Mr.

Robertson
Age: 75
11/02/2018

Nutrition Assessment:
This is a 45-minute face to face Medical Nutrition Therapy visit. Patient is a 75-year-old male admitted
for dietary management of co-morbidities along with diagnosis of prostate cancer.

Diagnosis and medical history: Family History: T2DM (mother); cardiovascular disease (father).
Diagnosis: medical checkup five years ago, diagnosed with prostate cancer; metastasized.
Previous nutrition therapy: He has made many positive dietary changes to manage his weight and help
with blood pressure and glycemic control. First consultation nutrition diagnosis: Excessive energy
intake, overweight, physical inactivity, undesirable food choices, not ready for diet/lifestyle change.
Second nutrition diagnosis: overweight, physical inactivity, undesirable food choices, excessive sodium
intake. Third nutrition diagnosis: overweight, physical inactivity, undesirable food choices. Fourth
nutrition diagnosis: overweight, inconsistent carbohydrate intake, food- and nutrition-related knowledge
deficit. 10 yrs ago, patient had several visits to a dietitian, but has not seen one for 9 yrs. Due shortly to
begin a course of radiotherapy. PG-SGA-score: 15 (≥9) indicates critical need for improved symptom
management and/or nutrient intervention. PG-SGA Global: Stage B.

Weight History: Height: 69 in/ 175 cm; Current weight: 170 lbs/ 77 kg; current BMI is 25 kg/m2
(Overweight). UBW: 184 lbs / 83.5 kg; % UBW: 92% (mild depletion); IBW: 160 lbs/ 72 kg; % IBW:
107% His clothes are getting looser, to the point that he has taken in his belt by a couple of notches.
Mr Robertson has lost 14 lb (6.4 kg) in the last six months, weight has been stable for two weeks.

Food and Nutrition Related History: Intake has been poor due to diminished appetite. For 2 months he
has left his evening meal unfinished and has been eating less in general for the past four weeks. He
finds food smells unappetizing, and no longer feels like a hot breakfast. He reports a distaste for greasy
food, and now uses a non-stick fry pan. Diet low in dairy, low in fruits and vegetables, low in lean meat,
contains salted margarine, low in occasional foods. No known food allergies.

Nutrition Impact Symptoms: High BP, high HbA1c, fatigue, decreased appetite, taste change.

Activities and Function: Sedentary, no energy for exercise. Feels weary after walking for 2 minutes.

Social history: Only has energy to catch up with his friends once a week and cannot stay out as long as
usual. Does not feel as healthy as others his age and is mourning the deaths of 2 close friends. Mr
Robertson says he is keen to “get his energy back” so he can continue to enjoy his retirement. Retired,
lives with wife; He and his wife do the shopping; wife prepares meals. Alcohol: 1 small glass, red wine
(12%), 3 floz 1 day/week.

Labs: Albumin 2.55 g/dL low/moderate depletion; Pre-albumin 8 mg/dL low/moderate depletion; Total
cholesterol: 4.0 mmol/L low; Triglycerides: 1.30 mmol/L low; LDL: 1.8 mmol/L low; HDL: 1.8 mmol/L
low. Blood Pressure: 130/85 mmHg hypertension stage 1. HbA1c” 42 mmol/mol (6%) High.

Current Meds: Anti-androgen medication (bicalutamide); antihypertensive agent (metoprolol); lipid-

lowering tablet (simvastatin); oral hypoglycemic agent (metformin).

Nutrition Diagnosis:
Inadequate energy intake (NI-1.2) related to nutrition impact symptoms including fatigue and decreased
appetite as evidenced by self-reported appetite loss, a diet history-reported less food intake than usual
and 14 lbs weight loss in the last 6 months.

Nutrition Intervention:
Nutrition Prescription
1. 2,310 – 2,695 kcals per day (30-35 kcal/ 77 kg, Current BW)
2. 92.4 - 115.5 g protein per day (1.2-1.5 g/ 77 kg, Current BW)
3. 1,925 – 2,695 mL fluid per day (25-35 mL / 77 kg, Current BW)
4. Sodium: 2 g (DASH diet recommendation)
7. Physical activity: encourage for about 30 minutes/day of light physical activity.
8. Have small frequent meals to combat decrease in appetite.

Implementation of Intervention
Recommend diet modifications to energy and protein dense foods by increasing patient’s awareness of
the variety of high-energy and high-protein foods/supplements (E-1.5). Discuss the negative health
impacts of co-morbidities and cancer, such as how uncontrolled disease will affect his life (E-1.4).
Provide nutrition education on energy and nutrient density of foods and alternatives, like supplements.
Also, discuss realistic goals and effective approaches for malnutrition management (E-1.1). Encourage
the use of food preparation methods to changes in taste, such as modifying recipes to increase calorie
intake, by developing food preparation skills (E-2.2). Involve family members in intervention by offering
emotional support, as well as, educate patient’s wife to keep food interesting to stimulate appetite (C-
2.5). Implement self-monitoring through keeping a journal of food consumption logs and
exercise/activity logs to monitor and keep track of changes (C-2.3).

Dietitian Assessment/Patient Response to Intervention

Excellent. Patient seems willing to follow recommendations discussed at this appointment and
verbalized understanding.

Education Materials Provided

1. Provide printed out documents of foods that contain high amount of sodium to avoid and low or no
sodium to consume.
2. Provide patient with useful and user-friendly websites as a reference for exploring different varieties
of foods suitable for his diet.
3. Provide patient with a pamphlet and/or documents on the symptoms and health impacts of
hypertension, cancer, and co-morbidities.
5. Provide patient with dietary logs to keep track of calories, protein, and sodium levels and teach
patient how to keep track of these values.

Referrals and RD Follow Up Plan for Monitoring and Evaluation

Patient is referred to an RDN with cancer and oncology expertise. Patient will return in a month 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.

Patient will be keeping a food consumption journal to keep track of calories, protein, sodium and dairy.
Patient will also keep an activity/exercise log to keep track of the kinds of activities the patient has been
performing. All logs will be evaluated every week by phone call. During once a month visits patient’s lab
values and weight status will be evaluated to indicate whether or not the prescription should be altered.

Medical Nutrition Therapy provided using the 2018 evidence-based practice guidelines from the
American Academy of Nutrition and Dietetics.

Carmen Chu