Obesity

Read the instructions carefully. Answer all the questions IN THE DOCUMENT.

Case study on Obesity.

Reference in the answer sheet

Paula Paulsen is a 48-year-old African-American woman employed as accounting clerk. Her family physician diagnoses her with hypertension and obesity. Ms. Paulsen has

repeatedly attempted to lose weight, about 10 times over the past 12 years. She had started to gain weight with her first pregnancy 16 years ago and would very much

like to regain her pre-pregnancy weight to “look better”.She furthermore complains of snoring to the point of waking up her domestic partner but denies waking up

herself or being overly tired during the day.
pMHx: no CVD, no gallbladder disease, 3 live births, each with excessive weight gain of 14-16kg, of which 8 were lost within one year after delivery.
Rx at home: 500mg Calcium plus 400µg vitamin D bid, fish oil capsules daily
FHx: Ms. Paulsen recalls her mother being obese and suffering from high blood pressure but not diabetes. The mother died of a myocardial infarction at age 59. Ms.

Paulsen has one brother who is obese and two brothers who are normal weight. She does not recall her father.
SHx: Ms. Paulsen reports drinking one glass of red wine with dinner daily, eating three meals daily and snacking when food is available or her tasks at work don’t

require her full attention.
Review of Systems:
Skin: rash in skinfolds
HEENT: all WNL (Note: this is not how it would be noted in an electronic record)
Neurologic:a&o x 4, no headaches, tremors, seizures or depression
Endocrine: normal menstrual cycle, denies abnormal heat or cold intolerances
Cardiovascular: RRR
Joints: no swelling, heat or redness

Physical Examination
Vital Signs
Temperature: 98.4?F (36.9?C)
HR: 88BPM, BP: 135/88 mm Hg,
RR (respiratory rate): 24
Height: 5’3”
Current weight: 208 lbs.
Waist circumference: 38 inches
Weight history: highest adult weight is current weight, lowest adult weight of 150 lbs prior to the first pregnancy

Exam
General: obese woman in no acute distress, no cushingoid features, negative for hirsutism, no dorsal, cervical, or supraclavicular fat
Skin:ecchymosis, abrasions and rash in skinfolds in abdominal area, no acanthosis nigricans
HEENT: unremarkable
Neck:nonpalpable thyroid
Chest:cta
Heart: S1 and S2 normal rate and rhythm
Abdominal: obese, no organomegaly
Extremities: no edema

Laboratory data
Glucose: 116 mg/dL
Potassium: 3.8 mEq/L
Cholesterol: 216 mg/dl
Triglycerides: 175 mg/dL
HDL-C: 42 mg/dL
Calculated LDL-C: 139 mg/dL

Usual intake:
Breakfast
Coffee    8 oz
Half and half cream    1 oz
Bagel    1 large
Cream cheese    2 Tbs
Orange juice    8 oz
Lunch
Chef salad (Turkey, ham, cheese, boiled egg)    2 cups
French dressing    3 Tbs
Bread sticks    2 small
Iced tea (sweetened)    12 oz
Snack
Pretzels    1.5 oz bag
Diet soda    12 oz
Dinner
Spaghetti    2 cups
Tomato sauce    ½ cup
Beef meatballs    3 oz
Garlic bread    1 pc
Red wine    5 oz
Snack
Vanilla wafers    10 small
Lemonade    12 oz

Total kcal 2691 kcal
Protein 94g (14%)
Fat 90g (30%)
Sat fat: 33g (11%)
MUFA: 21 g (7%)
Cholesterol: 334 mg
Carbohydrate: 355g (53%)
Fiber: 13g
Sodium: 4800mg
Calcium: 601mg

Case questions:
Answer the case questions using a different font color (blue or green).

1.    What are the current cutoff values for the classification of obesity?

2.    How are overweight and obesity clinically assessed in this patient? (I.e. what tool is used to assess her, what class is she in, and what data did you use for

the assessment?)

3.    What are the medical risks associated with obesity in this patient?

4.    Does Paula Paulsen meet the criteria to diagnose metabolic syndrome?

5.    Which of Ms. Paulsen’s current health concerns are likely related to her body weight (assuming that the excess weight is body fat)?

6.    What are appropriate treatment goals for Ms. Paulsen? Explain the expected benefits.

7.    Ms. Paulsen asks about weight loss drugs. Find and list prescription weight loss drugs. For one of these drugs, explain roughly how they work and list

indications and counter-indications. What is the success rate of these drugs?

8.    Ms. Paulsen asks if a high-protein, low carbohydrate diet would be appropriate for her. Describe the biochemical and metabolic effects of high protein, low

carbohydrate diet.

9.    Explain if a low carbohydrate diet is appropriate for this particular patient.

10.    Assess Ms. Paulsen’s height and weight. Calculate BMI. What would be a reasonable weight goal for Ms. Paulsen? Explain how you determined this. (Note: ideal

body weight is NOT the answer)

11.    Identify any abnormal biochemical indices and discuss the probable underlying etiology. How might they change after weight loss? (You could use a book like

Wallach’s Interpretation of diagnostic tests for this question. Information is available online and in Appendix F of your textbook as well)
1p each, 0.5 for etiology each

12.    Determine Mr. McKinley’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements.

13.    Identify the pertinent nutrition problems and the corresponding nutrition diagnoses. Write the diagnoses with the appropriate PES statements. (This is where

you use the eNCP)

14.    What dietary and exercise guidelines would you recommend for Ms. Paulsen specifically?

15.    Design a revised diet based on her usual intake listed above and contrast key values of the analytic parameters (total energy, fat, protein, etc.). To do this

easily, I recommend entering the original data to a diet analysis program (supertracker is the default), noting the analysis, then changing specific menu items to

achieve your goal.

16.    Would Ms. Paulsen qualify for bariatric surgery: What are the standard adult criteria for consideration as a candidate for bariatric surgery, and which of

these criteria does Ms. Paulsen meet? (Use the table for your answer)

17.    Fill out the ADIME form below for this patient. (The form is on the next page.) Note: you will need to define INTERVENTION(S), and MONITORING/EVALUATION

criteria. Use the eNCP for this. Make sure your interventions address the problems you listed in the PES statements, and your M/E criteria check if you have resolved

the problems.

A – Assessment
S – Subjective
Chief Complaint:

UBW:

Weight change: gain / loss

Appetite:

Chewing / swallowing problem / sore mouth

Nausea / vomiting / diarrhea / constipation

Food intolerance / allergies:

Diet prior to admit:    Nutritional supplement:

Vitamins / herbs:

Food  preparation:

Factors affecting food intake:

Social / cultural / religious / financial

Other:

O – Objective
Current Diet Order:

Medical Diagnosis:
Past Medical History:

Nutrition Focused Physical Signs &Symptoms:

Age:

Gender: Male      ?
Female  ?    Ht:    Wt:        Admit    ?
Current   ?    DBW:    BMI:
% UBW:

% wt?:    % DBW:    Other:
Nutritionally Relevant Laboratory Data:

Drug Nutrient Interaction:

Estimated Energy Need:

______________ kcal / day
Based on:
Estimated Protein Need:

_______________  g/day
Based on:    Estimated Fluid Need:

_____________ ml / day
Based on:
Nutrition Diagnosis (D)
A – Assessment (A)
State no more than 2 priority Nutrition Diagnosis  statements in PES Format. Use Nutrition Diagnosis Terminology sheet
ND Term (Problem)  related to (Etiology) as evidenced by (Signs and Symptoms) :

1.

2.

Nutrition Intervention (I)
P – Plan

List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems (diagnoses).

Goal(s):

Plan for Monitoring and Evaluation (M E)

List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the plan for monitoring would indicate if

interventions are addressing the problems).

Signature:

Date: