Case 993: Ruth
Ruth is a 22 year old 5 foot 4 inch white female who comes to see you for her annual exam. Your partner who has retired has been taking care of Ruth's family since she was an infant. You see Ruth's mother regularly to treat her for her diabetes and Ruth's father is being treated for hypertension. Both of Ruth's parents are overweight.
    Ruth is married and had her first child one year ago. In your discussion with Ruth she tells you that she is quite concerned about her weight. Ruth tells you she wants to lose weight. She says, "I've been fat all my life. I want to go on that Ultra Slimfast diet like Willard Scott and lose 60 pounds." She says she can't seem to lose any weight since she moved to her new house. Ruth had lived in town all her life. After her marriage, she and her husband moved to an apartment two blocks from her parent's house. Although she and her husband had only one car they got along fine because Ruth could walk to her job at the variety store and do most of her chores such as shopping by walking. She was also able to visit friends and family by walking.
    After Cindy was born, Ruth and her husband moved to a new house which is about ten miles out of town. Ruth had to quit her job because she had no way to get there and no one to take care of Cindy. Now she only gets into town about once a week. She says to you "I really love my baby but sometimes I feel so alone with no adults to talk to."
    She describes her typical day as follows. She gets up at 5:00 AM to take care of Cindy and make breakfast for her husband. After he leaves for work she eats breakfast with Cindy. Breakfast usually consists of a bowl of cereal and some apple juice. About 9:00 AM she gives Cindy a snack and she has what she describes as a coffee break (coffee and maybe some of Cindy's snack). She watches Barney and Sesame Street with Cindy until lunchtime. At lunch she usually eats a sandwich with some chips. She drinks a sweetened lemonade drink and has some cookies for dessert. After lunch she puts Cindy down for a nap. She does some housework for about an hour then watches her "programs" on TV. She has some lemonade and chips while she watches. When Cindy wakes up she give her a snack and Ruth has about 6 cookies. Then she makes dinner and when her husband comes home they have something like hamburger helper, buttered green beans, french fries and a small lettuce salad with thousand island dressing. She and her husband both drink Coke with their dinner. While Ruth cleans up after dinner,her husband plays with Cindy and then Ruth bathes Cindy and puts her to bed. Then she joins her husband and they watch TV until about 10:00 PM. Last night they each had a beer and ate some peanuts while they watched TV.
    You review Ruth's folder and find that at age 5, Ruth was 42 inches tall and weighed 50 pounds and at age 14 she was 62 and 1/2 inches tall and weighed 145 pounds.  Rith's pregnancy and Cindy's birth were normal. Her pre-pregnancy weight was 155 pounds and she gained 25 pounds during the pregnancy. At her 6 week postpartum visit she weighed 165 pounds and she felt that she was steadily losing weight and had no worries about regaining her pre-pregnancy weight.
    At this visit you note that the nurse has recorded a weight of 170 pounds.  The rest of the exam is unremarkable.


Treatment:

Goals:  Ideal Body weight

Diet:
Energy Requirements

Composition
Comparison of SlimFast and Instant Breakfast

Exercise: