At-risk Client Assessment

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Zahie El Kouri is a 39 year old lactating woman. She is 5” 1’ and weight at time of interview weight was

135 lbs. This gives her a BMI of 25.51 She is considered to be at nutritional risk because while breastfeeding, her body is utilizing greater amounts of vitamins, minerals, and energy to produce milk.

The temptation to reduce energy requirements below the recommendations poses a nutritional risk for women whom wish to lose their pregnancy weight. Energy intake must be maintained at a certain level to compensate for the production of breast milk.

The Food Frequency Questionnaire (FFQ) nutritional report gave an estimated energy intake for the participant as 2228.6 kcals per day. According to the nutritional report generated from Food

Processor Program, her recommended energy needs are 2303.35 kcals. From the Food Processor, 24hour recall, her energy intake was reported at 2441.99. Her macronutrient balance is in the range of the

Dietary Reference Intake (DRI) for Acceptable Macronutrient Distribution Range (AMDR). She is over the

DRI for alpha-linolenic polyunsaturated fats, and over the fiber recommendations. She is also over the protein needs in suggested gram amount, but compared to the percent per calories, she is within range.

Carbohydrate

45-55%

Protein

10-35%

(῀71 grams)

Fat

20-35%

Polyunsaturated

Linoleic

5-10% total fat

53.7% 14.1%

87.76 grams

32.2% 16.6%

The FFQ gave her average intake for the macronutrients as:

Polyunsaturated

Alpha-linolenic

0.6-1.2%

3.1%

Fiber

29 grams

56.21 grams

Carbohydrate

41.91 %

Protein

14.10%

Fat

47.51%

Fiber

39.34 grams

While interviewing the participant for information for the FFQ, she exclaimed dissatisfaction with the questionnaire. The issue was with the fact that the question were geared for general intake over the year, while it was noted that for 9 months out of the year, she ate different foods that the other months. Therefore, I do not feel that the FFQ questionnaire is representative of the client’s general food intake.

From the information obtained from Food Processor 24-hour recall, the client is not meeting the DRI for lactating woman over the age of 30 for most micronutrients. She is a pescatarian, and I believe that the lack of meat contributes to deficiency of certain vitamins. In particular, thiamin (Vitamin B

1

,) riboflavin

(B

2

), niacin (B

3

), and B

12 were very low. Only 50% DRI of B

3

and B

6

was consumed and the others barely met 25% DRI.

Quinoa and lentils contributed most of the B

3

. Trace amounts of other B Vitamins were found in the other foods. Vitamin B

12

was found in no foods in the 24-hour recall.

Iron levels are above the DRI by 300%. The consumption of 1 cup of steel cut oats provided almost the complete DRI for iron and also provided a large amount of the calcium in the diet. Most of the calcium was obtained from the 1 cup of milk, with the DRI was only met up to 57%. Some calcium was also provided by walnuts, chickpeas, tomatoes, lentil, and yogurt.

Along with calcium, Vitamin D was supplied by milk. There is no DRI for Vitamin D, but a tolerable upper intake level (IU) was recently set by the Institute of Medicine at 600 International Units

(IU). The client intake was 100 IU of Vitamin D. Vitamin E intake was extremely low, less than 20% DRI consumed with a majority from olive oil. An apple provided vitamin C, along with lemon juice, zucchini, onion, and cherry tomatoes. The DRI intake for Vitamin C was met to 66 %. The intake of Vitamin A for

DRI for lactating women over 30 is approximately 4333 IU. Client’s intake was recorded at 6429.35 IU.

Salad greens, tomatoes contributed the greatest to Vitamin A intake.

Folate was found to meet less than than 75% DRI amounts, with quinoa, lentils, and tomatoes contributing the most. Vitamin K DRI is 90 mcg, and was met to about 43%. Onions and tomatoes were the main source for Vitamin K. Potassium levels met 1/3 DRI, and were found in lentils, quinoa, tomatoes, zucchini and walnuts in the highest amounts. Besides iron, the only micronutrient to meet and exceed the DRI was manganese, and molybdenum. Phosphorous and copper were just under 100%

DRI value. Sodium met less than 50% of the DRI and majority was obtained from the canned chickpeas, sauce, and mustard.

Choose MyPlate is the United States Department of Agriculture’s (USDA) visual teaching tool that emphasis healthy eating habits and its information is consistent with the Dietary Guidelines for

Americans. The Food Frequency Questionnaire provides an average intake based on questions regarding food intake for one year. It also provides recommended amounts of intake for food groups based on USDA’s Choose MyPlate.

The client consumed within the AMDR range for protein, on both the FFQ and Food Processor.

The MyPlate amounts recommended for protein for then FFQ were given in a range, and the client’s protein amount fell close to right in the middle of the range at 14.1 % total calories. For Food Processor, the client did not meet the protein recommendation, and but was within 5 grams, with 14.1% of total calories coming from protein.

The carbohydrate amounts recommended from MyPlate for both the FFQ and Food Processor were met by the client. Carbohydrates made up little more than half my clients diet in the 24 hour recall, and less than half in the FFQ. The intake for fat exceeded the recommendation in both nutrient analysis programs. Food Processor recommended 71.66 grams and intake was 89.18 grams, with 32.2% calories from fat; 9.4% from saturated, 6% polyunsaturated, and 4.7% monounsaturated. FFQ recommended the AMDR of 25-35% calories from fat and calculated an estimated intake of 47.51%.

From the information generated by FFQ, my client was slightly below intake recommendation of whole grains as well as the bread/pasta/rice group. Together, she got the recommended 8 oz of grains.

She was also over in vegetable groups with/without potatoes and good oils. Vitamins which met the

MyPlate recommendations included all B-vitamins calcium, potassium, magnesium, iron, and vitamins E,

C, and A. Fiber exceeded the recommended amounts. Folate intake was very high from food sources, and a large amount was supplied from prenatal supplements as well. Prenatal vitamins also attributed large amounts of Vitamin A, C, E plus iron and zinc.

I was very impressed with your diet. The amount of wholesome foods was amazing and contributes to a high fiber and proper amounts of carbohydrate, fat and protein diet. High levels of iron are great for you as a lactating woman and your energy intake was very close to the recommended level. The lack of processed food contributes to a low sodium diet and the abundance of wholesome foods, such as lentils and quinoa, contribute to beneficial nutrients such as folate and magnesium. Steel cut oats for breakfast are a great way to start the day. A good breakfast is important to sustain energy through the morning, which is particularly helpful while caring for an infant. Although not included in the computer food analysis, I know that you have a great intake of fluids in the form of water, which is necessary to maintain while lactating

Some vitamins levels were low and I believe that can be easily remedied with a few ideas and little effort. Being that you are incredibly busy and crammed for time as the mother of a 4 month old, a good way to ensure you are getting enough vitamins is to have a container of pre-cut and sliced vegetables in the fridge for easy access. This can be prepped once a week to last for the week. The addition of a few carrots, peppers, and broccoli would increase your levels of Vitamin C and trace elements that contribute to a healthy diet. Broccoli would also help increase levels of chromium, which is a trace mineral that works alongside carbohydrates for various functions, as well as increase vitamin

K. Vitamin K is important for blood clotting as well as strengthening bones. The large salad eaten in the evening is great as a daily fixture for fiber and vitamin A. It would be easy to add more vegetables to gain extra vitamins. I would recommend another addition to the salad to be spinach and/or kale greens.

These greens are loaded with vitamins and low in calories. They also can be included into stir-fry’s and added to any vegetable mixture, as they both cook down and do not require a lot of preparation.

An important nutrient that needs to be addressed is the intake of calcium. You reported very few food sources of calcium. The cup of milk is great in the morning, and if possible, and another in the evening would be beneficial. If drinking more milk is not what you would like to do, the inclusion of

more leafy greens and broccoli would contribute to calcium, though not in the amount that milk does.

Since calcium is of great importance, I would recommend a supplement if food sources are not contributing enough. There are several reputable supplements on the market, available at stores or online from Amazon on average for less than $10.00 for over 50 servings. One other supplement I would recommend is a Vitamin D. Very few food sources supply vitamin D and most is obtained from the sun. Living in an area such as Eugene that has numerous grey and rainy days, it is not uncommon to see low vitamin D levels.

Due to your vegetarian lifestyle, you are low in B vitamins that are normally found in meat and animal products. This is a concern as B vitamins are essential for several functions within the body. I am not sure on your opinion of eggs, but they are a good source of B

12 and B

2.

Hardboiled eggs are easy to incorporate into a daily diet-simply prepare 5-6 eggs and store in the fridge a quick, healthy snack.

Vegetarians are commonly low in vitamin B

12

, as it is primarily only found in animal sources. One nonanimal source is wheat germ. This is a ground up grain with a nutty flavor that can be easily added onto salads or to your morning oatmeal. Wheat germ can be found in most stores and one brand is produced locally by Bob’s Red Mill out of Oregon City. His price is around $7.00 for a 10 oz bag. Less expensive ones can be found by other manufacturer. Another source of B

12 is nutritional yeast, which is yeast that is grown from beet sugar and molasses to which B

12

had been added. It has a cheesy, nutty flavor that can be made into sauces or sprinkled on salads, stir-fry’s, or popcorn. It is commonly found in the bulk section of health stores, including Whole Foods and Market of Choice.

If you would like some more nutritional counseling, I would recommend contacting the Pediatric

Dieticians’ at Sacred Heart Medical Center at River Bend, Eugene, ph: 541-222-6832. Another local resource is the Clinic of Natural Medicine, located at 247 th

W. 10 th

Ave, ph: 541-338-9494. I highly admire you eating habits, and with just a few suggestion and additions to your diet, you are on your way to an incredibly healthy, well rounded diet which will impact the health of your beautiful baby.

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