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

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Britton Matthews
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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) Sleep Apnea is a serious sleep disorder that occurs when a person s breathing is interrupted during sleep. Untreated sleep apnea can cause people to stop breathing repeatedly during their sleep, which may cause the brain and the rest of the body to not get enough oxygen. Obstructive sleep apnea, OSA, is a serious disorder in which breathing repeatedly stops for 10 seconds or more during sleep. The most common cause of OSA is excess weight and obesity due to the tongue and throat muscles that relax during sleep, causing this soft tissue to block the airway. It is believed that the airway of obese individuals can become obstructed due to increased neck fat, and enlarged tonsils and tongue, which press on the airway when the muscles relax during sleep. 2. ZZ s BMI is 31.61_kg/m^2, which indicates that she is Obese Class I. (2 pts) PR p.18 Weight=201# Convert pounds to kilograms: 2.2lb=1kg 201lb/2.2lb/kg = kg Height=5 7 1 foot=12 inches 5 feetx12 inches=60 inches+7 inches= 67 inches Convert inches to meters: 1inch= 2.54cm 67 inchesx2.54cm =170.18cm =1.70m BMI=wt(kg)/ht (m^2) [Metric] BMI=91.36kg/(1.70)^2m^2 BMI= ZZ s IBW is 61.36kg and her percent IBW is _%. (2 pts) PR p.15 IBW can be approximated using the HAMWI formula. Women: 100 # for first 5 plus 5 # for every inch over 5 +/- 10% (depending on frame size) Pt: height is lb+(5lbx7in)= 135lb IBW=135lbs/2.2lb/kg IBW=61.36kg Percent IBW %IBW= (actual body weight/ibw)*100 = (91.36kg/61.36)*100 = Using the Mifflin-St Jeor equation (from PR), calculate ZZ s kcal needs for weight maintenance. (2 pts) 2369kcal/day kcal/day PR p.3 Mifflin-St Jeor Equation Women: RMR= (9.99xweight)+(6.25xheight)-(4.92xage)-161 =(9.99x91.36kg)+(6.25x170.18cm)-(4.92x25)-161 = kcal/day pg 9 Activity Factor: (seated work, little movement, little leisure activity) kcal/day*1.4= kcal/day=2369 kcal/day kcal/day*1.5= kcal/day= 2538 kcal/day 3

4 Range: 2369 kcal/day to 2538 kcal/day 5. How much protein does ZZ need? (2 pt) g protein/day PR p Protein Requirement: Albumin levels at 4.8 which is in the normal range of Normal Nutrition (Healthy Adults): 3.5 gm/dl pg10 Protein Requirement for Normal Nutrition: gm/kg/day Weight x Protein Requirment 91.36kgx0.8gm/kcal/day=73.09 g protein/day 91.36kgx1.0gm/kcal/day=91.36 g protein/day Range: g protein/day 6. How much fluid does ZZ need each day? (1 pt) 2741mL to 3197mL Based on her 24-hr recall, is she receiving adequate x inadequate fluid in her diet? PR p.11 Method I: wt (kg) x 30mL=Daily fluid Requirment 91.36kg x 30mL= mL=2741mL wt(kg)x30ml=daily Fluid Requirment 91.36kgx35mL=3197.6mL Fluids based on 24 hr recall: 4oz+4oz+8oz+12oz+12oz+20oz+12oz+ 2oz (1/4 cup) +12oz=86 oz 86 oz=2543ml Her fluid intake does not meet her fluid needs. The range she needs to intake is 2741mL to 3198mL. She is not within the normal limit for fluid intake and even if the foods she eats contain fluid she still would be on the low side of the normal range and would need to increase her fluid intake regardless. 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) Two nutrients that that I am concerned about for this patient are calcium and protein. The patient s calcium is at 9.2 while the normal range is This is concerning because it is on the low end of the range. If the patient is not getting enough calcium, the body will use up the calcium stored in her bones to make sure the body has enough to meet the body s needs. Calcium is used for the formation of bones, and for other bodily functions such as blood clotting. The patient needs to ensure that she is getting adequate calcium intake in order to maintain bone strength and keep bones strong as she ages. The patient s protein is at 6.2, on the lower end of the normal range of 6-9. Protein plays a major role in many body systems including cell replication and cell repair. Signs of minor protein deficiency include muscle and joint pain and general feelings of weakness or fatigue. While the patient does have a general tiredness due to OSA, not getting enough protein will not help her situation. Also, as her results show that she is not getting very much protein this means that the foods she is eating are likely calorie dense and have little nutrients including protein. The calorie dense foods do not fill one up and would cause for an overeating of calories to feel satisfied. Eating protein rich foods such as beans and legumes will likely cause the patient to eat less calories and consume more protein. 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) Dr. Smith ordered a lipid profile and blood gluocose tests which contain pt levels of HDL, LDL, total cholesterol, trigycerides, VLDL and glucose. Pt s glucose level was at 108 which is on the high end of the normal range of Her HDL was at 50, which is not within the normal limit of greater than 55. Her LDL was at 110 which was less than 130, which means it is within normal limits. Her total cholesterol was 190 which on the high end of the normal range of Her 4

5 triglyceride level was at 114 which is in the normal range of Her VLDL was at 30 which was on the high end of the normal range of Her LDL/HDL ratio was 2.2 which is within the normal range of less than 3.2. Dr. Smith ordered a lipid profile and blood glucose tests to see if she is at risk for CVD. Any obese person is at risk for CVD, and by ordering these tests the Doctor would be able to look at these values and see if any are of concern that could increase her risk of CVD. All her values are within normal range except her HDL cholesterol which is her good cholesterol. Pt will need to increase heart healthy foods including plant foods which will increase her HDL and decrease her LDL. 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: 25 yo female, diagnosed with OSA. Ht:67 inches, Wt: 201 pounds, BMI 32, %IBW %, 2369 kcal/day to 2538 kcal/day kcal needs for weight maintenance, BP 123/80 mmhg, grams protein/day requirement, 2741mL/day to 3197mL/day fluid requirement Lab: Calcium 9.2, Protein 6.2, Glucose 108 Pt lives with family that reports pt to stop breathing for several seconds at night. Pt reports feeling very sleepy at work, waking up frequently in the night, having headaches in the morning and being irritable. Pt reports being too exhausted to exercise. Mother had possible gestational DM and grandmother has type 2 DM. 24 hour recall reveals a lot of sweetened beverages, fried, and fatty foods. Pt reports being overweight since birth. D: PES: Excess energy intake (NI-1.3) R/T undesirable food choices including high fat foods and fried foods as evidenced by her dietary food recall. PES: Physical inactivity (NB-2.1) R/T sedentary behavior as evidenced by pt reporting symptoms of fatigue and exhaustion. I: Pt will receive a handout of low fat foods and a handout of ways to increase fruit and vegetable consumption. Switching from high fat foods to low fat foods will decrease her calorie consumption. The handout will have pictures as well as compare fat content in high and low fat foods. The fruit and vegetable consumption hand out will show pt the benefits of increasing fruit and vegetable consumption as related to weight loss. Pt will also receive a handout with easy and quick ways to increase one s physical activity. M/E: Pt will write in a food diary and keep an exercise log everyday for the next two weeks. Pt will lose weight as measured by daily weights. Pt will state understanding of decreasing high fat foods and swapping them out with low fat alternatives. I will evaluate progress at the next visit in two weeks. Signature: Tess Soper UC Davis Nutrition Major November 12, :00 PM 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 40lbs/6months=6.67 lbs lost in one month 6.67/4.3=1.55 lbs lost per week 1.55*3500=5426 kcals per week 5426 kcals/7= 775 kcals per day 775 kcals per day ZZ has to lose ZZ s kcal needs: kcal/day-775kcal/day= kcalkcal/day kcal/day-775kcal/day= kcal/day Range: 1594kcal/day-1763kcal/day 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 x no I do not think that this goal of losing this much weight in 6 months, by diet alone is realistic. Weight loss and weight management should be based on a comprehensive weight management program including diet, physical activity, and behavior therapy. Diet alone will not successfully allow for weight loss or weight maintenance. The combination therapy is more successful than using just one intervention alone. With a combination therapy approach this would be possible as the AWM states 1-2 lbs per week for the first 6 months is an optimal rate. 12. ZZ is in which stage of the Stages of Change? Provide evidence for your choice. (1 pts) Stage # 3, Preparation. Pt is in Stage 3, Preparation, in the Stages of Change. Evidence includes pt saying that she is ready and motivated to work on her weight and ready to change her lifestyle, due to the advantages weighing out the disadvantages which is a sign of Stage 3. She has reported a small change in her exercising. She now walks her dog for ten minutes every day, which is a change from no physical activity at all. She has also maintained her weight at 200# which is also a small change due to the fact that she previously weighed 201#. Patients in Stage 3 Preparation usually report small changes as well as intend to take action in the next 30 days. It seems that she is ready to take action within the next 30 days and has made many small changes to improve her health. 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) Four dietary food strategies to make her healthier include swapping out soda for water, switching from ranch and blue cheese dressing to low-fat dressings, eating breakfast at home so as not to be tempted with fast food, and bringing lunch from home as not to be tempted by the unhealthy options in the cafeteria. 6

7 14. List 4 realistic ways for ZZ to increase her physical activity, aside from going to a gym. (1/2 pt ea = 2 pts) Four ways for ZZ to increase her physical activity, aside from going to the gym include walking her dog for a longer period of time after work, walking her dog before going to work, do exercises, stretches, or pedal a stationary bike while watching tv instead of being sedentary, and replace a break at work with a brisk walk. 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) Four behavioral strategies that pt could use to reduce her kcal intake includes weighing herself regularly, keeping a food diary, not going past Mc Donalds on the way to work, and remove the salt shaker off the table. 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) A measurable goal for pt to increase her physical activity would be walking her dog for ten minutes before work everyday for the next two weeks. A measurable goal for pt to become healthier would be to swap out her one can of soda for snack for a bottle of water every day for the next two weeks. A measurable goal for pt to reduce her kcal intake (behavioral strategy) includes not going past Mc Donalds on the way to work every day for the next two weeks. 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) If she reaches a plateau it would be best to reevaluate her goals and make sure she is on track. Going one step further to decrease her kcal intake is crucial to her continuing to lose weight and exercising for longer periods of time.i think the next step would be to limit consumption of caloric beverages including sweet tea, soda, and juice. Water should replace pt s beverages at all times of the day. Sugar-sweetened beverages contribute to weight gain as well as contribute little to no nutritional value to the pt. Swapping out these beverages for water, will allow pt to largely decrease the number of empty calories she eats. She should increase her physical activity to more than 10 minutes a day and find other ways to exercise besides short walks with her dog. 18. What is the optimal length of weight management therapy for ZZ? (1 pts) The optimal length of weight management therapy for the pt would be at least 6 months or until weight loss has been achieved. The weight maintenance program would follow up after that time. Individualized goals of weight loss therapy should be reducing body weight at an optimal rate of 1-2 lbs per week for the first 6 months and achieving the initial weight loss goal of up to 10% from the baseline weight. 19. ZZ asks about gastric bypass surgery. Is she a candidate for gastric bypass surgery? Why or why not? (2 pt) 7

8 Pt is not a candidate for gastric bypass surgery. She is in the Obese I category with a BMI of 32 and does not have any comorbidities. A BMI of 40 or higher would qualify one for gastric bypass surgery as well as having a BMI of 35 to 39.9 and a serious weight-related problem. She is not obese enough to be a candidate for gastric bypass surgery. After losing the 20 lbs her BMI would be 28kg/m^2 which is now in the overweight category. She is not a candidate for the gastric bypass surgery. She will be able to lose weight due with physical activity, diet and behavioral changes. BMI Calculation: 180lb/2.2lb/kg= 81.82kg BMI=81.82kg/(1.70)^2m^2=28.31kg/m^2 =28kg/m^2= Overweight 20. What would you assess during this follow-up counseling session? (2 pts) During the follow-up counseling session I would weigh her at the session, ask the patient if she has noticed her clothing getting looser and how she is feeling about the changes she has made to maintain her weight loss. If she was not able to achieve the small goals that we planned in the previous meeting I would ask her if there were any obstacles she faced that caused her to not be able to achieve the goals. I would provide positive feedback and help her overcome these obstacles. If she were not able to achieve these goals I would modify the goals to help her reach them easier if she was having trouble. This would allow for her to see progress in her weight maintenance and may keep her on the right track and motivated. If she was able to achieve her goals I would give her positive reinforcement and congratulate her on her success and formulate more small goals for her to follow to reach her overall goal of weight maintenance. These small goals could include increasing her morning and afternoon walks to 20 minutes instead of 10 minutes each, cooking breakfast at home instead of grabbing something on the go, and continuing to keep a food diary. 8

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

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