Summative Question:

Overview: Analysis of a pre-set diet using a reputable software tool for a multi-symptomatic moderately obese individual followed by a critical evaluation of a personalised nutritional intervention that takes account of government guidelines, the use, selection and interpretation of anthropometric and laboratory assessments and a reflection on the potential difficulties individuals with complex pathology might encounter with implementing and sustaining diet and lifestyle change. 

Learning Outcomes for this assignment:

LO 1: Critically evaluate nutrient requirements for individuals with complex symptoms and obesity taking government guidelines and concepts of optimal nutrient intakes into account : Extensive critical evaluation, demonstrating capacity to synthesise

and critique the literature to justify the recommendation; highly appropriate and salient use of evidence to  justify nutritional strategy taking government guidelines and concepts of optimal nutrient intakes into account together with dietary analysis. Succinctly written. Well considered in terms of client’s aims and objectives i.e. weight loss.  Offers a clear narrative that is appropriate for the particular client in light of appropriate and best available evidence.

Good accurate analysis of diet using software tool and sensible assumptions made. Well-presented making appropriate use of tables to tease out key data from the analysis and embed within the report.  Clear and specific in relation to the guidelines that are used. 

Comprehensive use of appendixes to inform commentary.  Appendixes completed to an exceptional standard

LO 2: Offer resolution when data is conflicting and/or incomplete when meal planning for individuals with complex symptoms and obesity : Critically evaluates the literature in the context of client’s aims and objectives, shows awareness of the limitations of the evidence where appropriate and offers a clear & balanced discussion of the literature in key areas of intervention. Offers resolution to contradictory /incomplete data.  Exhibits excellent writing skills & capacity to discuss information in a concise & salient way, of a high academic standard.

LO 3: Justify and evaluate the use of diet and supplemental active ingredients based on client history, laboratory assessment, social, cultural, ethical and economic status for individuals with complex symptoms and obesity making a personalised approach transparent :

Excellent justification and well-argued discussions indicating where appropriate information on dosages and Upper Tolerable Limits. Clear, precise and scientific description on mechanisms contributing to obesity with very good critique of the scientific literature. Overall sharply defined, robust and balanced use of evidence to support client recommendations that have been well applied to the case.  Includes statistical detail (e.g. power of study, p values, effect sizes) where appropriate. 

Highly appropriate example diet and supplement recommendations. Excellent example diet & appendices completed to a highly professional standard. Good clear client centred food plans informed by report. Completed to an exceptional standard.  Supplement and DNI forms included. 

Instructions for the summative

Part A: Undertake a dietary analysis for the client and comment on your findings. Based on a review of the scientific evidence critically evaluate the macronutrient intake that you consider the most appropriate to recommend for this client in relation to their major aim and objective of weight loss.

Identify a micronutrient that you consider this client is at significant risk of deficiency and evaluate why you consider this to be the case.

(approx. 900 – 1000 words)

Additional points

• Use scientific evidence to support your analysis and recommendations & attempt to offer resolution when data is contradictory and/or incomplete. This may entail evaluating individual studies and synthesising research from different sources.  Be precise and succinct in your writing and where appropriate refer to an in depth analysis of the studies cited (e.g. type of study, any methodological problems, statistical detail etc). In evaluating the evidence on the new macronutrient intake that you consider appropriate for the client you may wish to focus your exploration on the ratio of protein, carbohydrates and fats in the new diet based on randomised controlled trials investigating the outcomes of different macronutrient ratios on appropriate subjects.  Note that you should only consider one micronutrient that you consider this client is at significant risk of deficiency and ensure that your exploration here is why you consider this to be the case.  Ensure that you keep focused on answering the question here. Within this section students normally use the larger part of the word count on the macronutrient section]

I have performed the analysis and based on the findings:

Low Protein Intake

Low vitamin D

Part B: Evaluate any implications of the GP results (fasting glucose, cholesterol (HDL, LDL, triglycerides, blood pressure).

The client visited the GP within the last month and had her lipids, glucose and blood pressure measured.  These are her results. (Based on UK Government Guidelines)

GP test results
Cholesterol	5.2 mmol/L. elevated
LDL	3.8 mmol/L.  elevated
HDL	0.8mmol/L.  lower
triglycerides	1.4 mmol/L  under the Reference range
Fasting glucose	5.9 mmol/L  elevated/pre-diabetic
Blood pressure	120/80mmHg -Normal

Critically evaluates test results referring to reference ranges set by appropriate guidelines with a high level of precision and evaluation. Excellent evaluation of the potential impact of nutrition plans on test results

Part C: Choose four key mechanisms from the mechanistic subheadings that you consider may be relevant to the client and their aims and objectives. Review each of the four mechanisms separately relating to the scientific literature and considering how the mechanism intersects with the client’s aims.  Choose one recommendation for each of the mechanism areas explored that you would make to the client.  This could either be a change to the client’ diet, lifestyle, a supplement or a functional test recommendation. Where you are recommending functional tests discuss one or two markers that you would deem appropriate.  Where you are recommending a diet, lifestyle change or supplement ensure that you are specific around dosages, form and quantities for your recommendations based on the scientific literature.

(approx. 2300 words for this whole section)

Additional points

• Use scientific evidence to support your analysis and interventions & attempt to offer resolution when data is contradictory and/or incomplete. Ensure that you select appropriate and relevant evidence to support your intervention. 
• Where appropriate ensure you include information on dosages.  If recommending supplementation ensure that your recommendations do not exceed Upper Tolerable Limits.
• Aim to relate the discussion to the client’s aims and objectives.
• Aim to approach the work with a good level of precision and offer a clear narrative in your application of your chosen mechanisms to the client.]

I have chosen:

Mechanism 1: HPA Axis Dysregulation and cortisol Activity

Interventions:

Mechanism 2: Blood Lipids and Hypercholesterolemia

Interventions:

Mechanism 3: Insulin resistance

Interventions

Mechanism 4: Beta Cell Dysfunction

Interventions:

Part D: In light of your review of the optimal macronutrient intake for this client alongside your exploration of the areas of the functional matrix critically evaluate the strengths and weaknesses of the government guidelines as they relate to the client.

Based on UK government guidelines (400 words)

Pointers for this Summative:

• Remember to keep the clients aims and objectives as a focus e.g. weight loss rather than discussing other areas of her health which she has not highlighted as a current priority to address

• It is good practice to define the type of study (e.g RCT, animal, meta-analysis) that you are referring to as this gives the marker a sense of the weight of the evidence that supports your point.
• Tables are not included in the word count but it is important not to “hide” word count in tables. As such tables are best used for summarising numerical data.
• Ensure that there is a flow or argument in your report.  From a writing perspective it can therefore be useful to use joining words at the start of sentences such as “furthermore” or “however” rather than using bullet points.
• Paragraphs should be on one topic perhaps around 4 – 6 sentences on average but obviously highly variable in length. Ensuring good paragraph construction improves the flow of the report and makes it clearer to read.
• Ensure that your interventions are based on human evidence.
• Be as precise as possible
• Try not to use text books as sources of evidence but refer to the original papers.  Similarly don’t reference the Natural Medicines Database but refer to the original papers.
• In the report section avoid non-scientific or emotional language such as “afflicting”.
• Always use the third person in the report rather than the “I”.
• The food plans 1,2, and 3 are client centred.  They should therefore be written in client friendly language.  They don’t need to be referenced but should reflect what you discuss in your report. 
• When discussing the evidence be critical and evaluative.  Also if you are discussing various bits of evidence ensure that you draw it all together and are clear in how this applies to the client; for example your discussion and analysis may culminate in a particular recommendation for the client.
• When analysing and critiquing the evidence base ensure that you report this as accurately, precisely and succinctly as possible.  It is important that you consider the appropriateness of the study design in relation to the point that you are making.  As a related point ensure that your extrapolation is appropriate.
• Please remember to use Harvard referencing for the summative.  The following website is very useful if you are unsure on referencing. http://libweb.anglia.ac.uk/referencing/harvard.htm
• Aim to ensure that your searches of the scientific literature are as non-biased as possible. The objective of the summative assignment is making a non-biased review and analysis of the scientific literature to inform recommendations for the case study.  At this point you are not making recommendations based on books you have read or lectures you have viewed but rather exploring the scientific evidence for yourself from scratch and making recommendations based on this.   Rather than assuming the recommendations that you are making for the client at the outset you need to review the scientific evidence and make your argument before concluding that you are going to recommend a particular intervention. 

How to write Mechanism and Intervention Example:

Example 1 mechanism

“Caffeine primarily promotes wakefulness by antagonizing A1 and A2A adenosine receptors (Ribeiro and Sebastiao, 2010) which play a putative role in sleep homeostasis. Blockage decreases stage 3-4 and EEG slow wave sleep (Roehrs and Roth, 2008), and chronic consumption may alter adenosine receptor function and A1/A2A balance (Ribeiro and Sebastiao, 2010).” 

Example 1 intervention

“It is recommended that caffeine consumption is stopped after 2pm, as caffeine has a 3-7 hour half-life (Roehrs and Roth, 2008), thus allowing adequate time to be cleared from the body.”

Example 2 mechanism

Assuming a client had come with the aim and objective of dealing with his IBS symptoms then one mechanism which could be explored might be the link between HPA axis dysregulation or elevated cortisol and IBS.

Example 2 intervention

Following on from the above mechanism exploring the link between stress and IBS, the intervention below focuses on meditation as a way of reducing stress.

“Control trials have shown that 8 weekly 2.5-hour sessions with one 7 hour session of learning and practicing meditation have shown to decrease morning salivary cortisol (d=0.35, p=0.04) (Brand et al., 2012), cortisol response to cognitive stress (d=2.780, p<0.05), and self-rated stress scores (d=0.926, p<0.05) (Bottaccioli et al., 2014). Additionally, a negative correlation exists between meditation experience and morning cortisol levels (r=-0.66, p=0.03), demonstrating longitudinal benefits (Brand et al., 2012). Furthermore, an RCT applying topical capsaicin (1%) to initiate an inflammatory response, observed meditators to have reduced inflammation compared to non-meditators (t=-2.98, p=0.005) (Rosenkranz et al., 2014).”

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