Bailey Fisher

10/06/2015
GERD ADIME
NUTR 425 Fall 2015
Nutrition Therapy: Initial
Assessment:
49-year old male referred by medical doctor after evaluation and treatment for increased
indigestion over the past year. Patient reports weight gain of 35 pounds since knee surgery
and has little physical activity except when he plays with his 5 and 9-year old children. He
states he has increased energy (3600 kcals/day) and alcohol intake (1-2 beers 3-4
times/week) due to stress. He takes aspirin daily for heart disease, and tums several times
throughout the day. Patient does not smoke.
Family History: Father has coronary artery disease.

Diet: Low Fat Diet

Dietary Intake:
Usual Intake:

AM: 1 - 2 c dry cereal (Cheerios, bran flakes, Crispix), - c skim milk, 16-32 oz.
OJ

Lunch: 1 oz. ham on whole wheat bagel, 1 apple or other fruit, 1 c chips, diet
soda

Snack (at home): Handful of crackers, cookies, or chips, 1-2 16 oz. beers

Dinner: 6-9 oz. meat (grilled, baked), pasta, rice or potatoes, 1-2 c fresh fruit, salad
or cooked veggie, bread, iced tea

Late PM: Ice cream, popcorn or crackers

Drinks: 5-6 12-oz diet sodas and/or iced tea daily

Family schedule has been busy recently, so the order pizza or stop for fast food 1-2
x/week

Height: 69 inches
Weight: 215 lbs.
Body Mass Index: 31.7 kg/m2 (overweight)
Usual Body Weight: 180 lbs.
% Usual Body Weight: 119%
Ideal Body Weight: 160 lbs.
% Ideal Body Weight: 134%
Medications:
Atenolol (50 mg/day): Beta-blocker for blood flow circulation
Aspirin (325 mg/day): Salicylate for pain and inflammation

Multivitamin
Ibuprofen (500mg 2x/day): Nonsteroidal anti-inflammatory drug for pain and
inflammation
Estimated Energy Needs:
Kcal: 1800 kcal - 2200 kcal (empirical formula- 20-35 kcal/kg from ideal body weight)
Protein: 58 g -72 g (0.8 1 g/kg)
Carbohydrates: 200 g 300g; 810 kcal 1210 kcal (45% of kcal)
Fat: 40 g 50 g; 360 kcal 440 kcal (20% of kcal)
Fluid: 1800 mL 2200 mL (1 mL/1 kcal)

Labs reviewed:

Total Cholesterol: 220 mg/dL (high)

Triglyceride: 178 mg/dL (low)
High-Density Lipoprotein: 20 mg/dL (high)
Calculated Low-Density Lipoprotein: 165 mg/dL (high)

Nutrition Diagnosis (PES):

Excessive energy intake related to frequent consumption of fast food (1-2 times/week) and
high fat foods (fried chicken, pizza and ice cream) as evidence by typical consumption of
3650 kcals/day compared to recommended calorie intake of 1800 kcal/day and BMI of 31.7
kg/m2.
Nutrition Intervention:
1. Meals and Snacks: General/healthful diet: Replace high fat foods with more whole
foods for snacks
2. Meals and Snacks: Composition: Fat-Modified diet: Lower daily fat intake to <7%
based on TLC diet
3. Meals and Snacks: Specific beverages: Eliminate alcohol intake
4. Nutrition Education: Nutrition relationship to health/disease: Educating patient
about GERD and nutritional health relationship and what can cause his condition to
worsen and get better
Goal: Patients fat intake is down to <7%, stops drinking alcohol and continues choosing
healthful food choices.

Monitor/Evaluate:
1. Food and Nutrient Intake: Energy Intake: Total energy intake: Evaluate total energy
intake based on usual intake over 3 months
2. Food and Nutrient Intake: Food Intake: Evaluate fat intake over 3 months
3. Food and Nutrient Intake: Beverage Intake: Evaluate alcohol consumption over 3
months