Case Study: AR Type 2 Diabetes Mellitus and Pediatric Obesity

ND 420: Medical Nutrition Therapy 2

Marywood University
Sydnie Leroy
October 31, 2016

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Patient Description:
AR is a 9-year-old female who is obese and was recently diagnosed with Type 2 Diabetes
Mellitus during her school physical exam. She is in the third grade and is 52 tall, and weighs
140 pounds. This means that her BMI (or Body Mass Index) is 36.4 (Nelms & Roth, 2014). A
patient is considered obese at a BMI of 30 or above, but for children they are considered obese if
their BMI for age is greater than the 95th percentile on the CDC growth charts (Gulati, Kaplan, &
Daniels, 2012). According to the CDC growth charts for BMI for age for females ages 2 to 20
years (cdc.gov), she is above the 95th percentile for BMI for age.
AR is of African-American ethnicity. She lives at home with her mother, her
grandparents, and 3 siblings (sisters ages 14 and 12 and brother age 10). Her only occupation is
as a full-time student. She does not smoke or consume any alcohol. AR is an African Methodist
Episcopal and is an English speaker (only) (Nelms & Roth, 2014).
AR is not currently on any medications and has had no previous surgeries. Her medical
history does indicate that she had frequent ear infections as an infant and toddler. She was a fullterm infant with a birth weight of 10 pounds and 4 oz, and a length of 20 (Nelms & Roth,
2014). According to the CDC growth charts, this would indicate that she was between the 75th
and 90th percentile for height and above the 98th percentile for weight at birth (cdc.gov). The
medical history also indicates that her mother had gestational diabetes when pregnant with AR.
In terms of additional family history, the patients record indicates that her mother and
her grandmother both have type 2 diabetes Mellitus (T2DM). It is also noted that her grandfather
has high cholesterol and hypertension (Nelms & Roth, 2014).
Her physical examination indicated that her heart rate and rhythm are regular. ARs ears
and nose are clear, her head is within normal limits, and her eyes are PERRLA which means

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Pupils are equal, round, and reactive to light and accommodation or are otherwise considered
to be normal. ARs throat was found to have dry mucous membranes, but there are no exudates
or lesions (Nelms & Roth, 2014).
The rest of ARs physical exam also seemed to be normal. She was alert and oriented, her
skin was warm and dry, and her respirations were also found to be within normal limits. Her
pulse was taken and was 72, and her peripheral pulse was found to be 4+ bilaterally, meaning
that she is not having any vascular issues and her pulse in her extremities is considered to be
bounding. Her Blood Pressure is 100/ 59, which is slightly low, but not concerning. Her bowel
sounds were classified as x4, which indicates there are bowel sounds in all four quadrants and
she has active bowels. Finally, ARs body temperature was taken and was 98.6, which is perfect
(Nelms & Roth, 2014).
Disease Information:
AR actually has compounding diseases of both obesity and Type 2 Diabetes, which
frequently are comorbidities. According to data collected by the NHANES surveys in both 2005
and 2008, the chances of obesity in women were increased by having a lower income, and those
of non-Hispanic black race (which our patient is) (Nelms, 2016). Obesity causes a number of
adverse health effects. One of the most severe is that an estimated 300,000 deaths per year may
be associated with obesity and even a moderate excess (10-20 pounds) in weight can increase
your chances of death, with the risks increasing steadily along with the weight. Individuals who
are obese have a 50%-100% increased risk of premature death compared to those individuals
who have a healthy BMI (Nelms, 2016). Obesity also leads to an increase in the risks for heart
disease, with high blood pressure (hypertension) found to be twice as frequent in patients who
are obese. There is also an association with elevated serum triglycerides and decreased serum

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HDL- cholesterol (commonly referred to as good cholesterol), both of which are risk markers
for cardiovascular disease (Nelms, 2016). Obesity also increases a patients risk of cancers
including endometrial, colon, gallbladder, prostate, kidney, and postmenopausal breast cancers
(Nelms, 2016). In obese patients there is also a higher prevalence of breathing problems,
specifically sleep apnea and asthma (Nelms, 2016). Arthritis is also associated with obesity,
because for every 2-pound increase in weight gain, the risk of developing arthrosis increases by
9-13% (Nelms, 2016). Obesity is also associated with a number of reproductive complications,
particularly in females, and babies born to an obese mother have higher chances of birth defects,
delivery complications, obesity later in life, and higher risk for Type 2 Diabetes (Barlow, 2007).
Finally, obesity increases a patients chances of diabetes significantly. Over 80% of
people who are diagnosed with Type 2 diabetes are obese. Similarly, a weight gain of 11-18
pounds will increase a patients chances of developing Type 2 diabetes by 2 times, compared to
individuals who do not gain weight (Nelms, 2016). Clearly, there is an association between
obesity and Type 2 diabetes, which is consistent with the findings in AR.
The simple explanation is that obesity develops when a persons energy intake exceeds
their energy expenditure, over a period of time. However, it is actually a complex endocrine and
metabolic combination of diseases, which makes the treatment and management of obesity very
difficult. Obesity is also greatly influenced by a genetic factor, although this is difficult to tease
out from the compounding effects of environmental factors. For example, twin studies show that
50%-90% of a persons BMI is genetic, but in most of these studies the twins are also being
raised in the same exact environment. It is nearly impossible to identify the exact specific causes
of obesity due to all of the interactions with the physical, social, cultural, and economic
environmental factors (Nelms, 2016).

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Most concerning with our patient, AR (and almost certainly related to the diagnosis of
obesity), is the fact that she has been diagnosed with Type 2 diabetes (T2DM) at such a young
age. Approximately 90-95% of all of the cases of diabetes diagnosed in the United States are
Type 2 (as opposed to Type 1) and while this disease was historically diagnosed in older adults, it
is being seen in children and adolescents with significantly increasing frequency. Children now
account for up to 45% of all cases of T2DM, while they used to account for only approximately
3% (DAdamo & Caprio, 2011). The increasing frequency of T2DM in children is particularly
concerning because the most common diabetes-related complications that develop over time
impair quality of life and/ or reduce the overall life span (Caprio, 2012). When this disease
previously was only seen in adults, the complications of diabetes would develop in mid to later
life but with the increasing incidence in children, it is even more important to manage the
symptoms to minimize these complications to try to keep a high quality of life for these patients
as long as possible.
Factors that increase the risk of T2DM include overweight/obesity, sex (with females at a
higher risk), family history, history of gestational diabetes, impaired glucose metabolism, and
physical inactivity, most of which AR presents with. Similarly, the rates are increased in nonHispanic blacks compared to non-Hispanic whites (Nelms, 2016).
Type 2 Diabetes Mellitus develops from a combination of insulin resistance and abnormal
insulin secretion. In T2DM, the patient still creates insulin, but the cells become insulin resistant,
meaning that essentially the cells cannot uptake the glucose from the blood stream. The body
signals the pancreas to produce even more insulin, which it does. However, over time the
pancreas is unable to maintain these high levels of production and this diminish in production of

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insulin is considered to be the onset of T2DM (although the actual insulin resistance typically
develops as early as a few years before this point) (Nelms, 2016).
Laboratory Findings:
ARs lab results are pretty characteristic of a patient with T2DM. Below are a few of the
important lab values from her full report.
REF RANGE

8/3 0800

8/4 0940

CHEMISTRY
Sodium
136-147
137
Potassium
3.5-5.5
4.1
Glucose
70-110
171
155
Calcium
9-11
9.2
Protein (total)
6-8
6.9
Albumin
3.5-5
4.2
Prealbumin
16-35
22
cholesterol
<170
210
Triglycerides
<150
175
HbA1c
3.9-5.2
6.9
EAG
__
151
c-peptide
.51-2.72
2.75
Urinalysis
Protein
negative
trace
glucose
negative
positive
Prot Chk
negative
positive
ARs hematology was all found to be in the normal ranges, but her Chemistry and
Urinalysis show a few laboratory values outside the expected ranges. Her blood sodium and
potassium are within the normal ranges which could indicate that she is in electrolyte balance or
could be indicative of being dehydrated, which based on her dietary recall should be something
to monitor (see below). ARs blood glucose levels were very high in both tests, indicating that
she has a high blood sugar at the moment, which may not necessarily be indicative of having
diabetes; however, her HbA1c levels were also high, which is indicative of her blood glucose
status over the past approximately three months (Kapadia, 2013). We can see from this elevated
value that this is a chronic problem, not a one-time occurrence.

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Her high blood triglycerides are also characteristic of a patient with diabetes, because the
body releases its own fat stores into the blood stream in order to try and feed the cells, due to the
fact that they are now unable to uptake the glucose from the blood stream (Kapadia, 2013). This
is a lab value that is important to monitor in a diabetic patient.
Another important lab value in the diagnosis of T2DM is the C-peptide (Nelms, 2016).
This is essentially a measure of insulin production, so when this value is out of the accepted
range, it indicates an issue with insulin production, characteristic of diabetes (both Type 1 and
Type 2).
Finally, the urinalysis showed a few lab values outside an accepted range. Specifically,
the protein and glucose. The glucose is found in the urine when it reaches a high enough level in
the blood stream that the kidneys can no longer reabsorb the glucose, so it gets excreted in the
urine. Protein in the urine is also a characteristic sign of diabetes and a number of other diseases.

Dietary Intake
ARs 24-hour dietary recall is highly concerning. It reveals that she consumes very few
fruits and vegetables, has a very high intake of artificially sweetened beverages, and consumes a
lot of sugary snacks essentially daily, among other things. According to her diet analysis, she is
consuming approximately 4300kcals per day, when her Daily Recommended Intake (DRI) is
only 1750 kcals per day. This is an excess of about 2550 kilocalories per day, meaning that she
consumes about 250% of her overall recommended kilocalories.
ARs protein intake is approximately 107g, but she only needs to be consuming
approximately 60g total. This puts her overall protein intake at about 177% of her recommended

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protein consumption. Even more concerning, though, is ARs consumption of both carbohydrates
and fats. Her carbohydrate consumption is about 612g daily (when her recommended intake is
between 191 and 276g), which comes to approximately 222% of her recommended carbohydrate
intake. Her fat consumption is approximately 170g, which is 258% of her total recommended
intake of fat (between 37g and 66g). Looking at her fat intake more closely, her saturated fat
consumption is almost 50g from saturated fat, which is 285% of her recommended fat intake
from saturated fats. Her saturated fats should be less than 17g, meaning that she needs to
decrease her intake of this by over 30g. Finally, another major concern is the fact that her sodium
intake is approximately 5400mg per day, which is 3.6 times higher than the recommended intake
of only 1500 mg per day.
Another concern with ARs diet is that while she is consuming more than double her
recommended intake in calories per day, she is still falling short of meeting her recommended
daily intakes of certain vitamins and minerals. She is only consuming about 85% of the amount
of fiber that she should be, at 22g as opposed to the recommended 26g. She is also falling short
of meeting her recommendations for Vitamin D (only getting 47%), Calcium (81% of
recommended) and Potassium (also 80% of recommended. Finally, she is only consuming about
65% of the amount of water that she should be drinking and this puts her at serious risk for
dehydration and a number of other serious concerns. However, in contrast to deficiency, she is
also at risk of developing a toxicity of a number of vitamins and minerals, because she is
consuming 300-400% of the DRI for a number of these nutrients.
This patient poses a unique challenge in their diet intervention die to the fact that she is a
9-year-old girl who more than likely does not cook for herself or do the grocery shopping in her
household. Therefore, it will be imperative to plan an intervention for the entire family,

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particularly whoever is responsible for providing and cooking the food in ARs family. Based on
the fact that both her mother and grandmother (both of whom live with AR) also have T2DM,
one might assume that they have had counseling before and are familiar with how to follow a
diabetic diet, but that may not be the case.
The very first thing that I would want to recommend for this patient is to stop drinking
the sugar sweetened beverages and colas. Throughout the day, her dietary recall showed that she
consumed about 5 glasses of fruit punch, 1 soda, and 1 sweetened ice tea. This accounts for
about 600 kcals a day and they provide absolutely no nutritional benefit. Also, these types of
drinks are particularly dangerous for diabetics because they raise blood sugar extremely quickly.
The next thing that I would try to do with this patient is reduce the overall amount of
kilocalories that she is consuming. While it is difficult with any patient to reduce intake, it is
challenging in children due to the fact that they are still growing, and we need to ensure adequate
calories for growth and development. I would counsel AR to understand that she is consuming
too much throughout the day, and work with the family to try to limit some of her snacking.
In addition to reducing the overall calories, I would recommend replacing her snacks with
healthier options. Throughout the day AR snacked on toast with butter and jam, chocolate chip
cookies, 2 bags of Cheetos, 2 popsicles, potato chips, and pizza rolls. These foods are all
convenience foods that are high in calories, simple sugars, saturated fats, and devoid of most
nutrients. If AR could switch some of these snacks for healthier alternatives like fruit, vegetables,
nuts, trail mix, granola bars, or vegetables, this could really go a long way towards improving her
overall diet.
Nutrition Care Process:

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One PES statement that might be relevant to this patient is Excessive oral intake related
to overeating as evidenced by dietary recall showing overall calorie consumption of 250%
recommended calories. The intervention for this would be a decreased energy diet, in order for
the patient to get closer to consuming the appropriate number of kilocalories per day. The goal of
this would be to consume less calories, and indirectly an effect of this goal may include weight
loss or in the case of a growing child, weight maintenance while she continues to grow.
Another PES statement that may be relevant to AR is Inconsistent carbohydrate intake
related to poor diet choices as evidenced by consumption of 222% more carbohydrates than
recommended. The intervention could include a plan to develop a consistent carbohydrate diet
and reduce the overall amount of carbohydrates in her diet. The goal of this specific intervention
would be to lower ARs carbohydrate intake to an acceptable amount (within the recommended
grams of intake) as well as space them throughout the day to create a consistent carbohydrate
diet for her (Hoelscher, Kirk, Ritchie, Cunningham-Sabo, 2013).
A third PES statement that would be appropriate for AR is Lack of Nutrition related
knowledge related to diabetes as evidenced by poor food choices as reported in the dietary
recall. The intervention for this would be nutrition education, and in this case it would be
imperative to involve the entire family. Because AR is a child, she is not responsible for most of
her dietary choices, and may have little say in the matter. If the entire family can understand the
importance of helping AR manage her diabetes, they will be a greater support network for her.
The goals of this would be to increase her knowledge. One way that we may test this intervention
is by asking her to describe appropriate snacks or explain the idea of consistent carbohydrates,
etc., after the intervention has taken place.
Conclusion:

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Overall, ARs case is concerning. The very young age of this patient is alarming for a
health care professional. The complications of both obesity and T2DM can be very painful,
reduce the quality of life significantly, and lead to premature death. Having to explain these
concepts to a 9-year-old is incredibly challenging, which is why it is imperative to include the
entire family in the nutrition intervention. The increasing prevalence of T2DM diagnosis in
children is something that should be addressed in a preventative campaign in order to slow the
progression of this horrible disease in children.

References
(2010). Retrieved October 31, 2016, from http://www.cdc.gov/growthcharts/cdc_charts.htm
Barlow, S.E., Experiment recommendations regarding the prevention, assessment, and treatment
of child and adolescent obesity research summit report. Pediatrics. 2007; 120 (Suppl 4):
S164-S192
Caprio, S. Development of type 2 diabetes mellitus in the obese adolescent: a growing challenge.
Endocr Pract. 2012; 18 (5): 791-795.
DAdamo, E., & Caprio, S. Type 2 diabetes in youth: epidemiology and pathophysiology.

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Diabetes Care. 2011; 34: 161-165
Gulati, AK, Kaplan, DW, & Daniels, Sr. Clinical Tracking of severely obese children: a new
growth chart. Pediatrics. 2012; 130 (6):1136-40
Hoelscher, D.M., Kirk, S., Ritchie, L., Cunningham-Sabo, L., Academy Positions Committee.
Position of the Academy of Nutrition and Dietetics: interventions for the treatment and
prevention of pediatric obesity. Journal of Nutrition & Dietetics. 2013; 113: 135-94
Kapadia, C. Are the ADA hemoglobin A(1c) criteria relevant for the diagnosis of type 2 diabetes
in youth? Current Diabetes. 2013; 13 (1) 51-55.
Nelms, M. & Roth, S. Medical Nutrition Therapy: A Case Study Approach. 2014
Nelms, M., Sucher, K., & Lacey, K. Nutrition Therapy and Pathophysiology. 2016.

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