Iron Deficiency Case Study

Mickinzie Lopez Assignment: Case Study #1 TR5320

Learning Objectives1. To use the Nutrition Care Process (NCP) to assess, diagnose, intervene, and monitor/evaluate an adult patient

with an upper GI disorder.2. To create a 1 day menu that supports the NCP and the client’s need for food as medicine.3. To document all stages of the NCP in ADIME chart note format.

Meet AgustínAgustín is a 28 year old Hispanic male who is single and has no children. He lives alone and most of his close relatives live in southern California. He comes to you today to get “fresh advice” about how to improve his diet to support his health. He saw a nutritionist 3 years ago to help him the weight he gained when he quit smoking. He successfully lost 25 pounds, mostly by making changes to reduce meat, soda, and “junk” food and working out 5 days per week. Unfortunately, about 1 year ago he injured his back lifting weights and began managing the pain with ibuprofen pills. Excessive use of the ibuprofen led to gastritis and diagnosis of a bleeding ulcer 6 months ago.

Laboratory data collected 2 weeks agoLab Test Normal Result Interpretation

Ferritin 12-300 ng/mL 60 ng/mL WNL, low endHgb 14-18 g/dL 14 g/dL WNLHct 42-52% 41%

MCV 80-99 fl 82 fl WNLMCH 27-31 pg/cell 28 pg/cell WNLMCHC 32-36 g/dL 31 g/dL

Total cholesterol <200 mg/dL 205 mg/dL

Fasting blood glucose 70-99 mg/dL 85 mg/dL WNL

Note: see http://www.nlm.nih.gov/medlineplus/ency/article/003490.htm to interpret ferritin levels. Use your notes to interpret iron tests. Use Appendix 30 to interpret other tests.

He reports his parents are “reasonably healthy,” but clarifies that his mother has pre-diabetes and his father has hypertension. He says they don’t exercise enough or eat well. His only sibling, a younger sister, struggles with her weight. He is proud of his 25 pound weight loss and his ability to remain weight stable since then.He describes his diet as “flexitarian,” eating meat about once per week. He reports no food allergies, intolerances, or significant dislikes/preferences. For the purposes of the assignment, assume his 24 hour recall (below) is representative of his usual, long-term intake. He continues to take a 10 mg iron pill twice daily as requested by his doctor. However, since it causes him stomach pain when consumed on an empty stomach, he usually takes it with a glass of milk in the morning and a bowl of ice cream in the evening. He consumes two beers while watching sports on Sundays, but very infrequently otherwise. He cross-trains (weight lifting, running, cycling) about 60-75 minutes/d, 6 days/wk.

Agustín is a college-educated (MS degree) architect working in a busy office setting. He typically works long hours in the office (60 hrs/wk), mostly sitting at his computer using design software. His job is particularly stressful since he does not always get along well with his work supervisor. He is financially secure, owns his own home, and has the ability to purchase needed foods and supplements.

Measurements you collect today: Blood pressure – 118/67 mm Hg, height – 180.3 cm, 80.9 kg. He is relaxed and engaged during the visit, asking relevant questions and clarifying your suggestions to him.

Time Food Amount5:00 AM 2% fat milk (taken with iron supplement) 1 cup

http://www.nlm.nih.gov/medlineplus/ency/article/003490.htm


Before workout(Alone)

Water 1 cup

6:30 AM Breakfast

Cottage Cheese, 1% fat, topped with: Banana, fresh Corn flakes, Erewhon brand

Orange juiceWater

1.5 cups1 medium1 cup6 fluid ounces12 fluid ounces

7:15 (Driving to work)

Caffe latte w/whole milk, Starbucks 16 fluid ounces

1:00 PMlunch(at desk)

Home-made fajita Tortilla, corn, 7”, Mission brand Cheese, Monterey jack, shredded Red bell peppers, sautéed Yellow onions, sautéed Light sour cream Guacamole, Trader Joe’s

Apple, fresh, largeWater

21 cup1 cup1 cup0.5 cup0.25 cup116 fluid ounces

5:00 PMSnack(Alone, at desk)

Barbeque flavored mini rice cakes, Quaker brandRed grapefruitWater

15216 fluid ounces

8:00 PMDinner(Alone, at table)

Vegetable fried rice, frozen, Trader Joe’sZucchini squash slices with skin, microwaved, drained

Topped with butter2% fat milk

3 cups1 cup1 Tbsp1 cup

10:00 PMSnack, at TV

Vanilla Ice Cream, Breyer’s lightWater

1 cup16 ounces

Questions:

1. Analyze his current diet using Food Processor. Attach the required printout to this packet. [4 points]a. Using the handout “Calorie and Macronutrient Needs for Adults,” calculate his estimated energy needs

and add that to the Energy/Criteria amount box. Add the DRI values (RDA, AMDR, AI) for macronutrients and water in the Criteria amount boxes as well. Be sure to include units for your amounts. Then, complete the “His diet provides” column by taking the data from your Food Processor report. Interpret the data in the final column – expressed either as a % of a recommended amount or , , WNL for ranges. [7 points]

Component or Nutrient

Criteria method Criteria amount His diet provides Interpretation

Energy Kcal/kg method 3,236 kcal 3,321 kcal 102.62%

Carbohydrate RDA 130 g 407 g 313.07%

AMDR 45-65% 49% WNL

Fat AMDR 20-35% 35.81%

Protein RDA 56 g 141 g 251.78%

AMDR 10-35% 17% WNL


Water AI 3.7 L/d 4.1 L/d 110.81%

b. Make a list below of at least SIX areas of his diet/lifestyle that you feel could be improved – this could be about a food, a nutrient, or any aspect of her diet/lifestyle (e.g. eating too close to bedtime, insufficient physical activity). Rate how high of a priority you think each is on a scale of 1-10 (1=low, 10=high). Consider the word “priority” as we have defined it in unit 1 in relation to prioritizing nutrition problems/diagnoses. [6 points]

Area for improvement Evidence that this is a problem Priority (1-10)

Consumption of dairy with iron supplement (impaired nutrient absorption).

Hct 41% (normal: 42-52%), MCHC 31 g/dL (normal: 32-36 g/dL), despite supplementation of 20 mg/d.

10

Inadequate consumption of bioavailable iron.

Hct 41% (normal: 42-52%), MCHC 31 g/dL (normal: 32-36 g/dL). Limits meat consumption. Fe 60 ng/mL is on the low end of normal (<70ng/mL).

9

Dietary imbalance. Reported meat restriction. 8

Excessive fat intake. Dietary fat 35.81% of total kcal intake (recommended: 20-35%).

8

Excessive calcium intake. Dietary calcium 2,705.83 mg > UL (2,500 mg)

5

Reduce consumption of foods close to bedtime.

Dinner at 8:00 PM and evening snack at 10:00 PM. Gastritis dx.

5

2. Consider your list of problems in #1b, their priority, and whether they are best listed as an individual nutrition diagnosis or grouped into a more general nutrition diagnosis.

a. Write four possible PES statements in proper format below. Your first two PES statements in the chart should be the two that you feel are the highest priority to be addressed at this initial visit. [6 points]

PROBLEMnutrition diagnosis

related to

ETIOLOGYcause or contributing

factors

as evidenced by

SIGNS & SYMPTOMSevidence from

assessment data

Food-Medication Interaction (Iron-Calcium NC-2.3) related

to

Consumption of dairy products to ease GI

distress as evidenced by

24-hour recall and suboptimal Hct 41%

(normal: 42-52%) and MCHC 31 g/dL (normal:

32-36 g/dL), despite reported

supplementation of 20 mg/d.

Inadequate mineral intake (Iron NI-5.10.1]

related to

Suboptimal consumption of

bioavailable iron food sources and limited

attention/knowledge to iron-rich foods

as evidenced by

Suboptimal Hct 41% (normal: 42-52%) and

MCHC 31 g/dL (normal: 32-36 g/dL), and

reported dietary intake of non-heme iron (7.45

mg/d).


Undesirable food choices (NB-1.7)

related to

Food/nutrition related knowledge deficit and restricted meat intake

as evidenced by

24-hour recall (no meat consumption) and

reported avoidance of meat.

Less than optimal intake of types of fat

(Saturated fats NI-5.6.2]

related to

Food/nutrition related knowledge deficit

as evidenced by

24-hour recall (35.81% of total kcal from fat; recommended: 20-

35%).

b. Defend your choice of why these two diagnoses should be addressed today. Be sure your defense explains why the top two choices are highest priority AND why the other two are not. [4 points]

AL’s poor Hct and MCHC lab values and iron-poor diet recall indicate the presence of iron deficiency, further evidenced by his MD’s prescription of iron supplementation. Supplementation is the quickest way to improve his medical condition and is considered an essential component of his medical care at the moment. His consumption of the iron supplement with calcium-rich meals inhibits the absorption of the iron and is preventing his recovery. Failure to address food-drug interactions will lead to anemia, and a severe decrease in AL’s health. Nutritional intervention is relevent and appropriate, and within the scope of practice for an R.D.

AL’s inadequate mineral intake, relating to his choices of non-heme iron-containing foods is important and immediate, as it directly relates to his iron deficiency status. A discussion regarding the value of heme iron in regards to absorption and maintenance of good iron status is needed and within the scope of practice for nutrition professionals. Because AL is “flexitarian”, he may be open to increasing his weekly intake of heme food sources, especially if he understands the health benefits associated with lean meat consumption. AL can also benefit from education regarding appropriate sources and required quantities of non-heme iron, should he refuse to increase his meat intake. The goal of educating him on this topic is to eliminate his need for supplemental iron, once he has recovered from deficiency. I hope that in the future he will obtain adequate iron from his diet. “Let food be thy medicine”.

AL explains that his method of losing weight 3 years ago was accomplished, in part, by his reduction of meat consumption. He has since then maintained a restricted meat diet, for no other apparent reason than either out of fear of gaining his weight back, or as a means of improving his health—both of which are unsupported by nutritional education. Because this is an initial intake, I did not choose to tackle this directly just yet, as the book notes to use this diagnosis with caution. He may become distrustful of my advice if he does fear weight gain, and may not return. I opted to gently offer information about the benefits of consuming heme iron under the diagnosis of inadequate mineral intake (above) in hopes that he may begin to consider the possibility of increasing his meat intake. If he refuses to include more meat, further counseling may be required, in which case this diagnosis will become more relevant in future sessions.

AL’s excessive fat intake exceeds the AMDR for fat consumption. His elevated cholesterol levels indicate a need for action, but since they are considered “borderline high”, they are prioritized second to his iron deficiency. Because he is at an increased risk for CVD due to family hx of hypertenstion and weight gain, this is a problem I would like to address in the near future. Nutritional intervention can positively impact his cholesterol levels and is within the scope of practice for an R.D. We have the chance to remedy the situation before medical intervention and Rx use is required.


3. Type up a chart note for this initial visit on using the provided template and follow all charting guidelines discussed in class/lecture. [15 points]

4. Using the BCNH form for patient goals, translate your two professional goals into 2 patient goals that are accessible and behavior-oriented. [4 points]

5. Write a 1 day whole-foods, therapeutic menu for this client that will address his nutrition diagnoses and medical condition(s). The menu should include at least 3 meals and one snack. List all foods and beverages included in the day’s meal plan here. [4 points]

Pre-workout Snack (5:00 AM) 1 slice whole grain bread, toasted 1 TB chunky peanut butter 6 oz orange juice 8 oz water

Breakfast (6:30 AM) 1.5 cup 1% cottage cheese 1 medium banana, sliced 1 cup corn flakes, Erewhon brand 1 large orange 12 oz water

Morning Snack (7:15 AM) Coffee latte w/ 2% milk, Starbucks 1 oz walnuts

Lunch (1 PM) Home-made fajita:

o 2 tortillas, corn 7”o .5 cup low fat Monterey cheese, shreddedo 1 cup bell peppers, sauteedo 1 cup yellow onions, sauteedo 2 oz light sour creamo .25 cup guacamoleo 4 oz flank steak, lean, brld

1 large apple 16 oz water

Afternoon Snack (5:00 PM) 15 mini rice cakes, BBQ, Quaker 1 red grapefruits 16 oz water

Dinner (8:00 PM) 3 cups vegetable fried rice, frozen 1 cup zucchini squash slices w/skin, drnd .5 Tb butter .5 cup spinach, ckd 8 oz water

Evening Snack (10:00 PM) 1 cup peach sorbet, fat free (taken w/iron supplement) 16 oz water


6. Analyze your proposed menu using Food Processor. Attach the required printout to this packet. [4 points]

7. Briefly (1 paragraph) summarize the therapeutic aspects of your proposed menu – what were the important changes you made and why? Then, briefly (1 paragraph) describe at least three foods you added to the menu for specific therapeutic purposes (e.g. for nutrient density, healing, etc.) and explain those choices. [4 points]

In an effort to improve his absorption of the iron supplement, I recommended that AL abstain from consuming dairy within 1.5-2 hours of his medication. Since he experiences GI distress with the supplement, I recommended non-dairy sources of food, and offered suggestions for foods that may increase his absorption of the pill, such as citrus. I also chose to substitute ingredients in his diet for additional sources of both heme and non-heme iron throughout his day in hopes of improving his iron intake. I chose to focus solely on increasing his mineral intake and absorption, so I did not change other aspects of his diet that may be considered “unhealthy” for him. For example, I allowed him to keep his evening dessert before bed, but changed the composition of the meal to prevent inhibition of the iron supplement. I want him to focus on making a few small changes to his diet that will restore his iron status. Also, because AL is Hispanic, there is a possibility that quesadillas may be part of his regular diet, depending on how relevant his culture is on his food choices. Rather than eliminating a key cultural menu item, teaching him how to improve the meal for his benefit may lead to increased compliance, effectiveness, and client satisfaction.

As mentioned above, I substituted his pre-workout and evening snacks for non-dairy containing choices to prevent inhibition of the iron supplement absorption. The orange juice, toast and peanut butter contain an appropriate mix of carbohydrates and proteins that are suitable for an easily-digestible pre-workout snack. Additionally, the citrus from the orange juice increases absorption of the iron supplement. To ensure an easy transition from his nightly ice cream habit, I suggested a non-dairy alternative such as fat-free sorbet. He can still enjoy the quality of the dessert, while minimizing the detrimental effects of dairy with iron absorption. Furthermore, fat-free sorbet will not contribute to his secondary problem of high fat intake, which will be discussed in a later visit. I also substituted .5 cup of cheese in his quesadilla for lean flank steak, in hopes of increasing his heme iron intake. As a Hispanic, AL may consume quesadillas frequently, so substituting ingredients in his usual foods may prove to be most effective in the long run.

8. Briefly (1 paragraph) describe one natural medicine remedy that may complement the medical management provided by the health care team. Using this website: naturaldatabase.therapeuticresearch.com/ briefly summarize: 1) the main therapeutic ingredient(s), 2) the remedy’s effectiveness, and 3) safety considerations. [2 points]

According to the natural database, English walnut fruit is frequently recommended for hypertension, lowering cholesterol, gastritis, ulcers, anemia, and more. Research shows that the walnut may possibly be beneficial for the treatment of CHD and high cholesterol, but there is currently insufficient evidence for its effective treatment of any other disease. Walnuts are considered safe when consumed in usual amounts as food. Individuals at risk include people with a nut allergy. Weight gain is also a concern if walnuts are consumed in excessive quantity. Walnuts may be particularly beneficial to AL for his range of medical conditions and history, and as such, I have included an ounce of walnuts in his morning snack routine.



BASTYR CENTER FOR NATURAL HEALTH

Nutrition Team Care

CLIENT INITIALS: AL DATE OF CONSULT: 2/5/14

ASSESSMENT

Client History:

28 y/o Hispanic male Dx of gastritis and bleeding ulcer 6 mo. ago, due to chronic NSAID use (from sports injury). Client wants to “improve his diet to support his health”. Single, no children, and no family members nearby. High-stress job. Owns home.

Food and Nutrition-Related History:

Self-reported “flexitarian”; eats meat 1x/wk. Weight gain 3 years ago. 10 mg iron 2x/day, per recommendation of MD. Pill causes him stomach pain, so he takes it with milk or ice cream (dairy). 2 beers on Sundays only. Exercises 60-75 min/d, 6d/wk (Very Active). Otherwise sedentary desk job (60 hrs/wk, ~12hrs/d). Frequently eats alone at home, at desk, and in car. Able to purchase food/supplements as needed. Shops at Trader Joe’s (eats “healthy”, convenient meals; packaged dinners). Diet analysis: Iron is 93.17% of recommended intake (non-heme sources). B1 is 69.36% of recommended intake. B3 is 36.19% of recommended intake.

Anthropometric Measures:

Height: 180.3 cm. Weight: 80.9 kg. BMI is normal (24.89; normal: 18.5-24.9). Weight is normal (IBW 78.18 kg +/- 10%; 80.9 is WNL). Stable weight management.

Biochemical Data, Medical Tests, and Procedures:

Hct (41%; normal: 42-52%); MCHC (31 g/dL; normal: 32-36 g/dL); Total cholesterol (205 mg/dL; normal: <200 mg/dL). Ferritin is on the low range of normal (60 ng/ML; normal: >70 ng/mL). Lost 25 lbs with help of nutritionist.

Nutrition-Focused Physical Exam Findings:

AL appears relaxed and engaged.

Diagnosis

PES #1:

Food-Medication Interaction (Iron-Calcium) [NC-2.3] related to limited knowledge of dairy interaction with iron supplement consumption as evidenced by food record and suboptimal Hct 41% (normal: 42-52%) and MCHC 31 g/dL (normal: 32-36 g/dL), despite reported supplementation of 20 mg/d.


PES #2:

Inadequate mineral intake (Iron) [NI-5.10.1] related to suboptimal consumption of bioavailable iron food sources and limited attention/knowledge to iron-rich foods as evidenced by suboptimal Hct 41% (normal: 42-52%) and MCHC 31 g/dL (normal: 32-36 g/dL), and reported dietary intake of non-heme iron (7.45 mg/d).

Intervention

Nutrition Prescription: General diet; total iron from diet and supplements between 8-45 mg/day (between RDA and UL), avoiding iron consumption with calcium-rich meals.

Intervention #1: Nutrition Education—Content—Priority Modification (E-1.2)

Discuss calcium’s role in the inhibition of iron intake and its relationship to iron status and anemia. Discuss ideas about ways to reduce nausea by substituting non-calcium-rich foods for his current choices. Educate client about foods that may increase iron absorption. Suggest orange juice as an appropriate substitute for milk. Vitamin C will increase absorption of iron.

Intervention #2: Nutrition Education—Content—Nutrition Relationship to Health and Disease (E-1.4)

Discuss importance of bioavailable iron sources/omnivore diet in relationship to iron intake and anemia. Identify what he already knows about meat’s role in health, and educate him in areas where information is lacking. Offer resources to help him understand the role of meat in relation to nutritional health. Disucss ways to adjust his diet to increase dietary meat intake.

Monitoring/Evaluation

Professional Goal #1:

At the end of today’s session, patient will be able to successfully answer questions about calcium’s inhibitory effects on iron absorption and will be able to identify appropriate food choices to substitute in place of his current choices.

Professional Goal #2:

At the end of today’s session, patient can clearly explain the bioavailability differences between heme and non-heme iron sources in relation to his recovery from iron deficiency. Patient can identify 3 sources each of heme and non-heme iron-rich foods.

Follow up in 2 weeks. Follow up activities: Will assess client’s success/failure in implementing dietary changes. Were the substitutions for dairy as effective in relieving nausea, or has his nausea increased? Will assess client’s intake of meat and evaluate reaction to doing so. How does the client feel?

Clinician Signature (electronic): Mickinzie Lopez Date: 2/6/14


BASTYR CENTER FOR NATURAL HEALTH

Nutrition Team Care

NUTRITION CONSULTATION

Name: Augustine Lopez Date of Birth: September 25, 1986

Clinician: Mickinzie Lopez

Date: 2/6/14

Nutritional Recommendations:

Starting 2/6/14, patient agrees to avoid consumption of dairy products within 2 hours of iron supplement to ensure adequate absorption. Client will take iron supplement with citrus foods to increase absorption.

Starting 2/6/14, patient agrees to:

review pamphlet/website about increasing dietary sources of heme iron consume 2-4 servings of iron (red meat, fortified cereal, etc.) from food and

supplements daily complete a 3-day food log prior to 2-week follow-up appointment

Next Appointment: 2/20/14

Clinic Phone: (206) 834-4100


Documents

Iron Deficiency Case Study