Pediatric Type 1 Diabetes Mellitus Chelsea Stegman and Kelly Davis Test your Knowledge Type 1 Diabetes Mellitus is a/an _____ disease. a. Thyroid b. Bacterial c. Viral d. Autoimmune Test your Knowledge Type 1 Diabetes is most commonly diagnosed amongst: A. Overweight adults B. Children and adolescents C. Overweight children and adolescents Type 1 Diabetes • • • • Most often diagnosed in children, adolescents, or young adults. Causes of type 1 diabetes are complex and still not completely understood but type 1 diabetes can not be prevented. People with type 1 diabetes are thought to have an inherited or genetic predisposition to developing the disease The disease process is believed to be stimulated by an environmental trigger such as a virus, toxin, drug or chemical Type 1 Diabetes: Etiology • • T1DM is characterized by the autoimmune destruction of beta cells. Patients with type 1 diabetes produce little or no insulin via beta cells due to this destruction. o Insulin is a hormone produced in the pancreas by beta cells. o Insulin is needed to move blood sugar, glucose, into the cells where it is stored and later used for energy. o Without using insulin, glucose builds up in the bloodstream instead of going into the cells. o The body is unable to use this glucose for energy, which leads to the symptoms of type 1 diabetes. Symptoms: • • • • • • • • • • Extreme thirst Frequent urination Drowsiness Sugar in urine Sudden vision changes Increased appetite Sudden weight loss Fruity, sweet, or wine-like odor on breath Heavy, labored breathing Stupor and unconsciousness Diabetic Ketoacidosis • • • • Severe Hyperglycemia Most commonly found in patients with T1DM Individuals experiencing DKA experience weight loss due to decreased blood volume (hypovolemia) and muscle metabolism Precipitating factors include: o Lack of blood glucose self monitoring o Severe illness/infection o Increased insulin needs with growth spurts o Inappropriately stored insulin Diagnostic Measures: • • • Symptoms of diabetes plus casual plasma glucose concentration greater than/ equal to 200 mg/dL Fasting plasma glucose greater than/ equal to 126 mg/dL 2- hour post-prandial glucose greater than/ equal to 200 mg/dL during an oral glucose tolerance test (OGTT) Diagnostic Measures: T1DM • • • • • Islet Cell Cytoplasmic Autoantibodies (ICA antibodies) Glutamic Acid Decarboxylase Autoantibodies (GADA antibodies) Insulin Autoantibodies (IAA) If an autoimmune disease is present in the family, their first-degree family members may be at risk for developing the same or different autoimmune disease. Generally, T1DM is a childhood onset disease Patient: Rachel Roberts • • • • • • • • • • 12 year old female 7th grade Height: 5’ 60 in Weight: 82 lbs 70 kg BMI: 16.0 kg/m2 IBW: 89 lbs Upon hospital admittance: acute-onset hyperglycemia Serum glucose 724 mg/dL Chief Complaints: Increased thirst, increased urination, slight weight loss Diagnosis: Type 1 Diabetes Mellitus Abnormal Lab Values: Rachel’s Diagnosis ● Rachel was diagnosed with T1DM due to: ○ Her symptoms of unexplained weight loss, polyuria, and polydipsia. ○ A serum glucose level of 724 mg/dL upon ER assessment (above 200). ○ The presence of B-cell destroying autoantibodies ICA, GADA, and IAA. ○ Low C-peptide levels, indicative of low insulin secretion. ○ There is a history of autoimmune diseases in her family. Her mother hyperthyroidism and her sister has Celiac’s disease. Rachel’s Nutritional Diagnosis ● PES Statement 1: Altered nutrition-related lab values (NC 2.2) related to Type 1 Diabetes Mellitus as evidenced by a blood glucose concentration of greater than 110 mg/dL. ● PES Statement 2: Unintended weight loss (3.2) related to inadequate insulin due to Type 1 Diabetes as evidenced by a reported weight loss of 8 lbs. Pharmacological Treatment ● A physician prescribes a type of insulin, insulin dosage, and insulin regimen per individualized case. ● Rachel is prescribed a combination of Apidra prior to meals with glargine given in the a.m. and p.m. Both are administered via insulin injection ● Prescribed discharge dosages: 7 u glargine with Apidra prior to each snack, which is a 1:15 insulin: carbohydrate ratio. Justification of Prescription ● Injection is used because oral pills are only used with Type II Diabetes. ● The lower dosage of insulin is due to the temporary “honeymoon” phase. ○ honeymoon phase: relative self-sufficient insulin production after T1DM is clinically diagnosed and insulin treatment is initiated. ● Glargine is given in the a.m. and p.m. for maintenance of the “dawn phenomenon” that Rachel is experiencing. ○ dawn phenomenon: consistently high blood glucose levels in the morning. This is a result of the lack of insulin injections while the individual is sleeping. Types of Insulin ● Glargine ○ Onset of action: 2-4 hours. ○ Peak of action: peakless. ○ Duration of action: 20-24 hours. ● Apidra ○ Onset of action: 5-15 minutes. ○ Peak of action: 30-90 minutes. ○ Duration of action: 3-5 hours. Treatment: MNT ● Daily kcals: 2400-2500 ○ 15-20% of kcals from protein ○ 25-35% kcals from fat ○ 50-60% kcal from carbohydrates. Insulin should be taken accordingly to eliminate unsafe postprandial glucose responses. ● Insulin Carbohydrate Ratio (ICR)- 1:15 ○ Patient and parents are educated on the importance of carbohydrate counting and are given literature on carbohydrate counting. Treatment: MNT ● Rachel’s active lifestyle should also be taken into account [she is a soccer player] ○ Blood glucose levels should be monitored before and after exercise to recognize hypoglycemic or hyperglycemic conditions. ○ She should consume an additional 15 g of carbohydrates for every hour of moderate physical activity and 30 g for every hour of strenuous activity. ○ She will not have a decrease insulin dosage levels prior to exercise because of the regularity of her exercise regimen. Prognosis ● T1DM cannot be cured, yet it can be managed. ● Prescribed insulin doses will most likely increase based on the transitory nature of the current “honeymoon” phase. ● Self monitoring of blood glucose should be done at home. ○ Purpose: to identify patterns and the ways in which food, exercise, and other factors affect glycemic control. ○ Method: a drop of blood obtained via a finger prick is applied to a chemically treated reagent strip. ○ This is recommended at least three times daily because hypoglycemia and hyperglycemia are dangerous conditions. Rachel and her family should be cognoscente of symptoms of hypoglycemia: rapid heartbeat, weakness, shakiness, perspiration, and hunger. Prognosis Continued ● Rachel should attend routine follow-up visits with her physician and dietitian to analyze laboratory values, diet logs, and adherence to glycemic goals. ● Microvascular and macrovascular complications generally occur 15-20 years after the onset of T1DM. ● She is also at risk for nephropathy, retinopathy, and nervous system damage. ● The incidence is reduced through intensive treatment and strict adherence to insulin regimens to prevent hypoglycemia or hyperglycemia. Resources (2004). Autoimmune Disorders. Emory University School of Medicine. (2013). Calculating Insulin Dose. Retrieved November 17th, 2013 from University of California Diabetes Education Online website: http://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insulinrx/calculating-insulin-dose/ (2013). Can Diabetes Pills Help Me. Retrieved 7 November 2013 from http://www.diabetes.org/living-with-diabetes/treatmentand-care/medication/oral-medications/can-diabetes-pills-help-me.html Bolli, G.B., Brunetti, P., De Feo, P., Fanelli, C., Perriello, G., Santeusanio, F., Torlone, E. (1991). The Dawn Phenomenon in Type 1 (insulin-dependent) diabetes mellitus: magnitude, frequency, variability, and dependency on glucose counterregulation Coppieters, K. T., Van Belle T.L., & Von Herrath M. G. (2011). Type 1 Diabetes: Etiology, Immunology, and Therapeutic Strategies. American Physiological Society. 91: 79-118 Nelms, Marcia, Kathryn P. Sucher, Karen Lacey, and Sara L. Roth. Nutrition Therapy and Pathophysiology. Belmont, CA: Wadsworth, 2011. Print. Strayer, D., & Schub, T. (2013). Diabetes Mellitus, Type 1.