Name: Erik Leacock 1

ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

Assignment 4: Case Study (6 hours –Writing: 6 hours)

In Krause’s Food and the Nutrition Care Process, read and answer the 5 questions for the
Clinical Case Study at the end of Chapter 26 in 150 words each.

Suzie is a 55-year-old female who is referred to the outpatient clinic with dumping syndrome
that has started to interfere with her daily life. She travels for work, and keeping up with her busy
schedule has become more difficult with symptoms at unpredictable times when she needs to be
driving or in a meeting. A nutrition consultation with a registered dietitian specializing in
gastrointestinal disorders is requested by her thoracic surgeon to help with relief of symptoms.

Nutrition assessment

 Medical History: a short bout with dumping syndrome in 2014 after a Nissen
fundoplication for a hiatal hernia that resolved a short period after surgery. After a
minor hernia repair surgery to redo the fundoplication in early 2018, she began
experiencing it again but with more severity. Symptoms include sudden weakness,
shakiness, and hunger. She has occasional nausea during episodes, but no vomiting.
Suzie also has a new diagnosis of gastroparesis, discovered before her second
fundoplication. Upon discovering this, her surgeon also did a pyloroplasty during her
second fundoplication surgery to try and help with gastroparesis, and she will have
another gastric emptying study in 3 months. Other history includes elevated blood
pressure that she reports controlling with diet, heartburn, and blood glucose levels
within normal limits unless she is having a dumping episode, when it dips as low as 30
mg/dL. She also reports occasional numbness and tingling in her hands and feet.
 Medications: Reglan, Tums, and Omeprazole.
 Nutrition History: Suzie travels for work as a sales manager and is on the road
constantly, eating mostly packaged and prepared foods on the go, and frozen dinners at
home since she lives alone and does not enjoy cooking. Immediately after her
fundoplication surgery she ate only soft foods but has recently graduated to some more–
normal texture foods after ok from her surgeon to do so. She is unable to determine any
food triggers for her dumping` with her food journal and has not documented how soon
an episode happens after eating. She tries to eat 6 smaller meals per day because her
doctor told her this would be better. She also stays well hydrated, drinking at least one
24-ounce water bottle with each meal. She met with a registered dietitian once but says
the dietician did not specialize in this condition, so it was not as helpful as she would
have hoped. She is mostly vegetarian but occasionally has fish or chicken. She says she
is not opposed to eating meat but mostly avoids cooking it. She is open to nutrition
recommendations and arrives at the appointment ready to learn.
 Dietary recall:
o Breakfast: She has coffee with cream and one slice of toast with butter or jam before
leaving to drive to an adjacent city for a few hours for meetings.
o Snack: In the car, she has a cooler packed with applesauce, peach cups, or a banana,
of which she selects one or two for a snack midmorning.
Name: Erik Leacock 2
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

o Lunch: She stops at a grocery store deli and has her favorite on-the-go meal, a large
plate of macaroni and cheese, or sometimes has a chef salad now that her doctor has
allowed her to eat regular-texture foods again. She eats the meal in her car most
days.
o Snack: In the afternoon she eats another of her cooler items, and occasionally has a
string cheese that she picked up at the grocery store deli.
o Dinner: Frozen meal of Michelina’s fettuccine Alfredo, which she describes as high
protein. She may alternate out with another frozen pasta meal if she wants some
variety, but the nutrition is about the same, according to her.
 Anthropometrics: Height: 170.2 cm (67 inches); Weight: 66.4 kg (146 lb); body mass
index (BMI): 22.9 kg/m2
 Usual Body Weight: 68.2 kg (150 lbs); weight change: 2.6% decrease in 3 months
(clinically insignificant)
 Nutrition Focused Physical Assessment: No evidence of muscle or fat loss; no lower or
upper extremity edema. Tongue is sore and inflamed. Her nails are brittle and her skin is
very pale.
 Functional Capacity: Unable to exercise over the past few months due to fatigue and
low energy. She is feeling more forgetful lately as well and has to write everything
down.
 Laboratory Data: Blood glucose: 70–100 mg/dL at fasting laboratory draws, only drops
low temporarily during dumping episodes; blood pressure: 144/92 (H); gastric emptying
study results: 78% of gastric contents left in the stomach after 4 hours.

1. What dietary changes would you recommend for Suzie?

She could try including certain foods that can reduce lower esophageal sphincter

pressure, such as coffee and carminatives like peppermint or spearmint. Suzie should reduce or

avoid fermented alcoholic beverages that can stimulate the secretion of gastric acid, such as beer

and wine. She should avoid foods that can cause a backflow of stomach contents, such as citrus

fruits and juices, fatty or fried foods, spicy foods, vinegar or vinegar-containing foods. She

should reduce or limit she intake of packaged and prepared foods, and frozen dinners. She

should consume a well-balanced diet with adequate fiber. Her diet should consist primarily of

proteins and fats, as well as complex carbohydrates (starches) like tuber vegetables. By adding a

serving of fat such as olive oil, nut butter, or avocado to meals can help encourage slower gastric

emptying. Suzie may benefit from taking dietary fiber supplements, both soluble and insoluble
Name: Erik Leacock 3
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

fiber, which can help delay GI transit. Foods that are rich in fiber include apples, oats, beets,

carrots, and beans.

2. What changes would recommend for Suzie about her eating pattern?

I would encourage Suzie to continue eating small rather than large meals, which

will help reduce the chances that gastric contents will reflux into the esophagus. She should

continue eating smaller, more frequent (6-8) meals throughout the day rather than three larger

meals each day. She should limit the amount of liquids taken with meals or when drinking

liquids between meals without solid foods. For example, omit drinking liquids 30 to 40 minutes

before and after meals is recommended for dumping syndrome (Raymond & Morrow, 2021). In

addition, she could try lying down or sit reclined for at least 30 minutes after eating. It is also

very important that she crew food thoroughly when eating.

3. Would you recommend any micronutrient testing or supplementation? If so, which ones?

I would encourage Suzie to consider doing a complete blood count test to

assessment and identify any deficiencies or abnormalities. It may be warrant for her to receive

prophylactic vitamin B12 supplementation or take synthetic oral supplementation. In addition,

vitamin D and calcium supplements may be needed when intake in inadequate. She may also

benefit from iron supplementation. Overall, Suzie would likely benefit from taking a daily

multivitamin and multimineral supplement. She may also benefit by taking probiotics and or

prebiotics to improve and support her gut health.

4. How would you prioritize education needs for Suzie?

Name: Erik Leacock 4
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

I would highly encourage Suzie to find a registered dietitian that specializes in her

condition(s) who can help provide education in dietary guidelines and recommendations. The

priority in her education should focus on malnutrition caused by inadequate intake,

malabsorption, or a combination of both. I would inform Suzie that the objective of nutrition

therapy is to restore nutrition status and quality of life. I would tell Suzie that during her

nutrition therapy she will learn how to manage and reduce her symptoms through dietary

guidelines and protocols.

Suzie should try to identify what factors besides diet that could trigger reflux symptoms, such as

caffeine, alcohol, tobacco, or stress.

5. Would you do any coordination of care with Suzie’s doctor about anything you learned?

As a result of her new diagnosis of gastroparesis her treatment and medications

may need to be reassessed. Any medications that slow gastric emptying should be avoided, if

possible, because of the increased risk of bezoar formation. Suzie may need to shift to a diet of

more pureed and liquefied foods and avoid high-fiber foods and fiber supplements. I would

coordinate and work closely with Suzie’s doctor to avoid any detrimental outcomes or further

aliments, as well as any complications or unwanted interactions between her medications and

nutrition therapy.

_____________________________________________________________________________

In Krause’s Food and the Nutrition Care Process, read the Clinical Case Study at the end of
Chapter 27 How would you counsel this patient? Jimmy is on a strict diet now; explain what the
progression to a normal diet would be? What are your recommendations for food intake?
Explain. (500 words)

Jimmy is a 76-year-old male with a recent emergent small bowel resection due to a ruptured
mesh hernia causing traumatic injury to his small intestine. He had a difficult postoperative
Name: Erik Leacock 5
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

course complicated by Clostridium difficile infection, clinically involuntary weight loss,

diarrhea, and dehydration. At his readmission for C. difficile infection, a nutrition consult was
received for management of diarrhea and hydration status, and to assess for any nutrient
malabsorption.

Nutrition assessment

 Anatomy: During surgery, 100 cm of the small intestine was removed, including the
ileocecal valve (ICV). The majority of the colon remains intact.
 Oral intake history: Decline in appetite and oral intake since surgery due to very poor
appetite and diarrhea. Before admission Jimmy was eating ¼ of his usual meals with ½ of
the usual snacks and taking one oral nutrition supplement per day. Fluids: drinks coffee,
iced tea, and water, and estimates he is taking in 3 to 4 cups per day.
 Current intake: In the hospital, Jimmy is eating 50% of meals provided, tolerating snacks,
and sipping up to 500 mL of commercial electrolyte beverage per day. He reports never
feeling hungry, is apathetic about eating, and reports not wanting to “overdo it” for fear
of more bathroom trips.
 Weight and body mass index (BMI): Height: 177.8 cm (70 inches), Weight: 75 kg (165
lb), BMI: 23.7 kg/m2
 Usual body weight (UBW): 100 kg (220 lb): 25% weight loss × 3 months (clinically
significant loss)
 Physical examination: pale skin; dark eye sockets; slight depression at temples; scapula
pronounced; noted losses at quadriceps, gastrocnemius, and triceps; no edema noted
 Functional capacity: low energy level over past 3 months, unable to garden or cook
meals, which he previously enjoyed, fatigued and tired all the time, memory slightly
decreased
 Medications: started loperamide 2 mg before meals and bedtime, senior multivitamin,
potassium chloride (KCl) sustained-release tablet, lisinopril dose reduced due to weight
loss, statin discontinued due to cholesterol levels normalized within a few months of
surgery
 24-hour urine and stool output: 650 mL and 2200 mL
 Pertinent labs: high serum sodium (147), low serum potassium (3.0 mEq/L), low normal
serum magnesium (1.3), high blood urea nitrogen (BUN): 7.6 mmol/L, stool toxin
analysis for C difficile: positive
 Current diet: General diet

Nutrition diagnostic statements

 Severe protein calorie malnutrition related to poor appetite as evidenced by energy intake
25% to 50% x 3 months, involuntary weight loss at 25% x 3 months, subcutaneous fat
loss, muscle loss, and decline in strength and functional capacity
Name: Erik Leacock 6
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

 Suboptimal protein-energy intake related to altered gastrointestinal (GI) function as

evidenced by diarrhea, involuntary weight loss at 25% x 3 months, UBW 220 lbs

Interventions

 Estimated energy needs: 2625 to 3000 calories/day (35 to 40 kcal/kg/day)

 Estimated protein needs: 115 to 150 g protein/day (1.5 to 2.0 g protein/kg/day)
 Nutrition goal(s): Oral intake to meet estimated needs, decrease stool output to the point
where patient’s hydration is maintained; maintain optimal micronutrient status.
 Replace electrolyte and fluid losses. Monitor fluid balance.
 Continue general diet with moderate insoluble fiber until diarrhea is under control, reduce
simple sugars in the diet. Patient to make high-salt, high-starch, low-simple sugar food
choices from the menu. Encourage separation of beverages at mealtimes.
 Provide salty/starchy snacks between meals. Encourage “thickening foods,” such as
boiled white rice, pasta, noodles, bread, potatoes, banana, oatmeal, applesauce, peanut
butter, cheese, and tapioca pudding.
 Sip 2 L of oral rehydration solution (ORS) between meals as an alternative to commercial
electrolyte beverage.
 Avoid caffeinated and hypertonic fluids.
 Consider trial of soluble fiber supplement to slow down transit time and thicken stool.
 Continue antidiarrheal medications with dosage adjusted by physician depending on
volume and consistency of stool.
 Diet education: Discuss with patient and family nutrition management of micronutrient
status, including intake of water-miscible versions of fat-soluble vitamins, and vitamin
B12 shots monthly, and maintaining adequate weight and hydration status with changed
bowel length.
 Recommend outpatient follow up with nutrition professional specializing in GI nutrition.
 Evaluate micronutrient status.

Monitoring and evaluation

 Monitor oral intake via calorie counts with a goal of meeting 75% to 100% of estimated
energy and protein needs.
 Monitor stool and urinary output and weight trends to assess need for home intravenous
fluids (HIVF) or home parenteral nutrition (HPN) if weight and fluid status do not
stabilize with increased intake and ORS.

How would you counsel this patient? Jimmy is on a strict diet now; explain what the progression
to a normal diet would be? What are your recommendations for food intake? Explain.
Name: Erik Leacock 7
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

Firstly, I would ensure Jimmy was aware of the potentially consequences from a

C. difficile infection if he does not take his treatment and recommendations serious, such as

colitis, secretory diarrhea, severe dilation of the colon (toxic megacolon), perforation of the

bowel wall, peritonitis, or even death (Raymond & Morrow, 2021). I would mention to Jimmy

he may also be suffering from short-bowel syndrome due to his inability to maintain nutrition

and hydration needs if he does not progress to a normal fluid and food intake. While making

progression towards a normal diet, until the diarrhea has diminished the main objective is

replacement of necessary fluids through oral rehydration solutions, soups and broths, vegetable

juices, and isotonic liquids. I would recommend Jimmy to slow start a progression of starchy

carbohydrates, such as cereals, breads, and low-fat meals, followed by small amounts of

vegetables and fruits, followed by fats. The objective with this progression protocol is to limit

large amounts of hyperosmotic carbohydrates that may be maldigested or malabsorbed, foods

that stimulate secretion of fluids, and foods that speed the rate of GI transit. Small, frequent

snacks provide some oral gratification if her can only tolerate parenteral solutions initially. I

would encourage Jimmy to resume to a regular diet as tolerated that contains moderate amounts

of soluble fiber. By eating soluble fiber and resistant starches colonic bacteria produce short-

chain fatty acids, which may help regulate GI motility (Raymond & Morrow, 2021). As the

diarrhea has resolved the addition of more normal amounts of fiber to the diet may help to

restore normal mucosal function, increase electrolyte and water absorption, and increase the

firmness of the stool. The transition to more normal foods may take weeks to months, and for

some individuals may never tolerate normal concentrations or volumes of foods and always
Name: Erik Leacock 8
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

require supplementation to maintain adequate fluid and nutritional status. A multivitamin and

mineral supplement may be required to meet his nutritional needs.

I would recommend Jimmy to avoid sugar alcohols, lactose, fructose, and large

amounts of sucrose, which may worsen symptoms of diarrhea. In addition, Jimmy should

initially avoid caffeinated fluids, chocolate, bran cereals, raw vegetables, spicy foods, fried

foods, high-fat foods, or foods high in refined sugar or sorbitol. I would suggest to Jimmy that

having six to ten small feedings with avoidance of lactose, large amounts of concentrated sweets,

and caffeine may help to reduce symptoms of bloating, abdominal pain, and diarrhea. I would

suggest to Jimmy that he may want to consider taking soluble fiber supplements, as well as

probiotics and or prebiotics. Micronutrient replacement or supplementation may help support

normal regeneration of damaged mucosal epithelial cells. Lastly, I would encourage Jimmy to

stay strong and be patient with his diet and progression back to normal and that maximum

adaptation of his GI tract may take 1 to 2 years after surgery. Also, I would remind Jimmy that

complex, intact nutrients are the most important stimuli of the GI tract (Raymond & Morrow,

2021).
Name: Erik Leacock 9
ID#: 2561LEA
Nutrition Therapy I
Topic 5 Assignment 4

References

Raymond, J.L. & Morrow, K. (2021). Krause and Mahan’s Food & The Nutrition Care Process

(15th ed.). Elsevier, Inc.

Requirements: xx/20
Demonstrates Understanding: xx/25
Analysis and Evaluation: xx/25
Recommendations: xx/15
Articulation of Responses: xx/15

Points Earned: xx/100