Mary Wek

Mary is a 44 year old woman who has chronic kidney disease, diagnosed 3 years ago. The cause is unclear and you do not have recent bloodwork available. She takes Ramipril (ACE inhibitor) 10mg when she can afford it.

 

She asks you how her diet could help improve her health.

There are a number of nutrients of importance to discuss with Mary, including:

• Fluid intake – she could develop dehydration or edema
• Electrolytes (Na, K, P) – homeostasis of ICF and acid/base balance
• Protein – sufficient intake of essential amino acids
• Calcium and Vitamin D – decreased ability to produce hormone Vitamin D3

You are also concerned about the adequacy of her overall caloric and nutrient intake.

 

 

There are a variety of helpful questions to assess the usual energy and nutrient intake of Mary, including:

• what she ate yesterday (as detailed as possible) - timing of meals and snacks, amounts, homemade vs. purchased

• fluid intake - assess amount of water, tea, etc. she drinks each day

• foods that are high in salt and rich in potassium

• variety of foods, suggesting consumption of all essential vitamins and minerals

• daily protein intake, specifically high quality protein sources daily (ie meat, fish)

• herbs (e.g. herbal teas) that could affect blood pressure

Questions to help understand her situation better could include:

• does May live alone or with family?  

• who does the food procurement and cooking?

• inquire about Mary’s ability to afford healthy foods, and medications

• if necessary, could she provide more of her own food (for example does she grow a  vegetable garden, and/or raise chickens, goats, etc.) or is she dependent on what’s available in the food markets?

• how far away does she live from a health clinic? If she needs to travel for healthcare does she have family/friends to assist her and provide her residence if out of town?

Collect a weight and ask about recent weight loss (if she does not have access to a scale ask if her clothes fit differently)

Assess for loss of muscle mass.

Assess for edema.

 

Assess her blood pressure.

Mary weighs 101 pounds and has noted her clothes seem to be getting bigger and bigger over the past few months. She reports her strength is failing, she can no longer lift up her youngest grandchild anymore and hasn’t been able to lift the soup pot for months.

Mary does not seem to consume adequate calories or dietary fat and protein.

Her usual breakfast is sweet tea and a banana.  Midday she has a small bowl of Aseda (millet porridge) and boiled water to drink.

Common evening meals are vegetable stews with kisera (flatbread). Typically she and her daughter make a large pot of vegetable stew (e.g. eggplants, sweet potato and peanut butter in a tomato broth) and that feeds the family (3 adults and 4 children) for a couple days.  Mary will eat a bowl of stew and one piece of homemade whole wheat flat bread each evening and boiled water to drink. Before bed each night she eats another piece of fruit, typically a banana or mango.

They have a vegetable garden and raise chickens for eggs and meat.

You do not think Mary is consuming enough calories each day and in particular believe there is a lack of dietary protein to meet her essential amino acid needs.  You are also concerned about the amount of fluids she’s consuming. You recommend:

Fluids: Monitor frequency and colour of urine – Mary may need to increase her fluid intake if she is not producing pale urine throughout the day.

Sodium: Encourage Mary to flavour stews with herbs and spices to limit salt intake as much as possible.

Potassium: if urine output declines, Mary will need to watch her potassium intake. Bananas, mangos, sweet potatoes, tomatoes are all rich in potassium - choose only one fruit rich in potassium each day (but maintain the stew).

Protein: Add one chicken egg for breakfast, and ensure one serving of high quality protein each day at the supper meal (~3oz of fish or meat - a portion about the size of the palm of her hand).

Calories: increase daily calorie intake by adding sesame seeds, peanuts and dried fruit to porridge.

Calcium: if available, supplement with calcium carbonate 500mg bid, along with Vitamin D3.