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Independent Project

Nutrition 407
Medical Nutrition Therapy Lab
Brenda O’Day
By: Karina Jaime Carbajal
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Table of Contents

ADIME Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Nutrition Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Nutrition Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nutrition Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Meal Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Exchanges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Day 1 Meals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Day 2 Meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Nutrition Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
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ADIME Note
12/07/17: Robert Ramirez is a 47-year-old man with T2DM and CVD. He was diagnosed with
both 2 years ago. Before then, he didn’t have health insurance. He works as a truck driver and
always eats away from home. When he eats at home, his wife likes to treat him to really good
meals that aren’t necessarily healthy-good. He came in for a check-up, but after seeing his serum
blood glucose, he was kept in to run further tests. He admits to feel dizzy and tired frequently.

Nutrition Assessment
 Diagnosis: Type 2 Diabetes Mellitus, Cardiovascular Disease
 Nutrition related PMH, treatments, surgeries: N/A
 Age, Gender: 47 y.o. male
 Dietary intake: NPO
 Food preferences, allergies, intolerances: Enjoys fast food
 Exercise habits: N/A
 Functional/behavioral factors: Sedentary RT work
 Resources for obtaining prepared food: Eating out RT job as truck driver
 Symptoms: fatigue, dizziness
 Anthropometric measurements:
o Ht/wt: 6’3” / 1.9 meters and 220# / 100 kg
o BMI: 100/(1.9 x 1.9) = 27.7 kg/m2
o IBW: 106# + (6# x 15 inches over six feet) = 106# + 90#= 196#
o IBW%: 220#/196# = 112%
o ABW: (220#-196#) x 0.25 + 196# = 202# or 91.8 kg
 Energy, protein and fluid needs
o Total energy:
 Using a factor of 20-25 kcals/kg
 20-25 x 91.8 kg = 1,836-2,295 kcal/day
 2,000 kcal goal b/c prescribed Heart Healthy, 2,000 kcal diet
o Protein:
 0.8-1.0 g/kg
 0.8-1.0 x 91.8 = 73- 92 g/day
o Fluid:
 40mL/kg
 40 ml x 91.8 kg = 3.6 L/day
 Lab/test- can indicate high or low, normal or abnormal
o BP: 90/70- low
o Pulse: 105 BPM- high
o Respiration rate: 26- high
o Fasting Serum Glucose: 318 mg/dL- high
o Triglycerides: 172 mg/dL- high
 Medications/supplements:
o Glyburide
o Dyazide

Nutrition Diagnosis- PES format


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 Inconsistent carbohydrate intake (10673) RT lack of diabetes education AEB fasting


serum glucose of 318 mg/dL.
 Overweight (10767) RT sedentary lifestyle, high fat foods intake AEB a BMI of 27.7
kg/m2 and being at 112% IBW.

Nutrition Intervention
 Nutrition Education: Nutrition relationship to health/disease: Diabetes (10591)
 Carbohydrate modified diet (10832)
Goals
 Learn how to manage Type 2 Diabetes with the help of nutrition education within 2
weeks of discharge
 Increase physical activity to 30-45 min/day of moderate to intense activity 3-5 days a
week.

Nutrition Monitoring and Evaluation


 Follow-up call on 1-2 weeks to check if receiving or have received diabetes nutrition
education
 Check blood glucose levels 3x/day.
 Come back for a progress update in 3 months
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Meal Plan
Exchange:

B S L S D S Total CHO (g) Pro (g) Fat (g) Kcals


Starches 2 1 2 2 2 1 10 (15g) (3g) (1g) 810
600 kcal 120 kcal 90 kcal
Fruit 2 1 3 (15g) 180
180 kcal
Milk 1 1 1 3 (12g) (8g) (1,5,8g) 375
144 kcal 96 kcal 135 kcal
Vegetables 2 1 3 (5g) (2g) 84
60 kcal 24 kcal
Meats/Substitutes 2 1 2 5 (7g) (3,5,8g) 365
140 kcal 225 kcal
Fats 1 2 1 4 (5g) 180
180 kcal
CHO Choices 4 2 4 2 3 1
Kcals 984kcal/ 380kcal/ 630kcal/ TOTAL Kcals:
246g 95g 70g 1,994

%Kcals 49% 19% 32%

Day 1 Meals:

Breakfast Snack
 1 cup bran cereal (2 oz) (2 starch)  ¼ cup granola (1 oz) (1 starch)
 1 cup reduced fat milk (1 milk)  2/3 cup reduced fat yogurt (1 milk)
 1 extra small banana (1 fruit)
 1 apple (1 fruit)
Lunch Snack
 ¾ cup blueberries (1 fruit)  6 cups of popcorn (2 oz) (2 starch)
 1 cup oatmeal (2 oz) (2 starch)  1 oz beef jerky (1 meat)
 1 tbsp peanut butter (0.5 oz) (1 meat)
 1 cup cooked carrots (2 vegetable)
 2 tbsp reduced fat salad dressing (1 fat)
 1 turkey hot dog (1.5 oz) (1 meat)
Dinner Snack
 ½ large baked potato (6 oz) (2 starch)  ¼ bagel (1 oz) (1 starch)
 2 tbsp reduced fat mayo (2 fat)  1 tbsp regular cream cheese (1 fat)
 ½ cup cooked baby corn (1 vegetable)
 2 oz canned salmon (2 meat)
 1 cup fat free chocolate milk (1 milk)
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Day 2 Meals:

Breakfast Snack
 1 cup bran cereal (2 oz) (2 starch)  ¼ cup granola (1 oz) (1 starch)
 1 cup reduced fat milk (1 milk)  2/3 cup reduced fat yogurt (1 milk)
 1 extra small banana (1 fruit)  ¾ cup blueberries* (1 fruit)
 1 ¼ cup whole strawberries (1 fruit)
Lunch Snack
 ½ bagel (2 oz) (2 starch)  ½ cup refried beans (1 starch and 1
 2 egg whites (1 meat) meat)
 1 oz mozzarella cheese (1 meat)  ¾ oz tortilla chips (1 starch)
 1 tbsp reduced fat mayo (1 fat)
 1 cup tomatoes (1 vegetable)
 ½ cup cooked baby corn (1 vegetable)
Dinner Snack
 2/3 cup cooked pasta (2 oz) (2 statch)  ¼ bagel (1 oz) (1 starch)
 ½ cup cooked summer squash  1 tbsp regular cream cheese (1 fat)
(1 vegetable)
 1 oz mozzarella cheese (1 meat)
 1 turkey hot dog (1/10th pound)
(1 meat)
 2 tsp olive oil (2 fat)
 1 cup fat free chocolate milk (1 milk)
* Lunch’s fruit transferred to the first snack
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Budget

Grocery Shopping List Purchasing Purchasing Size Purchasing


Location Price
2 cup bran cereal 99 cent store 9.25 oz $0.99
2 cup reduced fat milk 99 cent store 945 ml $0.99
2 extra small banana Trader Joe’s 2 bananas $0.28
1 apple Trader Joe’s 1 apple $0.45
1 ½ cup blueberries 99 cent store 5 oz $0.99
1 cup oatmeal 99 cent store 1 lb $0.99
1 tbsp peanut butter 99 cent store 6 oz $0.99
1 cup cooked carrots 99 cent store 1 lb $0.99
2 tbsp reduced fat salad dressing 99 cent store 8 fl oz $0.99
2 turkey hot dog (1/10th pound) 99 cent store 16 oz $0.99
½ large baked potato (6 oz) Trader Joe’s 1 potato $0.20
1 cup cooked baby corn 99 cent store 15 oz $0.99
2 oz canned salmon 99 cent store 2 1 oz cans $1.98
2 cup fat free chocolate milk 99 cent store 945 ml $0.99
1/2 cup granola 99 cent store 11 oz $0.99
1 1/3 cup reduced fat yogurt 99 cent store 32 oz $0.99
6 cups of popcorn 99 cent store 4 bags of popcorn $0.99
1 oz beef jerky 99 cent store Jerky stick $0.99
1 bagel (1 oz) 99 cent store 4 bagel bag $0.99
2 tbsp regular cream cheese 99 cent store 8 oz $0.99
1 ¼ cup whole strawberries 99 cent store 1 lb $0.99
2 egg whites Trader Joe’s 12 eggs $1.49
2 oz mozzarella cheese 99 cent store 6 oz $0.99
3 tbsp reduced fat mayo 99 cent store 445 ml $0.99
1 cup tomatoes Trader Joe’s 2 tomatoes $0.75
2/3 cup cooked pasta 99 cent store 1 lb dry pasta $0.99
½ cup cooked summer squash 99 cent store 2 lb bag squash $0.99
2 tsp olive oil 99 cent store 500 ml $0.99
½ cup refried beans (starch and 99 cent store 1 15 oz can $0.99
meat)
¾ oz tortilla chips 99 cent store 8 oz $0.99

Total: $28.91
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Nutrition Analysis
(See Appendices A and B for nutrition breakdown of both days’ meals.)

Day 1:
According to MyFitnessPal, on Day 1 the patient’s meal plan was 274 kcals above the
goal of 2,000 kcals. His meal plan included 352 grams of carbohydrates, 98 grams of protein,
and 74 grams of fat. This translates to approximately 1,408 kcal from carbohydrates, 392 kcals
from protein, and 666 kcals from fat. Which means approximately 57% of kcals came from
carbohydrates, 16% came from protein, and 27% came from fat.
The exchange chart recommended that the patient had 246 grams (or 984 kcals) come
from carbohydrates. This meal shows to have had 106 more grams of carbohydrates than
planned. They were only supposed to make up 49% of his kcals as opposed to the 57% they did
make up with this meal. The chart also recommended that the patient had 95 grams (or 380 kcal)
from protein. He was only 3 grams (12 kcals) off in this area; though, because of the kcal
difference, the % protein this meal gave him was 3% less than recommended. Finally, the chart
recommended 70 grams (or 630 kcals) from fat. The meal provided 4 more grams (36 more
kcals) of fat. However, even though the meal plan gave the extra 4 grams, the chart
recommended 32% of kcals to be from fat and only 27% were from fat. The excess of grams of
carbohydrates was the biggest issue here; protein and fat were only 3-4 grams off which is
negligible.
MyPlate suggests having 2 cups of fruit, 2 ½ cups of vegetables, 6 ounces of grains, 5 ½
ounces of protein, and 3 cups of milk. The patient had almost 3 cups of fruit, 2 cups of
vegetables (1 cup raw, ½ cup cooked), 14 ounces of grains (starches), 5 ounces of protein, and 2
2/3 cups of milk. The fruit was a little high, vegetables could have been higher, the grains were
extremely high, protein was good, and milk was good. The excess of starches/grains were the
only big issue in this respect.
The DRIs go as follows: 1,500 mg of sodium, 4.7 grams of potassium, 980 mcg of
vitamin A, 90 mg of vitamin C, 1,000 mg of calcium, 38 grams of fiber, and 8 mg of iron. In the
meal plan, the patient got 3,198 mg of sodium, 2.75 mg of potassium, 1,314 mcg of vitamin A
(146% with 900 mcg being 100%), 65 mg of vitamin C (109% with 60 mg being 100%), 1090
mg of calcium (109% with 1,000 mg being 100%), 65 grams of fiber, 20 mg of iron (111% with
18 mg being 100%). The meal plan had more than twice the recommended amount of sodium,
only half as much potassium, plenty of vitamin A, two thirds the amount of vitamin C, a perfect
amount of calcium, 27 grams too many of fiber, and more than double the amount of iron. The
biggest issues with the plan being with the excess of sodium and fiber.

Day 2:
According to MyFitnessPal, on Day 2 the patient’s meal plan was 240 kcals above the
goal of 2,000 kcals. His meal plan included 365 grams of carbohydrates, 97 grams of protein,
and 62 grams of fat. This translates to approximately 1,460 kcal from carbohydrates, 388 kcals
from protein, and 558 kcals from fat. Which means approximately 60% of kcals came from
carbohydrates, 16% came from protein, and 23% came from fat.
The exchange chart recommended that the patient had 246 grams (or 984 kcals) come
from carbohydrates. This meal shows to have had 119 more grams of carbohydrates than
planned. They were only supposed to make up 49% of his kcals as opposed to the 60% they did
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make up with this meal. The chart also recommended that the patient had 95 grams (or 380 kcal)
from protein. He was only 2 grams (8 kcals) off in this area; though, because of the kcal
difference, the % protein this meal gave him was 3% less than recommended. Finally, the chart
recommended 70 grams (or 630 kcals) from fat. The meal provided 8 less grams (72 less kcals)
of fat. The excess of grams of carbohydrates was the biggest issue here; protein was fine and fat
was lower which is only a problem because carbohydrates were so high.
MyPlate suggests having 2 cups of fruit, 2 ½ cups of vegetables, 6 ounces of grains, 5 ½
ounces of protein, and 3 cups of milk. The patient had almost 3 cups of fruit, 3 cups of
vegetables (1 cup raw, 1 cup cooked), 8 ounces of grains (starches), 6 ounces of protein, and 2
2/3 cups of milk. The fruit was a little high, vegetables were perfect, the grains were a little high,
protein was good, and milk was good. The excess of starches/grains were the only issue in this
respect.
The DRIs go as follows: 1,500 mg of sodium, 4.7 grams of potassium, 980 mcg of
vitamin A, 90 mg of vitamin C, 1,000 mg of calcium, 38 grams of fiber, and 8 mg of iron. In the
meal plan, the patient got 3,724 mg of sodium, 2.69 mg of potassium, 486 mcg of vitamin A
(54% with 900 mcg being 100%), 161 mg of vitamin C (269% with 60 mg being 100%), 1,470
mg of calcium (147% with 1,000 mg being 100%), 59 grams of fiber, 20 mg of iron (111% with
18 mg being 100%). The meal plan had more than twice the recommended amount of sodium,
only half as much potassium, only half as much of vitamin A, plenty of vitamin C, a great
amount of calcium, 21 grams too many of fiber, and more than double the amount of iron. The
biggest issues with the plan being with the excess of sodium and fiber and the lack of vitamin A.
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Summary
This project has been very similar to work I do in my internship. There, I have been
working on finding recipes that we (Health Promotion @ SDSU) can cook for students using the
mobile demonstration kitchen. These recipes all have a theme, should be very healthy, should be
easy to make, and need to cost a about a dollar a serving. Since I have done so many of those
recipes, the I knew the budgeting wasn’t going to be hard. A side benefit is that I do a good
amount of my personal grocery shopping at the 99 Cent Store and know that they sell just about
everything. Similarly, many projects at my internship and for other classes required me to use a
nutrient analysis program so I am very comfortable with MyFitnessPal and know how to make
sure all the numbers are accurate.
The only real new part of this project was doing the exchange plan. I found it very fun
though! I learned that the best way to go about it was to start backwards. I used the ideal calories
and then broke it down into the %’s for the macronutrients. From there, I converted them all into
grams in order to know how many serving of each category I needed. After that, I just assembled
the servings throughout the day while trying to be realistic about it. It was like a fun little puzzle!
I enjoyed.
I do see this being very helpful as a future RDN. It’s really helpful to see the exchange
list and know all of what goes into it. Even if we know other ways to do it now, I like seeing the
basics that go into this. It also helped me really realize what serving sizes look like; I feel like I
vaguely knew them, but this project engrained them in my head more. I can see knowing the
serving sizes being very helpful as an RDN. Finally, II think it was good seeing the discrepancy
of the meal plan I was trying to provide and the nutrient analysis. It’s a nice reminder that
numbers are never typically exact; with so much processed foods it’s hard to ever really
understand what is in everything or how one company’s version of something can be drastically
different than another company’s.
Overall, I think this was a very good project to assign. Though I do have some experience
from my internship, more practice never hurts. Plus, I got to see and use the exchange list which
will help me with my career.
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Appendices
Appendix A: Day 1 Nutrient Breakdown
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Appendix B: Day 2 Nutrient Breakdown


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