Obesity ADIME 2020

Assessment:
Overview Information: 38 y/o male with no complaints and no acute distress in for annual physical. Missed last
year’s annual physical.

Client History (CH):

Medical hx: Seasonal allergies

Family hx: Mother is alive and well, Father is 62 y/o and has HTN and Type 2 DM, pt has one older
sibling and two sons

Past Surgeries: N/A

Allergies: Latex, Penicillin

Current Medications/supplements: Psuedoephedrine Hydrochloride, Fexofenadine hydrochloride

Anthropometric Measurements (AD):

Ht.: 69 in.
Wt.: 104.3 kg, 229.5 lbs.
UBW/weight hx: weight gain noted, UBW is 223 lbs.
IBW: 72.7 kg, 160 lbs.
BMI: 34.04, obese

Biochemical Data, Medical Test and Procedures (BD):

Lab values
CMP 10/30/20:
Glucose test: 235 mg/dl, high
Lipid profile 10/30/20:
Total cholesterol: 288 mg/dl, High
Triglycerides: 420 mg/dl, high
Urinalysis 10/30/20:
Glucose: 280 mg/d, high
HbA1C 10/09/18:
6.3%

Nutrition-Focused Physical Findings (PD):

Physical appearance:
Abdomen: soft, non-tender, central obesity; no organomegaly
Orbital fat pads: well nourished; slightly bulged
Buccal fat pads: well nourished; full, round cheeks; bounce
Muscle: no signs of muscle wasting, tone in all limbs
Appetite:
Strong, “big eater”

Food/Nutrition Related History (FH):

Food and Nutrient Intake:
1
 24-hour recall
12 piece chicken nuggets, afternoon
6 Tbsp BBQ dipping sauce, afternoon
5 oz French fries, afternoon
32 ox diet soda, afternoon
6 oz roasted chicken thighs, evening
1.5 cups mashed potatoes, evening
3 Tbsp margarine on potatoes, evening
.5 tsp salt on potato, evening
2 cups green salad, evening
¼ cup ranch dressing on salad, evening
1.5 cups non-fat milk, evening
2 biscuits, evening
1 cup chocolate pudding, late evening
24-hour recall analysis
Patient consumes approx. 275 grams carbs, 107 grams protein, 147 grams fat, and 3,000
calories based on 24-hour recall.
Patient consumes approx. 7,451 mg sodium based on 24-hour recall.
Patient consumes a diet high in refined carbohydrates and energy dense foods and low
in fruits and vegetables based on 24-hour recall.
At home diet
Occasional alcohol use
Eats out every day for lunch with colleagues
Eats out 2-3 times per week with family
“Big eater”
Doesn’t eat breakfast
Eats lunch around 1 pm
Eats dinner around 7 pm, largest meal of the day

Physical Activity: Less than 30 minutes/day; reports lack of energy in evenings, especially after dinner

Knowledge/Attitudes/Beliefs: Smokes 1 pack/day (cut down from 2 packs/day a few months ago),
knows he should quit; Speaks English

Comparative Standards/Calculated Needs:

ABW: 84 kg, 185 lbs.
Estimated needs were calculated using ABW
Estimated energy needs: 2,631 kcal/day (Mifflin St. Jeor: 1,754*1.5{AF})
Estimated energy needs for weight loss: 2,131 kcal/day (2,631 kcal/day - 500 kcal/day)
Estimated protein needs: 126-168 g/day (1.5-2.0 g/kg)
Estimated fluid needs: 2,131 ml/day
Sodium needs: <2,300 mg/day
Estimated vegetable intake needs: 8-10 servings/day of vegetables (DASH diet)

Nutrition Diagnosis:
1. Undesirable food choices related to eating out often and consuming a high amount of energy
dense foods as evidenced by a 24-hour recall in which the patient reported consuming a diet

2
 high in refined carbohydrates, approximately 7,500 mg of sodium, approximately 3,000
calories, and a minimal amount of whole grains, fruits, and vegetables.

2. Excessive energy intake related to consuming a high calorie diet that consists of energy dense
foods as evidenced by a BMI of 34.04 and a 24-hour recall in which the patient consumes
approximately 3,000 calories when the recommended calorie intake for weight loss is 2,131
kcal/day.

Nutrition Intervention

 Prescription: Follow the DASH diet by consuming less than or equal to 2,300 mg of sodium per day and
aiming to consume 8-10 servings of vegetables per day.
 Recommend: Nutrition influence on health education about the DASH diet and the effects it can have
on Type 2 diabetes and HTN.
 Goals: Patient will be educated about the DASH diet and the effects it can have on Type 2 Diabetes and
HTN in order to improve the patient’s blood pressure and increase the overall healthfulness of the
patient’s diet.

 Prescription: Consume 2,131 kcal/day

 Recommend: Decreased energy diet of 2,131 kcal/day
 Goals: Patient will decrease the number of calories consumed per day to the recommended 2,131
kcal/day in order to promote weight loss.

Nutrition Monitoring and Evaluation:

 Indicator: Energy intake
 Criteria: By the next visit, the patient will consume calorie goal of 2,131 kcal/day based on a kept food
journal.
 Indicator: General healthful diet
 Criteria: By the next visit, the patient will consume 8-10 servings of vegetables (from DASH diet) based
on a kept food journal.
 Criteria: Sodium estimated intake in 24 hours
 Indicator: By the next visit, the patient will consume less than or equal 2,300 mg sodium/day based on
a kept food journal.
 Indicator: Physical activity frequency
 Criteria: By the next visit, the patient will participate in at least 30 minutes or 3.5 hours a week of
moderate-intensity physical activity in order to assist in weight loss.