Brown 1

Client History
Age: 48
Gender: Female
Ethnicity: White
Language: English
Role in family: Cook, grocery shopper, mother, babysitter for grandkids
Diseases, Conditions, and Illnesses: Weight gain, cant remember if she was diagnosed
with GDM (two babies over 9 lbs), grandma and father DM, brother hypertension
Socioeconomic Status: Middle class, married with 4 kids, 2 grandkids she babysits, very
busy, part time job as a secretary at a construction company
(4 days, 8 hours), shops about once every 2/3 weeks,

Food & Nutrition History

AVERAGE DAILY INTAKE
Kcals
Protein
Carbs
2936 kcal
94g
338g

Fat
130g

Fluids
48 oz or
1420 mL
Composition/Adequacy of food and nutrient intake: loves sweets, eats out for lunch at
work
Meal/snack patterns: 3 meals a day plus 2 snacks (usually sweets)
Diet hx: Not on a diet currently, on and off all of her life, was on the Atkins diet, liked
eating veggies and meat and she could still eat her sweets
Eating environment: eats alone at the restaurant or brings it back to her desk at work. She
eats family dinners in front of the TV and eats with the kids when she is babysitting them.
Medications and supplements: Daily vitamin
Knows she needs to change and needs to lose weight but slightly discouraged
Motivation is at an 8 out of 10
Very busy which makes planning healthy meals and taking the time to cook them difficult
Plenty of access to fresh, healthy food and water
Physical activity: no gym, taking care of kids and normal movement on the job,
completely self reliant for feeding, likes staying active but never played sports
She knows intervention will help with her energy levels and weight
Noticed that her weight gain started to pick up once she started going to the vending
machines more
Not fully aware how many calories she should be taking in
Knows the standard 2000 calorie diet
Does not like seafood or baked chicken. Does not like milk because of the taste but does
like yogurt
Ready to change but also discouraged and does not want to give up sweets

Brown 2
Anthropometrics
Height: 55 (60+5)x2.54=165.1cm=1.651m
Weight: 175lbs/2.2= 79.5
BMI: 29.1 (overweight)
Weight hx: weight always fluctuating with diets. Gained 45 pounds within last 4 years
after quitting Adkins. Currently the highest weight she has ever been. 30% body weight
added in 4 years, which is severe. She is most comfortable at 150.
UBW:168
IBW: 100+5(5)=125 lbs
% IBW (175/125)x100= 140%
%UBW (175/168)x100= 104%
Biochemical/Tests/Procedures
Fasting glucose: 140 mg/dL (high)
Hgb A1C: 7.1% (high risk, above 5.7-6.4 increased risk zone)
Albumin: 4.0 mg/dL
Total chol: 245 mg/dL (high)
LDL: 100 mg/dL (high)
HDL: 33 mg/dL (low)
TG: 150mg/dL (close to at risk)
Nutrition Focused Physical Findings
Normal Appetite
Thirsty
Craves Sweets
Discouraged about weight gain
Tired/sluggish (drinks coffee)
BP: 128/80

Comparative Standards
Estimated kcal needs: -161+10(79.5)+6.25(165.1)-5(48)=1426x1.0x1.5=2139kcal
Average intake: 2936 kcal
% Intake: (2936/2139)x100=137% kcal
Protein: 79.5kg x 1.0=79.5g protein needs
Average intake: 94g
% Intake: (94/79.5)x100= 118% protein
Fluid Needs: 30mL x 79.5kg=2385mL
Average Intake: 1420 mL
% Intake: (1420/2385)x100=60% fluids

Brown 3
Assessment Statement
Client is a 48 y/o white female coming to RD for wt/lifestyle management.
Referred by MD. Client is a part time secretary at a construction company and babysits
her grandchildren when she is not at work. Apart from looking after kids, she is fairly
sedentary. Client eats three meals a day and two snacks. While at work, she usually buys
lunch from a restaurant and the rest of her family also buys their lunches. She enjoys
sweets and usually choses something sugary for her snacks. She eats breakfast on the way
to work, lunch at the restaurants or at her desk unless she is home with the kids, and
diners with the family (husband, 4 kids, 2 grandkids) in front of the television. Client
shops and cooks for the family and is always busy. She gets to the store once every two
or three weeks and is food secure. Client complains of feeling sluggish and overweight
(gained 30% wt gain in 4 years). She is motivated to change and knows that it will help
her.
Client has a family hx of DM (father and grandmother) and HTN (brother). She
thinks the doctor may have told her she had GDM and her last two children were over 9
lbs. Client has a BMI of 29.1 which is overweight. Most of her labs came back abnormal
such as fasting glucose, which was 140 mg/dL (high), hgb A1C, which was 7.1% (high
risk, above 5.7-6.4 increased risk zone), total chol, which was 245 mg/dL (high), LDL
which was 100 mg/dL (high), HDL which was 33 mg/dL (low), and TG, which was
150mg/dL (close to at risk). Also, client has high daily intakes of kcals (2936 kcal; 137%
estimated needs) and protein (94g; 118%). She also only took in 60% of the fluids she
needs daily. Due to her family history, current weight gain, current diet, sedentary
lifestyle, and lab results, client is at risk for DM, CVD, and HTN.