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Aurash Jason SorooshSteven MachekCase Study #1: Case 7 (GERD)Answer the following questions:Disease and PathophysiologyHow is acid produced and controlled within the gastrointestinal tract? (3 points)There are many factors affecting hydrochloric acid (HCL) production and control. HCL is synthesized by parietal cells in the stomach. Gastrin, histamine, and acetylcholine are ligands that are released when we smell or taste food. They stimulate the production of HCL. HCL activates certain enzymes, like pepsinogen to pepsin, to start breaking down proteins. The extreme acidity of HCL also is meant to kill any pathogens that we consume. Mucus is released by mucous cells to protect the stomach from being damaged by HCL. Once the HCL combined with the food bolus in the stomach it becomes chyme. The chyme enters the duodenum at a low pH. This acidity is controlled by a combination of bile produced by the liver and bicarbonate produced in the pancreas. They are both released through the Sphincter of Odi. The pH of the chyme needs to be neutralized for pancreatic enzymes to function, and the bicarbonate is produced to do exactly that. Bile has many functions, but does aid in the neutralization of chyme. Somatostatin is an inhibitory ligand that is released when gastric pH becomes too low. It decreases HCL production/release. What role does lower esophageal sphincter (LES) pressure play in the etiology of gastroesophageal reflux disease (GERD)? What factors affect LES pressure? (3 points)Atmospheric pressure is greater in the esophagus than in the stomach, and this pressure of about 30cm H2O is what prevents the stomach contents from going back into the esophagus and preventing large amounts of air from entering the stomach. The acidity of the stomach juices (pepsin and gastric acid) can cause a degradation of the lining in the esophagus, therefore Barrett’s metaplasia and the accompanying change in the epithelial cells of the esophageal mucosa may be a complication to explore when a patient is diagnosed with GERD. Factors that can lower LES pressure and trigger detrimental effects include increased secretion of hormones gastrin, estrogen and progesterone. Also, the presence of medical conditions such as hiatal hernia, scleroderma, or obesity may also contribute. Smoking and use of medications such as dopamine, morphine, and theophylline also can affect LES pressure. Lastly, foods such as chocolate, spearmint, peppermint, alcohol, coffee (caffeinated or decaffeinated), and fried/high fat foods can lower LES pressure. What are the complications of GERD? (3 points)Complications of GERD can be inflammation and eventually perforation of the esophagus, aspiration of gastric contents into lungs, impaired swallowing, and eventually Barrett’s esophagus. What are common symptoms of GERD? Which symptoms does the patient experience? (3 points)Symptoms of GERD include heartburn/indigestion, belching, pain, increased salivation, and dysphasia. This patient has been experiencing indigestion and epigastric tenderness. What risk factors does the patient present with that might contribute to his diagnosis? Be sure to consider lifestyle, medical, and nutritional factors. (4 points)The risk factors that contributing to the diagnosis are his mainly diet and lack of exercise. He is obese, with a BMI of 32. He drinks a lot of soda, alcohol, caffeine, and eats a lot of high fat foods, all of which can decrease lower esophageal sphincter pressure. He also takes 325 mg aspirin daily, which can contribute to his symptoms. He had knee surgery, which he claims prevents him from exercising. Nutrition AssessmentCalculate the patient’s % usual body weight (UBW) and body mass index (BMI). What does this assessment of weight tell you? In what ways may this contribute to his diagnosis? (4 points)Male, Age:48, 69’’(175cm), 215lbCBW(97.5kg)+180lbUBW(81.5kg) BMI = 97.5/1.75^2(3.06)= 32UBW = 215/180 = 1.19x100 = 119%IBW = 160lb or 72.5kgThe assessment of Mr. Nelson’s weight clearly indicates that he is clinically obese and has also gained a significant amount of weight in the last 5 years since his knee arthroplasty. When he states that he has gained about 35 pounds since that procedure, his weight stays consistent with the lifestyle of someone who has become sedentary. Because he has not been able to find a sufficient replacement for exercise, eating fatty foods such as fried chicken breast and consumption of multiple caffeinated drinks and alcohol contributes to the decreased pressure in the lower esophageal sphincter causing his increased indigestion over the last year. Calculate calorie and protein requirements for Mr. Nelson. Use Mr. Nelson’s current weight and the Mifflin St. Jeor Equation to calculate his calorie needs (Mifflin-St. Jeor = 10W + 6.25H – 5A + 5). How would this recommendation be modified to support a gradual weight loss? (5 points)10(72.5kg) + 6.25(175cm) – 5(48) + 5= 725+1094-240+5 = 1584kcal/day x 1.2AF = 1900kcal/dayProtein = 72.5kg(0.8) = 58g pro/dayFor healthy weight loss a deficit of 300-500 calories, or a total of 1400-1600kcal, would be sufficient. His protein intake should remain at 58 grams per day regardless of the reduction in calories.Mr. Nelson could opt for a less of a deficit if he increases his physical activity. He plays with his son on occasion, however other sustainable options include upper body weight training, swimming, and light resistance knee strengthening exercises. Exercise would also contribute to the reduction of stress, which is a factor that the patient felt relevant to mention in regards to his current dietary status and associated indigestion. Nutrition DiagnosisIdentify pertinent nutrition problems and corresponding nutrition diagnoses and write at least two PES statements for them. Please use appropriate nutrition diagnostic terminology from Appendix C2 in your textbook. (5 points)Pertinent nutrition problems in this patient are his obese health status (BMI=32) and sedentary lifestyle. His diet consists of high fat and fried foods, caffeinated beverages throughout the day, alcohol, and calorically dense deserts. His lab values show a triglyceride level of 178 mg/dl, LDL levels of 165 mg/dl, cholesterol level of 220 mg/dl, and his HDL level is 20 mg/dl. Hyperlipidemia related to excessive fat intake as evidenced by a triglyceride level of 178 mg/dl.Altered GI function related to undesirable food choices as evidenced by gastrointestinal reflux disease.Obesity related to excessive energy intake as evidenced by a BMI of 32.Nutrition InterventionSummarize all current nutrition and lifestyle recommendations for nutrition therapy for GERD. Indicate which of these recommendations pertain to the nutrition diagnoses in the previous question. (10 points)Current nutrition recommendations for GERD are to avoid cured meats, chocolate, peppermint/spearmint, fried foods, coffee (regular and decaf), tea, alcohol, spicy foods, high fat dairy products, pastries, fruits and vegetables that exasperate symptoms. Patients should also avoid or reduce their intake of non-steroidal anti-inflammatory medications like aspirin and ibuprofen. Current lifestyle changes are to increase physical activity levels in order to decrease weight (if patient is overweight/obese). Also, patient should not lay down after eating, or elevate their head 30 degrees when laying down. Eating small, frequent meals may also help. The recommendations that pertain to this patient are reducing his consumption of high fat/fried foods, eliminating alcoholic and caffeinated beverages from his diet, and reducing his consumption of acidic high-sugar fruits/fruit juices. Increasing his daily physical activity level will help him lose weight and decrease the symptoms of GERD. He should also reduce the dosage of aspirin he is taking every day. Using Mr. Nelson’s 24-hour recall on page 74, outline any necessary modifications (specific food items or meal ideas) and the rationale for these modifications (why the patient has to make modifications). Please make sure that all recommendations are appropriate for a patient with GERD. (10 points)Food ItemModificationRationale CrispixNone necessary, but may change to oatmeal or a whole grain alternative.This cereal will not antagonize symptoms of GERD. However, a more nutritious choice may be beneficial to patient’s overall health.Skim milkNone necessary, but switching to a nut milk like almond or soy milk may benefit patient. Skim milk is non-offensive to GERD, however drinking a nut milk which is contains unsaturated fat may increase his HDL levels and decrease his cholesterol levels. Orange juiceOrange infused waterOrange juice is very acidic food and can exaggerate the patients symptoms. Water does not antagonize the issue, and soaking orange slices in water can add some flavor without causing irritation. Diet PepsiDecrease intake and eventually replace completely with waterCaffeine in sodas and citric acid as an ingredient can lower LES pressure, potentially causing gastric juice and pepsin to reflux. Decreasing his intake and drinking more water will improve the symptoms. Fried chicken sandwichGrilled Chicken SandwichFried foods can decrease LES pressure, potentially causing gastric juice and pepsin to reflux. A grilled chicken sandwich is a common fast food item and is much lower in fat.French friesRoasted Potatoes/Mashed PotatoesFried foods can decrease LES pressure, potentially causing gastric juice and pepsin to reflux. Roasted potatoes and/or mashed potatoes are a healthy alternative and contain less fat than deep fried potatoes.Iced teaNon Caffeinated Herbal TeaCaffeine, spearmint, or peppermint can lower LES pressure, potentially causing gastric juice and pepsin to reflux. So the patient can still have decaf herbal tea that does not contain spearmint or peppermint.ChipsVegetable/fruit sticks or air-popped pop cornFatty foods can decrease LES pressure, potentially causing gastric juice and pepsin to reflux. Instead of packaged fried potato chips, the patient should eat fruit or vegetable sticks that do not irritate his symptoms, or he can have air-popped popcorn. BeerReduce/eliminateAlcohol can promote relaxation of the LES causing a decrease in LES pressure, resulting gastric juice and pepsin to reflux. It may be unrealistic to eliminate alcohol, however reducing the amount can have a significant impact on the symptoms of indigestion that the patient is experiencing.Fried chickenGrilled ChickenFried foods can reduce LES pressure, potentially causing gastric juice and pepsin to reflux. Grilled chicken is lower in fat and still allows the patient to have a similar food.Potato saladKFC Cole-SlawPotato salad at KFC has a very heavy mayonnaise base. Fatty foods like mayo can decrease the LES pressure, potentially causing gastric juice and pepsin to reflux. Cole-slaw is another option at KFC and is lower in fat than their potato salad.Green bean casseroleSteamed Green Beans/Baked Green BeansGreen bean casserole is usually made with a high-fat dairy base like cream of mushroom soup. Fatty foods can reduce LES pressure, potentially causing gastric juice and pepsin to reflux. A lightly seasoned steamed plate of green beans or oven-baked green beans would be a low fat alternative.Fruit saladEnsure that little to no citrus is in the fruit salad, therefore eliminate lemon, orange, lime, etc.Acidic fruits can increase painful symptoms of GERD. Citrus is higher in citric acid, so foods such as berries, banana, etc may be more suitable for the patient’s condition, while still allowing him to have a nutritious fruit salad.Baked beansDepending on recipe, reduce fatty ingredients that may include bacon, butter, etc. Can also substitute lentils or other legumes. Potential fatty ingredients can contribute to decreased LES pressure, which can lead to complication such as Barrett’s esophagus. A homemade baked bean recipe that does not use high fat or spicy ingredients can be a good modification. Also, replacing the beans with lentils can be a nutritious alternative. MilkshakeLow Fat Yogurt/KefirMilkshakes are usually calorically dense, and especially high in fat and sugar, which contribute to the patient’s obese health status and GERD. Fatty foods can lower LES pressure, potentially causing gastric juice and pepsin to reflux. A low fat flavored yogurt drink or a kefir probiotic drink can provide him with nutrient while helping ease his digestive issues by contributing to a healthier intestinal micro-biome.Sources CitedNelms, M. & Roth. S. (2014). Gastroesophageal Reflux Disease. Medical Nutrition Therapy: A Case Study Approach (69-79). Stamford, CT: Cengage Learning.Nelms, M. & Sucher, K. & Lacey, K. (2016). Nutrition Therapy and Pathophysiology. Boston, CA: Cengage Learning.Spoek, K. (2016). Upper GI Tract: Chapter 14 [Powerpoint Slides and Lecture]. San Francisco State University. ................
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