HPDP Case

Kliti Shentolli

12/2/18

Case Study: Calandra James

Calandra James is a 66-year-old recently retired administrator for City Harvest, a group that gathers leftover food from restaurants and distributes it to food banks and soup kitchens. She is a recovering alcoholic (sober for 8 years) and she now describes her health as basically good, but says that she struggles with what she calls “an addictive nature”. This has expressed itself in her history of drinking and a past history of smoking (she quit 5 years ago after a total of 40 pack-years), and more recently she has noted that her eating has an addictive aspect as well. She says that eating is “a giant issue for me”. She joined Weight Watchers and lost 75 pounds over a year and a half. However, she has gained back 15 pounds of it over the past year. She says, “I spend way too much time trying to stave off hunger, trying to keep calories to 1500-1800/day and pushing myself to get in enough exercise to achieve a daily calorie deficit (she takes long brisk walks, rides a bike to do errands, swims at the local beach during the season, and has a set of free weights and resistance bands that she uses at home). I am trying to focus on healthful eating and respecting my body, but it’s really a struggle.”

Her family history includes an alcoholic father and brother who are still actively drinking, a mother who had breast cancer at age 52, but has been cancer free since then and is now 88, and a sister who has Type 2 Diabetes. She has a long-term lesbian partner who lives a few towns away. She also has 2 adult sons who live several states away. She says she is looking forward to retirement because she hopes to find a way to relax and stop beating herself up all the time.

When you talk to her a little more about her eating habits, you learn that she does not really cook much. She mostly eats salads and prepared foods from the grocery store. A typical breakfast is scrambled egg whites with whole wheat toast. Lunch is a yogurt and sliced fruit with peanut butter spread on it. Snacks are humus and pita chips and or vegetables, and dinner is salad with some sort of protein. She allows herself two pieces of dark chocolate (80 calories) as dessert most nights. She says she finds her current diet tolerable, but “joyless”.

Other information:

BP 128/74 T 99 P 68, regular R 18

Hgt 5 ft 6 in Wgt 160 lbs Waist circumference 37 in

Immunizations:

Annual influenza shot– I would ask Ms. James if she got her annual influenza shot this year and if not, I would give it to her.
Td/Tdap vaccination– Ms. James does have her childhood vaccinations completed meaning that she already took Tdap, and I would ask her if she has been taking Td booster every 10 years. If yes, then I would check when she took the last Td booster and estimate the next Td booster. If she has an unknown history of completing 3-dose, then I would begin a primary vaccination series including a Tdap dose. I would administer the first 2 doses at least 4 weeks apart and the third dose 8 months after the second.
Zoster vaccination– single dose of zoster is recommended for adults who are 60 years old or older. Ms. James is 66 years old.
Pneumococcal 13-valent conjugate- I would ask Ms. James if she received either PCV-13 and PPSV-23. If not then a single dose of PCV-13 is recommended for those 65 years old or older.
Pneumococcal 23-valent polysaccharide– After I give PCV-13 to Ms. James, I would then have her come back one year later and give her PPSV-23. Or vice-versa, if she takes PPSV-23 first, then I would give her PCV-13 in the next year.

Screening:

Alcohol misuse- even though the patient states she’s been sober for 8 years, I would monitor her since she has a significant past history of alcohol usage, family history of alcohol usage (father and brother) and an “addictive nature”.
Tobacco misuse– the patient also states she quit smoking 5 years ago, I would still screen and monitor her due to her significant past history of smoking (40-pack year), and “addictive nature”.
Depression– it’s a grade B recommendation, meaning likely moderate benefit, and since she also quit both smoking and alcohol, she is at risk of suffering from withdrawals symptoms.
Hypertension– grade A recommendation, especially since Ms. James is 66 years old and has been a past user of both alcohol and smoking which can lead to hypertension.
Obesity– Ms. James expresses concerns about her recent weight gains (15 lb over the past year) and also fears her “addictive nature” is also applied to eating.
BRCA gene screening– since her mother has already been diagnosed with breast cancer at age 52, I would have her screen for the BRCA gene.
Breast cancer screening (Mammogram)- it’s generally recommended for women over 50 to be screened for breast cancer and have a mammogram done every 2 years. Since Ms. James has a family history and a past pack year of 40, I would do a mammogram on her.
Intimate partner violence– although Ms. James is not a childbearing-aged woman and in a lesbian relationship, I would still ask her how are things at home? Do you feel safe? and so on.
Abnormal Glucose and Diabetes Mellitus screening– Ms. James is at risk for DM. Her BMI is 25.8, which puts her on the overweight category and has a family history of DM (sister type 2 DM).
Hepatitis C infection– USPSTF recommends this screening test for both men and women who are born between 1945-1965.
Colon Cancer– usually recommended at age 50 or older. I would talk to Ms. James about the multiple modalities available but recommend colonoscopy as it’s the “gold standard” and also talk to her about risks and benefits of colon cancer screening and leave it up t her to decide.
Lung Cancer– both USPSTF and American Cancer Society, recommend lung cancer screening with LDCT for in patients 55 years old or older with 30-pack year and currently smoking or quit within last 15 yrs. Ms. James had a 40-pack year and quit 5 years ago, which makes this screening appropriate.
Osteoporosis– recommended by USPSTF for women age 65 or higher.

Injury Prevention:

Wear helmet when riding bike for errands.
Wear comfortable and appropriate footwear when taking long brisk walks. Advice on safety when crossing the road.
Make sure to have the appropriate equipment (ex. swimming cap) when going swimming and make sure to always have a lifeguard keeping an eye on you when you swim by yourself at the beach. Also use sunscreen when swimming.
Appropriately use the free weights. Do not attempt to lift heavy weights, use proper form, don’t drop weights on the floor, use collars when appropriate, and always pay attention when using free weights.

Diet Plan:

Looking at Ms. James’ diet, I think overall her diet is not so bad. She mentions, she tries to keep her calories low (1500-1800 calories) from the normally suggested diet of 2000 calories, which can be a problem. To effectively lose weight and maintain that weight loss (which Ms. James had trouble before) is by aiming to lose 10% of their current weight annually. Since Ms. James currently weights 160 lb, so she should aim to lose about 16 lb/year. Consuming less calories can also lead to slowing down her metabolism and no top of it, Ms. James works out, which can further increase that calorie deficiency and lead to more serious problems such as low basal metabolic rate. BMR refers to the number of calories needed to cover basic everyday functions and proper functioning of your internal organs such as brain, heart, kidneys, lungs and so on. A large calorie deficiency number and excessive workout (swimming at the beach for a long period of time or working out with weights) can also lead to her passing out or experiencing fatigue during these exercises which can also lead to her physically harming herself. My new diet plan for Ms. James would mainly focus on her consuming 2000 calories daily while at the same time continue to promote healthy eating. For breakfast I would suggest Ms. James to keep consuming the egg whites and whole wheat toast and maybe switch it up with avocado toast with eggs or Quinoa fruit salad since she states that her diet can be “joyless” sometimes. Overall, I like her current breakfast routine as she gets protein from the egg whites and whole wheat bread which is high in nutrient, B vitamins, and fibers. For lunch, I would suggest Ms. James to consume a bit more calories than what she’s currently consuming. I would suggest her to keep the yogurt and sliced fruit (make sure the yogurt is plain, no added sugar, but just add the fruits inside of it) but get rid of peanut butter spread on it. Although peanut butter is not terrible when consumption is done at a low rate, because high consumption of peanut butter can lead to artery-clogging atherosclerosis as it’s high in saturated fats. Instead, I would suggest Ms. James to replace the peanut butter and yogurt once in a while with a grilled chicken salad since she loves salads and is not processed food like peanut butter. By consuming a grilled chicken salad, she gets lots of protein, fibers and less processed sugar if she puts little to no dressing, than eating peanut butter. And since she just retired, she has more free time to cook, or if she still doesn’t like to cook, she can get the chicken salad from a local supermarket or restaurant. For snacks she usually has humus and pita chips and vegetables. The only change I would suggest here is to make sure the pita chips are baked and not fried as baked pita chips are healthier because they have less fat and less saturated fat. For dinner, Ms. James usually has salad and some protein which does sound “joyless” given the fact that I already suggested chicken salad for lunch already. Instead for dinner, I would suggest her to try vegetables soups such as Vegetable Cabbage Soup, Spring Minestrone Soup, Creamy Broccoli Cheddar Soup or any other soups as they are high in nutrients such as dietary fiber, proteins and have low calories from fat and are very delicious. Another option for dinner is fish. Salmon, sardines, herring and anchovies are rich in omega-3 fatty acid which is good cholesterol and DHA and EPA which are also great for the heart by reducing inflammation and improve arterial function. For someone like Ms. James who is at risk for diabetes (overweight and family history) consumption of fish is great. Ms. James also consumes dark chocolate most nights which can be good as dark chocolate has shown to lower the risk of heart disease, improve blood flow and lower blood pressure, all to which can be related to diabetes. The only recommendation I would suggest here is to have those dark chocolates during lunch or once in a while replace those pita chips snacks with a dark chocolate instead. Eating dark chocolate before sleeping can be a bit heavy, especially after having fish as well. Lastly, I would suggest Ms. James to in-cooperate cooking as much as possible and avoid processed food because of high volume of processed sugar and other carcinogenic factors that could cause cancer. So far though, I think she’s doing a good job eating healthy but since she got more free time due to retirement, I’d also suggest her to pick up cooking as it will keep her mind busy (away from her addictive nature of smoking and drinking) while at the same time promoting a healthier diet. Homemade salad, fish, soups are usually are more healthy than pre-packaged and pre-cooked food at the supermarket or restaurant.

Exercise Plan:

Ms. James mentions that one thing she’s looking forward to retirement is to not beat herself up all the time and relax a bit. So far, she has stated that she takes long walks, swims, rides the bike to do errands, uses free weights and resistance bands. Based on these descriptions, I think she’s getting more than enough exercise. The normal guideline for exercise is about 140-150 minutes of moderate aerobic activity and as we mentioned before, the most efficient way to lose and maintain that weight loss is by aiming 10% weight loss/year which is roughly 16lb for Ms. James. I would explain to Ms. James that this weight loss plan is very realistic and that she’s already experienced a greater weight loss which has resulted in her gaining some of that weight back. I would explain in simple words how sudden weight loss does not mean leptin levels (chemical that tells our brain we are full) would also decrease, but it takes roughly one year for it to return back to normal levels. First, I’d suggest 30 minutes of moderate-level physical activity for 3-4 days a week. I would suggest for Ms. James to cut back a bit and not overwork herself. She should minimize the use of free weights as they can be dangerous, especially for her age. Instead, to stimulate all her muscles, especially upper body, I would suggest her to maybe join a local gym with a swimming pool (if there’s any nearby) and swim not only during the season, but throughout the whole year since it looks like she likes to swim. Also, I think swimming in a swimming pool can be safer since it’s smaller with no risk of harmful radiations. In this plan, I would also encourage biking, which she already does when going to do errands. I would suggest biking over long walks because extensive walking can be a high impact activity, especially on her knees and feet and at her age, Ms. James can be at risk for osteoporosis. To organize this exercise plan I would recommend it as follows:

2 days a week (Monday and Wednesday) 40 mins total- start with stretches at home using the resistance bands. Then go to the local gym and use the swimming pool for about 30 mins. First 15 mins can do freestyle stroke, 10 min break and the other 15 mins can do butterfly stroke. (can switch strokes whenever you want)
2 days a week (Tuesday and Thursday) 40 mins total- start with stretches at home using the resistance bands. Then bike at a nearby park, or even run errands for about 15 mins with the bike, 10 mins break and then bike back at home for approximately 15 more mins.

I believe these are moderate- level exercises that she would enjoy while at the same time she’s not pushing herself too hard. On the next visit, if she likes this exercise routine, I would increase the intervals to 45- 50 mins and maybe throw some different exercises in there to keep it interesting.

Brief Intervention:

Obesity- Although Ms. James is not considered obese when looking at BMI, I would still do a motivational interviewing with her and go through the 5 A’s to make sure she continues this healthy diet and exercise.

Ask– Ms. James, do you mind if we discuss your current weight and the effects it might be having on your health?
Assess– Can you please tell me more about your past weight gain or loss? Can you tell me more about that time when your loss 75 lb in a year and a half?
Advise– What do you know about the possible health risks related to obesity and overweight? Can you tell me more about your ideal weight loss goal(s)?
Agree– What is your ideal weight and weight loss goal? Do you think being retired from work will help you to achieve those goals?
Arrange/Assist– Would you like for us to sit down and come up with a diet and exercise plan that best fits your personal life? So far, you’ve done an amazing job keeping a healthy diet and getting enough exercise, would you like for me to refer you to a personal trainer or dietician who can keep you on the right track?

Smoking Cessation- Although Ms. James quit smoking 5 years ago, I would still do motivational interview to encourage her to continue on being smoke-free and also use the 5 A’s to make sure she continues to stay away from smoking. In this case I would also use the 5 R’s to motivate resistance.

Ask– Ms. James, I understand you have quit smoking 5 years ago, but do you mind if we explore different options to reinforce smoking cessation?
Assess– Can you tell me more about your past smoking history, and why did you stop 5 years ago? What method of smoking cessation helped you to stop smoking? How’s that working so far? Do you ever feel the need to go back to smoking?
Advise– What do know the possible health risks related to smoking? What was the main reason you stopped smoking and do you know the long-term benefits of smoking cessation?
Agree– Would you like to know other methods that can help reinforce smoking cessation? Did you use any kind of medication to help you stop smoking? Would you like to know more about those medications?
Arrange/Assist– Would you like for us to sit down and come up with additional ways to help you stay away from smoking? So far, you’ve done an amazing job staying away from smoking and I know it can be hard, would you like additional support?
Relevance– What were the reasons you first stopped smoking? Are those the same reasons that are keeping you motivated today to stay away from smoking?
Risks– Do you know the effects of smoking on yourself? Do you know the effects smoking can have on people around you?
Rewards– Have you noticed any benefits you had from not smoking for 5 years? Do you know the long-term benefits of smoking cessation, and the benefits it can have on your internal organs, especially lungs?
Roadblocks– Have you encountered any barriers so far that have made it challenging for you to continue to not smoking? Do you have active smokers around you that can present a challenge in your continuation of being smoke-free?
Repeat– If anything from the above questions was not clear, repeat or formulate the questions differently.

Substance use (Alcohol)- Although Ms. James has been sobered from alcohol for 8 years now, I would still do motivational interviewing with her just like I did for obesity and smoking, just to make sure she’s on the right track. I would use the 5’A again to make sure she continues to stay away from alcohol.

Ask– Ms. James, I understand you have been sobered from alcohol for 8 years now, but would you mind if explore the topic and discuss your approach to being sober for so long?
Assess– Can you tell me more about your past alcohol history and what made you stop drinking 8 years ago? What methods have you used to stop drinking alcohol and which ones have worked and not worked so far?
Advise– Do you know the health risks associated with alcohol? Was there any particular health risk that made you stop the consumption of alcohol? Do you know the long-term benefits of being alcohol-free?
Agree– Would you like to know other methods that can help you remaining alcohol-free? Did you use any kind of medication to help you stop drinking? What is the ideal goal you are trying to achieve when it comes to drinking?
Arrange/Assist– Would you like for us to sit down and explore other options that may come to your aid in remaining alcohol-free? So far, you’ve done an amazing job staying away from alcohol and I know it can be hard, would you like additional support?

Looking at Ms. James case, the first issue that should be addressed is her “addictive nature”. She seems concern about it and blames this “addictive nature” for her past alcohol and smoking abuse, and currently she’s afraid that this “addictive nature” will also be applied in her eating habits as well. Overall, I think she’s doing a great job staying away from alcohol, smoking and watching what she eats. She is self-conscious and seems motivated to change, but just needs that little bit of push and support to achieve her goals. After proposing the diet and exercise plan, I would check up with her the following month and go from there.

Source:

https://www.healthline.com/nutrition/calorie-restriction-risks#section2

https://www.foodnetwork.com/healthyeats/2012/07/baked-chips-are-they-healthy

https://www.healthline.com/nutrition/7-health-benefits-dark-chocolate#section1

https://www.nutritionix.com/food/vegetable-soup/1-bowl-2-cups

https://www.delish.com/cooking/recipe-ideas/g3733/healthy-dinner-recipes/?slide=1

PowerPoint Presentation “Smoking”

PowerPoint Presentation “Alcohol”

PowerPoint Presentation “Obesity”

PowerPoint Presentation “Motivational Interviewing”