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Ana Luisa de CastroNUTR 407Professor O’DayFINAL PROJECTDecember 20142-Day Nutritional diet:Day 1Food itemPortion sizeBreakfastWhole grain bread (toasted)Low fat MargarineLow fat granolaFat free milkRed Apple1 slice1 tbsp.1/4 cup1 cup1 small unitSnackEnglish muffinLow fat margarineDeli Turkey breast1/2 unit1 tbsp.1 thin sliceLunchTomato and spinach salad with olive oil/lime dressing:Roma Tomato (raw)Baby Spinach (raw)Olive oilBroccoli pasta:Whole wheat pasta (cooked)Broccoli (cooked and seasoned with sautéed garlic and black pepper)* Grilled round steak strips (seasoned with Black pepper and sautéed garlic)*Navel orange 1/2 cup1/2 cup1 tbsp.1 cup1/2 cup3 oz1 small unitSnackSaltine crackers 6 unitsDinnerBrown rice (cooked)Carrots (cooked – seasoned with black peppers and olive oil)Olive oilChicken (without skin, grilled, seasoned with black pepper and lime)Fat free milkPlum1 cup1 cup1 tbsp.4 oz.1 cupOne small unitSnackPita chips (baked)3/4 oz.Day 2Food itemPortion sizeBreakfastEnglish muffinWheat branKiwiFat free milkLow fat margarine1/2 unit1/2 cup1 small unit1 cup1 tbsp.SnackWhole wheat bread (toasted)Low fat margarine Deli turkey breast 1 slice1 tbsp.1 thin sliceLunchYam (baked, seasoned with black peppers and green onions)Brown rice (cooked)Beets (cooked) Olive oilChicken (grilled, seasoned with black pepper and lime)Red Seedless Grapes1/2 cup2/3 cup1 cup1 tbsp.3 oz.3 oz.SnackPita chips (baked)3/4 oz.DinnerPasta salad with beets, zucchini, olive oil and green onions:Whole wheat pasta (cooked)Eggplant (sautéed with garlic and black peppers)*Zucchini (cooked with sautéed garlic and black peppers)*Olive oilPork loin roast (grilled, seasoned with peppers, garlic and lime)Fat free milkPersimmon2/3 cup1/2 cup1/2 cup1 tbsp.4 oz.1 cup1 small unitSnackSaltine crackers 6 units*The items were sautéed using no calorie cooking spray.Budget:Food itemProduct purchasedPriceUS$Amount purchasedPrice paid US$Whole grain bread1.88 a bag1 bag1.88Fat free milk1.49 a carton1 carton1.49Kiwi5 for 1.005 units1.00Red apple49 cents per pound1 small unit 6 ounces0.19Navel oranges88 cents per pound1 small unit 7 ounces0.38Red seedless grapes98 cents per pound17 grapes3 ounces0.50Plums88 cents per pound1 unit5 ounces0.28Persimmon68 cents each1 unit0.68Carrots79 cents a bag1 bag0.79Brown rice1.69 cents a bag1 bag1.69Whole wheat pasta0.77 a package1 package 0.77Whole wheat bran99 cents per pound5 ounces0.31Roma tomatoes68 cents per pound1 small unit5 ounces0.31English muffin1.69 a bag1 bag1.69Pita chips1.99 a bag1 bag1.99Spinach1.99 a bag1 bag 1.99Yams88 cents per pound1 medium unit9 ounces0.50Saltine crackers1.69 a package1 package1.69Beef top round2.99 per pound3 ounces0.60Pork loin1.79 per pound4 ounces0.45Chicken breast0.99 per pound7 ounces0.44Eggplant88 cents each1 unit0.88Lime 33 cents each1 unit0.33Italian squash (zucchini)59 cents per pound1 small unit6 ounces0.22Low fat granola From Ocean Beach Farmers Market 1.99 per pound2 ounces0.25Beets From Ocean Beach Farmers Market1.00 per pound8 ounces0.50Broccoli1.49 per crown1 crown1.49Deli turkey breast7.99 per pound2 thin slices (2 ounces)1.00GarlicFrom a mexican mini market3.00 per pound1 ounce0.19Green onions48 cents a bunch1 bunch0.48TotalUS$ 24.96Nutritional Analysis: NUTRIENTSGOALDay 1Day 2Average Calories1,900 Kcal1,876 Kcal1,906 Kcal1,891 KcalFat56 g57 g59 g58 gCarbohydrates239 g244 g249 g247 gProtein110 g103 g112 g108 gCalcium, Ca100?% DRI 999396Cholesterol< 250 mg151 mg175 mg163 mgCopper, Cu100?% DRI 256746Fiber, total dietary> 30 g31g41g36gFolate, total100?% DRI907884Magnesium, Mg100?% DRI 57107136Fatty acids, total saturated< 25 g8 g10 g9 gPotassium, K4,700mg1,567 mg2,557 mg2,062 mgSodium, Na1,300 mg1,632 mg2,069 mg1,851 mgVitamin A, IU100?% DRI659172416Vitamin B-6100?% DRI 869189Vitamin B-12100?% DRI651138Vitamin C100?% DRI 292201247Vitamin D100 % DRI 605859Vitamin E100?% DRI 252123Zinc, Zn100?% DRI394944Iron, Fe100?% DRI 516357g/Kg protein/day - Day 1: 1.2 g/Kg/dayDay 2: 1.3 g/Kg/dayDRIs Recommendations (50 - 70 years old)My findings45 to 65% total energy from carbohydrate20 to 35% from fat10 to 35% from proteinTotal fiber: 30gSodium: 1,300 mgPotassium: 4,100 mgDay 1Day 251 %27 %22 %31 g1,632 mg1,567 mg50%27 %23 %41 g2,069 mg2,557 mgMy plate recommendations (51 + years old):(based on a 2,000 Kcal diet)My findings:Fruits: 2 cupsVegetables: 2.5 cupsGrains: 6 oz/ 3 oz. whole grainsDairy: 3 cupsProtein foods: 5 ? oz.Oils: 6 tea spoonsDay 1Day 2~ 2 cups2.5 cups8 oz. 2 cups3.6 oz.12 tea spoons~ 2 cups2 cups7 oz.2 cups4 oz.12 tea spoonsMy goalsMy findings1,900 KcalCarbohydrate: 50 %Protein: 23 %Fat: 27 %Fiber: > 30 gmsDay 1Day 21,876 Kcal (98.7 %) 51 % 27 % 22%31 gms1,906 Kcal (100.3 %) 50 % 27% 23 %41 gmsIn comparison to the DRI recommendations, my findings were similar in regarding to macronutrients percentage, however, those recommendations are for healthy individuals. In the case of a patient with diabetes, 20% of calories coming from protein would be a more appropriate approach, yet, because of having a 55 years old male that is overweight, I included lean meats in almost every meal, ending up with 60 g over the 20%. When taking in consideration that the patient also has Crohn’s disease, and that the g/Kg/day were 1.2 and 1.3, which falls in the recommended for weight loss in diabetes, the extra amount of protein would be beneficial.For fiber, the 36g average for the two days sounds satisfactory. If our goal is a high fiber diet, maybe a slight increase in those numbers would be necessary, however, for a patient that was used to eat processed foods, it may take some adaptation until the desired amount is reached. Also, as my findings show, the amounts consumed may vary from day to day, and might average appropriately by the end of a week, for example. The grams of fat were also in the desired range, and the saturated fat was kept under 25g, with an average of 9g per day. The same was achieved for cholesterol that was kept under 250 mg, with an average of 163g/day. The biggest discrepancy was for sodium. The value of almost double the recommended value on the second day seems to be due to the industrialized snacks that contained a lot of salt and for my surprise, the deli turkey breast, which accounted for a large amount as well. If the patient shows adaptation, those salty snacks could be substituted for fruits or a fat free yogurt artificially sweetened, which would probably increase his fiber intake as well. I was surprised that by including 2 cups of milk per day my findings were close to the recommended intake for Calcium, at 99 and 93 % for days one and two. The nutritional analysis shows a 13 g calcium content for a slice of whole grain bread, which also contributed for the total calcium.For the remaining micronutrients, most of them were under the recommended values with the exception of vitamins A and C. The addition to fruits and fresh vegetables to his meal plan helped achieve the recommendations for those vitamins. What we have to take in consideration is that most values will vary along the days and to meet the daily recommendations is almost impossible. A multivitamin and mineral supplementation might be appropriate and help the patient meet the recommended needs for the micronutrients as well.When comparing my findings to MyPlate guidelines, the recommendations for fruits, vegetables and grains are satisfactory, however, I was one cup short of dairy for each day. Also, all the fruits were to be consumed whole or cut-up, instead of juice, as suggested by their guidelines. The daily amount for oils in my findings were double for both days, reaching 12 tea spoons over 6 teaspoons suggested by MyPlate guidelines. It could be a challenge to reduce the amount to 6, seeing that the amount of fats totaled for both days is within the desired percentage and the saturated fats and cholesterol are under the maximum values recommended. Some particular recommendations from MyPlate were for the week, such as dark green vegetables, red and orange veggies and beans and peas, therefore, these cannot be compared to two days of meal planning. Also, some differences in classification might affect the comparisons. MyPlate does not consider yam as a starchy vegetable, which may cause confusion to the patient when trying to find equivalents for his diet and also might differ from the amounts totaled recommend for vegetables. Also, the recommendations from MyPlate were given based on a 2,000 Kcal diet, since it only allows a 200 calories increase. So, a patient like the one for this meal plan of 1,900 Kcal would have to choose recommendations for either 1,800 or 2,000 Kcal, which could go over or under the desired values.When comparing my findings with my goals the values for fat and protein were 5% off. As mentioned before, for a male patient at 55 years old, the menu plan included a variety of lean meats, which elevated the protein amount and might have reduced the total value of fats. Taking in consideration that he is overweight and losing weight is one of the goals for the control of diabetes, a decrease in the amount of fats, especially saturated fats and cholesterol is desired. Also, the fact that he is a patient with Crohn’s disease will benefit of the extra protein and reduced fats in the diet. The total fiber value was higher than 30 grams goal for a 55 year old, and 10 grams above on the second day. The calories for both days averaged 1,891 Kcal, which is close to the goal of 1,900 Kcal. This project not only got me to think about the limitations some individuals might have regarding their diet, but we also added another limitation, which a lot of times goes unnoticed: the budget. This is an important consideration that RDs need to account for when thinking meal plans and recommendations. A perfectly balanced diet is of no use if the patient has no access to the food items. A well prepared dietitians will make sure the patient will receive an individualized meal plan and nutritional counseling that fits into his daily routine and financial situation. It also showed me how a balanced, nutritional and creative meal can be achieved with a limited budget, and sometimes we spend a lot more than we should simply for focusing only on the nutritious side of the task.Besides the budget, another interesting challenge was to make the meal interesting. I tried to balance nutrients and realized the plate might look of all one color or all one consistency. Again, a well-balanced meal is going to be of no use if it is not attractive to the patient’s eyes and taste. If your calculations are on point, but your patient only consumes half of the meal, it will not be effective. Especially with a reduced budget, when no waste is welcome. For this reason, I tried to also balance colors, consistency and texture, which was a challenge using the budget give, but then again, possible.Also, when comparing my findings to sources such as textbooks, DRIs and MyPlate, I realized how much they differ in the information provided. One source might classify the food items differently than the other, making it harder to a person without the proper knowledge to manage their diet. Some measurements also differ, accounting for discrepancies in the total values. This showed me that it is up to us to clarify those informations to the patient, giving the best counseling possible, so they can feel secure to make choices and improve their condition.ADIMENutrition Assessment55 y.o male pt admitted with acute hyperglycemia. Pt reports constant fatigue and headache.Hx of DM2 X 2 years, hyperlipidemia, Crohn’s disease X 2 years. Ht: 1.78m (5’10”) Wt: 86Kg (190lbs). BMI: 27 kg/m2 (overweight). IBW: 166lbs (75.5kg), %IBW: 114%. Pt works at home on the computer, orders pizza or picks up food at nearby restaurants (sandwiches, fast-food, burritos or wraps). No chewing or swallowing difficulties. Reports abdominal pain when drinking soda, alcohol, caffeine or eating spicy food. Alcohol use: 2-3 beers per week. No tobacco use. Reports no physical activity.Medication Hx: 500 mg b.i.d. metformin. EER: 1,720 – 2,150 (1,900) kcal/ day (20 - 25 kcal/kg) Pro: 86 – 103g/day (1 -1.2 g/Kg) Fluid= 2,000-2,100 mL/dayBiochemicals: Glucose: 800 mg/dL Total Cholesterol: 203 mg/dL HDL: 32 mg/dL LDL: 200 mg/dL LDL/HDL ratio: 4.5 Triglycerides: 179 mg/dLHbA1c: 9.5% Nutrition DiagnosisOverweight (NC 3.3) R/T excessive energy intake AEB BMI of 27 Kg/m2 and 114% IBW. Altered nutrition related lab values (NC 2.2) R/T type II diabetes AEB hyperglycemia (800 mg/dL)Nutrition Intervention2-day nutritional diet guide and meal plan provided. Goals: decrease energy intake to 1,900 kcal/day. Lose 0.5 to 1 pound/week. Reduce blood sugar to less than 150 mg/dL. Increase protein to a high concentration-low volume intake of 155 g/day. Increase fluid intake to 2,000-2,100 mL/day. Improve blood lipid panel values. Increase fiber consumption to at least 14 gms/1,000 Kcal consumed. Increase physical activity (30 min/day). Multivitamin and mineral supplementation once/day. Monitoring and evaluating: Evaluate weight. Monitor calorie, fat and cholesterol intake, protein, liquid and fiber intake. Monitor blood sugar and blood lipid panel in 3 months. Evaluate adherence to the prescribed diet. ................
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