ADIME Nutrition Documentation Form

Section: Thursday

Name: Jonny Wymore

Nutrition Note: Case Study 9

Date:

4/08/2013

Time: 0800

A: Nutrition Assessment (Assessment info related to Nutrition Dx)

Client Hx
Nutrition-Focused Physical Findings

Anthropometrics

Obese
Ht: 5 9
Chronic and consistent indigestion over the past year
Wt: 215 lbs
Age: 48
BMI: 31.7 kg/m2
Male
Causasion
Pt Hx: Hypertension 1y
Family Hx: Father had CAD
Food/Nutrition-Related Hx & Comparative Standards
Biochemical, Medical Tests & Procedures

Name: Jack Nelson

Gained 35lbs in the last 5 years

Food intake: increased food intake over the past year related to stress
Medicine: Atenolol 50mg/d, Aspirin 325mg/d, daily multivitamin, Ibuprofen
500mg 2x/d for the last month
Energy intake: 4,360calories

CHOL
HDL-C
LDL
TG

200 mg/dL (H)

20 mg/dL (L)
165 mg/dL (H)
178 mg/dL (H)

D: Nutrition Diagnosis (PES statement)

1) Food and nutrition-related knowledge deficit of GERD-specific diet, related to habitual consumption of foods which
increase gastric acidity and lower GES pressure, as evidenced by dietary recall containing high fat foods, soda, and
alcohol.
2) Obesity related to excessive energy intake of 150% of daily caloric needs, as evidenced by 24-hour recall of 4,360
calories compared to his needed 2,900.

I: Nutrition Intervention
Prescription:
PES #1
Goal: Increase nutrition-related knowledge to decrease a) foods that increase gastric acidity, and b) lower
GES pressure.
Intervention: Restrict foods that increase gastric acidity and lower GES pressure, including soda, alcohol,
caffeine, and high fat foods.
PES #2
Goal: Weight loss
Intervention: Prescribe a 2,500 calorie diet, and provide nutrition education on new GERD diet as well as making
healthful dietary choices using the TLC eating plan.

TLC diet: <7% sat fat, <200 mg/d cholesterol, increased physical activity to 30 minutes 3 d/wk, 10-25 g/d viscous
(soluble) fiber, 2 g/d of plant stanols/sterols. Patient should consume the refer to the following:
Vegetables: 3-5 serv/d (without added fat, sauce or salt)
Fruits: 2-4 serv/d
Dairy products: 2-3 serv/d (fat free or low fat milk, yogurt, cottage cheese &cheese)
Eggs: <2 egg yolks/wk (use egg whites or egg substitutes)
Meat/poultry/fish: <5 oz/d
Fats/oils: unsaturated oils, seeds and nuts

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M & E: Monitoring and Evaluation
1) Monitor dietary patterns using a FFQ in 6 weeks
2) Monitor weight status. Long term weight loss goal of 10% of body weight, or approximately 21 pounds.
Signatures: