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Chelsie Fellman

KNH 411
November 17th, 2015
Type 1 Diabetic Case Study

Understanding the Disease and Pathophysiology

1. Define insulin. Describe its major functions within normal metabolism.
According to Nelms, Insulin is defined as, a hormone
produced by the beta cells of the islets of Langerhans in the pancreas to
regulate blood glucose; it promotes uptake, utilization, and storage of
nutrients (p. 470).
Insulins major function in metabolism is to break down
sugars and starches consumed in the diet so that they can enter cells and
readily be used for energy.
2. What are the current opinions regarding the etiology of type 1 diabetes mellitus
Type 1 diabetes is an autoimmune diseases characterized
by the gradual decline in beta cell mass within genetically susceptible

individuals. There is no known cause for the onset of this disease.

Genetics can be somewhat linked but they are overall fairly low: 3-4%
chance if the parent has T1DM and 5-15% chance if a sibling is T1 as well
(p. 481).
3. What genes have been identified that indicate susceptibility to type 1 diabetes
The primary gene that is associated with the susceptibility of
type 1 diabetes is located in the HLA region on chromosome 6.
Polymorphisms in the HLA complex account for 40-50% of the genetic risk
of developing type 1 diabetes. There are more than 20 different gene
associations that have been linked to the onset of T1 however (p. 481).
4. After examining Susans medical history, can you identify any risk factors for type
1 DM?
The overarching risk factor based on Susans medical history
is that her maternal grandmother had Diabetes Mellitus as well. According
to the National Institutes of Health, it is 12% more likely for the T1 gene
variant to skip a generation (National Institutes of Health, 2014). Susan
also experienced symptoms of polyphagia, polydipsia, and polyuria, all of
which are primary symptoms to look for in diagnosing T1DM (p. 481).
5. What are the established diagnostic criteria for type 1 DM? How can the
physicians distinguish between type 1 and type 2 DM?
According to the American Diabetes Association (ADA),
T1DM accounts for only 5% of the total diabetic population. Assigning a
specific type of diabetes to an individual depends greatly on the
circumstances present at the time of diagnosis. There are a few different
options available for health professionals to use in order to diagnose
diabetes and what type it is classified under. An oral glucose tolerance
test, a fasting blood glucose level, or even a diagnostic tool called a
hemoglobin A1c test, which depicts how many glucose molecules have
been attached to the hemoglobin in the blood over approximately the past
three months (American Diabetes Association, 2010). The diagnostic
cutoff point is an A1c lab value greater than 7.0% according to the ADA,
and an A1c value greater than 6.5% according to the American
Association of Clinical Endocrinologists (which tend to use much stricter
values) (AACE, 2015).
An A1c of 6.5 indicates an average blood glucose level of
about 153 mg/dL when the target range is 70-110 mg/dL (A1c of 4.55.8%).

Type 2 diabetes is generally diagnosed during adulthood but

is increasing as a diagnosis in children due to the uprise in childhood
overweight and obesity. Type 2 diabetes is diagnosed if the A1c value
rises above 5.8%, which means the average blood glucose level is 126
mg/dL or above (NIH, 2014).

6. Describe the metabolic events that led to Susans symptoms (polyuria, polydipsia,
polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of
the disease.
According to Nelms, insulin deficits in the body cause
numerous and potentially fatal consequences. When the glucose cannot
enter the cells (due to the lack of being broken down by the hormone
insulin), two things happen: hyperglycemia and the cells begin to starve.
This signals gluconeogenesis in the liver as well as stimulation of the
process glycogenolysis. The kidneys then begin to filter out as much of the
excess glucose they can which causes glycosuria and frequent urination
(polyuria). The loss of fluid then stimulates the thirst mechanism and
causes the person to become very thirsty (polydipsia). The cells are
starving due to the lack of glucose for energy and in turn, the body
responds and promotes hunger (polyphagia) (p. 481).
As the body continues on this path of degeneration if insulin
deficiency persists, the body breaks down fat stored in adipose tissue for
additional energy (this explains the weight-loss). The resulting fatty acids
are then transformed into keto acids in the liver. As the increased amount
of keto acids are produced, pH falls in the body from 7.3-6.8, which is
much more acidic than usual and ketones are secreted in the urine. The
amount of ketones that are released through the urine (measured using a
ketone stick that the patient urinates on) can be used to determine what
state of Diabetic Ketoacidosis (DKA) the patient is in (p. 481).
This entire process leads to fatigue in the patient due to the
bodys immense amount of work as it is trying to compensate for the lack
of insulin.

7. List the microvascular and neurologic complications associated with type 1

Prolonged exposure to high blood glucose is directly related
to nerve damage. Many factors can contribute to diabetic neuropathy.
These include, but are not limited to: metabolic factors, such as high blood
glucose levels, long duration of diabetes, and abnormal blood fat levels.

Neurovascular factors as a result of sustained high blood glucose levels,

lead to the inevitable damage of the blood vessels that are responsible for
carrying oxygen and nutrients to the nerves, particularly in the outer
extremities. In other words, the tiny blood vessels that are responsible for
carrying oxygenated blood to the outer extremities burst over time due to
the higher volume of glucose molecules passing through when blood
glucose levels remain high. Glucose is a large molecule, and if the
hormone insulin has not broken it down, it has the ability to burst open the
little blood vessels in the body (NIH, 2014).
The microvascular complications associated with type 1
diabetes include nephropathy and retinopathy. The neurologic
complications associated with type 1 diabetes include peripheral
neuropathy and autonomic neuropathy (pg. 487).

8. When Susans blood glucose level is tested at 2 AM, she is hypoglycemic. In

addition, her plasma ketones are elevated. When she is tested early in the morning
before breakfast, she is hyperglycemic. Describe the dawn phenomenon. Is Susan likely
to be experiences this? How might this be prevented?
The Dawn Phenomenon, described by the American
Diabetes Association, is a surge of hormones that the body produces
daily around 4:00 a.m. to 5:00 a.m. (ADA, 2010).
It is something that occurs in people with diabetes and
people without. Due to the fact that people with diabetes do not have
insulin to regulate these changes in hormones through the night, they may
see their fasting blood glucose levels rise. Susan is very likely to
experience this because she has type 1 diabetes.
The Dawn Phenomenon can be prevented by either eating
dinner earlier in the evening, doing something active following dinner such
as taking a walk, or simply increasing the amount of insulin given in the
night if the patient uses an insulin pump. If the patient uses a long-acting
insulin, it can be a bit more tricky to combat the Dawn Phenomenon (ADA,

9. What precipitating factors may lead to the complication of diabetic ketoacidosis?

List these factors and describe the metabolic events that result in the signs and
symptoms associated with DKA?
See question 6 for the metabolic events that result in the
signs and symptoms of DKA.

Diabetic ketoacidosis is a serious condition that if not

corrected, can lead to diabetic coma, or even death (ADA, 2010).
Following the starvation of the cells for energy, they begin to
use fat that is stored in the adipose tissue. The fatty acids are then
converted into ketones and are extremely harmful to the body. The
kidneys do their best to filter the excess glucose and ketones out, but
theres only so much they can do to combat the increase in acidic
compounds (ADA, 2010).
DKA develops slowly, but life-threatening symptoms can
occur within just a few hours. Very dry mouth, excessive thirst, frequent
urination, and fatigue are the first warning signs of DKA. It is imperative
the patient checks their blood glucose and ketone levels immediately and
administer rapid-acting insulin as quickly as possible to avoid further
complications such as vomiting. Treatment for DKA most usually takes
place in a hospital (ADA, 2010).

Nutrition Assessment
10. Determine Susans stature for age and weight for age percentiles.
Height in cm= 157.48; Age= 15
According to the CDC growth charts, she is in
the 25th percentile for stature for age.
Weight in kg= 45.45; Age= 15.
According to the CDC growth charts, she is in
the 25th percentile for weight for age.

11. Interpret these values using the appropriate growth chart.

For both the stature for age and the weight for age
percentiles according to the CDC Growth Charts, Susan is in the normal
weight and height range for her age (CDC Growth Charts, 2015)
12. Estimate Susans daily energy and protein needs. Be sure to consider Susans
Girls aged 9-18 EER: 135.3 - (30.8 x age [yrs]) + PA (1.6) x
(10 x wt [kg] +934 x ht[m]) +25
2,700-2,800 kcal/day
It is important for a newly diagnosed type one
diabetic to have a very strict dietary regimen to follow in terms of
carb counting. It is important for the patient to become familiar and
comfortable with administering the correct amount of insulin before

there can be any sort of variations in the amount of carbohydrates

the patient consumes daily.
Protein needs: 1.0g/kg = 1.0 X 45.45kg = 45g Protein daily.
45g X 4 g/kcal = 180kcal/day/pro

According to Brown in her book Nutrition Through the

Lifecycle, females aged 14-18 require 2,368 kcal/day and 46g protein daily
(Brown, 2011).

13. What would the clinician monitor in order to determine whether or not the
prescribed energy level is adequate?
The clinician would monitor to ensure that Susan is not
losing or gaining any weight. As long as Susan follows the correct insulin
regimen that her endocrinologist prescribes, she will be able to live a
healthy life.
14. Using a computer dietary analysis program or food composition table, calculate
the kcalories, protein, fat (saturated, polyunsaturated, and monounsaturated), CHO,
fiber, and cholesterol content of Susans typical diet
According to SuperTracker, Susans target EER range was
1,600-1,700 kcal/day. This is nearly half of what Brown stated girls aged
14-18 years needed daily.



Average Eaten Status

Total Calories

1600 Calories

3391 Calories


Protein (g)***

46 g

105 g


Protein (% Calories)***

10 - 30%

12% Calories


Carbohydrate (g)***

130 g

483 g


Carbohydrate (%

45 - 65%

57% Calories


Dietary Fiber

26 g

23 g


Total Sugars

No Daily
263 g
Target or Limit

No Daily
Target or

Added Sugars

No Daily
160 g
Target or Limit

No Daily
Target or

Total Fat

25 - 35%


Saturated Fat

< 10% Calories 11% Calories


Polyunsaturated Fat

No Daily
7% Calories
Target or Limit

No Daily
Target or

Monounsaturated Fat

No Daily
10% Calories
Target or Limit

No Daily
Target or

Linoleic Acid (g)***

11 g

25 g


Linoleic Acid (%

5 - 10%

7% Calories


-Linolenic Acid (%

0.6 - 1.2%

0.7% Calories


-Linolenic Acid (g)***

1.1 g

2.5 g


Omega 3 - EPA

No Daily
1 mg
Target or Limit

No Daily
Target or

Omega 3 - DHA

No Daily
0 mg
Target or Limit

No Daily
Target or


< 300 mg


32% Calories

207 mg

15. What dietary assessment tools can Susan use to coordinate her eating patterns
with her insulin and physical activity?

Susan can keep a food and insulin log of everything all the
meals and snacks that she consumes throughout the day. She will have to
become quite proficient at counting carbohydrates so that she can
correlate how many units of inulin she needs to count for the carbs.
It is also important for Susan to test her blood glucose levels
frequently in the first few weeks following the diagnosis. She can either
write down her BGs into a BG log, or with todays technology, she can
download her glucose meter to a computer and that will document the
numbers for her to save the time. This will enable Susan to see what times
of day she is running higher and what times of day she runs lower.
16. Dietitians must obtain and use information from all components of a nutrition
assessment to develop appropriate interventions and goals that are achievable for the
patient. This assessment is ongoing and continuously modified and updated throughout
the nutrition therapy process. For each of the following components of an initial nutrition
assessment, list at least three assessments you would perform for each component:


Assessments you would perform


1) Blood glucose levels to

monitor current BG and A1c test to
monitor average BG over the last 3
2) Lipid profile to check for
fluctuations in the triglycerides
3) Check for ketones in the


1) 24-hour dietary recall to

examine what Susan ate in the last
24 hours
2) Find out where Susans
food comes from, and how often
food is readily available (juices and
pb crackers to treat low blood
sugars, for example)
3) Conduct a usual diet form to
explore what foods Susan eats and
how often she eats these foods

Weight history

1) Examine current weight

2) Usual weight and if any

weight is gained or lost in the
3) Will plot and monitor using
CDC Growth Charts
Physical activity history

1) Compare usual food and

activity level to EER to make sure
food is sufficient
2) Find out how often and how
vigorous her exercise regimens are
3) Note what times of day she
is more physically active


1) Educate patient and parents

on how to test and monitor her BG
using a glucose meter
2) Educate how to test for
ketones using ketone test strips
3) Educate on the importance
of testing often (5-8 x day) and
taking insulin accordingly


1) Educate patient to not let

her diabetes stop her from living
the life she desires
2) Educate patient on patient
outreach programs such as
diabetes summer camp
3) Discuss and explore
insurance options to check for
patient to have the highest quality
insulin administration tools.

Knowledge and skills level

1) Explore the level of

knowledge on carbohydrate
counting from both Susan and her
2) Explore whether or not there
is any background knowledge on
type one diabetes
3) Practice injections in the
clinic prior to sending Susan and
her parents home to ensure
adequate knowledge and
education has been conveyed.

Also- making sure that Susan

becomes comfortable with
injections is imperative to success
with her type one diabetes
Expectations and readiness to change

1) Find out how Susan is

feeling about the diagnosis
2) Lay out a set of goals for
Susan and her family to try and
reach before the next visit
3) Draw up a scale of
readiness to change for Susan to
choose a number 1-10 based on
how she is feeling about changing
her lifestyle- make changes to the
education plan if Susan is not
feeling well about the diagnosis

Clinical Domain
17. Does Susan have any laboratory results that support her diagnosis?
The overarching laboratory result that supports Susans
diagnosis is her blood glucose level of 250 mg/dL. This is more than
double the highest limit of the target range.
Her HBA1c test came back as 7.95% which indicates that
her average blood glucose over the past 3 months was around 175 mg/dL.
18. Why did Dr. Green order a lipid profile?
Dr. Green ordered a lipid profile to check and make sure that
Susans lack of diabetes control did not negatively impact her cholesterol
and triglycerides. Certain aspects of a persons lifestyle, including the diet,
level of physical activity, level of diabetes control, and smoking status, can
affect the lipid profile (ADA, 2010).

19. Evaluate Susans laboratory values:


Normal Value

Susans Value

Reason for



8-18 mg/dL

20 mg/dL

Kidneys are
having to filter
out increased
amounts of
urea nitrogen
due to elevated
blood glucose

BUN directly
correlates with
however in
patients, it is
more likely for
them to have a
higher BUN
test due to
fluctuations in
the blood

Blood Glucose

70-110 mg/dL

250 mg/dL

mellitus: Beta
cells (insulin
cells) in the
pancreas no
longer work
due to

cannot produce
insulin to break
down sugar
and starches,
which leads to




amounts of
insulin in the
body to break
down the
consumed in
the body. This
is an average
of the last three

The pancreas
is unable to
enough insulin
to cover the
consumed in
Susans diet
and so





When higher
amounts of



glucose are
attached to the
hemoglobin in
the blood, the
osmolality in
the body then

20. Compare the pharmacological differences in insulin:

Type of

Brand Name

Onset of



5 15 min

30 90 min

3 5 hours


5 15 min

30 90 min

3 5 hours



5 15 min

30 90 min

3 5 hours


Humulin N

2 4 hours

4 10 hours

10 16 hours



2 4 hours


20 24 hours



2 4 hours

6 14 hours

16 20 hours


30 60 min

2 4 hours

10 16 hours

50/50 premix


30 60 min

2 5 hours

10 16 hours

60/40 premix


30 min

2 5 hours

18 24 hours


70/30 premix

Peak of

Duration of

(p. 491)
21. Once Susans blood glucose levels were under control, Dr. Green prescribed the
following insulin regimen: 24 units of glargine in PM with the other 24 units as lispro
divided between meals and snacks. How did Dr. Green arrive at this dosage?
Insulin doses are determined based on the individual's type
of diabetes, age, body size, insulin sensitivity, hepatic function, and the
ultimately the physicians clinical judgement. The 24 units of glargine

insulin (lantus) is the slow-acting insulin that mimics the pancreas in a way
that insulin is secreted in little amounts throughout the entirety of the day.
He chose 24 units based on Susans body size, age, and physical activity
level (p. 490).
The 24 units of lispro (humalog) is to be divided up and
injected at meals and snacks that contain carbohydrates. It is important to
divide up her allotted amount of carbohydrates throughout the day to avoid
extreme fluctuations in her blood glucose levels (p. 490).
The algorithm that Dr. Green most likely used to determine
her insulin needs is 0.55 X weight (kg). This comes to a total of 24.9 units.
He could have also taken her weight in pounds and divided it by 4 (comes
to 25) to determine her total insulin needs (p. 491).

Behavioral-Environmental Domain
22. Identify at least three specific potential nutrition problems within this domain that
will need to be addressed for Susan and her family.
Susan and her family need to be 100% understanding on the
importance of monitoring blood glucose levels throughout the day. If
Susan neglects to test her blood sugar for an extended period of time, this
can easily lead to a rise in her blood glucose level to an unhealthy level
(>250 mg/dL), which could result in ketone bodies being spilled in the
It is imperative for Susan and her family to understand how
to read a nutrition label and to be able to evaluate how many
carbohydrates are in each serving of a food product. This will allow Susan
to accurately count her carbs so that she is able to give the correct dosage
of insulin to combat the carbohydrates.
Education on the consequences of not taking insulin for a
meal containing carbohydrates is critical for Susan to understand.
Ensuring that Susan is well aware of the potential consequences will
ensure a successful diabetic regimen.
Explaining to Susan that she can still eat the foods she
wants, just as long as her blood glucose is stabilized, is key. I will explain
to her that if she wants to eat a brownie after dinner for example, she can
have the brownie as long as her BG is within or close enough to the target
range. She will also need to take insulin for the brownie if she chooses to
consume it as well.
Addressing Susan and her family on the importance of
keeping a BG log and food log will also ensure a successful diabetic


regimen. This will allow them to see the different fluctuations in Susans
blood glucose levels- allowing them to make changes to her insulin
regimen (if the doctor approves) if needed.
23. Just before Susan is discharged, her mother asks you, My friend who owns a
health food store told me that Susan should use stevia instead of artificial sweeteners or
sugar. What do you think? What will you tell Susan and her mother?
I would tell Susan and her mother that Susan is okay to eat
real sugar, just as long as she takes insulin for the carbohydrates she is
consuming. Sugar-free beverages and artificial sweeteners are okay in
moderation, but they should be avoided in large quantities. If Susans
blood sugar is above normal before she decides to indulge in a snack, it
makes sense for her to choose an option with less carbohydrates to avoid
the maintaining of the high blood glucose level. I would tell them that
artificial sugars are okay to eat in moderation, but theyre still largely
undermined in research today so I personally advise against them. It is
imperative that Susan and her mother understand the fact that just
because something says it is, sugar-free does not mean that Susan can
eat it without taking insulin. There are most likely carbohydrates in the
food, despite the fact that it is sugar-free. Carbohydrates are what Susan
needs to take insulin for.

Nutrition Diagnosis
24. Select two high-priority nutrition problems and complete the PES statement for
Food and nutrition related knowledge deficit (NB- 1.1)
related to patients usual dietary intake as evidenced by patients
consumption of 11% total calories of saturated fat.
Excessive energy intake (NB-1.3) related to patients usual
dietary intake as evidenced by SuperTracker analysis of 3,391 kcalories
consumed on average.
(IDNT, 2011)

Nutrition Intervention
25. For each PES statement that you have written, establish and ideal goal (based
on the signs and symptoms) and an appropriate intervention (based on the etiology).
Food and nutrition related knowledge deficit (NB- 1.1)
related to patients usual dietary intake as evidenced by patients
consumption of 11% total calories of saturated fat.

Goal: lower total daily saturated fat percentage

to below 10% daily calories.
Intervention: Educate Susan on foods that are
high in saturated fats and encourage her to choose foods with
unsaturated fats.
Excessive energy intake (NB-1.3) related to patients usual
dietary intake as evidenced by SuperTracker analysis of 3,391 calories
consumed on average.
Goal: decrease total daily calories to target
range of 2,700-2,800kcals
Intervention: Start by decreasing the amount of
added sugar consumed in Susans typical diet (i.e- the coke, ice
cream, and the high calorie snacks such as a peanut butter and
jelly sandwich). This will allow for Susan to reach her goal of
obtaining enough carbs that her total daily dose of insulin will cover.

26. Does the current diet order meet Susans overall nutritional needs? If yes,
explain why it is appropriate. If no, what would you recommend? Justify your answer.
The current diet order states Susan should consume 2,400
kcals (300 g CHO, 55-65 g pro, and 80 g lipids).
This is a good starting grounds for Susan to consume daily
to meet her overall nutritional needs. As a diabetic, it is critical to have
balance at all meals or snacks to avoid blood sugar spikes. For example,
a snack with just a bag of pretzels and an apple only provides
carbohydrates. Adding a tablespoon of peanut butter or one cup of milk to
this snack would ensure that Susans blood glucose levels out nicely
rather than spiking to 300 mg/dL and then coming down quickly once the
insulin was fully absorbed.
Her target protein goal is 40g (rounded up) and her diet
order states she should be consuming 55-65g protein. This will inevitably
benefit her for the reasons stated in the previous bullet. Protein helps to
stabilize blood glucose levels (ADA, 2010).

Monitoring and Evaluation

27. Susan is discharged Friday morning. She and her family have received
information on insulin administration, SMBG, urine ketones, recordkeeping, exercise,
signs, symptoms, and Tx of hype-/hyperglycemia, meal planning (CHO counting), and

contraception. Susan and her parents verbalize understanding of the instructions and
have no further questions at this time. They are instructed to return in 2 weeks for
appointments with the outpatient dietitian and CDE. When you come into work Monday
morning, you see that Susan was admitted through the ER Saturday night with a BG of
50 mg/dL. You see her when you make rounds and review her chart. During an
interview, Susan tells you she was invited to a party Saturday night after her discharge
on Friday. She tested her blood glucose before going to the party and it measured 95
mg/dL. She took two units of insulin and knew she needed to have a snack that
contained approximately 15 grams of CHO, so she drank a beer when she arrived at the
party. She remembers getting lightheaded and then woke up in the ER. What happened
to Susan physiologically?
There are a couple things that went awry that Saturday night
with Susans diabetes management. First things first, she tested early in
the night and her BG was 95 mg/dL. This is without a doubt in the normal
range and so she did not need to take any insulin. Assuming she took
insulin to cover a snack that she inevitably forgot to eat, her blood sugar
dropped. On top of already having a low BG due to too much insulin, she
decided to drink a beer. Alcohol (beer in particular) has a unique effect on
diabetes. Alcohol has the effect of raising a persons blood sugar and then
bringing it down on its own (ADA, 2010). This is why T1 diabetics are
informed not to take any insulin for alcohol. Now, this gets tricky in terms
of mixed drinks because more often than not, mixed drinks come with a
significant amount of carbohydrates. Unless the diabetic watched the
bartender measure out the juices and/or mixers in the mixed drink, they
should just avoid mixed drinks at all costs. It then gets tricky if the diabetic
has to guess the amount of carbohydrates in the mixed drink.
Susan knows that she is only 15 years old and she will most
likely face the consequences of underage drinking with her mother and
father. As the dietitian, I will encourage her to stay away from alcohol for a
while. At least until she gets older and has a deeper understanding of how
her diabetes and insulin regimen work- especially when paired with
alcohol. Teenagers will be teenagers, so it is imperative that Susan be
educated on the effects of alcohol and T1 diabetes; for if not, she might
possibly end up back in the hospital again in the future.
28. What kind of educational information will you give her before this discharge?
Keep in mind that she is underage for legal consumption of alcohol.
First things first, I will start by telling Susan that there is no
such thing as a perfect diabetic. T1 diabetes affects every single aspect of
a persons life and it is easy to make mistakes. There will be good days
with T1 and there will be bad days; thats okay because this disease in

particular is extremely difficult to manage. I will also inform her that it can
be done! There are so many resources online that would be helpful for
Susan to use as support in managing her type 1 diabetes. The American
Diabetes Association in particular has many useful tools and resources
that aid in support and help with managing this difficult disease.
As stated previously in the answer to question 27, teenagers
will be teenagers. I, as the dietitian, will take a realistic point of view
regarding the education that I will provide for Susan. First and foremost,
she will be encouraged to refrain from drinking until she is at the legal age
of 21. Prior to this discharge, I will inform her on the details of the many
ways that alcohol affects a diabetics body. It is important and critical for
her to be aware of how insulin affects her for if she ever decides to go
against the law again and drink before she is 21 years of age. See
question 27 for the details of the effect of alcohol on diabetes
Before this discharge, we would also review everything that
she was educated on previously before the first discharge. Clearly, she is
not quite understanding how insulin will affect her body if she does not eat
a corresponding amount of carbohydrates to meet her needs. We will
simply review the education materials used in the first education session
so she leaves this discharge 100% aware of what can and cannot be done
with her diabetes management.


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