Nutritional Management

of Type 1 Diabetes:
Counseling and Education
Interventions
Nicole Castro
Queens College Dietetic Internship
March 17, 2019
 Chronic Disease Description
• Type 1 Diabetes Mellitus
• Pathophysiology
• Insulin deficiency due to destruction of pancreatic β cells
• Over time, the β cells are completely destroyed resulting in cells unable to use glucose
for energy
• Destruction of β cells is still being researched, but there seem to be triggers from genes,
autoantigens and environmental factors1
 Chronic Disease Description
• Etiology
• Results from an autoimmune disorder  decline in β cell mass, especially in genetically
susceptible individuals3
• The immune system attacks the insulin-producing beta cells in the pancreas
• Primary gene for type 1 diabetes (DM) is in the human leukocyte antigen (HLA) region
on chromosome 6
• Polymorphisms or variations in the HLA complex lead to 40-50% genetic risk for
developing type 1 DM4
4
 Chronic Disease Description
• Etiology
• Autoantigens: glutamic acid decarboxylase, insulin, proinsulin, insulinoma-associated
protein, zinc transporter ZnT8 and other proteins in the beta cells released during
normal beta cell injury3
• T cell-mediated immune response is activated beta cell destruction
• Viruses: coxsackievirus, rubella virus, cytomegalovirus, Epstein-Barr virus,
retroviruses all linked to onset of type 1 DM3
• May infect or destroy beta cells; indirectly expose autoantigens that activate lymphocytes that
mimic autoantigens that stimulate an immune response
 Chronic Disease Description
• Etiology
• Diet: dairy products in infancy (cow’s milk & milk protein beta casein), high nitrates in
drinking water, low vitamin D  linked to DM1
• Infant feeding practices-length of breastfeeding
• Exposure to gluten/cereals earlier than 4 months or later than 7 months  increased
islet cell autoantibody production3
 Chronic Disease Description
• Epidemiology
• 5-10% of all diagnosed cases in diabetes1
• Most frequent in children/adolescents; however, there are more adults/elderly being
diagnosed as well
• Type 1 diabetes among gender distributed equally1
 Clinical Manifestations
• Signs and Symptoms
• 60-80% of beta cells are destroyed by the time patient experiences symptoms
• Glycosuria
• Polyuria
• Polydipsia
• Polyphagia
• Elevated blood sugars
• Hypovolemia & Muscle Catabolism  weight loss in patients in ketoacidosis1
 Criteria for Diagnosis of Diabetes Mellitus

• A1C >= 6.5% using standardized laboratory measures3

• Fasting plasma glucose >= 126 mg/dl
• Symptoms of diabetes (polyuria, polydipsia & unexplained weight loss) plus random plasma
glucose concentration >= 200 mg/dl
• 2-hour post-prandial glucose >= 200 mg/dl during and oral glucose tolerance test (OGTT) 3
 Case Presentation
• Visited Diabetes Clinic since Sept. 2018 for diabetes education
• Initially thought to have type 2 DM; then found patient actually has type 1 DM
• History of type 1 DM for ~26 years
• Currently on insulin regimen – interested in insulin pump therapy
 Assessment: Client History
• Client History (CH-1)7:
• Personal (CH-1.1):
• Medical/Health (CH-2.1): hx of type 1 DM for ~26 years, hyperlipidemia,
hypertension, and chronic back pain
• Family: Divorced; 6 children; 1 grandchild; lives with daughter was patient’s home
attendant before; no family hx of DM
• Social History (CH-3.1): Needs assistance cooking/shopping; transports in taxi/bus;
receives Social Security Disability (SSD)
Assessment: Food/Nutrition-Related History
• Food/Nutrition-Related History (FH-1) 8
• Food and Nutrient intake (FH-1.2): Usually 3 meals; no snacks in between meals/no
bedtime snack
• 24-hour Dietary Recall (FH-1.2.2.2)
• Breakfast (~9-11 a.m.): 2 frozen waffles with margarine; no syrup; 1 cup Lipton tea with
milk & 2 Splenda
• Lunch (3 p.m.): Rice with mixed veggies and shrimp; water
• Dinner (7-8 p.m.): Mixed veggies with chicken and potato; water
Medications (FH-3.1) Mechanism of Action9 Food-Drug Interaction9
Novolog Fast-acting insulin; works ~15 min after injection; Avoid/limit alcohol  may affect blood glucose
peaks in ~1 hr.; keeps working 2-4 hrs. levels

Gabapentin 300 mg 1x/day To treat epilepsy; to treat nerve pain Avoid alcohol; may interact with antacids; may cause
drowsiness

Duloxetine (Cymbalta) 60 mg 1x/day To treat pain due to nerve damage-diabetic Avoid alcohol; limit caffeine (increases blood levels
neuropathy and effects of the drug)

Atorvastatin (Lipitor) 40 mg 1x/day HMG-CoA reductase inhibitor- blocks production of Avoid grapefruit
cholesterol

Hydralazine 25 mg TID To lower blood pressure Possibility of Vitamin B6 deficiency

Carvedilol 25 mg BID Beta-blocker to treat heart failure and HTN Avoid alcohol; MVI may decrease effect of drug

Ethacrynic acid 50 mg 1x/day Diuretic (water pill) helps get rid of excess water Electrolyte loss

Sodium bicarbonate 650 mg BID Reduces stomach acid-treats heartburn & indigestion May decrease effect of iron supplements

Magnesium gluconate 500 mg 1x/day Laxative for constipation; antacid for acid indigestion Antacids might reduce laxative effect of Mg; might
reduce absorption of gabapentin

Docusate sodium 100 mg BID, as Stool softener; Laxative Alters intestinal absorption of water and electrolytes

needed
Ergocalciferol (Vitamin D) 50,000 IU Regulates calcium & phosphorus; maintains proper Caution with increased aluminum (in most antacids)
bone structure especially with kidney disease
1x/week
 Assessment: Food/Nutrition-Related History

• Food/Nutrition-Related History
• Physical Activity (FH-7.3): none due to chronic back pain
• Nutrition quality of life (FH-8.1): good appetite; mainly eats at home-daughter
cooks; receives SSD; higher carbohydrate intake; limited non-starchy vegetables & fruit
intake; low fiber intake
• Behavior (FH-5): No change in mood or sleep patterns
• GI Problem: constipation ~3x/week
Assessment: Nutrition-Focused Physical Findings
• Skin Intact (PD-1.1.17)
• Obese Class I (BMI 34.8)
• No oral problems noted; Denies chewing/swallowing difficulty
• Good appetite
• Malnutrition: No malnutrition noted.
• Two out of six criteria must be met
• Zero out of six criteria met
• No decreased energy intake, weight loss, fluid accumulation, loss of body fat, muscle mass wasting or
reduced grip strength
 Assessment: Nutrition-Focused Physical Findings
• No malnutrition noted based on Nutrition-Focused Physical Assessment10-11
 Assessment: Anthropometric Measurements12

• Height (AD-1.1.1): 68 inches (5’8’’)

• Weight (AD-1.1.2.1): 229.34 lb. (104.03 kg)
• Body Mass Index (AD-1.1.5.1): 34.8 obese class I
• Weight change: 5.2% weight gain in 3 months (11.5 lb. wt. gain)
• IBW (+/- 10%): 154 lb. (70 kg)
• Percent Ideal Body Weight: 149%
Assessment: Biochemical Data, Medical Tests and
Procedures 13

Test Results & Date Interpretation

Hgb A1C 9.6% (228.82 mg/dl) – (2/25/19) High health risk; poor degree of
control; at risk for microvascular
complications of diabetes
Hgb A1C 10.6% (252.52 mg/dl) – (12/4/18) High health risk; poor degree of
control; at risk for microvascular
complications of diabetes
Hgb A1C 12.2% (303 mg/dl) - (9/7/18) Extremely high health risk;
extremely poor degree of control;
at risk for microvascular
complications of diabetes
 Assessment: Biochemical Data, Medical Tests
and Procedures13
Test Results Date Interpretation
Fasting Blood Sugar 172 mg/dl (9 AM) (9/20/18) High; injected 80 units Basaglar
Random Point of Care (POC) 118 mg/dl (3:07 PM) (9/20/18) Within normal limits
Fasting Blood Sugar 164 mg/dl (9 AM) (12/13/18) High; injected 140 units Basaglar
Random Point of Care (POC) 53 mg/dl (3:33 PM) (12/13/18) Low; 15-15 rule (1/2 cup orange
59 mg/dl (3:47 PM) (12/13/18) juice); re-checked in 15 min
Random Point of Care (POC) 101 mg/dl (1:42 PM) (1/16/19) Within normal limits
Random Point of Care (POC) 320 mg/dl (12:24 PM) (2/13/19) High; recently had breakfast
239 mg/dl (1:41 PM) (2/13/19) High; corrected with 11.9 units
Fasting Blood Sugar 162 mg/dl (8:30 AM) (2/27/19) High; injected 140 units Basaglar
 Assessment: Biochemical Data, Medical Tests
and Procedures
Before:
• Original Total Daily Dose (TDD): 380 units of insulin/day : Basaglar14 140
units/day; Apidra15 80 units TID before meals
• Checking blood sugars: fasting, pre-lunch, & pre-bedtime (until 2/13/19)
 Assessment: Biochemical Data, Medical Tests
and Procedures
Current:
• Started on Dexcom G6 sensor & on Tandem t:slim X2 insulin pump (Novolog insulin)16-17
• Insulin-to-Carb Ratio (ICR): 1:3 g CHO (from 1:5 g CHO) (500 rule; 500/380 = 1.3) 18
• 1 unit of insulin covers 1 g CHO
• Correction Factor (CF): 1:10 mg/dl (1800 rule- insulin sensitivity factor; 1800/380) 18
• 1 unit of insulin lowers ~5 mg/dl
• Delivering background insulin: 4.5 units/hr. from 3 units/hr. - 3.5 units/hr.- now receiving about
half
• Basal insulin from 72-108 units/day ; Has to change infusion pump daily
Tandem t:slim X2 Insulin Pump Dexcom G6 Continuous Glucose
With Basal-IQ feature Monitoring System
288 Glucose Readings/Day
 Assessment: Nutrition Needs20
• Calories: 1845 calories using Actual Body Weight (ABW)
• Based on Mifflin-St. Jeor Equation – according to Evidence Analysis Library better
for predicting RMR in obese/non-obese patients, non-critically ill 20-21
• Protein: 83-104 g protein/day using ABW 20-21
• Based on 0.8-1.0 g/kg/day for normal-maintenance requirements (Nutrition Care
Manual)
• Fluids: 1845 ml 20-21
• Based on 1ml/kcal
 Assessment: Nutrition Needs 21-22

Mifflin St. Jeor Formula Simple Formula using Ideal Simple Formula using
using Actual Body Weight Body Weight (IBW Adjusted Body Weight
(ABW) (Adj.BW)

= (9.99 x wt) + (6.25 x ht) – IBW = 106 lb. +. (6 lb. X every Adj.BW
(4.92 x age) + 5 in. over 60’’) =0.25(ABW – IBW) + IBW
= 1845 kcal = 154 lb. (70 kg) = (79.3 kg)

x activity factor (1.2) 25-30 kcal/kg 25-30 kcal/kg

= 2214 kcal 25-30 kcal x (70 kg) 25-30 kcal/(Adj.BW)

= 1750 – 2100 kcal = 1983-2389 kcal

*Recent research shows,
Adj.BW not recommended
to use.
 Diagnoses & Interventions
• 1. Food and Nutrition Related Knowledge Deficit* (NB-1.1) 23 related to
limited understanding of carbohydrate counting and insulin to carb ratio as
evidenced by demonstrating limited ability select the right amount of insulin
to match the carbohydrate foods during meals.
• Intervention: Content related nutrition education (E-1.1) 24
• Educated patient on carb counting- provided handout and used “teach back”
method to practice applying.
• Reviewed carbohydrate foods and adjusted insulin to carb ratio; 1:3 – more insulin to
cover carbs
 Diagnoses & Interventions
• 2. Self Monitoring Deficit* (NB-1.4) 25 as related to sensory impairment with motor skills
and lack of understanding of usage of insulin pump as evidenced by observations of
patient having difficulty adjusting/setting up features on the insulin pump and reporting
taking pump off for the weekend.
• Intervention: Content related nutrition education (E-1.1) 24
• New administration of treatment for DM: inserting sensor (2 hr. warm up period-calibrate), ICR,
CF, exceeding max bolus on pump, provided handouts
• Additional time allotted for patient to learn using “teach back” technique
• Daughter & home attendant present during consult (education session) to help patient at home
 Diagnoses & Interventions
• 3. Limited Adherence to Nutrition Related Recommendations (NB-1.6) 26
related to previous lack of value and success in making health-related changes as
evidenced by reported overconsumption of starchy foods (i.e. rice) and lack of
physical activity.
• Intervention: Motivational interviewing (C-2.1) 27 using Molly Kellogg counseling techniques:
open questions, affirmations, mirroring, and summarizing 28
• To understand the patient better and acknowledge his efforts for making changes
• Problem Solving (C-2.4) 29 – measuring cups to portion out serving size of rice
• Goal Setting (C-2.2) 30 – to include 30 min. phys. activity; more non-starchy veg.; portion rice
 Monitoring & Evaluating
• Recommendations
• To include more non-starchy veg. (1/2 plate/meal)
• To limit starchy veg./whole grains to 1-2 servings/meal
• To include 30 min. physical activity per day
• To match insulin to carbs using the ICR (1:3) and correct using CR 1:10
• To continue using the t:slim pump and G6 sensor
 Monitoring & Evaluating
• Goals
• To lose 5% of current weight- 11.5 lb. in ~3 months
• A1C <7.0%
• To follow monitoring schedule with G6 sensor
blood sugar target: 80-120 mg/dl; 2 hrs. post-prandial <140 mg/dl
 Monitoring & Evaluating
• Initial Assessment: 9/20/2018
• Follow-Ups: 12/13/2019; 1/16/19; 2/13/19; 2/27/19
• Plan to follow-up in 3 months: to review carbohydrate counting, check
blood glucose patterns, insulin pump and sensor review, and weight
management
• Maintain follow up with RD at least once a year-EAL studies show
continued MNT helps maintain/reduce HbA1C in type 1 DM patients up to
6.5 years31
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