General Initial Dietetic Consult

REASON FOR REFERRAL Patient referred for assessment and management of newly diagnosed Type 2 Diabetes. REFERRED BY Dr. Emily Carter, General Practitioner, City Medical Centre SOCIAL HISTORY • 62-year-old male, retired accountant. • Lives with his wife in a suburban home. • Enjoys gardening and reading. MEDICAL HISTORY • Type 2 Diabetes (newly diagnosed). • Hypertension (controlled with medication). • Hypercholesterolemia. Medications • Metformin 500mg twice daily. • Lisinopril 10mg daily. • Atorvastatin 20mg daily. Nutrition Supplements • Multivitamin (contains Vitamin D, Calcium). BOWELS • Regular bowel movements, once daily, formed stool. EXERCISE • Incidental only NUTRITION RELATED FINDINGS • Appetite: Good. • Bloodwork: Elevated HbA1c (8.2%), elevated cholesterol. DIET • No known allergies or intolerances. • Patient is not following any specific diet. DHx: BF: 2 slices of toast with butter and jam OR cereal with milk and fruit, 5/7 MT: Nil L: Sandwich with meat and salad, 5/7 AT: Biscuits and tea, 3/7 D: Meat and 2 vegetables, 7/7 S: Nil Concerns/Issues with current diet: • High intake of refined carbohydrates. • Portion sizes are too large. • Limited intake of vegetables. Nutrition assessment of diet: The patient's diet is high in carbohydrates and saturated fats, contributing to poor blood glucose control and elevated cholesterol levels. Fibre intake is low. Previous diet attempts: Nil ANTHROPOMETRY Weight: 95kg Muscle: Not assessed. Fat: Not assessed. Weight history: Patient has gained 5kg in the last year due to reduced physical activity. GOALS: 1. Reduce HbA1c to below 7%. 2. Improve cholesterol levels. 3. Achieve a healthy weight. 4. Increase fibre intake. PLAN: • Education provided on carbohydrate counting and portion control. • Provided a sample meal plan with balanced macronutrient distribution. • Discussed strategies for increasing vegetable intake. • Recommended regular physical activity. • Scheduled a follow-up appointment in 4 weeks.