SR is a 29-year-old woman recently diagnosed with type 1 diabetes based on her symptoms of dizziness, fatigue, frequent urination, excessive thirst and hunger, and electrolyte disturbances. Her blood glucose levels were very high at 720 mg/dL and her A1C was 8.5%, indicating her insulin levels were too low and she was not producing enough insulin. Her meal plan needs to be modified using carbohydrate counting to better manage her blood sugar levels, with the goal of keeping her A1C below 7% and blood glucose levels within normal ranges. She should monitor her blood glucose levels before and after exercise and meals to determine how activities and food affect her levels.

1. Tera Fischer
FND431
Diabetes Case Study
1. What information above indicates that SR has type 1 diabetes? Other
than the diagnosis of type 1 diabetes, why would you not think it is type
2?
It is evident that SR has type 1diabetes mellitus (T1DM) due to the fact that
she is experiencing dizziness, fatigue, frequent urination, and excessive thirst
and hunger and electrolyte disturbances as evidenced by her lab values. SR is
also underweight and recently lost 9lbs (unknown if due to cold); people with
T1DM are often lean and experience significant weight loss. Although non
obese persons can develop T2DM it is most often associated with obesity.
Given SR’s age of diagnosis (29), weight, and symptoms; it is evident that she
has T1DM and not T2DM.
2. Explain how SR’s symptoms and laboratory tests are related to the
absence of insulin.
High blood sugar occurs when insulin levels are too low. SR’s lab values of
BG levels at 720mg/dl and hgb A1C test value of 8.5% are above normal.
Her symptoms of thirst, urination, fatigue/drowsiness, and weight loss are
signs of elevated BG and indicate that she is not getting enough insulin.
Electrolyte disturbance as evidenced by low sodium lab value at 128 mEq/L,
and extremely low bicarbonate lab value at 7 mEq/L. The amount of glucose
in the blood, due to lack of sufficient insulin, can offset the proportion of
electrolytes. With hyperglycemia, the body tries to rid itself of the excess
blood glucose by increasing urinary output. Increased urination produces
water and electrolyte loss, which then upsets the body’s balance of
electrolytes. Symptoms of electrolyte imbalance include headache, fatigue,
and irritability; all of which SR has signs of.
SR’s acetone levels are at an extremely high level, 4+. Near complete
deficiency of insulin causes diabetic ketoacidosis (DKA). Excessive
production of ketone bodies lowers the pH of the blood, which explains why
SR’s venous pH is at 7.1 (normal value is 7.41).
Having very high blood sugar can make the kidneys filter too much blood;
years of this stress on kidneys can contribute to dysfunction or failure. As a
result, waste products, including urea nitrogen will build up in the blood and
raise BUN levels. Normal levels are within 6-21 mg/dl for woman and SR’s
levels were at 35 mg/dl. Her BUN levels might also be elevated due to
dehydration.

2. Tera Fischer
FND431
3. Calculate SR’s BMI and kcaloric need and protein need. Show your
calculations. Is her current intake meeting her needs if she is sedentary?
BMI=weight in kilograms/height in meters squared
BMI= 51kg/ (1.65)²
BMI= 51kg/ 2.72
BMI= 18.8kg/m²
Harris Benedict-Female
REE=655.096 + 9.563 (W) + 1.850 (S) – 4.676 (A)
REE=655.096 + 9.563 (51) + 1.850 (165) – 4.676 (32)
REE=655.096 + 487.7 + 305.3 + 149.6
REE=1598 x 1.3 (activity factor)
Kcaloric needs = 2077kcals/day
Protein needs (normal)
Protein needs =0.8g/kg
Protein needs = 0.8 x 51
Protein needs = 41g/day
Based on her food log, she is currently consuming around 2500kcals/day and
100g of protein/day. She is exceeding her current energy and protein needs.
4. Modify SR’s current meal plan using CHO counting. Describe how you
would teach her how to use CHO counting. Specify meals, snacks, and #
of CHO for each meal and snack. Consider the BG monitoring record
given above.
Sample meal plan:
Breakfast: 60g CHO
1 whole grain english muffin
1 small banana
1 T peanut butter
½ orange juice
Coffee with 2 T milk
Snack: 30g CHO
¾ oz pretzels
1 apple
Lunch: 60g CHO
Subway 6” cold sub (turkey)
Iced tea (sweetened with 1pk stevia)

3. Tera Fischer
FND431
3 c fat free popcorn
Snack: 30g CHO
½ c sugar free chocolate pudding
3 graham cracker squares
Dinner: 60g CHO
2/3 c brown rice
1 c stir fry vegetabls
3oz tofu
1 T low sodium soy sauce
¾ c blueberries
½ c frozen yogurt
Total CHO for day= 240g CHO
I would first explain that Carbohydrate (CHO) counting is a way of keeping
track of the amount of CHO’s she gets from foods. CHO counting can help
her manage her blood glucose levels by ensuring she is spreading them out
throughout the day. We would then go over the following steps:
1. Know the foods that contain CHO’s and learn to read nutrition labels
2. Know the amount of each food that contains 15g of CHO
3. Know what counts as a serving of CHO foods
4. Know what foods are considered “free” foods
5. Count the amount of CHO in the foods you eat
6. Check to see how a certain meal affects you by taking your blood
glucose level before you eat and 2 hours after
5. How would this meal plan be different if you were using the Exchange
System? Give an example of the exchanges you would use for one of SR’s
meals.
CHO counting counts the carbohydrates of each meal or food, whereas the
exchange list groups foods together because they are alike and includes
exchanges for all macronutrients. Foods on each list have about the same
amount of cho, protein, fat, and calories. In the amounts given, all choices on
the list are equal. Any food on the list can be exchanged or traded for any
other food on the list. The lists are grouped into three main groups:
carbohydrate group, meat and meat substitute group, and fat group. The
following is an example of how SR’s meal plan would look if using the
exchanges:
Breakfast:
2/3 c brown rice
1 c stir fry vegetabls
3oz tofu
1 T low sodium soy sauce

4. Tera Fischer
FND431
¾ c blueberries
½ c frozen yogurt
starches fruits milk Non-
starchy
vegetables
Meat/
Meat
substitute
fats
Dinner 2 1 1 2 1
6. What would you recommend to SR for care before and after she goes to
the gym? What advice would you give SR for managing her blood
glucose when she drinks alcohol with friends?
I recommend SR start out by exercising for 30-60min/day at a moderate level
to see how her body reacts. She should keep a record of the type and amount
of exercise along with the CHO intake, changes in insulin doses and blood
glucose levels. She should do this before and after. Since I recommend she
exercise for less than 1 hour, she may prefer to adjust insulin instead of
increasing CHO. In general, the mealtime insulin taken before exercise can be
decreased by 1 or 2 units to prevent blood glucose levels from dropping too
low during and/or after exercise. Additional adjustments, including adding
CHO, may be necessary once she determines she can exercise for a longer
duration. If she decides she would rather consume a snack before exercise,
she should consume a snack with 15g CHO. (might be only necessary if
activity is longer than 1 hour). Moderate exercise of less than 30 minutes
generally does not require any additional CHO or insulin adjustment, unless
blood glucose is below 100mg.dL, in which case a small snack may be
needed. Fluid intake is important. She can dilute a sports drink with water to
provide fluid and CHO. She should also wear adequate ID and carry a source
of readily available CHO during exercise (nutrition care manual). Consuming
CHO immediately after exercise optimizes the repletion of muscle and liver
glycogen stores. For the exerciser with diabetes, this is important because of
increased risk for late onset hypoglycemia (mahan, 689).

When SR goes out to drink with friends, she should ditch the high sugar/CHO
laden frozen margaritas. She should also limit her intake to 1 drink. Her
drink of choice should contain the least amount of sugar possible; mix liquor
with water or diet soft drink. She should also consume food when drinking.
7. Consult the Nutrition Care Manual for Type 1 diabetes. What outcomes
measures are appropriate for SR? What should be monitored in the
future? See NCM, include outcomes for present and future.

5. Tera Fischer
FND431
Achieve and maintain blood glucose levels in the normal range or as close to
normal as is safely possible. Achieve and maintain a lipid and lipoprotein
profile that reduces the risk for vascular disease. Achieve and maintain blood
pressure levels in the normal or as close to normal as is safely possible.
Prevent/slow the rate of development of the chronic complications of diabetes
by modifying nutrient intake and lifestyle. Address SR’s nutrition needs,
taking into account personal and cultural preferences and willingness to
change. Maintain the pleasure of eating by only limiting food choices when
indicated by scientific evidence. Glycemic goals should be HbA1c <7.0%.
Prepradial capillary plasma glucose within 70-130 mg.dL. Peak pospradial
capillary plasma glucose <180 mg/dL. Goal for systolic pressure is <130
mmHg. Lipid goals are LDL <100 mg/dL and triglyceride levels <150 mg/dL
and high HDL >50 mg/dL (nutrition care manual).
References:
Lee, D. R., Neiman, D. C. Nutritional Assessment, 5th
Ed. 2010
Mahan, L. Stump, S. and Raymond, J. Krause’s Food and the Nutrition Care
Process. 2012
Nutrition Care Manual found at www.nutritioncaremanual.org