CASE STUDY #3 - NUT 116AL

Type I Diabetes Mellitus

DUE Wednesday 12/7 by 4:00 pm in Meyer 3135 (Nutrition Dept. office).

Instructions:
Read all questions before starting on the case study as many are related to each other.
Review the pts medical record below. Answer each question and show your calculations (if
necessary) for each. You may include your calculations in the answer box and, if needed, attach
as a separate, hand-written sheet. Use the following conversion factors: 1=2.54 cm and 1
kg=2.2#.
Reference all calculation formulas with the text and page number from the Pocket Resource (i.e.,
PG p. ___). Only use the PG for all calculations. You may use lecture notes and the textbook for
all other questions. Cite lecture notes as 116AL CVD Lecture, slide#.
After you have EXHAUSTED your search for answers to your CS questions and you are still
unable to find the answer, you may use outside resources as long as they are credible
resources. e.g.: Mayo Clinic, medline plus, research articles, etc., NOT wikipedia. Remember to
conduct a thorough search of the resources available to you prior to using outside references to
avoid losing points.
In your citation, please include the resource name (i.e.: Mayo Clinic), title of page/article,
& exact URL link.
You must type your answers! If not, questions will not be graded and you will receive 0 points.
To familiarize yourself with medical terminology, utilize an online dictionary such as:
http://www.medilexicon.com/medicaldictionary.php
CS #3 is worth 50 pts.
____________________________________________________________________________________

Cxxxxxx, Oxxxx Male 33 yo

Allergies: NKA Code: FULL Isolation: NONE
Pt. Location: RM 1307 Physician: J. Robinson Admit Date: 12/02/16

Pt Summary: O.C. is a 33 yo male admitted through the ED with c/o excessive thirst and frequent
urination of 2 wk duration, in addition to increased appetite and weight loss of 12 pounds in 3
weeks.

PMH: Pt was product of normal pregnancy and delivery; had varicella at age 6, and an
appendectomy at age 15. No Medications. NKA.

FH: Parents L&W. Paternal uncle has Type 1 DM; Maternal grandfather died of CVD 2 to Type 2
DM. Other grandparents L&W. Has 1 sibling, a younger brother, L&W.

Social Hx: 33 yo male, post-doc at UC Davis. Pt used to play soccer three times a week, but says
he now tires easily so he has not played in 3 weeks.

ROS:
GI: No hx of N/V, or diarrhea
GU: No hx of urgency, frequency, or burning urination except for present
complaint of polyuria
CNS: Alert and oriented, no hx of impaired LOC, convulsions, or difficulty walking

PE:
General: Slightly underweight, tired appearing male; wt: 170# ht: 73
Vitals: T 98.2F; P 120; R 27 with fruity odor; BP 110/70 mm Hg
Lungs: Clear to percussion and auscultation
Heart: Normal sinus rhythm, no murmurs
HEENT: Non-contributory

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Abdomen: Flat, non-tender, no liver enlargement
Genitalia: nl
Extremities: Non-contributory
CNS: Normal gait and deep tendon reflexes
Skin: Smooth, warm, dry, no edema
Peripheral Vascular: Pulse +4 bilaterally

Laboratory Results
Ref. Range 12/02/16 1210
(non-fasting)
Chemistry
Sodium (mEq/L) 136-145 129 !
Potassium (mEq/L) 3.5-5.5 3.6
Chloride (mEq/L) 95-105 101
Carbon dioxide (CO2, mEq/L) 23-30 32 !
BUN (mg/dL) 8-18 17
Creatinine serum (mg/dL) 0.6-1.2 1.1
Glucose (mg/dL) 70-110 372 !
Phosphate, inorganic (mg/dL) 2.3-4.7 2.0 !
Magnesium (mg/dL) 1.8-3 1.9
Calcium (mg/dL) 9-11 10
Osmolality (mmol/kg/H2O) 285-295 303 !
Bilirubin total (mg/dL) 1.5 0.2
Bilirubin, direct (mg/dL) <0.3 0.01
Protein, total (g/dL) 6-8 6.9
Albumin (g/dL) 3.5-5 3.2 !
Prealbumin (mg/dL) 16-35 14 !
Ammonia (NH3, umol/L) 9-33 9
Alkaline phosphatae (U/L) 30-120 110
ALT (U/L) 4-36 6.2
AST (U/L) 0-35 21
CPK (U/L) 30-135 F; 55-170 61
M
Lactate dehydrogenase (U/L) 208-378 229
Cholesterol (mg/dL) 120-199 180
Triglycerides (mg/dL) 35-135 F; 40-160 150
M
T4 (ug/dL) 4-12 8
T3 (ug/dL) 75-98 81
HbA1C (%) 3.9-5.2 8.55 !
C-peptide (ng/mL) 0.51-2.72 0.52
ICA - + !
GADA - + !
IA-2A - -
IAA - + !
tTG - -
Hematology
WBC (x 103/mm3) 4.8-11.8 10.6
RBC (x 106/mm3) 4.2-5.4 F; 4.5-6.2 5.8
M

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Urinalysis
Collection method - Clean catch
Color - Yellow
Appearance - clear
Specific Gravity 1.003-1.030 1.008
pH 5-7 4.8 !
Protein (mg/dL) Neg +1 !
Glucose (mg/dL) Neg +4 !
Ketones Neg +4 !
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.1 Neg
Leukocyte esterase Neg Neg
Protein check Neg tr !
WBCs (/HPF) 0-5 0
RBCs (/HPF) 0-5 0
Bacteria 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0

Dx: New Onset Type 1 Diabetes Mellitus

MDs Plan: Admit, achieve glycemic control with Regular Insulin then adjust to daily therapy with
mixed insulin therapy; initiate DSM training; nutrition consult for hospital and home diet planning
and pt. education.

You are the in-patient RD.

You meet with O.C. to do a nutrition assessment and begin a general introduction to dietary
management of diabetes. You take a diet history (listed below) as part of your assessment. O.C.
states that these are the types of foods that he usually eats, but the quantity is much greater than
usual because he has felt so hungry lately. O.C. is Muslim and follows Islamic dietary laws.

Breakfast (eaten at home):

1 c. oatmeal with brown sugar and cup of 2% milk
1 c. juice (orange, apple, or cranberry)
Toast (2 slices or English muffin) w/ butter & jelly
Coffee with sugar and 2% milk
(occasionally 2 scrambled eggs instead of the cereal)

Lunch (eaten at the CoHo/Silo on weekdays):

2 slices of cheese pizza with a small salad or
Grilled cheese and French fries or
Meal from Shahs Halal Food cart Gyro or Rice Plate (lamb/chicken)
16 oz of sweetened iced tea
dessert such as cookies or a brownie
(sometimes 8 oz of 2% milk instead of the iced tea)

Mid afternoon:
medium mocha or latte,
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A cookie or a piece of fruit

Dinner:
~6 oz. meat (chicken/lamb/beef, occasionally fish)
1 cup of rice
Vegetables in season (will eat w/ salt & butter)
12 ounces of 2% milk
or
A vegetarian sandwich and chips and soda if he does not have time to cook

HS:
O.C. eats one of the following:
Bag of microwave popcorn w/ 1-12 oz can of regular soda
2 scoops of ice cream
1 c 2% milk and 4-5 cookies
2 oz. cheese and 12 Wheat Thin crackers

1. Compare O.C.s admission laboratory values with normal values. What does
each value indicate, based on the hospitals lab value reference ranges above? Use
your texts for non-fasting BG values. (5 pts)
Test nl Values O.C.s Compariso What do O.C.s lab values suggest
Values n: about his metabolic state?
</=/> nl
values
BG 70-110 372 mg/ dL > Little to no insulin is being produce
mg/dL to allow glc uptake into the cell.
Could also indicate that CHO dense
meal was just consumed and glc is
not being taken up by the cells in
the boy leaving glc to circulate in
blood
- B/c O.C. is not fasting, should
be less than 140 mg/ dL 2 hrs
after eating further
suggesting O.C. is diabetic
Urinary Neg +4 > Excretion of glucose into urine is a
glucose cause of concern b/c indicates glc is
not being taken up by cells and
instead is being excreted in urine if
not circulating
Urinary Neg +4 > Excretion of ketones in urine is a
ketones cause of concern b/c it is an
indication that lean muscle masses
are being broke down for energy
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 but instead excreted through urine
PreAlb 16-35 mg/ 14 mg/ dL < Lower values of prealbumin would
dL be present in O.C.s lab values b/c
the prealbumin protein is being
degraded at a higher rate than it is
being produced by the liver
HbA1C 3.9-5.2% 8.55% > Higher values of hbg is glycosylated
b/c circulating glc in blood in
greater proportion for a longer
amount of time

2. What is HbA1C and what does HbA1C measure? (1 pt)

HbA1C is the amount of glycosylated hemoglobin that is a measure and
representation of average blood glucose over the past 3 months.
Dr. Steinberg, Fall 2016: NUT 116A. Power Point: DM Part 1, Slide 23

3. List the following HbA1C ranges. (2 pts)

Normal non-diabetic: 4-6%

Pt w/ controlled <7%
diabetes:

Pt w/ fair to poorly 7%
controlled diabetes:

Citation:
Dr. Steinberg, Fall 2016: NUT 116A. Power Point: DM Part 1, Slide 23

4. Explain the role/relationship of HbA1C in the development of micro- and macro-

vascular complications of diabetes. (2 pts)
Microvascular complications of diabetes include: Nephropathy including end stage
renal disease, Retinopathy including blindness, Neuropathy including peripheral
neuropathy, foot problems
Macrovascular complication of diabetes include: Cardiovascular Dz including both
CHD and stroke; furthermore including atherosclerosis and HTN
The relationship of HbA1C and long-term complications of diabetes including micro-
and macrovascular complications ultimately occur with the accumulation of
intermediate products that are glycosylated. These intermediate products are a
result from key cellular mechanisms such as glycolysis where glucose molecules
become attached to proteins. With this accumulation, there is a change in cell
signaling and gene expression that cause inflammation, metabolic change and

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cellular dysfunction. Ultimately, chronic high HbA1C values result in the micro- and
macro-vascular complications listed above.

Dr. Steinberg, Fall 2016: NUT 116A. Power Point: DM Part 1, Slide 22 and Slide 24

5. What are three metabolic reasons for O.C.s weight loss (number each for full
credit). (2 pts)
The cells in the body are unable to uptake glc, the body begins to think it is in
starvation, the following will occur:
1. Increase protein degradation and decrease in AA uptake, which will lead to
muscle wasting and weight loss
2. Increase in lipolysis, decrease in TG formation which increase the availability of
FAs as an alternate energy source
3. Increase in glc output and decrease in glc uptake lead to polyphagia, polyuria
and polydipsia which ultimately result in dehydration

Dr. Steinberg, Fall 2016: NUT 116A. Power Point: DM CVD Wrap Up, Slide 6

6. Describe and explain Islamic dietary laws and any dietary restrictions you would
need to consider when counseling O.C. (2 pts)
- Food must be classified as halal or lawful including animal slaughtered
properly, in the name of Allah and are alive prior to slaughtering, must be non-
carnivorous animals (such as pork, improperly slaughtered animals and
alcohol), are not birds of prey, must have external ears and exclude blood,
alcohol and foods contaminated with either. All fish and seafood are classified
as halal.
- Prohibitions of drugs and alcohol, including as an ingredient including vanilla
extract
- There needs to be careful consideration when shopping for food ingredients
that may come from several sources, such as gelatin, emulsifiers, and
enzymes (pork products)
- Foods mentioned in Quran such as olives, dates, figs, honey, yogurt,
pomegranate, beans, grapes are excluded from diet related to the practice of
Prophet Mohammad
- Fasting during the day time during the month of Ramadan is crucial
component for the spirituality in the religious practices and essential to
consider

Important to find out specific levels of observance prior to adjusting diet.

Citation:
http://www.eatrightpro.org/resource/news-center/in-practice/dietetics-in-
action/understanding-the-diverse-culinary-traditions-of-islam
http://www.todaysdietitian.com/newarchives/072709p56.shtml
https://www.utsc.utoronto.ca/~facilities/documents/GuidetoHalalFoods.pdf

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7. Based on O.C.s diet history information and what you know about MNT
management of Type 1 DM, name 3 nutrition-related topics that are important to
discuss in educating O.C. as he prepares to head home from the hospital. (3 pts)
1. Food intake including reduced energy and fat intake
2. Implementation of CHO counting
3. Appropriate CHO substitutions and appropriate serving sizes

Professor Frank, Fall 2016- Nut 116AL, Diabetes: Slides 24 and 31

8. You determine that O.C. needs 3000-3300 kcals/day based on EER calculations
and the fact that O.C. needs to gain weight to achieve his normal weight. You want
to follow his normal eating pattern as much as possible while still meeting his
protein requirements and keeping the kcal from fat at 30-40% of total kcals. Using
the Exchange Lists, develop a pattern for O.C.s diet. (15 pts)
Food group Number of CHO Protein Fat grams
Exchanges grams grams
Breakfast
Starch/CHO 1 15 3 1
Fruit 1 15 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1 (2%) 12 8 5
Protein (medium-fat) 1 0 7 5
Fats 2 0 0 10
Morning Snack
None
Lunch
Starch/CHO 1 30 6 1
Fruit 5 75 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1 (2 %) 12 8 5
Non-starchy vegetables 2 10 4 0
Protein (lean) 1 0 7 2
Fats 3 0 0 15
Afternoon Snack
Starch/CHO 3 45 9 3
Milk (2%) 1 12 8 5
Fat 1 0 0 5
Dinner
Starch/CHO 4 45 9 3
Fruit 5 75 0 0
Milk & Subs.(skim, 1%, 2%, or 1 (2%) 12 8 5
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whole)
Non-starchy vegetables 4 20 8 0
Protein (lean) 1 0 7 2
Fats 3 0 0 15
HS Snack
Milk (2%) 1 12 8 5
Starch/CHO 3 45 9 3

Fats 3 0 0 15
Total grams 435 109 105
X4 X4 X9
kcal from each macronutrient 1740 436 945
TOTAL KCAL: 3121 55 % 15 % 30 %

9. O.C. is taught about his diet, insulin injections, SMBG, and other self-care issues
prior to discharge. He is discharged on a basal injection of Levemir, with bolus
injections of Novolog regular insulin at mealtimes. Provide the generic name and
indication of each medication and its effects. Also note any dietary
recommendations, contraindications/precautions, and interactions. What effect will
these medications have on his nutritional care? Refer to the medication
information in the FMI text. (3 pts)
Levemir FMI p. 180 *dose dependent
Generic name: Insulin Detemir
Classification: Long Acting Basal Insulin
Onset of Action: 0.8 to 2 hrs*
Peak: No peak
Duration: 12 to 24 hr*

Novolog FMI p. 180

Generic name: Insulin Aspart
Classification: Rapid Acting Bolus Insulin
Onset of Action: 10 to 20 min
Peak: 40 to 50 min
Duration: 3 to 5 hr

Levemir & Novolog FMI p. 179

Indication: Hypoglycemic, antidiabetic
Diet: Diabetic meal plan to balance CHO cc insulin form
Possible FMI: Alcohol could potentially cause hypoglycemic effect
Potential N/A
Nut/Oral/GI Side
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Effects:

10. Write an ADIME note for O.C., using the information that you have obtained up
until this point. Base your note on the pertinent information given in the
presentation data, diet history, and questions above. Write the ADIME note below
and attach a separate sheet with all calculations. Include two PES statements. (8
pts)

A:
Patient hx: 33 yo M admitted through ED for excessive thirst, frequent urination,
and increased appetite.
Social and FHx: Paternal uncle w/ T1DM
Wt Hx: wt loss of 12# (Wt loss: 6.6%).
Diet order: N/A
Anthropometrics:
Ht: 185.42 cm
CBW: 77.27 kg
IBW: 83.64 kg (92% IBW)
BMI: 22.5 kg/ m2 (nl)

Biochemical data: (12/02/16)

Chemistry:
High: CO2, Glc, Ca2+, HbA1C , ICA, GADA, IAA
Low: Na+, P, Alb, PAB
Urinalysis:
High: Pro, Glc, Ketones
Low: pH

Medications upon discharge: Levemir, Novolog

Estimated Needs
Based on 83.64 kg (IBW):
kcal
Energy: BEE: 2753 3212
D
Pro: 8 4 109 g/ D
Fluid: 3093 to 3351 mL/ D

Food and Nutrition Hx:

- Pt reports excessive polyphagia, and polydipsia
- Pt follows Islamic dietary laws, specify diet according to religious beliefs

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Assessment of Current Diet:
Dietary Analysis of 24-hr recall (based on Food Processor foods): 2974.54 kcals,
402.53 gm CHO (113%), 137.66 gm Pro (223.15%), Fat 93.27 gm (116.07%),
743.64 mL/D fluid
- Diet is eaten in higher proportions as of recently and should

D:
1. Unintended wt loss (NC-3.2) r/t undiagnosed and untreated T1DM AEB
polyphagia, polyuria, polydipsia and altered nutrition-related lab values
2. Excessive energy intake (NI-1.3) r/t undesirable food choices AEB excess
CHO intake, excess Pro intake, excess fat intake

I:
MNT Goal: To provide nutrition education and optimize pt understanding of how
to follow appropriate dietary choices c/w SMBG, medication usage and
appropriate CHO counting and CHO exchanging

Recommendations:
Follow diet for IBW to gain wt lost (12#) r/t untreated T1DM
Achieve and maintain BW goals
Follow CHO counting and exchange system mentioned above
Behavioral Goals:
Make adaptions for personal and cultural preferences
Practice willingness to make behavioral changes
Discussed using other forms of non-meat pro such as beans and soy products
Discussed which foods to select less often and which foods to increase more often
Diet Rx
- for IBW: Total kcal: 3139 to 3422 kcal/D, Pro: 101 to 109 g/D, Fluids: 3139 to
3422 mL/ D

Nutrition Education/ Diet Instruction:

Provide written material discussing:
CHO counting, insulin-to-CHO ratios, teach usage of exchange lists, behavioral
strategies, intake including reduced energy and fat intake, appropriate CHO
substitutions and appropriate serving sizes

Compliance: Pt was able to express willingness and interest for the adaptions
needed to T1DM

M/E
F/U in 1 wk

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SMBG logs (2 hr PP BGs, qds or as needed) and Food diary
Monitor wt at F/U

x Nutrition Student, Karina Almanza

11. O.C. does well over the next few months in learning to manage his diabetes.
However, he is finding it difficult to keep his activity and intake constant due to the
fact that his schedule is variable, and he wants to resume playing soccer. He and
the health care team agree to use an insulin pump with intensive therapy in order
to make his self-care more flexible and achieve tighter glucose control. You begin
teaching O.C. about carbohydrate counting. Describe briefly how this will differ
from the exchange-based diet plan that he was using. (1 pt)
The exchange-base diet plan is designed for the pt to exchange a certain a food
within a food group for another food in the same food group. This ultimately
means that O.C. would change his diet by substituting a food with a food from the
same food list; foods cannot be exchanged with foods from another group.
Exchange-base diet lists take into account calculations with consideration of the
individuals preferences and is useful for wt control.
CHO counting, on the other hand, measures a consistent amount of CHO per meal
and accounts primarily for starches, milk/ yogurt and sweets. CHO counting takes
into account food counting in terms of 15 g CHO or total grams of CHO and is
established with set menus illustrating the amount of CHO in each.
Professor Frank, Fall 2016- Nut 116AL, Diabetes: Slides 56, 60 and 62
NTP 501-502

12. O.C. brings his SMBG record in for review when he comes for nutrition
counseling. The pre-prandial BG goal is 70-130 mg/dl. Several pre-meal entries are
listed below.
Day Breakfast Lunch Dinner HS Snack
1 94 152 110 100
2 90 106 97 69
3 142 108 95 102

a. Circle/highlight the values that are outside the desirable range. (1 pt)
b. What adjustment(s) should O.C. make if the values are above the desirable
range? (1 pt)
Both Day 1, Lunch and Day 2, HS Snack were above range the desired BG goal
(70 to 130 mg/ dl). O.C. can either decrease or exclude CHO-exchange consumed
at breakfast or increase the amount of insulin estimated and double check CHO
counting when before estimating amount of insulin required.
If values of hypoglycemia are consistent, O.C. should consume 15 to 20 g of any
fast-acting CHO (e.g. cup fruit juice or 3 to 4 glc tablets). 15 minutes after, O.C.
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should recheck BG levels to see if they are within normal values. If values are not
within normal range yet, consume an addition 15 to 20 g of fast-acting CHO.
NTP. P. 505

c. What adjustment(s) should O.C. make if the values are below the desirable
range? (1 pt)
Day 3, Breakfast was a slightly lower than desired value, to compensate, O.C. can
either incorporate 1 additional food exchange of CHO into HS Snack or decrease
amount of insulin secreted, double-checking the correct value secreted.
NTP. P. 505

13. What adjustments should O.C. make on the days when he plays soccer? (1 pt)
If soccer games last less than 30 minutes, addition of CHO or insulin is rarely
needed.
If soccer games last longer than 30 minutes, and BG values are within normal
limits, a small snack is recommended and it is strongly recommended that insulin
dosage is adjusted (typically about 20% decrease of insulin).
Rule of thumb: addition of 15 grams CHO/ hr of moderate PA; strenuous activity:
30 grams of CHO/hr. If soccer game is before breakfast or later in the afternoon,
CHO should be consumed before the soccer game.
NTP p. 505

14. O.C. has caught a cold and has a fever of 102 F. He feels miserable and is not
eating much. He calls you to ask if he should reduce his insulin dose since his diet
is just a few foods (chicken noodle soup and diet 7-up). What advice would you
give him and why? (2 pts)
O.C. should not reduce his insulin dose and might have to instead, increase his
insulin dose because counter-regulatory hormones that can be stimulated during
times of illnesses and increase BG levels, despite lower CHO intake. O.C. should
check BG 4x/ D, adjust for insulin therapy and attempt to maintain regular diet
despite lacking desire to do so. O.C. should contact physician if BG values are >
250 mg/ dL even with extra insulin.

PG p. 60
Dr. Steinberg, Fall 2016: NUT 116A. Power Point: DM Part 2, Slide 54

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Calculations
kcal
MSJ EER (CBW ) : ( 10 ) ( 77.27 kg ) + ( 6.25 ) ( 185.42 cm) ( 533 yo )+ 5=1766.575
D
1.2

(1766.575 kcal
D )
1.3 AF ( 1.0 IF )=2119.89 2296.5475
( )
kcal
D

1.3
Pro :77.27 kg ( 1.5 ) =100.451 115.905 kcal grams of Pro

2119.89
50
1059.945
kcal =264.986 513.279 grams of CHO
CHO: ( 2296.5475 ) ( 60 ) = 2053.116 kcal
D kcal
4
D

2.2
[ 106+ (6 )( 13 ) ]
IBW : /kg =83.64 kg

kcal
MSJ EER (IBW ): (10 )( 83.64 kg ) + ( 6.25 ) ( 185.42 cm) ( 533 yo )+ 5=1835.275
D
1.5
kcal
( 1835.275 kcal ) ( 1.75 AF ) ( 1.0 IF )=2752.9125 3211.73125
D

1.0
g
Pro for maintenance: 83.64 kg ( 1.3 )=83.64 108.732 g/ D
kg

3158.62
50
1579.31
[ 1895.172kcal ]
CHO: ( 3421.86 kcal ) ( 60 ) = =394.8275 473.793 grams of CHO
kcal
4
g

789.655
[ 1197.651 ]
Fat : ( 3158.62 )( 25 ) ( 3421.86 ) ( 35 ) = =87.74 133.07 grams of Fat
kcal
9
g

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