kaitlynclick.weebly.comkaitlynclick.weebly.com/.../case_study_16_diabetes.docx · Web viewCase Study #16 Type 2 Diabetes Mellitus I. Understanding the Diagnosis and Pathophysiology

Kaitlyn Click Professor Matuszak KNH 41118 November 2014

Case Study #16 Type 2 Diabetes Mellitus

I. Understanding the Diagnosis and Pathophysiology

1. What are the risk factors for developing type 2 DM as a child? What do the current ADA standards of medical care recommend concerning screening at-risk children?

Risk factors for children developing type 2 DM include obesity, an increase in BMI, family history, ethic minority, puberty, female gender, and feature of “syndrome X”. Insulin resistance is the shared linkage among these risk factors. The current ADA standards of medical care recommend testing for type 2 DM in children (ages 18 and younger) starting at the age of 10 or at the onset of puberty and then re-testing every three years. The preferred test is the fasting plasma glucose test. Criteria for type 2 DM in children includes:

Overweight with a BMI greater than the 85th percentile for the child’s age and sex, weight for height greater than the 85th percentile, or a weight greater than 120% of their ideal weight for height

In addition, two of the following criteria are applicable to the child: Family history of type 2 DM in a first or second degree relative Race/ethnicity (Native American, African-American, Latino, Asian American, or Pacific

Islander) Signs of insulin resistance or conditions associated with insulin resistance such as

acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth weight

Material history of diabetes or GDM during the child’s gestation

(Nelms, Sucher, Lacey & Roth, p. 499)

Arslanian. (2002). Type 2 diabetes in children: Clinical aspects and risk factors. Retrieved

November 10, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/11979018

Standards of Medical Care in Diabetes 2014. (2104). Retrieved November 10, 2014, from

http://care.diabetesjournals.org/content/37/Supplement_1/S14/T5.expansion.html

2. Evaluate Adane’s medical record. Identify which risk factors most likely led to the routine screening for DM during her school physical.

After evaluating Adane’s medical record, there are several risk factors that most likely led to the routine screening for DM during her school physical. These risk factors include:

Her mother had gestational diabetes during her pregnancy.


http://www.ncbi.nlm.nih.gov/pubmed/11979018

Her mother and grandmother have type 2 diabetes. Her ethnicity is African-American. Her BMI is 36.4 kg/m2.

3. What are the ADA standard diagnostic criteria for T2DM? Which are included in Adane’s medical record? The current ADA standard diagnostic criteria for T2DM include:

A1C ≥ 6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT. **

OR FPG ≥ 126 mg/dL (7.0 mmol/L)

Fasting is defined as no caloric intake for at least 8 hours. **OR

Two-hour Plasma Glucose (PG) ≥ 200 mg/dL (11.1 mmol/L) during an OGTTThe test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. **

OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random

plasma glucose ≥ 200 mg/dL (11.1 mmol/L).

**Note that in the absence of unequivocal hyperglycemia, there should be repeat testing to confirm results.

Adane’s medical record shows that her A1C is 6.9% (greater than the ADA standard diagnostic criteria of 6.5%) and her estimated average glucose level is 151 mg/dL (greater than the ADA standard diagnostic criteria of 126 mg/dL).


http://care.diabetesjournals.org/content/37/Supplement_1/S14.full

4. Adane’s physician requested additional testing that included autoantibody levels and C-peptide. Explain why these tests were done and what the results indicate for Adane.

Autoantibody testing is a valuable screening for high-risk individuals for developing diabetes up to seven years before onset of the disease. The test is usually performed to differentiate between type 1 diabetes and type 2 diabetes (resulting from obesity and insulin resistance). The autoantibodies are indicators of the body’s destructive immune response against B-cells. The tests that are used to measure these autoantibodies include islet cell cytoplasmic autoantibodies (ICA), insulin autoantibodies (IAA), glutamic acid decarboxylase autoantibodies (GADA), and insulinoma-associated-2 autoantibodies (IA-2A) (Nelms, Sucher, Lacey & Roth, pp. 484-485). Adane tested negative for all of these tests, which indicates that she does not have type 1 diabetes. Consequently, she should be treated for type 2 diabetes.

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C-peptide testing is done to measure the insulin production in the body. Insulin is secreted as two polypeptide chains that are connected by a disulfide bond. When the two chains separate, C-peptide is released. Sometimes, autoantibodies do not always show the beta cell function of the pancreas. For both type 1 and type 2 diabetes, C-peptide levels can determine this (Nelms, Sucher, Lacey & Roth, pp. 484-485). C-peptide levels can also be tested in type 2 diabetes to see if any insulin is being produced or in cases of hypoglycemia to see if too much is being produced. According to the U.S. National Library of Medicine, a normal range of C-peptide levels is between 0.5 to 2.0 nanograms per milliliter (ng/mL). Patients with type 2 diabetes, obesity, and insulin resistance may have high C-peptide results. A low C-peptide level suggests that little or no insulin is being produced by the pancreas. Adane’s C-peptide level is 2.75 ng/mL, which is consistent with type 2 diabetes and insulin production by the pancreas, possibly too much, which may result in hypoglycemia.

(Nelms, Sucher, Lacey & Roth, pp. 484-485)

Insulin C-peptide test. (2013). Retrieved November 10, 2014, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004164/



5. Insulin resistance is a major component of T2DM. Explain this pathophysiology. How could you determine whether Adane is exhibiting insulin resistance?

In type 2 diabetes, the pancreas produces insulin but their tissues become resistant to it. This creates a greater need for insulin in the body so the pancreas keeps producing more insulin to accommodate. However, after awhile, the pancreas can no longer produce any more insulin. This can lead to two metabolic defects in the body: insulin resistance and relative insulin deficiency. Insulin resistance, in particular, is caused by a cell-receptor defect, which causes the inability to use insulin in the body. Cells subsequently lack the ability to take up glucose from the blood for fuel. Since insulin usually inhibits glycogenolysis and gluconeogenesis when glucose in the blood is high, defective insulin secretory response results in an over-production of glucose from the liver, resulting in fasting hyperglycemia.

Several tests can be done to assess whether or not Adane is exhibiting insulin resistance. First, her glucose levels can be monitored. If her glucose levels are consistently high, this could indicate that she has a defective insulin secretory response. Tests such as A1C can be measured against the ADA standard and C-peptide can be measured to determine insulin production from the pancreas to see if her values correspond to those of a patient experiencing insulin resistance.


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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004164/

6. Children with T2DM are at a high risk for early cardiovascular disease. Why does this complication occur with diabetes? Evaluate Adane’s lipid profile. How does this compare to the lipid goals for children with diabetes?

Cardiovascular disease is one of the major causes of morbidity as well as mortality in individuals with diabetes. The two most common conditions that coincide with type 2 diabetes are hypertension and dyslipidemia, which are both risk factors for CVD. In addition, those with obesity, lack of physical activity, and poorly controlled blood sugars/out of the normal range are at an increased risk of developing CVD. Those with insulin resistance in combination with one or more risk factors are at an even greater risk of CVD. Adane currently has cholesterol and triglyceride levels above the normal range (listed in the table below) as well as obesity, lack of physical activity, poor diet and nutrition which has lead to her poorly controlled blood sugars, and indications of insulin resistance (as discussed in the previous question). According to these risk factors and Adane’s current lifestyle, she is at a high risk for developing early cardiovascular disease. Lipid goals that should be set for children with diabetes in this situation, such as Adane, include:

Dietary intervention (specifically a decrease in saturated fat to 7% of total kcal in the diet and dietary cholesterol to 200 mg/day) and increase physical activity.

Improve glucose control (shown to correlate with a favorable lipid profile) LDL cholesterol value <100 mg/dL Return cholesterol and triglyceride levels back to the reference/normal range

Reference Range AdaneCholesterol (mg/dL) <170 210Triglycerides (mg/dL) <150 175

Cardiovascular Disease & Diabetes. (n.d.). Retrieved November 10, 2014, from

http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/

Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp



7. Adane’s grandmother asks about medication for treating high cholesterol as her husband is on this medicine. What are the recommendations for the use of statin drugs in children?

Statins have not yet been approved for use in children under the age of 10 years. There have been no long-term safety or cardiovascular outcome effectiveness established in for children at this time. Current recommendations for the use of statin drugs in children are for those over the age of 10 years old, as an addition to MNT and lifestyle changes, with LDL cholesterol >160 mg/dL or LDL cholesterol >130 mg/dL and one or more CVD risk factors. Further research of the safety

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http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp


and cardiovascular benefits for children needs to be performed before approval of statin drugs for the younger age group.



8. Adane’s urinalysis is positive for protein. What does this mean and how may this be related to her diabetes?

Adane’s urinalysis indicates that she has a condition known as proteinuria, which is also called albuminuria or urine albumin. This means that her urine contains an abnormal amount of protein. Proteins have essential roles in the body such as blood clotting, protection against infections, fluid circulation, and building blocks of all body parts. In a healthy kidney, blood is filtered and waste products are excreted in urine, leaving behind protein and other useful substances. Protein is too big to pass through the tiny blood vessels of the kidney so it stays in the blood. Diabetes can damage this filter because higher levels of blood sugar make the kidneys filter too much blood and work extra hard. This damage can cause protein in the blood to leak into the urine. This is a sign of chronic kidney disease (CKD). If left untreated, this can lead to end stage renal disease, and the kidneys will completely shut down. It would be appropriate for Adane to control her blood sugars and keep her blood pressure within a healthy range by eating a healthy diet, increasing her physical activity, and monitoring her blood glucose often, in order to prevent further damage to her kidneys.

Kidney Disease (Nephropathy). (2013). Retrieved November 13, 2014, from

http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-

nephropathy.html

Proteinuria. (n.d.). Retrieved November 13, 2014, from

http://kidney.niddk.nih.gov/KUDISEASES/pubs/proteinuria/index.aspx

9. Should Adane and her family be taught about self-monitoring of blood glucose (SMBG)? If so, what are the standard recommendations for daily frequency of testing? What would be the appropriate fasting and postprandial target glucose levels for Adane?

It is important that Adane and her family be taught about self-monitoring of blood glucose (SMBG). The SMBG can assist in adjusting eating patterns on a daily basis to maintain glucose control. It is a useful way to identify patterns and fluctuations associated with certain foods, exercise, and other factors. A typical SMBG test is done via a finger prick with a home monitor. Frequency and timing of testing is determined based on individual needs and goals of the health care team. SMBG is recommended three or more time times daily. Appropriate fasting and postprandial target glucose levels for Adane are listed in the table below.

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http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.html



Normal GoalFasting target glucose levels <100 mg/dL 70-130 mg/dLPostprandial target glucose levels

<140 mg/dL <180 mg/dL


II. Understanding the Nutrition Therapy

10. Outline the basic principles for Adane’s nutrition therapy to assist in control of her T2DM.

Some basic principles for Adane’s nutrition therapy to assist in control of her T2DM include: Treatment and goals should be centered on compliance of the individual in order to make

the therapy realistic for their lifestyle. The aim of intervention is to support and encourage changes in lifestyle and behavior that

will improve metabolic control. Educate Adane and her family about self-monitoring of blood glucose (SMBG). Encourage moderate weight loss (which is shown to improve glycemic control and lower

risk of CVD) through healthy changes in diet and exercise. Educate about monitoring total grams of carbohydrate by using the exchange system

and/or carbohydrate counting. Low-carbohydrate diet is not recommended. Protein intake should not exceed 20% of energy intake. Total fat intake should not exceed 25-35% of total kcal intake. Saturated fat intake should

not exceed 7%. Limit or eliminate trans fat intake. A variety of fiber-containing foods should be consumed. Educate about different types of

fiber-containing foods and amounts --14 grams for every 1000 kcal. Explore different physical activities that Adane could become excited about and involved

in and educate about the importance, frequency, and intensity of exercise with her and her family.


III. Nutrition Assessment

11. Using the charts on pp. 188-189, assess Adane’s ht/age; wt/age; ht/wt; and BMI. What is her desirable weight?

According to the charts, Adane’s height-for-age (52 in/9 years) is just below the 50th percentile. Her weight-for-age (140 lbs/9 years) percentile is well above the 97th percentile. Her BMI (36.4 kg/m2) is well above the 97th percentile as well. A desirable weight for Adane would be between 53 and 74 pounds (between the 5th and 85th percentile), according to the KidsHealth BMI Calculator.

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Body Mass Index (BMI) Charts. (2013, September 1). Retrieved November 14, 2014, from

http://kidshealth.org/parent/growth/growth/bmi_charts.html

12. Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T2DM.

Adane’s abnormal laboratory values measured upon her admission are shown in the table below. Her glucose, cholesterol, triglycerides, HbA1C, EAG, C-peptide, protein in urine, glucose in urine, and prot chk were all high upon admission and related to her newly diagnosed T2DM. High glucose is related to the fact that Adane’s liver is in overdrive because of her defective insulin secretory response (Nelms, Sucher, Lacey & Roth, p. 499). Her high cholesterol and triglyceride levels are linked to her lack of nutrition in her diet and her obese status/high BMI. Adane’s HbA1C results give an average blood glucose control value for the last 2 to 3 months. Since her value is high, it indicates that her blood glucose has not been under control. A EAG value, or estimated average glucose, directly correlates with the HbA1C value, expressed in glucose meters, and may help an individual better understand their HbA1C. The protein and glucose found in Adane’s urine is related to her kidney function. This indicates protein and glucose are leaking into her urine from her blood because her kidneys have been overworked and are starting to become damaged.

Reference Range Values upon Admission

Glucose (mg/dL) 70-110 171Cholesterol (mg/dL) <170 210Triglycerides (mg/dL) <150 175HbA1C (%) 3.9-5.2 6.9EAG -- 151C-peptide (ng/mL) 0.51-2.72 2.75Protein in urine (mg/dL)

Neg tr

Glucose in urine (mg/dL)

Neg +

Prot chk Neg +

A1C and eAG. (n.d.). Retrieved November 14, 2014, from http://www.diabetes.org/living-with-

diabetes/treatment-and-care/blood-glucose-control/a1c/

13. Determine Adane’s energy and protein requirements. Be sure to explain what standards you used to make these estimations. Should weight loss be a component of your estimation of energy requirements?

Total Energy Expenditure (TEE) for Overweight Females Aged 3 through 18 Years: TEE = 389 – 41.2 x age + PA x 15.0 x weight + 701.6 x height

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http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/a1c/



Adane

TEE: PA = 1.18 for low active Age = 9 years oldWeight = 140 lbs/2.2 = 63.6 kgHeight = 52 in x 0.0254 = 1.32 m

TEE = 389 – 41.2 x 9 + 1.18 x 15.0 x 63.6 kg + 701.6 x 1.32 m = 2070 kcal = ~2000-2100 kcal

Protein requirements: 0.95 g/kg a day

63.6 kg x 0.95 g/kg = 60.42 g = ~60 g/day

Weight loss should not be a component of the estimation of energy requirements for Adane because weight loss is not recommended for children who are still growing and developing. Adane is still growing and developing at the age of nine; therefore, the focus with her weight management should be just to maintain her weight and work toward a healthy diet and lifestyle that will prevent her from gaining any more weight.


14. Using Adane’s diet history, assess the approximate number of kilocalories her intake provided, as well as the energy distribution of calories for protein, carbohydrate, and fat, using the exchange system. Compare this to the recommendations that you made in question #10.

Amount Exchange Carbohydrate Protein Fat Calories

BreakfastFruit punch/Koolaid

1 cup 1 cup= 2 CHO

15g x 2= 30g

30g x 4 kcal/g= 120 kcal

0g x 2= 0g 0g x 2= 0g

120

Frosted flakes

2 cups 2 cups= 4 starch

15g x 4= 60g


1g x 4=4g


1g x 4=4g


292

Whole milk 1 cup 1 cup= 1 milk 12g x 1= 12g

12g x 4

8g x 1= 8g

8g x 4

8g x 1=8g

152

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kcal/g= 48 kcal

kcal/g= 32 kcal


Total at Breakfast:

408 kcal 48 kcal 108 kcal 564 kcal

MidmorningToast 2 slices 2 slices= 2

starch15g x 2= 30g


1g x 2= 2g


0g x 2= 0g

128

Butter 1 tsp 1 tsp= 1 fat 0g x 1= 0g 0g x 1= 0g 5g x 1= 5g


45

Jam 1 ½ tbsp 1 ½ tbsp= 1 CHO

15g x 1= 15g


0g x 1= 0g 0g x 1= 0g

60

Total at Midmorning:


SnacksChocolate chip cookies

2 cookies

2 cookies= 2 CHO + 1 fat

15g x 2= 30g


0g x 2= 0g 5g x 1= 5g


165

Small bag of Cheetos

2 bags 2 oz= 2 starch + 4 fat

15g x 2= 30g


2g x 2= 4g


5 g x 4= 20g


316

Fruit punch 3 cups 3 cups=6 CHO

15g x 6= 90g


0g x 6= 0g 0g x 6= 0g

360

Popsicles 2 2= 1 CHO 15g x 2= 30g30g x 4

0g x 2= 0g 0g x 2= 0g

120

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kcal/g= 120 kcal

Total at Snacks:


LunchPeanut butter 4 tbsp 4 tbsp=4 high

fat meat0g x 4=0g 7g x 4=

28g


8g x 4= 32g


400

Bread 4 slices 4 slices= 4 starch

15g x 4= 60g


2g x 2= 4 g


0g x 2= 0g

256

Banana 1 1 banana= 2 fruit

15g x 2= 30g


0g x 2= 0g 0g x 2= 0g

120

Mayonnaise 2 tbsp 2 tbsp= 6 fat 0g x 6= 0g 0g x 6= 0g 5g x 6= 30g


270

Fruit punch 2 cups 2 cups= 4 CHO

15g x 4= 60g


0g x 4= 0g 0g x 4= 0g

240

Chips 1 oz 1 oz= 1 starch + 1 fat

15g x 1= 15g


1g x 1=1g


5g x 1= 5g


109

Total at Lunch:


DinnerFried pork chop

3 oz 3 oz= 3 meat 0g x 3= 0g 7g x 3= 21g

8g x 3= 24g

300

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Greens ½ cup ½ cup= 1 vegetable

5g x1= 5g5g x 4 kcal/g= 20 kcal

0g x 1= 0g 2g x 1= 2g


38

Potatoes ½ large potato

½ large= 2 starch

15g x 2= 30g


0g x 2= 0g 3g x 2= 6g


174

Cornbread 1 cube 1 cube= 1 starch + 1 fat

15g x 1 = 15g


0g x 1= 0g 3g x 1= 3g


87

Butter 1 tsp 1 tsp= 1 fat 0g x 1= 0g 0g x 1= 0g 5g x 1= 5g


45

Iced tea made with sugar

1 tbsp 1 tbsp=1 CHO

15g x 1= 15g


0g x 1= 0g 0g x 1= 0g

60

Total at Dinner:


BedtimePizza rolls 4 ½ oz 4 ½ oz= 3

CHO + 1 lean meat + 2 fat

15g x 3= 45g


2g x 3= 6g6g x 4 kcal/g= 24 kcal + 7g x 1= 7g


3g x 1= 3g


259

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24 kcal + 28 kcal= 52 kcal

Coke 1 can 1 can= 2 ½ CHO

15g x 2 ½ = 37.5g

37.5g x 4 kcal/g= 150 kcal

0g x 1= 0g 0g x 1= 0g

150

Total at Bedtime:


OverallTotals:

2558 kcal 340 kcal 1368 kcal

4266 kcal

Carbohydrate: 2558 kcal/4266 kcal= 0.599= ~60% of kcal from carbohydrates

Protein: 340 kcal/4266 kcal= 0.0796= ~8% of kcal from protein

Fat: 1368 kcal/4266 kcal= 0.321= ~32% of kcal from fat

After analyzing Adane’s dietary intake from her 24-hour recall using the exchange system, her total calories were about 4200-4300 kcal a day. Her caloric intake is about 2100 calories over the energy recommendations of 2000-2100 kcal from using the Total Energy Expenditure (TEE) equation for overweight females. Her recommendations for protein are 60 grams per day. According to this recommendation, her intake of just 8% of her overall calories is inadequate. However, she should consume no more than 20% protein. While Adane’s fat intake (32%) is within an acceptable range of 25-35% of her total caloric intake, a lot of her fat choices are most likely high in saturated fat (which should not exceed 7%) and contributing to her weight gain and overall health. The amount of calories coming from carbohydrates in her diet is also high (60%). She should decrease her fat and carbohydrate intake, while paying special attention to the kinds of fats in her diet (avoiding saturated fats), and increase her overall protein intake by 5-10%. Choosing healthier fat options will help to decrease her total caloric intake as well. She should also be consuming more fiber in her diet, which can be accomplished by switching out cookies and chips for other options such as high fiber crackers. (Nelms, Sucher, Lacey & Roth, pp. A109-A122)

IV. Nutrition Diagnosis

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

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PES #1: Excessive energy intake (NI-1.3) related to high intake of calories and fat as evidenced by 24-hour recall of 4266 kcal and patient’s food preferences.

PES #2: Overweight/obesity (NC-3.3) related to diagnosis of type 2 diabetes and an excessive caloric intake as evidenced by a BMI of 36.4 kg/m2 and growth chart classification of well above the 97th percentile for weight-for-age and BMI.

(Academy, 2014)

V. Nutrition Intervention

16. Determine Adane’s initial nutrition therapy prescription using her diet record from home as a guideline, as well as your assessment of her requirements.

My recommendation for Adane’s initial nutrition therapy prescription would be centered on both educating Adane and her family about healthy eating and also emphasizing the importance of physical activity. The goal for Adane is to maintain her weight and prevent any more weight gain. Right now she is consuming over 4000 kcal a day, with high fat foods and disproportions of macronutrients. I would put Adane on a meal plan that consists of her energy requirements to maintain weight (from my calculations of her requirements in question 13) of 2000 to 2100 calories a day. Her proportions of macronutrients should consist of 25-35% of calories from fat (no more than 7% from saturated fat), about 50% of her calories from carbohydrates, and no more than 20% from protein sources. Adane and her family should be educated about how they can lower Adane’s caloric intake by making rather small changes in her current diet. By simply changing from fried foods to grilled or baked options, she can decrease calories and fat. Instead of whole milk, Adane should have skim milk. Adane should cut back on the calorie-dense beverages as well such as fruit punch and sweetened tea. She may enjoy a real fruit drink or smoothie instead that has natural sugars and is much more healthy for her. Adane should also be consuming more fiber in her diet, which can be accomplished by including high fiber cereals and whole grain crackers instead of frosted flakes or cookies and also more vegetables in her diet. Aside from these modifications, Adane and her family should be educated about appropriate portion sizes. Some helpful tools for this could be MyPlate and food models to give Adane visuals of what she should be eating. I would also suggest that Adane refrains from eating a heavy meal right before bedtime. Right now she is consuming pizza rolls and coke before bed. Not only are these options high in fat and sugar but the coke especially could potentially interfere with her sleep, which is important for a growing young girl. A small cup of skim milk and a handful of pretzels would be a more appropriate choice while she gets used to minimizing her nighttime eating. Adane and her family should be educated about fresh foods that will fill Adane up faster and the easy ways to incorporate them into her diet to replace the empty calories that she may feel like she needs more of to become full and satisfied. Lastly, physical activity is important for Adane right now. She should try to become involved for at least 30 minutes a day in an enjoyable activity of her choice. Her parents should work with her to find something she has fun with such as activities at a local gym or walking with her family outside.

17. Outline the initial steps you would use to teach Adane and her family about nutrition and diabetes. What education materials could you use?

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First, I would get Adane’s whole family involved in her nutrition goals for managing her weight and diabetes. I would emphasize the importance of their support with her health and newly modified lifestyle. Then, I would educate them about SMBG (self-monitoring of blood glucose) and the timing of testing, frequency of testing, and appropriate fasting and postprandial target glucose levels so that they feel confidence in monitoring her glucose at home and adjusting her levels when appropriate. Next, I would instruct Adane and her family on suitable portions of macronutrients for Adane on a daily basis. Some useful education materials for assisting her and her family in accomplishing these proper percentages would be the exchange system to monitor carbohydrate counting, sample menus that meet her needs, MyPlate, and food models for a visual of appropriate serving sizes. The exchange system would also be helpful in distinguishing simple versus complex carbohydrates, which play an important role in her glucose management. Additionally, I would suggest that the whole family becomes active together. They could start walking as a family or invest in membership to a local gym or YMCA-like facility that offers many different options for Adane to enjoy exercise and fitness. A useful tool for physical activity could be a sticker chart. Every time Adane is active for 30 minutes or more on a certain day, she can add a sticker to her chart to monitor her progress. Her and her family can set achievable (SMART) goals and objectives for her (and even her family) to reach. A visual of these stickers can work as a motivation tool for Adane to keep up her hard work. Once she reaches a certain amount of stickers, some sort of reward (not related to food) can be an option.

18. Considering that Adane will not be started on medication, is it necessary to teach her and her family about hypoglycemia, sick-day rules, and exercise?

Considering that Adane will not be started on medication, it is necessary to teach her and her family about hypoglycemia, sick-day rules, and exercise. First, physical activity is very beneficial in improving blood glucose levels. Muscle blood glucose uptake is enhanced during or shortly after exercise and insulin sensitivity is better. It is recommended that T2DM individuals stay active for 30 to 45 minutes for 3 to 5 days a week for weight management, glycemic control, and to decrease the risk of developing CVD. In individuals taking insulin, physical activity can cause hypoglycemia, or low blood sugar. Therefore, it is important for Adane to check her blood glucose levels before and after exercise to prevent this from occurring. On the other hand, if Adane becomes sick, her blood sugar levels can become very high. It is important to establish sick day rules so that her and her family have a plan of action ahead of time. Your body is put under stress when you become sick, which causes hormones that help fight the sickness to be released. These hormones cause blood glucose levels to rise and, in turn, interfere with the effect of insulin in the body. Another complication to be aware of when someone with diabetes becomes sick is ketoacidosis, which can be monitored by measuring urine ketones. An effective sick-day plan is prepared in advance with the help of a diabetes educator, dietitian, or professional that instructs on how often to measure blood glucose and urine ketones and how and what to eat on those days. When sick, it is recommended to test blood glucose as often as every 2 to 3 hours and check urine ketones as often as every 4 hours. It is important to drink lots of non-caloric liquids to stay hydrated as well. Your usual meal plan should be adjusted for a sick day meal plan with the normal number of calories with easy-on-the-stomach foods such as gelatin, crackers, applesauce, and soup. A list of contact phone numbers should be ready and on hand for these sick days. It is appropriate to contact the diabetes team if you have a fever for a couple

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days without signs of improvement, vomiting or diarrhea for more than 6 hours, a high number of ketones in your urine, glucose levels outside the target range, lacking the ability to keep liquids down, or any signs of dehydration or ketoacidosis such as difficulty breathing, chest pain, fruity smelling breath or dry lips. It is also suggested to keep a written record of changes in sickness to keep track of changes. A “sick day notebook” could also be helpful which would include contact numbers at every hour, the child’s insurance card, meal plans, a list of over the counter medications, a record of glucose readings, insulin, and carbohydrate counting, and poems and pictures that could help the child feel better.


When You're Sick. (2013). Retrieved November 15, 2014, from http://www.diabetes.org/living-

with-diabetes/treatment-and-care/whos-on-your-health-care-team/when-youre-sick.html

Sick Days. (n.d.). Retrieved November 15, 2014, from http://www.diabetes.org/living-with-

diabetes/parents-and-kids/everyday-life/sick-days.html

19. Adane’s mom is worried that none of the children will ever be able to have birthday cake or other sweet treats. She feels that she cannot offer these to the other children if Adane cannot have them. What would you tell her?

I would tell Adane’s mom that Adane could still enjoy sweet treats on special occasions such as birthday parties. The diagnosis of T2DM requires some modifications but should not take away from the fun experiences of a child growing up. I would inform her of several easy options to make the birthday party diabetic-friendly without Adane or her friends even noticing the difference. First, I would suggest that she “slim down” the recipe for the sweet treats at the party. This can be accomplished by using skim milk instead of whole milk as well as artificial sweetener instead of sugar. The kids would not even be able to tell the difference while cutting back on added sugar and extra calories. Instead of a large cake where portion sizes can be difficult to manage, single serving cupcakes or cookies may be more appropriate. Instead of filling goodie bags with loads of candy, kids are sure to enjoy little knickknacks such as yo-yos or beach balls. Lastly, Adane’s mom can focus the birthday party fun on activities at the party such as a scavenger hunt instead of on food. Overall, Adane and her friends can still enjoy a normal birthday party with simple changes that will most likely even go unnoticed by guests.

Food & Fun. (2013). Retrieved November 17, 2014, from http://www.diabetes.org/living-with-

diabetes/parents-and-kids/everyday-life/food-fun.html

VI. Nutrition Monitoring and Evaluation

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

Assessment:

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http://www.diabetes.org/living-with-diabetes/parents-and-kids/everyday-life/food-fun.html


http://www.diabetes.org/living-with-diabetes/parents-and-kids/everyday-life/sick-days.html


http://www.diabetes.org/living-with-diabetes/treatment-and-care/whos-on-your-health-care-team/when-youre-sick.html


A: Ht: 52” (1.32m); Wt: 140# (63.6kg); BMI: 36.4 kg/m2; Age: 9 years old; African American; Mother and grandmother with T2DM; mother had gestational diabetes during pregnancy; high birth weight born full-term

B: High blood glucose (171 mg/dL); high cholesterol (210 mg/dL); high triglycerides (175 mg/dL); high HbA1C (6.9%); high EAG (151 mg/dL); high C-peptide (2.75 ng/mL); positive urinalysis test for protein and glucose

C: Type 2 diabetes mellitus; obesity D: 24 hour recall of ~4200 kcal (60% carbohydrate, 32% fat, 8% protein); diet consists of

mainly simple carbohydrates, saturated fats, low fiber sources, and calorie-dense beverages; Estimated needs of 2000-2100 kcal/day; Estimated protein requirement of 60 grams/day

Diagnosis: Excessive energy intake (NI-1.3) related to high intake of calories and fat as evidenced

by 24-hour recall of 4266 kcal and patient’s food preferences. Overweight/obesity (NC-3.3) related to diagnosis of type 2 diabetes and an excessive

caloric intake as evidenced by a BMI of 36.4 kg/m2 and growth chart classification of well above the 97th percentile for weight-for-age and BMI.

Intervention: Educate Adane and her family about T2DM management with tools such as food models

for portion sizes, the exchange system for carbohydrate counting, MyPlate for healthful eating suggestions, and example menus with diabetic-appropriate options

Start at a 2000-2100 kcal/day diet for Adane with modifications in macronutrients and food options

Educate Adane and her family about proper proportions of macronutrients in her diet: ~50% carbohydrate (less than her 24 hour recall), 25-35% fat (less than 7% saturated—less than her 24 hour recall), and no more than 20% protein (more than her 24 hour recall)

Educate about the differences in carbohydrate choices, the importance fresh foods especially of fruits and vegetables for fiber instead of empty calories, types of fats and the different ways in which meat can be cooked (fried vs. grilled/baked) for less saturated fat, and alternative beverage options in place of the high-sugar calorie-dense choices she currently consumes

Educate about the importance of physical activity; recommend a membership to local YMCA-like facility and family involvement in exercise; starting with 30 minutes of physical activity a day and increasing to up to 1 hour when confidence and enjoyment of exercise increases

Monitoring/Evaluation: Have Adane and her family work together to keep a food log Have Adane and her family work together to keep a physical activity log Have Adane and her family keep records of her SMBG and use of the exchange system—

how she is managing her glucose levels Measure Adane’s weight at the follow up—compare BMI and growth charts with initial

visit

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Continue to monitor her labs, especially the initial abnormal lab results, to see if there is any change and/or improvement with lifestyle changes (focusing on her blood glucose, HbA1C, lipid profile, and urinalysis results)

Evaluate Adane and her family’s compliance and motivation to continue making healthy changes and how she is adjusting to the new lifestyle (questions, concerns, complaints, improvements, praises, etc.)

21. Adane’s grandmother suggests that perhaps Adane should have “stomach surgery” so that she will lose weight more quickly. What are the recommendations for pediatric bariatric surgery?

Pediatric bariatric surgery is normally done when there are other health complications in relation to the overweight/obese state of the individual. Some general guidelines that determine if a child is a candidate for the surgery are 1) a BMI of or above 35 kg/m2 with a serious health condition associated to obesity and 2) a BMI of or above 40 kg/m2 with a less serious health condition associated to obesity. Serious health conditions may include diabetes, pseudotumor (pressure in the skull), severe sleep apnea, or severe inflammation of the liver. Less serious health conditions may include high blood pressure, high cholesterol, mild sleep apnea, or depression. Other factors that should be taken into consideration are if the child was unable to lose weight through diet and exercise for a period of at least 6 months, whether or not the child has finished growing (usually 13 years or older for girls), and whether or not the patient and family is psychologically ready for the lifestyle changes following the surgery. Given these guidelines, I would say that Adane is currently not a candidate for the surgery for several reasons. Even though her BMI is currently above 35 kg/m2 (36.4 kg/m2) and she has a serious health concern of type 2 diabetes, other factors that should be considered place her unfit to be a candidate. First, she has yet to see if she is able to lose weight with changing her diet and physical activity for at least six months. Second, she is only 9 years old, therefore, her body is still growing and developing. Lastly, it is not clear yet how compliant and/or willing her and her family are to making drastic lifestyle changes since she was just referred for education and counseling on her lifestyle. Further analysis of Adane’s progress, compliance, growth, and health would need to monitor over the next couple years to see if bariatric surgery is an option for the future to be revisited. Currently, it is best for Adane and her family to focus on healthy eating and increasing physical activity to maintain a baseline weight and prevent any further weight gain that would increase her BMI.

Weight-loss surgery and children. (n.d.). Retrieved November 14, 2014, from

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000356.htm

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References

Academy of Nutrition and Dietetics (2014). Pocket guide for international dietetics & nutrition

terminology (IDNT) reference manual: Standardized language for the nutrition care

process. Chicago, Ill: Academy of Nutrition and Dietetics.

Arslanian. (2002). Type 2 diabetes in children: Clinical aspects and risk factors. Retrieved

November 10, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/11979018

A1C and eAG. (n.d.). Retrieved November 14, 2014, from http://www.diabetes.org/living-with-

diabetes/treatment-and-care/blood-glucose-control/a1c/

Body Mass Index (BMI) Charts. (2013, September 1). Retrieved November 14, 2014, from


Cardiovascular Disease & Diabetes. (n.d.). Retrieved November 10, 2014, from

http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/

Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp

Food & Fun. (2013). Retrieved November 17, 2014, from http://www.diabetes.org/living-with-

diabetes/parents-and-kids/everyday-life/food-fun.html

Kidney Disease (Nephropathy). (2013). Retrieved November 13, 2014, from

http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-

nephropathy.html

Nahikian-Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study approach.

Stamford, Connecticut: Cengage Learning.

Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and

pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.

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http://www.ncbi.nlm.nih.gov/pubmed/11979018

Proteinuria. (n.d.). Retrieved November 13, 2014, from


Sick Days. (n.d.). Retrieved November 15, 2014, from http://www.diabetes.org/living-with-

diabetes/parents-and-kids/everyday-life/sick-days.html





Weight-loss surgery and children. (n.d.). Retrieved November 14, 2014, from


When You're Sick. (2013, January 1). Retrieved November 15, 2014, from

http://www.diabetes.org/living-with-diabetes/treatment-and-care/whos-on-your-health-

care-team/when-youre-sick.html

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