1. Case
Study
Type
1
Diabetes
Medical
Nutrition
Therapy
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
lbs.
and
height
is
5’5”.
Body-­‐mass
index
is
24.2
Kg/
M2.
Her
blood
pressure
is
148/95
mmHg.
Her
general
assessments,
including
cardiorespiratory,
abdominal,
and
neurologic
examinations,
were
normal.
Her
HA1c
level
is
8.1%
and
her
creatinine
0.9
mg/dl,
BUN
27,
Hgb
12.1,
Hct
37%.
Liver
function
tests
are
normal.
Her
urine
albumin
is
4+
(>300
mg/dl).
The
patient’s
physician
is
going
to
add
an
additional
antihypertensive
drug
and
adjust
insulin.
An
outpatient
nutrition
consult
was
ordered.
Her
24-­hour
dietary
recall
revealed
a
typical
day:
AM:
½
cup
of
orange
juice,
2
boiled
eggs,
a
slice
of
wheat
toast
with
butter
and
unsweetened
jam
(about
1TBSP),
coffee
with
sugar
substitute
and
¼
cup
1%
milk.
NOON:
1
personal
pizza
with
pepperoni
and
cheese
(or
McDonald’s
Big
Mac
with
medium
fries)
and
a
large
diet
coke.
2PM:
1
diet
coke
and
1
chocolate
chip
cake
about
(about
3”
in
diameter)
5:30PM:
1
chicken
breast,
½
cup
broccoli,
1
cup
mashed
potatoes
with
4
TBSP
gravy,
½
cup
vanilla
ice
cream
7:30PM:
1
cup
popcorn
with
salt
and
butter
HS:
1
cup
1%
milk
and
4
Oreo
cookies

2.
Drug/
Nutrient
Interactions:
Aspirin(81mg/day):
Increases
BUN.
Insure
adequate
fluid
intake/hydration.
Hydrochlorothiazide
(25mg/day):
Increases
glucose
levels.
Increases
BUN.
Lispro
(10U
at
each
of
3
meals;
30U
total):
May
mix
with
NPH
only.
Will
decrease
glucose.
Diabetic
meal
plan
to
balance
CHO
with
insulin.
Exercise,
stress,
illness
or
large
weight
gain
increase
needs.
Monitor
serum
glucose,
HA1c
and
urine
ketones.
Lisinopril
(20mg/day):
Transient
increase
in
BUN.
Caution
with
patients
with
diabetes-­‐
decrease
in
glucose.
Monitor
diabetics
for
low
blood
glucose.
NPH
(20U
in
morning
and
10U
at
bedtime):
Will
decrease
glucose.
Diabetic
meal
plan
to
balance
CHO
with
insulin.
Exercise,
stress,
illness
or
large
weight
gain
increase
needs.
Monitor
serum
glucose,
HA1c
and
urine
ketones.
Assessment:
35
y/o
Ht:
5’5”
Wt:
145lbs
BMI:
24.2
(normal)
Medical
hx:
no
history
of
retinopathy,
or
neuropathy,
no
cardiovascular
events,
no
cardiac
symptoms,
diagnosed
with
type-­‐1
diabetes.
Family
hx:
CVD
General
assessment:
cardiorespiratory,
abdominal,
neurologic
examinations
all
normal.
Current
issue:
Poorly
controlled
hypertension,
moderate
albuminuria
Lab
Test
Patient’s
Value
Normal
Range
Reason
for
Variance
HA1c
8.1%
4.0-­‐6.0%
(High)
poorly
controlled
DM
Creat
0.9
mg/dL
0.4-­‐1.2
mg/dL
WNL
BUN
27
mg/dL
8-­‐23
mg/dL
(High)
DM
Hgb
12.1
g/dL
12.1-­‐15.6
g/dL
WNL
Hct
37%
34-­‐45%
WNL
Urine
ALB
4+
Should
Be
0
(High)
acute
renal
failure
Fasting
Glucose
Morning:
120-­‐140
mg/dL
and
post
meal:
160-­‐180
mg/dL
70-­‐99
mg/dL
(High)
DM,
medications
(anti-­‐
hypertensives)
Blood
Pressure
148/95
Less
than
120/80
(High)

3. Meds:
Hydrochlorothiazide
(antihypertensive,
diuretic),
Lisinopril
(antihypertensive),
Aspirin
(NSAID),
NPH
(antidiabetic,
hypoglycemic),
Lispro
(antidiabetic,
hypoglycemic)
Labs:
HA1c
8.1%
(high),
Creat
0.9
mg/dL
(normal),
BUN
27
mg/dL
(high),
Hgb
12.1
g/dL
(normal),
Hct
37%
(normal),
Urine
ALB
4+
(normal),
fasting
glucose
morning:
120-­‐140
mg/dL
&
post-­‐meal
160-­‐180
mg/dL
(high),
LFTs
normal.
24
hour
diet
history:
Diet
high
in
refined
sugars,
high
in
CHO,
high
in
fat,
could
use
more
protein
intake.
Poorly
balanced.
Diagnosis:
Self
monitoring
deficit
(NB-­‐1.4)
r/t
medical
dx
of
Type
1
DM
AEB
24-­‐hour
diet
recall
of
typical
day,
high
HA1c
values,
high
BUN,
high
fasting
glucose.
Intervention:
1. Educate
patient
about
importance
of
proper
control
of
diabetes.
2. Educate
patient
on
healthful
eating
habit
guidelines
in
general.
3. Suggest
joining
a
diabetes
support
group.
4. Create
goals
with
patient
in
order
to
better
daily
eating
habits
and
diabetes
control.
a. Goal
1:
To
try
incorporate
MyPlate
guidelines
into
the
diet.
This
will
encourage
the
patient
to
eat
a
more
well-­‐balanced
diet,
rather
than
one
high
in
fats
and
carbohydrates.
b. Goal
2:
Try
to
lower
lab
values
to
close
to
or
at
normal
levels
within
the
next
4-­‐6
weeks.
By
working
on
getting
the
lab
values
down
this
will
encourage
the
patient
to
control
her
diabetes
properly.
All
of
the
labs
that
came
back
abnormally
can
be
indicators
of
proper
control
or
improper
control
of
diabetes.
c. Goal
3:
Try
and
attend
a
diabetes
support
group
once
every
month.
Attending
the
support
groups
might
help
the
patient
realize
that
others
are
going
through
the
same
thing
and
to
encourage
her
to
keep
monitoring
her
diabetes
sufficiently
in
order
to
maintain
good
health.
Monitoring/
Evaluation:
1. Follow-­‐up
for
goals:
a. Goal
1:
Have
the
patient
present
a
48-­‐hour
diet
recall
one
week
after
intervention.
Note
improvements
and
areas
that
may
need
some
improvement.
b. Goal
2:
Suggest
outpatient
follow-­‐up
with
medical
doctor
in
order
to
obtain
new
lab
values.
Look
for
improvements
in
the
values.
c. Goal
3:
6
weeks
after
intervention
follow-­‐up
with
phone
interview.
Ask
patient
whether
or
not
they
had
attended
a
support
group.
If
they
had,
ask
if
they
had
helped
and
how
she
liked
it.

4. Diabetes
Education:
In
order
to
help
the
patient
attain
her
goals,
diabetes
education
will
be
necessary.
This
education
will
consist
of
providing
the
client
with
information
on
properly
counting
carbohydrates
to
insure
that
the
client
knows
how
to
do
this
properly.
Also
it
will
consist
of
bracketing
her
blood
glucose
levels
so
that
she
can
learn
how
to
properly
adjust
her
injections
to
maintain
better
control
over
them.
Another
suggestion
to
be
made
to
the
patient
might
be
to
monitor
her
glucose
levels
maybe
four
or
five
times
per
day
instead
of
just
three.
This
will
provide
her
with
more
information
on
her
blood
glucose
levels
throughout
the
day
so
that
she
can
make
better
adjustments
throughout
the
day
to
avoid
levels
too
high.
Some
self-­‐care
activities
that
I
would
suggest
for
this
patient
would
just
be
to
eat
a
balanced
diet
using
MyPlate
as
a
guideline.
Another
suggestion
would
be
to
incorporate
exercise
into
her
daily
routine
if
she
is
cleared
to
do
so.

5. I
chose
this
article
because
it
discusses
the
importance
of
education
for
patients
with
diabetes
and
its
effect
on
their
control
habits.
Also
because
the
article
discusses
the
importance
of
continuous
support
after
a
patient
incorporates
changes
important
to
control
of
diabetes.
Abstract:
Aims and objectives: To explore patients' experiences of, views
about and need for, social support after attending a structured education
programme for type 1 diabetes. Background Patients who attend
structured education programmes attain short-term improvements in
biomedical and quality-of-life measures but require support to sustain self-
management principles over the longer term. Social support can influence
patients' self-management practices; however, little is known about how
programme graduates use other people's help. Design This study was
informed by the principles of grounded theory and involved concurrent
data collection and analysis. Data were analysed using an inductive,
thematic approach. Methods In-depth interviews were undertaken
postcourse, six and 12 months later, with 30 adult patients with type 1
diabetes recruited from Dose Adjustment for Normal Eating courses in
the United Kingdom. Results Patients' preferences for social support from
other people ranged from wanting minimal involvement, to benefiting
from auxiliary forms of assistance, to regular monitoring and policing.
New self-management skills learnt on their courses prompted and
facilitated patients to seek and obtain more social support. Support
received/expected from parents varied according to when patients were
diagnosed, but parents' use of outdated knowledge could act as a barrier to
effective support. Support sought from others, including
friends/colleagues, was informed by patients' domestic/employment
circumstances. Conclusion This study responds to calls for deeper
understanding of the social context in which chronic illness self-
management occurs. It highlights how patients can solicit and receive
more social support from family members and friends after implementing
self-care practices taught on education programmes. Relevance to clinical
practice Health professionals including diabetes specialist nurses and
dietitians should explore: patients' access to and preferences for social
support; how patients might be encouraged to capitalise on social support
postcourse; and new ways to inform/educate people within patients' social
networks. [ABSTRACT FROM AUTHOR]