Natalie Rohr

KNH 411
Professor Matuszak
Case Study 22: Type 1 Diabetes
1. Define insulin. Describe its major functions within normal metabolism.
Insulin is 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 (Nelms
470). Insulin is an anabolic hormone that controls the metabolic fate of carbohydrate,
protein, and lipid. In general, insulin promotes the uptake of glucose into hepatic, muscle,
and adipose cells as well as the stimulation of glycogen, triglyceride, and protein
synthesis. Insulin secretion is stimulated by an increased level of blood glucose and by
the action of counter-regulatory hormones including growth hormone (Nelms 476).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.
2. What are the current opinions regarding the etiology of type 1 diabetes mellitus
(DM)?
Type 1 DM results from a cell-mediated autoimmune response causing a gradual decline
in beta cell mass within genetically susceptible individuals. Polymorphisms in the HLA
complex account for 40-50% of the genetic risk of developing type 1 DM, but more than
20 different gene associations have been linked to risk for the disease. The genetic
component of T1DM supports increased risk of relatives of individuals with T1DM but
relative risk is fairly low. Research suggests that the interaction of several environmental
factors with genes contributes to the onset of the autoimmune response. Potential triggers
include viruses and gluten. Other environmental factors include vitamin D levels and
infant feeding practices including length of breastfeeding and exposure to cows milk
proteins (Nelms 481).

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.

3. What genes have been identified that indicate susceptibility to type 1 DM?
The first reports of genetic association to T1DM were for the human leukocyte antigen
(HLA) region. Researchers have searched not only to determine which alleles of which
HLA-encoding genes are responsible for the T1DM association but also for which other
genetic loci, in addition to HLA, contribute to T1DM risk, with dozens of loci reported to
be associated with T1DM. After HLA, the strongest T1D genetic association comes from
polymorphism in the promoter region of the insulin gene. All studies of T1DM genetic
susceptibility must take HLA into account to interpret association data for any other
candidate loci.
Cited: Noble, J., & Erlich, H. (2012). Genetics of Type 1 Diabetes. Retrieved November
17, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3253030/
4. After examining Susans medical history, can you identify any risk factors for
T1DM?
The only risk factor that I identified from Susans medical history was that her maternal
grandmother also was diagnosed with diabetes. While family history does not the
strongest correlation to developing the disease, the fact her maternal grandmother had
diabetes still slightly increases her risk.
5. What are the established diagnostic criteria for type 1 DM? How can the
physicians distinguish between type 1 and type 2 DM?
Type 1 DM is characterized by the deficiency of insulin due to destruction of pancreatic
beta cells, resulting in the inability of cells to use glucose for energy (Nelms 481). The
onset of T1DM is sudden while the onset of T2DM is insidious. There are four ways to
diagnose diabetes. Diagnosis can be made on the basis of fasting plasma glucose of less

than 126 mg/dL or a casual plasma glucose less than 200 mg/dL with the presence of
classic symptoms (unexplained weight loss, polydipsia, polyuria). The A1C value will be
less then 6.5% as well Nelms 481). If the symptoms happen all of a sudden, then the
physician can say that the patient has type 1. Type 1 also develops most frequently in
children and adolescents but is becoming increasingly diagnosed later in life.
Hypovolemia and muscle catabolism are also usually present at diagnosis due to
ketoacidosis. Type 2 diabetes starts with being insulin resistant. Over time the pancreas
wont be able to produce enough insulin when blood sugar levels rise. It can affect people
of any age but usually starts to develop in middle-aged people. People who are
overweight and inactive are more at risk to develop T2DM.
Cited: YourGuidetoDiabetes:Type1andType2.(n.d.).RetrievedNovember17,2015,
fromhttp://www.niddk.nih.gov/healthinformation/healthtopics/Diabetes/yourguide
diabetes/Pages/index.aspx
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.
The acute consequences of an insulin deficiency are numerous and potentially fatal.
When glucose cannot enter cells, two things happen: plasma glucose levels rise
(hyperglycemia) and cells starve. This signals an increase in gluconeogenesis in the liver
as well as stimulation of glycogenolysis. These further contribute to the hyperglycemic
state. To compensate for the hyperglycemia, excess glucose is lost in the urine because
the kidneys can filter only so much glucose from the blood. As a result of this, Susan
experienced polyuria, or frequent urination. Lost of fluid stimulates the thirst mechanism
and leads to polydipsia. Cells dependent on glucose for energy have none available so in
turn, the body responds to this emergency by promoting hunger, or polyphagia.
Decreased fluid volumes in the body (hypovolemia) and muscle catabolism are the causes
for considerable weight loss in people with ketoacidosis and often are present at
diagnosis of T1. All of these things led to Susans symptoms and ultimately the diagnosis
of her T1DM (Nelms 481).

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.
7. List the microvascular and neurologic complications associated with type 1
diabetes.
The microvascular complications associated with T1DM include retinopathy,
nephropathy, and neuropathy. Retinopathy is a complication that can affect the peripheral
retina, the macula, or both and is a leading cause of visual disability and blindness in
people with diabetes. Approximately one half of people with diabetes have some form of
neuropathy. Nephropathy is a serious and progressive complication of both T1 and
T2DM. The first manifestation is typically microalbuminuria, which progresses to overt
albuminuria and eventually to kidney failure. Neurological complications associated with
T1DM include neuroglycopenia, which is when there is not enough glucose getting to the
brain.
Cited: Cade,W.(n.d.).DiabetesRelatedMicrovascularandMacrovascularDiseasesin
thePhysicalTherapySetting.RetrievedNovember17,2015,from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579903/

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 experiencing this? How might this be prevented?
This dawn phenomenon is most likely due to her overnight fasting since there is an
increase of blood glucose in the early morning most likely due to the increased glucose
production in the liver at night. If she had not consumed the right amount or proper foods
for dinner, this can explain the hypoglycemia and the hyperglycemia. By monitoring her

blood glucose levels and watching what she eats (how much and at what time), this
problem could be prevented.
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.
As the insulin deficiency persists, production of additional hormones (catecholamines,
cortisol, glucagon, and growth hormone) increases, leading to lipolysis. As the body
breaks down fat stored in adipose tissue, the resulting fatty acids are transformed into
keto acids in the liver. In the non-diabetes state, keto acids can be used for energy by
muscle and brain cells. As increased production of keto acids occurs, pH falls, and ketone
bodies are secreted in the urine. Metabolic acidosis develops as bicarbonate concentration
is reduced and ketoacidosis results (Nelms 481).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.
10. Determine Susans stature for age and weight for age percentiles.
Stature for age percentile 25th percentile (62 inches)
Weight for age percentile 15th percentile (45.45 kg)
Cited: 2to20years:Girls:StatureforageandWeightforagepercentiles.(n.d.).
RetrievedNovember17,2015,from
http://www.cdc.gov/growthcharts/data/set1clinical/cj41l022.pdf
11. Interpret these values using the appropriate growth chart.
With Susan being in the 25th percentile for her height based on age, this means that her
height is either greater than or equal to 25% of the population of girls who are also her
age and less than 75% of that specific reference population. This means that she is within
the normal ranges for girls her age. She was in the 15th percentile for her weight to age,

which means that her weight is either greater than or equal to 15% and 85% less than the
reference population.
12. Estimate Susans daily energy and protein needs. Be sure to consider Susans
age.
EER = 135.3 - (30.8 x age [y]) + PA x {(10.0 x weight [kg]) + (934 x height [m])} + 25
135.3 (30.8 x 15) + 1.6 x [(10 x 45.45 kg) + (934 x 1.57 m)] + 25
EER = 2771 kcal/day (roughly 2500 3000 kcal)
(PA of 1.6 was chosen because Susan is on the girls volleyball team so she is considered
active).
Protein needs:
0.85 g/kg of protein 0.85 g/kg x 45.45 kg 38.6 (~39) g/day of protein
13. What would the clinician monitor in order to determine whether or not the
prescribed energy level is adequate?
In order to make sure that Susan is receiving adequate calories to meet her energy needs,
the clinician should be monitoring her weight fairly regularly. She had lost a lot of weight
upon her arrival to the hospital, so the clinician needs to make sure she gets up to her
normal weight appropriately and then to maintain that weight. She should not be losing
any weight once her normal weight has been stabilized. She is still only 15, so she should
be gaining weight at an appropriate rate with her growth. How Susan feels throughout the
day as well as at her volleyball practices should also be monitored to make sure she isnt
feeling fatigued from lack of energy.
14. Using a computer dietary analysis program or food composition table, calculate
the calories, protein, fat (saturated polyunsatured and monounsaturated), CHO,
fiber, and cholesterol content of Susans typical diet.

Nutrients

Target

Average Eaten

Total Calories

2200 Calories

3404 Calories

Protein (g)***

46 g

100 g

Protein (% Calories)***

10 - 30% Calories

12% Calories

Carbohydrate (g)***

130 g

499 g

Carbohydrate (% Calories)***

45 - 65% Calories

59% Calories

Dietary Fiber

26 g

27 g

Total Fat

25 - 35% Calories

32% Calories

Saturated Fat

< 10% Calories

11% Calories

Polyunsaturated Fat

No Daily Target or Limit

7% Calories

Monounsaturated Fat

No Daily Target or Limit

10% Calories

Cholesterol

< 300 mg

190 mg

15. What dietary assessment tools can Susan use to coordinate her eating patterns
with her insulin and physical activity?
Most patients with T1DM perform a Self-Monitoring of Blood Glucose (SMBG) two to
three times a day to ensure that their blood sugar is at the correct level. This test would
require Susan to prick her finger and then the drop of blood would be analyzed. She
would be able to see her blood glucose level in that instant and then be able to adjust
what she is eating or her physical activity level accordingly. It will also show her if she
needs to take more insulin at that time or not as well. Susan could also use a tool called
Continuous Glucose Monitoring. This device places a sensor just under the skin. Every
five minutes, the device will send a blood glucose reading to a receiver that is worn
around the waist. Both of these devices would be useful for Susan and she would be able
to detect patterns within her food, physical activity, and glycemic index.
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.

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. The 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:

Component
Clinical data

Nutrition history

Weight history
Physical activity history
Monitoring
Psychosocial/economic

Knowledge and skills level

Assessments You Would Perform

1. Lipid profile (LDL, HDL, total
cholesterol)
2. Renal assessment (BUN)
3. Hematological assessment
(hemoglobin)
1. Any symptoms she experiences
with certain foods
2. Food allergies
3. Nausea, vomiting
1. Usual body weight
2. Current weight
3. BMI
1. Frequency of activities
2. What activities
3. Length of time
1. CHO intake
2. Blood glucose levels
3. Weight
1. Does Susan have anyone she can
turn to if she has any questions
about diabetes
2. Family socioeconomic status
3. How much will familys health
insurance cover, if they have health
insurance
1. Has she ever received nutrition
education
2. Does she feel comfortable with
checking her blood sugar
3. Does she know how to tell if her
blood sugar is too high or too low

Expectations and readiness to change

1. Is she willing to learn how to

change her diet
2. Is she willing to learn about
lifestyle changes
3. Is she following her diabetic
regimen

17. Does Susan have any laboratory results that support her diagnosis?
Chemistry
Normal Range
Susans Value
Why?
Pre-albumin
16-35 mg/dL
40 mg/dL
High levels seen in
patients diagnosed
with diabetes
Osmolality
285-295
304
High levels also due
to diabetes
Glucose
70-110 mg/dL
250 mg/dL
Indication of
diabetes
BUN
8-18 mg/dL
20 mg/dL
Kidneys not able to
remove urea from
blood normally
HbA1c
3.9 5.2%
7.95%
High levels indicate
high blood sugar

18. Why did Dr. Green order a lipid profile?

Dr. Green ordered a lipid profile in order to assess her HDL, LDL and total cholesterol
levels. If Susan is experiencing hyperglycemia, this can negatively affect her cholesterol
and triglyceride levels. Hyperglycemia can actually raise her cholesterol levels. Diabetes
also tends to lower HDL cholesterol and raise LDL levels, which can increase the risk for
heart disease and stroke. This condition is called diabetic dyslipidemia. In order to
monitor and make sure Susans cholesterol is not being affected by hyperglycemia and to
make sure her lipid profile is going in the right direction, Dr. Green ordered a lipid profile
test.
Cited: CholesterolAbnormalities&Diabetes.(n.d.).RetrievedNovember17,2015,from
http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/Cholestero
lAbnormalitiesDiabetes_UCM_313868_Article.jsp#.VkjVkGTBzGc

19. Evaluate Susans laboratory values:

Chemistry

Normal Value

Susans Value

Reason for
Abnormal
ity

Nutritional
Implicatio
ns

Pre-albumin

16-35 mg/dL

40 mg/dL

Diabetes

Protein not
adequately
absorbed

Osmolality

285-295
mmol/kg/H2O

304
mmol/kg/H2O

Hyperglycemia,
diabetes

Dehydrated

Glucose

70-110 mg/dL

250 mg/dL

Hyperglycemia

Will cause
hunger

BUN

8-18 mg/dL

20 mg/dL

Kidneys arent
functioning
properly

GI tract
complications,
kidney failure

Total Cholesterol 120-199 mg/dL

169 mg/dL

Normal

Can increase risk

for CVD and
other diseases if
levels are too
high

LDL Cholesterol

<130 mg/dL

109 mg/dL

Normal

Can increase risk

for CVD and
other diseases if
levels are too
high

HbA1c

3.9-5.2%

7.95%

Diabetes

Polyuria,
polydipsia

20. Compare the pharmacological differences in insulin:

Type of Insulin Brand Name
Onset of
Peak of Action
Action
Lispro
Humalog
5-15 min
30-90 hrs
Aspart
Novolog
5-15 min
30-90 hrs
Glulisine
Apidra
5-15 min
30-90 hrs
NPH
Humulin N
2-4 hrs
4-10 hrs
Glargine
Lantus
2-4 hrs
Peakless
Detemir
Levemir
1-3 hrs
6-8 hrs
70/30 premix
Humulin 70/30 30-60 min
Dual
50/50 premix
Humulin 50/50 30-60 min
Varies

Duration of
Action
3-5 hrs
3-5 hrs
3-5 hrs
10-18 hrs
20-24 hrs
18-22 hrs
10-16 hrs
10-16 hrs

60/40 premix

Novolin

30-60 min

2-8 hrs

18-24 hrs

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.
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 dosages are determined based on the individuals type of diabetes, age, body size,
insulin sensitivity, and hepatic function and, ultimately, the physicians clinical judgment.
A method that Dr. Green used in order to arrive at the dosage for Susan was this formula:
0.55 x weight (kg)
When inserting Susans weight into that formula, you come out with 24.9 units. Then the
dosage is divided 50% basal; 50% rapid with meals. This is how Dr. Green came up with
the dosage for Susan (Nelms 491).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.
22. Identify at least three specific potential nutrition problems within this domain
that will need to be address for Susan and her family.
Common nutritional diagnoses associated with diabetes that Susan demonstrates include
inappropriate intake of carbohydrates, undesirable food choices, and food and nutrition
related knowledge deficit (Nelms 495). Based on Susans usual diet history, her
carbohydrate intake is relatively high. Some of her food choices, including lots of Coke,
Snickers, etc., are undesirable food choices and could be swapped out with healthier
options. She may have an easier time swapping out those options if she had more
nutrition education, which is why I also believe that she and her family have a food and
nutrition related knowledge deficit.

Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.
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?
When someone has diabetes, including sweets in their diet requires careful planning. The
FDA has approved many artificial sweeteners so that people with diabetes can use them
in order to help curve their craving for something sweet. Stevia is a highly purified
product that comes from the stevia plant and is several hundred times sweeter than sugar.
According to the FDA, stevia is considered safe as a food additive and tabletop
sweetener. Stevia is low-calorie and can be found in most stores. I would tell Susan and
her mom that the use of stevia is okay, just as long as Susan watches the amount that she
adds to foods; only a small amount is needed when you use sugar substitutes due to the
increased sweetness.
Cited: LowCalorieSweeteners.(n.d.).RetrievedNovember17,2015,from
http://www.diabetes.org/foodandfitness/food/whatcanieat/understanding
carbohydrates/artificialsweeteners/?referrer=https://www.google.com/
24. Select two high-priority nutrition problems and complete the PES statement for
each.
Excessive energy intake (NI-1.3) related to diet as evidenced by diet history.
Excessive carbohydrate intake (NI-5.8.2) related to diet and diagnosis of T1DM as
evidenced by diet history and glucose lab values.
25. For each PES statement that you have written, establish an ideal goal (based on
the signs and symptoms) and an appropriate intervention (based on the etiology).

Susan was consuming well over 1000 kcal than her recommended energy needs. A goal
for her would be to cut back on the foods she eats with saturated fats, since those have
high caloric values and many empty calories. Examples of these foods would be the Coke
she drinks as well as her Snickers. As an intervention, I would have her switch out these
foods with healthier options that are more nutrient dense and then monitor her lab values
and weight to make sure she is consuming fewer calories while maintaining a healthy
weight.
Susan was consuming roughly 500 grams of carbohydrates on a daily basis. A goal would
be to help her lower her carbohydrate intake from 500 grams to 300 grams (her current
diet order). Limiting her breads and grains in one day can do this. Based on her usual
dietary intake, she usually consumes pizza, a sandwich, and spaghetti all in one day. By
switching out her spaghetti with grilled chicken will lower her carbohydrate intake, lower
her caloric intake, and raise her protein. Teaching Susan how to carb count will be a vital
area to teach her. Monitoring her blood glucose levels as she counts her carbs will also be
important.
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.
Yes, for the most part Susans diet order does meet her nutritional needs. Calculated in a
previous question, Susans estimated energy needs is about 2500-3000 kcal. She is
receiving 2,400 kcal from her current diet order, which falls just short of her daily needs.
By calculating her protein needs, she needs about 40 grams of protein. Her diet order
calls her to have 55-65 grams of protein. By consuming more protein foods into her diet,
will help raise her caloric intake from 2400 kcal to 2500-3000 (her recommended intake).
From her 24-hour recall, she was consuming roughly around 500 grams of carbohydrates.
Lowering that number to 300 grams in her diet order will help keep her blood glucose
level more in check. Overall, I think her diet order does meet her nutritional needs.

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 hypo-/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 in to 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 2 units of insulin and knew
she needed to have a snack that contained approximately 15 grams of CHO, so she
drank one beer when she arrived at the party. She remembers getting lightheaded
and then woke up in the ER. What happened to Susan physiologically?
Upon leaving the hospital, Susan and her family did not receive any information on
diabetes and alcohol, rightfully so considering she is not yet of age. However, because of
this lack of knowledge, Susan experienced a couple things regarding her diabetes
management on Saturday night. Alcohol can raise a persons blood sugar and then bring it
down on its own. Therefore, Susan had no need to take extra insulin in order to try and
make up for the alcohol. When she tested earlier in the night, her blood glucose level was
95 mg/dL, which is a normal level. She took insulin for a snack, which she ended up not
eating, causing her blood sugar to drop. So between her blood glucose dropping due to
the lack of snack and then dropping some more due to the alcohol, that is why Susan felt
lightheaded and had to be admitted back into the hospital.

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.
Susan is well below the of age line as far as alcohol consumption is concerned. However,
it is clear that she still participates in the consumption of alcohol from time to time. I
would encourage her to stay away from alcohol until she has a better handle on her

diabetes and insulin regimen. Her parents will probably punish her to some extent for
participating in the illegal activities, which may help her shy away from alcohol, but as
the dietitian, you dont know for she how they will handle that issue. Susan is going to do
what she wants to do, as all teenagers think, so educating her on the effects of alcohol and
T1DM would be beneficial after that specific situation occurred. If Susan choses not to
listen or if the dietitian overlooks alcohol education, there is an increased risk that she
will end up back in the hospital for the same reason.

References

2to20years:Girls:StatureforageandWeightforagepercentiles.(n.d.).Retrieved
November17,2015,from
http://www.cdc.gov/growthcharts/data/set1clinical/cj41l022.pdf

Cade,W.(n.d.).DiabetesRelatedMicrovascularandMacrovascularDiseasesinthe
PhysicalTherapySetting.RetrievedNovember17,2015,from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579903/
CholesterolAbnormalities&Diabetes.(n.d.).RetrievedNovember17,2015,from
http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/Chol
esterolAbnormalitiesDiabetes_UCM_313868_Article.jsp#.VkjVkGTBzGc
LowCalorieSweeteners.(n.d.).RetrievedNovember17,2015,from
http://www.diabetes.org/foodandfitness/food/whatcanieat/understanding
carbohydrates/artificialsweeteners/?referrer=https://www.google.com/
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 480-510). Boston, MA:
Cengage Learning.

Noble,J.,&Erlich,H.(2012).GeneticsofType1Diabetes.RetrievedNovember17,
2015,fromhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3253030/
YourGuidetoDiabetes:Type1andType2.(n.d.).RetrievedNovember17,2015,from
http://www.niddk.nih.gov/healthinformation/healthtopics/Diabetes/yourguide
diabetes/Pages/index.aspx