Nutrition Counseling: A JourneyColleen Poling

The Client at the time of session one:• Demographics:

• Age: 52 YO• Race: White • Material Status: Single• Sex: Female• Education: Master’s degree• Location: Albany Ohio• Household:93 YO mother living

at home.

The Client at the time of session one:• Significant Data:

• Meds: Lipitor, Verapamil, Diovan, Calcium/Vit D supplements, Immitis, Excedrin,

• Frame size: Medium • Waist: 39 inches, Hips: 46 inches,

Wrist Circumference: 6.5 inches• Family history-HTN, High Cholesterol,

Cancer, Osteoporosis, Arthritis.• History of HTN, Elevated cholesterol

and osteoporosis.

The Client at the time of session one:• Diet History:

• Has good appetite• Does the cooking• Eats out 10 time a week

• Initial Assessment of food recall:• Only one serving of milk• Only one serving of fruit• Low on vegetables• High in sweets, sodium saturated

fat and cholesterol

The Client at the time of session one:• Dietary intake in relationship to

lifestyle, medical and physiological problems:• States she has elevated

cholesterol, diet high in saturated fat and cholesterol could contribute.

• States she has hypertension, diet high in sodium could contribute.

• States she has Osteoporosis, diet low in Ca could contribute

The Client at the time of session one:• Etiology and conditions to be

assessed:• Poor diet control• Inadequate exercise

The Client at the time of session one:• Initial nutrition diagnoses:

• Excessive energy intake as related to poor diet control as evidenced by body mass index. (NI-1.5)

• Physical inactivity as related to no exercise regime as evidenced by body mass index. (NB-2.1)

• Overweight/obesity as related to inadequate exercise as evidenced by IBW%. (NC-3.3)

Evaluation Nutrition Plan of Care:

• Initial dietary recommendations:– Diet pattern: DASH– Dietary recommendations in relation to nutrition

diagnosis:• 1800kcal DASH eating plan• Emphasis on potassium, magnesium and calcium rich foods.

– Dietary recommendations in relation to DRIs:• Increase Vitamin D• Increase K, Mg and Ca

Evaluation Nutrition Plan of Care:

• Initial Nutrition plan: DASH eating plan– Third: Modified to more specific focus on Mg,

K and Calcium rich foods, to advance her understanding of the DASH eating plan.

– Fourth: Modified to concerns with combination food and meal planning with elderly mother.

Beans-black, kid-ney. Nuts-Almonds, Halibut, Seeds, Spinach, Okra

Calcium– Milk prod-ucts-yogurt, broc-coli, Salmon, Perch, Sardine, Tofu.

These minerals are expected to lower your blood pres-sure. The recipes I provided for you in your new cook-book are full of these minerals.

Potassium rich foods-

1 medium potato, medium sweet po-tato, Spinach, Zuc-chini, Banana, Apri-

cots, Lentils, Soy-beans, Milk, Yogurt, Pork Tenderloin.

Magnesium rich foods-

What is sodium?

Sodium is an electrolyte that is mainly located outside the cells in fluid. The sodium helps to regulate the fluid vol-ume. Without sodium we would not be able to

properly move, because sodium helps us contract our muscles. Sodium also plays a large part in the nervous system, be-cause it helps to make the nerve impulses actu-ally happen. Sodium also helps to regulate proper

acid/base balance in our bodies. Sodium can also affect blood pressure. Where sodium goes, wa-ter follows. The more so-dium in the diet the harder the heart has to work. in

1 ) G e t i n y o u r M a g n e s i u m , P o t a s s i u m a n d C a l c i u m

“Ill-health of body or of mind, is defeat. Health alone is victory. Let all men, if they can manage it, contrive to be healthy!”

Thomas Carlyle

2 ) R e d u c i n g S o d i u m i n y o u r d i e t

Top 3 Things to Focus on

"Success doesn't come to you…you go to it."

Marva Collins

Cured meats: ba-con, bologna, hot-dogs, & ham

Canned vegetables and soups

Boxed mixes: rice, noodles, & scal-loped potatoes

Processed cheeses

and cheese spreads

Condiments: soy sauce, barbecue sauce, steak sauce, salad dressing, MSG, ketchup, gar-lic salt

Frozen dinners and pizzas

Fresh poultry, fish, and lean meat

Fresh, plain frozen or canned “with no salt added” vegeta-bles

Fruits

Loaf breads, plain rice & noodles

meal a day to half of what you would nor-mally eat.

Focus on the portion sizes for the specific food groups.

If you decide to have

Simply by just eating half of everything you eat could account for a significant weight loss.

Start out by cutting back at least one

a desert, maybe eat half instead of the whole.

Take a log of ex-actly what you eat.

Remove the salt shaker

Add salt only after tasting

the food first

Cut down on the amount

of salty prepared sauces or condiments you use

Choose foods without

sauces. Ask for a sauce or salad dressing to be served “on the side.”

Ask for your meal to be

prepared without salt or MSG

Only add a small amount

of salt after you taste it.

Use spices, herbs, and

low sodium seasonings

Sprinkle lemon juice over

vegetables

Season or marinate meat

ahead of time with fresh onion before cooking.

Rinse canned vegetables

and fish like tuna to re-move sodium.

W h a t a r e s o m e h i g h a n d l o w s o d i u m f o o d s ?

3 ) P o r t i o n S i z e s

S u g g e s t i o n s f o r r e d u c i n g s o d i u m i n t a k e Shopping Tips:

Shop on the perimeter of the grocery store to find fresh and low sodium foods.

<5% Low Sodium >20 High

T o p 3 T h i n g s t o F o c u s o n

High Sodium Foods: Low sodium

In the kitchen… At the dinner table… At a restaurant...

Combination foods

It can be difficult to determine the amount of each food group that is in a dish. But with some practice, and help from this chart, you can get a better feel. Start by

imagining each component of the dish. Are there vegetables, fruits, meats, grains, pasta, beans, milk products or oils? Remember the serving sizes, according to the

DASH eating plan for each food group, and translate it from there.

For example think of a slice of pizza. What does it consist of? Bread, cheese, sausage.

How much bread? About 2 servings How much cheese? 3 ounces= 2 servings

Food group Serving sizes

Grains and grain products

1 slice of bread, 1/2 English muffin or bun, 1/4 bagel, 1 ounce dry cereal, 1/2 cup

cooked cereal, pasta, corn, rice

Fruits

6 ounces by weight of fruit, 6 ounces of juice, 1 medium piece of fruit, 1/2 cup canned, frozen fruit, 1/4 cup dried fruit

Vegetables

1/2 cup cooked or raw vegetables, 1 cup leafy raw vegetables, 6 fluid ounces

vegetable juice

Dairy foods (low-fat or fat-free)8 fluid ounces (1 cup) milk or yogurt, 1 1/2

ounces of cheese, 6 oz yogurt

Meats, poultry and fish1 ounces, cooked, 1/2 cup tofu, 1/ cup tuns or

cooked ground meat

Nuts, seeds and dry beans

1/2 cup cooked beans, lentils, or peas, 1/4 cup or 1 ounce nuts, 2 Tbsp or 1 ounce seeds, 2 Tbsp

peanut butter

Fats and oils

1 tsp soft margarine, 1 Tbsp low-fat mayonnaise, 2 Tbsp light salad dressing , 1

tsp vegetable oil

Others1 Tbsp sugar, jam, syrup, 4 oz soft drink,

1.4c sorbet gelatin.

Food Serving size Vegetable Fruit Breads and cereals Milk Beans, Nuts and Seeds Meat FatChili with beans 1 cup 1 1

Lasagna with meat and cheese 1 cup 2 1Macaroni and cheese 1 cup 2 1 1Spahgetti and sauce 1 cup 2

Stew, meat and vegetables 1 cup .25 1Tuna noodle casserole 1 cup 1 1 1Tuna or chicken salad .5 cup 2 1

Bean soup 1 cup 1Instant soup 1 cup 1Tomato Soup 1 cup 1Vegetable beef 1 cup 0.25 1Chow mein 2 cups 1 2 1

Pizza-cheese 6 oz 2 1Pizza-meat 6 oz 2 1 1Pot Pie 1 (7 oz) 2 1 3

Burrito with beef 1 (6 oz) 3 1 1Chicken nuggets 6 1 2 1

Grilled Chicken sandwich 1 2 3French fries 1 medium, 5 oz 2 2

Hamburger-large 1 2 3 1Hot dog with bun 1 2 1 1

Taco 1 (3 oz) 1 1 1Sub Sandwich 6 inches 1 3 2 2 1

Combination foods

I know that you are living with your mother, and cooking for the both of you can seem diffi-cult at times. You mentioned before that you would rather have her eating something that is

maybe unhealthy that she likes, than nothing at all. And I agree with you, in the sense that she definitely needs adequate food intake, or else she can lose energy and fall into a cycle of leth-

argy and have very little energy to do much about it. You do not have to make two separate meals for you and her. You can make enough for the both of you, and then take her portion out

and add salt or seasonings that she likes.

Meal planning for you and your Mom

Taking the time to meal plan one night a week will save you stress during the week. Meal planning can help avoid random stops at the fast food restaurants. Meal planning guide: 1) Start with a list of the things you already have in the house. 2) Next sit down with the meal planning spreadsheet and start to fill it out, in re-

alistic terms. Pick 3 nights a week to eat out. 3) Be sure to plan 2 snacks during the day. You mentioned that you are very hun-

gry when you get home from work. The planned snacks will help prevent this. 4) Plan all dinner meals to take 15-20 min max. 5) Make a grocery list of everything that you do need.

You do not need to make two separate meals at dinner time! Here are a couple tips for making just one meal, and other meal planning tips:

-Omelets- add bacon or other desired things in that your mom likes -Try making a grilled cheese on whole wheat bread, with low fat cheese on yours, and regular cheese on hers. Add bacon to hers. -Low sodium tomato soup for you, regular soup for her. Whole wheat spaghetti- boil two small pots of water. Add salt to her pan and leave out the salt in your pan. -Pork chops with canned salsa adds a lot of flavor. Casseroles– Make the recipe first and cut it in half. Add salt and other ingredients to your moms, and leave it out in yours. Put in two separate dishes. -Sautee a basic fish and serve with vegetables. Add salt to your mother’s fish and not yours. -Try making homemade pizza- pizza dough with desired toppings such as vegetables and chicken. -Try preparing a soup on Sunday’s, this way you can have it for lunch a couple times a week. -Try preparing special breads on Sundays, so you can have it every morning of the week. -Try frozen yogurt, pudding and sugar free jello as a desert alternative.

Evaluation Nutrition Plan of Care:

• Impacts of materials: – The education on DASH might have been overwhelming at first,

since she had no nutrition background. The cookbook education might have been drawn-out and redundant for her.

• How would I change materials:– I would have made a different eating guide for the DASH eating

plan. I would now have allowed more time for education on DASH.

• Would I use fewer?: – I would focus more on her understanding, and use constant

evaluation throughout the education. • Was the health literacy accurate for client?: Yes

Evaluation Nutrition Plan of Care:

• Dietary Changes over time:– Decreased calories: while increasing

carbohydrates, increasing protein, and decreasing total fat. (Just like what we aimed for)

– Decreased sodium and dietary cholesterol– Increased K, Mg, Ca, Vitamin D and Fiber

(just like what we aimed for)

Evaluation Nutrition Plan of Care:• Final Food log assessment vs. Inital:

Initial Food Log/Date: Second Food Log/Date: Average Kcalorie Intake

2860 kcal 2475 kcal

Estimated Kcalorie-Maintenance 2050 kcal Revised: 2050 kcal

Estimated Kcalorie-Weight Loss 1800 kcal Revised: 1800 kcal

Evaluation Nutrition Plan of Care:• Final Food log assessment vs. Inital:

Nutrient Initial - Intake Recommended Intake Second – Intake % Change (+/-) Protein (g)

137.9 81 106 -22%

Calcium (mg)

873.3 1250 1082 +24%

Iron (mg)

20 8 20 0%

Vitamin C (mg)

146 75 149.7 -2%

Vitamin A

543 700 550 +.01%

Folic Acid

360 400 526.4 +46%

Magnesium (mg)

323 280 387.6 +20%

Vitamin D (microg)

3.15 5 6.72 +114%

Sodium (mg) 4812 2300

3952 -17%

Potassium (mg) 3441 4700

3883 +12%

Dietary Fiber (g)

20.5 30 25.9 +26%

Cholesterol (mg) 385.6 150

255 -34%

Final Eval of Client Progress

• Dietary changes:– Decreased calories: while increasing

carbohydrates, increasing protein, and decreasing total fat. (Just like what we aimed for)

– Decreased sodium and dietary cholesterol

– Increased K, Mg, Ca, Vitamin D and Fiber (just like what we aimed for)

Final Eval of Client Progress

• Lifestyle changes:– Increased physical activity from

no times per week to two times per week for 20 min each.

Final Eval of Client Progress

• Anthropometric changes:– Waist circumference increase by

4 inches (39 to 43inches)– Hips circumference increase by 1

inch (46 to 47 inches)– Weight change: +0.01% (198-

200 pounds)

Final Eval of Client Progress

• Change in nutrition diagnosis:– I would still emphasis the DASH

eating plan, increasing physical activity, portion control and meal planning.

Future Nutritional needs

• She needs a continuous accountability partner to help keep her on track.

• She needs more practice with portion control.

• She needs further education and practice with the DASH eating plan.• Maybe a more in depth

explanation on physiological changes associated with the DASH eating plan.

Overall Summary of My effectiveness

• What did I learn about myself as a counselor: – I became more confident in my knowledge as a future dietitian. With

some work on my weaknesses, I discovered I have the potential to become a great nutrition counselor.

– I feel more prepared to answer nutrition-related questions off the top of my head

• What did I learn about educational preparations:– The preparations are what make you a good counselor, because it

shows exactly what you will be presenting to the client. They are vital

• Recommendations to future counselors: – The process does not happen in one day (it is a journey!), and that it

takes time and effort to make things happen and change. Four sessions may not be enough, so don’t worry if things don’t work out the way you hoped.

– Be prepared to set some time aside for your client, they deserve your full attention.

THANK YOU!