Case Study of a Woman Nutrition status and Question regarding her energy intake

Question

Jane is a 42-year-old female who presents with acute onset of epigastric

abdominal pain associated with nausea and bilious vomiting, poor appe-

tite, and 20-pound (9-kg) unintentional weight loss over the past

3 months. A nutrition consult is requested for assessment of nutritional

status and strategies for treating nutritional issues associated with

gastroparesis.

Nutrition Assessment

• Past medical history is significant for type I DM, GERD, gastroparesis,

hypertension, chronic low back pain, and recent back surgery 3 months

ago. Jane was discharged on narcotics, and then was recently hospital-

ized for similar symptoms that were attributed to diabetic gastroparesis

exacerbated by narcotics use.

• Her medications on admission include insulin, Zofran, Prilosec, Reglan,

lisinopril, Ultram.

• Oral intake has gradually decreased over the last 3 months to sips of liq-

uids (water, soup, tea), and toast or crackers for the past 2 weeks. Upon

further questioning, Jane reports frequent hypoglycemia after meals,

early satiety, chronic constipation, and often wakes up in the morning

feeling full. She has persistent epigastric abdominal pain accompanied

by vomiting.

• Anthropometrics: Ht: 162.5 cm (64 inches); Wt: 72.7 kg (160 lb); BMI :

27.5 kg/m2

• Usual body weight: 81.8 kg (180 lbs); weight change: 11% change in

3 months (significant weight loss).

• Jane’s nutrition-focused physical examination (NFPE) reveals the follow-

ing: No evidence of muscle loss; stomach is smaller per patient report

but otherwise no visible evidence of fat loss; no upper or lower extremity

edema. Tongue is beefy red and swollen for the past few weeks (glossitis

resulting from possible iron, folate, and vitamin B12 deficiency).

• Functional capacity: Little energy or motivation to do anything for past

3 months. Dizzy and lightheaded for past 1 week.

• Laboratory data: Hb A1C (glycosylated hemoglobin) level: 9.5% (high),

blood pressure: 178/95 (high), blood glucose: 293 mg/dl (high)

Nutrition Diagnostic Statements (PES Statements)

• Suboptimal oral intake (P) related to inability to consume sufficient

calories (E) as evidenced by report of nausea, vomiting, and persistent

abdominal pain (S).

• Unintended weight loss (P) related to altered GI function (E) as evidenced

by 11% weight loss over past 3 months (S).

Nutrition Interventions

1) What would you estimate to be Jane’s daily energy and protein require-

ments?

2) What would you work out with Jane for timing and size of her meals?

3) Would you recommend a trial of oral nutrition supplements?

4) In educating Jane on dietary guidelines for DM and gastroparesis, what

would you discuss with her?

5) What concerns would you have related to her use of antiemetics or

prokinetic agents.

6) Would you recommend any nutritional supplements for Jane? Which

nutrients would concern you?

Nutrition Monitoring and Evaluation

1) What would you monitor during your followup visits with Jane to ensure

that her nutrition goals are being met?

Answer 1

1) Calories estimation: 18250-2055kcals ( 25-28kcal/kg at 73kg), Protein Estimation: 90-95g/day (1.2-1.3g/kg at 73kg)

2) For diabetic gastroparesis, I would normally recommend 3 meals/day and 2 snacks in between, one snack being a nighttime snack 2 hours before bed, Her hypo, and hyperglycemia are the most concerning problems. She is also insulin-dependent so mealtime must be coordinated with the timing of medications as well. Insulin is active in the body for 4 hours. Since she experiences frequent low after eating, I worry that the sizes of her meals are too small or too low in carbs in comparison to her mealtime insulin dose. In her case, I would recommend working with her endocrinologist to change her insulin to be administered after meals rather than pre-meal.

3) yes, since liquids are better tolerated than solids in most patients with gastroparesis. I would recommend a trial of oral nutrition supplements that have at least 15g protein and 20-40g Carb/per serving.

4) Risk and Treatment for hypo/hyperglycemia with T1DM and gastroparesis, Sick day management, Nutrition Label reading, Carb counting (if pt can) and appropriate insulin dosing,

5) Narcotics and Antiemetics both have the side effects of slowing GI motility -- very undesirable in the setting of gastroparesis. It will be ideal if we could decrease our dependence on these medications by using non-opioid pain meds and only using antiemetics as needed.

6) physical exam reveals glossitis resulting from possible iron, folate, and vitamin B12 deficiency. Because iron supplementation can worsen her chronic constipation, I would defer Iron supplementation after a complete iron panel and ferritin return, I may consider recommending IV iron sucrose if pt is severely iron deficient. Based on the above findings, I would recommend at least a complete multivitamin with minerals that contain B vitamins at 100% Daily Value. I would also recommend checking vitamin D25OH based on weight loss and chronic fatigue