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Nutrition Care Process This assignment is for NUTR 73400, applying nutrition science in a clinical setting, addressing a disease(s) and medical-nutrition states. The case study provides subjective and objective data in order to complete the Assessment, Diagnosis, Intervention, Monitoring and Evaluation (ADIME). Client History: 41-year-old female/mother of two teenage children. She was an athlete in high school and never was concerned about her weight during this time period. During the time she was in college, she discontinued playing sports and gained ~20lbs. After graduation, she lost 15lbs. before her wedding and then regained ~40-50lbs. with each pregnancy. The first baby was born at 8lbs. 13 ozs. and the second baby weighed 9lbs at birth. After her children were born, she never lost all of the weight and has tried various diets however never stuck to any of them and her weight has fluctuated however gradually gaining over the few years. Currently, she does not participate in any activity because she is busy. She is being referred to you for weight loss and states that her two children just eat “junk” food and she is not interested in making separate meals for dinner. 1. Anthropometric Measurements: Wt.: 178lbs., Hx: 168lbs. 1 year ago. Ht.: 5’6”; Weight at age 21 years: 140lbs.; Waist circumference: 38 inches 2. Biochemical Data The following are the patient’s fasting measures - PLEASE FILL IN THE REFERENCE RANGES and REFERENCE THE VALUES Parameter

Result

Reference Range1

Sodium

141 mEq/L

135-145 mEq/L (Lab_Values_Table_PSAP.pdf, n.d.)

Potassium

3.5 mEq/L

3.5-5 mEq/L (Lab_Values_Table_PSAP.pdf, n.d.)

Chloride

106 mEq/L

96-106 mEq/L (Lab_Values_Table_PSAP.pdf, n.d.)

CO2

22 mEq/L

22-28 mEq/L (Lab_Values_Table_PSAP.pdf, n.d.)

Blood Urea Nitrogen (BUN)

13 mg/dL

8-23 mg/dL (Lab_Values_Table_PSAP.pdf, n.d.)

Creatinine

0.7 mg/dL

0.6-1.2 mg/dL (Lab_Values_Table_PSAP.pdf, n.d.)

Glucose, serum (fasting)

126 mg/dL

70-110 mg/dL

(Lab_Values_Table_PSAP.pdf, n.d.) Albumin

4.0 g/dL

3.5-5 g/dL (Lab_Values_Table_PSAP.pdf, n.d.)

Hemoglobin

11 g/dL

12-16 g/dL (Lab_Values_Table_PSAP.pdf, n.d.)

Hematocrit

35%

36-45% (women) (Lab_Values_Table_PSAP.pdf, n.d.)

Hemoglobin A1C

6.1%

4-7% (Lab_Values_Table_PSAP.pdf, n.d.)

Total Cholesterol2

193 mg/dL

HDL cholesterol2

38 mg/dL

≥ 60 mg/dL (Lab_Values_Table_PSAP.pdf, n.d.)

LDL cholesterol2

99 mg/dL

< 100 mg/dL (Lab_Values_Table_PSAP.pdf, n.d.)

Triglyceride

189mg/dL

< 150 mg/dL (Lab_Values_Table_PSAP.pdf, n.d.)

Vitamin D3

15 ng/mL

25-80 ng/mL (Vitamin D3 25-Hydroxyvitamin D, 2020)

35 inches for women increases the risk of developing T2DM, hypertension, CVD, and dyslipidemia, therefore the patient’s waist circumference of 38 inches and elevated BMI puts her at risk of developing these conditions (“Obesity Education Initiative Electronic Textbook— Treatment Guidelines,” n.d.). 4. What does her medical history of delivering heavier than average children suggest? Maternal obesity (BMI >25) and diabetes before pregnancy increases the risk of having heavier children because it increases the rate of fetal growth and can result in fetal macrosomia (“Fetal macrosomia—Symptoms and causes,” n.d.). Maternal obesity likely contributes to fetal macrosomia through mechanisms such as maternal insulin resistance (even if she does not have T2DM), higher fetal glucose/insulin levels, and the excessive transfer of free fatty acids into the growing fetus through the placenta (Gaudet, Ferraro, Wen, & Walker, 2014). The risks of having heavier than average children increases the risk of developing childhood obesity, childhood metabolic syndrome, and having lower than normal blood sugar levels (“Fetal macrosomia—Symptoms and causes,” n.d.). This can be prevented by limiting weight gain during pregnancy to 25-35 lbs and including physical activity into daily routine (“Fetal macrosomia—Symptoms and causes,” n.d.). 5. Does she meet the criteria for Metabolic Syndrome? ___Yes____Why? The patient meets the criteria for metabolic syndrome because she has elevated blood pressure, low HDL cholesterol, high triglycerides, elevated waist circumference, and elevated fasting blood glucose (“Metabolic syndrome—Diagnosis and treatment—Mayo Clinic,” n.d.). These criteria put her at a greater risk of heart disease, stroke, and T2DM (“Metabolic syndrome—Diagnosis and treatment—Mayo Clinic,” n.d.). In addition, the patient lives a sedentary lifestyle, had weight gain of 10 lbs over the past 1 year, and consumes an atherogenic diet, which also increases her risk of metabolic syndrome. 6. Is she at risk for Type 2 diabetes? __ Yes___ Why? Because the patient meets the criteria for metabolic syndrome, she is at a risk for developing T2DM. Diabetes can be defined as a raised plasma glucose concentration in addition to impaired glucose metabolism. The patient’s labs indicate high fasting blood glucose (126 mg/dL), which may be a result of growing insulin resistance and dysfunction of pancreatic beta cells where they cannot produce adequate insulin. This may eventually lead to complete insulin resistance and the need for oral medications to

control blood sugar levels. 7. What are the potential comorbidities? Metabolic syndrome is a cluster of numerous different conditions, therefore it can cause multiple potential comorbidities such as dyslipidemia, hypertension, cardiovascular disease, type T2DM, NAFLD and reproductive disorders (Cornier et al., 2008). Some of the main aspects of metabolic syndrome that contribute to these comorbidities include increased abdominal adiposity and insulin resistance (Cornier et al., 2008). 8. What is the therapeutic treatment for Metabolic Syndrome? The therapeutic treatment of metabolic syndrome depends on addressing several conditions but mainly focuses on lifestyle modification, however pharmacotherapy is a second line form of therapy (Mallare, Karabell, Velasquez-Mieyer, Stender, & Christensen, 2005). The abdominal obesity aspect of metabolic syndrome can be treated using both exercise and lower calorie diets, therefore decreasing waist circumference and decreasing the risk of CVD. For the elevated glucose/insulin intolerance aspect of metabolic syndrome, high fiber and low saturated fat diets in addition to increased exercise has been found to reduce the incidence of diabetes by 60% and will also improve the patient’s lipid profile (Wagh & Stone, 2004). If necessary, medications such as statins, angiotensin converting enzyme inhibitor drugs, angiotensin receptor blockers, and metformin may also treat and prevent further complications resulting from metabolic syndrome (Wagh & Stone, 2004). 9. Briefly describe the DASH diet: The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes a long term dietary approach to treat/prevent hypertension without medications by emphasizing portion sizes, a variety of fruits and vegetables, whole grains, and lean protein (“How to make the DASH diet work for you,” n.d.). The diet also encourages the reduction of sodium and emphasizes foods rich in minerals and vitamins such as potassium, calcium and magnesium which have blood pressure lowering capabilities (“How to make the DASH diet work for you,” n.d.). The diet recommends 6-8 servings of whole grains per day, 4-5 servings of vegetables per day, 4-5 servings of fruits per day, 2-3 servings of dairy per day, 6 oz or less of lean protein, 4-5 servings of nuts/seeds/legumes a week, and 2-3 servings of fats and oils per day (“How to make the DASH diet work for you,” n.d.). This diet is high in fiber, omega 3 fatty acids, protein, vitamins, minerals and low in saturated/trans fats and sodium. The diet also limits sweets to 5 times or fewer a week and limits the intake of alcohol and caffeine. 10. What are some guidelines you can provide this client to help motivate her to implement behavioral changes in regards to her meals/diet and physical activity? I would first ask the client what food options her children prefer and what food options she would realistically make at home so I could provide recipes. I would ask her how comfortable she is with her cooking skills and demonstrate cooking techniques as necessary. If she is comfortable, I would suggest having her children engaged in the cooking process to make cooking interactive and fun. I would also recommend making some slight substitutions to her typical daily food intake, such as switching from 2% milk

to 1% milk, baking chicken instead of frying, incorporating at least one fruit and one vegetable in every meal, and limiting her processed food intake. I would also mention to the client that she can meal prep at the beginning of the week so she can have time during the day to exercise. I would discuss what exercise option is most realistic for her; is she more likely to go to the gym or do a home work out, is there a track or field in a close vicinity where she can bring her kids and play outside, are there hiking trails nearby that are safe and are suitable for her kids. After discussing these options, I would help formulate a SMART goal that would illustrate how she can lose a realistic amount of weight in a certain time frame by doing more physical activities, cutting down on processed foods, and increasing her cooking skills. Please include calculated calories based on Mifflin-St. Jeor equation – use an ideal body weight and adjusted body weight as indicated – show all calculations DO NOT ROUND UP OR DOWN EXCEPT FOR FINAL NUMBER BMR for women: (kcal / day)= 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y) – 161 (kcal / day) kcal/day for current body weight = 10 x 80.74 kg + 6.25 x 167.64 cm - 5 X 41 years 161 = 1,489.15 kcal/day kcal/day for ideal body weight (145 lbs, BMI of 23.4)= 10 x 65.77 kg + 6.25 x 167.64 cm - 5 X 41 years - 161 = 1,339.45 kcal/day Adjusted BW=IdealBW+(0.4x(ActualBW−IdealBW)) Adjusted BW= 65.77kg + (0.4x (80.74 kg- 65.77)) = 71.758 kg 11. What suggestions could you provide in handling family meals? I would first ask the client what the types of foods that her children would realistically eat. I would then discuss options on how to make these types of meals healthier for both herself and her children. For example, her recent intake showed that she had fried chicken with mashed potatoes, I would discuss with her that she can make oven baked breaded chicken with roasted potatoes and sweet potatoes to decrease the saturated fat content and add additional vitamins and minerals. I would also suggest to her to try to engage her children in the cooking process such as adding olive oil to the potatoes or breading the chicken. If she does prefer purchasing and cooking frozen meals, I would review how to read nutrition labels so that she can choose options with less saturated fat and sodium. 12. Write 4 PES statements for this case study based on the following nutrition diagnoses: (HTN: Hypertension; WM: Weight Management; PD: Prediabetes) a. Nutrition Diagnosis: Overweight (HTN, WM) Excessive weight gain (P) related to the increased consumption of foods high in saturated fat and

simple sugars (E) as evidenced by increased waist circumference and elevated BMI (S). b. Nutrition Diagnosis: Physical inactivity Physical inactivity (P) related to the lack of time to exercise during the week (E) as evidenced by waist circumference of 38 inches, elevated BMI, and 10 pound weight gain over the past 1 year (S). c. Nutrition Diagnosis: Altered nutrition-related laboratory values Altered nutrition-related laboratory values (P) related to the overconsumption of processed foods high in saturated fat, sodium, and simple sugars (E) as evidenced by elevated fasting blood glucose, decreased HDL cholesterol, and elevated triglycerides shown in recent labs (S). d. Nutrition Diagnosis: Excessive energy intake (HTN, PD, WM) Excessive energy intake (P) related to consumption of processed foods and knowledge deficit on how to prepare home cooked meals (E) as evidenced by changing anthropometrics: 10 lb weight gain in 1 year, BMI 28.7 (S). Identify criteria of any possible deficiencies in the patient (if applicable). Please kindly include signs & symptoms of deficiencies if present. Note you can use tables in the Nelms textbook (Appendix G, pg. A-77-78). For each deficiency you identify, add appropriate assessment of nutrient status and recommended treatment. If there are several assessment tools, distinguish between available tests and test appropriate to use in this case. Fill in the chart below. Please reference at the bottom of the chart. Possible Nutrient Deficiencies

Signs and Symptoms of Deficiency

Name of Deficiency

Appropriate Assessment tool, e.g., lab. Test-reference range

Recommended Treatment

Foods That Have This Nutrient

RDA

Role of Nutrient

Iron

Fatigue, weakness, pallor

Iron deficiency anemia

Labs: Hemoglobin12-16 g/dL Hematocrit36-45% (women).

Increasing iron consumption through consumption of iron rich foods or supplementatio n through over the counter iron supplements in the case of severe deficiency

Red meat, poultry, beans, eggs, leafy greens, iron fortified foods (cereal, bread and pasta) .

18 mg/day

Iron is used to produce hemoglobin which allows red blood cells to carry oxygenated blood throughout the body.

Vitamin D

Fatigue, bone pain, muscle

Vitamin D deficiency, Hypovitami

Labs: 25hydroxyvitam

Increasing sun exposure, consuming

Fatty fish (tuna,

600 IU/day

Maintains bone strength,

weakness/ac hes, mood changes

nosis D, ricketts (severe)

in D - 25-80 ng/mL

more vitamin D rich foods such as fatty fish or fortified products such as dairy and cereal

mackere l, salmon), fortified foods such as dairy, orange juice, soy milk, cereal.

assists in calcium absorption

“Iron Deficiency Anemia.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 18 Oct. 2019, www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/symptomscauses/syc-20355034. “Vitamin D Deficiency: Symptoms & Treatment.” Cleveland Clinic, my.clevelandclinic.org/health/articles/15050-vitamin-d--vitamin-d-deficiency. Nelms, M. Sucher, KP, & Lacey, K. (2020). Nutrition Therapy and Pathophysiology. 4rd ed., Publisher: Boston, MA : Cengage, [2020] ©2020; ISBN-13:978-1-305-11196-7 Fill out in the ADIME template: NOTE if does not apply please kindly write N/A Electronic Medical Record (EMR)

What You Enter

Date/Time

19 March 2020 @ 13:23

Assessment

The patient’s diet has fluctuated since after college. She has been gradually gaining weight over the past few years and gained 40-50 lbs after each of her two pregnancies. She currently lives a sedentary lifestyle and consumes “junk food” because her kids eat it.

Age; Gender; Dx; PMH

41 yo female; non smoker; Dx: chronic constipation; PMH: delivery of macrosomia infants. Family Hx: Obesity, T2DM

Ht. Wt., UBW, %UBW; BMI

Ht. 5’6”; Wt. 178#; UBW 168#; %UBW 5.95; BMI 28.7.

Labs. – “significant”

Glucose 126 mg/dL; hemoglobin 11 g/dL; hematocrit 35%; HDL 38 mg/dL; triglycerides 189 mg/dL; vitamin D 15 ng/mL.

Medications

Multivitamin

G.I.

Chronic constipation

I/O

Fluid intake: N/A; Fluid output: N/A

Physical Assessment

Well developed, waist circumference 38”.

Skin

N/A

EER; EPR; Fluid requirements

EER: N/A; EPR: 64.59 (80.74kg x 0.8g); Fluid Requirements: 2,422.18 mL (30 mL/kg)

Current Diet

The patient’s current diet is high in processed foods, saturated fat, and simple carbohydrates. Typical food options include sweets such as cookies and cake, simple carbohydrates such as white bread, and fried foods. The patient’s diet is lacking lean protein, vegetables, fruits, and fiber.

Diagnosis: write the PES statements here

Excessive weight gain (P) related to the increased consumption of foods high in saturated fat and simple sugars (E) as evidenced by increased waist circumference and elevated BMI (S). Physical inactivity (P) related to the lack of time to exercise during the week (E) as evidenced by waist circumference of 38 inches, elevated BMI, and 10 pound weight gain over the past 1 year (S). Altered nutrition-related laboratory values (P) related to the overconsumption of processed foods high in saturated fat, sodium, and simple sugars (E) as evidenced by elevated fasting blood glucose, decreased HDL cholesterol, and elevated triglycerides shown in recent labs (S). Excessive energy intake (P) related to consumption of processed foods and knowledge deficit on how to prepare home cooked meals (E) as evidenced by changing anthropometrics: 10 lb weight gain in 1 year, BMI 28.7 (S).

Dietary/Therapeutic Intervention

1. Provide the patient with simple and culturally acceptable recipes that incorporate lean protein, fruits, vegetables, and whole grains and limit saturated fat and sodium. 2. Review how to read nutrition labels with the client so she can make educated decisions when purchasing foods. 3. Provide exercise ideas and examples to the patient so she can engage in physical activity at least 3 times per week for

approximately 1 hour. 4. Instruct the patient how to meal prep and how to make healthier alternatives for her children’s preferred foods. 5. Provide evidence-based nutrition information on managing metabolic syndrome. Monitoring and Evaluation

1. The patient will have increased knowledge on cooking nutritionally balanced meals. 2. The patient’s BMI and waist circumference will reach healthy levels as measured by monthly measurements. 3. The patient’s blood pressure and lab work will be monitored monthly and will reveal lower blood pressure, decreased fasting blood glucose, increased HDL cholesterol, decreased triglycerides, and improved hematocrit,hemoglobin, and vitamin D levels. 4. The patient will be able to review what recipes were acceptable to herself and her children to build her cooking knowledge. 5. The patient will be able to read nutrition labels and make educated decisions on what foods are preferable options for herself and her children.

Signature

Donna Varamo, SIGNATURE...