©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Initial Progress Note—Case #1
Name: _____Alice Jones_____________________________
MR# _0596283________ DOB: _2/10/1939
______ Date: _ 7/15/2005____________
Recommendations:
Physician encouragement of physical activity might move patient toward action in this area.
Please recheck lipid profile before her next nutrition therapy appointment on 9/9/2005
Nutrition Diagnosis:
Nutrition Diagnosis (Problem)
√
√
NI-1.5 Excessive energy intake
NI-2.2 Excessive oral food/bev. intake
NI-4.3 Excessive alcohol intake
X
NI-51.3 Inappropriate intake of food fatsspecify:
NI-53.3 Inappropriate intake of types of
carbohydrate—specify:
NI-53.5 Inadequate fiber intake
Other:
X
NC-2.3 Food-medication interaction
NC-3.3 Overweight/obesity
NB-1.1 Food, nutrition and nutrition
related knowledge deficit
NB-1.3 Not ready for diet/lifestyle change
NB-1.6 Limited adherence to nutritionrelated recommendations
NB-2.1 Physical inactivity
Inappropriate intake of saturated and trans-fat (NI-51.3) related to food and nutrition knowledge deficit as evidenced by
LDL cholesterol >130 mg/dL and reports of high saturated fat foods in 24-hour recall.
Additional Nutrition Diagnoses:
Not ready for diet/lifestyle change (NB-1.3) related to inability to focus as evidenced by unwillingness to commit to short
term goals for lifestyle change.
Nutrition Assessment Recommendations and Nutrition Diagnosis are based on the following:
Patient is a 66 y/o white female referred by Dr. John Morgan for combined hyperlipidemia and metabolic syndrome.
This is a 45 minute Initial MNT encounter. Patient states she is depressed over recent loss of husband 6 months ago.
Client History (medication/supplement [cholesterol-lowering meds and folate, B6, B12, CoQ
10], social [smoking and alcohol habits], medical/health [S/P angioplasty or CABG] and personal):
Pertinent Meds: Levoxyl, Coumadin, Atenolol, Prozac
Social Hx: retired, lives in her own home with 2 grown sons.
Family Hx: premature CVD—father died after an MI at age 44
Medical Hx: Patient has been on statin therapy to lower LDL cholesterol, but it
was discontinued due to elevated LFT’s. Hypothyroidism, Depression
Pt has a mechanical tricuspid valve, placed 25 years ago
Baseline for Outcomes Monitoring:
Biochemical Data:
Lipid Profile
Total Cholesterol
LDL calculated or X direct
HDL
TG
Non HDL (if TG > 200 mg/dL)
Other Labs
Date: 7-10-05
255
mg/dL
152
mg/dL
25
mg/dL
386
mg/dL
230
mg/dL
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Glucose
Others:
ALT
AST
TSH
112
mg/dL
40
46
4.16
units/L
units/L
uIU/mL
Anthropometric Measurements:
Ht. 5’2” Wt. 159 lbs. BMI 29.1 WC 37”
Weight History: weight had been stable at 150 lbs. for years until 6 months ago when husband died
Physical exam findings (oral health, physical appearance [abdominal obesity, xanthomas], muscle/fat wasting, affect):
Well nourished with abdominal obesity
BP_152/90__
Food and Nutrition History (food consumption [Intake of fat, % calories from fat, type, sources of fat, total and soluble
fiber, fish, soy, plant sterols] nutrition/health awareness and management, physical activity/exercise, food availability):
She eats only one meal per day plus sugared tea throughout the day; frequent use of high fat meats and large servings of
starch. She has limited fruit and vegetable intake.
Results of computerized nutrient analysis of a 24 hour recall.
Nutrient
Kcalories
% Energy from Fat
% Energy from Saturated and Trans Fat
Dietary cholesterol (mg)
Dietary Fiber (g)
Soluble Fiber (g)
Omega-3 (g)
Patient’s Intake
Recommended Level
2343
27%
10%
342
38
6
0.27
1720
25-35%
< 7%
<200
20-30
7-13
1
Sedentary lifestyle
The patient came with a limited knowledge base regarding nutrition for prevention of heart disease. She appeared to grasp the
concepts well, but current psycho-social issues limit her interest in making significant changes.
Additional Pertinent Information: n/a
Nutrition Intervention:
Food and/or Nutrient Delivery (meals/snacks, medical food supplements, vitamin/mineral supplement, bioactive
substance supplement, feeding environment and nutrition-related medication management, [meal plan]):
1. Cardioprotective dietary pattern with <7% saturated and trans fat and 20-30 g dietary fiber
2. Include 2-3 g plant sterols/stanols/day
3. Keep vitamin K intake consistent to assist in careful titration of coumadin
Nutrition Education (instruction/training in a skill or knowledge to help manage/modify food choices and eating
behavior, [risk factors, physical activity]):
Education provided on low sat/trans fat intake with reduction in refined starch and sugar, while increasing fiber.
Instructed on use of light margarine with plant stanols
Patient advised to keep vitamin K intake consistent to assist in careful titration of coumadin
Nutrition Counseling (set priorities/goals and action plans for self-care, [self-monitoring and individualized behavioral
goals to address nutrition diagnosis]):
1. Eat 3 small meals per day
2. Substitute low calorie sweetener for sugar in tea
3. Select leaner choices of animal protein
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
4. Incorporate use of plant sterol/stanol fortified light margarine and yogurt
Coordination of Care (referral to or coordination of nutrition care with other health care providers [referral,
recommendations]): (see top of progress note)
Expected Outcomes (Biochemical, Anthropometric, Physical and Food/Nutrition).
Outcome
Amount (if applicable)
Timeline
1. Decrease BMI
2. Decrease serum TG
3. Decrease LDL-C
by 1 unit
3 months
6 weeks
3 months
by 10%
Materials Provided
√
X
X
√
Hypercholesterolemia Nutrition Therapy *
Hypertriglyceridemia Nutrition Therapy *
Label Reading, Shopping Tips, Cooking Tips
Trans Fat Tips
Other: Vitamin K food list
X
X
Omega-3 Fat Tips
Soluble Fiber Tips
Plant Sterols and Stanols Tips *
Nuts Tips
Alcohol Tips
* from ADA Nutrition Care Manual; ** from ADA Disorders of Lipid Metabolism EAL Toolkit
Follow Up Plan for Monitoring and Evaluation
Follow-up on Expected Outcomes
Appt in 6 weeks to assess for improvement in dietary intake according to behavioral goals listed above and for improvements in
lipid profile.
Future plans for care
At follow-up visit, consider issue of increasing physical activity and inclusion of omega 3 fatty acids
Next Visit: 9/9/2005_______ RD Signature: ______Holly Huffman, RD____
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Follow-Up Progress Note—Case #1
Name: _____Alice Jones_____________________________
MR# _0596283________ DOB: _2/10/1939
______ Date: _ 11/08/2005____________
Medical Diagnosis: Combined Hyperlipidemia; hypothyroidism
Recommendations:
Based on significant, but not optimum triglyceride lowering, please have lipid panel checked again the beginning of November,
before 11-8-05 follow-up appointment.
Continue reinforcement of the benefits of improved diet and activity to normalized serum lipids and reduce risk of heart
disease.
Nutrition Diagnosis:
Food, nutrition and nutrition related knowledge deficit (NB-1.1) related to lack of adequate exposure to how to select
products with plant sterols as evidenced by demonstrated inability to identify and use plant sterol containing products
correctly.
Excessive energy intake (NI-1.5) related to depression as evidenced by reports of large portions of high-fat foods.
Physical inactivity (NB-2.1) related to lack of social support as evidenced by reports of large amounts of time spent in TV
watching.
Nutrition Assessment Recommendations and Nutrition Diagnosis are based on the following:
This is a 45 minute follow-up MNT encounter. Patient states she is less depressed and has become more interested in trying to
eat healthier.
Client History (medication/supplement [cholesterol-lowering meds and folate, B6, B12, CoQ10], social [smoking and
alcohol habits], medical/health [S/P angioplasty or CABG] and personal):
Meds Continue as: Levoxyl, Coumadin, Atenolol, Prozac
Outcomes for Monitoring:
Biochemical Data:
Lipid Profile
Total Cholesterol
LDL calculated or X direct
HDL
TG
Non HDL (if TG > 200 mg/dL)
Other Labs
Glucose
Other:
Date: 7-10-05
255
152
25
386
230
112
Date: 9-7-05
231
146
30
275
201
101
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
Anthropometric Measurements:
Ht. 5’2” Wt. 157 lbs. BMI 29 WC 37” Weight History: Weight is only 1 pound less than 2 months ago.
Physical Exam Findings (oral health, physical appearance [abdominal obesity, xanthomas], muscle/fat wasting, affect):
BP 148/88 She appears more vibrant than on last visit.
Food and Nutrition History (food consumption [Intake of fat, % calories from fat, type, sources of fat, total and soluble
fiber, fish, soy, plant sterols] nutrition/health awareness and management, physical activity/exercise, food availability):
Her estimated intake of plant sterols appears to be only 0.5 g/day. Inadequate use of plant sterols limited LDL lowering effect.
Adherence/Barriers to Behavioral Goals:
She has begun using sucralose sweetener in place of sugar in her tea and has begun eating breakfast, usually cereal with 1% milk
and sweetener.
She is using leaner meat and some vegetarian lunch options, but has not decreased portion size.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
She purchased light yogurt and light margarine, however the margarine was not fortified with plant sterols/stanols.
Progress/Barriers towards Biochemical, Anthropometric, Physical and Food/Nutrition Goals:
Her weight has not improved significantly, but her eating pattern is better.
Values in her serum lipid profile have moved in the right direction, but none have met recommended levels yet (4% decrease in
LDL; significant drop in triglycerides from 386 to 275, but ideally triglycerides will lower to <150 mg/dL).
Additional Pertinent Information: n/a
Nutrition Intervention:
Food and/or Nutrient Delivery (meals/snacks, medical food supplements, vitamin/mineral supplement, bioactive
substance supplement, feeding environment and nutrition-related medication management, [meal plan])
Careful use of 2-3 g plant sterols/day
Nutrition Education (instruction/training in a skill or knowledge to help manage/modify food choices and eating
behavior, [risk factors, physical activity])
Demonstrated with product labels how to incorporate 2 g plant sterols/stanols per day.
Addressed ways to increase physical activity and the benefits related to depression and weight control.
Nutrition Counseling (set priorities/goals and action plans for self-care, [self-monitoring and individualized behavioral
goals to address diagnosis])
1. Increase physical activity, begin walking around the block once daily for at least 15 minutes.
2. Enlist neighbor as a buddy for walking together.
3. Daily use of 1 ½ tablespoon of light margarine with plant sterols
Coordination of Care (referral to or coordination of nutrition care with other health care providers [referral,
recommendations]) (see top of progress note)
Expected Outcomes (Biochemical, Anthropometric, Physical and Food/Nutrition)
Outcome
Amount (if applicable)
Timeline
1. Decrease BMI
by 1 unit
2. Further decrease in serum TG
3. Decrease LDL-C
by additional 5%
2 months
2 months
2 months
Materials Provided:
√
√
Hypercholesterolemia Nutrition Therapy *
Hypertriglyceridemia Nutrition Therapy *
Label Reading, Shopping Tips, Cooking Tips
Trans Fat Tips
Other:
X
Omega-3 Fat Tips
Soluble Fiber Tips
Plant Sterols and Stanols Tips *
Nuts Tips
Alcohol Tips
* from ADA Nutrition Care Manual
Follow Up Plan for Monitoring and Evaluation
Follow-up on Expected Outcomes
Will talk with patient by telephone in 2 weeks to check on plant sterol intake.
Will check weight and serum lipids at follow-up.
Continue/modify intervention as needed
Future plans for care
Next follow-up visit in 2 months
Next Visit: __11-8-05___________
RD Signature: __ Holly Huffman, RD