1. Alexis De Genaro
MNT Case 3
November 13, 2012
1. Define insulin. Describe its major functions within normal metabolism.
Insulin is an anabolic hormone produced in the pancreas that regulates the amount of
glucose in the blood. Insulin regulates glucose metabolism and lipogenesis. It also promotes
the uptake, utilization and storage of nutrients. Insulin helps to move nutrients into the cells
of the body.
4. After examining Susan’s medical history, can you identify any risk factors for type 1 DM?
Susan experienced polyuria, polydipsia fatigue and polyphagia. She also reported
unintentional weight loss, as evidenced by her lose fitting clothes. Her lab reports showed
increased blood glucose, osmolality and prealbumin levels. She also has a family history of
diabetes from her grandmother, which increases her risk as well.
5. What are the established diagnostic criteria for type1 diabetes? How can the physicians
distinguish between type 1 and type 2 diabetes?
T1DM is clinically diagnosed when plasma glucose concentration is > 200 mg/dL. Fasting
blood glucose should be > 126 mg/dL. Susan displays many of the symptoms seen in T1DM,
including extreme thirst, fatigue and urination. Diabetes related antibody testing is often
performed to differentiate between T1 and T2 DM. T1DM is an insulin resistance condition,
while T2DM is an autoimmune disease.
6. Describe the metabolic events that led to Susan’s symptoms (polyuria, polydipsia,
polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of the
disease.
Susan’s insulin deficiency is caused by increased hepatic glucose output, decreased glucose
uptake by cells, decreased triglyceride synthesis, increased lipolysis, decreased amino acid
uptake by cells, and increased protein degradation. Hyperglycemia was caused by increased
hepatic glucose output and decreased glucose uptake by cells.Hyperglycemia led to
glucosuria and caused osmotic diuresis, leading to polyuria. Polyuria causes dehydration,
which then leads to polydipsia. Decreased triglyceride synthesis caused her body to use fat
for energy, which produces ketones and caused her fatigue, polydipsia, polyuria, and
polyphagia. Decreased amino acid uptake by cells and increased protein degradation and
caused increased blood amino acids. Gluconeogenesis was formed in response andled to
hyperglycemia. Increased protein degradation also causes muscle wasting, which explains
herunintentional weight loss.
7. List the microvascular and neurologic complications associated with type 1 diabetes.
Microvascular complications include: retinopathy and nephropathy. Neurological
complications include peripheral neuropathy, cardiovascular autonomic neuropathy,
genitourinary autonomic neuropathy andgastroparesis autonomic neuropathy
8. When Susan’s blood glucose level is tested at 2 AM, she is hypoglycemic. In addition, her

2. plasma ketones are elevated. When she is tested early in the morning before breakfast, she is
hyperglycemic. Describe the dawn phenomenon. Is Susan likely to be experiencing this? How
might this be prevented?
The dawn phenomenon is when hyperglycemia occurs around 4-8 am and is not due to
previous hypoglycemia. They have normal blood glucose levels between the house of 2 and
3 am. Susan does not have the dawn phenomenon because she is hypoglycemic at 2 am.
Susan is most likely experiencing the somogyi effect. Her early morning hyperglycemia is
due to her previous hypoglycemia at 2 and the rebound secretions of counterregulatory
hormones. To treat the somogyi effect Susan should be given an HS snack. Her insulin
should not be altered.
9. What precipitating factors may lead to the complication of diabetic ketoacidosis? List these
factors and describe the metabolic events that result in the signs and symptoms associated
with DKA.
Diabetic ketoacidosis is associated with high blood sugar levels and ketones. It is caused
from dehydration during a state of insulin deficiency.In response to stress, hormones break
down the muscle fat and liver cells into glucose (and used as fuel). Fatty acids are converted
into ketones by oxidation. Signs and symptoms associated with DKA include: excessive
thirst, frequent urination, vomiting, loss of appetite, confusion, shortness of breath, low
blood pressure and a distinctive fruity odor on the breath.
II. Nutrition Assessment
A. Evaluation of Weight/Body Composition
10. Determine Susan’s stature for age and weight for age percentiles.
Stature for age: 23th percentile
Weight for age: 17th percentile
11. Interpret these values using the appropriate growth chart.
Susan is not below the 5th percentile, which is considered healthy. However it would be
more beneficial to track her growth and see if she was once in a higher percentile.
B. Calculation of Nutrient Requirements
12. Estimate Susan’s daily energy and protein needs. Be sure to consider Susan’s age and
activity level.
25 kcal/kg * 45 kg = 1125 kcal
0.8 g/kg * 45 kg = 36 g PRO
13. What would the clinician monitor in order to determine whether or not the prescribed
energy level is adequate?
The clinician should monitor Susan’s weight to determine whether or not the prescribed
energy level is adequate.

3. C. Intake Domain
15. What dietary assessment tools can Susan use to coordinate her eating patterns with her
insulin and physical activity?
Susan can use a Self-Monitoring of Blood Glucose (SMBG) to help her adjust her daily eating
patterns and medications as necessary to maintain glycemic control. By taking
measurements of her urine ketones, she will be able to keep accurate statuses of her levels
despite illness or stress.
D. Clinical Domain
17. Does Susan have any laboratory results that support her diagnosis?
Susan has increased osmolality, glucose, BUN and HbA1C tests that support her diagnosis.
18. Why did Dr. Green order a lipid profile?
Dr. Green ordered a lipid profile to check Susan’s cholesterol, triglyceride, HDL and LDL
levels.
19. Evaluate Susan’s laboratory values at admission:
Chemistry Normal Value Susan’s Value Reason for Nutritional
abnormality Implications
Osmolality 285 – 295 Admit 304, d/c High levels of CHO – steady
mmol/kg/H20 297 glucose in the meal plan to
blood due to control glucose
dehydration levels,
supplemented
with the correct
amount of
insulin
Glucose mg/dL 70 – 110 Admit 250, d/c Glucose is not CHO – steady
120 being absorbed meal plan to
into the cells control glucose
from the blood levels,
stream because supplemented
she is not with the correct
producing amount of
insulin insulin
BUN mg/dL 8 – 18 Admit 20, d/c Excessive CHO – steady
18 protein meal plan to
breakdown and control glucose
impaired kidney levels,
function supplemented
with the correct
amount of

4. insulin
HbA IC % 3.9 – 5.2 Admit 7.95 Long – term CHO – steady
glucose in blood meal plan to
stream is control glucose
elevated to levels,
about 200 supplemented
mg/dL with the correct
amount of
insulin
F Nutrition Diagnosis
24. Select two high-priority nutrition problems and complete the PES statement for each.
1.Impaired nutrient utilization related to polydipsia, polyuria, polyphagia, weight loss and
fatigue as evidenced by lab results of 304 mmol/kg/H2O osmolality level, 250 mg/dL
glucose level, 20 mg/dL BUN level and 7.95% HbA1C.
2.Food- and nutrition-related knowledge deficit related to lack of prior exposure to accurate
nutrition related information on Type 1 Diabetes as evidenced by new diagnosis of Type 1
Diabetes.
III. Nutrition Intervention
25. For each of the PES statements that you have written, establish an ideal goal (based on
the signs and symptoms) and an appropriate intervention (based on the etiology).
Goal #1: Control blood glucose levels. We can reach out goal by aiming HbA1C below 7%,
osmolality levels between 285-295 mg/dL andglucose levels between 70-110 mg/dL. We
will aim to have BUN levels between 8-18 mg/dL. To this, we will enroll Susan in nutrition
education classes to teach her how to control her glucose levels and inject insulin. Meal
interventions will take place to set food plans for her that coincides smoothly with her
lifestyle.
Goal #2: Learn how to manage Type 1 Diabetes. This will be done by educating Susan on
foods, glycemic index and insulin administration. She will learn her limits for
carbohydrates, protein and calories and learn to live up to her caloric needs. We will
recommend more water intake, though the intervention will help to quench her extreme
thirst.
26. Does the current diet order meet Susan’s overall nutritional needs? If yes, explain why it is
appropriate. If no, what would you recommend? Justify your answer.
No it does not meet her overall nutritional needs. Susan should be consuming a1125 kcal
diet with her activity level. Her carbohydrate intake is slightly high at 300 grams. I would
recommend a diet of about 140 grams of carbohydrates.
1125kcal * 0.5 = 562.5kcal /4 g = 140 grams CHO. This equates to 9 15-gram servings of
CHO.
In addition, please answer the following:

5. Using CHO counting, how many CHO choices will you recommend for each meal and snack?
I would recommend 9 15-gram choices for Susan throughout the day. For each meal
and snack, I would give Susan the freedom to decide on when she needs the most
carbohydrates. Some days, she may need more in the morning because of volleyball in the
afternoon. This will help her to learn how to read her body’s needs. Typically, I would
recommend more carbohydrates in the morning to give her energy for her after school
games.
Develop a meal plan that meets the diet order and write out the sample menu with the CHO
choices highlighted.
AM (3 servings) ½ banana 15 Grams CHO
½ cup oatmeal 30 grams CHO
Lunch (2 servings) 2 slices WW bread 30 grams CHO
2 oz tuna fish N/A
½ cup tomato 5 grams CHO
Snack (1 serving) 3 cups popcorn 15 grams CHO
PM (2 servings, carried over 1 cup broccoli 10 grams CHO
from the 5 grams from 3 oz. lean turkey breast N/A
lunch) ½ dinner roll 15 grams CHO
HS Snack (1 serving) ¾ oz pretzels 15 grams CHO
Finally, write an ADIME note reflecting your diet counseling that incorporates a PES
statement.
A: Patient is 15 year old active female. Patient exhibits excessive thirst, urination and
fatigue. She experienced unintentional weight loss. Lab levels indicate high levels of blood
glucose, prealbumin and osmolality.
D: Patient is diagnosed with T1DM.
I: Patient will work with RD to devise a new meal plan that will fit in with her busy schedule
and meet calorie, carbohydrate and protein needs. Pt will also take nutrition education
classes to learn to administer insulin and learn how to become independent in managing
her new health status.
M/E: Patient will keep communication with RD to understand how meal plan is working
into her life. If need for modification, patient and RD will revise the meal plan to better
accommodate.
PES: Impaired nutrient utilization related to polydipsia, polyuria, polyphagia, weight loss
and fatigue as evidenced by lab results of 304 mmol/kg/H2O osmolality level, 250 mg/dL
glucose level, 20 mg/dL BUN level and 7.95% HbA1C.