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NUT116BL Name: __Karina Almanza___

DUE: Friday 2/3/2017 by 11 am Points possible: 20

Mini Case Study #2

1. Please be concise and use the space provided.

2. Please cite sources as necessary.
3. You may use your textbook and the MNT the Pocket Guide
4. Type your answers and submit online through CANVAS

Patient History: Miss R is an 11 year old Hispanic female referred to you by her PCP for a consult on
treatment for obesity & fatty liver. Miss R. is accompanied by her mother who does most of the talking
as the patient is embarrassed and withdrawn. Patient is an only child who enjoys watching movies and
reading books. Patient has recently complained of being tired, falling asleep at school, and mild
abdominal pain. She was born LGA (large for gestational age) at 10 lbs 2 oz. Mother states she has
always been a big girl.

PMH: LGA, Childhood Obesity

Meds: none
Fhx: mother and father are overweight and have T2D

Physical History:
General Exam: obese female
- Temp 98.6 F (WNL)
- BP 138/89 mm Hg (slightly above average of 120/ 80 mm Hg)
- HR 84 BPM (WNL)
- RR 23 (slightly above average of 12- 16 breaths/ min)

Ht: 57 (25th %tile) Wt: 152lb (>95th %tile) BMI 32.9 (>95th %tile)
CT scan (recent) shows the presence of a hepatic steatosis

Nutrition History:
General: Reports adequate appetite. Miss R. will eat some vegetables and fruit but prefers starchy and
high fat foods. She sneaks candy from her cousins after school. Mom cooks traditional Hispanic meals at
home, but a couple times per week they will go to fast food and get a burger or pizza.
Usual Dietary Intake:
Breakfast: 2 breakfast burritos with cheese, eggs, sausage, beans, and homemade tortillas (made
with lard), and a large glass of juice
Snack: granola bar
Lunch: school lunch (pizza or burger, with fries, maybe a fruit, chocolate milk or juice, with a
Snack: she is offered fruit but prefers candy and dried cereal (Fruit Loops) with regular soda
Dinner: 3-4 tortillas (made with lard), cheese, beef or chicken, maybe a vegetable (corn or peas),
and a glass of whole milk
Snack: microwavable popcorn with butter or ice cream
Food allergy/intolerance: NKFA
1. In the table of laboratory values below, place an X or a checkmark in the appropriate
Interpretation column l to indicate whether the values are high ( ), low ( ) or within normal
limits (WNL). (2 points) 0.25 each item
Fasting Labs 1/20/2017 Patient: Miss R.
Lab Value Interpretatio
ALT 80 U/L X
(4-31 U/L)
AST 28 U/L X
(10-31 U/L)
Glucose 117 mg/dL X
(<110 mg/ dL)
Hemoglobi 6.9% X
n A1c (4-6%)
Total 245 mg/dL X
Cholestero (High > 240 mg/dL)
LDL 163 mg/dL X
Cholestero (<100 mg/ dL)
HDL 22 mg/dL X
Cholestero (40-60 mg/ dL)
Triglycerid 198 mg/dL
es (Borderline High: X
150-199 mg/dL)

Citation: Pocket Guide p. 8 -14

2. Briefly explain how Insulin Resistance can promote Non-Alcoholic Fatty

Liver Disease (NAFLD). (2 points)

- Insulin Resistance can promote NAFLD because it decreases the

inhibitory action of insulin on hormone sensitive lipase and inhibits
GLUT 4 functional uptake of glucose from CHO foods consumed to be
stored in muscle and instead encourages glucose to be taken to the
liver for de novo lipogenesis to take place and convert glucose into free
fatty acids and stored as triglycerides in the liver. Insulin resistance
decreases the inhibitory action of insulin on hormone sensitive lipase.
Furthermore, insulin resistance encourages lipolysis to take place in
adipose tissues and convert triglycerides into free fatty acids and be
taken to be stored in the liver.

Dr. Angela Zivkovic NUT 116B Lecture # 9 Slide #14

3. List which type of nutrient and specific foods in Miss Rs diet that are
contributing the most to each of the parameters below: (3

a. Triglyceride level:
i. Nutrient: Fat, Carbohydrates
ii. Foods: cheese, sausage, homemade tortillas (lard), pizza or
burger, fries, cookie, butter, ice cream, juice and soda
(CHO turns to fat in liver)

b. Total Cholesterol and LDL-cholesterol level:

i. Nutrient: Fat
ii. Foods: cheese, eggs, sausage, lard from tortillas, pizza,
burger, milk, beef or chicken, butter

c. Fasting blood glucose level:

i. Nutrient: Glucose (CHO- simple CHO, simple sugars)
ii. Foods: tortillas, juice, fries, chocolate milk, juice, cookie,
candy, dried cereal, regular soda, ice cream, popcorn

4. Would you recommend that Miss R cut out the 5-6 tortillas she eats
each day? Why or why not? You must justify your answer & provide a
dietary suggestion. (2 points)

- I would recommend that Miss R. eliminates her daily 5 to 6 tortillas a

day because the tortillas yield refined carbohydrates and saturated fat
from lard, both of which will be stored as fat in the liver due to insulin
resistance. This combination of simple carbohydrates and saturated
fatty acids, encourages NAFLD when insulin resistance is taking place
by enlarging the liver with excess triglyceride storage. My dietary
suggestion would be to limit tortilla intake to 1 to 2 a day and
eventually, try to eliminate all together, or make tortillas without lard
and/ or make a whole wheat tortilla (the limit of which would still be 1
to 2 a day maximum).

Use the following supplemental reading to answer the next 2 questions:

2013 Position Paper of the Academy of Nutrition & Dietetics:
Intervention for Prevention and Treatment of Pediatric Overweight
and Obesity

5. This case study represents an example of clinical secondary prevention

and management of pediatric weight and obesity. Select which stage
of intervention you feel will be most appropriate for this situation: (1

______ Stage 1: PCP intervention

______ Stage 2: PCP & RD or other professional lifestyle behavior

___X___ Stage 3: Multi-component family-based intervention

6. What type of dietary intervention plan has typically resulted in the best
outcomes and sustainability for adherence: (1 point)

______ Structured meal plan

__X___ Non-diet plan (Better food choices approach)

7. Write an appropriate MNT goal statement for this case: (2 points)

- Miss R should achieve and maintain appropriate weight through diet

and lifestyle modifications.

Citation: NUT 116L Lecture #3, PowerPoint: Liver Disease Slide Number 16

8. List 4 Dietary Recommendations that you would include in your

Intervention Plan & which would relate to your MNT goal: (4 points)

a. Reduce saturated and trans fat intake

i. Replace lard from tortillas with another ingredient that is
not high in saturated fat, and reduce fast food intake
including fries, cookies, burgers, pizza and instead focus on
foods made at home with an emphasis of incorporating
good fats.

b. Reduce simple and total CHO intake

i. Replace simplified carbohydrate intake with carbohydrates
that are complex and foods that are not as processed.
Modifications that can be made can be popcorn without
butter, and limiting intake of juice, fries, chocolate milk,
juice, cookie, candy, dried cereal, regular soda, ice cream,
popcorn. This could also be done by choosing low glycemic
index foods when identifying foods that work for desired

c. Increase fruit and vegetable intake (and total fiber intake 20-30
i. Increase fruit and vegetable intake, this can be done in
home meals and packing snacks for Miss R to consume
while at school or while at home.

d. Choose more mono unsaturated fatty acids and omega-3 fats

i. Replace fast food meals with more nutrient dense meals
such as fish, salads prepared with olive oil and the
incorporation of avocados.

9. List 3 items that you would Monitor and Evaluate at a 3-month follow-
up: (3 points)

a. Diet Intake (24 hr Recall)

b. Weight

c. Lab Values (lipid panel, HA1c, FBG, TG)

Citation: NUT 116BL Lecture #3, PowerPoint: Liver Disease, Slide Number 16