Critical care and Nutrition support

(Case study Osteoporosis )

Pro: Hashem Suleiman

Dt: Mohammed Kamal
Master of Science in Clinical Nutrition
Program
Osteoporosis

X is a 68-year-old lady, married with two children who are living abroad. She lives with her
husband who does the shopping and cooking. Mary was a cleaner but had to stop work because
of her difficulty in mobility and she takes little exercise. She attends the outpatient bone health
and osteoporosis clinic in a large teaching hospital and has been referred to you for dietetic
assessment and advice

Anthropometry,

Current weight 42.5 kg

Weight 4/12 ago 49 kg

Stadiometer height 1.53 m

Knee heel height 1.59 m

Demispan (left arm) 1.58 m

BMI

18.2 kg/m2 using stadiometer height

Tricep skinfold thickness 11.9 mm

Mid upper arm circumference (left) 21.8 cm

Mid arm muscle circumference (left) 18.1 cm

Calf circumference 28.8 cm

Physical activity – low score (incidental and planned activity

questionnaire)

Smoker for 40 years. Has reduced to 10/day from 20/day

Biochemical and

haematological

24 h urinary calcium 2.14 mmol/L

Serum calcium 2.32 mmol/L

Serum albumin 42 mmol/L

ALP 90 mmol/L

Phosphate 0.88 mmol/L

Osteocalcin 21.7 mmol/L

Parathyroid hormone 24.3 mmol/L

C-terminal telopeptide of type 1 collagen (CTX)

0.273 mmol/L

Procollagen type 1 N propeptide (P1NP) 37.6 mmol/L

Serum 25 (OH)D 23 mmol/L

WCC 7.0 mmol/L

Hb 14.9 mmol/L

Mean cell volume 95.9 f/L

Platelets 283 mmol/L

TG 1.1 mmol/L

Clinical Past medical history:

Hypertension, hypercholesterolaemia, asthma, depression,

osteoporosis – spinal fracture T10, T12, L2, L3

Medication

Crestor, metoprolol, was on Fosamax for 4 years, but no

improvement on recent DXA so switched to daily

injection – parathyroid hormone

Calcichew D3 Forte BD (non-compliant)

Ventolin, betide

Diet 24 h recall
Breakfast

Small bowl of porridge (made with water and a drop of low-fat

milk (110 g))

Two slices white bread toasted (2× 27 g) with butter (20 g)

and marmalade (2× 15 g)

Cup of tea (190 mL)with a teaspoon sugar (5 g) and a drop of

low-fat milk (15 mL)

Lunch

1 slice white bread toasted (27 g) with butter (10 g)

1 sausage fried (40 g)

Cup of tea (190 mL) with teaspoon sugar (5 g) and drop of

low-fat milk (15 mL)

Dinner

1 slice white bread (27 g) with tomato (17 g) and 1 slice

Burger (23 g)

Cup of tea (190 mL) with 1 tsp sugar (5 g) and a drop of

low-fat milk (15 mL)

2–3 glasses water during the day

Note: Appetite has reduced significantly as a result of pain

and she has experienced some nausea (possibly due to new

medication)

1. Diagnosis

Problem:
Inadequate nutrition and dietary intake contributing to osteoporosis and impaired bone health.

Etiology :

1. Inadequate calcium and vitamin D intake: X consumes a low amount of dairy products .

2. Inadequate protein intake: X consumes a low amount of protein, which is essential for
maintaining muscle mass and bone health.

3. Inadequate energy intake: X's weight has decreased over the past four months, indicating a
potential energy deficiency.

4. Sedentary lifestyle: X takes little exercise, which can further contribute to muscle weakness
and bone loss.

5. Smoking: X has a history of smoking for 40 years, which is a risk factor for osteoporosis.

Signs and Symptoms:

1. Low body weight (42.5 kg) and low BMI (18.2 kg/m2): X's weight is below the normal range,
indicating potential malnutrition.

2. Reduced muscle mass: The mid arm muscle circumference (18.1 cm) and tricep skinfold
thickness (11.9 mm) measurements suggest decreased muscle mass.

3. Fragility fractures: X has a history of spinal fractures (T10, T12, L2, L3), indicating compromised
bone health.

4. Low serum calcium (2.32 mmol/L) and 25-hydroxyvitamin D (23 mmol/L) levels: These values
suggest inadequate calcium and vitamin D status.

5. Elevated parathyroid hormone (PTH) level (24.3 mmol/L): High PTH levels can indicate
secondary hyperparathyroidism due to vitamin D deficiency or inadequate calcium intake.

2.the aims and objectives

- Increase energy intake: Provide X with a well-balanced and nutrient-dense diet to ensure
adequate energy intake and prevent further weight loss.

- Improve protein intake: Recommend protein-rich foods such as lean meats, poultry, fish, dairy
products, legumes, and eggs to support muscle mass and bone health.

- Increase calcium and vitamin D intake: Advise X to consume foods rich in calcium (e.g., dairy
products, leafy green vegetables, fortified foods) and ensure adequate sun exposure or vitamin D
supplementation.

- Support smoking cessation:

- Provide information on available resources and support services to help her quit smoking.
 - Discuss the benefits of quitting and develop a plan to address her nicotine addiction.

3. Nutrition Intervention:

IBW = [(153 - 152)/2.54] × 2.2 + 45=45.8

ABW= (42.5 – 45.8 )× 0.25+ 45.8 = 44.9

Women = (10 x 44.9) + (6.25 x 153) - (5 x 68) - 161 = 903.25

Calorie needs = 903.25 *1.3AP= 1,174.225

Estimated energy intake: 1,174 Kcal

Estimated carbohydrate intake: 1,174*60/100/4=176gm

Estimated protein intake: 1,174*20/100\4=58gm

Estimated fats intake:

1,174 *20/100/9=29gm

diet plan

**Meal 1: Breakfast**

- 1 slice of bread (15 grams carbohydrates, 2 grams protein, 0.5 grams fat)

- 1 boiled egg (0 grams carbohydrates, 6 grams protein, 5 grams fat)

- 1 small apple (15 grams carbohydrates, 0 grams protein, 0 grams fat)

**Meal 2: Morning Snack**

- 1 cup of yogurt (10 grams carbohydrates, 10 grams protein, 2 grams fat)

- 1 10 almonds (4 grams carbohydrates, 3 grams protein, 6 grams fat)

**Meal 3: Lunch**

- 1 small bowl of cooked rice (30 grams carbohydrates, 2 grams protein, 0 grams fat)

- 100 grams of grilled chicken breast (0 grams carbohydrates, 25 grams protein, 3 grams fat)

- 1 cup of mixed vegetables (10 grams carbohydrates, 2 grams protein, 0 grams fat)
**Meal 4: Afternoon Snack**

- 1 medium-sized banana (30 grams carbohydrates, 1 gram protein, 0 grams fat)

- cup milk (8gm protein, 5g fat, 12g carbohydrates)

**Meal 5: Dinner**

- 1 small baked potato (30 grams carbohydrates, 2 grams protein, 0 grams fat)

- 100 grams fish (0 grams carbohydrates, 22 grams protein, 7 grams fat)

- 1 cup of steamed broccoli (10 grams carbohydrates, 3 grams protein, 0 grams fat)