ABCD Dietetics Consultation

Seen remotely with the patient's permission.

Goals

• Dietitian's goals: Achieve 5–10% weight reduction over 6 months to offload knee joints and improve glycaemic control.
• Other staff's goals: Physiotherapist aims to reduce BMI to < 30 kg/m² to facilitate lower limb rehabilitation and improve mobility.
• Patient's goals: Lose weight to reduce bilateral knee pain and increase walking distance without fatigue.

Anthropometry

• 24/10/2023: Height 1.65 m, weight 92.4 kg, BMI 33.9 kg/m².

Biochemistry

• 10/10/2023: HbA1c 56 mmol/mol, total cholesterol 5.4 mmol/L, triglycerides 2.1 mmol/L, eGFR > 90 mL/min/1.73m², vitamin D 32 nmol/L.

Clinical

• Bilateral knee OA, T2DM, HTN. Right knee arthroscopy (2018).
• Metformin 1,000 mg PO BID, amlodipine 5 mg PO OD, paracetamol 1,000 mg PO QID PRN.
• NKDA.
• Central adiposity noted on video; mobilises with a single-point stick indoors.

Dietary

• Referred by MSK physiotherapy for weight management secondary to knee OA. Reports gradual weight gain of 8 kg over the past 2 years due to reduced mobility and comfort eating.
• Skips breakfast. Lunch: 2 slices white bread with cheddar cheese and crisps. Dinner: large portions of pasta or white rice with meat sauce, minimal vegetables. Snacks on 3–4 chocolate digestives in the evening. Drinks 4 cups of tea daily (whole milk, 1 tsp sugar) and 1 L water.

Other

• Husband has recently retired and does most of the grocery shopping, frequently buying processed snacks.
• Sedentary; walks < 1,500 steps/day due to knee pain. Performs seated physiotherapy exercises 3x/week.
• Lives with husband in a two-storey house. Ex-smoker, nil ETOH.
• PHQ-9 score 6 (mild low mood related to chronic pain).

Assessment

• Excessive energy intake (NC-1.4) related to frequent consumption of energy-dense snacks and large carbohydrate portions, as evidenced by BMI 33.9 kg/m², elevated HbA1c, and diet history.
• High motivation for lifestyle change, though limited mobility restricts energy expenditure. Vitamin D insufficiency noted.

Dietetics Plan

• Adopt plate model: 1/2 vegetables, 1/4 lean protein, 1/4 high-fibre carbohydrates. Switch to semi-skimmed milk and artificial sweeteners in tea. Introduce a high-protein breakfast (e.g., Greek yoghurt with berries) to reduce evening snacking.
• Telephone review in 6 weeks. Copy of clinic letter sent to MSK physiotherapist and GP.
• Provided education on carbohydrate awareness, portion sizes, and reading food labels for saturated fat and sugars.
• Colecalciferol 1,000 IU PO OD recommended for vitamin D insufficiency (GP to prescribe).