Student

Name Kayleigh Caito

Patient Name Mrs. Jones

Nutrition Assessment:

Client History:
Age: 48
Gender: Female
Job: part time secretary at construction company
Role in family: married with 4 kids, 2 teens, 2 adults

Food & Nutrition History:
Patient referred by doctor, nervous about visit
Rank of 8 on motivation/readiness to change
Eats three meals a day and two snacks
Eats breakfast on-the-go
Eats fast food for lunch
Home cooks dinners for the family traditional American meals
Typically consumes sweets, such as candy, for snacks
Consumes night time snacks in front of TV
Has tried the Atkins diet lost 35#, gained 45# back
No prescriptions or over-the-counter medications
No herbal medications
Does not engage in physical activity, although used to play basketball and soccer

Anthropometrics:
Height: 55
Weight: 175
IBW: 125# +/-10%
%IBW: 140% over
UBW: 175 for last 4 years
%UBW: 100%
%wt change: 100%
BMI: 29.2 kg/m2 - overweight

Biochemical/Tests/Procedures:
Fasting Glucose: 140 mg/dL - high
Hgb A1C: 7.1% - high
Albumin: 4.0mg/dL - normal
Total Chol: 245 mg/dL - high
LDL: 100mg/dL - normal
HDL: 33mg/dL below normal
Triglycerides: 150mg/dL borderline high

Nutrition Focused Physical Findings:

Appetite: good
BP: 128/80 borderline high

Comparative Standards:
EER: 1854 kcal/d
Pro: 79.5 g/d
Fluid: 2385 cc/d

Assessment Statement:

Mrs. Jones is a 48 yo female, who works part time as a secretary at a construction
company. She is a wife, and mother of 4 children. She typically eats three meals a day and
two snacks. She eats breakfast on-the-go, eats fast food for lunch at work, and makes meals
at home for dinner. The family will typically eat meals together for dinner. Her snacks are
usually sweet desserts. She consumes an average of 2409kcal/d (166% overconsumption).
She consumes an adequate amount of protein (120%), and under consumes her fluid needs
(21% of needs). Mrs. Jones has tried the Atkins diet in the past. She lost 35#, but gained
back 45#. She does not currently take any medications. She does not engage in physical
activity.

Mrs. Jones is considered overweight at 175# (BMI 29.2kg/m2). She has been 175#
for the last four years, making her UBW 175# and her %UBW 100%. Her labs show that she
has high levels of fasting glucose (140mg/dL), Hgb A1C (7.1%), and total cholesterol
(245mg/dL). She has borderline high levels of triglycerides (150mg/dL). She has
borderline high blood pressure (128/80).

Mrs. Jones was referred to the dietitian by her doctor. She states that she is ready to
make a change in order to lose 20#. She consumes meals that are high in calories, fat,
carbohydrates, and sugar. She does not engage in any physical activity. These contribute
to her high lab results and high weight. If she does not make changes, she could be at risk
for diabetes, CVD, and obesity. Education on eating properly on-the-go and at work, eating
healthier snacks, and increasing physical activity will improve her quality of life and
promote weight loss.

Nutrition Diagnosis/Goals:

Diagnosis 1:
Excessive energy intake r/t undesirable food choices AEB a BMI of 29.2 (overweight),
140% of her ideal body weight, overconsumption of calories (166%), and an intake of high
fat and sugary foods (high fat meats, fried foods, baked goods).

Diagnosis 2:
Excessive fat intake r/t undesirable food choices AEB 60% of kcal from fat, high total
cholesterol (245mg/dL), high triglycerides (150mgl/dL), high LDL (100mg/dL), borderline
high blood pressure (128/80), and foods high in fat (high fat meats, fried foods, baked
goods).

Nutrition Interventions:

Nutrition Rx:
General, healthful diet - 2500 kcal/d

Interventions:

Relationship to Disease:
-At risk for T2DM due to overweight, high fasting glucose (140ml/dL), high sugar intake,
high calorie intake (166%), and physical inactivity

-At risk for CVD due to overweight, high calorie consumption (166%), borderline high
blood pressure (128/80), high total cholesterol (245mg/dL), high triglycerides
(150mgl/dL), high LDL (100 mg/dL), and physical inactivity.

-At risk for obesity due to excess calorie consumption (166%), poor eating habits,
inactivity, high fat intake (60% of kcal).

Education:
-Eating breakfast on the go
-Breakfast is one of the most important meals because it gives energy for the day, so it is
necessary to eat breakfast
-Breakfast should be balanced (make sure there is protein)
-Some quick breakfast ideas are Greek yogurt and fruit, peanut butter toast, granola bar
with protein

-Tips for eating out
-Be sure to look at the menu before eating out: look for terms like baked, broiled, grilled,
and avoid terms like breaded, fried, crispy
-Eat lean meats (chicken) instead of high fat meats (burgers)
-Get a baked potato instead of fries because it is higher in nutrients (fiber)
-Go easy on dressings and condiments


-Healthy snacking
-Think of snacks like mini-meals and incorporate balance (carbs, protein, fat)
-Do not snack because of boredom or stress, only snack when hungry
-Some ideas are peanut butter and crackers, fruit and yogurt, popcorn sprinkled with
parmesan cheese

-Portion control
-Go over handout with hand comparisons to food sizes: ex. 1 cup vegetables is size of fist
-MyPlate handout which shows how plate should be distributed between food groups
-Go over some serving sizes from MyPlate handout: ex. 1 grain = 1 slice of bread or 1
dairy serving = 1 cup of milk
-Give brief overview of amount of each food group that should be eaten each meal: ex. 1

 2 servings of fruit or 2-6oz of meat

-Physical Activity
-Go on a walk during lunch break and even get coworkers involved
-Start small and build up to more exerting exercises
-Be active with the family

Counseling Techniques:
-Goal Setting allowed patient to determine goals she felt were realistic and attainable for
her lifestyle

-Health Belief Model
-Related how patients poor eating behaviors were putting her at risk for CVD, T2DM,
and obesity
-Gave ideas to help jump start eating behavior changes
-Patient became optimistic that her changes will have a positive impact on her weight

-Motivational Interviewing
-Identified several of patients barriers: eating out, unhealthy snacking, large portion
sizes, lack of exercise
-Provided education to promote healthier eating behaviors
-Identified and clarified several goals to accomplish and had patient write goals

Referral of Care:
Clearance from physician to begin exercise
Follow up labs- 1 month

Goals:
1. By next visit, patient will pack lunches 2 times a week AEB food log.
2. By next visit, patient will exercise for 20-30min for 3 times a week AEB physical activity
record.


Monitoring and Evaluation:

(Criteria/ Parameter)
Monitor weight; weight to be 170-175 (1 week)
Monitor activity level; physically active for 20-30 min for 3 times a week
Monitor fat intake; fat will be <45% of total kilocalories
Monitor calorie intake; total calories per day will be 2500kcal or less
Monitor labs; cholesterol and fasting blood sugar levels to drop