Olivia Wooliver, Erin Norton, Louise Peery, Emily Smith, Dana Omari November 6th, 2013 Type I Diabetes

in the Adult 1. What are the differences among T1DM, T2DM, and LADA? Type 1 DM is characterized by the bodys inability to synthesize adequate insulin for proper functioning, therefore necessitating exogenous insulin to keep the body functioning. This can be done by injection at multiple times per day, or with the use of an insulin pump that runs continuously. Conversely, while Type 2 DM is characterized by the bodys adequate production of insulin, the bodys cells are insensitive to the hormone, preventing its action on cells. Patients are typically diagnosed with T1DM by age 30, whereas T2DM can develop much more slowly and people with the disease can be diagnosed at any time during their life. Most cases of T1DM are recognized as autoimmune in nature, while the etiology of T2DM is widely known as diet- and lifestyle-related, stemming from obesity and other factors involved in the metabolic syndrome. The autoimmune character of T1DM is also strongly tied to ones genetic history. There is a genetic component related to T2DM, but likely in terms of genes involved in metabolism and weight status. Latent Autoimmune Diabetes of Adults (LADA) is a slowly progressing type of autoimmune diabetes. It is diagnosed later than most cases of T1DM, but is not related to weight status or diet like T2DM is. LADA requires insulin therapy over time, but the insulin-secreting cells in the pancreas remain functional for longer over time so that insulin therapy does not need to be as aggressive. 2. What are the standard diagnostic criteria for each of these diagnoses? The standard diagnostic criteria for T1DM and T2DM are: a value of 126 mg/dL on a Fasting Glucose Test, a value of 200 mg/dL on a 2-Hour Plasma Glucose Test, specifically a 75-gram Oral Glucose Tolerance Test, or a Hemoglobin A1c value of 6.5%. A positive result from any two of these tests is grounds for a diagnosis of diabetes. The most widely accepted diagnostic criteria for LADA are: the presence of circulating islet antibodies including islet cell autoantibody (ICA), GADA, and protein tyrosine phosphatase antibody, age at onset of diabetes 30 years, and insulin independence for at least 6 months after diagnosis. 3. Why do you think he was originally diagnosed with T2DM? Why does the MD now suspect he may actually have T1DM or LADA? He was probably originally diagnosed with T2DM because of his age; most cases of diabetes beyond age 30 are due to T2DM rather than of autoimmune etiology. At his diagnosis, he likely had lab values, including blood glucose and Hemoglobin A1c levels, consistent with a Diabetic state, and the doctors may have opted against further testing in favor of diagnosing him with the most common type of Diabetes seen in individuals his age. The MD now suspects he may actually have T1DM or LADA because his assessment was positive for the presence of islet cell autoantibody (ICA), GADA, and IAA that is consistent with one of these types of

Diabetes. These are biomarkers that indicate an autoimmune disorder, in which the bodys own cells (in this case those responsible for producing insulin) are being destroyed by the immune system. 4. Describe the metabolic events that led to Armandos symptoms and subsequent admission to the ER (polyuria, polydipsia, fatigue, and weight loss), integrating the pathophysiology of T1DM into your discussion. T1DM results in increased blood sugar levels due to the deficiency of insulin that would allow glucose into the bodys cells. Armando experienced polyuria (excessive urination) because with an elevated blood sugar level, the kidneys have to work hard to rid it from the body via the urine. Since the condition is chronic, the kidneys have to do this continuously, producing extra urine to maintain homeostasis. Armando experienced polydipsia because as the kidneys are working to excrete extra glucose in the urine, fluids are drawn from the rest of the bodys tissues and organs to produce the urine. This results in a dehydrated state, and the person will feel thirsty. Armando experienced fatigue because with the insulin deficiency, glucose from the blood cannot get into cells, so energy is not as readily available for the bodys cells. Glucose is also rapidly excreted via the urine, and thus is unavailable. The cells must seek other sources of energy, which takes longer and the person feels fatigued. Armando experienced weight loss because of this; since the body is unable to use carbohydrate as an energy source, it must hydrolyze triglycerides from its fat stores (adipocytes) in order to produce energy. This results in the shrinkage of fat cells and thus weight loss. Additionally, as the body rids itself of excess glucose, it does so by eliminating water along with it via the urine. This results in dehydration and lowered body weight. At the same time, lean body tissue is broken down for the process of gluconeogenesis. This is done to provide the body with some carbohydrate source, as carbohydrate is being excreted rapidly and the body still recognizes the need for it. This process of catabolizing muscle tissue results in further tissue loss, and therefore body weight loss. 5. Describe the metabolic events that result in the signs and symptoms associated with DKA. Was Armando in this state when he was admitted? What precipitating factors may lead to DKA? When the body must utilize lean tissue and fat stores for the production of energy and functioning, it splits fat into long chain fatty acids and glycerol molecules. The most efficient way to produce energy is by converting these to acetyl-CoA molecules that can go through the citric acid cycle and be oxidized to produce energy. However, the body can be overwhelmed by the production of acetyl-CoA, and turn these molecules (fatty acids) into ketone bodies instead. These ketone bodies can also be used to produce energy, but if there is an overwhelming quantity of these ketones in the blood, the pH can drop severely due to the acidic nature of the molecules. This can lead to a state of overly-acidic blood known as acidosis, or Diabetic Ketoacidosis, which is characterized by impaired brain function and in very severe cases, coma.

In addition to ketogenesis, several other factors arising from DKA can exacerbate the diabetic state. These include the breakdown of lean muscle tissue for gluconeogenesis, and the hydrolysis of triglycerides in fat stores to release glycerol molecules. The process of gluconeogenesis results in the creation of glucose molecules, which enter the bloodstream and further raise blood glucose levels due to the bodys inability to utilize this source of energy. Glycerol, cleaved from triglycerides in fat cells, is a sugar alcohol and when it circulates in the blood stream it acts to raise blood sugar. With both of these added factors, we see the persistence of hyperglycemia, polyuria, polydipsia, and the reliance on other energy stores to provide energy for the body. This in turn leads to the continued pathogenesis that causes DKA. Armando was in an early state of DKA when he was admitted, as he was found groggy and nearly unconscious in his home. His state could have advanced to coma if he had not been brought to the hospital when he was. The precipitating factors that may lead to DKA are the new onset of T1DM, infection, pancreatitis, myocardial infarction, or the discontinuation of insulin therapy/inadequate insulin therapy by a patient being treated for diabetes. 6. Armando will be started on a combination of Novolog prior to meals and snacks with glargine given in the a.m. and p.m. Describe the onset, peak, and duration for each of these types of insulin. Novolog is a fast-acting insulin analog taken with meals. Novologs onset time is 15 minutes, peak is 45-90 minutes and its duration is 3-5 hours. It addressed carbohydrate intake from meals and snacks. Glargine is a long-acting insulin analog taken once daily. Glargines onset time is 2-4 hours, it is considered peakless because it is a steady-release, and its duration is 24 hours, so it provides basal insulin throughout the day. 7. Using his current weight of 165 lbs, determine the discharge dose of glargine as well as an appropriate ICR for Armando to start with . Kg x .2 = Number of Glargine Units. Armando weighs 165 lbs. 165 lbs / 2.2 kg/lb = 75 kg 75 kg x .2 = 15 units of Glargine ICR (insulin:carb) of Glargine = grams of carbs/units of insulin. 500 g/15 units = 33.33 ICR Glargine = 1:33.33 ICR of both Glargine and Novolog combined = 1:15 Normal intake= 70-80 g breakfast, 70-80 g lunch, 85-95 g dinner, and 30 g for a snack. Low intake = 255 g high intake = 285 g Thus, ICR should be between 1:17 and 1:19 8. Intensive insulin therapy requires frequent blood glucose self-monitoring. What are some of the barriers to success for patients who begin this type of therapy? Give suggestions on how you might work with Armando to support his compliance.

There are many barriers to success with frequent self-monitoring of Glucose. It can be painful, expensive, time-consuming, inconvenient, and its a reminder that one has Diabetes. To help support Armando with his compliance in self-monitoring, I would give him different options for self-monitoring such as finger-prick machines, alternative site machines and continuous glucose monitoring machines - so that he could choose the one he is both most comfortable using and would fit his lifestyle and budget best. I would discuss that importance of managing his blood sugar so that he feels his best and in order to prevent hypoglycemia and complications related to hypoglycemia. 9. Armando tells you that he is very frightened of having his blood sugar drop too low. What is hypoglycemia? What are the symptoms? What information would you give to Armando to make sure he is well prepared to prevent or treat hypoglycemia? Hypoglycemia is low blood glucose (less than 70 mg/dl). Symptoms include: shakiness, irritability, sweating and chills, confusion and delirium, hunger, nausea, rapid heartbeat, impaired or blurred vision, headaches, fatigue, and unconsciousness. Armando should be educated on insulin and his ICR, carbohydrates, and how to check his blood sugar. Since he is on a combination of long- and fast-acting insulin, he needs to check his blood sugar in the morning, before and after meals, before and after exercise, and before bed; and adjust carbohydrate intake and Novolog use accordingly. He must also be taught about exercise and how it affects carbohydrate intake. 10. Armandos mother has T2DM. She is currently having problems with vision and burning in her feet. What is she most likely experiencing? Describe the pathophysiology of these complications. You can tell that he is worried not only about his mother but also about his own health. Explain, using the foundation research of the Diabetes Control and Complications Trial (DCCT) as well as any other pertinent research data, how he can prevent these complications. She is experiencing diabetic neuropathies. Neuropathies are nerve disorders. Diabetes can cause nerve damage especially in those with uncontrolled (high) blood glucose. The pathophysiology of diabetic neuropathy include: increased levels of intracellular glucose in nerves leading to the breakdown of nerve cells and oxidative stress. Retinopathy is the loss of vision or visual impairment, and it happens similarly to neuropathy. The DCCT states the prevention of diabetic neuropathy and retinopathy requires: testing blood glucose levels four or more times a day; adjusting insulin with carbohydrate intake and exercise; following a diet plan; and meeting with a healthcare team regularly. The DCCT also states that all diabetesrelated complications may be prevented by controlling blood glucose, blood pressure and blood lipid levels. Although they have different forms of diabetes, both types need to keep blood sugar in control to help avoid complications.

11. Outline the basic principles for Armandos nutrition therapy to assist in control of is DM. The American Diabetes Association (2008) recommends the following nutrition therapy goals for those with T1DM: Achieve and maintain blood glucose levels in the normal range/as close to the normal range as possible Achieve and maintain a lipid/lipoprotein profile, reducing the risk for vascular complications. Achieve and maintain normal blood pressure level Modify nutrient intake & lifestyle to reduce the rate of development of chronic complications There is no evidence to support special macronutrient recommendations for those with diabetes, so Armando should aim for the DRI for normal adults. Address individual nutrient needs Only limit food choices when indicated by scientific evidence, so as to maintain the pleasure of eating 12. Assess Armandos height and weight. Calculate his BMI. Height: 511 Weight: 165lbs BMI= 23.1 BMI is within the healthy weight range of 18.5 24.9 13. Identify any abnormal laboratory values measured upon his admission. Explain how they may be related to his newly diagnosed DM. Armandos high HBA1C levels should be noted, because this is a measure of blood sugar levels over the past three months, and his current high glucose levels point toward DM. As for his high cholesterol and triglycerides, this may suggest hyperlipidemia or uncontrolled hyperglycemia. A low C-peptide level can show how much insulin is being made by the pancreas. Armandos levels are low, indicating deficiency of insulin production by the pancreas. Additionally, the presence of ICA (Islet Cell Autoantibody), GADA (Glutamic Acid Decarboxylase Autoantibody), and IAA (Islet Autoantibody) in the blood are diagnostic criteria for LADA. As for his urinalysis results, the low pH suggests starvation and poorly controlled diabetes (which it is becoming evident that he has). His urine has a high protein level. Along with carbohydrate metabolism, protein metabolism is affected by insulin deficiency. In a normal individual, insulin lowers blood amino acid and glucose levels, aids in amino acid incorporation into tissue protein, and decreases gluconeogenesis. With insulin deficiency, gluconeogenesis increases and amino acid release (proteolysis) occurs in muscle, therefore increasing protein levels. There is a high level of glucose in Armandos urine, which indicates the excretion of excess glucose from the blood. Due to this hyperglycemic condition, Armandos kidneys increase urine production to accommodate additional excretion of glucose, in an effort to maintain homeostatis. The high ketone level is present with poorly controlled diabetes,

starvation and fasting, fever, and vomiting. This makes sense because it is likely he is suffering from DKA, in which the body is trying to utilize fat stores for energy, but the blood is highly acidic, leading to cerebral impairment. His urine is also cloudy and amber-colored, indicating a kidney malfunction and dehydration. His high CO2 levels with normal respirations indicated in his ABG test indicate increased CO2 retention, which is common with DKA. 14. Determine Armandos energy and protein requirements. Be sure to explain what standards you used to make this estimation. Would you recommend that he either gain or lose weight in the future? Energy requirements determined using REE and TEE from Mifflin St. Jeor REE= (10x75)+(6.25x180)-(5x32)+5=1720kcal TEE= 1720x1.0 and 1720x1.39=1720-2391kcal *TEE was determined using a sedentary activity factor and no stress factor Protein requirements determined using 0.8g/kg Body Weight 0.8(75)=60g protein daily Armando should try to maintain weight rather than try to gain because there is no evidence to support special macronutrient recommendations for diabetics. 15. Prioritize two nutrition problems and complete the PES statement for each. Armandos nutrition problems: 1) High blood glucose and HbA1C levels: Clinical domain- Biochemical (P) Altered nutrition-related laboratory values (NC- 2.2) related to (E) uncontrolled DM as evidenced by (S) serum glucose level of 610 mg/dL and HBA1C level of 12.5%. 2) Knowledge deficit: Behavioral and Environmental domain- Knowledge and beliefs (P) Food and nutrition-related knowledge deficit (NB- 1.1) related to (E) lack of education regarding newly diagnosed T1DM diagnosis as evidenced by (S) confusion and numerous questions regarding diet, physical activity, and hypoglycemia. 16. Determine Armandos initial CHO prescription using his diet record from home as a guideline, as well as your assessment of his energy requirements. What nutrition education material would you use to teach Armando CHO counting? Armandos energy requirements (using Mifflin St. Jeor): a) REE = (10 x 74.84kg) + (6.25 x 180.34cm) (5 x 32) + 5 = 1,720 kcal/day

b) TEE based on activity factor of 1.2 (because he is currently bed-bound) TEE = 1,720 x 1.2 = 2, 065 kcal/day c) Carb requirements: 45-65% of daily kcal 2,065 x .45 = 930 kcal from carbs/ 4kcal/g = 232g/carbs/daily 2, 065 x .65 = 1,342.25 kcals from carbs/ 4kcal/g = 336 g/carbs/daily *232-336g/carbs/daily Armandos initial CHO prescription: Because there is no evidence to support special macronutrient recommendations for diabetics1, Armando should stick to his usual intake, which meets the recommended intake for healthy adults (DRI for males ages 3150 y = 130 g/d)2 judging from his diet record. In terms of nutrition education material, the American Diabetes Association website offers excellent material and advice for persons with Diabetes as well as resources for professionals. The ADA recommends people with diabetes should receive DSME and diabetes self-management support (DSMS) according to National Standards for Diabetes Self-Management Education and Support when their diabetes is diagnosed and as needed thereafter (2013). We would definitely recommend that Armando explore the Living With Diabetes tab, which provides information on treatment, care, and even a section for those who have been recently diagnosed. As for tangible materials, various booklets on carb counting, exchange lists, and meal planning are available. 17. Armandos usual breakfast consists of 2 slices of toast, butter, 2 tbsp jelly, 2 scrambled eggs, and orange juice (~1 c). Using the ICR that you calculated in question #7, how much Novolog should he take to cover the carbohydrate in this meal? Armandos usual breakfast consists of 2 slices of toast: 30 g/carb (15g per slice or 2 carbohydrate exchanges) butter: 2 tbsp jelly: 30 g/carb (15g per tbsp or 2 carbohydrate exchanges) 2 scrambled eggs: 2g/carb (~1g per egg) 1 cup orange juice: 24g/carb (12g per cup or 2 carbohydrate exchanges) Total carbs: 86g or 6 carbohydrate exchanges Because 1 unit of Novolog covers 15 grams of carbs (or 1 carbohydrate exchange,) Armando would need about 6 units to cover his breakfast meal containing 86 grams of carbs (or 6 carbohydrate exchanges). 18. Using the ADA guidelines, what would be appropriate fasting and postprandial target glucose levels for Armando? The American Diabetes Association suggests these targets for most adults with diabetes; as always, each individual will vary in terms of appropriate glycemic goals. a. Fasting (preprandial) plasma glucose: 70-130 mg/dl

b. Postprandial plasma glucose (1-2 hours after beginning of meal): less than 180 mg/dl 19. Write an ADIME note for your initial nutrition assessment. Assessment: Client is a 32 year old Hispanic male originally diagnosed with T2DM one year ago. Consumes toast, jelly, coffee, orange juice, scrambled eggs and coffee for breakfast; Subway sandwich, chips and diet coke for lunch; and cooked pasta, rice, vegetables and some type of meat for dinner. Also eats out 3-4 times per week for dinner (FH2.1.3.1). Reports not being physically active lately due to bed rest but likes to exercise regularly and enjoys long distance cycling, which he plans to start again (FH-7.3.1). Was not compliant with Metformin medication after T2DM diagnosis (FH-3.1.3). Mother has history of T2DM, and client expresses concern over his mothers and his own conditions. Anthropometric data: 511, 165 lbs. BMI of 23.1 Biochemical data: Elevated blood glucose level of 683 mg/dL and elevated HbA1c level at 12.5% (BD-1.5), elevated cholesterol level of 210 mg/dL, elevated trigylcerides level of 175 mg/dL, and low C-peptide level of 0.09 ng/dL (BD-1.7), low sodium level of 130 mg/dL, low phosphate level of 2.1 mg/dL (BD-1.13). Nutrition-focused physical findings: Temp. 99.5, resp. rate 25, pulse 82, BP 101/78, dry mucous membranes, lethargic, able to arouse, Glasglow Coma Scale score 13 Diagnoses: (P) Altered nutrition-related laboratory values (NC- 2.2) related to (E) uncontrolled DM as evidenced by (S) serum glucose level of 610 mg/dL and HBA1C level of 12.5%. (P) Food and nutrition-related knowledge deficit (NB- 1.1) related to (E) lack of education regarding newly diagnosed T1DM diagnosis as evidenced by (S) confusion and numerous questions regarding diet, physical activity, and hypoglycemia. Intervention & Prescription: Nutrition Prescription: Follow consistent and controlled diet so that nutritionrelated laboratory values will normalize. Nutrition Intervention: Modify composition of eating bouts, specifically a carbohydrate-modified diet (ND-1.2) in order to control the amount of carbohydrate consumed and ensure the adequacy of prescribed insulin therapy. This includes following a consistent carbohydrate-controlled diet, consuming breakfast and lunch with 70-80g carbohydrate each, dinner with 85-95g carbohydrate, and an afternoon and bedtime snack each with 30g carbohydrate. Total daily carbohydrate intake should be between 232 and 336 grams.

Nutrition Prescription: Provide nutritional education regarding new T1DM diagnosis so as to enhance patient ability to consume a controlled yet adequate diet necessary for improvement of current condition. Nutrition Intervention: Provide nutrition-related education to the patient regarding priority modifications to the diet (E-1.2) and nutrition relationship to health/disease (E-1.4), in order to ensure he has the needed information to control his disease via his diet. Continue to provide application-centered education, in which result interpretation (E-2.1) and skill development (E-2.2) are assessed to ensure the patient is fully competent in managing his T1DM. This includes ensuring patient is capable of calculating carbohydrate content of foods, understanding glycemic index, making healthful dietary choices in order to meet carbohydrate goals, and staying within daily recommendations for carbohydrate intake. Also that the patient understands physical activity interaction with blood glucose levels. Monitoring & Evaluation: Client self-monitor preprandial and postprandial plasma glucose to meet target T1DM goals for these values per AND (FH-5.1.4). Monitor serum glucose and Hg-A1c levels over time (BD-1.5) compared to normal ranges, to evaluate dietary control of T1DM. Continue nutrition education sessions to monitor patients understanding of T1DM (FH-4.1) until knowledge proficiency is evident and patient is able to take necessary steps in controlling his disease on his own (FH-4.2.8). Monitor for perceived importance of compliance to medications (FH-3.1.3). Monitor client-reported dietary intake to ensure adherence to carbohydrate intake recommendations for T1DM (FH-5.1). Monitor BMI to ensure body weight is being maintained (CS-5.1.1). 20. Armando comes back to the clinic 2 weeks after his diagnosis. List the important questions you will ask him in order to plan the next steps for providing the additional education that he might need. After his diagnosis, it is important to follow up with the monitoring/evaluation section of ADIME. Having undergone a change of diagnosis from T2DM to T1DM, the patient now needs to begin regular insulin injections. He should be taking 3-4 injections a day, of basal, prandial insulin, or using a pump for a steady flow. Biochemical data needs to be redrawn and monitored, to ensure that the patient is taking his insulin as prescribed. This biochemical data should also show more normal lab values, such as sodium and HbA1C, as well as phosphorous, cholesterol and triglycerides. Glucose should be within the normal range for T1DM, being 70130 mg/dL OR less than 180 postprandial within 1-2 hours after a meal. Since hes been on his own for the past two weeks, its important to ask him questions about his daily regimen, including how often he is checking his blood glucose, his eating habits, exercise, how he has been feeling, what his blood sugar range has been, and any concerns or questions he has. If there are any signs that he isnt following his insulin regimen or he is having hypoglycemic events despite treatment, Armando may need additional interventions, including counseling and education, to prevent future events and decrease his risk for co-morbidities.

21. Armando states that he would like to start exercising again as he is feeling better. He is used to playing tennis several times per week as well as cycling at least 2 days per week for over 20 miles each time. Again, he expresses his concern regarding low blood sugar. How would you counsel Armando regarding physical activity, his diet, and his blood glucose monitoring? Since he plans to increase his exercise, Armando needs to understand the link between exercise and insulin sensitivity, as well as the importance of monitoring his glucose before and after exercise. Because regular exercise can often increase insulin sensitivity, Armando should be regularly checking his glucose levels and know how to adjust his insulin accordingly. At the same time, he needs to understand the importance of his glucose levels prior to exercise. If Armando plans to increase his exercise, he should test his blood glucose before, to make sure it is high enough to maintain through his activity, and to prevent hypoglycemic events after he exercises. If glucose is too high, exercise can add extra stress on the body; at the same time, if glucose is too low, exercise can lead to hypoglycemic events. For this reason, he needs to be aware of the normal 70-130 mg/dL ranges for T1DM, and make sure he is staying within this range as much as possible. In summation, Armando needs to have a very clear idea of why self-monitoring his glucose levels throughout the day and, specifically prior to exercise, since he is planning on becoming much more active. 22. Armando states that one of his friends has talked about using glycemic index as a way to manage his diabetes. He says that he has also seen some nutrition programs advertise their food products as being low glycemic index on TV. Explain glycemic index, glycemic load, and how he might use this information within his nutrition therapy plans. The glycemic index is a measurement and grading system used to evaluate a foods effect on glucose levels. The glycemic load is a number than indicates how much blood glucose will rise after a meal; one unit of glycemic load approximates the effect of consuming one gram of glucose. This can be a useful tool in diabetes, because it can indicate how many units of insulin will be needed to counteract the rise in glucose. Although Armando now seems to be very enthusiastic about his T1DM maintenance, it is still important for him to regularly test his glucose levels (6-8 times a day) to make sure he is not becoming hypoglycemic; if he plans to exercise very often, he will need to test his glucose more often. If he remains interested in low glycemic index foods, more education would be needed, to ensure that a change in diet wouldnt drastically affect his glucose levels, especially with increased exercise. At the same time, Armando needs to make sure that if he is planning to decrease his carbohydrate intake, his ICR should be adjusted. If he plans to decrease his carbohydrates, but doesnt decrease his insulin, he will most likely cause his glucose to drop too low, resulting in hypoglycemia. References: 1. The Academy of Nutrition and Dietetics. Nutrition Care Manual.

2. Dietary Reference Intakes (DRIs). http://www.iom.edu/Activities/Nutritio n/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/5_Summ ary%20Table%20Tables%201-4.pdf.