Appendix A: Case Studies

By Katelyn Barker, MS, RDN; Mary Marian, DCN, RDN, FAND, FASPEN; Amy A. Drescher, PhD, RDN; Lily McNair, PSM, RDN; Farshad Fani Marvasti, MD, MPH

Introduction

This appendix consists of 7 case studies. Each case study includes a patient history and interview, as well as student application questions for practice developing patient-focused medical and nutrition interventions using culinary medicine principles to promote health and treat different conditions. With each case study, learners will have the opportunity to:

• Develop assessment, monitoring, and treatment skills
• Review the etiological and risk factors of the condition
• Gain knowledge related to patient’s experience of the condition
• Recommend patient-focused interventions, including medical, nutrition, and culinary medicine, based on patient’s background, diet, lifestyle, and condition
• Understand the roles of an interdisciplinary health-care team

These case studies are based in a clinical, individual patient setting. Because culinary medicine principles and interventions are relevant to diverse health professionals who may work in a variety of community and clinical health settings with individual visits and group classes, these case studies may be shortened and/or adapted (as relevant to the setting, needs, and role of the learner), as long as they include the core culinary medicine principles.

Resources are provided to support use of culinary medicine principles into screening, assessment, and interventions in clinical practice.

Case Study No. 1: Anemia

Chief complaint: Fatigue, feeling tired all the time

History of present illness: Andrea is a 23-year-old woman who has come to the clinic and is presenting with generalized fatigue. Andrea states she changed her eating habits 6 months ago because she wanted to become a vegan and heard that the vegan diet was heathier. She’s made an appointment with you because she often feels tired and weak. She also tells you she’s having trouble concentrating, is dizzy at times, and she can feel some tingling in her feet.

Care team members:

• Physician
• Registered dietitian nutritionist (RDN)

Past medical history: Gastrointestinal reflux disease

Family medical history: Breast cancer (maternal grandmother), hypertension (brother and father)

Social history: Andrea lives alone in a small apartment in an urban area. She moved out of her family home at age 21 years to go to college and has been living independently since then. She currently is a full-time college student pursuing a degree in environmental science. She works part-time at a local café to support herself while in school. She maintains a close relationship with her family, who live in a different state. She regularly communicates with them but feels somewhat isolated in her current city. She has a small circle of friends, primarily from her college, but mentions feeling overwhelmed and less engaged in social activities due to her fatigue.

Medications/supplements: Pantoprazole (a proton pump inhibitor [PPI])

Allergies/intolerances: none

Diet history:

• Breakfast: one-half cup of oatmeal with honey, almonds, and apples; 8 oz black coffee
• Morning snack: one-half cup of edamame (soybeans)
• Lunch: salad and a candy bar from a grab-and-go coffee shop
• Afternoon snack: 2 small bags of potato chips
• Dinner: lentil soup, side garden salad (mixed greens, olives, vegan feta cheese, and tomatoes), 2 slices of sourdough bread
• Dessert: fruit sorbet

Positive exam findings: You notice her skin looks pale and her tongue is smooth and red.

Vital signs	Reference range	Date: 8/19/23
BP, mm Hg	<120/80	124/79
HR, bpm	60-100	77
RR, per minute	12-20	14
Temperature, °C (°F)	36.1-38 (~97-100.4)	37.2 (~99)
Height, feet (′) and inches (″)		5′ 5″
Weight, lb		146
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory value	Reference range	Date: 8/19/23
Mean corpuscular volume, fL	80-100	105
Hb, g/dL	14-18	12.8
Abbreviations: dL = deciliter (one-tenth of a liter); fL = femtoliter (10−15 L); g = gram; Hb = hemoglobin.

Student Application Questions

1. What type of anemia do her laboratory values reflect?

Answer: Macrocytic anemia

2. What vitamin is she most likely deficient in? Discuss factors that can contribute to this deficiency? What is Andrea’s greatest risk factor?

Answer: Vitamin B₁₂. The laboratory values support that her symptoms of fatigue are caused by macrocytic anemia. Fatigue as well as numbness and tingling in extremities all point to a vitamin B₁₂ deficiency as a likely cause of her symptoms. Factors that can contribute to a vitamin B₁₂ deficiency include malnutrition, malabsorption, and medications such as proton pump inhibitors (PPIs) and metformin. Andrea’s greatest risk factor is vegan diet.

3. This vitamin deficiency can mask another vitamin deficiency. What other nutrient levels must be checked before starting intervention?

Answer: Folate, because a folate deficiency can contribute to macrocytic anemia. Additionally, magnesium can be checked, because PPIs deplete magnesium levels in addition to B₁₂ and this can contribute to symptoms of anxiety, as well as to muscle cramps.

4. List components of the medical treatment and monitoring plan.

Answer:

• • Daily multivitamin supplement containing vitamin B₁₂
  • Oral vitamin B₁₂ supplementation with crystalline cyanocobalamin
  • Consider sublingual vitamin B₁₂ instead of oral because this is better absorbed and is as effective as intramuscular injections
  • Supplemental folate
  • Monitor methylmalonic acid levels [>150 picograms/mL is normal]

Vitamin B₁₂ and folate deficiencies mask each other, so an underlying cause must be preferentially addressed.

• • Long-term PPI use not only can deplete B₁₂ and magnesium levels, it can also increase the risk of osteoporosis and pneumonia. Advise Andrea to discuss with her physician options to wean off PPI as soon as possible, consider alternative medications such as histamine type 2 blockers (H2 blockers) that do not have the same side effects.

5. Develop nutrition and culinary medicine interventions for this patient and condition.

Answer:

Nutrition and Lifestyle Interventions

• • Increase dietary intake of target nutrient.
    • Animal proteins typically contain higher amounts of vitamin B₁₂; if Andrea was not following a plant-based diet, her clinician could recommend increased intake of animal products such as meat, dairy, and fish. However, because she follows a vegan diet, it is important to work with her to identify plant-based sources of food that are rich in vitamin B₁₂ (see the following section).
  • Recommend she take vitamin B₁₂ supplements to support plant-based diet.
  • Provide teaching on vitamin B₁₂. Handouts are helpful tools to provide to patients.
    • Example: Vitamin B₁₂ Fact Sheet for Consumers (National Institutes of Health)

Culinary Medicine Interventions

• • Advise Andrea to eat a whole-food, plant-based diet with the rainbow of whole vegetables and fruits, as well as nuts and seeds.
  • Advise Andrea to avoid processed foods that may still be vegan (e.g., french fries, potato chips, candy bars) because these processed foods are high in calories and low in nutrients.
  • Vitamin B₁₂ is only naturally found in animal products, so people who follow vegan eating patterns may have more difficulty in consuming adequate vitamin B₁₂ through their diet. See chapter 5 for additional information.
  • Many foods are fortified with vitamin B₁₂; thus, people who follow vegan diets can still consume vitamin B₁₂ through their diet by planning consistent intake of foods that are fortified with vitamin B₁₂.
    • Common foods that are fortified with vitamin B₁₂ include fortified nondairy milk, breakfast cereals, and nutritional yeast.
      • Fortified nondairy milk may be substituted for milk in a 1:1 ratio in most recipes.
      • Nutritional yeast is a multipurpose seasoning that has a savory, umami-rich flavor. Most nutritional yeast is fortified with B vitamins, including B₁₂. Nutritional yeast can be used like grated cheese, sprinkled over salads, rice, pasta, vegetables, and popcorn. It can also be used in soups, stews, and smoothies. Links to a few recipes that use nutritional yeast are provided here. For more information on recipes and recipe adaptations, see appendix B.
        • Vegan Pesto Spaghetti Squash With Mushrooms and Sun-Dried Tomatoes (EatingWell)
        • Vegan Mac and Cheese (EatingWell)
        • Easy Vegan Pizza (EatingWell)
  • It is important to teach patients how to pay careful attention to Nutrition Fact labels, because not all fortified foods contain vitamin B₁₂ or contain it in adequate amounts. See chapter 1 for more information about Nutrition Fact labels and meal planning.

Case Study No. 2: Beriberi

Chief complaint: Too much weight loss

History of present illness: Yasin is a 45-year-old Turkish American man who has come to the clinic to meet with his health-care team. His doctor referred him to a dietitian for unintentional weight loss secondary to gastric bypass surgery 2 months ago. Yasin’s doctor referred him because he’s lost 90 lb since the surgery. Yasin shared he has felt irritable and easily forgets things lately. He’s had persistent vomiting, blurred vision, and numbness and tingling in his hands and feet. He also notes that he has been forgetting to take his daily multivitamin, and when he has, he just vomits it back up. The persistent vomiting has been going on since 2 weeks after his surgery.

Care team members:

• Physician
• Registered dietitian nutritionist (RDN)

Past medical and surgical history: Roux-en-Y gastric bypass, hypertension, type 2 diabetes mellitus (T2DM)

Family medical history: T2DM (paternal grandfather, father, brother and cousin); heart disease (paternal grandfather and father)

Social history: Yasin holds a bachelor’s degree in business administration and works as a project manager at a local construction company. He has been with the same employer for over a decade. He lives with his wife and 2 teenage children. He has a strong support system, including his wife and children, who are concerned about his health and well-being.

Medications/supplements: Multivitamin/mineral supplement, metformin, ondansetron

Allergies/intolerances: none

Diet history:

• Breakfast: one-half cup of black tea and half-slice simit bread (Turkish sesame bread)
• Morning snack: whey protein supplement mixed into 8 oz of almond milk, cucumber slices
• Lunch: one-half cup red lentil soup and one-half cup shepherd’s salad (tomatoes, cucumbers, green peppers, radishes, onions, parsley)
• Afternoon snack: whey protein supplement mixed into 8 oz of almond milk
• Dinner: one-half of a stuffed eggplant (eggplant, ground beef, pepper, and tomato), one-half cup white rice
• Drinks: adequate water throughout day

He tends to vomit about 2 to 3 times per day, so he’s only able to follow this type of meal pattern 1 or 2 days/week.

Vital signs	Reference range	Date: 9/29/24
BP, mm Hg	<120/80	131/86
HR, bpm	60-100	87
RR, per minute	12-20	17
Temperature, °C (°F)	36.1-38 (~97-100.4)	37.4 (99.3)
Height, feet (′) and inches (″)		6′ 1″
Weight, lb		234
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory values: No current laboratory values available

Student Application Questions

1. What vitamin is Yasin likely deficient in? What are the risk factors for this vitamin deficiency and why?

Answer: Thiamin (vitamin B₁). Bariatric surgery is a risk factor for thiamin deficiency because it can cause malabsorption, which leads to nutrient deficiencies. Other common micronutrient deficiencies that may occur after gastric bypasses include vitamin B₁₂, vitamin D, iron, and copper. An additional risk factor is malnutrition, because it could lead to dietary insufficiency of thiamin. Yasin has had a 90 lb weight loss over 2 months and his estimated oral intake is less than 50% of estimated energy intake. Yasin should also receive a malnutrition assessment and nutrition-focused physical exam.

2. List components of the medical treatment and monitoring plan.

Answer: Thiamin supplementation (intravenously or oral thiamin alone, in B complex or multivitamin containing thiamin). Measure erythrocyte transketolase.

3. Develop nutrition and culinary medicine interventions for this patient and condition.

Answer:

Nutrition and Lifestyle Interventions

• • Increase dietary intake of thiamin (grains, fortified and enriched foods, beans, fish, dairy).
  • Take a thiamin supplement.
  • Take a daily multivitamin supplement containing thiamin.
  • Provide teaching on thiamin. Use handouts whenever possible to help provide patients with tangible and reputable sources of information.
    • Example: Thiamin Fact Sheet for Consumers (National Institutes of Health)

Culinary Medicine Interventions

• • It is important to note that although Yasin has other factors (likely malabsorption, symptoms of nausea and vomiting, having had gastric bypass) affecting his ability to orally consume adequate thiamin in his diet and will require supplementations, there are recommendations that can be made to help Yasin optimize thiamin intake through culinary interventions.
  • At the 2-month post-operation mark, Yasin should be able to consume regular foods; however, he has persistent symptoms of nausea and vomiting. It is important to be mindful of these gastrointestinal symptoms when recommending thiamin-rich foods. For instance, the stronger odors of fish, a thiamin-rich food, may not be appropriate. However, counseling Yasin on how to identify if the breads and plant-based milk (identified in his 24-hour recall) in his diet are fortified with thiamin would be patient-focused and appropriate. (See chapter 1 for more information about nutrition labeling.) Furthermore, it would also be helpful to acknowledge the thiamin-rich foods that Yasin is already eating, such as lentils.
  • For nutrition interventions to help with nausea and vomiting, vitamin B₆ supplementation may be indicated. Additionally, infusing water with ginger, peppermint, or lemon may also be beneficial for nausea symptom management.
  • It would also be helpful to ask open-ended questions regarding Yasin’s cultural and religious background. For example, Muslim and Jewish dietary laws forbid the eating of pork, a thiamin-rich food. For more information regarding culturally centered approaches, see chapter 12.

Case Study No. 3: Cancer

Chief complaint: Weight gain

History of present illness: Jennifer is a postmenopausal 49-year-old, non-Hispanic White woman who has an appointment with her oncology treatment team in the outpatient clinic. She wants to know how to improve her lifestyle and diet to prevent a recurrence of breast cancer. She reports gaining weight during chemotherapy and has been unable to lose the weight. She finished chemotherapy 2 months ago and has slowly increased her physical activity. She is now walking for 20 minutes, 3 days/week.

Care team members:

• Physician
• Nurse practitioner, certified in oncology
• Registered dietitian nutritionist (RDN), certified in oncology
• Pharmacist
• Exercise physiologist

Past medical history: Bilateral mastectomy for stage 2 breast cancer (estrogen-receptor positive [ER⁺] and progesterone-receptor positive) with reconstructive surgery (3 months ago) and chemotherapy (docetaxel and doxorubicin) followed by radiation (6 weeks). Jennifer became menopausal due to chemotherapy. Her dual-energy X-ray absorptiometry T-score (measures bone density) is −2.2.

Family medical history: Jennifer was adopted and she doesn’t have any information about her family history. She was born in New York but raised in Illinois and has lived there all her life.

Social history: Married to Matt for 20 years; 2 children (18 and 15 years). She just went back to work; she teaches second grade but is only teaching half days for now. She is very fatigued by noon when she’s done with her day, so she goes home and takes a nap. Jennifer has no remaining side effects related to chemotherapy besides the fatigue. Matt and the children have been making most meals because Matt is the primary cook in the family.

Medications/supplements:

1. An aromatase inhibitor that increases bone loss; it is prescribed for ER⁺ breast cancer tumor types after treatment for breast cancer. Most women will take it for 5 to 10 years to reduce their risk of recurrence.
2. No supplements, because she was told to stop all supplements before beginning chemotherapy.

Allergies/intolerances: None

Diet history:

• Breakfast: cinnamon toast with peanut butter (3 tbsp) and 2 cups of black coffee
• Lunch: turkey sandwich (wheat bread and 3 oz deli turkey) and apple or tuna sandwich with large banana; water or bottled iced tea (not a lot of time to eat lunch)
• Snack: grabs crackers, pretzels, raisins, or cookies while finishing up the day at school
• Dinner: snacks (e.g., nuts, olives, chips, cheese) when she gets home because the kids are busy with sports activities until 8 PM. Family tend to eat dinner when traveling to activities (e.g., fast food [hamburgers, french fries, large soda; chicken sandwiches; bean burros, tacos]). When the family eats at home, dinner typically consists of some type of meat, chicken, or fish; rice, mashed potatoes, or macaroni; salad with tomatoes, and a vegetable (e.g., green beans, spinach, corn, carrots); wine or beer with dinner at home (1-2 servings on Fridays, Saturdays, and Sundays).
• Snacks while watching TV: popcorn or nuts (2-3 times/week)

Survivorship treatment plan:

• Continue surveillance for breast cancer recurrence: follow up with medical oncologist and/or nurse practitioner every 3 months for the first year after treatment for breast cancer. Continue the aromatase inhibitor.
• The RDN will collaborate with Jennifer to design a lifestyle plan that meets her desires and promotes risk reduction.
• The exercise physiologist will design a therapeutic physical activity plan including both aerobic and weight-resistance activities.

Vital signs	Reference range	Date: 3/17/23
BP, mm Hg	<120/80	137/84
HR, bpm	60-100	89
RR, per minute	12-20	15
Temperature, °C (°F)	36.1-38 (~97-100.4)	36.6 (97.9)
Height, feet (′) and inches (″)		5′ 10″
Weight, lb		210-218
Weight prior to diagnosis, lb		170-175
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory value	Reference range	Date: 3/17/23
Na, mEq/L	136-145	136
K, mEq/L	3.5-5.1	3.5
Cl, mEq/L	96-110	101
HCO3, mEq/L	20-29	28
BUN, mg/dL	7-20	20
SCr, mg/dL	0.5-1.2	0.8
Glu, mg/dL	70-110	189
Vitamin D, nmol/L	30-100	27
CBC count
WBC count	3.4-10.4 × 103/mm3	4.0
Hb, g/dL	13.5-17.5	13.9
Hct, %	40-54	41
LDL, mg/dL	<100	100
HDL, mg/dL	>45	40
TRG, mg/dL	<150	190
Total cholesterol, mg/dL	<200	178
Abbreviations: BUN = blood urea nitrogen; CBC = complete blood cell; Cl = chloride; dL = deciliter (one-tenth of a liter); fL = femtoliter (10−15 L); g = gram; Glu = glucose; Hb = hemoglobin; HCO3 = bicarbonate; Hct = hematocrit; HDL = high-density lipoprotein; K = potassium; LDL = low-density lipoprotein; mEq = milliequivalent; mg = milligram; mm = milliliter; Na = sodium; nmol = nanomole; SCr = serum creatinine; TRG = triglyceride; WBC = white blood cell.

Student Application Questions

1. List risk factors for a reoccurrence of Jennifer’s breast cancer.

Answer: Age, history of breast cancer, diet, alcohol intake, increase in weight, and low physical activity level.

2. Develop nutrient and culinary medicine interventions for this patient and condition.

Answer: Based on the practice guidelines for lifestyle modifications, the following are recommended:

Nutrition and Lifestyle Interventions

• • Educate regarding the benefits of making lifestyle changes to improve prognosis and to optimize overall health after treatment.
  • Collaborate with the patient to develop an individualized plan to slowly incorporate lifestyle changes.
  • Address nutritional needs based on personal and cultural preferences; maintain pleasure of eating through positive health messages.
  • Create eating plans that promote an energy intake deficit and so promote weight loss (individualized based on Jennifer’s personal preferences and resources), may reduce the risk for a recurrence, reduce mortality and cardiovascular disease (CVD) risk factors, and improve quality of life are recommended for individuals who have excess adiposity.¹
    • Weight gain is common during cancer treatment due to multiple factors, including eating comfort foods, less physical activity due to fatigue, and possible reduced metabolic rate from chemotherapy. Weight gain during treatment has consistently been associated with a higher risk for breast cancer–related death, and further weight gain after treatment is common in the breast cancer population with 30% to 35% of breast cancer survivors meeting the guidelines for obesity.² Furthermore, excess adiposity is associated with an increased risk of recurrence and poorer survival from breast cancer, as well as overall survival and reduced quality of life.^2,3 Although the exact mechanisms involved are unknown, adipokines, chronic low-grade inflammation, and metabolic dysfunction are thought to play a role. Breast cancer survivorship practice guidelines recommend survivors achieve a healthy weight through diet and physical activity.³ However, data reflect that 37% of breast cancer survivors meet these guidelines for physical activity, whereas only 18% do so for diet.⁴
  • Whether weight loss reduces the risk for recurrence is unclear, although some data reflect positive benefits related to reduced recurrence and increased disease-free survival.⁵ Several randomized clinical trials are under way to evaluate whether weight loss after treatment will reduce the risk for a recurrence. Weight loss, however, may reduce the risk for developing common chronic conditions such as CVD, hypertension, and type 2 diabetes. Research also reflects successful long-term maintenance of weight loss by breast cancer survivors.⁵
  • Achieve ≥150 min/week of physical activity incorporating both aerobic and weight resistance training (at least twice weekly). A recent review of the effect of lifestyle factors on breast cancer–associated deaths concluded that physical activity has the most robust effect of all lifestyle factors on reducing breast cancer recurrence.⁶ Lowered endogenous hormone levels, reduction of inflammation, and reversal of insulin resistance have all been hypothesized to mediate the effects of exercise.⁷
  • Consume 1,200 mg/d calcium and at least 800 IU/d vitamin D through diet and supplementation as needed, given Jennifer’s history of osteoporosis.

Culinary Medicine Interventions

• • Encourage clinically meaningful weight loss of 5% to 10% for risk reduction of breast cancer recurrence. Eating plans that promote an energy intake deficit and so promote weight loss (individualized based on personal preferences and resources) may be recommended for individuals who have excess adiposity.¹ It is important to provide counseling and coaching to both Matt (because he is primary cook) and Jennifer. Some helpful strategies for weight management include:
    • Pairing proteins with each meal and snack to promote satiety. Work with Matt and Jennifer on how to incorporate proteins with snacks such as cheese with crackers or peanut butter with celery. Also identify lean proteins that can be easily cooked at home or purchased at the store or restaurant when necessary, such as grilled chicken or steamed fish. See chapter 2 for additional recommendations.
    • Start the day with a protein-rich meal that is also low in added sugar to promote satiety throughout the day. Recommend that Matt and Jennifer use whole-grain bread and no-sugar-added peanut butter.
      • Smoothies could be recommended, which are a helpful way to increase fruit and/or vegetable consumption by blending with a protein source (including milk, yogurt, and/or chia seeds, flax seed, peanut butter) while maximizing time and energy.
    • Recommend that Jennifer identifies how much she is currently eating, using measuring cups or scales, and reduce portion sizes of foods. If Jennifer is too busy or is unable to use a measuring cup, using hand-portion-size methods can be a helpful strategy on the go.
      • See Serving-Size Chart (Dairy Council of California)
  • Slowly move to a plant-based diet aiming for 2 to 3 servings of vegetables and 2 servings of fruits daily; focus on getting a variety of colorful fruits and vegetable daily. Clinical practice guidelines highlight the importance of consuming a healthy diet for reducing the risk for breast cancer recurrence, CVD, and type 2 diabetes, and improving quality of life.^3,8,9 A heathy eating plan includes a plant-based diet rich in fruits, vegetables, whole grains, and omega-3 fatty acid–rich foods. These dietary components reflect the foundation of the Mediterranean-style diet, which also aligns with the dietary principles of culinary medicine. See chapter 8 for more information about popular diets.
    • Omega-3–rich foods tend to be cold-water fish and seafood (e.g., tuna, salmon, sardines), nuts and seeds (e.g., chia seeds, walnuts, canola oil), as well as some vegetables, including spinach, brussels sprouts, and soybeans. Soy contains isoflavones (a natural plant compound found in soy foods) that have a similar structure to estrogen, but function differently in the body. It is important to note that soy-containing products in orally consumed foods are safe for patients with breast cancer and breast cancer survivors. These foods may be incorporated as parts of snacks or meals based on Matt and Jennifer’s lifestyle and eating habits.
      • It is sometimes easier to start by incorporating new foods as snacks (e.g., eating walnuts instead of cookies) or adding foods to existing meals (e.g., using spinach greens regularly for side salads or added to sandwiches).
      • Afterward, in a step-wise fashion, Matt and Jennifer can start to incorporate more omega-3–rich foods using energy- and time-saving meal techniques (e.g., 1-pan salmon) to center meals around these foods.
    • It is important that Jennifer is aware she can use fresh, frozen, and canned (low- or no-sodium vegetables or no-sugar-added fruits and fruits in water or juice) for meals or snacks to help reduce time needed to prepare vegetables and fruits.
      • Additionally, other strategies of increasing vegetables to existing foods, such as adding lettuce and tomatoes to sandwiches, may also help promote vegetable consumption. Fruits may be used as snacks, added to breakfasts, or blended into smoothies. These fruits and vegetables are not only rich in fiber (which will help increase satiety), they are also rich in phytonutrients and antioxidants that can help promote health. See chapter 7 for more information on bioactive compounds. Certain fruits and vegetables may also be more affordable and fresher, depending on when they are in season.
        • Make the Most of Your Vegetables (MD Anderson Cancer Center)
        • Your Seasonal Guide to Cancer-Fighting Foods (Loma Linda University Health)
    • While increasing consumption of plant-based foods for reducing risk of breast cancer recurrence and improving cardiometabolic health, it is also important to increase consumption of calcium-rich and vitamin D–rich foods after a new diagnosis of osteopenia, which is related to the aromatase inhibitor treatment.
      • Animal sources of calcium, such as milk and yogurt, are generally more bioavailable than plant-based sources of calcium. However, bioavailability varies, and both animals and plants are good sources of calcium.
      • Vitamin D–rich foods include fortified cereals, milks, juices, eggs, and mushrooms, as well as omega-3–rich foods such as salmon and tuna. Mindful planning of ingredients can be beneficial to maximize nutritional benefits for health.

Case Study No. 4: Cardiovascular

Chief complaint: Follow-up for laboratory results

History of present illness: Norma is a 42-year-old Hispanic woman who has an appointment with her health-care team in the outpatient clinic to discuss her laboratory results. Norma reports that during the COVID-19 pandemic, she wasn’t eating “healthy” or taking care of her health, due to family responsibilities and death of father and uncle 2 years prior. She states that she still daily experiences feelings of grief and has trouble sleeping at night. She shared that she feels anxious most days and lacks energy and motivation to do anything except what is “absolutely necessary.” Norma states that now is the time for her to “focus on her health” and she is motivated to make significant dietary and physical activity changes to promote her health and prevent disease. She also states that she has experienced muscle pain and weakness and read online that those were common side effects of atorvastatin; she would like to reduce the number of medications she is taking, if possible. Norma also notes that she has noticed her family only wants to eat out and is not physically active; she wants to incorporate healthier changes with her whole family.

Care team members:

• Physician
• Nurse practitioner
• Registered nurse
• Registered dietitian nutritionist
• Pharmacist
• Behavioral health counselor

Past medical history: History of gestational diabetes, prediabetes, dyslipidemia, hypertension, generalized anxiety disorder, prolonged grief disorder

Family medical history: Mother with type 2 diabetes (T2DM) and osteoporosis; father had T2DM (died of COVID-19–related causes in 2021); uncle had T2DM, chronic kidney disease stage III (died of COVID-19–related causes in 2021); and brother and sister with T2DM and dyslipidemia. Her spouse with dyslipidemia.

Social history: Norma has been married 21 years. Her husband works as a field supervisor for an agricultural company. She is a busy stay-at-home mom and has 4 children: a 17-year-old daughter, 15-year-old daughter, 12-year-old son, and 10-year-old daughter. Norma also states she is primary caregiver for her 64-year-old mother, who lives in separate city 20 minutes away. She does not smoke. She drinks alcohol occasionally, mostly during holidays or birthdays.

Medications/supplements: Lisinopril (10 mg/day), atorvastatin (20 mg/day)

Allergies/intolerances: No known drug allergies

Diet history: Norma follows a combination of traditional Mexican diet and Standard American Diet. She states she normally eats 2 meals (skips breakfast) and 1 or 2 snacks per day. Norma states that she and the family eat out 4 to 5 times/week; she often picks up food on the way home from taking care of her mother. She shares that she used to enjoy cooking and would like to cook more but is too tired to cook during the week. Norma also reports that she knows she and her family do not eat enough fruits and vegetables (no more than 1-2 servings per day). During the winter and spring, the family eats vegetables almost daily because her husband brings them home from work, but during summer and fall, they only eat vegetables about once per week. Norma states that she is willing to try a diet if recommended but doesn’t want to end up cooking a meal for herself and separate meals for her family. She also states that she likes to eat seafood but doesn’t eat it much anymore because salmon is too expensive and she heard shrimp is high in cholesterol. Norma states that in the past 2 weeks, she is “cutting back on carbs” and reports that she misses eating tortillas.

Usual diet recall:

Breakfast: around 4:30 AM during agricultural harvest season or around 5:30 AM during nonpeak agricultural times (makes breakfast of eggs, chorizo, tortillas, and salsa for husband)

• 1 cup of coffee with no creamer, no sugar, 1-2 flour tortillas with 1 tbsp butter (occasionally)

Snack: around 9:30 or 10 AM

• 1-2 cups of coffee with 1-2 tbsp creamer, no sugar
• 1-2 servings of pan dulce (Mexican pastries [e.g., conchas, cuernos, empanadas)
• Sometimes in the spring and summer, she also eats 1 cup of melon or 1 orange

Lunch: usually around 1:30 or 2 PM

• 1 cup of sweetened tea
• 1 cup of salad greens with one-quarter cup combined tomatoes, cucumber, and carrots, 2 tbsp reduced-fat salad dressing, 2 tbsp croutons; or a sandwich (2 slices multigrain bread, 3 oz sandwich meat, 2 tbsp full-fat mayonnaise, 1 slice full-fat cheese)
• Quesadilla (8-in flour tortilla, one-quarter cup cheddar cheese, 1 tbsp butter or lard), one-quarter cup salsa or burrito (8-in flour tortilla, one-half cup pinto beans), one-quarter cup salsa

Dinner: usually around 5:30 or 6 PM

• 1-2 cups of sweetened tea
• 3-4 oz carne asada, grilled chicken, or pork, three-quarters cup white rice, one-quarter cup refried beans; or 1-1/2 cups of soup (e.g., sopa de fideo [noodle soup], caldo de res [Mexican beef soup], albondigas [meatball soup]) with 1 or 2, 4-in corn tortillas
• Three-quarters cup spaghetti and 4 to 5 medium-sized meatballs with one-quarter cup tomato sauce
• Takeout: burgers and fries, pizza, orange chicken and rice, tacos or flautas or sopes (corn tortilla with meat, cheese, and/or veggies)

Snacks

• Will sometimes snack on chips or crackers. Prefers savory to sweet.

Drinks: Drinks 2 to 3 cups of coffee and 2 to 3 cups of sweetened tea, occasionally water, rarely alcohol.

Physical activity: 15-20 minutes walking in neighborhood (in winter and spring), 1-2 days/week.

Vital signs	Reference range	Date
		9/8/23	8/30/23	8/16/21	2/8/20
BP, mm Hg	<120/80	134/78	135/82	142/87	129/72
HR, bpm	60-100	84	89	95	80
RR, per minute	12-20	17	18	20	15
Temperature, °C (°F)	36.1-38 (~97-100.4)	36.4 (97.5)	37.3 (99.1)	37.8 (100)	36.8 (98.2)
Height, feet (′) and inches (″)		5′3″	5′3″	5′3″	5′3″
Weight, lb		181	183	187	164
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory value	Reference range	Date
		9/8/23	8/16/21	2/8/20
BMP
Na, mEq/L	136-145	138	142	137
K, mEq/L	3.5-5.1	4.4	4.8	4.2
Cl, mEq/L	96-110	99	102	101
HCO3, mEq/L	20-29	23	25	22
BUN, mg/dL	7-20	17	18	16
SCr, mg/dL	0.5-1.2	0.7	1.0	0.9
Glu, mg/dL	70-110	135	150	120
CBC count
WBC count	3.4-10.4 × 103/mm3	3.8	4.0	3.8
Hb, g/dL	13.5-17.5	14.5	14	15
Hct, %	40-54	44	47	43
Plt	150-425 × 103/mm3	180	201	175
Lipid panel
LDL, mg/dL	<100	130	140	99
HDL, mg/dL	>45	36	33	44
TRG, mg/dL	<150	240	220	199
Total lipids, mg/dL	<200	253	260	185
Liver panel
Albumin, g/dL	3.5-5.5	4.4	5.2	4.0
AST, Units/L	10-36	33	31	29
ALT, Units/L	8-48	32	30	27
Alk phos, Units/L	44-147	126	124	100
Miscellaneous
HbA1C, %	5-5.8	6.2	6.4	5.8
PT, sec	11-15	13	12	13
INR	<1.3	0.8	0.9	0.8
Ca, mg/dL	8.5-10.8	9.5	9.1	9.3
Mg, mEq/L	1.5-2.2	1.9	1.8	2.1
Phosphorus, mg/dL	2.5-4.5	3.3	3.1	2.7
Abbreviations: Alk phos = alkaline phosphatase; ALT = alanine transaminase; AST = aspartate transaminase; BMP = basic metabolic panel; BUN = blood urea nitrogen; Ca = calcium; CBC = complete blood cell; Cl = chloride; dL = deciliter (one-tenth of a liter); g = gram; Glu = glucose; Hb = hemoglobin; HbA1C = glycated hemoglobin; HCO3 = bicarbonate; Hct = hematocrit; HDL = high-density lipoprotein; INR = international normalized ratio; K = potassium; L = liter; LDL = low-density lipoprotein; mEq = milliequivalent; mg = milligram; Mg = magnesium; mm = milliliter; Na = sodium; Plt = platelet; PT = prothrombin time; SCr = serum creatinine; sec = second; TRG = triglyceride; WBC = white blood cell.

Student Application Questions

1. Explain the significance of the lipid panel results for this patient and how they relate to the diagnosis of prediabetes.

Answer: Norma has an elevated triglyceride level at 240 mg/dL and low HDL at 37mg/dL. This pattern of high triglycerides and low HDL is a sign of insulin resistance.

2. What is the top dietary contributor to the patient’s high triglyceride levels?

Answer: Outside of familial hypercholesterolemia, high triglyceride levels in most patients, including this patient, come from excess sugar in the form of refined carbohydrates or grains and other high-sugar and low-fiber processed foods. Excess sugar in the diet is converted to triglycerides and deposited as fat mostly in the liver (contributing to fatty liver disease) and abdomen.

3. List components of the medical treatment and monitoring plan.

Answer:

• • Recommend daily blood pressure monitoring while implementing dietary changes (Dietary Approaches to Stop Hypertension principles [e.g., reduced salt, increased potassium]). May need to increase lisinopril to 20 mg/day if blood pressure does not improve. Follow up in 3 months.
  • Begin an exercise program to raise heart rate eventually to goal of 80% of maximum for 30 to 45 minutes 4 times/week; work up to this gradually.
  • Refer to behavior health counseling for grief and anxiety counseling.
  • Refer to registered dietitian for medical nutrition therapy.
  • Recommend enrollment in the local diabetes prevention program to support healthy eating and lifestyle behaviors, education on diabetes prevention, moral support, cooking tips, and sharing of healthy recipes. Online and in-person classes exist.
  • Maintain atorvastatin at 20 mg/day while initiating therapeutic lifestyle changes to lower LDL level by decreasing saturated fat intake, increasing fiber intake, and increasing healthy fat intake, including monounsaturated fat, tree nuts, and seeds. Repeat a follow-up lipid panel in 3 months to assess progress. If Norma is able to implement and maintain lifestyle changes and her lipid panel levels improve, consider reducing statin dose.

4. Develop nutrition and culinary medicine interventions for this patient and condition.

Answer:

Nutrition and Lifestyle Interventions

• • Increase dietary intake of omega-3 fatty acids (including omega-3 fatty acid fish, and plant-derived omega-3 fatty acid foods). See chapter 7 on bioactive compounds for more information.
  • Recommend total fat limited to 25% to 35% of total energy intake, saturated and trans fat <7%, cholesterol limited to 200 mg/day.
  • Recommend Norma consume plant stanols and sterols: 2 to 3 g/day. See chapter 7 for more information.
  • Increase intake of fruits and vegetables to at least 5 to 10 servings per day.
  • Goal fiber intake: 21 to 25 g/day (women) and 25 to 38 g/day (men)
  • Limit sodium to 2,300 mg/day initially.
  • Limit added sugar to 6 tsp or 25 g/day.
  • Increase foods higher in potassium, magnesium, and calcium. Provide teaching on thiamin. Use handouts whenever possible to help provide patients with tangible and reputable sources of information.
    • Example: Potassium Fact Sheet for Consumers in English or Spanish (National Institutes of Health)
    • Example: Magnesium Fact Sheet for Consumers in English or Spanish (National Institutes of Health)
  • Recommend avoiding grapefruit consumption while taking the statin medication.
  • May recommend limiting caffeine intake in beverages. Although chronic caffeine consumption’s effect on blood pressure may not adversely affect hypertension, and some coffee intake may be beneficial for hypertension, high amounts of caffeine can increase anxiety and insomnia. Because Norma is diagnosed with generalized anxiety disorder, limited caffeine is recommended.

Culinary Medicine Interventions

• • A key intervention for Norma will be reducing food consumed from restaurants and takeout. It will be important to provide coaching and expert advice on how to increase home cooking in a way that is manageable for her lifestyle.
    • Culinary skills training is not indicated, because Norma has indicated that she knows how to cook. The focus would be on optimizing cooking for her lifestyle.
    • It would be warranted to provide resources to help increase home cooking, such as batch cooking, multipurpose meals, and meal prepping, to provide Norma with the tools to keep healthy ingredients and meals on hand to help increase consumption of fruits and vegetables while decreasing consumption of takeout or restaurant food. See chapter 1 for more information. Other consumer resources include:
      • Staple Ingredients for Quick Healthy Meals (American Heart Association)
      • Cook Once, Eat Safely throughout the Week (Academy of Nutrition and Dietetics)
      • The 39 Best Base Recipes to Make for Meal Prep (EatingWell)
  • It’s always important to recognize what individuals are already doing well. Acknowledge that Norma is eating beans and whole-grain bread, which are both high in fiber, and evaluate cooking and preparation methods for nutrition optimization.
    • Also recommend other foods that are high in fiber that may be used as snacks (e.g., fruit or avocado). Encourage patients to use a combination of fresh, frozen, or canned (low- to no-salt or sugar) vegetable and fruits as ways to increase fiber intake.
  • Norma specifically stated that she is cutting back on carbohydrates but is missing a common cultural staple food: tortillas. It is important for Norma to receive nutrition education so she can make informed decisions of what type of carbohydrates she can eat, including tortillas.
    • Nutrition education can include different types of carbohydrates (limit simple, refined and increase whole, complex) and timing and portion size of carbohydrates (limit to 2-3 carbohydrate servings with each meal, pair with proteins).
    • Discuss with Norma how to increase other whole grains in her diet, such as identifying how to buy whole-grain corn tortillas or nopal tortillas (tortillas that increase fiber amount by adding nopales [a vegetable]).
  • When recommending changes in dietary fat consumption, it’s important to assess what type of fats that Norma already cooks with and/or eats.
    • A diet promoting decreased saturated fat intake would recommend more plant oils such as canola, avocado, or olive oil, while decreasing amounts of butter, lard, or shortening. See chapter 4 on macronutrients for a more in-depth breakdown of types of fats in commonly consumed solid fats and oils.
    • Norma mentioned concerns about dietary cholesterol in shrimp. Although shrimp is higher in dietary cholesterol than other lean proteins, recent research has indicated dietary cholesterol does not have a significant impact on blood lipid levels. In recommended serving sizes (about 3 oz/day), shrimp is a heart-healthy option because it is a lean protein (low in calories and total fat) and high in omega-3 fatty acids.
    • Other plant sources of omega-3 fatty acids include chia seeds, walnuts, and canola oil.
  • Plant stanols and sterols are also important interventions to help promote healthy lipid levels (see chapter 7 for more information about plant stanols and sterols). Plant stanols are in foods such as broccoli, avocadoes, tomatoes, lentils, and many whole grains. Plant sterols are in olive oil, certain spices (e.g., thyme, oregano, paprika), and some nuts including pistachios and almonds. Discuss with Norma how these ingredients may be realistically added into her diet and her family’s.
  • It is essential to meet individuals where they are and respect traditional ingredients for cultural dishes. It would be important to ask Norma how willing she would be to swap fats, in which dishes, and ask about her culinary comfort level in substituting fats in recipes. See chapter 2 on preparing food, chapter 12 on culturally centered approaches, and appendix B for recipes and recipe modifications.
  • To increase potassium, magnesium, and calcium while reducing sodium, it is important to make sure Norma knows how to identify amounts on Nutrition Facts labels. See chapter 1 for more information.
  • When reducing sodium intake, it is important to also increase other flavors, including sour, sweet, bitter, and umami, through addition of ingredients such as vinegar, peppers, herbs, spices, and citrus.
    • Some seasonings, including hibiscus and cardamom, may help lower blood pressure. These doses may be higher than normally consumed in a diet; however, overall antioxidant effects of a combination of seasonings may be beneficial. Ask Norma what other herbs and spices she may use and work with her to integrate other flavors. See chapter 2 for additional information.
    • Also, Norma reports eating sandwich meat and chips or crackers, which tend to be high in added salt. Help Norma identify low- and no-sodium options that she can incorporate into her diet and meals. Also recommend other options for sandwich meat, such as sliced homecooked chicken breast, tuna, or other meats that are less processed. Low-sodium nuts can also be helpful alternative to crackers and chips.
  • For reducing sweetened tea consumption (to decrease added sugar), it may be helpful to recommend ways to increase flavor of water. For instance, infuse water with fruit or no-sugar flavorings.

Case Study No. 5: Liver Disease

Chief complaint: Fatty liver

History of present illness: Juan is a 46-year-old Peruvian man with nonalcoholic fatty liver disease (NAFLD) who has an appointment with his health-care team in the outpatient clinic. Juan is here today for follow-up; things are going relatively well related to his treatment plan. He has been taking his medication consistently and he always gets enough exercise through work. He reports, however, that he has been trying to follow a diet that is good for NAFLD but feels frustrated. He has tried seeking nutrition information for NAFLD, but he feels the information isn’t culturally relevant to him.

Care team members:

• Physician
• Registered nurse
• Registered dietitian nutritionist
• Social worker
• Exercise physiologist

Past medical history: Diagnosed with NAFLD 2 years ago and hyperlipidemia 1 year ago.

Family medical history: Father with NAFLD, hypertension, and hyperlipidemia; mother with hyperlipidemia

Social history: Juan is married to Paula and they have 2 children together; they live in New York. Juan is originally from Peru and moved to the United States in 2002; he primarily speaks Spanish and knows minimal English. He follows a traditional Peruvian diet, and this helps him feel more connected to his family and culture. He works for a local moving company, which is very physically demanding. He and his family earn enough money to pay for their basic needs, but their income is limited, and this is stressful for them. Juan used to drink 3 to 4 beers per day, but he has stopped drinking alcohol completely since being diagnosed with NAFLD.

Medication/supplements: Lisinopril 20 mg, 1 tablet daily

Allergies/intolerances: None

Diet history: Juan follows a traditional Peruvian diet, and this helps him feel more connected to his family and culture. Juan describes that in his culture, “food is love,” and preparing and eating traditional Peruvian foods together is very important to his family. He has had past providers recommend the Mediterranean diet for his NAFLD, but the foods in this diet don’t match his cultural food preferences. Juan reports he has been trying to avoid sugar and carbohydrates because he reports they are “bad” for him. He has seen recipes for the Mediterranean diet (e.g., salad, salmon, brown rice). He does not like brown rice and prefers white rice, because he grew up eating this and it reminds him of his mother. A few of his friends at work have told Juan about how the ketogenic (“keto”) diet can “reverse” liver disease and that he should try cutting out all breads and starches. Potatoes are a cultural staple in his diet, and Juan reports that he feels guilty for eating them.

Usual diet recall:

Breakfast: usually eaten at ~7 AM. Common breakfasts include:

• 1 bread roll with 4 oz chicharron (fried pork, typically used as a topping, snack, or part of a larger dish), 1.5 cups of coffee with 1 tsp sugar
• 2 to 3 tamales made with eggs and vegetables, 1.5 cups of coffee with 1 tsp sugar

Lunch: usually the “main” meal of the day eaten at around noon. Common lunches include:

• 2 cups lomo saltado (stir-fried beef with vegetables) served over 1 cup of white rice; side salad with lettuce, tomato, cucumber, with lime juice as the dressing
• 12 oz ceviche served over 1 cup of white rice; side salad with lettuce, tomato, cucumber, with lime juice as the dressing
• Arroz con pollo (1 cup of cilantro white rice with 12 oz chicken) served with one-half cup peas, carrots, and onions
• Papa a la huancaina (1 potato with 1 cup of spicy cheese sauce) served with 2 hard-boiled eggs and one-quarter cup olives
• Papa rellena (2 small potatoes stuffed with one-half cup of ground beef and onion), served with 1 cup of cilantro rice, one-half cup of salad (peppers, onions, and carrots)

Dinner: something light; usually eaten at ~7 PM

• Whatever was eaten for lunch is also eaten for dinner; usually about half portion that was eaten at lunch.
• A 16 oz smoothie, either jugo surtido or jugo especial (fruit juice)

Drinks: 12 oz of chicha morada (beverage made from purple corn, water, cinnamon, cloves, sugar, and fruit) once per day, 12 oz of coffee in the morning, 64 oz of water, occasionally one 12 oz can of Inca Kola (~3 times/week)

Physical activity: Juan works as a mover for a local moving company and his position is very physically demanding. He considers himself very active.

Vital signs	Reference range	Date: 3/17/23
BP, mm Hg	<120/80	127/81
HR, bpm	60-100	78
RR, per minute	12-20	18
Temperature, °C (°F)	36.1-38 (~97-100.4)	36.9 (98.4)
Height, feet (′) and inches (″)		5′ 6″
Weight, lb		150
Waist circumference, inches	<35 for women, <40 for men	42
Usual body weight, lb		145-155
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory value	Reference range	Date: 3/17/23
Na, mEq/L	136-145	141
K, mEq/L	3.5-5.1	3.9
Cl, mEq/L	96-110	107
HCO3, mEq/L	20-29	22
BUN, mg/dL	7-20	15
SCr, mg/dL	0.5-1.2	0.7
Glu, mg/dL	70-110	100
HbA1c, %	Normal <5.7; prediabetes 5.7-6.4; diabetes >6.5	5.8
Vitamin D, nmol/L	30-100	37
CBC count
WBC count	3.4-10.4 × 103/mm3	3.5
Hb, g/dL	13.5-17.5	15.5
Hct, %	40-54	49
LDL, mg/dL	<100	136
HDL, mg/dL	>45	37
TRG, mg/dL	<150	285
Total cholesterol, mg/dL	<200	253
Abbreviations: BUN = blood urea nitrogen; CBC = complete blood cell; Cl = chloride; dL = deciliter; g = gram; Glu = glucose; Hb = hemoglobin; HCO3 = bicarbonate; Hct = hematocrit; HDL = high-density lipoprotein; K = potassium; L = liter; LDL = low-density lipoprotein; mEq = milliequivalent; mg = milligram; mm = milliliter; nmol = nanomole; SCr = serum creatinine; TRG = triglyceride; WBC = white blood cell.

Student Application Questions

1. What other chronic conditions is Juan at high risk for, given he has NAFLD?

Answer: NAFLD is closely linked to metabolic syndrome. Does Juan meet criteria for metabolic syndrome? Metabolic syndrome is defined as having any 3 of the following 5 factors: hypertension, high triglyceride level, low HDL level, increased waist circumference, prediabetes.

Juan has a high triglyceride level (285 mg/dL), low HDL (37 mg/dL); he also has hypertension, is prediabetic, and also has an increased waist circumference, so he meets all 5 criteria for metabolic syndrome. This syndrome is a common pathway to cardiovascular disease (CVD), diabetes, and obesity. Having several metabolic abnormalities confers an even greater risk of histological progression of nonalcoholic steatohepatitis and all-cause mortality. NAFLD can be progressive and is associated with increased mortality risk from CVD, extrahepatic cancers, and liver complications.^10-12

2. Considering the social determinants of health, what factors might have affected or are currently affecting the development and progression of Juan’s NAFLD?

Answer: Juan is part of a racial/ethnic minority, he is first-generation immigrant, and he is limited in his English proficiency. He and his family have a limited income, and they report this is stressful for them. Given that the patient is Hispanic, male, and has lower socioeconomic status, he may be at higher risk for development of other chronic diseases, disease progression, and poorer outcomes, when considering health inequities, health disparities, and genetic profiles for patients with NAFLD.^13,14 See chapter 12 for further information on culturally centered approaches to helping Juan.

3. Complete a comprehensive nutrition assessment.

Answer: A 46-year-old Peruvian man presents as adequately nourished as evidenced by no recent weight changes and diet recall showing adequate kilocalorie and protein intake. Weight has been stable for the past 3 years. Laboratory values show elevated total cholesterol, LDL, and TRG levels. Prior diagnoses include NAFLD (2 years) and hyperlipidemia (1 year). BP is within normal limits. Diet recall and patient preference shows a traditional Peruvian diet. He reports he has been trying to avoid sugar and carbohydrates because they are “bad” for him. He feels frustrated because the nutrition tips and recipes for people with NAFLD aren’t culturally relevant to him. He feels guilty for eating potatoes even though they are a cultural staple in his diet. Current intake shows regular meals and snacks throughout the day. The patient does not drink alcohol. There is room for improvement in the addition of monounsaturated fats and fiber to support heart health and long-term prevention of diabetes, CVD, and hypertension. Patient reports he has a physically demanding job and considers himself to be very active. Will provide nutrition counseling to discuss heart-healthy diet and lifestyle recommendations in a way that is relevant to the patient. Special consideration should be given to help him maintain the joy he feels with eating his traditional Peruvian foods while making additions or adjustments to meet his goals.

4. List components of the medical treatment and monitoring plan.

Answer:

• 1. Continue lisinopril and consider the Dietary Approaches to Stop Hypertension (DASH) diet and cardiovascular exercise to improve hypertension management.
  2. Continue lifestyle interventions for NAFLD and hyperlipidemia (avoiding refined and simple carbohydrates and, instead, increasing fiber and nutrient-rich, healthy carbohydrate sources as well as healthy fats; exercise).
  3. Meet with dietitian to discuss culturally relevant nutrition recommendations.
  4. Repeat laboratory values in 3 to 4 months to verify if patient’s values are stable and improving. Consider an annual liver ultrasound for fatty liver disease reassessment.

5. Develop nutrition and culinary medicine interventions for this patient and condition.

Answer:

Nutrition and Lifestyle Interventions

First, it is important to recognize that NAFLD is primarily caused by excess simple carbohydrates or refined carbohydrates or grains in the diet with inadequate fiber usually found in processed foods and juices. So, the primary target of dietary management will be to educate the patient on the types of carbohydrates and to decrease the refined and processed as well as excess simple carbohydrates in his diet. For a great discussion on the biochemistry of NAFLD and fructose, we recommend the YouTube video “Sugar: the Bitter Truth” by Dr. Robert Lustig.

1. When possible, diets with limited carbohydrates and saturated fat and enriched with high fiber and unsaturated fats (e.g., Mediterranean diet, cardiometabolic protective eating pattern) should be encouraged, due to their additional cardiovascular benefits.

Given this patient’s cultural food preferences, rather than recommending that he stops eating Peruvian foods and adopt a Mediterranean diet, his health-care team can work with him to incorporate heart-healthy components of the Mediterranean diet, such as increasing fruit and vegetable intake, increasing monounsaturated fat intake, and decreasing saturated and trans fat intake. Dietary changes should maintain the important connection of this patient’s culture. Health-care providers can work with this patient to determine what aspects of a heart-healthy diet, if any, would be reasonable and/or realistic to adopt.¹⁵

This patient also reports limited income, so he should be screened for food insecurity. If food insecurity is present, this can have a profound impact on the patient and his health outcomes. The health-care team can work together to provide resources and support for accessing enough food. Before implementing any other nutrition interventions, it is important for the patient to have adequate access and intake of food.¹⁴

If the patient has adequate access to food, nutrition recommendations would also include prevention or treatment of other comorbid conditions that are commonly associated with NAFLD, including CVD, type 2 diabetes, hyperlipidemia, and hypertension. Addressing carbohydrate intake specifically will be important for this patient because he has disclosed that he is trying to avoid them altogether. A modest intake of carbohydrates balanced with protein, healthy fat, and fiber can help support glucose levels for people at risk for diabetes. Avoiding carbohydrates altogether is a sign of an unhealthy relationship with food and may lead to other disordered eating thoughts or behaviors.^16,17

Instead, the patient should learn about healthy sources of carbohydrates that are from whole vegetables and whole grains and that also are high in fiber, rather than refined carbohydrates. If he wants to continue to eat potatoes and white rice, the concept of resistant starches can be introduced and Juan can be advised to let these foods cool down, or cook enough for the week, then reheat them so as to lower their glycemic load and prevent further worsening of the NAFLD.

In patients with NAFLD, alcohol can be a cofactor for liver disease progression, and intake should be assessed regularly. This patient previously consumed 2 to 3 beers per day, but no longer consumes alcohol. His health-care providers can provide support in continuing to consume limited amounts of alcohol. His health-care providers also regularly can reassess his intake of alcohol.^11,12

2. Recommending weight loss may not be appropriate for lean patients with NAFLD, but dietary modifications and exercise in this group may be beneficial.

This patient’s health-care providers should monitor his weight to ensure unintended weight loss does not occur. As liver disease progresses, a patient’s risk for malnutrition also increases. Unintended weight loss could be an early or late indicator of malnutrition.¹⁶

3. Patients with NAFLD should be strongly encouraged to increase their activity level to the extent possible. Individualized prescriptive exercise recommendations may increase sustainability and have benefits independent of weight loss.

This patient is doing some physical activity at baseline, and it would be important to get more information about the intensity and duration. Additionally, the patient notes that there are limited places where he can exercise outside of his current activity; his health-care team should obtain more information about this, too. The health-care team should work with the patient to develop an individualized plan for how he can increase his activity level in a safe, sustainable way.

Culinary Medicine Interventions

• • It is important to identify and share resources and interventions that are appropriate for Juan’s language and cultural and social background. It would be helpful to ask more open-ended, nonjudgmental questions regarding the culinary preparation of foods that Juan eats. It is common for Juan’s wife to be primarily responsible for preparation of meals. Nutrition and culinary interventions should include Juan’s family and eating habits; it will also increase likelihood of sustaining dietary changes. If the Peruvian diet is not familiar to the clinician, it is appropriate to demonstrate openness and curiosity regarding dishes and foods. See chapter 12 for examples of cultural nutrition counseling questions and the prepare-engage-respond model for engaging with clients of diverse cultural backgrounds.
  • Because Juan has shared interest and questions regarding the ketogenic diet, it would be important to provide education regarding the pros and cons of the keto diet. It should be emphasized that although the keto diet is a low-carbohydrate diet, it is also a high-fat diet, which would be contraindicated for patients with NAFLD, because it is difficult to consume the recommended macronutrient distribution for NAFLD (particularly consuming adequate fiber and less saturated or trans fat) with the strict macronutrient intake recommendations that are an inherent part of the keto diet. It is appropriate to reinforce recommendations of heart-healthy diets with Juan while discussing the indications and contraindications of the keto diet. For more information about the keto diet and other popular diets, see chapter 8.
  • Juan has expressed guilt about eating certain foods, the importance of “food is love,” and eating for family and social relationships. It is essential to honor Juan’s cultural food preferences, not stigmatize certain food groups or ingredients, as well as not treat any food or diet as a panacea. Knowledge is power, and providing objective nutrition education about different food groups and their roles in health is key. See chapter 3 for more information on enjoying food at home and beyond.
  • It is helpful to keep a collection of recipes that highlight traditional meals of different cultural backgrounds of patients a clinician may see. Even having 1 recipe available for patients helps to demonstrate cultural awareness. For Juan, an example of a nutrient-rich traditional coastal Peruvian dish is quinotto (Peruvian quinoa risotto). Additionally, it is important to learn from Juan and his family how they prepare meals, what staple ingredients they use, and, after providing foundational nutrition education, to use that information to help them personalize culinary changes to promote nutritional and overall health. See appendix B for recipes and recommendations for recipe adaptations.
  • It is also best practice to be aware of the different food distribution resources available in the community to help promote access to fresh fruits and vegetables, as well as other nutritious food. These can include farmers markets, mobile markets, community gardens, and gleaning programs. See chapter 10 for more information about these seed-to-table programs.

Case Study No. 6: Metabolic Syndrome

Chief complaint: Here for annual wellness exam

History of present illness: Lemond (Lee), a 49-year-old man, has an appointment with his medical team today for his annual wellness checkup. Lemond is interested in learning how to manage his blood pressure with diet if he can and asks if the team can suggest healthy meals that are easy to make for 1 person. He is curious if he should be taking any supplements to lower his blood pressure. In the past 3 years, his lifestyle changed due to having knee surgery to repair an old football injury and caring for his spouse, whom he lost to cancer. He has gained some weight and is doing some physical therapy to strengthen his knee so he can resume his physical activity.

Care team members:

• Physician
• Nurse practitioner
• Registered dietitian nutritionist
• Pharmacist
• Exercise physiologist

Past medical history: Kidney stone while in college, none since. Low vitamin D level 4 years ago; resolved after supplementing. Knee surgery related to old sports injury. Reinjured trying to get back into shape with running and lifting weights after a couple years of inactivity taking care of wife. Had repair surgery and is doing well. Has had “borderline” high blood pressure in past that he was able to control with increasing his exercise; no previous blood sugar elevation. Does not smoke and drinks alcohol moderately (limits to 3-4 beers/week).

Family medical history: Ethnicity: Polynesian. Parents have mild hypertension. His father has type 2 diabetes; his brother has high blood pressure. His sister and his college-age son are healthy.

Social history: Lost wife to breast cancer 3 years ago. Was her primary caregiver for a year before her death. Has used a grief support network online and has a supportive friend group. Works from home in the technology industry in software business management.

Medications/supplements: Was briefly taking antidepressants (sertraline) but decided he was feeling better and weaned from them. Takes vitamin D “when he remembers,” because his level was low in the past; takes 1,000 international units (IU) 3 to 4 times/week.

Allergies/intolerances: Mild lactose intolerance. Tolerates cheese and yogurt. Shellfish allergy.

Diet history: He has been eating more convenience meals, packaged snacks, and fast food due to not being able to stand for cooking and challenges with using crutches while shopping. Since losing his wife and his son going away to college, he has struggled to make meals for himself.

Usual diet recall:

• Breakfast/first meal: sausage and egg biscuit, sweetened instant oatmeal, or frozen pancakes and syrup with bacon. 10 oz of coffee with cream.
• Lunch: 1 to 2 slices of pizza, or ham (4 oz) or turkey (4 oz) sub sandwich (4 in long), flavored chips (snack bag size), 32 oz of lemonade or electrolyte drink.
• Snack: 1 to 2 times per day: prepackaged fruit cups in syrup (4 oz), individual packs of cheese crackers or chips, ice cream bar or protein bar (provides 12 g of protein). Has chips, salsa, wings, and nachos when watching football.
• Dinner: 2 to 3 frozen burritos; 2 sub sandwiches (4 in long with 3 oz ham or turkey plus 2 oz provolone cheese); 2 to 3 cheese quesadillas; or 2 to 3 hot dogs; occasionally hamburger with fries or Caesar salad with chicken from fast-food place. 32 oz soda 1 to 2 times/week.
• Alcohol: Has “a few beers” weekly during football season, does not drink other alcoholic beverages.

Vital signs	Reference range	Date: 2/9/23
BP, mm Hg	<120/80	136/85
HR, bpm	60-100	75
RR, per minute	12-20	15
Temperature, °C (°F)	36.1-38 (~97-100.4)	38 (100.4)
Height, feet (′) and inches (″)		5′ 10″
Weight, lb		218
Usual weight, lb		195-200
Waist circumference, inches	<40 for men, <35 for women	42
Hip circumference, inches		37
Waist to hip ratio	≤0.90 for men, ≤0.85 for women	1.05
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory value	Reference range	Date: 2/9/23
Na, mEq/L	136-145	140
K, mEq/L	3.5-5.1	3.5
Cl, mEq/L	96-110	100
HCO3, mEq/L	20-29	22
BUN, mg/dL	7-20	17
SCr, mg/dL	0.5-1.2	.8
Glu, mg/dL	70-110	100
LDL, mg/dL	<100	125
HDL, mg/dL	>45	35
TRG, mg/dL	<150	197
Total cholesterol, mg/dL	<200	240
Albumin, g/dL	3.5-5.5	5.0
AST, Units/L	10-36	35
ALT, Units/L	8-48	45
Alk phos, Units/L	44-147L
HbA1C, %	Normal <5.7; prediabetes 5.7-6.4; diabetes ≥6.5	6.0
Fasting glucose, mg/dL	Normal level <99; prediabetes 100-125; diabetes ≥126	120
25-hydroxyvitamin D, ng/mL	30-50	32
Abbreviations: Alk phos = alkaline phosphatase; ALT = alanine transaminase; AST = aspartate transaminase; BUN = blood urea nitrogen; Cl = chloride; dL = deciliter; g = gram; Glu = glucose; Hb = hemoglobin; HbA1C = glycated hemoglobin; HCO3 = bicarbonate; Hct = hematocrit; HDL = high-density lipoprotein; K = potassium; L = liter; LDL = low-density lipoprotein; mEq = milliequivalent; mg = milligram; ng = nanogram; SCr = serum creatinine; TRG = triglyceride.

Student Application Questions

1. What are the criteria a patient needs to meet to be diagnosed with metabolic syndrome?¹⁸

Answer: Meets at least 3 of 5 criteria for metabolic syndrome:

• • Prediabetes (HbA_1c 6.0)
  • Stage 1 hypertension (BP >130/80 mm Hg)
  • Low HDL level
  • High triglyceride level
  • Elevated waist circumference¹⁹

2. Complete a comprehensive nutrition assessment.

Answer: Lee’s weight is 110% of his usual body weight, and his increased waist to hip ratio suggests increased health risk. He has elevated fasting glucose and HbA_1c values, elevated lipid levels (high total, low HDL, and elevated TRG). From his diet history, Lee’s intake reflects heavy reliance on convenience and processed foods, high-calorie meals, simple carbohydrates, and sodium. He has frequent sugar-sweetened beverage intake and moderate alcohol intake. He has a low intake of fiber and fruits, vegetables, whole grains, nuts, seeds, healthy fat sources, and fish. He does not drink adequate amounts of plain water.

Physical activity has been decreased due to knee surgery recovery period. He has been attending physical therapy. Lee has had family life changes and grief from loss of spouse and currently adjusting to living alone. He has a support system in place. Medical history includes elevated BP that he was able to control with lifestyle changes and “getting in shape.” He missed his last annual medical appointment. He is currently not taking any medications. Plan to assess knowledge of nutrition and readiness to change, help elicit his motivation, assist Lee with making goals for meaningful lifestyle changes to achieve healthy BP, glycemic control, and stabilize his weight to prevent further gain and promote gradual return to his usual weight as appropriate. Provide education and resources on healthy meal planning for one. Recommend he continue his vitamin D supplementation and consider increasing it, because optimal levels are closer to 60 ng/mL, so he is still at low end of normal range.

3. What are some barriers based on Lee’s life experiences that may influence him being successful with lifestyle changes, including use of culinary medicine practices?

Exercise

Answer: He is still in the healing phase from his knee surgery, which puts constraints on building an exercise routine. He is a currently deconditioned former athlete who may need help with more gradual progression of exercise difficulty to avoid exacerbating knee healing and to help avoid injury. He has a sedentary job and spends the day seated in front of a computer screen.

Nutrition

Answer: Lee is adjusting to meal preparation for one and has experienced grief with loss of a spouse and adjustments in his routine with his son leaving for college. He may need help in this period of transition with planning meals and shopping and preparing meals that align with his goals of healthy, easy-to-prepare meals. His past nutrition and activity patterns as a former athlete are very different from what he needs at this stage of his life. He may need help making realistic lifestyle goals.

4. How can the health–care team approach this patient in a way that promotes collaboration and patient-centered care?

Answer: The use of motivational interviewing techniques assists patients making successful lifestyle changes.¹⁹ It is important to assess Lee’s readiness to change, sources of personal motivation, and nutrition knowledge. Lee has expressed interest in learning to cook easy but healthy meals for one, showing readiness to change, and motivation for staying off medications. He has mentioned previous success controlling his BP through lifestyle changes. We can ask him open-ended questions to learn about his previous habits and knowledge. Information he offers can be used to offer affirmations to build his confidence in making lifestyle changes. By asking what strategies he has used in the past when trying to reduce his BP, Lee may be able to identify habits he is comfortable with reestablishing, or we can offer an opportunity to refine or modify the behavior for his current stage in life, addressing barriers he may mention that may interfere with sustaining lifestyle changes.

Use motivational interviewing counseling techniques to see what changes Lee wants to focus on in terms of nutrition changes and goal setting, and to help him set his own goals for changes that align with his nutritional concerns and honor his culture and preferences. Assess his knowledge of nutrition principles to help with BP, blood lipid, and glycemic control, and ask his permission to offer education as applicable. We could help him define how to make meals healthier: Ask what he already knows about that and what changes he feels would help most for BP, lipids, and blood glucose control. Clarify anything that is incorrect as needed; ask if he has questions and what he wants to learn specifically. Asking permission before sharing education or information with him allows for him to feel in control of the conversation and more likely to engage in the change process.¹⁹

Lee has a Polynesian cultural background. Using motivational interviewing counseling techniques and cultural humility, be curious about foods and practices that are important to Lee and if there are any that honor his culture. Practicing cultural humility will build a stronger relationship with Lee and empower him to adhere to his treatment plan.²⁰ He may offer some cultural meal choices that could be built into his culinary medicine interventions to increase his meal enjoyment and adherence, and he may have physical activities or other lifestyle behaviors that align with his culture. See chapter 12 for additional information about cultural approaches to culinary medicine.

5. List components of the medical treatment and monitoring plan.

Answer:

• • What should his first–line medication be if BP continues to rise? Lisinopril (or other angiotensin-converting enzyme inhibitor)
  • What first–line medication should be considered if his blood sugar values do not decrease? Metformin²¹
  • What medications or supplements may help improve his lipid levels? In this case, Lee’s triglyceride levels are elevated and can be lowered by supplementing with omega-3 fish oil (3-4 g/day eicosapentaenoic acid + docosahexaenoic acid split among meals). If his LDL level was more elevated, he could use a statin medication; however, these also worsen insulin resistance and can increase risk of diabetes.²¹

If Lee agrees to some diet changes and activity increases, his fasting glucose level could be retested in 1 to 2 months and HbA_1c in 3 to 4 months. Recommend frequent BP testing with a home monitor to ensure BP is trending down. His waist circumference and waist to hip ratio could be rechecked after 3 months of lifestyle change to assess if progress is being made; assess weight change if client desires. Consider assessing his sleep habits; these can affect his BP and glycemic control.

6. List nutrition and culinary medicine interventions for this patient and condition.

Answer:

Nutrition and Lifestyle Interventions

• • Achieve ≥150 min/week of physical activity, incorporating both aerobic and weight resistance training (at least twice weekly) and work up to 30 to 60 minutes of daily physical activity.^22,23
  • Increase intake of fruits and nonstarchy vegetables, aiming for 2 to 3 servings of vegetables and 2 servings of fruits daily; focus on getting a variety of colorful fruits and vegetables daily to increase intake of nutrients and bioactive compounds in foods.²²
  • Encourage reduction of simple and refined carbohydrates and increase use of nutrient-dense carbohydrate sources that are high in fiber, balance carbohydrate intake throughout the day, and increase fiber intake gradually to meet Daily Reference Intake of 38 g/day.²²
  • Decrease intake of saturated fats to 10% or less of total calories by reducing processed and fast foods and cooking with olive or avocado oils.²²
  • Increase use of fresh herbs and spices to assist with success of reducing sodium intake and increase intake of bioactive compounds that decrease inflammation and chronic disease risk.²⁴

Work up to 150 min/week of moderate exercise, or 75 minutes of vigorous activity, as recommended for healthy individuals per week. For metabolic syndrome, the literature recommends 30 to 60 min/day of activity. Suggest Lee start with swimming or other low-impact activity, starting with 20 min/day. His goal should be to increase vigorous and moderate activity for cardiovascular fitness and resume strength training at least twice per week using free weights or body weight exercises. Weight training can increase mitochondria in muscles, increase lean mass, help with blood glucose management and metabolism, and decrease visceral fat. Lee could consider using a standing desk or taking regular walking breaks throughout the day to decrease hours of sedentary time.^22,23

Culinary Medicine Interventions

Answer:

• • BP: Consider a modified Dietary Approaches to Stop Hypertension (DASH) diet, which has been clinically shown to decrease BP on par with medication.²⁵ The focus of this diet is increased fiber in the form of whole vegetable and fruits, as well as decreased sodium. One way to achieve this is to avoid processed and prepackaged foods, paying attention to labels regarding sodium content. In cooking, a good strategy is to cook with as little salt as possible and limit to salting to taste at the table while eating a meal, which reduces overall sodium consumption. Also increase foods rich in magnesium and potassium, because these minerals can contribute to decreased BP.²⁵
  • Lipids: Increase fiber in the form of whole plant–based foods (e.g., whole vegetables and fruits, not juice), increase plant and lean proteins from beans, fish, seeds, and nuts. Additionally, increase healthy fats, focusing primarily on monounsaturated fats in foods, such as extra-virgin olive oil (cook with as little oil as possible, avoid reaching the oil smoke point, and consider adding it as a finishing oil on top of food). For polyunsaturated fats, focus on omega-3 from wild seafood, flaxseeds, and walnuts. Decrease sources of saturated fats (increase LDL level), as well as simple sugars and refined grains (increase triglyceride levels).^22,25
  • Glycemic control: Compare categories of carbohydrates based on the glycemic index and glycemic load of foods. Review carbohydrate counting and serving sizes and strategies to improve the quality, quantity, and distribution of carbohydrates, including smaller servings and consuming simple and refined carbohydrates, such as sugar-sweetened beverages, less often;²¹ explore options to increase use of high-fiber options and use of nuts and healthy fats for satiety and to aid blood lipid management.²⁵ Increase use of plain water as a beverage, nonstarchy vegetable intake, use MyPlate type tools to provide education on portion sizes and ways to balance meals.
  • Meal preparation: Could use some Mediterranean diet and/or DASH diet recipe sources, including videos; refer patient to cooking seminars; healthy meal prep kits. Free meal plans may be found online, including through EatingWell and Mount Sinai. Additionally, MyPlate offers free software, the MyPlate Plan, in English and Spanish to help patients identify their food group targets so they can plan meals and snacks based on recommended food group servings. These tend to be more generic. A registered dietitian can help develop a personalized meal plan for patients.
  • Culinary coaching is a combination of motivational interviewing and nutrition education that uses coaching skills and expert nutrition, culinary, and sometimes medical knowledge to provide patient-centered education and counseling.

Case Study No. 7: Diabetes

Chief complaint: High blood sugar

History of present illness: Mrs. Fuentes is a 43-year-old Mexican American woman who has been referred to the clinic for diabetes management. She is coming to the clinic today to meet with the diabetes clinic care team. Mrs. Fuentes is employed as an operating room nurse and was recently diagnosed with type 2 diabetes mellitus (T2DM). She developed gestational diabetes while she was pregnant with her second child. Her blood glucose levels returned to normal in the postpartum period, and she was advised to get regular checkups, maintain a desirable weight, and engage in regular physical activity. Although she reports that she has been trying to consume a healthy diet and that she exercises regularly (1-2 times/week for 20 minutes), she has struggled with sticking to her eating plan and has had a history of weight cycling. She is 5 ft 3 in tall and currently weighs 153 pounds; her weight is stable. She is motivated to improve her health because she wants to lose some weight, and she has joined a gym because she is concerned about the long-term effects of diabetes and wants to avoid the possibility of needing insulin injections. She is also concerned about her husband and children because they are overweight and not very active. She has a healthy body image but knows that she can make some changes in her lifestyle to reduce the complications associated with poor glycemic control. She has been checking her blood glucose level a couple times a week in the morning before eating, and it is usually in the 140 to 150 mg/dL range.

Care team members:

• Physician
• Registered nurse*
• Registered dietitian nutritionist*
• Pharmacist*
• Exercise physiologist

*These team members are also Certified Diabetes Care and Education Specialists

Past medical history: T2DM recently diagnosed; history of gestational diabetes

Family medical history: Two daughters who are healthy (ages 9 and 5 years), mother with T2DM and osteoporosis, father deceased (stroke in 2001), brother with T2DM and hypertension

Social history: Married to Henrique for 15 years, has 2 daughters ages 9 and 5 years. Employed as a surgical nurse, works 3 days/week; 12-hour days. She reports not “drinking” too much but does report she will have a glass of wine on most nights to “unwind.” Does not, and never has, smoked.

Medications/supplements:

• Metformin 500 mg once daily
• Aspirin 81 mg once daily

Allergies/intolerances:

• Penicillin (rash)
• Enalapril (cough)

Diet history:

• Breakfast: 2 scrambled eggs, 2 pieces whole-wheat toast, 1 medium banana, and 8 oz of grape juice; or 1 cup of oatmeal with 1 medium banana and 6 oz of orange juice
• Lunch: turkey (2 oz) and cheese (1 slice) sandwich on 2 slices of whole-wheat bread with mayonnaise (1 tbsp), lettuce (1 large leaf), and 2 slices of tomato, and a diet soda; or a large green salad with turkey or chicken (2 oz of 1 or the other) and cheese (~1.5 oz) with just a few vegetables, like celery and tomatoes, diet soda, and large whole-grain roll with butter (1 pat).
• Snack: grazes on whatever is available at the hospital (e.g., popcorn, chips, nuts, cookies, hard-shelled chocolate candies). Difficult to estimate portion sizes but she guesstimates 1 to 3 handfuls except cookies, of which she might have 3 to 4; doesn’t usually snack when she is not working.
• Dinner: approximately 4 oz of chicken, hamburger, steak, hot dogs (2 on buns), or pork chops with 1 cup of mashed potatoes, rice, or pasta with ~1 tbsp of margarine; typically approximately one-half cup of some type of veggies (e.g., peas, corn, mixed vegetables), or small salad with a few slices of cucumber and tomatoes. Usually has ~1 tbsp of ranch or Italian dressing on her salad. Also eats boxed hamburger casserole mix, tuna noodle casserole, Mexican food, and Italian, among others. She usually has some type of dessert (e.g., ¾ cup of pudding, 1 cup of ice cream, 2 cookies, a small slice of pie). Has a glass of wine (~5 oz) before or with dinner on most nights. Fuentes and her family eat out about twice a week (e.g., pizza, Chinese, gourmet hamburgers).

Mrs. Fuentes states she’s too tired to cook on workdays, but her daughters love to cook.

Vital signs	Reference range	Date
		3/16/21	3/7/21	3/1/20
BP, mm Hg	<120/80	132/84	134/85	129/72
HR, bpm	60-100	89	91	82
RR, per minute	12-20	15	16
Temperature, °C (°F)	36.1-38 (~97-100.4)	36.6 (~98)	36.8 (98.2)
Height, feet (′) and inches (″)			5′3″	5’3″
Weight, lb			153	145
Abbreviations: BP = blood pressure; bpm = beats per minute; HR = heart rate; lb = pound; min = minute; mm Hg = millimeters of mercury; RR = respiratory rate.

Laboratory value	Reference range	Date
		3/16/21	3/7/21	3/1/20
BMP
Na, mEq/L	136-145		136	139
K, mEq/L	3.5-5.1		3.5	3.9
Cl, mEq/L	96-110		101	102
HCO3, mEq/L	20-29		28	21
BUN, mg/dL	7-20		20	15
SCr, mg/dL	0.5-1.2		0.8	0.7
Glu, mg/dL	70-110		189	164
CBC count
WBC count	3.4-10.4 × 103/mm3		3.5	4.1
Hb, g/dL	13.5-17.5		13.5	14
Hct, %	40-54		45	41
Plt count	150-425 × 103/mm3		175	201
Lipid panel
LDL, mg/dL	<100		136	99
HDL, mg/dL	>45		37	41
TRG, mg/dL	<150		400	201
Total lipids, mg/dL	<200		253	180
Liver panel
Albumin, g/dL	3.5-5.5		3.9	4.1
AST, Units/L	10-36		33	28
ALT, Units/L	8-48		40	30
Alk phos, Units/L	44-147		110	109
Miscellaneous
HbA1C, %	5-5.8		8.9	6.1
PT, sec	11-15		12	13
INR	<1.3		0.8	0.9
Ca, mg/dL	8.5-10.8		10	9.9
Mg, mEq/L	1.5-2.2		2.1	1.9
Phosphorus, mg/dL	2.5-4.5		2.9	2.9
Microalbumin, mg/g	0-30		36	24
Ankle-brachial index	1-1.4		1.1
Abbreviations: Alk phos = alkaline phosphatase; ALT = alanine transaminase; AST = aspartate transaminase; BMP = basic metabolic panel; BUN = blood urea nitrogen; Ca = calcium; CBC = complete blood cell; Cl = chloride; dL = deciliter (one-tenth of a liter); g = gram; Glu = glucose; Hb = hemoglobin; HbA1C = glycated hemoglobin; HCO3 = bicarbonate; Hct = hematocrit; HDL = high-density lipoprotein; INR = international normalized ratio; K = potassium; L = liter; LDL = low-density lipoprotein; mEq = milliequivalent; mg = milligram; Mg = magnesium; mm = milliliter; Na = sodium; Plt = platelet; PT = prothrombin time; SCr = serum creatinine; sec = second; TRG = triglyceride; WBC = white blood cell.

Student Application Questions

1. Explain the significance of the lipid panel results for this patient and how they relate to the diagnosis of T2DM.

Answer: Mrs. Fuentes has elevated triglyceride level at 400 mg/dL and low HDL at 37 mg/dL. This pattern of high triglyceride and low HDL levels is a sign of insulin resistance.²⁶

2. What is the top dietary contributor to the patient’s high triglyceride levels?

Answer: Outside of familial hypercholesterolemia, high triglyceride levels in most patients, including this patient, come from excess sugar in the form of refined carbohydrates or grains and other high-sugar and low-fiber processed foods. Excess sugar in the diet is converted to triglycerides and deposited as fat mostly in the liver (contributing to fatty liver disease) and abdomen.

3. List risk factors for acute and chronic complications for this patient with T2DM.

Answer: Hypoglycemia, cardiovascular disease (CVD), chronic kidney disease, nonalcoholic fatty liver disease, neuropathy, and retinopathy

4. List components of the medical treatment and monitoring plan.

Answer:

Medical Treatment and Monitoring Plan

• • Develop a monitoring plan. Ask Mrs. Fuentes to check her blood glucose level every morning after fasting and 2 hours after either lunch or dinner, and to send this log to the care team every 2 weeks. She is encouraged to keep a diary of food, activity levels, sleep, and stress to make connections between these and her blood sugar levels. This will help her identity the foods and lifestyle components that can increase her blood sugar level and reinforce positive changes to lower it. Sending the log every 2 weeks will help with continued monitoring and accountability.
  • Practice guidelines recommend a distribution of carbohydrate intake that is consistent at each meal, with protein, fiber, and healthy fats.²⁷
  • Consider increasing metformin to 1,000 mg/day with meals and titrate up as needed. The maximum daily dose of metformin is 2,000 mg/day. Assess her vitamin B₁₂ status annually because metformin can reduce B₁₂ absorption.
  • Check HbA_1c in 3 months or at least 4 times per year for individuals with poorly controlled glucose levels or when adjusting pharmacological therapy.²⁸
  • Initiate therapeutic lifestyle changes to lower LDL level by decreasing saturated fat intake, increasing fiber intake, and increasing healthy fat intake, including monounsaturated fat, tree nuts, and seeds. Repeat a follow-up lipid panel in 3 months to assess progress.²⁷
  • Although the diabetes practice guidelines recommend initiating any dietary pattern that incorporates healthy interventions that the patient will follow, initiation of the Dietary Approaches to Stop Hypertension (DASH) diet may also be useful, in addition to considering hibiscus tea to help lower BP. Also begin an exercise program to increase her HR eventually to a goal of 80% of her maximum HR for 30 to 45 minutes 4 times/week; work up to this gradually.²⁹ Advise patient to get a good BP monitor and monitor her BP at home, recording the measurements in a log; she should send log in every 2 weeks. If BP not improving, consider medication.
  • Refer Mrs. Fuentes to a registered dietitian nutritionist for medical nutrition therapy.²⁷ Share information about group nutrition classes in the community and refer to diabetes self-management education and support classes to support healthy eating and lifestyle behaviors, education on diabetes management, moral support, cooking tips, and sharing of healthy recipes. See appendix B for recipes and recipe adaptations.
    • Curating a collection of recipes and nutrition education resources can be a helpful tool for clinicians to share with patients, especially in areas where there are dietitian and nutrition education shortages.

5. List nutrition and culinary medicine interventions for this patient and condition.

Answer:

Nutrition and Lifestyle Interventions

Based on the practice guidelines for diabetes²⁷, best practices include:

• • Education on diabetes self-management:
    • Refer patients for individualized, focused education at time of diagnosis and as needed thereafter based on health status to build and support healthy eating patterns. Medical nutrition therapy education and counseling can help patient lower HbA_1c levels similarly or better than prescribed medications.
  • Address nutritional needs based on personal and cultural preferences; maintain pleasure of eating through positive health messages. (For additional information on how to make patient-centered nutrition interventions, see chapter 3 on enjoying food at home and beyond, and chapter 12 on culturally centered approaches.)
  • Encourage regular physical activity; goal is ≥150 min/week. Continue to go to the gym but also plan family-centered activities to promote enjoyable family time.
  • Goals include to improve HbA_1c, BP, and cholesterol levels (goals differ based on age, duration of diabetes, health status, and other factors).

Culinary Medicine Interventions

• • Evidence reflects lack of ideal percentages for carbohydrates, protein, and fat; macronutrient distribution should be based on health status, eating patterns, and outcome goals. Individuals should be encouraged to meet the daily fiber recommendations for adults through diet or supplementation, because this may reduce HbA_1c levels. It is helpful to recommend different recipes that have high-fiber ingredients; these may include snacks, beverages, and meals. For recipes and recipe adaptation information, please see appendix B.
  • The quality of carbohydrates consumed ideally should be rich in fiber, vitamins, and minerals and low in refined grains, sodium, and simple carbohydrate sources such as processed foods or food products with added sugar. The Mediterranean and DASH diets are good examples of evidence-based meal patterns that can be used as a foundation when providing dietary advice. Low-carbohydrate diets are also a viable approach for improving glycemic control. See chapters 2, 4, 5, 6, and 10 for further discussion. A teaching sheet on the different types of carbohydrates should be provided to the patient.
  • Increase healthy fat consumption; focus on monounsaturated food sources, including extra-virgin olive oil, avocados, and tree nuts such as walnuts, pecans, pistachios, and almonds. Monounsaturated fats are the hallmark of the Mediterranean diet and can increase insulin sensitivity and decrease glucose absorption, leading to lower glucose levels and lower triglyceride levels. The Standard American Diet is high in omega-6 and omega-9 polyunsaturated fats, so advise the patient to focus on omega-3 fatty acid food sources, including wild-caught, cold-water fish such as salmon, mackerel, or sardines. Plant sources of omega-3 include flaxseed and walnuts.
  • Eating plans that promote positive dietary changes to promote diabetes management based on personal preferences and resources, improve glycemic control, reduce CVD risks factors, and improve quality of life are recommended for individuals who have excess adiposity. An energy deficit may occur from these dietary changes (especially if combined with physical activity) that promotes weight loss. A loss of ~7% to 10% of starting weight can promote health benefits.
  • Attend a nutrition and/or culinary medicine class to gain better insight to management for diabetes, learn more how to cook with a busy lifestyle, and encourage the children in preparing meals.
    • State Cooperative Extension agencies often offer nutrition courses that include food demonstrations, recipes sharing, and meal planning strategies. These classes are free and open to the community. Examples include:
      • Rite Bite Diabetes Cooking School (University of Georgia Cooperative Extension)
      • Med instead of Meds (North Carolina State Cooperative Extension)
    • Virtual and in-person culinary medicine classes are becoming more prevalent. Depending on the area, health-care organizations or individual clinicians may offer these classes for free or for a fee. A few virtual examples include:
      • NuCook–The Recipe for a Healthy Life (virtual, free)
      • Thrive Kitchen from Kaiser Permanente (nonmembers pay fee for virtual class; culinary skills cooking videos available for free)
      • Pursuit App from Rewire Health (fee for recipe and culinary skills app; designed to be implemented by organizations to be given to patients)

Further Resources

These additional resources are provided to help medical, nutrition, and other allied health students and professionals incorporate culinary medicine principles in their patient screening, assessment, and interventions. These resources may be used to help complete these culinary medicine case studies and in current and future clinical practice.

Nutrition Screening

The Rapid Eating Assessment for Participants–Shortened Version (REAPS) is a dietary screening tool that can be completed by patients in less than 10 minutes.³⁰ Findings from REAPS can be used by clinicians to provide insight into general trends and habits of a patient’s eating.³⁰ It is based on a scored rating, with higher scores correlating with lower dietary quality.³⁰

Nutrition Assessment and Intervention

The Meal, Anthropometrics, Nutrition, and Activity (MANA) pocket guide was adapted from the Weight, Activity, Variety, Excess (WAVE) pocket guide. The WAVE card was developed by the Nutrition Academic Award to help physicians and clinicians incorporate nutrition assessment and counseling into their clinical practice.³¹ The MANA was adapted from the WAVE card to promote a clinician’s ability to recommend nutrition and culinary medicine interventions. It is similarly designed to have 1 assessment side and 1 intervention or counseling side to promote use of nutrition and culinary medicine interventions in a clinician’s practice.

References

Cancer Case Study

1. Chan DS, Vierira AR, Aune D, et al. Body mass index and survival in women with breast cancer-systematic literature review and meta-analysis of 82 follow-up studies. Ann Oncol. 2014;25:1901–1914. doi:10.1093/annonc/mdu042
2. Greenlee H, Shi Z, Molmenti CLS, Rundle A, Tsai WY Trends in obesity prevalence in adults with a history of cancer: results from the US National Health Interview Survey, 1997 to 2014. J. Clin. Oncol. 2016;34:3133–3140. doi:10.1200/JCO.2016.66.4391
3. Ligibel JA, Basen-Engquist K, Bea JW. Weight management and physical activity for breast cancer prevention and control. Am Soc Clin Oncol Educ Book. 2019;39:e22–e33. doi:10.1200/EDBK_237423
4. Blanchard CM, Courneya KS, Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society’s SCS-II. J. Clin. Oncol. 2008;26:2198–2204. doi:10.1200/JCO.2007.14.6217
5. Lisevick A, Cartmel B, Harrigan M, et al. Effect of the Lifestyle, Exercise, and Nutrition (LEAN) study on long-term weight loss maintenance in women with breast cancer. Nutrients. 2021;13(9):3265. doi:10.3390/nu13093265
6. Dieli-Conwright CM, Orozco BZ. Exercise after breast cancer treatment: current perspectives. Breast Cancer (Dove Med Press) 2015;7:353–362. doi:10.2147/BCTT.S82039
7. Lahart IM, Metsios GS, Nevill AM, et al. Physical activity, risk of death and recurrence in breast cancer survivors: a systematic review and meta-analysis of epidemiological studies. Acta Oncol. 2015;54:635–654. doi:10.3109/0284186X.2014.998275
8. World Cancer Research Fund, American Institute for Cancer Research. Diet, nutrition, physical activity and breast cancer. Continuous Update Project Expert Report 2018. Accessed December 20, 2024. https://www.wcrf.org/wp-content/uploads/2024/10/Breast-cancer-report.pdf
9. Porciello G, Montagnese C, Crispo A, et al. Mediterranean diet and quality of life in women treated for breast cancer: a baseline analysis of DEDiCa multicentre trial. PLoS One. 2020;15:e0239803. doi:10.1371/journal.pone.0239803

Liver Disease Case Study

10. Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology. 2023;77(4):1335. doi:10.1097/HEP.0000000000000004

11. Younossi ZM, Zelber-Sagi S, Henry L, Gerber LH. Lifestyle interventions in nonalcoholic fatty liver disease. Nat Rev Gastroenterol Hepatol. 2023;20(11):708–722. doi:10.1038/s41575-023-00800-4

12. Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797–1835. doi:10.1097/HEP.0000000000000323

13. Talens M, Tumas N, Lazarus JV, Benach J, Pericàs JM. What do we know about inequalities in NAFLD distribution and outcomes? A scoping review. J Clin Med. 2021;10(21):5019. doi:10.3390/jcm10215019

14. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease
among low-income NHANES participants. J Nutr. 2010;140(2):304–310. doi:10.3945/jn.109.112573

15. Rose-Francis K, Alexis A. Healthy eating includes cultural foods. Healthline. July 7, 2021. Accessed August 3, 2023. https://www.healthline.com/nutrition/healthy-eating-cultural-foods

16. Nahikian-Nelms M. Nutrition Therapy and Pathophysiology. Cengage; 2020.

17. Thorne R. Everything you need to know about disordered eating, according to experts. Healthline Media; 2022. Accessed December 20, 2024. https://www.healthline.com/health/disordered-eating-vs-eating-disorder#risk-factors-and-demographics

Metabolic Syndrome Case Study

18. Huang PL. A comprehensive definition for metabolic syndrome. Dis Model Mech. 2009;2(5-6):231–237. doi:10.1242/dmm.001180

19. Chiang LC, Heitkemper MM, Chiang SL, et al. Motivational counseling to reduce sedentary behaviors and depressive symptoms and improve health-related quality of life among women with metabolic syndrome. J Cardiovasc Nurs. 2019;34(4):327–335. doi:10.1097/JCN.0000000000000573

20. Dragomanovich HM, Shubrook JH. Improving cultural humility and competency in diabetes care for primary care providers. Clin Diabetes. 2021;39(2):220–224. doi:10.2337/cd20-0063

21. Blonde L, Umpierrez GE, Reddy SS, et al. American Association of Clinical Endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan—2022 update. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2022;28(10):923–1049. doi:10.1016/j.eprac.2022.08.002

22. Pérez-Martínez P, Mikhailidis DP, Athyros VG, et al. Lifestyle recommendations for the prevention and management of metabolic syndrome: an international panel recommendation. Nutr Rev. 2017;75(5):307–326. doi:10.1093/nutrit/nux014

23. Pesta DH, Goncalves RLS, Madiraju AK, Strasser B, Sparks LM. Resistance training to improve type 2 diabetes: working toward a prescription for the future. Nutr Metab. 2017;14(1):24. doi:10.1186/s12986-017-0173-7

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Diabetes Case Study

26. Alidu H, Dapare PPM, Quaye L, Amidu N, Bani SB, Banyeh M. Insulin resistance in relation to hypertension and dyslipidaemia among men clinically diagnosed with type 2 diabetes. Biomed Res Int. 2023;2023:8873226. doi:10.1155/2023/8873226

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Further Resources

30. Johnston CS, Bliss C, Knurick JR, Scholtz C. Rapid Eating Assessment for Participants [shortened version] scores are associated with Healthy Eating Index-2010 scores and other indices of diet quality in healthy adult omnivores and vegetarians. Nutr J. 2018;17(1):89. doi:10.1186/s12937-018-0399-x

31. Gans KM, Ross E, Barner CW, Wylie-Rosett J, McMurray J, Eaton C. REAP and WAVE: new tools to rapidly assess/discuss nutrition with patients. J Nutr. 2003;133(2):556S–562S. doi:10.1093/jn/133.2.556S