NUT 116AL CASE STUDY #1

Due 11/12/14
Instructions:
Review the pts medical record below. Answer each question and show your calculations for each, if required. Reference all
calculation formulas with the text and page number from PR (i.e., PR p. ___). You must type your answers! If not, questions
will not be graded and you will receive 0 points. CS#1 is worth 50 points.
Client Name: ZZ
DOB: 2/15/89
Sex: Female
Education: High school diploma; some vocational school
Occupation: Office receptionist
Hours of work: Monday Friday 9:00 5:00
Household members: Mother 45, younger siblings (18, 20)
Ethnic background: Biracial (African American and Caucasian)
Religious affiliation: None
Referring physician: D. Smith, M.D.
Chief complaint:
Family noticed that ZZ appears to stop breathing for several seconds several times a night. She is extremely irritable when
she gets up in the morning. She reports getting very sleepy while at work and fell asleep at her desk yesterday.
Pt hx:
Pt describes sleep disturbance for the past several years, including: sleeping with her mouth open, cessation of breathing for
at least 10 seconds (per episode), snoring, restlessness during sleep, h/o enuresis, and morning headaches. ZZs co-workers
have described deficits in attention span at work. Additionally, she has been overweight since she was born (14# at birth).
Onset: Actual date of onset unclear; pt first noticed onset of the above-mentioned symptoms about 1 year ago.
Type of Tx: None at present.
Meds: None at present.
Smoker: No
Family Hx: Mother: possible gestational DM; grandmother: type 2 DM.
PE:
General appearance: Somewhat tired and irritable 25 yo female.
Anthropometrics: ht: 57; wt: 201#
Vitals: Temp 98.5F, BP 123/80 mmHg, HR 85 bpm, RR 17 bpm.
Heart: Regular rate and rhythm, heart sounds nl.
HEENT: Eyes: Clear; Ears: Clear; Nose: nl mucous membranes; Throat: Dry mucous membranes, no inflammation, tonsillar
hypertrophy
Genitalia: nl
Neurologic: Alert, oriented x 4
Extremities: No joint deformity or muscle tenderness, but pt complains of occasional knee pain. No edema.
Skin: Warm, dry; reduced capillary refill (approximately 2 seconds); slight rash in skin folds
Chest/lungs: Clear
Abdomen: Obese
Nutrition Hx:
General: Very good appetite with consumption of a wide variety of foods. Pts physical activity level is generally low. Pt
reports feeling too exhausted to exercise after work. Prefers to watch television or read books. 24-hour recall:
Breakfast:
2 breakfast burritos, 4 oz whole milk, 4 oz apple juice, 8 oz coffee with c cream and 2 tsp sugar
Break:
12 oz coffee with c creamer and 2 tsp sugar
Lunch:
2 bologna & cheese sandwiches (2 slices enriched bread with 1 slice bologna & 1 slice American
cheese with 1 Tbsp mayonnaise per sandwich), 1-oz pkg corn chips, 2 mini donuts, 12 oz Coke
Snack:
Peanut butter & jelly sandwich (2 slices enriched bread with 2 Tbsp peanut butter and 2 Tbsp grape
jelly), 12 oz Coke
Dinner:
Fried chicken (2 legs and 1 thigh), 1 c mashed potatoes (made with whole milk and butter), 1 cup
fried okra, 20 oz sweet tea
Snack:
3 c microwave popcorn, 12-oz Coke
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Food allergies/intolerances/aversions: NKA

Previous nutrition therapy? No
Food purchase/preparation: Primarily mother
Vit/min intake: Daily MVI
Dx:
R/O OSA secondary to obesity and physical inactivity
Tx Plan:
Polysomnography to diagnose OSA, FBG, HbA1C, lipid panel, psychological evaluation, nutrition assessment
ZZs Non-fasting Lab Values

Questions:
1. ZZ has been diagnosed with OSA. Define sleep apnea and explain the relationship between sleep apnea and obesity.(2 pts)
Sleep apnea is a common disorder in which the individuals who have one or more pauses in breathing or shallow breaths
while sleeping. It usually is a chronic condition that disrupts the quality of sleeping as the breathing pauses often move out of
deep sleep and into light sleep (National Institutes of Health.com).
Obstructive sleep apnea is much more common in obese individuals because the airway of the obese individual becomes
obstructed by large tonsils, enlarged tongue and increased fat in the neck, all pressing on the airway when the throat muscles
are relaxed with sleep. Obese individuals with relatively larger neck circumference have a greater chance for sleep apnea
(Health Central.com).

2. ZZs BMI is ___31.48____, which indicates that she is ______Obese_________ Class ___I__. (2 pts)
BMI = wt. (kg)/ht (m) (PR p.18)
= (201 pounds/ 2.204 pounds /1 kg) / (67 inches X 0.0254 meters / 1 inch)^2
= 91.17 kg/ (1.70 m)^2
= 31.48 kg/m^2
She is Obese Class I.
3. ZZs IBW is ____61.23kg____ and her percent IBW is ____148.89%____. (2 pts)
The ideal body weight for women is 100 lbs for first 5 plus 5 lbs for every inch over 5 +/- 10%, depending on frame size
(PR p.15).
The IBW for ZZ is 100# + 5# (7 in) = 135lbs or 61.23 kg (+/- 13.5#), which range from 121-149 lbs
The percent IBW = (Actual Weight / Ideal Body Weight) X 100 (PR p. 16)
= ( 201#/ 135#) X100
= 148.89% of IBW

4. Using the Mifflin-St Jeor equation (from PR), calculate ZZs kcal needs for weight maintenance. (2 pts) __________
RMR = 9.99weight + 6.25height 4.92age 161 (PR p.8)
= (9.99X 91.17kg) + (6.25 X 170.18cm) (4.92 X 25 y) -161
= 1690 kcal/day
Activity Factor = 1.4 or 1.5
No Injury Factor
Kcal needs for weight maintenance = RMR X AF
= 1690.4 kcal/day X 1.4 to 1690.4 kcal/day X 1.5
= 2367 to 2536 kcal/day
5. How much protein does ZZ need? (2 pt) __________
Protein requirements = 0.8-1.0 gm/kg/day for mild depletion (PR p.10)
= 61.2 kg X 0.8 g/kg/day to 61.2 kg X 1.0 g/kg/day
= 49 to 61 g/day
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6. How much fluid does ZZ need each day? (1 pt) __________

Based on her 24-hr recall, is she receiving adequate inadequate fluid in her diet?
Daily fluid requirements = Wt (kg) x 30 ml
= 91.17 kg X 30ml
= 2741 ml (around 92.6 oz)
She is receiving inadequate fluid in her diet.
7. List 2 nutrients or dietary components (not kcals) that you might be concerned about for this patient, stating the reason for
your concern. (2 pts)
1.
2.

High sugar intake: the pt has a high sugar intake, mostly from sugary drinks in her diet based on the 24 hr recall.
Those empty calories from the sugar may lead to nutrient deficiencies and high blood glucose level.
Low fiber intake: the pt has low vegetables and fruits intake (only 1 cup of vegetables in 24 hr recall) which lead to
inadequacy of fiber, low hunger satiety in meals, and increasing the risk of colon cancer and nutrient deficiencies.

8. Why did Dr. Smith order a lipid profile and blood glucose tests? What lipid and glucose levels are considered altered (i.e.,
outside of normal limits)? Evaluate ZZs lab results. (2 pts)
Based on the family history of the pt, her mother is a possible gestational DM and grandmother with DM type II, thus the pt
has a strong heredity diabetes component in her genetics. It is known that the pt has a high sugar, high fat and low fiber diet
in the 24 hour recall, therefore ordering the lipid profile and blood glucose tests is reasonable.
Most of the pts lipid and glucose levels are within the normal ranges, however, those values should be in concern as most of
them are on the high end. The pts HDL level is lower than normal values (greater than 55 mg/dL for women), at 50mg/dL.
Her non-fasting glucose is at an upper range of 108 mg/dL (greater than 110 mg/dL is considered as high blood glucose). The
cholesterol, VLDL and LDL are also on the higher end of 190 mg/dL for cholesterol (greater than 199 mg/dL is considered as
high cholesterol), 30 mg/dL for VLDL (greater than 32 mg/dL is considered as high VLDL level) and 110 mg/dL for LDL
(greater than 130 mg/dL is considered as high LDL level) separately.

9. Write an ADIME note for ZZ. Select two nutrition problems and complete PES statements for each within the note. For
each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on
etiology). Include calculations on an attached sheet, including references for equations (PR p.__). (4 pts each = 16 pts)
A:
25 yo female. Ht: 67 inches, Wt: 201 pounds, BMI 31.48 in obese class I, BP 123/80 mmHg. Non-fasting glucose 108
mg/dL, cholesterol 190 mg/dL, HDL 50 mg/dL, VLDL 30 mg/dL, LDL 110 mg/dL. Pt lives with her mother and young
siblings and reports she has been overweight since she was born. Pt reports a family history of possible gestational DM in
mother and type II DM in grandmother. Pt is not taking medication, treatment, and is a non-smoker. Pt is diagnosed with
OSA, reports sleep disturbance of cessation of breathing for at least 10 seconds, restlessness during sleep, h/o enuresis, and
morning headaches for at least 1 yr. Co-workers report deficits in attention at work. Pt reports occasional knee pain and slight
rash in skin folds. 24 hour diet recall reveals a low intake of vegetables, fruits, complex carbohydrates and high intake of
sugary beverages, refined grains and added fats.
D:
1.

Excessive intake of high energy and low nutrient diets, which related to excessive added sugar, refined grains,
saturated fats and inadequate fiber as evidenced by BMI greater than 30, HDL below recommended range, nonfasting blood glucose, VLDL and LDL at upper ends.

2.

Fatigue and deficits in attention related to obesity caused OSA as evidenced by sleeping disturbances such as
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sleeping with mouth open, snoring, restlessness during sleep, and cessation of breathing for at least 10 seconds.
I:
1.

Recording calories, fat, sugar intake for each day to assist patient in understanding and eventually making changes
in food selection.

2.

Motivational interviewing to assist patient in increasing physical activities.

3.

Instructing on how to choose healthier food choice and portion to assist patient in having the right food in right size
for her weight loss and maintenance.

M/E:
Pt states she has not participated in physical activity, determine a method to increase her physical activity within this month.
Pt weight will stabilize as measured by daily weights. Set up appointment once a week for weight, blood glucose, lipid level
monitoring and evaluation. Pt set goal to participate in hospital-sponsored eating patterns and weight management education
classes. Will evaluate progress at the next visit to further determine and restructure goals.

____________________________________
Oi Yi Chan, R.D.
November 11st , 2014

You see ZZ two months later in the out-patient clinic and she is 4 weeks s/p T&A and is ready and motivated to work on her
weight. She has maintained her weight at 200#. She states that her sleeping habits have improved and she is ready to change
her lifestyle. She is following no special diet. With adequate sleep she has more energy and she is able to exercise now and is
currently walking her dog 10 minutes per day after work.
A 24-hour recall reveals:
Breakfast: (on way to work)
McDonalds Egg McMuffin
Hash browns x 2
Large coffee
4 creamers
2 packets sugar

Lunch: (work cafeteria)

Cheeseburger (double)
Small salad (lettuce, tomato)
Ranch dressing
Large diet soda

Dinner: (at home)

Collard greens with bacon
Macaroni and cheese
Green salad
Blue cheese dressing
1 can soda

Snack: 1 can soda

10. If ZZs goal is to reduce her weight to 160 pounds in the next 6 months how many kcals should she eat each day? (2 pt)
(assume that there are 4.3 weeks per month) __________kcals/day
The kcal deficit for weight loss = (200 160 lbs) X 3500 kcal/ lbs in 6 months X 4.3 weeks/months X 7 days/ week
= 140000 kcal in 180.6 days
= 775 kcal/ day
Assume kcal the pt consume = 2367 to 2536kcal/day
The kcal the pt should consume to reduce wt to 160lbs = 2366.6 to 2535.7kcal/day - 775.2 kcal/ day
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= 1591 to 1761 kcal/day

11. Do you think that a goal of losing this much weight in 6 months, by diet alone, is a realistic one for ZZ? Why or why not?
(1 pt) yes no
It is not realistic for ZZ to lose 40lbs in 6 months.
Even though it seems reasonable to lose 40lbs in 6 months (1.6lbs/week) based on the calculation, a successful weight
management requires the combination of healthy diets, daily physical activity, and behavioral changes. ZZ requires further
improvement on her physical activity level and behavioral modification.
12. ZZ is in which stage of the Stages of Change? Provide evidence for your choice. (1 pts) Stage # __3__,
__________Preparation____________.
ZZ is already aware of her health problem and is ready to change her lifestyle, also she has reported small change as she is
currently walking her dog 10 minutes per day. She fits in the stage 3 preparation and ready to develop an action plan.

13. List 4 dietary (food) strategies that ZZ can incorporate into her eating pattern to make her diet healthier. (1/2 pt ea = 2 pts)
Increase vegetables and fruits intake
Change regular coke to diet coke or zero kcal coke
Consume whole grains carbohydrates instead of processed carbohydrates e.g. whole grains bread in sandwich
Cut the amount of sugar and creamer in her coffee into half
14. List 4 realistic ways for ZZ to increase her physical activity, aside from going to a gym. (1/2 pt ea = 2 pts)
Walk her dog twice per day, before and after work
Exercise at least 30 minutes per day at holidays
Go to work and grocery shopping by walk or bike if appropriate
Find an accompany to exercise together and motivate each other
15. List 4 behavioral strategies (other than diet/physical activity) that ZZ could use to reduce her kcal intake.(1/2 pt ea =2 pts)

Bring self-made lunch to work

Track food intake and kcal intake each day
Limit amount of eat out
Shop for her own food instead of relying on family

16. ZZs long-term (outcome) goal is to weigh 175 pounds; she will need measurable short-term goals as well. Please choose
one strategy from each of the questions 14-16 and set a measurable goal for each of these that ZZ can work toward during the
two-week period between her appointments with you. RememberSMART goals. (3 pts)
SMART goals are specific, measureable, achievable, realistic and timely goals.
1.

Increase vegetables and fruits intake for at least 2.5 cups/ day (ChooseMyPlate.gov) to fulfill the requirements of
fiber intake per day. Learn to measure the portion of vegetables and fruits via ChooseMyPlate.gov, booklets
provided in hospital, or from the education classes.
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2.

Walk her dog twice a day to increase involvement in physical activity. Walking can be done before and after work
for at least 10 minutes per walk and increase the time interval gradually once the pt is ready.

3.

Limit amount of eating out to 3 times per week to decrease the access to high energy junk foods, and therefore
increase the chance to practice healthy eating patterns learned from the hospital education classes.

17. If the above interventions do not work and ZZ reaches a plateau after losing 20 pounds, what do you think the next
appropriate step should be and why? (1 pt)
Identify and handle the plateau which ZZ are encountered, then develop a new weight loss plan, such as shorten the interval
required for success. ZZ may have lost her motivation and having a difficult time, a suitable change should be applied to the
plan in order to get along with ZZs plateau.
18. What is the optimal length of weight management therapy for ZZ? (1 pts)
6 months, with a least 14 encounters.

19. ZZ asks about gastric bypass surgery. Is she a candidate for gastric bypass surgery? Why or why not? (2 pt)
ZZ is not a candidate for gastric bypass surgery.
ZZ still have room to improve her diet, physical activity and behavioral therapy for weight loss and long-term weight
management. Bypass surgery is recommend for pt with BMI of 40 or greater and BMI of 30 or greater with 1 or more
comorbidities. ZZ has family history of comorbidities (gestational diabetes and diabetes type II), but not herself.
20. What would you assess during this follow-up counseling session? (2 pts)
Follow up with her records on calories, fat, sugar intake to see if there are any difficulties or mistakes on the tracking. Give a
motivational interview for her weight loss, increase physical activity and behavioral changes as the preparation stage is easy
to be stopped by the patient if they encounter obstacles or lose motivations. Monitor her lipid profile and blood glucose level.
Discuss if there are any obstacles, if no, further discuss the chance of making improvement and changes based on pts
experience.