Nutrition Assignment

Rehmatullah Khan Aga Khan University 4th March 2013

Demographics Name: swaliha saleem Age: 20years Gender: female Marital Status: Single Occupation: Student on home economics Site: AKUH, chc Case History: Ms swaliha was young female patient who presented to us in chc clinic at aku with the complains of fever and sore throat. She had been having this complain from two days and the fever was remitting and 39 F. it was continuous and no history of chills and riogors. In the review of symptoms her mother (who was the attendant) informed us that she has gained weight in last 6 months and they were worried about this weight gain. On further inquiry it came to our information that the family has recently shifted (one year back) to Islamabad and the whole family setup, their life styles etc have been changed due to it. They have come here for her brothers wedding. Past Medical History: She had her septoplasty five-six years back due to repetitive allergic sympyoms. No other significant history. Past Surgical History: septoplasty Menstural Hx: 5/28, menarche at 12, normal flow, slight dysmennorhea (around 4-5 on pain scale) Family History: Mother had HTM, DM, father had IHD. Social History: College student with a sedentary lifestyle, no exercise, daily activities involve watching movies, tv shows and frequent out-eating. Sometimes sheesha with friends (two three times in a month from last two years)

Drug History: Panadol for fever

Physical Examination Weight: 80 kilograms Height: 160 cm BMI: 31.25 Vital Signs Pulse: 80 beats/minute Blood Pressure: 110/70mmHg Respiratory Rate: 14 Temperature: 39 F The general Physical examination was unremarkable Assessment and Plan: Strep throat Obesity Smoking sheesha

Dietary Assessment: Nutrition History Ms swaliha has breakfast at her home which usually consists of homemade paratha daily with egg or curry and halwa puris on the weekends are a must. For lunch she generally consumes 2 rotis plus saalan at home. Finally, at dinner he normally consumes a similar amount of food. However, her daily intake is around 4-5 meals a day. she tells us that she consumes snacks on daily basis at her college and then at her home in the evening. This includes a mid-morning snack of either rolls or samosas at her college with her friends. Then she states that she generally has an evening snack of tea

accompanied by fried/baked items such as pakoras, brownies, donuts e.t.c. In addition, she states that she goes out for fast food approximately 3 times per week and food items generally include roll parathas, fried chicken, zinger burgers, French fries e.t.c. she tells us that she does not like fruits and vegetables except for mangoes and the day her mom cooks vegetables at home that is her party day as she goes out for eating. She states that this diet has become part of her lifestyle since she has moved to Islamabad and made new friends out there and due to increase security there compared to Karachi her eat-outs have increased considerably.

Meal Breakfast

Foods 1 Paratha

Total Proteins Carbohydrates Fats Calories (g/serving) (g/serving) (g/serving) 250 11 46 13

Omelette 1 cup of tea Lunch 2 nan Chicken/Beef Curry Dinner Chicken/Beef Curry 2 chapatees Yogurt/lassi

220 130 110 455 455 75 x 2 149

6.24 8.3 4 41 41 3.3 8.5

0.43 20.6 19 19 19 16 11.5

9 0.2 5 50 50 0.41s 8.1

Snacks

Brownies/donuts

215x2

25

92

30

2 biscuits

100 x 2

1.8 6.3

13.7 48.1

4.8 17.6

Samosa/pakoraas 360 etc

Estimated Total Calories

2910

We saw very easily that she is not taking a balance diet and being a student she spends most of her time in the class room (8am till 2pm) and the rest of her time is spent mostly in her room where she loves to read books and watch movies and definitely have snacks along with the reading and watching tv. She said that despite the fact that a very beautiful park is near her home in Islamabad but she has not visited the place in one year and neither has she intended to go there for a regular walk. So Her BMI was 31.25 Based on guidelines provided by WHO, she was classified as OBESE. Furthermore her daily caloric requirements were calculated using the Harris Benedict Formula for sedentary lifestyle and the Metric BMR formula. BMR= 66 + (13.7 x weight in kilos) + (5 x ht. in cm) (6.8 x age in years) BMR=1826 Caloric Req. = BMR x 1.2= 2192 calories Based on the calculations above it is obvious that Ms. Swaliah is consuming around 700 calories extra on dialy basis. Calculations show that 500 Cal in excess per day increases upto 1lbs per week. At this rate, if left uncontrolled having a family history of DM, HTN and CAD she will be a high risk for developing diabetes mellitus, uncontrolled hypertension and coronary artery disease in the near future. Her dietry habits and sedentary lifestyle, in addition, having a strong family history of DM, HTN adds to her health risks. We had to advice her very strictly regarding the dangers her current diet and lifestyle poses to her health.

Dietary Plan Since, she currently has issues with obesity and is at the risk of developing other chronic diseases in the near future we decided to advise Ms. swaliha on the DASH diet plan. The DASH eating plan is a balanced planned that was created to decrease blood pressure. This plan is low in such things as saturated fat, cholesterol. It focuses on increasing fruits, vegetables and low fat dairy products. Is created to increase the fiber content of those taking the diet to include such things as whole grains, beans, seeds and nuts. Lastly, it contains fewer sweets, added sugars and sweetened beverages and red meat as compared to a typical diet. In summary it is a complete balanced diet with evidence that it prevents the development of future complication for her such as hypertension and DM etc. moreover a daily brisk walk for 30 minutes was advised and her snacks were reduced in an orderly manner i.e we asked her to switch to low calorie snacks such as pop corns (without butter) so that she can take small steps to reduce her snacks because sudden changes have always failed. Daily Nutrient Goals Used in the DASH Studies (for a 2,000-Calorie Eating Plan) Total fat Saturated fat Protein Carbohydrate Cholesterol Sodium Potassium Calcium Magnesium Fiber 27% of calories 6% of calories 18% of calories 55% of calories 150 mg 2,300 mg* 4,700 mg 1,250 mg 500 mg 30 g

Thus we decided after much negotiation with our initially reluctant patient to add approximately 30 min of walking/ day to her dietary plans.

To ensure better compliance we encouraged our patient to keep a food diary that can help her record everything that she eats so that she may keep an eye on her intake. For breakfast we advised him to decrease the intake of fried breads such as puri and parathas by decreasing the amount consumed to every alternate day instead of every day, with the intention of slowly encouraging him to stop its use entirely and substitute with breads and then finally with bran bread. In addition we asked her to take no more than one egg yolk with her breakfast. Moreover we noticed that in lunch she takes two naans that have higher calorific value than the two cahaptees she consumes in dinner, hence we advised her to take two cahapaatees in the luch as well. Finally we asked her to reduce her snacks at her college by keeping herself busy during the breaks and using sugar free chewing gums We also did opportunistic counseling regarding sheesha and explained to her the dangers it poses to her health and the fact that one sheesha contains as much tobacco as 20 cigarettes. She explained to us that it usually occurs at weekends with her friends, so we counseled her that peer pressure is an understandable reason but she need to explain it to her friends as well the danger of sheesha and the way it has been sugar-coated by the sheesha industry so that youth is more comfortable in having sheeshaas than cigarettes. At the conclusion of our meeting we drew a rough sketch of a food pyramid for her and explained the concept of balanced diet. Then we gave her several pamphlets from our AKUH CHC to advise her on how to minimize her risk for getting the complications of obesity .

References 1. 2. 3. 4. 5. 6. 7. WHO guidelines for BMI-www.who.int http://www.mayoclinic.com/health/dash-diet http://dashdiet.org DASH eating plan, NHLBI Wikipedia Caloriecount.com Epocrates software for calculating BMI etc.