Christina Inouye November 13, 2013, 12:10pm S. Henry is Type 1 diabetic with stable wt.

Pt and his wife prepare most of meals at home. Reports breakfast and dinner are eaten at home, while lunch and snack are eaten at work. Likes fish, chicken, and meat over vegetarian foods. Pt does not use nonfat products or has ever tried them. He is a non-smoker, non-drinker, and doesnt take supplements. O. 32YOM Dx: Type 1 DM Meds: Insulin shots 2x daily Anthropometrics: Ht: 6ft Wt: 167# (stable) BMI: 22.6 (normal) IBW: 178# %IBM: 94% Labs: HgbA1C: 8.2% TGs: 190 mg/dL CH: 250 mg/dL BG: Before breakfast: 190 mg/dL Before lunch: 100 mg/dL OK Before dinner: 220 mg/dL Before bed: 150 mg/dL Requirements: EER: 2600 kcal/day (AF 1.5) RER: 1730 kcal/day 76g pro(12%, 1 g/kg), 87g fat/day(30%), 377g CHO(58%) Fluids: 2600mL/day (1mL/kcal) 24 hr recall: 3250kcal, 125g pro (15%, 1.65g/kg), 306g CHO (38%), 161g fat (44%) A. Excess fat and energy intake related to poor food choices as evidenced by 24hr recall showing pt consuming 125% estimated energy requirement. Pts wt is stable and BMI is within normal range. However, pt is consistently consuming more (125% of need) than the recommended calories, which may cause gradual wt gain if insulin is increased. His HgbA1C is high (8.2%) which means his diabetes has not been managed well. He is hyperglycemic before breakfast is associated with increased need of protein intake before bed, and hyperglycemic before dinner, which is associated with high CHO in the meals prior. He has fluctuating BG levels, which are of concern. He maintains normal BG when he is at work (before lunch); however, when Henry leaves home, he tends to become hyperglycemic. There is concern because his food at home is prepared with added fat (meats are fried and butter and salt are added to all vegetables.) Reducing added dietary fat would bring fat intake to a more appropriate amount and decrease high triglyceride and cholesterol levels. The diet is reasonably balanced, though diet is high in fat and saturated fat. Henry currently consumes 185% of the recommended amount of fat. Although he consumes adequate dairy, he could easily cut down on fat/saturated fat intake by switching to reduced-fat options. Pt should eat less than 7% kcal from saturated fat. Excess calories from saturated fats like 2% milk and added butter to his foods likely contribute to high triglycerides and cholesterol levels, which puts pt at increased risk for CVD. He could reduce the total amount of fat by consuming more vegetables and reducing salt and butter added, as well as by grilling his meats instead of frying them. Pt should also choose whole grains over refined carbohydrates. These changes will increase the amount of fiber in his diet to potentially improve glucose management. Henry is eating 165% of his recommended protein; he should reduce this to ~1g/kg of protein in order to reduce the stress of his kidneys. Pt is extremely motivated to work on his diet and willing to try new things to improve his HgbA1C and overall wellness.

P. Reduce total calorie consumption to 2600kcal/day, 87g fat (17 fat exch), 76g protein (3 oz lean meats), and 377g/day of carbohydrate (25 CHO servings/day 3 dairy, 7 fruit, 15 starch) Check BG before every meal and snack. Consume at least 5 fruit and vegetable servings per day. Replace at least 5 servings refined carbohydrates with whole grains. Choose reduced-fat meat and dairy options. Add a snack between breakfast and lunch, and a bedtime snack that contains protein. Provide a Choose your Foods manual and a days meal plan. Discussed with pt and his family how to make a sample meal plan on their own using CHO exchanges. Request lab work for triglycerides and cholesterol. Follow up: 1 month with a 3-day food record, BG log/insulin records and lab results. In 3 months, check current HgbA1C. Christina Inouye, RD in training