Case StudyType 1 Diabetes Case

Fall 2016Assignment 4

Due date: Oct 7, 2016

Yeyan JinCSUID:829840439

FSHN 450

I pledge on my honor that I have not given or received any unauthorized assistance on this assignment

FSHN 450Type 1 Diabetes Case

Due Date: October 7, 2016

Mrs. DM is a 35-year-old woman with type 1 diabetes. She presents for her annual visit with poorly controlled hypertension and moderate albuminuria. She has been under a physician’s care for diabetes for the past 20 years. She has no history of retinopathy, or neuropathy. She has never had a cardiovascular event and reports no cardiac symptoms. She monitors her fasting glucose levels three times a day using a personal glucometer, and her morning fasting glucose levels have ranged between 120 and 140 mg/dl and post meal 160 - 180. Her hypertension is treated with hydrochlorothiazide (25 mg daily) and lisinopril (20 mg daily). She takes aspirin (81 mg daily), 30 Units NPH ( 20 U in the am and 10 U at bedtime) and uses 30 U Lispro at meals( 10 U at breakfast lunch and dinner) . She notes that she consistently takes her medications. She has a family history of cardiovascular disease. Her Weight is 145# (65.9 Kg) and Ht is 5’5”. Body-mass index is 24.2 Kg/M2. Her blood pressure is 148/95 mm Hg. Her general assessment, including cardiorespiratory, abdominal, and neurologic examinations, is normal. Her HA1c level is 8.1%, and her creatinine 0.9 mg per deciliter, BUN 27, Hgb 12.1, Hct 37%. Liver function tests are normal. Her urine albumin is 4+ (> 300 mg/dl). An additional antihypertensive medication was prescribed and an outpatient nutrition consult was ordered.

Her 24 hour dietary recall revealed a typical day:AM 1/2 cup orange juice, 2 boiled eggs and 1 slice of toast with butter and unsweetened strawberry jam (about 1TSP), coffee with sugar substitute and ¼ cup 1% milk.NOON1 personal pizza with pepperoni and cheese (or MacDonald’s Big Mac, with medium fries) and a large diet Coke. 2PM 1 diet coke and 1 chocolate chip cake (about 3” in diameter)5:30 PM 1 chicken breast, 1/2 cup broccoli, 1 cup mashed potatoes with 4TBSP gravy, ½ cup vanilla ice cream7:30 PM 1 cup popcorn with salt and butter HS 1 cup 1% milk and 4 Oreo cookies

Assess the patients laboratory data and provide an interpretation in table format.Patients Value Normal Range Explanation

Assess drug:nutrient interactions. When reporting these interactions, report only those interactions which pertain to this patient

Assess the patient’s nutritional intake and nutritional status. Use the ADIME format to communicate the patient’s nutritional needs and provide an appropriate nutrition diagnosis and PES statement and intervention for three goals (one in each domain- clinical, intake, behavioral). Explain the rationale for each goal. P Include follow-up plans. Provide a reference for your intervention from the recent literature and include the abstract. Describe the diabetes education which you would provide to this patient to help her achieve her dietary goals. What self-care activities would you suggest for this patient?

1.Assess drug:nutrient interactions. When reporting these interactions, report only those interactions which pertain to this patient hydrochlorothiazide (25 mg daily) and lisinopril (20 mg daily). She takes aspirin (81 mg daily), 30 Units NPH ( 20 U in the am and 10 U at bedtime) and uses 30 U Lispro at meals( 10 U at breakfast lunch and dinner)

Hydrochlorothiazide: That drug side effects may cause high blood sugar.Magnesium, Potassium and Zinc. These diuretics promote urination. Minerals are often lost in the process.

Lisinopril :NegativePotassium: Consuming potassium while taking lisinopril may increase the risk of hyperkalemia.Arginine: Supplementation with arginine while taking lisinopril may alter potassium levels.

PositiveZinc: Consuming zinc while on lisinopril may help combat drug-induced depletion of this mineral.Iron: Iron supplementation concurrent with lisinopril use may help alleviate the undesired side effect of a dry cough. (Iron should be taken with caution, as it may also decrease drug absorption.)

Aspirin:Aspirin increases urinary excretion of vitamin C. Decreased vitamin status with respect to vitamin C as well as folate have been noted.Taking vitamin E together with aspirin has been associated with bleeding problems.The use of over three grams of aspirin has been associated with zinc depletion.

There is no specific nutrient interaction with NPH and Lispro. CHO intake may decrease the effects of NPH and Loispro.

2.Provide a reference for your intervention from the recent literature and include the abstract.

Add one cup of orange for breakfast and lunch to increase fruit intake. According to that article, proper fruit can help control high blood pressure.

Domingos TB, Pereira AF, Yokoo EM, Salles-Costa R. Low fruit consumption and omission of daily meals as risk factors for increased blood pressure in adults. British Journal of Nutrition Br J Nutr, 116(04), 683-691. doi:10.1017/s0007114516002397

AbstractA population-based cross-sectional survey with cluster sampling design and with inverse sampling was conducted in 2010, in a sample of 1590 adults (19-60 years old) exposed to a high prevalence of food insecurity, in the municipality of Duque de Caxias, metropolitan region of

Rio de Janeiro, Brazil. The objective of the study was to evaluate the association of socio-demographic factors, the consumption of fruits and vegetables and the number of meals with increased blood pressure (BP). A hierarchical model that considered variables related to the basic, intermediate and immediate determinants of increased BP was adopted. By using Poisson's regression, univariate models were tested to obtain the prevalence ratio (PR) and its respective 95% CI. After fitting the model, age (age group 50-59 years) (PR 1.62; 95% CI 1.09, 2.41), low consumption of fruits in a week (PR 1.37; 95% CI 1.07, 1.74), fewer meals per day (PR 1.72; 95% CI 1.21, 2.43) and overweight (PR 1.78; 95% CI 1.31, 2.20) remained significantly associated with increased BP. Therefore, the results found here reinforce the importance of encouraging and developing strategies that ensure access to healthy foods to minimise increased BP in similar populations.

3.Describe the diabetes education which you would provide to this patient to help her achieve her dietary goals. I would like to show her a chart about normal range of blood sugar level. And educate her how to control her blood sugar level and why she needs to do it. I will educate her to know how to estimate how many CHO she takes for each meal. Controlling CHO intake is to help her control her blood sugar level. I will also educate her to know the relationship between dietary intake to diabetes.

4.What self-care activities would you suggest for this patient? 1. Healthy eatingShe need to know the nutrient (especially carbohydrate) content of foods, how to read labels, how to cook foods to maintain nutrient content and avoid adding extra saturated fat and sodium and learn how to choose appropriately in restaurants.2. Being activeShe needs engage in aerobic activity, strength building and flexibility training most days of the week.3. MonitoringShe needs to check her blood glucose and allow her health care provider to see how her blood sugars are responding to the medications and lifestyle.4. Taking MedicianIt is important to understand how the medication works, how to properly take the medication and what side effects it may have. Knowing these things will make it easier for her to determine if her medication is working properly.5. Problem SolvingShe needs to know how to respond to high and low blood sugars with appropriate changes in activity, food and medicine.6. Risk ReductionBlood pressure checks, regular eye, foot, dental exams, lab tests for microalbumin, cholesterol and lipid labs –knowing what these tests measure, what the therapeutic goals are, how frequently she should get them checked will help her plan her care more responsibly.

ADIME

Assessment

Patients Value Normal Range ExplanationFasting glucose120 to 140 mg/dl

70 to 100 mg/dl Higher than normal. Diabetes

Post meal glucose160 to 180 mg/dl

Less than 140 mg/dl Higher than normal. Diabetes

BUN 27 mg/dl 7 to 20 mg/dl Higher than normal. Excessive protein levels

HA1c 8.1% Less than 5.7% Higher than normal. DiabetesCreatinine 0.9 mg/dl 0.6 to 1.1 mg/dL Normal

Urine albumin 4+ >300mg/dl

<300 mg/dl Higher than normal. Diabetes, albuminuria.

Hgb 12.1 g/dl 13.5 to 17.5 g/dl NormalHct 37 % 38.8 to 50 % Lower than normal. Too little

iron, folate, vitamin B12, and vitamin B6 in the diet

BMI 24.2 Kg/ M2 BMI is in normal range.Blood pressure 148/95 mmHg. Normal range is 120/80 mmHg. Higher than normal because of her hypertension.BMR=1354 Calories/dayProtein needs per day= 65.9*1.4=92.26 gm/day

Medical: She has hypertension and albuminuria. And she has type 1 diabetes for many years. She has no retinopathy or neuropathy. No symptoms of any heart disease. Glucose test, HA1c test, and Urine albumin test showed she is in diabetes condition. BUN test and Urine albumin test showed she has albuminuria.

Social: She likes to eat fast food for lunch. Looks like she doesn’t have much time to eat a “healthy lunch”. Or she just likes to eat junk food. That is not good for her long term hleath.

Diet: Her Hct test is lower than normal, so she may lack of iron, folate, vitamin B12, and vitamin B6 intake. Look through her 24 hour dietary recall. I found out that she still take many foods that is not good for her diabetes condition. Such as juice, chocolate chip cake, and ice cream. These foods may increase her blood glucose level. And she is taking fast food as lunch. Fast food has high calories but low nutrients that may relate to her low Hct. The another reason for that is she doesn’t eat enough vegetable.

Diagnosis

BehavioralLikes to eat sweeten foods r/t lack of knowledge of diabetes AEB high blood glucose

ClinicalMay have microvascular disease in the future r/t she has diabetes for a long time AEB high blood pressure

IntakeLow intake of vegetables r/t too much junk foods intake AEB hypertension and low Hct

Intervention

Drink ½ cup of tea instead of juice in the morning. (Juice has high content of sugar will increase her blood sugar level) Add one cup of orange for breakfast and lunch to increase fruit intake. (It is good for her high blood pressure control (reference see previous page) )Take ½ cup sugar free vanilla ice cream instead of the regular one during dinner.(High sugar content food will increase her blood sugar level)

Mornitoring/Evaluation

Have a 3 day’s food intake recall, I want to see if she changes her food intake. The expected outcome is she start eating more vegetables and reduce sugar intake.