___________________________________________

NDFS 4900

Leukemia with Bone Marrow Transplant

Case Study

__________________________________________________________

Reviewed and analyzed by:

Lea Palmer

Introduction

LP visited the outpatient-registered dietitian (RD) at Logan Regional

Hospital on October 18, 2015 in preparation for a bone marrow transplant (BMT)

due to the progression of acute lymphoblastic leukemia (ALL) in the patient. The

following case study addresses the disease state and nutrition care plan done for

the patient.

Profile and Social History

LP was a 22-year-old, Caucasian female. Patient was divorced and had

lived with roommates in Logan, Utah for two years. LP was employed, while

attending classes and rotations for a dietetic program at a local university. Family

lived in Arizona and visited patient 1-2 times per year. At the age of six, LP was

diagnosed with acute lymphoblastic leukemia (ALL). Patient received

chemotherapy twice during that time and had a seemingly successful remission.

In the past year, symptoms of ALL appeared once again for a month and

progressed to a complete relapse. Attempts of intrathecal chemotherapy were

unsuccessful and the medical doctor (MD) highly recommended having an

allogeneic BMT. After finding financial community support and a family donor, LP

consented to having an allogeneic BMT. In preparation for this organ transplant,

LP was treated with a low dose radiation treatment along with a high dose

immunosuppressive therapy. The MD also ordered a strict low bacteria diet with

20% of calories coming from protein, and consistently consuming 30-60

carbohydrates (CHO) every 3-4 hours.

Literature Review

ALL is a form of acute leukemia characterized by abnormally high amounts

of lymphoblasts or lymphocytes in the bone marrow and blood. ALL is the most

common form of cancer in children1. In fact, two thirds of ALL cases are children2.

ALL can also be found in adults, especially as a relapse from a childhood

diagnosis. When too many lymphoblasts or lymphocytes are produced,

suppression of normal hematopoiesis (synthesis of new blood cells) occurs. An

individual can show signs of ALL with frequent fevers, fatigue, easy bruising and

bleeding2, being prone to infections, having pain in bones or stomach, and having

lumps around neck, underarm, stomach, or groin. During medical assessments of

such individuals (child or adult), a MD will look at physical exams, family history,

complete blood count (red blood cells (RBC) platelets, white blood cells (WBC),

HgB, and percent (%) RBC), blood chemistry studies (what is being released into

blood by organs and tissues), peripheral blood smear (blast cells), and bone

marrow aspiration and biopsy. After all the samples have been obtained, the best

way to determine if someone has ALL is by doing immunophenotyping on the

samples3. Typically when a patient has ALL, the initial treatment includes a

combination- chemotherapy (which includes a combination of prednisone,

vincristine, antracycline, and any other medications the doctor feels necessary).

Sixty to eighty % of cancer patients typically have a complete remission after

chemotherapy3. If the patient experiences a relapse, however, chances for

survival decrease with increased one year mortality risk, even if a second

chemotherapy is administered. At this point, reinduction therapy followed by an

allogeneic BMT should be considered if patient is under the age of 553. A BMT is

the process of restoring damaged stem cells in an individual. The three types of

transplants, according to the national cancer institute, are autologous transplants

(stem cells are harvested from patient), syngeneic transplants (stem cells are

donated by an identical sibling of patient), and allogeneic transplants (stem cells

are donated by a relative or non-related individual) 3. These transplants are done

to make it possible for the ALL patient to go through the extremely high doses of

chemotherapy treatments needed for survival4. After the doctor has ordered a

BMT, a RD can then do a nutritional care plan. For oncology patients, malnutrition

is often the focus point of the nutrition assessment. Physical assessments (such

as measurements of muscle mass, subcutaneous fat, ulcers, change in appetite,

functional indicators, fluid accumulation), social history (social support), and client

history (family health history, medical treatments or therapy, other diseases

including cancer cachexia) are all important to look at when assessing for

malnutrition. Unintentional weight loss is extremely common in ALL patients, so

getting to a healthy weight and maintaining that weight is critical to preventing

further complications 5.

Additionally, immunosuppressive therapy will lower healing rate, which

increases the chances of secondary cancer, or other diseases. This means that

adequate protein intake is important for tissue reconstruction during cancer

treatment and recovery. The Institute of Medicine and current Federal Guidelines,

as well as the American Heart Association (AHA) recommend that 10-35% of

energy should be in the form of protein. With higher risk factors, there are higher

protein needs 6. In the case of ALL, diagnosis on nutrient intake and malnutrition is

common and essential. During an intervention, any form of that malnutrition needs

to be addressed quickly and immediately in order to prevent mortality. Education

can be given on the protein and calorie needs of the individual as well as the

importance of having a well balanced diet.

Neutropenia (weakened immune system) from the immunosuppressive

therapy is another issue that should be suppressed. Safe food handling should be

taught for this. There is conflicting evidence on whether or not a fully microbial

free diet (neutropenic diet) is actually effective or not, as will be discussed later,

but in this case the patient went through the neutropenic diet to prevent further

infections. A neutropenic diet means that the majority of foods are to be cooked,

and all foods must be in a safe temperature zone. Malnutrition is fairly common

among ALL patients due to the numerous diet restrictions. Patients are put at a

high nutritional risk and therefore must be evaluated and monitored frequently.

Each abnormal component looked at in the initial assessment should be

reassessed during each follow up visit to monitor and evaluate any status

changes.

A BMT to a patient with ALL is highly stressful on the body, but can be the

key to survival. Intensive nutritional and medical care is required, and with strict

adherence, an individual with ALL can go into remission and live a healthy life

once again.

Assessment

Upon admission, LP weighed 55.45 kilograms (kg) and was 171.6

centimeters (cm) in height. Body mass index (BMI) was 18.8 kg/m2 indicating a

normal, healthy weight7. A wrist circumference of 15.5 cm and an elbow breadth

of 43 mm indicated a small frame size 8. Waist measured at 70 cm indicating a

low risk for obesity, but when compared to hip measurement of 82 cm, the waist

to hip ratio was .85 indicating a high risk for obesity or other related diseases. The

concern for risk was lowered, however, as the patient reported overall healthful

diet and active lifestyle. LP had a subscapular skin fold measurement of 9 mm

placing patient between the 5th and 10th percentile range (normal range) 7. A tricep

skinfold measured 6 mm, putting patient below the 5th percentile range and

indicating a low fat composition 8. Midarm circumference measured at 26 cm

making the AMAc 39.8 cm (indicating average musculature ranking) 7. LP had an

ideal body weight (IBW) of 56.25 kg, making a %IBW of 99%. Usual body weight

(UBW) is 56.8 kg and weight has been stable for the past two years. Weight was

maintained throughout the BMT diet prescribed.

LP was assessed and appearance was pale but healthy. HEENT was

unremarkable. No edema noted, and skin was in good condition. Notably, the liver

and spleen were enlarged possibly due to the damage done by the

immunosuppressive therapy drugs

Labs were obtained for LP upon admission with several abnormalities

reflecting the radiation, chemotherapy, hepatotoxicity, and nephrotoxicity. The

following is a summary of the labs received.

Lab Admit Analysis

WBC (white blood cells) 700 (low) The WBC count was low possibly due
to (d/t) the medications taken,
specifically cyclosporine, which is
known to lower WBC count9. Other
factors included the radiation: which
was suppressing bone marrow, and
decreasing WBC production; as well as
the cancer itself: which was
suppressing hematopoiesis including
WBC formation.
HgB (hemoglobin) 8.6 (low) HgB and Hct levels low possibly d/t the
Hct 34 (low) radiation causing the breakdown of red
blood cells (RBC). Levels could have
been low d/t low folate levels. Folate is
needed in the growth and production of
RBC.10
MCV 88 (WNL) With low HgB/Hct levels and a normal
MCV level, there was indication of a
chronic disease state, which in this
case was the ALL.11
Platelets 110 (low) The low platelet levels
(thrombocytopenia) could have been a
result of the ALL, which was
decreasing the production of platelets
in the bone marrow. The enlarged
spleen caused by the leukemia could
also have been harboring too many
platelets to fight the infection, and not
enough of the platelets were
circulating.13
Reticulocyte count .25 (low) Low reticulocyte count could have been
a side effect of the bone marrow
suppression that occurred with the
radiation and chemotherapy.
Reticulocytes are immature platelets,
so the low reticulocyte count could
have also been contributing to the low
platelet count.
Albumin 2.9 (low) Low albumin levels are an indicator of
an acute phase reaction, which in this
case was ALL. The ALL was causing
the body to burn more calories than
being consumed, which put the body in
a hyper metabolic state and lowered
albumin levels. It could have potentially

been lower d/t liver damage that was

caused by the immunosuppressant
medications taken. Low albumin levels
could have also indicated chronic
malnutrition, but was not an accurate
indicator of current malnutrition status.7
Total Protein 5.5 (low) Total protein levels were low d/t the low
albumin, RBCs, and WBCs.
Prealbumin 13 (low) Decreased prealbumin levels were
potentially indicators of the acute
phase reaction. It could have also been
a sign of protein or calorie
malnutrition.7
CRP 12 (WNL) Within normal limits
Sodium 138 (WNL) Within normal limits
Potassium 3.7 (WNL) Within normal limits
Chloride 108 (high) A high chloride level (hyperchloremia)
was potentially d/t the kidney damaged
caused by the methylprednisolone
medication taken.13
Phosphorus 10 (high) High phosphate (hyperphosphatemia)
levels were most likely caused by
kidneys not being able to regulate
phosphate excretion. This could have
been d/t the kidney damage or failure
from the immunosuppressive therapy
medications. 13
Total Co2 36 (high) CO2 is often an indicator of nutritional
status. These slightly elevated levels
could have indicated some type of
nutritional discrepancy.
BUN 24 (high) High BUN levels were possibly a of the
side effects of cyclosporine 9, but could
also be an indicator of dehydration.7
Creatinine 1.6 (high) High creatinine levels are another side
effect of cyclosporine 9
ALT 55 (high) High ALT levels indicated liver
damage, which was being done by the
cyclosporine. 9
AST 48 (high) In addition to ALT, AST also indicated
the status of the liver. Higher AST
levels indicated the liver damage that
could have been caused by the
cyclosporine. 9
bili 1.8 (high) High bili was a side effect of
cyclosporine 9

PATIENT 10.3 (short) With liver damage, PATIENT time is

(Prothrombin Time) typically longer d/t blood clotting too
slowly. The reason the labs were
longer could potentially be cause by
birth controls, or high consumption of
Vitamin K.14
Vitamin D 10 (low) Through cancer, radiation, and
immunosuppressive therapy, bone
marrow suppression was occurring,
which also broke down the Vitamin D
that was in the bone.9
Folate 99 (low) Folate is used in the production of
RBC, and since the therapy damaged
cells, the folate was rapidly being used
for cell/ DNA repair, and was not being
replenished fast enough through diet.
The actual cancer also could have
lowered folate levels. 9
Zinc 18 (low) Low levels of zinc were a side effect of
methylprednisolone. 9
Magnesium 1.3 (low) Low magnesium, or
hypomagnesaemia, was most likely
caused by kidney damage.14
Lactate dehydrogenase 2,500 High LDH levels indicated tissue
(LDH) (high) damage. This could have been caused
from the cancer, therapies, liver
damage, and kidney damage.9
Uric Acid 6 (WNL) Within normal limits
Fasting blood glucose 282 (high) High blood glucose levels were caused
by multiple factors. It might have been
an indicator of an acute phase reaction,
and could have been caused by the
stress of being in the hospital, by the
hypermetabolism, and was also a side
effect of the methylprednisolone.9

Altered lab values were potentially due to the high dose

immunosuppressive therapy (antithymocyte globulin, cyclosporine,

methylprednisolone, and metformin), malnutrition related to hypermetabolism,

leukemia itself, and the radiation.9 Cyclosporine has a side effect of decreasing

WBC production and causing liver damage (hepatotoxicity) and kidney damage

(nephrotoxicity). Both of these problems can increase the amount of lactate

dehydrogenase (LDH) in the blood, thus accounting for the abnormally high

levels. High levels of LDH can also indicate a lower survival rate of cancer and/ or

unsuccessful chemotherapy 9.

Kidney damage also increased the BUN, creatinine, ALT, AST, and

bilirubin levels. Another influential prescription was the methylprednisolone.

Methylprednisolone was a possible factor for the increased chloride levels,

decreased zinc levels, and increased fasting blood glucose. Metformin was

prescribed to assist in lowering those blood glucose levels 9, but there may have

needed to be a higher dose given in order to bring them lower. The increased

need for DNA repair required more folate and without increased consumption, a

folate deficit formed. Low folate levels along with effects from radiation could have

accounted for the low RBC count. A typical symptom of cancer is

hypermetabolism as the body uses more stores and sources to repair damage.

The hypermetabolism in the patient increased nutrient needs and d/t a possible

lack of increased nutritional intake, LP had signs of chronic malnutrition as

indicated by low levels of prealbumin, albumin, Vitamin D, and magnesium levels

14
. Atrophy of bone is typical with radiation 15, which was a possible cause of

lowered phosphorus value, and decreased reticulocyte count. Due to the low

count of reticulocytes along with an enlarged spleen, the platelet count was

abnormally low. The radiation also lowered all blood cell production, causing a

decreased total protein.

Medications/ Drug Nutrient Reactions9

10


Name Purpose Negative Food Side Effects

Interactions
Antithymocyte Immunosuppressant N/A Dizziness, fevers,
globulin to prevent organ weakness
rejection.
Cyclosporine Immunosuppressant K supplements Causes liver and
taken to prevent Salt substitutes kidney damage
organ rejection Citrus
Methylprednisolone Anti-inflammatory, Citrus Causes
(corticosteroid): Immunosuppressant hypoalbuminemia,
hormone kidney damage,
and increased
blood pressure
Metformin Anti-hyperglycemic Diabetic Diet Decreases liver
agent: potentiates needed glucose
the effect of insulin production,
decreases liver
function

Diet:

In preparation for BMT, LP was advised to consume a strict low bacteria

diet (or neutropenic diet). A high protein diet (minimum 20% of calories from

protein), and consistent carbohydrate intake every 3-4 hours of 30-60 grams was

also ordered. According to the Mifflin St Jeor equation, patient estimated energy

needs were 1,364 kcal/day. LP was at a high malnutrition risk, so consuming

more calories would not have had a negative impact on weight. Consider taking

out the word. A baseline 3- day diet recall, menu plan, and a 12- day food diary

were obtained with the following results.

During the baseline diet recall, average protein intake was 18% of total

calories, which was within healthy limits. The carbohydrates made up 45% of total

calories, which was on the low end, but within normal limits of a healthy range
7
.The most concerning component was the average calories consumed prior to

11


disease state, which was 1,158 kcal. LP was not meeting recommendations of

1,6664 kcal/day (based off of WHO standards for a healthy individual) 22. Patient

reported tiredness and difficulty focusing, which may have been a side effect of

inadequate energy intake.

Nutritional Diagnosis
LP was at high nutritional risk because of the impact the radiation,

chemotherapy, and diabetic effects of medications. Due to the patient expressed

knowledge deficit of food safety and a neutropenic diet, baseline diet showing 3

out of 3 days containing food inconsistent with neutropenic diet (water from tap,

temperatures not taken of prepared foods, fresh produce consumed without

proper sanitation), the patient has been diagnosed with an intake of unsafe food

(NB-3.1). This was related to a knowledge deficit and intervention was done to

reverse the problem.

Intervention

Medical Intervention: Allogeneic Bone Marrow Transplant (BMT)

When an individual is at notably high risk of a cancer relapse, medical

teams might consider a BMT. A patient would be considered at high risk if full

response to current treatment is not observed, or if a relapse occurs after a

previously successful treatment 16. In this case, the patient experienced a

successful treatment at a young age, and within the past year, experienced a

relapse, in which chemotherapy treatment was not proving successful for a

12


second time. With ALL patients, the likelihood of recovering from a relapse without

the use of a BMT is negligible and the moment the patient is not progressing with

a second treatment, the medical team typically starts discussing a BMT. The MD

recommended the patient receive an allogeneic transplant, which meant stem

cells were to be harvested from another individual (related or non related) versus

an autologous transplant where the stem cells would come from the blood or

healthy tissues of the patient. There are multiple phases of an allogeneic BMT. A

surgeon first harvests 700-1500 mL of bone marrow stem cells from a donor

whether it is from a family member or unrelated donor. The donor is then treated

with various recombinant growth factors to stimulate cell regrowth. Prior to actual

transplant, the patient is typically put through a high-intensity conditioning

regimen. This typically involves a high dose immunosuppressive therapy that will

suppress immune system cells in the body enough to prevent organ transplant

rejection. Due to this suppression, dietary treatments might be recommended in

order to prevent infection, illnesses, or other complications. After this regimen, the

actual transplant can be made. It is important to have experienced surgeons who

can work efficiently and quickly so as to prevent surgical infections on an already

compromised immune system. After the stem cells are transplanted, the surgeon

will follow-up with colony stimulating factors, anti-infective drugs, and more

immunosuppressants so that the body can successfully engraft the donor cells

and thrive without rejection or infection. A successful engraftment will occur within

10-20 days after a transplant. Thirty to forty percent of patients who had relapsed

after chemotherapy have had successful BMT, meaning the body is rid of all

13


cancerous cells9. Although 30-40% is relatively small, it is extremely high in

comparison to the almost guaranteed year mortality without the BMT. Transplants

are expensive and have quite a bit of risk associated with it, but can be the

difference between life and death.

Nutrition-Related Intervention: Neutropenic, high protein, consistent

carbohydrate diet

As per order of the MD, a neutropenic, high protein, and consistent

carbohydrate diet was chosen as an intervention for this patient. The patient

expressed a deficit in knowledge on the diet and was referred to an outpatient-

registered dietitian for further education and counseling.

During initial visit, the RD discussed with LP the components of the diet

order. The high protein component of the diet was ordered to build up damaged

tissue. Between the cancer destroying healthy cells, the radiation suppressing

bone marrow, and chemotherapy suppressing immune system cells, the body was

experiencing a vast amount of breakdown stress. By providing increased protein

into the diet, the patient had a higher chance of building those tissues back up to

a healthy status.

The consistent carbohydrate component of the diet was in regards to the

effects of Metformin, which was one of the medications in the immunosuppressive

therapy. Metformin potentiated the effect of insulin, and decreased glucose

absorption in the gastrointestinal tract. These effects were similar to the signs and

symptoms of diabetes, and to be controlled, a diabetic diet of consistent

carbohydrates was prescribed.9

14


Restriction of all raw fruits and vegetables, raw and undercooked meats,

raw nuts, unpasteurized dairy products, and unpurified water were the criteria that

characterized the neutropenic diet. Additionally, strict sanitation and safety

adherence was required during food preparation and storage16. This diet has

been ordered in many institutions when a patient has a suppressed immune

system shown by the neutrophil count. Neutrophil cells are white blood cells that

fight off infection, and when the count is less than 500, the immune system is

highly compromised. Neutropenic diets are ordered in order to prevent exposure

to infection-causing bacteria. In allogeneic BMT patients, it is recommended to be

on a neutropenic diet for 4-6 months post transplant, and for autologous patients,

it is recommended follow the guidelines for 1-3 months post transplant.

Although many hospitals and other institutions recommend neutropenic

diets, there has been a more recent controversy on whether or not this diet is

actually beneficial. In one meta-analysis study 18, several studies were looked at

comparing the neutropenic diet and a regular diet. When major infection rate was

looked at, there was no difference between the two diets but when fevers and

minor infection rates were added to the equation, there was actually a slightly

higher hazard ratio in the neutropenic diet patients (P=0.007). The risk of

bacteremia and fungemia was also equal between the two diets. Although the

idea behind the neutropenic diet is to avoid bacteria-caused infections, it might

actually be increasing that risk. The limitations on various foods increase the risk

of inadequate nutrient intake, including nutrients that build the immune system.

Fiber is another component of nutrition that enhances immunity. By primarily

15


having fully cooked foods in the diet, most of the fiber is removed from the diet

along with the benefits.

Neutrophils are destroyed in cancer patients, but there is another

component in the body that can enhance the immune system- the gastrointestinal

microbiotia. A neutropenic diet might potentially change the gastrointestinal

microbiotia composition, however, which could increase infection rates and

decrease nutrient absorption.

Current research is leading towards the conclusion that there is no benefit

to a neutropenic diet versus a normal diet following proper food handling

procedures. With this being said, not enough research has been done to

completely discredit neutropenic diets altogether, and due to the familiarity and no

severe consequences; many doctors will refer back to this diet. In this case, the

MD chose to put the patient on a neutropenic diet due to a high infection risk

history (e coli and c diff) and familiarity with the diet. The RD was asked to inform

the patient on the diet and counsel on various methods to be used.

The RD formed the following goals with the patient:

Patient expected to be able to follow the one-week diet plan made from

appointment and record consumption in a food diary for at least 75% of the

time.

Patient expected to be able to identify and utilize 5 new safe food-handling

techniques w/o assistance after discussion.

Patient expected to eat 30-60 g of carbohydrates every 3-4 hours 75% of

the time over two week period.

16


Monitoring and Evaluation

Adherence to intervention is critical for an ALL patient in order to prevent

severe complications including death. Due to the intensity of the intervention,

frequent monitoring and evaluation should be done. Frequent evaluation of meals,

as well as evaluation of patient understanding of BMT diet is recommended. The

RD checked and evaluated food and meals of food log 3 days after initial

assessment to monitor protein intake (FH-1.5.3), and energy intake (FH 1.1.1). A

follow-up appointment with the patient was scheduled 2 weeks after initial visit.

The follow-up appointment was to evaluate the patient understanding of BMT diet,

monitor the food intake and food safety techniques used. Evaluation on if patient

is able to successfully identify safe food was also performed (FH-6.2.6). If patient

adhered to RD recommendations, there was a high anticipation that infection risk

would decrease, quality of life (QoL) would improve, recovery time would

decrease, and hospital admission prior to BMT would be prevented.

Follow up information:

The RD met with LP for a follow-up two weeks after initial visit. During the

two weeks, patient weight remained stable with no fluctuation, and no other

anthropometrics that notably changed. LP kept a food diary that was discussed in

detail. It was observed that LP was compliant to the diet order and new goals

were set.

One point of discussion was protein intake. The patient food diary revealed

that on average, LP consumed the minimum amount of 20% calories from protein.

17


Due to overall good compliance, RD encouraged LP to focus on increasing that

protein intake to assist in tissue repair throughout medical treatment. The goal

was made to have a minimum of 20% calories from protein daily, rather than just

an average. Sources of protein within a neutropenic diet were discussed and

patient stated understanding and ability to increase protein.

A second discussion point was Omega 3 intake. In a 3 day analysis of the

2 week food diary, it was discovered that LP had a very low Omega 3 intake of .3

g. Education on Omega 3 sources and benefits were given to LP and a goal was

made to consume fully cooked fish two times a week to increase Omega 3 and

protein intake.

LP expressed difficulty consuming 30-60 carbohydrates every 3-4 hours

with adherence to sanitation. Patient had a very full schedule and was not home

very long, so most of the food was consumed away from home. RD and LP

discussed snacks that LP enjoyed and ways to properly prepare them at the

beginning of the week so that it would be easy to grab the food in the morning on

the way to work or school.

Additional recipes, and support group resources were given to LP for

assistance in BMT preparation. RD observed compliance and understanding and

patient adherence to new goals were expected.

Two-week diet summary

Prior to diagnoses and diet order, patient had no prior knowledge about

ALL or BMT. Throughout the two weeks, the patient expressed an extensive

18


change in lifestyle and meal preparation. The three main components of the diet

order were high protein intake, carbohydrate counting, and low bacteria.

The first component was protein intake. The patient expressed difficulty in

finding enough foods that were high in protein, while still low in calories to keep

the percent high. Patient found that adding protein powder, to supplement foods,

helped bring percent calories from protein up. Patient expressed nausea for first

couple days, which is potentially d/t chemotherapy and sudden high increase in

protein. As patient adapted to diet change, response to protein was improved.

Patient began to crave protein often; noticeable improvement in composition of

nails occurred (patient stated nails were much smoother and stronger), and

overall ability to adhere to protein recommendation simplified. Increase in protein

was the most drastic change for patient.

The second component was the carbohydrate counting. Some

chemotherapy medications impact the human body to have comparable

symptoms to diabetes. In order to control those symptoms, a consistent carb

intake is required. This patient expressed the challenge in remembering to eat

frequently enough, as well as making sure that there were just the right amount of

carbs in each snack or meal. Patient meals were noticeably smaller, but were

more frequent. In order to adhere to a consistent schedule, a timer was set to

remind patient to eat. Upon observation of patient diet log, RD noticed the last

meal one day was at 6 pm. After asking patient, it was discovered that patient

went to bed by 7 that night and therefore did not need to consume any food later.

Other than that occurrence, patient typically ate about 6 times a day. The patient

19


also expressed difficulty in adhering to the consistent carb intake while

maintaining a low bacteria diet. Patient carried a container of Clorox wipes and

hand sanitizer in backpack in order to simplify the challenge. Adherence to diet

was less challenging when snacks and meals were planned the day before. The

patient found that common components of a regular diet had more carbohydrates

than the patient realized (pasta, bagels, etc.). During a school rotation, patient

bought prepackaged food (cinnamon bears) to adhere to neutropenic diet but

quickly realized the carbohydrate count would only allow a couple bites before

entire meal was accounted for. Patient expressed quite a bit of hunger during the

period before the next. Despite the challenges faced, patient expressed an energy

balance consistently throughout the day.

The third component of the diet was the neutropenic part. Patient had an

understanding of proper food handling and safety precautions but found the

extremity of detail needed tedious. Patient found ways to schedule daily events

around eating times rather than eating on the go. Components of the neutropenic

diet included sterilizing counters and equipment before cooking, taking

temperatures, and eating without going anywhere to prevent cross contamination.

Patient found that carrying Clorox wipes and hand sanitizer around in bag helped

for busy days when meals needed to be consumed quickly. Patient also kept a

bleach bucket on the counter in the kitchen that was changed out daily for easy

access to a sterile rag for food preparation. Patient also found the convenience of

prepackaged foods during busy days. Patient expressed concern with cost of

such items, but continued to utilize the product because of the resulted increase in

20


nutrient content while maintaining a bacteria free diet on the go.

As part of the bacteria free component, patient was allowed to only drink

sterile, boiled water. Patient found the necessity to always have a sterile water

bottle throughout the day because of the limited sources of allowed water. Patient

had two days where the water bottle was left at home and patient had to spend

extra time and money to drive back to get the bottles between scheduled classes.

Patient expressed the diet as time consuming and challenging. A

misunderstanding on allergies was discussed in follow-up appointment. Patient

did not initially realize that bananas were off limits due to latex allergy, but after

repercussions of consumption after first day and patient looking up detailed

information, patient has avoided bananas. Patient expressed stress of craving

fresh produce constantly, knowing that the safest foods to eat have to be canned,

cooked, or frozen. Patient learned that in order to really adhere to this diet,

planning ahead of time was essential. Due to overwhelming information given

during initial visit, the follow- up visit included discussion of available resources for

recipes, menu planning skills, support groups, and referrals. The in-depth

education during the visit proved more beneficial to patient, and patient appeared

more optimistic and knowledgeable in current treatment.

Conclusion:

A patient going through chemotherapy and radiation in preparation for a

BMT must strictly adhere to oral intake recommendations. Medication reactions,

immune system failure, and other factors involved all affect how well an individual

21
 Day 1 (11/4/2015) 24.36 0.40 110.13 2.38 24.94 123.30 44.67 18.07
Day 2 (11/5/2015) 23.05 0.14 36.66 0 12.46 104.67 57.04 13.33
Day 3 (11/6/2015) 24.51 0.68 23.83 2.16 13.38 91.41 50.66 19.31
Average 23.97 0.41 56.87 1.51 16.93 106.46 50.79 16.90
% Recommendation 70.16 66.89 69.25

MonoFat TransFat Vit A-IU Vit A-RAE Caroten

Item Name PolyFat (g) Chol (mg) Water (g)
will heal. BMT is a critical
(g)
point that could
(g)
lead to remission
(IU)
or mortality,
(RAE)
and
(RE)

Lea Palmer
Day 1 (11/4/2015) 6.99 3.96 0.50 312.61 806.42 3579.71 203.56 145.66
having adequate nutrition throughout
Day 2 (11/5/2015) 16.73 13.37
this0.19
time is crucial
72.28
for survival.
606.41 12440.65
LP was
651.17
noted
1218.25
Day 3 (11/6/2015) 11.46 8.67 0.17 81.56 549.96 12178.29 668.32 1198.89
to adhere well to the prescribed
Average 11.73 diet,
8.66 which
0.29 increased
155.48 chances
654.26 9399.55for 507.68
survival854.27
of the
% Recommendation 43.24 35.50 51.83 24.23 72.53

BMT. Patient continued to follow the strict bacteria free, high protein, and
Retinol BetaCaro Vit B1 Vit B2 Vit B3 Vit B3-NE Vit B6 Vit B12
Item Name
(RE) (mcg) (mg) (mg) (mg) (mg) (mg) (mcg)
consistent carb diet until the BMT, at which time reassessment was done and
Lea Palmer
Day 1 (11/4/2015) 130.73 783.28 1.57 2.57 26.66 32.24 2.14 6.38

further nutritional care plans were then determined.

Day 2 (11/5/2015) 42.05 232.83 1.74 1.39 16.94 23.73 0.87 2.42
Day 3 (11/6/2015) 68.87 244.32 1.31 1.22 14.89 21.95 0.95 2.06
Average 80.55 420.14 1.54 1.73 19.50 25.97 1.32 3.62
% Recommendation 139.97 157.07 139.28 185.52 101.66 150.75

Page 1

22


Appendix

Assessment
Identification of safe food (FH-6-2.6)

Monitoring/Evaluation Diagnosis:
Identification of Safe food (FH 6- 2.6) Intake of unsafe food (NB-3.1) r/t immunosuppressant drug
therapy AEB pt reporting lack of food safety knowledge, 3/3
Monitor food intake and food safety days baseline contained foods inconsistent with neutropenic
techniques used through food log diet.

Intervention:
Nutrition Education: Disease management and prevention nutrition education (E-1.1)
Pt was taught importance of food safety and prescribed a neutropenic diet.

23


A 22 y/o F, Dx ALL at 6 y/o. Chemotherapy x 2 followed by remission and relapse.

Current wt 55.45 kg, ht 171.6 cm. BMI 18.8 (normal) with %IBW of 99% (well
nourished). Noted labs: low WBC, HgB/Hct, platelet, reticulocyte count, and total
protein r/t chronic medical state, medications, and radiation; low albumin,
prealbumin, and high fasting glucose r/t ongoing inflammation; prealbumin also
an indicator of possible protein deficiency or inadequate nutrient intake; high
chloride, phosphorus, LDH and low magnesium r/t kidney damage; high total
CO2 r/t poor nutritional status; low zinc r/t medication side effects; low Vit D, and
folate r/t radiation. Tx included immunosuppressive therapy w/ antithymocyte
globulin (No DNI known), metformin (diabetic diet needed), cyclosporine (K
supplement, salt substitutes, and citrus DNIs), and methylprednisolone (citrus
DNI) for BMT. Pt presented w/ hepatosplenomegaly (r/t ALL). PMH includes
multiple occurrences of e. coli, and c. difficile. PO PTA included adequate zinc
intake (9 u), low vitamin D intake (2 u), average protein intake (53g/18% total
calories), inadequate caloric intake (1,364 kcal). MD ordered microbial free, 20%
protein, and CHO count diet. Pt expressed concern on ability to CHO count.
Protein Intake (FH- 1.5.3); Energy Intake (FH 1.1.1); Glucose/ Endocrine profile
(BD 1.5); Identification of safe food (FH-6.2.6)
D Intake of unsafe food (NB-3.1) r/t immunosuppressant drug therapy AEB pt
expressed knowledge deficit of food safety and neutropenic, 3/3 days baseline
diet containing foods inconsistent w/ neutropenic diet (water from tap,
temperatures not taken of prepared foods, fresh produce consumed without
proper sanitation).
I Nutrition Education: Disease management and prevention nutrition education (E-
1.1) RD to collaborate w/ pt to plan 1-wk menu appropriate for BMT diet.
Discussion on recommended modifications for BMT preparation including food
safety, high protein intake, food and drug reactions, and CHO counting.

Pt expected to be able to follow the one-week diet plan made from

appointment and record consumption in a food diary for at least 75% of the
time.
Pt expected to be able to identify and utilize 5 new safe food-handling
techniques w/o assistance after discussion.
Pt expected to eat 30-60 g of carbohydrates every 3-4 hours 75% of the
time over two week period.
M/E RD to f/u x 3 days to check and evaluate food/meals with food log (Protein Intake
(FH- 1.5.3); Energy Intake (FH 1.1.1); Glucose/ Endocrine profile (BD 1.5).)
Evaluate pt understanding of BMT diet.
Monitor food intake and food safety techniques used through food log
(Identification of safe food (FH-6.2.6))

Anticipate pt adherence to RD recommendation will avoid complications that may

hinder a successful BMT, reduce infection, improve QoL, decrease recovery time,
and prevent hospital admission.

24


Baseline patient diet

Day 1:
Breakfast- Smoothie, toast with peanut butter
Lunch: Chicken, instant mashed potatoes, carrots and hummus
Dinner- Roasted Vegetables- potatoes, carrots, zucchini onions, milk

Day 2:
Breakfast: quinoa, warm blueberries, roasted coconut and walnuts
Lunch: Sandwich- tomatoes, ham, avocado, spinach, hummus
Dinner: Hawaiian Haystacks- rice, cream of chicken, pineapple, tomatoes, chow
mien noodles, olives

Day 3:
Breakfast: Toast, avocado, tomatoes, egg, and cheese
Lunch: Baked Ziti
Dinner: Peanut Butter and Jelly Sandwich

Baseline Nutrient Analysis

Nutrients Target Average Status

Eaten
Total Calories 2000 Calories 1158 Calories Under
Protein (g)*** 46 g 53 g OK
Protein (% Calories)*** 10 - 35% 18% Calories OK
Calories
Carbohydrate (g)*** 130 g 130 g OK
Carbohydrate (% Calories)*** 45 - 65% 45% Calories OK
Calories
Dietary Fiber 25 g 24 g Under
Total Sugars No Daily Target 30 g No Daily Target or Limit
or Limit
Added Sugars No Daily Target 7 g No Daily Target or Limit
or Limit
Total Fat 20 - 35% 40% Calories Over
Calories
Saturated Fat < 10% Calories 9% Calories OK
Polyunsaturated Fat No Daily Target 10% Calories No Daily Target or Limit
or Limit

25


Monounsaturated Fat No Daily Target 18% Calories No Daily Target or Limit

or Limit
Linoleic Acid (g)*** 12 g 11 g Under
Linoleic Acid (% Calories)*** 5 - 10% 8% Calories OK
Calories
-Linolenic Acid (% 0.6 - 1.2% 1.3% Calories Over
Calories)*** Calories
-Linolenic Acid (g)*** 1.1 g 1.6 g OK
Omega 3 - EPA No Daily Target 3 mg No Daily Target or Limit
or Limit
Omega 3 - DHA No Daily Target 21 mg No Daily Target or Limit
or Limit
Cholesterol < 300 mg 132 mg OK

Minerals Target Average Status

Eaten
Calcium 1000 mg 431 mg Under
Potassium 4700 mg 2132 mg Under
Sodium** < 2300 mg 1664 mg OK
Copper 900 g 1558 g OK
Iron 18 mg 12 mg Under
Magnesium 310 mg 310 mg OK
Phosphorus 700 mg 860 mg OK
Selenium 55 g 68 g OK
Zinc 8 mg 9 mg OK

Vitamins Target Average Status

Eaten
Vitamin A 700 g RAE 780 g RAE OK
Vitamin B6 1.3 mg 1.9 mg OK
Vitamin B12 2.4 g 1.1 g Under
Vitamin C 75 mg 64 mg Under
Vitamin D 15 g 2 g Under
Vitamin E 15 mg AT 16 mg AT OK
Vitamin K 90 g 85 g Under
Folate 400 g DFE 440 g DFE OK
Thiamin 1.1 mg 0.9 mg Under
Riboflavin 1.1 mg 1.0 mg Under

26


Niacin 14 mg 18 mg OK
Choline 425 mg 197 mg Under

3-Day sample of menu planned by RD and patient

Day 1:
Breakfast: Strawberry Smoothie with protein powder, Toast with Peanut Butter
(carbs- 50 g)
Snack: 2 Graham Crackers, 4 oz. cup of applesauce (carbs- 35 g)
Lunch: Chicken Breast, c mashed potatoes, steamed carrots with hummus
(carbs- 40 g)
Snack: 6 crackers, peach cup (carbs- 30 g)
Dinner: Roasted Vegetables, milk, 2 slices bread (carbs- 52 g)

Day 2:
Breakfast: cup oatmeal, apple, c crushed pecans, 1 tsp. cinnamon; 1-cup
milk (48 g)
Snack: 6 crackers, 3/4 c unsweetened canned fruit (31 g)
Lunch: c cottage cheese, 2/3 c veggie spaghetti (35g)
Snack: 1 cup roasted Vegetables (potatoes, onion, zucchini, carrots), 1-cup milk
(30 g)
Dinner: Peanut Butter and Jelly Sandwich, 1 c steamed broccoli and cheese:
(58 g)

Day 3:
Breakfast: c oatmeal, apple, cinnamon, and pecans; 1 c milk (46g)
Snack: Protein Powder and 2 c milk (30 g)
Lunch: cottage cheese, fruit cup, and spaghetti (55g)
Snack: 2 Graham Crackers, 4 oz. cup of applesauce (carbs- 35 g)
Dinner: Peanut Butter and Jelly Sandwich, 1 c steamed broccoli and cheese:
(58 g)

27


Meal Plan Nutrient Analysis

Nutrients Target Average Eaten Status

Total Calories 2000 Calories 1879 Calories OK

Protein (g)*** 46 g 100 g OK

Protein (% Calories)*** 10 - 35% Calories 21% Calories OK

Carbohydrate (g)*** 130 g 256 g OK

Carbohydrate (% Calories)*** 45 - 65% Calories 54% Calories OK

Dietary Fiber 25 g 35 g OK

Total Sugars No Daily Target 126 g No Daily Target

or Limit or Limit
Added Sugars No Daily Target 37 g No Daily Target
or Limit or Limit
Total Fat 20 - 35% Calories 28% Calories OK

Saturated Fat < 10% Calories 7% Calories OK

Polyunsaturated Fat No Daily Target 7% Calories No Daily Target

or Limit or Limit
Monounsaturated Fat No Daily Target 11% Calories No Daily Target
or Limit or Limit
Linoleic Acid (g)*** 12 g 13 g OK

Linoleic Acid (% Calories)*** 5 - 10% Calories 6% Calories OK

-Linolenic Acid (% Calories)*** 0.6 - 1.2% 0.4% Calories Under

Calories
-Linolenic Acid (g)*** 1.1 g 0.9 g Under

Omega 3 - EPA No Daily Target 4 mg No Daily Target

or Limit or Limit
Omega 3 - DHA No Daily Target 12 mg No Daily Target
or Limit or Limit
Cholesterol < 300 mg 128 mg OK

Minerals Target Average Eaten Status

Calcium 1000 mg 1427 mg OK

Potassium 4700 mg 3768 mg Under

Sodium** < 2300 mg 2169 mg OK

28


Copper 900 g 2216 g OK

Iron 18 mg 20 mg OK

Magnesium 310 mg 514 mg OK

Phosphorus 700 mg 1864 mg OK

Selenium 55 g 111 g OK

Zinc 8 mg 15 mg OK

Vitamins Target Average Eaten Status

Vitamin A 700 g RAE 1711 g RAE OK

Vitamin B6 1.3 mg 2.6 mg OK

Vitamin B12 2.4 g 4.0 g OK

Vitamin C 75 mg 124 mg OK

Vitamin D 15 g 6 g Under

Vitamin E 15 mg AT 19 mg AT OK

Vitamin K 90 g 185 g OK

Folate 400 g DFE 603 g DFE OK

Thiamin 1.1 mg 1.5 mg OK

Riboflavin 1.1 mg 2.5 mg OK

Niacin 14 mg 21 mg OK

Choline 425 mg 356 mg Under

Assistive Resource handout for patient:

29


The Ultimate Guide to BMT Preparation

Remember you are not alone! There are resources, support groups,
recipes and much more to help you as you take your journey preparing
for a bone marrow transplant.

Support: Strategies/ Tips

Online BMT support group hosted chat rooms

Guidelines to eating a bacteria free
open three times a week to allow concerns,
diet:
questions, and experiences to be shared among

individuals. Available at: http://bmtsupport.org
http://www.uofmchildrenshospital.or

g/healthlibrary/Article/86539

BMT blog: Available at:

http://punkamunka.blogspot.com

Protein-Packed Acorn Squash

Ingredient Amount Directions
Acorn Squash 2 each Cut acorn squash in half, clean out seeds and
put on a pan in the over for 30 minutes at 375o
Once tender, scoop out squash, and put
shells aside.
Ground beef 1 lb. Brown beef until there is no pink, and
temperature is above 145o
Brown Rice 1 cup Cook rice until tender
Canned black beans 1 can Mix together beef, brown rice,
Chili powder 2 TB beans, spices, vegetables,
and squash.
Garlic Powder 1 TB
Black Pepper 1 TB
Put mixture back in squash shells and serve
Frozen vegetable mix 1 cup hot.

30


Two-Week Diet Log

Following is the 12-day food diary discussed in follow-up appointment.

12-Day Food Diary*

October 17
Today I did the grocery shopping for my first week of the BMT transplant. I first
made a menu that had all the accurate components of the diet, and then made a
grocery list. At the grocery store I first bought all the nonfood and non-perishable
items before I started on the cold foods. Then I went as quickly as possible to pick
up all the cold foods, check out and bring to my car which had a small cooler to
put the cold items in. I tried to make sure they got put in the fridge quickly to so
that the food was never really out of the safe temperature zone.

Day 1: October 19
First day of diet! This morning I started with cinnamon apple oatmeal. I actually
boiled the apples with the oatmeal so that I didnt have to worry about bacteria on
the fruit. I then temped both the oatmeal and the milk that I was drinking. The
other thing I did throughout the day was keep a bleach bucket on the counter and
made sure all the dishes and counters were sterile before preparing food on them.
Since I am on campus all day I got a lunchbox that I can put in the freezer
overnight and the insulation stays frozen all day. This helped me transport the
food to the fridge at the nutrition building without putting anything in danger zone
temperatures.

6:30 am: cup oatmeal, apple, 2 TB crushed pecans, 1 tsp. cinnamon, (152o) 1-
cup milk (40o)
9:30 am: 6 crackers, c unsweetened canned fruit,
12:30 pm: c cottage cheese (38o), 2/3 c veggie spaghetti (165o)
4:30 pm: banana, protein bar
7:30 pm: Peanut Butter and Jelly Sandwich (34o), 1 c steamed broccoli and
cheese (182o):
9:30 pm: 1 cup roasted Vegetables (potatoes, onion, zucchini, carrots) (180o), 1-
cup milk (40o)

Day 2: October 20
Today I was able to stick to my scheduled times, but then I forgot my water bottle
at home! Between classes I had to run back to the house to grab it since I couldnt
drink from the water fountains. I also found out this afternoon that latex allergies
could also cause a banana allergy. So goodbye bananas! For breakfast I made
scrambled eggs and put all the vegetables mixed in to make sure all the
ingredients were cooked hot enough. I figured out a cool trick to keep my yogurt
well in the safe temperature zone when I am taking it to campus. I put frozen

31


berries in the yogurt, so by the time I ate it was the perfect temperature. I also
made sure it was in the fridge as soon as I got to campus.

6:30 am: 2 pieces whole grain toast, 3 slices avocado, 3 TB canned diced
tomatoes, 1egg and cheese (148o); 1cup milk (38o)
9:30am: banana, snickers bar
12:30 pm: c yogurt, 1cup berries (34o), cup cucumber, c. tomato, c
olives, Italian dressing salad (40o)
3:30 pm: fruit cup, 6 crackers
6:30 pasta salad 2/3 c pasta, 1 med chicken breast, broccoli, garlic, and lemon,
(155o)
9:30: 1-cup milk, fruit cup

Day 3: October 21
This diet is starting to become stressful. Getting up early enough so that I can
make sure everything is sanitized before I prepare the food, preparing the food,
and then packing enough sterile foods for the whole day takes quite a bit of time.
Preparing food takes twice the length it used to because I am making sure every
dish is sterile before I use it, and I have to really think through any critical control
points to make sure the food never goes into danger zone temperatures. I really
love the prepackaged single serving foods; they make things so much easier.

8:30 am: Strawberry smoothie: 1cup berries, c yogurt, c almond milk, c

spinach (34o), whole grain toast with peanut butter
1:00 pm: Peanut Butter and Jelly Sandwich (40o), c steamed vegetables (165o)
3:30 pm: trail mix pack (2 oz.), Peanut M&Ms- 2.83 oz., c. cottage cheese
(38o)
7:30pm: 1 cup roasted Vegetables (potatoes, onion, zucchini); 1 cup milk
9:30 pm: small burrito 6-inch tortilla, c beans, and 1 Tb cheese (165o)

Day 4: October 22
This morning I was about to put my bagel in the toaster and wasnt sure if a
combination of cold cream cheese and hot bagel would be safe enough, so I
decided to just go with a cold bagel and cream cheese from an individual serving
package. I think the main challenge that I am starting to see is getting enough
protein in my diet. 20% is quite a bit. I decided to pack down the protein with
powder, a protein bar, and filling an acorn squash with beans, hamburger, and
cheese.

6:30 am: bagel+ cream cheese, 2-cup milk with protein powder (38o)
9:30 am: applesauce, 2 graham crackers,
12:00 pm: 4.5 oz. yogurt (40o), 1 cup vegetable spaghetti (190o)
3:30 pm: protein bar, Mrs. Thinsters cookie thins

32


7:30 pm: stuffed acorn squash with brown rice, beans, hamburger, mushrooms,
and spinach, peppers, onions, cheese (170o)

Day 5: October 23
Nothing too exciting happened today. The diet is pretty stressful trying to make
sure I eat every 3-4 hours. Dinner was pretty easy though because I just heated
up the leftovers from the squash filling last night. I may be using this as a meal
quite a bit since there is quite a bit of leftover and I want to make sure it is all
eaten before the quality goes down and bacteria could begin to form. I made sure
that it got up to at least 165o
6:30 am: Smoothie: (1 cup berries, c berries, c almond milk, c spinach, 1
TB flaxseed, protein powder)-(32o); bagel (40o)
9:30 am: cup cottage cheese (34o), 6 crackers
12:30 pm: 1 c broccoli and cheese- (174o); PB & J sandwich- (38o)
3:30 pm: trail mix, fruit cup
6:30 pm: c acorn squash leftovers (178o); 1 c milk (38o)
9:30 pm: roasted veggies (1/4 c potato, c carrot, c onion) (190o), baked
apple with cinnamon (195o)

Day 6: October 24
Today I was pretty busy so I hope I got all of my protein in. The protein powder
actually tastes really good, so I dont mind doing that extra protein boost each
day. I am starting to get used to the taste of boiled water finally. I also got a large
pitcher to put in the fridge so that I can fill that up to have cooling throughout the
day. This makes it much easier than just filling the two water bottles like I was
doing earlier. When I run out I have some cold-water ready, rather than having to
wait for water to boil and cool enough to drink.

8:30 am: 4 oz. yogurt (36o), muffin (165o)

11:30 am: 2 pieces whole grain toast, avocado, 3 TB canned tomatoes, 1egg,
and cheese (152o), 1cup milk (32o)
3:30 pm: Cookie thins, 1 small wheat tortilla, 2/3-cup acorn squash/meat mix
leftovers (180)
6:30 pm- 2-cup milk with protein powder (36o)
10pm -peaches, protein bar

Day 7: October 25
This morning I woke up late and needed to go to church, hence all the
prepackaged foods and hand sanitizer. I ate the protein bar and crackers really
quick before I left and brought peaches and trail mix with me to eat. Tonight I am
going to bed around 7 or 8 with how tired I am, so I wont have a meal at 9 most
likely.

8:00 am: protein bar, 6 crackers

11:00 am: peaches, trail mix

33


2:00 pm: c noodles, cream of mushroom, sausage meal

6:00 pm: roasted veggies ((1/4 c potato, c carrot, , c onion) (186o), 1 piece
bread with 1 tsp. jam (38o)

Day 8: October 26
Today I had a rotation down in Ogden so I was a little worried about getting
enough time to eat something but there ended up being a perfect opportunity. I
was able to prepare some pumpkin pancakes for myself, and I almost put some
applesauce on it, but it was in a large jar that had been sitting out and other
people had been scooping out of it, so I avoided that. The egg, sausage muffins
were great fillers too and were prepared with sanitary utensils and bowls.

5:30 am: smoothie- with protein powder

8:30 am: protein bar, crackers
12:30 pm: Leftover squash meal with tortilla
3:30 pm: Trailmix packet, c applesauce
6:45 pm: 2pumpkin pancakes plain (170o), egg/sausage/peppers/onions muffin
(182o)
9:00 pm: 1-cup milk, thin cookies

Day 9: October 27
I forgot my water again! Between driving home to grab my water, and driving
home for easier sanitary preparation of meals, I feel like I have driven more this
week than all semester. I am starting to feel really good with the meal plan.
Having smaller portions several times a day is keeping my energy consistent
rather than having peaks of hunger and then feeling tired and overfull. After this
diet, I may still try and keep doing smaller, more frequent meals.

9:00 am: c canned peaches, 10 crackers

12:30 pm: 1-cup sausage stroganoff leftovers (172o), 1 cup vegetables (192o)
4:30 pm: c applesauce, trail mix
8:30 pm: c bean, squash, rice mix with 1 tortilla (168), 1 c milk (38)
11:30 pm: 1/3-cup cottage cheese cup, 1.74 oz. trail mix

Day 10: October 28, 2015

Today I was at the hospital for a rotation and realized that choosing food from
their cafeteria is really difficult. I ended up sticking to the packaged snacks, and
bought some energy chews and cinnamon bears. I was going to eat all of the
cinnamon bears after the energy chews and realized that it would be too many
carbs so I only had 3 and ended up being really hungry throughout the shift, so I
came home and got some more filling foods for the same amount of carbs.

7:30 am: smoothie with protein powder (36o)

10:30 am: applesauce, trail mix
12:30 pm: bagel-40, fruit cup

34


4:30 pm: Bolt organic energy chews 2.1 oz., 3 chocolate cinnamon bears
8:30 pm: 1 cup boiled edemame (194o), c bean, squash, and rice mix with 1
tortilla (172o)

Day 11 October 29
Again, I needed to do a really quick breakfast this morning, so I went to grab a
bagel and realized that a whole bagel is my maximum on carbs so I just ate a cold
plain bagel. I am really missing all the flavorings I usually put in my foods with
fresh produce and mixed temperature foods such as cold avocado and tomato on
hot eggs and toast. One more day!!
7:30 am Wheat Bagel- 40
10:30 am Trail mix+ 10 crackers
2:30 pm Grilled Cheese- 150, mixed vegetables- 195
5:30 pm wheat tortilla with c bean squash rice mix, 1 c milk, 2 TB cheese 175

Day 12 October 30
Its the last day! I came so close to breaking today when a coworker came around
handing out some delicious cupcakes to everyone. Tomorrow I will indulge no
doubt about it. I started out with a smoothie, and I didnt have time to make a
lunch so I put half a bagel in my frozen lunch box along with several prepackaged
items like apple sauce, trail mix, protein bar, a Greek yogurt cup, and crackers to
keep me going throughout the day. I have to say having all these snacks available
does make it nice when I am trying to run out the door. I may have to start
portioning out snack bags each week. It is too expensive to buy prepackaged
portion sizes every week but I could put something together on my own.

7:30 am: 1 c smoothie with protein powder, Greek yogurt (34o)

10:45 am: Foodie Friday
2:00 pm: wheat bagel, 1 yogurt cup with blueberries
5:30 pm: spaghetti with 5 frozen meatballs and veggie packed sauce
8:30 pm: protein bar, 6 crackers

35


Analysis of diet log:

Spreadsheet: Lea Palmer | All Days

Spreadsheet

FatCals SatCals
Item Name Quantity Measure Wgt (g) Cals (kcal) Prot (g) Carb (g)
(kcal) (kcal)

Lea Palmer
Day 1 (11/4/2015) 1450.97 1989.82 402.03 162.60 142.73 263.48
Day 2 (11/5/2015) 1297.14 1759.03 513.39 119.95 85.05 233.60
Day 3 (11/6/2015) 906.96 1445.35 455.90 173.75 66.71 186.52
Average 1218.35 1731.40 457.11 152.10 98.16 227.87
% Recommendation 70.94 66.89 69.25 221.74 67.90

MonSac
Item Name Fib (g) SolFib (g) Sugar (g) Disacc (g) OCarb (g) Fat (g) SatFat (g)
(g)

Lea Palmer
Day 1 (11/4/2015) 24.36 0.40 110.13 2.38 24.94 123.30 44.67 18.07
Day 2 (11/5/2015) 23.05 0.14 36.66 0 12.46 104.67 57.04 13.33
Day 3 (11/6/2015) 24.51 0.68 23.83 2.16 13.38 91.41 50.66 19.31
Average 23.97 0.41 56.87 1.51 16.93 106.46 50.79 16.90
% Recommendation 70.16 66.89 69.25

MonoFat TransFat Vit A-IU Vit A-RAE Caroten

Item Name PolyFat (g) Chol (mg) Water (g)
(g) (g) (IU) (RAE) (RE)

Lea Palmer
Day 1 (11/4/2015) 6.99 3.96 0.50 312.61 806.42 3579.71 203.56 145.66
Day 2 (11/5/2015) 16.73 13.37 0.19 72.28 606.41 12440.65 651.17 1218.25
Day 3 (11/6/2015) 11.46 8.67 0.17 81.56 549.96 12178.29 668.32 1198.89
Average 11.73 8.66 0.29 155.48 654.26 9399.55 507.68 854.27
% Recommendation 43.24 35.50 51.83 24.23 72.53

Retinol BetaCaro Vit B1 Vit B2 Vit B3 Vit B3-NE Vit B6 Vit B12
Item Name
(RE) (mcg) (mg) (mg) (mg) (mg) (mg) (mcg)

Lea Palmer
Day 1 (11/4/2015) 130.73 783.28 1.57 2.57 26.66 32.24 2.14 6.38
Day 2 (11/5/2015) 42.05 232.83 1.74 1.39 16.94 23.73 0.87 2.42
Day 3 (11/6/2015) 68.87 244.32 1.31 1.22 14.89 21.95 0.95 2.06
Average 80.55 420.14 1.54 1.73 19.50 25.97 1.32 3.62
% Recommendation 139.97 157.07 139.28 185.52 101.66 150.75

Page 1

36


37


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