case study: dm/chd version 7

Case Study: DM/CHDVersion 7

Erica Frost, Katlyn RhodesSamantha Mallik, Onalee Neff

Chad, 28 year old high school graduate Employed at a drug store Doesn’t eat fruit and vegetables, only meals

with minimal preparation States abnormal thirst and hunger, and not

feeling right Admitted after found throwing up blood and

barely responsive

Patient

Breakfast:◦ 2 strawberry poptarts◦ 1 glazed doughnut◦ 1 cup lowfat milk

Snack:◦ 2 cups of coffee◦ 1 fruit danish

Dinner:◦ 1 frozen dinner, Hungry man Salisbury Steak◦ 12 oz Mountain Dew◦ 1 slice white bread◦ 1 tsp. butter

Snack:◦ 5 slices pepperoni pizza◦ 5, 12 oz light beers

Diet Assessment

24 hour recall◦ 13 medium fat meat exchanges◦ 1 low fat milk exchange◦ 22.5 starch exchanges◦ 30 fat exchanges

Kcals:◦ Carbohydrates: 1398◦ Protein: 666◦ Fat: 2183◦ Total: 4247

Diet Evaluation

Sex: Male Age: 28 Height: 5’10” (70 inches) Weight: 230 lbs (104.5 kg) Ideal body weight: 166 lbs % Ideal body weight: 139 BMI: between 33-34 Interpretation: Obese

Anthropometry

pH: 7.0 ◦ Indicates acidosis

HCO3: 19◦ Low

Interpretation:◦ Metabolic acidosis due to decrease in both pH and

HCO3

Acid/Base Balance

Diabetes*polydypsia and increased hunger- evident by patients subjective history. *Weight=139% IBW, 33-34 BMI, upon admission*Diet high in trans fatty acids, contributed more than 7% of his daily fat intake *Hyperglycemia- evident by

*Excessive alcohol consumption *Blood Glucose=560*Too much food *Nausea

*Diabetic Ketoacidosis (DKA)- evident by*Hyperglycemia*BP indicated Hypertension, which is a screening factor

for diabetes *Pt. HCO3 and PCO2 levels are low

Laboratory and physical data

Cardiovascular disease* Stage 1 hypertension- BP= 150/90*Poor diet-

*Pt. diet is high in Saturated and Trans fatty acids, more than 50% of his current dietary intake are from Fat*Alcohol consumption-

*more than 1-2 drinks a day increases BP* HDL lowers and Triglycerides raise

*Obesity- *BMI: 33-34 *related to hypertension*glucose intolerance

*Lab values-*Cholesterol: 325-elevated undesirable*LDL: 265-elevated*HDL: 40-borderline* elevated serum triglycerides

*Microalbuminuria-*marker of increased cardiovascular risk and hypertension

Laboratory and physical data

Primary◦ Excessive fat intake related to frequent

consumption of high risk lipids as evidenced by serum cholesterol level of 325 mg/dL, LDL of 265, and triglyceride of 300.

Secondary◦ Inappropriate intake of types of carbohydrates

related to cultural practices that affect the ability to regulate carbohydrates consumed evidenced by hyperglycemia and random blood glucose level of 560.

Nutrition Diagnosis

Angiotension II◦ Avapro

Reduces hypertension by restricting narrowing of blood vessels

Lovastatin◦ Lowers cholesterol by blocking the production of

cholesterol in the body◦ Reduces LDL and total cholesterol levels ◦ Lovastatin combined with a cholesterol lowering

diet plan is very effective

Medications

Caloric needs ◦ RMR= 10xwt(kg)+6.25xht(cm)-5x28+5

10x104.5+6.25x171.5-5x28+5RMR= 1982 Kcal *Ambulatory *BMR=1.3x1982=2577 Kcal *Adjusted BMR=1.5x2577= 3866 Kcal

* The Pt. calorie need is 2,577 Kcal

Metabolic Needs

Protein needs◦ Oral anabolic requirements

*Protein needs 1.2-1.5g/Kg*Kg actual body wt. 104.54x1.2=125

104.54x1.5=157 g Protein/day

◦ Grams of Nitrogen= 3866/150=25.7 g N required◦ 25.7N x 6.25=161 g Protein/day

*The Pt. protein need is125-161 g Protein/day

Metabolic Needs

Pt. IBW would be between 156-176lbs, this is a unrealistic short term goal, but could be a great long term goal for the patient to strive for

*We do recommend a 5-10% reduction of his current weight of 230lbs/104.54 kg

- with this reduction his weight would then be 207-218 lbs which is a realistic goal

* We do not recommend any weight loss until the Pt. is in a stable condition

Weight Loss Recommendation

The prescribed diet will consist of:◦ 55% of calories from carbohydrates◦ 20% of calories from protein◦ 25% of calories from fat

RMR= 2,577 kcal daily◦ 1417 kcal, 354 g carbohydrates◦ 515 kcal, 129 g protein◦ 644 kcal, 72 g fat

MNT Diet Prescription

Calorie Consumption:◦ The pt. is currently consuming 4247 kcal◦ Prescription: Reduce caloric intake to 2558 kcal

Fat Intake:◦ Current Intake: 242 kcal (150 g) ◦ Prescription: 70 kcal (35 g)

Protein Intake:◦ Current Intake:167 kcal (42 g) ◦ Prescription: 129 kcal (32 g)

Fruit and Vegetable Intake:◦ We recommend he adds fruits and vegetables to his diet.

Meat:◦ We are encouraging him to eat lean meat instead of medium meat.

Milk:◦ We are encouraging a higher milk consumption

Patients Intake vs. Prescription

Number of exchanges

Protein Carbohydrate

Fat

Meat 8 56 g -- 24 g

Milk 4 32 g 48 g --

Vegetable 4 8 g 20 g --

Starch 11 33 g 165 g 11 g

Fruit 8 -- 120 g

Fat 7 -- -- 35 g

TOTAL 42 129 g 353 g 70 g

Exchange Plan

Exchange Food

Breakfast 3 starch3 fruit2 milk1 fat

Lunch 3 meat2 starch2 fat1 vegetable1 fruit

Snack 3 fruit1 milk1 fat

Dinner 5 meat4 starch2 fat2 vegetable1 milk1 fruit

Snack 2 starch1 vegetable1 fat

11 starch exchanges : 11 g 8 meat exchanges : 24 g 7 fat exchanges : 35 g 4 milk exchanges (skim) : 0 g TOTAL : 70 g

Fat Calculations

5-10% weight reduction, short term goal Glucose maintained to desirable limit Achieve and maintain desirable lipid levels,

through diet and therapeutic lifestyle changes◦ LDL cholesterol < 130-159◦ HDL > 40◦ Triglycerides < 150-199◦ Cholesterol < 200-240◦ Blood Pressure 130-139/85-89

Patient Goals

Patient will regularly see RD, 4-8 times within 6 month period.

Set timeline with RD for setting goals, and visits

Record 3-day or weekly diet record for first visit showing understanding of prescription

Lab values will be taken to ensure BGL and lipid profile are effectively being reduced.

Implementation & Monitoring