ADIME Documentation Weight Management

ASSESSMENT
Food/Nutrition-related History
Nutrition-Focused Physical Findings
Intake is about 3200 kcal/day with 600
Blood Pressure = 130/85 mmHg
kcal coming from energy dense
Significant weight gain since retirement,
occasional foods.
6 months ago
Intake of vegetables, fiber, and dairy
are low.
Wife does all of the shopping and
cooking.
Social gatherings have increased since
retirement and tend to be focused
around food.
Anthropometric Measurement
Client History
Height = 5 9
Age = 65
Current Weight = 198lb
Gender = male
Current BMI = 29.4
Family history of type 2 diabetes and
Previous (6 months) Weight = 172lb
heart attacks
Previous (6 months) BMI = 25.5
Recently retired; lives with wife
Comparative Standards
Mifflin-St. Jeor:
10(90) + 6.25(175) - 5(65) + 5 = 1664
kcal
1664kcal x 1.4 = ~2300 kcal/day
Mr. Robertson should be eating 1000
less calories per day compared to his
self-reported calorie intake of 3200
kcal.
DIAGNOSIS
Problem Excessive Energy Intake (NI-1.3)
Etiology as related to excessive snacking
Signs & Symptoms as evidenced by average energy intake at 3200kcal/day
compared to assessed intake of 2300kcal/day and intake of ~600 kcal/day of
occasional foods that are energy dense.
INTERVENTION
Food and/or Nutrition Delivery
Prescription decrease intake by
Meals and Snacks
~600 kcal from occasional foods to
provide ~2500 kcal/day by limiting nuts
and baked goods to prevent further
weight gain.
Nutrition Education
Goal - decrease energy dense

Provided information about:

- Associated risks with
obesity/overweight
- Energy and nutrient density of
favorite foods and alternative options
- Realistic weight-loss goals
Nutrition Counseling
Cognitive-behavioral theory excessive
energy intake & increased drinks and
snacks (set goals for occasional food
selection)
Strategies:
- Goal setting
- Self-monitoring
- Social support
Coordination of Nutrition Care
Food Record was taken for this
consultation.

occasional foods (600kcal) consumed to

prevent further weight gain.

Plan
1. Decrease total energy intake to
2500 kcal for maintenance in one
month and 2000 kcal for weight
loss in two months.
2. Decrease food intake of
occasional foods to 4 half-sized
servings per week by next
consultation.

MONITORING AND EVALUATION

Follow-up Time
At the next visit, Mr. Robertson should have reduced food intake of occasional
foods to 4 half-sized servings per consultation.
Mr. Robertson has an average energy intake at 3200kcal/day compared to
assessed intake of 2300kcal/day and intake of ~600 kcal/day of occasional foods
that are energy dense.