CASE 7 QUESTIONS

I. Understanding the Disease and Pathophysiology

1. How and where is acid produced and controlled within the gastrointestinal tract?

The acid in the stomach also called hydrochloric acid which produces from the
gastric glands. In the gastric glands, parietal cells secrete hydrochloric acid and
the intrinsic factor. The function of hydrochloric acid is activating pepsinogen,
killing microorganisms, and denature proteins. The control of hydrochloric acid
secretion is completed by the complementary actions of the nervous and endocrine
systems, and it also would involve four important chemical messengers:
acetylcholine, histamine, gastrin, and somatostatin. The gastrin will stimulate
gastric secretion, and somatostatin will inhibit gastric secretion. The Histamine,
which is paracrine, works on the parietal cell to increase the production of
hydrochloric acid.

(Nelms 2016, p. 323, 324)

2. What role does the lower esophageal sphincter (LES) pressure play in the etiology
of gastroesophageal reflux disease? What factors affect LES pressure?

Since the atmospheric pressure is greater in the esophagus than in the stomach
under a normal condition, the LES pressure help for preventing stomach content to
reflux back into the esophagus. Additionally, it also can prevent a big amount of air
to enter our stomach, and the etiology of gastroesophageal reflux is multifactorial
which also includes both physical and lifestyle factors. The factor that would affect
LES pressure is included: increasing secretion of the hormones gastrin, estrogen,
and progesterone; the presence of hiatal hernia, scleroderma, obesity, or other
medical conditions; smoking of cigarette; using of medication like dopamine,
morphine, and theophylline; and eating some specific food which is high in fat,
chocolate, spearmint, peppermint, alcohol, and caffeine.

(Nelms 2016, p. 347, 356)

3. What are the complications of gastroesophageal reflux disease?

The complication of gastroesophageal reflux disease includes impaired swallowing,

aspiration of gastric contents into the lungs, ulceration, and perforation or stricture
of the esophagus. In addition, Barrett’s Esophagus also is considered as a
complication of GERD, and Barrett’s Esophagus is “a change in the epithelial cells
of the esophageal mucosa” (Nelms 2016, p.360).

(Nelms 2016, p.356, 360)

4. The physician biopsied for H. pylori. What is this?

The H. pylori. also known as Helicobacter pylori, and it is a spiral-shaped,

flagellated, Gram-negative rod that lives under the mucous layer of the stomach;
this rod also attaches to mucus-secreting cells lining the stomach. H. pylori are the
main factor in the development of gastric and duodenal ulcers, there are about
92% of duodenal ulcers and 70% of gastric ulcers which are caused by H. pylori.
The complications from H. pylori is depending on the individual’s immune
response, the strain of H. pylori, and environmental difference. The H. pylori would
produce various proteins that can damage mucosal cells, attracting lymphocytes
and causing persistent inflammation, and H. pylori organisms can break down urea
to produce ammonia which will help neutralize the acid to enhance their survival in
this environment.

(Nelms 2016, p.368)

 5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease.

Mr. Gupta has been experiencing increased indigestion over last year, and
indigestion was only at night previously, but he experiences indigestion almost
constantly now. Secondly, he has gained almost 30 lbs. since he had a knee
surgery at 3 years age which is a big risk factor of GERD.

6. Describe the diagnostic tests performed for this patient.

In order to diagnosis GERD, the Ambulatory 48-hour pH monitoring with Bravo™

pH Monitoring system is used, and this test involved placing a pH probe into the
distal esophagus for a 12 to 24 hour period, and then it can generate a graph
which show a continuous pH reading. In the next, the Barium esophagram is used
to demonstrate reflux by using abdominal pressure and positional changes.
Barium esophagram is important which allow the physician to monitor swallowing
and the movement through stomach into duodenum, and Mr. Gupta is required to
drink the barium sulfate, which is a chalky, white radiopaque substance since
barium can visualize by X-ray. Finally, the Endoscopy with biopsy also used for
diagnostic test, and the Endoscopy (EGD) is placing a fiberoptic endoscopy to
introduce through the oral pharynx and move through the esophagus and stomach
then into then duodenum. EGD can help physician to inspect the mucosa of the
organs and detect abnormalities.

(Nelms 2016, p.357)

7. What risk factors does the patient present with that might contribute to his
diagnosis? (Be sure to consider lifestyle, medical, and nutritional factors.)

The first risk factor is that Mr. Gupta has gained almost 30 lbs. since the Knee
surgery, and he also is physically inactive which also impute to knee surgery.
Secondly, he takes an aspirin each day, herb fenugreek, and turmeric, and it also
can be risk factor. Thirdly, his 24-hr dietary recall show that he drinks alcohol
which may cause increasing of acid level in the stomach, and he also ate ice cream
mixed with skim milk for milkshake which is high fat food. He also admits that he
eats fried food which will make his indigestion getting worse.

(Nelms 2016, p.356)

8. The MD has decreased the patient’s dose of daily aspirin and recommended
discontinuing his ibuprofen. Why? How might aspirin and other NSAIDs affect
gastroesophageal disease?

The MD has decreased the patient’s dose of daily aspirin and recommended
discontinuing his ibuprofen because they are non-steroidal anti-inflammatory drug,
and, Aspirin and other NSAID will irritate our esophagus and cause heartburn pain.
Secondly, Aspirin and ibuprofen also may affect the controlling of gastric secretion
which may cause over secretion of acid.

“Drugs, Herbs and Supplements.” MedlinePlus, U.S. National Library of Medicine, 28 Apr.
2015, medlineplus.gov/druginformation.html.

9. The MD has prescribed omeprazole. 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?

Omeprazole is in the class of medication that called proton-pump inhibitors, and it

is using to decrease the amount of acid made in the stomach. The basic
mechanism of the drug is blocking the H+, K+-ATPase enzyme and a component in
HCl production. Lansoprazole, pantoprazole, rabeprazole, and esomeprazole are
available in this class. The other groups of medication are used to treat GERD are
Histamine H2 Receptor antagonists, and its basic mechanism is blocking histamine
receptors which is a component for one of stimulatory paths for acid secretion.
 (Nelms 2016, p.358)

“Drugs, Herbs and Supplements.” MedlinePlus, U.S. National Library of Medicine, 28 Apr.
2015, medlineplus.gov/druginformation.html.

II. Understanding the Nutrition Therapy

10. Summarize the current recommendations for nutrition therapy for GERD.

The goal in the nutrition therapy is trying to reduce gastric acidity and food
restriction that exclude food that will lower LES pressure. The recommendation for
nutrition therapy for GERD is identifying food that will make patient’s symptoms
worse and decreasing intake of those foods. The food which may relax the lower
esophageal sphincter should avoid peppermint or spearmint, chocolate, fried foods
or those with high amount of added fat, alcohol, and coffee. The food that may
increase gastric acid secretion should avoid coffee, alcohol, and pepper. The
smaller, more frequent meals also recommend because of meals with larger
quantity tend to stimulate more acid secretion and increase the risk of reflux.
Finally, the patient also need to change their lifestyle such as avoid smoking,
increase physical activity level, be more careful about their diet.

(Nelms 2016, p.359,360)

III. Nutrition Assessment

11. Calculate the patient’s %UBW and BMI. What does this assessment of weight tell
you? In what ways may this contribute to his diagnosis?

Patient’s weight(lbs.): 215 lbs.= 98kg / Height: 5’9” = 1.8m

BMI = 98kg/(1.8m)2=30.2kg/m2

His current body weight is 215 lbs., and his usual body weight is 180 lbs. since he
has gain 35lbs. due to his knee surgery(215lbs.- 35lbs. = 180 lbs.)

%UBW= current body/UBW *100% =215/180 * 100% = 119%

Bas on Mr. Gupta BMI, I consider he is obesity since his BMI is 30.2kg/m 2>30
kg/m2. The obesity is a important risk factor of GERD, and obesity have a definite
relationship with GERD since it increase intragastric pressure, and it will increase
acid contact time in the esophagus which leading to increase reflux symptoms. I
think %UBW may contribute to his diagnosis because of excess body weight may
beget rising of BMI, and rising BMI may lead to obesity which is important risk
factor of GERD.

(Krause 2012, p.513), (Nelms 2016, p.360)

12. Calculate energy and protein requirements for Mr. Gupta. How would this
recommendation be modified to support a gradual weight loss?

Since the Mr. Gupta is overweight with BMI 30.2kg/m 2, we will used his adjusted
body weight to determine his calorie and protein needs.

Using Hamwi method: 106 + (9*6) =160lbs.

ABW=IBW+0.25(UBW-IBW) =160+0.25(215-160)=174lbs.=79kg

Seated Work PAL of 1.4-1.5 since he had a knee surgery

Mifflin-St.Jeor/EER=[10*79kg+6.25*180cm-5*48+5]*1.4=2352kcal/day

Protein requirement is 2352kcal/day * 20% =470.4kcal/day 470.4/4=117.6g

 I recommend him that lower his total energy intake in order to weight loss and fall
into a healthy weight range.

13. Mr. Gupta and his wife are originally from India. Are there components of their
traditional diet that may aggravate his symptoms of GERD?

Since Mr. Gupta and his wife are originally from India, curry is an important
component of their traditional diet. Curry may aggravate his symptoms of GERD
since curry is a complex combination of spices and herb which include turmeric,
cumin, coriander, ginger, and dried or fresh chilies. Chilies is made from the
pepper which will cause and aggravate the symptoms of GERD.

(Nelms 2016, p.360)

14. What considerations related to Hinduism should you keep in mind when assessing
Mr. Gupta’s diet?

The consideration related to Hinduism that we should keep in mind when assessing
Mr. Gupta’s diet are the majority of Hindus are lacto-vegetarian, and lacto-
vegetarian is eliminating all dietary sources of animal protein except dairy
products. Mr. Gupta was eating chicken and eggs base on his usual dietary intake,
but beef should always be avoided because cow is considered a holy animal in the
Hinduism

Patience, Sara, et al. “Religion and Dietary Choices.” Independent Nurse, 19 Sept. 2016,
www.independentnurse.co.uk/clinical-article/religion-and-dietary-choices/145719/.

(Krause 2012, p.1057)

15. Estimate his caloric intake from his 24-hour recall. How does this compare to your
calculated energy requirements?

I use Myplate to calculate Mr. Gupta’s 24-hr recall, and his estimate caloric intake
from his 24-hr recall is about 3954Kcal which is huge. When this compare to my
calculated energy requirement, it is much higher than 2352kcal/day, and he
almost eat 1602kcal more than he should eat. (3954kcal – 2352kcal=1602kcal)
 16. Are there any abnormal labs that should be addressed to improve Mr. Gupta’s
overall health? Explain.

Base on his laboratory results, his cholesterol level is 245mg/dL on 11/1 which is
higher than 200mg/dL(Below 200mg/dL is normal range), and his LDL level is
157mg/dL which is higher than 130mg/dL (below 130mg/dL is the normal range).
His VLDL level is 35mg/dL which is not in the normal range of 7-32 mg/dL, and his
triglycerides level is higher than the safety range of 40-160 mg/dL for man. Since
his LDL level, cholesterol level, VLDL level, and triglycerides all higher than normal
range, these may lead him to have a high risk of cardiovascular disease like MI.
Mr. Gupta should control his fat intake and loss body weight to improve his overall
health.

17. Mr. Gupta’s history includes the use of fenugreek and turmeric as alternative
treatments for his symptoms of GERD. Examine the evidence regarding these
supplements. What could you tell Mr. Gupta? Are there any concerns with the
ingestion of these supplements?

Firstly, the turmeric (Curcuma longa) is possibly effective for osteoarthritis, and it
has “insufficient or conflicting evidence for Alzheimer’s disease, colorectal cancer,
Crohn’s disease, irritable bowel syndrome, rheumatoid arthritis, ulcerative colitis”
(Krause 2012, p.206). The higher doses of turmeric could lower blood pressure
and blood sugar and increase the risk of bleeding, and you need eat some especial
meal for better absorption. Secondly, fenugreek (Trigonella foenum graecum) have
an effective for galactagogue without documented, and its side effect include
“maple syrup odor in urine and sweat (mother and baby); may cause diarrhea,
hypoglycemia, dyspnea”(Krause 2012, p.289). Fenugreek should not be used
during pregnancy, and recommended dosage is about 2-3 capsules of 3 times
daily.

(Krause 2012, p.206,289)

18. What other components of lifestyle modification would you address in order to help
in treating his disorder?

There are several components of lifestyle modification that I would address in

order to help in treating his disorder. Firstly, he needs to increase his physical
activity level to about 150-300 minutes per week, and this would help him to
reduce his LDL level, cholesterol level, VLDL level, and triglycerides level. In
addition, decreasing of all four levels can also help him to lose body weight. He
also needs some change in his diet. He needs eliminate of curry which will contain
pepper, coffee with both caffeinated and decaffeinated, and alcohol for reducing
gastric acidity. Instead of three large meal per day, he needs to break down his
meal into five to six smaller meal which can reduce stimulation of gastric acid
production. Finally, he also needs to reduce consumption of fatty food (like ice
cream, chai tea) and fried food.

(Nelms 2016, p.360)

IV. Nutrition Diagnosis

19. Identify pertinent nutrition problems and corresponding nutrition diagnoses and
write at least two PES statements for them.

Overweight/obesity NC-3.3 / Physical Inactivity NB-2.2

Excessive oral food/beverage intake:NI-2.2 / Excessive fat intake:NI-5.6-2

Overweight/obesity related to high caloric intake and secondary lifestyle as

evidenced by BMI 30.2kg/m2 higher than 30kg/m2.

Excessive fat intake related to intake of high fat food and intake of fast food or
fried food as evidence by 24-hr recall and cholesterol level higher than 200mg/dL.
V. Nutrition Intervention

20. Determine the appropriate intervention for each nutrition diagnosis.

For physical inactivity diagnosis, I plan Mr. Gupta reduce his body mass index
below 24.9kg/m2 by a 45 min brisk walking everyday about seven time a week.

For Overweight/obesity diagnosis, I plan Mr. Gupta 2352 calorie intake – 500
calorie deficit = 1852 calorie for his diet for promote one-pound weight loss per
week.

For Excessive fat intake diagnosis, I plan Mr. Gupta reduce lipid intake to 78g and
lower his LDL level, cholesterol level, VLDL level, and triglycerides level to normal
range.

(Fat requirement = 2352kcal/day * 30%= 706kcal 706/9=78g)

21. Does the long-term use of proton pump inhibitors have nutritional effects? Are
there specific interventions that you might implement to address these effects?

The long-term use of proton pump inhibitor has nutritional effect is decreasing
absorption of calcium, iron, B12, and magnesium. The decreasing of calcium
absorption may lead to osteoporosis. The specific intervention that I might
implement to address these effects are monitoring iron studies, vitamin B12,
magnesium level, and bone density for long-term use of proton pump inhibitor,
and the supplement also need to be used for lower absorption.

(Krause 2012, p.1009)