MNT 2 - Exam #3 (Part 1) Flashcards
What is the prevalence of T1DM?
- 5-10% of all DM cases
- About 5% of these cases are idiopathic
What are the causes of T1DM?
- Immune mediated versus idiopathic;
- About 5% of these cases are idiopathic
- Rate of beta cell destruction variable;
- “honeymoon period”still maintains insulin production;
- Causes → NOT clearly understood;
- Multiple genetic predispositions;
- Environmental factors (coxsackie virus, cow’s milk protein, rubella = possible triggers)
What is the pathophysiology of T1DM?
- Absolute deficiency of insulin = beta cells are totally destroyed and they make none;
- Elevated plasma glucose
- Cells cannot use glucose for energy
What are the clinical manifestations of T1DM?
S/S”s of body’s efforts to compensate:
- Glycosuria – glucose in the urine
- Polyuria – excessive urination
- Polydipsia – increased thirst
- Polyphagia – increased hunger
How is an Oral Glucose Tolerance Test (OGTT) used with T1DM diagnosis?
-Oral glucose tolerance test (OGTT)- to dx IGT, IFG, GDM
What are the diabetes related Autoantibodies?
- Glutamic acid decarboxylase autoantibodies (GADA);
- Islet cell autoantibodies (ICA);
- Insulin autoantibodies (IAA);
- C-peptide
What are Glutamic Acid Decarboxylase Autoantibodies (GADA)?
- Test measures specific islet cell antigens
2. Most sensitive marker for T1DM risk
What are Islet Cell Autoantibodies (ICA)?
- Also indicator or T1DM risk;
- Will not be as accurate an indicator as the T1 progresses as the antibodies are lost ;
- Prevalence of ICA decreases as T1DM continues
What are the Insulin Autoantibodies (IAA)?
- Evidence of ongoing Beta-cell destruction
- Not accurate if patient injecting insulin
What are the C-peptides?
- Released as insulin’s 2 polypeptide chains separate
- So c-peptide can be used to measure insulin production
What are the goals of MNT for T1DM?
- Achieve and maintain optimal BG, BP, and lipid levels
- Improve overall health (diet and exercise)
- Address individual energy and nutrients needs while considering personal/cultural preferences, lifestyle, and pt’s readiness to change
- Prevent or delay, and treat long-term complications of DM
What is the focus of education with T1 Diabetics?
- T1 starts earlier in life so there is a longer lifespan for risk of complications
- Acute complications and sick day management education is key
What the main MNT approaches for T1DM?
- Integrate insulin therapy with an individual’s food and physical activity
- Base food plan on assessment of appetite, preferred foods, usual eating and exercise
What are the methods of insulin therapy?
- Flexible or intensive insulin therapy: (CSII or MDII) → Continuous Subcutaneous Insulin Injections; Multiple daily insulin injections
— Determine and adjust pre-meal insulin doses based on the total amount of CHO in the meal
— Test BG 30 minutes prior to a meal and adjust insulin accordingly
— Use a carbohydrate-to-insulin ratio - Fixed daily insulin dose
— Emphasize consistency in day-to-day meal CHO content
What are the macronutrient needs with T1DM?
-PRO — RDA: .8-1.0 g/kg;
- Kcals =
1. Sedentary: 25 kcal/kg
2. Normal: 30 kcal/kg
3. Undernourished or active: 45-50 kcal/kg
-Determine fat and CHO intake based on lipids and weight levels
What are the assessment consideration for T1DM?
- Relevant medical history
- Present health status
- Diabetes knowledge and skills
- Cultural influences
- Health beliefs/attitudes
- Support systems
- Readiness to change
- Barriers to learning
- Socioeconomic factors
- Client goals
- Level of glycemic control
- Insulin regimen
- Usual schedule
- Usual food intake = Meal times, composition, and macronutrient content)
What are the T1DM insulin medical treatments?
- Syringes or pens
- Syringes disposable
- Pens refillable 150-300 U insulin - Insulin pumps
- Battery powered size of pager
- Duplicates endogenous insulin best
What are the T1DM goals fro preprandial glucose?
Normal = <100mg/dL GOAL = 70-130 mg/dL;
What are the T1DM goals fro postprandial glucose?
Normal = < 140mg/dL; GOAL = <180mg/dL
What are the T1Dm goals for AIC?
Normal = 4-6;
GOAL = <7
What is the care plan documentation for T1DM?
- Physician referral for MNT
- Patient name (ID information)
- Date of visit/ time spent
- Reason for visit
- Current & past Dx
- Pertinent test/lab results
- Current medications
- Others present during visit
Nutrition Assessment for T1DM
- nutrition hx, medical hx, social hx
- assessed needs for macronutrients/ micronutrients
- labs/biochemical;
- nutrition focused physical;
- for follow up: achievement of goals (behavioral and clinical);
Nutrition Diagnosis and Intervention for T1DM
-Nutrition Diagnosis (PES)
-Nutrition Interventions
— Nutrition RX always first
— Food and meal planning
— Short and long term goals (clinical/ behavioral)
— Educational topics covered/ materials provided
Monitoring and Evaluation for T1DM
- Impression of patient acceptance and understanding
- Anticipated compliance
- Additional skills or information needed
- Recommendations and plans for ongoing care
Evaluation for T1DM
- Weight/Height (q visit)
- HgbA1c (Initially, 4-6 wks after changes, then 3-4 times a year)
- Lipid profile (initially, 6 months after lifestyle changes, then annually)
- Blood pressure (follow up visit)
- Self Monitoring (follow up visit) = Food record, BG and medication records (changes in meds?), Activity/exercise patterns
- Specific behavior changes per plan (q visit) Schedule changes (follow up visit)
What are the goals for Gestational DM?
- PRE-prandial </= 120
- When insulin is used, post prandial SMBG is preferred as these values directly R/T rates of macrosomia, neonatal hypoglycemia and C-section.
What is Diabetic Ketoacidosis (DKA)?
- Inadequate insulin = gluconeogenesis
- Lipolysis stimulated by counter regulatory hormonesà ketones
- Metabolic acidosis
- Osmotic diuresis occurs = Dehydration and electrolyte imbalances
- Hyperglycemia
DKA affects….
–
Labs for DKA…
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Treatment and Prevention for DKA…
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What are the 3 steps in CHO counting for pumps?
- Identify the anticipated CHO intake at meals and snacks
- Accurately determine the CHO intake based on grams of CHO or CHO choices or a combination of grams and choices
- Administer a rapid-acting or short-acting pre-meal insulin dose based on a pre-determined carbohydrate-to-insulin ratio
What are the insulin requirements for T1DM?
- Type 1DM: (normal weight) 0.5-1.0 units insulin /kg body weight /day
- 40-50% of total insulin for basal
- Remainder (rapid acting insulin)- divided for meals
- Can be divided proportionately to CHO content
- Or divided as 1-1.5 units of insulin/ 10-15g CHO consumed
What are the insulin requirements for T2DM?
- Type 2 DM: 0.5-1.2 units insulin /kg body weight/ day
- Larger dose may be needed (> 1.5units/kg BW) initially due to insulin resistance;
What can alter dosing of insulin?
- Larger amount often needed to cover breakfast due to effect of morning counter regulatory hormones;
- Smaller dose may be used when insulin combined with oral meds.
How do you determine total daily insulin requirements?
- Total daily insulin requirement:[ wt (lbs.) divided by 4] or [0.55 X wt (kg)]= units insulin;
- Dosage divided: 50% basal; 50% rapid with meals;
- T1DM w/ trace to sm. Amt. ketones or T2DM w/ BMI</= 27: 0.2-0.5 units/kg
How much of daily insulin is BASAL?
*Basal: 50% of Total Daily Insulin
-Example: If TDI = 50 units
— 50% of 50 units = 25 units of long acting (or rapid if pump)
— 50% of 50 units = 25 units for bolus (then divided into 3 meals à 8 units/meal)
How much of daily insulin is BOLUS?
(Bolus insulin dose may be adjusted for individual meals based on glucose response)
What are CHO to Insulin ratios
- Based on matching the CHO content of food to be eaten with rapid-acting or short-acting insulin
- Each person can have different ratios
- CHO: insulin can vary from meal to meal
- C:I allows pt to figure out how many units of insulin would be needed to cover a meal
- Could also be used to decrease insulin if decreasing CHO intake in that meal or snack
What are the general guidelines for insulin adjustments?
- Limit changes in insulin up or down to 1 or 2 units of one insulin (basal or bolus)
— No more than once in 3-4 days - Adjust only the insulin that affects the abnormal bg value
— ↑ insulin if bg is too high
— ↓ insulin if bg is too low
What is Gestational DM?
- Pathophysiology - similar to type 2 DM
- Decreased islet cell function (decreased insulin secretory response)
- Peripheral insulin resistance (decreased insulin sensitivity)
What causes GDM?
- Hyperglycemia of GDM due to inability to compensate (with insulin) for:
1. Increased nutrient needs of gestation
2. Increased adiposity of pregnancy
3. Increased secretion of other hormones - *Increased maternal blood glucose causes increased fetal insulin production
What hormones can lead to GDM?
- Human placental lactogen
- Prolactin
- Cortisol
- Progesterone
What are the clinical manifestations of GDM for the MOTHER?
Increased risk for:
- HTN (preeclampsia)
- Polyhydramnios
- Difficult birth
- Pre term delivery < 38 weeks
- Increased rate of C-sections
What are the potential fetal/neonatal complications of GDM?
- Macrosomia (infant birth weight >90th%ile)
- Hypoglycemia at birth
- Respiratory distress syndrome
- Hypocalcemia
- Hyperbilirubinemia
What is the protocol for testing for GDM?
- Usual testing at 24-28 weeks gestation unless low risk
- High risk → Most people are tested these days
What individuals are considered LOW risk for GDM?
- < 25 years old
- Normal BW
- No family hx of Diabetes
- No hx of abnormal glucose tolerance
- Not of ethnic race with prevalence of DM
How is GDM tested?
- 50gm oral glucose challenge
- Results of > 135-140mg/dl @ 1 hr. = testing with 100gm. oral glucose load
What is the diagnostic criteria for GDM?
- Diagnosis of GDM: 2 plasma glucose values exceeding:
- 95mg/dl (fasting)
- 180mg/dl (1 hr.)
- 155mg/dl (2 hr.)
- 140 mg/dl (3hr.)
What are the treatment goals for GDM?
- Achieve and maintain normoglycemia
- Optimal nutrition for mother and fetus
- Adequate energy to promote appropriate weight gain
- Absence of ketosis
How are maternal energy needs assessed with GDM?
INDIRECT evaluation with:
- Appetite/ intake
- Physical activity
- Blood glucose/ ketones
- Changes in weight
What are the guidelines for weight gain with GDM?
SAME as normal pregnancy:
- Normal BW: 25 – 35#
- Underweight: 28 – 40#
- Overweight: 15 – 25#
-Rate of weight gain = 0-2# during first trimester → Little fetal growth and maternal GI discomfort
— or approx. 2/3 # per week
What are the recommendations for weight loss during pregnancy?
NOT generally recommended (risk of ketosis) - Obese patient with GDM: — May decrease kcal. By 30% — To decrease rate of weight gain — Monitor for ketonemia
What are the benefits of exercise and GDM?
- Can decrease peripheral insulin resistance
- Can help control fasting and post-prandial glucose
What are the guidelines for CHO with GDM?
- Controlled CHO, but minimum of 175gm/day
- Limit CHO at breakfast (10-30gm): increased levels of cortisol/ growth hormone early am
- Lunch and dinner (3-4 CHO servings)
- Snacks (1-2 CHO servings)
- Include HS and possibly 2am snack (prevent ketosis)
What are the guidelines for PRO with GDM?
- 0.8gm/kg DBW + 25gm/day
- May include 2-3oz. Protein mid am to decrease hunger / promote compliance
What are the guidelines for fat with GDM?
Fat: per energy needs and CV risk
What are the guidelines for multivitamins with GDM?
MVI: suggest taking @ bedtime if patient c/o nausea
What is the meal plan for GDM?
- 3 meals and 2-4 snacks
- Consistent CHO per previous guidelines:
- CHO counting with exchanges
-Adjust per:
o SMBG,
oChanges in appetite
oChanges in intake
What medications are prescribed with GDM?
- Insulin (with insulin Rx, SMBG recommended post prandially to decrease risk for macrosomia)
- Some clinics considering metformin
What should be monitored with GDM?
- Weight
- Appetite/ Intake
- Fasting ketones
- SMBG
What are the Blood Glucose Goals with GDM?
-pre prandial: </= 120
What are the guidelines for starting insulin with GDM?
- FPG > 105
- 1hr PPG> 155
- 2hr PPG> 130
- To reduce fetal mortality
What is Pregnancy Induced HTN (PIH)?
- Gestational HTN vs Preeclampsia
- Gestational HTN = BP> 140/90 and no proteinuria
- Preeclampsia= BP > 140/90 with urinary protein of 300mg/ 24 hrs.
- Severe preeclampsia= BP >160/110 with 5gm protein/ 24 hrs.