CASE STUDY #1 – Obesity

NUT 116AL – Due 10/28/2016
Case Study Adapted from: https://www.ncbi.nlm.nih.gov/pmc/articles/

Instructions:
 Review the pt’s medical record below. Answer each question and show your calculations (if necessary)
for each. You may include your calculations in the answer box and, if needed, attach as a separate, hand-
written sheet.
 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. After you have EXHAUSTED your search for answers to your CS questions and you are still
unable to find the answer, you may use outside resources as long as they are credible resources. e.g.:
Mayo Clinic, medline plus, research articles, etc., NOT wikipedia. Remember to conduct a thorough
search of the resources available to you prior to using outside references to avoid losing points.
 In your citation, please include the resource name (i.e.: Mayo Clinic), title of page/article, & exact
URL link
 You must type your answers! If not, questions will not be graded and you will receive 0 points.
 To familiarize yourself with medical terminology, utilize an online dictionary such as:
http://www.medilexicon.com/medicaldictionary.php
 CS #1 is worth 50 pts.

MD NOTES:
_____________________________________________________________________________________________________
Axxxxx, Axxxxx Female 52 yo
Allergies: NKA Pt ID: XXXXX1234 DOB: 02/01/1964
Pt. Location: Ambulatory Clinic Physician: C. Johnston Date: 10/26/2016
_____________________________________________________________________________________________________

Pt Summary: WDWN 52yo overweight, otherwise healthy female with a positive family history of CHD.
Routine PE follows.

PMH: Pt had measles, mumps, and chicken pox in childhood and an appendectomy approximately 20 years
ago. No hx of rheumatic fever, DM, or kidney disease. Gravida 2 Para 1.

FH: Pt’s father died of acute MI at age 49 and older brother had MI at 55. Both siblings with high s.
cholesterol. Both parents and all grandparents with high cholesterol levels. No hx of diabetes.

Social Hx: Employed at bank; strong network friends/family.

ROS: Patient has no complaints except C/O occasional mild tension headaches.

PE: Somewhat overweight white female; 65” 240#, med. frame, waist circumference 96 cm. BP 120/79
right arm, sitting, without postural changes. P 76 and regular. R 15. Neck without thyromegaly, venous
distention, or bruits. Lungs clear to P&A. Heart: regular rhythm without murmur or gallop. Abdomen
slightly obese, soft and without bruit. Extremities revealed no edema. Screening neurologic exam, including
mental status exam, is completely WNL.

EKG: normal sinus rhythm with rate of 80, normal intervals and no evidence of ischemia, strain, or
hypertrophy. CXR unremarkable.

Rx: none; OTC: MVI, 1000 mg Ca, asa prn

Plan: nutrition consult for weight reduction and pt. education.

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Laboratory Results (non-fasting)
Chemistry Ref. Range 10/28/16
Sodium (mEq/L) 136-145 138
Potassium (mEq/L) 3.5-5.5 3.6
Chloride (mEq/L) 95/105 99
Carbon dioxide (CO2, mEq/L) 23-30 27
BUN (mg/dL) 8-18 15
Creatinine serum (mg/dL) 0.6-1.2 0.9
Glucose (mg/dL) 70-110 110
Phosphate, inorganic (mg/dL) 2.3-4.7 3.9
Magnesium (mg/dL) 1.8-3 2.0
Calcium (mg/dL) 9-11 10
Osmolality (mmol/kg/H2O) 285-295 289
Bilirubin total (mg/dL) ≤1.5 0.8
Bilirubin, direct (mg/dL) <0.3 0.07
Protein, total (g/dL) 6-8 6.8
Albumin (g/dL) 3.5-5 4.2
Prealbumin (mg/dL) 16-35 22
Ammonia (NH3, umol/L) 9-33 11
Alkaline phosphatae (U/L) 30-120 118
ALT (U/L) 4-36 21
AST (U/L) 0-35 10
CPK (U/L) 30-135 F, 55-170 M 125
Cholesterol (mg/dL) 120-199
HDL-C (mg/dL) >55 F, >45 M 55
VLDL (mg/dL) 7-32 30
LDL (mg/dL) <130 106
LDL/HDL ratio <3.22 F, <3.55 M 2
Triglycerides (mg/dL) 35-135 F, 40-160 M 135
T4 (ug/dL) 4-12 6.1
T3 (ug/dL) 75-98 82
HbA1C (%) 3.9-5.2 5.0
Hematology
WBC (x 103/mm3) 4.8-11.8 10.2
RBC (x 106/mm3) 4.2-5.4 F, 4.5-6.2 M 4.5
Hemoglobin (Hgb, g/dL) 12-15 F, 14-17 M 13
Hematocrit (Hct, %) 37-47 F, 40-54 M 40
Mean cell volume (um3) 80-96 85
Mean cell Hgb (pg) 26-32 27
RBC distribution (%) 11.6-16.5 14.1
Platelet count (x103/mm3) 140-440 261
Transferrin (mg/dL) 250-380F, 215-365 M 273
Ferritin (mg/mL) 20-120 F, 20-300 M 80
Vitamin B12 (ng/dL) 24.4-100 72
Folate (ng/dL) 5-25 15
Urinalysis
Collection method - Clean catch
Color - Yellow
Appearance - Clear
Specific Gravity 1.003-1.030 1.004
pH 5-7 6.1
Protein (mg/dL) Neg Neg

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Glucose (mg/dL) Neg Neg
Ketones Neg Neg
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.1 Neg
Leukocyte esterase Neg Neg
Protein check Neg Neg
WBCs (/HPF) 0-5 0
RBCs (/HPF) 0-5 0
Bacteria 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0

RD OVERVIEW:
AA is a 52-year old WDWN woman desiring weight loss. She presented for treatment following a recent
routine PE during which her primary care physician noted concerns about her increasing weight. The
physician recommended that she try to lose weight but did not provide any specific or further guidance. In
light of her previous “failed” experiences with commercial weight loss programs, she decided to seek
treatment at a university-based outpatient program. At initial evaluation, she is 65 inches tall and weighs
240 pounds. She has normal blood pressure and borderline high cholesterol but is otherwise in good
health. Pt completed college and has been employed at a bank in the same job for 13 years. She lives with
her husband of 25 years, and one of her three adult children. She reports that her relationships with her
husband and family are good, her job is enjoyable and rewarding, and she has a good circle of close friends
and family.

AA reports the onset of overweight during adulthood. She reports having been involved in sports
throughout childhood, viewed herself as “big-boned,” did not have body image concerns nor did she recall
feeling dissatisfied with her weight or shape when younger. She denies any significant dieting behaviors
until age 30. She reports maintaining a weight of approximately 150 pounds until age 30, at which age she
became pregnant with her second child. She reports that she never fully lost the “baby weight” and
subsequently began to gradually gain weight throughout her 30s despite numerous dieting efforts. She
reports a rapid weight gain of approximately 25 pounds in the past 6 months following the death of her
mother.

AA reports that she had enrolled in commercial weight loss programs approximately five different times,
and had, in addition, tried to follow multiple magazine-based fad diets. She reports that when she was
following a weight loss plan, she could successfully lose approximately 10 pounds, but that she would ‘hit a
wall’ and discontinue after about one month of dieting. Pt reports that she has not engaged in any formal
dieting in the past 18 months, although she frequently skipping meals in an effort to reduce her weight.

AA is of Russian/Ukrainian decent and she is a first-generation American. Traditional foods are only
consumed on holidays. AA’s daily pattern of eating is to skip breakfast and to consume a standard work
cafeteria lunch at 1:00 p.m. She typically does not eat again until preparing the evening meal, at which point
she will “graze” while cooking. AA reports eating a “normal” meal with her family most evenings, consisting
of 5-6 ounces of meat/protein, 2 or 3 types of vegetables, kasha or noodles, and bread. She often eats the
“leftovers” while cleaning up after the meal, often consuming the equivalent of a 2nd meal. She then eats
various foods throughout the rest of the evening until bedtime, usually alternating between salty and sweet
snacks.

AA reports that she does not follow an exercise program. Most weekends she and her husband will go for a
morning walk to Starbuck’s.
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A 24-hour recall revealed AA’s “typical” weekday diet (weekends fairly similar):
Breakfast: 1-16 oz tea
Break: 1-12 oz coffee with ¼ c creamer and 2 tsp sugar
Lunch: 1 turkey & cheese sandwich (Subway 6” type) on white roll with mustard, mayonnaise,
lettuce, tomato, onions, pepperoncini
Small soda
Dinner: 4 oz Beef roast, 1 c kasha (made with olive oil, onion), ½ cup red beet & potato salad
(with vinaigrette dressing), ½ cup cooked spinach (made with garlic and olive oil)
Water to drink
“Snacking” on leftovers while cleaning up
Snack: 3 c microwave popcorn
½ cup ice cream (vanilla)

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First Name: Akarin Last Name: Mittongtare

1. AA’s BMI is 40.02, which indicates that she is OBESE Class (III).
Interpret the results in relation to her health risks. (3 pts) (show calculations)
BMI = kg/m2

240#, 1# = 2.2kg, 240lbs = 109.09kg
65in, 1m = 39.370in = 1.651m

BMI = 109.09kg/39.3702 = 40.02

Based on the lecture slides on obesity, obesity is often associated with increased morbidity and mortality.
Risk of diabetes and heart disease are both doubled in adults who are obese according to the slides presented
by Dr. Steinberg. This is of course, in comparison to adults of a normal weight. Medical complications of
those who are obese also includes, pulmonary disease, nonalcoholic fatty liver disease, gallbladder disease,
gynecologic abnormalities, osteoarthritis, cancer, severe pancreatitis, diabetes, coronary heart disease,
cataracts and even stroke.

PR: pg. 1

2. AA’s IBW is 125lbs and her percent IBW is 192%. (2 pts) (show calculations)
IBW Women: 100# for 1st 5 feet (height) + 5lbs for each individual additional inch >5 feet

IBW = 100# + 5(5in) = 125#

%IBW = (CBW/IBW)x100
%IBW = (240#/125#)x100 = 192%

PR: pg 2

3. Using the Mifflin-St Jeor equation, calculate AA’s kcal needs for weight maintenance. Use AA’s
ABW. (2pts) (show calculations)
Mifflin-St Jeor for Women: (10xWeight(kg)) + (6.25xHeight(cm)) – (5xAge) – 161

Use CBW for weight maintenance: 240# x 2.2kg = 109.09kg
MSJ = [(10x109.09kg) + (6.25x165.1cm)] - (5x52) – 161 = 1702kcal/day
AF: 1.4-1.5

1924kcal/day x (1.4-1.5) = 2383kcal/day – 2553kcal/day

PR: pg 3

4. How much protein does AA need? 45g Using evidence-based information, why is this amount of
protein adequate to meet her needs? (2 pt) (show calculations)

Average protein requirements on Non-stressed/well nourished: 0.8g protein/kg BW
0.8g protein x 56.7kg IBW = 45g

PR: pg 5

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5. Based on the Adult Weight Management Guidelines, what is a reasonable wt goal for AA and
over what time period? Explain your rationale. Is this a reasonable wt goal for AA’s current
lifestyle? (2 pts) (show calculations)
The Adult Weight Management Guidelines state that the patient should have an energy deficit of
approximately 500-750 kcal/day in order to lose weight. A realistic weight loss goal would be to lose up to
two pounds per week because this is attainable and not a stretch. Since one pound of fat is approx. 3500
kcal, this is very possible. At a 500-750kcal deficit per day, she should be lowering her intake by 3500-5250
kcals/ week correlating to 1-1.5 lbs/week.
Exercise would also be a good option since the patient is willing to change. For AA, this is a reasonable
goal because she is aware that she needs to lose weight and is also willing to diet. She will also be less likely
to “hit a wall” if she has follow-up visits.

(116AL OBESITY LECTURE, SLIDE 46)

6. Determine AA’s energy and protein requirements to promote weight loss considering Question
#5. Explain the rationale for the method you used to calculate these requirements. (2 pts) (show
calculations)
EER - 500 =
2383kcal - 500kcal = 1883kcal/day
2553kcal - 500kcal = 2053kcal/day

Energy requirement for patient AA would be approx. 1883kcal/day and her protein requirement at
45g/day would stay the same. 3500kcal is approx. equal to 1# so if you take 3500 and divide that into
7 days, it equals 500kcal/day. Thus, a deficit of 500kcal/day is required to lose 1# a week. Also, since
only weight loss from kcal deficit is desired, protein requirement does not need to change.

(116AL OBESITY LECTURE, SLIDE 46)

7. Evaluate the following lab results and describe what these values indicate. How might they
change after weight loss? (4 pts)

Test nl Values AA’s Comparison What do AA’s lab values suggest?
Values (+/-)
BG 70-110mg/dL 110mg/dL +/- AA’s value is on the higher end of the
normal range.
Total 120- 201mg/dL + AA’s value is slightly higher than the
Chol. 199mg/DL normal range.
HDL >55mg/dL 55mg/dL +/- AA’s value for HDL is on the borderline.
LDL <130mg/dL 106mg/dL - AA’s value for LDL is within the normal
range.
TGs 35-135mg/dL 135mg/dL +/- AA’s value for TGs are borderline on the
higher end.

After weight loss, we would see a:
Decrease in BG
Decrease in cholesterol
Increase in HDL
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Decrease in LDL
And a decrease in TGs

(116AL OBESITY LECTURE, SLIDE #24)

8. AA is in which stage of the “Stages of Change?” Provide evidence for your choice. (2 points)
Preparation stage
AA is in the Preparation Stage. She is compliant with her physician who said she should lose weight,
because she is aware of her weight issue. Previous weight loss attempts also prove she is aware and
willing to lose weight.

(116AL NUTRTION COUNSELING LECTURE, SLIDE #25)

9. Write a nutrition note to be included in AA’s medical record. (8 pts; 2 pts each)

S:
Pt AA desires weight loss due to a recommendation from her primary physician that should lose
weight and a positive family history of CHD. Pt has not tried dieting in the last 18 months as her
previous attempt at dieting had not been successful. Pt skips breakfast, eats a standard cafeteria lunch
and snacks on “leftovers” as she cleans up after dinner. Her typical daily diet consists of high amounts
of sodium and sugars. Pt has been working at a bank for the last 13 years and does not follow and
exercise program.

O:
Patient AA is a 52 year old female who was recommended to lose weight by her physician.

Anthropometrics:
Ht: 165.1cm, Wt: 109.09kg, BMI: 40.02 (Obese Class III), IBW: 56.7kg, %IBW: 192%

Lab:
BP: 120/79, BG: 110 mg/dL, Total cholesterol: 201 mg/dL, HDL: 55 mg/dL, LDL: 106 mg/dL, TGs:
135 mg/dL

A:
1. Excessive oral intake (NI-2.2) r/t physical inactivity (NB-2.1), excessive fat intake (N1-5.6.2),
and overeating after dinner AEB BMI 40.02 indicating class III obesity and %IBW 192%.
2. Physical inactivity (NB-2.1) r/t sedentary occupation and lack of exercise program.
Pt is in good health with normal blood pressure however, she has borderline high cholesterol.

P:
MNT Goal: Set a realistic wt loss goal; 1-2# per week for the first 4 months to achieve 16# wt loss.
Recommendations:
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1. Recommend Pt begin a meaningful and well thought-out diet as opposed to a fad diet that may
not be backed by scientific evidence.
2. Recommend consuming a nutrient-dense breakfast as well as snacking on nutrient dense
snacks between meals in order to avoid over-eating post dinner.
3. Have spouse clean up post-dinner so that she is not tempted to snack on “leftovers.”
Diet instruction given to pt and family; handout provided on how to decrease calories by switching
methods. Expected compliance is good due to willingness of pt to attempt weight loss and due to good
relationship with family.
Monitor: HDL, LDL, TG levels, and total cholesterol.
Follow up in 2 weeks via in-person apt.

Signature: Akarin Mittongtare, Nutrition Student

10. Write a similar note in the ADIME format. (4 pts; 1 pt each)

A:
52 year old F pt who was recommended to lose weight by her physician. Pt and immediate family
have borderline high cholesterol levels and hx of CHD. AA works at a bank and does not exercise. Pt
has attempted multiple fad diets to no success but shows willingness to lose wt. Pt has a tendency to
skip breakfast in an attempt to lose weight and snacks on “leftovers” post-dinner; often consuming
the equivalent of a second meal. Pt consumes late night sweet and salty snacks throughout the
evening. Pt reports not following an exercise program, but walks to Starbuck’s every weekend with
her spouse.

Anthropometrics:
Ht: 165.1cm, Wt: 109.09kg, BMI: 40.02 (Obese Class III), IBW: 56.7kg, %IBW: 192%

Lab:
BG: 110 mg/dL, Total cholesterol: 201 mg/dL, HDL: 55 mg/dL, LDL: 106 mg/dL, TGs: 135 mg/dL

D:
1. Excessive oral intake (NI-2.2) r/t physical inactivity (NB-2.1), excessive fat intake (N1-5.6.2),
and overeating after dinner AEB BMI 40.02 indicating class III obesity and %IBW 192%.
2. Physical inactivity (NB-2.1) r/t sedentary occupation and lack of exercise program.

I:
MNT Goal: Set a realistic wt loss goal; 1-2# per week for the first 4 months to achieve 16# wt loss.
Recommendations:
1. Recommend Pt begin a meaningful and well thought-out diet as opposed to a fad diet that may
not be backed by scientific evidence.
2. Recommend consuming a nutrient-dense breakfast as well as snacking on nutrient dense
snacks between meals in order to avoid over-eating post dinner.
3. Have spouse clean up post-dinner so that she is not tempted to snack on “leftovers.”
Diet instruction given to pt and family; handout provided on how to decrease calories by switching
methods. Expected compliance is good due to willingness of pt to attempt weight loss and due to good
relationship with family.

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M/E:
Monitor:
1. Cholesterol levels, HDL, LDL, and TG levels
2. Wt
Follow up in 2 weeks via in-person apt.

Signature: Akarin Mittongtare, Nutrition Student

11. List 4 realistic dietary (food) strategies that AA could incorporate into her eating pattern to
make her diet healthier. (2 pts)

1. Eat breakfast regularly.
2. Spread kcal throughout the day to avoid overeating at night.
3. Reduce amount of high fat foods to one meal a day as opposed to each of her meals.
4. Incorporate fruits into high caloric dessert by substituting half of usual dessert intake with
fruit.

12. List 4 realistic ways for AA to increase her PA, not including a gym membership. (2 pts)

1. Take a short walk during her work break.
2. Take some time out of the weekend to play sports with her spouse as she reported playing
sports throughout her childhood. It might be nostalgic.
3. Park as far front door of her work place as possible, making it so she has to walk farther.
4. Take family walks after dinner.

13. List 4 behavioral strategies (not diet and PA) that AA could use to reduce her kcal intake. (2
pts)

1. AA can practice listening to her hunger cues and intuitive eating a.k.a eating when she’s
hungry to avoid overeating after dinner.
2. Keep a food diary to monitor food intake.
3. Use physical activity as a reward for celebratory occasions. (ex. Going out for a family sports
night, or 1 on 1 with her spouse to celebrate positive events)
4. Have her spouse clean up after dinner so that she doesn’t snack on “leftovers.”

14. AA’s 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 11, one from question 12, and one
from question 13 and set a measurable goal (SMART) for each of these that AA can work toward
over the next two weeks between visits. (3 pts)

11. Eat breakfast regularly.
Goal: Over the next two weeks, AA will eat breakfast 2-3 times/week.

12. Take a short walk during her work break.
Goal: Over the next two weeks AA will take a 15 minute walk 2-3 times/week during her work
break.

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13. Have her spouse clean up after dinner so that she doesn’t snack on “leftovers.”
Goal: Over the next two weeks AA will have her spouse clean up after dinner 3 times/week.

15. If the interventions outlined above do not work and AA reaches a plateau after losing 20
pounds, what do you think the next appropriate step should be and why? (2 pts)

The next appropriate step would be for AA to be guided through a kcal adjustment. As weight is lost,
metabolism changes and the body’s kcal requirements change as well. In adjusting kcal intake, we are
adapting to AA’s new, lower weight body.

16. In column one, list each food in AA’s diet that is high in a potentially harmful nutrient. In
columns 2-5, put a check by the foods that are high in these constituents. In column 6, give an
example of a potentially healthier food that can be substituted for the food in column 1. (6
pts). Add additional lines if needed.
1. Food 2. Tot. Fat 3. Sat. Fat 4. Na 5. Sugar 6. Substitution:
¼ c creamer 72g 2g 40mg 19g Low fat or Non-fat Milk
2 tsp sugar 0g 0g 0g 8g Splenda
White Roll 12g 0g 180mg 2g Whole Grain Roll
Mayonnaise 93g 2g 88mg 0g Avocado Spread
Small Soda 0g 0g 45mg 47g Juice + Carbonated water
(diluted)
3 c Microwave 118g 6g 300mg 0g Assorted nuts
Popcorn
½ c Ice Cream 66g 5g 53mg 11g Low-Fat Yogurt
(vanilla)

17. AA believes it is OK to skip breakfast, eat a light lunch, and eat a big meal at night. Is anything
wrong with this kind of thinking? If so, identify the problem and describe the solution. (2 pts)

There is something wrong with this kind of thinking because when AA skips breakfast and eats a light
lunch, she is much more likely to be extremely hungry by dinner and overeat. When she overeats at
dinner and throughout the night, this causes her to gain weight. A good solution would be to eat
smaller, more frequent meals as to spread out kcal through the course of the day. This will be greatly
decrease the change of AA overeating.

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