NUT 116AL CASE STUDY #1 Due 11/12/14

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1 NUT 116AL CASE STUDY #1 Due 11/12/14 Instructions: Review the pt s medical record below. Answer each question and show your calculations for each, if required. Reference all calculation formulas with the text and page number from PR (i.e., PR p. ). You must type your answers! If not, questions will not be graded and you will receive 0 points. CS#1 is worth 50 points. Client Name: ZZ DOB: 2/15/89 Sex: Female Education: High school diploma; some vocational school Occupation: Office receptionist Hours of work: Monday Friday 9:00 5:00 Household members: Mother 45, younger siblings (18, 20) Ethnic background: Biracial (African American and Caucasian) Religious affiliation: None Referring physician: D. Smith, M.D. Chief complaint: Family noticed that ZZ appears to stop breathing for several seconds several times a night. She is extremely irritable when she gets up in the morning. She reports getting very sleepy while at work and fell asleep at her desk yesterday. Pt hx: Pt describes sleep disturbance for the past several years, including: sleeping with her mouth open, cessation of breathing for at least 10 seconds (per episode), snoring, restlessness during sleep, h/o enuresis, and morning headaches. ZZ s co-workers have described deficits in attention span at work. Additionally, she has been overweight since she was born (14# at birth). Onset: Actual date of onset unclear; pt first noticed onset of the above-mentioned symptoms about 1 year ago. Type of Tx: None at present. Meds: None at present. Smoker: No Family Hx: Mother: possible gestational DM; grandmother: type 2 DM. PE: General appearance: Somewhat tired and irritable 25 yo female. Anthropometrics: ht: 5 7 ; wt: 201# Vitals: Temp 98.5 F, BP 123/80 mmhg, HR 85 bpm, RR 17 bpm. Heart: Regular rate and rhythm, heart sounds nl. HEENT: Eyes: Clear; Ears: Clear; Nose: nl mucous membranes; Throat: Dry mucous membranes, no inflammation, tonsillar hypertrophy Genitalia: nl Neurologic: Alert, oriented x 4 Extremities: No joint deformity or muscle tenderness, but pt complains of occasional knee pain. No edema. Skin: Warm, dry; reduced capillary refill (approximately 2 seconds); slight rash in skin folds Chest/lungs: Clear Abdomen: Obese Nutrition Hx: General: Very good appetite with consumption of a wide variety of foods. Pt s physical activity level is generally low. Pt reports feeling too exhausted to exercise after work. Prefers to watch television or read books. 24-hour recall: Breakfast: 2 breakfast burritos, 4 oz whole milk, 4 oz apple juice, 8 oz coffee with ¼ c cream and 2 tsp sugar Break: 12 oz coffee with ¼ c creamer and 2 tsp sugar Lunch: 2 bologna & cheese sandwiches (2 slices enriched bread with 1 slice bologna & 1 slice American cheese with 1 Tbsp mayonnaise per sandwich), 1-oz pkg corn chips, 2 mini donuts, 12 oz Coke Snack: Peanut butter & jelly sandwich (2 slices enriched bread with 2 Tbsp peanut butter and 2 Tbsp grape jelly), 12 oz Coke Dinner: Fried chicken (2 legs and 1 thigh), 1 c mashed potatoes (made with whole milk and butter), 1 cup fried okra, 20 oz sweet tea Snack: 3 c microwave popcorn, 12-oz Coke 1

2 Food allergies/intolerances/aversions: NKA Previous nutrition therapy? No Food purchase/preparation: Primarily mother Vit/min intake: Daily MVI Dx: R/O OSA secondary to obesity and physical inactivity Tx Plan: Polysomnography to diagnose OSA, FBG, HbA1C, lipid panel, psychological evaluation, nutrition assessment ZZ s Non-fasting Lab Values 2

3 Questions: 1. ZZ has been diagnosed with OSA. Define sleep apnea and explain the relationship between sleep apnea and obesity.(2 pts) (webmd.com) Sleep apnea is a sleep disorder that happens when breathing is interrupted during sleep. Obese individuals are likely to suffer from sleep apnea because of soft tissues surrounding the throat and tongue muscles of obese individuals. 2. ZZ s BMI is 31.6 kg/m 2, which indicates that she is Obese Class I. (2 pts) 201 lbs x 1 kg/ 2.2 lbs = 91.4 kg Based on her BMI ZZ is obese class I. 5ft x cm/ 1 ft. = cm 7 in x 1 cm/ in = 17.8 cm 152.4cm cm = cm cm x 0.01m/ 1 cm = 1.7 m BMI = (91.4kg)/(1.7m) 2 = 31.6 kg/m 2 3. ZZ s IBW is 61.4 kg and her percent IBW is 148.9%. (2 pts) (PR 2009 pg.15-16) 5 = 100# % IBW = (91.4 kg/ 61.4 kg) x 100 = % 7 in = 35# IBW= 135# or 61.4 kg 4. Using the Mifflin-St Jeor equation (from PR), calculate ZZ s kcal needs for weight maintenance. (2 pts) _2369 kcals/day or 2538 kcals/day._ (PR 2009 pg. 3) RMR= (9.99 x 91.4kg) + (6.25 x 170.2cm) - (4.92 x 25yrs) 161 = kcals Kcal needs = RMR x AF = x 1.4 = 2369 kcals/day Kcal needs = RMR x AF = x 1.5 = 2538 kcals/day 5. How much protein does ZZ need? (2 pt) 49.1 g/day (PR 2009 pg. 10) 0.8 gm/kg/day 61.4 kg x 0.8gm/kg/day = 49.1 g/day 6. How much fluid does ZZ need each day? (1 pt) 2741 ml Based on her 24-hr recall, is she receiving adequate inadequate fluid in her diet? (PR 2009 pg.11) Fluid requirement, Method 1: 91.4 kg x 30mL = 2741 ml Based on her 24-hr recall she is receiving: Inadequate fluid intake 4 oz whole milk x 30 ml/ 1 oz = 120 ml 3

4 4 oz apple juice x 30 ml/ 1 oz = 120 ml 8 oz coffee x 30 ml/ 1 oz = 240 ml 12 oz coffee x 30 ml/1 oz = 360 ml 12 oz coke x 30 ml/1 oz =360 ml 12 oz coke x 30 ml/1 oz = 360 ml 20 oz sweet tea x 30 ml/1 oz = 600 ml 12 oz coke x 30 ml/1 oz = 360 ml Total calculated = 2520 ml 7. List 2 nutrients or dietary components (not kcals) that you might be concerned about for this patient, stating the reason for your concern. (2 pts) (mayoclinic.org) 1. Fiber is a dietary component of concern. The pt is not consuming adequate amounts of fruits and vegetables. Additionally, the pt is not consuming adequate amounts of whole grains. For two of her meals she ate enriched bread. From the 24-hour recall, there were no reported fresh fruits consumed and only one serving of vegetables which included 1 cup of okra. Fiber is important because it helps regulate digestion, it can help maintain a healthy weight and decrease blood glucose levels. 2. Healthy fats are nutrients of concern. Based on the pt s 24 hour-recall, pt is consuming several foods high in saturated fats such as fried chicken and fried okra, whole milk, butter and mayonnaise. Healthy fats such as unsaturated fats is important because they can decrease the risk of heart disease, type 2 diabetes and help improve blood cholesterol levels. 8. Why did Dr. Smith order a lipid profile and blood glucose tests? What lipid and glucose levels are considered altered (i.e., outside of normal limits)? Evaluate ZZ s lab results. (2 pts) (labtestonline.org) Dr. Smith ordered a lipid profile to look at total cholesterol, high-density lipoprotein (HDL) cholesterol and triglycerides, and to assess the risk of pt to develop CVD.Total cholesterol levels: within normal levels ( mg/dl), upper end (190 mg/dl), HDL-C: within normal levels (>55 mg/dl), upper end (50 mg/dl), VLDL: within normal levels (7-32 mg/dl), upper end (30mg/dL), LDL: within normal levels (<130 mg/dl), upper end (110 mg/dl) and TG: within normal levels ( mgdl), upper end (114mg/dL). Blood glucose tests were also ordered to assess the pt s risk of developing DM since her family Hx indicates that mother possibly had gestational DM and grandmother had type 2 DM and pt is consuming beverages high in sugar content (soda and sweet tea). Blood glucose level lab results: within normal levels ( mg/dl), higher end 108 mg/dl. 9. Write an ADIME note for ZZ. Select two nutrition problems and complete PES statements for each within the note. For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on etiology). Include calculations on an attached sheet, including references for equations (PR p. ). (4 pts each = 16 pts) A: 11/12/14 25 yo female referred by a physician. Ht: 67 inches, Wt: 91.4 kg, IBW: 61.4 kg, BMI 31.6 amd blood glucose 108 mg/dl. Pt s estimated protein requirements: 49.4g/day, estimated fluid requirements: 2741 ml and calculated fluid requirements: 2520 ml. Pt s has been overweight since she was born and her mother possibly had gestational DM and grandmother had type 2 DM. Pt s mother is the primary purchaser and preparer of food. Pt is not currently taking any medications. 4

5 D: PES: Excessive energy intake (NI-1.3) R/T consumption of high calorie foods AEB high intake shown in 24-hour recall, blood glucose in the upper level (108 mg/dl), BMI of 31.6 kg/m 2 and wt (91.4 kg) significantly greater than IBW: 61.4 kg. PES: Undesirable food choices (NB-1.7) R/T insufficient knowledge of food preparation AEB food choices from the 24- hour recall, estimated fluid requirements compared to calculated fluid requirement from 24-hour recall and food prepared primarily by mother. I: Provide pt with nutrition education to assist in food-related behavior. Provide pt with motivation interviewing to assist pt in losing weight to reach IBW. Stabilize blood glucose levels by providing nutrition counseling on healthy fats and fruits vegetables. Follow up in 2 weeks. M/E: Pt will need to have blood glucose levels drawn to assess if they are within normal range. Pt will be weighted to determine weight loss. 24-hour diet recall to assess if pt has made significant diet modifications. Clinical Nutrition Student Veronica Lua 11/12/14 5

6 You see ZZ two months later in the out-patient clinic and she is 4 weeks s/p T&A and is ready and motivated to work on her weight. She has maintained her weight at 200#. She states that her sleeping habits have improved and she is ready to change her lifestyle. She is following no special diet. With adequate sleep she has more energy and she is able to exercise now and is currently walking her dog 10 minutes per day after work. A 24-hour recall reveals: Breakfast: (on way to work) Lunch: (work cafeteria) Dinner: (at home) McDonald s Egg McMuffin Cheeseburger (double) Collard greens with bacon Hash browns x 2 Small salad (lettuce, tomato) Macaroni and cheese Large coffee Ranch dressing Green salad 4 creamers Large diet soda Blue cheese dressing 2 packets sugar 1 can soda Snack: 1 can soda 10. If ZZ s goal is to reduce her weight to 160 pounds in the next 6 months how many kcals should she eat each day? (2 pt) (assume that there are 4.3 weeks per month) kcals/day 3,500 kcal = 1# To lose 40# x 3,500kcal = 140,000 kcals # of days to lose weight: 6 months x 4.3 weeks x 7 days =180.6 days to lose weight 2369 kcal/day x days = 427, kcals being consumed (hypothetically) 427,481.4 kcals 140,000) /180.6 = 1,591.8 kcal/day ( too lose weight) 11. Do you think that a goal of losing this much weight in 6 months, by diet alone, is a realistic one for ZZ? Why or why not? (1 pt) yes no No, losing 40# by only dieting is unrealistic because pt must also incorporate physical activity and behavioral changes. Currently pt is consuming 2369 kcal/day and subtracting this value to the goal amount of kcal/day (1,591.8 kcal/day) is 777 kcal. Typically pt s are asked to modify their diet so that there is a 500 kcal/day deficit and 777 kcal/day is a bit too high. Such a diet modification is not quite realistic. 12. ZZ is in which stage of the Stages of Change? Provide evidence for your choice. (1 pts) Stage #,. ZZ is in stage #3: preparation of stages of change. Pt states that she is ready to change her lifestyle. Pt has made small changes such as incorporating 10 minutes of exercise per day after work. Patient is not following any special diet but based on her 24-hour recall she has incorporated more green vegetables in her diet. 13. List 4 dietary (food) strategies that ZZ can incorporate into her eating pattern to make her diet healthier. (1/2 pt ea = 2 pts) 1. Switch from 2 packets of sugar to 1 packet. 2. Switch from soda to water. 3. Switch from ranch dressing to low fat dressing. 4. Eat 2 servings of fresh fruits. 14. List 4 realistic ways for ZZ to increase her physical activity, aside from going to a gym. (1/2 pt ea = 2 pts) 1. Park the car farther in the parking lot to get more walking into daily routine. 2. Walk dog for an extra 10 minutes. 3. Take the stairs instead of the elevator when possible. 4. During lunch break go for a walk. 6

7 15. List 4 behavioral strategies (other than diet/physical activity) that ZZ could use to reduce her kcal intake.(1/2 pt ea =2 pts) 1. Pack a bottle of water to take to work. 2. Prepare a healthy breakfast the night before. 3. Pack a low fat dressing to take to work. 4. Pack a piece of fresh fruit to take to work. 16. ZZ s long-term (outcome) goal is to weigh 175 pounds; she will need measurable short-term goals as well. Please choose one strategy from each of the questions and set a measurable goal for each of these that ZZ can work toward during the two-week period between her appointments with you. Remember SMART goals. (3 pts) 1. Walk dog for an extra 10 minutes: Walking the dog for a total time of 10 minutes 5 out of 7 days of the week. 3. Pack a low-fat dressing to take to work: Buying pre-packed low fat dressing and reminding oneself the night before to take to work. 17. If the above interventions do not work and ZZ reaches a plateau after losing 20 pounds, what do you think the next appropriate step should be and why? (1 pt) The next step should be to make more diet modifications. I would suggest the pt to incorporate more fresh vegetables and whole grains into her diet. If she doesn t enjoy the taste of water I would ask if there are any other low calorie drinks she is comfortable drinking. I would also suggest pt to increase physical activity to minutes per day. She could increase physical activity by waking up earlier to take a walk or by asking family members to take a walk with her so that she feels more motivated. 18. What is the optimal length of weight management therapy for ZZ? (1 pts) The optimal length of weight management therapy is over 6 months. (Lecture 9- Obesity Slides). 19. ZZ asks about gastric bypass surgery. Is she a candidate for gastric bypass surgery? Why or why not? (2 pt) (Lecture 9- Obesity Slides and mayoclinic.org) No, this pt is not a candidate for gastric bypass surgery. Candidates for bypass surgery must have a BMI to 35 kg/m 2 and 2 to risk factor (type 2 DM, high BP or severe sleep apnea) or a BMI to 40 kg/m 2. With a BMI of 31.6 kg/m 2, this pt does not satisfy either of this requirements. Candidates for gastric bypass surgery must also have significant diet modifications to show that they are able to modify their diet after surgery because gastric bypass surgery requires special diet modifications. 20. What would you assess during this follow-up counseling session? (2 pts) I would assess weight loss by weighing the pt or by asking the pt if her pants fit her loser. I would measure blood glucose levels to determine if it has dropped to normal levels and assess if diet modifications have helped her blood glucose return to normal levels. I would also ask for a 24-hour diet recall to determine if there have been significant diet changes. 7

April Ramos Dela Fuente ID # NUT 116AL Joan Frank NUT 116AL CASE STUDY #1 Due 11/12/14

April Ramos Dela Fuente ID # NUT 116AL Joan Frank NUT 116AL CASE STUDY #1 Due 11/12/14 April Ramos Dela Fuente ID #997219315 NUT 116AL Joan Frank NUT 116AL CASE STUDY #1 Due 11/12/14 Instructions: Review the pt s medical record below. Answer each question and show your calculations for each,