Name / Date / Time: John Doe / 7 March 2025 / 10:07 AM
Reason for Referral/Presenting Complaint/Diagnosis: Referred for nutritional assessment due to recent diagnosis of Type 2 Diabetes and concerns about weight management.
A - NUTRITION ASSESSMENT
Age: 45
Height: 175 cm
Weight: 85 kg
BMI: 27.8
Estimated Energy Needs: 2000 kcal/day, calculated using the Mifflin-St Jeor equation.
Estimated Protein Needs: 75 g/day, based on 0.8 g/kg body weight.
Other (specify): Fluid needs estimated at 2.5 litres/day.
Client History: John has a family history of diabetes and hypertension. He is currently on metformin and has a sedentary lifestyle. He lives alone and has limited social support.
Food/Nutrition-Related History: John follows a high-carbohydrate diet with frequent consumption of sugary snacks. He has a preference for fast food and reports low vegetable intake. He is independent in feeding but has not adhered to previous dietary advice.
Anthropometric Measurements: Waist circumference: 102 cm.
Biochemical Data, Medical Tests and Procedures: - HbA1c: 8.2% - Fasting glucose: 9.5 mmol/L
Physical Exam Findings: Mild muscle loss observed in upper arms, no signs of nutrient deficiencies.
Assessment, Monitoring and Evaluation Tools: Mini Nutritional Assessment (MNA) score: 11/14, indicating risk of malnutrition.
Comparative Standards: Dietary recommendations based on ADA guidelines for diabetes management.
D - NUTRITION DIAGNOSIS
PES Statement(s): Excessive carbohydrate intake related to lack of knowledge about diabetes management as evidenced by high HbA1c levels and dietary recall.
Etiology Category: Knowledge, Behavior
I - NUTRITION INTERVENTION
Aims/Goals (SMART): - Reduce HbA1c to below 7% within 6 months. - Increase vegetable intake to 5 servings per day within 3 months. - Achieve weight loss of 5 kg in 6 months.
Goal Progress Evaluation: New goal identified
Nutrition Prescription: Prescribed a balanced diet with 45% carbohydrates, 25% protein, and 30% fats, with emphasis on whole grains and vegetables.
Details of Intervention/Plan
Food and/or Nutrient Delivery (ND): - Introduce whole grains and reduce sugary snacks.
Nutrition Education (E): - Educated on carbohydrate counting and reading food labels.
Nutrition Counseling (C): - Motivational interviewing to address barriers to healthy eating.
Coordination of Nutrition Care by Nutrition Professional (RC): - Referral to diabetes educator for further support.
Nutrition Intervention Encounter Context (IC): - Conducted in outpatient clinic setting.
M/E - NUTRITION MONITORING AND EVALUATION
Specific Indicators, Criteria and Time Frame: - HbA1c levels to be checked every 3 months. - Dietary recall to assess vegetable intake monthly. - Weight to be monitored bi-weekly.
NUTRITION MONITORING AND EVALUATION TERMINOLOGY DOMAIN
Food/Nutrition-related History (FH): - Parameter: Vegetable intake - Indicator for Success: 5 servings/day - Time Frame for Measurement: Monthly
Anthropometric Measurements (AD): - Ongoing weight monitoring
Biochemical Data, Medical Tests and Procedures (BD): - HbA1c levels
Physical Exam Findings (PD): - Monitor muscle mass and fat distribution
Assessment, Monitoring & Evaluation Tools (AT): - Use MNA at follow-up to reassess nutritional risk.
