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Weight Management Case StudyHMD 515Fall 201163 pointsLeslie A. LooneyCLIENT #1Mrs. Jones, a 55 year old female client has scheduled an appointment with you for advice on how to lose weight faster. Client’s weight is 220# and height is 5’3”. Learn – Learn from your resourcesUsing the Nutrition and Diagnosis-Related Care section on Obesity and Undernutrition, summarize the recommendations regarding energy recommendations and physical activity. (2 points)Diet should be: 35-50% carbs, 25-35% moderate fat, and 25-35% proteinTry to eat foods with a lower glycemic index; this includes most fruits and veggies.Eat 6-8 small meals a day to prevent cheating and/or overeating.Always eat breakfastChoose foods high in fiber, and drink plenty of water approx. 30cc/kg/dayExercise is integral to weight loss. Encourage moderate physical activity for 30-60min daily.Examples of moderate exercise include:Stationary bicyclingSexual activityCalisthenics, home exercisesWalkingBicycling < 10mphCalculate BMI (Show calculation) (1 point)(220*705)/(622)= 39.07 BMI= 39 Client’s BMI is classified as: (1 point)A BMI of 39 is classified as obese.Estimate calorie needs using actual weight and Mifflin-St. Jeor equation using an activity factor of 1.3 and subtracting 500 kcals per day for weight loss. (1 point)(99.9*100kg) + (6.25*160.02) – (4.92*55) -161 = 1567.5251567.525*1.3 = 2037.72037.7-500 = 1537.78 kcals approx. 1538 Kcals dailyUsing adjusted body weight, estimate calorie needs using 20 kcal/kg/day. Show calculations. Round to whole number. (1 point)IBW= 100+5+5+5= 115lbs((220-115)*.25)+115=141.25lbs141.25/2.2= 64.2kg *20= 1284 Kcals/dayAdjusted body weight = [(actual wt. – IBW) x .25] + IBWLearn – agenda settingWrite an open-ended question you could ask Mrs. Johnson when she arrives in your office. (1 point)What parts of your daily routine would you like to improve or work on?She tells you she has been counting calories and tries to keep intake between 1300 and 1500 calories per day. Client tells you she has lost 4# in the last 2 months and feels discouraged. States she knows she has not been exercising as much as she should or has in the past and has a desk job.Reflect back what is important to Mrs. Johnson and what you hear as the initial agenda for the visit. (1 point)It is important to you to see adequate results in your weight loss. From what you have told me you are keeping your daily intake at a low level. You have not had as much time to exercise and you feel discouraged. For this visit we need to come up with a healthy diet and exercise plan that will show you results.Learn – learn from the clientWhen asked about her typical day she reported:Breakfast: ? cup quick-cook oats, 1 piece of fruit, 12oz skim milkLunch: Large vegetable salad with assorted vegetables, 2 oz. turkey or canned salmon or tuna, 2 Tbsp. Regular olive oil based dressing, 6 Triscuits and 16 oz. bottle of water.Supper: 3 ounce grilled lean beef or fish or poultry, ? cup potato or brown rice, 1 cup cooked vegetable, 2 cups salad with 2 Tbsp. low fat dressing, ? cup canned fruit and 1-1” sugar cookie or 1 snack size candy bar and 12 oz. skim milk.One OTC vitamin mineral supplement with breakfast and one 500mg calcium/500 IU Vitamin D supplement in the evening.When asked about exercise, patient stated she had been part of an exercise class but quit because she was embarrassed about how she looked in exercise clothes and could not keep up with other class member who were much thinner and more fit. Client stated she does a floor-type exercise tape maybe once per week and likes it “ok”.Using reflective listening, summarize what Mrs. Johnson told you about her typical day. (1 point)You eat only three times a day and try to keep your meals low in fat. You are getting limited exercise on a daily basis. You do not like to go to the gym because you are uncomfortable and self conscience. You would rather find an exercise program that you can do at home. Guide - Identify discrepancies between current status and recommendationsEstimate daily calorie intake from typical day. How does this compare with estimated calorie needs? Estimate, do not use software. (1 point)Estimated daily intake was approx. 2100kcals from the typical day recallI calculated that she should only be consuming 1578Kcals to loose weight which is a difference of 522kcals. The client needs to cut her daily intake of pare recommendation for physical activity for weight management and client’s current level of activity, how do they differ? (1 point)The recommendations for daily exercise are 30-60minutes of working out daily. The client is exercising maybe once a week, and she is in need of increasing her daily exercise. She almost has no daily activity through out her whole week.Guide - Describe discrepancies to the clientBased upon your conversation so far and your calculations, what would you say to this client about her food intake? (1 point)I would tell her that she is making very good choice with her foods, but we can change a few things that will lower her total daily intake. I would let her know that she is consuming around 500 calories that she should be. We need to bring her total daily intake down to around 1538Kcals/day. Some of the things that she can change are:Changing the dressing she eats on her salad to Fat free.Increase her water consumptionCut her milk down to only 8oz at breakfast and dinnerChoose a cracker that is low in fat or fat free, triscuits are very high in fat and caloriesChoose more veggies and fruits for snacks What would you explain to this client about her activity level? What would you explain about physical activity to this client? (2 points)I would tell her that if she really wants to see results she really needs to make time for exercise in her day. At minimum she needs to be exercising 3-4 days a week for at least 30minutes. She does not have to go to the gym, but I would talk to her about joining curves. Curves is an all female gym that is for women of all sizes and can provide a great support system. I would also give her some other options for working out like:Doing different workout videos at home, a new thing out that is very fun and popular is ZumbaJoin curvesDancing to music at homeWalking outsideRiding a bike, either stationary or regularGuide – Discuss expected outcome and possible behavior changesWhat transition statement and question could you use at this point in the discussion to move from discrepancies to possible behavior changes? (2 points)Now that we have found some things that we can change in your daily diet and exercise plan let's set some goals that you can work toward. How do you think you can add more exercise to you daily life?Mrs. Johnson states she would consider walking after work in her neighborhood which includes walking up several hills. Client states she could also use the muscle toning exercise tapes more often in the morning before work, maybe three times per week. Client states she also wants to feel stronger and more confident in her ability to walk longer distances.Guide -Write goal, objective and craft action plansBased upon your conversation so far, what would you suggest to this client as an agreed upon goal? (1 point)Since exercise is important to you and you think you can start exercising more lets frame that into a measurable goal. Provide this client with a suggestion as an objective. (1 point)I would suggest that you try to do a workout video 3 days a week and try walking around the neighborhood 2 nights a week. Each workout should be at least 30minutes long and should be at minimum 5 days a week.Write four suggestions you could give this client to allow her to develop her own action plan and meet her objective. (1 point)Here are 4 suggestions that might help you with your diet and exercise:What if you choose foods that are lower in fatTry to increase your water consumption at every mealWhat if you exercised 3-5 days/week for at least 30minutesTry to only eat one sweet treat at night. Only fruit or the cookie/candy not both.Using the ADA position paper on weight management, describe the 2005 Dietary Guideline that supports your objective and action plan. (1 point)Guide - Communicate to implement action planWhat question would you ask the client to encourage her to select options for her own action plan? (1 point)Out of the suggestions that I have given you, which do you see your self being successful at?What question(s) would you ask to assess readiness? (1 point) Do you have a support team at home or in your life? Are the diet changes something you can see yourself doing everyday? Evaluate - Evaluate outcomes and satisfactionWhat would you ask the client to monitor? (1 point)I would like the client to monitor:Amount of exercise completed each weekDaily food logWeekly weigh herself and keep a logWhat would you ask about/measure at a follow-up visit? (1 point)At the follow up visit I would ask about/measure:How the client is feelingIf the client has more energyHer BMI and current weightI would look at her daily log and see how she did with her diet planI would look at her exercise log and see if she is meeting the exercise goal that we agreed onI would like to know if she is happy with her results and how she feels on the new planEvaluate - Evaluate client satisfaction.What question would you ask to determine client satisfaction with the exchange of information? (1 point)Are there any other questions or concerns that I have not answered for you today?Do you feel like we have made positive changes to your diet and exercise plan?Did this session address your needs?Document - Communicate with the medical recordA: Assessment – write a summary of what you learned from the client. Add IDNT assessment codes with discrepancy descriptions that best fit with your summary. (2 points)Female, 55yrs old, wt=220 ht=5'3" BMI=39 EER=1538KcalClient is trying to loose weight by lowering calorie intake; total weight loss of 4lbs in the last 2 months. Client's daily intake from typical day is approx. 2100Kcals. Client does little to no exercise each day.FH-1.1.1 Total energy intakeAD-1.1.4 Weight ChangeFH-7.3.1 Physical activity historyD: Diagnosis Statement – PES format (include IDNT nutrition diagnosis code) (3 points) NI-1.5 Excessive energy intake related to typical day recall of food as evidence by current weight of 220 lbs and IBW is 115lbs.NB-2.1 Physical inactivity related to lack of daily activity in typical day recall as evidence by current BMI of 39I: Interventions: Write a summary of your discussion with the client and include the IDNT intervention code that best describes the intervention? (2 points)E-1.5 Recommended modificationsClient has agreed to increase physical activity to 3-5 times a week for 30minutes or more each day. Goal is to work up to 5 days a week at 30-60minutes. Another goal is to lower total energy intake to 1538 Kcals a day to eventually lower her current BMI of 39.M: Measure - what do you intend to measure at next visit? (Include IDNT assessment code) (1 point)FH-1.1.1.1 Total energy intake, client is going to keep a daily intake log of the food she consumes.AD-1.1.4 Weight change, client is going to log her weight weekly and record any changes.FH-7.3.1 Physical activity history, client is going to keep track of how much she is exercising each week, including what type of exercise and for how long.E: Evaluation: How will progress be evaluated based upon goal and expected outcome? (Include IDNT assessment code) (1 point)AD- 1.1.5 Body mass index, we will calculate the clients BMI at he next follow up visit.CLIENT #2Mr. Carson, a 42 year old male scheduled an appointment with you concerned that he cannot control his appetite for sweets and wants to try a lower carbohydrate, higher protein meal plan. Client states he is not concerned about exercise; he works out 60 minutes 5-6 days per week. Client’s height is 5’11” and weight is 245#.Learn – learn from your resourcesUsing the Nutrition and Diagnosis-Related Care section on Obesity and Undernutrition, list the recommendations that might help this client better manage his appetite. (2 points)He should choose foods higher in fiber, and always eat breakfast. He should drink adequate amounts of water through out his day. He should increase his meals to 6-8 small meals a day. His diet should be approx. 35-50% carbs, 25-35% moderate fats, and 25-35% protein.Using Hamwi Method, calculate IBW and % IBW. Show calculations. (1 point)IBW= 1.6+(6*11)= 172lbs *.1= 189lbsUsing Mifflin-St Jeor, estimate this client’s REE using his actual weight. Use a 1.5 activity factor and subtract 500 calories for weight reduction. (1 point)(9.99*111.36)+(6.25*180.34)-(4.92*42)+5= 2037.9 2037.9 * 1.5= 3056.953056.95-500= 2556.9KcalsUsing adjusted body weight, estimate calorie needs using 25 kcal/kg/day. Show calculations. Round to whole number. (1 point)((245-172)*.25)+172= 190.25190.25/2.2= 86.47 kg86.47*25=2162KcalsAdjusted body weight = [(actual wt. – IBW) x .25] + IBWWhich energy level would you recommend and why? (1 point)I would recommend the Mifflin equation because it takes into account his actual weight, height, activity level and age.How many servings of carbohydrate would this client need if he were to consume 45% of estimated calories to reduce weight? A serving of carbohydrate is equivalent to 15 grams. (Show your calculations) (1 point)2557*.45=1150kcals1150/4=287g287/15= approx 19 servings of carbohydratesLearn – agenda settingWrite an open-ended question you could ask Mr. Carson when he arrives in your office. (1 point)What are your wanting to change in your life and daily activities?Client stated he has gained 20# in the last year after taking a new job that requires him to eat out more frequently when traveling. Client states he wants to lose the recent weight he has gained. Client stated he is not sure what or how to eat with his new job. Client stated he walks/jogs 60 minutes 5 times per week and does weight training 1-2 times per week at home and when traveling. Reflect back what is important to Mrs. Johnson and what you hear as the initial agenda for the visit. (1 point)It is important to you to loose the 20lbs of recent weight gain. You want to learn how to eat healthier when you are eating away from home. Exercising is very important to you and you make time everyday for exercising.Learn – learn from the clientWhen asked about typical day, client reports the following:Breakfast: Large bowl of sweetened cereal with 2 cups of 2% milk. Or continental breakfast at hotel that consists of Bagel with cream cheese, 8 ounces of juice and 1 carton of 2% milk.Lunch: 6” sub sandwich with low fat turkey or chicken (2oz) and no cheese 2oz bag of baked chips or pretzels, 16 oz. diet soft drinkAfternoon snack: one bag low fat microwave popcorn and a low fat cappuccino (24oz)Supper: (Eats out 5x/week) Small steak or chicken breast, baked potato with butter, salad with low fat dressing, 3-4 dinner rolls with 3 tsp. margarine, water and 6 ounces wine. OR Large plate of pasta with marinara sauce, salad with dressing, 4 slices of garlic bread and ice tea.Evening snack: 6-10 Oreos and 2 cups of fat free ice cream or sorbet while watching TV.Client states once he begins eating bread or cookies or ice cream, he has trouble stopping. Stated he has tried Weight Watchers in the past but could not follow when traveling and noticed he felt very hungry between meals.Using reflective listening, summarize what Mr. Carson told you about his typical day. (1 point)Typical day recall:Eats three meals a day and 1 snackChoosing foods that are simple carbs with every meal.Eating food high in sugarChooses large portion sizesGets plenty of exerciseGuide - Identify discrepancies between current status and recommendationsEstimate the number of servings of carbohydrate client is currently consuming during the day and convert those servings to grams of carbohydrate. Estimate – do not use software and think about portion sizes. Compare this with the carbohydrate servings recommended for energy level to reduce weight. (1 point)I estimated that he is consuming around 25 servings of carbohydrates. 25*15= 375375*4= 1500 kcalThis is 6 serving higher that the recommended amount or 360Kcals above the recommended pare recommendation for physical activity for weight management and client’s current level of activity. (1 point)This client is meeting the recommendations for physical activity. He might even be exceeding the current expectations. He is exercising:Jogs/walks 60minutes 5 times a weekWeight training 1-2 times a weekGuide - Describe discrepancies to the clientDescribe the discrepancies to this client in a way that also engages his participation in decision making and affirms what he is doing well. (1 point)What the calculations indicate is that you need to lower your total carbohydrate intake, which will lower your total caloric intake. When it comes to exercising you are exceeding the recommendations for weight loss. What some people find helpful when trying to loose weight is eating food lower in fat and sugar. Research indicates that eating smaller more frequent meal can help with overeating and cheating on your diet.Guide – Discuss expected outcome and possible behavior changesWhat transition statement and question could you use at this point in the discussion to move from discrepancies to possible behavior changes? (2 points)Now that we have talked about your current diet and exercise plan, let's find ways to improve it. What part of your diet would you most like to change? Client states he knows his snack choices are not very healthy but he tends to be really tired between meals and at the end of the day. Client states his lunch feels pretty good and he has known for some time that he needs to eat less bread and pasta at dinner.Guide -Write goal, objective and craft action plansWhat would you suggest as an agreed upon goal for this client? (1 point)I would suggest:Increase fruits and vegetables portions at all mealsLower the amount of carbs eaten at each mealIncrease meal to 6-8 smaller ore frequent meals each dayTry to incorporate different types of physical activities, this will help you see better resultsWhat would you suggest as an objective for this client? (1 point)The objective should be to lower the amount of carbs to 21 servings a day or lower and to eat smaller more frequent meals. I would also suggest that the client drinks 8oz of water before each meal to help him feel more satiated. Using this client’s typical day as a guide, provide this client with four action plan suggestions on how he can decrease refined carbohydrate intake within his current lifestyle. (1 point)What if you add fruits and veggies into each mealWhat if you eat 6-8 smaller meals throughout the dayWhat if you drink a glass of water before each meal to help make you feel full fasterWhen you have a snack eat a piece of fruit , veggie sticks or a low fat granola bar.Using the position paper on weight management as a reference, write the EAL recommendation that supports your action plan. (1 point)Guide - Communicate to implement action planWhat question would you ask the client to encourage him to select options for his own action plan? (1 point)Which action plan suggestion do you think you can be most successful at? Is there anything else you would like to add to your action plan?What question could you ask to assess readiness? (1 point)Are you willing to put in the extra effort in you diet to make sure you choose healthier choices for food?Are you willing to choose eating vegetables over carbohydrates with each meal?Evaluate outcomes and satisfactionWhat would you ask the client to monitor? (1 point)I would like to monitor:Weekly exerciseDaily log of calorie intakeWeekly weigh inWhat question would you ask to determine client satisfaction with the exchange of information? (1 point)In there anything I haven't addressed in this session for you?Are there any other questions you would like me to answer for you?Document - Communicate with the medical recordRemember, a well-written charting note can be read and understood in <60 seconds.) A: Assessment – write a summary of what you learned from the client. Add IDNT assessment codes with discrepancy descriptions that best fit with your summary. (2 points)Male, 42yrs old, Wt= 242lbs, Ht= 5'11"Client is exercising 6 days a week for 60minutes; he wants help lowering the amount of carbohydrates in his diet.FH-1.5.3 Carbohydrate IntakeFH-2.1.3.1 Eating environment(Location)AD-1.1.4 Weight ChangeD: Diagnosis Statement – PES format (include IDNT nutrition diagnosis code) (3 points) FH-1.5.3-Carbohydrate intake related to typical day recall as evidence by current weight of 245lbs and IBW is 172lbs.I: Interventions: Write a summary of your discussion with the client and include the IDNT intervention code that best describes the intervention? (2 points)Today we talked about lowering his total carbohydrate intake E-1.5 recommended modification (nutrition education), He needs to lower his carbohydrate intake to 19 portions or less and he needs to increase to 6-8 small meals a day. He also needs to increase his fruit and veggies at each meal.M: Measure - what do you intend to measure at next visit? (Include IDNT assessment code) (1 point)I plan on monitoring his daily intake of FH-1.5.3 carbohydrate intake to insure that his is lowering his intake. I want him to take is weight every week to see if the diet plan is effective. AD-1.1.4 weight changeE: Evaluation: How will progress be evaluated based upon goal and expected outcome? (Include IDNT assessment code) (1 point)I will be weighting the patient to evaluate AD-1.1.4 weight change. I will also be looking at his AD-1.1.5 body mass index to see if it has changed. I will also look at his diet log to evaluate if we have him on the right FH-1.5.3 Carbohydrate intake. ................
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