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

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1 April Ramos Dela Fuente ID # 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, 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 1

2 Dinner: Snack: 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 3 c microwave popcorn, 12-oz Coke 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 sleeping disorder in which an individual is characterized by pauses in breathing, shallow breaths and infrequent breaths during sleep. Pauses in breathing can last seconds to minutes. Other characteristics include loud snores and/or choking sounds. Obesity may cause enlarged tonsils and increase fat disposition in the neck. This increase fat deposit in the neck presses on throat muscles that are relaxed during sleep and cause obstruction causing obstructive sleep apnea. (MedlinePlus) 2. ZZ s BMI is 31.6, which indicates that she is _Obese_ Class _I_. (2 pts) Weight 201# x (1kg/2.2#) = 91.4kg Height 5 7 = 67in x (2.54cm /1m) x (1m / 100cm) = 1.70m = cm BMI BMI = (kg / m 2 ) BMI = 91.4kg / (1.70m 2 ) = 31.6 PRp ZZ s IBW is _61.4kg_ and her percent IBW is _149%_. (2 pts) IBW 100# for the first 5, then 5# every in. over 5in. Height = # + 5(7#) = 135# 135# x (1kg/2.2#) = 61.4kg %IBW %IBW = (actual BW/expected BW) x 100 %IBW = (201#/135#) x 100 = = 149% PRp Using the Mifflin-St Jeor equation (from PR), calculate ZZ s kcal needs for weight maintenance. (2 pts) kcal/day RMR RMR = (10 x kg) + (6.25 x cm) (4.92 x age) 161 RMR = (10 x 91.4kg) + (6.26 x cm) (4.92 x 25yo) 161 = = 1693 kcal/day AF : IF : x 1.4 x 1.0 = = 2370 kcal/day 1693 x 1.5 x 1.0 = = 2540 kcal/day PRp How much protein does ZZ need? (2 pt) 49g protein/day Normal Adult = 0.8g protein / day Ideal Body Weight x protein/day IBW = 135# x (1kg / 2.2#) = = 61.4kg 61.4kg x (0.8g/kg) = = 49 g protein/day PRp.19 3

4 6. How much fluid does ZZ need each day? (1 pt) _ ml/day OR oz/day_ Based on her 24-hr recall, is she receiving [X] adequate inadequate fluid in her diet? Method III: RDA Method 1.0 ml / kcal 2370kcal x (1ml / 1kcal) = 2370ml x (1oz / 30ml) = = 79oz 2540kcal x (1ml / 1kcal) = 2540ml x (1oz / 30ml) = = 85oz Based on recall: 84 oz/day Therefore, patient is receiving adequate fluids intake. PRp.20 Method III in PR 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) High blood glucose lab values. Patients has blood glucose of 108mg/dL when the normal ranges are mg/dL. This is seen by the amount of sugary drinks she reported in her food recall. Low dietary fiber as per dietary recall. Calcium levels are at the lower end of the normal values due to inadequate intake of foods with calcium. 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) The lipid profile and blood glucose tests were ordered due to patient s family history of diabetes. Patient has a BMI of 31.6, which indicates that she is Obese Class I. Patient s mother had possible gestational DM and grandmother had type 2 DM. Looking at ZZ s lipid profile, her HDL-C levels are below normal range, which is >55mg/dL (women). Her VLDL level is 30, which is on the higher end of the normal range (7-32mg/dL) and cholesterol is 190mg/dL, also on the higher end of the normal range of mg/dL. Normal glucose levels are considered to be mg/dl. ZZ s level is 108mg/dL, cutting close to the high end of the normal limits. 4

5 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 patient reports being sleepy during the day at work and reports sleep disturbances in the past several years. Sleep disturbances include cessation, snoring, restlessness and morning headaches. Reports being overweight since she was born (14# at birth). Patient reports family history of diabetes: grandmother having type 2 DM and mother having possible gestational DM. Patient also reports that food purchases and preparations are primarily done by her mother. Ht: 67 inches. Wt: 201#. BMI: IBW: 61.4kg. %IBW: 149%. Blood glucose 108. HDL 50. VLDL 30. HbA 1c 5.5. Consumption of foods high in fat and carbohydrates as per 24-hour diet recall. D: Excessive carbohydrate NI intake related to food preferences/choices listed during 24-hour recall as evidence by elevated blood glucose at high end of recommended normal values. Excess fat intake NI related to food and nutrition-related knowledge deficit as evidenced by VLDL levels at high end of normal values in addition to HDL-C levels below normal value for women. I: Overall goal: Nutrition Education Provide written and verbal instruction to patient on nutrition and how to choose healthy food choices. Carbohydrate-modified diet to decrease blood glucose levels. Fat-modified diet to decreases VLDL levels and increase HDL levels. Nutrition relationship to health/disease classes to attain nutrition-related knowledge. Goal setting to reach desired weight loss. Motivational interviewing to assist patient in making changes in food-related behaviors. M/E: Monitoring diet food intake with the use of food logs and dietary recall. Taking tests for lipid profile to determine changes in lipid levels and blood glucose. Taking weight to determine progress of weight loss. Will evaluate progress at next visit. April Ramos Dela Fuente April R. Dela Fuente Clinical Nutrition Student 11/12/2014 2:00pm 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 40# x (3500kcal / 1#) = 140,000 kcal reduction in 6 months (140,000kcal / 6months) x (1month / 4.3weeks) x (1week / 7days) = 775.2kcal/day = 775kcal/day deficit 2370kcal/day 775kcal/day = 1595 kcal/day 2540kcal/day 775kcal/day = 1765 kcal/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 No. Patient must increase her physical activity and change her behavior, in addition to changing in her diet, in order to see significant effects on weight loss. By increasing her physical activity even up to min/day of walking will really help her attain her goal more realistically than just diet alone. Intervention focusing on diet, physical activity, and change in behavior work significantly better than interventions focusing on diet, physical activity or change in behavior alone. 12. ZZ is in which stage of the Stages of Change? Provide evidence for your choice. (1 pts) Stage # 3, Preparation. Patient reports to be ready and motivated. Reports small changes already and feels good about them. Patient reports adequate sleep and more energy to exercise, showing small changes. Patient also reports ready to work on her weight. 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. Substitute a can of soda for a bottle of water. 2. Replace high-fat dressings with low-fat dressings such as light ranch or Italian vinaigrette. 3. Increase fruit intake by having at least one serving of fruit with each meal. 4. Increase fiber intake by eating oatmeal for breakfast at least three times a week. 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. Patient can walk to work or walk to destinations within walking distance. 2. Attain a pedometer or step counter and set a daily goal. 3. Get family members to join her on her walks with her dog. 4. If the option is available, take the stairs rather than the elevator. 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. Prepare lunch to bring to work the night before. 2. Make it a goal to eat meals at the dinner table rather than in front of the tv or any other activities that may be distracting. 3. Eliminate cues that cause undesired eating such as taking alternate routes in the mall to refrain from being tempted by the food court. 4. Have a reward system for weight lost per month, such as patient taking a day off from work to spend time with family. 6

7 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. In the next two weeks, patient will park her car at the far end of the parking lot allowing her to walk to work in 10 minutes. 2. Patient will have a daily goal of at least 5,000 steps a day for the first two weeks. 3. In the next two weeks, patient will take lunch to work at least 3 days a week. 4. Patient will eat at the dining table during at least 2 meals a day. 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) Reassessment of what patient s diet, physical activity, and change in behavior. May have to adjust certain weight goals. May have to initiate an even lower daily calorie count, increase physical activity, or changes in behavior. 18. What is the optimal length of weight management therapy for ZZ? (1 pts) Weight lost therapy should be over the course of 6 months. Weight management therapy entails at least one or more encounters with RD over a period of at least a year. But the high-frequency comprehensive weight maintenance interventions result in maintenance of weight loss. If patient comes in often for follow-ups, will result in a higher chance of managing and maintaining weight loss. (NUT 116AL Obesity Lecture Slide 42) 19. ZZ asks about gastric bypass surgery. Is she a candidate for gastric bypass surgery? Why or why not? (2 pt) No. Patient is not a candidate for gastric bypass. Patient would have to have a BMI equal to or greater than 40 or BMI of with co-morbidities. (NUT 116A Obesity Part II Lecture Slide 6) 20. What would you assess during this follow-up counseling session? (2 pts) Assess food logs and 24 dietary recall done during the follow-up counseling session. If patient is comfortable with it, take weight and determine BMI and weight that was lost. Possibly take tests to determine blood glucose and lipid levels. Ask patient how they feel physically and mentally. Ask if satiety is being achieved with the diet she is eating. 7

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