Eleanor Baker

DIE 3213: Medical Nutrition Therapy 1

Janine Dray
Case Study #1

QUESTIONS
1. Convert her height and weight to centimeters and kilograms. Calculate her % IBW, % UBW, and BMI. Interpret her
weight and weight change based on these parameters. (5 points)
%IBW (using Hamwi Equation):
IBW= 100lbs for the first 5 feet of height and 5lbs per inch over 5 feet.
100lbs + (2inx5lbs) = 110lbs1
145 / 110IBW x 100 = 131 %IBW
131% - 100% = 31%
Marian J. is 31% over her ideal body weight.
%UBW:
UBW= 155lbs
%UBW = actual wt / UBW x 100% usual wt
145/155lbs x 100%= 93.5%UBW1
Marian J. is 93.5% of her UBW when using her current body weight. Since the %UBW number calculated is less
than 100% of her UBW this data reveals that Marian J. has lost weight as indicated by the case study that said she has
lost 10lbs over a period of one month potentially due to chronic diarrhea. Fortunately, 93.5% does not classify Marian J.
as being malnourished. In order for a patient to be considered malnourished they would be less than or equal to 90%
UBW.2
BMI:
BMI= weight (lb)/ height (in)2 x 7031
145 / (62)2 x 703 = 26.5 BMI
According to the Body Mass Index scale Marian J. is overweight since her calculated BMI is 26.5. A normal BMI
ranges from 18.5-24.9 whereas an overweight BMI ranges from 25.0-29.9. Marian J. is currently in the mid to low range
of the BMI scale, if she were at her calculated ideal body weight of 110lbs this would place her at a BMI of 20.1 which is
safely in the normal BMI range.2
2. Calculate her nutritional requirements (calories, protein, and fluid) and compare her current intake to her needs. (5
points)
CALORIES:
Mifflin-St. Jeor Equation:1
Females: kcal/day = 10 (wt in kg) + 6.25 (ht in cm) 5 (yrs) - 161
Weight: 145 / 2.2 = 65.9kg
Height: 62 x 2.54cm = 157.5 cm
Kcal/day = 10 (65.9kg) + 6.25 (157.5 cm) 5 (79yrs) 161
659 + 984.25 395 -161
1643.25 556 = 1087.25 kcal/day1
According to the Mifflin-St. Jeor Equation, Ms. Marian J. needs about 1090 kcal/day. This is a measurement for her
Resting Energy Expenditure, meaning if Marian J. bed restricted she would only need 1090 kcal/day.1
PROTEIN:
1g x kg body weight
1g x 65.9kg = 65.9g
Marian J. needs 65.9g of protein daily for her age, activity level and current weight. The increased protein need of 1g is
due to her elderly age.1

FLUID:
Holliday-Segar Method (fluid need recommendations)
100mL per kg body weight for the 1st 10kg
50mL per kg body weight for the next 10kg
20mL per kg body weight for each kg after 20kg
65.9kg 10kg 10kg = 45.9kg
100ml + 50mL + (20mL x 45.9kg) => 150mL + 918mL = 1068mL
Actual fluid intake
237mL milk + 237mL coffee + 237mL tomato soup + 237mL milk = 948mL of fluids daily 4
The Holliday-Segar Method is the weight method for estimating fluid needs. By using this method I was able to calculate
that the patient would need to consume 1068mL of fluid daily to meet her needs. Daily fluid needs does not need to be
consumed solely through beverages but can also be added by eating foods that contain fluids (fruits, vegetables,
oatmeal, etc.). According to her diet history she is consuming 948mL of fluids daily, that is 120mL less than what she
needs.3
3. Are any major food groups and nutrients obviously missing from her diet? Explain your answer. (5 points)
By entering her diet into the USDA Supertracker I was able to see that her fruit, vegetable, dairy and protein
intakes are lower than her recommended amount. The amount of refined grains that she consumes is too high. In order
to achieve a healthier and better balanced diet Marian J should increase her vegetable in take by a cup, her fruit intake
by 1 cup, milk and yogurt by 1 cup and protein should also increase by 1.5 oz. Another goal for her to focus on is her
grains, is to make half of her grains whole. Right now her dietary intake consists of 60-70% refined grains. She should try
replacing her morning bowl of cornflakes with oatmeal or choose whole grain bread for her peanut butter and jelly. The
whole grain calculation was assuming the buttered noodles she ate for dinner were whole grain. She is also eating less
than the recommended calorie amount and is low on nutrients: fiber, calcium, potassium, magnesium, zinc, vitamins A,
C, D, E, and K, and choline. This was calculated through Supertracker as well. 4
4. Do you think she could be experiencing any drugnutrient interactions? If so, what dietary suggestions would you
make? (5 points)
Marian reported taking Trilisate, Bumex, Kaopectate, and a self-prescribed use of mineral oil for regularity.
Trilisate is a nonsteroidal anti-inflammatory (NSAID), that is often prescribed for the osteoarthritis that Marian J has. The
drug may cause high blood sugar results. Marian has a high blood glucose level which maybe affected by Trilisate.5,6
Bumex is an antihypertensive and diuretic drug. Due to the diuretic side effects of this drug Marian has experienced
chronic diarrhea, this is a direct correlation to her below average levels of potassium, she has 3.2mEq/L and the normal
range is 3.5-5 mEq/L.1,7 A dietary suggestion for her while she is taking Bumex is to increase the amount of potassium in
her diet. The adequate intake for a woman >70 years of age is 4.7 g/day.1
Kaopectate is an antidiarrheal and antinauseant drug. If the patient has a urinary test for glucose, kaopectate can create
a false positive glucose reading. According to Marian Js Labs her glucose levels were 108 mg/dL, a glucose level of >100
mg/dL is an indicator of insulin resistance.7
The mineral oil that Marian J is using is a laxative which will contribute to her chronic diarrhea. It may also be
contributing to her 10lb weight loss within one month. She also had low dietary levels of vitamins A, D, K, and calcium all
of which mineral oil can decrease the absorption of. She should discontinue her use of the mineral oil, this will help with

her diarrhea and she maybe able to cease her use of Kaopectate if her stool becomes normal. Discontinuing use of the
mineral oil will also let her body absorb vitamins A, D, K, and calcium better too. 7
5. Interpret her serum albumin and prealbumin. In addition to nutritional intake, what factors can cause these indices
to drop? What factors would cause them to be elevated? (5 points)

Parameter
Albumin
Prealbumin

Lab value
3.2
11

Normal Range
3.5-5 mg/dL
15-36 mg/dL

LOW
LOW

Low albumin can suggest liver disease maybe present. Her low albumin levels maybe due to her malnutrition or
inflammation (osteoarthritis) as well. If Marian has become dehydrated from her chronic diarrhea that could result in low
albumin levels as well. Low amounts of zinc and vitamin A in her diet may create a deficiency in those diseases are
associated with low levels of serum albumin.8
Marian Js low prealbumin level may be due to malnutrition, chronic diarrhea, and inflammation (osteoarthritis).
Prealbumin is a more sensitive protein-energy balance indicator than ALB even during inflammatory conditions zinc
deficiency reduces prealbumin levels.8 Looking at her diet history she may have a zinc deficiency that would lead to low
prealbumin levels. Her caloric and protein intakes were below the recommended values and could also be lowering her
prealbumin.
6. Describe how factors in her anthropometric, biochemical, clinical, and dietary nutritional assessment data all fit
together to form a picture of her nutritional health. (5 points)
According to the data collected Marian J is an overweight 79-year-old female who has had a medical history of CVA,
hypertension, chronic diarrhea, osteoarthritis and recent weight loss of 10 lbs over a one-month period. She lived alone
and experienced depression and is now in an acute care facility. Her son is able to visit her every evening and could help
her prepare meals if needed. According to her diet history she has the potential for multiple macro and micronutrient
deficiencies as well as a low calorie intake that may be the reason for her rapid weight loss. She is taking medications
that could increase the severity of those deficiencies due to malabsorption or diarrhea. Her blood work shows that she
has low levels of potassium, albumin and prealbumin. The low potassium could be due to her chronic diarrhea, from
taking Bumex and poor diet. Her albumin and prealbumin are more closely related to her diet or a potentially underlying
cause such as liver disease. She had a high glucose level which maybe from the drug Trilisate or from poor dietary
choices.9
7. Write a PES statement based on the nutritional assessment data available.
(5 points)
Problem: Unintentional weight loss
Etiology: Chronic diarrhea and poor intake
Signs and symptoms: 6.5% weight loss in a one-month period.
Unintentional weight loss as related to chronic diarrhea and poor intake as evidenced by 6.5% weight loss in a onemonth period.1
8. What dietary and social changes would you suggest to improve her nutritional intake? (5 points)
Marian J should focus on increasing her vegetable, her fruit, milk and yogurt, and protein intake. This would aid in
helping her to meet the recommended caloric, vitamin and mineral needs as well. She could eat a banana with her cereal
to increase her fruit intake and the potassium in her diet. Marian should choose whole wheat bread for her peanut butter
and jelly sandwiches and whole grain noodles for her butter noodles to increase her whole grains. For lunch the patient
can chose a fish or hummus sandwich with lettuce and tomatoes to boost the protein and vegetables in her diet. To help

increase her appetite the son should be asked to have dinner with her in the evenings. The dinners together may help
with her depression as well. Since she is in an acute care facility she should dine with other people for her daily meals as
well to help encourage her to eat more.4
9. What are your nutritional goals for her, and how would you monitor the effectiveness of your interventions from
question #8? (5 points)
The nutritional goals for the patient are:
Increase daily intake of vegetables by cup, fruit by 1 cup, dairy by 1 cup, and protein by 1.5 oz.
Increase daily caloric intake to about 1090 kcal/day1
Have the patient keep a meal diary and reenter the information into USDAs Supertracker after one week to see if she is
still meeting the nutritional goals that were set for her.4
Blood work can also be done to help track her progress and see if her albumin, prealbumin, and potassium have
increased and her glucose levels have decreased.
10. Write a note documenting your assessment in SOAP format. (5 points)

S: widowed, lived alone for past 7 years

Pt seems depressed and is not eating well in facility
Pt does not eat pork, beef or chicken but will eat fish occasionally

O: prescribed a 2 gm sodium diet

79 year old white woman.
Height 52, 145 current body weight, 131%IBW, 93.5%UBW, 26.5 BMI1
Labs: blood pressure 170/100, sodium 140mEq/L, Potassium 3.2mEq/L, chloride 103mEq/L, carbon dioxide 29mEq/L,
BUN 19mg urea nitrogen/dL, creatinine 1.0mg/dL, glucose 108mg/dL, hemoglobin 12.0mg/dL, hematocrit 38.1%,
albumin 3.2mg/dL, prealbumin 11mg/dL
Chronic diarrhea, hypertension, osteoarthritis, poor dental condition, history of CVA 5 years ago, 6.5% weight loss in onemonth period
Inadequate intake of energy (78% of RI), potassium (37%), zinc (63%), calcium (61%), vitamins A (61%), C (40%), D (47%),
E (33%), and K (21%), fiber (67%), magnesium (65%), and choline (46%)4
Inadequate intake of vegetables (72% of RI), fruits (35%), dairy (67%), protein (72%), and whole grains (75%)4
Trilisate, Bumex, Kaopectate, mineral oil
Pt was previously instructed on a low sodium diet; given a diet instruction sheet

A: caloric needs for weight maintenance, pt consumes 1090kcal/day

Pt eats three meals per day; low energy, protein, and micronutrient intake
Need to provide low sodium options, vegetables, fruits, dairy and protein sources during meals
Pt seems hesitant to follow or does not understand a low sodium diet
Pt weight is expected to remain constant or increase
Increase daily intake of vegetables by cup, fruit by 1 cup, dairy by 1 cup, and protein by 1.5 oz.4 Increase daily caloric
intake to about 1090 kcal/day1

P: Will gather more information on pts micronutrient profile to better see correlations with dietary patterns and drugnutrient interactions
Recommend pt cease use of mineral oils; increase intake of calories, fruit, vegetables, protein, and whole grains
Recommend pt to include fruit with breakfast, source of protein, another vegetable and whole grain source at lunch, and
increase fluid intake by 120mL per day.
Will monitor food selections to meet above goals; monitor weight every other day
Return visit weekly for review, follow up, and continuing goal setting
Upon return, we will begin the next goal of reducing her blood pressure.

References
1. Mahan K., Escott-Stump S., Raymond J. Krauses Food and the Nutrition Care Process, Thirteenth Edition. St.
Louis, MI: Saunders; 2012.
2. No Author. Nutrition Assessment Practice Guideline: General. Handout.
http://www.mercycares.com/uploads/pdf/Adult%20nutrition%20assessment.pdf Accessed September 28, 2014.
3. HYD: Estimating Fluid Needs. Academy of Nutrition and Dietetics web site.
http://andeal.org/topic.cfm?menu=2820&cat=3217 Published 2007. Accessed September 30, 2014.
4. Supertracker: My Plan. United States Department of Agriculture web site.
https://www.supertracker.usda.gov/foodtracker.aspx Accessed September 30, 2014.
5. Dictionary of Cancer terms: Trilisate. University of Maryland Medical Center web site.
http://www.umgcc.org/patient_info/dictionaryEn/definition/Trilisate.htm Accessed October 1, 2014.
6. Trilisate (Oral). Health Digest: Drug Information Online web site.
http://www.healthdigest.org/topics/category/6958-trilisate-drug-and-prescription-information-side-effects-useand-dosage Accessed October 1, 2014.
7. Pronsky Z, Crowe J. Food-Medication Interactions, Seventeenth Edition. Birchrunville, PA: Food-Medication
Interactions; 2012.
8. Prealbumin. Lab Tests Online web site. http://labtestsonline.org/understanding/analytes/prealbumin/tab/test
Accessed October 1, 2014.
9. Knox T, Zafonte-Sanders M, Fields-Gardner C, Johansen D, Paton N. Assessment of Nutritional Status, Body
Composition, and Human Immunodeficiency Virus Associated Morphological Changes. Clin Infect Dis. 2003;
(supplement 2): S63-S68. doi: 10.1086/367560