University Hospital

Weight Management

Mr. Robertson
22229999
01/03/1952
65
10/15/2017
Nutrition Assessment:
This is a 45 minute face to face Medical Nutrition Therapy visit. Patient is a 65 yr old male
referred for dietary counseling by Dr. Conrad

Diagnosis and medical history:

Pt has family history of T2Diabetes
Pt has general examination and discovers blood pressure and weight are higher than previous
times
Weight History:
Height: 69in/175cm; Current weight: 198lbs/90; current BMI is 29kg/m2.
Usual body weight: 172lbs/78kg; 115%usual body weight:
15% weight gain over last 6 months
waist hip ratio 1.0
BMI 29

Food Intake: 3 meals and 3 snacks a day

AM Meal and Snack: toast, butter, jam, egg, juice, coffee with milk and sugar.
Lunch meal and Snack: sandwich, cookies cream filled, coffee with milk and sugar
PM Meal and Snack: Meat, potatoes, gravy, vegetable, nuts
Weekend: toast, bacon, eggs, butter, coffee, spaghetti Bolognese, fruit, ice cream
Occasional foods: beer, fruit cake, chocolate, donuts, chips

Nutrition Impact Symptoms: No applicable symptoms

Activities and Function: recently retired, chores around the garden 15 minutes daily, bowling 60
minutes weekly, walks slowly 30 minutes weekly.

Social history: goes grocery shopping with wife, recently retired, busy social life, bowls every
week, part of film club, spends time with grandchildren on Sunday, drinks 2 beers 5 days a
week

Labs: N/A

Current Meds: No current medication

Nutrition Diagnosis:
Undesirable food choices related to 15% weight gain in 6 months as evidenced by diet history
Excessive energy intake related to high food consumption as evidenced by nutrient intake
analysis.

Nutrition Intervention:
Estimated Nutrition Requirements
1. 1560-1950 kcals per day (20 - 25kcal/kg UBW)
2. 62-78 g protein per day (0.8 1.0 g/kg UBW)
3. 2250-3150 ml fluid per day (25 - 35 ml/kg Actual BW)

Individualized Treatment Goals

A balanced diet according to MyPlate. The patient will eat the recommended amounts of food
from each food group. Paying special attention to his protein and fat intake. Pt will increase
vegetable and fiber intake and reduce alcohol consumption.

Implementation of Intervention
Pt will gradually increase fiber intake by adding more fruits and vegetables to his diet. He will
also incorporate lean protein sources instead of high fat protein sources. He will also reduce the
amount of protein he consumes for dinner. The pt will also limit the amount of butter in his diet.
Pt will slowly increase his fluid intake.

Dietitian Assessment/Patient Response to Intervention

Excellent. Patient seems willing to follow recommendations discussed at this appointment and
verbalized understanding.

Education Materials Provided

1. MyPlate My Wins
https://choosemyplate-
prod.azureedge.net/sites/default/files/printablematerials/mini_poster.pdf
2. USDA The Five Food Groups
https://fns-prod.azureedge.net/sites/default/files/tn/dmp_tgfive.pdf

Referrals and RD Follow Up Plan for Monitoring and Evaluation

Patient will return in 4 evaluation of progress towards treatment goals. Provided patient with
contact information and encouraged to call with any additional questions. Patient was
agreeable with this plan. Pt was given referral to supermarket dietitian.

Medical Nutrition Therapy provided using the 2016 evidence based practice guidelines from the
American Academy of Nutrition and Dietetics.

Alex Hinton