NUT 4700 MNT I
Case Study 1: Malnutrition and Depression
Copy and paste the questions at the end of this case study to a Word document. Type
your answers, and turn in a hard copy in class on the due date as noted on the syllabus.
You will also submit your case study into Blackboard Learn.
Note that there are terms that you may need to look up. In addition, you will need to
identify the information relevant to the nutrition assessment (not all information in
medical records is pertinent to nutrition – part of the assessment is judging what the
relevant information is.)
Case Presentation
ML is an 80 year old widower who was brought to his primary care physician’s office by
the local Older Americans Transportation Service. He had missed his two prior scheduled
office visits because of the recent death of his wife and a subsequent fall, which resulted
in an intertrochanteric fracture of his right hip.
On presentation, ML appeared withdrawn and much frailer than on previous visits. He
answered in a monotone with terse, nonspontaneous speech, and he lacked expression.
When asked about how he has been coping after the loss of his wife, he became tearful.
He admitted that, in addition to the loss of companionship, his wife had done all of the
cooking and grocery shopping which has caused additional hardship.
Past Medical History
ML tripped on the steps in his house 2 months ago and fractured his hip. He underwent
an open reduction/internal fixation surgery to repair the fracture, and the operation went
well. He had no serious operative complications, but he lost approximately 250cc blood
during the procedure (1 unit = 500cc). ML underwent inpatient rehabilitation for 10 days
after discharge from the surgical service and then returned home, where he lives alone.
He ambulates slowing with a cane and can climb stairs only with difficulty.
During his inpatient rehabilitation stay, he was diagnosed with depression and was started
on an antidepressant. He has no major chronic diseases except for osteoporosis,
discovered at the time of his hip fractures 2 months ago. ML had an appendectomy at age
46 and bilateral cataract surgeries 10 years ago. He has no previous history of
pneumonia, tuberculosis, hepatitis, or urinary tract infection.
Medications
ML is currently taking fluoxetine (Prozac), 20mg daily, for depression and an iron
supplement for anemia three times per day. He also self-medicates with over the counter
(OTC) ibuprofen (200-400mg three times a day) and frequently uses OTC laxatives and
glycerin suppositories for constipation, which he attributes to the iron tablets. He does not
take a multiple vitamin, calcium or vitamin D. He has no known food allergies.
Social History
ML lives alone in the four-bedroom, two-story home that he has occupied since he
married 55 years ago. His son and daughter both live out of state. Although they call him
every few weeks, they have not visited since his wife’s death. ML also explains that he
used to attend church and visit the local senior center regularly with his wife but has not
been to either lately. ML explains that he has no energy to “get up and go” anymore and
he falls asleep in front of the television. He also reports being constipated and that his
food does not have much taste. He avoids alcohol and tobacco and drinks three cups of
coffee daily.
Review of Systems
General: Weakness, fatigue, weight loss, and depression.
Mouth: Food lacks taste (hypoguesia); dry, “thick-feeling” tongue; sores in corners of
mouth.
Gastrointestinal (GI): Poor appetite, constipation.
Extremities: Hip pain when climbing stairs, some tenderness at old incision site, and
chronic low back pain
Physical Examination
Vital Signs
Temperature: 97.0 deg F
Heart rate: 88 BPM
Respiration: 18 BPM
Blood pressure: 130/80 mm Hg
Height: 5’11”
Current weight: 145 lb
Usual weight: 170 lb
General: Thin, elderly man who is appropriately conversant but withdrawn. He is well
groomed, but his clothes are loose fitting, suggesting weight loss.
Skin: Warm to touch, patches of dryness and flaking to elbows and lower extremities
Head, ears, eyes, nose, throat (HEENT): Temporal muscle wasting, no enlargement of
thyroid
Mouth: Ill-fitting dentures, sore beneath bottom plate, cracks/fissures at corners of mouth
(angular cheilitis)
Cardiac: Regular rate at 88 BPM
Abdomen: Well-healed appendectomy site scar, no enlargement of liver or spleen,
diffusely diminished bowel sounds.
Extremities: Well-healed hip surgery incision with slight surrounding erythema, no sores
on feet, traces pretibial edema to both lower extremities
Rectal: Hard stool in vault, stool test for occult blood negative
Neurologic: Alert, good memory, no evidence of sensory loss
Gait: Slightly wide-based with decreased arm swing, antalgic and tentative but with safe,
appropriate use of cane
Laboratory Data
Albumin: 2.5 g/dL (normal 3.5-5.8g/dL)
Hemoglobin: 11.0 g/dL (normal 11.8-15.5 g/dL)
Hematocrit 33.0% (normal 36-46%)
ML’s 24 hour dietary recall:
At his physician’s request, ML provided the following 24 hour recall, stating that this
represents his usual daily intake:
Breakfast (home)
1 Jelly donut
1 slice white toast
2 tbsp Jelly
1 cup coffee
Lunch (home)
1 cup chicken and noodle soup
3 saltine crackers
2 butter cookies
1 cup coffee
Dinner (home)
1 slice white bread
2 tbsp jelly
2 tbsp peanut putter
2 butter cookies
1 cup coffee
Total kcals: 1270
Protein: 25 gm/day (8% of kcals)
Fat: 42 gm (30% of kcals)
Carbohydrate: 201 gm (62% of kcals)
Calcium 153mg
Iron 4 mg
Kelsey Starck
HCM 4700-01
Case Study 1 Questions
1. Calculations:
a. BEE (using Mifflin St Jeor and Harris Benedict- compare the results)
RMR Mifflin= (9.99 x weight) + (6.25 x height) – (4.92 x age) + 5
= (9.99 x 65.91kg) + (6.25 x 180.34cm) – (4.92 x 80) + 5
=1396.97 kcal/day
RMR HBE= 66+ (13.7 x weight) + (5 x height) – (6.8 x age)
= 66 + (13.7 x 65.91 kg) + (5 x 180.34cm) – (6.8 X 80)
= 1326.67 kcal/day
b. Total energy needs for repletion (weight gain)
Weight gain = (HBE X AF) + 500 kcal/day
Activity Factor (AF) = 1.2 (sedentary)
500 kcal/day = 3,500 kcal/ wk = 1 pound / week
= (1326.67 kcal/day x 1.2) +500 kcal/day = 2,092 kcal/day
I decided to use HBE and an activity factor because it gave me the closest
estimate of ML’s calories expended per day. Because ML needs to gain
weight, and gaining one pound a week is healthy weight gain, 500 kcal
/day must be added to his diet.
c. Protein needs
RDA= 1.2 g/kg
=(1.2 g/kg)(65.91kg) =79.08 g/day
d. Fluid needs
>75years = 30 ml/kg
(30 ml/kg) (65.91kg)=
1,977 ml/day
e. Ideal body weight
106lbs + 6lbs every inch over 60in) +/- 10%
106 + 66 = 172 pounds
+10% : 189.2 pounds
-10%: 154.8 pounds
f. Percent ideal body weight (current / IBW) x100
(145/ 172) x 100 = 84.3%
g. Percent usual body weight (current / usual) X100
(145/ 170) x 100 = 85.3%
Evaluation: moderately/ mildly underweight
h. BMI (kg/ (m^2)
=(65.91/ 1.803^2) = 20.27
18.5 – 24.9 = Normal BMI
2. What do ML’s BMI and percent weight change indicate about his nutritional
status?
Percent weight change= (current wt – usual wt) / usual wt
=(145- 170) / 170 = -14.7% ~ 14.7%
BMI= 20.27
ML’s percent weight change and BMI indicate that he has lost a significant
amount of weight recently, 14.7%. Although he has lost this weight, which is
concerning, his BMI still falls within normal values of 18.5 – 24.9. BMI is not
usually a good indicator of nutritional status because it is likely that ML is
malnourished, based on other lab values, even though his BMI is normal. Percent
weight change is a better indicator of nutritional status because it is known that
unintentional weight lost is a sign towards malnutrition. ML did not plan his
weight loss, and therefore indicates that his nutritional status isn’t normal.
3. What nutrition-related issues do his lab values indicate?
-Albumin: ML’s albumin results of 2.5 g/dL are significantly lower than normal
(3.5 g/dL – 5.8 g/dL). This most likely indicates chronic malnutrition. Because
there is no storage of protein, when a patient is chronically malnourished the body
begins pulling active visceral and somatic proteins to make glucose to fuel the
brain, via gluconeogenesis. Albumin is a visceral protein. Albumin has a long
half-life, and will show nutritional habits three months prior, therefore marking its
chronic nature. It is important to realize, however that low albumin levels could
mark liver disease and dehydration. The albumin levels alone do not suffice for a
malnutrition diagnosis.
-Hemoglobin & Hematocrit: ML’s hemoglobin (11.0 g/dL) and hematocrit (33%)
levels were slightly under normal values. Hemoglobin and hematocrit lab values
help diagnosis anemia and evaluate the number of red blood cells. These levels
change in regards to patient’s hydration level, and can help diagnosis many issues
including bone cancer, anemia, dehydration, and inflammatory diseases. If ML is
anemic, which is diagnosed from complete blood count test, it is likely that he is
low in iron, folate and Vitamin B12. Anemic patients usually present with fatigue
and weakness, as ML does. It is noted that ML currently takes iron supplement.
4. Would a functional assessment of this patient yield any extra valuable
information? Justify your answer.
-It is noted in the physician’s note that ML presents with temporal muscle
wasting, which is a clear sign of malnourishment. Further functional testing will
be beneficial in helping diagnosis of malnutrition. Clavicle assessment and
shoulder assessment will provide registered dietitian with further information
regarding muscle wasting. Muscle wasting is prevalent in malnourished people
because when one is energy deficient, the body will break down somatic proteins
in muscle to help fuel the body. Muscle wasting is prevalent in marasmus, and
therefore functional assessments are vital to determine this.
5. What medical, environmental, and social factors have led to nutritional
problems in this patient?
-ML’s depression diagnosis contributes to his nutritional problems because it is
likely he doesn’t feel motivated to eat. ML suffers from constipation and may
want to avoid foods that will prolong constipation symptoms. Potential chronic
pain from fractured hip will lower desire to eat.
-Recently ML fractured his hip and spent 10 days in an inpatient rehabilitation
facility. It is likely he did not prefer food available. ML lives in a two-story house,
it is noted that ambulating is difficult; therefore traveling to the grocery store to
obtain food would be difficult. ML does not live close to family that can help him
prepare meals.
-Socially, ML just lost his wife and is now living alone. ML’s wife did all of the
cooking, and without her he doesn’t get groceries or cook. ML no longer goes to
church or senior center.
6. What general conclusions can you draw regarding the adequacy of his
current diet?
-According to ML’s 24-hour dietary recall his usual daily intake excludes all fresh
fruits and vegetables and lacks a significant amount of protein. As calculated in
1c, ML requires 79.08 g/day of protein. ML is only consuming 25 g/day of
protein, and therefore is not consuming adequate amounts of protein per day. The
current RDA for carbohydrates is 130 g/day and ML is consuming 201 g/day. ML
is exceeding his carbohydrate need. As calculated in 1a, according to ML’s
current BW he should be consuming at least 1397 kcal/day to maintain his current
weight, and ML is only consuming 1270 kcal/day. Therefore, ML is losing
weight, instead of gaining weight. ML must increase calorie intake per day to
2,092 kcal/day (see 1b) to gain weight. ML’s current diet is absolutely not
adequate to support his nutritional needs.
7. How can ML’s diet be improved to meet his energy requirements, achieve
weight gain, and relieve constipation? Plan a 1-day menu with specific
amounts of foods and times to eat that would improve ML’s nutritional
status.
-ML’s diet can be improved to meet his energy requirements, achieve weight gain
and relieve constipation by incorporating fresh fruits and vegetables, and adding
higher calorie founds containing protein. Furthermore, ML needs to meet his fluid
requirement by addition of water and fibrous juices in his diet.
8am: Breakfast
-1 glass of prune juice (120kcal, 29g CHO, 2g protein)
-1 cup of coffee
-1/2 grapefruit w/ sugar (60kcal, 1g protein)
-1 piece of whole grain toast (85kcal, 4.35 g protein, 13.9 g CHO)
-2T peanut butter (188kcal, 8g protein, 6.3g CHO)
Breakfast Total:
465kcal
49.2 g CHO
15.35 g Protein
10am: Snack #1
-1 apple (130kcal, 0g protein, 30.8g CHO)
-2T peanut butter (188 kcal), 8g protein, 6.3g CHO)
Snack Total:
318 kcal
37.1 g CHO
8 g protein
12pm: Lunch
-Turkey Sandwich (297 kcal, 25g protein, 43g CHO)
-2 Butter cookies (200kcal, 2g protein, 29g CHO)
-1cup carrots (30kcal, .5g protein, 7g CHO)
Lunch Total
527 kcal
27.5 g Protein
79 g CHO
Dinner: 5pm
-Italian sausage (286 kcal, 15.9g protein, 3.5g CHO)
-Spaghetti and sauce: (444kcal, 18g protein, 44g CHO)
-Garlic bread: (160kcal, 4g protein, 22g CHO)
Dinner Total
890 kcal
37.9 g protein
69.5 g CHO
Day Total
2200 kcal/day
243.3 g CHO
117.85g protein
In order for ML to gain weight, it is necessary to drastically increase his energy
intake, CHO and protein intake. Gaining weight should be done healthfully, but it
is important to provide ML with foods that he is interested in and he can easily
make himself. It may be beneficial to provide ML with a weekly grocery list and
resources that can deliver groceries to him. Educate the patient that prune juice,
fresh fruits and vegetables will decrease his incidence in constipation. Overall
energy intake will provide ML with more energy and likely make him feel better.
Educate patient regarding simple ways to incorporate protein into meals using
meats, peanut butter and nuts. Potential referral to occupational therapy could be
beneficial to stimulate musculature via light lifting, and making tasks easier
without his wife.
*All nutritional data was found on www.caloriecount.about.com