Wendy Barth

MNT: I
December 14, 2017

Case Questions
I. Understanding the Diagnosis and Pathophysiology
1. The current thoughts regarding the etiology of T1DM is that it is a beta cell destruction
process brought on by genetic, environmental, or autoimmune factors. With T1DM genetic
predisposition, carriers have a combination of human leukocyte antigen coded genes that deal
with the disease susceptibility along with genes that relate to T1DM resistance. It is not
uncommon that she has the disease even though no one else in her family has it, but with T1DM
she has a decrease in amylin production, which is also found in people with celiac disease. Her
sister currently has CD so there is a correlation between the production of amylin in both the
sisters, suggesting the parents should be checked for possible risk factors.
2. Standard diagnostic criteria for T1DM include: an A1c > 6.5, FPG > 126, a 2-hour PG > 200
during an overnight glucose tolerance test, a glucose test > 200 with hyperglycemic symptoms,
and tests for autoantibodies and traces of C-peptide. In Rachel’s case, her A1c and glucose
concentrations are elevated, and she has autoantibodies in her blood along with a decrease in C-
peptide levels.
3. Islet cell antibodies screen: relate to T1DM because they are clusters of cells on the pancreas
that are sensitive to blood glucose levels and distribute insulin as needed. TSH: there is an
increased prevalence of thyroid dysfunction in individuals with T1DM. Thyroglobulin
antibodies: T1DM is assessed by measuring TGA using a sensitive enzyme immunoassay. Tests
how much is present in blood to determine autoimmune disease. C-peptide: relate to T1DM by
measuring amounts of c-peptide in blood stream. The levels usually match with insulin levels
which can help determine, if tested, how much insulin a person is producing. Immunoglobulin A
level: used to evaluate autoimmune conditions. Higher concentrations suggest a condition and in
this case, T1DM. Hemoglobin A1c: measures the % of blood sugar attached to red blood cells.
The higher your blood sugar concentrations, the more hemoglobin you will have with sugar
attached. Tissue transaminase antibodies: found in higher concentrations in individuals with
autoimmune conditions such as CD or in this case T1DM.
4. Factors that would allow the physician to distinguish between T1DM and T2DM from
Racheal’s medical records are her weight and height with her BMI being in a normal range, her
increased weight loss, and her signs and symptoms of polydipsia, polyphagia, and polyuria. The
DM can test for auto-antibodies in the blood which would suggest that certain antigens are in the
process of destroying beta-cells. She also has low C-peptide concentrations suggesting that there
is very little insulin production in the pancreas.
5. Pancreatic beta-cells secrete insulin are currently in the destruction process, so her body can’t
take up glucose from what she is eating. Since this is happening her body doesn’t think she has
enough to supply energy/fuel for activity, increasing her hunger. If the body can’t use glucose for
fuel, it will switch to other tissues and macro’s, causing weight loss and possibly diabetic
ketoacidosis. While this is happening, the kidneys are trying to get rid of the extra glucose in the
blood, causing an increase in polydipsia and polyuria. Rachels fatigue is caused by not getting
enough glucose for energy in the cells which causes the body to not have sufficient energy.
6. Metabolic events for signs and symptoms with DKA deal with disturbances in carbohydrate,
protein, and fat intake. Since the body isn’t taking up glucose and using it for energy, fat is being
metabolized and used for fuel which forms ketones. An increase in FA breakdown causes an
overproduction of byproducts causing the acidosis. Ketones are then over produced and spill
over into the urine which is where DKA shows the increased glucose concentrations with
ketones also in the blood and urine. Yes, Racheal was in this state when being admitted because
of her polydipsia, polyuria, dehydration, and fatigue. Rachel also had recently had step which is
another indicator because DKA can be caused by an illness. DKA can then lead on to
hypoglycemia, hypokalemia, coma, and death in server cases.
8. The honeymoon phase is where people with T1DM have a period of time after their initial
diagnosis where the pancreases is still able to produce enough insulin to reduce insulin needs and
help control blood glucose concentrations. With Racheal, this means her concentrations can last
up to a year, but her beta-cells will still be destroyed, and her insulin needs will increase, which
means her doses will need to increase over time to help maintain a healthy concentration.
9. An increase in physical activity has been shown to help with upping insulin sensitivity,
reducing cardiovascular risk factors and helping manage weight. Since Racheal is a soccer
player, which is a more intense activity (constant running), she will need to be very carful and
check her blood glucose concentrations before and immediately after her practices and games.
She could potentially fall into a hyperglycemic or ketosis state without careful monitoring during
this intense exercise.
10. The dawn phenomenon is a condition where the blood glucose concentrations are higher in
the morning than they are at night. This happens because the liver is breaking down glycogen
stores thinking the body is fasting. Rachel does have higher glucose concentrations in the
morning, so I do suspect she is experiencing this. This can be prevented by not administering
insulin at peak times (1 to 3 am) to avoid over use of insulin which leads to hypoglycemia.
II. Understanding the Nutrition Therapy
11. The rational of the MD ordering a CHO-controlled diet for when Racheal can eat again is for
monitoring her rate of glucose removal under certain insulin does to know what would be best
for her. Everyone’s rate is different due to activity, weight, age, sensitivity factor, etc. Giving her
a controlled CHO diet, the DM will be able to address her insulin needs better to fit her lifestyle
at home. Because of this, doctors need to educate her specifically on her needs to help her into a
successful insulin therapy process to ensure her optimal health.
12. The major nutritional goal for Racheal would be to achieve optimal growth and
development which would include determining the appropriate energy intake for age, along with
consistent CHO (3-4 choices per meal), limiting protein to recommended amount, discouraging
meal skipping. Racheal should be educated and counseled on food intake, and medication, and
physical activity, along with self-care, meal planning, carb counting, insulin administration, and
reading food labels.
III. Nutrition Assessment
13. Racheal’s ht/age is on the 50th %tile line and her wt/age is on the 25th %tile, meaning that her
weight needs to increase. Her BMI suggests that she is underweight with a BMI of 16. Her
desirable weight can be achieved by adding an additional 12# to her current weight making her
~94#.
14. Sodium: related to poor dietary intake; Phosphate: decrease is associated with nonfunctional
intake, poor distribution, or renal failure; Osmolarity: increase is associated with hydration status
suggesting she was dehydrated; HbA1c: increase was associated with the amount of glucose in
her blood; C-peptide: released along with insulin, since insulin secretion decreased so did her C-
peptide amount; ICA, GADA, IAA: antibodies that increase in T1DM that lead to the destruction
of beta-cells. Having these helps doctors determine that one has T1DM; Specific gravity: an
increase could suggest water loss, and fluid concertation; pH: her blood is a little on the acidic
end due to an increase in FA metabolism. Tissues are not using the glucose, so they use fat
instead, which causes the acidity; Glucose: Since she had insulin resistance, glucose is elevated
in her blood and not being taken into the tissues for energy; Ketones: she has more ketones
because of the high concentration of glucose in her blood from her insulin resistance. Since
tissues are not using glucose they turn to fats, which increases the number of ketones in the blood
stream.

IV. Nutrition Diagnosis

16. PES statements
 Unintended weight loss r/t new T1DM diagnosis AEB a weight of 82lbs. with an
underweight BMI and a low growth %tile on growth charts.
 Undesirable food choices r/t lack of knowledge pertaining to pt’s condition AEB dietary
recall, extremely high glucose concentration, and HbA1c of 14.6
 Inconsistent carbohydrate intake r/t consuming high amounts of simple CHO AEB
dietary recall and HbA1c of 14.6

V. Nutrition Intervention
17. Rachel has a decent insulin sensitivity factor and is a very active 12 y/o. She would need
~45% of her calories should come from CHO to maintain a good glucose level with her active
lifestyle; so ~70g carbs at breakfast and lunch, ~85 carbs at dinner and a 10g snack after the
school day is over along with a 15g snack before soccer practice or a game. (2200 x .45%= 990
/4= 250 g /15 = ~17 choices/day)
18. The insulin:CHO ratio is a principal suggesting that 1-unit-per-10-grams of CHO is applied.
Meaning that 1 unit of insulin will cover 10 grams of CHO. With Rachel, her physician ordered a
1:15 ratio where 1 unit of insulin would cover 15 grams. According to her usual breakfast: 2 pop-
Tarts (~72g), 8 oz skim milk (~12g) of carbohydrates. This adds up to ~84g of CHO. In order to
fit with the 1:15 ICR, Racheal would need to use about 6 units of insulin to fit with her breakfast.
19. You would need to find Racheal’s insulin sensitivity level to come up with a correct ratio to
cover her blood glucose (1700/33: 52; so 1:52 ratio). Therefore, her dosage needs to be corrected
by adding 1.5 to 2 units of insulin to her daily total need in order to lower her blood glucose in
the am to get it WNL.
 ADIME Chart Note
Assessment- Pt, 12 y/o Caucasian female, admitted with acute-onset hyperglycemia and later
diagnosed with T1DM. Pt presented to ED after fainting at soccer practice, when assessed she
was noted to have serum glucose of 724 mg/dL. Pt has recently gotten over strep throat a few
days prior and complains of being very thirsty and having to urinate often. Nutrition consult
referral. Racheal has a weight loss of 8# since last weigh in when being treated for strep. Pt’s
appetite is normal, she states that she has been hungrier, relating increased thirst and urination to
exercising more. Racheal usually consumes ~1500-1700 kcals/day, consisting mostly of simple
carbs/sugars, with fruit, vegetable, and protein consumption low. Pt is a picky eater. All labs
reviewed and noted. Current medications noted. Racheal’s ht/age is on the 50th %tile line and her
wt/age is on the 25th %tile.
Diet order: Consistent CHO-controlled diet (70-80g breakfast and lunch; 85-95g dinner; 3-15g
snack)
Fluid requirement: 1840 mL
Ht: 5’, Wt: 82#, UBW:90#, BMI: 16
Recommended kcal intake: 2200 kcals/kg BW
Recommended protein intake: 30-34 g

Diagnosis-
Inconsistent carbohydrate intake r/t lack of knowledge of T1DM with consumption of high
amounts of simple CHO AEB dietary recall and HbA1c of 14.6

Intervention- RDN recommends a consistent CHO-controlled diet with 250 g; ~17 CHO
choices/day. RDN will educate and counsel both patient and her parents on CHO counting and
recommended amount of choices per meal along with timing and portions sizes of said meals,
insulin to carbohydrate ratio (1:15 for Racheal) with how to cover CHO consumed with proper
amount of insulin, and importance of consistency related to CHO consumption.

Monitor & Evaluation- RDN will monitor and evaluate pt’s food intake and blood glucose
concentrations while in hospital. RDN will follow-up with pt by phone call in 2-3 weeks with pt
and a parent to asses CHO consistency and choices and then again 3-4 months after discharge to
reassess food intake (focused on CHO), blood glucose concentrations, and HbgA1c.
1-Day Meal Plan (17 CHO choices; 250 g)
Breakfast- 2 pieces if whole wheat toast w/ 1 Tbsp. Jam/jelly, w/ 8 oz milk (4 CHO choices)
- or – ½ c oatmeal w/ 8 oz milk, 1 cup blueberries, w/ 1 Tbsp honey (4 CHO choices)
Lunch- 1 turkey and cheese sandwich on 2 slices of whole wheat bread, Mixed fresh veggies (½
c carrots, ½ broccoli, ½ c cauliflower), 10-15 chips or pretzels, water (4 CHO choices)
After school snack- 1 medium banana (2 CHO choices)
Before practice snack- 8-10 snack crackers w/ water (2 CHO choices)
Dinner- 3 oz chicken breast, 1 c mashed potatoes w/ 1 tbs butter, 2 c salad, 8 oz chocolate milk, 1
(3”) cookie (5 CHO choices)