Name: _____Morgan Lindsay__________________ Instructions: This is not a group case study; it is an individual assignment! Complete the following questions using the background information above. Use this as a template and type in your answers. Remember RD’s are experts in researching evidence-based practice for their patients so you can use other credible sources. ***Be sure to reference your answers in-text and provide a Work Cited page at the end.*** 1. What factors found in the medical and social history are pertinent for determining Mr. Watkins’ heart disease risk? Medical Social Mild obesity for 10 years Smoking 2ppd for 30 years Hypertension Alcohol use: 2 cans of beer per week BP 160/100 Intake: ex: cheeseburgers/bacon/butter BUN 20 Cuts salt intake Bilirubin 1.1 Came to appointment because advised, but not willingly on own terms C-reative protein 1.0 HDL low (30) LDL high (210 Ratio LDL:HDL (7) Triglycerides (165) Apo A/B 75/140 Cholesterol (250) 2. Briefly describe the DASH eating plan. The DASH diet stands for Dietary Approaches to Stop Hypertension, which was discovered in the 1990's. The DASH diet focuses on food choices that are low in sodium and reduce sodium, as well as increase potassium, magnesium, calcium, and fiber. Along with other lifestyle adaptations, the DASH diet is shown to lower blood pressure (Nelms et all, 293). 3. Using the EAL, describe the association between sodium intake and blood pressure in hypertensive individuals. Dietary sodium intake should be limited to no more than 2300 mg sodium (100 mmol) per day. Reduction of dietary sodium to recommended levels lowers systolic blood pressure by approximately 2 - 8 mmHg. If the patient demonstrates adherence to a 2300 mg sodium diet but has not achieved the treatment goal, then the dietitian should recommend the DASH dietary pattern and/or reduction in sodium to 1600 mg to further reduce blood pressure. Optimal body weight should be achieved and maintained (BMI 18.5 - 24.9) to reduce blood pressure. Weight reduction lowers systolic blood pressure by 5 - 20 mmHg per 22 lbs (10 kg) body weight loss. 4. What are the Therapeutic Lifestyle Changes? Outline the components of the nutrition therapy interventions. The Therapeutic Lifestyle Change is included in the current recommendations or treatment of hyperlipidemia. TLC focuses on reducing total fat intake and reducing saturated and trans fats from the diet. Nutrition therapy is a major component of this treatment process to treat cardiac disease, hyperlipidemia, and hypertension. The TLC diet requires the following: “- Less than 7 percent of your daily calories from saturated fat - Less than 200 mg a day of cholesterol - 25–35 percent of daily calories from total fat (includes saturated fat calories) - Diet options you can use for more LDL lowering - 2 grams per day of plant stanols or sterols (see pages 27–28) - 10–25 grams per day of soluble fiber (see pages 23, 27–29) - Only enough calories to reach or maintain a healthy weight - In addition, you should get at least 30 minutes of a moderate intensity physical activity, such as brisk walking, on most, and preferably all, days of the week” (NCEP, et all. 22). 5. Calculate Mr. Watkins’ body mass index (BMI). What are the health implications of this number? BMI= wt (Kg)/ Ht (meters)^2 = 34.2. This puts Mr. Watkins in the Class 1 obesity category. This indicates a risk for cardiovascular disease and hypertension. 6. Calculate Mr. Watkins’ total energy needs. Identify the formula/calculation method you used and explain your rationale for using it. The TEE equation used for Mr. Watkins is: 1086-10.1xAge + PAx (13.7xweight+416xheight) PA = 1.0 – sedentary 1086 - (10.1) 53 + 1.0 x (13.7 x 102 + 416 x 1.7) = 2655 – 500kcal/day = 2155kcal/day I used this calculation because I felt it would give an accurate energy requirement. I used 1.0 for the PA because the case study does not say that Mr. Watkins does any additional physical activity in addition to daily activity. Also, since Mr. Watkins’ is in the obese category, it was important to use the correct calculation for obese males. I subtracted 500 kcal per day from Mr. Watkins daily energy needs to promote healthy weight loss. 7. Using a computer dietary analysis program or food composition table, compare Mr. Watkins’ “usual” dietary intake to her prescribed diet (DASH/TLC diet). NUTRIENT kcal PATIENT Prescribed DISEASE Your diet INTAKE diet (per IMPLICATIONS based recommendations (per day) day) on diet comparison 3280 2000 Obesity, CVD Decrease total caloric intake levels by eliminating high energy/ low nutritional content items. % kcal Pro % kcalCHO 17% 43% 15% 55% Protein levels are Protein levels are within within healthy range. a healthy range. Carbohydrates are Increase fiber content of essential in fat burn, CHO. therefore, fat storage can occur if CHO levels are too low. % kcal Fat 49% 25-30% High fat diets can result Decrease overall fat in higher risk of consumption and make obesity, CVD, and high sure “good” fats are cholesterol. being put into diet (low saturated fat). %SFA 48% </= 7% High cholesterol, Decrease animal fat obesity, CVD. sources, eliminate sat. fat products from diet. %MUFA 13% ~20% Adequate intake of Use olive or canola oils MUFA’s reduces the in dressing and risk of CVD, lower preparation of foods. LDL levels, have no effect on HDL levels, and lower apoliprotein AII lipoprotein levels. Protective of metabolic syndrome and type 2 diabetes if correct amounts are consumed. %PUFA 6% ~10% Adequate amounts of Adding corn, PUFA’s lead to a cottonseed, soybean, reduction of LDL and safflower, and sunflower are associated with oils to diet. decreased CVD risk (Nelms,et all. 313). Cholesterol 1634 mg </= 200mg Hypercholesterolemia, Avoid high cholesterol heart disease. foods such as shrimp, tilapia, and animal fats. Fiber 16.6 g 20-30 g Adequate amounts Increase fruit & reduce LDL levels, vegetable consumption, serum cholesterol whole grains, and beans. levels. Reduces risk for CVD. Supports healthy liver function and the synthesis of bile. Na 4076.16 mg < 1300 mg High blood pressure, Reduce sodium intake, sodium modification provide education on reduces risk of sodium content foods, hypertension by as DASH diet (Nelms,et much as 17%, all. 295). cardiovascular disease, renal disease, and stroke. Ca 966.29 mg 1200mg Reduces BP and Atleast 3 cups of dairy treatment of into diet (low fat or fat hypertension if free), get Ca from adequate amounts are whole foods not reached. Low calcium supplements. intake can increase risk for HBP K 4173.68 mg 4700 mg Reduces BP and High potassium foods treatment of such as apricots, prunes hypertension. (or juice), avocado, Potassium levels lower cantaloupe, banana, than recommended black beans, artichokes, levels is associated bran, milk, legumes, etc. with high blood pressure (Nelms, et all. 313-317) 8. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Less than optimal intake of types of fats, inadequate fiber intake, Predicted food-medication interaction, overweight/obesity, hypertension, and hyperlipidemia. 9. Dr. Clemmer ordered the following labs: fasting glucose, cholesterol, triglycerides, and creatinine. He also ordered an EKG. In the following table, outline the indication for these tests (tests provide information related to a disease or condition). Parameter Normal Patient’s Value Value Reason for Abnormality Your diet recommendations based on results Glucose 70-110 110 Diet may affect his Lower CHO content in relatively high glucose diet. level. Also, stress and illness can run high glucose levels. Hyperglycemia causes osmotic diuresis and decreased blood volume (Nelms, et all. 128) Parameter Normal Patient’s Value Value Reason for Abnormality Your diet recommendations based on results BUN 8-18 20 BUN and creatine levels Add more water and elevate during ARF. fluids to the diet to see Congestive heart failure can if dehydration is the be a reason or recent heart problem. Also, monitor attack. Dehydration can kidney function. also be a reason for elevated BUN levels Creatinine 0.6-1.2 0.9 Within normal limits N/A Total 120-199 250 Overweight, high Reduced saturated fat/ cholesterol/saturated fat trans fat content. diets Reduce overall total fat cholesterol consumption. Avoid trans fats and refined carbohydrates. Also, instead of using butter on toast, try a heart healthy buttery spread that will lower bad cholesterol. Parameter Normal Patient’s Value Value Reason for Abnormality Your diet recommendations based on results HDL- >45 30 cholesterol Smoking, overweight, lack Quit smoking; start of physical activity, diet. participating in some physical activity if possible. Reduced saturated fat/ trans fat content. Reduce overall total fat consumption. Avoid trans fats and refined carbohydrates. (TLC diet) LDL- <3.55 7.0 cholesterol Unhealthy diet, overweight, Adding more fiber to inactivity, possibly genetics. the diet. Lowering fat and cholesterol in diet. Apo A 94-178 75 HDL is low, which results Adding more fiber to in low Apo A because it is a the diet. Lowering fat major protein component of and cholesterol in diet. HDL. Parameter Normal Patient’s Value Value Reason for Abnormality Your diet recommendations based on results Apo B 63-133 140 Since Apo B is the major Adding more fiber to protein of LDL, it directly the diet. Lowering fat correlates with LDL levels. and cholesterol in diet. Meaning, since LDL levels are high, Apo B levels will be high. Triglycerides 40-160 165 Reduce lipid intake (lipid-free nutritional formulas) 10. Calculate Mr. Watkins 10-Year Risk for a Heart Attack (using the pamphlet posted on Angel; Box 5)? 6+ 4+ 3+2+2= 17= greater than or equal to 30% 11. Indicate the pharmacological differences among the antihypertensive agents listed below. Medications Mechanism of Action Potential food-drug interactions Medications Diuretics Mechanism of Action Potential food-drug interactions Decrease blood volume by Hypokalemia, hyperlipidemia, increasing urinary output; inhibit hypertriglyceridemia, glucose renal sodium and water intolerance; N/V anorexia, reabsorption. hypercholesterolemia, dry mouth, diarrhea, constipation, potassium supplements may be necessary, effect antagonized by NSAIDS, avoid natural licorice. Beta-blockers Blocks B-receptors in heart to Nausea, diarrhea, calcium may decrease heart rate and cardiac interfere with absorption, upset output stomach, dry mouth, stomach pain, gas or bloating, heartburn. Calcium- Affect the movement of calcium, Edema, nausea, heartburn, channel cause blood vessels to relax, contraindications: heart failure or blockers therefore, reduce vasoconstriction greater than first degree heart block, avoid Alcohol, caffeine, and natural licorice. ACE inhibitors Vasodilators that reduce BP by Hypotension (especially in elderly decreasing peripheral vascular patients), can worsen renal resistance by interfering with the function, hyperkalemia, dysgeusia, production of angiotensin II from causes dry non-productive cough, angiotensin I and inhibiting contraindications: pregnancy, avoid degradation of bradykinin. Natural licorice and salt substitutes. Medications Mechanism of Action Potential food-drug interactions Angiotensin II Interferes with renin-angiotensin May increase serum potassium, receptor system without inhibiting avoid salt substitutes, dysgeusia, blockers degradation of bradykinin nausea. Alpha- Blocks the vascular muscle Avoid natural licorice, adrenergic response to sympathetic nausea/vomiting, diarrhea, mouth blockers stimulation; reduces stroke volume dryness. (Nelms,et all 291) 12. What are the most common nutritional implications of taking hydrochlorothiazide? The reason for taking hydrochlorothiazide is to decrease blood volume by increasing urinary output. Also, this drug inhibits renal sodium and water reabsorption. 13. Mr. Watkins’ physician has decided to prescribe an HMGCoA reductase inhibitor (Zocor). What is its mechanism of action and what changes can be expected in his lipid profile as a result of taking this medication? Zocor is a lipid-lowering agent, it reduces levels of "bad" cholesterol (LDL) and triglycerides in the blood, while increasing levels of "good" cholesterol (HDL). Mr. Watkins’ can expect healthier cholesterol levels in terms of HDL and LDL. 14. What are some possible barriers to compliance? The fact that Mr.Watkin’s came to the appointment because he was told to and not willingly going because he was concerned with his own heath may show that he is not ready for change. Also, removing many things from him lifestyle may be hard for him (such as fats and smoking). 15. Select two KEY nutrition problems and complete the PES statement for each. P- Less than optimal intake of types of fats: saturated & trans (NI-5.6.3) E- Related to high levels of saturated fat S- As evidenced by high LDL level (210), and low HDL level (30). P- Excessive oral intake (NI-2.2) E- Related to energy intake levels higher than recommended amount. S- As evidence by food analysis software of a day’s intake, BMI of 34.2, class 1 obesity. 16. When you ask Mr. Watkins how much weight he would like to lose, he tells you he would like to weigh 170, which is what he weighed most of his adult life. Is this reasonable? What would you suggest as a goal for weight loss for Mr. Watkins? I do not think losing ~55 lbs is reasonable, but rather a goal weight of 200 within the first 6 months is a little more reasonable. I would recommend Mr. Watkins to lose about 10% of his weight over 6 months; this would be about a 22-pound weight loss, and then I would recommend education on weight maintenance for the next 6 months. After the first year, discussion of more weight loss can be brought up. 17. How quickly should Mr. Watkins lose this weight? I recommend 10% weight loss over 6 months. Which would be about a 22pound weight loss. 18. Write Nutrition Prescription for patient. Include Diet type, kcal level, % kcal from CHO, PRO, FAT, Saturated fat, cholesterol, Na. The nutrition prescription for Mr.Watkins is a ~2155 kcal diet composed of 55% total kcal from CHO, 15% total kcal from PRO, 25-30% total kcal from fat, </= 7% total kcal from saturated fat, </= 200 mg cholesterol, and </=1300 mg Na daily. 19. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). Use IDNT manual to label Intervention domains and subclasses; and give details of exactly what you are going to do. PES #1 o Goal: Decrease saturated fat in diet and incorporate healthy fats into diet to ultimately decrease LDL levels and increase HDL levels. o Intervention: Eliminating as much saturated fat from the diet through diet modification. Changing items in typical diet such as adding plant sterols/stenols to the diet. Switch butter for BENECOL spread. PES #2 o Goal: Healthy weight loss to decrease BMI and prevent risk of CVD. o Intervention: proved patient with education on healthy ways to lose weight, educate on weight maintenance, adjust diet for weight loss. 20. Write a concise ADIME note by pulling the key components from you answers. Handin a double-spaced typed version only A- 53 y/o male. Ht:70’’, wt: 225# (102.27 kg), BMI: 34.2 kg/m2. Dx: grade 1 hypertensive retinopathy, hypertensive heart disease, and early COPD. Pulse88, resp rate:18, temp: 96.4. Abnormal lipid profile, No prior therapy, mild obesity for past 10 yrs, mild hypertension, no diabetes history, thyroid indices are normal, TSH is normal. Tobacco use: 1 ppd for 30 yrs, alcohol use: 2 cans of beer per week. Family istory: CAD in 48yr old brother, s/p coronary artery surgery. General appearance: overweight AA male in NAD. Good appetite, eats 3 meals per day and 1 evening snack. Labs: BUN 20, Bilirubin, direct 1.1, C-reactive protein 1, cholesterol 250, HDL-L 30, LDL-C 210, LDL/HDL ratio 7.0, Apo A 75, Apo B 140, triglycerides 165. Reflecting hypertension, possible CVD, risk of stroke/heart attack. D- Less than optimal intake of types of fats: saturated & trans (NI-5.6.3) related to high levels of saturated fat as evidenced by high LDL level (210), and low HDL level (30). Excessive oral intake (NI-2.2) related to energy intake levels higher than recommended amount as evidence by food analysis software of a day’s intake, BMI of 34.2, class 1 obesity. I- The nutrition Rx: ~2155 kcal diet composed of 55% total kcal from CHO, 15% total kcal from PRO, 25-30% total kcal from fat, </= 7% total kcal from saturated fat, </= 200 mg cholesterol, and </=1300 mg Na daily. Goal: decrease kcal content and fat consumption for healthy weight loss and cardiovascular problem prevention. Also eliminate saturated fats as much as possible. Overall goal: healthy weight loss and prevention of CVD or other cardiac problems. Food and/or nutrient delivery: decrease saturated fat consumption and increase healthy fat consumption instead. Use plant sterol/stanols to decrease LDL and increase HDL such as BENECOL. M/E- Monitor Food and Nutrient Intake: Total kcal, sat, fat, total fat, and food and supplement intake. Outcome: pt will decrease sat. fat consumption and total energy intake to reach a healthier weight and reduced risk of cardiovascular issues. Monitor: Anthropometric Measurements: Weight Outcome: Promote weight loss at a healthy stable pace of eliminating 500kcal per day through diet or PA. Monitor: biochemical data: Total cholesterol, HDL, LDL, triglycerides, ApoA/B Outcome: decrease LDL levels and increase HDL levels. Decrease triglycerides as well, all to reduce risk of CVD and other cardiac complications and return to closer to normal status. Follow up in 3 months. Morgan Lindsay 10/27/13 1. Mr. Watkins had a myocardial infarction. Explain what happened to his heart. Myocardial infarction is commonly called a heart attack. This means that blood stopped flowing properly to part of the heart, resulting in injured heart muscles from lack of oxygen. Usually this is a result of a blockage in the coronary arteries. 2. Mr. Watkins was treated with an angioplasty and stent placement. Explain this medical procedure and its purpose. Angioplasty is done using a thin, soft tube called a catheter. A doctor inserts the catheter into a blood vessel in the groin or wrist. The doctor carefully guides the catheter through blood vessels until it reaches coronary arteries on the heart. A small amount of contrast material is injected through the catheter and is photographed with an X-ray as it moves through the heart's chambers, valves, and major vessels. From the digital pictures of the contrast material, the doctors can tell whether the coronary arteries are narrowed and whether the heart valves are working correctly. If the decision is made to perform angioplasty, the doctor will move the catheter into the artery with the blockage. He or she will then perform one of the interventional procedures described below. A stent is a small metal mesh tube that acts as a scaffold to provide support inside your coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed coronary artery. Once in place, the balloon tip is inflated and the stent expands to the size of the artery and holds it open. The balloon is then deflated and removed while the stent stays in place permanently. Over a several-week period, your artery heals around the stent. Stents are commonly placed during interventional procedures such as angioplasty to help keep the coronary artery open. Some stents contain medicine and are designed to reduce the risk of reblockage (restenosis). 3. What are the current recommendations for nutritional intake during a hospitalization following a myocardial infarction? Bed rest is usually recommended for the first 24-48 hours of hospitalization. Oral intake may be decreased because of pain, anxiety, fatigue, and shortness of breath. Caffeine is omitted from the diet and a clear liquid diet is adopted immediately after MI. Oral diets progress from liquids to soft diets and eventually a regular textured diet once the patient is stabilized. The TLC dietary recommendations should be followed and specified to the patients’ individual situation (Nelms, et all 319). 4. Examine the chemistry results for Mr. Watkins. Which labs are diagnostic of the MI diagnosis? Explain. Troponin l, troponin T- proteins release from myocardial cells which are elevated after cardiac injury (Nelms,et all. 320). Total cholesterol: =240 or above can aide in MI, as well as HDL levels below 40 and LDL levels above 190. 5. Mr. Watkins was prescribed the following medications on discharge. What are the foodmedication interactions for this list of medications? Medication Possible Food-Medication Interactions Lopressor 50 mg daily Nausea, diarrhea, calcium may interfere with absorption; upset stomach, dry mouth, stomach pain, gas or bloating, heartburn. Lisinopril 10 mg daily Hypotension, esp. in elderly patients; can worsen renal function, hyperkalemia, dysgeusia; causes dry, nonproductive cough, hyperkalemia; contraindications: pregnancy, avoid natural licorice, avoid salt substitutes Nitro-Bid 9.0 mg twice Nausea, vomiting, abdominal pain, dryness of mouth daily NTG 0.4 mg sl prn chest Nausea, vomiting, abdominal pain, dryness of mouth pain ASA 81 mg daily Do not drink on ASA, nausea 6. You talk with Mr. Watkins and his wife, a teacher at the local high school. They are friendly and seem cooperative. They are both anxious to learn what they can do to prevent another heart attack. What questions will you ask them to assess how to best help them? Are you willing to change your eating habits to a healthier and preventative lifestyle? How willing is Mr. Watkins to quit smoking? Will Mrs. Watkins change her eating habits to influence and help support Mr. Watkins? 7. What is the rationale for the use of plant stanols/sterols and list some products that you may recommend? Plant stanols and sterols help block the absorption of cholesterol from the digestive tract, which helps to lower LDL—without affecting HDL or triglycerides. Studies show that a daily intake of about 2 grams of either stanols or sterols reduces LDL cholesterol by about 5– 15 percent—often within weeks. Stanols and sterols are added to certain margarines and some other foods, such as a special type of orange juice (NCEP,et all. 31). 8. Mr. Watkins and his wife ask about supplements. “My roommate here in the hospital told me I should be taking fish oil pills.” What does the EAL say about fish oil supplementation for this patient? According to the EAL, “In studies of patients with high triglycerides, not following specific dietary advice and not on concurrent statin therapy, fish oil was associated with a 844% increase in LDL-C. In studies of people taking fish oil capsules and statins, LDL-C decreased 0-20%” (EAL, ref. 1). Although fish oils are shown to lower LDL levels in patients and associated with reduced cardiac mortality from CHD or sudden death in American men, fish oil pills are not the end all, be all. I would recommend Mr. Watkins and his wife to incorporate fish into their diet 23 times per week to increase their EPA/DHA intake instead of rushing straight into supplemental treatment. Meal Pattern # of exchanges CHO (g) PRO (g) FAT (g) Starches 10 150 30 10 Fruit 5 75 Vegetables 5 25 10 Skim or 1% 2 24 16 0-6 Lean 3 21 0-18 Med-fat 2 14 10 Milk 2% 4% Sweets/Other carbs Meat/substitutes Plant-based proteins High-fat Fat group 5 25 TOTAL (g) xxx 274 91 45-69 % kcal xxx 54.8 % 18.2% 20.25-31% # of exchanges CHO (g) PRO (g) FAT (g) Starches 4 60 12 4 Fruit 3 45 XXX XXX Vegetables XXX XXX XXX XXX 1 12 8 0-3 XXX XXX XXX XXX Meal Pattern for Breakfast Milk Skim or 1% 2% 4% XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1 XXX 7 0-3 XXX XXX XXX XXX XXX XXX XXX 2 XXX XXX 10 117 27 14-20 # of exchanges CHO (g) PRO (g) FAT (g) Starches 3 45 9 3 Fruit 1 15 XXX XXX Vegetables 2 10 4 XXX 1 12 8 0-3 2% XXX XXX XXX XXX 4% XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2 XXX 14 0-6 Med-fat XXX XXX XXX XXX High-fat XXX XXX XXX XXX 2 XXX XXX 10 82 35 13-22 Other carbs Meat/substitutes Plant-based Lean Med-fat High-fat Fat group TOTAL (g) xxx Meal Pattern for Lunch Milk Skim or 1% Other carbs Meat/substitutes Plant-based Lean Fat group TOTAL (g) Meal Pattern for Dinner xxx # of exchanges CHO (g) PRO (g) FAT (g) Starches 3 45 9 3 Fruit 1 15 XXX XXX Vegetables 3 15 6 XXX Skim or 1% XXX XXX XXX XXX 2% XXX XXX XXX XXX 4% XXX XXX XXX XXX XXX XXX XXX XXX Plant-based XXX XXX XXX XXX Lean XXX XXX XXX XXX Med-fat 2 XXX 14 10 High-fat XXX XXX XXX XXX 2 XXX XXX 10 75 29 18 Milk Other carbs Meat/substitutes Fat group TOTAL (g) xxx ~ Menu ~ Breakfast: Choose: 3 fruit, 4 starches, 1 milk, 1 lean meat (egg), 2 fat (condiments) - Fruits: (pick 3) 1 large apple/banana/orange , ½ cup fresh squeezed apple/orange/prune juice - Starch: (pick4) ¾ cup hot/cold cereal, 1 4’’ waffle, 1 whole large bagel (counts as all 4 starches), 1 slice toast, ½ English muffin - Entrée of the day: Western omelet (made with egg whites, peppers, onions, ham, and RF cheddar cheese) - Lean Meat: (pick 1) - choice of scrambled or omelet – 2 egg whites, ¼ c egg substitute - Milk: (pick 1) 8 oz. fat free milk, ¾ C plain yogurt (with sugar substitute if wanted) - Condiments ( fats): (pick 2) 1 slice turkey bacon, 1 ½ tbsp. reduced fat cream cheese, 1 tsp. margarine (BENECOL) , 1 ½ tsp. peanut butter, 2 tbsp. cream half& half - Free foods: coffee (black), Tea (unsweetened or sweetened with sugar substitute) Lunch/Dinner: Lunch choose: 3 starch, 2 vegetable, 1 fruit, 1 milk, 2 lean meats, 1 fats Dinner choose: 3 starch, 3 vegetable, 1 fruit, 2 med-fat meat, 2 fats - Salads/soups: 1 Cup bean/lentil soup (1 starch+ 1 lean meat), 1 Cup low sodium Tomato soup (1 Starch), ½ Cup Coleslaw (1 starch, 1 ½ fat) - Entrees: ½ Cup Tuna/Chicken salad ( ½ starch, 2 lean meat, 1 fat), turkey, avocado & lettuce sandwich on whole grain bread (2 starch, 1 fat, 2 lean meats), 1 Cup Beef and Vegetable stew ( 1 starch, 1 med-fat meat, 2 fats) - Starch: ½ cup wild rice, 1/3 cup couscous, 1/3 cup plain pasta, ½ hot dog bun - Med-fat meats: corned beef (1 oz.), meatloaf (1 oz.), pork chop (1 oz) - Lean meats: 1 oz. tuna, ¼ cup cottage cheese, 1 oz. grilled chicken - Vegetable: ½ cup cooked broccoli/ cauliflower/ asparagus/squash - Fruit: apple, pear, banana, orange, ½ cup fresh squeezed apple/orange/prune juice - Beverages: diet cola (caffeine free), unsweetened black tea (10 oz.), 8 oz. skim or 1% milk, water - Condiments (fats): 2 tbs. avocado, 6 almonds/cashews, 10 green stuffed olives, 16 pistachios, 1 tsp. margarine (BENECOL) - Dessert: 1 ¼ Cup strawberries, 1 slice watermelon, frozen fruit juice bar (1 starch), ½ cup light ice-cream- chocolate, vanilla, strawberry (1 starch + 2 fat) Evaluation of Nutritional Adequacy of Menu After inputting a specific one day menu into the Food Processor, I will admit that there were a few components that need slight improvement. According to the guidelines provided, I exceeded the protein requirements very slightly as well as the carbohydrates. However, I do not find this to be an alarming amount since it is very close to the range requested. For the total fat content, I was slightly lower than I wanted but I made a conscious effort to incorporate healthy fats such as avocados and pistachios. Swapping out butter for BENECOL margarine spread decreased total fat content as well however, the BENECOL would be more beneficial to the client than high fat butter. In terms of vitamins and minerals, I think nutritional goals were met for Mr. Watkins 1-day meal plan. I found it very important to make sure sodium levels did not exceed recommended amounts especially because of the cardiovascular complications Mr. Watkins has been experiencing. Also, according to the TLC diet he should not exceed 1300 mg per day which I made sure did not happen. Also, calcium levels were important to maintain. A recommended amount was 1,000 mg per day and the menu I created delivered 1167mg per day which I found important and beneficial. For potassium levels, the reports say that the levels for the menu created are low, however I do not think that is an issue for multiple reasons. First off, I was unable to enter all items on the menu as USDA supplier products with the Food Processor; therefore the potassium levels can be skewed. The potassium levels were not alarmingly low, so I’m assuming if all products had potassium levels recorded, Mr. Watkins would be meeting the recommended amount. Overall, I think this menu plan is both beneficial and accurate for Mr. Watkins. It provides a healthy number of kcal, macronutrients vitamins, and minerals. Although the numbers are not 100% exact, I believe the nutritional benefits of this menu will not only benefit Mr. Watkins but teach him a new way to eat for health. References: Academy of Nutrition and Dietetics. (n.d.). Academy of Nutrition and Dietetics. Retrieved October 29, 2013, from http://www.eatright.org/ Nelms, M. N. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning. U.S. Department of Health and Human Services(2005). Your Guide To Lowering Your Cholesterol With TLC. National Institutes of Health, National Heart, Lung, and Blood Institute.