Patient Food Log



YOUR NAME: Susie Lewis

DIABETES PROJECT

FN 434

Each member of the class will play the role of the R.D. and the role of the patient. Choose someone to work with, decide who will be the "R.D." first - plan, instruct, follow up while the "patient" follows diet and keeps food records – then reverse roles. You will need to turn in your own individual project

Role of the "R.D."

1. Interview your “patient” and gather the information needed to plan a diet and menu. Use the Diet History Form provided. You have considerable latitude in deciding the specific history of this patient and what kinds of issues you want to cover. You don’t have actual laboratory data, so make up plausible lab values that are realistic for your patient. The “patient” must be an insulin-dependent diabetic. Assume that this is a newly diagnosed diabetic who is motivated to make changes. Beyond that, individualize the diet as much as possible to the “patient’s” lifestyle.

Hand in the Diet History [page 3] for this portion of the project.

Don’t leave any blank spaces! If there is no information for a space, write “NA.”

2. A. After the interview, set the desired caloric level, calculate the total number of exchanges and distribute them

according to the "patient's" insulin dosages and lifestyle.

B. Translate the calculated diet pattern into an actual menu for the “patient”. Fill out the Menu with actual foods for one day. Then, using the Carbohydrate Counting Method – calculate the carbohydrate counts for these foods.

Hand in Energy Estimate, Insulin Dosage [page 4], Calculating Diet Pattern, and Menu [pages 5,6].

There should be continuity in your work. For example, the estimated caloric need that you calculate should be reflected in the calculated diet pattern, and the menu.

3. Show the diet pattern, CHO counts and sample menu to your “patient”. Make sure the “patient” understands the pattern, and the timing of meals. The “patient” will then follow the pattern for 3 days and keep a food log.

4. After the "patient" has followed the diet and kept a food record for 3 days, check that the patient correctly counted the food groups and carbohydrate counts consumed each day. Assess compliance and understanding - determine if the diet plan was followed, portion sizes appropriate, food distributed properly - based on the plan that you had developed. Then evaluate if changes are needed if this patient were to continue to follow the diet. Write a progress note (SOAP note) based on your evaluation.

Hand in RD Evaluation of Patient – Follow-up and Patient Food Record – Days 1,2, and 3 [pages 7-9 and 11,12].

Role as the “Patient”

1. Meet with the “R.D.” for the interview session. It is to your advantage to provide preferences and lifestyle factors, since you are actually going to have to follow this diet.

2. Meet with the “RD” to go over the diet pattern and schedule for meals and snacks.

3. Follow the diet as prescribed for three consecutive days! Timing of meals is important – remember, you are taking insulin. Keep a food record that reflects your actual intake. If you skip a snack or over eat, record it. You may use the “RD’s” sample menu for one day, only. For each day, calculate the number of food groups and carbohydrate counts consumed [document on pages 7-9 and give to your “RD”].

4. Complete Patient Evaluation form [page 13]. Hand it in with your work.

GRADING

Interview – hand in the Diet History Form 5 points

Calculation of diet (“RD”) – setting energy level,

distribution of macronutrients, coordination of insulin

and foods, writing menu, checking with carbohydrate counts 40

Evaluation of Compliance and follow-up; ADIME (“RD”) 20

Diabetes Medication Chart 15

Following Diet, Food Records (“Patient”) 10

“Patient” reaction to experience 10

Regard yourself as a professional. Your work should be complete, legible and neat, and grammatically correct. Check your spelling. Check for continuity between sections. Remember that designation of quantities is important. Your grade will reflect all these areas.

Checklist – Each student will be evaluated fulfilling both roles. Final grade will be determined from all components summarized below:

Role as Dietitian

1. Complete Drug Chart

2. Diet History and 24-hour recall (page 3)

3. Pattern of Insulin and Meals (page 4)

4. Calculating Diet Pattern – Exchange System (page 5)

5. Menu and Carbohydrate Counting (page 6)

6. RD Evaluation of Patient – Follow-up and SOAP note (pp. 11-12)

Role as Patient

1. Patient Food Records – 3 days (pp. 7-9)

2. Patient Reaction (page 13)

Diabetes Medications

Insulin Therapy:

Describe mechanism of action (how does this drug work?): Replaces the hormone insulin. Controls blood sugar levels

| |Onset of action (time) |Peak (time) |Duration of action (hours) |

|Short acting (regular) |30-60 min |4 hrs |5-8 hrs |

|Rapid acting (lispro) |15 min |1-2 hrs |3-5 hrs |

|Intermediate (NPH) |3-4 hrs |4-12 hrs |12-20 hrs |

|Long acting (ultralente) |6-10 hrs |minimal |18-20 hrs |

Biguanides

Describe mechanism of action (how does this drug work?): Tells liver to decrease production and absorption of glucose

| |Onset (hr) |Duration (hrs) |Max dose per day |

|Metformin |Unk |12 hrs |2550 mg/day |

|Metformin XL |Unk |24 hrs |2000 mg/day |

Sulfonylureas

Describe mechanism of action (how does this drug work?): Stimulates insulin release by beta cells and increases insulin receptors; increases insulin production in pancreas

| |Onset (hr) |Duration (hrs) |Max dose per day |

|Glimiperide (Amaryl) | |18-28 hrs |4-8 mg/day |

|Glipizide (Glucoatrol) | |10-24 hrs |40 mg/day |

|Glyburide (DiBeta) |1.5 hrs |16-24 hrs |20 mg |

Alpha-Glucosidase Inhibitors

Describe mechanism of action (how does this drug work?): delays carbohydrate absorption

| |Usual starting dose |Max dose/day |

|Acarbose |25 mg 3x/day |100 mg 3x/day |

TZDs

Describe mechanism of action (how does this drug work?): improve peripheral insulin sensitivity

| |Usual starting dose |Max dose/day |

|Rosiglitazone (Avandia) |4 mg/day |8 mg/day |

|Pioglitazone (Actos) |15 mg/day |45 mg/day |

Dipeptidyl Peptidase (DPP-4) Inhibitor

Describe mechanism of action (how does this drug work?): increases GLP-1 and increases insulin release. Prevents degradation

| |Usual starting dose |Max dose/day |

|Sitagliptin (Januvia) |100 mg/day |100 mg/day |

Glucagon-like peptide (GLP-1)

Describe mechanism of action (how does this drug work?): Food ingested, GLP-1 is secreted which enhances insulin secretion, glucagon release, slows gastric emptying, improves insulin sensitivity

| |Duration (hr) |Usual starting dose |Max dose/day |

|Exenatide (byetta) |6-8 hrs |5 mcg |10 mcg 2x/day |

|Liraglutide (Victoza) | |0.6-1.2 mg/day |1.8 mg/day |

Synthetic Analog of Human Amylin

Describe mechanism of action (how does this drug work?): lowers postprandial glucose, lowers postprandial glucagon and delays gastric emptying

| |Usual starting dose |Max dose/day |

|Pramlintide Injection |60 mcg |120 mcg |

Diet History

Name ___Kala M. Geiss_____________MD __Dr. Vicki Brown________________ Age _23____ Date _10-16-12____

Occupation ___student_________________ Dx _DM Type I_________________ Sx __excessive thirst, frequent urination, recent severe weight loss of 25# in 3 months_____

Diet Order _50-30-20 diet, Complex CHO-healthy fats to increase satiety-Protein but smaller amount to be less harsh on kidneys___ Diets previously followed _ None_____________________________________

Prior instruction? __none_______________ Social hx _Full time student, part time Burger King Asst Mgr, goes out 1-2 days/week_____

Height __67 in__ Weight _155#__ IBW _____135#__ % IBW _87.1%__ Desired wt _______ BEE _1545.8__ TDE 2103__

Wt hx _recent, unplanned weight loss of 25# in the past 3 months___________

Medications None_____________________ Side effects? __None_______________________

do you take insulin? Yes what kinds? Lispro, Lantus

where do you store your insulin when you are not suing it? I store my insulin in the refrigerator, but when I’m at work for my lunch doses, I store it out of direct sun light and heat in a plastic Ziploc bag in my purse

Do you exercise? Yes What type? Walking duration? 25 min, 3x/week

do you use diabetes oral medications? no

do you test your blood sugars? Yes what is your testing schedule? Before every major meal (generally 730am, 1130 am, 330 pm and just before bed

Pertinent labs:

FBS _195__ 1 hr ppd 215__ 2 hr ppd __206_ 3 hr ppd _209__ HgA1C 8.2%___ Cholesterol _199___ HDL _51__

LDL _105__ TG _165__ BP _145/90_

Medical History:

MI __none_______ cancer __none_____ diverticulosis, arthritis, hypertension, renal disease, hiatal hernia __none__________

CVA __none________ COPD ___none_________ other _none__________________________________________

Family History:

Heart disease __none__________ NIDDM or IDDM _Grandfather, T2DM___ cancer, diverticulosis, arthritis, hypertension _grandfather –paternal and father - hypertension________

Hypoglycemia _none__________

Coffee or tea_ coffee___ Smoking_ NO__ Packs/day __0___ Quit ____ Alcohol _none____ Water _2/3 gal/day___ Pop _only diet, when eating out____

Difficulty chewing _none___ or swallowing __none____________ Constipation _none________

Recent changes in eating habits __none_________

Food allergies or intolerances _none____________________ Supplements _multi vitamin__________________________

Dining out frequency _3x/week________ Typical meal 4 oz lean meat, ½ c starch, ½ c steamed/grilled vegetables, side salad w/1T vinaigrette dressing____________________

Fast food meal _grilled chicken wrap, small fry, small diet pop______________________

Exercise history walking for past 9 years 3x/week_______________________________________

Meals at usual times? _yes, 3 meals/day_________________________ Shift work? _3-9 hr shifts every other weekend__________

24 hour diet recall:

1-20oz bottle water

1 packet SF maple and brown sugar oatmeal w/ ¼ c. 2% milk added

½ c no sugar added applesauce w/cinnamon and 1 packet Splenda

3 slices turkey bacon

1-20 oz water bottle

Grande Café Americano w/ 2 pumps SF van syrup and 1 oz half & half

1 med banana

Panda Bowl w/ 1 c. steamed white rice and 1 c. orange chicken

1-20oz bottle water

1 c. romaine lettuce, 1 T. dried cranberries, 1T roasted sunflower seeds, 6 baby carrots, 1T Free Italian Vinagrette dressing

½ c. small curd Kroger brand cottage cheese

1 c. cheese, spinach tortellini from Buitoni

¼ c. Classico roasted red pepper alfredo sauce

1-4oz grilled chicken breast

1 T. shredded parmesan cheese

1 c. steamed broccoli

1-20 oz bottle water

½ large gala apple w/ 2T. Peter Pan crunchy peanut butter

8 oz 2% milk

1-20oz bottle water

Please list any other information that may be helpful

Energy Estimate, Insulin Dosage

Patient Ht _5’7”__ cm170.18____ Wt _70.45____ kg; IBW _135# +/- 10%___; %IBW _115%__

Determine estimated caloric needs. Show your calculations and consideration of activity level, %IBW, and any other considerations you used in your estimation.

REE= (10x70.45) + (6.25x170.18) - (5x23) -161 x1.5x1.0 = 2238 kcal/day

_2238__ kcal per day

Coordination with Insulin. Use a “flexible insulin regimen” as outlined in Mahan Chapter 33

This is a combination of rapid-acting insulin (e.g. lispro) at meals and long-acting or basal in the evening before bed (e.g.glargine) as a baseline insulin at bedtime.

Fill out the schematic below to represent the time your “patient” will eat meals and snacks and when the insulins will be injected – and their peak actions (your graph should list specific times for meals – that fit your patient’s schedule, injection times/types of insulin). You also need to incorporate strenuous exercise – and coordinate it with snacks and meals. This template should then show how the diet (i.e. meals and snacks) and exercise will be coordinated with the insulin regimen. This is the pattern your “patient” is to follow for 3 days.

Type(s) of insulin Times administered

________Lispro_______________________ _8am, 12pm,4pm_____ ________Lantus______________________ __9pm____________

____________________________________ ___________________

Any considerations due to strenuous exercise? (describe) – for example you may need to have an extra snack or adjust timing of meals to accommodate when someone works-out.

Patient will have 3 snacks per day and possibly another small snack first thing in the morning upon waking up; if there is a considerable amount of time until breakfast.

Draw in insulin curve: for Rapid _ Lispro _ Intermediate/Longer acting _Lantus__

Indicate when meals and snacks will be consumed. Adjust this to when the “patient” typically gets up. There is no way to skip breakfast. If someone has strenuous exercise – read the handout on the web – you need to be sure that the insulin is not peaking then, and you may need to add a snack.

NOTE:

**Insulin curve is hand-drawn and is an additional attachment to project submission**

[pic]

Meal or____ _B___ _S___ _L___ S ____ _D___ _S___ ____ ____ ___ ____S ___

Snack:

Insulin injection (indicate with an arrow)

Exchange System

|Food Group |Breakfast |Snack |Lunc|Snack |

| |8:00 AM |10:00 |h |2:00 |

| | | |12:0| |

| | | |0PM | |

|Breakfast | 1/3 c. |Oatmeal | | | | |

|  | 1 small |Banana | | | | |

|  | 1 c. |1% milk | | | | |

|  | 1 tsp. |Stick margarine (in oatmeal) | | | | |

|  |  |  | | | | |

|  |  |  | | | | |

|  |  |  | |  |  |42 g CHO |

|Snack |¾ oz. |Pretzels | | | | |

|  | 1 C. |Sticks Celery | | | | |

|  | 12 Tbs. |Lite Cream Cheese | |  |  | 15 g CHO |

|Lunch | 2 slices |Whole Wheat Bread | | | | |

|  | 1 Tbsp. |Reduced-fat Mayonnaise | | | | |

|  | 1 Lg. |Egg, hard-boiled | | | | |

|  | ½ c. |Low-fat cottage cheese | | | | |

|  | 1 C. |1% milk | | | | |

|  | 1 |Kiwi | | | | |

|  |  |  | | | | |

|  |  |  | |  |  | 42 g CHO |

|Snack | ½ C. |Jello, sugar free | | | | |

|  | 1/8th |Avocado | | | | |

|  |  |  | |  |  | 15 g CHO |

|Dinner | 1/3 c. |Brown rice, cooked | | | | |

|  | 1 C. |1% Milk | | | | |

|  |1 C. |Salad Mix | | | | |

|  | 3 oz. | Pork Chop | | | | |

|  | 1/3 c. |Peas, cooked | | | | |

|  | 1Tbs. |Salad Dressing | | | | |

|  | 1 tsp. |Stick Margarine, on rice | | | | |

|  |  |  | | | | |

|  |  |  | |  |  | 57 g CHO |

|Snack | 5 |Saltines | | | | |

|  | 1 Small |Orange | | | | |

|  |  |  | |  |  | 30 g CHO |

| | | | | | | |

| | | | | | | |

| | |TOTAL | |  |  | 201 g CHO |

Patient Food Record - Day 1

The “Patient” will record everything eaten, amount, and time of day. Try to be honest about what you actually consumed. Then evaluate food eaten with respect to food groups and calculate total macronutrients and calories consumed for that day. The “RD” is then responsible for checking the calculations and evaluating whether appropriate amounts and types of foods were eaten at appropriate times.

| | | |Food Groups |Carbohydrate Counts |

|Time |Food Item and Method of Preparation |Amount Eaten |Starch |Fruit |

|Time |Food Item and Method of Preparation |

Daily Totals: 238.5 g CHO 78.5 g protein 47.5 g fat 1695.5 total Kcalories

Patient Food Record - Day 3

The “Patient” will record everything eaten, amount, and time of day. Try to be honest about what you actually consumed. Then evaluate food eaten with respect to food groups and calculate total macronutrients and calories consumed for that day. The “RD” is then responsible for checking the calculations and evaluating whether appropriate amounts and types of foods were eaten at appropriate times.

| | | |Food Groups |Carbohydrate Counts |

|Time |Food Item and Method of Preparation |

Daily Totals: 238.5 g CHO 78.5 g protein 47.5 g fat 1695.5 total Kcalories

RD Evaluation of Patient - Follow-up

From the "patient's" food record, check that food groups and calculation of CHO, fat, protein and total calories is correct. Look at all 3 days of records and make a general evaluation of the following:

1. diet was followed as instructed (i.e. appropriate number of exchanges, and/or carbohydrate counts consumed)

Kala followed the plan pretty closely to my suggestions. The eating plan I created for her was to contain 226 g. CHO, 90 g. Pro, 72 g. Fat, and 1900-2000 kcals/day. She was able to consume 238.5 g. CHO, 78.5 g. Pro, 47.5 g Fat, and approximately 1695 kcals. She is a college student on a budget so she had to tailor her needs the best she could for what she had available to her. She stated this seemed to be the best option that worked in her schedule.

2. all snacks and meals were consumed at appropriate times

All of her meals and snacks were consumed at the appropriate times.

3. meals and/or snacks were not skipped

Kala did not skip any meals or snacks.

4. Compared to the calculated diet – how closely did actual intake compare in terms of total calories,

total carbohydrate, and the distribution of CHO, fat, and protein? Using the carbohydrate counting method, do you reach the same conclusions?

The eating plan I created for her was 226 g. CHO, 90 g. Pro, 72 g. Fat, and 1900-2000 kcals/day. She was able to consume 238.5 g. CHO, 78.5 g. Pro, 47.5 g Fat, and approximately 1695 kcals.

She was under the recommended amounts by approximately 10%.

The carb counting method was significantly lower (201 g.) than what I recommended for my patient.

Patient _Kala Geiss_________________________

RD _Susie Lewis___________________________

Follow the Nutrition Care Process (ADIME) and evaluate the patient

A:

D:

I:

M:

E:

NUTRITION ASSESSMENT:

Food and Nutrition Hx:

*medications: multi-vitamin

*beverage intake: coffee, diet soda, water

*consumes a variety of nutrient-dense foods; willing to try new foods if finances allow

*consumes 3 meals and 2-3 snacks/day

*Client cooks for herself and occasionally eats out

*protein needs: 0.8 g x 70.46 kg = 56.36 g/pro/day

*energy needs: (10x70.45)+(6.25x170.18)-(5x23)-161 x1.5x1.0 = 2238 kcal/day

*fluid needs: 30 cc x 70.46 kg = 2113 cc/day

*kcals 1695/day. Client consumes 80% less kcal than the recommended daily amount for her diabetic condition.

**Client is newly diagnosed DM Type1 and has limited income for groceries. Based on client’s food record, she is consuming approximately 1695 kcal/day; 80% of the recommended level of 2113 kcal/day.

Anthropometrics:

*Height: 5’7” (170.18 cm)

*Weight: 155# (70.5 kg)

*UBW: 175# (79.5 kg)

*IBW: 100 + (5x7) = 135#+/- 10%

*%IBW: 175/135 x 100 = 129.6%

*%UBW: 155/175 x 100 = 88.57%

*%wt loss: 175 – 155 / 175 x 100 = 11.43%

*BMI = 24.4

*BMI measurement indicates normal weight. Patient states UBW 175# three months ago. Recent, unplanned weight loss of 25#.

Biochemical/Tests/Procedures:

FBS 195

1 hr ppd 215

2 hr ppd 206

3 hr ppd 209

HgA1C 8.2%

Cholesterol 199

HDL 51

LDL 105

TG 165

BP 150/90

*Client results as compared to NHLBI recommended levels of Glu ................
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