Kyla Kurczewski

NFS 2420
Prof. Susan Okonkowski
27 November 2015
Final Case Study
Obesity is considered a national health crisis. Over one-third of
adults over the age of sixty-five were obese in 2007-2010, according to
the National Health and Nutrition Examination Survey. Ages sixty-five
to seventy-four showed the highest level of obesity, and Paul is no
exception. Paul is seventy-one years old, is five feet and eleven inches
tall, and weighs three hundred and fifty four pounds. He has a blood
pressure of 154/89, a total cholesterol level of 265 with 28 HDL, and
has tried all sorts of diets in the past. Paul is considering gastric bypass
surgery, but doesnt want to try any sort of physical activity due to
painful joints. He is currently taking a multivitamin, probiotics, garlic,
St. Johns Wort, and Lasix.
Given Pauls height and weight measurements, he stands at a
BMI of 49.5; this is WELL over the healthy range of 18.5-24.9, and even
the overweight range of 25-29.9. The first line of order is to lower this
BMI. Weight loss will take time, so aiming for a loss of 2-3 pounds per
week until Paul weighs about 200 pounds, a BMI of 28, sounds like a
reasonable goal. Though this BMI is still in the overweight range, the
best health status and lowest risk of mortality for those over the age of
seventy lies between the BMIs of 25 and 32. If Paul meets this goal, he
will be at the goal weight of two hundred pounds in about one year.

Losing weight requires energy expenditure to be greater than

energy, or caloric, intake. Using the Harris-Benedict equation, Pauls
basal metabolic rate is as follows:
66.47 + (13.75 x 160.9 kg) + (5.003 x 180.34 cm) (6.755 x 71 years)
= 2,701 kcal
To lose 2-3 pounds per week, well need to eliminate roughly 1,200
calories per day. I would recommend an 1,800-calorie meal plan with
slowly increasing physical activity. We could start with just ten minutes
per day, adding 5 minutes per week up to forty-five minutes. Aerobic
exercises will help to burn fat, and strength or resistance training two
or three of the days each week should help to give Paul a decent
amount of lean body mass that will burn calories twenty-four hours a
day.
Though Paul has tried certain diets before, such as cabbage
soup, Atkins, South beach diet, and the alli weight loss pill, they all
sound quite extreme. Most people will either not be able to stick to
these diets very long or bounce right back as soon as they begin to eat
normal again. Instead, Pauls 1,800-calorie meal plan will include a
healthy balance of carbohydrates, protein, and fat eating at four
different times throughout the day. In order for 1,800 calories to
provide 50% carbohydrates, 25% protein, and 25% fat, the meal plan
will aim for 225 grams of carbohydrates, 113 grams of protein, and 50
grams of fat each day, along with 25 grams of fiber and at least 8 cups

of water. Whole grains, fruits, and vegetables will be vital sources of

carbohydrates and dietary fiber, and we will try to stay away from
simple sugars.
Pauls cholesterol levels are of strong concern as well. HDL levels
below 35 predict heart disease mortality for those over the age of 70,
and total cholesterol above 240 indicates a very high risk of
cardiovascular disease. Using healthy, unsaturated fats to fulfill the
recommended fat grams in Pauls meal plan, and keeping saturated
fats to a very minimum, will be a key in helping to lower his total
cholesterol and raise the good cholesterol. Adding physical activity to
his daily regimen should also help, as well as the weight loss goal we
are aiming for. His high blood pressure should lower as a result, too.
We will aim to meet Pauls vitamin and mineral needs through a
variety of whole foods, but he should continue to take his multivitamin
to assure no deficiencies. The loop diuretic, Lasix, which Paul is taking,
will hopefully not be necessary with the recommended lifestyle
changes. He is most likely taking it to treat his high blood pressure, but
by eating whole, nutritious foods for a large majority of his daily
calories, Pauls sodium should not need to be counteracted. And again,
the weight loss should help to lower his blood pressure as well.
Paul can continue to take his probiotic supplement too, as there
is no harm in doing so. His garlic supplement may be helping to keep
his blood pressure and cholesterol levels lower than they would be

without the supplement, and though we are aiming to lower these

numbers naturally, continuing the supplement will do no harm. If
anything, it would hopefully get Pauls blood pressure and cholesterol
levels into healthy range more quickly. St. Johns Wort is an herbal
supplement typically used to treat depression, nervousness, and
insomnia. Unless Paul reports or shows signs of depression or
insomnia, we can most likely discontinue this supplement. Although it
is an herb, it can interact with multiple common pharmaceuticals,
other antidepressants, anti-rejection medications, heart medications,
and cause enzyme induction (when the body produces more of the
enzymes needed to clear drugs and chemicals from the bloodstream).
Herbal or natural does not always mean no harm.
I fully believe Pauls goal weight can be reached without gastricbypass surgery. It will take a lot of hard work, dedication, and patience,
but it will be great for his body and health. I would not be against the
surgery, as weight would come off quickly for at least a couple of
months, but I believe Paul could almost abuse the perks. He may not
think he needs to change any of his unhealthy habits, as the weight is
going to come off anyway. His high cholesterol and blood pressure may
improve on paper due to the weight loss, but eating habits and activity
levels may not change. By having to work for the weight loss,
implementing healthy lifestyle changes and routines, Paul can feel a
huge sense of accomplishment and have a strong motivation to stay

healthy. If the weight is just going to come off, his already nonexistent
motivation for physical activity, due to painful joints, is not going to
improve.
To get Paul started with activity, pushing him past the complaint
of the pain in his joints, we can start with extremely low impact
activities. Things like swimming or treading water, cycling, rowing, and
many of the different cardio machines should not cause pain. As
weight begins to come off, activity becomes more natural, and a
healthy diet is observed, Pauls joint pain should decrease immensely.
We should assure his vitamin D and omega-3 fatty acid intakes are
optimal as well; 800 IU of vitamin D and at least 1,000 mg of omega-3
fatty acids per day, which will help with Pauls heart health, too. If Paul
has inflammation in his joints, using turmeric while cooking, or a
supplement if need be, can help to reduce this.
Most likely, Paul is going to need somewhere that he can go to
exercise. There are multiple different gyms, recreation centers, and
group classes in the area, which will also add a nice social aspect to
Pauls life. Being social tends to brighten peoples moods and make
events, especially something like a workout, much more enjoyable.
Having an accountability buddy can help to keep each of them on
track, too.
Paul will come in for a weight check/check-in once per week until
he weighs 300 pounds. From 300 to 250, we will check every two

weeks, and once per month thereafter. His cholesterol levels will be
checked every three months until they are normalized, then reducing
to once per year as long as his weight stays on track. Nutrition
recommendations will be made accordingly as results or a need for
change is seen. We will have Paul keep track, to the best of his ability,
of what he eats and the exercise he completes to help keep him
accountable and to give us a better gauge as to what he is
accomplishing. As we feel progress is being made and Paul can be a
little bit less watched, guidelines can be softened.
If Paul does not turn things around, more negative health effects
are right around the corner. His hypertension can lead to heart attack
or stroke, aneurysms, heart failure, and/or metabolic syndrome.
Continued exertion of over 350 pounds on his joints can cause
osteoarthritis, only worsening the pain he is already feeling. He is at
risk of developing sleep apnea and trouble breathing, as well as having
an increased risk for different cancers.
In addition to dietitian and doctor visits, Paul could attend
educational classes about healthy cooking techniques, ways our bodies
change as we age, or general health and nutrition information. We are
looking to completely change the way Paul is living, and it is going to
take an extremely large amount of dedication, change, accountability,
hard work, and time. Once Paul gets started, hopefully good results will
help to keep him motivated and persistently on the right track.