Peyton Goodman

FCS 362
Problem Based Learning
03 April 2021

Nutrition Therapy for Upper Gastrointestinal Disorders

Gastroesophageal Reflux Disease
Case Questions
I. Understanding the Disease and Pathophysiology
1. How and where is acid produced and controlled within the GI tract?
There is about 1-2 liters of gastric acid produced in the stomach daily. This is produced in the
gastric parietal cells. The mucosa layer in the stomach and the duodenum protects and controls
the lining from the gastric acid.

2. What role does the lower esophageal sphincter (LES) pressure plan in the etiology of
gastroesophageal reflux disease? What factors affect LES pressure?
The lower esophageal sphincter is part of the antireflux barrier in the GI tract. It is made up of
smooth muscle. This is triggered when you have gastric distention. There have been studies to
support foods that lessen the functions of the LES which are caffeine, highly acidic foods,
carbonated beverages, tobacco, peppermint and alcohol. Along with foods, stress can inhibit the
LES’s functions. It’s advised to eat more frequently smaller meals than larger meals to avoid
gastric reflux. Obesity can also add addition pressure to the LES.1

3. What are the complications of gastroesophageal reflux disease?

- Increased salivation1
- Dysphagia1
- Heart burn1
- Belching1
- Neck, back, and jaw pain1
- Trouble swallowing1
- Ulcers in the esophagus1

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

H. pylori is a gram-negative bacterium in the mucus layer in the small intestine. This type of
bacteria can survive in very acidic environments. There is increased acid production in the
duodenum which causes ulcers. The physician biopsied for this, because this can tell you if a
patient with upper gastrointestinal distress is susceptible to future ulcers and other diseases.1

5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease.
- Frequent indigestion
- Shoulder pain
- Pain around the heart
- Back, neck, and jaw pain

6. Describe the diagnostic tests performed for this patient.

Chem 24 test: this is a metabolic panel that tests for HDL, LDL, triglycerides, Nitrogen,
Albumin, blood urea, cholesterol, etc.6
Ambulatory 48-hour pH monitoring: a pill is swallowed and attaches itself to the esophagus and
records pH of the esophagus for 48 hours. This will help us know if and how much acid is
coming back up into the esophagus.7
Barium esophagram: this is swallowed so it can show up on an x-ray. This will let the doctors
see any abnormalities in the GI tract.8
Endoscopy with biopsy: this is used to biopsy for H. Pylori in the stomach. If it comes back
positive, then the doctors will prescribe an antibiotic to treat it.1

7. What risk factors does the patient present with that might contribute to his diagnosis? (Be
sure to consider lifestyle, medical, and nutritional factors).
- Class I obesity
- BMI 32
- Weight gain in the last 3 years
- Decrease in physical activity
- Inconsistent eating patterns
- Overconsumption
- Hypertension
- Frequent alcohol intake
- Stress
- Long work hours
- Ibuprofen consumption
- Aspirin consumption
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?
Pain relief medications such as ibuprofen and Advil can irritate the lining of the esophagus.
Irritation causes heart burn.3 Having Mr. Gupta decrease his intake in pain relievers can help
with the reflux.

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 a proton pump inhibitor, which is an antiacid. Its generic name is Prilosec. Over a
long period of time, decrease long-term acid. This medication may decrease Vitamin B12 and
Calcium absorption. A decrease in calcium absorption can lead to osteoporosis. Low magnesium
can also occur. This medication can lead to PPI therapy, Small Intestine Bacterial Overgrowth
(SIBO), and IBS. When using Prilosec, avoid SJW and Gingko. Don’t tube feed an hour before
or after taking medication. Other medications that are similar to Omeprazole are lansoprazole,
esomeprazole, pantoprazole, and dexlansoprazole. H2 blockers can also help to treat GERD.

II. Understanding the Nutrition Therapy

10. Summarize the current recommendations for nutrition therapy for GERD.
Foods Mr. Gupta want to strive for are lean meats and poultry that’s well cooked, fat-free/low-
fat/non-fat dairy products, whole grains, green and orange vegetables (if cooked, without added
fats), eat a variety of fresh fruits, limit fat intake, and avoid caffeinated beverages. Foods to
avoid eliminating GERD symptoms are peppermint or spearmint, chocolate, alcohol, caffeinated
beverages, teas, pepper, high-fat foods, and any other fruits and vegetables that may cause
symptoms.3

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?
Height: 175.3 cm
Weight: 97.7 kg
BMI: 32 kg/m2
UBW: 185
 UBW%: 116%
His rapid weight gain has contributed to his. Diagnosis of GERD. Weight gain can put pressure
on the abdomen which can cause acid reflux. His decrease in physical activity due to his knee
surgery is one of the contributions. He also reports high stress and longer workdays, and this can
cause someone to increase calorie intake.

12. Calculate energy and protein requirements for Ms. Gupta. How would this recommendation
be modified to support a gradual weight loss?
IBW: 154 lbs.
IBW%: 71.6%
Weight Range: 139-169 lbs.
RMR: 1842.5 kcals/daily for weight loss
REE: 1842.5 kcals x 1.2 = 2210.4 kcals with a sedentary lifestyle
Protein: 78.2-98 grams/daily
Fluid Requirement: 1842 mL/daily

13. Mr. Gupta and his wife are originally from India. Are there components of their traditional
diet that may aggravate his symptoms of GERD?
He reports eating curry which could cause reflux and also drinking tea. That’s really all from his
traditional diet that can provide some evidence that it is a contributing factor to his GERD. His
typical diet also includes carbonated beverages, frequent fast-food trips, chips and others
processed foods that are high in fats.

14. What considerations related to Hinduism should you keep in mind when assessing Mr.
Gupta’s diet?
Hindus are typically lacto-vegetarian, which means they don’t eat meat and eggs. However,
some may eat chicken, lamb, and fish. He reports eating eggs, so I would include those in his
new menus.

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

Meal Food/amount Total kcal CHO PRO FAT

Breakfas 2 scrambled eggs 182 2g 12g 14g
t
Breakfas Nann 150 26g 4g 3.5g
t
Breakfas Hot black tea 2 0 0 0
t
Mid- 3-12 oz. Diet Pepsi 0 0 0 0
morning
Lunch Curry with spinach and 223 38g 9g 5g
chickpeas
Lunch 2 cups rice 400 90g 12g 1g
Lunch Hot black tea 0 0 0 0
Mid- 2 c. chips 300 30g 4g 20g
afternoo
n
Mid- 1 beer 153 12g 2g 0g
afternoo
n
Dinner 2 c. Lentil dal 460 80g 36g 1.6g
Dinner 2 c. rice 400 90g 12g 1g
Dinner 2 slices of naan 300 52g 8g 7g
Dinner 2 c. hot chai tea
Bedtime 2 c. ice cream 548 64g 9.2g 28g
Bedtime 1 c. skim milk 166 25g 16.6g 0.4g
Total 3,144kcals 509g x 4= 124.8g x 4= 82.5g x 9=
2036 kcals 499.2 kcals 742.5kcals

His estimated kcals came out to be 3,144 kcals and my estimated energy intake was 1842 kcals.
This explains the rapid weight gain with a decrease in physical activity over the last three years.

16. Are there any abnormal labs that should be addressed to improve Mr. Gupta’s overall
health? Explain.
Cholesterol Ref. Range <200 245
VLDL Ref. Range 7-32 35
LDL Ref. Range <130 157
Triglycerides Ref. Range 40-160 178
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?
Both fenugreek and turmeric can be used as supplements to help with indigestion. There is not a
lot of proven evidence of it working; however, the study Thavorn, Mamdani, and Straus
conducted confirms the use of these supplements to support acid reflux.4 There can be some bad
interactions between turmeric and Omeprazole. Taking these two things together can have
adverse reactions to acid reflux. There will be an increase in stomach acid production when
taking turmeric and Omeprazole.5

18. What other components of lifestyle modification would you address in order to help in
treating his disorder?
According to the Nutrition Care Manual recommendations for treating GERD is to2:
- Exercise at least 3-4 times weekly
- Choose looser fitting clothes
- Avoid smoking
- Use a foam wedge to elevate your head in bed
- Wait 3 hours to lay down after eating
- Eat small meals throughout the day
- Sit down while eating
- Eat in a calm place

IV. Nutrition Diagnosis

19. Identify pertinent nutrition problems and corresponding nutrition diagnoses and write a least
two PES statements for them.
P: Excessive energy intake related to
E: rapid weight gain and decreased physical activity as evidenced by
S: his 24-hour food recall as

P: Deficit in food knowledge related to

E: overconsumption of saturated fats and intaking large meals as evidenced by
S: his diagnosis of GERD

V. Nutrition Intervention
20. Determine the appropriate intervention for each nutrition diagnosis.
1. Aim for a 2000 calorie diet and increase physical activity, as patient stated. Try to eat smaller
meals more frequently throughout the day rather than larger meals. Drink less tea to lessen acid
reflux.
2. Patient will receive a GERD Nutrition Therapy Education and keep a food log. Reduce
serving sizes, eat 1 cup of rice instead of 2 cups of rice. Reduce intake of sweet treats and
processed chips. Aim for low fat chips. Decrease Alcohol intake.

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?
Long-term proton pumps can have irreversible effects, such as suppressing acid secretions,
increase risk of GI infections, iron deficiency, gastric tumors, B12 deficiency, and increase risk
for gastric and colon cancer.1 To support the vitamin malabsorption, Mr. Gupta may have to take
different supplements. He reports taking a multi-vitamin daily, so we would need to evaluate the
amounts in the vitamin to assess if he needs additional supplements.

VI. Nutrition Monitoring and Evaluation

Monitor weight and reflux incidents. Keep food log to see eating patterns. Suggested, smaller
melas more frequently throughout the day. Pay attention to the foods being consumed and avoid
spicy foods, foods high in fat, sweet treats, caffeinated beverages, etc.
VI. ADIME
Assessment
CH:
48-year-old male. Married with 2 sons. Indian ethnicity and Hindu religion. Patient experiencing
indigestion for the last year. Gained 30 pounds in 3 years after having a knee surgery. Increased
energy intake. Father has CAD. Diagnosed with hypertension last year.

FH:
24-hour recall
Breakfast
2 scrambled eggs
Naan
Hot black tea
Mid-morning
3-12 oz. Diet Pepsi
Lunch
Curry with spinach and chickpeas
2 cups rice
Hot black tea
Mid-afternoon
2 c. chips
1 beer
Dinner
2 c. Lentil dal
2 c. rice
2 slices of naan
2 c. hot chai tea
Bedtime
2 c. ice cream
1 c. skim milk
Total average intake: 3,144 kcals
RMR: 1842.5 kcals/daily for weight loss
REE: 1842.5 kcals x 1.2 = 2210.4 kcals with a sedentary lifestyle
Medications:
Ibuprofen 500mg 2x daily
Aspirin 325mg
Multi-vitamin daily
Atenolol 50mg daily
Physical activity:
Leisurely 15-minute walk
BD:
Cholesterol Ref. Range <200 245
VLDL Ref. Range 7-32 35
LDL Ref. Range <130 157
Triglycerides Ref. Range 40-160 178

AD:
Height: 175.3 cm
Weight: 97.7 kg
BMI: 32 kg/m2
UBW: 185 lbs.
UBW%: 116%
IBW: 154 lbs.
IBW%: 71.6%
Weight Range: 139-169 lbs.
PD:
Visual adiposity

CS:
RMR: 1842.5 kcals/daily for weight loss
REE: 1842.5 kcals x 1.2 = 2210.4 kcals with a sedentary lifestyle
Protein: 78.2-98 grams/daily
Fluid Requirement: 1842 mL/daily

Diagnosis
P: Excessive energy intake related to
E: rapid weight gain and decreased physical activity as evidenced by
S: his 24-hour food recall
P: Deficit in food knowledge related to
E: overconsumption of saturated fats and intaking large meals as evidenced by
S: his diagnosis of GERD
Nutrition Prescription:
- Decrease weight
- Eat a low-fat diet
- Be more aware of portion sizes

Intervention
1. Aim for a 2000 calorie diet and increase physical activity, as patient stated. Try to eat smaller
meals more frequently throughout the day rather than larger meals. Drink less tea to lessen acid
reflux.
2. Patient will receive a GERD Nutrition Therapy Education and keep a food log. Reduce
serving sizes, eat 1 cup of rice instead of 2 cups of rice. Reduce intake of sweet treats and
processed chips. Aim for low fat chips. Decrease Alcohol intake.

Monitor and Evaluation

Monitor weight and reflux incidents. Keep food log to see eating patterns. Suggested, smaller
melas more frequently throughout the day. Pay attention to the foods being consumed and avoid
spicy foods, foods high in fat, sweet treats, caffeinated beverages, etc.
 References

1. Mahan LK, Raymond JL. Krause's Food & the Nutrition Care Process. St. Louis, MI:
Elesevier; 2017.
2. American Dietetic Association. Nutrition Care Manual®. Consistent Carbohydrate Diet.
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=123. Accessed
March 29, 2021.
3. Michael F. Picco MD. GERD: Can certain medications make it worse? Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/gerd/expert-answers/heartburn-
gerd/faq-20058535. Published January 22, 2020. Accessed April 5, 2021.
4. Thavorn K, Mamdani MM, Straus SE. Efficacy of turmeric in the treatment of digestive
disorders: a systematic review and meta-analysis protocol. Syst Rev. 2014;3:71.
Published 2014 Jun 28. doi:10.1186/2046-4053-3-71
5. Vad V. Do Curcumin Supplements Have Drawbacks? Arthritis. https://www.arthritis-
health.com/treatment/diet-and-nutrition/do-curcumin-supplements-have-
drawbacks#:~:text=Turmeric%20may%20increase%20the%20production,%2C
%20and%20ranitidine%20(Zantac). Published October 1, 2015. Accessed April
5, 2021.
6. 22419 Chemistry 24 Panel // . Chemistry 24 Panel.
https://www.marshfieldlabs.org/sites/ltrm/Human/Pages/22419.aspx. Accessed
April 5, 2021.
7. 48-hour bravo pH monitoring. Stanford Health Care (SHC) - Stanford Medical Center.
https://stanfordhealthcare.org/medical-treatments/e/endoscopy/types/48-hour-ph-
monitoring.html. Published September 12, 2017. Accessed April 5, 2021.
8. Hanson L. Radiology Exam: Barium Swallow (Cine Esophagram): Johns Hopkins
Radiology. Radiology Exam: Barium Swallow (Cine Esophagram) | Johns
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information/exams-procedures/barium-swallow.html. Published March 15, 2021.
Accessed April 5, 2021.