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# First Name:____________Amanda___ Last Name: ______Alonzo__________

## CASE STUDY #1 - NUT 116AL Due 11/6/15

Instructions:
Review the pts 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 the Pocket Resource (i.e., PR p. ___). Only
use the PR for all calculations. You may use lecture notes and the textbook for all other questions. You must type
LP is a 35 yo F Filipina who is married with two children, ages 7 and 10. She was raised in the San Francisco Bay Area
and loves to eat traditional Filipino foods but also enjoys trying new recipes and experimenting with new foods. LP takes
pride in her cooking abilities and she and her family seldom eat in restaurants. Weekends are typically spent with the
extended family and revolve around family meals.
LP works as a teacher and she does not exercise. Occasionally, she will walk the family dog if the kids are too busy to do
so. Sometimes walking the dog means driving to the local dog park and letting it run loose. LPs love of food and lack
of exercise have created a weight problem. Her family and friends are concerned about her weight and recently they have
begun to express concern about her overall health.
FH: Her father died of a heart attack at age 49 and her two older brothers have had heart attacks. She has two other
siblings who have high serum cholesterol and follow strict diets. Both of her parents and all of her grandparents had high
cholesterol levels. None of this really bothered LP until recently. Since her birthday last week, she has become very
concerned about her health and decided to do something about her weight.
LP is 5' 2" and weighs 200 lbs. Throughout college she weighed 115 lbs and, according to her husband, "looked great."
He wants her to look like that again, so she has decided that she needs to get back to her college weight. She has even
talked about joining a gym and starting an exercise program to get back in shape. Because of her strong family history of
cardiovascular disease, her husband convinced her to obtain medical advice first. The family physician found her to be
generally healthy, despite her weight and a recent complaint of fatigue. Her blood pressure was 119/75 and her lipid panel
shows total cholesterol of 199mg/dL, HDL of 55mg/dL and LDL of 106mg/dL. Her triglycerides are 135mg/dL. She has a
history of anemia.
Her doctor reinforced what others had been telling her about losing weight and exercising more. The MD emphasized that
she should start slowly and sent her to see an RD to discuss her weight problem. You are the outpatient RD who
interviewed her and obtained the following information:
LP is usually in a rush in the morning. She only eats breakfast on weekends. She drinks a cup of coffee (with sugar and
coconut milk) while getting ready and another in the car on her way to work. She does not eat in the school cafeteria at
lunch because she says it is not home cooked. For lunch, she brings leftovers from home and drinks a bottled Starbucks
Frappuccino in the afternoon. Leftovers often consist of fried rice, fish/chicken, and vegetables. Sometimes she eats
lumpia or pancit instead of rice.
LP does not eat again until dinner. After picking up the children from daycare, she likes to go home and help them with
their homework before preparing dinner. Her goal is to save dinner until all of her work is done. She usually prepares
dinner for the family and this is the meal she lives for. The way she sees it, she works hard during the day, skips breakfast,
eats a home-cooked lunch, and does not snack during the day so she deserves a big meal at night. Occasionally the family
will eat out at Jollibee because this is her husbands favorite. Recently she has complained of feeling too tired to do much
at night and has been going to bed early with the kids. She states that she takes her iron pills when she remembers.
Most meals are centered on a small portion of chicken or fish and some form of rice or noodles. Lots of seasoning, salt,
and oil are important. She loves vegetables and has at least two different varieties included in dinner. Generally, one item
at each meal is fried (either the meat, the lumpia, or sometimes it is a stir-fried vegetable dish). Dessert is generally ice
cream, cookies, cake, or some combination of these. LPs weakness is halo halo, a Filipino dessert that she consumes at
least once a week on the weekends. Serving sizes vary a great deal, depending on the combination of foods served.
However, large amounts of each food item are the norm rather than the exception. After eating, LP plays with her children
before watching TV for an hour and then going to bed. Weekend meals are not that much different except that she eats
more for breakfast.
Laboratory Results
Chemistry
Sodium (mEq/L)
Potassium (mEq/L)
Chloride (mEq/L)

Ref. Range
136-145
3.5-5.5
95/105

11/1/15
138
3.6
99

First Name:____________Amanda___
Carbon dioxide (CO2, mEq/L)
BUN (mg/dL)
Creatinine serum (mg/dL)
Glucose (mg/dL)
Phosphate, inorganic (mg/dL)
Magnesium (mg/dL)
Calcium (mg/dL)
Osmolality (mmol/kg/H2O)
Bilirubin total (mg/dL)
Bilirubin, direct (mg/dL)
Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
Ammonia (NH3, umol/L)
Alkaline phosphatae (U/L)
ALT (U/L)
AST (U/L)
CPK (U/L)
Cholesterol (mg/dL)
HDL-C (mg/dL)
VLDL (mg/dL)
LDL (mg/dL)
LDL/HDL ratio
Triglycerides (mg/dL)
T4 (ug/dL)
T3 (ug/dL)
HbA1C (%)
Hematology
WBC (x 103/mm3)
RBC (x 106/mm3)
Hemoglobin (Hgb, g/dL)
Hematocrit (Hct, %)
Mean cell volume (um3)
Mean cell Hgb (pg)
RBC distribution (%)
Platelet count (x103/mm3)
Transferrin (mg/dL)
Ferritin (mg/mL)
Vitamin B12 (ng/dL)
Folate (ng/dL)
Urinalysis
Collection method
Color
Appearance
Specific Gravity
pH
Protein (mg/dL)
Glucose (mg/dL)
Ketones
Blood
Bilirubin
Nitrites
Urobilinogen (EU/dL)
Leukocyte esterase
Protein check
WBCs (/HPF)
RBCs (/HPF)
Bacteria
Mucus
Crys
Casts (/LPF)
Yeast

## Last Name: ______Alonzo__________

23-30
8-18
0.6-1.2
70-110
2.3-4.7
1.8-3
9-11
285-295
1.5
<0.3
6-8
3.5-5
16-35
9-33
30-120
4-36
0-35
30-135 F, 55-170 M
120-199
>55 F, >45 M
7-32
<130
<3.22 F, <3.55 M
35-135 F, 40-160 M
4-12
75-98
3.9-5.2

27
15
0.9
110
3.9
2.0
10
289
0.8
0.07
6.8
4.2
22
11
118
21
10
125
199
55
30
106
2
135
6.1
82
5.0

4.8-11.8
4.2-5.4 F, 4.5-6.2 M
12-15 F, 14-17 M
37-47 F, 40-54 M
80-96
26-32
11.6-16.5
140-440
250-380F, 215-365 M
20-120 F, 20-300 M
24.4-100
5-25

10.2
3.1 !
7.8 !
23.1 !
73 !
20 !
18.5 !
261
245 !
18 !
72
15

1.003-1.030
5-7
Neg
Neg
Neg
Neg
Neg
Neg
<1.1
Neg
Neg
0-5
0-5
0
0
0
0
0

Clean catch
Yellow
Clear
1.004
6.1
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0
0
0
0
0

First Name:____________Amanda___

## Last Name: ______Alonzo__________

1. LPs BMI is __36.7 k/m2___, which indicates that she is ____obese_____ Class _2___. (2 pts)
kg/m2
200/2.2= 90.9 kg
52= 62 in= 157.818 cm= 1.578 m
90.9/ (1.5748)2= 36.7

2. LPs IBW is ___110 lb___ and her percent IBW is __181.8%____. (2 pts)
IBW=100 +2(5)= 110
(current/IBW) x100= 200 lbs/110 lbs= 1.818x100= 181.8%

3. Using the Mifflin-St Jeor equation, calculate LPs kcal needs for weight maintenance. Use LPs ABW.
(2pts)
(10 x wt [kg]) + (6.25x ht [cm]) (5 x age)- 161
(10 x 90.9 kg) + (6.25x 157.48 cm) (5 x 35)- 161= 1557.25 kcal
AF= sedated= 1.4-1.5 1557.25 x 1.4= 2180.15 kcal; 1557.25x 1.5= 2335.88 kcal
4. How much protein does LP need? Is this an adequate protein intake for LP? If not, using evidencebased information, what amount of protein would be adequate to meet her needs? (2 pt) _________
Adequate= 15% of total calorie intake:
(.15x2180)/4 kcal/g protein= 82g
or
1-1.3 g/kg weight= 50-65 g, also adequate
5. Based on the Adult Weight Management Guidelines, what is a reasonable wt goal for LP and over
what time period? Explain your rationale. Is this a reasonable wt goal for LPs current lifestyle?
(2 pts) (show calculations)
According to AWM, a realistic weight loss goal for LP would include losing up to 10% f baseline body
weight in 6 months. This would be 100 lbs(.10)= 20 lbs/6 mo= 3.33 lbs/mo= 0.83 lbs/wk
At present moment, LPs current lifestyle would not make this a reasonable goal for her to achieve. Her
diet is heavy in salt, oil, and high energy, low nutrient dnese foods and she often eats one large portion
with few meals in a given day. She is mostly sedentary.
6. Determine LPs energy and protein requirements to promote weight loss. Explain the rationale for the
method you used to calculate these requirements. (2 pts) (show calculations)
0.83 lbs(3500 kcal/lb)=2905 kcal/wk=reduce 415 kcal/day
This would require that she deduct 100-500 kcal per day to reach the 10% weight loss goal in 6 months.
7. Evaluate LPs lipid panel results and describe what LPs lab values for cholesterol, HDL, LDL and
Triglycerides indicate. How might they change after weight loss? (4 pts)
Total cholesterol= 199 mg/dL. High end of desirable range.

First Name:____________Amanda___

## Last Name: ______Alonzo__________

HDL (55 mg/dL), LDL (106 mg/dL, although below 100 mg/dL is optimal), Triglycerides (135 mg/dL)
are at normal ranges. Serum total cholesterol, LDLD, TGs may decrease after weight loss due to the loss
of body fat. This would put her in more ideal and safer normal ranges. HDL may increase, which if
between 40 mg/dL and 60 mg/dL, would still be in a desirable, normal range.

8. Identify and interpret any abnormal hematological indices (including cell morphology) and discuss
the probable underlying etiology. (4 pts)
Hgb= 7.8 g/dL, lower than 12-15 g/dL range
Hct= 23.1%, lower than 37-47% range
MCV > 73, microcytic (small)
MCH= 20 pg, hypochromic (pale)
RDW> 16.5%, anisocytosis
Transferritin and ferritin are less than normal ranges
A low Hgb and Hct classify LP as anemic. This is further proven with hypochormic and microcytic cells as
they are losing iron and changing in size. Low transferritin and ferritin prove that the loss in iron has been
continuous as her body has been attempting to keep up with the continuous loss in iron, hence the anisocytosis.
Thus, she is specifically iron deficient anemic.

9. LP is in which stage of the Stages of Change? Provide evidence for your choice? (2 points)
LP shows signs of uncertainty and low confidence. She and her family members recognize that her health is at
risk due to her weight and weight loss is needed. She acknowledges that her family history of hear diseases
and health issues could affect her health. She expresses desire to return to a weight she was happy and
comfortable at, 115 lbs in college, and has even contemplated joining a gym and an exercise program to get
back in shape. However, it is important to note that she does not express confidence to change.
LP would be categorized in stage II contemplation.

10. Write a nutrition note to be included in LPs medical record. (8 pts; 2 pts each)
S:
Subjective
SHx: works as a teacher, has two kids. Eats with and as a family and seldom in restaurants. Loves to cook, and
looks forward to eating a big dinner with her kids during the week. She waits all day for this dinner and eats
very little before. She only eats breakfast on weekends. Often forgets to take iron pills
Typical food she eats is Filipino food, centered on small portion of chicken/fish and some form of
rice/noodles. Lots of seasoning, salt, and oils. At least one item in the dish is fried.
FHx: history of heat problems and high cholesterol; father died of heart attack at 49 y/o, 2 older brothers who
have had heart attacks, two other siblings with high serum cholesterol.
MHx: referred to an RD by an MD, emphasized losing weight
O:
35 y/o, 52, 200 b

First Name:____________Amanda___

## BMI: 36.7 k/m

Obese, class 2
Iron deficiency anemic, takes iron pill when remembers
BP= 119/75, total cholesterol 199 mg/dL, HDL= 55 mg/dL, LDL 106 mg/dL, TGs= 135 mg/dL
EER= 2180 kcal- 2336 kcal
EPR= 40g protein
APN= 191g protein
Labs: RBC= 3.1x103/mm3; Hgb= 7.8 g/dL; Hct= 23.3%; MCV= 73 um3, MCH= 20 pg, RBC distribution=
18.5%, Platelet Count= 261x103, Ferritin= 18 mg/mL
A:
Based off of LPs BMI and physical inactivity/lifestyle, she is classified as obese Class II. Her diet and typical
foods she eats suggest a problem with Predicted Excessive Energy Intake and Undesirable food choices, as she
consumes a great deal of high fat foods (fried, with lots of oils; high energy carbohydrates and sugars). Her
blood work along with her diet also suggest Inadequate mineral iron intake, as she has low ferritin levels and is
microcytic/hypochromic. She does not regularly take her iron pills, so there is an issue of Self-monitoring
deficit.

P:
A plan to reduce LPs body weight as well as improve her blood work, particularly lower her TGs and glucose,
her cholesterol (although it is borderline, she is high risk due to FHx), address her iron deficient anemia and
lastly address her fatigue needs to be implemented.
I would encourage her to begin including high iron foods (such as red meat) her meals as well as consumptions
or foods that will improve the absorption of iron, such as Vit C, that can be found in fruits and vegetables. I
would emphasize her taking her iron pills and institute a time in the day that works best for her to take them
(perhaps after getting out of bed, right before bed). Sitting down and coming up with foods that she is
accustomed and will improve her overall health, would be effective.
In order to achieve weight loss, I would reduce her energy intake and monitor this by counting calories. I
would recommend that she eats small frequent meals to curb her hunger, so she avoids eating one giant meal at
the end of the day. Increasing physical activity is necessary, and so we would need to brainstorm ideas on how
to increase her exercise everyday, perhaps by walking the dog instead of just letting it lose on the leash.
Lastly, education on obesity, high cholesterol, CVD and metabolic disease as a whole would need to be
provided. She is borderline of this disease, so education on what it is and what it entails could suffice to help
her stick with this plan. Furthermore, education could encourage her to share with family members and help
get the family involved.
11. Write a similar note in the ADIME format. (8 pts; 2 pts each)
A:
LP looks forward to cooking a big dinner for her family at the end of a busy day. She works all day, snacks
little and eats very little because she is so busy. Right after work, once she pick up her kids from school, she is
on the go rushing to get everything done so she can get to cooking dinner. Very rarely do her family and her
eat out, as she prefers home cooked food. They typically eat Filipino food, of which some staples are a meat
and some form of fried rice/noodles, or some other fried side. They often have desserts which are ice cream or
cake like food. She rarely exercises and often forgets to take her iron pills. She has become aware of her poor
health and would like to make a change. Has considered joining a gym and beginning an exercise program.

First Name:____________Amanda___

## 35 y/o, 52, 200 b

BMI: 36.7 k/m
Obese, class 2
Iron deficieny anemic, takes iron pill when remembers
BP= 119/75, total cholesterol 199 mg/dL, HDL= 55 mg/dL, LDL 106 mg/dL, TGs= 135 mg/dL
EER= 2180 kcal- 2336 kcal
EPR= 40g protein
APN= 191g protein
Labs: RBC= 3.1x103/mm3; Hgb= 7.8 g/dL; Hct= 23.3%; MCV= 73 um3, MCH= 20 pg, RBC distribution=
18.5%, Platelet Count= 261x103, Ferritin= 18 mg/mL

D:
Based off of LPs BMI and physical inactivity/lifestyle, she is classified as obese Class II. Her diet and typical
foods she eats suggest a problem with Predicted Excessive Energy Intake and Undesirable food choices, as she
consumes a great deal of high fat foods (fried, with lots of oils; high energy carbohydrates and sugars). Her
blood work along with her diet also suggest Inadequate mineral iron intake, as she has low ferritin levels and is
microcytic/hypochromic. She does not regularly take her iron pills, so there is an issue of Self-monitoring
deficit.

I:
I would set a goal to reduce her BMI to a healthy range of 18.5-24.9 through improving her dietary intake. I
would first promote a diet low in saturated fat and cholesterol, rich in whole grains, fish, lean meat, fruits and
vegetables. Due to her iron deficiency, I would suggest eating lean red meats and mixing them with some sort
of Vitamin C food to increase absorption. Emphasize the importance of continuing her daily dose of iron
supplements. I would ask that she monitor her eating, and eat more small meals throughout the day instead of
waiting for one big meal at the end of the day. I would also discuss with her about exercise and what it means
to get the 30 min/day to promote weight loss. Ways to get her family and kids involved could also help in
making these lifestyle changes. Evidence-based information about these components and of diseases she is at
risk of (CVD, metabolic disease, etc.) would also be provided to better help her understand the behavior
changes that must take place.

M/E:
Monitor: weight, foods eaten, dietary intake, nutrient intake (fat, iron, vitamins, minerals), blood levels
(ferritin, transferrin, hemoglobin, hematocrit, TGs, blood glucose, cholesterol)
Documentation: food log, iron supplements, exercise log

12. List 4 realistic dietary (food) strategies that LP could incorporate into her eating pattern to make
her diet healthier. (2 pts)
1) Steam vegetables instead of frying them; bake lumpias instead of frying them. Explore other methods of
cooking instead of using oil and heat.

First Name:____________Amanda___

## Last Name: ______Alonzo__________

2) Snack on lower calorie foods (vegetables, fruits, etc.) instead of frappacinos which are calorie high and little
nutrients
Based off of LPs BMI and physical inactivity/lifestyle, she is classified as obese Class II. Her diet and typical
foods she eats suggest a problem with Predicted Excessive Energy Intake and Undesirable food choices, as she
consumes a great deal of high fat foods (fried, with lots of oils; high energy carbohydrates and sugars). Her
blood work along with her diet also suggest Inadequate mineral iron intake, as she has low ferritin levels and is
microcytic/hypochromic. She does not regularly take her iron pills, so there is an issue of Self-monitoring
deficit.

13. List 4 realistic ways for LP to increase her PA, not including a gym membership. (2 pts)
1) Walk dog instead of letting it loose for 30 min/day
2) Making time for more physical activities with family members (after finishing school work or after dinner,
3) Take stairs instead of elevators
4) Practice breathing routines throughout the day so that she is not as fatigued, tired, or stressed by the end of
the day so that she may engage in PA

14. List 4 behavioral strategies (not diet and PA) that LP could use to reduce her kcal intake. (2 pts)
1) Change the snacking environment around her, get rid of Starbucks gold member (if she has it), dont keep
2) Keep a food log of what she eats and keep the food log in a convenient area (in her kitchin, on her
computer, on her phone) so that it can easily be recorded
3) Get her family involved/get social support. Incorporate healthier foods/ food modifications into her
weekend family meal gatherings
4) Creating a normal dinner plate for herself and automatically splitting that with someone (since her dishes
are big as it is)

15. LPs long-term (outcome) goal is to weigh X pounds by June; she will need measurable short-term
goals as well. Please choose one strategy from question 12, one from question 13, and one from question
14 and set a measurable goal (SMART) for each of these that LP can work toward over the next two
weeks between visits. (3 pts)
1) Steam vegetables instead of frying them; bake lumpia instead of frying them. Explore other methods of
cooking instead of using oil and heat. (#12)
1) Walk dog instead of letting it loose for 30 min/day (#13)
2) Keep a food log of what she eats and keep the food log in a convenient area (in her kitchin, on her
computer, on her phone) so that it can easily be recorded (#14)

## 16. Is LP a candidate for bariatric surgery? Why or why not? (3 pts)

No, LP is not a candidate. Her BMI is 36.7 (needs to be greater than 40) and she does not have any co-

First Name:____________Amanda___

## Last Name: ______Alonzo__________

morbidity. At this moment, the risks of bariatric surgery outweighs her risk of obesity. Her health can still be
improved through dietary intervention or medicine.