Sample Nutrition Consultation
The report listed below is a sample. The length of a report is dependent on the service selected, questions asked during the online process, and the complexity of the review by the dietician.
Dear Mrs. Doe,
Thank you for your recent request for a nutrition consultation with Cleveland Clinic's Center for Human Nutrition. Please find below your completed nutrition assessment written by Joe Nutritionist, MS, RD, LD, Cleveland Clinic Center for Human Nutrition. Should you have any questions that need to be answered before your scheduled follow up appointment with the registered dietitian, feel free to contact our Cleveland Clinic MyConsult staff at 1.800.223.2273 ext 43223, 8 a.m. - 5 p.m. EST, Monday through Friday.
MyConsult Office H2-260
9500 Euclid Avenue
Cleveland, OH. 44195
Tel: 1.216.444.3223 or 1.800.223.2273 ext 43223
Nutrition Consultation Assessment
Patient Name: Jane Doe
Dietitian's name: Joe Nutritionist, MS, RD, LD
Department: Center for Human Nutrition
CCF # (MRN): 1-222-333-4
Date of Birth: 11/15/1948
123 Nowhere Lane
St. Louis, MO 99999
Reason for Consultation:
Mrs. Jane Doe has sought the opinion of The Cleveland Clinic dietitian for issues related to elevated triglycerides and weight loss.
Summary of Medical History:
Mrs. Doe is a 55-year old female with no known coronary disease. She has a past medical history of migraines, hypercholesterolemia and obesity. She is seeking nutrition advice for weight loss and triglyceride lowering.
Most recent lab data (from 11-20-2002) reveals the following: triglycerides (TG) 320mg/dl, total cholesterol 230mg/dl, low-density lipoprotein (LDL) 120mg/dl, and high-density lipoprotein (HDL) 45 mg/dl. Currently her LDL is considered to be within normal limits, however HDL is considered low (goal >60 mg/dl) and TG elevated (goal <150 mg/dl). In addition to achieving TG goals, Mrs. Doe seeks to reach a goal weight of 140 pounds.
Mrs. Doe's current medication and supplement regimens are as follows: Aspirin 81mg daily, Lipitor 10mg daily, Centrum Silver 1 daily, Folic acid 400mcg daily, Caltrate with Vitamin D 2 caplets (600mg) daily. She reports to be following a very low fat diet regimen.
Analysis of Weight Status:
Mrs. Doe is 5'2" tall and currently weighs 180#. Her goal is to lose weight. Her body mass index (BMI) is 33, which is considered obese. This places her at an increased risk of diabetes, heart disease and certain cancers. Her goal weight is 140 pounds, which would place her at a more desirable body mass index of 26. To keep risk factors as low as possible, a body mass index less than 25 should be achieved, which correlates to a body weight of 130-135 pounds. It is noteworthy to add, however, that even a 5% loss of body weight (9 pounds) would significantly cut her risk for heart disease and diabetes.
Patient's Nutritional Goals:
Mrs. Doe's three primary goals are as follows:
1. To learn what foods raise triglycerides and which foods help to
2. To lose 30-40 pounds. Requests how many calories she should be consuming each day to achieve this weight loss, in time for her son's wedding in 8 months.
3. To learn how to properly read food labels.
Nutritional Assessment and Recommendations:
You report that a very low fat diet best represents your current eating style over the past six months. While a very low fat diet can be ideal for reducing risk of heart disease in certain people, it is not always ideal for people with elevated triglycerides. Before we discuss your diet, I want to explain what triglycerides are and why they increase risk of heart disease.
Triglycerides are fats carried in the blood from the foods we eat. Most of the fat we eat, including butter, margarines and oils, are in triglyceride form. When we consume excess calories, fats, alcohol or sugar, our bodies convert them into triglycerides and store them in fat cells throughout the body. High triglyceride levels increase risk for heart disease by lowering the "good" cholesterol (HDL) and making our "bad" cholesterol (LDL) more sticky and dense, promoting it's adhesion to the inside of our arteries. If not controlled, this could lead to a heart attack or stroke. Following a meal, blood triglycerides are normally high. For an accurate reading, blood samples for triglyceride tests should be taken after a 12-hour period of not eating or drinking. Guidelines for triglyceride levels in healthy adults are:
|Normal||Borderline High||High||Very High|
|Under 150 mg/dL||151-200 mg/dl||201-499 mg/dl||500 mg/dl or higher|
While too much fat, especially saturated and trans fats, can lead to elevated triglycerides, in most cases, it's an excess of calories from sugar, alcohol and refined foods (e.g. white bread) that leads to high triglycerides.
To answer your first question, let's look deeper into what foods raise
and lower triglycerides. We will review the following topics to answer
A. Simple sugars
B. Naturally occurring sugars
C. Refined carbohydrates
D. Portion sizes
G. Weight management and exercise
(A) Foods high in simple sugars significantly contribute to high triglycerides. Your dietary recall indicates that your simple sugar intake comes from cookies, pie, ice cream and certain cold cereals. In addition, beverages, such as soda or sugar-filled iced teas can contribute to elevated triglycerides because they contain large amounts of sugar.
Below are some tips on reducing 'simple sugars' in your diet:
Limit foods that contain any of these as the main ingredients - sucrose, high fructose corn syrup, corn syrup, molasses, glucose, honey, maltose. All of these are sugar..
Avoid adding table sugar and brown sugar to foods and beverages. Instead, substitute with Equal , Splenda , Sweet-n-Low , Sugar Twin or Brown Sugar Twin These products contain few calories and no sugar.
Substitute sugar-rich beverages like colas, fruit drinks, iced tea, lemonade, Hi-C and Kool-Aide with water or artificially sweetened beverages labeled "sugar-free" or "diet."
Snack on whole fruit instead of fruit roll-ups and other fruit-flavored treats.
Try light or low-sugar syrups on pancakes and waffles.
Spread breads and crackers with no-sugar-added jelly or preserves.
Limit hard candies, chocolates, candy bars and gummy bears.
Choose sugar-free gum or mints.
When selecting cereals, limit the sugar to no more than 8 grams per serving. Sugars can be found on the Nutrition Facts Panel below "dietary fiber".
Try sugar-free gelatin and puddings instead of their regular versions.
Be aware that desserts labeled "fat-free" usually contain more sugar and equal calories than the full-fat varieties. Sugar-free desserts are available, however most are high in fat.
Cut down your dessert (cookies, pies, pastries, cakes) intake to only a couple times per week, and always monitor your portion size (e.g. eat half of what you'd normally eat or share dessert with a friend!)
Reduce your intake of ice cream, frozen yogurt, sherbet, gelato, and flavored ices - all contain high levels of sugar.
(B) Naturally occurring sugars, when eaten in excess, can also raise your triglycerides. Follow these guidelines to help limit natural sugars:
Use honey and molasses sparingly
Choose light yogurt (which use artificial sweeteners) instead of regular yogurt
Choose whole fruit instead of fruit juice
Limit your intake of dried fruits to � cup per day
Avoid canned fruits packed in heavy syrup; choose fruit canned in it's own juice or extra light syrup
Monitor your portion size of baked potatoes, mashed potatoes, yams, beans, corn and peas to 1 cup (or about the size of your fist) at each meal. Although these starchy vegetables are a great source of fiber and nutrients, they can contribute to high triglycerides when eaten in excess.
You can work on this area by cutting down on fruit juice. I would recommend you eliminate your fruit juice at this time and substitute with no more than 2 servings of whole fruit each day until your triglycerides a level under 150mg/dl. Once your triglycerides resume to the normal range, you may slowly increase your fruit servings to three daily, allowing no more than 6 ounces of 100% fruit juice each day. In addition, you consume a large portion of your vegetables from starchy sources (corn, peas, potatoes). I would recommend increasing your intake of a variety of non-starchy vegetables like broccoli, cauliflower, carrots, squash, spinach, romaine, eggplant, zucchini, peppers and green beans. Make it a point to eat two to three different colors of vegetables (and fruits) each day!
(C) Because "refined" breads, cereals, rice, pasta and crackers convert to sugar in the body more quickly than whole grain ones they tend to increase triglycerides when eaten in large quantities. The process of refinement strips away the coarse outer part of the grain that contains essential nutrients, fats and fiber. When you eat "enriched" breads, for example, the flour to make the bread is enriched back with the nutrients that had been stripped during refinement, but dietary fiber is not added back. Dietary fiber is an important component in keeping your blood sugars and triglycerides in check. Examples of highly refined foods you are currently eating include Special K cereal (which has no sugar but also has no fiber!), regular wheat bread (not 'whole' wheat bread), Honey Bunches of Oats, Italian bread and white pasta. To limit refined grains try these suggestions:
Choose breads, crackers and cereals that contain whole grains (like oats, barley, corn, or wheat) listed as the first ingredient. Look for words like stone ground whole wheat, 100% bran, 100% whole-wheat flour, etc. Avoid the words listing "bleached" and/or "enriched" flour as the first ingredient.
Try whole-wheat pasta, buckwheat pasta or brown rice instead of their refined versions.
Choose breads, crackers, rice and pasta with 2 or more grams of dietary fiber per serving.
Select hot and cold cereals with 5 or more grams of dietary fiber per serving.
Substitute brown rice, wild rice, barley, bulgur, couscous, millet or wheat berries for refined side dishes like white rice or pasta.
Enjoy soup with whole-wheat crackers soup instead of saltines.
The fiber in whole grains (also called unrefined starches) reduces how quickly your food is digested and turned into sugar. Dietary fiber found in whole grains (as well as fruits, vegetables and dried beans) helps to control blood sugar, lowers cholesterol, and makes you feel more satisfied or "full" after a meal, reducing your risk of overeating. This will in turn help you to lose weight. I recommend you make an initial goal to choose whole grain foods at least 50%-75% of the time. Save the refined breads, pastas, and rice when eating out or for special occasions. An easy way to implement this is to start the day with a bowl of whole grain cereal, a sandwich on whole grain bread for lunch and brown rice or whole-wheat pasta with dinner. That's four servings of fiber-rich whole grains and can add about 15 grams of fiber to your day!
(D) Watching your overall portion size of the above foods is also a
key component to triglyceride control. Below are examples of a single
1 slice of bread
1 hot dog or hamburger bun
1/2 bagel (1 ounce)
1 matzoh cracker
4 slices melba toast
2 to 6 baked whole-wheat crackers
3 cups popped light popcorn
1 cup cooked cereal (e.g. oatmeal, cream of wheat, oat bran)
2 slices of reduced-calorie bread
1 English muffin
1 oz most cold cereals (1/4 to 1 cup)
2 graham crackers
1 cup cooked rice, pasta, mashed potatoes
In another part of this assessment, I have provided you with the number of servings you should be eating from each food group. We will discuss this later on.
(E) Alcoholic beverages are another significant contributor to elevated triglycerides. Examples are beer, wine, spirits, mixed drinks, wine coolers and coffee drinks containing alcohol. Your diet recall indicates you consume about 5-7 servings of wine each week. Women should limit their alcohol intake to one serving per day. One serving is equal to: 1.5-ounce spirits, 4 ounces wine or 12 ounces beer. However, I would recommend you cut your alcohol intake by half until your triglyceride levels reach the normal range (less than 150 mg/dl). Cutting down on 'liquid calorie' beverages such as beer, soda, juice, wine, and other calorie-rich drinks is a sure-fire way to cut down those triglycerides - and help you lose weight!
(F) As I stated before, eating too much of the 'bad fats' - saturated and trans - can also contribute to high triglycerides. You currently consume excesses in saturated fat from regular cheese, mayonnaise, fast foods (filet-o-fish, whopper junior with cheese, etc.) and blue cheese dressing. However, you are choosing a good, trans-fat free margarine and cook with healthful, monounsaturated fat-rich olive and canola oils. Continue doing this.
It is important to understand that getting adequate amounts of fat in your diet is actually helpful in lowering your triglycerides. Eating too little fat gives you more room to consume simple sugars and refined starches - both of which contribute to high triglycerides.
The best way to lower triglycerides is to increase a specific type of fat called omega-3. Omega-3 fatty acids are one of two essential polyunsaturated fats that our bodies cannot make on it's own; we must get them from food sources. Good food sources of omega-3 fats include fatty, cold-water fish like salmon, mackerel, sardines, tilapia, sea bass and lake trout. In order to help you lower triglycerides, you should be consuming anywhere between 2 and 4 grams of omega-3 fats each day. See the table below to determine good sources of omega-3. Note where orange roughy and cod (fish you reported to eat most often) fall on the list:
Foods Serving Size Amount of Omega-3 Fat
Atlantic Salmon or Herring 3 ounces cooked 1.9 grams
Blue Fin Tuna 3 ounces cooked 1.5 grams
Sardines, canned 3 oz in tomato sauce 1.5 grams
Anchovies, canned 2 ounces drained 1.2 grams
Atlantic Mackerel 3 ounces cooked 1.15 grams
Salmon, canned 3 ounces drained 1.0 gram
Swordfish 3 ounces cooked 0.90 gram
Sea Bass (mixed species) 3 ounces cooked 0.65 gram
Tuna, white meat canned 3 ounces drained 0.5 gram
Sole, Flounder, Mussels 3 ounces cooked 0.4 gram
Wild Catfish, crabmeat, clams 3 ounces cooked/steamed 0.3 gram
Prawns (jumbo shrimp) 6 pieces 0.15 gram
Atlantic Cod, Lobster 3 ounces cooked/steamed 0.15 gram
Trout, Orange roughy 3 ounces cooked <0.1 gram
As you can see, it may be difficult to eat this much fish on a daily. However, I do encourage you eat at least 2, 3-ounce portions of the good sources of omega-3 fats each week. There are some plant foods that are also a good source of omega-3 fatty acids. Good plant sources are flaxseeds, flax oil, canola oil, walnuts and soybean oil. Currently, there are no established serving size recommendations for these foods on lowering triglycerides but focus on adding these foods to your diet regularly, as they provide additional heart-health benefits. For example, you may enjoy adding 2 Tablespoons of ground or milled flaxseed (not whole seeds) to cereal or yogurt each day. Flaxseeds can be found at natural health food stores, bulk food stores or on the Internet.
Taking fish oil capsules is yet another way to help you lower triglycerides, especially when getting 2-4 grams of fish oil is a tough feat! However, the above recommendations on cutting out juice, limiting alcohol, choosing more whole grains, limiting portion sizes and others should be done first before taking fish oil capsules. And check with your physician before taking to determine if any side effects could occur.
If you and your physician decide fish oil capsules are for you, read
To determine how many grams of omega-3 fats are in a capsule, look for the words "EPA" and "DHA" on the supplement label. Adding up the number of grams or milligrams (mg) of EPA and DHA will tell you how much omega-3 fat is in each capsule. For example, a 1 g capsule may contain 250 mg EPA and 250 mg DHA, which adds up to 500 mg or 0.5 g of omega-3 fat. Reaching 4 grams daily may consist of a large number of fish oil capsules, so choose ones that contain the largest amount of EPA and DHA (omega-3 fats) per capsule.
Now I know the above information was a lot to chew! But start with a few simple steps like cutting out juice, limiting or eliminating alcohol, cutting down on desserts and watching your portion sizes and you will be a few steps closer to success!
Now, let's review your second goal: lose approximately 30-40 pounds.
Your goal of 30-40 pounds is a reasonable one, given you have approximately 7 months to lose it. Safe, effective and long-term weight loss can be achieved at a rate of no more than 2 pounds weight loss per week. If we estimate 28 weeks until the wedding you could lose anywhere from 28 to 56 pounds! However, please note that a consistent loss of 2 pounds per week may be difficult to achieve.
Weight loss is simply taking in fewer calories than your body uses up each day. However, this is just an equation - much harder when you're dealing with day-to-day life and the challenges it brings. Excess body weight increases your triglyceride levels, as well as risk for heart disease, diabetes and certain cancers, so I commend your on your effort to shed some excess weight. Research has shown us that as little as 5% loss of body weight (which for you would be approximately 9 pounds) significantly cuts risk for debilitating diseases like diabetes.
Two rules of thumb for weight loss: 1. Monitor your portion sizes. Refer to this link to determine what a portion size should be for all of the food groups (Portion Sizes). 2. Get moving. Weight loss is a big feat when you are trying to cut calories alone. I recommend you talk with your physician first before trying any exercise program. He or she will determine if there you have risks for certain exercises. Do this as soon as possible!
I have attached a 1400-calorie meal plan that, incorporated with regular aerobic exercise as instructed by your physician, should help you reach your goal weight. Using the serving sizes handout along with the 1400-calorie meal plan will be your key to weight loss. Here are some additional tips to get you started:
Bring healthful snacks with you to work. Have healthy snacks
available in the car too. It's as easy as packing the following:
o Fresh fruit
o Fruit canned in it's own juice or extra light syrup
o Nonfat or 1% fat cottage cheese
o Nonfat plain or fruited yogurt
o Fresh cut-up veggies
o 1T peanut butter and all-fruit-preserves sandwich on whole wheat
o 1/2 tuna or turkey sandwich on whole wheat bread
o 1 cup of dry whole grain cereal
o Part-skim milk mozzarella stick and an apple
o Nature Valley granola bar
o Light microwave popcorn single serving bag
Limit late night snacking - try not to eat anything 2-3 hours
before you go to bed. It's best to front-load your calories earlier
in the day. During daylight hours you are more active and have the
potential to burn more calories.
At our next session we will review any questions you have about your 1400-calorie plan. Remember that you do not have to follow it completely. Small changes over time will make a big difference. Start with planning what you'll bring for lunch and snacks to work; and start planning quick yet healthy meals you can prepare at home.
To answer your third question about food labels, see below:
To help people understand serving sizes more clearly, the Food and Drug Administration redesigned food labels, ordering that serving sizes must be clearly stated and consistent for all foods in a given product line. These "Nutrition Facts" labels can be found on most every packaged food product made in the United States.
There is a small but important difference between the serving sizes determined by the USDA and those that appear on food labels. The USDA serving sizes are units of measure that can be used to as guidelines to help balance your overall diet. Those on "Nutrition Facts" food labels, however, are intended to give the consumer information about the specific packaged food in question. Measurements of fat, cholesterol, sodium, carbohydrate, protein, vitamins and minerals are calculated for a "typical portion," but the amount of that portion is not a recommendation, it is, simply a unit of measure. Below is an example of a Nutrition Facts label, along with explanations of its components.
Nutrition labels and an ingredient list are required on most foods.
Use the package label information to help you to make low-fat
A. Nutrition information is provided for a specific serving size. This may or may not be the serving amount you normally eat.
B. The number of calories and grams of nutrients are provided for the stated serving size. This is the part of the food label where you will find the amount of fat per serving.
C. Daily Values are the label reference numbers. These numbers are set by the government and are based on current nutrition recommendations. Some labels list daily values for both 2,000 and 2,500 calorie diets.
% Daily Value shows how a food fits into a 2,000 calorie reference diet. For diets other than 2,000 calories, divide by 2,000 to determine the % Daily Value for nutrients. However, you do not want to follow this column because you are trying to follow 1,400-calories.
D. Calories per gram information shows the number of calories in a gram of fat, carbohydrate and protein.
E. Ingredients on the label are listed from largest to smallest amount (by weight). This means a food contains the largest amount of the first ingredient and the smallest amount of the last ingredient.
Another aspect of food labeling is label claims.
Some food labels make claims such as "low cholesterol" or
"low fat." These claims can only be used if a food meets
strict government definitions. Here are some of the meanings:
Label Claim Definition
(per standard serving size)
Fat-free or sugar-free Less than 0.5 gram (g.) of fat or sugar
Low fat 3 grams of fat or less
Reduced fat or reduced sugar At least 25% less fat or sugar
Cholesterol free Less than 2 milligrams (mg.) cholesterol and 2 grams or less of saturated fat
Reduced cholesterol At least 25% less cholesterol and 2 grams or less of saturated fat
Calorie free Less than 5 calories
Low calorie 40 calories or less
Light or lite 1/3 fewer calories or 50% less fat; if more than half the calories come from fat, fat content must be reduced by 50% or more
Refer to the tips I also provided to you with regards to the amount of fiber you should be looking for in cereals and breads.
Mrs. Doe, as a summary, I would like to highlight some important points to get you started on making appropriate, long-term nutrition changes. These will aid in lowering your triglycerides and weight:
1) Cut out juice at this time. Replace most of your juice with water or decaffeinated calorie free beverages. And don't forget to eat two servings of whole fruit each day.
2) Cut alcohol down by 1/2 at this time. This means no more than 3 servings per week. Try to have these three servings on different days - not at the same time.
3) Cut your intake of desserts by half (e.g. cheesecake, cookies, pastries). Save for a special occasion or split dessert and share with a friend. Even better, substitute dessert with a piece of fruit or nonfat light yogurt.
4) Call your primary care physician and tell him or her that you are thinking about starting an exercise program. See if your doctor will require a physical before you do so.
5) I know you have a very hectic and busy schedule, but take 15-30 minutes each evening to prepare the next day's meals. Plan what you will have for breakfast, for example, by getting the box of whole grain cereal out of the pantry and onto your countertop, placing your bowl and spoon right next to it. All you will need to do the next morning is reach for the milk. Also, cut up some fresh veggies and throw them in a zip lock bag. Grab a piece of fruit, toss in a tuna fish sandwich with light mayonnaise on whole wheat, a yogurt, and even a 1/4 cup of almonds and you are set for lunch and snacks. To get tomorrow's dinner prepared, defrost chicken or ground meat, take it out of the freezer, place on a tray or plate (to avoid any juices getting on other foods) and put in the refrigerator. All of this may take 15-30 minutes of your time, but it'll save you tons of time the next day - which will in turn REDUCE YOUR STRESS!
6) Follow the 1,400-calorie menu plan I provided to you as closely as you can, placing foods on your plate like I suggested above. Even if you don't follow it exactly, just cutting out white breads, adding a serving or two of vegetables to your day, and increasing your fish will make a big difference.
7) To further help lower triglycerides, try and eat two 3-ounce servings of fatty fish each week. Or add ground flaxseeds, walnuts and soy to your daily diet.
Take each of the suggestions one day at a time. You can't conquer it all overnight! Logging what you eat is a good first step to discovering your diet patterns. I look forward to our follow up session. In four weeks I will send you a follow-up questionnaire and await your responses. A three-day food diary will be asked of you before we begin. Good luck! And thank you for choosing e-Cleveland Clinic to help you achieve your goals!
Joe Nutritionist, MS, RD, LD
Center for Human Nutrition
Cleveland Clinic Disclaimer
By using this remote nutrition consultation service, you agree to abide by the Terms and Conditions posted the Cleveland Clinic MyConsult Web Site, including particularly the Terms and Conditions described below:
The service provided through our Web site is different from the services typically provided by a registered dietitian. The Cleveland Clinic Foundation (CCF) registered dietitians providing this service will not have the benefit of information that would be obtained by assessing you in person and observing your physical condition. Therefore, the dietitian may not be aware of facts or information that would affect his or her assessment. TO REDUCE THE RISK TO YOU OF THIS LIMITATION, CCF STRONGLY ENCOURAGES YOU TO SHARE THIS NUTRITION CONSULTATION WITH YOUR PHYSICIAN. BY DECIDING TO ENGAGE THIS SERVICE, YOU ACKNOWLEDGE AND AGREE THAT YOU ARE AWARE OF THIS LIMITATION AND AGREE TO ASSUME THE RISK OF THIS LIMITATION.
BY REQUESTING A REMOTE NUTRITION CONSULTATION PURSUANT TO THIS WEB SITE, YOU ACKNOWLEDGE AND AGREE THAT:
* THE ASSESSMENT THAT YOU WILL RECEIVE IS LIMITED AND PROVISIONAL;
* THE NUTRITION CONSULTATION IS NOT INTENDED TO REPLACE A FACE-TO-FACE VISIT WITH A REGISTERED DIETITIAN, NOR A FULL MEDICAL EVALUATION WITH A PHYSICIAN;
* THE DIETITIAN DOES NOT HAVE IMPORTANT INFORMATION THAT IS USUALLY OBTAINED THROUGH A FACE-TO-FACE VISIT;
* THE ABSENCE OF A FACE-TO-FACE VISIT MAY AFFECT THE DIETITIAN'S ABILITY TO ASSESS YOUR NUTRITIONAL NEEDS;
BY ENGAGING OUR SERVICES, YOU ACKNOWLEDGE AND AGREE TO ASSUME THE RISK OF THESE LIMITATIONS. YOU FURTHER UNDERSTAND THAT NO WARRANTY OR GUARANTEE HAS BEEN MADE TO ME CONCERNING ANY PARTICULAR RESULT OR CURE OF MY CONDITION..