Michelle Hoffman
KNH 411
GI Case Study
1. How is acid produced and controlled within the gastrointestinal tract?
a. During the cephalic, gastric, and intestinal phase, the body secretes gastric
juices in order to prepare the stomach and small intestine for digestion.
The stomach is responsible for the secretion of gastric juices that aid in
processes such as protection of the mucosal lining and digestion.
Specifically, parietal cells are necessary to secrete hydrochloric acid (HCl)
and intrinsic factor, two important substances that aid in the breaking
down process. Intrinsic factor is needed in order to absorb vitamin B12
and HCl activates pepsinogen, which begins protein digestion. This also
inactivates salivary amylase, which controls carbohydrate digestion in the
mouth. There are three major chemicals that stimulate gastric secretions
that work to produce the HCl found in the stomach: acetylcholine,
histamine, gastrin. These act to increase the amount of H+ available to
form HCl within parietal cells. In order to inhibit gastric secretions, the
chemical messenger, somatostatin, is utilized. This occurs if the acidity
level in the stomach increases, causing the somatostatin to act on each
stimulatory mechanism to decrease gastric secretions.
i. Pg.’s 345-346, “Nutrition Therapy & Pathophysiology”
2. What role does lower esophageal sphincter (LES) pressure play in the
etiology of gastroesophageal reflux disease? What factors affect LES
pressure?
a. The LES is important because it transports the bolus from the mouth to the
stomach during digestion and then closes to prevent food from traveling
back up the esophagus once it enters the stomach. The LES is able to
close properly because normally the atmospheric pressure in the
esophagus is greater than it is in the stomach. When a person suffers from
GERD, however, the LES does not function correctly and gastric acid and
pepsin travel back up the esophagus causing various amounts of pain and
burning when the LES is relaxed. There are several factors that affect
LES pressure such as increased secretion of gastrin, estrogen, and
progesterone, having a hiatal hernia, obesity, cigarette smoking, various
medications, and diet. Obesity affects the pressure, especially, because of
the added stress on the stomach, thus lowering the pressure of the LES and
potentially causing a reflux in the esophagus.
i. Pg. 352, “Nutrition Therapy & Pathophysiology”
3. What are the complications of gastroesophageal reflux disease?
a. A major problem that may arise from GERD complications is Berrett’s
Esophagus, occurring when the epithelial cells of the esophageal mucosa
(the lining of the esophagus) are damaged from persistent HCl exposure.
The squamous cells are altered to metaplastic columnar and goblet cell
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ethithelium, which is dangerous because if gone untreated, can result in
esophageal cancer. Berrett’s Esophagus is particularly dangerous because
there are virtually no symptoms and the signs are only detected with a
biopsy.
i. Pg. 353, “Nutrition Therapy & Pathophysiology”
4. What is H. pylori and why did the physician want to biopsy the patient for H.
pylori?
a. Helicobactor Pylori is a bacterium that breaks down urea to create
ammonia in the stomach, neutralizing the acid in the area these bacteria
live in and allow them to survive in the environment. However, they also
produce proteins that damage mucosal cells, eventually causing Type B
Gastritis, or inflammation of the gastric mucosa. The physician wants to
perform an endoscopy with a biopsy on Mr. Nelson in order to rule out
this infection as a cause for his acid reflux and thus be able to effectively
treat his GERD.
i. Pg. 361, “Nutrition Therapy & Pathophysiology”
5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease.
a. Mr. Nelson’s primary signs and symptoms include increased indigestion
as well as heartburn. These are two of the major symptoms that if the pain
is persistent to the point of affecting daily functioning, one needs to be
evaluated by a physician as soon as possible.
6. Describe the diagnostic test performed for this patient.
a. In order to test for GERD and various complications for Mr. Nelson, his
pH levels were monitored for 24 hours using the Bravo pH Monitoring
System. He also had a barium esophagram as well as an endoscopy with
biopsy. pH monitoring involves placing a pH probe into the esophagus for
~24 hours, or long enough so a graph can be generated for one to
accurately read pH levels. An endoscopy (EGD) test involves placing an
endoscope from the oral pharynx down to the duodenum in order for a
physician to view the mucosa of the organs to see if there are any
abnormalities. Finally, a barium esophagram test was necessary because it
allowed for Mr. Nelson’s physician to inspect the patient from an x-ray
standpoint. This process involves drinking a barium/water mixture, and
under an x-ray, this outlines the pathway of the esophagus and is used as a
marker to help make out the lining of organs or tubes in the body, which
allows another way to view any abnormalities in the body, including
GERD.
i. Pg. 356, “Nutrition Therapy & Pathophysiology”
7. What risk factors does the patient present with that might contribute to his
diagnosis? (Consider lifestyle, medical, and nutritional factors.)
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a. Mr. Nelson has several risk factors that may be contributing to his GERD
diagnosis. First of all, Mr. Nelson is an obese individual, with a BMI of
31.7, putting a lot of pressure on the stomach. He is also physically
inactive (especially after his knee surgery), only exerting himself on the
weekends when he plays with his children. Mr. Nelson’s diet may also be
a factor. He admits that he eats fast food and fried foods, which worsens
his indigestion. In addition to fried foods, Mr. Nelson eats pizza when his
wife doesn’t cook dinner, another fatty and oily food. He generally drinks
1-2 bottles of beer per day, and this amount of alcohol may be contributing
to increased acid levels in the stomach. He also drinks large doses of
unsweetened iced tea, and the caffeine in iced tea may affect his diagnoses
as well. He drinks diet soda as well, and the carbonation may be
worsening his symptoms. Due to his family history of heart disease, he
takes aspirin and ibuprofen chronically, which may also influence the
development of GERD.
i. Pg.’s 105-106, “Medical Nutrition Therapy: A Case Study
Approach”
8. The MD has decreased this patient’s dose of daily aspirin and recommended
discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect
gastroesophageal disease?
a. Nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen, tend
to increase the severity of symptoms who have GERD as well as be the
cause of peptic ulcers due to the decrease in mucosal lining. Since Mr.
Nelson has been taking these drugs daily, it is important to decrease his
intake so as not to worsen his diagnoses.
i. http://www.umm.edu/altmed/articles/gastroesophageal-reflux000068.htm
9. The MD has prescribed lansoprazole. What class of medication is this? What
is the basic mechanism of the drug? What other drugs are available in this
class? What other groups of medications are used to treat GERD?
a. Lansoprazole can be classified as a Proton Pump Inhibitor, which blocks
the H+, K+-ATPase enzyme thereby suppressing HCl production. In
addition to Lansoprazole, other PPI’s include omeprazole, pantoprazole,
rabeprazole, and esomeprazole. In addition to PPI’s, other drugs used to
treat GERD include antacids, foaming agents, H2 Antagonists, and
Prokinetics. Antacids use different combinations of magnesium, calcium,
and aluminum with hydroxide or bicarbonate ions in order to neutralize
HCl. Foaming agents also use different combinations of magnesium,
calicium, and aluminum. Although they should only be used for shortterm relief, H2 Antagonists block histamine receptors in parietal cells,
decreasing the production of acid in those cells. Finally, Prokinetics aid in
strengthening the phyloric sphincter and increase the speed of gastric
emptying. One should be careful with these drugs because they tend to
have frequent side affects.
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i. Pg. 353, “Nutrition Therapy & Pathophysiology”
10. Are there specific foods that may contribute to GERD? Why or why not?
a. There are some foods that one shouldn’t consume once the symptoms of
GERD begin to set in because they tend to worsen symptoms. These
foods include coffee, pepper, alcohol, chocolate, mint, foods high in fat
(including some dairy products), carbonated beverages, and spicy foods.
Coffee, pepper, and alcohol are all known to increase gastric acid
production, and chocolate, mint, and fatty foods may possibly lower the
pressure of the lower esophageal sphincter, which makes the possibility of
reflux more likely.
i. Pg. 354, “Nutrition Therapy & Pathophysiology”
11. Summarize the current recommendations for nutrition therapy in GERD.
a. The nutrition therapy recommendations for those diagnosed with GERD
are very important to follow because it’s possible for the symptoms to be
reversed. First the patient must be assessed: there are lifestyle factors,
such as diet, smoking habits, and physical activity that may influence if a
person is suffering from GERD. It’s common that patients diagnosed with
dysphagia, have excessive fat intake, are obese/overweight, or take certain
medications suffer from GERD as well, and should be analyzed for these
diagnoses. Once a person is assessed and diagnosed with GERD, the
proper nutrition intervention involves making changes to decrease gastric
acidity and restrict certain foods from the diet. As mentioned, the patient
should avoid coffee, pepper, alcohol, chocolate, mint, foods high in fat
(including some dairy products), carbonated beverages, and spicy foods
because most claim that their symptoms are ameliorated once these foods
are cut from their diet. The patient should also consume smaller and more
frequent meals so the stomach doesn’t have to work as hard to create more
stomach acid. If obese or overweight, one should increase their physical
activity levels and consume a well-balanced diet to lose weight. Finally,
there are several medications the patient may be prescribed in order to
lesson the reflux symptoms such as antacids, foaming agents, H2
antagonists, PPI’s, or prokinetics.
i. Pg. 353-354, “Nutrition Therapy & Pathophysiology”
12. Calculate this patient’s percent UBW and BMI. What does this assessment of
weight tell you? In what ways does this contribute to his diagnosis?
a. In order to calculate Mr. Nelson’s BMI, one must know his weight and
height:
b. BMI= weight (lbs)
height (in.) x height (in.) x 704.5
c. Height: 5’9”, Weight: 215 lbs
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215 lbs
69 in. x 69 in. x 704.5
=31.8 kg/m^2
d. In order to calculate Mr. Nelson’s UBW, one must know his usual body
weight and actual body weight
e. %UBW= (100 x actual weight)
usual body weight
Mr. Nelson’s usual weight is 180 lbs, but due to his nutrition history
report, he claims he has gained ~ 35 pounds after his knee surgery, and
currently weighs 215 lbs.
f. %UBW= (100 x 215 lbs)
180 lbs
=119%
g. According to charts, Mr. Nelson is considered obese since his BMI is >30
mg/m^2. Obesity is a risk factor for GERD because when one is
overweight or obese, they have a large amount of fat in their abdomen,
increasing the severity of their symptoms. Excess fat may also compress
the stomach causing reflux. There have been studies that show a link
between obesity and esophageal cancer.
i. http://www.webmd.com/heartburn-gerd/news/20050801/obesityacid-reflux-disease-linked
h. Mr. Nelson’s percent usual body weight (%UBW) may contribute to his
diagnosis because the excess weight he put on (35 lbs) contributed to his
rising BMI, and it’s known that GERD may be triggered by weight gain.
According to a study in the New England Journal of Medicine, even
relatively small changes in weight can increase the severity of GERD
symptoms and complications.
i. http://www.everydayhealth.com/gerd/preventing-gerd/changes-inbody-weight-gerd.aspx
13. Calculate energy and protein requirements for Mr. Nelson. Identify the
formula/calculation method you used, and explain the rationale for using it.
a. In order to calculate Mr. Nelson’s energy requirements, his total energy
expenditure must be calculated using the Mifflin St. Jeor equation for
men. The reason for using this equation versus the Harris Benedict
equation is because it’s a newer method that has been validated in over ten
studies in the past decade. Therefore, the accuracy seems to be more
legitimate. This equation is also tailored to his physical activity level,
which is 1.12 for low-active (only active when plays with his kids on the
weekends), weight, and gender.
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b. Resting Energy Needs:
i. 10 x weight (kg) +6.25 x height (cm)-5 x age (yrs.) + 5
ii. 10 x 97.7 kg + 6.25 x 175.3 cm – 5 x 48 + 5
=1,839.6 kcals
c. Total Energy Needs:
i. 1,839.6 x 1.12 (PA level)=2,060. 4 kcals
ii. Based on Mr. Nelson’s current total energy needs, he should
require ~2,100 kcals /day.
iii. I would recommend that he lower his total energy intake, however,
in order aid in his needed weight loss and fall into a healthy weight
range.
Pg.’s 242-243, “Nutrition Therapy & Pathophysiology”
d. Based on Mr. Nelson’s low-active lifestyle and the standard RDA of
protein, ~20% of his calories should come from protein, which is ~105
kcals (.20 x 2100/4).
14. Complete a computerized nutrient analysis for this patient’s usual intake and
24-hours recall. How does this caloric intake compare to your calculated
requirements?
Food item:
Crispix (2 c.)
Skim milk (1 c.)
Orange juice (16. oz)
Diet Pepsi (12 oz. x’ 3)
Fried chicken sandwich
French fries (sm.)
Iced tea (32 oz.)
Chips (2 c.)
Beer (12 oz.)
Fried chicken (1 breast)
Potato salad (1 ½ c.)
Green bean casserole (1/4 c.)
Fruit salad (½ c.)
Baked beans (1 c.)
Ice cream (2 c.)
Skim milk (1 c.)
Total:
Kcals
219
83
206
0
581
249
9
274
155
363
260
78
63
314
197
42
3,093
kcals
Protein
3.6 g
8.3 g
3.1 g
0g
27.8 g
2.5 g
2g
3.3 g
1.7 g
53.2 g
3.2 g
2.1 g
0.7 g
14.2 g
5.1 g
4.1 g
134.9 g
Carbs.
49.9 g
12.2 g
49.4 g
0g
43.4 g
30.3 g
0g
24.9 g
12.8 g
0g
34.1 g
8.5 g
11.3 g
51.4 g
30.2 g
6.1 g
364.5 g
Fat
0.7 g
0.2 g
0.3 g
0g
32.3 g
13.2 g
0g
18.7 g
0g
15.3 g
12.9 g
4.2 g
2.8 g
7.6 g
8.6 g
0.1 g
116.9 g
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Vitamin and mineral analysis from 24-hour recall:
RDA % RDA
RDA % RDA
Vitamin A
1,003.2
mcg
Vitamin A
4,867.3
IU
Vitamin B6
6.0
mg
Vitamin B12
7.4
mcg
Vitamin C
281.6
mg
Vitamin D
5.8
mcg
Vitamin D
230.7
IU
Vitamin E
10.7
mg
Vitamin E
16.0
IU
700.0 143 Calcium
mg
5.0
215
--
-- Phosphorus 1,874.5
mg
700.0
268
mg
0.9
279 Potassium 6,521.8
mg
4,700.0
139
41.7
mg
18.0
231 Riboflav
4.6
mg
1.1
416
75.0 375 Magnesium 569.8
mg
320.0
178 Selenium
137.8
mcg
55.0
251
5.9
mg
1.8
327 Sodium
5,697.3
mg
1,500.0
380
60.9
mg
14.0
435 Thiamin
4.7
mg
1.1
429
2,898.7
g
--
--
22.6
mg
8.0
283
-- Cholesterol
1.3 462 Copper
2.4 306 Iron
5.0 115 Manganese
--
-- Niacin
mg
1,000.0
319.5
mg
2.5
RDA % RDA
10.7
--
1,311.9
131 Pant. Acid
15.0 72
--
--
Water
Zinc
http://www.fitday.com/fitness/FoodLog.html
i. According to the 24-hour recall of Mr. Nelson’s diet analysis, he
consumed roughly 3,000 calories, which is 900 calories higher
than what he should me consuming. It’s necessary that he decrease
the amount of energy he’s consuming as well as increase his
physical activity levels to lose weight and get to a normal-healthy
weight. He also needs ~105 grams from protein, and he surpassed
that by 30 grams, higher than recommended.
15. From the information gathered within the intake domain, list possible
nutrition problems using the diagnostic term.
a. Excessive energy intake: NI-1.5
b. Excessive oral food/beverage intake: NI-2.2
c. Excessive fat intake: NI-5.1-2
d. Excessive protein intake: NI-5.2-2
e. Excessive carbohydrate intake: NI-5.3-2
16. Are there any other abnormal labs that should be addressed to improve Mr.
Nelson’s overall cardiac health? Explain.
a. According to his labs, his LDL (“bad fat”) levels were 165 mg/dL when
they should be <130 mg/dL, showing that his cholesterol levels are
dangerously high, and this could result in heart disease or a heart attack if
these levels aren’t lowered. His overall cholesterol level appears to be 220
mg/dL, and should be between 120-199 mg/dL. High cholesterol is
associated with heart disease as well and if not lowered maybe lead to a
heart attack and even death. Finally, Mr. Nelson’s HDL cholesterol level
is 20 mg/dL, when healthy levels are > 45 mg/dL for men. According to
the vitamin & mineral analysis chart in q. 14, it appears that he has met
most of his vitamin and mineral needs during his 24-hour recall. The area
highlighted in red, however, shows that he did not meet his vitamin E
needs. If this continued to be a problem, he might want to supplement
with almonds, spinach, hazelnut, avocado, etc.
i. Pg. 107, “Medical Nutrition Therapy: A Case Study Approach”
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17. From the information gathered within the clinical domain, list possible
nutrition problems using the diagnostic term.
a. Altered GI function: NC-1.4
b. Food-medication interaction: NC-2.3
c. Overweight/obesity: NC-3.3
i. http://www.capitalhealth.ca/NR/rdonlyres/e3jbirru52mmysbztfq57r
hal4nxlusxd2vqjoz4iywdco3jlcf2r4zojueywsy6qks72zyfozgjt4bb5ho
dxkkuspa/FRamNCPDiagnosticterminology2007Ed.pdf
18. What other components of lifestyle modification would you address in order
to help in treating his disorder?
a. Mr. Nelson needs to make several lifestyle modifications in order to help
treat his disorder. He needs to increase his physical activity to 3-5 days
per week, for 30-60 minutes. This will aid in lowering his LDL
cholesterol levels as well as help him lose weight, lessening the severity of
his symptoms. In addition, he should decrease his energy intake. He also
needs to change his diet in several ways: he should cut out caffeinated
beverages, such as unsweetened iced tea, cut out alcohol from his diet
completely, and even the diet soda he consumes. Both increase gastric
acid levels and lead to reflux and pain. He should decrease his
consumption of fatty foods, and can do this by ceasing to eat at fast food
establishments, which he tends to indulge in frequently. Mr. Nelson tends
to eat three large meals per day as well, and should break up the amount of
food he eats into smaller, more frequent meals.
19. From the information gathered within the behavior-environment domain, list
possible nutrition problems using the diagnostic term.
a. Limited adherence to nutrition-related recommendations: NB-1.6
b. Undesirable food choices: NB-1.7
c. Physical inactivity: NB-2.1
i. http://www.capitalhealth.ca/NR/rdonlyres/e3jbirru52mmysbztfq57r
hal4nxlusxd2vqjoz4iywdco3jlcf2r4zojueywsy6qks72zyfozgjt4bb5ho
dxkkuspa/FRamNCPDiagnosticterminology2007Ed.pdf
20. Select two high-priority nutrition problems and complete the PES statement
for each.
a. Excessive energy intake related to consumption of energy-dense food
choices and beverages as evidenced by obese BMI classification, of 31.8
kg/m^2 and 24-hour diet recall analysis.
b. Excessive fat intake related to consumption of fatty food choices and the
regular consumption of fast food as evidenced by 24-hour diet recall and
total cholesterol levels >199 mg/dL.
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21. For each PES statements that you have written, establish an ideal goal (based
on the signs and symptoms) and an appropriate intervention (based on the
etiology).
a. PES statement #1: Excessive energy intake related to consumption of
energy-dense food choices and beverages as evidenced by obese BMI
classification, of 31.8 kg/m^2 and 24-hour diet recall analysis.
b. Ideal goal: Reduce energy intake to 2,100 kcals per day.
c. Appropriate intervention: Educate patient on healthier meals and how to
cook healthier foods in the home and decreasing caloric intake, learning
how to eat favorite foods in moderation, and limiting eating out to a
minimal level.
d. PES statement #2: Excessive lipid intake related to consumption of fatty
food choices and the regular consumption of fast food as evidenced by 24hour diet recall and total cholesterol levels >199 mg/dL.
e. Ideal goal: Reduce lipid intake to ~60 g per day, or 525 kcals and lowering
total cholesterol level to lie between 120-199 mg/mL.
f. Appropriate intervention: Patient education on how to choose food low in
fat and instruct family members on the dangers of high cholesterol.
22. Outline necessary modifications for his within his 24-hour recall that you
could use as a teaching tool.
Food Item
Crispix
Modification
Rationale
Replace with heart healthy oats
Skim milk
Orange juice
Keep
Water
Diet Pepsi
Replace with water
Fried chicken sandwich
Grilled chicken or turkey
French fries
Spinach and pear salad
Iced tea
Water
Chips
Heart healthy chips (Kashi)
Beer
Cut out completely
Fried chicken
Grilled fish
Although this isn’t the worst
choice, he could replace with a
lower calorie, higher fiber cereal
No fat in this dairy product
This is a high acidity beverage,
which could affect reflux
Carbonated beverages worsen
GERD symptoms by ^ gastric
acid production
Consumption of greasy, fatty
foods worsen GERD symptoms
Consumption of fried, fatty foods
worsen GERD symptoms
Consumption of caffeinated
beverages worsen GERD
symptoms
Chips tend to be high in fat, this
would satisfy the craving with
less fat, more fiber
Consumption of alcoholic
beverages are known to worsen
GERD symptoms
Should not consume fried
chicken, especially not twice in 1
day. Grilled fish is low in fat and
may help increase HDL levels
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Potato salad
Use non-fat mayonnaise
Green bean casserole
Remove fried onion garnish, use
fresh green beans
Fruit salad
Apples, watermelons, and
apricots
Green beans with whole wheat
bread
Baked beans
Milkshake
Watermelon Sorbet with a dollop
of low-fat non-dairy topping
This will make it easier for the
body to digest
Onions tends to cause reflux, and
some canned green beans will
cause pain as well
Tend to be low-acidity fruits
Baked beans upset stomach and
are linked to reflux in some
patients
Lower in fat option with similar
consistency and taste
Prior knowledge from past nutrition courses
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