Case Questions

I. Understanding the Diagnosis and Pathophysiology

1. What are the current thoughts regarding the etiology of type 1 diabetes mellitus (T1DM)? No
one else in Rachel’s family has diabetes—is this unusual? Are there any other findings in her
family medical history that would be important to note?

The type 1 diabetes mellitus is pancreatic beta-cell destruction process which cause by genetic,
autoimmune, and environmental factor. T1DM is results from a cell mediated autoimmune
response causing a gradual decline in β cell mass within genetically susceptible individuals. The
main gene for T1DM is located in the human leukocyte antigen region of chromosome 6. There
are more than 50 different gene relationship have been liked to risk for this disease and are
estimated to account for 80%-85% of the inheritability of Type 1 diabetes mellitus. HLA-SR3-DQ2
and DR4-DQ8 alleles are associated with autoantibodies against insulin. Moreover, the genetic
components of T1DM support our understanding of the increased risk for relatives of individuals
with T1DM.

This is not unusual that no one else in Rachel’s family has diabetes. She had a family history of
celiac disease which her sister had, and celiac disease is immune-mediated disease that occur
with increased frequency in persons with type 1 diabetes.

(Krause 2012, p.587)

(Nelms 2016, p.489)

2. What are the standard diagnostic criteria for T1DM? Which are found in Rachel’s
medical record?

The standard diagnostic criteria for T1DM are A1C≥6.5% using standardized laboratory
measures, or Fasting plasma glucose(FPG)2≥126 mg/dL(7.0 mmol/L), or Symptoms of diabetes 3
plus random plasma glucose concentration≥200 mg/dL(11.1 mmol/L), or 2-hour postprandial
glucose ≥200 mg/dL(11.1 mmol/L) during an oral glucose tolerance test(OGTT) 4. The Type 1
Diabetes Mellitus is diagnosed using at least one of four tests.

In Rachel’s medical record, I found her Hb A1c are 14.6% which are much higher than 6.5%. I
also found that her serum glucose of 724 mg/dL and glucose concentration of 683 mg/dL are
both outside of the normal range.

(Nelms 2016, p.489,494)

3. Dr. Cho requested these labs be drawn: Islet cell autoantibodies screen; TSH;
thyroglobulin antibodies; C-peptide; immunoglobulin A level; hemoglobin A 1c; and
tissue transglutaminase antibodies. Describe how each is related to the diagnosis of
type 1 diabetes.

Islet Cell autoantibodies screen is valuable in individuals at high risk for developing diabetes. It
is performed to differentiate between autoimmune T1DM and T2DM, and Islet cell
autoantibodies serve as indicators of the body’s destructive immune response against its own β
cells.
 TSH is thyroid-stimulating hormone, and it is the single best screening test for primary thyroid
dysfunction. The diabetic patients are more likely to be affect by the thyroid dysfunction, so it is
related to the diagnosis of type 1 diabetes.

Thyroglobulin antibodies: they are immune cells that indicate the immune system is attacking
thyroglobulin in the thyroid gland. It also can help diagnose hypothyroidism.

C-peptide: The insulin is secreted as two polypeptide chains joined by disulfide bonds, and the
C-peptide is released when the two chain separate. C-peptide levels can be used as an indicator
for endogenous insulin production. Since autoantibodies are not always useful in determining
the overall beta-cell function of the pancreas, the C-peptide levels allow the determination of
insulin production in T1DM.

Immunoglobulin A level: when the beta-cell are destructing, we observed the immunoglobulin
A level elevated.

Hemoglobin A1C: in the blood is related directly to the average blood glucose levels for the
preceding 2 to 3 months and does not reflect more recent change in glucose level. It is useful in
differentiating between short-term hyperglycemia in individuals under stress or who have had
an acute myocardial infarction and those with diabetes.

Tissue transglutaminase antibodies: it uses to evaluate the celiac diseases for patient since
people who have type 1 diabetics are easier to develop the celiac diseases.

(Krause 2012, p.109,621,622)

(Nelms 2016, p.495,496)

4. Using the information from Rachel’s medical record, identify the factors that would
allow the physician to distinguish between T1DM and T2DM.

Firstly, Rachel is 12-year-old children, and T1DM develops most frequently in children and
adolescents. Moreover, she also has the symptom of polyuria, polydipsia, polyphagia, and a
sign of weight loss recently. These symptoms also are caused by T1DM. When we are looking
to her lab result, we also found her C-peptide level are much lower than the normal range,
and it indicate that there is almost no endogenous insulin production.

(Krause 2012, p.587)

(Nelms 2016, p.489)

5. Describe the metabolic events that led to Rachel’s symptoms and subsequent
admission to the ED (polyuria, polydipsia, polyphagia, fatigue, and weight loss),
integrating the pathophysiology of T1DM into your discussion.

The pancreatic beta-cell destruction usually leads to absolute insulin deficiency and result in
hyperglycemia, polyuria, polydipsia, polyphagia, weight, fatigue. The acute consequences of an
insulin deficit are numerous and potentially fatal. Hyperglycemia is plasma glucose level rise
when glucose cannot enter cells. The polyuria is caused by the excess glucose is filtered out into
the urine because the kidneys can filter only so much glucose from the blood to compensate for
the hyperglycemia. The polydipsia is caused by loss of fluid stimulates the thirst mechanism.
Moreover, cell dependent on glucose for energy have none available, so the body responds to
 this emergency by polyphagia. Weight loss in persons with Ketoacidosis is cause by
Hypovolemia and muscle catabolism, and it often present at the diagnosis of T1DM.

(Nelms 2016, p.491)

(Krause 2012, p.587)

6. Describe the metabolic events that result in the signs and symptoms associated with
DKA. Was Rachel in this state when she was admitted? What precipitating factors
may lead to DKA?

The hyperglycemia can lead to diabetic ketoacidosis (DKA). The DKA is a life-threatening but
reversible complication which characterized by severe disturbances in carbohydrate, protein,
and fat metabolism. DKA is the result of inadequate insulin for glucose use, and it is
characterized by elevated blood glucose levels (>250 mg/dl but generally <600 mg/dl) and the
presence of ketones in the blood and urine. The symptoms of DKA include polyuria, polydipsia,
hyperventilation, dehydration, the fruity odor of ketones, and fatigue. Rachel have the
symptoms of polyuria, polydipsia, polyphagia, fatigue when she was admitted, and these are the
signs or symptoms associated with DKA. Some acute illnesses such as flu, colds, vomiting, and
diarrhea, if not managed appropriately, can lead to DKA.

(Krause 2012, p.612)

7. Rachel will be started on a combination of Apidra 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. Her discharge dosages are as follows: 7 u glargine with
Apidra prior to each meal or snack—1:15 insulin: carbohydrate ratio. Rachel’s
parents want to know why she cannot take oral medications for her diabetes like
some of their friends do. What would you tell them?

The Apidra is rapid-acting Insulin called Glulisine. The onset of action is 5-15 min, the peak of
action is 30-90 min, and duration of action is about 3-5 hours. The glargine’s onset of action is 1
hours, and it have no peak. The duration of this action is up to 24 hours. Individual with T1DM
must depend on daily administration of exogenous insulin in conjunction with nutrition therapy
and physical activity to mimic the insulin secretion in an dividual without diabetes. Rachel’s
situation is different with their friends who may have T2DM. Since Rachel have the T1DM, she
cannot produce insulin at all due to the destruction of the beta-cells in the pancreas. Therefore,
she needs inject the prescribed insulin which can help her unchanged blood to circulate.

(Nelms 2016, p.496, 500)

8. Rachel’s physician explains to Rachel and her parents that Rachel’s insulin dose may
change due to something called a honeymoon phase. Explain what this is and how it
might affect her insulin requirements.

The honeymoon phase is the time after diagnosis of T1DM when insulin production is variable,
and it also is the recovers hyperglycemia, metabolic acidosis, and ketoacidosis, endogenous
insulin secretion after diagnosis. During the honeymoon phase, exogenous insulin requirement
decreases dramatically for up to 1 year or longer, and good metabolic control may be easily
achieved.
 (Krause 2012, p.587)

9. How does physical activity affect blood glucose levels? Rachel is a soccer player and
usually plays daily. What recommendations will you make to Rachel to assist with
managing her glucose during exercise and athletic events?

The physical activity should be an integral part of the treatment plan for person who have
diabetes. Exercise help all person with diabetes improve insulin sensitivity, reduce
cardiovascular risk factors, control weight, and improve well-being. Hypoglycemia can occur
because of insulin-enhance muscle glucose uptake by the exercising muscle. In the person with
T1DM, the glycemic response to exercise varies, and it depend on overall diabetes control,
plasma glucose and insulin levels at the start of exercise, timing, intensity, and duration of
exercise. Since Rachel is a soccer player, and this is intense exercise. Therefore, the glucose
uptake is increased by 8 to 13g/hr. I recommend her to add 15 g carbohydrate for every 30 to 60
minutes of activity over and above normal routines. She can eat a pre-exercise snack to raise her
blood glucose.

(Krause 2012, p.597,598)

10. At a follow-up visit, Rachel’s blood glucose records indicate that her levels have
been consistently high when she wakes in the morning before breakfast. Describe
the dawn phenomenon. Is Rachel experiencing this? How might it be prevented?

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. It results from the effect of
hormones involved in controlling circadian rhythms. Cortisol and GH stimulate gluconeogenesis,
and it cause hyperglycemia between 5:00 am and 9:00 am. I think Rachel is experiencing this
since her blood glucose level have been consistently high when she wakes in the morning before
breakfast. For the prevention, I recommend her to have bad time snacks or adjust insulin
regimens.

(Nelms 2016, p.512)

II. Understanding the Nutrition Therapy

11. The MD ordered a carbohydrate-controlled diet for when Rachel begins to eat.
Explain the rationale for monitoring carbohydrate in diabetes nutrition therapy.

Rationale for monitoring carbohydrate is that the carbohydrate found in foods is the major
macronutrient influencing postprandial glucose variations and that it influences premeal insulin
requirements more than the protein and fat content of the meal. Carbohydrate counting is an
eating plan method based on this principle that all types of carbohydrate are digested with the
majority being absorbed into the bloodstream as glucose and that total amount of
carbohydrate consumed has a big effect on blood glucose elevation. The way to count
carbohydrates is that one carbohydrate choice is a portion of food containing 15 grams of
carbohydrate. The person with diabetes recommends to create an eating plan that lists the
number of carbohydrate choice.

(Krause 2012, p.595)

(Nelms 2016, p.509,510)

 12. Outline the basic principles for Rachel’s nutrition therapy to assist in control of her
T1DM.

The basic principles of medical nutrition therapy in control of her T1DM

 Promote and support healthful eating patterns, emphasizing a variety of

nutrient-dense foods in appropriate portion sizes to improve overall diet, attain
individualize glucose and lipids goals, achieve and maintain healthy body
weight goal, and prevent complication of T1DM for Rachel.
 To address Rachel’s nutrition needs based on personal and cultural
preferences, health literacy and numeracy, access to healthful food choices,
willingness and ability to make behavior changes.
 Help Rachel maintain the pleasure of eating by providing nonjudge mental
messages about food choices.
 Provide Rachel with practical tools for developing healthy eating patterns
rather than focusing on individual macronutrients, micronutrients, or single
foods.

(Krause 2012, p.594)

(Nelms 2016, p.506)

III. Nutrition Assessment

13. Assess Rachel’s ht/age; wt/age; ht/wt; and BMI. What is her desirable weight?

Height: 5’=60 inch = 152cm Age=12-year-old

Weight: 82lbs = 37.2kg

BMI= 37.2kg/1.522m=16.1 kg/m2

Base on the growth chart for 2 to 20 years: Girls, and BMI chart

Her ht/age is in the 50th percentile, and her wt/age is in the 25 th percentile. Her BMI are
placing at the 18th percentile for girls aged 12 years.

Her desirable weight is about 92lbs to put her in the 50 th percentile. She need 10 more pound
of body weight to meet desirable weight.

14. Identify any abnormal laboratory values measured upon her admission. Explain how
they may be related to her newly diagnosed T1DM.

Sodium: 126 mEq/L Lower than Reference Range Poor dietary intake, dehydration

Glucose:683 mEg/L Higher 70-99 Ref. Range Insulin resistance

Phosphate, inorganic Lower 2.2-4.6 Ref. Range Hyperglycemia, renal function

1.9 mg/dL

Osmolality Higher 275-295 Ref. Range dehydration

295.3mmol/kg/H2O
 HbA1c 14.6% Higher 3.9-5.2 Ref. Range Insulin resistance, hyperglycemia

C-peptide 0.10ng/mL Lower 0.51-2.72 Ref. Range Insulin secretion decrease,

β-cell destruction

ICA, GADA, IA-2A, Higher (-) Ref. Range Autoimmune response

IAA (+)

Specific gravity Higher 1.001-1.035 Ref. Dehydration

1.036 Range

pH 4.9 Lower 5-7 Ref. Range Increasing of fatty acid metabolism,

Ketoacidosis complications

Ketones 1 Higher Negative Ref. Range Increasing ketones level,

breakdown fat, insulin resistance

Protein +4 mg/dL Higher Negative Ref. Range Kidney failure, increasing of protein
breakdown

Prot Chk +4 Higher Negative Ref. Range Protein in urine

15. Determine Rachel’s energy and protein requirements. Be sure to explain what
standards you used to make this estimation.

I use EER equation Girls 9-18 years old to calculate energy requirements

EER=135.3- (30.8 x 12yrs) + 1.6 x[(10.0 x 37.2kg) + (934 x 1.52m)]+25=

135.3- 369.6 + 2866.7+25=2657.4 kcal/day

https://globalrph.com/medcalcs/estimated-energy-requirement-eer-equation/

Protein requirement which about 15%-20% of energy need

2657.4 X 15%=398.6kcal 398.6 kcal/ 4kcal/g=100g

2657.4 X 20%=531.5kcal 531.5 kcal/ 4kcal/g=133g

 Protein requirement are 100g – 133g of protein per day.

IV. Nutrition Diagnosis

16. Prioritize two nutrition problems and complete the PES statement for each.

N.C.2.2 Altered nutrition-related laboratory values

sodium, glucose, phosphate, osmolality,

Altered nutrition-related laboratory values of
HbA1c, c-peptide, ICA, GADA, IA-2A, IAA, ketones, protein, Prot Chk related to
diagnosis of T1DM as evidence by the current laboratory results.
N.B.1.1 Food and nutrition related knowledge deficit

Food and nutrition related knowledge deficit related to lack of access to information as
evidenced by new diagnosis of T1DM.

V. Nutrition Intervention

17. Determine Rachel’s initial nutrition prescription using her usual intake at home as a
guideline, as well as your assessment of her energy requirements.

Base on her daily energy requirement 2657kcal/day, I figure out she need CHO about 45-65%
of her energy requirement which about 299g to 432g. Her CHO choice will be around 20-29
choice per day. Since her usually have 3 meal a day, and 2 snacks. Therefore, we can
distribute her CHO choice to be 5-7 choice for each meal, and 3-4 choice for each snack to
help her maintain a good glucose level with her active lifestyle.

CHO 2657kcal x 0.45=1196kcal 1196kcal/ 4kcal/g=299g 299g/15=20 choices

CHO 2657kcal x 0.65=1727kcal 1727kcal/ 4kcal/g=432g 432g/15=29 choices

18. What is an insulin:CHO ratio (ICr)? Rachel’s physician ordered her ICr to start at
1:15. If her usual breakfast is 2 pop-Tarts and 8 oz skim milk, how much Apidra
should she take to cover the carbohydrate in this meal?

Base on the Insulin-to-Carbohydrate Ratio, 1 unit of rapid-acting insulin is taken for every 10-
15g of carbohydrate. 2 pop-Tarts has about 76g of carbohydrate and 8oz skim milk has about
12g of carbohydrate. Therefore, there is total about 88g carbohydrate.

76g+12g=88g CHO

88g/15g=5.9 doses

This is about 5.9 doses of Apidra should she take to cover the carbohydrate in this meal.

(Nelms 2016, p.510)

 19. Dr. Cho set Rachel’s fasting blood glucose goal at 90–180 mg/dL. If her total daily
insulin dose is 33 u and her fasting a.m. blood glucose is 240 mg/dL, what would her
correction dose be?

The correction factor is determined by using the “1700 rule”, in which 1700 is divided by the
total daily dose.

1700 / 33= 51.5 mg/dL ≈ 52 mg/dl (correction factor)

240 mg/dL- 52 mg/dL=188

To correct the does to below 180 mg/dL, we would add about 1.5 – 2 u of insulin to total daily
to decrease blood glucose.

(Krause 2012, p.603)

VI. Nutrition Monitoring and Evaluation

20. Write an ADIME note for your initial nutrition assessment.

a. Assessment:
Rachel is a 12-year-old female admitted with acute-onset hyperglycemia.
During ER assessment, patient was noted to have serum glucose of 724
mg/dL. For family history, her father have HTN, her mother have
hyperthyroidism, and her sister have celiac disease. Her height is 5’, and her
weight is about 82 lbs. Her BMI is 16.1kg/m^2.Her ht/age is in the 50 th
percentile, and her wt/age is in the 25th percentile. Her BMI are placing at the
18th percentile for girls aged 12 years. She had the abnormal value of sodium,
Glucose, Phosphate, Anion gap, Osmolality, HbA1c, C-peptide, ICA, GADA, IA-
2A, IAA, Specific gravity, pH, protein, ketones, Prot chk. Her energy
requirement is 2657kcal/day.
b. Diagnosis:
N.C.2.2 Altered nutrition-related laboratory values

Altered nutrition-related laboratory values of sodium, glucose, phosphate,

osmolality, HbA1c, c-peptide, ICA, GADA, IA-2A, IAA, ketones, protein, Prot
Chk related to diagnosis of T1DM as evidence by the current laboratory
results.
N.B.1.1 Food and nutrition related knowledge deficit

Food and nutrition related knowledge deficit related to lack of access to

information as evidenced by new diagnosis of T1DM.
c. Intervention:
Base on her daily energy requirement 2657kcal/day, I figure out she need
CHO about 45-65% of her energy requirement which about 299g to 432g. Her
CHO choice will be around 20-29 choice per day. Since her usually have 3
meal a day, and 2 snacks. Therefore, we can distribute her CHO choice to be
5-7 choice for each meal, and 3-4 choice for each snack to help her maintain a
good glucose level with her active lifestyle.

Base on the Insulin-to-Carbohydrate Ratio, 1 unit of rapid-acting insulin is

taken for every 10-15g of carbohydrate. 2 pop-Tarts has about 76g of
carbohydrate and 8oz skim milk has about 12g of carbohydrate. Therefore,
there is total about 88g carbohydrate. This is about 5.9 doses of Apidra should
she take to cover the carbohydrate in this meal.
 d. Monitoring/Evaluation:
Self-monitoring of blood glucose and record A1C level by herself, I will review
for her next session.
Providing food log for her to assist in dietary change and counting of
carbohydrate.

21. When rachel comes back to the clinic, she brings the following food and blood
glucose record with her.
a. Determine the amount of carbohydrates she is consuming at each
meal.
b. Determine whether she is taking adequate amounts of Apidra for each
meal according to her record.

Insulin dosages
BG What What you
Time Diet Grams of CHO Exercise
(mg/dL) patient would
took recommend
2 Pop-Tarts

1 banana 140g 9.3 units

7:30 a.m. (Pre) 150 5 u Apidra

16 oz skim milk with Ovaltine (2

tbsp)

10:30 a.m.

2 slices of pepperoni pizza

12 noon 2 chocolate chip cookies 86g (Pre) 180 6 u Apidra 6-7 units

Water

25g PE class— 2 units

2 p.m. Granola bar
30 minutes
Apple

4:30 p.m. 38g (Pre) 110 2.5 units

6 saltines with 2 tbsp peanut
butter
Soccer
5–6:30 p.m. 16 oz Gatorade 31g practice— (Pre) 140 2 units
1.5 hours
Chicken with broccoli stir-fry (1 c
fried rice, 2 oz chicken, ½ c
broccoli)
6:30 p.m. 93g (Pre) 80 5 u Apidra 6 units
Egg roll—1

2 c skim milk
2 c ice cream
8:30 p.m. 70g (Pre) 150 4 u Apidra 4.5 units
With 2 tbsp peanuts

Bed