Willett Wellness

Sophie Willett Degree Pending

ADIME for Henry

Assessment
 Client History
o 30 YOM
o Medical Dx: Type 1 Diabetes
o PMH: NKA, 3 injections of insulin/day
o Social history: Patient lives in a home with his wife, non-smoker
 Anthropometrics
o Ht: 6’ CBW: 163# BMI: 18.6kg/m2 UBW: 163# IBW: 178# TSF: NA
MAC: NA
o %IBW: 92% %UBW: 100% %change: NA TSF: NA AMA: NA
o Assessment: Patient has a healthy BMI and no weight changes recently
 Biochemical – Triglycerides: 190 mg/dL (very high) Total Cholesterol: 250 mg/dL
(high) HgA: 8.2 (very high)
o Blood sugar levels:
 Before breakfast: 190 mg/dL (very high)
 Before Lunch: 100mg/dL (okay)
 Before Dinner: 220 mg/dL (high)
 Before bed: 150 mg/dL (okay if not too long after dinner)
 Clinical S/Sx – None known
 Diet
o Patient eats breakfast and dinner at home, lunch and snack at work, patient
rarely eats out
o 24 hour recall: 3435kcal 135g pro (1.8g/kg) 305g CHO (35% kcal)
171g fat (45% kcal)
o According to 24 hour recall, patient is consuming 130% of energy needs and
almost half of calories are coming from fat
Willett Wellness
Sophie Willett Degree Pending

o Diet consists of fried or baked meats, buttered and salted vegetables, full or low
fat dairy products, and 1-2 cans of beer 2x per week
o No known intolerances or preferences, patient is willing to try new things
o No known vitamin, mineral, or other supplement intake
 Daily Nutrient Needs
o Energy: 2600 kcal (calculated with MSJ with 1.5 AF)
o Protein: 11% kcal 1g/kg 74 g
o Carbs: 58% kcal 377g
o Fat: 31% kcal 89g
o Fluid: 1ml/kcal 2600 ml
 Motivation: Unknown
Diagnosis
1. Excessive energy intake related to food and nutrition knowledge deficit on balanced diet
and high fat intake as evidenced by 130% of recommended kcals consumed according to
24 hour recall, high blood triglyceride and cholesterol levels.
2. Inconsistent carbohydrate intake related to varying amounts of carbohydrate consumed
throughout the day and no am or HS snack consumed as evidenced by a high HgA level
at 8.2 and inconsistent blood glucose levels throughout the day.
Intervention
 Goals:
o Decrease total energy intake to recommended amount of 2600 kcal over the
course of 2-4 weeks.
o Increase patient’s consumption of fruits and vegetables to include 1-2 servings
per meal over course of 2-4 weeks.
o Lower HgA levels to 6% or less over course of 2-3 months by consuming more
consistent carbohydrates throughout the day following a meal pattern of 6,6,6
and a snack pattern of 2,2,3.
Willett Wellness
Sophie Willett Degree Pending

 Diet Rx
o Diet to provide at least 2600 kcal and 74g protein, consistent carbohydrates, 2g
sodium, and 2600 ml fluids per day. Based on nutrient recommendations diet
will provide 100% of energy, 100% of protein, and 100% of fluid needs.
 Intervention strategies listed
o Educate patient on cooking with less fats and oils to decrease calories from fat
and provide patient with recipes for examples.
o Encourage patient to cook only one component of each meal with oil or butter
instead of all of them.
o Educate patient on increasing fruit and vegetable consumption to have at least
one fruit and vegetable serving at each meal.
o Encourage patient to consume snacks low in fat and to incorporate vegetables
and fruits into his snacks.
o Provide patient with recommended meal and snack pattern (6-6-6 and 2-2-3)
and educate him on the meaning of carb exchanges.
o Recommend patient take a food log to increase awareness of what he eats.

Total B L D am pm hs
servings snack snack snack
CHO 25 6 6 6 2 2 3
NF Dairy 2 1 1
Fruit 7 1 2 2 1 1
Starch 16 4 3 4 1 2 2
Pro, MF 4 oz 1 oz 2 oz 1 oz
fat 14 3 4 3 1 2 1
Willett Wellness
Sophie Willett Degree Pending

Monitoring and Evaluation

Indicator (based on PES Current level of indicator Criteria for success
statements)
1. Energy consumption High Consumes 2600 kcals daily

2. Blood Triglyceride and High Cholesterol < 200 mg/dL

cholesterol levels Triglycerides < 150 mg/dL

3. Blood Glucose levels Inconsistent Pre-eating levels between

70-130 mg/dL
Post eating levels < 180
mg/dL

 Follow-up plan
o RD to follow up twice in next month to go over food log and discuss how well
patient has been able to change meal/snack patterns. RD to address any barriers
or issues patient is having with making these changes.
o Lab values to be observed and evaluated so that appropriate intervention can be
adjusted accordingly.
o From there RD to follow up monthly until goals have been met.

Sophia Willett, Degree Pending

January 27th, 2020 3:10 pm

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