Nafld Cs

Name:
__Ziying Tan__________________
Winter 2015

Case Study #1

Patient History: Miss R is a 12 year old Hispanic female referred to you by her PCP for
fatty liver. Miss R. is accompanied by her mother who does most of the talking as the
patient is embarrassed and withdrawn. Patient is an only child who enjoys watching
movies and reading books. Patient has recently complained of being tired, falling asleep at
school, and mild abdominal pain. She was born LGA at 10 lbs 2 oz. Mother states she has
always been a big girl.
PMH: LGA, Childhood Obesity
Meds: none
Family hx: mother and father have Type 2 Diabetes

Physical History:
General Exam: obese female
Vitals: Temp 98.6 F, BP 138/89 mm Hg, HR 84 BPM, RR 23
Ht: 57 (25th %tile) Wt: 152lb (>95th %tile)
BMI 32.9 (>95th %tile)

Nutrition History:
General: Reports adequate appetite. Miss R. will eat some vegetables and fruit but prefers
starchy and high fat foods. She sneaks candy from her cousins after school. Mom cooks
traditional Hispanic meals at home, but a couple times per week they will go to fast food
and get a burger or pizza.
Usual Dietary Intake:
Breakfast: 2 breakfast burritos with cheese, eggs, sausage, beans, and homemade
tortillas (made with lard), and a large glass of juice
Snack: granola bar
Lunch: school lunch (pizza or burger, with fries, maybe a fruit, chocolate milk or juice,
with a cookie
Snack: she is offered fruit but prefers candy and dried cereal (Fruit Loops) with
regular soda
Dinner: 3-4 tortillas (made with lard), cheese, beef or chicken, maybe a vegetable
(corn or peas), and a glass of whole milk
Snack: microwavable popcorn with butter or ice cream
Food allergy/intolerance: NKFA

Treatment Plan
Weight Management:
- Reduce simple sugar intake
- Reduce portions at meals
- Aim for half plate fruits and vegetables at meals
- Choose low fat foods
- Increase physical activity, 30 minutes daily
Weight loss of 5-10% over 3-6 month period

Reassess labs in 3 months

Fasting Labs 12/20/2013
Lab
Value
Interpretation

ALT
80 U/L
GGT
28 U/L
WNL (PR p.36)
Glucose
115 mg/dL
(PR p.37)
Hemoglobin A1c
6.8%
(PR p.37)
Total Cholesterol
245 mg/dL
(PR p.36)
LDL Cholesterol
148 mg/dL
WNL (PR p.36)
HDL Cholesterol
22 mg/dL
(PR p.36)
Triglycerides
198 mg/dL
(PR p.39)

CT scan (12/20/2013) shows the presence of a hepatic steatosis

1. In the table of laboratory values above, for the column labeled Interpretation,
indicate whether the values are high (), low () or within normal limits (WNL).
(4 points)

2. Briefly explain how Insulin Resistance can lead to Non-Alcoholic Fatty Liver Disease
(NAFLD). (6 points)

Insulin resistance is strongly associated in patients who have Non-Alcoholic Fatty
liver Disease (NAFLD). In adipose tissue, insulin resistance decreases the inhibitory
action of HSL, leading increased plasma free fatty acids that then taken up by the
liver. Insulin resistance causes an increased in insulin/ glucose (hyperinsulinemia)
level, which then increases the De Novo lipogenesis. De Novo lipogenesis, increased
plasma free fatty acids, and excess dietary fatty acids will enter the liver, therefore
more free fatty acids in the liver that induces more triglyceride synthesis.
Triglycerides export via VLDL pathway, resulting an increased in blood triglycerides.
In conclusion, insulin resistance leads to free fatty acids accumulation in
hepatocytes via lipolysis and hyperinsulinemia.

3. Which foods in Miss Rs diet are contributing most to: (2 points)
a. Triglyceride level:
Homemade tortillas (made with lard) in breakfast
Whole milk in dinner
Microwavable popcorn with butter for snack

b. Fasting blood glucose level:
Soda in lunch
Fries in lunch
Cookie in lunch

4. Explain the rationale for the following interventions: (4 points)

a. Reduce simple sugar intake
By reducing simple sugar intake, it reduces the level of blood glucose. Also,
by looking thru Miss Rs family history, it is time to ask her to reduce simple
sugar intake in order to prevent to develop type 2 diabetes. Reducing simple
sugar intake also helps to lose weight.

b. Reduce portions
By reducing portions at each meal, it reduces the total calories intake, which
then reduces total fat intake. And, by reducing portions at each meal, it
supports weight loss that meets the goal of treatment plan.

c. Choose low fat foods
Choosing low fat foods lowers the blood triglycerides. It is because it helps
less dietary fat enter into the liver, and less free fatty acid accumulation in
the hepatocytes to induce triglyceride formation. Also, by looking thru Miss
Rs lab values, her results from lipid panel are not good values; for example,
she has high total cholesterol (245 mg/dL), high triglycerides (198 mg/dL),
and low HDL cholesterol (148 mg/dL). Therefore, choosing low fat foods will
help her to improve her lab values next time.

d. Increase physical activity

Increasing physical activity helps to lose weight because Miss R is an obese
female. It also helps to improve insulin resistance, which then helps to get
better on her non-alcoholic fatty liver disease.

5. Write 2 PES statements using the Intake domain. (4 points)
1) Excessive fat intake (NI-5.6.2) related to poor food choices from usual dietary
intake such as tortillas that made with lard as evidenced by hepatic steatosis,
high level of total cholesterol (245 mg/dL), high level of triglycerides (198
mg/dL), and low level of HDL cholesterol (148 mg/dL).
2) Excessive carbohydrate intake (NI-5.8.2) related to food-and nutrition-related
knowledge deficit such as pizza or burger with fries from usual dietary intake as
evidenced by high Hemoglobin A1c level (6.8%) and high glucose level (115
mg/dL).

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Weight loss of 5-10% over 3-6 month period

4. Explain the rationale for the following interventions: (4 points)

d. Increase physical activity

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