302L NCP Notes

Ashley Hayslip Nutr. 302L Recorder: Ashley Hayslip

Experiment: Anthropometry lab Subject gender: male Subject age: 27 years 1. Ideal Body Weight (IBW) Weight: 184#, 83.6 kg. Height: 71 inches, 180 cm

Date: Nov. 1, 2012

Elbow Breadth: 2.91 inches, 7.4 cm Frame size: medium Life Insurance Table Weight Range: 152-165#, 69-75 kg. Hamwi IBW: 172 % IBW: 107% (Ideal) Comment: The patient is within an ideal body weight. 2. Body Mass Index (BMI) BMI: 25.8 Category: normal 3. Waist-to-Hip Ratio Waist: 85.1 cm Hip: 105.4 cm Waist-to-Hip Ratio: 0.8 Comment: The patients waist-to-hip ratio is at a desirable value (<0.9) 4. Arm Circumference and Triceps Skinfold Comparison Triceps: 7 mm, 25th percentile Mid-arm Circumference: 342.9 mm Arm Muscle Area: 7,200 mm2, 75-90th percentile Total arm area: 9,200 mm2 Arm Fat Area: 2,000 mm2, 50-75th percentile

5. Body Composition A. Circumferences Buttocks constant Abdomen constant Subtotal Foreman constant Subtotal

42 +29 71 -34.5 36.5 -10 Approximate body fat 29.5%

B. Bioelectrical Impedance Analysis (BIA) Body Fat: 28.8#, 15.7% C. Three and Seven Site Skinfolds Three Site Skinfolds (men) Chest: 5,4,4,4.5 mean= 4.4 Abdomen: 12.5, 13.5, 14, 14 mean=13.5 Subscapular: 13, 12, 12, 14.5 mean=12.8 Sum= 30.7 (X1) Seven Site Skinfolds Chest: 5, 4, 4, 4.5 mean=4.4 Midaxillary: 6, 8, 9, 9 mean=8 Triceps: 7, 7.5, 8, 7 mean=7.4 Subscapular: 13, 12, 12, 14.5 mean=12.8 Abdomen: 12.5, 13.5, 14, 14 mean=13.5 Suprailiac: 7.5, 9, 9, 9 mean=8.6 Thigh: 11, 11, 11, 10 mean=10.8 Sum=65.5 (X3) Body Density from 3 skinfolds site: 1.078 BD=1.1093800-0.0008267(30.7)+0.0000016(30.7)2-0.0002574(27) Body Density from 7 skinfolds sites: BD=1.11200000-0.00043499(65.5)+0.00000055(65.5)20.00028826(27) Three Site Skinfold Body Composition Results Body Fat: 7.7 kg, 9.18% Lean Body Mass: 75.9 kg, 90.8% Seven Site Skinfold Body Composition Results Body Fat: 6.9 kg, 8.3% Lean Body Mass: 76.9 kg, 91.7%

D. Hydrostatic weighing (gold standard) Residual Volume: 1.49 RV=21.6(180)+23.9(27)-16.3(83.6)-1680 Trial #1: 3.807, #2: 3.668, #3: 3.629, Ave=3.7 UWW=3.7 Body Density=1.06 83.6 BD= ___________________ ( ) - 1.49 Body Fat: 14.2 kg, 16.98% %Body Fat= (495/1.06)-450 Body fat=total BW - %body fat Lean Body Mass: 69.4 kg, 83.02% Lean body mass= total BW - body fat % Lean body mass= 100% - % body fat Comment: The value for the circumference method for body fat was very inaccurate compared to the hydrostatic weight. (29.5% verses 16.96%) The bioelectric impedance analysis was fairly accurate compared to the hydrostatic weight. (15.7% verses 16.96%) The skin fold tests were very inaccurate. The three site skinfold was 9.18% body fat and the seven site skinfold was 8.3% body fat.

Ashley Hayslip Nutr. 302L Experiement: Blood albumin Date: Sept. 13, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Diagnosis: Bladder cancer Age, gender: 55, female Dietary intake: PO intake Symptoms: Decreased appetite since chemo, N/V when tries to eat Anthropometric measurements o Ht/wt: 55/165.1cm and 112#/50.9 kg o BMI=18.7 kg/m2 (normal) o IBW=125#/56.8 kg, %IBW=89.6% (mild malnutrition) o UBW=123#/55.9kg, %UBW=91% (mild malnutrition) o % wt loss: 8.9% (mild degree of malnutrition) Energy, protein and fluid needs o Give a Range Total energy= 1998-2306 kcal/d Protein= 50.9-63.6 g/d Fluid= 1782 ml/d o Basis for estimations (based on ABW of 50.9 kg) For energy, used Harris-Benedict formula to determine REE then multiplied by activity (1.3) & injury factor (1.3-1.5) For protein, used stress factor for tumor: 1.0-1.25 g PRO/kg For fluid needs, used 35 ml/kg/day Labs/tests- can indicate high or low, normal or abnormal o Total PRO = 5.5 g/dL, low (<6.0 g/dL) o Serum albumin = 2.8 g/dL, low (<3.8 g/d;) Nutrition Diagnosis Inadequate protein intake (or inadequate energy intake) R/T poor appetite and N/V caused by chemotherapy AEB <90% IBW 8.9% wt loss, low total protein and low serum albumin. Nutrition Intervention 1) Meals and snacks a. Supplemental protein drinks TID between meals. b. Eggs, chicken, fish, dairy products, lentils, and beans. 2) Nutrition-related medication management a. REC appetite stimulant Goals: 1) Dietary intake to meet >75% of estimated energy needs 2) Weight gain of 1#/wk until patient reaches UBW/IBW 3) Protein need: 50.9-63.6 g/d 4) Increase total protein and serum albumin to within normal ranges in 4 wks.

Monitoring and Evaluation Follow-up phone call after 3 days or 1 wk later Ask the patient to do 3-day food record and bring it to the clinic to reassess BW, protein intake have increased from previous visit. Reassess total protein and serum albumin in 4 wks to determine if within normal ranges Consult MD if the patient needs a TPN in case the patient still has low blood albumin and loses body weight.

Ashley Hayslip Nutr. 302L Experiment: Glucose Assessment Date: Sept. 18, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Diagnosis: Type 1 diabetes mellitus Age, gender: 24, male Dietary intake: Skips breakfast daily. A typical lunch includes a hamburger, French fries, and a large soda. Dinner typically consists of a frozen dinner or pizza, dessert, and a soda. Three to four snacks are consumed daily and consists od chips, cookies, or cake. Symptoms: Frequent urination and excessive thirst and hunger. Anthropometric measurements o Ht/wt: 510/177.8 cm and 165#/74.8 kg o BMI=23.6 kg/m2 (normal) o IBW=166#/75.3 kg, %IBW=99.3% (ideal) Energy, protein and fluid needs o Give a Range Total energy= 2362-2479 kcal/d Protein= 59.8-74.8 g/d Fluid= 2,618-2,992 ml/d o Basis for estimations (based on ABW of 50.9 kg) For energy, used Harris-Benedict formula to determine REE then multiplied by activity (1.3) & injury factor (1) For protein: 0.8-1.0 g PRO/kg For fluid needs, used 35-40 ml/kg/day Labs/tests- can indicate high or low, normal or abnormal o HbA1c= 9.4%, very high (>6.5-7%) o Fasting blood glucose = 180 mg/dL, high (>200 mg/dL) Nutrition Diagnosis Limited adherence to nutrition-related recommendations R/T consumption of a poor diet, especially for a diabetic pt, inadequate exercise and lack of blood glucose self-monitoring AEB excessive hunger and thirst, fasting BG= 180 mg/dL and HbA1c= 9.4% Nutrition Intervention 3) Meals and snacks a. Dont skip breakfast. Meals should include lean proteins, whole grains, vegetables, and fruit. For example: a chicken sandwich on a wholewheat bun with a side salad and low fat dressing. b. Snacks should include fresh fruit and vegetables such as veggie sticks. Low sodium nuts make for a good snack as well. Water is the beverage of choice, but diet-soda should be chosen over regular soda beverages.

Goals: 5) To lower blood glucose. 6) Develop a regular exercise habit within the next 2 wks. (Refer pt to an exercise physiologist.) 7) Develop carbohydrate counting skills within 1 wk. 8) Develop the habit of checking blood glucose 3-4 times daily. (Before meals and before bed.) Monitoring and Evaluation Follow-up phone call after 1 wk later to see to see if meal plan is working and to see if an appointment with an exercise physiologist has been made. Ask the patient to do 3-day food record. Recommend a BG log: date and time Reassess HbA1c in 3 months.

Ashley Hayslip Nutr. 302L Experiment: Calcium Lab Date: November 8, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Age, gender: 67, male Dietary intake: PO intake: high protein diet and lactose intolerance. Symptoms: No symptoms Anthropometric measurements o Ht/wt: 58/ 172.7 cm and 166#/75.5 kg o BMI= 25.5 kg/m2 (overweight) o IBW=154#/70 kg, %IBW=107% (ideal) Energy, protein and fluid needs Total energy= 1,425.2 kcal/d Protein= 60.4-75.5 g/d Fluid= 1,425.2 ml/d o Basis for estimations For energy, used Harris-Benedict formula to determine REE then multiplied by activity (1.3) & injury factor (1) For protein, used 0.8-1.0 g/kg For fluid needs, used 1 ml/kcal Labs/tests- can indicate high or low, normal or abnormal o Urinary Ca= 300 mg/day, high (100-240 mg/day) o Albumin = 3.8 g/dL, normal (<3.8 g/d) o Glucose= 112 mg/dl, normal (70-110 mg/dl) o Cholesterol= 188 mg/dl, normal (<200 mg/dl) o Triglycerides= 89mg/dl, normal (<150 mg/dl) o Serum Ca= 9.8 mg/dl, normal (8.5-10.5 mg/dl) Nutrition Diagnosis Imbalance of nutrients R/T high protein and low calcium diet AEB urinary calcium level of 300 mg/day and protein intake of 150 g verses DRI of 50 g/day. Nutrition Intervention 4) Provide meal plan, snack plan, and fluid plan emphasizing nondairy Calcium rich foods such as dark leafy greens, legumes, fish with bones, and fortified foods such as orange juice. 5) Take a calcium supplement of 500 mg/day 6) Begin nutrition education on high protein diet and the relationship between calcium and bone health. Goals: 9) Lower protein intake to meet DRI 10)Consume Ca rich food sources immediately

11)Begin Ca supplementation immediately 12)Reach sufficient fluid intake immediately 13)Normalize urinary Ca within 2-3 weeks. Monitoring and Evaluation Follow-up phone call after 3 days Ask the patient to do 3-day food record with fluid intake included Reassess urinary Ca levels in 2-3 weeks.

Ashley Hayslip Nutr. 302L Experiment: Diet Lab Date: Oct. 16, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Diagnosis: Age, gender: 24, female Dietary intake: PO intake Symptoms: Anthropometric measurements o Ht/wt: 54/ 162.6 cm and 115#/52.3 kg o BMI= 19.8 kg/m2 (normal) o IBW=120#/54.5 kg, %IBW=96% (normal) Energy, protein and fluid needs o Give a Range Total energy= 1738-1825 kcal/d Protein= 42-52.3g/d Fluid= 1830.5 ml/d o Basis for estimations (based on ABW of 52.3 kg) For energy, used Harris-Benedict formula to determine REE then multiplied by activity (1.3) & injury factor (1) with a range of 5% For protein, used 0.8-1.0g PRO/kg For fluid needs, used 35 ml/kg/day
Energy (Kcal) Recall DRI %DRI 2017 1825 110.5 CHO (g) 276.18 100 276.18 Fiber (g) 9.3 25 37.2 Fat (g) 63.3 65 97 Sat. Fat (g) 19.8 <20 99 Chol (mg) 153 <300 51 Pro (g) 103.4 46 224 Vit A (mg) 530 500 106 Vit D (mg) 1.25 15 8.3 Vit C (mg) 57 60 95 Iron (mg) 12.45 8.1 153 Ca (mg) 924.7 800 115 Sodium (mg) 4,008 2,300 174.3

Nutrition Diagnosis Inadequate fiber intake, inadequate vitamin D intake, and excessive sodium intake R/T low consumption of high fiber foods and vitamin D and overconsumption of sodium-rich foods AEB 24 hour diet recall data: fiber intake of 37.2%DRI, vitamin D intake of 8.3%DRI, sodium intake of 4,008 mg verses upper limit of 2,300 mg. Nutrition Intervention 7) Meals and snacks a. Eat foods rich in fiber such as whole grains, legumes, fruits, and vegetables. Eat foods rich in vitamin D such as fortified dairy

products, salmon, and eggs. Avoid foods high in sodium such as processed foods. 8) Vitamin Supplements a. Take vitamin D supplement Goals: 14)To meet 75% of DRI for fiber and vitamin D 15)Decrease consumption of sodium. Monitoring and Evaluation Follow-up phone call after 1 week Ask the patient to do 3-day food record

Ashley Hayslip Nutr. 302L Experiment: HDL and LDL Date: October 23, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Diagnosis: Recovery from coronary artery bypass graft Age, gender: 54, female Dietary intake: PO intake Symptoms: High fat and refined carbohydrate intake. Anthropometric measurements o Ht/wt: 54/162.6 cm and 148#/ 67.3 kg o BMI=25.3 kg/m2 (overweight) o IBW=120#/54.5 kg, %IBW=123% (overweight) Energy, protein and fluid needs Total energy= 1,717.5-2,126 kcal/d Protein= 84-101g/d Fluid= 1,717.5-2,126 ml/d o Basis for estimations (based on ABW of 50.9 kg) For energy, used Mifflin-St. Jeor formula to determine REE then multiplied by activity (1.3) & postoperative stress factor (1.31.5) For protein, used stress factor for: 1.25-1.5g PRO/kg For fluid needs, used 1ml/kcal/day Labs/tests- can indicate high or low, normal or abnormal o Total cholesterol=240 mg/dl, high (<200 mg/dl) o AST=76 U/L, high (10-34 U/L) o ALT=31 U/L, normal (8-40 U/L) o LDH=322 U/L, high (85-286 U/L) o CPK=268 U/L, high (24-195 U/L) o Bilirubin (total)=0.5mg/dl, normal (0.2-1.4 mg/dl) o Bilirubin (direct)=0.1mg/dl, normal (0-0.4 mg/dl) o TG=250 mg/dl, high (<150 mg/dl) o HDL=34mg/dl, low (>50 mg/dl) o LDL=156 mg/dl, high (<130 mg/dl) o Total fat intake=120g, high (DRI=65g) Nutrition Diagnosis Undesirable food choices R/T lack of nutritional knowledge on healthy diet AEB blood lipid profile, %IBW of 123%, and total fat intake of 120 g verses the DRI of 65g. Nutrition Intervention 9) Meals and snacks

a. Provide a 7-day sample menu plan emphasizing foods high in fiber and low in fat such as whole grains, fruits, vegetables, and low fat dairy products. b. Nutrition education on healthy diet c. Refer patient to exercise physiologist to develop an exercise plan d. Refer to specialist for cessation of smoking Goals: 16)Practice healthy diet immediately 17)Lower blood lipid profile to normal ranges within 3-6 months 18)Reduce and quit smoking within one month 19)Develop regular exercise pattern within two weeks Monitoring and Evaluation Follow-up phone call in 1 week. Ask the patient to do 3-day food record. Check progress on patients efforts to quit smoking. Reassess blood lipid profile within 3-4 months.

Ashley Hayslip Nutr. 302L Experiment: Hb/Hct Lab Date: Sept. 24, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Diagnosis: Inadequate iron intake and lactation Age, gender: 22, female Dietary intake: Vegetarian diet, stopped vitamin and mineral supplementation Symptoms: Exhaustion Anthropometric measurements o Ht/wt: 54/162.6 cm and 108#/48.9 kg o BMI=18.5 kg/m2 (normal) o IBW=120#/54.4 kg, %IBW=90% (mild malnutrition) Energy, protein and fluid needs o Give a Range Total energy= 2176-2276 kcal/d Protein= 55.5-66.4 g/d Fluid= 2176-2276 ml/d o Basis for estimations (based on ABW of 48.9kg) For energy, used Mifflin-St. Jeor formula to determine REE then multiplied by activity (1.3) & injury factor (1) and added 500 kcal for lactation. For protein needs, used: 0.8-1.0 g PRO/kg plus 12 g (lactation) For fluid needs, used 1 ml/kcal/day Labs/tests- can indicate high or low, normal or abnormal o Hb = 9.5 g/dL, low (<12 g/dL) o Hct = 30%, low (< 34%) Nutrition Diagnosis Inadequate iron intake and energy intake R/T lactation, vegetarian diet with no supplements AEB the lab values of low Hb and low Hct and %IBW is malnutrition. Nutrition Intervention 10)Meals and snacks a. Increase calorie intake greater than 95% of the recommendation and supplement diet with a multivitamin. b. Plant based foods rich in iron should be consumed frequently: spinach, lentils, nuts, tofu, and enriched cereals. Goals: 20)Increase body wt by increasing kcal intake

21)Get Hb and Hct back to a normal range by consuming iron-rich plant foods. Start iron-rich diet immediately. 22)Begin to take a multivitamin immediately Monitoring and Evaluation Follow-up phone call after 3 days Ask the patient to do 3-5 day food record Reassess Hb and Hct in 4 months to see if at a normal range.

Ashley Hayslip Nutr. 302L Experiment: Triglyceride Date: Oct. 3, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Diagnosis: Type II diabetes mellitus Age, gender: 37, female Dietary intake: PO intake Symptoms: No symptoms Anthropometric measurements o Ht./wt.: 51/154.9 cm and 152#/69 kg o BMI= 28.97 kg/m2 (overweight) o IBW=105#/47.7 kg, %IBW=144.8% (obese) Energy, protein and fluid needs Total energy= 1269-1590 kcal/d Protein= 55.2-69 g/d Fluid= 69 ml/d o Basis for estimations (based on ABW of 69 kg) For energy, used Harris-Benedict formula to determine REE then multiplied by activity (1.3) & injury factor (1) with a 5% range For protein, used 0.8-1.0 g PRO/kg For fluid needs, used 1 ml/kg/day Labs/tests- can indicate high or low, normal or abnormal o TG= 250 mg/dL, high (<150 g/dL) o Blood glucose = 145 mg/dL, high(70-110 mg/dL) Nutrition Diagnosis Type II diabetes mellitus due to being overweight R/T preference of high kcal diet and no exercise AEB by a BMI of 28.9 and IBW% 144. Nutrition Intervention 11)Meals and snacks a. Snacks and meals should be low in fat, high in fiber and whole grains, and have plenty of vegetables and fruit. Fast foods and high fat, high sugar snacks should be avoided. `Goals: 23)Weight loss to lower BMI to a normal range. 24)To avoid high fat and energy dense foods. 25)Refer to an exercise physiologist for an exercise plan.

26)Refer to a diabetes educator to learn CHO counting. Monitoring and Evaluation Follow-up phone call after 1 week. Ask the patient to do 4-7 day food record. Reassess triglycerides and blood glucose in 3-4 weeks to see if decreased to normal ranges.

Ashley Hayslip Nutr. 302L Experiment: Cholesterol Lab Date: October 18, 2012 Recorder: Ashley Hayslip

Nutrition Assessment Age, gender: 39, male Dietary intake: PO intake. Typical breakfast involves breakfast cereal with whole milk. Lunch typically consists of fast-food restaurants. Dinner consists of meat loaf or fried chicken, mashed potatoes with gravy, cheesy broccoli, and whole milk. Anthropometric measurements o Ht/wt: 61/185.42cm and 245#/111.4 kg o BMI= 32.4 kg/m2 (obese) o IBW=184#/83.6 kg, %IBW=133% (obese) Energy, protein and fluid needs o Give a Range Total energy= 2,718-3,171 kcal/d Protein= 72.3-90.6 g/d Fluid= 90.6 ml/d o Basis for estimations (based on Adjusted Body Weight) For energy, used 30-35 kcal/kg For protein, used 0.8-1.0 PRO/kg For fluid needs, used 1 ml/kg/day Labs/tests o Total Cholesterol= 240 mg/dl high (<200 mg/dl) o Glucose= 93 mg/dl normal (70-110 mg/dl) o Hgb= 15.2 g/dl normal (13-18 g/dl) o Hct=43% normal (38%-52%) o Albumin=4.5 g/dl normal (3.5-5.0 g/dl) o TG=123 mg/dl normal (<150) Nutrition Diagnosis Obesity R/T high kcal diet with no regular exercise pattern AEB %IBW of133%, total cholesterol of 240 mg/dl, and BMI of 32.4 kg/m2. Nutrition Intervention 12)Meals and snacks a. Eat low kcal foods rich in fiber and low in fat and added sugars. Such as whole grains, vegetables, fruits, lean meats, and low fat dairy products. b. Breakfast could include high fiber cereal with fat free or 1% milk and some a serving of fruit. Lunch could consist of a turkey sandwich or

wrap with a side salad. Dinner could consist of baked chicken breast with a baked potato and steamed broccoli. Water is the beverage of choice, but juice or diet soda could be a replacement. 13)Nutrition-related medication management Goals: 27)Lower bw by 1-2#/wk until BMI is less than 25 kg/m2 28)Develop a regular exercise plan 29)Lower blood cholesterol levels to normal ranges within 6 months 30)Meet recommended kcal intake according to adjusted body weight Monitoring and Evaluation Follow-up phone call after 1 wk Ask patient to do 3-day food record Start a weekly weight loss log Reassess blood cholesterol levels within 3 months