Krause\'s Food & the Nutrition Care Process 14th edition Chapter 23 Case Study G
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Question
Krause's Food & the Nutrition Care Process 14th edition Chapter 23 Case Study
Guillermo is a 32-year-old former college athlete who has been competing in long-distance triathlon and marathon events for the past year. He complains of low energy as training and racing duration increases and is plagued by gut issues—gas and bloating after meals, nausea, and vomiting during races. He also suffers from sleep issues, waking up frequently during the night. He works full time at a stressful job as manager of an electrical contracting firm and trains in swimming, cycling, and running 10 to 12 hours/week.
Assessment
His height is 5ft 9 in and his weight is 174 lb. His body composition analy- sis as measured by the RD using the ISAK method was 6.8% (10.4 lb body fat, 164 lb [74kg] FFM). He is satisfied with his body fat percentage but would like to reduce his weight if possible to lighten up for the running portion of his events.
Urine specific gravity was assessed to determine hydration status on three visits: 1.035, 1.025, and 1.030
Cholesterol levels were 250, HDL 50, LDL 170, triglycerides 160; all other values were within normal limits.
Using the Cunningham method to calculate REE:
500 (22 x FFM [Kg]) 500 (22 74) 2128 REE
Day off training: Activity factor 1.2, approx. 2553 calories
1-2 hours steady state training: Activity factor 1.4 approx. 2979 calories
3-4 hours steady state training: Using Activity factor 1.6 approx.3404 calories
4-6 hours training steady state: Using 1.73 Activity factor approximately 4581 calories
Current Diet
Breakfast 1 hour before workout:
12 oz coffee with 1 oz coffee creamer
3 eggs fried with onions, 2 slices bacon, 2 slices ham
1 spiced apple bran muffin
Analysis: 570 calories, 30 grams fat (49%), 40 grams carbs (28%) 570 mg cholesterol
Workout: 2000-yard swim,2-hour bicycle ride, 4-mile run During swim portion of workout (less than 1 hour): nothing During cycle portion of workout: 2 hours
2 electrolyte pills every 20 minutes on bike—total 12 pills Each pill contains: 40 mg Na—480 mg sodium
3 16 oz bottles fluid:
1 170 cal, 32 g cho, 10 g pro
1 bottle high carbohydrate, hypertonic sports drink with maltodextrin-
270 cal, 54 g carb, 7 g sugar and protein, 220 mg Na, 25 mg caffeine • Water
1 gel pack every 30 minutes 6 packs
Double latte with caffeine 110 cal, 27g carbs, 200 mg Na
During run portion of workout (less than 1 hour): nothing
Total workout fuel: 1100 calories, 248 g carbohydrates (124 g/hr cycling, 900 mg Na)
Immediately after workout: nothing
Breakfast:
Coffee with half-and-half
1 plain bagel, cream cheese, jelly
Banana
12 ounces milk
Snack: none
Lunch:
2-6 oz chicken breasts grilled with skin, 2 cups white rice, 1 cup black beans, 12 cup fried plantains Snack: high-protein sports bar
Dinner:
1 onion soup with melted cheese 12 oz grilled steak
1 c yellow rice Sauteed mushrooms
Dietary Analysis:
3041 calories, 216 g protein (2.77 g/Kg) (28%), 249 g carbohydrates (3.15 g/kg)(33%), 13.5% saturated fat, 1172 mg cholesterol, 5634 mg Na RDA: 64% potassium, 85% Ca and folate, 26% C, 30% E, 13% K, dietary fluid intake 9 cups
Assessment
Gut/Energy Antagonists:
Whole food portion of diet appears to be:
Low in calories: 3041 calories (4141 with sport fuel) vs. 4581 calories required
Carbohydrates: 249 g carbohydrates (3.15 g/kg) (33%) (497 g sport fuel), vs. a minimum of 5 to 7 g/kg 395-553 g
High in fat (38% total cal), saturated fat and cholesterol 1172 mg and so- dium 5634 mg
Low in antioxidants
Excessive in fat pre-workout breakfast
Excessive in sport fuel carbohydrates and sodium for 2-hour bike portion of ride
Excessive in mealtime calories and protein
Questionable whether athlete can tolerate FODMAPs foods, i.e., onions, beans, mushrooms, cream cheese, dairy (lactose), sport fuel sources of HFCS, and gluten
Intervention
Increase meal frequency and calories while modifying fat, sat fat, and cholesterol
Increase plant-based tolerable sources of protein and complex carbohy- drates
Modify amounts of animal protein at mealtime to 4 to 5 oz (30 to 35 g Improve leafy green vegetable intake via juicing if whole food veggies not desired or tolerate
Improve intake of antioxidant rich fruits and fruit juices without added sugar
Recommendations
Probiotic, EAA to heal and strengthen gut; enzymes before meals
Adjust sport fuel intake, decrease electrolyte pills, reduce and modify carbohydrate-containing liquids and source, switch to waxy maize if maltodextrin or HFCS contributing to issue
Meditation or yoga on day off from training and/or prayer or meditation 5 to 10 minutes a day for relaxation
Melatonin and/or theanine for sleep issues, restlessness
Further Biochemical Evaluation and Testing
Hydrogen/methane breath testing, gut dysbiosis
Spectracell to determine extent of vitamin or mineral deficiency, assimilation, and absorption
Upper/lower GI series if elimination diet, FODMAPs diet, and adjustments in eating/sport fuel do not resolve problems during training and racing
Follow-up lipid profile after 9 to 12 weeks on modified fat, saturated fat, and cholesterol diet
1. Calculate calorie and macronutrient needs for Guillermo using Cunningham Formula and guidelines in Chapter 23
2. What eating/lifestyle behaviors are influencing this athlete’s performance?
3. List reasons to initiate FODMAPS and elimination diet
4. What supplements would you justify using for this athlete?
5. What training fuel formula for pre-workout would you suggest?
6. What intervention would you recommend? And why?
7. What does this athlete need to increase in his diet to provide antioxidants?
8. What would you recommend when the athlete asks you about “caffeine”?
9. What are guidelines for hydration before, during and after exercise?
10. What are this athlete’s electrolyte requirements?
Explanation / Answer
1) The calorie requirement of a person depends on his/her total daily energy expenditure (TDEE). TDEE can be calculated by estimating basal metabolic rate (BMR).
Cunningham formula for calculation of BMR is, BMR = 500 + (22 x lean body mass)
Lean body mass is total weight minus fat weight in kg.
Guillermo has a lean body mass of 74 kg
So, BMR = 500 + (22 x 74)
= 500 + 1628
= 2128
Total daily energy expenditure (TDEE) is calculated by multiplying BMR with a factor based on the activity level
Here, Guillermo is undergoing sports training in addition to his routine work. He is highly active. The multiplying factor for highly active individual is 1.9
TDEE = BMR x 1.9
= 2128 x 1.9
= 4043
Guillermo has to take 4043 calories per day.
Macronutrients are proteins, fats and carbohydrates
Fat intake: Around 20 -35% of energy requirements. Since, Guillermo is thinking of reducing his weight, we can place him under lower limit of fat intake level, 20% of TDEE requirement to come from fat
808.6 calories to come from fat (20% of 4043)
= 808.6 / 9 g of fat to be consumed per day
= 89.84 g of fat per day
Protein intake: It should be around 250 grams if we are taking lot of calories. 250 grams of proteins will provide 1000 Kcal.
Carbohydrate intake: The rest of TDEE should come from carbohydrates.
= 4043 - (808.6 + 1000)
= 4043 - 1808.6
= 2234.4
2234.4 calories to come from carbohydrates.
= 2234.4 / 4 grams of carbohydrates to be consumed per day
= 558.6 grams of carbohydrates to be consumed per day
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