Issues on Diabetes Type 1 - Case Study Example

?Running Head: QUESTIONS Questions for Questions for Diabetes type Questions for Diabetes type 1. Discuss the latest information in detail regarding the etiology and genetics of type 1 diabetes. Diabetes is an autoimmune disorder which requires insulin and is complicated by numerous other issues. It is established that “autoimmunity is the predominant effecter mechanism” for the development of the illness (Van Belle, Coppieters, & Von Herrath, 2011, p. 79). Van Belle, Coppieters, and Von Herrath (2011) suggest that while autoimmunity may create the potential for developing the illness, it is environmental factors that hold the true causality. It is possible that enteroviruses may have a triggering role while there are microorganisms that might hold protection against those triggers. The etiology of type 1 diabetes has been identified to be associated with at least ten different genes. Carel (2010) states that “the known functions of these genes indicate the primary etiological pathways of this disease including HLA class H and I molecules binding to preproinsulin peptides and T-cell receptors, T- and B-cell activation, innate pathogen-viral responses, chemokine and cytokine signaling and T-regulatory and antigen presenting cell functions” (p. 218). 2. Assess the patient’s physical examination. What is consistent with diabetic ketoacidosis (DKA) and give the physiological rational for all that you identify? The case study states that his symptoms were ‘fatigue, nausea, vomiting, and intense thirst. The ER physician noticed that his breath smelt of acetone’. Only about 30% of the population can smell the scent of acetone in a patient in DKA, so the patient was lucky on this count. The signs of fatigue, nausea, vomiting and intense thirst are only the beginning of the diagnosis, but the scent of acetone leads the diagnosis in that direction. His dryness and the noticeable irritability can also be signs of DKA. The difficulty that he is having breathing coupled with the existence of a fever for the last two weeks also suggest that he has dropped into a state of DKA. Although he has a history of taking care of himself nutritionally, he has lost weight (15.4 lbs) which also suggests that he is in DKA. 3. Examine the biochemical indices of the patient and list which are consistent with DKA and discuss why. In the incidence of DKA, certain biochemical measures will be shifted, primarily as a counterbalance to regulation of insulin through hormone shifts. Examples of these shifts can be seen in epinephrine, growth hormone, the plasma levels of glucagon and increases in cortisol. The changes in these chemicals are usually due to an insufficiency of insulin. The result is hyperglycemia which occurs as the production of ketone production increases. Glucose is decreased in being drawn into the tissues and gloconeogenesis and glycogenolysis are increased. Lipolysis is triggered due to the counter-regulatory hormones which are caused by the increased ketogenesis. As a result, low pH and low bicarbonate is the result of being consumed through the resulting buffering of the keto acids. Respiratory distress is caused by metabolic acidosis (Joshi & Mishra, 2009). Potassium and chloride will be in short supply during DKA, which is being shown in the patient. Phosphorus is increased, which is not normal for DKA. Mental status is known to change when osmolality is over 340 and the patient is dangerously close to that level when he is admitted, with CO2 levels being low which is due to the breathing difficulties. Glucose is well over normal, indicating that insulin is not enough. BUN, which stands for blood urea nitrogen is the result of protein breaking down. It is clear that after being in the hospital and under care it has dropped from 29 to 21. Begbi, Barber, Reddy, and Simpson (2010) discuss the correlation of HbA1c which correlates to high glucose and this is represented in the patient. Good measures of HbA1c are below 7%, but the patient’s measured at 12%. Increased WBC can be present, but this can also be indicative of an infection which could be the cause of some of the biochemical results for the patient. Urine was positive for ketones and for glucose, suggesting DKA. Blood pH is over 7.1, which depending on literature over 7.1 – 7.3 is indicative of DKA. 4. Discuss, in detail, coma due to severe hyperglycemia and what would occur if the patient remained untreated (seen notes at end of case study)? Coma due to ketoacidosis is caused by a decompensation of metabolic functions and without proper treatment is usually fatal. The major findings that would indicate the onset of ketoacidotic decompensation would indicate that the body has slipped into an uncontrollable catabolic state. The loss of electrolytes, dehydration, osmotic dieresis, and hyperketonemia with metabolic acidosis would result in extracellular hyperosmolality which causes cerebral dysfunction. As a result of too little insulin over a period of days or even just hours, the patient can lapse into a coma (Siegenthaler & Aeschlimann, 2007). 5. What might have precipitated the development of DKA and explain how? There are many causes for DKA, most of which are defined by the inability of the patient to follow their prescribed needs for self-administering insulin and following a good diet. The development of DKA comes from having a decreased level of insulin needed to support good metabolic balance, thus throwing all of the systems that depend on a good level of insulin out of step and resulting in the series of symptoms as described earlier. In the case of Mr. X, his diet and use of his prescribed insulin supplementation, as well as his use of the meter, suggest that the reason he would have fallen into DKA would be a change in his need for insulin. Although, because he appears to have been vigilant does not mean that he has been. DKA would have been brought about with a drop in insulin levels to the point that blood glucose was in excess, creating the chain reaction of counterregulatory hormones. 6. What could the patient have done to avoid DKA and discuss why? The first point of avoiding DKA is making sure to test regularly and to make sure that his insulin level was always within limits. The path to DKA is a drop in insulin. Proper diet, meter testing, injecting insulin and making sure to follow the doctor’s advice is the first way in which to avoid DKA. To avoid DKA in its extremes, going to the hospital at the first signs of problems would be the best way to avoid the worst consequences of DKA. 7. Define the following terms: a. Intensive insulin therapy: an aggressive treatment in which close monitoring of blood sugar is treated with frequent doses of insulin. Blood sugar levels before one eats should be 70-130 milligrams per decileter with two hours after meals measuring less than 180 (Mayo Clinic, 2012) b. Conventional insulin therapy: occurs at the same number and same time of day each day without variance (Mayo Clinic, 2012) c. Continuous blood glucose monitoring systems: a small sensor that has a catheter into the body that checks glucose every minute to five minutes in order to keep blood glucose at its optimum through knowledge (Mayo Clinic, 2012) 8. Discuss (not just list) the microvascular and neurological complications associated with type 1 DM. Microvascular Complications: Retinopathy is one of the growing complications of type 1 diabetes in which within 20 years of diagnosis. Osmotic stress due to sorbital accumulation is often the cause of retinopathy which is responsible for 10,000 cases of blindness per year within the United States (Fowler, 2008). Diabetic Nephropathy is a leading cause of renal failure in diabetic patients. Changes in the kidney that lead to nephropathy include meicroaneurysm, mesnagial nodule formation, and basement membrane thickness. The mechanisms that cause diabetic retinopathy are likely the same as those that cause nephropathy (Fowler, 2008). Neurological Complications Peripheral Neuropathy is the display of nerve damage in people with diabetes in which pain in the form of everything from tingling to widespread burning occurs when damage is done to nerve endings. Foot ulceration and injury cause amputation in those who suffer from this type of manifestation. There is not an exact cause of neuropathy, but there are many problems theorized for causation (Fowler, 2008). This type of neuropathy occurs primarily in the hands and feet. Autonomic Neuropathy is called the ‘stealth’ form as it affects systems of breathing, cardiovascular, perspiration, salivation, excessive perspiration, all of which can result in damage to a system before it is realized. Stroke and cognitive impairment can be an issue with diabetes as nerve endings and the swelling of membranes can cause pressure in the brain. 9. Describe the following insulin types including their action times: Rapid acting: include Humalog, Novolog, and Adipra give coverage for meal time and shortly after and help maintain insulin after meals. These insulins work within 20 minutes of taking them and up to about 2 hours after. Short acting: Acts within 30-60 minutes, with peak at 2-3 hours, with an effective duration of about 6-8 hours. These insulin types are considered regular. Long acting: Lantus and Levemir act between 18 and 26 hours, although it is usually taken about once a day and most do not get 24 hours from the dosage. It is best to split the dosage into two with 12 hour gaps so that peaking is not as often experienced. 10. Discuss all of the advantages of intensive insulin therapy in detail? There are a great many benefits to intensive insulin therapy including the potential to reduce the risk of heart attacks and strokes by 50% the risk of eye damage by 75%, nerve damage by 60% and the slow progression of kidney disease by 50%. Energy is boosted and it helps an individual to feel better in a very general way (Mayo Clinic, 2012). 11. Discuss all of the risks of intensive insulin therapy in detail? The risks associated with intensive insulin therapy are weight gain and low blood sugar. Due the change that will occur during the therapy, the risk for low blood sugar exists and so symptoms of low blood pressure should be monitored (Mayo Clinic, 2012) 12. Do you think that this patient would benefit from insulin infusion pump therapy with a continuous blood glucose monitor and why? This patient would benefit from insulin infusion pump therapy with a continuous blood glucose monitor because it appears that he has been following medical advice and yet his insulin is not in balance. Through using the monitor and the infusion pump, his levels can be balanced and information on where he is having difficulty can emerge. 13. Explain in detail how an insulin pump works, and the best types of insulin to use in an insulin infusion pump. Insulin pumps are computerized devices that are worn on a belt or other type of harness that have tubes that go into the body which deliver a continuous stream of rapid-acting insulin. The catheter is inserted under the skin and taped in place. The pump is intended to continually release insulin 24 hours a day in accordance with how it is programmed. The amount of insulin is dependent upon the need of the wearer of the pump. The basal rate is kept at a constant so that when food is eaten a “bolus does of insulin can be programmed into the pump” (Web MD, 2012). Blood sugar still must be monitored at least four times per day so that insulin can be set as needed. Food intake and exercise can cause differences so that the pump must be adjusted. The insulin pump frees the wearer from injections while providing a steady small dose that mimics how the body should keep a slow release of insulin across time. 14. Compare the actions of regular insulin and rapid acting insulin. Differences between regular insulin and rapid acting insulin are in the time that they take for usage. Regular insulin will act within a 6-7 hour time frame, depending upon the digestive rate of the individual. The action is slower than rapid insulin which is best used during meal coverage and for keeping glucose in check after food intake. They act within 20 minutes of being taken and activity will increase during the next 2 hours, falling off after an additional 3 hours. The injection should be taken at an early time before the meal so that it can be at work while eating. 15. How would you describe CHO counting to the patient and his family, and how is it used with an insulin infusion pump? CHO, or carbohydrate counting, helps to keep HbA1c below 7% and to support proper injection of insulin with balanced carbohydrates. Carbohydrate groups include fruit and fruit juices; milk and yogurt; breads, grains, cereals and pasta; rice, beans and starchy vegetables; and sugary foods (American Diabetes Association, 2012). The basic formula is: #grams of carbohydrate __________________ = 1 unit insulin per ___ g CHO #units of bolus insulin CHO is not an exact science and will need to be monitored and experimented with in order to get the correct balance with the insulin pump. 16. Discuss all of the pros and cons about using an insulin pump. Advantages: The need to inject using a syringe is eliminated. Leveling out blood glucose swings is possible There is increased flexibility in diabetic management. There is a possible reduction of blood sugar reactions through balancing insulin. The use of an insulin pump provides the ability to develop a deeper knowledge of how insulin is needed for the patient. The system creates a flexible system which provides for the ability to know when to make adjustments. Insulin is given through a catheter rather than through multiple injections every day through simply pushing a button. Risks: Infection is a risk. Blood checks need to be done more frequently. The pump is worn so can interfere with some life activity. Being disconnected from the pump puts the user at risk for high glucose levels which could lead to DKA. The pump has a great number of advantages, but also has some risks. The greatest risk is that the pump catheter could become infected if the cannula is not changed on a regular basis. Frequent testing must be done in order for good operation and if the pump is removed there is a risk that blood glucose could dangerously rise. 17. Calculate his energy requirements using the Harris-Benedict equation (give full details of your calculation). BMR = 66 + ( 13.7 x weight in kilos ) + ( 5 x height in cm ) - ( 6.8 x age in years ) 66 + 890 +840-149.6 =1646.4 BMR 1646.4 X 1.55 (for moderate activities with 3 sports activities per week) 2551.92 – or 2552 18. Calculate his macronutrient requirements and produce a balanced full daily menu, including snacks and drinks, for him with portion sizes of all foods and analysis using Nutritionist Pro or another nutrient analysis (your analysis should show the actual calculated values, but also what the values should be). There are a number of factors that need to be considered when evaluating the dietary needs of the patient. According to Holick (2004), Vitamin D is one of the more important vitamins to consider where type 1 diabetes is concerned. The best way to get Vitamin D is to get approximately 15 minutes of sun per day. Nutrition is more than just food intake. However the following diet will supply the patient with a good framework from which to adjust his needs as he perceives them through the insulin pump information and meter tests of his blood sugars. In addition, he needs to gain a bit of weight. Breakfast: Calories 3 Eggs 300 Ground Turkey Patties (6oz) 200 Berries (8 oz) 200 Mid Morning Snack: Almonds (30) 208 Lunch Portion of Protein (8 oz) 400 Portion of Whole Grain Bread 250 Portion of Salad Portion of Fruit (4oz) 100 Mid Afternoon Snack Portion of Protien (4oz) 150 Dinner Portion of Protein 500 Portion of Bread 200 Vegetable - starchy Evening Snack Portion of Protein (almonds) 208 Calories 2716 19.Discuss in detail the pro and cons and uses of glucose, fructose and sucrose in the diabetic diet. In order to use sugars in the forms of glucose, fructose and sucrose in the body of a type 1 diabetic the proper calculated use of insulin must be used in order to control the sugar in the blood. Using sugar in the diet is not the wisest use of food for the type 1 diabetic as sugar will release too quickly into the blood and cause a quicker need for insulin. Slow metabolizing of sugars through proteins and slow acting carbs are better for a diabetic food intake. When too much insulin has been given, however, a quick acting sugar such as glucose, fructose, or sucrose may be an answer. Overall, however, glucose, fructose and sucrose should be avoided as they can lead to problems in the glycemic load which would act unfavorably in relationship with blood lipids and HDL cholesterol (Slyper, Jurva, Pleuss, Hoffman, & Gutterman, D, 2005). 20.Discuss in detail the glycemic index of the 3 different monosacharides. Glucose – 70 or above Fructose - 55 or less Sucrose – 80, as it is half glucose and half fructose The glycemic index is the measurement between the increases of glucose from the consumption of carbohydrate in the blood. 21.Discuss in detail the pro and cons and uses of sugar alcohols in the diabetic diet. Sugar alcohols can create bloating and diarrhea, especially in children. Having said that, there is some use for sugar alcohols in the diet of someone with diabetes as they are somewhat more natural than other sweeteners, but the problem is that they might still have as much carbohydrates or more in a product to make up the difference in flavor between the lowered level through the use of the sugar alcohol. In order to use products that are lower in calorie due to sugar alcohols, one must also be careful about the level of carbohydrate and fats in the product to make up the difference in flavor. 22.Which are the main food product that use Aspartame and who should not use this sweetener? The main products in which Aspartame is found are diet carbonated drinks. Drinking diet soda is never a good idea for anyone as the ingredients in diet soda do nothing for the general health of the individual. Using any kind of sweetener that is not natural is a very bad idea. No one should use Aspartame as the consequences of its use are still not conclusive and the long term effects are only just starting to be realized. Aspartame is two amino acids held together by one methanol which binds the two amino acids together. Heating aspartame as low as 86 degrees Fahrenheit will result in breaking that bond, with the methanol then breaking down into formaldehyde and formic acid. This can cause retinol break down in the eye, interfere with the replication of DNA in the body, and cause birth defects. In addition, Aspartame has been associated with a number of illness, including exacerbating ADHD as aspartic acid, which is 40% of aspartame, is known to stimulate hyperactivity (Hull, 2012). There is no good reason to risk using aspartame as part of a diabetic diet. 23.Discuss in detail the use of Sucralose in the diabetic diet. Sucralose, also known as Splenda in its most common commercial brand, is chlorinated sucrose which is an artificial chemical sweetener that can be known to break down into particles that are similar to ingesting chlorinated pesticide. During the pre-approval process, the substance was shown to shrink the thymus glands and to enlarge the liver and kidneys. Post approval, animal research has shown mineralization in the kidneys with caecal enlargement (Hull, 2012). Although the amounts in those studies were large, using the product puts the user at risk. Artificial sweeteners fool the brain into believing it has had something sweet, but the risks in doing so and in ingesting these products are not worth the benefit of having something sweet to eat. 24.Discuss in detail Stevia as a non-caloric natural sweetener in the diabetic diet. The latest information on Stevia is that it is a bad idea, especially for men. Stevia has been shown in some reports to lower sperm count, making it a less attractive sugar substitute. Although of the six possible sugar substitutes that are available it has the lowest level of potential problems, the stevia plant is a natural substance that might carry chemically changing properties that include lowered sperm count. This means it could also have affects that are yet to be understood. Non-caloric sweeteners are generally a bad idea and although the search for sweeteners that can be used to substitute for sugar is an ongoing process, Non-caloric sweetening usually means that the body is being fooled into believing something is sweet, and that also indicates a trade-off is being made somewhere. Stevia can cause mild side effects which include nausea and an over feeling of being full, but also show signs of encouraging the mutation of cells so could be a contributing factor to cancer, although this research is still not conclusive. In addition, only certain kinds of stevia are considered safe by the FDA, therefore staying away from it seems prudent at this time (Zeratsky, 2012). 25.Discuss in detail the role of chromium in the treatment of diabetes. Chromium use can be traced back to the 1950s where it was determined that chromium had the capacity to help stabilize glucose metabolism in experimental animals. In the 1970s the nutritional supplement was seen to enhance normal carbohydrate metabolism. Chromium shows exceptional qualities in helping to metabolize and maintain glucose properly so it is often a part of the recommended supplements for diabetic care. Chromium is found in “egg yolks, whole grain products, high-bran breakfast cereals, coffee, nuts, green beans, broccoli, meat, brewer’s yeast, and some brands of wine and beer” (Cefalu & Hu, 2004, p. 2742). Chromium intake should be between 50 and 300 ug per day for men and women, but with on ly 60% of that minimum of 50 being average for the intake of adult in the United States. Chromium acts to facilitate the action of insulin and provides for increased metabolic actions for the balance of blood sugar in the body (Cefalu & Hu, 2004). References American Diabetes Association (2012). www.diabetes.org. Begbi, H., Barber, T., Reddy, N., & Simpson, H. (March 2010). Diabetic keto-acidosis in patients with Type 2 diabetes mellitus: a relatively common occurrence, the severity of which correlates with HbA1c. Society for Endocrinology. 21: 141-172. Carel, J.-C., Hochberg, Z., & European Society for Paediatric Endocrinology. (2010). Yearbook of pediatric endocrinology 2010. Basel: S Karger. Cefalu, W. T. & Hu, F. B. (November 2004). Role of chromium in human health and in diabetes. Diabetes Care. 27(11): 2741-2751. Fowler, M. J. (April 2008). Microvascular and macrovascular complications of diabetes. Clinical Diabetes. 26(2): 77-82. Hanas, R. (2009). Type 1 diabetes in children, adolescents and young adults: How to become an expert on your own diabetes. London: Class Pub. Holik, M. F. (March 2004). Vitamin D: Importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. The American Journal of Clinical Nutrition. 79(3): 362- 371. Howorka, P. (2011). Diabetes? insulin-dependent?: Functional use of insulin. New York: Xlibris Corp. Hull, J. S. (2012). Aspartame other sweeteners. Sweet Poison. Retrieved from http://www.sweetpoison.com/aspartame-sweeteners.html Joshi, S. R., & Mishra, A. (2009). Dietary considerations in diabetes. Haryana, India: Elsevier. Mayo Clinic (2012). Retrieved from www.mayoclinic.com Siegenthaler, W., & Aeschlimann, A. (2007). Differential diagnosis in internal medicine: From symptom to diagnosis ; 323 tables. Stuttgart: Thieme. Slyper, A., Jurva, J., Pleuss, J, Hoffman, R. & Gutterman, D. (February 2005). Influence of glycemic load on HDL cholesterol in youth 1,2,3. The American Journal of Clinical Nutrition. 81(2): 376-379. Web MD. (2012). Retrieved from www.webmd.com Zeratsky, K. (10 August 2012). Nutrition and healthy eating. Mayo Clinic. Retrieved from http://www.mayoclinic.com/health/stevia/AN01733 Read More