Theodore Mitchell

CSI Overweight and Anemia

LP is a 35 yo F Filipina who is married with two children, ages 7 and 10. She was raised in the San Francisco Bay Area
and loves to eat traditional Filipino foods but also enjoys trying new recipes and experimenting with new foods. LP takes
pride in her cooking abilities and she and her family seldom eat in restaurants. Weekends are typically spent with the
extended family and revolve around family meals.
LP works as a teacher and she does not exercise. Occasionally, she will walk the family dog if the kids are too busy to do
so. Sometimes walking the dog means driving to the local dog park and letting it run loose. LPs love of food and lack
of exercise have created a weight problem. Her family and friends are concerned about her weight and recently they have
begun to express concern about her overall health.
FH: Her father died of a heart attack at age 49 and her two older brothers have had heart attacks. She has two other
siblings who have high serum cholesterol and follow strict diets. Both of her parents and all of her grandparents had high
cholesterol levels. None of this really bothered LP until recently. Since her birthday last week, she has become very
concerned about her health and decided to do something about her weight.
LP is 5' 2" and weighs 200 lbs. Throughout college she weighed 115 lbs and, according to her husband, "looked great."
He wants her to look like that again, so she has decided that she needs to get back to her college weight. She has even
talked about joining a gym and starting an exercise program to get back in shape. Because of her strong family history of
cardiovascular disease, her husband convinced her to obtain medical advice first. The family physician found her to be
generally healthy, despite her weight and a recent complaint of fatigue. Her blood pressure was 119/75 and her lipid panel
shows total cholesterol of 199mg/dL, HDL of 55mg/dL and LDL of 106mg/dL. Her triglycerides are 135mg/dL. She has
a history of anemia.
Her doctor reinforced what others had been telling her about losing weight and exercising more. The MD emphasized that
she should start slowly and sent her to see an RD to discuss her weight problem. You are the outpatient RD who
interviewed her and obtained the following information:
LP is usually in a rush in the morning. She only eats breakfast on weekends. She drinks a cup of coffee (with sugar and
coconut milk) while getting ready and another in the car on her way to work. She does not eat in the school cafeteria at
lunch because she says it is not home cooked. For lunch, she brings leftovers from home and drinks a bottled Starbucks
Frappuccino in the afternoon. Leftovers often consist of fried rice, fish/chicken, and vegetables. Sometimes she eats
lumpia or pancit instead of rice.
LP does not eat again until dinner. After picking up the children from daycare, she likes to go home and help them with
their homework before preparing dinner. Her goal is to save dinner until all of her work is done. She usually prepares
dinner for the family and this is the meal she lives for. The way she sees it, she works hard during the day, skips
breakfast, eats a home-cooked lunch, and does not snack during the day so she deserves a big meal at night. Occasionally
the family will eat out at Jollibee because this is her husbands favorite. Recently she has complained of feeling too tired
to do much at night and has been going to bed early with the kids. She states that she takes her iron pills when she
remembers.
Most meals are centered on a small portion of chicken or fish and some form of rice or noodles. Lots of seasoning, salt,
and oil are important. She loves vegetables and has at least two different varieties included in dinner. Generally, one item
at each meal is fried (either the meat, the lumpia, or sometimes it is a stir-fried vegetable dish). Dessert is generally ice
cream, cookies, cake, or some combination of these. LPs weakness is halo halo, a Filipino dessert that she consumes at
least once a week on the weekends. Serving sizes vary a great deal, depending on the combination of foods served.
However, large amounts of each food item are the norm rather than the exception. After eating, LP plays with her children
before watching TV for an hour and then going to bed. Weekend meals are not that much different except that she eats
more for breakfast.
Laboratory Results
Chemistry
Sodium (mEq/L)
Potassium (mEq/L)
Chloride (mEq/L)
Carbon dioxide (CO2, mEq/L)
BUN (mg/dL)
Creatinine serum (mg/dL)
Glucose (mg/dL)

Ref. Range
136-145
3.5-5.5
95/105
23-30
8-18
0.6-1.2
70-110

11/1/15
138
3.6
99
27
15
0.9
110

Theodore Mitchell
Phosphate, inorganic (mg/dL)
Magnesium (mg/dL)
Calcium (mg/dL)
Osmolality (mmol/kg/H2O)
Bilirubin total (mg/dL)
Bilirubin, direct (mg/dL)
Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
Ammonia (NH3, umol/L)
Alkaline phosphatae (U/L)
ALT (U/L)
AST (U/L)
CPK (U/L)
Cholesterol (mg/dL)
HDL-C (mg/dL)
VLDL (mg/dL)
LDL (mg/dL)
LDL/HDL ratio
Triglycerides (mg/dL)
T4 (ug/dL)
T3 (ug/dL)
HbA1C (%)
Hematology
WBC (x 103/mm3)
RBC (x 106/mm3)
Hemoglobin (Hgb, g/dL)
Hematocrit (Hct, %)
Mean cell volume (um3)
Mean cell Hgb (pg)
RBC distribution (%)
Platelet count (x103/mm3)
Transferrin (mg/dL)
Ferritin (mg/mL)
Vitamin B12 (ng/dL)
Folate (ng/dL)
Urinalysis
Collection method
Color
Appearance
Specific Gravity
pH
Protein (mg/dL)
Glucose (mg/dL)
Ketones
Blood
Bilirubin
Nitrites
Urobilinogen (EU/dL)
Leukocyte esterase
Protein check
WBCs (/HPF)
RBCs (/HPF)
Bacteria
Mucus
Crys
Casts (/LPF)
Yeast

2.3-4.7
1.8-3
9-11
285-295
1.5
<0.3
6-8
3.5-5
16-35
9-33
30-120
4-36
0-35
30-135 F, 55-170 M
120-199
>55 F, >45 M
7-32
<130
<3.22 F, <3.55 M
35-135 F, 40-160 M
4-12
75-98
3.9-5.2

3.9
2.0
10
289
0.8
0.07
6.8
4.2
22
11
118
21
10
125
199
55
30
106
2
135
6.1
82
5.0

4.8-11.8
4.2-5.4 F, 4.5-6.2 M
12-15 F, 14-17 M
37-47 F, 40-54 M
80-96
26-32
11.6-16.5
140-440
250-380F, 215-365 M
20-120 F, 20-300 M
24.4-100
5-25

10.2
3.1 !
7.8 !
23.1 !
73 !
20 !
18.5 !
261
245 !
18 !
72
15

1.003-1.030
5-7
Neg
Neg
Neg
Neg
Neg
Neg
<1.1
Neg
Neg
0-5
0-5
0
0
0
0
0

Clean catch
Yellow
Clear
1.004
6.1
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0
0
0
0
0

Theodore Mitchell

1. LPs BMI is ___36.7__, which indicates that she is __NC3.3 Obese________ Class 2 _____.
200 (lb)/2.2(kg/lb)= 90.9090 kg; 62 in. * 2.54 cm/in= 157.48cm/100=1.5748 m2
BMI= Wgt. (kg)/Ht. (m2)
90.9090 kg/ 1.5748 m2= 36.65692874 or 36.7
(MNT Pocket Guide p. 1)
2. LPs IBW is ___110 lb_and her percent IBW is __181.8%______. (2 pts)
IBW= Female 5ft + 5 lb. for every in. over
52= 100 lb. + (5lb/in. * 2in.)= 110 lb./2.2kg/lb= 50 kg
200lb/110lb= 1.818 * 100%= 181.8%
(MNT Pocket Guide p. 2)
3. Using the Mifflin-St Jeor equation, calculate LPs kcal needs for weight maintenance. Use LPs ABW.
(2pts)
ABW= IBW + 0.25(actual weight IBW)= 132.5 lb./2.2 kg/lb.= 60.22727273 kg
MSJ= [10* Wt. (kg) + 6.25 * Ht. (cm) 5*Age (yr)] 161=
MSJ= (10*60.22727273 kg. + 6.25 * 157.48 cm. 5 * 35) -161= 1250.522727 kcal*1.5 (PAL)= 1875.78 kcal/d
Using Actual Body Weight= (10 * 90.9kg) + (6.25 * 157.48 5*35) 6=1712.25 * 1.3-1.5= 2225.9252568.375 kcal or 2225.9-2568.4 Kcal
(MNT Pocket Guide MSJ p. 3, PAL p. 5)
4. How much protein does LP need? Is this an adequate protein intake for LP? If not, using evidencebased information, what amount of protein would be adequate to meet her needs?
Protein Requirement based on maintenance requirements and ABW= 1-1.3g protein/d * for every kg BW
60.22727273kg * 1 = 60.22727273 and 60.22727273 * 1.3= 78.29546049 or 60.2-78.3 g of protein day
Using IBW * 0.8 g/kg protein 50 kg * 0.8g/kg= 40g per day of protein.
(MNT Pocket Guide Protein Requirement p.5)
5. Based on the Adult Weight Management Guidelines, what is a reasonable wt goal for LP and over
what time period? Explain your rationale. Is this a reasonable wt goal for LPs current lifestyle?
(2 pts.) (show calculations)
A reasonable weight goal is 160 lb. or 40 lb. of weight loss over a year period. If she loses 2 lb./ every
two weeks over the next 8-9 months or 33 weeks, and continues with her plan, she can meet the goal.
If healthy weight loss is 1-2 lb. week and she loses 1.25 lb./week for 33 weeks: 33 weeks* 1.2lb./week=
44 lb.
The remainder of the sessions would be used to allow for maintenance checkups and continued blood
monitoring.
6. Determine LPs energy and protein requirements to promote weight loss. Explain the rationale for
the method you used to calculate these requirements.
The AWM guidelines as presented in the Nutritional Care for obese patients lecture recommends as
calorie deficit of 500-700 kcal per day. Using the estimated energy requirements calculated in
Question 3: 2568.4 kcal/d- 500= 2068.4 kcal/d; 2568.4 kcal/d-750=1818.4 kcal/d avg. of two for
upper limit= 1943.4
2225.9kcal -500kcal = 1725.9 kcal and 2225.9 750= 1475.9 avg. of two for lower limit= 1600.9 kcal
Range 1600.9-1934.4 kcal day to promote 40 lb. weight loss.
To promote weight loss her PAL will have to increase in addition to her calorie intake decreasing.
This range will ensure adequate energy for physiological function and PAL.
Protein range would be the same as the IBW is used to calculate.
Nutritional care for Overweight Patients lecture
7. Evaluate LPs lipid panel results and describe what LPs lab values for cholesterol, HDL, LDL and
Triglycerides indicate. How might they change after weight loss?
LPs lipid panel indicates that she is bordering on high total cholesterol. HDL at the borderline of
deficiency, and VLDL levels. lDL was in the normal range as well as total triglycerides. The lipid profile
is most likely due to the amount of polyunsaturated vegetable oils used in the frying of foods at every
meal. If she changes the amount of food shes consuming and the amount of fatty foods and those foods

Theodore Mitchell

cooked in oils then she should be able to lower her total cholesterol and VLDL levels, while increasing
HDL levels. If there is no change in composition just calories its possible she could lose weight and still
develop high cholesterol. Low HDL and high total cholesterol can lead to increased risk and progression
of heart disease.
Cardio-vascular Disease and Hypertension Lecture
8. Identify and interpret any abnormal hematological indices (including cell morphology) and discuss
the probable underlying etiology.
The RBC is low, Hgb (7.8), Hct (23.1%) are both in the range indicating severe anemia. The cell
morphology is microcytic-hypochromic indicated by MCV, MCHC, and MCH. The patient is anemic r/t
insufficient iron in the diet and occasional adherence to supplementation. LP has a history of anemia
but transferrin and ferritin levels are not high indicating this progression in severity of the anemia is
due possibly is new. Or that there is an inability to absorb the Iron due to gut inflammation possibly r/t
increased visceral adiposity, excess carbohydrate and fatty acid intake, prolonged period of fasting. Her
blood sugar and blood pressure levels were normal but within the upper limits of classification.
(MNT Pocket Guide Protein Requirement p.71)
9. LP is in which stage of the Stages of Change? Provide evidence for your choice?
She is in the late stages of preparation and early Planning stage. She seems highly motivated to make changes
to please the people around her especially her husband (which is not a bad thing per se). She has consulted
with her physician to get a better understanding of her current state of health. She was referred to see a
dietician to determine the best way to lose weight. She acknowledges that there are pros and cons to losing
weight and how to do so. She also plans on joining a gym within 30 days. She doesnt mention beginning to
incorporate any new practices into her life. We dont know how long she has been walking the dog but she
clearly states a lack a physical exercise, and strong ties to cultural dietary and culinary practices.
Nutritional Counseling and Behavior Change
10. Write a nutrition note to be included in LPs medical record.
S:
Pt reports fatigue, loss of energy and inability to enjoy ADL;
SH-Married mother of two, works as teacher; loves to cook for her nuclear family and interact with extended
kin. Reports not eating breakfast r/t need to help prepare children (7&10) for school and herself for work;
FH. High cholesterol and heart attack. Patient reports being interested in losing weight at request of family and
growing personal concern. Strong family ties
MH- Iron supplement for persistent for anemia
O:
35yo Female Filipina.
Anthropometric
Ht- 52 (1.57 m) Wt- 200 lb. (90.9 kg) BMI- 36.7:
Dx hypocytic/hypochromic Anemia (severe) Obesity (class 2) Rx Fe supplement
Biochemical
Hgb- 7.8 Hct 23.1 % MCV- 73
Energy Requirements based on MSJ- 1105.8-1375.5.8 kcal/day
Protein Needs- 60.2-78.3 g/day
A:
Low Fe intake r/t deficiency in diet or visceral adiposity and inflammation, menses etc. Obesity Class 2 r/t
excessive energy intake and low physical activity levels
Pt. CH-1.1.2 Female, CH-1.1.1 25 yr. old; CH-1.1.3- FilipinaNC- 3.3 r/t NI- 1.3
BD- 1.7 results indicative of NI- 5.6.2.BD 1.7.1 and BD 1.7.2 at the upper limit r/t NI in FH 1.2.2.2,; P:
Encourage LP to eat breakfast at least 2-3 per week to prevent overeating later in the day. Encourage increased
consumption of Vitamin C and Fe rich foods and to take Fe supplement. Recommend increase in physical
activity. Monitor wt cholesterol, and Fe levels follow up in 2 weeks.
11. Write a similar note in the ADIME format.

Theodore Mitchell

A:
35yo Female Filipina referred by MD for weight loss Ht- 52 (1.57 m) Wt- 200 lb. (90.9 kg) BMI- 36.7: Dx
microcytic/hypochromic Anemia (severe) Obesity (class 2) Rx Fe supplement Hgb- 7.8 Hct 23.1 % MCV- 73
Pt reports fatigue, loss of energy and inability to enjoy the activities od daily life (ADL); SH-Married mother
of two, works as teacher; loves to cook for her nuclear family and interact with extended kin. Reports not
eating breakfast r/t need to help prepare children (7&10) for school, while preparing herself for work. Strong
family ties and relation with food history (FH) the diet is high in carbohydrates and fried foods, with two types
vegetables. High cholesterol and heart attack. Patient reports being interested in losing weight at request of
family and growing personal concern.
D:
Patient overweight (NC- 3.3) r/t to total diet and physical activity aeb CBW current body weight and patient
reports of weight gain.
Patient has altered nutrition related lab results (NC 2.2) r/t patient diagnosis of anemia aeb MCV 73% and
MCH 20, Transferrin and Ferritin 245 and 18 respectively indicating iron deficiency anemia.
I:
Encourage patient to reduce total calories consumed and increase PAL. Increase consumption of Fe rich foods;
Protein needs based on IBW 50 kg * 0.8g/kg= 40g per day of protein.
Kcal needs to encourage weight loss 2568.4 kcal/d- 500= 2068.4 kcal/d; 2568.4 kcal/d-750=1818.4 kcal/d avg.
of two for upper limit= 1943.4
2225.9kcal -500kcal = 1725.9 kcal and 2225.9 750= 1475.9 avg. of two for lower limit= 1600.9 kcal
Range 1600.9-1934.4 kcal day to promote 40 lb. weight loss.
Motivational interviewing style and emotional and psychological support to enhance compliance and mental
health.
M/E:
Monitor wt., cholesterol levels and Fe levels return in 2 weeks
Theodore R Mitchell
Theodore R. Mitchell B. Sci. Clinical Nutrition 11/6/2015
12. List 4 realistic dietary (food) strategies that LP could incorporate into her eating pattern to make
her diet healthier.
Decrease the amount of oil rich foods consumed by Switch out steamed rice for fried rice and steamed
vegetables for stir fry 2-3 times a week;
Decrease the total amount of carbohydrates consumed;
Choose Fruit for dessert instead of ice cream and cookies etc 3-4 nights a week;
Drink herbal infusions or black/green/white teas instead of frappucino and coffee.
Eat breakfast at least 3-5 days during the week.
13. List 4 realistic ways for LP to increase her PA, not including a gym membership.
LP has a supportive family so she could incorporate family dance time for 30-40 minutes a night 3-4 days a
week.
Lp and her husband could go for walks together early in the morning before work or after dinner, LP could
walk her dog on the leash.
LP could walk to and from lunch when at work, park the car a little further from the entrance and take the stair
instead of the elevator.
LP could incorporate movement and physical acitivty of some sort into her lesson plans.
14. List 4 behavioral strategies (not diet and PA) that LP could use to reduce her kcal intake.
LP could start practicing mindfulness activities.
LP could start to read or journal when feeling cued to eat
LP could make a contract with herself or her husband to help her reduce the calories.
Lp could also write her goals down and keep them visible in places she may be triggered or cued to eat.
15. LPs long-term (outcome) goal is to weigh X pounds by June; she will need measurable short-term
goals as well. Please choose one strategy from question 12, one from question 13, and one from question

Theodore Mitchell

14 and set a measurable goal (SMART) for each of these that LP can work toward over the next two
weeks between visits.
LP Diet S-eat 2-3 meals a week without frying the food or adding oils to them; M- use food log or food
journal to keep track of foods consumed and way they were prepared at each meal. A- This is deifintely
doable. R- The result would be to prevent the rise in cholesterol. T- Should see a decrease in total amount of
cholesterol.
LP PA- S- 30-40 minutes 3-4 times a week dancing with the family; M- Keep an activity/time log; take
pictures. A- Family is already involved should be easily adapted into routine. R & T Within 2 weeks up to 3
days a week, result will be an increase in energy expenditure
LP Behavioral- S. Make a contract with husband as accountability partner. Set goals together and place them
in common areas; M. Use food journals and activity log to monitor progress and share with each other daily or
nightly; A. Husband is very concerned about health and safety and makes an ideal partner. R. Will help
facilitate dietary changes necessary and wont leave either spouse feeling alienated. Within 2 weeks should
have a contract written out signed, and posted around the house and at work.
16. Is LP a candidate for bariatric surgery? Why or why not?
In my opinion LP is not a candidate for bariatric surgery. The patient is not morbidly obese, and has not
progressed into the chronic disease state comorbidities like DMII or CVD. The patient has also just been
introduced to the RD and has not qualified for extensive treatment. The patient has also not tried
pharmacotherapy yet. Patient BMI should also be 40 or higher. Even though she is above 35 at 36.7, she still
doesnt have the comorbidities that would warrant surgery.
Nutritional care for Overweight Patients lecture