Emily Simo

FSHN 429
Diabetes ADIME Note

Carle Hospital
Diabetes Clinic

Mr. Robertson
11111
09/20/1952
65
11/07/2017

Nutrition Assessment:
This is a 30-minute face-to-face Medical Nutrition Therapy visit. Patient is a 65-year-old male
referred for dietary counseling by Dr. Smith.

Diagnosis and medical history: Type 2 diabetes, history of obesity and hypertension.

Weight History:
Height: 5in/9cm; Current weight: 187lb/ 78.18 kg current BMI is 27.6kg/m2.
Usual body weight: 172lbs/78.18kg; % usual body weight: 108% usual body weight
Mr. Robertson gained weight in his retirement years. He has lost 11 pounds since his last visit
with a dietitian.
Fatigue, excessive need to urinate.

Food Intake:

Has reduced consumption of occasional foods since last visit.

White bread 7 days/week Margarine 7d/wk

Potato 6 days/week Oil 7d/wk
Pasta 1 day/week Salted butter 1d/wk
Unsalted nuts 7d/wk
Orange juice 6d/week No longer eats fat on meat
Canned fruit 1d/week
21 tsp sugar / week
Tomato 7d/wk Strawberry jelly 6d/wk
Cauliflower / broccoli 6d/wk
Onion 1d/wk Water every day
Other vegetable 1-2d/wk Full-strength beer 6d/wk

cup whole milk (3/day) 7d/wk Short bread cookies 7d/wk

Ham 1d/wk Ice cream 1d/wk
Roast beef 7d/wk
Steak/chicken 6d/wk
Ground beef 1d/wk
No salami, sausage, or processed meats
Emily Simo
FSHN 429
Diabetes ADIME Note

Nutrition Impact Symptoms: Constantly fatigued.

Activities and Function: Rides bike for 20 minutes 2 days a week. Bowls once a week with
friends and spends time in garden.

Social history: 1full strength beer 6 days/week. Goes grocery shopping with his wife and she
does the cooking. Goes bowling with friends 1 day per week. Family history of type 2 diabetes
and CVD.

Labs: Blood glucose levels: fasting 86mg/dL, at 2 hours: 263 mg/dL

Current Meds: None

Nutrition Diagnosis:
Overweight, obesity related to excessive energy intake and sedentary lifestyle post-
retirement as evidenced by a BMI of 27.6
Undesirable food choices related to continued consumption of occasional foods and
alcohol as evidenced by inability to meet weight loss goals.

Nutrition Intervention:
Estimated Nutrition Requirements
1. 1925-2550 kcals per day 24.6 32.6 kcal/kg Actual BW)
2. 22.08 g protein per day (0.8 g/kg Actual BW)
3. 1,954.5 2,736.3 ml fluid per day (25 - 35 ml/kg Actual BW)

Individualized Treatment Goals

1. Decrease caloric intake by 700 kcal per day
2. Maintain A1C at a level <7%
3. Eat no more than 30 g of carbohydrates per major meal
4. Return back to normal body weight in 1 year

Implementation of Intervention
1. Choose reduced/no fat and reduced /no sodium options at the grocery store.
2. Count carbohydrates at every meal by reading nutrition labels
3. Check blood glucose every morning, night, and before/after meals or exercising
4. Weigh self every Monday morning and keep track of weight changes.

Dietitian Assessment/Patient Response to Intervention

Excellent/Good/Fair/Poor. Patient seems willing to follow recommendations discussed at this
appointment and verbalized understanding.
Emily Simo
FSHN 429
Diabetes ADIME Note
Education Materials Provided
1) Material on managing blood glucose
2) Material on complications of uncontrolled diabetes
3) Material on losing weight in men > 65
4) How to read nutrition labels

Referrals and RD Follow Up Plan for Monitoring and Evaluation

Patient will return in 2 months for evaluation of progress towards treatment goals. Provided
patient with contact information and encouraged him to call with any additional questions.
Patient was agreeable with this plan. He will monitor and document his blood glucose values
and bring that to his next meeting. He will meet the following:
A1C will be <7%. A blood test will show this value.
Weight loss of 10 pounds in 2 months. Weight will be taken at the follow up
appointment.
In 2 months, he will be proficient in counting carbohydrates. Knowledge will be tested
at his follow up appointment by asking questions on nutrition labels.

Medical Nutrition Therapy provided using the 2016 evidence based practice guidelines from
the American Academy of Nutrition and Dietetics.

Emily Simo