Rajesh Koothrapali

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Introduction

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Rajesh Koothrapali is fo~y year old ~on-activ~ man who lives in San Diego. He has lived in San Diego almost all his life except for a few years that he lived out in Hawaii. His family is always trying to get him to follow t would help with his ailing health. At 5'9" and 220 Ibs Rajesh has a BMI ~hiCh
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Hindu faith w ich they have been practicing for many Hindu diet which

years. They also often suggest that maybe he should follow the traditional

is considered obese. He is currently upsets him because he knows He

consumlngover-Icalories to sus~in his-un heaiihy sizaihis -.----.~-.--". ----.,. predominantly

he needs to lose weight but he has created a bad cycle of seeking his comfort in foods, unhealthy ones, when the task of losing so weight becomes too daunting. wants to lose 55 pounds, which will get him to a healthy BMI of 24.4 (1). Rajesh works for Carefusion out of San Diego, California; he works in HR in the call center where he helps employees learn their systems and how to navigate it. As can be imagined working within a call center can be very stressful with long hours and can be detrimental to good eating habits. On some days Rajesh will work up to 14 hours, most, if not Since he is stuck at his desk for most of the day there isn't much all of this time, is spent hooked up to a phone system so he can be available to employees of Carefusion across the country. convenient. time to go and pick up some nutritious food from around the area just whatever is fastest and He does not always take his allotted 1 hour lunch and 2 ten minutes breaks in his shift stating that he can get more work done if he eats and takes his breaks at his desk. When Rajesh does take a lunch he eats at a restaurant that is close by work and instead of walking the 5 minutes it would take to get there he usually drives. Again, he orders something deep fried with extra appetizers. Sometimes he doesn't even order from the main entrees although his lunches are pre-paid by company expenses he chooses to eat what satisfies him. Moreover, after he gets off from work he stops by a fast food joint to pick up his dinner/breakfast. He is very picky when it comes to eating out. His attitude towards vegetables

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and fruits hasn't changed since he was a toddler and refuses to order anything that may contain leafy vegetables or have a sweet fruity taste because he believes he will not like them. His preferred meal consists of a meat source and bread with a side of anything fried, normally a hamburger and some french fries from the local fast food chain near his work and house. On top of that his choice of beverages consists of sugary drinks and beer. His current diet is very cheap and convenient but he is missing many vitamins and minerals. It's easy to conclude he doesn't get enough fiber from plant or fruit sources. And his fat intake takes up much of his calories leaving little room for his other macronutrient needs (1). He happens to live on the

third floor of an apartment building that is two blocks from a grocery store and three blocks from his office, yet he always takes the elevator to get to his apartment and drives the couple blocks to his work and the grocery store. He has a mild case of lactose intolerance, so he is unable to drink large glasses of milk and bowls of ice cream. However, he can handle fresh cheeses and yogurt but he refuses to consume any dairy products in fear that be will become very ill. Although his poor choice in food is to blame for his BMI at 35; his fast paced daily routines often cause him to select the unhealthy food with little to no nutritional has been quite stressful and he is constantly eating snacks throughout value that is fast and easy, rather than spend the time to make his own healthy meals at home. Lately his job the day. The only

physical activity he does is at his computer which isn't much at all. It is fall and winter is coming soon. He is dreading the holidays because he usually visits his family back home and they celebrate together by having many delicious home cooked meals. He is struggling hard to not gain any more weight and would like it very much to lose the excess weight and become! fit like he was in college. As a typical hard working American male he works full time 7am-Spm and lives allone. Although he works, his food budget is very tight. He doesn't have much time or energy to cook a well prepared meal mostly because his diet is so poor. His knowledge in cooking is elementary, for example he knows how to boil water and cook a steak. Most

Of the

time his

breakfast is leftovers from the previous day's meals. It is very rare for him to wake up extra early to cook something because he doesn't know what to make and it's much more convenient and efficient to eat last night's dinner. He prefers to choose his meals based on if he can eat them on the go. Nice quick and easy is his motto with no hassle to wash any dishes afterwards. Also, beer is one of his main beverages he likes to drink with up to three cans a day and more on the weekends. He refuses to give up the beer which will have to be included in his diet. Rajesh one day decided to take action and visit his health care physician to acquire knowledge on losing weight properly. His practitioner measured his weight and height, CIInd calculated his BMI and explained that by being overweight he is at risk for diseases such as high blood pressure, heart disease and stroke, diabetes, cancer, sleep apnea, gout, osteoarthritis, gallbladder disease and gallstones (2). Luckily, his health care physician practices Hinduism as well and advised him to follow a diet that doesn't have beef in it. By doing this, his physician states that not only would this cut out the high amounts of saturated fats in his diet, it would also cut down on his high salt intake. Although Rajesh considers himself a Hindu he currently does not uphold many of the traditional Hindu practices. He wants to start practicing Hinduism again in hopes that it will help him with his weight loss goal. He realizes that in order to be healthy he not only needs to change his physical state, but his mental

state as well. However, by becoming a true practitioner of Hinduism, Rajesh realizes that he must give up beef. Since beef is one of the main staples in his current diet he knows this will be extremely difficult but is determined to lose weight and to get back to his Hindu roots. He hopes that by eliminating beef in his diet he will be forced to consume leaner meats, such as chicken and fish. At this time in his life, Rajesh is very unhappy and wants desperately to make a change. He hopes that by participating in the traditional Hindu practices, it will help him have the determination and dedication to stick to his weight loss Ian and to help him make more. health conscious choices . ~----. - - --~ - -.- - - - .- ~ every day. Overall, Rajeesh's objective is to safely b[ingd(;lwnhisJH'!'IHcL24 by ~justing his calorie intake to around 1.800 calories a day, thus promoting 2 Ibs of weight loss per week. This will be
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done by a meal plan that accommodates his nutrient needs, while also taking into consideration his food intolerance, financial status, and religious practice.

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Sunday Breakfast 1 Medium Banana Monday 1 cup lactaid Fat-Free 100% lactose free 2 Scrambled eggs 1 slice Whole Wheat Bread 1 T Peanut butter lunch Curry Chicken Salad 2 slice Wheat Bread 1 cup lactaid Milk, Fat-Free free 1 cup Grapes 2 slices whole Wheat bread 3 oz Turkey 1 slice tomato J4cup avocado 1 cup pasta ~ cup putanesca sauce 1 02 mozzarella Tuesday

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7 Day Meal Plan
Wednesday Thursday ~ cup oatmeal 2 Eggs scrambled ~ cup Greek yogurt J4cup Blueberries 8 oz Orange juice 2 Slices Whole wheat bread 202 Turkey breast 1 slice Tomato 1 tsp Mayonnaise 802 Nonfat lactose free Friday ~ cup Oatmeal 1 cup soY(!!.l!~ 4 slices bacon 1 medium apple 4 oz turkey breast 10 oz baked potato 1 cup spinach sized Saturday

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1 cup of soy tllilk / 2 Hardboiled spray eggs oil 2 slice toast wlolive

~ cup Oatmeal @ardboiled 5.6 oz Banana 1 tsp Fish oil 2 oz Chicken breast 8 02 Brown rice 302 broccoli 4.8 oz avocado 1 tsp Fish oil Eggs 1 cup Orange Juice

g oz Orange Juice 1 Hash Brown

16 ~2;_~actose free nonfat((Tlil)

cup Honey Nut Cheerios

1 whole wheat 100g spinach

tortilla

~ cup sliced tomato 2 oz lite tuna in water 1 t mustard

100% lactose

1/2 T light mayo

1 Serving Original Sunchips Dinner W-Miller.l.ite.bottlJL. 3 oz boneless, skinless chicken breast 1 cup whole wheat pasta 1 cup frozen vegetables, T vegetable oil 1 Bottle miller lite 1 1 Tossed Salad wlbalsamic with veggies 402 fillet Tilapia w/satt 1 Miller Ute bottle
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20z Turkey Breast 8 oz Baked potato 30z Spinach 1 tsp Fish oil Miller Ute 1 Bottle
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1 Cup Steamed spinach 1 Cup Steamed carrots 20z Salmon Fillet tupBr-own rice

2 oz chicken 8 oz brown 1 T-coconut rice oil 1 cup spinach 1 Miller lite -.,--,-.~.~---:--

X cup quinoa 1 cup black bean and corn salsa 1 t chili powder 10 baked tortilla salad mix 2 T extra virgin olive oil 1 T balsamic vinegar 1 cup mushroom slices chips

& Fried Chicken Wing Meat & Skin

3 Flour-Coated 1 Blue Cheese Dip 4 cups Smart Pop! 94% Fat Free Butter Microwave Popcorn

vinaigrette

1 cup Tempeh sauteed

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1/2 package of spring

Snack

1 Peanut Butter Bar

Balance

101 almonds

1 cup baby carrots 2 T peanut butter 1 cup rice milk

24 Almonds 1 med Banana

24 almonds 1 Medium banana

1 cup mango slices 1cup kiwi X cup sunflower seeds

1 Medium

apple

Snack

1 cup yogurt 1 Apple 1 cup almont;;illk) ...... _

3/40 2 Walnuts

2 T Peanut butter ~ cup sliced apple

_----1741 1779 1762 1748

Total Calories

1788

1735

1771

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Nutrient Analysis Name: Rajesh Koothrapali Age: 40 Gender: Male Height: 5 feet 9 inches BMI: 32.5 Activity Level: Sedentary Weight: 220 Ib

Nutrient Analysis fo(atu'rd~)

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D 1,778.49 Calories from Fat Calories from Sat Fat Protein (g) Carbohydrates (g) Sugar (g) Dietary Fiber (g) Fat (g) Saturated Fat (g) Trans Fat (g) Mono Fat (g) Poly Fat (g) Cholesterol (mg) Water (g) Vitamin A (mcg) Thiamin (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Vitamin B12 (mcg) Vitamin C (mg) Vitamin D mcg VitaminEmg Folate (mcg) Calcium (mg) Iron (mg) Magnesium (mg) Phosphorus (mg) Potassium (mg) Sodium (mg) Zinc (mg) 76.85 211.77 89.52 28.78 71.81 10.61 0.25 30.72 14.42 41.75 4,292.91 758.61 1.36 1.35 21.49 2.04 3.22 301.04 5.93 24.06 648.80 1,541.04 18.64 435.54 885.95 3,778.81 2,372.41 8.79 24.90 55.33 17.78 19.76 17.78 300.00 3,700.00 900.00 1.20 1.30 16.00 1.30 2.40 90.00 116 130 60 155 81 14 116 84 113 lO4 134 157 134 334
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497.98 160.06 79.83 244.54 96 87

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% % % % % % % % % % % % % % % % % % % % % % % % :J . J

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15.00 400.00 1,000.00 8.00 420.00 700.00 4,700.00 1,500.00 11.00

160 162 154

104 127 80 158 80

Nutrient Analysis for Thursday

Nutrient Calories Calories from Fat Calories from Sat Fat Protein (g) Carbohydrates (g) Sugar (g) Dietary Fiber (g) Fat (g) Saturated Fat (g) Trans Fat (g) Mono Fat (g) Poly Fat (g) Cholesterol (mg) Water (g) Vitamin A (mcg) Thiamin (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Vitamin B 12 (mcg) Vitamin C (mg) Vitamin D - mcg (mcg) Vitamin E Folate (mcg) Calcium (mg) Iron (mg) Magnesium (mg) Phosphorus (mg) Potassium (mg) Sodium (mg) Zinc (mg)

Value 1,779.64 635.58 166.25 97.46 200.74 78.13 29.70 70.62 18.47 1.18 21.08 19.86 540.78 4,049.57 2,795.84 1.20 1.71 19.91 2.27 3.10 133.45 5.83 15.53 474.99 1,536.89 14.86 658.10 1,331.78 4,229.39 1,271.01

DRIGoal 1,778.49 100 497.98 128 160.06 104 79.83 122 244.54 82

Percent 0 % % % % % % % % % % % % % % % % % % % % % % % % % % % % %

5Q

100

150

24.90 119 55.33 128 17.78 104 19.76 107 17.78 112 300.00 180 3,700.00 900.00@ 1.20 100 1.30 131 16.00 124 1.30 174 2.40 129 90.00 148 109

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15.00 104 400.00 119 1,000.00 154 8.00 186 420.00 157 700.00 190 4,700.00 90 85 83

1,500.00 11.00 9.14

Menu Costing for Wednesday USDA Food Cost Plan (Specify Month): October Budgeted amount for one week: $54.00 Budgeted amount for one day: $7.71
Brand Name Quaker Dole Purchase Size 420z 59 fl oz
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Food item Hot Cereal Oatmeal Orange Juice With Pulp Eggs Large Grade Banana

Purchase Price ($) 2.99 2.50

Serving size 1.40z 80z

Cost per Serving

($)
.10 .32

Lucerne

12 eggs

3.29 1.60

3 egg

.81

Chiquita

5 bananas

5.60z

.28

1 LB Chicken Breast Boneless Skinless Thin Sliced Long Grain Brown Rice Beer Long Neck Bottles Turkey Breast Cutlet Russet Potatoes Fish oil Liquid Avocado Broccoli Spinach

Foster Farm

lib

6.99

20z

.86

Safeway

lib

5.49

80z

.56

Miller Lite

12 pack

12.00

1 bottle

1.20

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Zacky Farms Safeway Ascenta NutraSea Hass Safeway Fresh Express Salads

lib

7.99/lb .39/lb 19.59 .85/lb .99/lb 2.19

20z 80z 2 tsp 4.8oz 30z 30z

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1.00

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lib 1 bottle lib avocado lib broccoli 90z bag

.20 .98 .26 .18 .73

Total for one dayC".:J

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Discussion

When Rajesh recently visited his physician and learned that he was overweight and at risk for cardiovascular disease due to his bad eating habits he vowed to seek the help of a Registered Dietitian to help him create a meal plan that would be effective in helping him lose weight. He also decided to start practicing Hinduism again in hopes that the dedication to his religion would help him also stay dedicated to his new diet plan. He informed his dietitian of his Hindu beliefs and she made sure to substitute any beef in his diet with chicken or fish so that he could still consume plenty of protein. When creating his meal plan for a week, he also informed the dietitian that he consumes beer regularly and did not want to completely give that up. Also, with his recent visit to his physician he discovered he has mild lactose intolerance and that he could only consume dairy in small portions. His dietitian incorporated this into his meal plan by suggesting he try lactaid- free or soy milk, and that he try eating greek yogurt too provide plenty of calcium and vitamin 0 in his diet. The time and effort of preparing his meals was taken into consideration when planning his diet and foods were chosen that can be quick and easy to prepare. This way Rajesh will be able to make his own lunch and dinner each day instead of going out and buying whatever is convenient. The dietitian made sure to inform Rajesh of all the fresh and local fruits and vegetables he can buy in the fall season so that he will have the best quality produce and be more likely to enjoy them. Rajesh realized that he also needs to change his sedentary lifestyle in order to help him lose the weight. Because he lives so close to his office and grocery store he vows to start walking or biking to work and back instead of driving. He plans to take the stairs at his apartment from now on and to join a gym near his house. He recently read a study on the effects of a sedentary lifestyle and how television-viewing/screen based entertainment has been found to be associated with raised mortality and cardiovascular disease (CVD) risk regardless of physical activity participation (4). Since reading this journal article he set a goal to exercise for at least 30 minutes five times a week and to limit his TV time to only one hour a night. He believes by biking or walking to work each day he will only need to spend a small amount of time in the gym to reach his 30 minutes a day and this way he can still have plenty of time at home to relax and de-stress after a long day at work. Rajesh's stress level at work could also be negatively affecting his weight and so Rajesh talked to his manager about hiring an assistant to help lighten his work load (5). Hopefully with the help of a new assistant he will be able to take his allotted breaks and have more time to eat his lunch he packs from home. His manager informed him that he had some vacation time accumulated and so Rajesh plans to take some time off around the Holidays to visit with his family and to get back in touch with his Hindu roots.

Menu Plan
When planning Rajesh's menu for the week we took into consideration that fact that he is lactose intolerant. According to Paola's study on lactose mal-absorption and intolerance, subjects with lactose intolerance can ingest up to 15 g of lactose with no or minor symptoms,

however, it is recommended that treatment to reduce lactose exposure consists of a lactose restricted diet or the use of lactase supplements (6). We incorporated small amounts of greek yogurt into his diet to help with digestion and to increase his calcium levels and we also substituted any milk products consumed with some form of lactose free milk, whether it be lactaid or soy milk. Also, because Rajesh is an avid beer drinker we had to make sure we incorporated some light beer into his diet. We choose foods that would be easy to prepare and that would require little preparation time because as mentioned in the introduction he doesn't know a lot about cooking and has very little time to prepare meals due to his work schedule. Rajesh has never been on a diet before so we made sure to still include some of his favorite foods, just in smaller portions, so that he could still enjoy eating and be more likely to stick to his diet (7). We eliminated all sources of beef from his diet in accordance with his new Hindu beliefs and instead supplied his protein with items such as chicken and fish. We greatly reduced his calorie intake to only 1778 calories a day so that he could lose a healthy 2 pounds a week and lower his BMI to a healthier range so he could lower his risk for any health problems in the future (1). Nutrient Analysis To determine the nutrient analysis for two days of the menu we plugged Rajesh's profile, height, weight, age, and activity level, into a NutritionCalc Plus software program. The program calculated his BMI and set a calorie goal of 1,778 in order to safely loose 2 Ibs per week. Then we entered the menu items into the intake log and it calculated the calorie and nutrient breakdowns of each food item. Because he required such a low calorie intake, it was hard to meet at least 75% of the ORis without going over the calorie limit. It was especially hard to meet 75% of the poly and monounsaturated fats because food items high in these good fats are also high in calories. In order to not go over the calorie limit, we lowered the meat and fish amounts, and then raised the nuts and oils. This did not create a problem for his protein needs because he was still meeting around 100% of his protein recommendation. Meeting 75% of the vitamin 0 was another problem because of his minor lactose intolerance. We had to add more vitamin 0 fortified juice, lactose free milk, and Greek yogurt that did not produce a negative effect for him. Basicallv, all of the serving sizes had to be altered in order to keep the nutrients balanced and the calories at or below 1,778. One nutrient that is really important to Rajesh is calcium because since he is lactose intolerant and most calCium consumed comes from dairy products we had to make sure to include orange juice and lactaid milk that were fortified with calcium or vitamin 0 so that he could meet the ORI. Also, because Rajesh is used to eating way more than 1800 calories a day we made sure to provide lots of fiber, in the form of fruits and vegetables, in his diet so that he would be full from his meals longer and would not become hungry between meals (3). By cutting out beef from his diet we were able to greatly lower his saturated fat intake and make sure his meals did not exceed the DRI for fat and saturated fat. Because Rajesh chose to honor his Hindu beliefs by eliminating beef from his diet we had to make sure his ORI for protein was met by substituting beef for chicken and fish (3).

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Menu Costing

According to the USDA Food Cost Plan's low cost plan Rajesh should be spending no more than $53.80 a week or $7.69 a day on his meals (8). When we added up the cost of his meals for one day we came to a total of $7.48. This means that Rajesh's budget for food is under what he is allotted to spend on food a day. Therefore, Rajesh can no longer complain that he cannot afford to eat healthy because by purchasing his own food and spending roughly $7.00 a day he is virtually saving money because eating out for two or three meals a day like he did before his diet plan would cost him exceedingly more than $7.00. Rajesh should be able to effectively maintain his menu plan while also staying in his financial budget.
Conclusion

In summary, if Rajesh follows this diet plan, that not only takes into account his current lifestyle, but also his lactose intolerance, Hindu beliefs, and financial resources, he should lose the amount of weight he needs to lower his BMI into a healthy range. By losing approximately two pounds a week, Rajesh should reach his goal of 55 pounds in about 30 weeks. By incorporating exercise and physical activity into his-daily lifelle-snoura see-results much quicker. With his determination and focus to better his health and go back to his traditional Hindu roots, hopefully Rajesh will stay motivated enough to see his diet plan through and eventually achieve the results he desires.

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References
1 Healthy Weight: Losing Weight. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/healthyweight/losing_weight/index.html. Accessed October 19, 2012. 2 Wang Z, Nakayama T. Inflammation, a link between obesity and cardiovascular disease. Mediators Inflamm. 2010;2010:535918. 3 Sacks FM, Bray GA, Carey VJ, Smith SR, Ryan DH, Anton SO, McManus K, Champagne CM, Bishop LM, Laranjo N, Leboff MS, Rood JC, De Jonge L, Greenway FL, Loria CM, Obarzanek E, Williamson DA. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Eng/ j Med. 2009;360(9):859-73. 4 Pereira SP, Ki, M, Power, C. Sedentary Behaviour and biomarkers for cardiovascular disease and diabetes in mid-life: the role of television-viewing and sitting at work. PLoSONE. 2012; 7(2): e31132. 5 Koeneman MA, Verheijden MW, Chinapaw MM, Hopman-Rock M. Determinants of physical activity and exercise in healthy older adults: A systematic review. Int J Behav Nutr Phys Act. 2011; 8: 142. 6 Usai-Satta P, Scarpa M, Oppia F, Cabras F. Lactose malabsorption and intolerance: What should be the best clinical management? World J Gastrointest Pharmacol Ther. 2012 ~; 3(3): 29-33. ~ 7 Heymsfield SB, Van Mierlo CAJ, van der Knaap HCM, Heo M, Frier HI. Weight management using a meal replacement strategy: Meta and pooling analysis from six studies. Int j Obes. 2003;27:537-49. 8 U.S Average at Four Cost Levels. The USDA Food Cost Page. Available at: http://www.cnpp.usda.gov/USDAFoodCost-Home.htm. Accessed November 24, 2012.