Case studies

The following case studies outline relevant dietary advice relating to a number of health conditions. They have been developed by Cirrus Media in consultation with independent medical advisors and Accredited Practising Dietitians.

  • Case study: Investigation of spasms in overweight patient

    Case study

    John, aged 52, presents for a routine health check. He’s overweight so you ask him to elaborate about his diet. He mentions he has cut dairy and wheat products from his diet saying they make him feel unwell. He’s also trying to lose weight, and get fit and healthy which have also contributed to his decision to cut dairy. What’s your advice to John?


    After a taking a complete medical history, determine how long John has been avoiding wheat and dairy, if he is now symptom-free and what symptoms he felt after eating these foods. Ask if there are any other foods he avoids. He may have developed a gluten intolerance or Coeliac Disease with a secondary lactose intolerance.

    The Australian Bureau of Statistics 2014 Australian Health Survey1 reported that dairy intolerance affects just 4.5% of Australians, and gluten intolerance 2.5% but investigations can be undertaken to rule these out for John.

    Coeliac serology blood tests and small bowel biopsy can diagnose Coeliac Disease, although depending on how long he has removed gluten from his diet, these tests could result in a false negative. John would need to reintroduce gluten in his diet before these investigations are undertaken.

    Since dairy and wheat also contain FODMAPs, (Fermentable Oligosaccharides, Disaccarides, Monosaccharides and Polyols), which may not be digested in the small intestine and travel to the large intestine causing Irritable Bowel Syndrome (IBS) symptoms, it may be worth investigating fructose and lactose intolerance by referring John for a hydrogen breath test.

    John should be referred to an Accredited Practising Dietitian regardless of the test outcomes for a thorough diet history and to help John develop a healthy eating plan to achieve his weight loss goals while providing nutrient adequacy. A food and symptom diary will also prove useful during this time.

    A gluten-free or low-FOPMAP meal plan is more complex especially since gluten-free diets can be low in fibre and high glycaemic index (GI) which may impact his risks of other chronic diseases such as type 2 diabetes and heart disease.

    Once symptom-free, a gradual reintroduction of wheat and dairy foods independently of each other may also help determine the level of tolerance. Whether or not he has lactose intolerance, he still needs to meet his daily calcium requirement of 1000mg per day (2½ serves of dairy), where one serve equates to one cup of milk, two slices of cheese or ¾ of a cup of yoghurt) 2. Or low-lactose options may be better tolerated, for example, low-lactose milk, hard cheeses and yoghurts.

    For weight management a reduction in total energy of the diet is required although total removal of dairy is not recommended. The Australian Dietary Guidelines state: “The evidence suggests that consumption of dairy foods is not associated with weight change or risk of obesity in adults, and consumption of milk is not associated with BMI. Total energy intake is always important in weight management.2

    Further, “consuming adequate amounts of milk, cheese and yoghurt each day is associated with a reduced risk of ischaemic heart disease, myocardial infarction, stroke, hypertension, metabolic syndrome and type 2 diabetes2

    The Australian Health Survey found 35% of energy intake comes from discretionary food choices 3 generally high in fat, salt and sugars – energy dense but nutrient poor. Removal of these foods from John’s diet and replacing them with whole foods – fruits, vegetables, legumes, wholegrains, nuts, seeds, lean animal protein and dairy foods – will reduce John’s energy intake while also improving the nutritional adequacy of his diet and may make him better feel.

    Another point of investigation may be the functioning of his gall bladder and impacts on fat absorption / malabsorption.

    Exercise and stress management need to be addressed as they too may assist to relieve IBS symptoms.

    Suggested GP management tips

    • • Suggest appropriate tests to determine if intolerances are real or perceived.

    • • Determine John’s gut symptom history and what other foods he avoids, for example, high fat foods, spicy foods.

    • • Emphasise the importance of eating foods from each of the five food groups to achieve adequate nutritional intake, and explain the dangers of cutting out entire food groups like dairy or wheat – chronic disease risks.

    • • Suggest swapping discretionary foods for healthy whole foods to reduce energy intake and improve diet quality.

    • • Dispel the myth that dairy foods cause weight gain and reinforce that reduce fat dairy may be better accepted than low fat dairy – many men will avoid milk altogether if they have to use low-fat milk.

    • • Even if John is lactose intolerant, he may tolerate some dairy food spread throughout the day or could try lactose-free dairy foods to ensure nutrient adequacy of calcium and other bone-building nutrients

    • • Suggest he exercise regularly, accumulating an hour of activity a day to help with weight loss and potential gut symptoms. Referral to an exercise physiologist may help.

    • • Refer to an Accredited Practising Dietitian for further practical advice around making dietary changes.




    1 Australian Bureau of Statistics (2014) Australian Health Survey 2011-13Canberra: Australian Bureau of Statistics.
    2 National Health and Medical Research Council (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.
    3 Australian Bureau of Statistics (2014) Australian Health Survey 2011-13Canberra: Australian Bureau of Statistics

  • Case study: Managing lactose intolerance post-gastroenteritis

    In a series of case studies for GPs, a patient’s stomach cramps and diarrhoea after an overseas trip could be the result of gastroenteritis-induced lactose intolerance.

    Madeleine is a 22-year-old student in her last year studying psychology at university. Madeleine exercises regularly, eats a diet high in fruit and vegetables, doesn’t smoke and usually only drinks alcohol one night a week. A year ago she travelled in South America and had an episode of gastroenteritis. For a number of weeks after her trip she developed stomach cramps and diarrhoea whenever she drank milk and has avoided any dairy since. She tried calcium supplements but they cause constipation. Madeleine asks you about lactose intolerance and whether she should be tested. What do you say?


    The first priority would be to rule out temporary lactose intolerance post-gastroenteritis, says Accredited Practising Dietitian Simone Austin.

    “Often patients are temporarily lactose intolerant until the villi repair themselves. Gastroenteritis affects the top part of the villi which then regenerate and are normally OK, so I would expect her to get over her lactose intolerance over time.”

    Madeleine should gradually reintroduce dairy, says Ms Austin.

    Start by re-introducing milk to a level Madeleine can tolerate and consider lower-lactose dairy such as hard cheeses and yoghurt (see examples and practical tips below). If Madeleine’s symptoms return after re-introducing dairy, consider a Hydrogen Breath Test to determine true lactose intolerance.

    If Madeleine does have true lactose intolerance, she should still be able to tolerate 200ml of milk spread out across the day. Hard cheeses contain virtually no lactose and yoghurt has good bacteria, which helps to digest the lactose. There are also lactose-free dairy foods available. By gradually re-introducing dairy foods into her diet, she will be able to achieve her minimum daily calcium requirement of 1000mg which is important at this age to maintain bone density.

    It is recommended women aged 19-50 years consume at least 2½ serves per day from the dairy food group. A serve of dairy equates to one cup of milk, two slices of cheese or ¾ of a cup of yoghurt.1

    Management tips

    • Gradually reintroduce dairy foods by starting with lower lactose-containing varieties such as hard cheeses and yoghurt, says Ms Austin.

    • Spread dairy intake across the day, for example, by adding some milk to cereal and a slice of cheese to a sandwich.

    • Suggest Madeleine experiments with lactose-containing foods to determine her tolerance level.

    • Suggest probiotics as well as prebiotics (fibrous fruits, vegetables, grains and legumes) to restore gut flora.

    • Also advise regular weight-bearing exercise and vitamin D intake to maintain bone density.

    • Refer patient to an Accredited Practising Dietitian further practical advice around making dietary changes. For a directory of dietitians, visit


    1 National Health and Medical Research Council (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.

  • Case study: Post-menopause diet tips to offset risks from teen years

    Case study

    Julie, aged 50, hasn’t had a period in six months. Menopausal symptoms are confined to occasional hot flushes and sleeping difficulties. You discuss HRT, but Julie isn’t interested in taking hormones, claiming she can tolerate her symptoms. As a young adult, Julie was a keen ballet dancer and trained four days a week. She was amenorrhoeic for two years from age 16. She still exercises regularly and has a BMI of 21. She wants to know what changes she should make to her diet to ensure she is healthy post-menopausally.


    Julie’s two years of amenorrhoea as a teenager puts her at high risk of poor bone health and may have significantly increased her fracture risk, says Professor Kerrie Sanders, a musculoskeletal and nutrition specialist at the Australian Catholic University’s Institute for Health & Ageing. This risk of osteoporosis and bone fracture is then compounded by a decrease in female hormones after menopause.

    “I would be recommending investigating this with a DXA scan, even though at age 50 she would not be eligible for the Medicare rebate. However it would be great to know her bone density at the beginning of menopause as, if it’s low, then her five- to 10-year fracture risk would be quite high,” she says.

    If her DXA shows she’s not yet osteoporotic, dietary attention is most appropriate.

    Julie should also be encouraged to complete a food diary for a week and compare what she is eating with the Australian Dietary Guidelines, paying attention to the portion sizes of the foods consumed, says Associate Professor Lynn Riddell from Deakin University’s Centre for Physical Activity and Nutrition Research (C-PAN).

    “Most Australians consume many more servings of extra foods than recommended, too few vegetables and fruit, and choose refined cereal and cereals products more often than wholegrain. Identifying a couple of changes that Julie can make to her diet each day to better align her intake with these guidelines will help to maintain her health post-menopausally,” she says.

    It is particularly important that Julie should be advised about adequate dietary calcium and vitamin D intake to maintain her bone health. Calcium requirements increase for women aged over 50 from 1000mg per day to 1300mg per day, which is reflected in an increase in dairy food group recommendations –from 2 ½ to 4 serves per day. A serve of dairy equates to one cup of milk, two slices of cheese or ¾ of a cup of yoghurt.1

    The daily calcium requirements for women at age 50 are the same as at 80 - and higher than the daily recommended amount for women who are pregnant and breastfeeding.

    Suggested GP management tips

    • • Explain to Julie the importance of building bone density during adolescence and stress that her amenorrhoeic years make it even more crucial to minimise loss of bone density post-menopausally.

    • • Given her relatively low BMI, discuss her calcium and protein intake to ensure she is meeting her daily requirements and is not likely to become underweight.

    • • Explain the benefit of calcium derived from whole foods over calcium supplementation. Dairy foods contain calcium that is more readily absorbed than other sources and also offer other important nutrients including protein, potassium and magnesium, says Accredited Practising Dietitian Milena Katz.

    • • Encourage Julie to aim for four serves of dairy in her diet daily. This could include adding yoghurt to her regular breakfast cereal, adding a slice of cheese to a sandwich or making a smoothie for a snack.

    • • If Julie is concerned about weight gain, reassure her that consumption of milk, cheese and yogurt is not associated with weight change, even regular fat varieties.1

    • • Discuss Julie’s vitamin D requirements and suggest she follow the recommendations for adequate vitamin D absorption suggested by Osteoporosis Australia (visit

    • • Suggest she continue to exercise regularly, but add some weight training to build bone strength.

    • • GPs can refer patients to an Accredited Practising Dietitian for further practical advice around making dietary changes. For a directory of dietitians, visit


    1 National Health and Medical Research Council (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.

  • Case study: Five practical tips to reduce nutrition deficiency in toddlers

    In the first of a series on how to tackle troubling nutrition cases that present routinely in general practice, accredited dietitians answer GP questions on what advice to give patients and give tips on how to promote compliance.

    Case study: Molly is a first-time mother and presents with her two-year-old son Billy, who is a fussy eater. Despite Molly’s efforts to vary Billy’s diet, he rejects most offerings and is surviving on a diet of juice, vegemite toast, chicken nuggets, sausages and noodles. Molly asks for advice on what nutrients he is missing and suggestions about which foods she should be encouraging him to eat and how.

    For a fussy toddler presenting to the GP, Accredited Practising Dietitian Kellie Bilinski recommends the following:

    1. Offer new choices at every meal: Introduce a small amount of one new food at a time. Even if the child refuses initially, parents should persist in offering the food.  Toddlers eventually try new foods when they become more familiar and typically require repeated exposure – up to eight times – to develop a taste for new foods. Encourage trialling nutrient-rich foods from the five food groups, including different fruits, vegetables, dairy foods, grains and lean meats and their alternatives.

    2. Look for creative ways to incorporate nutrient-rich foods: Think laterally, for example, introduce a slice of cheese to the vegemite toast, offer a flavoured yoghurt or milk drink to replace the juice, or sprinkle grated cheese on the noodles. Dairy foods are generally palatable to young children and are a good source of many essential nutrients including readily absorbable calcium, protein, iodine, vitamin A, vitamin D, riboflavin, vitamin B12 and zinc.

    3. Cut back on undesirable foods: The child may be refusing new foods as they are filling up on the juice, sausages, noodles and nuggets. “Don’t let him think if he doesn’t eat something he will get nuggets later on,” says Ms Bilinski. Sometimes it can be motivating for children if they know that eating certain foods will help them “grow big and strong”. For example, eating foods like milk, cheese and yogurt will help them build strong bones so they can run, jump and play.

    4. Role modelling: Parents are role models and can shape their children’s dietary habits. For example, milk drinking mothers are more likely to have milk drinking daughters. Encourage parents to practice what they preach because if kids see their parents eating healthy foods, they’re more likely to do the same.

    5. Give patients information: Information on a toddler’s nutritional requirements is available at An Accredited Practising Dietitian may provide further advice about incorporating nutrient-rich foods into a toddler’s diet.

    Ms Bilinski says a limited diet, such as Billy’s, is lacking in the nutrients essential for adequate growth and development at this age.

    According to the Australian Dietary Guidelines1, children need sufficient nutritious foods sourced from a wide variety of foods from the five food groups.  At age two, the guidelines recommend the following:

    • • 2.5 serves of vegetables and/or legumes per day

    • • 1 serve of fruit

    • • 4 serves of grain (cereal) foods

    • • 1 serve of lean meats/fish/poultry and their alternatives

    • • 1.5 serves of dairy foods. One serve of dairy equates to one cup of milk, two slices of cheese or three quarters of a cup of yoghurt.

    These quantities grow as children grow. Offering children the recommended amounts from the five food groups and limiting junk foods that are lower in essential nutrients and likely to be higher in saturated fat, added sugars and added salt, may also reduce the future risk of chronic diseases such as heart disease, type 2 diabetes, obesity and some cancers. Establishing healthy eating habits at this age is an important way of ensuring dietary quality over the lifetime.

    GPs can refer patients to an Accredited Practising Dietitian for further practical advice around making dietary changes. For a directory of dietitians, visit



    1 National Health and Medical Research Council (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.

  • Case studies: The importance of dietary calcium for women

    Case study 1: Margaret

    Margaret, aged 63, recently tripped on her rake while gardening and suffered a Colles' fracture. You consider this to be a minimal trauma fracture. You commence Margaret on denosumab and question her about her vitamin D and calcium intake. Margaret said she gets plenty of sunshine, gardening any spare minute and playing tennis twice a week. She says she has avoided dairy food over the past 15 years or so as it made her feel bloated and gave her wind. She self- diagnosed lactose intolerance. She takes calcium supplements intermittently, but finds these make her constipated.

    What would you advise Margaret about her current calcium intake?

    What are some suggested strategies for Margaret to increase her calcium?

    Sharon Natoli, Accredited Practising Dietitian, Food & Nutrition Australia (

    Self diagnosing lactose intolerance is a frequent issue that can contribute to patients cutting out all types of dairy foods therefore limiting their intake of dietary calcium, along with a range of other nutrients including protein, iodine, riboflavin and vitamin B12.  One of the associated risks with this behaviour is that if a patient’s symptoms are not a result of lactose intolerance, this practise can delay diagnosis of other conditions. It is therefore important that lactose intolerance is confirmed with a hydrogen breath test before a dairy exclusion diet is adopted. If a patient is confirmed as being lactose intolerant, moderate evidence1 suggests 12-15g lactose (about 1 cup of milk) can be tolerated by most people daily, particularly if this is spread out over the day. Lactose free dairy products are also readily available and provide the same nutritional benefits as standard dairy.  Recommendations for women such as Margaret who fall in the 51-70 year age bracket are to consume four serves of dairy a day to assist in meeting calcium requirements2. One serve is one cup (250ml) milk, 200g yoghurt or 40g cheese.  Margaret will also benefit from a review of her vitamin D status with appropriate recommendations made regarding dietary intake and/or supplements pending the test results.



    1 Shaukat, A., et al. Systematic review: effective management strategies for lactose intolerance. Ann Intern Med 152, 797-803 (2010).

    2 National Health and Medical Research Council. Australian Dietary Guidelines.  (Commonwealth Department of Health and Ageing, Canberra, 2013).

    Case study 2: Olivia

    Olivia is a fifteen year old patient, whom you have seen since she was a baby. Over the past six months, her periods have become irregular, and when they do come, they are lighter. She is sleeping well. Her BMI is 27. She started jogging 10 months ago in order to get fit. She is jogging at least four times a week, up to five km. You question Olivia about her dietary intake, and she claims that she eats plenty of fruit and vegetables, eats meat a few times a week, but has recently stopped eating dairy foods as part of her weight loss program.

    What advice do you give Olivia regarding her lighter, irregular periods? 

    What advice do you give Olivia regarding weight loss strategies?

    How do you explain the importance of calcium intake, particularly for long term bone health?

    Sharon Natoli, Accredited Practising Dietitian, Food & Nutrition Australia (

    Olivia’s case notes indicate that in an attempt to lose weight, she may have adopted dietary habits which are too restrictive and which may in turn be affecting her health. At this time of life, girls often become more body conscious and may adopt weight loss strategies based on word of mouth from friends or advice heard through the media. Dairy and grains are the food groups most frequently cut out of fad style weight loss diets, and this is a concern given calcium intakes increase to 1300mg/day during adolescence3. The latest Australian Health Survey4 found nine in 10 girls in the 14-18 year age group have inadequate dietary calcium intakes which is a concern given this is a time of significant bone accrual.  Olivia would benefit from professional advice about how to adopt a healthy balanced diet that focuses on maintaining her intake of fruit and vegetables while ensuring she also includes sufficient foods from other core food groups including dairy (3½ serves daily), grains (7 serves daily) and meat/alternatives (2½ serves daily). Advice around appropriate serving sizes and how to prepare healthy meals and snacks will assist her to meet nutritional requirements while managing her overall kilojoule intake to achieve stabilisation of her weight along with an improvement in her health as she grows.



    3 National Health and Medical Research Council. Nutrient Reference Values for Australia and New Zealand including Recommended Dietary Intakes, (NHRMC, Canberra, 2006).

    4 Australian Bureau of Statistics. Australian Health Survey: Nutrition First Results - Foods and Nutrients, 2011-12  (ed. Australian Bureau of Statistics) (Canberra, ACT, Australia, 2014).


  • Article: Diet rethink – boosting calcium in the elderly

    The second in a series of nutrition case studies for GPs, experts share tips for a diet rethink in aged patients to boost calcium intake. 

    Case study: Alice is a 78-year-old grandmother who was diagnosed with osteoporosis a few years ago after a compression fracture of a thoracic vertebra. She was commenced on an oral bisphosphonate but eight months ago this was changed to six-monthly injections of Denosumab. You check her bone density and it appears to have deteriorated marginally in the past 12 months, despite improving up until then. Alice is supposed to be on a calcium and vitamin D supplement but admits she often forgets. She asks you how to supplement her calcium adequately given that she doesn’t like drinking milk.


    Marginal deterioration of bone density is not clinically meaningful and is unlikely to increase Alice’s fracture risk, says Professor Kerrie Sanders, a musculoskeletal, nutrition and health economics specialist at the Australian Catholic University’s Institute for Health & Ageing.

    However, it is important for Alice to obtain the recommended daily calcium intake for her age: 1300mg a day, or four serves of dairy. A serve of dairy equates to one cup of milk, two slices of cheese or ¾ of a cup of yoghurt.1

    “During this age span, supplemental forms of calcium and vitamin D are the most effective strategies to improve bone health, so I would discuss strategies with the patient that would assist her in remembering to take these supplements.

    In addition to this, dairy products such as cheese and yoghurt are also very useful sources of calcium,” says Associate Professor Lynn Riddell from Deakin University’s Centre for Physical Activity and Nutrition Research (C-PAN).

    Dietary calcium is preferable to calcium supplementation for several reasons. The calcium derived from dairy foods is more readily absorbed and requires a smaller amount of food intake to meet daily requirements than other calcium-containing foods such as broccoli and almonds – an important factor for the older adult whose appetite may be reduced.

    Whole foods such as dairy also provide a range of other nutrients essential for bone health including protein, phosphorus and magnesium.

    In addition, the Australian Dietary Guidelines suggest that consuming adequate amounts of milk, cheese and yoghurt each day may have cardiovascular benefits including a reduced risk of high blood pressure, heart disease and stroke.1

    Professor Sanders recommends if Alice is unable to derive adequate calcium from her diet due to potential food aversions or a small appetite, supplementation of 500mg/day should be considered, with the remaining daily calcium requirement to be derived from calcium-containing foods where possible.

    Protein is also important for overall repair and maintenance of the body so adequate intake is important. And since one in two women of this age in Australia has low vitamin D status, it is also important for Alice to maintain her vitamin D supplementation.

    “If she is taking 500mg/day of calcium I would add 800-1000Iu vitamin D per day,” says Professor Sanders.

    Five management tips for GPs

    1. • As with all older adults, ask questions to gain a full picture of Alice’s nutritional intake, says Accredited Practising Dietitian Simone Austin. Why doesn’t Alice like milk? Does she feel the same way about yoghurt or cheese?

    2. • Discuss other dietary sources of calcium including salmon, broccoli, tofu, fortified breakfast cereals and breads, and fortified soy milk. Highlight the poorer absorption and larger volumes generally required of these foods to get the same calcium as dairy foods.

    3. • Discuss ways of incorporating dairy foods into Alice’s existing diet, for example by adding a slice of cheese to a sandwich, having rice pudding made with milk, or custard for dessert, drinking milky coffee and tea, eating milky soups made with evaporated milk, or adding milk powder to cakes and scones.

    4. • Suggest small, regular intake of protein containing foods, which is important for maintaining muscles as well as overall repair and maintenance of the body. Ideas include snacking on cheese and biscuits or nuts, and trying to add protein sources to meals like natural yoghurt stirred through soups and cheeses such as cheddar or parmesan in salads. Mince is also an effective source of protein and appropriate for older patients who might have difficulty eating.

    5. • Talk to Alice about the importance of weight-bearing exercise to strengthen her bones and suggest she roll up her sleeves in the sunshine and follow the recommendations for adequate vitamin D absorption suggested by Osteoporosis Australia

    GPs can refer patients to an Accredited Practising Dietitian for further practical advice around making dietary changes. For a directory of dieticians, visit



    1 National Health and Medical Research Council (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.