Initial Dietetic Assessment

Date: 15/05/2024

Demographics

• Name: Robert James Henderson
• DOB: 12/08/1962
• Age: 61
• Gender: Male

Referral Details

• Referred by: Sarah Jenkins, Senior Musculoskeletal Physiotherapist
• Reason for referral: Weight reduction to offload bilateral knee osteoarthritis (OA) and improve glycaemic control for Type 2 Diabetes Mellitus (T2DM).

Medical History

• Relevant medical conditions: T2DM, bilateral knee OA, hypertension (HTN), dyslipidaemia.
• Medications: metformin (Diabex®) 1,000 mg PO BID, perindopril (Coversyl®) 5 mg PO daily, atorvastatin (Lipitor®) 20 mg PO nocte, paracetamol (Panadol Osteo®) 1,330 mg PO TID PRN.
• Allergies/intolerances: NKDA. Mild lactose intolerance (avoids large volumes of cow's milk).

Anthropometrics

• Height: 176 cm
• Weight: 104.5 kg
• BMI: 33.7 kg/m² (Obese Class I)
• Waist circumference: 112 cm

Biochemistry

• Recent pathology results: HbA1c 7.8 %, FBG 8.4 mmol/L, Total Chol 5.6 mmol/L, LDL 3.4 mmol/L, HDL 1.0 mmol/L, Trig 2.6 mmol/L, eGFR > 90 mL/min/1.73m² (dated 02/05/2024).

Nutrition-focused Physical Examination

• General appearance: Central adiposity; ambulates with mild antalgic gait.
• Oral health: Own teeth, intact, no chewing or swallowing difficulties (dysphagia) reported.
• Skin integrity: Intact, no lower limb ulcers or oedema.

Diet History

• Usual eating pattern:
  • Breakfast: 2x white toast with butter and jam, 1x instant coffee with 2 tsp sugar and splash of full-cream milk.
  • Mid-morning: 2-3 sweet biscuits, black tea.
  • Lunch: Bought meat pie or sausage roll, 600 mL cola (regular).
  • Afternoon: Packet of crisps (45 g) or chocolate bar.
  • Dinner: Large portion of meat (steak/sausages), mashed potato (2 cups), peas/carrots, gravy.
  • Supper: Bowl of ice cream while watching TV.
• Food preferences/aversions: Prefers savoury, traditional meat-and-three-veg meals. Dislikes fish and tofu.
• Appetite: Good.
• Fluid intake: ~1.5 L/day (2x coffees, 1x tea, 600 mL soft drink, ~400 mL water).

Nutrition-related Symptoms

• Gastrointestinal issues: Occasional mild constipation; nil nausea or reflux.
• Other relevant symptoms: Daytime fatigue and bilateral knee pain limiting prolonged standing for meal preparation.

Physical Activity

• Type and frequency: Hydrotherapy 2x/week (30 mins) and daily home exercise program (HEP) as prescribed by physiotherapist. Sedentary occupation (administration).

Psychosocial Factors

• Living situation: Lives with wife in a single-storey house.
• Support network: Wife does primary grocery shopping and evening cooking; very supportive of dietary changes.
• Barriers to dietary changes: Reliance on convenience foods during work hours, habitual evening snacking, limited knowledge of carbohydrate counting and glycaemic index (GI).

Nutrition Assessment

• Estimated energy requirements: 8,500 kJ/day (for weight maintenance); targeting ~6,500 kJ/day for gradual weight loss.
• Estimated protein requirements: 85–100 g/day (approx. 1.0–1.2 g/kg adjusted body weight) to preserve lean muscle mass during weight loss and physiotherapy rehabilitation.
• Identified nutrition issues: Excessive energy intake, excessive refined carbohydrate intake, inadequate dietary fibre, suboptimal fluid intake.

Nutrition Diagnosis: Excessive energy intake related to frequent consumption of high-fat, high-sugar convenience foods and snacks as evidenced by diet history and BMI of 33.7 kg/m².

Nutrition Intervention

• Goals:
  • Short-term: Replace sugary soft drinks with diet alternatives or water, and transition to low-GI, high-fibre breakfast options over the next 4 weeks.
  • Long-term: Achieve 5–10 % total body weight loss (5–10 kg) over 6 months to reduce knee joint load and lower HbA1c to < 7.0 %.
• Nutrition education provided: The Healthy Plate model, carbohydrate distribution, Low GI swaps, label reading (focusing on total sugars and saturated fats), and anti-inflammatory foods for OA.
• Strategies discussed:
  • Swap white toast for grainy/sourdough bread or rolled oats.
  • Swap regular cola for zero-sugar alternatives or sparkling water.
  • Pack leftover dinner or wholegrain sandwiches for work lunches to avoid bakery purchases.
  • Reduce potato portion at dinner by half and increase non-starchy vegetables to fill half the plate.
  • Replace evening ice cream with high-protein, low-lactose Greek yoghurt and berries.

Nutrition Monitoring and Evaluation

• Parameters to monitor: Weight, waist circumference, diet history compliance, fasting BGLs, and knee pain/function scores (in conjunction with physiotherapy).
• Follow-up plan: Review in 4 weeks to assess adherence to initial dietary swaps and check weight progress. Copy of assessment sent to referring physiotherapist and GP.

Chloe Davis, APD (Accredited Practising Dietitian)