Amanda Cravinho

NUTRITION 407

Two-Day Meal Plan

for Type II Diabetic
and Cardiovascular
Patient
Medical Nutrition Therapy Lab 1

PART A: NCP for Patient Cindy Lou Ho

NCP for Lou Ho, Cindy
Date: 05/01/15
Amanda Cravinho

Recorder:

1. Nutrition Assessment
59 year old female admitted to acute care for dehydration, confusion, weakness and chest
pain.
Admit dx: hyperosmolar hyperglycemic state (HHS) and CVD
Symptoms: Patients main complaint: I am too tired to do anything and my chest
hurts.
Complete lack of energy, pale color, confusion, 1 + pedal edema, chest pain, shortness of
breath, malaise and notable change in mental state
Diet order: Cardiac-TLC, 2000 kcal DM diet
Dietary Intake: PO intake
- Mostly pre-prepared or fast- food meals.
- Liquid intake consists mostly of diet coke and fruity beverages such as Snapple/Fuze.
- Patient states snacking frequently on calorie dense foods such as peanut butter,
cookies and pizza.
- Does not consume fruits and veggies on a weekly basis
Past Medical History: Clinical dx of Type II Diabetes Mellitus, HTN and HLP. Previous
complaints of heart palpitations. Recent weight gain of 27lbs over 6mo period. Currently
taking Metformin (1000mg BID) and Lantus pm (35u). Non-smoker. Drinks 1-3
alcoholic beverages/day, usually alone.
Allergies: KNA
Family/Social History: Family history of Type 2 DM (paternal), HTN (maternal) and
CAD (paternal). Father deceased: cardiac failure. Single with no living children. Lives
alone. Holds occupation as an attorney. Pt works long hours and into the weekend.
Physical Activity: Sedentary. Pt states not having time for exercise.
Nutrition Status: SGA score of B. Pt is experiencing disease states and comorbidities
detrimental to health and well -being. Pt is overweight and disregards importance of
proper nutrition for disease states. Anthropometrics:
- Ht/wt: 52/157.5 cm and 169 lbs/76.8 kg
- BMI = 30.9 kg/m (obese)
- IBW = 110#
%IBW = 153% (obese)
- UBW = 142# %UBW = 120%
Energy, Protein and Fluid Needs
- Energy = 1612.5 2257.5 kcals/d
- Protein = 64.5 77.4 g/d
- Fluids = 1612.5 2580 ml/d
Based on UBW of 64.5 kg
- For energy, used 25 35 kcals/kg/d for acute care pt
- For protein, used moderately stressed state of 1.0-1.2 g/kg

- For fluids, used 25-40 ml/kg/d as most common method for adults
Biochemical Lab Tests
- Plasma glucose = 654 mg/dL, high ( 70-110 mg/dL)
- HbA1C = 9.4%, high (3.9 5.2%)
- Serum osmolality = 349 mOsm/kg, high (285-295)
- Sodium = 159 mEq/L, high (136-145 mEq/L)
- Prealbumin = 13, low (16-35 mg/dL)
- Cholesterol = 341 mg/dL, high (120-199 mg/dL)
- TG = 216 mg/dL, high ( 35-135 mg/dL)
- HDL = 33 mg/dL, low (> 55 mg/dL)
- LDL = 239 mg/dL, high (<130 mg/dL)
- C-reactive protein = 3.1 mg/dL, high ( <1 mg/dL)

2. Nutrition Diagnosis (PES)

Overweight/Obesity (NC-3.3) R/T high fat, high Kcal diet and lack of exercise habit AEB
high TG levels of 216 mg/dL, high cholesterol level of 341 mg/dL, low HDL of
33mg/dL, high LDL of 239 mg/dL, an obese BMI of 30.9 kg/m2 and %IBW of 153%.

Limited adherence to nutritional related recommendations (NB-1.6) R/T consumption of

a poor diet especially for Type 2 diabetic patient, inadequate exercise and lack of blood
glucose monitoring AEB excessive thirst, episode of HHS, dangerously high blood
glucose of 654 mg/dl and HbA1c = 9.4%
3. Nutrition Intervention

Nutrition counseling: Nutrition-Related Behavior Modification Therapy

1) Reinforce the importance of proper nutrition (especially for Type II diabetic)
2) CHO counting as they relate to the patients medical needs
3) Importance of regular glucose monitoring, Stress importance of SFM and spacing out
CHOs throughout the day to help control blood glucose
4) Provide 2-day Meal Plan
5) Educate Pt on proper TLC diet, importance of fruits/veggies, fiber, low sodium and
increasing intake of N -3 FA
6) Educate Pt on importance of hydration, proper lean protein intake and replacing
animal proteins with plant proteins for reduced cholesterol intake
7) Educate Pt on importance of decreasing trans and saturated fats, consuming <
200mg/d of cholesterol and limiting daily fat to 25-35% of daily calories.
8) REC meal planning and make meals ahead of time to easily eat and take with pt
during busy work weeks
9) REC eliminating alcohol intake
10) REC increasing physical activity to at least 30 min/d to increase HDL and decrease
LDL cholesterol
Coordination of Nutrition Care
1) Referral to a certified diabetes educator

2) Referral to an exercise physiologist to start exercise routine and importance of staying

active for disease states
3) Encourage constant contact with healthcare provider for long term success
Short Term Goals
1) Effective immediately, Blood Glucose self-monitoring performed before meals, at
bedtime and before exercise
2) Within one week, patient will learn skill of CHO counting at meals
3) Within 2-3 wks, begin a regular exercise program of at least 30mins 5x/wk
4) Weight loss of 1-2 # per week, with a goal to lose 10% of BW within the next 3
months
5) Reduction of BG to <145 mg/dL in 2-4wks
6) Decrease HbA1c <7% in 3 months
7) Normalize TG in 2-3 mo
8) Normalize CRP within 1 mo
9) Normalize blood sodium levels to normal ranges within 1-2 mo
Long Term Goals
1) Continued weight loss of 1-2#/wk to reach UBW within 6mo
2) Consistent monitoring of blood glucose levels in effort to reduce blood glucose level
to <145mg/dL
3) Reduce HbA1C level <5.2% in 3 months.
4) 60-90 min/d moderate exercise 5x/wk
5) Normalize cholesterol levels within 3 -6 mo (including LDL and HDL)

4. Monitoring and Evaluation

1) F/U phone call q 2 days to assess Pts adherence to meal plan, and inquire about
meeting with exercise specialist
2) F/u appointment within 2 weeks, assess adherence to TLC and DM diet and ability to
cook and prepare meals at home for meal planning
3) Ask Pt to complete a 3 day food record (2 week days, 1 weekend day) and bring in
during next visit
4) Ask Pt to complete a weight log q day and assess weight, weekly, to monitor trends in
weight loss
5) Reassess lab values for blood glucose, HbA1C, HDL, LDL, cholesterol, and TG
within 3mo, determine if within normal range

X Amanda Cravinho MS RD (electronic signature)

__________________________________________
Part B: Meal Plan and Budget

DAY I
Breakfast:
cup plain low-fat yogurt
3 tbsp wheat germ (stirred in yogurt)
6 almonds, sliced (stirred in yogurt)
1 Bagel
1/8 medium avocado (spread on bagel)
Morning Snack:
1 oz fat free Swiss cheese
1 sliced apple (raw, 2-inches across)
oz pretzels
Lunch:
2 slices wheat bread
1/8 medium avocado (spread on bread)
1 oz white meat chicken, skinless
C Blackberries (raw)
1 C raw tomato
Afternoon Snack:
1 cup raw spinach
1 tbsp reduced-fat salad dressing
whole wheat English Muffin
1 C almond milk, unsweetened
Dinner:
2 oz fresh cod, baked
1 C cooked asparagus, steamed
1 C mashed potato
1 C almond milk, unsweetened
Evening Snack:
1 oz canned tuna, in water
1 slice wheat bread

Day 2
Breakfast:
1 slice wheat bread (toasted)
1/8 medium avocado (spread on toast)
cup plain low-fat yogurt

6 almonds, sliced (stirred in yogurt)

1 C cooked oatmeal
Morning Snack:
1 small banana
oz pretzels
1 oz fat free Swiss cheese
Lunch:
1 cup raw spinach
1 oz white meat chicken, skinless
1/8 medium avocado
17 small grapes
1 whole wheat English Muffin
Afternoon Snack:
1 C raw tomato
1/8 medium avocado
whole wheat English Muffin
C plain low-fat yogurt
Dinner:
2 oz white meat chicken, baked
C cooked spinach, steamed
C cooked zucchini, steamed
C lentils, cooked
C sweet potatoes, baked
1 C almond milk, unsweetened
Evening Snack:
oz pretzels
1 oz fat free Swiss cheese
Part C: Shopping List for 2-day Meal Plan
ITEM
Yogurt, plain
low fat
Bagel
Oatmeal
Almonds*
Wheat
Bread*

PLACE OF
PURCHASE
Food for Less

Vons
North Park
Produce
Sprouts
99cent Store

MEAL

AMOUNT

TOTAL COST

Breakfast Day 1 &

2, Afternoon Snack
Day 2
Breakfast Day 1
Breakfast Day 2

2 lb
container

$1.99

AMOUNT
SPENT
$1.99

1
8 oz. bulk

2 for $0.99
$0.99/lb

$0.49
$0.50

Breakfast Day 1 &

2
Breakfast Day 2,
Morning Snack Day

12 nuts
bulk
1 loaf

$4.99/lb

$0.50

$0.79

$0.79

Wheat Germ
Haas
Avocado*

Sprouts, Bulk
Sprouts

Apple*

North Park
Produce
Food for Less

Swiss
Cheese, lowfat*
Pretzels*

Vons

Banana,
Organic*
Chicken
Breast,
Skinless*
Black
Berries*
Tomato*

Sprouts

Spinach*

Sprouts

Grapes*
English*
Muffin,
wheat
Italian
Dressing,
reduced fat*
Almond Milk,
unsweetened
*
Fresh Cod*

Sprouts
Sprouts

Asparagus*
Russet
Potato*

Vons

2, Lunch Day 1,
Evening Snack Day
1
Breakfast Day 1
Breakfast Day 1&
2, Lunch Day 1 & 2,
Afternoon Snack
Day 2
Morning Snack Day
1
Morning Snack Day
1 & 2, Evening
Snack Day 2
Morning Snack Day
1, Evening Snack
Day 2
Morning Snack Day
2
Lunch Day 1 & 2,
Dinner Day 2

2 oz
1

$8.99/lb
$0.77/ea.

$1.12
$0.77

1 medium

3lb for $0.99

$0.29

1- 8oz
block

3 for $5

$1.67

1-10oz
bag

2 for $4

$2.00

1 loose

$0.68/lb

$0.53

1 8 oz
breast

$2.99/lb

$1.50

1-5.6 oz
pack
1 lb

2 for $5

$2.50

$0.88/lb

$0.88

5 oz

$1.98/ea.

$1.98

lb
1 pack/ 13
oz

$0.88
$1.99

$0.44
$1.99

1 - 16 oz
bottle

$1.49

$1.49

Afternoon Snack
Day 1, Dinner Day
1&2
Dinner Day 1

1 - 64 oz

2 for $5

$2.50

2 oz

$2.29

$0.29

Dinner Day 1 & 2

Dinner Day 1

1 lb
5lb bag

$1.98/lb
$0.98/ea.

$1.98
$0.98

Sprouts

Lunch Day 1

Sprouts

Lunch Day 1,
Afternoon Snack
Day 2
Lunch Day 2,
Afternoon Snack
Day 1, Dinner Day
2
Lunch Day 2
Lunch Day 2,
Afternoon Snack
Day 1 & 2
Afternoon Snack
Day 1

Vons

Sprouts

North Park
Produce
Sprouts
Sprouts

Zucchini*
Sweet Potato
Lentils*
Canned
Tuna, in
water*

Sprouts
Vons
Sprouts
99cent Store

Dinner Day 2
Dinner Day 2
Dinner Day 2
Evening Snack Day
1

1 loose
1 loose
lb bulk
1 5oz
can

$0.88/lb
1.69/lb
$0.99/lb
$0.79

Total

$0.62
$0.80
$0.50
$0.79

$29.89

*Special Coupon Sale

Part D: Nutrition Analysis

A healthy diet and paying attention to what your body needs is extremely important and
can even be the difference in life and death. In the case of Cindy, she was admitted to the hospital
in a hyperosmolar hyperglycemic state (HHS). HHS is 1 of 2 serious metabolic derangements
that occurs in patients with diabetes mellitus (DM) and can be a life-threatening emergency. For
Cindy, this episode was brought on by stress, unintended weight gain causing inflammation, and
a worsening heart condition resulting in a diagnosis of cardiovascular disease (CVD). Cindy was
diagnosed with type II diabetes mellitus 1 year prior and the acute hospital stay due to HHS
points to the fact that Cindy has not taken her type II DM seriously and has neglected her
nutrition recommendations necessary for her dx of HTN, HLP and type II DM. Immediate action
is being taken to create a meal plan for Cindy as macro and microvascular complications are
apparent. Cindys new dx of CVD can be described as a group of interrelated disease that include
coronary heart disease (CHD), atherosclerosis, hypertension, ischemic heart disease, peripheral
vascular disease, and heart failure. Healthy diet and body weight, normal blood glucose levels,
normal blood pressure and being physically active can to prevent CVD and manage type II DM
symptoms.
Cindy was prescribed a Therapeutic Lifestyles Changes diet to help lower her cholesterol,
specifically lowering LDL cholesterol and increasing HDL cholesterol. The TLC diet focuses
on modifying diet, maintaining healthy weight and increasing physical activity to at least
30 min 5x/wk in order to benefit the patient. In addition, the diet limits saturated and trans fats,
limits cholesterol to less than 200 mg/d, limit total fat consumption to 25-35% of total calories
per day, increase consumption of N-3 FA, and consume at least 20-30 g of dietary fiber each day.
Getting enough N-3 FA is especially important to decreased inflammation and Cindys current
CRP status of 3.1 mg/dL.
Cindy has been educated on CHO counting by using exchanges to allow for SFM and
appropriate spacing of CHOs throughout the day. Monitoring and controlling blood glucose as
well as follow the Cardiac-TLC diet is imperative for Cindy to carry out if she wants to reduce
symptoms of her disease states. I have advised her to follow a 2000 calorie diet. 50% of calories
are to come from complex CHOs, 20% of calories are to come from protein, and 30% from fat.
Furthermore, protein consumption of the upper end of her recommendation is important due to
her moderately stressed status and recent hospitalization.

Meal plans created for Cindy were designed to offer quick nutritious meals that can be
prepared fresh and taken on the go during her busy work schedule. Food items were mindfully
chosen to stay within the DRIs and recommendations of her Cardiac-TLC, 2000 kcal DM diet.
The following analysis will reflect the adherence to the diet plan and nutrient recommendations.
The meal plan for Day 1 contains 1,567 total calories which is under the recommendation
of 2,000 total calories. For Cindys stature this calorie amount is appropriate as it will allow her
to lose the weight she recently gained. Of the calories, 63% were from CHO, 24% were from
PRO and 17% were from fat. This means that the meal plan is meeting recommendations for
PRO and even slightly exceeding it. In Cindys case slightly high PRO is beneficial due to her
moderately stressed state as this will add in healing and maintenance. CHO is a bit high and may
need to be modified in order to meet guidelines for a diabetic diet at 50% CHO to keep blood
glucose levels stable. It is great to see such low fat from this meal plan at 17%. For the time
being this will help to quickly lower Cindys high cholesterol and TG levels to a heart healthy
range. In addition, saturated fat is only at 3% which is way below the DRI of < 10% and
cholesterol at 78 mg is on the lower end of the DRI of < 300 mg. Furthermore, fiber is high 44g
way over the DRI of 25g and is coming mostly from whole grains important for glucose control
and cardiovascular health. Myplate recommendations were met protein at 5 oz, fruit at 1 C,
met for veggies at 3 C, over for grains at 9 oz compared to the recommendation of 6 oz and
under for dairy at 1 C. For Cindys diet these values seem appropriate as she wants lots of
whole grains and fiber and low cholesterol.
It is important to note for Day 1 that most micronutrient DRIs were met, however, there were
a few concerning micronutrients imperative to heart health and diabetes management that were
not within guidelines. These micronutrients include potassium, iron, sodium and Vit D. Most
concerning is the high sodium level of 2,836 mg compared to the DRI of < 2,300 mg. This will
put Cindy at a higher risk to become more hypertensive and is harmful to her dx of CVD. This
high level may have been from carbs, such as bread and English muffins, and salad dressings. To
lower these sodium levels substituting fruits and veggies for salty carbs would be recommended.
Potassium is important in maintaining blood pressure, iron important in maintaining blood
volume, oxygen levels and fighting fatigue and Vit D beneficial in reducing inflammation. All of
these were low for Day 1 but the lowest was Vit D at 7 ug compared to the DRI of 15 ug. Vit D
can be hard to obtain from whole food sources. Some additions to the diet that can provide more
Vit D while still remaining low-fat and heart healthy are mushrooms and oysters.
The meal plan for Day 2 provided a bit more calories at 1,732 but was very similar to
Day 1 in macro and micronutrient content. PRO accounted for 24% of calories, CHO accounted
for 59% of calories and fat accounted for 20% of calories. These are acceptable ranges when
comparing recommendations. I would make the same recommendations as Day 1 to account for
overage on CHOs. Saturated fat is low for Day 2 at 7% and cholesterol continued to stay low at
129%. My plate recommendations were also similar to Day 1. Extremely beneficial of the Day 2
meal plan was the low sodium level of 1710 mg compared to the DRI of <2,300 mg. This will

help with heart health and is a meal plan that Cindy will want to replicate to keep sodium levels
low. However, there is still a deficiency of vit D at 3 ug compared to the DRI of 15 ug. This is
lower than Day 1 and may point to the fact that fish was not consumed on this day. Fish, oysters
and mushrooms should be increased in future meal plans for Cindy.

Part E: My Experience
This project was a very eye opening experience. Looking back on this project I realize I
took for granted the luxury of not having to buy groceries on a budget. The budgeting aspect was
the most difficult part of this project for me as the $30 2-day meal plan proved difficult when
adding variety and good quality whole foods into a high risk patients diet. The patients disease
state relied heavily on their diet and the food chosen needed to be heavy on whole grains, fiber,
N-3 FA, lean proteins and fruits and veggies. A lot of time went into searching for coupons in
order to get the patient these heart healthy foods. Many alterations in the meal plan had to be
made in order to accommodate the limited budget resulting in less variety. Even though the
budget limited variety for the patient, this offered a challenge to make each meal or snack as
creative as possible. For example, avocado was used not only as a source of fat but also as a
substitute for spreads, making meals more visually appealing and texturally satisfying for a
patient used to a rich, high fat and processed diet. In addition, choosing avocado as a fat source
provided the patient with good fats like N-3 FA to increase HDL, decrease LDL and decreased
harmful inflammation throughout the body. Planning the meals on a budget allowed me to
experience first-hand what it would be like to create a heart healthy and glucose controlled meal
plan as a dietitian. The strict budget taught me tools and resources to seek in my future career. I
now feel more prepared to find food combinations that not only taste good, but look appealing in
order to introduce new foods items to a patient who would not normally choose them for
themselves.
Another challenging aspect of the project was choosing the correct exchanges and then
spacing them evenly throughout the day while also choosing the best food item required for the
patient based on the exchange. This was by far the most important lesson that this project taught
me. As a future dietitian, my eyes were opened to the foresight and planning that is involved in a
using exchanges to create a meal plan for a patient with multiple disease states. After all my
planning and altering food items that would not fit in the budget, I was disappointed to see that
my nutrient analysis did not reflect the same macronutrient contribution as my exchange table
outlined. This was a huge learning opportunity to shape my understanding of just how difficult
the parameters of diabetic diet can be. My goal was to focus on spacing out carbohydrates
throughout the day and decreasing fat intake for the patient while stiff choosing foods the patient
would enjoy. Even though I accomplished this goal in my meal plan, macronutrient distribution
was shifted and the patient ended up receiving more calories from CHOs than anticipated. The
challenges I encountered in this project helped to prepare me in my desire to be a clinical

dietitian specializing in diabetes. This was the first hands on project I completed that focused on
diabetes and I feel that it will only further prepare me to succeed in my career goals.
APPENDICES
Appendix A: Carbohydrate Exchanges for Meal Plan
Appendix B: Nutrient Report for Day 1 from supertracker.com
Appendix C: Nutrient Report for Day 2 from supertracker.com
Appendix D: Coupons for Special Sale Items Purchased