and amounts of
alcohol and I will educate her on the consequences of not taking care of her diabetes while
drinking and how they can result in another hospital visit like this last time.

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