- What are the risk factors for developing type 2 DM as a child? What do the current ADA standards of medical care recommend concerning screening at-risk children?
The most common risk factors include obesity (as well as body fat distribution, esp. central body fat adiposity), family history, history of gestational DM, impaired glucose metabolism, and physical inactivity. Also, risk factors may include a high birth weight and there may be some genetic indication involved. According to the ADA, children with the following must be further tested: a BMI greater than the 85th percentile for age and gender, or weight for height greater than 85th percentiles, or weight greater than 120% of ideal for height. They must also have two of the following risk factors: Family history of T2DM in the first- or second-degree relative (especially maternal); race/ethnicity of native American, African American, Latino, Asian American, Pacific Islander; and/or signs of insulin resistance or conditions associated with insulin resistant such as acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovarian syndrome. If a child presents one of the first risk factors and two or more of the second risk factors, they must be tested every two years for fasting plasma glucose levels in order to test for T2DM. This starts at 10 years of age or at the onset of puberty [Nelms, 2011 (p. 498)].
- Evaluate Adane’s medical record. Identify which risk factors most likely led to the routine screening for DM during her school physical.
Adane is currently at a BMI of 36.4 which places her at greater than the 99th percentile for her age (see #11). Because she is greater than the 85th percentile, has a family history of T2DM in both the first her mother and grandmother, and is African-American, Adane has enough risk factors (even without looking at signs insulin resistance) to categorize her – according to the ADA’s standards – as a child who needs to be screened for DM [Nelms, 2011 (p. 498)].
- What are the ADA standard diagnostic criteria for T2DM? Which are included in Adane’s medical record?
There are four different tests that can be performed to diagnose diabetes mellitus. The first is the A1C test that is greater than 6.5% though there are some question as to how accurate these tests are as A1C levels might vary depending upon race/ethnicity. There is also some evidence that the rate of glycation may vary among different races, but these results have been somewhat controversial. The second test that can confer a diagnosis is a fasting plasma glucose (FPG) of greater than or equal to 126 mg/dL (7.0mmol/L). The third is of the two-hour plasma glucose or fasting glucose test which is a diagnosis if greater than or equal to 200 mg/dL (11.1 mmol/L) during oral glucose tolerance test. The last possible way to diagnose diabetes is by the symptoms – classic symptoms of hyperglycemia or hyperglycemic crisis which is a random plasma glucose of greater than or equal to 200 mg/dL (11.1mmol/L). The standards for pre-diabetes are figured through similar tests but the numbers vary – these numbers are considered “normal but high” [Nelms, 2011 (p. 498)].
Adane’s medical records included an HbA1C of 6.9% which is greater than the 6.5% reference number. Adane also had a glucose of 171 while the reference range is 70 to 110 which is supporting evidence that her glucose intolerance is abnormal. Adane’s estimated average glucose (EAG) was also at a high of 151. Based especially on Adane’s HbA1C level, Adane can be diagnosed with Diabetes Mellitus.
- Adane’s physician requested additional testing that included autoantibody levels and C-peptide. Explain why these tests were done and what the results indicate for Adane.
The reason Adane’s physician requested an autoantibody test as well as a C-peptide test is to ensure the Type 2 Diabetes diagnosis is not being confused with Type 1 Diabetes. In obese children, screening guidelines for both Type I Diabetes and Type 2 Diabetes are very similar. C-peptide level is based on blood sugar level and is a sign that the body is producing insulin. A low levels or no insulin C-peptide means that the pancreas is producing little or no insulin. Adane’s C-peptide was high at 2.75 while her GADA was negative. This means that Adane does in fact have T2DM and it is not being confused with Type 1 DM.
Sources: http://www.diabetes.co.uk/gad-antibody-test.html
http://www.diabetes.co.uk/c-peptide-test.html
- Insulin resistance is a major component of T2DM. Explain this pathophysiology. How could you determine whether Adane is exhibiting insulin resistance?
In T1DM, there is a lack of insulin caused by destruction of beta-cells. In T2DM, insulin is produced but the tissues are insulin resistant and the body therefore has an increased need for insulin. To combat this, the pancreas produces more but after too long the pancreas loses the ability to produce insulin at all. This results in T2DM which includes two metabolic defects: insulin resistance and relative insulin deficiency. Insulin resistance in T2DM is caused by a cell-receptor defect in which insulin cannot get into the cells and be taken up for fuel. Because insulin is what tells the body when blood glucose is high, an alteration then occurs in this pathway that results in a defective insulin secretory response from the liver. At first, postprandial glucose levels rise and then later hepatic gluconeogenesis steps up to compensate for the lack of glucose. This results in fasting hyperglycemia [Nelms, 2011 (p. 501)].
Insulin resistance can have an impact on metabolic reactions, one of which is the conversion of calories to fat – which may explain some of Adane’s excess weight. Also, the liver enzymes that produce cholesterol can be affected which would explain Adane’s high cholesterol and triglyceride levels.
- Children with T2DM are at high risk for early cardiovascular disease. Why does this complication occur with diabetes? Evaluate Adane’s lipid profile. How does this compare to the lipid goals for children with diabetes?
Obesity and insulin resistance syndrome go hand in hand. These both effect hyperinsulinemia, hypertension, hyperlipidemia, type 2 diabetes, and an increased risk of cardiovascular disease. Overweight and obesity increase the likelihood of developing T2DM during childhood. There is evidence that those who are overweight during childhood are highly likely to be overweight into adulthood. In correlation, data supports that being overweight as an adult increases the likelihood of high cholesterol and high blood pressure which both are signs of early onset cardiovascular disease. The direct link between childhood to diabetes and cardiovascular disease is unclear but some sort of correlation is prevalent. However, likelihood of both insulin resistance and cardiovascular disease decreases immensely with weight loss and exercise (Rosamond, 1998).
In Adane’s lipid profile, we can already see that she has high total cholesterol (210 mg/dL) and high triglycerides (175 mg/dL). These are both higher than the lipid goals for children with diabetes which are less than 170 mg/dL and less than 150 mg/dL, respectively.
- Adane’s grandmother asks about medication for treating high cholesterol as her husband is on this medicine. What are the recommendations for the use of statin drugs in children?
Trials have been conducted on the safety of the use of statins in children. Overall, the statins have shown to be effective at lowering LDL levels and have mild side effect of headache, GI distress, and myalgia. However, long term effects have not yet been determined. Adane is at such a young age that the first step in her treatment should be weight loss through diet and exercise, both of which have an impact on cholesterol levels. If the use of the drug is not needed or if other options are available first, they should be used. If Adane’s levels continue to increase with age and she develops other signs of cardiovascular disease, perhaps statins would be something worth considering. However, it is not approved to be used in children under the age of 10 and even when Adane is a year older, it’s not worth risking Adane’s health when long term effects are unknown. Statins should only be put to use if the benefits outweigh the negatives and there are no alternatives (Bellosta, 2004).
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- Adane’s urinalysis is positive for protein. What does this mean and how may this be related to her diabetes?
A person with diabetes should be tested several times a year for protein in the urine. This is a sign that there is diabetes related kidney damage as the kidney is allowing protein to escape the body without being absorbed. An extremely high amount of protein may be a sign of kidney disease. Kidney malfunctions and diabetes are related as kidneys are one of the organs that respond to the body’s glucose intolerance. Long-term glucose intolerance can harm the kidney, resulting with urine in the diet [Nelms, 2011 (p. 499)].
- Should Adane and her family be taught about self-monitoring of blood glucose (SMBG)? If so what are the standard recommendations for daily frequency testing? What would be the appropriate fasting and postprandial target glucose levels for Adane?
Adane and her family should be educated on SMBG – it is important to teach both Adane and her parents because Adane is so young and may need assistance until she gets used to the system. SMBG is recommended with individuals with T2DM because it has been found to be very effective in controlling blood glucose levels. Tests should be done frequently in the beginning until patterns emerge and should be continued to be monitored around meal times, before and after physical activity, and before and after sleep. If Adane becomes ill then she must test her blood glucose every 4 to 6 hours. The goal is to keep her glycemic indicator between 70 and 130 mg/dL preprandial as a normal glycemic indicator is less than 100 mg/dL, and her postprandial glucose should be less than 180 mg/dL as a normal postprandial glucose level is less than 140 mg/dL [Nelms, 2011 (p. 494)].
- Outline the basic principles for Adane’s nutrition therapy to assist in control of her T2DM.
The most prevalent goal is to stop Adane’s weight gain. The focus will not be on caloric restriction as that may interfere with Adane’s growth but the focus will be on using the exchange system in order to keep her blood glucose and A1C within the normal range. This will be done through lifestyle changes such as decrease of high calorie and high fat foods, as well as foods high in simple carbohydrates, especially sugar. Nutrition education will be provided that encourages 3 square meals and 3 healthy snack each day, as well as regular physical activity. This will have to be something taken on by the entire family and not just by Adane, as she is so young and this will be difficult for her without family support.
Total carbohydrate consumption will need to be monitored through either carb counting or the exchange system – whichever Adane feels most comfortable with. These carbohydrates should be complex carbohydrates (esp. legumes, fruits, vegetables, and oats) that help Adane increase her fiber intake as it takes the small intestine longer to absorb high fiber foods and therefore affects glucose levels. Because Adane’s kidney is not functioning properly (as evidence by protein in the urine), she will have to be careful not to consume any more than 08.g/kg or ~10% of total kcal at least until there is no longer protein present in her urine and then Adane should consume no more than 20% of her total kcals from protein (BOOK). Her total fat consumption should not exceed 25-35% of total kcal and saturated fat should not be higher than 7% of total kcals [Nelms, 2011 (p. 499)].
- Using the charts on pp. 188-189, assess Adane’s ht/age; wt/age; ht/wt; and BMI. What is her desirable weight?
Adane is 9 years old and 52” tall which places her at approximately the 50th percentile in height/age. When incorporating her weight of 140lbs into that, her height is above the 97th percentile for weight/age. Adane has a BMI of 36.4 which also places her beyond the 97th percentile for BMI/age. Adele’s ideal body weight would be somewhere between 65 and 75 pounds to place her between the 50th and 80th percentile for her age.
BMI = [weight (lbs) / height (in)² ] x 703
[140/(52)² ] x 703
= 36.4 kg/m²
- Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T2DM.
Adane has a high total cholesterol of 210 mg/dL as mentioned earlier as well as a high triglyceride level of 175 mg/dL. These are high due to her body’s inability to use blood glucose for energy and possibly a result of her high fat, high sugar diet, as well as her BMI or 36.4 kg/m². Her HbA1C levels are an indication specifically of diabetes which were at an elevated level of 6.9% which is a measure of blood glucose control. Her insulin C-peptide level was also at a high of 2.75 (ng/mL) and this is a test to see if Adane’s body is still producing insulin. Because the number was high, this shows that her pancreas is still trying to overcompensate for the cells’ inability to take in glucose for energy. There was also protein and glucose in Adane’s urine which indicate that the kidney’s filtration ability has been altered.
- Determine Adane’s energy and protein requirements. Be sure to explain what standards you used to make these estimations. Should weight loss be a component of your estimation of energy needs?
Weight = 140 lbs / 2.2 = 63.6 kg
Height = 52” x 2.54in. = 1.32 m
TEE for Overweight Females Aged 3-18 years
TEE = 389 – 41.2 x age + PA x 15.0 x weight + 701.6 x height
= 389 – (41.2 x 9) + (1.18 x 15.0 x 63.6kg) + (701.6 x 1.32m)
= 2,070 kcal
Basing Adane’s PA on a low active lifestyle factor of 1.18, her daily intake of calories to maintain weight is between 2,000 and 2,100 kcal/day. When considering the protein and glucose found in her urine, her estimated protein intake should not exceed 0.8 g/kg/day until protein is no longer present in the urine which means that Adane should take in
(0.8 g x 63.6 kg = 50.88 g protein/day.
Weight loss is not recommended for children who are overweight as it may interfere with growth and development. The goal here is to keep Adane from gaining additional weight with hopes that she will grow into her current weight. With healthy eating habits and incorporating exercise, the emphasis will be on Adane’s new healthy lifestyle. Once she is finished growing, if weight loss is a concern, it can then be implemented.
- Using Adane’s diet history, assess the approximate number of kilocalories her intake provided, as well as the energy distribution of calories for protein, carbohydrate, and fat, using the exchange system. Compare this to the recommendations that you made in question #10.
Adane’s daily caloric intake was about 3,737 calories which is nearly double the TEE calculated in number 13. This means that all of her intake values are in excess as far as grams. Her intake distribution is about 62% carbohydrates (610g), 31% fat (135 g), and 7% protein (66g). Her protein intake is too low, while her carbohydrate intake is too high. Her fat is within the range as far as percent but the amount of saturated fat is far beyond the recommendations at about 37g (fitday.com, 2014).
- Prioritize two nutrition problems and complete the PES statement for each.
- Obesity/overweight related to excessive energy intake as evidence by the estimated consumption of 3,737 kcal/day which is 182% of patient’s EET of 2,000-2,100 kcal/day and a BMI over the 97th percentile for age.
- Glucose intolerance related to inappropriate intake of carbohydrates as evidence by increased serum glucose levels of 171 mg/dL and a dietary intake of approximately 62% carbohydrates (610 g carbohydrates, 393 g of sugar).
- Determine Adane’s initial nutrition therapy prescription using her diet record from home as a guideline, as well as your assessment of her energy requirements.
I would start off by showing Adane (her parents would be included in all of this) how to use the exchange system for carbohydrates and recommend that she consume 3 meals and 3 snack per day, each meal would consist of about 45 g of carbohydrates (or 3 items from her exchange list) as well as 20-25 g of carbohydrates from each snack (or 2 items from her exchange list. I would do this by giving her examples of complex carbohydrates that provide fiber and no added sugars. Next, I would teach Adane what foods have high amounts of sugar and simple carbohydrate intake by providing her a list of things that are not so good for her. Next we would look at combining each carbohydrate with a healthy source of protein to keep her blood glucose levels steady and keep her satiety level up. I would also instruct Adane to use a food journal to track what she is eating, especially at school, so Mom and Dad can go over these with her at the end of each day.
Mom and Dad will be instructed on how to use fitday.com (which is where I got the calculations in #14) so they can compare Adane’s diet to the following recommendations and adjust as necessary: a total of 2,000-2,100 kcal/day consisting of 20% protein or 60 g/day (when there is no longer protein in the urine – so more long-term), 25-35% fat (less than 7% coming from saturated fats), and 45-55% carbohydrates, mostly complex with good amounts of fiber. To take steps towards a healthy lifestyle, I would recommend that Adane replace her high fat snack with lower fat alternatives, eliminate fried foods, discontinue the consumption of sugary drinks such as kool-aid and soda and replace these with water and low-fat milk, and replace processed snacks with fruits and vegetables.
- Outline the initial steps you would use to teach Adane and her family about nutrition and diabetes. What education materials could you use?
According to the American Association of Diabetes Educators, there are seven steps to educating those with diabetes. The first step is healthy eating as mentioned above, followed by being active. I would teach Adane and her family members different ways to incorporate exercise into their lifestyle such as going on family walk, taking more family outings that gets the family out of the home that are inexpensive alternatives to watching television (hiking, swimming, etc.). I would then teach Adane and her family about monitoring and taking medication. This would have to be under the supervision of her parents as Adane is just 9 years old. Monitoring would include how to use a blood sugar glucose meter, knowing when to check the numbers and the meanings, the target range, and how to record blood sugar levels. These sorts of things would also be kept in Adane’s food journal especially at school. Any medications prescribed by Adane’s physician would be included. I would stress the importance to Adane and her parents how important it is to follow this regimen. The next step is problem solving which looks at situations in which Adane may struggle to stick to her new, healthy lifestyle. For example, if there are no options at school for lunch that allow Adane to stick to her new diet or if she is at a sleepover with friends. The next step is healthy coping which is about adjustment to this new lifestyle, and the final step is about reducing risk which involves awareness of warning signs that may cause trouble.
All of these steps would not be included in one session as that is a lot to take in but handouts are available on the American Association of Diabetes Educators website. Also, I would take to Adane and her family about enrolling her in a diabetes camp during one of her school breaks to meet other kids in similar situations and hopefully help ease her adjustment into this new lifestyle, while finding support.
Source: http://www.diabeteseducator.org/DiabetesEducation/Definitions.html
- Considering that Adane will not be started on medication, is it necessary to teach her and her family about hypoglycemia, sick-day rules, and exercise?
It is very important to educate Adane and her family on these possible issues. Though Adane’s condition does not require medication now, it is important to take preventative measures in order to prevent further worsening of her disease state. These preventative measure include physical activity most (5 to 6) or all days of the week for 30-45 minutes. This has a positive effect on blood glucose levels by enhancing her muscle’s ability to take up glucose. It can also improve insulin sensitivity. Adane and her family will need to understand that if Adane becomes ill, she will need to monitor her blood glucose levels every 4-6 hours to prevent hyperglycemia or hypoglycemia.
- Adane’s mother is worried that none of the children will ever be able to have birthday cake or other sweet treats. She feels that she cannot offer these to the other children if Adane cannot have them. What would you tell her?
There are all sorts of recipes that can be found online for low sugar, sugar free deserts. There are even websites that specifically have diabetes-friendly treats. Adane may not be able to eat all of what the other kids eat or as much of those treats but that doesn’t mean she can’t have great deserts as well. She can help herself to a small amount of cake but with minimal frosting, but definitely pass on the sugary drinks. I would also recommend Adane’s mother pick up some sugar free treats at the store to have on hand. If Adane goes to a birthday party, pack her some sugar free diabetes friendly cupcakes or candy. Make it an opportunity for Adane to feel special by having “Baking Days with Mom” where Adane and her mother try different recipes. When Adane really likes one, save it and use it for her birthday party. Make Adane proud of her new healthy diet and proud to share her new deserts with her friends – the more colorful and creative the cake, the better!
- Write an ADIME note for your initial nutrition assessment.
Assessment:
- Patient brought in after school screening: excessive overweight, race/ethnicity of increased risk, family Hx
- Family Hx: patient’s mother and grandmother have T2DM
- 9-year-old female, 52”, 140 lbs, BMI: 36.4 kg/m²
- Labs: Hba1C 6.9%; EAG 151; C-peptide 2.75 ng/mL A1C; Glucose 171 and 155 mg/dL; Cholestrol 210 mg/dL; Triglycerides 175 mg/dL; Urinalysis: Protein: trace and Glucose: +
Diagnosis:
- Obesity/overweight related to excessive energy intake as evidence by the estimated consumption of 3,737 kcal/day which is 182% of patient’s EET of 2,000-2,100 kcal/day and a BMI over the 97th percentile for age.
- Glucose intolerance related to inappropriate intake of carbohydrates as evidence by increased serum glucose levels of 171 mg/dL and a dietary intake of approximately 62% carbohydrates (610 g carbohydrates, 393 g of sugar).
Intervention:
- Decrease caloric intake to EER of 2,000 to 2,100 kcal/day by decreasing the amount of high fat foods and nearly eliminating simple starches and high sugar foods. This will be done through three square meals each day with three healthy snack and cutting out all liquid calories with the exception of reduced fat milk. The incorporation of exercise will also help caloric levels.
- Increase glucose tolerance by limiting high carbohydrate foods, and getting carbohydrates from high fiber grains, fruits, and vegetables. Incorporation of exercise will also help with glucose intolerance.
- This will be done through education on T2DM management (see above), the exchange system, portion sizes, and reading nutrition labels. It will be recommended that 30 minutes of physical activity occur daily via walks with the family, hiking, riding bikes, and other inexpensive activities.
Monitor/Evaluation:
- Weight management will be the step to ensure that no additional weight is being gained, as well as height to monitor growth.
- Adane’s daily food journal and blood sugar levels will also be used as a 24-hour recall and an assessment of how well she has learned to use her new pump.
- Lab values: check all previously abnormal values, especially lipid profile, glucose, HbA1C, EAG, C-peptide, and a urinalysis should be performed to ensure no further kidney damage has occurred.
- Adane’s grandmother suggests that perhaps Adane should have “stomach surgery” so that she will lose weight more quickly. What are the recommendations for pediatric bariatric surgery?
Weight loss surgery is something taken into consideration in morbidly obese children over the age of 13 but is not recommended for those under the age of 13. Even so, all other approaches must be taken first, primarily the initiation of a healthy lifestyle that includes a healthy diet as well as exercise. The real goal is to improve the overall quality of Adane’s life and set up positive health habits that she can take with her for the rest of her life.
Source: http://pediatrics.aappublications.org/cgi/content-nw/full/120/Supplement_4/S164/T8
Sources
Bellosta S, Paoletti R, Corsinin A. Safety of statins: Focus on clinical pharmacokinetics and drug interaction.Circulation. 2004.
Fitday.com (2014). Retrieved from: http://www.fitday.com/app/log/
Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.
Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial
infarction and in mortality due to coronary heart disease, 1987 to 1994. 1998.
Ross, Insel Turner (2009). Discovering Nutrition.
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