Hackney
Leah Hackney
11/20/13 3pm
Diabetes Exchange SOAP
S. Pt. has not been very physically active since she got a job in a business firm. She
ahs been gaining wt wince she began working, and has gained about 20lbs in the
past 2 years. She states that she eats out often because she has a busy schedule and
rarely snacks during the day. Pt states that she enjoys yoga and Pilates but that she
doesn’t partake in it because she it too tired after work. The doctor has referred her
to get counseling on how to develop an eating plan that will help her glucose control
as well as achieve and maintain a healthy weight.
O.
Ht: 5’8” (68”, 172.72cm)
Wt. 200lbs (90.9kg)
BMI: 30.5 kg/m^2 (obese) IBW: 140lbs( 143% IBW)
UBW: 180 (111%UBW)
Labs:
HDL: 18 mg/dl (low)
FBG: 190 mg/dl (high)
LDL: 250 mb/dl (high)
Alb: 3.4 mg/dl (borderline low)
TG:450 mg/dl(high)
HgbA1c:9.9% (high)
Results from Glucose test:
Before Breakfast: 210 mg/dl (high)
Before lunch: 220mg/dl (high)
Before dinner: 210 mg/dl (high)
Before Bed: 185 mg/dl (high)
Energy Requirements:
EER: 2200kcal (24 kcal/kg)
Pro: 73g (.8g/kg; 13% kcal)
Fat: 73 g ( 7.2 kcal/kg; 30% kcal, <7% from saturated fat)
CHO: 312 g (57% kcal)
Fluids: 2200ml (1ml/kcal)
24 Hr Recall:
2622 kcal total
106 g pro (424 kcal; 1.16g/kg; 16%kcal), 277g CHO (1108kcals; 42%kcals),
113g fat (1017kcal; 39%kcal, >7% from saturated fat)
A.
Excessive energy intake related to large portion sizes, high fat diet and low physical
activity as evidenced by obesity, and 24 hr recall indicating intake of ~500kcal in
excess.
Hackney
Pt has an obese BMI, is 143% of her IBW, and 111% of her UBW. Pt is consistently
eating 120% of her recommended kcals, and will continue to gain wt if calories
aren’t reduced. Pt has elevated TG, and cholesterol (LDL) labs which are consistent
with her high fat intake, and her eating >7% of kcals from saturated fat. Pt has low
HDL levels which are not ideal and may contribute to hyperlipidemia. Pt’s elevated
HgbA1C is consistent with hyperglycemia, which may also be contributing to her
hyperlipidemia. Since Pt is obese, she may have chronic inflammation that is causing
her borderline low albumin levels. Pt has hyperglycemia before all three meals,
which may be due to lower physical activity levels, and no snacks in between meals.
Replacing refined carbs with complex carbs consistently throughout the day will
provide pt with more nutrients, and fiber to help feel full longer, as well as manage
fluctuating BG.
Pt’s diet is low in non-fat dairy as well as fruits and vegetables. Pt consumes 16% of
kcal from protein, 42% kcals from CHO and 39% kcal from fat. Pt is currently
consuming nearly 119% of recommended total calorie intake. Pt should be
consuming more kcals from CHO and less from fat, specifically saturated fat, to help
with weight gain and lipid labs. Pt’s chronic hyperglycemia multiple times a day,
puts pt at risk for of DKA, leading to neuropathy, nephropathy, retinopathy and
other chronic conditions. 24 hr recall indicates high intake of processed fast foods,
and pt likely has high sodium intake, which in combination with chronic
hyperlipidemia and hyperglycemia puts pt at higher risk for hypertension and other
cardiovascular related diseases. More physical activity may benefit pt by increasing
HDL levels, decreasing LDL levels, and allowing modification of EER so that she can
eat more calories and still stabilize wt before losing wt.
P. Stabilize weight by decreasing calorie consumption to 2200 kcal per day , 73g fat
(14 exch, 3 from sat fat), 312 g CHO (3 dairy, 4 fruit, 12 starch exch), 5 veg exch, 73g
pro (2 oz VLM exch)
Dairy
fruit
veg
fat
starch
pro
Exchange
#
3
4
5
14(3 sat)
12
2 VLM
B
L
1
1
1
1
2
3
3
3
3
D
1
3
4
3
2oz
Am
snack
Pm
snack
Hs
snack
1
1
1
1
1
1
2
1
-Consume at least 4 fruits and 5 vegetable servings per day
-Choose reduced fat meat and dairy options, whole grain breads for starches and
limit refined sugar products.
-Increase fiber to ~25g/day through fruits, whole grains and vegetables to help
maintain better control of fluctuating BG.
Hackney
-Choose lower fat meats and smaller portions (2 oz) of meats.
-Encourage pt to eat lower sodium foods and less processed foods. Limit sodium
intake to <1500mg /day
-Encourage pt do 150 min/week of moderate exercise per week to help stabilize wt,
increase insulin sensitivity and lower cardiovascular risks.
-Encourage pt to make healthier choices when eating out at restaurants. Such as
choosing lower calorie or lower fat options, choosing more fruit and vegetable
options as stated.
-<7% of total fat limit sat fat to ~17g per day. (3 exch) and provide educational
information on increasing monounsaturated and polyunsaturated fatty acid sources.
-Provide a day’s meal plan. Discussed with pt and her family how to make a sample
meal plan on their own using exchanges. Meal plan attached reflects lower calorie
and lower fat meal choices that meet pt’s daily energy requirements.
-Offer referral to nutrition/ DM classes
-website below shows tips for diabetes management:
http://www.diabetes.org
Follow up in: 1 month with 3 day food record, BG log/medication records.
-assess tolerance to lower calorie diet and exchange plan.
-Pre-albumin labs to see if Pt’s obesity is causing inflammation.
In 3 months:
-check current HgbA1C and lipid panel.
-pre-albumin labs to see if Pt’s obesity is causing inflammation.
RD to Be,
Leah Hackney