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Alyssa

Adler
Personal Portfolio
Fall 2016


Table of Contents
SKEWERS .............................................................................................................. 2
RESTAURANT DESIGN
Food Service Management | Boston University
ULCER DISEASE CASE STUDY ....................................................................... 45
Case Study Report and Presentation
Applied Nutrition Care | Boston University
BRAZIL NUTS ..................................................................................................... 68
Published Article
Cook For Your Life
NO NEED TO SAY NO TO THAT CUP OF JOE ............................................. 70
Published Article
Cook For Your Life
RENAL CASE STUDY ........................................................................................ 73
Case Report
Medical Nutrition Therapy 2 | Boston University

Alyssa Adler
Food Service Management
SAR HS 310
Professor DeBiasse

Table of Contents
Type of Organization4
Goals of the Organization..5
Marketing Plan.8
Menus..15
Recipe Modification22
Specifications.25
HACCP Plan.30
Staffing and Scheduling...36
Product Cost Analysis...39
Budget Preparation....41
References...43





Type of Organization

Skewers is a brunch full service restaurant located in the Boston Seaport. The

operation will provide reasonable prices for the average student or employee as
well as a relaxed atmosphere for a lunch break, date spot, or a place to bring friends
on the weekends. The Seaport is a prime area for a reasonably priced casual brunch
operation because the Seaport is a growing area with hundreds of offices and the
restaurants in that area are mostly upscale and expensive. Further, there are few
lunch places or fast stops to go for a lunch break. This brunch place will
conveniently be open 7 days a week which allows students to stop in before their 11
a.m. class or during a full time employees lunch hour. Further, this brunch place will
specialize in brunch-themed fondue as well as include traditional breakfast and
lunch items on the menu. In addition, this brunch place will have live music one day
during the week and on Saturdays and Sundays. According to a survey done in 2013,
36% males and 46% of women enjoy spending time with family and friends when
going to a brunch restaurant (Statista 2016). In addition, 27% males and 29%
females find brunch appealing because the restaurant has his or her favorite brunch
foods. Finally, 24% males and 14% females voted that brunch restaurants provide
these individuals with a chance to relax. Basing off of these statistics, it is favorable
for this food operation to have a neighborhood friendly atmosphere that is inviting
for all parties, big and small. Also, the menu of this operation will feature brunch
themed fondue, which is something different but the menu will also include some
classic breakfast and lunch favorites to appeal to everyone. Overall, this operation

will provide a warm atmosphere while customers enjoy the live music, the company
and the food in a relaxed and neighborhood friendly setting when coming for
brunch or stopping in for lunch during the work week.

Goals of the Organization


Objective and measurable goals for Skewers include that at least 50% of the

employees will be hired from a 10-mile radius from the restaurant location in order
to encourage a community feel. The other 50% of employees can include but are not
limited to employees who are willing to be trained to work in the food service
industry as well as employees who have had prior experience. This goal can be
achieved by being limited in the hiring process for specific employees. Further, the
manager in charge of the hiring process can clearly organize where each potential
employee is from when choosing whom to hire. In order to measure this goal the
other manager not in charge of hiring can access who was hired by the hiring
manager and check to see how many employees are local and how many of them are
not.
Limited employee turnover is desired with an average turnover rate of less
than 15% in a year (Bares 2015). This goal can be measured by recording the dates
that the employees are hired into the operation and when they leave the operation,.
This record sheet will be kept in the managers office and calculated on an annual
basis. If the goal is not met the managers will have a meeting to address this concern
and see what areas of the operation to improve.

Another goal for Skewers is that all employees should be trained thoroughly
and educated on all of the food served so that they can be knowledgeable to the
customers in order to generate good customer service. This goal can be achieved by
having weekly production meetings that will discuss and provide information
regarding any changes to the menu and address any questions that the staff has
regarding their duties. A quiz can be administered for every new employee that asks
specific questions about the food and staff procedures. The employee must get an 80
or higher on the quiz in order to be able to work in the operation. If the employee
fails he or she is allowed one more retake, otherwise the manager will access
whether or not the employee will stay on staff.
The next goal for Skewers is to achieve a review on yelp that is 4 stars or
higher. This goal can be met by focusing on customer service and food quality. In
doing this, the manager will emphasize customer service to the staff and teach the
staff to value the customers. The mangers can also observe the staff in the front of
the house to make sure that they are doing an adequate job of satisfying the
customers and putting the customers needs first. Regarding the food, the chef
should have open communication with the manager in regards to any problems with
the food or any patterns as to what dishes are sent back on a consistent basis. A way
this goal can be measured is by looking on yelp and online at reviews to see if
Skewers has 4 stars or higher. Another way to monitor this goal is to give out survey
cards with the check at the end of a customers meal asking them how the service
was. The survey cards can also advertise the social media platforms of the operation

such as Facebook, Instagram and the website in addition to encouraging the


customers to review the restaurant on yelp.

Skewers is also a for profit organization, with an expected profit margin of 3-

5% (Biery 2014). This value can be monitored weekly at the opening of the
operation, and then changed to monthly monitoring when the business has been
opened for 2 months. This goal can be identified by calculating the amount of food
waste, labor costs, food costs and utility costs against the money made from the
consumer purchases. Overall the profit margin can be found by computing all of the
operational costs against the revenue coming in from the customers. If the profit
margin is not being met, the managers will sit down to analyze if the menu prices
are too low, how much food is wasted, if there is enough food being ordered and the
amount of labor costs.
A final goal for the organization is to have a customer return rate of 50%. In
doing this, first time customer will receive coupons after their visit. An easy way to
identify this is by asking the customers or noticing if the customers use the coupon
that they received on their first visit into the restaurant. This goal is not completely
precise to measure, but the manager can have the servers keep a tally on how many
customers have been to the restaurant before, as an estimate for the customer
return rate. If this goal is not met, the managers can access possible reasons as to
why customers may not return. Key factors to look at are the possible competitors,
quality of the food and quality of the service offered.

Marketing Plan
Mission Statement:
Skewers aims to provide a cozy neighborhood atmosphere and be a place
where workers, students, and families can come to relax, chat, and eat unique
brunch food, while enjoying live music and a view of the Boston Seaport.

Marketing Strategy:

The target markets for this operation are local employees during the week

and locals and tourists on the weekends. More specifically, during the week Skewers
aims to be a prime lunch spot for workers in the Seaport. On the weekends, the
target market changes to locals and tourists in the Boston area looking for a unique
brunch spot in a popular location. The marketing plan for this operation will be a
bottom-up plan, where collaboration will be encouraged between the managers and
the employees in order to come up with the best way to market and advertise the
restaurant. Marketing for the initial opening of the restaurant would be advertising
with fliers that will be displayed in office buildings around the area. This will help
target the working population to come eat lunch during the workweek. Also,
coupons will be offered for first time guests and will be available in local
newspapers and given to office buildings. Advertisements in the local newspaper
will help to target locals and tourists to come and eat brunch during the week and
on the weekends. These coupons will encompass 15% off for first time diners (see
prototype below).

Further social media for Skewers will include a personal website, Facebook

page and an Instagram account. These social media pages will post information
about special events going on such as certain music playing over the weekends as
well as deals and pictures displayed to encourage customers to stop in. Also, posted
on the social media platforms, especially the Facebook page and website will be the
weekly specials. Importantly, the website and Facebook page clearly display photos
of food produced in the operation as well as information regarding the opening and
closing, and the address and phone number of the restaurant. Also, displayed on
these media platforms is a description of the operation in terms of dress code,
parking, transportation, and most importantly the menu. The Instagram account will
display mostly food pictures and pictures of the restaurant in order to advertise the
food and atmosphere. A goal for the Instagram page is to have customers often use
Skewers as a hash tag which will be a good social media promotion for the
operation. A goal for the social media marketing of Skewers is to gain as many
Facebook likes and Instagram followers as possible and convince the customers to
spread the name by using social media. These social media platforms will be
monitored by how many visitors visit the website and the Facebook page and by
how many people follow the Instagram account (see prototypes below).




Website Prototype:

10

Facebook Prototype

11

Instagram Prototype:

12

Flier Prototype:

Come join us on May 1st for


brunch and fondue!
150 Northern Ave, Boston, MA 02210
Open Daily 10:30AM-4PM





15% off entire check for first time guests

Visit us at www.skewersboston.com
Like us on Facebook Skewers Restaurant
Follow us on instagram @skewersboston
(617)735-2610
13

Situations Analysis:
Strenghts

Weaknesses

Lower prices than other food


operations in Boston Seaport
Innovative product: Brunch themed
fondue
Not many causal lunch places around
Boston Seaport
Location in the Boston Seaport is a
growing area for employees and
tourists
Workers can conveniently grab lunch
during break

Serve primarily brunch or breakfast


foods with fewer lunch options
Not open for dinner or after work
hours (closes at 4 pm)
Misses the early morning crowd by
opening at 10:30 am
Not many people want brunch during
the work week
No reputation prior to opening

SWOT
Opportunities
New social media platforms can
become available and popular to
customers
Can expand operation by opening
earlier hours to provide coffee, tea
and breakfast to workers before they
go into the ofhice in the morning
Develop a trend for brunch fondue

Threats
Brunch or lunch operations with
similar styles begin to open
Costs of live music performances may
hinder prohits
Brunch fondue trend is unsuccessful
Competitiion with other lunch
operations around area such as
restaurants and food trucks can limit
prohits

14

Marketing Mix:

Product

Brunch-themed fondue

Price

Ranging from $8-12 per food


item

Place

Boston Seaport

Promotion

Social media platofrms such as facebook,


instagram, and personal website in
addition to hliers and coupons

Menu

Skewers is a brunch restaurant that features brunch themed fondue. That

being said, the first page of the menu consists of savory fondues and sweet fondues.
The fondues are themed for breakfast such that they are served with eggs and
potatoes and other ingredients that one would see in breakfast style foods.
Following the fondue menu is a make-your-own omelet section, where the customer
has their choice of a 2 egg, 3 egg or egg white omelet. In addition, the customer can
choose 2 vegetables, 1 cheese, and 1 protein. Any additional ingredients would be an
extra charge. In addition to omelets and fondue there are 2 frittatas offered on the
menu as well as classic breakfast favorites such as French toast, pancakes and
waffles.

15

Also on the Skewers menu are some lunch options. This was created in order

to appeal to the working crowd during the week, in case the workers wanted lunch
food instead of breakfast. Lunch options include a couple of salad options, burgers,
sandwiches, and paninis. Not much is offered for lunch but there are a variety of
food items, including vegetarian options. In addition to the food menu is a cocktail
menu. This cocktail list has some classic cocktails and unique brunch cocktails that
are offered every day. Some cocktails are offered in a pitcher, in addition to a glass
while some are just singular portions. The goal of the Skewers menu is to fit the
needs of most people, especially the crowd looking for a fun brunch place with
interesting brunch cocktails as well as the working crowd in the Seaport who are
looking for lunch on their break. This menu also features quite a few vegetarian
options, with at least one in each category. Further, this menu is designed to be
versatile and accommodating for everyone, but it is not limited in the fact that the
kitchen staff will be happy to tweak any menu item or ingredient in order to
accommodate the customers.







16

SKEWERS MENU
Savory Fondue
Loaded Potato
Gruyere and Cheddar cheese blend. Served with potatoes, bacon, eggs &
broccoli. Sour cream on the side. Topped with chives.
8.25

The Western
Cheddar and gruyere cheese blend.
Served with ham, eggs, peppers, onions, & potatoes.
8.5

Huevos Rancheros
Cheddar and pepper jack cheeses with black beans and cilantro.
Served with eggs, tortilla chips, sausage, peppers & onions.
Guacamole and sour cream on the side.
10

Veg Head
Gruyere and pepper jack cheese blend.
Served with eggs, broccoli, mushrooms, potatoes, peppers, zucchini &
potatoes.
9

Sweet Fondue
Signature Chocolate
Pancakes, waffles, bananas, strawberries.
8

Chocolate Peanut Butter


Pancakes, waffles, bananas, strawberries.
8

Smores
Graham pancakes, waffles, bananas, strawberries.
8
**Consuming raw or undercooked meats, poultry, seafood, shellfish or eggs may increase your risk of foodborne
illness

17

Omelets
Make your own

2 Egg Omelet
8

3 Egg Omelet
9

Egg Whites
9

Toppings: Choose 2
Zucchini, spinach, broccoli, peppers, onions, mushrooms
+1 additional

Cheese: Choose 1
Cheddar, pepper jack, gruyere
+1.5 additional

Protein: Choose 1
Ham, sausage, bacon, fresh turkey
+2 additional
All omelets served with home fries and toast

Frittatas
House
Leaks, potatoes, spinach, sausage, swiss
8

Hawaiian
Ham, pineapple, peppers, mozzarella
8
All frittatas served with home fries and toast

**Consuming raw or undercooked meats, poultry, seafood, shellfish or eggs may increase your risk of foodborne
illness

18

Classics
Original Pancakes
3 Buttermilk pancakes topped with seasonal berries and fresh whipped
cream
8.5

Banana Walnut Pancakes


Topped with blueberries and fresh whipped cream
8.5

Belgium Waffles
Topped with seasonal berries and fresh whipped cream
8.5

Challah French Toast


Served with bananas and maple syrup
8.5

Stuffed Challah French Toast


Stuffed with peanut butter and marshmallow fluff
9

Lunch Salads
Chopped
Mixed greens topped with avocado, tomatoes, candied walnuts, dried
cranberries, goat cheese & grilled chicken. House made balsamic.
9

Mediterranean
Romaine topped with tomatoes, feta, pepperoncini, kalamata olives,
cucumber & roasted peppers. Red wine vinaigrette.
8
+2 grilled chicken
+3 grilled shrimp
**Consuming raw or undercooked meats, poultry, seafood, shellfish or eggs may increase your risk of foodborne
illness

19

Lunch Plates
Patty Melt
Prime beef patty served with grilled onions and swiss on rye. French fries.
9

Turkey Burger
Lettuce, tomato, pickles & onions. Sweet potato fries.
9

Turkey Club
Bacon, lettuce & tomato. With thousand island & coleslaw
8

Panini
Spinach, roasted peppers, mushrooms, zucchini, mozzarella cheese &
balsamic.
8

**Consuming raw or undercooked meats, poultry, seafood, shellfish or eggs may increase your risk of foodborne
illness

20

Cocktail Menu
Bloody Mary
Fresh tomato puree, spices, vodka,
Bacon topper.
Glass or pitcher
10, 30

Mimosa
Fresh squeezed oj, prosecco
Glass or pitcher
10, 30

Man-mosa
Fresh squeezed oj, prosecco, vodka
Glass or pitcher
10, 30

Bellini
Peaches and prosecco
Glass or pitcher
10, 30

Maple Martini

Baileys, dark rum, milk, maple syrup


10

Sangria
White wine, peach schnapps, mango nectar, soda, fruit juices
Glass or pitcher
10, 30

Pirates Coffee
Dark rum, molasses, Kahlua
8

21

Recipe Modification
Original Recipe:
Loaded Potato Cheese Fondue

Portion Size: 5.15 ounces

Servings: 5
Scale: 1

Ingredients
Dry white wine

Quantity
8

Unit
oz

Shredded Cheddar
Cheese

1/2

lb

Shredded Gruyere
Cheese

1/2

lb

All-Purpose Flour

Tablespoon

Salt
Pepper

1/4
1/4

Teaspoon
Teaspoon

Procedure
Simmer wine in
fondue pot
Add cheddar
cheese to pot,
pound at a time,
stirring constantly
until melted
Add gruyere
cheese to pot,
pound at a time
until melted,
stirring constantly
Add flour to pot
and stir
When all cheese is
melted mix in salt
and pepper

Total yield
25.734 ounces

(calculations
below)
Topped with chives and accompanied with potatoes, bacon, eggs and broccoli
(Recipe from Sheila, 2016)








22

Calculations:
8 fluid ounces white wine x 0.065 pounds/fl ounce = .52 pounds
0.52 pounds wine + 1 pound cheese = 1.52 pounds x 16 oz/pound = 24.32 ounces
24.32 ounces + 1.33 oz flour + 0.042 oz salt + 0.042 ounce pepper = 25.734 ounces
Serving size = 5
25.734/5 = 5.15 ounces per serving

Quantity Calculation using Factor Method:
Derive
factor

Ingredients Original Converted Multiplied Change to


Amount Weight
by factor Measure
Change
of 10
and
Simplicity

Wine
8 oz
8 oz
80 oz
2
quarts
(1/2 gal +
quart)
250/25.734 Gruyere
lb
lb
5 lb
5 lb
= 9.7 10 Cheese

Cheddar
lb
lb
5 lb
5 lb
Cheese

Flour
2 T
1.33 oz
13.3 oz
1 C

Salt
t
0.042 oz .42 oz
2 t

Pepper
t
0.042 oz .42 oz
2 t
Total


25.734 oz 257.34 oz
Topped with chives and accompanied with potatoes, bacon, eggs and broccoli

Calculations: 80 oz x 0.065 lb/fluid ounce = 5.2 lbs + 2 lbs (cheeses) = 15.2 lbs x 16
ounces/lb 243.2 oz + 13.3 oz (flour) + 2(.42 oz-salt and pepper) = 257.34 oz total


23

Quantity Modified Recipe


Loaded Potato Cheese Fondue
Servings: 50
Scale: 10

Ingredients
Dry white wine

Quantity
2 1/2

Portion Size: 5.15 ounces

Unit
qt

Procedure
Simmer wine in
fondue pot
Shredded Cheddar 5
lb
Add cheddar
Cheese
cheese to pot,
pound at a time,
stirring constantly
until melted
Shredded Gruyere 5
lb
Add gruyere
Cheese
cheese to pot,
pound at a time
until melted
stirring constantly
All-Purpose Flour 1
C
Add flour to pot
and stir
Salt
2
Teaspoon
When all cheese is
Pepper
2
Teaspoon
melted mix in salt
and pepper
Topped with chives and accompanied with potatoes, bacon, eggs and broccoli

The recipe modification for loaded potato cheese fondue was done using the
factor method. The original recipe was modified to produce 50 servings instead of 5
servings. The factor calculated for this recipe modification was 10. This factor was
found by dividing the total desired yield by the yield of the original recipe. Next, all
of the original quantity units were converted to weight with decimals to make it
easier to multiply. Before multiplying by the factor these amounts were added up.
Then, each ingredient weight was multiplied by the factor, 10. The converted
decimal weights were then added up and compared to the total sum of the original

24

weights. The sum of the original weights multiplied by the factor should be the same
as the converted sum of the ingredient amounts. After comparison, the final
ingredient amounts were converted to simplistic measurements that are easy to use
when following the recipe.

Specifications
Food Specifications for loaded potato cheese fondue:
1. White Wine
Form

Dry white wine

Use

Loaded Potato Cheese Fondue

Varietal

Chardonnay or pinot grigio

Region

Any

Alcohol Percentage

10-15% alcohol by volume

Pack

1.5 liters, 6 per case

Price

Per case

25

2. Cheddar Cheese
Form

Cheddar cheese pasteurized, processed and shredded

Use

Loaded Potato Cheese Fondue

Preservation Form

38-40F on delivery in refrigerated truck

Quality

Must be grade 3, 2, or 1 by USDA standards and meet FDA


composition standards for cheddar cheese

Pack

5 pound bag

Price

By bag or case


3. Gruyere cheese
Form

Gruyere cheese shredded

Use

Loaded Potato Cheese Fondue

Preservation Form

38-40F on delivery in refrigerated truck

Quality

Must be grade 3, 2, or 1 by USDA standards and meet FDA


composition standards for gruyere cheese

Pack

5 pound bag

Price

By bag or case

26

4. Flour
Origin

Northern United States or Canada

Form

All-purpose

Use

Loaded Potato Fondue

Composition

Unbleached, enriched

Pack

10-pound sack

Price

By sack


5. Salt
Form

Pure Kosher salt

Use

Loaded Potato Fondue

Additives

None

Texture

Coarse

Quality

Kosher Certified

Pack

2 pound box

Price

Per box

27

6. Pepper
Form

Pure Ground Black Pepper

Use

Loaded Potato Fondue

Composition

100% black peppercorns

Texture

Coarse

Pack

2 pound box

Price

Per box


Equipment Specifications:
1. Sauce Pot
Type

Sauce pot with cover

Use

Fondue preparation

Material

Stainless steel or aluminum

Capacity

16 quart

Top Diameter

At least 10 inches

Height

At least 8 inches

Shape

Round

Cover type

Flat

Color

Any

Style

Straight sides

Quality

Meets safety standards of NSF International

Price

Per pot

(Webstaurant store, 2016)

28

2. Oven
Type

Range Oven

Use
Installation Type

Stove top for eggs, pancakes, waffles, fondue; oven for egg
casseroles and vegetables
Free standing

Width

Over 45 inches

Depth

Over 30 inches

Height

Any

Power Type

Gas

Number of Burners

Range Base Style

Standard Oven

Maximum
Temperature
Number of Ovens

At least 500F

Number of Racks

Quality

Meets safety standards of NSF International

Price

Per unit

(Webstaurant store, 2016)


29

HACCP Plan
HACCP Product: Cheddar cheese, received fresh. Delivered shredded in 5 pound
plastic bags. 6 Bags per boxed case received. Cheddar cheese melted and used to
serve cheese fondue.

HACCP: Table 1

Cold Storage
**Production**

Receiving
**Service**

Key: **CCP**






30

HACCP: Table 2
Process
Step

Potential Hazards:
(C) Chemical, (P) Physical, (B)
Biochemical, (M) Microbiological

Receiving C: Cheese package gets



contaminated with cleaning
supplies left out
P: Broken or ripped plastic in
cheese package due to poor
handling

P: Foreign objects inside of
cheese package such as glass,
metal or dirt due to punctured
package

Cold
Storage

Is this
potenti
al food
safety
hazards
signific
ant?
No
No



No

B: Cheddar cheese is not a


uniform yellow color




B: Cheese left at room
temperature for too long,
causing spoilage
M: Food not delivered at proper
temperature, allowing microbial
growth
M: Time and temperature of
cheese left out too long before
put into storage encourages
microbial growth, mostly molds
C: Cheese stored in refrigerator
next to cleaning chemicals

No





No

P: Cheese placed on the bottom


of other heavy storage foods,
allowing increased pressure on

No

No


No

No

Justification of decision re:


significant food safety
hazard.

Is this
step a
Critical
Control
Point
(CCP)?
(Y/N)
Cleaning supplies should be No
put away in proper supply
area immediately after use.
Policy that damaged
No
packages must be returned
upon receiving to the

supplier.

Receiver trained to inspect No
products upon arrival. If any
foreign objects are inside
packaging product returned
to supplier immediately.
Receiver trained to visually No
inspect products upon

arrival. If any discoloration
is evident, product is

returned to supplier

immediately.
No
Receiver trained to put food
items directly into storage
upon receiving.
Food kept in refrigerated
No
trucks, below 41F during


transit.
Receiver trained to put food
directly into proper storage No
when receiving occurs.
Cleaning chemicals kept in
non refrigerated storage in
separate containers in
separate storage unit
Cheese placed on its own
shelf in proper storage
area. Employees notify

No

No


31

the cheese packages




P: If package is punctured, dirt
can accumulate from other
items in storage




No

B: Refrigerator temperatures
No
too cold, allowing slight freezing
of cheese, allowing for
crystallization
M: Cheese stored next to or on
top of open meat products,
allowing cross contamination

M: Time and temperature can
allow for growth of microbes,
mostly molds, in storage

No



No

Productio C: Utensils used with chemicals


n
are accidently used when
melting the cheese
C: Cleaning solution or materials
left out in the cooking area

No


No

P: Hair gets into food from cook


or employee

P: Nails gets into food from cook
or employee

P: Piece of jewelry can get into
food from cook or employee

No


No


No

B: Cheese curdles when melting


cheese from increased
temperatures and increased
acidity


B: Cheese thickens and hardens

No





Yes

manager if there is not


enough space for all of the
storage items.
Receivers trained to
carefully and properly
handle food when being
brought to and from the
storage unit.
Refrigerator temperatures
kept between 36-40F and
policy in place that ensures
frequent temperature
monitoring by employees.
Separate storage units for
dairy and eggs, meat, and
frozen products in
operation.
Refrigerator temperatures
kept between 36-40F and
policy in place that ensures
frequent temperature
monitoring by employees.
Procedure to rinse, wash,
and sanitize cooking
utensils after each use
Cleaning supplies should be
put away in proper supply
area immediately after use.
Policy that all kitchen
employees must wear
bandanas or hairnets.
Policy that employees wear
gloves while handing food
directly.
Policy that kitchen
employees can wear only
plain ring bands.
One person is working the
strove area, and careful
following of the recipe is
enforced to ensure that the
cheese will be cooked at
low heat.
Due to high volume of




No

No

No



No

No


No
No


No


No
No





Yes
32

when cooking

Service

M: Cook coughs or
contaminates cheese with
bacteria

M: Cook is sick and can cross
contaminate germs or bacteria
to food


M: Cook hasn't washed hands
prior to cooking and can cross
contaminate



M: Not cleaning counter tops
before prepping with cheese, so
counter can be contaminated
with microbes from raw meat

M: Time and temperature after
cooking can allow for microbial
growth
C: cleaning supplies left out in
the service station


C: Towel used to wipe plate
clean before service was
previously used with cleaning
supplies

No



No




No





No




No

P: Glass from broken glass gets


into food before serving

P: Finger nails gets into food
from employee


No


No



No



No

orders, quality may be


affected by overcooking the
cheese causing it to obtain
undesirable consistency.
Cooks trained to cough or
sneeze away from the food
or go outside to do so.

Policy in place that cooks
should not come to work if
they are sick and at risk of
infecting others.

Employees trained with
proper hand washing
procedures and signs
posted in back of the house
of operation for reminders.

Policy about proper
cleanliness ensures that
utensils used are cleaned
immediately after use.

Cheese fondue served
immediately after cooking.
Cleaning supplies should be
put away in proper supply
area immediately after use.

Towel put into dirty laundry
to be washed immediately
after used for cleaning.
Ensure that clean towel is
used to wipe plates.
Expediter checks food
thoroughly before service.

Employees trained how to
handle plates in order to
allow lack of hand contact
with food. Policy that nails
kept short and unpolished

No



No




No





No




No
No



No

No


No




33



P: Employees hair gets into
food

P: Piece of jewelry can get into
the food from employee



P: Bugs get into food while
waiting to serve food



No


No




No

B: Cheese kept out too long in


service window and develops
unwanted texture and/or color

Yes

M: Time and temperature of


cheese left out for too long
before service, encouraging
microbial growth


M: Unwashed hands of
employee and can contaminate
food with bacteria


M: Employee coughs or sneezes
on food, causing bacteria spread

No





No




No

for all employees.



Policy that Servers must
wear hair back.

Policy that employees
should not wear any
dangling jewelry that may
be able to get into the food.

Food served immediately
after production. Policy in
place to keep kitchen clean
to keep bugs away.
High volume and lack of
efficient food runner can
cause food to be sitting out
for a length of time. Protein
coagulation can cause the
melted cheese to become
thick and increased
exposure to the air can
create a darker yellow color
on the top layer of the
melted cheese.
Cheese fondue served
immediately after cooking
and served in hot pots,
which allow optimal
temperatures to prevent
spoilage.
Servers trained and
instructed to wash hands
when handling food with
proper hand washing
procedures.
Employees trained for
proper procedures when
needing to cough or sneeze
around food.



No


No




No

Yes

No





No




No

34

HACCP: Table 3
Critical
Control
Point
(CCP)
Proces
s Step

Hazard
Descripti
on (C, P,
B, M)


Produc
tion

B: Melted
cheese
thickens
and
hardens
when
cooking

Critical
Limits
for each
Control
Measur
e

Monitoring

What

How

150160F
melting
temper
ature.
Do not
go past
160F
(Sargen
to)

Temper
ature

Using a
thermomet
er and eye
test for
melting of
cheese

Service B: Cheese Temper



kept out ature
too long
range
in service 150window
160F.
and
Should
develops not go
unwanted below
texture
150F
and/or
color

Temper
ature

Using a
thermomet
er

Frequen
Who
cy
For
Cook
each
or sous
batch of chef
fondue

For
Expedi
each
ter or
batch of chef
fondue

Corrective
Action for
each Control
Measure

If kitchen is
extremely
busy, call
another cook
to help if
available or
communicate
with head
chef that the
upcoming
orders
cannot be
made yet to
ensure
quality
If food is
sitting out for
too long,
expediter or
chef will call
upon the
food runner
to run the
food out. If no
food runner
is available
than the
expediter will
get a server
or manager
to run the
food out.

35

Employee Staffing and Scheduling


Skewers Brunch Bistro will be open 7 days a week from 10:30 A.M. until 4
P.M. This operation will also have a seating capacity of 60 seats and will serve 84
meals per hour (see calculation below). The FTE calculation was taken from the
total hours each employee is working on the employee schedule. The total hours per
week from each employee on the schedule was added up and then divided by 40
hours per week, which is the standard number of hours in an FTE. This number
came out to be 15 absolute FTEs and 23 adjusted FTEs.
The schedule was made based off of the peak times and non-peak times of
the operation. That being said, the peak times for Skewers is from 10:30 am to 4 pm
on Saturdays and Sundays and from 10:30am to 2 pm on Monday through Friday.
All day Saturday and Sunday a full staff is needed at the restaurant. This includes 4
servers, 1 chef, 1 sous chef, 2 cooks, 1 dishwasher, 1 food runner, 2 managers, and 2
bartenders. During the week from Monday to Thursday, not as many staff is needed
such that only 2 servers, 1 chef or sous chef, 2 cooks, 1 dishwasher, 1 manager and 1
bartender are put on the schedule. On Fridays, additional staff is put on except for
servers, due to the prep that is needed in the kitchen and in the bar for the busy
weekend. On Fridays, the staff consists of 2 servers, the chef, sous chef, 2 cooks, 1
dishwasher, 1 food runner, 2 managers and 2 bartenders. It is important to note that
the shift hours on the schedule are consistent for everyone except for the food
runners, because most of the employees have to do side work, preparation and clean

36

up. The shifts for all employees are 9am to 5 pm and shifts for the food runners are
from 10sm to 4 pm.
This staffing explanation is a minimum for what the operation will need in
order to run efficiently, given that there is a 60-seat capacity. Also, a goal for
Skewers is to have excellent customer service, with an aim for an average time spent
at the table to be 8 to 10 minutes. The full time employees at Skewers include the 2
managers, the 2 bartenders, 2 of the servers, chef, sous chef and 2 of the cooks.
These full time employees receive benefits as part of their pay. Benefits offered to
these employees include insurance coverage, paid time off and 401k contributions.
The benefit percentage for these benefits is 25% of that employees salary (see labor
budget page 40). The Skewers staffing policy allows for a 30 minute break for
employees that are working for more than 6 hours, part time or full time. This
includes everyone except for the food runner because the food runner only works a
6-hour shift. In addition, 10 paid vacation days are given to all full time employees.
These vacation days include sick time as well as vacations. Skewers will be closed on
Christmas but otherwise open on all other holidays, so time off for the holidays will
be part of the paid time off. Part time employees are responsible for filling in their
absence by calling another employee to fill in for their shift.
An online scheduling system called Hot Schedules will be used so that
employees can easily access the new schedules for the week from a computer or
phone. This is optimal so that employees do not have to call the restaurant asking
when they are working or have to make an extra trip to look at the schedule. This
software costs between $100 and $200 per month. This cost can be accounted for

37

the in the cash budget. This software can also be used to adjust for sick time and
vacation time because employees are able to put days that they are unable to work
into the software. A good use of Hot Schedules is for employees to coordinate and
communicate with each other to find replacements when they need time off.

Schedule:

Sun Mon

Tues

Wed

Thurs Fri

Sat

Server 1
Server 2
Server 3
Server 4
Chef
Sous Chef
Cook 1
Cook 2
Cook 3
Dishwasher
1
Dishwasher
2
Food
Runner
Manager 1
Manager 2
Bartender 1
Bartender 2

9-5
9-5
9-5
9-5
9-5
9-5
9-5
9-5
X
9-5

9-5
9-5
X
X
X
9-5
X
9-5
9-5
X

X
X
9-5
9-5
X
9-5
X
9-5
9-5
X

9-5
9-5
X
X
9-5
X
9-5
X
9-5
9-5

X
X
9-5
9-5
9-5
X
9-5
X
9-5
X

9-5
9-5
X
X
9-5
9-5
9-5
9-5
X
9-5

9-5
9-5
9-5
9-5
9-5
9-5
9-5
9-5
X
9-5

Total
hours
40
40
32
32
40
40
40
40
32
32

9-5

9-5

9-5

24

104
9-5
9-5
9-5
9-5

10-4

10-4

18

9-5
X
X
9-5

X
9-5
9-5
X

9-5
X
X
9-5

X
9-5
9-5
X

9-5
9-5
9-5
9-5

9-5
9-5
9-5
9-5

Total
hours

40
40
40
40

570

X =day off
Calculations:

Seating capacity

60 seats x 1.4 (productivity level for fine dining restaurant) = 84 meals per
hour

38

Hours of operation: 10:30-4 Monday-Friday


Peak times: 10:30-2 Monday-Friday and 10:30-4 on Saturday and Sunday
FTE Calculation:
482 hours per week/40 hours per FTE per week = 14.25 FTE absolute
14.25 x 1.55 = 22.08 adjusted FTEs
All shifts are from 9 am-5 pm for all employees, except for food runner, whos shift is
from 10am-4 pm. This time includes morning prep and side work and clean up side
work after the shift.

Product Cost Analysis



Loaded Potato Fondue
Recipe Modified Yield = 50 servings

Store prices discounted by 10% for commercial use.

Ingredient Quantity Amount Original
Discounted
per
Unit Price* Unit Price
serving
(dollar/oz) (dollar/oz)
Dry White 80 oz
1.6 oz
$0.29
$.261
White
Shredded
80 oz
1.6 oz
$0.356
$0.32
Cheddar
Cheese
Shredded
80 oz
1.6 oz
$1.036
$0.93
Gruyere
Cheese
All13.3 oz
.266 oz
$0.06
$0.05
Purpose
Flour
Salt
.42 oz
.0084 oz $0.06
$0.05
Pepper
.42 oz
.0084 oz $1.23
$1.12









Raw Cost




Food Cost
percentage

Price
per 1
serving
$0.418
$0.512
$1.488
$0.013
$0.0004
$.009

$2.44
30%

39





Final Price $8.25
*Prices found on Peapod, Stop and Shop (see references)
Calculations:

Quantity
5 lb cheese x 16 oz/lb = 80 oz
Amount per serving

80 oz/50 servings = 1.6 oz

13.3 oz/50 servings = .266 oz

.42 oz/50 servings = .0084 oz
Price per 1 serving

$1.12 x .0084 oz = .009408
Factor Method:

100/30 = 3.33

$2.44 x 3.33 = $8.13 rounded to $8.25

Explanation:


A single serving of loaded potato fondue is used for the cost analysis. The
menu pricing method used was the factor method, and the food cost percentage
used was 30%. By using this method, there was a calculated factor of 3.3, which
turns the raw food cost of $2.44 into the selling price of $8.25. This price is
comparable with prices of the fondue restaurant, The Melting Pot, such that their
price for cheddar cheese fondue is $8.95 per person. This ends up being comparable
to the price calculated in the analysis because there are additional toppings that are
being served with the fondue, such as potatoes, eggs, broccoli and bacon. The addons to the fondue can be comparable to The Melting Pots additional $4.95 charge
per plate of assorted meat toppings. Overall, the selling price for the fondue on its
own is similar to potential competitors, which makes the selling price accurate.

40

Labor Budget

Position

Pay
Rate

Work
Salary/week Benefits
Hours/week
(25%)

Total

Server 1

$8/hr

40

$320

$80

$400

Server 2

$8/hr

40

$320

$80

$400

Server 3

$8/hr

32

$256

$256

Server 4

$8/hr

32

$256

$256

Chef

$48,000
/year
$46,000
/year
$12/hr
$12/hr
$12/hr

40

$923.08

$230.77

$1153.85

40

$884.62

$221.15

$1105.77

40
40
32

$480
$480
$384

0
0
0

$480
$480
$384

Dishwasher 1 $9/hr

32

$288

$288

Dishwasher 2 $9/hr

24

$216

$216

Food Runner

$9/hr

18

$162

$162

Manager 1

40

$769.23

$192.30

$961.53

40

$769.23

$192.30

$961.53

Bartender 1

$40,000
/year
$40,000
/year
$10/hr

40

$400

$100

$500

Bartender 2

$10/hr

40

$400

$100

$500

$8504.68

Weekly
Labor
Cost
Monthly
Labor
Cost
Annual
Labor
Cost

Sous Chef
Cook 1
Cook 2
Cook 3

Manager 2

$34,018.72
$408,224.64

41

Salaries found on Indeed (see references)




This budget was based off of the total number of hours per employee on the
schedule (page 37). Further, the total labor for Skewers is displayed as having 4
servers, 1 chef, 1 sous chef, 3 cooks, 2 dishwashers, 1 food runner, 2 mangers, and 2
bartenders. The labor budget is displayed above with the weekly, monthly and
yearly labor costs, including benefits. The benefit percentage given to the full time
employees is 25 percent of their salary. These full time employees include 2 servers,
the chef, sous chef, 2 cooks, both managers and both bartenders. The employees that
are paid by a salary as opposed to hourly pay include the chef, sous chef and both
managers. With all of the benefits and hours of work calculated, the total annual
labor cost comes out to be $408,224.64.













42

References
Bares, A. (2015, March 17). 2014 turnover rates by industry. Compensation Force.

Retrieved from http://www.compensationforce.com/2015/03/2014
turnover-rates-by-industry.html

Biery, M. E. (2014, June 22). U.S. restaurants seeing fatter margins. Forbes. Retrieved

from http://www.forbes.com/sites/sageworks/2014/06/22/us
restaurants-margins/#72b5934b1278

Cook Diary (2015, September). Fondue. Cook Diary. Retrieved from

http://cookdiary.net/fondue/

DiMella, M. (2008, October 20). Fan pier: Will bostons seaport waterfront ever be

built? Charlesgate Realty. Retrieved from

http://info.charlesgaterealty.com/Blog/bid/7006/Fan-Pier-Will-Boston-s
Seaport-waterfront-ever-be-built

Gregoire, M. B. (2013). Food service organizations: A managerial and systems

approach (8th ed). Boston, MA: Pearson.

Indeed. (2016). Restaurant chef salary. Indeed. Retrieved from

http://www.indeed.com/salary?q1=Restaurant+chef&l1=

Melting Pot (2016). Our Menu. The Melting Pot. Retrieved from

http://www.meltingpot.com/bedford-burlington-ma/restaurant-menu.aspx

Sargento (2016). Cheese melt meter. Sargento Food Service. Retrieved from

http://www.sargentofoodservice.com/trends-innovation/cheese-melt
meter/
Sheila (2016). Cheese fondue. Allrecipes. Retrieved from

http://allrecipes.com/recipe/13714/cheese-fondue/

Statista (2016). How often do you eat brunch at a cafeteria/buffet restaurant?

Statista. Retrieved from

http://www.statista.com/statistics/256497/frequency-of-us-consumers
eating-brunch-at-cafeteria-buffet-restaurants/

Stop & Shop (2016). Peapod home. Peapod. Retrieved from

http://www.peapod.com/index.jhtml;jsessionid=CKLXXZ20AF43SCQBD0WS

IIQ?NUM1=1460417726723

Webstaurant (2016). Garland sunfire series X36-6R 6 burner 36 gas range with

standard oven-213,000 BTU. Webstaurant Store. Retrieved from

http://www.webstaurantstore.com/garland-sunfire-series-x36-6r-6-burner
36-gas-range-with-standard-oven-213-000-btu/372X366R.html

43


Webstaurant (2016). Vollrath/Lincoln 3904 optio 16 qt. Sauce pot with cover.

Webstaurant Store. Retrieved from

http://www.webstaurantstore.com/vollrath-lincoln-3904-optio-16-qt
sauce-pot-with-cover/9223904.html





























44








Case 9: Ulcer Disease - Medical and Surgical Treatment
Alyssa Adler











HS486 Applied Nutrition Care
Dr. Staniec
7 October 2016

45

Case Questions:

1. One risk factor for Marias ulcer disease is that she smokes (Nelms, Sucher, &
Lacey, 2016). In addition, Maria was positive for the bacteria Helicobacter pylori, and
was diagnosed with gastritis and GERD. Another risk factor is that her father had
peptic ulcer disease, which makes Maria about three times more susceptible to ulcer
disease.

2. Smoking is related to ulcer disease because smoking can cause increased gastric
liquid emptying, decreased bicarbonate secretions, and interference in mucus
secretions (Eastwood, 1998). All of these effects on the body disrupts the protection
of the stomach and duodenum and eventually makes the stomach more acidic and
highly susceptible to ulcers (Nelms, Sucher, & Lacey, 2016). Additionally, smoking
decreases the blood flow in the stomach and body, which can also be a risk for ulcer
disease. Also, smoking can also decrease the effectiveness of some meds used to
treat ulcers.

3. H. pylori play a major role in ulcer disease. H. pylori attach to cells that secrete
mucus located in the stomach lining (Nelms, Sucher, & Lacey, 2016). It is normal to
have this strain of bacteria in the body, but development of ulcers or inflammations
are dependent on the immune response. For protective purposes, H. pylori create
ammonia from breaking down urea, which neutralize the acid environment of the
bacteria and increases their survival. On the flip side, this bacterium secretes

46

proteins that cause mucosal cell damage, resulting in inflammation. Other byproducts made by H. pylori cause destruction of the mucus barrier in the stomach as
well as in the epithelium. The complications of H. pylori result in damage to the
protective mucosal layer of the stomach, which is a major risk factor for peptic ulcer
disease.

4. Metronidazole and tetracycline are both antibiotics, which are used to treat the
bacterium, H. pylori. Metronidazole inhibits the DNA synthesis of specific bacterial
cells, which causes these cells to die (Drug Bank, 2016). Tetracycline disrupts
protein synthesis by interfering with the bond of the aminoacyl-tRNA and the
ribosome acceptor site (Chopra & Roberts, 2001). Bismuth subsalicylate is a
cytoprotective agent, which allows for mucus secretions and increased blood flow
through the GI tract lining. Also, this drug provides a protective coating on any
ulcerated tissue (Anand, 2015). Lastly, omeprazole is a proton pump inhibitor which
lowers gastric acid secretions and protects peptic ulcers caused by excessive NSAID
use as well as preventing peptic ulcers in the future for high frequency NSAID users.

5. Tetracycline can bind to calcium from dairy products, which decreases calcium
content in the body and drug absorption (Bobroff, Lentz, & Turner, 2009). However,
it is found that taking metronidazole with milk or water helps lessen stomach
disruption (Bareuther, 2008). The bismuth subsalicylate, may cause deficiencies in
Vitamins B12 and C, calcium, iron and magnesium by interfering with the vitamin
and mineral metabolism, if taken long-term (Heidelbaugh, 2013). The drug nutrient

47

side affects that are most pertinent to Marias condition are the calcium deficiency
side affects. Although Marias calcium levels are in the normal range, calcium
depletion can affect iron absorption, which is important for her overall nutrition
status. Other important side effects of these medications are nausea, vomiting and
diarrhea; which are critical to Marias condition because these symptoms can affect
her ability to eat. It is important to note also that the tablet form of bismuth
subsalicylate must be taken at least 1-3 hours prior to or after tetracycline because
the bismuth can reduce the effectiveness of the tetracycline.

6. Maria underwent a gastrojejunostomy, or Billroth II, in which a partial
gastrectomy is performed where a blind loop is put on the duodenum (Nelms,
Sucher, & Lacey, 2016). More specifically, the blind loop forms a connection
between the proximal end of the jejunum and the distal end of the stomach. Simply
put, this procedure removes part of the stomach and reconnects the top part of the
stomach with the small bowel.

7. The normal digestive process can change after this procedure because part of the
stomach was removed and the digestive track is now slightly altered (Nelms, Sucher,
& Lacey, 2016). Severe changes can occur such as reduced capacity of the stomach.
In addition, there may be lactose intolerance due to decreased enzyme function at
first post procedure preventing the enzyme lactase to break down lactose. With
healthy digestion, most foods stay in the stomach for 1 to 3 hours as it becomes
liquefied and partially digested before entering the duodenum. The food entering

48

the duodenum at a slow rate allows for the acidic contents to be neutralized by
pancreatic bicarbonate. When certain parts of the stomach are removed, like in
gastric surgeries, the stomach empties at a faster rate and the duodenum is
bypassed (faster transit time). Additionally, altered digestion can lead to
malabsorption, which can cause dumping syndrome and steatorrhea. This
malabsorption can cause certain vitamin and mineral deficiencies such as iron,
calcium and B vitamins, decreased intrinsic factor and increased acidity of the
stomach.

8. Dumping syndrome is the bodys physiologic response to the rapid emptying of
hypertonic contents from the stomach into the duodenum and jejunum (Nelms,
Sucher, & Lacey, 2016). The early stage of dumping syndrome occurs usually 10 to
20 minutes after eating and is accompanied by abdominal fullness and nausea. At
this stage, fluid is being pulled into the small intestine in order to dilute sugars
(carbohydrates) and other hypertonic contents. Other symptoms involved with
early dumping stages are flushing, sweating, faintness, and rapid heartbeat due to
fluid changes in vascular chambers. The intermediate stage of dumping syndrome
occurs between 20 and 60 minutes after eating. At this time, a patient may
experience abdominal bloating, flatulence, cramps and abdominal pain, and
diarrhea. These symptoms are a result of carbohydrate and nutrient malabsorption.
Further, these contents begin to ferment. Finally, the late stages of dumping
syndrome occur 1 to 3 hours after eating. This occurs mainly due to consumption of
simple carbohydrates such that the carbs are absorbed quickly into the small

49

intestine, which then triggers an insulin release. This insulin release causes blood
sugar levels to drop rapidly and cause hypoglycemia. Symptoms involved in this
stage are sweating, confusion, weakness and shakiness.

There are many interventions and prevention tactics to combat the

symptoms of dumping syndrome. To cope with hypoglycemia and hyperosmolality


it is recommended to avoid simple sugars. In general, a balanced diet is
recommended that favor protein and fat as opposed to carbohydrates. Consuming
high soluble fiber foods can also help slow gastric emptying. In addition, liquids in
between meals rather than at meal times are suggested in order to slow digestion.
Also, meals should be smaller and more frequent such as 5 to 6 smaller meals a day.
When eating patient should eat slowly and chew foods well. Patient should also lie
down after meals to ease digestion.

9. Common nutritional deficiencies that result from a gastrojejunostomy are iron,
calcium and vitamin B12. Macronutrient deficiencies include fat due to
malabsorption (Nelms, Sucher, & Lacey, 2016). Maria may be at risk for pernicious
anemia because her intestine would not be able to properly absorb Vitamin B12
from the intrinsic factor normally secreted by the stomach (Gersten, 2016). This can
cause Vitamin B12 deficiency leading to pernicious anemia. Maria is also at risk for
megaloblastic anemia because her surgery altered the absorption of Vitamin B12
and folate (Kim, 2015). Both Vitamin B12 and folate are needed to make red blood
cells. The lack of these nutrients alters the functioning of red blood cells, leading to
megaloblastic anemia. Similarly, Maria is at risk for iron deficiency anemia because

50

the gastric surgery affects her intestines ability to absorb iron due to decreased
hydrochloric acid, which increases the acidity of the stomach. This leads to anemia
because iron absorption occurs at low acidity (Cafasso and Nall, 2015).
Malabsoption can also affect the way lactose is digested in dairy, which can
contribute to a calcium deficiency as well.

10. When discharged, it is recommended that Maria take a liquid multivitamin in
order to keep up with the Dietary Reference Intakes, especially when Maria is
transitioning between her tube feeding and oral diet. Liquid may be better for a
multivitamin infusion because Maria is transitioning between her oral diet and tube
feeding, and the infusion allows for greater potency of supplements, are appropriate
for malabsoprtive patients, and have a more rapid onset of action. This multivitamin
should contain iron, because her iron levels are low and her transferrin levels are
high, which is indicative of iron deficiency. Iron deficiency is common after gastric
surgery due to impaired absorption in the intestine. Also, I would recommend a B12
intramuscular supplement (injection), a 1000-1500 mg calcium supplement, and a
Vitamin D supplement. All supplements should be injections in order to ensure
adequate absorption.

11. %UBW = 110/145 x 100 = 75.86% moderately malnourished
% Unintentional Weight loss = 145-110/145 x 100 = 24% significant weight
loss
BMI = 50 kg / (1.57)2 = 20.28 normal range

51

The percent usual body weight should be used over the body mass index

because according to standards, Marias BMI is in the normal range (Nelms, Sucher,
& Lacey, 2016). Contrastingly when looking at the percent usual body weight, the
percentage shows that Maria is moderately malnourished. The usual body weight
allows for the further calculation of unintentional weight loss, which is found to be
severe. Overall, the percent usual body weight can show the dietitian that the
patient needs a nutrition care plan to treat her unintentional weight loss from GERD
and further ulcer complications.

12. As stated above, calculating Marias unintentional weight loss is important to
indicate how significant and how fast she is losing weight. In addition, a skinfold test
could be used in order to calculate muscle mass loss, which can also be an indicator
for malnutrition. Other physical examination methods can include looking for upper
arm muscle mass for fat or muscle wasting can help indicate malnutrition.



13.
Energy Requirements:

Harris-Benedict: 655.1 + 9.6(50) + 1.9 (157) - 4.7(38) = 1254.8 x 1.3(SF) =

1631 kcals

Kcal/kg = 33kcal/kg = 1650 kcals

Protein:

52

20% of kcals 1631 x .2 = 326.2 kcals / 4kcals = 81 grams protein


1.5 g protein/kg/day = 1.5 x 50 = 75 grams protein

For energy requirements, Harris Benedict was used with a stress factor
because at this stage, Maria is chronically ill. In addition, 33 kilocalories per
kilogram was cross checked for energy requirements because Maria is hospitalized
and just came out of surgery.
For protein requirements, according to Nelms, Sucher and Lacey for dumping
syndrome and gastric ulcers it is recommended that 20 percent of calories should
come from protein. I also used 1.5 g protein per kilograms per day as a cross check
for patients that are healing, and need more protein especially after her
gastrectomy.

14. Pivot 1.5 is a specialized chemically defined formula for immune system support
(Nelms, Sucher, & Lacey, 2016). Further, Pivot 1.5 is a concentrated formula because
it has 1.5 kilocalories per milliliter, which means that it is good for patients who
need fluid restriction. Also, this is appropriate because Maria has higher calorie and
protein needs because she is post operative, has malnutrition and metabolic stress.
This formula is hydrolyzed, has soluble fiber and is specifically formulated for GI
dysfunction. According to the ASPEN guidelines, I agree with this choice to start
enteral feeding postoperatively because after surgery Maria was unable to eat
anything by mouth, and enteral nutrition support allows for gut functional integrity
and increased blood flow in the gut (McClave et. al., 2016). The ASPEN guidelines

53

state that when it is feasible, within 24 hours of surgery the primary choice of tube
feeding is through enteral nutrition because it results in better health outcomes
than parental nutrition. In addition, it is recommended post operatively to use an
immune-modulating formula that contains arginine and fish oils for the best results.
Pivot 1.5 is an immune modulating formula that contains arginine, and vitamins A, C,
and E (antioxidants).

15. The enteral formula would start at 25 mL/hr because this is the first time post
surgery that the GI system and new pathway in the digestive tract are going to be
exposed to nutrients. Using a pump to initiate feeding at a slow and continuous rate
can improve the feeding outcomes and gut integrity (Nelms, Sucher, & Lacey, 2016).
According to clinical practice, it is recommended to start formulas between 10
mL/hr and 40 mL per hour at full strength, and then depending on tolerance,
increasing the rate by 10-20 mL/hr at 6 to 8 hour intervals until the required rate is
reached. Also slow feeding is pertinent because Pivot has a high osmolality of 595
mOsm per kilogram, so it may be better tolerated to start feeding at a slower rate.

16. EN calculations for 25 mL/hr of Pivot 1.5
Kcals:
25 mL/hr x 24 hr = 600 mL/day

600 mL/day x 1.5 kcal/mL = 900 kcals/day

recommended 1631 kcals/day

54

Protein:

0.6 L x 94g prot/L = 56.4 g prot/day

recommended 81 g prot/day

Recommended EN dose:

1631 kcals/1.5 kcal/mL = 1087 mL/day formula needed to meet energy

requirements

1.087 L x 94 g prot/L = 102 g pro meets 81 g prot requirement

1087 mL / 24 hr = 45.29 mL/hr 45 mL/hr x 24 hr = 1080 mL/day = rate


1080mL/day x 1.5kcal/mL = 1620 kcal/day close to 1631 kcals
1.087 L x 94 g prot/L = 102.18 meets 81 g prot requirement
Need 1000 mL Pivot 1.5 to meet Vitamin and Mineral Requirements (Nelms,

Sucher, & Lacey, 2016), so meets RDAs.


Goals are not being met from this enteral nutrition prescription of 25 mL/hr
of Pivot 1.5. Maria is only getting 900 kcals of the 1631 kcals that Maria needs as
well as only getting 56.4 grams of protein when she needs 81 grams of protein per
day. With this continued regimen, Maria will unlikely gain or maintain weight and
correct her malnutrition. The end goal for her nutrition support should be to start at
25 mL per hour, but then increase by 15 mL every 4 to 8 hours as tolerated in order
to achieve the goal of 45 mL per hour (Nelms, Sucher, & Lacey, 2016).

55

17. When monitoring tolerance to enteral nutrition, the dietitian would monitor any
gastrointestinal symptoms such as nausea, vomiting, diarrhea, constipation, cramps,
abdominal distention or esophageal reflux (Nelms, Sucher, & Lacey, 2016).
Measuring intake and outtake inputs are also a good measure of enteral nutrition
tolerance. Pulmonary symptoms include respiratory distress or aspiration. Some
hydration issues to be aware of are urine output and weight changes. Some
laboratory values are also useful when monitoring for tolerance. Some values to be
mindful of are lab values that indicate dehydration such as BUN, serum sodium, and
creatinine. Electrolyte imbalances and glucose levels are also important to monitor.

18. The patient is receiving 450 mL of enteral nutrition according to the
Intake/Output record (Nelms, 2015). This is below the prescription of 25 mL per
hour, which is 600 mL per day.

19. Modifications in the diet include focusing the diet on large amounts of protein
(20 percent of calories) and moderate fat (between 35 and 45 percent of calories)
(Nelms, Sucher, & Lacey, 2016). Protein is helpful in buffering gastric secretions,
which can help with the ulcer. Overall, small meals are recommended to improve
nutrient absorption. Fibrous foods or complex carbs are favorable because they will
slower upper gastrointestinal transit and increase viscosity of the foods entering the
digestive tract. This will help slower gastric emptying into the duodenum and
jejunum and prevent dumping syndrome. Soluble fiber is better than insoluble fiber
in this case, because it is more easily digested because it can gel to other foods in

56

addition to slowing down digestion. Concentrated sugars and sweets should also be
limited. These may include soda, juice, cake, pie and cookies. Artificial sweeteners
are okay if tolerated. It is also important to see if the Maria can tolerate lactose. If
lactose is poorly tolerated then lactose-free or lactose-reduced dairy products are
recommended. Foods that should be avoided in general that are known to increase
acidity in the stomach are black and red pepper, caffeine, coffee (regular and
decaffeinated) and alcohol. A typical first meal for the patient can include 5 ounces
roasted chicken with 1 cup boiled potatoes without the skin and 1 cup well-cooked
steamed or sauted broccoli with a little olive oil.

20. Other recommendations to increase Marias food tolerance would be to not
drink during meals, but sip constantly throughout the day in order to prevent
dehydration (Nelms, Sucher, & Lacey, 2016). In addition, laying down after meals
and avoiding physical activity for about an hour after eating would help to slow
gastric emptying and increase absorption. As stated above, small meals and chewing
well and eating slowly are optimal to decrease stress on the digestive tract.

21. According to the admission biochemical lab values recorded on August 30th
(when Maria was admitted), Marias abnormal values include low glomerular
filtration rate, high bilirubin and total bilirubin, low total protein, albumin and
prealbumin, high creatinine phosphokinase, high white blood cell count, low
hemoglobin and hematocrit, low mean cell hemoglobin and mean cell hemoglobin

57

content, high red blood cell distribution, high transferrin, low ferritin and low iron
(Nelms, 2016).

a. Low albumin and prealbumin are indicative of protein energy

malnutrition, in addition to low total protein in the body (Nelms, Sucher, & Lacey,
2016). Low albumin and prealbumin can also show inflammation, malnutrition and
shock. Also, high white blood cell count, which can show an immune response of
infection. Low hemoglobin and hematocrit can show risk for anemia. High
transferrin levels can be indicative of protein energy malnutrition and importantly
iron deficiency anemia. Low iron levels are also another indicator for an iron
deficiency.

b. When diagnosing Marias duodenal ulcer, the lab values that lead to this

inclusion include the high white blood cell count, which can show an infection such
as H. pylori invading the gut (Nelms, Sucher, & Lacey, 2016). Albumin and
prealbumin levels are important because these values indicate inflammation, in
which gastritis may be present, which is a cause of duodenal ulcers. Similarly, low
hemoglobin and hematocrit values can show poor blood flow into the stomach,
which can lead to anemia and low iron levels. Transferrin is also another good
indicator of iron deficiency. In combination, the hemoglobin, hematocrit, iron and
transferrin abnormal lab values show evidence of poor blood flow leading to iron
deficiency anemia. Also, possible bleeding from the duodenal ulcers. Iron deficiency
and poor blood flow are indicators of duodenal ulcers. In addition low transferrin,
albumin and prealbumin levels can show protein energy malnutrition, in which poor

58

absorption of nutrients occurs with ulcers. Finally, percent segs can indicate
bacterial infection from H. pylori.

22. Maria has severe malnutrition in the context of acute illness because she has
unintentional weight loss of more than 7.5% in 3 months and has an energy intake
of less than 50% since her ulcer was diagnosed 2 weeks ago (AND, 2012).

23.

1. Unintended weight loss related to duodenal ulcer as evidenced by 23%

weight loss in over 6 months.


2. Altered GI function related to duodenal ulcer and gastric surgery as

evidenced by NPO status, pt s/p gastrojejunostomy and abdominal pain.


3. Malnutrition related to duodenal ulcer as evidenced by unintentional

weight loss of more than 7.5% in 3 months and has an energy intake of less than
50% since her ulcer was diagnosed 2 weeks ago.

24. A goal for the first PES statement would be to establish weight maintenance by
altering diet via enteral nutrition tube feeding or starting an oral diet. If still remain
on tube feeding, feed Pivot 1.5 at 25 mL per hour and then increase based on
tolerance until reach 40 mL per hour with a vitamin elixir 15 mL to get all calorie
and nutrient requirements. If going on to oral diet, PO diet should include a wellbalanced diet with small meals, concentrated on protein, fat, and soluble fiber (foods
that are easy to digest and not concentrated in sugars). A goal for the second PES

59

statement would be to increase intake so that intake is more that output value. This
can be done by altering the EN feeding rate as stated above, in addition to altering
the PO diet once off of the tube feeding. In general, lying down after meals and
drinking water between meals will help to increase food tolerance and slow
digestion.

25. The patient has to be educated on proper ways to decrease malabsorption,
indigestion and increase nutritional intake. This can be done by describing how the
digestive tract was altered in surgery and how part of stomach was removed from
the digestive tract. Educating the patient on what foods slow the digestive time such
as soluble fiber, fat and protein as opposed to carbs can be beneficial. In addition,
the patient should know that limiting foods such as caffeine, coffee, red and black
pepper, and alcohol will be better for digestion because these foods will increase the
acidity of the stomach which increase indigestion and discomfort. Looking at Marias
diet history, Maria should limit her coffee intake completely and her soft drinks, if
the soft drinks contain sugar. Small meals and lying down after meals is important
for the patient to know because that will also slow digestion and limit symptoms for
dumping syndrome. Knowledge about dumping syndrome and knowing that gastric
surgery patients are at high risk are significant information. The diet for dumping
syndrome is very similar to the diet prescribed earlier. For micronutrients, it is
important to explain to Maria that taking a multivitamin, including Calcium, Vitamin
D, B12 and iron supplements may be beneficial to prevent any deficiencies. The

60

quantity of supplements needed can be monitored by serum levels for these


micronutrients.

26. Lifestyle issues that need to be addressed are lying down and avoiding activity
after eating for at least an hour postprandial (Nelms, Sucher, & Lacey, 2016). With a
computer programming job such as Marias, it is key to find an area to lie down after
eating lunch or snacks throughout the workday. Other changes include smoking
cessation. Smoking is a major risk factor for gastritis and ulcers and decreased blood
flow to the tissues and should be eliminated. Finally, coming into the doctor to check
out serum micronutrient levels is helpful for keeping track of supplementation and
nutrient deficiency risk and prevention.

Support Groups for Ulcer Disease Patients:

With technology infinitely growing, there are tons of online support groups

that are offered for gastric ulcer disease patients. Daily Strength (2016) and
Drugs.com (2006) provide support groups where you can sign up for free, and then
post comments or questions while other people in the support group can respond.
Both of these groups are similar, the Daily strength support group is smaller, with
about 30 members while the drugs.com support group has about 50 members. Both
sites are easy to navigate and sign up for, which is a benefit for the patient. These
support groups are a great opportunity to show patients that they are not alone, and
give them a chance to communicate with one another and help build self confidence
and strength in their recovery.

61

Application for Ulcer Disease Patients:


There are a few cell phone apps that can be useful for ulcer disease patients.

Applications vary from explaining signs, symptoms and prevention of peptic ulcers
to evaluating which foods to avoid and which foods are okay to eat. There is an
application called Choose This Not That for Ulcers (Personal Remedies, 2016). This
app contains comprehensive nutritional guidelines on how to prevent and treat
ulcers in terms of food and lifestyle changes. This app allows one to search any food
and the app will present a colorful wheel which labels the food as either most
helpful (green zone) or avoid (red zone) or somewhere in the middle. In addition,
the app allows the user to make a personal profile. There are also questions asking
about other complications that the patient may have such as anemia, diabetes,
cancer risk, obesity, stress, vitamin D deficiency etc. The app will then change
certain guidelines that personalize for that patients health complications. Food
suggestions in this app consist of the best food items to eat in each specific food
group. This can be beneficial for the patient when at a restaurant or grocery store
when trying to buy foods that are more comforting for the digestive system. Overall,
this application provides and easy and comprehensive way for patients to gain
knowledge and self-efficacy of certain lifestyle changes that can be used to treat
their chronic illness.



62

ADIME
Assessment

Diagnosis

Maria Rodriguez is a 38 yo F who underwent a


gastrojejunostomy for perforated duodenal ulcer after
suffering from GERD. Patient put on EN tube post operation.
-Patient understands feeding through her EN tube. Patient says
she has eaten very little since ulcer diagnosis 2 weeks ago.
Patient wants to know how long before she can eat normally
again.
-Admitted date: 8/30/16
-Diet hx: AM: coffee, 1 slice dry toast. Weekends cook large
breakfast for family: omelets, rice, pozole, or pancakes, waffles,
fruit. Lunch: sandwich with 2 oz turkey on whole wheat bread
with mustard, 1 piece fruit, 2-3 cookies. Dinner: 2 C rice, meat
(2-3 oz chicken), fresh vegetables (steamed tomatoes, peppers,
onions), coffee; 8-10 C coffee per day an 1-2 (12 oz) soft drinks
per day
-Self and daughters prepare meals. Live with daughters
-No previous nutrition therapy
-No vitamin and mineral intake previously
-PMH: gravida 2 para 2, GERD
-PSH: s/p endoscopy (2 weeks ago outpatient) revealing 2-cm
duodenal ulcer with generalized gastritis and positive biopsy
for H. pylori
-Meds: completed 10 of 14 days of bismuth subsalicylate 525
mg 4xd, metronidazole 250 mg 4xd, tetracycline 500 mg 4xd,
omeprazole 20 mg 2xd
-Social history: tobacco use, no alcohol use
-Codeine allergy
-EN prescription Pivot 1.5@25 mL/hr
-Abdomen-tender with guarding, absent bowel sounds
-Skin-warm and dry to touch
-Ht: 52; Wt 110#; BMI: 20.28; %UBW 75.86; % Unintentional
Weight loss 24%
-Labs from 9/2 taken in hospital: Na 140; K 4.2; Chloride 101;
Bicarb 23; BUN 15; Creatinine 0.9; BG 128; Ca 8.7; prot 5.8; alb
3.3; prealb 14; Hg 10.2; Hct 31
-Labs from 8/30: Fe 63; B12 45; folate 15; ferritin 15;
transferrin 401
-Intake since 8/30 admission: -593 mL/kg
-Nutrition prescription: 1461 kcals (Ireton-Jones), 73 g prot,
1461 mL fluid

-Maria has severe malnutrition in the context of acute illness
because she has unintentional weight loss of more than 7.5%
in 3 months and has an energy intake of less than 50% since
63

Intervention

Monitoring &
Evaluation

her ulcer was diagnosed 2 weeks ago.


-Inadequate enteral nutrition infusion related to patient
receiving less than prescribed EN as evidenced by increased
input of 450 mL formula per day on I/O instead of prescribed
600 mL per day.
- Unintended weight loss related to nutrient malabsorption as
evidenced by 23% weight loss in over 6 months.
-Altered GI function related to duodenal ulcer and gastric
surgery as evidenced by NPO status, pt s/p gastrojejunostomy
and abdominal pain.
- Abnormal lab values since 9/2: high glucose, high bilirubin,
high total protein, low albumin and prealbumin, high white
blood cell count, low hemoglobin and hematocrit, low mean
cell hemoglobin and mean cell hemoglobin content.
-Labs from 8/30: high transferrin, low ferritin and low iron
-food and nutrition related knowledge deficit
-Establish weight maintenance by altering diet via enteral
nutrition tube feeding or starting oral diet. For EN feed Pivot
1.5 at 25 mL per hour and then increase based on tolerance
until reach 40 mL per hour with a vitamin elixir 15 mL to get
all calorie and nutrient requirements. If going on to oral diet,
DO should include a well-balanced diet with small meals,
concentrated on protein, moderate fat, and soluble fiber (foods
that are easy to digest and not concentrated in sugars),
avoiding caffeine, coffee, alcohol, red and black pepper. Sipping
fluids in-between meals not during. Avoid high sugar foods.
-Increase intake so that intake is more that output value by
altering the EN feeding rate as stated above.
-Lying down after meals and drinking water between meals
will help to increase food tolerance and slow digestion.
-Iron supplement to correct risk for anemia and poor blood
flow seen in hemoglobin and hematocrit levels
-Get patient on adequate EN or PO diet to correct nutrient and
micronutrient imbalances
-Measure recent serum levels for iron, B12, folate, transferrin
and ferritin
-No smoking
-Educate patient on altered digestive system post surgery and
how altered diet and lying down after meals is adequate to
slow digestion. Educate patient on side effects and symptoms
of dumping syndrome
-Measure intake and output for patient daily
-Assess food tolerance if start PO diet
-Measure weight every day for weight maintenance
-Assess serum micronutrient levels for adequate
supplementation
64

-Side effects for EN or PO diet include indigestion symptoms


such as vitamin and mineral malabsorption, dumping
syndrome, indigestion, cramps, abdominal pain

Works Cited

Anand, B. S. "Peptic Ulcer Disease Medication." Medscape. Ed. Julian Katz. N.p., 9 Jan.
2015. Web. <http://emedicine.medscape.com/article/181753-medication#2>.
Bareuther, Carol M. "Dangerous Food-Drug Interactions." Aging Well 1.4 (2008): n. pag.
Today's Geriatric Medicine. Web. 04 Oct. 2016.
<http://www.todaysgeriatricmedicine.com/archive/101308pe.shtml>.
Bobroff, Linda B., Ashley Lentz, and R. Elaine Turner. "Food/Drug and Drug/Nutrient
Interactions: What You Should Know About Your Medications." University of
Florida, May 2009. Web. 4 Oct. 2016.
<http://edis.ifas.ufl.edu/pdffiles/He/HE77600.pdf>.
Cafasso, Jacquelyn, and Rachel Nall. "Iron Deficiency Anemia." Healthline. N.p., 15
Oct. 2015. Web. 4 Oct. 2016. <http://www.healthline.com/health/iron-deficiencyanemia#Overview1>.
Chopra, Ian, and Marilyn Roberts. "Tetracycline Antibiotics: Mode of Action,
Applications, Molecular Biology, and Epidemiology of Bacterial Resistance."
Microbiology and Molecular Biology Reviews 65.2 (2001): 232-60. NCBI. Web. 4
Oct. 2016. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC99026/>.
Eastwood, Gregory L. "The Role of Smoking in Peptic Ulcer Disease." Journal of
Clinical Gastroenterology 10 (1988): S19-23. PubMed. Web. 4 Oct. 2016.
<https://www.ncbi.nlm.nih.gov/pubmed/3053883>.

65

Journal of the Academy of Nutrition and Dietetics 112.5 (2012): 734-35. Web. 4 Oct.
2016.
<http://www.andeal.org/files/Docs/White%202012%20Malnutrition%20Consens
us%20-%20Table%20Clinical%20Characteristics.pdf>.
Kim, Steven. "Megaloblastic Anemia." Healthline. N.p., 30 Sept. 2016. Web. 4 Oct.
2016. <http://www.healthline.com/health/megaloblastic-anemia#Overview1>.
McClave, Stephen A., et al. "Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient." Journal of Parenteral and
Enteral Nutrition 40.2 (2016): 159-211. Sage Journals. Web. 4 Oct. 2016.
<http://pen.sagepub.com/content/40/2/159.full>.
Nelms, M., Sucher, K.P., and Lacey, K. Nutrition Therapy and Pathophysiology. 3rd ed.

Boston: Cengage Learning, 2016. Print.

Nelms, Marcia N. Medical Nutrition Therapy: A Case Study Approach. 5th ed. Boston:

Cengage Learning, 2017. Print.

Peptic Ulcer Support Group. Daily Strength. Sharecare Inc, 2006. Web. 6 Oct. 2016.

<https://www.dailystrength.org/group/peptic-ulcers/members>.

Personal Remedies. Ulcers (Peptic Ulcer). iTunes. Apple, 9 July 2016. Web. O6 Oct.

2016. <https://itunes.apple.com/za/app/ulcers-peptic-

ulcer/id865614270?mt=8>.

Stomach Ulcer Support Group. Drugs.com. 2 Aug. 2016. Web. 6 Oct. 2016.

<https://www.drugs.com/answers/support-group/stomach-ulcer/>

Todd Gersten. "Pernicious Anemia." Medline Plus. N.p., 1 Feb. 2016. Web. 4 Oct. 2016.
<https://medlineplus.gov/ency/article/000569.htm>.

66

Wishart, D. S., et al. "Metronidazole." Drug Bank. The Metabolomics Innovation Centre,
13 June 2005. Web. 4 Oct. 2016. <https://www.ncbi.nlm.nih.gov/pubmed/3053883>.

67


Brazil Nuts

Not Too Nuts!


By Alyssa Adler

Interestingly, Brazil nuts are technically seeds that are found inside of a coconut-like
shell. This shell can contain up to 20 to 30 nuts and is grown on 150-foot treetops in
Latin American countries.

Similar to all nuts, Brazil nuts are nutrient dense and contain high amounts of fats,
fiber, protein and antioxidants (NIH). The fats in Brazil nuts are mostly
polyunsaturated and monounsaturated, which are heart healthy and help lower
cholesterol. These nuts are also a good source of calcium, magnesium and
potassium.

Brazil nuts contain high amounts of the element selenium. In fact, one Brazil nut
alone gives you all the selenium that you need for the day! According to the National
Institute of Health, selenium is suggested to have preventative effects with cancer
such as targeting DNA repair, cell destruction, and immune system functioning. On
the flip side, excess consumption of Brazil nuts can lead to selenium poisoning from
aflatoxins, which are carcinogenic. So, incorporating small amounts of Brazil nuts
can be beneficial for your health, but dont go too nuts!

Anns Tips


Brazil nuts can be found in grocery stores raw (shelled or unshelled), roasted or
salted. The high fat content in these nuts makes them more susceptible to rancidity

68

when exposed to air or sunlight. But, buying these nuts in the shell allows for a
longer shelf life. Look for nuts that are whole, firm, unbroken and brown in color.
Store these nuts in an airtight bag in the refrigerator to preserve freshness.

Recipe Tips


Brazil nuts have a variety of uses in the kitchen. Consume these nuts for a snack, or
add them over a fruit or vegetable salad. Brazil nuts are also used as a topper on
baked goods, puddings, and fruitcakes. Additionally, Brazil nut oil is an ingredient
used in baking or salad dressings. Although Brazil nuts are extremely versatile, it is
important to be mindful of the total consumption of Brazil nuts due to high aflatoxin
levels.




Alyssa Adler is a recent Boston University Graduate from Long Island, New York.
She is a 2016 CFYL summer web intern. She graduated in May 2016 with a
bachelors degree in Nutrition Sciences with a concentration in Dietetics. Her goal is
to attend graduate school in the fall of 2017 in pursuit of a Masters degree in
dietetics and eventually obtain her Registered Dietitian license. Last June, Alyssa
started a food blog called Red Delicious and Nutritious. Her blog focuses on healthy
eating and living and how decadent foods can be made wholesome and delicious.

69

No Need to Say No to that Cup of Joe


By Alyssa Adler

New Research Shows That Coffee Can Be Cancer Protective


Previously researched to be a possible carcinogen in 1991, the World Health
Organization concluded that coffee is indeed a protective agent against certain
cancers. A press release on Wednesday June 15th, 2016 stated that drinking
coffee is not cancer causing to humans. There has been adequate evidence based
on human and animal studies that drinking coffee has no cancer causing effects
on pancreas, prostate, and female breast cancers. In addition, drinking coffee was
shown to decrease risks of liver and endometrial cancers.
Fun fact: According to the The National Coffee Association, this is
the first time that scientists have ever positively reclassified a food
or beverage.
Although coffee is no longer found to be cancer causing, some studies have
found that hot beverages may cause esophageal cancer. This can include coffee,
tea, and even hot water. Esophageal cancer is the 8th most common cancer
worldwide and consists of 5 percent of cancer deaths (WHO). However, smoking
and drinking are still the major causes of esophageal cancer. In general, please be
mindful when drinking your daily cup of Joe to make sure its not too hot.

70

An article posted by New York Times spoke about incorporating coffee as a part
of a healthy diet. There is a large amount of research indicating the health
benefits of coffee such as reduced risks of heart disease, Type 2 Diabetes,
neurological disorders and some cancers. Further, coffee is included in the recent
2015 Dietary Guidelines such that 3 to 5 cups of coffee is harmless and moderate
coffee drinking may decrease chronic disease. There are new recommendations
that state that even 5 to 8 cups of coffee a day is harmless.
Try these great coffee recipes: Coffee Granita, Mocha
Chocolate Mousse
In Cook for Your Lifes article, it is noted that coffee provides certain health
benefits. Some of these benefits include riboflavin (Vitamin B2), antioxidants and
phytochemicals. Riboflavin can help with metabolism while antioxidants helps
get rid of oxidized compounds that cause cell damage. The AICR describes a
compound in coffee called N-methylpyridinium (NMB), which becomes
prominent in the roasting process. Further, this compound increases the action
of antioxidants in coffee. Also, the phytochemicals in coffee can help prevent the
growth of cancer cells. A common phytochemical in coffee is known as quinic
acid, which gives coffee its acidic taste.
Importantly, science and technology are ever changing for the better. What was
once a carcinogen such as coffee is now a cancer preventative. Cholesterol had a
similar trend in science such that in the 1960s it was shown to be harmful while
the new dietary guidelines in January suggested otherwise. The opposite effect
goes for certain foods such as red meats and cancer. In the past red meats were
promoted to be health promoting, but now red meats, specifically hot dogs and
bacon, are suggested to be carcinogens. Now, daily coffee drinkers can drink
coffee and reap the new known benefits! Who would have thought that a persons
daily cup of coffee could become the new super food?

71

------------------------------------------------------------------------------------------------------------
Alyssa Adler is a recent Boston University Graduate from Long Island, New York.
She is a 2016 CFYL summer web intern. She graduated in May 2016 with a
bachelors degree in Nutrition Sciences with a concentration in Dietetics. Her goal is
to attend graduate school in the fall of 2017 in pursuit of a Masters degree in
dietetics and eventually obtain her Registered Dietitian license. Last June, Alyssa
started a food blog called Red Delicious and Nutritious. Her blog focuses on healthy
eating and living and how decadent foods can be made wholesome and delicious.

72

Alyssa Adler
Renal Case Study
Judy is a 61 year-old woman with hypertension, coronary artery disease (history of
coronary artery bypass grafting 6 years ago), peripheral vascular disease, and end-stage
renal disease. She started hemodialysis two years ago. Her husband died last year and
shes been quite ill since then with multiple hospitalizations for infections (pneumonia,
infected lower-extremity ulcerations, and infections of her AV fistula). She recently
moved from Pennsylvania to Massachusetts to live with her daughter and son-in-law
and is new to your dialysis clinic. She will be dialyzed 3 times/week for 4 hours. You are
asked to evaluate her nutritional status and develop a diet plan with her.
Judy tells you during the interview: Its been a tough yearlosing my husband, being in
the hospital so many times, then moving here. I know nutrition is supposed to be a
priority, but Im sure that you can understand why it hasnt been for me. My appetite
has been horrible. I am starting to feel a little better now, and I know I need to eat
more. Id love to hear your suggestions.
Judy gives you the following diet recall:
Breakfast: Snack: Lunch:
Snack: Dinner:
HS snack:
1 slice of toast with margarine & jelly 12 cup of coffee with milk and sugar
2 graham crackers with a small amount of peanut butter 2 oz apple juice
12 turkey sandwich with American cheese, lettuce & mayo on white bread 10 tiny
twist unsalted pretzels
4 oz milk
canned peaches (drained of juice)
small piece of baked chicken, green beans, rice (all small portions) 12 cup tea with milk
and sugar
3-4 saltines (unsalted tops), 1 slice of Swiss cheese 4 oz cola
Judy tells you that she tries not to drink more than what she tells you, but she does feel
thirsty frequently. She asks: Do you think I can have more fluid? My diet has been so

73

hard to manage lately I figured that Id just be really strict and hope for the best. You
review Judys chart and see that she makes no urine.
Current medications:
PhosLo (two 667 mg capsules with meals) Nephrocaps1 capsule daily
Zestril 10 mg daily
Epogen 5000 units three times/week
25 mg Ferrlecit (ferric gluconate) IV once/week with dialysis
Vancomycin 1g IV given every-other dialysis session (shes scheduled to receive it for 2
more weeks)
Lipitor 40 mg daily
See next page for laboratory and anthropometric data.















74

Laboratory Data

Normal
Predialysis Postdialysis
Range

Sodium

132

136

Potassium

4.6

4.3

Glucose

92

---

BUN

45

22

Creatinine

3.2

2.9

Calcium

8.6

---

Corrected Ca for low


albumin

9.56

---

Phosphorus

6.1

---

Cholesterol

102

---

Albumin
2.8
Prealbumin
10
C-rective protein (CRP) 96

---
---
---

Hemoglobin

9.6

---

Hematocrit
MCV
RDW

29
82
12.8

---
---
---

135-145
mEq/L
3.5-5.0
mEq/L
70-110
mg/dL
6-24 mg/dL

Ideal Range for Dialysis


Patients
Same as non HD patients
Upper end of normal pre
HD
Same as non HD patients
Close to 100 mg/dL, pre
HD

0.7-1.3
10-15 mg/dL
mg/dL
8.5-10.5
Same as non HD patients
mg/dL
8.5-10.5
Same as non HD patients
mg/dL
2.7-4.5
Same as non HD patients
mg/dL
165-250
Same as non HD patients
mg/dL
3.5-5.0 g/dL > 4 mg/dL
20-40 mg/L Expect high levels in ESRD
0-3 mg/L
Same as non HD patients
11.5-16.4
Same as non HD patients
g/dL
36-48%
Same as non HD patients
80-98 FL
Same as non HD patients
11.5-14.5 Same as non HD patients

Anthropometric data:
Height: 65 Estimated dry weight: 50.6 kg Usual dry weight: 1 year ago 62.7 kg; 6
months ago 56.8 kg Judy looks thin on observationshe has little subcutaneous fat in
her arms and she has temporal wasting. Predialysis weight: 52.0 kg Postdialysis weight:
50.6 kg

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Questions:
1. What is Judys ideal body weight? (1 point)
IBW using Hamwi: 100 + 5(5) = 125# or 112.5-137.5 with a 10% range

2. What is her percent ideal body weight? (1 point)
Percent IBW = 111.32/125 x 100 = 89%
Using the lower 10% weight: 111.32/112.5 x 100 = 98.95%

3. What is your interpretation Judys percent ideal body weight? (1 point)
According to the ideal body weight without the 10% range, Judy is mildly
underweight. If using the lower end of the 10% range of the ideal body weight, Judy is
99% of her ideal weight, meaning that she is not malnourished or underweight.

4. What is Judys percent usual body weight? (1 point)
% UBW from 6 months ago = 111.32#/124.96# x 100 = 89%
% UBW from 1 year ago = 111.32#/137.94# x 100 = 80.70%

5. What is your interpretation of her percent usual body weight and the timeframe of
her weight loss? (2 points)
% weight loss for 6 months = [(124.96-111.32)/124.96] x 100 = 10.9%
% weight loss for 1 year = [(137.94-111.32)/137.94] x 100 = 19.3%
According to Judys percent usual body weight for the past 6 months she is
mildly malnourished, but when looking at her percent usual from one year ago Judy is

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moderately malnourished. Judys weight loss is greater than 10 percent which indicates
severe unintentional weight loss.

6. What is Judys BMI? (1 point)
BMI = 50.6 kg / (1.65m)2 = 18.6 9 kg/m2

7. What is your assessment of her BMI? (1 point)
Judys BMI is normal because it is in the range of 18.5-24.9 kg/m2

8. What does Judys appearance suggest about her nutritional status? (2 points)
Judys appearance suggests that she is malnourished because she has body fat
wasting, significant weight loss in 6 months and loss of subcutaneous fat in her arms in
addition to temporal wasting. Also, according to the given data Judy has a thin
appearance.

9. Is Judys albumin mildly, moderately, or severely depleted? (1 point)
Judys albumin is mildly depleted.

10. Is Judys prealbumin mildly, moderately, or severely depleted? (1 points)
Judys prealbumin is mild-to-moderately depleted.
11. How does the C-reactive protein level assist in your interpretation of albumin and
prealbumin? Why do you think Judys C-reactive protein is elevated? (2 points)

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Albumin and prealbumin are negative acute phase respondents; meaning that

their depleted values mean that ones body is in a state of disease or inflammation
(Nelms, Sucher and Lacey, 2016). Knowing this when interpreting the C reactive protein
is helpful because Judys C reactive protein value is approximately 100x the normal,
which means that Judy is in a moderate stress state. Further this moderate stress state
can be due to her chronic end state renal disease, kidney function weakening, and her
recent infections, which can cause stress on the body and increase C-reactive protein.

12. What is your assessment Judys diet recall? (3 points)

When looking at Judys diet recall it is evident that she is not consuming enough

protein because the only quality protein that she is consuming is the turkey at lunch and
the chicken at dinner. Also, although Judys fluid intake should be limited based on her
hemodialysis, she is consuming caffeinated beverages such as cola, tea, and coffee,
which can contribute, to her thirsty complaint because these beverages can make one
dehydrated. In addition, Judy is not consuming enough total calories in her diet in
general. If using the lower end of the calorie recommendations for hemodialysis, she
would need 30 kcal per kilogram, which would be 1518 kcals per day. She is consuming
approximately 1070 kcal according to Judys diet recall, which would mean she is
consuming only about 70% of her caloric needs.

13. How is the assessment of a patient with end-stage renal disease different from a
standard nutrition assessment? Is there anything different that you need to evaluate

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when you are conducting a nutrition assessment of a patient with end-stage renal
disease? (5 points)

When making the nutrition assessment it is important to use the patients actual

weight if the patient is underweight when calculating nutrition requirements. Also, it is


important to use the patients dry weight, or post dialysis weight when calculating. The
subjective global assessment should be altered when assessing a patient with ESRD.
More so, areas to look closely at are the fat pads below the eyes, muscle wasting in the
temples, clavicle, shoulder, ribs, scapula, knee, calf, quads and interosseous muscles.
Also, an RD should check for muscle mass by pinching the skin above the triceps and
biceps. Additionally the BUN to creatinine ratio should be taken into considering such
that a high ratio is indicative of dehydration. Finally, it is important to check for ascites
and edema after the dialysis session, not before.

14. Do you think Judy is malnourished? What type of malnutrition (in the context of
chronic disease or acute illness) and what degree of malnutrition (moderate or severe)
does she have? (3 points)

It can be suggested that she has severe malnutrition in the context of chronic

disease because of the severe weight loss and temporal wasting. Since she has little
subcutaneous fat, Judy is also evident of severe wasting. In addition, Judy is consuming
about 70% of her caloric needs, which would put her in the category of severe
malnutrition in the context of chronic illness.

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15. Write a PES statement addressing Judys nutritional status. (5 points)


Malnutrition related to poor appetite as evidenced by 10.9% weight loss in 6

months and an estimated energy intake of 70% of 1518 kcal/day needs.



16. What can contribute to malnutrition in end-stage renal disease? What specific issues
are impacting Judys nutritional status? (10 points)
Note: a 10-point question requires an in-depth discussion of the issues. Go into detail as
to why so many patients with ESRD develop malnutrition (elaborating on issues brought
up in lecture). Give a detailed analysis of why Judy has had a decline in nutritional status.
This question should be answered with at least 2-3 full paragraphs.

Many factors can contribute to malnutrition in end-stage renal disease. Some of

these factors include chronic illness, inadequate activity, catabolic effect of dialysis,
infections, oxidative stress, and inflammation and increased circulating cytokines
(Nelms, Sucher and Lacey, 2016). Judy already has chronic illnesses such as
hypertension, coronary artery disease and peripheral vascular disease that puts her at
greater risk for malnutrition. More specifically, one can develop malnutrition with endstage renal disease because lack of activity leads to decreased lean body mass with the
addition of the dialysis pulling off amino acids and protein creating protein losses.
Dialysis causes a severe catabolic state in patients, which can lead to an increased stress
state in the body and decreased nutrient absorption, which leads to malnutrition.
Further, dialysis causes oxidative stress because dialysis creates protein catabolism,
which causes inflammation due to increased protein needs, and results in a membrane

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that is not biocompatible for absorption. Cytokines also cause malnutrition with dialysis
because the body is in a state of stress and inflammation and the body is trying to react
and create an immune response. Increased stress on the body can further lead to
increase energy expended as decreased absorption.

Other common factors that can contribute to malnutrition with dialysis are lack

of adequate food intake due to physiological barriers, social factors and blood loss.
Some physiologic factors include taste alterations, emotional instability, unpalatable
diet, other medications used at the same time, fatigue, and nausea and vomiting. Some
social factors can include low income, lack of ability to prepare meals, lost motivation
and family support, depression and missed meals because of treatments. Blood is
commonly lost due to GI bleeding, loss in the dialyzer or loss through blood samples.
In general, patients with ESRD are at high risk for hyperlipidemia and heart
disease. In Judys situation, she is especially at risk for these occurrences because of her
history of hypertension, coronary artery disease and peripheral vascular disease.
Overall, Judy is at an even higher risk for hyperlipidemia and heart disease because of
her preexisting conditions. Also, Judys anuria is highly contributed to hemodialysis
because typically hemodialysis results in fluid gains, therefore less fluid is released. Also,
the hemodialysis is negatively affecting Judys protein status such that she is not
consuming enough dietary protein to counteract the amino acid losses with the dialysis.
This is evident due to her loss of subcutaneous fat in her arms which means a loss of
lean body mass as well as her low creatinine levels. Loss of lean body mass can put Judy
at further risk for bone disease, which is a common risk of dialysis.

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17. What are Judys energy, protein, and fluid requirements? Be sure to show your math
for full credit. Can Judy have more fluid than what she is consuming now? (5 points)

-Energy needs: 30 kcal/kg method: 30 kcal/kg x 50.6 kg = 1518 kcal/day

-Protein needs: 1.4 kcal/kg: 1.4 kcal/kg x 50.6 kg = 70.84 g protein/day

I used the upper end of the protein and calorie requirements because

Judy has already shown malnutrition by the loss of subcutaneous

fat in her arms and the temporal wasting.

-Fluid needs: 1000 mL because anuric

-Judy can consume more fluid than what she is consuming now because she is

only consuming about half of her fluid requirements.


18. Plan a diet for Judy to meet her calculated energy, protein, and fluid requirements.
You should plan for three small meals and three small snacks (you can use the template
belowsee example breakfast), following the principles of meal planning for renal
patients. Give Judy a basic generic meal plan with a menu idea that provides an example
of each generic food choice you are recommending for her. See the example below and
use the template to make your meal plan. You may use a liquid oral nutritional
supplement to help meet her needs, if you think that is appropriate. Your menu will be
graded on adherence to the renal menu planning guidelines reviewed in lecture and
palatability. This menu must fit on a single page (see next few pages)

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19. Cross-check your menu to be sure that it meets Judys calorie, protein and fluid
requirements and is appropriately restricted in sodium, potassium, and phosphorus. Fill
in the nutrient analysis for each item in your menu idea. Please be sure the menu is on
a single page (see next few pages).


















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18. Meal Plan Template

Meal/snack

Food choices

Breakfast

1 serving corn or rice based


cereal (not whole grain)
4 oz milk
4 oz fluid (extra calories)
low sodium condiments

1 serving low potassium


Mid-morning snack fruit
5 oz caloric beverage
1-2 serving lean meat (high
protein)
2 pieces of white
starch/bread (no added salt)
Lunch
Lettuce
Condiments low sodium
6 oz extra calorie fluid
4 oz fluid (extra calorie)
1 serving of crackers or
Mid-afternoon snack
chips or cookies

Dinner

Evening snack

cup starch-rice/noodles
1-2 serving high protein
meat
cup low potassium
vegetable (if canned or
frozen no salt added)
6 oz caloric beverage
4 inch square cake
4 oz non caloric beverage

Menu idea
1 cup corn flakes
4 oz whole milk
4 oz coffee
2 tsp sugar
1 tbsp non dairy creamer
cup blueberries
5 oz apple juice
4 oz turkey
2 slices white bread
1 slice lettuce
1 tablespoon mayonnaise
6 oz soda water

4 oz grape juice
2 graham crackers

cup white rice


4 oz roasted pork
cup zucchini fresh steamed no salt
added
6 oz cola
4 in square yellow cake
4 oz tea

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19. Nutrient Analysis Template


Calorie
s

Protein (g)

1 C corn flakes

100

2.1

204

47

29

--

4 oz whole milk

74

3.84

52

161

102

120

4 oz coffee
2 tsp sugar

0
30

0
0

2
0

58
0

4
0

120
--

1 T non dairy
creamer

33

11

49

25

--

C blueberries

42

0.45

30

22

--

Menu item

Sodium
(mg)

Potassium Phosphorus
(mg)
(mg)

Fluid
(mL)

5 oz cran-apple
juice
3 oz turkey

87

155

150

161

24

54

323

235

--

2 slices white bread

150

275

64

58

--

0.34

69

--

94

0.13

88

--

6 oz soda water

37

180

4 oz grape juice

107

11

41

120

2 graham crackers

119

185

50

57

--

C white rice

67

1.76

--

3 oz roasted pork

54

26

56

347

264

--

C zucchini
Steamed no salt

14

238

33

--

6 oz cola

77

17

180

245

3.6

233

62

80

--

1
60
15200

0
0
71.22

3
0
1261

1
0
933

120
0
990

1518

70.84

14
46.5
1771.5
<20003000

1 slice lettuce
1 T mayo

1/12th of cake of 8
diameter in square
yellow cake
4 oz tea
3 oz applesauce
Totals
Recommendations

<2000

800-1000

1000

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Bibliography

Nelms, M., Sucher, K.P., & Lacey, K. (2016). Nutrition Therapy and Pathophysiology (3rd
ed.). Boston: MA: Cengage Learning

https://ndb.nal.usda.gov/ndb/foods

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