Case study Dr. Salah Darwish, BCNSP, OMP, SSN, CPT Clinical Nutrition Specialist Specialist in Sports Nutrition Obesity Management Professional Certified personal trainer Personal data • Susan is a 41-year-old. • She is divorced and currently is not in a relationship. • She lives with her son, and her daughter lives nearby with her 2-year-old twin daughters. • Susan works in a nursery, so spends much of her day looking after young children and comes home at night very tired. History & lifestyle • Susan reports she has always been bigger than others. As a child she remembers being bigger than other children and having to get clothes from a different shop as she was unable to buy from the normal school uniform shop. • She puts her weight gain down to her mother giving her very large portions of food, and believing that she ‘has to finish everything on her plate as there were starving children in Africa’. • She says she was rarely allowed ‘junk food’ or takeaways, but reports that as she got older she started consuming more ‘junk food’, takeaways and large quantities of fizzy drinks especially in her teens and 20s and her weight really increased. • She has tried losing weight in the past through increasing exercise, eating smaller portions and Weight Watchers and meal replacement shakes, but does not stick to it. Although she loses weight she regains when she finishes the diet. Susan was referred for bariatric surgery (she wanted the gastric band as this was reversible), but after reading more about the operation and watching a documentary on TV she became afraid of what might happen and decided she wanted to lose weight ‘the natural’ way. Susan was referred by her GP due to her high BMI and uncontrolled type 2 diabetes . Psychological factors • The anxiety and depression score indicated moderate anxiety and depression. • Susan also indicated during the consultation that she comfort ate when she is feeling sad or depressed. • These foods are usually sweets foods such as cakes, biscuits, chocolate and ice-cream. She reports bingeing on these food approximately once per week. • She did not report any purging measures such as vomiting or using laxatives to eliminate the food. Anthropometry, body composition and functional Environmental, behavioural and social Biochemistry and haematology Assessment Diet Clinical Anthropometry, body composition and functional • Weight 150 kg • Height 1.70 m • Physical activity and functions of daily living indicated moderate difficulty in performing usual activities (e.g. functions of daily living including washing and dressing herself) and reported moderate pain in her left knee and lower back, especially when bending down to pick up the children at work She completed a 2 min sit to stand test in which she scored 32 Biochemistry and haematology • • • • Total cholesterol 3.8 mmol/L HDL cholesterol 0.91 mmol/L LDL cholesterol 1.49 mmol/L TG 3.08 mmol/L HbA1c 67.2 mmol/mol (8.3%) BP 158/109 mmHg Clinical • Type 2 diabetes • Medication – Gliclazide (160 mg, qd) – Sitagliptin (100 mg, qd) – Metformin (1 g bds) • Hypertension • Medication – Ramapril (10 mg qd) • Hypercholesterolaemia • Medication – Simvastatin (20 mg qd) – Aspirin (75 mg qd) Diet Breakfast • Nothing Mid-morning Lunch Fruit (110 g) • Jacket potato (220 g) or spaghetti bolognaise (470 g) • or chicken (161 g) and chips (165 g) from local shop • A chicken wrap (175 g) from the local shop or • sandwiches (145–205 g) • Usually chicken (250 g) and rice (300 g) or pasta (430 g) – very large portions. • Take-aways such as pizza 2/7 Mid-afternoon Dinner – at home Ice-cream (150 g) or cake (130 g) Snacks throughout day • Crisps (will eat whole big bag in the day) (150 g) , sweets(120 g) Drinks • 2 cups coffee with 1 sugar (5 g) and semi-skimmed milk (25 mL) Environmental, behavioural and social • Susan does all the shopping and cooking for the household, although she will get take-aways some evenings during the week when she is tired. • She lives in a 2-bedroom flat on the first floor with no lift, so does have to climb stairs, with which she struggles especially with food shopping Questions 1.What was Susan’s initial BMI? What does this mean in terms of co- morbidities? 2.Why would the dietitian not measure Susan’s waist circumference in the consultation? 3.What other blood tests might you have wanted to ask the GP to organise? 4.Are there any other referrals or investigations that should be made for Susan? 5.What is the nutrition and dietetic diagnosis? 6.How would you involve Susan in her dietetic goal setting? 7.What advice would you provide to a weight management patient? 8.What could the dietitian do to help Susan reduce the number of takeaways she eats? 9.What tools can be used to help Susan identify normal portion sizes? 10.What self-monitoring tools could Susan use? 11.Can you think of any barriers to Susan changing her behaviour habits? 12.How would you document your care and ensure good communication with the MDT, particularly the physiotherapist and psychologist? 13.What outcome measurements would you collect to evaluate your care?
