Nutritional Assessment for SMIntroduction:Obesity is an epidemic. During the last twenty years, obesity in America has risen twenty percent in adults and affects more than 60 million people. Americans are eating larger portions, more soft drinks, and more high fat foods. Due to the increasing number of overweight and obese adults, obesity is the largest health crisis America faces today.
SM, our subject, was chosen for this project because he is 32 years old and obese. SM was recently cautioned by his doctor that he is at high risk for diabetes, has high cholesterol, and is hypertensive. SM is looking for ways he can change his diet and lose the weight he has gained. The subject carries much of his weight in his midsection, but has somewhat of a pear shape to his body. Persons that carry the majority of their fat in their midsection are known to have an increased risk for hearth disease and diabetes (2).
Health History:
According to SM, both of his parents are hypertensive, have some heart disease, and one is diabetic. SM’s weight problems are recent; most of his weight gain has been within the last five years. SM is hypertensive, has high cholesterol, and his doctor is concerned that he may soon develop type 2 diabetes. SM is currently very depressed and he believes his depression is the source of him becoming obese. Before his weight gain, SM was not experiencing any health problems. SM is currently attempting some daily exercise, but hasn’t had a lot of success being consistent about working out.
SM recently had outpatient cyst removal surgery, but he does not believe that is related to his overweight. The subject has an occasional drink, but is not an alcoholic. SM has recently been experiencing bouts of insomnia and when he sleeps, he wakes up at different points through out tonight. SM believes that he may have sleep apnea, but hasn’t had this tested yet.
Socioeconomic History:SM is currently a project manager at a software company. His job is highly stressful and he described his management as unreliable. SM is also still a contractor with this company and doesn’t qualify for health benefits (although he can get them by paying very high premiums). He doesn’t believe that he has very good job security and is constantly applying to new jobs. SM also gambles and a good portion of his paycheck goes into this hobby; he claims to win often, but the times he loses, he has difficulty making his bills for the month.
When SM prepares food at home, he often gets canned soups, TV dinners, and other types of bagged, ready to heat meals. SM says he eats at home about three times a week and eats at restaurants and fast food for the rest. SM realizes that this is not helping his weight problem, and he’d like to figure out a way to maintain this lifestyle and also learn how to make healthier selections at restaurants and grocery stores.
Drug and Supplement History:SM has not been prescribed medication for any of the above conditions, mainly because he has informed his doctor that he cannot afford any sort of medication (due to his lack of health coverage). After his last appointment, SM said that his doctor is recommending change in diet and adding exercise to his routine. SM still has his Albuteral prescription from a couple of years ago and uses it if he has symptoms of asthma. SM also takes over the counter Claritin for his allergies. Two years ago, SM began taking flax and fish oil at the recommendation of his doctor, friends, and a pharmacy worker. SM does not take a multivitamin.
Diet History:The DASH diet has been recommended to SM by his doctor, but SM finds it difficult to follow. SM eats things that already have salt added into them, so the sodium is difficult to see. SM is currently following no structured diet, but he says that he is trying to eat healthier in general. According to SM’s 24-hour recall (Appendix G-1), SM has been eating fewer calories, but still eats many high fat, non-nutritious foods.
Anthropometric Measurements:SM’s height is 72.07 inches and he weighs 281 pounds. The subject’s waist circumference is 52.5 inches and his hip circumference is 39.8 inches. SM’s BMI is 38. According to his doctor, the subject’s blood pressure is 142/89 and his cholesterol levels are 155 for his LDL and 215 for his total cholesterol count. His triglyceride levels were not provided. Please see Figure 1 for a complete listing.
Waist to hip ratio (waist/hip) should be 0.8-0.9 in healthy individuals. SM’s waist to hip ratio is 1.32, which puts him at high risk for heart disease and diabetes (2). Figure 2 shows the healthy waist circumferences for men and women.
Dietary Analysis:The following section will detail SM’s dietary intake information.
Energy and Macronutrient Intake:Calorie Intake:
SM’s calorie intake average per day is 1683.91 kcal, according to his three day diet record (Appendix A-1,2,3). The estimated energy requirement (EER) for a 32 year old male is 2937 kcal/day, assuming that the person is healthy and “active” (1). According to the Food Processor software, our client needed to consume 4739 kcal/day in order to maintain his current weight. To lose weight at a reasonable weight (no more than one pound a week) SM will need to consume 4239 kcal/day from nutritious and healthy foods. The subject’s kcal intake is well below the amount of calories his body needs. The calories SM does consume, however, are higher in fat than any other macronutrient value.
BMI:The subject’s body mass index (BMI) is a 38 (fig 1), indicating a high level of obesity. His obesity could be caused by the ratio of fat and saturated fat in his diet. Kcalories should be added to SM’s diet, but fat intake should be lowered. SM’s diet consisted of several fried items such as: french-fries, refried beans, tacos, fried chicken, and doughnuts. SM also ate other items high fat and others containing empty calories such as: several regular colas, brownies, milk shakes, pizza, cheese enchiladas, cake, and ranch dressing. If the fried items are substituted with baked or grilled items, this would lead to a significant reduction of fat calories in SM’s diet. If SM were to switch to diet coke, he would lose empty calories from regular cola and be able to replace them with healthier and more nutritious choices.
Healthy Weight Goal:SM’s ideal weight is 172 lbs (according to % IBW equation Men: 106 lbs for 5’ + 6 lbs for each). SM currently weights 281 lbs (fig 1). SM will have to gradually decrease his weight through diet and exercise. SM can do this by eating more nutrient dense foods in place of his usual high fat diet. SM can also attempt to exercise 30 minutes a day by doing physical activities that raise his heart rate. SM owns an exercise bike and may be willing to do this activity more often. While attempting exercise is commendable, SM should strive to exercise everyday for thirty-sixty minutes.
Protein:SM’s daily intake of protein is 59.99 g/day; the goal range (RDA-2x RDA) for a person of his weight is 101.968 g/day – 203.936 g/day (Appendix B-1). SM is consuming well under his goal range of protein; this is due to his lack of caloric intake. The protein SM consumes comes almost entirely from meat. Meat sources from protein are good because plant protein sources are incomplete and require protein pairing to be efficiently absorbed. Unfortunately meat sources of protein tend to be higher in fat and may be the cause of his high cholesterol count. Since SM is not eating enough protein, he should eat more protein but from lower fat source. Some leaner protein suggestions would be baked or grilled fish, turkey breast or other poultry, reduced fat peanut butter, and/or pinto beans.
Carbohydrate:SM’s daily recommended intake of carbohydrate is 130 g/day; SM’s actual intake is 258.98 g/day (Appendix B-1). Since SM’s goal caloric intake is 4239 kcal/day, his upper limit of added sugar intake is 105.975 g/day. SM is currently consuming 69.48 g of added sugar per day which is below his upper limit, but above the amount of recommended added sugar for his actual intake (1683.91 kcals). Since SM’s sugar intake is high for his actual intake, this could compound his obesity and increase his risk for diabetes. Limiting soft drinks, glazed pastries, ice cream, and other sweets would greatly reduce SM’s added sugar total. Fruits, vegetables, and whole grains are a better source of carbohydrates and would provide more essential nutrients than empty calorie and dessert type foods. Since SM will not wish to part with desserts entirely, he should treat himself with sweets in small portions on special occasions.
Dietary Fiber: The AI value for dietary fiber in males is 38 g/day (Appendix B-1). SM’s dietary fiber intake is 15.83 g/day, well below the AI value. Soluble fiber could help SM keep his cholesterol under control, as it lowers LDL and decreases blood cholesterol. Insoluble fiber aids in preventing constipation and helps the stomach feel full. Some examples of foods with fiber are some fruits, vegetables, legumes, oatmeal, and whole grain breads. Oatmeal is especially easy to prepare because it comes in instant packs where SM could just add water and microwave.
Fats:
Total Fat:According to the dietary guidelines, fat intake should be 20-35% of the total calories consumed. For SM’s calories consumed he is getting 44.6 g/day of fat in his diet which falls into SM’s recommended range of 37.42-65.48 g/day (Appendix B-1). SM’s saturated fat count is also acceptable according to the dietary guidelines; the dietary guidelines recommend saturated fat be 10% or less of the total kcals consumed per day, SM’s saturated fat intake was 18.44 g. Despite SM’s good marks, he still consumed several high fat items that could be substituted for monounsaturated fat, Omega 3s, or Omega 6 fats. SM’s monounsaturated fat intake was only 7.93 g/days and SM’s consumption of Omega 3 and Omega 6 fats was well below the goal intake (Omega 3 intake was .88 g versus the recommended 17 g and Omega 6 intake was .11 g versus the recommended intake of 1.6 g). SM could improve the fats he eats by cutting out some of his high fat choices like milk shakes, beef, and pastries and replace them with lean meats like fish that contain Omega 3 and nuts like almonds and walnuts.
Cholesterol:SM’s total cholesterol of 215 and his LDL count of 155 (fig 1) are both above optimal ranges (fig 3). In addition to the other warning signs stated previously in this assessment, SM’s borderline high cholesterol counts put him at risk for heart disease. SM can reduce his cholesterol by eating less animal products and consuming more soluble fiber. SM can also eat reduced cholesterol animal products like Eggland’s Best Eggs.
Micronutrients:
Thiamin:
The RDA for thiamin is currently 1.2 mg per day. SM’s intake of thiamin is 0.3 mg per day (Appendix D-1). “Thiamin, a water-soluble vitamin, helps the body release energy from carbohydrates during metabolism. Thus, persons who expend more energy and have a higher intake of calories need more thiamin than those who eat fewer calories. Thiamin also plays a vital role in the normal functioning of the nervous system (3).” Meats like poultry and fish are good sources of Thiamin.
Riboflavin:The RDA for riboflavin in males is currently 1.3 mg per day. SM consumes 0.49 mg of riboflavin per day (Appendix D-1). Like thiamin, riboflavin also plays a crucial role in metabolic reactions. It is also known to work as an antioxidant. The best sources of riboflavin are: brewer's yeast, almonds, organ meats, whole grains, wheat germ, wild rice, mushrooms, soybeans, milk, yogurt, eggs, broccoli, Brussels sprouts and fortified grains/cereals.
Niacin:The RDA for Niacin is 16 mg per day. SM currently only consumes 7.17 mg of Niacin (Appendix D-1). Niacin helps the body get energy from fat, protein, and carbohydrates during metabolism. Breads, cereals, and grains are good sources of niacin, but SM could also make it in his body by using tryptophan, an essential amino acid found in fish and poultry (3).
Vitamin B6:
The RDA for Vitamin B6 is 1.3 mg per day. SM currently consumes 0.27 mg of Vitamin B6 (Appendix D-1). Vitamin B6 has several roles; it assists with metabolic function, nervous system function, red blood cell formation and function, hormone function, and nucleic acid formation. Good sources of Vitamin B6 are fortified cereals, bananas, and salmon.
Vitamin B12:
The RDA for Vitamin B12 is 2.4 mcg per day. SM currently consumes 0.94 mcg of Vitamin B12 (Appendix D-1). Vitamin B12 has several roles, but its primary role is to assist in metabolic function. Good sources of Vitamin B12 are clams, mussels, crab, and beef.
Biotin:Biotin is instrumental in enzyme function. The RDA for biotin is 30 mcg. SM is currently consuming 1.57 mcg of biotin (Appendix D-1), well below the RDA. Food sources of biotin are eggs, liver, baker’s yeast, and wheat.
Vitamin D:The AI for vitamin D is 5 mcg. SM’s current vitamin D consumption is 0.72 mcg per day (Appendix D-1). Vitamin D used in the body for calcium balance, cell differentiation, immunity, and insulin secretion (4). Food sources for vitamin D are canned salmon, canned sardines, vitamin D fortified orange juice, vitamin D fortified milk, and egg yolks.
Vitamin E:Vitamin E functions as an antioxidant in the body. The RDA is 15 mg per day and SM currently consumes 0.85 mg of vitamin E (Appendix D-2). Olive oil, canola oil, and avocadoes are good sources if eaten sparingly. Spinach is also a good source of vitamin E.
Folate:
The RDA for folate or folic acid is 400 mcg per day. SM consumes 88.66 mcg of folic acid per day (Appendix D-2). Folate enzymes are required in amino acid metabolism, and folate also assists vitamin B6 and B12 interactions (4). Lentils, spinach, fortified cereals, and chick peas are good sources.
Vitamin K:The AI for vitamin K is 400 mcg; SM consumes 120.08 mcg of vitamin K (Appendix D-2). Vitamin K assists with blood clotting, bone mineralization, and cell growth. Kale, swiss chard, and spinach are good sources of vitamin K.
Pantothenic Acid:Pantothenic Acid is found in the body as coenzyme A, a vital coenzyme in many chemical reactions (4). The AI for pantothenic acid is 5 mg a day; SM consumes 1.05 mg per day (Appendix D-2). Good food sources of pantothenic acid are yogurt, sweet potatoes, avocado, milk, and chicken.
Calcium:
Calcium plays an important role in developing bone structure and cell signaling. Vitamin D also assists in the absorption of calcium, so consuming them together will allow for optimal absorption. The AI for calcium in adult males is 1000 mg per day; SM is consuming 643.31 mg per day (Appendix D-2), which is a good start. SM can consume more calcium by eating dairy products, tofu, rhubarb, spinach, kale, or fortified foods.
Copper:Copper is instrumental in energy production, connective tissue formation, and iron metabolism. The RDA for copper is 900 mcg a day; SM currently consumes 330 mcg per day (Appendix D-2). Liver, oysters, cashews, and mushrooms are all good sources of copper.
Iodine:
Iodine is an essential component of thyroid hormones, thus, deficiency in iodine causes goiter. The RDA for iodine is 150 mcg; SM consumes 45 mcg from his food (Appendix D-2). Since SM should avoid iodized salt due to his hypertension, some other good foods with iodine in them are: cod, shrimp, milk, and potatoes with their peel.
Magnesium:Magnesium has several functions; energy production, cell structure, ion transport across cell membranes, and cell signaling. The RDA for males is 420 mg a day; SM consumes 70.94 mg a day (Appendix D-2). Magnesium is found in the following foods: bran cereal, brown rice, spinach, and almonds.
Manganese:Manganese assists with antioxidant function, metabolism, and bone development. The AI for manganese is 2.3 mg per day for males; SM gets .7 mg per day (Appendix D-2). Food sources for manganese are: pineapple, pecans, and raisin bran cereal.
Potassium:
Potassium is used in maintenance of cell membrane potential and is a cofactor for certain enzymes. Not consuming enough potassium can lead to fatigue and muscle cramping. The RDA for potassium is 4700 mg per day; SM consumes 1437.51 mg per day (Appendix D-2). Good sources of potassium are cantaloupe, orange juice, and almonds.
Selenium:
The body uses selenium in a number of specific enzymes that require this mineral in order to function. The RDA for selenium is 55 mcg; SM consumes 26.83 mcg (Appendix D-2). Food sources for selenium are shrimp, salmon, pork, and brown rice.
Zinc:
Zinc plays a catalytic roll for several enzymes. Additionally, it also plays a roll in the structure of cell membranes and proteins. The RDA for men is 11 mg per day; SM consumes 2.89 mg per day (Appendix D-2). Food sources for zinc are oysters, beef, dark poultry meat, baked beans, and cashews.
History of Disease:Since 1932, diabetes has been a leading cause of death in the United States. Type II diabetes is a very serious condition; it can cause blindness, renal failure, congenital malformation, and lower extremity amputation (5). Most patients with type II diabetes are obese or have an increased amount of fat tissue in the abdominal region (2). One of SM’s parents is a diabetic, so it is especially important that he watches his risk factors. Figure 4 shows SM his risk factors, but does not diagnose him. By showing SM this chart we, as nutritionists, are allowing him to see how dangerous his situation is. If SM adds regular exercise to his routine and eats healthy diet of well portioned, nutrient dense foods, his risk for type II diabetes will be greatly reduced.
Summary:
Goals and Recommendations:
The following a list of goals and guides for SM based on the information gathered from his 24 hour recall (Appendix G-1), 3-day record (Appendix A-1,2,3), his anthropometric measurements (fig 1), and his health history form (Appendix H-1,2).
Lifestyle Modifications to Manage Hypertension:
Since SM is borderline hypertensive it is important that he adopts healthy lifestyle modifications to manage it (fig 5).
GOALS:
- Reduce weight through health diet and exercise (fig 5)
- Adopt the DASH diet (fig 5)
- Reduce salt intake (fig 5)
- Exercise (fig 5)
- Limit consumption of alcohol (fig 5)
Weight reduction will not only reduce SM’s blood pressure, it will also reduce his overweight and his risk of heart disease. Adopting the DASH (Dietary Approaches to Stop Hypertension) diet will also lower his fat intake and help him lose weight. Sodium reduction for SM is important; he tends to eat a lot of processed foods, so he will need to follow the DASH diet and avoid adding salt to his food. Exercise will help regulate SM’s blood pressure and also assist in weight loss. SM does not currently consume more than 2 alcoholic beverages a day, but should be advised not to begin doing so.
Lowering Cholesterol:SM has borderline high total cholesterol and LDL levels, below are some things he can do to lower those levels.
GOALS:
- Limit the intake of foods high in saturated fat and cholesterol (such as red meat)
- Substitute grains and unsaturated fatty acids from vegetables, fish, legumes, and nuts
- Consume soluble fiber
SM should begin to check labels of foods for their cholesterol content, this will help him determine whether a food item is a healthy choice. Substituting vegetables, fish, and legumes for meat items will help SM lower his LDL and total cholesterol count. SM does not have to eliminate these foods from his diet, but small portions of these items are recommended. Soluble fiber has been shown to lower cholesterol; foods that contain soluble fiber are oatmeal, legumes, strawberries, and citrus fruits (6).
Recommendations to Reach Goal Weight:GOALS:- Set realistic goals
- Exercise
- Watch portion sizes
- Eat nutrient dense foods
- No liquid calories
SM should not expect to lose more than 1 lb a week, any more would not be healthy. Aerobic exercise for 30 minutes a day will cause the body to burn calories from fat stores, losing fat stores will help SM achieve a healthier weight. Eating proper portion sizes is a must, especially for high fat items like meats. Looking at the palm of your hand (without the digits) is an easy way to remember what a good portion size is. A nutrient dense food is a food that gives you a lot of nutrients for the amount of calories the food is. Eating nutrient dense foods at meals will ensure that you are getting all the nutrients you need and guarantee that you are consuming healthier choices. SM should avoid drink soft drinks and sugary flavored drinks; these drinks are nothing but empty calories that SM’s body will store as fat.
Conclusion:SM is at a difficult point in his life right now due to his personal and work situations. It is critical that SM gets help with his depression from a psychologist so he can begin helping himself get healthy and feel better. SM’s health problems likely began with his depression and it is our opinion that he is likely undereating due to this as well. Gradually, as SM is able to feel better about himself and his life, he will be able to approach this assessment and use its advice accordingly. The most important thing for SM to remember is that the road back to good health begins with baby steps, this assessment will be his tool when he is ready to begin this journey.
References List
1.) Brown, J. E. (2005.) Nutrition through the life cycle. Belmont, CA: Thompson Wadsworth.
2.) Lee, R. D., Nieman, D. C. (2007.) Nutritional Assessment. New York, NY: McGraw Hill.
3.) Hopkins University Technology. Vitamin Data. Available at: http://www.hoptechno.com/book29g.htm. Accessed November 1, 2006.
4.) Oregon State Nutrition. Vitamin/Mineral Data. Available at: http://lpi.oregonstate.edu/infocenter/. Accessed November 1, 2006.
5.) American Diabetes Association. Information on diabetes. Available at: http://www.diabetes.org/home.jsp. Accessed November 1, 2006.
6.) American Heart Association. Information on heart disease. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4494. Accessed November 1, 2006.