Last 4 digits of PSU ID: 9546

Nutrition 453-PES Homework (14 pt) Spring 2016

See class handouts and lecture notes for examples and guidance.
Mr. Sparrow is a 45 year-old African-American male with a medical history of hypertension,
hypercholesterolemia, and diabetes mellitus (type II). His physician has requested that he meet
with you, the dietitian, for dietary counseling. The goal of dietary counseling is to assist Mr.
Sparrow in improving his lab values through diet changes.
Anthropometrics:
Ht: 60
Wt: 270 lb; gradual 30 pound weight gain over past few years
Labs:
Total cholesterol = 255 mg/dL
Fasting triglycerides = 350 mg/dL

BMI: 36.6

HDL = 30 mg/dL
LDL = 185 mg/dL
Fasting blood glucose = 130 mg/dL

Client History:
Patient is a manager in a fast food restaurant. His wife is a law enforcement officer with a
rotating schedule. The couple has no children. Patient states the family rarely prepares their
own meals, maybe 1-2 days per week we cook at home. Mr. Sparrow often skips breakfast due
to his schedule at the restaurant. Patient stated because of convenience he consumes most
meals at the restaurant where he works. His favorite pastime activity is watching sports on
television with his friends. Often these televised games turn into big events with lots of chicken
wings and pizza. Mr. Sparrow states he often feels tired and unmotivated to perform any
physical activity, especially after being on his feet at the restaurant.
Food/Nutrition History:
Patient does not cook or prepare his own meals. His wife often does the cooking 1-2 days per
week when her schedule allows. Mr. Sparrow states he eats when he is at work. His diet consists
of fast/convenient foods (burgers, fries, sodas). Patient stated he does not eat his meals at the
same time every day but when I have time, if I think of it. It is usually late in the day. Mr.
Sparrow stated when he does consume breakfast (approximately 2-3 days per week) he will go
through the drive through at his favorite coffee/donut shop or pick up an egg sandwich at the
closest convenience store. He purchases snacks for his home such as snack cakes, potato chips,
and occasionally beer.
Mr. Sparrow completed a 24-hour food record before his appointment, as instructed. The 24-hour
food record showed he is consuming ~3200 kcal, with most of his foods being high in
carbohydrate (CHO representing ~55% of kcal with ~20% from added sugars) and fat (fat
representing ~38% of kcal with ~15% of total kcal from saturated fatty acids). However, you
notice his portion sizes are described inaccurately and with some discrepancies. After the initial
consultation, you estimate that he needs to be consuming ~3000 kcal/day just to maintain his
current weight. You send him home with instructions to complete a more detailed 7-day food
record; you also provide a booklet with illustrations of appropriate food portions.

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Last 4 digits of PSU ID: 9546

1. List one nutritional problem that was addressed during this session. (P)
One nutritional problem that was addressed during this session was Mr. Sparrows problem of
obesity. I discussed with the patient how obesity is correlated with the diseases in his medical
history: hypertension, hypercholesterolemia, and type II diabetes mellitus. I explained to patient
that obesity is defined as having a very high amount of body fat in relation to lean body mass.
2. What aspects of his lifestyle have contributed to this problem? (E)
The aspects of the patients lifestyle that contribute to this problem are:
Patient feels tired and unmotivated to perform any physical activity. He said that this is
due to being on his feet all day at his job: fast food restaurant manager.
Additionally, patient stated that he oftentimes skips breakfasts and ends up eating meals
at the fast food restaurant where he is employed: diet consisting of fast/convenient foods
such as burgers, fries, sodas
On the 2-3 times per week that the patient does eat breakfast it is often a convenient drive
through choice such as coffee and donut or an egg sandwich.
Snacks at home include snack cakes, potato chips, and beer
Patient does not cook/prepare his meals. He eats meals at home when his wife prepares
them usually 1-2 times per week. Other than that, his choices are made with convenience
usually his fast food choices.
Based on 24-hour recall, patient seems to inaccurately depict portion sizes. I directed him
to complete a more thorough 7-day food diary in hopes of gaining more insight. I also
gave the patient a booklet with proper portion size illustration to educate him on what he
should be recording as a portion in his food diary.
Based on the 24-hour recall, it is evident that Mr. Sparrows diet is high in carbohydrates,
approximately ~55% caloric intake is from CHO with 20% of the CHO from added
sugar. Note that Mr. Sparrow does fall within the recommended carbohydrate range of
45-65% of kcal from carbohydrates. However, the 2016 Dietary Guidelines suggest
limiting added sugars to less than 10% of calories per day. Mr. Sparrow is currently twice
that recommendation with 20% of kcal from added sugar. The 2016 Dietary Guidelines
suggest that eating patterns with lower intake of added sugars (below 10% of kcal) reduce
risk of obesity, type II diabetes, and cancer.
Additionally, 38% of patients caloric intake is from fat with 15% saturated fat sources. I
explained to patient the recommended percent of total fat is 20-35% of kcals. The 2016
Dietary Guidelines recommended less than 10% of calories from saturated fats. Patient is
above recommendations for both total fat and saturated fat. Sources of saturated fat
should be replaced with unsaturated fats. PUFAs will assist in lowering cholesterol.
Patients 24-hour recall noted intake of ~3200 kcal per the recorded day (although
portion size discrepancies noted meaning the caloric intake is likely higher). Patient
needs ~3000 kcal/day to maintain current weight.
3. What laboratory or anthropometric value(s) (or other information, above) provide(s)
evidence of this problem? (S)

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Last 4 digits of PSU ID: 9546

Laboratory and anthropometric values that serve as evidence to this problem are:
Patients is overweight
o BMI of 36.6 categorized as obesity class II (35.0-39.9)
o Obesity class II suggests patient is at increased risk of developing CVD and
further health complications. Weight loss is recommended.
Patient has high total cholesterol, LDL cholesterol, fasting triglycerides, and blood
glucose levels.
o Total cholesterol level: 255 mg/dL
o LDL: 185 mg/dL. For high risk individuals such as Mr. Sparrow the optimal LDL
is <70mg/dL.*Note that patients HDL: 30 mg/dL. Patients HDL level falls low
of optimal lipoprotein profile with HDL cholesterol >60 mg/dL In other words,
patients bad cholesterol (LDL) is high and good cholesterol (HDL) is low.
o Fasting triglycerides: 350 mg/dL. Patients triglyceride level falls within the
high range (200-499 mg/dL). Optimal triglyceride level is <150mg/dL.
o Fasting blood glucose: 130 mg/dL. Fasting blood glucose greater than 126
mg/dL termed diabetes.
4. Write one PES statement (using your answers from 1, 2, & 3 above) and one
intervention statement (including both the RD and patient portions) that you would
include in his chart after your first visit with Mr. Sparrow. You can either use the
interventions noted in the paragraphs above to shape your PES and intervention
statements, or develop your own. Regardless, be sure that your intervention targets
the E of your PES statement, use relevant eNCPT within your statements and make
sure that the patient portion of your intervention statement is a WRAP.
PES Statement based on Intake Domain:
Excessive fat intake (NI-5.5.2) related to frequent consumption of fast/convenient food meals as
evidenced by 38% of kcal from fat, 15% kcal from saturated fat and BMI of 36.6.
Intervention/Nutrition Prescription:
Intervention: I will provide nutrition counseling to set a goal to reduce fat intake to within the
recommended 20-35% of total kcal from fat along with less than 10% of kcal from saturated fat
sources by reducing the patients consumption of fatty fast food with healthier alternatives. (C2.2)
Goals: To decrease consumption of total fat and saturated fat sources, Mr. Sparrow will pack a
healthy lunch to avoid eating unhealthy fast food options at work. Patients packed lunch should
consist of a sandwich on whole wheat bread and lean meat. Patient is encouraged to top his
sandwich with spinach, tomato, avocado etc. for added nutrients. Packed lunch should also
include a healthy side such as an apple, orange, banana, bag of unsalted nuts, etc. Patient should
also pack one of these healthy side options as a snack to eat throughout the day. Mr. Sparrow
will work on achieving this goal at least 3 days out of his workweek until we meet again.

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Last 4 digits of PSU ID: 9546

At the two-week follow up appointment, Mr. Sparrow arrives late and was only able to complete
3 days of his 7-day food record. He states he has had no time to do this and couldnt possibly be
expected to spend this much time recording what he eats. He has tried to make some changes
during the past two weeks, but is frustrated because his weight has not gone down. He tells you
that he has started consuming more sweetened iced tea and frappuccino at the restaurant, since
soda contributed so many of his calories last time he saw you. He also has been consuming more
chicken nuggets and fish sandwiches instead of burgers, as he heard from some patrons of the
restaurant that chicken and fish were better for you. After reviewing his food records, you
estimate his intake to be ~3200-3500 kcal.
5. List one problem that you identified during this session. (P)
One problem identified during the session was a food and nutrition-related knowledge deficit
along with statements that suggest perhaps patient is not ready for diet/lifestyle change.
6. What about his lifestyle may be contributing to this problem? (E)
Patient stated that he has had no time to do this and couldnt possibly be expected to spend this
much time recording what he eats. Patient expressed frustration with lack of progress in terms
of weight loss.
This suggested to me that perhaps the patient has not yet devoted the necessary time to
implementing a healthy lifestyle. As his RD, I emphasized to him the importance of making time
to allow for results. I discussed with him methods of doing so: meal preparation ahead of time,
planning a grocery list, etc.
Furthermore, patient stated that he had been choosing what he believes to be healthier
alternatives than what he would normally consume. Patient needs educated on nutritious choices.
7. What signs and symptoms provide evidence of this problem? (S)
Patient stated that he has tried to consume more sweetened iced tea and Frappuccino at the
restaurant rather than soda. Furthermore, patient said that he had been consuming more chicken
nuggets and fish sandwiches rather than burger due to hearing from others that these choices are
better for you. It appears that Mr. Sparrow is trying, but he is experiencing a knowledge deficit:
Although it is evident that Mr. Sparrow is making an effort to choose better choices than
soda, sweetened iced tea and Frappuccino are not ideal choices in terms of sugar.
Although chicken and fish may be better alternatives than a fatty burger, it is ideal for
Mr. Sparrow to eat only lean meat in order to limit fat intake and stay on track to losing
weight. In order for patient to know that his meat is lean and good quality, he should be
packing his own lunch rather than eating fast food meat.
8. Write one PES statement (using your answers from 5, 6, & 7 above) and one
intervention statement that you would include in Mr. Sparrows chart after your

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Last 4 digits of PSU ID: 9546

second visit with him. Use relevant eNCPT within your statement; be sure that the
patient portion of your intervention statement is a WRAP.
PES Statement based on Environmental/Behavioral Domain:
Food-and nutrition-related knowledge deficit (NB-1.1) related to poor food choices as evidenced
by sugar sweetened beverages: sweetened iced tea and Frappuccino and fast food choices:
chicken nuggets and fish sandwiches.
Intervention/Nutrition Prescription:
Intervention: I will provide nutrition education on nutrition basics to guide Mr. Sparrow in the
right direction concerning healthy versus unhealthy choices with recommended modifications.
(E-1.5)
Specific Details: Avoid fast food choices and sugar sweetened beverages when at all possible
Goal: Mr. Sparrow will continue to work on the goal discussed at our previous meeting
regarding packing his lunch. (See above if needed). To ensure healthy choices, he needs to
prepare his own food and bring it to work, rather than choosing options at work. In addition,
patient will begin another goal of drinking only water rather than sugar-sweetened beverages.
Note that 39% of the added sugars in the US Diet comes from sugar-sweetened beverages. If
patient desires the sweetness I encourage him that water does not have to be boring and he can
flavor his water with sliced fresh fruit such as strawberries, limes, raspberries, or fresh herbs
such as mint. Furthermore, if the patient desires the caffeine from the Frappuccino/soda he
should drink black coffee for a healthy alternative. Together, these goals with time (and
adjustments) will help improve Mr. Sparrows lab values; the reason the Physician referred
patient.

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