Question
What risk factors indicated in his medical record can be addressed through nutrition therapy?
Step 1
Step 1: Review the medical record to identify any existing health conditions or risk factors that may be influenced by nutrition, such as obesity, diabetes, hypertension, high cholesterol, or gastrointestinal issues. Show more…
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Edwin is a 42-year-old white male who has been human immunodeficiency virus (HIV) positive for 20 years. His viral load is undetectable, and his CD4+ count is 643. Edwin’s medical history also includes depression, gastroesophageal reflux disease (GERD), high blood pressure, and hyperlipidemia. His current HIV antiretroviral regimen was recently changed to Genvoya; he also takes atorvastatin (Lipitor) and ranitidine (Zantac). His height is 5’9”, and his current weight is 188 lb, up from 175 lb. His fasting lipid profile shows a total cholesterol of 235 mg/dL, triglycerides of 304 mg/dL, high-density lipoprotein of 25 mg/dL, and low-density lipoprotein of 96 mg/dL. Since his last visit 3 months ago, he has been having moderate diarrhea with general gastrointestinal (GI) upset that he states is "left over" from when he had the flu and took 2 rounds of antibiotics a few months ago. Edwin lives by himself and doesn't like to cook. He also receives one meal per day from a community program and gets groceries once per week from a food bank. He walks his dog for 30 minutes daily. Upon taking a 24-hour recall, you find his caloric intake to be 2700 kcal/day coming primarily from ready-to-eat items. He also expresses that ice cream is his emotional comfort food, which he eats 5 to 7 days per week. Nutrition diagnostic statements: - Excessive dietary intake (NB-1.7) related to frequent intake of highly processed foods and limited food access, as evidenced by a 24-hour recall reflecting an intake of 2700 kcal per day and weight gain of 13 lb (7.4%) in the past 3 months. - Altered GI function (NC-1.4) related to a history of antibiotic use and high intake of lactose, as evidenced by the patient's report of moderate diarrhea since taking 2 rounds of antibiotics in the past few months and a diet recall revealing eating ice cream 5 to 7 days a week. Nutrition care questions: 1. What factors may be contributing to the GI symptoms that Edwin is experiencing? What recommendations do you suggest for these symptoms? Are there any drug-nutrient interactions of which you need to be aware? 2. What nutrition and lifestyle interventions would you recommend to address his nutrition diagnoses? 3. What are some biochemical and nutritional parameters you would monitor to determine whether the nutrition interventions are effective?
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