CASE STUDY 12Advanced Dietary Management in Type 1 Diabetes

30 Year old male, Diagnosed T1 diabetic at age 13

low blood sugar 2-4 times per week Snacks in car to avoid hypoglycemia (fruit,

pretzels) Mentioned using soda/candy to control blood

sugar Busy work schedule causes meal times to

vary (especially late lunches) Recently passed out from hypoglycemia

Basal insulin consequently adjusted (from 50 units per evening to 40)

Mild scarring on right side of umbilicus due to insulin injections

History, Nutritional/Physical Findings

Estimated carbohydrate needs are 288 g - 416 g (AMDR of 45-65% of kcal) (CS-2.3.1-3).

Pt currently at approximately 330g/d Ideal Body Weight (CS-5.1.1) 172lb

(Hamwi method Pt current weight: 175lb

Patient estimated energy needs are 2561 kcal (Harris-Benedict Equation) (CS-1.1.1-2)

Comparative Standards

• 5’11, 175 lb (BMI 24.4)• Glucose, casual (BD-1.5.2) 195 mg/dL

(70-110mg/dL)• HbgA1c (BD-1.5.3) 8.1% (<7%)• Lipid profile: Normal

Anthropometrics/ Lab data

TYPICAL DAYFood Intake Blood Sugar

LevelCarbohydrate (g)

Pre-breakfast 62Breakfast-2c Cereal-1.5c Milk

741820

2 hr after breakfast

356

Pre-lunch 105Lunch-tuna salad sandwich-1oz bag chips-1 apple

30

1620

2 hr after lunch

210

Food Intake Blood Sugar Level

Carbohydrate (g)

Snack-1oz bag pretzels-1 peach

22

15Pre-dinner 250

Dinner-2 slices frozen pizza-2 c salad (oil/vinegar)

53

10

Snack- 1.5 c ice cream

50

Bedtime 298

Total Carbohydrate

328g

Problem: Inconsistent carbohydrate intake (NI-5.8.4)

Etiology: related to food and nutrition knowledge

deficit concerning physiological causes requiring careful timing and consistency in the amount of carbohydrate consumed

Signs/Symptoms: recent episodes of hypoglycemia of

increasing severity and frequency, elevated casual blood glucose, HA1c, and meals/snacks varying greatly in carbohydrate content.

Diagnosis

Prescription: 2561 kcal/d healthy diet (45-65% CHO, 10-

30% PRO, 25-35% Fat) Intervention 1: (ND-1.2.4.2)

R.D. will recommend consistent CHO intake regarding meals/snacks

Goals: Meals 20-30% CHO needs Snacks: 10-20% CHO needs

Intervention: Intervention 2: (E-1.2), (E-2.2)

R.D. will provide nutrition education Priority modification/skill development pertaining

to CHO counting/exchange systems Goals:

Pt. will have portioned, healthy carbohydrate source available at work

Pt. will learn CHO exchange for 5 common foods Intervention 3

R.D. will collaborate with CDE to facilitate successful long term management of diabetes

Goals: Pt. will learn how to calculate/apply insulin sensitivity

factor Pt. will learn proper insulin dosage based on meal

CHO content Pt. will meet with CDE bi-monthly to monitor progress

Indicator: Patient does not take lisopro with snacks (FH-3.1.3)

Criteria: Patient will begin using fast acting insulin each time he consumes a snack.

Indicator: Patient has erratic meal timing due to work and goes hypoglycemic 2-4 times per week( FH-1.2.2.3)

Criteria: Patient will reduce the frequency in which his blood sugar unexpectedly goes too low to one time per week or less via proper meal timing.

Monitor/Evaluate: begins 1 month post intervention

Indicator: Glucose, casual (BD-1.5.2) Criteria: Casual glucose will decrease to

<135 mg/dL Indicator: HbgA1c (BD-1.5.3)

Criteria: Hemoglobin A1c will decrease to <7%

ADDITIONAL DIAGNOSES Problem:

Intake of excessive carbohydrate type : simple carbohydrates/sugars (NI-5.8.3)

Etiology: related to food and nutrition knowledge

deficit requiring use of modified carbohydrate intake.

Signs/Symptoms: recent episodes of hypoglycemia of

increasing severity and frequency, snacks consisting of mainly sweets/convenience foods, and prevention of hypoglycemia via intake of simple carbohydrates.

Problem: Undesirable food choices (NB-1.7)

Etiology: related to food preference

Signs/Symptoms: recent episodes of hypoglycemia of

increasing severity and frequency, regular consumption of pizza and ice cream as indicated by food records and routine treatment of hypoglycemia with soda and candy.

REFERENCES• Multiple Daily Injections vs Insulin Pumps. (n.d.). Retrieved March 30, 2015, from

http://www.diabetes.co.uk/insulin/mdi-vs-insulin-pumps.html• Gilles, G. (2014, November 25). Understanding Basal and Bolus Insulin. Retrieved March 30,

2015, from http://type1diabetes.about.com/od/insulinandmedications/p/Basal-And-Bolus-Insulin.htm

• Checking Your Blood Glucose. (2015, March 3). Retrieved March 30, 2015, from http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html

• Hypoglycemia Causes, Symptoms, and Treatment. (n.d.). Retrieved March 30, 2015, from http://www.webmd.com/diabetes/diabetes-hypoglycemia

• Insulin Routines. (2015, March 3). Retrieved March 30, 2015, from http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-routines.html

• How to Become a Certified Diabetes Educator (CDE). (n.d.). Retrieved March 30, 2015, from http://www.umassmed.edu/uploadedFiles/diabetes/resources/BecomeCertifiedDiabetesEducator.pdf