Case Study 4

Medical Nutrition Therapy I

Professor Elkadi
Ryan Struder
November 24, 2015

Case Study 4
1. What weight would be most appropriate to use in starting point in your nutritional
assessment?
The patient admission BW and UBW should be used for her nutritional assessment. Her actual
BW of 245.5ibs during admission is being influenced by her fluid status. Sense this patient
claims to have been 230lbs 2 weeks ago as her normal BW, means that she has recently gained
15lbs unintentionally. This means she had a 6.7% BW change in 2 weeks which can imply severe
nutritional risk.1
2. Calculate and interpret her BMI. How would you estimate the energy / protein needs of a
HF patient? Estimate her needs and show work.
She has a BMI of 36 using her UBW and currently is at a BMI of 38.4, both of which scores
place her into the obese category. Using the total energy expenditure equation for overweight and
obese females aged 19 years and older (TEE=448-7.95 x age + PA x (11.4 x weight + 619 x
height), the patient should be getting around 2,290.98Kcal per day. Protein requirements like
energy requirements are going to be affected by metabolic stress, trauma, and disease. Because
of her limited mobility and the fact she is not working, she has a low activity factor but will still
need some additional calories due to her body having to work harder from her condition. Her
protein amounts should be increased to 1-1.5 grams of protein per kg of body weight per day,
(111-166g).1
3. Would she benefit from multivitamin/ and vitamin supplementation?
A multivitamin should be recommended for her daily. Use of multiple diuretics in treatment of
heart failure may lead to losses of multiple water soluble nutrients such as potassium,
magnesium, thiamin, riboflavin, and others. Diuretics such as Lasix that she is taking increase
the excretion of potassium, sodium, calcium, and others and a potassium supplement is
recommended when taking loop diuretics. She may also want to consider a calcium supplement
sense she has been taking corticosteroids (prednisone), which enhance calcium excretion, to help
reduce the risk of osteoporosis. Supplementation of thiamin, magnesium, vitamin d, folate,
Vitamin B6 and B12 in HF patients show a reduced risk of mortality and improved conditions. 1
4. What non nutritional factors could be effecting her hyperglycemia?
The corticosteroid prednisone that she is taking in effort to control her inflammation with her
temporal arteritis could be aggravating her hyperglycemia. Being on this drug is what is also
causing her post prandial blood glucose levels to spike, and her fasting levels are left unaffected.
Corticosteroids blunt the action of insulin and promote hepatic gluconeogenesis.1
5. Why do you think her albumin is low in the face of a good appetite?
Low levels of albumin is common in patients with heart failure and increases with age and
illness. Inflammation can cause a significant drop in serum albumin levels. Albumin is produced
in the liver and during inflammation the liver must change production to other proteins to fight.
Heart failure can result in edema from impaired cardiac function. When plasma proteins such as

albumin no longer sustain colloid osmotic pressure to counterbalance hydrostatic pressure,

edema develops.2
6. Estimate sodium and fluid content of her usual diet using a nutrient database such as the
one on the USDA website. Show your work.

According to Super tracker, she is over by 1000 mg in sodium daily according to the
daily diet she gave us. She is taking in nearly 3500 mg of sodium daily. Foods she is
eating such as deli meat, white bread, and salad dressings are very high in sodium.3

72 fluid oz daily of direct liquids3

Sodium was at 3412mg which is 1112mg over the 2300mg daily allowance.3
7. How does her sodium and fluid intake compare with common sodium and fluid
recommendations for diet in heart failure? What advice would you give her to improve her
diet habits and help avoid exacerbations of congestive heart failure?
The recommendation for sodium varies between 1200-2400 mg /day in diets designed for HF
patients. Her sodium is just over 1,000 mg above this.1
She needs to limit total fluid intake to 1500mL daily which is the standard or an UL of 2L.1
To improve the diet, the first step is to minimize/ eliminate table salt and high-sodium foods.
[Cultural / regional differences should be considered when talking about goals for sodium intake,
and individualized instructions should be given in each patient.1]
8. Would your recommendations on sodium and or fluid change at all if this patients
appetite had been poor? Why or why not?
Depending on how poor her diet was it shouldnt have too much of an effect on the
recommendation. A low-sodium diet must be maintained because all the body's sodium has
shifted from the blood to the tissues. Its standard for HF patients to be limited to a 2000mg a day
sodium limit and 1.5-2L of fluids.1
9. Write a PES statement base on the available nutritional assessment data.
Impaired nutrient utilization related to sodium and fluid retention from CHF as evidenced by a
sodium intake of > 2000 milligrams daily and edema.1
10. Name a specific intervention that would address her nutritional diagnosis, and specify
how you would monitor its effectiveness. In addition to diet and fluid status, what other
parameter might you monitor in a HF patient?
Intervention: Talk with patient about sodium in foods. Explain to her foods that have a
natural high sodium content. Educate on cooking with spices. Educate about how to read
labels and various cooking methods that can be used to lower sodium (Ex: rinse canned
vegetables)
Monitor: Food diary /Patients should record weight daily. For severe HF, if 1 lb a day is
being gained they should alert their doctors. (Moderate HF, >2 lb a day. Mild HF, >3-5
lbs.)
Also need to monitor the patients activity levels. The heart can become decondition with
lack of exercise. Therefore, regular exercise is advised.1

References:
1. Mahan KL, Escott-stump S, Raymond JL. Krause's Food and Nutrition Care Process.
13th ed. St. Louis MO: Elsevier Sounders; 2012.
2. Arques S, Ambrosi P. Human serum albumin in the clinical syndrome of heart failure.
2011. http://www.ncbi.nlm.nih.gov/pubmed/21624732. Accessed November 20, 2015.
3. Super tracker. USDA. Web. https://www.supertracker.usda.gov/. Accessed November 22,
2015.

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Case4's Meals
Your plan is based on a 1800 Calorie allowance.

Date

11/24/15

Breakfast

Lunch

Dinner

1 medium (7" to 77/8" long) Banana,

raw

1 medium (2-3/4"
across) Apple, raw

1 medium breast
Chicken, breast,
boneless, skinless,
baked

2 cup Milk, fat free

(skim)

2 regular slice Bread,

white, low sodium or
no salt

1 cup Milk, fat free

(skim)

1 cup Oatmeal,
regular, cooked
(no salt or fat
added)

1 slice (1 oz)
Cheese, Cheddar or
Colby, low sodium

1 cup Mushroom,
fresh, cooked (no
salt or fat added)

1 cup Jello (gelatin)

dessert, with low
calorie sweetener

1 medium roll (21/2" across) Roll,

100% whole wheat,
homemade or
bakery

2 cup, mixed greens

Romaine lettuce, raw

1 tablespoon
Rosemary, fresh

1 large/thick slice
(1/2" thick) Tomato,
raw

1 cup Spinach,
fresh, cooked (no
salt or fat added)

Snacks
EMPTY

2 slice (1 oz) Turkey

or chicken breast,
luncheon meat,
prepackaged or deli,
low salt (low sodium)

Case4's Nutrients Report 11/24/15 - 11/24/15

Your plan is based on a 1800 Calorie allowance.

Nutrients

Target

Average Eaten

Status

Total Calories

1800 Calories

1241 Calories

Under

Protein (g)***

46 g

97 g

OK

Protein (% Calories)***

10 - 35% Calories

31% Calories

OK

Carbohydrate (g)***

130 g

175 g

OK

Carbohydrate (% Calories)***

45 - 65% Calories

57% Calories

OK

Dietary Fiber

21 g

25 g

OK

Total Sugars

No Daily Target or Limit

79 g

No Daily Target or Limit

Added Sugars

No Daily Target or Limit

5g

No Daily Target or Limit

Total Fat

20 - 35% Calories

17% Calories

Under

Saturated Fat

< 10% Calories

7% Calories

OK

Polyunsaturated Fat

No Daily Target or Limit

3% Calories

No Daily Target or Limit

Monounsaturated Fat

No Daily Target or Limit

5% Calories

No Daily Target or Limit

Linoleic Acid (g)***

11 g

3g

Under

Linoleic Acid (% Calories)***

5 - 10% Calories

3% Calories

Under

-Linolenic Acid (% Calories)***

0.6 - 1.2% Calories

0.4% Calories

Under

-Linolenic Acid (g)***

1.1 g

0.6 g

Under

Omega 3 - EPA

No Daily Target or Limit

9 mg

No Daily Target or Limit

Omega 3 - DHA

No Daily Target or Limit

20 mg

No Daily Target or Limit

Cholesterol

< 300 mg

152 mg

OK

Minerals

Target

Average Eaten

Status

Calcium

1200 mg

1583 mg

OK

Potassium

4700 mg

4170 mg

Under

Sodium**

1500 mg

1520 mg

Over

Copper

900 g

1887 g

OK

Iron

8 mg

17 mg

OK

Magnesium

320 mg

466 mg

OK

Phosphorus

700 mg

1834 mg

OK

Selenium

55 g

124 g

OK

Zinc

8 mg

11 mg

OK

Vitamins

Target

Average Eaten

Status

Vitamin A

700 g RAE

1719 g RAE

OK

Vitamin B6

1.5 mg

2.2 mg

OK

Vitamin B12

2.4 g

4.3 g

OK