Megan SuttonFND431L

I. Demographics – SR is a 24 year old female of African descent. SR came to the United States from Uganda and has been in the United States for four months. SR is learning to adjust her shopping and eating habits in the United States and is currently seeking to lose weight and take part in a healthy active lifestyle. A. Patient initials: SRB. Age, Race, Gender: 24, Female, African

II. Chart ReviewA. Diagnosis: etiology, symptoms, treatmentSR has rupture of anterior cruciate ligament of right knee. Injury has limited SR’s ability to be physically active. SR has surgery planned for the following month. SR suffers from LTBI (latent tuberculosis infection) and has been prescribed isoniazid and priftin. SR has BMI of 32.0-32.9 and has been referred to an RD for consultation. SR’s high BMI will be treated through weight loss and weight maintenance therapy. SR’s weight maintenance and weight loss therapy will include diet, physical activity, and behavior therapy.

PES: Food and nutrition related knowledge deficit (NB-1.1) related to lake of understand of healthy food items in a new country as evidenced by diet history and BMI of 32.

B. Pertinent medical/surgical historySR has no known surgical history. History of malaria Lumbar back pain Chronic viral hepatitis B Dental disorder Right knee pain Left medial knee pain PTSD

C. Nutrition principles of treatment of diagnosis– brief paragraph for each diagnosisPES: Food and nutrition related knowledge deficit (NB-1.1) related to lake of understand of healthy food items in a new country as evidenced by diet history and BMI of 32.

SR was referred to a RD for consultation on how to get within a healthy BMI. The RD will teach SR about the different food groups with an emphasis on MyPlate. SR will be taught what a portion size is and how to appropriately portion her meals and snacks. SR will learn what a calorie is and how to determine how many calories a day she should be eating. High calorie vs. low calorie foods and beverages will be discussed and how to burn calories throughout the day.

III. MedicationsA. Purpose of drug and side effects

Naproxen 500 mg 2 x day: Prescribed to treat pain and swelling of her right knee. Common side effects include indigestion, heartburn, stomach pain, nausea, diarrhea, constipation, and headaches.

Isoniazid 300 mg 3 x week: Antibiotic prescribed to treat tuberculosis. Common side effects include nausea, vomiting, and an upset stomach.

Priftin 150 mg 6 x week: Prescribed to treat tuberculosis and is being used with isoniazid to prevent active tuberculosis infections. Common side effects include nausea, vomiting, stomach pain, headaches, joint pain, mild rash, and brown discoloration of skin, tears, sweat, saliva, urine, or stool.

Prazosin 1 mg x day: Prescribed to treat high blood pressure. Common side effects include dizziness, lightheadedness, tiredness, and allergic reaction.

B. Drug/Nutrient interaction

Naproxen: Naproxen should not be taken with alcohol because it can cause stomach bleeding. Stomach irritation is common so drug should be taken with food. Iron depletion can occur if stomach bleeding or mucosal damage occurs. Some folate-depended enzymes may be inhibited by naproxen which could deplete folate absorption (1).

Isoniazid: Isoniazid will interfere with pyridoxine metabolism. Supplementation of B6 is recommended with doses above 10 mg/kg/day. Isoniazid also inhibits the conversion of tryptophan to niacin and has structural similarities as niacinamide which may interfere with its activity. If taken for long periods of time this drug could induce pellagra (2).

Prifitin: Will increase hepatic metabolism of vitamin D due to enzyme induction. If use of this drug lasts for more than one year osteomalacia can occur. It could possibly decrease gastrointestinal absorption of vitamin K and interfere with the regeneration of vitamin K from inactive metabolites. Supplementation is only needed if patient exhibits other risk factors of vitamin K deficiency (1).

Prazosin: There are currently no known nutrient depletion or interferences with this drug (2).

IV. Laboratory ValuesA. Serial values by date in table form

Test 3/3/2016 2/25/2016 2/18/2016 2/11/2016 2/4/2016 1/28/2016 1/21/2016Weight (lb) 191.18 190.74 189.2 188.76 185.46 184.58 186.78Height (in) 64.25 64.25 64.25 64.25 64.25 64.25 64.25BMI (kg/m2) 32.68 32.6 32.34 32.27 31.7 31.55 31.93BP systolic (mm Hg) 100 110 110 105 100 114 100BP diastolic (mm Hg) 60 60 70 60 60 60 60Pulse rate (/min) 80 70 72 76 70 64 72HDL (mg/dL) 40.7LDL (mg/dL) 88Triglyceride (mg/dL) 73

B. Normal values

SR’s blood pressure is currently within a normal rage with her systolic falling below 120 mm Hg and diastolic falling below 80 mm Hg. SR’s pulse rate at 80 beats per minute falls within the normal resting range for an adult which is between 60-100 beats per minute. SR’s LDL level is within the optimal rage falling below 100 mg/Dl. Triglyceride levels are normal at 73 mg/dL.

C. Brief discussion of abnormal valuesSR’s BMI falls within the obesity category at 32.68. Her BMI has fluctuated some but seems to be rising. SR’s HDL level is low and if it falls below 40 this will allow for heart disease to be a major risk factor for SR.

V. AnthropometricsA. Height 64.25 inCurrent weight: 191.18 lbsB. Weight: usual, ideal, percent of usual, percent of ideal

Usual: 188.1 lbs Ideal: 120.59 lbsPercent of usual: 102% Percent of ideal: 159%

VI. Diet History – from patient (family member) interview and medical chartA. Diet prior to admission – modifications previously prescribed

This is SR’s first consultation with a RD therefore no modifications have previously been prescribed. The recall conducted for this patient was the first for her record.

B. Usual intake – from recallMeal Protein Kcal

(grams)Breakfast1/2 cup milk 2% 4 611 Cup Cap'N Crunch 1.6 1441 Cup Grape Juice 2 280Banana 2 200Snack 1 Cup Cheez Its 6 3121/2 Cup Green Grapes 2 52Lunch Fried Chicken 3 Pieces 9 162Mashed Potatoes 1/2 cup 2 118.53 TBSP Butter 0 3002 Slices White Bread 4 15812 oz Coca Cola 0 143Snack Fruit Roll Up 0 50Capri Sun 0 50Chef Boyardee Mac and Cheese 7 oz 6 190DinnerThree Cheese Tortellini Frozen Dinner 16 42016 oz Mountain Dew 0 2031 Slice White Bread 2 79Snack 1 Icecream Sandwhich 3 166TOTALS 59.6 3089

C. Any supplements usedNo supplements are currently used at this time.

VII. Estimation of NeedsA. Energy: formulas or factors used to calculate

Because SR is currently sedentary the Miffli-St. Jeor equation was used to estimate her resting metabolic rate (RMR) and an activity factor of 1.3 was chosen as recommended by the nutrition care manual for obese patients (3).

(9.99 x actual weight) + (6.25 x height) – (4.92 x age) – 161(9.99 x 86.7) + (6.25 x 163.2) – (4.92 x 24) -161 866.1 + 1020 – 118.1 – 161 = 1607 = RMR RMR x AF = Total estimated Kcal 1607 x 1.3 = 2089 Kcal

B. Protein needs Nitrogen needs Gm/kg Calorie:Nitrogen ratioTo calculate SR’s protein needs 1.4 g/kg was used. This was chosen because SR will be undergoing a calorie restricted diet to aid with her weight loss. Leidy et al. found that roughly 1.4 g/kg is the optimal protein intake for women on an energy restricted weight loss diet to have greater amounts of lean body mass preservation, reduction in satiety, and increased pleasure while losing body weight and body fat compared to obese women consuming 0.8 g/kg of protein per day (4).

1.4 g/kg X 54.7 kg = 77 g protein/day

1 gram Nitrogen = 6.25 g protein

77 g protein/day / 6.25 g protein = 12.32 gram nitrogen/day 1 g protein = 4 kcal 77g protein * 4kcal = 308 kcal/day from protein 2089 kcal/day – 308 kcal from protein = 1781 kcal not from protein 1781 kcal not from protein / 12.32 g nitrogen = 145Calorie: Nitrogen Ratio = 1:145 This indicates that SR’s nitrogen balance would be within a normal range if she consumed the calculated amount of calories and grams of protein per day.

B. FluidAs recommended by the nutrition care manual 35 ml/kg was used to calculate fluid needs (3).35 ml/kg X 54.7 kg = 1915 ml fluid per day

D. Vitamins/Minerals – increased requirements An increased requirement of vitamin B6 will be needed due to the current prescribed amount of Isoniazid that SR is taking because this drug interferes with vitamin B6 absorption. Although supplementation of B6 is not recommended for SR at this time. Instead SR will be taught which foods are high in B6 and encouraged to try to eat more of the listed items that she likes to eat.

VIII. Assessment of Nutritional StatusA. Statement or paragraph listing current nutritional problems based on all the above

SR’s BMI of 32.6 falls within the category of obesity and her BMI has been rising since her first visit to Idaho Family Medicine. SR currently has a food and nutrition related knowledge deficit and is struggling to find foods at the market that are healthy. She has been feeling overwhelmed by the size of the grocery store and all the options that are available. SR only speaks Swahili and has found it difficult to read food labels at the store and instead just looks at the picture. SR has only been in the country for four months and is just learning about what a calorie is and how to portion the different food groups during meals throughout the day. She currently has an excessive calorie intake of 3089 calories from her 24 hour recall and enjoys eating convince foods. SR’s protein intake also falls slightly below where it should be for her weight loss plan. SR’s is currently at risk for vitamin B6 deficiency because her Isoniazid interferes with pyridoxine metabolism. SR enjoys drinking soda throughout the day which has been contributing to her excessive calorie intake. SR’s HDL level is low which could put her at risk for heart disease.

B. Overall nutritional status: poor, fair, good, excellentSR’s is considered to have a fair nutritional status. Her excessive calorie intake and food and nutrition related knowledge deficit should be manageable with education. SR should be able to manage her B6 intake and HDL levels with the proper food choices. C. Patient feedback of nutrition intervention (comprehension, individual goals, willingness to comply)SR’s seemed to comprehend the calorie restriction goals that were set by the RD and was

excited to start working towards her weight loss goals. SR was given an English/Swahili handout about nutrition labels that she can bring to the store to help her read the labels as she shops. She feels that this will help her greatly in making healthy food choices at the store. SR has also set a goal to try a new fruit or vegetable that does not look familiar to her each week. SR cannot exercise more than small walks but is excited to try new exercises once she has recovered from her surgery.

IX. Nutrition Care Plan

A Hx: Obese 24 yo female, sedentary, with a dx of LTBI (latent tuberculosis infection) and ruptured anterior cruciate ligament of right knee. Pt. referred to dietitian for having a BMI >32. Wt: 192 lbs.; Ht 5’3”; BMI = 32.7; %IBW:159; IBW = 120.6 lbs ± 10% (109-132 lbs). Estimated energy needs: 2089 kcalEstimated Ptn needs: 1.4g/kgBW/day: (77g/day)Diet Hx: Current diet is hypercaloric, rich in saturated and total fat, sugar, sodium and low in fiber, vegetables, fruits and whole-grains. Labs: TG: 73 mg/dL (low) HDL: 40.7 mg/dL (low) LDL: 88 mg/dL (low) Meds/supplements: Prescribed naproxen 500 mg/day, isoniazid 300 mg/day, priftin 150 mg 6/week, prazosin 1mg/day

D PES: Food and nutrition related knowledge deficit (NB-1.1) related to lake of understand of healthy food items in a new country as evidenced by diet history and BMI of 32.

I Nutrition-related behavior modification therapy, using goal setting to guide the client to decrease consumption of foods rich in cholesterol, saturated fats and sugar. Emphasize on portion sizes and the different food groups. MyPlate handout will be used as a guideline for planning healthy meals. A list will be provided with different types of foods that are in each food group. Pt. will be taught how to read a food label and will be provided with a Swahili/English nutrition label handout to make reading food labels more accessible. Diet adequate for initiate weight loss nutrition therapy by reducing 1000 kcal from estimated energy needs. Pt. goals are to eat at least 3 servings of vegetables per day and to try one new fruit or vegetable per week. Pt. would like to lose 5 lbs by her next appointment in a month. SR is going to try to exercise at least 10 minutes per day.

M/E Pt has follow up appointment in 4 weeks. Monitor compliance with prescribed diet and nutrient intake adequacy (cholesterol, saturated fat, kcal); Monitor any changes in biochemical panel and weight;Provide nutrition education and counseling on healthy food choices;Client will record food and activity log at least 75% of the time.

X. Outcome/EvaluationA. Statement or paragraph regarding nutrition intervention and impact on patient outcome

Nutrition intervention will consist of combination therapy of education, dietary interventions, and physical activity. SR is currently unable to exercise on a regular basis but plans to start exercising once she has recovered from surgery. SR has been taught what a calorie is and how to burn them by exercising. SR has been shown the MyPlate diagram and has been taught about proper portion sizes and how to incorporate the different food groups into her meals throughout the day. SR will use the translated nutrition label handout to read food labels when she is making purchases at the grocery store. It has also been recommended that SR try to shop the perimeter of the store to feel less overwhelmed by the size and amount of options presented. A reduced calorie intake of 1000 kcal per day has been set for SR. To decrease SR’s daily calorie intake she will try to choose fruits, vegetables, and whole grains throughout the day. Reducing soda consumption was discussed and crystal light was suggested as an alternative to drinking soda. SR will be encouraged to eat more tuna, turkey, and chicken because they are high in vitamin B6. A focus on substituting olive oil instead of eating butter should help raise SR’s HDL levels but she will also be taught about the proper portion size when using oils to prevent an elevated calorie intake. SR has been provided with a log book that she can fill out to track her meals and calories throughout the day. SR has been excited about changing her lifestyle and is very willing to make the covered dietary changes. She plans to use the handouts provided to help make meal planning and grocery shopping less stressful. Nutrition intervention should have a beneficial impact on patient outcome because the patient is very willing to comply with the dietary and lifestyle changes that were suggested. Weight loss will decrease SR’s BMI and put her less at risk for obesity related complications.

XI. ReferencesA. Show adequate referencing to demonstrate the diagnosis and treatment were researched

1. Natural Medicines Comprehensive Database. Drug Influences on Nutrient Levels and Depletion, 2010. Web. 16 March. 2016.

2. Gaby, R. Alan., Forrest, Batz., Chester, Rick., Constantine, George. A-Z Guide to Drug-Herb-Vitamin Interactions. New York, NY. Healthnotes, 2006. Print.

3. Academy of Nutrition and Dietetics. Nutrition Care Manual. [Overweight & Obesity]. [https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=272986&lv2=16997&ncm_toc_id=16997&ncm_heading=&]. Accessed [March 16, 2016].

4. Leidy JH, Carnell NS, Mattes RD, Campbell WW. Higher protein intake preserves lean mass and satiety with weight loss in pre-obese and obese women. Obesity. 2007; 15(2): 421-229. doi:10.1038/oby.2007.531