Arianna Adorno-Williams
Nutrition and Dietetics Major 

This marks the beginning of the end for the Nutrition Assistant Program 2017 at City College of San Francisco!

 

 

 

As part of our program we work at our colleges student health center and try out some didactic training with students who have signed up to come for a little nutrition assessment. We work with our teacher from the our Nutrition Assistant clinic course she is also a Registered Dietitian (R.D). We are to complete our clinic hours in pairs for two days at 9am to 4p.m, even though we come as pairs we each have speak with our own patients, however everyone (our teacher and classmate) is welcome to chime in too. The outline for our clinic hours is to work off our patients 24 hour recall, basically what they ate in the last 24 hours, what time they ate it and how much. The form also asks questions like:

 

‘What are you nutrition related concerns?’

 

‘What are you food allergies and food intolerance's?’

 

‘How often do you eat out’

 

‘How often do you exercise and for how long?’

 

‘Who cooks the food at home? Who plans meals?

 

‘If they are experiencing poor concentration, low energy, constipation etc’

 

 

Based on these questions we will discuss with the patient blood sugar level or whether they are meeting adequate MyPlate guidelines for all the required food groups.

 

 

Blood sugar Worksheet/Handout: This gives a great example of how a persons blood sugar level dips when they have not eaten or not eaten enough. Not eating enough leads to symptoms like low energy, poor concentration, weakness, headaches, irritability, sugar or fat cravings, tendency to overeat and hunger. This connects to the original worksheet that the patients filled out beforehand, they are asked questions about their energy level and if they answer yes to having symptoms like describe above we take their 24 hour recall and begin to chart by drawing a line which moves up or down, it all depends on how much was eaten and at what time that determines what brings the line up or down and also where your blood sugar is. Whether you eat determines if your blood sugar falls below the normal range will determine if feel weak or tired and hungry.

 

 

Blood sugar level is a measure of glucose in the blood, glucose is like a precious fuel for cells in the body, it fuels nearly all of the brains activities, glucose and its storage form glycogen provide about half of all the energy muscles and other body tissues use.

 

 

 

‘Every body cell depends on glucose for its fuel to some extent, and the cells of the brain and the rest of the nervous system depend almost exclusively on glucose for their energy. The activities of these cells never cease, and they have limited ability to store glucose. Day and night, they continually draw on the supply of glucose in the fluid surrounding them. To maintain the supply, a steady stream of blood moves past these cells bringing more glucose from either the small intestine (food) or the liver (via glycogen breakdown or gluconeogenesis)’

 

 

‘Balancing with in the Normal Range' The maintenance of normal blood glucose depends on foods and hormones. When blood glucose falls below normal, food can replenish it, or in the absence of food, glucagon can signal the liver to break down glycogen stores. When blood glucose rises above normal, insulin can signal the cells to take in glucose for energy. Eating balanced meals that provide abundant carbohydrates, including fibers, and a little fat help to slow down the digestion and absorption of carbohydrate so that glucose enters the blood gradually. Eating at regular intervals also helps the body maintain a balance between the extremes’

 

 

'People don’t eat glucose and glycogen. When they eat foods rich in carbohydrates, their bodies receive glucose for immediate energy and convert some glucose into glycogen for reserve energy.’ Different foods and amounts hold a persons blood sugar in the good range but nothing holds it for a long as a meal of of protein, grain, fruit and or vegetable which keeps blood sugar in a good range for 3-4 hours, add 1-2 tbsp of healthy fats to each meal increases satiety as well. A protein and high fiber grain, fruit or vegetable snack lasts 2 hours and, grains can last 2 hours and a fruit or vegetable snack lasts our body just an 1 hour.

 

 

MyPlate Nutrition Evaluation sheet: This sheet focuses on a daily evaluation, the main food groups being grains, vegetables, fruits, milk, protein foods and oils. Oils are not considered a food group but there are healthy oils high in essential fatty acids and vitamin E which also add to the satiety of meals. Recommended daily servings for each food group are:

 

 

 

5-7 for grains

 

2-3 for vegetables

 

2-3 for Milk

 

5-7 for protein foods

 

2-3 for oils

 

 

Then we categorize each food into its food group, our teacher helped determine how much of what they ate measures out a severing, for instance a glass of soy milk, we pull up different cup sizes because at home people cups are different sizes. We draw ticks in each box that determines a serving, a long tick mark for full serving and a half tick mark for half a serving. Each food group box is also divided in half because in each food group there are high quality foods and low quality, for example the difference between whole wheat bread and refined enriched white bread, the whole wheat is high quality.

 

 

My first patient of the day came in a bit late, she filled out her sheet and we looked it over before she came in to talk. She wanted to know about eating more vegetables and some of her worst food habits were eating in her car on her way to work. She ate out at least once a week and didn’t exercise because she didn’t know what type of exercise she wanted to do, she felt undecided. She drank at least 5 cups a water for her 24 hour recall diet and tends to skip breakfast. Her full 24 hour recall consisted of

 

9:15 1 cup of soy milk with a Chinese roll 

 

1pm 1 cup of white rice with 3oz fried chicken and 1/2 cup steamed veggies 

 

4:30 1/3 cup of dried fruit

 

8pm 1cup of white rice,1/2 cup of tofu, 2oz of pork.

 

 

Since she didn’t report any fatigue we kind of just went into the My Plate evaluation. We put her 24 hour recall into the MyPlate sheet and she didn’t meet most of the requirements, we explained to her the difference between high quality and low quality ingredients. Her first meal was soy milk and a bread roll, she understood about whole grains so her bread roll was refined flour which would go into the low quality section under grains. The soy milk was not so easy, my teacher asked her questions about where she got her soy milk and then we discussed the difference between regular soy milk and fortified soy milk. We let our patient know she should be looking for calcium fortified soy milk and orange juice, fortified to 30% to 35% and tofu at 20%. Most of the servings in the grain section for her 24 hour recall that day were low quality like white rice and white bread rolls, I understand the hardship between changing from white rice to more brown rice coming from a Latin household myself I told her, the struggle is real. We talked a bit about watching out for dried fruits, if you think about eating a handful of raisins v.s eating the same amount of grapes you realize you would get full faster from the grapes. Dried fruit is great but it can be misleading because you get full a lot slower because there is not as much liquid but you still get the same amount of sugar. For the protein section low quality meats will be fatty cuts of meat so for her it was just the fried chicken, lean meats and and other plant based sources of protein will be higher quality. There was definitely a bit of time between her breakfast and lunch, 9:15 to 1pm, her soy milk and bread roll couldn't have lasted her more than and hour her blood sugar definitily dropped. So we went over blood sugar and its meaning, my teacher has great resources and papers and one paper that she pulled out fairly often over the course of our clinic was the Grab n’ Go sheet. This Grab n’ Go sheet has a list of the foods under protein a, grain, fruit and or vegetable, the sheet shows a list of foods in each category and encourages picking an item from each category and making a meal out it. My go to was peanut butter and apples with some kind of grain but my client wasn’t into peanut butter at all so I went for the hummus, she was definitely into that. She chose hummus, cucumber,and pita bread, as something that she could add to her meals. I mentioned whole wheat pita bread is also pretty palatable in the whole grain department for her to eat with her hummus :D She can also use the Grab n’ Go sheet while she is grocery shopping to create other variations!

 

 

In terms of her wanting to exercise Since our community college is free to local residents I mentioned that she could try to look through the list of physical activity classes to take this summer, they have loads of options and if anything it will get her thinking. These tips were all written on a goal sheet for the patient, she also took some handouts we with worked on.
 

Progress Notes

 

Nutrition Note

 

SOAP: Subjective Objective Assessment and Plan, everything we have went over is documented under this format that has been employed by health care providers to write out notes for a patients chart, there is also some format and wording used specifically.

 

Subjective: Wants to eat more fruits and vegetables/wants to exercise more, she usually eats every four hours/ no complaint of poor energy, concentration

 

Objective: 90 lbs. small build, 16.5 BMI female (this would also include ethnicity and any other objective facts)

 

Assessment: Inadequate intake of fruits/vegetables/whole grains/ inadequate physical activity. 

 

 

Plan: Practice fully body stretches/ check out physical education at community college. Discussed dietary sources of calcium, orange juice, soy milk fortified calcium 30% - 35%

 

 

Grab n’ Go sheet pick a fruit and vegetable while shopping to eat as a snack/ she likes hummus so pick a veggie from the Grab n’ Go sheet or whatever she likes eat w/hummus and whole wheat pita bread/ eat more whole grains like brown rice too.

 

Second Patient

 

8am awake 

 

12am 4oz pizza macaroni/ 4oz potato salad 

 

2pm one small bag of almonds, cashew/cranberry mix 

 

She didn’t eat until 7 that night which means her blood sugar definitely dropped. 

 

7pm 2 cups refried beans, w/lettuce, tomatoes, 3/4 avocado and 4 oz cheese

 

 

Subjective: Came in to lose weight; C/o (complained of) of low energy headaches, constipation, skips breakfast regularly; late dinner; Drinks up to two sweetened beverages/day; Drinks lots of water while at work.

 

Objective:female; Hgt/Wgt deferred Assessment: 

 

Inadequate physical activity; Inadequate fruits/vegetable/whole grain intake; 

Excess hrs between meals; Discussed fiber in fruits and vegetables and whole grains; Eating mindfully; Make half of the plate fruits and vegetables;

Try using measuring cups as servings utensils; 

Pt (patient) goal is to eat two fruits and large serving of vegetables for dinner;

Exercise video at least three times a week.

 

This patient had been drinking soft drinks which is one of the easiest ways to over-do you sugar intake, by drinking it. She had discussed having problems with constipation and had been told to try metamucil, my teacher then said that a serving/piece of equals to taking a metamucil which was amazing to hear! We had talked about making half the plate fruits and vegetables, her and her family were having homemade nachos that night so I recommend she try eating part of her veggies first.

 

 

During clinic we are paired with another one of our classmates, we are all present for all of them I get two patients and my classmate gets two and each of the appointments can take at the very least an hour because its a lot of communication, listening and story telling etc.

 

That's one way preventative care works!

 

 

Sources used:

 

MyPlate

Understanding Nutrition 14th edition