Patient
OO

Height: 5 ft 10 in

Weight: 183 lbs

BMI: 26.3

Registered Dietitian

Rosemary Rodriguez, RD

Insurances: Aetna,Anthem,Blue Cross Blue Shield,Cigna,United Healthcare

Diagnosis and Treatment Plan

Nutrition Diagnosis

Overweight related to excessive oral intake as evidenced by a BMI of 25.7.

Unbalanced diet pattern related to food and nutrition-related knowledge deficit as evidenced by patient self-reporting consuming a protein shake for breakfast and a McDonald's breakfast sandwich for lunch during 24-hour recall.

Nutrition Intervention

Education materials provided:

Nutrition Facts Label (Interactive), Healthy Fats Handout

Intervention

1. Meals and Snacks (ND -1) and Nutrition Education (E -)

  1. Patient reports going out of town to California last week. Patient reports consuming Dave's hot chicken, poke bowl, carne asada fries, and an Italian sandwich. Patient reports eating out often while on vacation, although patient reduced portion sizes. Discussed with patient how his eating pattern while on vacation compared to his previous eating pattern while on vacation. Patient reports consuming 4 meals per day with snacks while he was on vacation, as well as consuming smaller portion sizes. Patient states in the past, patient would consume two large meals per day. Encouraged patient to continue consuming meals consistently. Patient reports not adequately nourishing his body prior to engaging in physical activity once over this past week. Advised patient to adequately nourish his body prior to engaging in physical activity to reduce feelings of fatigue during and after his workout.
  2. Continued going over the nutrition facts label with patient. Went over sodium with patient. Advised patient sodium is a nutrient to get less of as diets higher in sodium are associated with an increased risk of developing cardiovascular disease, which can increase the risk of stroke, heart failure, MI, and kidney disease. Discussed with patient how sodium is a mineral whereas table salt is sodium chloride. Discussed with patient how most dietary sodium comes from packaged and processed foods, including deli meat, pizza, poultry, soups, burgers, and tacos. Discussed with patient how sodium is in nutrient that is necessary for fluid balance, muscle contraction, and nervous system function. Advised patient to consume less than 2300 milligrams per day of sodium. Advised patient to select food products containing 5% of the daily value or less of sodium per serving. Advised patient to select low and reduced sodium food products, limit packaged sauces, use no salt seasoning blends, rinse canned goods, and consume foods that are higher in sodium less often.
  3. Went over healthy fats handout with patient. Discussed with patient how unsaturated fats lower LDL cholesterol. Discussed with patient food sources of monounsaturated fats, including olive oil, canola oil, nuts, and nut butter. Discussed with patient how omega-3 and Omega 6 fatty acids are types of polyunsaturated fats. Discussed with patient food sources of omega-3 fatty acids, including walnuts, flaxseeds, and soybeans. Discussed with patient food sources of Omega 6 fatty acids, including eggs, olive oil, and peanuts. Discussed with patient ways to add healthy fats to his regimen, including cooking with canola or olive oil, consuming a snack with nuts or nut butter, consuming fish with green, leafy vegetables for lunch, eating eggs for breakfast, and eating avocado with toast.

2. Nutrition Counseling (C-1): Goal Setting For Physical Activity

B. Planned Exercise: Pt will engage in moderate PA for 1 hr/3-4x/wk.

3. Nutrition Counseling (C-1): Self-Monitoring

A. Journal - Keep daily journal of intake

Monitoring and Evaluation

Follow up

Pt will eat according to new dietary suggestions, resulting in wt loss, pt will report in visual food journal. Next session, will continue going over the nutrition facts label. In future sessions, will go over types of fiber, healthy eating on the run handout, low FODMAP diet, high triglycerides nutrition therapy, managing cravings and emotional eating, healthier menu options, and 20 health tips. Will assess progress and determine if any changes are needed. Will continue to assess and monitor for foods that pt does not tolerate. Will continue to assess and monitor for episodes of binge eating.

Topics Discussed

Weight Loss,General Nutrition

Appointment History

Number of Sessions: 13

Last Updated: May 20, 2024