Student Name Rebecca Hoffman

Nutrition Assessment:
Client History:
20-year-old Caucasian male
English speaking
Full time student (Programing Technologies)
Full time employee (Assistant Manager at a technology retail store) (has one
day off each week)
Family history of CVD and high cholesterol
Lives in an apartment with college roommate
Not Married
Food & Nutrition History:
Sedentary Lifestyle
Was active in high school played tennis
Does not eat breakfast regularly
Eats convenience and fast foods due to busy lifestyle
Few snacks will occasionally have popcorn if watching a movie
Can cook convenience foods but usually does not cook full meals
Does not take a multivitamin
Allergic to bananas and grapes
Prefers canned fruits and vegetables over fresh
No diet history
Willingness to change 7 because he knows he needs to make the change
but is unsure of how or if he can
The patient has problems when he eats in front of the TV with over
consumption
Shops mainly by price
Anthropometrics:
59
210 # (IBW=160#)
BMI 31 Obese
Biochemical/Tests/Procedures:
No recent tests
Nutrition Focused Physical Findings:
Busy lifestyle between homework school and work
Comparative Standards:
Basal) Energy Expenditure= 5 + 10 (95.45) + 6.25 (175) 5(20)=1953
*1.3 (AF) * 1.0 (IF) = 2540 kcal per day
actual = 2153 (85%)(low)

Fluid needs = 30cc * 95.45 kg = 2863cc needed per day

Actual = 1486 per day (51%) (low)
Protein needs = .8 * 95.45 kg = 76.36 g protein per day
Actual = 98.6 grams per day (130%) (high)
Carbohydrate needs = 45-65% = 285.75-412.75 grams per day
Actual = 317 grams per day (76-110%)(high)
Fat needs= 20-35% = 56.4-98.7 grams per day
Actual = 83 grams per day (84-148%) (high)
% IBW = 210/160 *100 = 131%
Assessment Statement:
The patient is a 20-year-old Caucasian male that is coming to the RD
for a weight loss solution. He is hoping to lose one pound a week and prevent
high cholesterol. The patient leads a sedentary lifestyle and is a full time
student and a full time assistant manager. The Patient has no history of
dieting and enjoyed tennis as a high school student. The patient consumes
mostly convenience foods due to his busy lifestyle and because he lives with
just one other college roommate. The patient is 59 and weighs 210# (131
IBW) and has a BMI of 31 (obese). After a 3-day food analysis it was shown
that the patients intake of carbohydrates (317 g/day) (76-110% needs), fats
(83 grams per day) (84-148% needs), protein (98.6 grams per day) (130%
needs), calories (2153) (85% needs) were all high. The patient consumed
around 1486 cc of fluids each day, which was too low. Due to all this
information and the patients family history of CVD and high cholesterol I
believe that the patient is at risk for developing CVD, high cholesterol, and
furthering his obesity.
Nutrition Diagnosis/Goals:
Diagnosis 1:
Suboptimal nutrient intake related to undesirable food choices as evidence
by BMI of 31 and lack of fruits and vegetables on a 3-day food record.
Nutrition Interventions:
Nutrition Rx:
Decreased Kcal needs to around 2100 kcal per day for weight loss and
avoiding convenience foods and consuming more fresh foods
Interventions:
I talked with the patient about meal preparations on days that he does not
work. We also talked about portion sizes and MyPlate to ensure balanced
meals. We talked about healthy canned fruits and vegetable also. We also
talked about the use of My Fitness Pal to keep a food record
Relationship to Disease:

The patient agreed that if he did not change his habits that he could further
his obesity and develop cholesterol problems like his father and would be
stuck taking medications and fearing a heart attack.
Education:
I taught the patient how to measure certain food items for the correct portion
size and how meal prep and packing his lunches would save him money and
be healthier in the long run. I showed him what MyPlate looks like and I
taught him how to read labels. We also discussed how he could get more
active after doctor approval.
Counseling Techniques:
We used goal setting because the individual was ready to change and
seemed like a success driven individual due to his responsibilities as a
manager and student
Referral of Care:
MD for activity approval
Goals:
Eat at the kitchen table instead of in front of the TV to avoid mindless eating
Meal prep for the week on Mondays when the patient does not have work
and little school to consume less convenience foods
Become more active by playing Tennis with his girlfriend at least twice a
week (log all activity)
Pack a lunch for work to avoid going out to eat
Lose 1 # per week with 2100 kcal diet and activity
Consume at least 3 servings of fruits and vegetables each day to start out
with.
Monitoring and Evaluation:
(Criteria/ Parameter)
Monitor food record for 2100 kcal per day
Monitor food record for correct portion sizes and 3 servings of fruits and
vegetables per day
Monitor activity log (tennis 2 times per week)
Monitor weight for weight loss of 1 # per week
Talk with patient about where he has been eating (should be at kitchen table)
and how the food preparation for the week has been going (prep on Mondays
and pack lunches for work)