Case Study: Damien Jackson

Damien Jackson is a 33-year-old black male who is overweight (BMI: 28.7) and has hypertension and gout. He has not had a regular health care provider in in 15 years and has been addressing his health in the interim by going to urgent care centers when he needs new prescriptions or if he has an acute problem. After getting information from Damien, the first issue (apart from refilling his hydrochlorothiazide, diltiazem, and allopurinol) to address is his immunizations. 

Immunizations: Damien’s weight and hypertension put him at risk for diabetes and heart disease, which put him at risk for complications of the flu. For this reason (and because it is flu season), Damien should receive the influenza (inactivated or recombinant) vaccine. Damien should also receive a Tdap booster because I assume that he has not received one in 15 years if he only sees a provider for prescriptions and acute problems. He can also receive hepatitis A and hepatitis B vaccines if he wants protection (he has no indicating risk factors).

Diet: The next most important item to be addressed is Damien’s diet. Given what he shared with me about his typical eating habits, I found many areas of concern that should be addressed. Depending on the meat he eats, I would modify his diet to limit red meat and include more lean meat. Damien drinks 1 gallon of full fat milk a day, so his diet should be modified to significantly limit dairy. If/when he does consume dairy, he should choose low-fat sources. Damien did not mention any consumption of fruits or vegetables, so his diet should be modified to include more fruits, non-starchy vegetables, dried beans, and legumes. Damien likes pastries, which are typically processed grains that are high in trans fats, saturated fats, cholesterol, added simple sugars, and refined carbohydrates. His diet should be modified to consume much less pastries, especially given his weight and risk for diabetes or heart disease. Damien also mentioned that he drinks alcohol very rarely, so modification to his diet in this regard is minimal. Based on my assessment of Damien’s diet and the modification goals I think should be made, I would outline the following plan:

• When he goes to the supermarket and is purchasing his meat, he should purchase meats that are low in fat. His shopping cart should include: white-fleshed fish, chicken breast, round/chuck/sirloin/tenderloin beef, and 90% lean/10% fat or higher ground beef.
• When he is cooking, he should trim and skim any fat, use low-fat cooking methods (e.g. steaming, grilling, poaching, baking, and broiling), and use spices instead of fats (e.g. butter, oils). 
• Stop drinking 1 gallon of milk and limit dairy to lower-fat sources (e.g. reduced fat, skim milk, cottage cheese, low-fat/reduced-fat yogurts without added sugars [even the ones with “fruits” added at the bottom!]). Additionally, find ways to replace dairy (e.g. oat milk without added sugars, hazelnut milk without added sugars).
• Eat two or more servings of fresh (not packaged or dried) fruits every day. I would recommend that Damien eat them as snacks, as toppings on breakfast meals, in salads (this might inspire him to explore more ways to make the salads he says he enjoys), and as desserts.
• Consume “leaves and greens” (vegetables) at every meal: in smoothies for breakfast (spinach is great and tasteless!), in soups (but be mindful about salt content), in salads, baked as snacks, as a side to dinners, etc. Like meat, vegetables are another food group with which he can get creative and healthy with spices.
• Limit sugary pastries by: replacing them with fruits or vegetables, and by consuming more fiber-rich and lean protein-rich meals throughout the day to increase satiety longevity.
• Replace refined carbohydrate sources (the pastries, any white breads, white rice) with more complex carbohydrates (oatmeal, brown rice, brown breads).
• Continue being mindful and limited with his alcohol intake.

Exercise: As a supplement to diet, I also want to address Damien’s physical activity. According to the CDC’s current guidelines, individuals should get 150mins/week of moderate-intensity aerobic activity or 75 mins/week of vigorous–intensity and a muscle-strengthening activity that involves all major muscle groups > 2 times/week (CDC). Based on these guidelines and the information Damien provided, he does not get adequate exercise. However, Damien did mention to me that he wants to get more exercise, which makes crafting an exercise plan an easy conversation to have. I would recommend that Damien begin with a few minutes of physical activity per day and slowly increase slowly to 30mins. For example, he can start with intentional walking for 10min each day, then gradually increase to 30min each day. When that becomes habitual, he can swap one day of walking with 15min of a moderate-intensity activity (and eventually work up to 30) and one day of walking with a muscle-strengthening activity. If Damien finds intentional walking each day difficult, I would suggest incorporating physical activity into his normal routine (e.g. running around with his son at park while he is on the tricycle, playing basketball with his son, playing basketball more often with his friends or finding a neighborhood group, park further from grocery store if he has access to a car, walk to get takeout if he does ever get takeout).                                 

Screening: There is no clinical preventative screening indicated for Damien at this time given his risk factors and age. Even though he smokes, he is not of age for lung cancer screening as recommended by United States Preventive Services Task Force (USPSTF).

Injury prevention: Given Damien’s age, extracurricular activities, and occupation, the injury prevention concerns I think are most important to discuss with him are:

• Traffic safety
• Burn prevention
• Sports safety
• Falls prevention

Brief intervention: Damien smokes about 4 cigars a week. As I consider his medical history and current diet, this is also very important to address. I could not find any information on how cigars translate to a pack-year calculation, and I don’t know for how long Damien has smoked cigars, but I would still counsel him on quitting. A brief intervention would look like:

• At this first appointment, I would say to Damien, “So you told me you smoke about 4 cigars a week. Are you interested in getting help with how to quit?”
  • If he says no, I would reply, “Ok, if you ever change your mind, I would be happy to help. You can come right back to me here, or I can give you contact information for a more intensive treatment program.”
  • If he says yes, I would reply, “Great! I know you already provided me with some information, but I’m going to ask some questions that might require you to repeat some of the things you’ve already told me so that we can create a good quit plan.” I would then ask: “What kind of tobacco do you use?”, “Do you smoke anything other than cigarettes?” “Do you use smokeless tobacco?”, “Are there any events or triggers that you think usually prompt you to smoke or grab a cigar with friends?”, “Are there any factors or situations – even things like certain moods you may be in – make you want to smoke?”, “Have you ever tried to stop smoking? If so, how did that work and how long did it work?”.
    • Then together, Damien and I would establish an exact quit date and time and develop a plan by preparing his physical and mental environment (e.g. throwing away current unfinished cigarette packs, downloading phone apps that can help him quit), choosing a method or combination of methods (e.g. tobacco cessation medications), choosing a pharmacy, developing relaxation strategies, exploring other coping mechanisms for stress, etc. 

Harm reduction: Lastly, although Damien and I created a smoking plan, I recognize that it might not be realistic for him to stick to the recommendations as prescribed. In those situations, I might recommend harm reduction actions that lessen the negative consequences associated with his smoking, such as nicotine replacement patches or e-cigarettes.

References:

Centers for Disease Control and Prevention. (2022, June 2). How much physical activity do adults need. Centers for Disease Control and Prevention. Retrieved November 22, 2022, from https://www.cdc.gov/physicalactivity/basics/adults/index.htm