Nutrition

First Office Call

Pt Initials: EK



Appointment length: 60 min

ASSESSMENT

Client History
Reason for visit: Wants to reduce Sx exacerbations and reduce prescription Rxs. ND recommended SWANK diet.
Personal hx: Married 46 yo AA F. Denies tobacco use. Limited mobility.
Medical hx: Dx c Relapsing and Remitting MS at age 42 after high stress life event( mothers death) when pt had
difficulty with speech and fell twice, along with numbness, prickly feelings, and general lack of coordination. Flare ups tx
c Solu-medrol c Prednisone taper. Two severe flare ups in 4 years; last flare up was 2 mo ago. Occ episodes of
clumsiness and coughing/choking from fluids. Current Sxs include frequent HA, variable moods, drowsiness, weakness.
Family Med hx: CVD (Fa) and colon CA (PGF)
Social hx: Librarian; switched to half time status after last exacerbation. Enjoys job and wants to continue working as
long as possible. Spouse is emotionally supportive. Two children, local 22 yo daughter and 20 yo son in college on East
Coast. Pt and spouse recently moved to one story home to accommodate pts physical abilities. Pt reports financial
security.

Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results: Energy intake is approximately 2067 kcal/d (115%
RDA). Eats 3 meals, two afternoon snacks, and one evening per day. Protein intake is 71 g (120% of g/kg). Fat intake is
39% of kcal (AMDR 20-35%). Saturated fat is 35 g (180% DRI and 233% of SWANK diet). Omega-3 FA intake is 1.36 g
(70% DRI). Omega-6 FA intake is 7.81 g (45-65% DRI). CHO intake is 47% kcal (WNL). Dietary fiber intake is 18 g (47-86%
DRI). Vitamin D intake is 2.96 mcg (20% DRI). Vitamin E intake is 3.2 mcg (21% DRI). During the week, lunch is sandwich
or leftovers from dinner. Consumes 40 oz caffeinated beverages/d (167% of SWANK diet). Main protein sources are of
animal origin. Dairy choices are full fat. Vegetable intake is 50% SWANK recommendation.
Food and Nutrition History: Stopped ETOH b/c of Rx. Has not be interested in nutrition until visit with ND.
Knowledge/Beliefs/Attitudes/Behaviors: Pt and spouse eat dinner out 2-3 x/wk and 1-2 meals (breakfast or lunch)
x/wknd. Packs lunch for work. Dislikes radishes and milk. ND recommended SWANK diet. Pt wants to know where to
start to eat right.
Food Access and Preparation: Pt and spouse grocery shop together at Trader Joes and QFC. Occ shop at Whole Foods.
Pt and spouse share cooking tasks. Pt likes to cook but has trouble b/c of Sx.
Food allergies/Intolerances: NKFA.
Physical Activity: Works c personal trainer at gym 1x/wk. 15 min of stretching q am. Swims 30 min 3x/wk. Pt reports
slowing down over last 5 years.
Medications and Dietary Supplements: Rx meds: Avonex, Klonopin, Baclofen, Ducolax; Supplements/OTC: 1 Tbs fish
oil/d, 8 capsules Thorne Meta-Fem/d (currently only taking 4/d), occ Tylenol PM for mild HA, Flare ups tx c Solu-medrol c
Prednisone taper.

Anthropometric Measurements
Height (in/cm): 67 in/170 cm


Weight (lb/kg): 162 lb/73.6 kg
BMI: 25.5 (overweight)
Weight hx: Was weight stable at 150# until 5 years ago; slow gain of 10#.
Other measurements: None

Ideal/reference weight: 121 - 149 lb
%ideal/reference weight: 108%
Usual weight: 150 lb


%usual weight: 108%
% Wt change: +8% in 5 years

Weight change classification: of concern
Desired weight: Not applicable.


Biochemical Data, Medical Tests and Procedures

Pertinent labs/tests/procedures: Alb 4.1 g/dL (WNL), Total Cholesterol 202 mg/dL (borderline), HDL 62 mg/dL (WNL),
LDL 97 mg/dL (WNL), Vit D 22 ng/ml (Low), HCT 36% (WNL), Hgb 12.8 g/dL (WNL)

Nutrition Focused Physical Exam Findings
GI Function: Denial of N/V/D. BM usually qod - hard and small. Pt reports no BM problems before Rx. BMs more
frequent with laxative Rx.
Sleep hx: 7 hrs/night
Energy: 3:10
Stress: 9:10 due to difficulty caused by MS symptoms
Blood pressure: 116/78 (WNL, 3/14/15)
Overall clinical observation: Pt is motivated and wants to change but doesnt know where to start.

DIAGNOSIS

Problem: Intake of types of fats inconsistent with needs (excessive saturated fat, NI-5.6.3) related to
Etiology: lack of exposure to nutrition related information for MS as evidenced by
Signs and Symptoms: reported saturated fat intake 233% of SWANK, omega-3 intake 66% of DRI, and omega-6 intake
45% of DRI.

Problem: Undesirable food choices (NB-1.7) related to
Etiology: lack of exposure to SWANK DIET as evidenced by
Signs and Symptoms: excessive red meat consumption, low vegetable intake (50% SWANK recommendation), excessive
caffeine intake (167% SWANK recommendation), consumption of full fat diary products (SWANK recommends
low/nonfat), low fiber intake (65% DRI), low fluid intake (87% DRI).

Problem: Swallowing difficulty (NC-1.1) related to
Etiology: multiple sclerosis symptoms as evidenced by
Signs and Symptoms: reported coughing/choking while drinking liquids.

INTERVENTION

Nutrition Prescription
REE/ Kcals: 1408 (Mifflin x 1.2-1.3) = 1689 - 1830 kcal/day
Protein (g/kg): 0.8 - 1.0 g/kg = 59 - 74 g/day
Fluids (ml/kg): 35 mL/kg = 2576 mL/day
Other: SWANK anti-inflammatory diet - unsaturated fats 20-50 g/d, 2 svgs/d low-fat dairy, saturated fat less than or
equal to 15 g/d, cod liver oil 1 tsp/d, multivitamin with minerals, 2 cups vegetables, 2 fruit servings

Intervention 1: Meals and Snacks-Fat Modified Diet-Decreased saturated fat diet (ND-1.2.5.5.1): Explained how
saturated fat can contribute exacerbation of Sxs, while omega-3s can help. Provided pt with PUFA handout and noted
full-fat cheese and butter as main sources of saturated fat in pts diet. Pt agreed to switch to low-fat cheese (no more
than 1 g sat fat per serving) for 2 weeks to find best tasting brand. Agreed to eat maximum 2 ounces of cheese per day.
Brainstormed other snack alternatives and pt agreed to swap two afternoon snacks to one snack that includes 1 ounce
walnuts and 1 cup vegetable of choice. Pt agreed to cook without butter and check with servers when eating out about
cooking methods. Provided food log to record cheese and afternoon snack choices.

Intervention 2: Nutrition Education-Content-Priority Modification (E-1.2): After reviewing the remaining SWANK
recommendations, pt expressed preference to address red meat consumption as she eats it 2-3 times per week for
dinner. Pt agreed to stop eating red meat for two weeks and replace with two servings of Atlantic salmon, halibut or
trout and one serving of poultry. Explained anti-inflammatory benefits of eating fish. Pt enjoys eating fish, but doesnt
often shop for it or cook with it. Provided pt with Benefits of Eating Fish and Seafood Watch handouts. Used food
models to demonstrate appropriate portion size. Provided food log to record dinner protein choices.

Intervention 3: Collaboration and Referral of Nutrition Care-Referral to other providers (RC-1.5): Discussed dysphagia
with pt, and explained that as disease progresses, Sxs may worsen. Recommended a referral to a speech language
pathologist to address Sxs early. Pt agreed to contact SLP prior to next nutrition visit.

MONITORING /EVALUATION

Professional goal #1: To address MS symptoms, at two week follow up pt will show food log showing low-fat cheese
choices (2 oz/d) and afternoon snack of ounce walnuts and cup vegetable on 10 of 14 days.

Professional goal #2: To address MS symptoms, at two week follow up pt will show food log showing four total fish
servings, two total poultry servings, and zero red meat servings for dinner meals.

Professional goal #3: To address dysphagia caused by MS, at two week follow up pt will report making contact with SLP.

Follow up: Vegetable intake, caffeine intake, low fiber and water intake, possible dysphagia, SWANK appropriate
convenience foods if cooking continues to be a problem
Handouts provided: Essential guide to polyunsaturated fatty acids, Benefits of Eating Fish, Seafood Watch, Food Logs

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