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Jeremy Bartel

Medical Nutrition Therapy I


April 28, 2014
Mrs. is a 48 !"# $ho is a Nati%e American li%in& on a reser%ation in Ari'ona. (he has li%ed there
$ith her )amily all o) her li)e. (he is married and has three children. *er hus+and $or,s in a near+y
)actory- she is a house$i)e. All o) Mrs. .s children ha%e )inished hi&h school. "ne still li%es at
home and is unemployed. The income )or Mrs. .s )amily is mea&er and they depend on home/
&ro$n %e&eta+les and $ild &ame to supplement their )ood supply. 0o%ernment commodities
contri+ute a small amount.
Mrs. has a pronounced )amily history o) Type II dia+etes mellitus. (e%eral )amily mem+ers ha%e
had se%ere complications +ecause o) poor control o) +lood &lucose. Mrs. is $ell a$are o) the
pro+lems in her )amily.s past, +ut this has not stopped her )rom eatin& $hate%er she $ants. (he is
1234 and $ei&hs 150 l+s. $ith a medium )rame. (he is not %ery acti%e. (he has &raduated )rom
hi&h school and reads and $rites ade6uately. "n se%eral occasions she has +een treated )or 7TI
and has )re6uent colds. (he does not ha%e a history o) any ma8or illness. 9urin& the past month,
Mrs. noticed some si&ni)icant chan&es in the $ay she )eels. (he +ecomes )ati&ued easily and
has to &o to the +athroom more )re6uently, e%en durin& the ni&ht. (he is also hun&ry all the time
and is eatin& more +ut she only &ained 1 l+s. in the last three $ee,s and her %ision has +ecome
+lurred. Mrs. $ent to the doctor +ecause she de%eloped another +ladder In)ection. (he can
al$ays tell $hen she has a +ladder in)ection +y the pain in her lo$er a+domen and the )re6uency
o) her urination. (he there)ore decided to &o to the doctor )or the in)ection and, $hile there,
e:plained the other pro+lems she $as ha%in&.
*e o+tained a )astin& +lood test and )ound the )ollo$in&;
T<(T <(7=T N"M T<(T <(7=T N"M T<(T <(7=T N"M
*&+ 12.0 &>dl 12/13 B7N 23 m&>dl ?/18 M@A 8B
C
m
B
82/58
*ct B?D B3/B8 @r 1.B m&>dl 0.3/1.B E 4.8 m<6>= B.1/1.B
0lucose B4? m&>dl 31/110 Na 14? m<6>= 1B1/141 @l 104 m<6>= 58/103
@hol 231 m&>dl 140/150 Tri& B10 m&>dl 40/130 *9= 21 m&>dl 40/81
A=T B8 7>= ?/13 A(T 22 7>= 1/40 *+A1c 12.2D 1.1/8.1
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QUESTIONS:
1.9etermine Mrs. .s IBF and percent o) IBF.
G100H I J1H )or each inch o%er 30 inchesKL M 100H I J3 : 1K M 100 I B0 M 1B0H
2.@alculate Mrs. 2s BMI and interpret the results.
BMI = weight (kg) / height(m)2 = 86 / 1.68 x 1.68 = 86 / 2.82 = 30
B.Fhat is *+A1c and ho$ is it used to detect dia+etesN
ed +lood cells ha%e &lucose on the outside that can +e detected as *+A1c. I) the *+A1c is hi&h
in an indi%idual it means that +lood &lucose has not +een under control )or a lon& period o) time.
4.=ist the symptoms o) Type II dia+etes that are mani)ested in Mrs. .
Mrs. has a hi&h amount o) &lucose, hi&h total cholesterol, lo$ amount o) *9= cholesterol, hi&h
tri&lycerides, hi&h urea nitro&en, and hi&h *+A1c +lood le%els. Mrs. &ets )re6uent colds and
urinary tract in)ections. (he2s inacti%e, +ecomes )ati&ued easily, has needed to use the +athroom
more o)ten, she2s hun&ry o)ten, and has +lurred %ision.
1.<:plain the pathophysiolo&y o) these symptoms.
The raised &lucose in her +lood Jhyper&lycemiaKis de)initely causin& pro+lems, li,e the )re6uent
colds, the urinary tract in)ections, and +lurred %ision. The hi&h *+A1c le%el sho$s that Mrs. has
had pro+lems $ith hyper&lycemia )or an e:tended period o) time. The hi&h total cholesterol and
lo$ *9= cholesterol contri+utes to o+esity and the )actor $hich cause dia+etes. The hi&h urea
nitro&en sho$s that her li%er and ,idneys aren2t $or,in& %ery $ell, $hich could also +e caused +y
the hyper&lycemia.
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The M9 dia&nosed Mrs. $ith dehydration, o+esity $ith Type II dia+etes, and anemia. *e +ased
his decision on her )amily history, la+ %alues, hei&ht and $ei&ht, and the symptoms he descri+ed
as polydipsia, polyuria, polypha&ia, hyper&lycemia, and )ati&ue. *e prescri+ed a 1200 ,cal diet
and &lipi'ide J0lucotrolK, and re)erred her to the clinic2s re&istered dietitian. *e told her that she
had to lose $ei&ht and that, i) she did, she could pro+a+ly stop ta,in& her medication and +e )ree
o) the symptoms.
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QUESTIONS CONTINUED:
3. A)ter Mrs. .s +lood su&ar JB0K is corrected, $hat chan&es in other +lood %alues $ould you
e:pectN <:plain your ans$er.
I $ould e:pect that her +lood urea nitro&en $ill correct. *er ,idneys and li%er are not $or,in& $ell
+ecause o) the hyper&lycemia and the dama&e that the &lucose is doin& to the capillaries in the
li%er and ,idneys. *er cholesterol and tri&lycerides $ould also correct. The li%er is con%ertin&
some o) the &lucose to cholesterol and tri&lycerides.
?. Fhat is the &oal )or serum B0 )or dia+eticsN Fhat is considered &ood control and $hat is
considered poor controlN
80/120 m&>dl preprandial and 100/140 m&>dl +e)ore +ed. 0ood control is ,eepin& $ithin the a+o%e
ran&es. Bad control is ha%in& s$in&s o) mainly hyper&lycemia and some hypo&lycemia.
8. Fhy should the physician +e concerned a+out the a+normal lipid pro)ile o) a dia+etic $ho is
out o) control li,e Mrs. N
The &lucose in Mrs. 2s +lood can cause dama&e to the arteries in the heart. esearch has )ound
that $hen there is dama&e in arteries cholesterol can &ather $here there is dama&e and cause
+loc,a&es.
5. 9escri+e the )unction o) &lipi'ide J0lucotrolK and list any nutritional complications.
Impro%es insulin secretion in people $ith residual +eta cell )unction. There may +e a ris, o)
hypo&lycemia i) Mrs. doesn2t eat at the proper times o) day, +ecause there is more insulin in
the +lood.
10. The M9 told Mrs. that i) she lost $ei&ht she mi&ht not need the medication and could +e
)ree o) her symptoms. 9escri+e the relationship +et$een o+esity and dia+etes.
The ris, )or type 2 dia+etes is enhanced +y central o+esity. =i)estyle choices, li,e +ein& o+ese can
acti%ate &enes that can tri&&er dia+etes. Adipose tissue secretes chemicals that can cause insulin
insensiti%ity.
11. Appro:imate Mrs. .s ener&y needs )or $ei&ht reduction. (ho$ your $or,.
11/14 ,cal>,& actual BF M 83 : 11 M 543, 83 : 14 M 1204, 543 to 1204 ,cal>day
12. Fould you prescri+e a 1200 ,cal dietN Fhy or $hy notN (ho$ your calculations )or her ,cal,
protein and )luid needs.
I don2t thin, I $ould prescri+e a 1200 ,cal diet, +ecause it $ould +e hard )or her to do. I $ould
prescri+e a diet that $ould reduce her ,cal &radually, so she $ould not )eel uncom)orta+le then )ail
at the diet. I $ould start her on a 1?00 calorie diet )or a month, then reduce do$n to 1100 calories
)or a month, and see i) there is any $ei&ht loss, and &ood control o) +lood su&ar. I) there is $ei&ht
loss and &ood control o) +lood su&ar I $ould lea%e her at the 1100 calories, i) not I $ould mo%e her
do$n to 1200 calories.
M M J5.55 O $ei&htK I J3.21 O hei&htK P J4.52 O a&eK P 131 M
J5.55 : 83K I J3.21 : 13?.34K / J4.52 : 48K / 131 M 815.14 I 104?.?1 / 2B3.13 / 131 M 1110 ,cal
Qrotein )or BMI B0 P 40; R 2 &>,& IBF M 15 ,& : 2 &>,& M 118 & protein
#luid needs M B1 ml>,& M B1 ml>,& : 83 ,& M B010 ml
1B. @onsiderin& the 1554 &uidelines esta+lished +y the American 9ia+etes Association, $hat
recommendations )or dietary inter%ention $ould you &i%e Mrs. N Fould you )ollo$ the
standard 9ia+etic <:chan&e =ists )or Meal Qlannin& or $ould you use the @ar+ohydrate
@ountin& methodN <:plain your ans$er.
The nutrition counselin& needs to +e +ased on &oals to ma,e Mrs. )eel +etter and li%e healthier.
(he needs realistic &oals that she can start on as soon as possi+le. Fe need to determine $hat
she could do to ma,e these chan&es and )ind out $hat she could )irst.
Mrs. needs to +e eatin& more )ruits and %e&eta+les $ith )i+er. I $ould encoura&e her to eat more
)oods that are nati%e to her people. I thin, it $ould +e easier )or Mrs. to use the car+ohydrate
countin& method, +ecause o) the nati%e )oods that I $ould li,e her to include in her diet. (he needs
to lo$er the amount o) )ry +read that she eats, so I $ould encoura&e her eatin& to &o in a di))erent
direction.
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The 9 inter%ie$ed Mrs. and disco%ered that she ate a hi&h/)at, lo$/protein, hi&h/car+ohydrate
diet $ithout much )i+er. (he did not )ollo$ her traditional tri+al eatin& patterns +ut ate li,e any
modern American $ith a )e$ e:ceptions. (he li,ed )ry +read and on rare occasions, $ould )i:
$o8api. (he consumed a lar&e amount o) soda, candy, coo,ies, potato chips, corn chips, etc. The
sodium content o) her diet $as hi&h. (he did not tolerate mil, and ate cheese only $hen it could +e
o+tained throu&h &o%ernment commodities. The only )resh %e&eta+les she ate $ere those her
)amily could &ro$; s6uash, +eans, and some &reens. There $as %ery little )ruit in her diet, and she
did not eat meat o)ten.
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QUESTIONS CONTINUED:
14. Accordin& to the list o) li,es and disli,es a+o%e, Mrs. consumes a si&ni)icant amount o)
s$eets. The ne$ &uidelines )or dia+etic diets allo$ )or a limited amount o) su&ar to +e
incorporated into the diet plan. Thin, a+out ho$ you $ould persuade Mrs. to limit her
su&ar inta,e and descri+e ho$ you $ould teach her to use su&ar in her diet. Include in your
discussion any possi+le pit)alls o) allo$in& su&ar in the diet plan.
I don2t ,no$ i) Mrs. $ould +e a &ood candidate to ha%e su&ar as part o) her diet. (he eats
a lot o) s$eets and it may +e +etter to allo$ her to ha%e the periodic s$eet rather then
ha%in& s$eets as a re&ular part o) her diet. Mrs. seems to +e addicted to su&ar and it
may +e hard )or her to &i%e up i) she continues ha%in& su&ar on a re&ular +asis.
Mrs. could use su&ar in her diet i) she limits inta,e and doesn2t end up $ith uncontrolled
+lood su&ar. I thin, it $ould +e $ise i) most o) the su&ars that she2s &ettin& come )rom )ruit.
I $ould tal, to Mrs. a+out ho$ she could li%e a more com)orta+le, lon&er li)e i) she eats a
healthier diet. (he needs to do this +ecause she cares a+out hersel), not )or anyone else.
11. Fhat nutritional de)iciencies are li,ely to result )rom )ollo$in& the diet Mrs. descri+edN
<:plain.
Mrs. could ha%e protein/ener&y malnutrition since her protein inta,e is lo$. It seems li,e
she could also ha%e pro+lems $ith B12 inta,e sense she doesn2t eat a lot o) meat, can2t
tolerate mil, and rarely eats cheese. *er hemo&lo+in and hematocrit %alues are lo$/normal
and she could ha%e lo$ iron le%els. (he could also ha%e lo$ calcium le%els. (he could +e
dehydrated +ecause o) the poly urea.
13. Fhat +eha%ioral chan&es $ould you recommend to Mrs. N
I $ould encoura&e Mrs. to &arden more. (he $ould +e &ettin& e:ercise $or,in& in the
&arden and she $ould +e eatin& )resh )ruits and %e&eta+les.
1?. 7sin& the ,cal le%els and the proportions o) each ma8or nutrient you recommended, plan a
day.s menu )or Mrs. +ased on )ood a%aila+ility. =ist the )oods you $ould &i%e her in
dia+etic e:chan&es J"ption; usin& the latest &uidelines, incorporate s$eets into Mrs. .s diet
planK.
A meal plan )or a day $ould +e;
Brea,)ast; 1 @up "atmeal $ith )resh or )ro'en +erries. The oatmeal pro%ides B0? ,cals, 8 &
o) dietary )i+er and 3 & o) protein. A 6uarter cup o) +erries pro%ides an additional 20 ,cals
and 1 & o) )i+er.
I2d li,e the main meal to +e durin& the middle o) the day, so she can utili'e some o) the
calories that she ta,es in.
=unch; 1 split roasted chic,en +reast, $hich $ill pro%ide 114 ,cal and 1? & o) protein and
can +e o+tained throu&h 7(9A commodities li,e the cheese she sometimes eats. <ach o)
the commodities pac,a&es contains 1 pounds o) split +reasts.
1 sliced &reen +ell pepper, adds B3 ,cal
1>2 sliced onion, add 43 ,cal
1>2 @up pinto +eans Jalso a commodity itemK, adds BB1 ,cal
1>2 @up +ro$n rice, adds 108 ,cal
2 corn tortillas, +a,ed, adds 113 ,cal
(lice the chic,en and saute $ith +ell pepper and onions to ma,e )a8itas. (er%e $ith pinto
+eans, +ro$n rice and tortillas.
9inner;
(and$ich $ith lettuce, American cheese, roasted summer s6uash, and roasted &reen
+eans. 2 slices o) $hole $heat +read 1B8 ,cal, 2 lea%es o) lettuce 10 ,cal, 1 slice American
cheese B8 ,cal, 1>2 @up roasted summer s6uash 14 ,cal, 1>2 @up roasted &reen +eans 1?
,cal
1 @up o) condensed %e&eta+le soup, adds 80 ,cal
This menu adds up to 1B?5 calories, $ill ,eep her satiated and has the +ul, o) her calories
in the middle o) the day. The menu $ill also &i%e her &entle s$in&s in her +lood su&ar rather
then spi,es. (he2ll &et a lot o) the )i+er that she needs to help lo$er her cholesterol le%el,
too.
18. Frite a Q<( statement )or Mrs. .
<:cessi%e ener&y inta,e as e%idenced +y pro+lems $ith +lood su&ar related to o+esity and
type 2 dia+etes.