Case Study

Presentation
Alex Merrill
NUTR 4920
November 17, 2014

Session #1:
Demographic Data

Client is a 23 y/o female

From Fairfield, Ohio

Family: Parents, older brother, younger twin sisters

5th year senior at Ohio University

Majoring in exercise physiology
Minoring in applied nutrition
Lives off-campus in apartment

Not currently employed

Client Health History: None

Family Health History: Cancer

Session #1:
Anthropometrics & Assessments
Height: 58

BMI: 26.3

Initial Weight: 172.4 lbs

IBW: 140 lbs

Initial Waist
Circumference: 37.3 cm

IBW%: 123%

Wrist Circumference: 6.4

in

Frame Size: Medium

Session #1:
Pertinent Nutrition History
Exercise & Physical
Activity
Treadmill 4-5
days/week
(30
minutes)
Resistance Training: 34 days/week (30
minutes)
Ranked Interests
1. CHO counting
2. Eating away from
home

Alcohol Consumption
5-6 drinks, 2 day/week
Beer & liquor
Client comfortable with
weight
Client generally
interested in eating
healthier

Session #1:
Typical Food Recall Analysis
Calories: 1,480 kcals

Dietary Fiber: 20 g

CHO: 172 g

Sodium: 1,407 mg

Protein: 63 g

Total Fat: 67 g
Saturated Fat: 20 g
MUFAs: 14 g
PUFAs: 5 g

Cholesterol: 481 mg

Session #1:
Effect on Health & Lifestyle
No client/family health history related to
cardiovascular or heart disease
High saturated fat & cholesterol intake presents as
a risk to client
Could contribute to weight retention/gain; not ideal
Otherwise, no known health condition present

Session #1:
Initial Nutrition Diagnoses
Food- and nutrition-related knowledge deficit (NB1.1) related to lack of prior nutrition-related education
as evidenced by patients comments about lacking
confidence in her current nutrition, in addition to
clients uncertainty in how to apply nutrition
information, specifically information regarding
carbohydrate intake.
Overweight (NC-3.3) related to food- and nutritionrelated deficit as evidenced by patients BMI of 26.3,
IBW% of 123%, and waist circumference of 37.3 cm.

Session #2:
Initial 3-Day Food Log Analysis
Calories: 1,095 kcals

Dietary Fiber: 8g

CHO: 129 g (47%)

Sodium: 1,873 mg

Protein: 50 g (18%)

Total Fat: 43 g (35%)

Saturated Fat: 15 g (12%)
MUFAs: 11 g (9%)
PUFAs: 5 g (4%)
Alcohol: 0 g

Session #2:
Initial 3-Day Food Log
Calcium: 456 mg

Vitamin D: 3 mcg

Iron: 9 mg

Linolenic Acid: 0.2 g

Vitamin C: 9 mg

Potassium: 659 mg

Vitamin A: 497 mg

Cholesterol: 442 mg

Folic Acid: 267 mcg

Note: Calorie intake inaccurate because client did not record alcohol
consumption

Session #2:
Initial Dietary Recommendations

Calories: 1,500 kcals

Calcium: 1,000 mg

CHO: 176 g (47%)

Iron: 18 mg

Protein: 75 g (20%)

Vitamin C: 75 mg

Total Fat: 45 g (27%)

Vitamin A: 700 mcg

Folic Acid: 400 mcg

Vitamin D: 15 mcg

Linolenic Acid: 1.1 g

Potassium: 4,700 mg

Cholesterol: <300 mg

Saturated Fat: 7% ( 12 g)
MUFAs: 12% (20 g)
PUFAs: 8% (13 g)
Alcohol: 6% ( 14 g)

Dietary Fiber: 25 g

Sodium: <2,300 mg

Session #2:
Rationale for Recommendations
Based on DRI for 23 y/o women
Observed Diet Pattern
High in saturated fat
High in cholesterol

Increase CHO & protein intake

Nutrition Plan Based on Clients Interests
Teach CHO counting using Choose Your Foods
CHO distribution meal plan
Divided up prescribed 176 g CHO into CHO choices for
breakfast, lunch, and dinner

Session #2:
Rationale (cont.)
Dietary Recommendations to Meet DRIs
Decrease intake of foods high in saturated fat &
cholesterol
Limit egg intake; try egg whites
Consume low-fat/fat-free dairy products

Increase intake of fruits & vegetables

Consume salads twice/week
Add more spinach into diet (i.e. on sandwiches)
Eat carrots with lunch

Session #2:
Rationale (cont.)
Rationale Regarding Nutrition Diagnoses
Knowledge Deficit
Client interested in nutrition, but uncertain of how to
apply nutrition information (knowledge deficit)
Regarding appropriate CHO and fat intake

Overweight
Client is comfortable with her weight; not a main
concern
However, improper balance of macronutrients (CHO, fat)
could contribute to unnecessary weight retention/gain

Session #2:
Educational Materials
Fruits and Vegetables: Easy Ways to Add More to Your
Diet
http://www.nutrition411.com/patient-educationmaterials/fruits-and-vegetables/item/1579-fruits-andvegetables-easy-ways-to-add-more-to-your-diet/
Client struggled adding vegetables into her diet
Encourages creativity

Carbohydrate Basics
http://www.nutrition411.com/patient-educationmaterials/protein-fats-and-carbohydrates/item/622carbohydrate-basics/
To supplement CHO counting education
Condensed

Session #2:
Nutrition Diagnoses
Excessive alcohol intake (NI-4.3) related to foodand nutrition-related knowledge deficit concerning
moderate alcohol intake of 1 drink per day for women
as evidenced by patients comments about biweekly
alcohol binge of 5-6 drinks.
Excessive fat intake (NI-5.6.2) related to food- and
nutrition-related knowledge deficit concerning
appropriate amount of dietary fat as evidenced by
dietary intake analysis results indicating a high
average intake of 442 mg of cholesterol and 15 g
saturated fat.

Session #3:
Second 3-Day Food Log Analysis
Calories: 1,326 kcals

Dietary Fiber: 14 g

CHO: 111 g (33%)

Sodium: 1,873 mg

Protein: 59 g (18%)

Total Fat: 56 g (38%)

Saturated Fat: 14 g (9%)
MUFAs: 13 g (9%)
PUFAs: 11 g (4%)
Alcohol: 23 g (16%)

Session #3:
Second 3-Day Food Log
Calcium: 697 mg

Vitamin D: 1.4 mcg

Iron: 9 mg

Linolenic Acid: 0.1 g

Vitamin C: 49 mg

Potassium: 1,347 mg

Vitamin A: 1,065 mg

Cholesterol: 210 mg

Folic Acid: 206 mcg

Session #3:
Evaluation of Initial Nutrition Plan
CHO distribution meal plan was not a success
Client felt intimidated; not enough time to fully explain
concept of CHO distribution
Daily time constraints made following the plan difficult
Inadequate average CHO intake (111 g)

Very carb-focused; Not sure if carbohydrates were the

main issue, but it aligned with clients initial interest
Excessive fat intake
Total fat exceeded recommendations
Saturated fat remained high

Session #3:
Evaluation (cont.)
Successes
Client demonstrated accurate understanding of CHO
counting
Client was able to meet goals of incorporating more
salads, fruit, and vegetables into her diet
Significant increases in vitamin/mineral intake

Increased calories, protein, healthy fat, & dietary

fiber intake
Decreased cholesterol intake

Session #3:
Modification of Nutrition Plan

Provide fat education using Choose Your Foods

Fat counting/fat choices

Challenge client to monitor intake of nutrients

Consume adequate vitamin D & calcium for bone health
Consume adequate omega-3s & MUFAs
Limit saturated fat & cholesterol

Meet DRIs
Increase consumption of fruits & vegetables
Consume low-fat/fat-free dairy products
Try flax seeds, nuts, and vegetable-based oils to increase healthy
fats
Increase consumption of whole grains

Client wasnt truly ready to make a significant lifestyle change

Session #3:
Educational Materials
Calcium & Vitamin D: Important at Every Age
http://www.niams.nih.gov/Health_Info/Bone/Bone_Health/Nut
rition/Default.asp?print=yes

Omega-3 Fatty Acids Q & A

http://www.nutrition411.com/patient-educationmaterials/protein-fats-and-carbohydrates/item/627-omega-3fatty-acids-q-a/

Alcoholic Beverages: Some Lower Calorie Options

http://www.nutrition411.com/patient-educationmaterials/grocery-shopping-and-food-preparation/item/1245alcoholic-beverages-some-lower-calorie-options/

Educational Tool: The Basics of Dining Out & Meal Planning!

Quick Tips for

Weekly Meal Prep!
Wash & dry your
produce after buying
Chop vegetab les &
store in refrigerator
Use food processor
for quick chopping!
Buy vegetable
steaming b ags
Buy frozen produce
Prepare meals the
night before to b e
heated the next day

The Basics of Dining Out and Meal Planning!

Dining O ut Healthfully
! Check r estaurants menu online
fir st to find a healthy option
! Look for key wor ds like
steamed , b aked , and
b roiled
! Avoid fried and creamed
dishes that ar e high in fat
! Or der a salad for an appetizer as
an alter native to b read
! Ask for b r eadb asket not to b e
b rought to the tab le
! Or der salad dr essing and entr e
sauces on the side
! Cut down on portion size b y
sharing a dish with a friend

Nutritious Choices at Chipotle

! Soft tacos with b arb acoa or
chicken, b rown r ice, fajita
veg etab les, & gr een salsa
! Burrito bowl with steak or
chicken, b rown r ice, b lack
b eans, fajita vegetab les,
guacamole, & green salsa
! Salad with lettuce, chicken or
steak, b lack b eans, fajita
veg etab les, and chipotle-honey
vinaigrette
! Try sub stituting beans for meat
as nutritious source of b oth
protein and fib er

Spinach & Lentil Soup Recipe

Tips for Easy M eal Planning

! Spend a little time once each
week b rowsing recipes on sites
like Pinterest
! Plan for theme nights, such as
soup night and p asta night.
! Choose one shopping day each
week and make a list of
ingredients
! Look for fresh pr oduce thats inseason and on-sale
! Plan for leftover s for lunches and
future dinner s
! Prep food fir st thing
! Buy items you can fr eeze and
have on hand

Directions
1. Preheat lar ge pot on medium &
I ngredients
spr ay with cooking spray. Add
2-3 gar lic cloves, crushed
gar lic & onions and cook until
1 lar ge onion, fi nely diced
translucent.
3 lar ge carr ots, diced
2. Add car rots & celer y and saut
2 cups green lentils, rinsed
for 5 more minutes. Add lentils &
14 oz. can diced tomatoes (w/ liquid)
saut for another 3-5 minutes.
6 cups low-sodium vegetab le br oth 3. Add diced tomatoes, veg b r oth,
2 cups water
water, b ay leaves, salt & pepper.
3 b ay leaves
Br ing to b oil, cover & cook on
teasp oon salt
low for 30 minutes. Add spinach
teasp oon pep per
& remove from heat. Top with
2 handfuls of spinach, chopped
Parmesan cheese if desir ed.

Session #3:
Educational Materials (cont.)
Impact: Increased Self-Efficacy
Client felt more confident in her ability to
incorporate more fruits & vegetables
Client appreciated educational tool; practical
options for eating at Chipotle
Quick guide to freshen memory on omega-3s
Lower-calorie alcoholic beverages tool allows
client to enjoy alcohol while choosing better
options

Session #3:
Evaluation of Educational Materials
Would not necessary change content of materials,
but would customize them
Would not change the amount of materials
provided
Materials were appropriate for the health literacy
level of the client; Nutrition411.com keeps nutrition
information basic for individuals at any level of
understanding

Session #3:
Nutrition Diagnoses
Limited adherence to nutrition-related recommendation
(NB-1.6) related to perception that lack of time prevents
changes, food- and nutrition-related knowledge deficit
concerning how to make nutrition-related changes, and
inconsistent interest in applying information as evidenced by
lack of compliance with plan (not meeting recommended
nutrient goals, not following CHO plan).
Less than optimal intake of types of fats (NI-5.6.3)
related to food- and nutrition-related knowledge deficit
concerning appropriate amount and type of dietary fat as
evidenced by dietary intake analysis results indicating a high
average intake of saturated fat (14 g), and consumption of
total fat (38% of kcals) that exceeds diet prescription (27%
of kcals).

Client Progress:
Dietary Changes
Prior Eating Habits

Eating 2 eggs/day
White bread/flour tortillas
Sandwiches/wraps for lunch with lunch meat, no vegetables
Granola bar for breakfast
Very low fruit & vegetable intake

Improvements
Limited eggs; Replaced eggs with fruit & protein smoothie
Spinach wraps
Replaced sandwiches/wraps with salads
Spinach, tomatoes, carrots, cucumber

Added sunflower seeds & almonds as a snack

Client Progress:
Anthropometric Changes
Initial Session

Final Session

Weight: 172.4 lbs

Weight: 168 lbs

BMI: 26.3

BMI: 25.5

IBW%: 123%

IBW%: 120%

Waist Circumference:
37.3 cm

Waist Circumference:
36.5 cm

Future Nutritional Needs

Client-counselor discussions were balanced
Client is open, receptive, and responsive
However, client ultimately lacks interest
Nutrition/lifestyle changes are not currently a high priority

Motivational interviewing would be an appropriate

next-step
Elicit emotion
Dig deeper to understand why client is not ready for
change & what it would take to initiate change

What I Learned
About Myself as a Counselor
Well-organized (documents, stay on track with plan)
Informative and resourceful
Interactive (include client in conversation, check in for
understanding)
Professional
Supportive
Struggle with time-management
Perfectionistic, sometimes overly detailed

What I Learned
About My Educational Preparation

Very organized
Detail-oriented
All-inclusive, try to hit on all the points
Struggle to manage my time in preparation
May be too detailed?

Recommendations for
Future Counselors
Give yourself plenty of time to prepare
Refresh your memory of basic nutrition education from
previous classes
Review food sources!

Practice at least once or twice

Make an outline of your session to give you something
to follow in order to stay on track
Be warm & friendly; Take a genuine interest in your
clients life/wellbeing