Case Study #22 Diabetes Mellitus:

Type 1

Diabetes

Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With type 1 diabetes, your body does not make insulin. With type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood. You can also have prediabetes. This means that your blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts you at a higher risk of getting type 2 diabetes.

Diabetes Mellitus: Type 1Type 1 Diabetes Mellitus results from a deficiency

in insulin production and insulin action causing hyperglycemia.

Immune meditated or Idiopathic

Deficiencies caused by the cellular mediated destruction of pancreatic beta cells

Results in cells being unable to use glucose for energyPlasma glucose levels rise (Hyperglycemia) and cells

starve Glycosuria, Polyuria, Dehydration, Poydipsia, Polyphagia,

Fatigue and Electrolyte Imbalanace

Diabetes Mellitus: Type 1Commonly diagnosed in children and

adolescentsJuvenile Diabetes

Some cases develop later in lifeLatent Autoimmune Diabetes of Adulthood (LADA)

Long term complicationsCardiovascular Disease, Nephropathy, Retinopathy,

Autonomic Neuropathy

The Patient Susan Cheng

Asian American

15 years old, HS student

Active: Starter for the girls’ volleyball teamPractices four nights a week and has games two nights a

week

Lives with her parents, older sister,

and younger brotherAll are in excellent health

Uneventful medical history, no significant illness until recently

Has recent complaints of polydipsia, polyuria, polyphagia, weight loss and fatigue.

Chief Complaint“I’ve been so thirsty and hungry. I haven’t slept

through the night for 2 weeks. I have to get up several times a night to go to the bathroom. It’s a real pain. I’ve also noticed that my clothes are getting loose. My mom and dad think I must be losing weight.”

Physical Exam General Appearance: Tired-appearing adolescent female

Vitals: Temp 98.6 F, BP 124/70 mm Hg, HR 85 bpm, RR 18 bpm

Heart: Regular Rate and rhythm, heart sounds normal

HEENT: Noncontributory

Genitalia: Normal adolescent female

Neurologic: Alert and oriented

Extremities: Noncontributory

Skin: Smooth, warm, and dry; excellent turgor; no edema

Chest/lungs: Lungs are clear

Peripheral vascular: Pulse 4+ bilaterally, warm, no edema

Abdomen: Nontender, no guarding

Chemistry Normal Value Susan’s ValueReason for

AbnormalityNutritional

Implications

Albumin 3.5-5 g/dL 4.2 g/dL Normal -

Total Protein 6-8 g/dL 7.5 g/dL Normal -

Prealbumin 16-35 mg/dL 40 mg/dLDecreased fluid

volume in the bodyDehydration

Sodium 136/145 mEq/L 140 mEq/L Normal -

Potassium 3.5-5.5 mEq/L 4.5 mEq/L Normal -

Chloride 95-105 mEq/L 98 mEq/L Normal -

PO4 2.3-4.7 mg/dL 3.7 mg/dL Normal -

Magnesium 1.8-3 mg/dL 2.1 mg/dL Normal -

Osmolality285-295

mmol/kg/H2O304 H

mmol/kg/H2ODecreased fluid

volume in the bodyWeight loss, dehydration

Glucose 70-110 mg/dL 250 H mg/dL

High blood sugar due to diabetes, in

ability to use glucose due to

insulin deficiency

Hyperglycemia, frequent thirst,

urination, hunger, drop in pH,

ketoacidosis

BUN 8-18 mg/dL 20 HIncreased glucose

levelsDehydration

Creatinine 0.6-1.2 mg/dL 0.9 mg/dL Normal -

Calcium 9-11 mg/dL 9.5 mg/dL Normal -

CHOL 120-199 mg/dL 169 mg/dL Normal -

LDL <130 mg/dL 109 mg/dL Normal -

HbA1C 3.9-5.2% 7.95%Increase in glucose

binding to hemoglobin

Diabetes complications, eye

disease, heart disease, kidney disease, nerve damage, stroke

Admission Diagnosis:Type 1 diabetes

mellitus

Risk Factors and EtiologyMember of high risk ethnic group

Asian American

Stressful lifestyle

Maternal grandmother had diabetes (but not first-degree relative)

EtiologyGenetics

HLA (human leukocyte antigen) markersEnvironment

High birth weight, viral infection, dietary factors

TreatmentAchieve glycemic control

Evaluate serum lipid levels

Monitor blood glucose levels

Initiate self-management training for patient and parents on insulin administration, nutrition prescription, meal planning, signs/symptoms and Tx oc hypo-/hyperglycemia, monitoring instructions (SBGM, urine ketones, and use of record system), exercise

Baseline visual examination

Contraception education

Insulin

Types of Insulin

Brand Name

Onset of Action

Peak of Action (Hours)

Duration of Action (Hours)

Lispro Humalog 10-20 min 1-3 3-5

Aspart NovoLog 10-20 min 1-3 3-5

Glulisine Apidra 10-20 min 1-3 3-5

NPH Humulin NNovolin N

1-3 hours 8 20

Glargine Lantus 1 hour None 24

Detemir Levemir Same as above

70/30 premix MixtardHumulin 70/30

30-60min Dual 10-16

50/50 premix Humuli 50/50 30-60 min Dual 10-16

60/40 premix Mixtard 40 30 min 2-8 24

•Most patients with T1DM require approximately 0.6 units of insulin per kilogram of body weight per day•Dosage adjusted according to blood glucose levels

Pharmacological Differences:

AnthropometricsHeight: 5’2”

Weight: 100 lbs

BMI:45.45kg/(1.6m)2= 17.75

Susan is at a normal weight for her age and height and falls just below the 25th percentile on the CDC growth chart.

Nutrition HistoryMother describes Susan’s appetite as good.

Meals are somewhat irregular due to Susan’s volleyball practice/game schedule. She is a starter on the girls’ volleyball team,

practices four evenings per week, and participates in approximately two games per week, some of which are away games.

Susan eats lunch in the school cafeteria.

Food Serving Calories CHO (g) Protein (g)

Fat (g)

Kellogg’s Frosted Flakes Dry Cereal

1 ½ cup 215 kcal 53.15g 2.54g 0.123g

2% Milk 1 cup 122 kcal 11.71g 8.05g 6.044g

Orange Juice

1 cup 112 kcal 25.79g 1.74g 0.248g

Total 449 kcal

90.65 12.33g 6.415g

Breakfast

LunchFood Serving Calories CHO (g) Protein

(g)Fat (g)

Pizza 6 inch, pepperoni

770 kcal 69g 35g 16g

Mixed Salad

1 cup 17 kcal 3.35g 1.3g 0.049g

Thousand Island Salad Dressing

¼ cup 178 kcal 7.03g 0.52g 14.973g

Snickers 1 candy bar

280 kcal 35.06g 0.26g 11.376g

Total 1245 kcal

114.44g 37.08g 42.378g

SnackFood Serving Calories CHO (g) Protein

(g)Fat (g)

Peanut Butter

2 tbsp 188 kcal 25.79g 7.7g 15.181g

Grape Jelly

1 tbsp 50 kcal 13g 0g 0g

White Bread

2 slices 133 kcal 25.3g 3.82g 1.377g

Coke 1 12oz can

136 kcal 35.18g 0.26g 0g

Total 507 kcal

99.27g 11.78g 16.558g

DinnerFood Serving Calories CHO (g) Protein

(g)Fat (g)

Spaghetti

2 cups noodles

442 kcal 25.79g 16.24g 1.753g

Spaghetti Sauce

½ cup 111 kcal 17.61g 2.28g 3.165g

Ground Beef

1 oz 77 kcal 0g 7.24g 4.628g

Steamed Brocolli Stalks with salt

3 stalks 147 kcal 30.15 10g 1.215g

2% Milk 2 cups 244 kcal 23.42g 16.1g 11.667g

Total 1021 kcal

96.97g 52.04g 22.428g

HS SnackFood Serving Calories CHO (g) Protein

(g)Fat (g)

Ice cream

2 cups, chocolate

572 kcal 89.6g 10g 28g

Coke 1 12oz can

136 kcal 35.18g 0.26g 0g

Total 708 kcal

124.78g 10.26g 28g

Estimated Energy and Protein Requirements

EER for females 9 through 18 Years=

135.3-30.8(15 years)+1.56(10(45.5kg)+934(1.6m))+25=

2,739 kcals/day

Physical activity coefficient: 1.56 for very active

Protein

RDA for 14-18 year old female= 46g/day

Diet Plan ComparisonTotal Daily Patient Intake

Recommended Diet Plan Intake

% of Recommended Intake

Kcal 3643 kcal 2800 kcal 130%

CHO 473.73g 300g 157.9%

Protein 118.33g 55-65g 182% - 215.4%

Fat 95.15g 80g 118.9%

Nutrition Care ProcessStep 1: Assessmento Appropriate and reliable data were collected

to determine the existence of specific nutrition problems

Step 2: Diagnosis o Food and nutrition-related knowledge deficit o Self-monitoring deficit

Achieve HbA1c <5.2%Educate both patient and family about…

Role of nutrition in diabetes managementCarbohydrates and diabetesHow certain foods effect blood glucosePreventing hyperglycemiaFood purchasing/preparation

Decrease Frequency of Poor Carbohydrate Choices

Nutrition Education/Counseling:

Outpatient appointmentsMeal planningPractice skills

Carb counting, blood glucose monitoring

Reviewing logs of meals, snacks, blood glucose readings, insulin administrations

Psycho/social statusEffects of alcohol consumption

Effects of AlcoholSusan is admitted to the ER the night after she is

discharged. She had a BG of 50 mg/dL. She was invited to a party Saturday night and tested her blood glucose before leaving. It measured 95 mg/dL so she took 2 units of insulin. She knew she needed to have a snack that contained 15g CHO so she drank a beer when she arrived at the party. She remembers getting lightheaded then woke up in the ER.

Effects of AlcoholOnce Susan administered the insulin, her blood

glucose was going to drop

Normally, liver will begin changing stored CHO into glucose

The glucose then sent to blood to slow down low blood glucose reaction

When alcohol ingested, liver wants to clear it as quickly as possible

Alcohol must be completely metabolized

If blood glucose is low, alcohol can lead to passing out

Effects of AlcoholAlcohol may be consumed occasionally WITH

FOOD

Do not count alcohol

as a carbohydrate

Hypoglycemia can

occur easily, especially

with nocturnal intake

Underage consumption

What about Stevia? Native to Central and South America

Grown for its sweet leaves - ~200-300x sweeter than sugar

Not approved in the US as a food additive or sweetener- only as a “dietary supplement”

Banned in several countries as food additive, approved as dietary supplement in others

Has been shown to lower blood glucose by increasing insulin secretion in lab studies

May want to focus more on Reb A extract of stevia “Rebiana”

Truvia and PureViaContain Reb A “Rebiana”

Extracted from stevia leaf, erythritol, and other natural flavors

Received GRAS recognition in US

Questions?

Diabetes Case Study I. Understanding the Disease

and Pathophysiology

1. Define insulin. Describe its major function within normal metabolism.

Insulin is hormone produced in the beta cells of pancreas it is responsible for facilitating the movement of glucose from the blood into the body muscles and fat cells it is secreted in response to an increase in blood glucose

2. What are current opinions regarding the etiology of type 1 diabetes mellitus (DM)?

type 1 DM result from the autoimmune destruction of pancreatic cells preventing the synthesis and secretion of insulin the trigger for autoimmune destruction is debated and hypotheses include environmental toxins or infections

3. What genes have been identified that indicate susceptibility to type 1 diabetes mellitus?

Genes that influence that function of pancreatic (BETA) cells have been examined for possible links to T1DM . Additionally genes related to function influencing metabolic syndrome are being reviewed for a link to T2DM for example PPAR is being reviewed for its possible role in insulin resistance.

4. After examining Susan’s medical history, can you identify any risk factors for type 1 DM?

Susan’s history showed that the grandmother on her mother’s side had diabetes. Her medical history report showed that her blood glucose levels were high as well as her osmolality and BUN levels. Also, according to her usual dietary intake, her CHO amounts are much higher than what her current diet order should be. She has been experiencing polydipsia, polyuria, polyphagia, weight loss and fatigue from a result.

5. What are the established diagnostic criteria for type 1 DM? How can physicians distinguish between type 1 and type 2 DM?

There are three ways to diagnosis type 1 DM. These include symptoms of diabetes and a plasma glucose concentration greater than 200 mg/dL, fasting plasma glucose greater than 126 mg/dL, or 2 hour post prandial glucose greater than 200 mg/dL during an oral glucose tolerance test. The symptoms are made in the absence of hyperglycemia. Type 1 DM accounts for 5- 10% of all diabetes causes. This type is more frequent in children and adolescents rather than adults . These individuals could not survive without exogenous insulin treatment .

Physicians can distinguish the two because type 1 DM results from a lack of insulin from the destruction of beta cells while type 2 DM produces insulin, but their tissues are insulin resistant. Since type 2 DM individuals have an increase need for insulin, the pancreas increases the production. This could result in insulin resistance or relative insulin deficiency because they pancreas loses the ability to produce insulin after trying to keep up. A problem is that glucose cannot take up glucose in the blood for fuel. Type 2 DM is when insulin cannot be used by the body when type 1 DM cannot produce insulin.

6. Describe the metabolic events that led Susan’s symptoms (polyuria, polydipsia, polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of the disease.

Due to the destruction of pancreatic beta cells causing insulin deficiency, the glucose cells cannot be used for energy. A result from this causes glucose levels to rise and cells to starve. To counteract for the glucose levels rising, glucose is excreted in the urine, which causes polyuria. A loss of fluids causes an increase in thirst (polydipsia). Cells that are dependent on glucose do not have any available so the body responds by polyphagia. As insulin deficiency continues, the addition of other hormones increases .

7. List the microvascular and neurologic complications associated with type 1 diabetes.

A cause of a microvascular complication is retinopathy. Retinopathy is the most frequent cause of blindness and is strongly associated with diabetes. The damage of the eye is related to hyperglycemic damage to the blood vessels. Other eye ailments include glaucoma and cataracts. Hypertension is also associated with retinopathy. Another microvascular complication is nephropathy. This occurs in 20-40% of individuals with diabetes that can lead to chronic kidney disease. Hyperglycemia causes changes in the structure of blood vessels that affect the functioning of the kidney. Neurological complications are when there are functional changes in the peripheral nervous system. This can be caused complications with hyperglycemia

8. When Susan’s blood glucose level is tested at 2 AM, she is hypoglycemic. In addition, her 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?

This describes an abnormal early-morning increase in glucose between two a.m. and 8 a.m. in people who have diabetes. Insufficient insulin the night before, incorrect medication dosage or eating CHO snacks before bed can cause elevated blood sugar in the morning (Collazo-Clavell, 2009). Susan may be experiencing this because she may have eaten a CHO snack before she went to sleep. By breakfast, she has high levels of glucose, which is a sign. The dawn phenomenon can be prevented by not eating a CHO snack before bed, adjusting the medication properly, switching medication, or using an insulin pump in the early morning hours (Collazo-Clavell, 2009).

9. What precipitating factors may lead to the complication of diabetic ketoacidosis? List these factors and describe the metabolic events that result in signs and symptoms associated with DKA.

DKA is a severe form of hyperglycemia that’s occurs more often with people who have type 1 DM during an acute illness. The risk increases during an illness, an infection, from emotional stress, or an omission of insulin. Symptoms include nausea, vomiting, stomach pain, fruity breath, respirations, and medical status changes. When adequate insulin is not available, gluconeogenesis and lipolysis is stimulated to avoid starvation. Lipolysis can generate ketones. As glucose and ketones accumulate in the blood, it results in dehydration and electrolyte imbalance causing hyperglycemia .

II. Nutrition Assessment A. Evaluation of Weight/Body Composition

10. Determine Susan’s stature for age and weight for age percentiles.

100# = 45.5kg 20th percentileـــ CDC weight-for age percetile

52’’ = 1.38m percentile ـــ CDC stature-for age percentile

health 11. Interpret the values using the appropriate growth

chart. Stature and weight for age percentiles between the 10 and

85 % are considered normal. Considering this, Susan full in normal range according to the stature for age (25th %) and weight for age (20th %) growth curves. There is slight concern that Susan’s weight may be a bit low for her stature considering the difference in these two percentiles.

B. Calculation of Nutrient Requirements 12. Estimate Susan’s daily energy and protein

needs. Be sure to consider Susan’s age. 135.3 – (30.8×15) + 1.31 [(10×45.45) +

(934×1.57)] + 25 = 2320 calories She is a pretty active individual, so she needs more calories to take in to compensate for all the calories that are lost.

Protein DRI requirement: 34 g/day Based on her EER requirements, the amount protein she needs is:

2320 calories x 0.15 = 348/4 = 87 grams

13. What would the clinician monitor in order to determine whether or not the prescribed energy level is adequate?

To monitor whether or not Susan is receiving adequate energy her weight should be measured daily. Additional measures of her nutritional adequacy would include

lipid panel, albomin an nitrogen balance.

C. Intake Domain

14. Using a computer dietary analysis program or food composition table, calculate the kcalories, protein, fat (saturated, polyunsaturated, and monounsaturated), CHO, fiber, and cholesterol content of Susan’s typical diet .

Chol Fiber CHO Mono Poly. Sat. Protein

Calories

324mg

25g 617g 56g 32g 66g 134g 4,435 Total

15. What dietary assessment tools can Susan use to coordinate her eating patterns with her insulin and physical activity?

Susan can use the MyPyramid tracker website to record what she eats on a daily basis and what physical activity she has done. She can also use Fitday to keep track of what she is eating. A comprehensive nutrition assessment, a self-care treatment plan, and the client’s health status, learning ability, readiness to change, and current lifestyle are what can lead to Susan being in control of the type 1 DM .

16. For each of the following components of an initial

nutrition assessment, list at least three assessments you would perform with

each component:

Obtain height, weight, BMI, waist/hip ratio

Determine reasonable body weight

Estimate daily energy needs

Clinical data

Evaluate who prepares food and shops for food

Determine frequency/choices when eating out

Evaluate energy intake and macronutrient composition

Nutrition History

Obtain weight history, recent weight changes and weight goals

Weight History

Determine activity types and frequency

Estimate energy expenditure

Assess willingness and ability to become more physically active

Physical Activity History

Assess knowledge of target blood glucose ranges.

Asses blood glucose method/frequency of testing

Assess clients benefits from monitoring

Monitoring

Assess level of stress

Assess level of family and social support

Assess living situation, finances and educational background

Psychosocial/Economic

Asses survival or continuing education knowledge level

Knowledge/skill level

Attitude towareds diagnosis

Personal short-and long-term goals

Desire to remain in compliance

Expectations/readiness to change

Chemistry Normal Value Susan’s valueAbnormal Reason

Nutrition Intake

Albumin 3.5-5g/dL 4.2g/dL normal  

Total Protein 6-8 g/dL 7.5g/dL normal  

Prealbumin 16-35 mg/dL 40 mg/dLDecreased fluid vol. Dehydration

Sodium 136-145 mEq/L 140mEq/L normal  

Potassium 3.505.5 mEq/L 4.5 mEq/L normal  

Chloride 95-105 mEq/L 98 mEq/L normal  

PO4 2.3-4.7 mg/dL 3.7 mg/dL normal  

Magnesium 1.8-3 mg/ dL 2.1 mg/dL upnormal  

Osmalility285-295 mmol/kg/H2O 304 mmol/kg/H2O

Decreased fluid volume

Weight loss, dehydration

Glucose 70-110 mg/dL 250 mg/dL

High blood sugar, inability to use glucose from insulin

Hyperglycemia, frequent thirst, urination, hunger, ketoacidosis

BUN 8-18 mg/dL 20 mg/dLIncreased glucose levels  

Creatinine .6-1.2 mg/dL .9 mg/dL normal  

Calcium 9-11 mg/dL 9.5 mg/dL normal  

CHOL 120-199 mg/dL 169 mg/dL normal  

LDL <130 mg/dL 109 mg/dL normal  

HbAlc 3.9-5.2% 7.95%

Increase in glucose binding to hemoglobin

Diabetes complications, eye sight, heart, kidney disease

D. Clinical Domain17. Does Susan have any laboratory results

that support her diagnosis?Susan’s laboratory response shows that she

has high levels of glucose in her blood, high BUN levels and high osmolality levels. High levels of glucose can show hyperglycemia. BUN is blood urea nitrogen, which is the amount of nitrogen that comes out in the urea from the blood. This test shows how the kidneys are working and if there is any problems with them, such as causing dehydration. Then osmolality tests shows the concentration of a solution. This can include the fluid portion in the blood.

18. Why did Dr. Green order a lipid profile?Dr. Green ordered a lipid profile to check

and see if it could have been another factor in what was causing her symptoms. Lipids can affect certain aspects of a lifestyle including the level of diabetes control. People who have type 1 DM, such as Susan, tend to have lipid levels that are similar to people who do not have diabetes. This is different from people who have type 2 DM where they are higher and lower. This can tell the difference as to which type she had and if she had diabetes.

20.Compare the pharmacological differnce in insulins:

Duration of action

Peak of action Onset of action Brand Name Type of insulin

3-5 hr 1-3 hr 10-20min Humalog Lispro

3-5 hr 1-3 hr 10-20min Novolog Aspart

3-5 hr 1-3 hr 10-20min Apidra Glulisine

20 hr 8 hr 1-3 hr Humulin N, Novlin N

NPH

24 hr non 1 hr Lantus Glargine

24 hr non 1 hr Levemir Determir

10-16 hr Dual 30-60min Mixtard,Humulin 70\30

70\30 permix

10-16 hr Dual 30-60min Humulin 50\50 50\50 permix

24 hr 2-8 hr 30min Mixtard 40 60\40 permix

21. Once Susan’s blood glucose levels were under control, Dr. Green prescribed the following insulin regimin: 24 units of glargine in PM with the other 24 units as lispro divided between meals and snacks. How did Dr. Green arrive to this dosage?

A single dose of insulin is rarely able to provide glycemic control with type 1 DM, which is why it is best to combine the insulin with another one or even a few more. Glargine is peakless and has a duration of 20-24 hours. This could be good for when Susan sleeps so she will not have to set timers and wake up for an insulin regimin. Lispro has a shorter duration of 3-5 hours, which is why Dr. Green divided it between meals and snacks to hold Susan over.

E. Behavioral-Environmental Domain22. Identify at least three specific potential

nutrition problems within this domain that will need to be addressed for Susan and her family.

Susan and her family need to be educated about the roles of nutrition in diabetes management, carbohydrates and how it affects people with diabetes, and how to prevent hyperglycemia. Another thing that needs to be addressed is who is dealing with food purchasing and preparation. Learning how to eat as a diabetic is very important to someone’s health. This includes learning how to CHO count and making sure they are getting the right amount.

23. Just before Susan is discharged, her mother asks you, “My friend who owns a health food store told me that Susan should use stevia instead of artificial sweeteners or sugar. What do you think?” What will you tell Susan and her mother?

It would be okay for her to use stevia. It has been approved to be a dietary supplement, and has shown to lower blood glucose levels by increasing insulin secretions. Stevia is an all- natural herbal product that is non-toxic, which helps in avoiding the artificial factors. It would just have to be monitored and treated by a qualified physician or health care practitioner .

F. Nutrition Diagnosis24. Select two high-priority nutrition

problems and complete the PES statement for each.

Lack of food and nutrition knowledge related to newly diagnosed type 1 DM as evidenced by HbA1c at 7.95%.

Inappropriate intake of carbohydrates related to newly diagnosed type 1 DM as evidenced by diet history.

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 etiology).

One goal to educate Susan would be to teach her how to watch her intake and provide her with an appropriate idea of what to eat and how to continue on to make her life as healthy as she can. She needs to lower the high levels in her blood chemistry test by eating the right types of food. Providing Susan with a nutrition therapy intervention will allow her to understand better of what she needs to do to keep her blood levels normal.

Her blood glucose levels were high which could be affected by the inappropriate amounts of CHO eaten. She could be taught the exchange system and how to CHO count to help control her CHO intake and her blood glucose levels. An effective intervention would be nutrition therapy where she could properly learn how to watch her food intake

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.

Susan’s current diet order is good when it comes to getting her macronutrients into her diet. She has to get the most CHO to help monitor her glucose and insulin levels. She is getting the appropriate amount of each macronutrient for her body to live off of. She is recommended 300 grams of CHO, 55-65 grams of protein, and 80 grams of lipid to be at 2400 calories. For being active, the large amount of CHO and lipids will help

IV. Nutrition Monitoring and Evaluation27. What happened to Susan physiologically?Susan appeared to be very tired and

complained of weight loss. Her body has not been able to work appropriately. Her kidneys have been overworking to try to get rid of the extra high levels of glucose. Her body is can go through many different pathways. The loss of fluid made her thirsty where the cells on glucose have to respond by making her hungry. Hormones increase and her body broke down fat into fatty acids transformed to keto acids. Ketone bodies are secreted in the urine (483)

28. What kind of educational information will you give her before this discharge? Keep in mind that she is underage for legal consumption for alcohol.

I would give her knowledge on how to do CHO counting and how much each food group counts for. That way she can take serving sizes, calories, and grams to CHO count more easily. Talking about the exchange system, meal planning and how to control glycemic levels would also have to be discussed. Teaching her how to self-monitor her blood glucose is also another option .