Medical Nutrition Therapy: A Case Study Approach 4th Edition Solution Manual

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Nutrition Diagnoses Correlations forMedical Nutrition Therapy: A Case Study Approach4thed.Table 1: Nutrition Diagnoses Covered in Each CaseCaseNutrition Diagnoses1 Pediatric Weight ManagementOverweight/obesityNC-3.3Excessive energy intakeNI-1.3Physical inactivityNB-2.1Undesirable food choicesNB-1.7Food and nutrition-related knowledge deficitNB-1.12 Bariatric Surgery for Morbid ObesityInadequate vitamin intakeNI-5.9.1Overweight/obesityNC-3.3Inadequate protein intakeNI-5.7.1Food and nutrition-related knowledge deficitNB-1.13 Malnutrition Associated with Chronic DiseaseInadequate oral intakeNI-2.1Increased energy expenditureNI-1.1Inadequate fluid intakeNI-3.1MalnutritionNI-5.2Inadequate protein-energy intakeNI-5.3Inadequate protein intakeNI-5.7.1Unintendedweight lossNC-3.24 Hypertension and Cardiovascular DiseaseExcessive energy intakeNI-1.3Excessive fat intakeNI-5.6.2Less than optimal intake of types of fatsNI-5.6.3Inadequate fiber intakeNI-5.8.5Inadequate mineral intakeNI-5.10.1Excessivemineralintake(sodium)NI-5.10.2Altered nutrition-related laboratory valuesNC-2.2Overweight/obesityNC-3.3Limited adherence to nutrition-relatedrecommendationsNB-1.6Undesirable food choicesNB-1.75 Myocardial InfarctionInadequate bioactive substance intakeNI-4.1Food-medication interactionNC-2.3Food and nutrition-related knowledge deficitNB-1.16 Heart Failure with Resulting CardiacCachexiaInadequate oral intakeNI-2.1Inadequate enteral nutrition infusionNI-2.3Altered nutrition-related laboratory valuesNC-2.27 Gastroesophageal Reflux DiseaseExcessive energy intakeNI-1.3Undesirable food choicesNB-1.7Excessive fat intakeNI-5.6.2Excessivemineralintake(sodium)NI-5.10.2Overweight/obesityNC-3.3Altered nutrition-related laboratory valuesNC-2.2Food and nutrition-related knowledge deficitNB-1.1Physical inactivityNB-2.18 Ulcer Disease: Medical and SurgicalTreatmentInadequate enteral nutrition infusionNI-2.3Increased nutrient needsNI-5.1malnutritionNI-5.2Altered GI functionNC-1.4Impaired nutrient utilizationNC-2.1Unintendedweight lossNC-3.2

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CaseNutrition DiagnosesFood and nutrition-related knowledge deficitNB-1.19 Celiac DiseaseFood and nutrition-related knowledge deficitNB-1.1Undesirable food choicesNB-1.710 Irritable Bowel SyndromeInadequatefiber intakeNI-5.8.5Food and nutrition-related knowledge deficitNB-1.1Overweight/obesityNC-3.311 Inflammatory Bowel Disease: Crohn’sDiseaseIncreased nutrient needsNI-5.1Inadequate oral intakeNI-2.1Inadequate enteralnutrition infusionNI-2.3Altered GI functionNC-1.4Unintendedweight lossNC-3.212 Cirrhosis of the LiverInadequate protein-energy intakeNI-5.3malnutritionNI-5.2Excessivemineralintake(sodium)NI-55.2Unintendedweight lossNC-3.2Food and nutrition-related knowledge deficitNB-1.1Disordered eating patternNB-1.513 Acute PancreatitisInadequate protein-energy intakeNI-5.3Inadequate oral intakeNI-2.1Altered GI functionNC-1.4Increased nutrient needsNI-5.114 Pediatric Type 1 Diabetes MellitusAltered nutrition-related laboratory valuesNC-2.2Food and nutrition-related knowledge deficitNB-1.1Inconsistent carbohydrate intakeNI-5.8.4Impaired nutrient utilizationNC-2.1UnderweightNC-3.115 Type 1 Diabetes Mellitus in the AdultAlterednutrition-related laboratory value(glucose, hemoglobinA1c)NC-2.2Food and nutrition-related knowledge deficitNB-1.116 Type 2 Diabetes Mellitus—Pediatric ObesityOverweight/obesityNC-3.3Excessivecarbohydrate intakeNI-5.8.217 Adult Type 2 Diabetes Mellitus: Transitionto InsulinAltered nutrition-related laboratory valuesNC-2.2Food and nutrition-related knowledge deficitNB-1.118 Chronic Kidney Disease (CKD) Treated withDialysisInadequate protein-energy intakeNI-5.3Inadequate fiber intakeNI-5.8.5Less than optimal intake of types of fatsNI-5.6.3Overweight/obesityNC-3.3Altered nutrition-related laboratory valuesNC-2.2Limited adherence to nutrition-relatedrecommendationsNB-1.6Undesirable food choicesNB-1.719 Chronic Kidney Disease: Peritoneal DialysisAltered nutrition-related laboratory valuesNC-2.2Predicted suboptimal nutrient intakeNI-5.11.120 Acute Kidney Injury (AKI)Altered nutrition-related laboratory valuesNC-2.2Predicted suboptimal nutrient intakeNI-5.11.121 Anemia in PregnancyAltered nutrition-related laboratory valuesNC-2.2Inadequate mineral intakeNI-5.10.1Inadequate protein intakeNI-5.7.1Inadequate energy intakeNI-1.222 Folate and Vitamin B12DeficienciesImpaired nutrient utilizationNC-2.1Altered nutrition-related laboratory valuesNC-2.2Overweight/obesityNC-3.3Excessive energy intakeNI-1.3

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CaseNutrition DiagnosesPhysical inactivityNB-2.123 Ischemic StrokeInadequate oral intakeNI-2.1Swallowing difficultyNC-1.1Chewing difficultyNC-1.2Excessive energy intakeNI-1.3Inadequatemineralintake(potassium)NI-510.1Inadequate fiber intakeNI-53.5Overweight/obesityNC-3.324 Progressive Neurological Disease:Parkinson’s DiseaseInadequate oral intakeNI-2.1Inadequate fluid intakeNI-3.1Swallowing difficultyNC-1.1Food-medication interactionNC-2.325 Alzheimer’s DiseaseInadequate energy intakeNI-1.2Inadequate oral intakeNI-2.1Increased nutrient needsNI-5.1Altered nutrition-related laboratory valuesNC-2.2Unintendedweight lossNC-3.2Inability to manage self careNB-2.3Self-feeding difficultyNB-2.626 Chronic Obstructive Pulmonary DiseaseInadequate oral intakeNI-2.1Unintendedweight lossNC-3.2Altered nutrition-related laboratory valuesNC-2.2malnutritionNI-5.2Impaired ability to prepare foods/mealsNB-2.4Poor nutrition quality of lifeNB-2.527 COPD with Respiratory FailureInadequate oral intakeNI-2.1Inadequate protein-energy intakeNI-5.3UnderweightNC-3.1Unintendedweight lossNC-3.2Inadequate enteral nutrition infusionNI-2.3Excessive intake from enteral nutrition infusionNI-2.428 Pediatric Brain Injury: Metabolic Stress withNutrition SupportIncreased energy expenditureNI-1.1Inadequate enteral nutrition infusionNI-2.3Excessive fluid intakeNI-3.2Swallowing difficultyNC-1.129 Metabolic Stress and Trauma: OpenAbdomenInadequate protein intakeNI-52.1Increased energy expenditureNI-1.2Excessive fat intakeNI-51.230 Nutrition Support for Burn InjuryIncreased energy expenditureNI-1.2Inadequate enteral nutrition infusionNI-2.331 Nutrition Support in Sepsis and MorbidObesityIncreased protein needsNI-5.1Inadequate oral intakeNI-2.1MalnutritionNI-5.2Altered GI functionNC-1.4Predicted suboptimal vitamin intakeNI-5.11.132 Acute Lymphoblastic Leukemia Treatedwith Hematopoietic Cell TransplantationPredicted suboptimal energy intakeNI-5.11.1Increased nutrient needsNI-5.133 Esophageal Cancer Treated with Surgery andRadiationInadequate protein-energy intakeNI-5.3Inadequate enteral nutrition infusionNI-2.3Unintendedweight lossNC-3.234 AIDSIncreased energy expenditureNI-1.2Inadequate oral intakeNI-2.1

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CaseNutrition DiagnosesInadequate vitamin intakeNI-54.1Inadequate mineral intakeNI-55.1Inadequate protein-energy intakeNI-5.3MalnutritionNI-5.2Altered nutrition-related laboratory valuesNC-2.2Food-medication interactionNC-2.3Swallowing difficultyNC-1.1UnderweightNC-3.1Unintendedweight lossNC-3.2Food and nutrition-related knowledge deficitNB-1.1Table 2: List of Cases for Each Nutrition Diagnosis CoveredNutrition DiagnosisCaseNI-1.1Increased energy expenditure3 Malnutrition Associated with ChronicDisease28 Pediatric Brain Injury: Metabolic Stresswith Nutrition SupportNI-1.2Inadequate energy intake21 Anemia in Pregnancy25 Alzheimer’s DiseaseNI-1.2Increased energy expenditure29 Metabolic Stress and Trauma: OpenAbdomen30 Nutrition Support for Burn Injury34 AIDSNI-1.3Excessive energy intake1 Pediatric Weight Management4 Hypertension and Cardiovascular Disease7 Gastroesophageal Reflux Disease22 Folate and Vitamin B12Deficiencies23 Ischemic StrokeNI-2.1Inadequate oral intake3 Malnutrition Associated with ChronicDisease6 Heart Failure with Resulting CardiacCachexia11 Inflammatory Bowel Disease: Crohn’sDisease13 Acute Pancreatitis23 Ischemic Stroke24 Progressive Neurological Disease:Parkinson’s Disease25 Alzheimer’s Disease26 Chronic Obstructive Pulmonary Disease27 COPD with Respiratory Failure31 Nutrition Support in Sepsis and MorbidObesity34 AIDSNI-2.3Inadequate enteral nutrition infusion6 Heart Failure with Resulting CardiacCachexia8 Ulcer Disease: Medical and SurgicalTreatment11 Inflammatory Bowel Disease: Crohn’sDisease27 COPD with Respiratory Failure

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Nutrition DiagnosisCase28 Pediatric Brain Injury: Metabolic Stresswith Nutrition Support30 Nutrition Support for Burn Injury33 Esophageal Cancer Treated with Surgeryand RadiationNI-2.4Excessive intake from enteral nutrition infusion27 COPD with Respiratory FailureNI-3.1Inadequate fluid intake3 Malnutrition Associated with ChronicDisease24 Progressive Neurological Disease:Parkinson’s DiseaseNI-3.2Excessive fluid intake28 Pediatric Brain Injury: Metabolic Stresswith Nutrition SupportNI-4.1Inadequate bioactive substance intake5 Myocardial InfarctionNI-5.1Increased nutrient needs8 Ulcer Disease: Medical and SurgicalTreatment11 Inflammatory Bowel Disease: Crohn’sDisease13 Acute Pancreatitis25 Alzheimer’s Disease31 Nutrition Support in Sepsis and MorbidObesity32 Acute Lymphoblastic Leukemia Treatedwith Hematopoietic Cell TransplantationNI-5.2Malnutrition3 Malnutrition Associated with ChronicDisease8 Ulcer Disease: Medical and SurgicalTreatment12 Cirrhosis of the Liver26 Chronic Obstructive Pulmonary Disease31 Nutrition Support in Sepsis and MorbidObesity34 AIDSNI-5.3Inadequate protein-energy intake3 Malnutrition Associated with ChronicDisease12 Cirrhosis of the Liver13 Acute Pancreatitis18 Chronic Kidney Disease (CKD) Treatedwith Dialysis27 COPD with Respiratory Failure33 Esophageal Cancer Treated with Surgeryand Radiation34 AIDSNI-5.6.2Excessive fat intake4 Hypertension and Cardiovascular Disease7 Gastroesophageal Reflux DiseaseNI-5.6.3Less than optimal intake of types of fats4 Hypertension and Cardiovascular Disease18 Chronic Kidney Disease (CKD) Treatedwith DialysisNI-5.7.1Inadequate protein intake2 Bariatric Surgery for Morbid Obesity3 Malnutrition Associated with ChronicDisease21 Anemia in PregnancyNI-5.8.2Excessive carbohydrate intake16 Type 2 Diabetes Mellitus—PediatricObesity

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Nutrition DiagnosisCaseNI-5.8.4Inconsistent carbohydrate intake14 Pediatric Type 1 Diabetes MellitusNI-5.8.5Inadequate fiber intake4 Hypertension and Cardiovascular Disease10 Irritable Bowel Syndrome18 Chronic Kidney Disease (CKD) Treatedwith DialysisNI-5.9.1Inadequate vitamin intake2 Bariatric Surgery for Morbid ObesityNI-5.10.1Inadequate mineral intake4 Hypertension and Cardiovascular Disease21 Anemia in PregnancyNI-5.10.2Excessive mineral intake (sodium)7 Gastroesophageal Reflux Disease4 Hypertension and Cardiovascular DiseaseNI-5.11.1Predicted suboptimal nutrient intake19 Chronic Kidney Disease: Peritoneal Dialysis20 Acute Kidney Injury (AKI)31 Nutrition Support in Sepsis and MorbidObesity32 Acute Lymphoblastic Leukemia Treatedwith Hematopoietic Cell TransplantationNI-51.2Excessive fat intake29 Metabolic Stress and Trauma: OpenAbdomenNI-52.1Inadequate protein intake29 Metabolic Stress and Trauma: OpenAbdomenNI-53.5Inadequate fiber intake23 Ischemic StrokeNI-54.1Inadequate vitamin intake34 AIDSNI-55.1Inadequate mineral intake (potassium)23 Ischemic StrokeNI-55.1Inadequate mineral intake34 AIDSNI-55.2Excessive mineral intake (sodium)12 Cirrhosis of the LiverNC-1.1Swallowing difficulty23 Ischemic Stroke24 Progressive Neurological Disease:Parkinson’s Disease28 Pediatric Brain Injury: Metabolic Stresswith Nutrition Support34 AIDSNC-1.2Chewing difficulty23 Ischemic StrokeNC-1.4Altered GI function8 Ulcer Disease: Medical and SurgicalTreatment11 Inflammatory Bowel Disease: Crohn’sDisease13 Acute Pancreatitis31 Nutrition Support in Sepsis and MorbidObesityNC-2.1Impaired nutrient utilization8 Ulcer Disease: Medical and SurgicalTreatment14 Pediatric Type 1 Diabetes Mellitus22 Folate and Vitamin B12DeficienciesNC-2.2Altered nutrition-related laboratory values4 Hypertension and Cardiovascular Disease6 Heart Failure with Resulting CardiacCachexia7 Gastroesophageal Reflux Disease14 Pediatric Type 1 Diabetes Mellitus15 Type 1 Diabetes Mellitus in the Adult17 Adult Type 2 Diabetes Mellitus: Transitionto Insulin18 Chronic Kidney Disease (CKD) Treatedwith Dialysis

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Nutrition DiagnosisCase19 Chronic Kidney Disease: Peritoneal Dialysis20 Acute Kidney Injury (AKI)21 Anemia in Pregnancy22 Folate and Vitamin B12Deficiencies25 Alzheimer’s Disease26 Chronic Obstructive Pulmonary Disease34 AIDSNC-2.3Food-medication interaction5 Myocardial Infarction24 Progressive Neurological Disease:Parkinson’s Disease34 AIDSNC-3.1Underweight14 Pediatric Type 1 Diabetes Mellitus27 COPD with Respiratory Failure34 AIDSNC-3.2Unintended weight loss3 Malnutrition Associated with ChronicDisease8 Ulcer Disease: Medical and SurgicalTreatment11 Inflammatory Bowel Disease: Crohn’sDisease12 Cirrhosis of the Liver25 Alzheimer’s Disease26 Chronic Obstructive Pulmonary Disease27 COPD with Respiratory Failure33 Esophageal Cancer Treated with Surgeryand Radiation34 AIDSNC-3.3Overweight/obesity1 Pediatric Weight Management2 Bariatric Surgery for Morbid Obesity4 Hypertension and Cardiovascular Disease7 Gastroesophageal Reflux Disease10 Irritable Bowel Syndrome16 Type 2 Diabetes Mellitus—PediatricObesity18 Chronic Kidney Disease (CKD) Treatedwith Dialysis22 Folate and Vitamin B12Deficiencies23 Ischemic StrokeNB-1.1Food and nutrition-related knowledge deficit1 Pediatric Weight Management2 Bariatric Surgery for Morbid Obesity5 Myocardial Infarction7 Gastroesophageal Reflux Disease8 Ulcer Disease: Medical and SurgicalTreatment9 Celiac Disease10 Irritable Bowel Syndrome12 Cirrhosis of the Liver14 Pediatric Type 1 Diabetes Mellitus15 Type 1 Diabetes Mellitus in the Adult17 Adult Type 2 Diabetes Mellitus: Transitionto Insulin34 AIDSNB-1.5Disordered eating pattern12 Cirrhosis of the Liver

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Nutrition DiagnosisCaseNB-1.6Limited adherence to nutrition-relatedrecommendations4 Hypertension and Cardiovascular Disease18 Chronic Kidney Disease (CKD) Treatedwith DialysisNB-1.7Undesirable food choices1 Pediatric Weight Management4 Hypertension and Cardiovascular Disease7 Gastroesophageal Reflux Disease9 Celiac Disease18 Chronic Kidney Disease (CKD) Treatedwith DialysisNB-2.1Physical inactivity1 Pediatric Weight Management7 Gastroesophageal Reflux Disease22 Folate and Vitamin B12DeficienciesNB-2.3Inability to manage self care25 Alzheimer’s DiseaseNB-2.4Impaired ability to prepare foods/meals26 Chronic Obstructive Pulmonary DiseaseNB-2.5Poor nutrition quality of life26 Chronic Obstructive Pulmonary DiseaseNB-2.6Self-feeding difficulty25 Alzheimer’s Disease

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Answer Guide forMedical Nutrition Therapy: A Case Study Approach4thed.Case 1–Pediatric Weight ManagementI.Understanding the Disease and Pathophysiology1.Current research indicates the cause of childhood obesity is multifactorial. Briefly outline the roles ofgenetics, environment, and nutritional intake in development of obesity in children.Biological (genetics and pathophysiology):•30%-75% of adiposity in children is related to genetics•In children < 3 years of age, the strongest predictor of adulthood obesity is parental obesity•Both prenatal undernutrition and overnutrition appear to increase lifelong risk for obesity•Genetic/hormonal: Some of the most common are:oPrader-Willi syndromeoCushing’s syndromeoHypo-/hyperthyroidismEnvironmental (sedentary behaviors, SES, modernization, culture, dietary intake):•Video and computer games and cable and satellite television have made sedentary activities more appealingo98% of children in the U.S. live in homes with at least one televisiono80% of children live in homes with at least one DVD playeroHalf of the children who live in the U.S. have at least one video game system in their homesoOn average, children spend 3 hours per day watching television•African American and Hispanic children participate in fewer vigorous activities and/or more sedentaryactivities than Whites•Girls are less physically active than boys•Dietary factorsoLow intake of vegetables and fruitsoHigh intake of fast foods and sweetsoIncreased consumption of sugar-sweetened soft drinksoSkipping breakfastoIncreased consumption of refined carbohydrates (ready-to-eat cereals, potatoes, cakes, biscuits, softdrinks)Global (society, community, organization, interpersonal, individual):•Community design focused on cars has discouraged walking and bike riding•Increased concerns about safety limit timesand areas in which children play outside•Time in physical education classes in schools has decreased•Limited number of parks and recreation areas in communities2.Describe health consequences of overweight and obesity for children.•OrthopedicoAbnormalities affecting feet, legs, hipsoSlipped capital femoral epiphysisoBlount’s disease (bowing of lower legs & tibial tortion)•NeurologicaloPseudotumor cerebri (increased pressure in skull)oRecurrent headaches•PulmonaryoAsthmaoSleep disordersoSleep apnea•GastrointestinaloCholecystitisoHepatic steatosis

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oGallstones•EndocrineoType 2 DMoPolycystic ovary syndrome (PCOS)oHirsutismoAcneoAcanthosis nigricansoEarly puberty & menarche•PsychologicaloLow self-esteemoDepressionoPeer rejection•CardiovascularoHypertensionoHyperlipidemia3.Jamey has been diagnosed with obstructive sleep apnea. Definesleep apnea.•Sleep apnea literally means “sleep without breath.”•It is diagnosedin individuals who experienceperiods (at least 10 seconds) of not breathing for a variety ofreasons.•In the case of Jamey, obstructive sleep apnea is caused bythecollapse of soft tissue in the throat, whicheffectively blocksher air passage.4.Explain the relationship between sleep apnea and obesity.•Strong correlations existbetween weight and occurrence of sleep apnea, especially with the size of aperson’s neck and visceral fat.•Larger neck sizes putastrain ontheairway, and visceral fat puts pressure on the lungs, decreasing lungfunction (although the function is not decreased during waking periods at rest).•Additionally, Jamey may have tonsillar hypertrophy (another factor to consider with sleep apnea).II.Understanding the Nutrition Therapy5.What are the goals for weight loss in the pediatric population?•Since children are still growing in height, weight-loss goals should be realistic and should not necessarilyattempt to fully normalize weight.•For children at risk for overweight with no identified complications,maintenance of current weight isrecommended. Prolonged maintenance will allow a gradual decline in BMI units as children grow inheight.•For children who are overweight and those overweight with complications, gradual weight loss isrecommended.•Rate of weight loss should be based on health risks and recommended with caution. Primary goals oftreatment are:oPromote healthful lifestyle behaviors to achieve and maintain a desirable body weightoWell-balanced diet that supports growth and developmentoBehavior modificationoIncreased physical activityoFamily involvementoImprove/resolve complications of obesity if present6.Under what circumstances might weight loss in overweight children not be appropriate?•Pregnancy•HIV/AIDS

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•Oncology treatment•Severe psychiatric disorders•Metabolic diseases such as Prader-Willi syndrome7.What would you recommend as the current focus for nutritional treatment ofJamey’s obesity?•Involve the entire family and/or all caregivers.•Encourage family activities that provide everyone with exercise.•Low-fat, low-cholesterol,reduced-sugar diet per age, weight, or BMI and nutritional requirements.•Encourage planned meals, especially breakfast. Discourage skipping meals.•Discourage eating while watching television.•Avoid use of food as a reward or punishment.•Stock refrigerator with healthy food and drink choices.•Familyshouldeat meals together as often as possible.•Learn to read food labels for healthier food selections.•Select appropriate portion sizes at home and when eating out.•Reduce number of meals eaten outside the home.•Encourage 30-60 minutes of moderate physical activity most days of the week.•Promote a variety of exercises to prevent boredom or overtraining.III.Nutrition Assessment8.Evaluate Jamey’s weight using the CDC growth charts provided: What is Jamey’s BMI percentile? How isher weight status classified?Use the growth chart to determine Jamey’s optimal weight and height for age.•BMI: 24.9, percentile: >95th.•Jamey would be classified asobese. The CDC and others regard this childto bein the highest weightclassification for age.•The approximate optimal weight for Jamey’s age is 70-72 lbs and her approximate optimal height for age is55 in.9.Identify two methods for determining Jamey’s energy requirements other than indirect calorimetry, and thenuse them to calculate Jamey’s energy requirements.•Total Energy Expenditure, or TEE1(for weight maintenance in overweight ages 3-18 years):oTEE = 389–(41.2age[y]) + PA(15weight [kg] + 701.6height [m])Where PA is the physical activity factor:PA = 1.00 ifphysical activity level (PAL)sedentaryPA = 1.18 if PAL low activePA = 1.35 if PAL activePA = 1.6 if PAL very activeoTEE = 389–41.2(10) + 1[15(52.3 kg) + 701.6(1.45 m)]oTEE = 389–412 + 785 + 1017oTEE = 1779 orround to1800 kcal/day for ease•kcal/cmo12-15 kcal/cm for very low energy needs (sedentary)o12 × 145 = 1740 kcalo15 × 145 = 2175 kcal1National Academy of Sciences Food and Nutrition Board.Dietary Reference Intakes for Energy, Carbohydrate,Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, D.C.: The National Academies Press,2005.

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10.Dietary factors associated with increased risk of overweight are increased dietary fat intake and increasedcalorie-dense beverages. Identify foods from Jamey’s diet recall that fit these criteria.•Whole milk•Apple juice•Coffee with cream and sugar•Mayonnaise•Fritos® corn chips•Bologna & cheese sandwich•Twinkies®•Peanut butter•Fried chicken•Fried okra•Mashed potatoes with whole milk and butter•Sweet tea•Coca-Cola®11.Calculate the percent of kcal from each macronutrient and the percent of kcal provided by fluids for Jamey’s24-hour recall.•Total kcal:~ 4419;44% fat, 42% CHO, and 14% protein•Fluid kcal:~ 957; 22% of kcal12.Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey’sdiet fall into these categories?Apple juice, fried okra, and potatoes are the only fruit and vegetables sheconsumed.13.Use the ChooseMyPlate online tool (available from www.choosemyplate.gov; click on “Daily Food Plans”under “SuperTracker and Other Tools”) to generate a customized daily food plan. Using this eating pattern,plan a 1-day menu for Jamey.Example (answers will vary):oAM: 1 c frosted shredded wheat with 4-8 oz skim milk, 1 c orange juice, and whole-wheat bagel (can use atbsp of cream cheese or butter if desired). Drink at least 8 oz of water.oLunch: PB&J sandwich (use whole-wheat bread), 15 wheat thins (or 21 small pretzels), 8 oz skim milk.oAfter-school snack: Turkey sub (2 or 3 slices of deli turkey, spinach, and 1 tbsp low-fatRanch on hoagie orpreferably whole-wheat bread), 8 oz skim milk. Drink at least 8 oz water.oDinner: Beef burrito (2 oz ground beef, 1 oz refried beans, 1 oz salsa, 1 oz cheddar cheese), dress withtomato, lettuce, onion, corn. 20 oz water (or 12 oz juice).oSnack: Banana, orange, or any other fresh fruit you like.14.Now enter and assess the 1-day menu you planned for Jamey using the MyPlate SuperTracker online tool(http://www.choosemyplate.gov/supertracker-tools/supertracker.html). Does your menu meet macro-andmicronutrient recommendations for Jamey?Answers will vary according tothe answer to #13.15.Why did Dr. Lambert order a lipid profile and blood glucose tests?What lipid and glucose levels areconsidered altered (i.e., outside of normal limits) for the pediatric population?EvaluateJamey’s lab results.•The combination of being overweight, nightly urination, HTN, and increased appetite along with a familyhistory of gestational diabetes are cluesthatthere may be an increased risk for diabetes.•Weight status, HTN, and family history are all risk factors for CVD, so performing a lipid panel helps toscreen for additional risk factors that can be controlled early on.

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•Altered lab results:Total Cholesterol>170 mg/dLLDL Cholesterol>110 mg/dLHDL Cholesterol≤35 mg/dLTriglycerides≥150 mg/dLGlucose60-100 mg/dL•Cholesterol and triglycerides are fine.•LDLand HDL levels are dangerously close to being outside oftheacceptable range.•The glucose levelisjust outside normal range,but she just ate breakfast two hours before she came in. Tobe sure, a fasting glucose would be prudent.16.What behaviors associated with increased risk of overweight would you look for when assessing Jamey’s andher family’s diets?What aspects of Jamey’s lifestyle place her at increased risk for overweight?Behaviors to look for:•Sedentary lifestyle•Snacks•Family’s dinner-time ritual: TV trays or together at the dinner table?•Parents’ knowledge about benefits of fruits, vegetables, whole grains, and physical activity should beassessed.•It may help to explain that she feels tired because of the sleep apnea. Once that is treated and she begins aregular schedule of physical activity she may want to be more active.Being sedentary is the biggest. She also seems to habitually snack while doing nothing.17.You talk with Jamey and her parents, who are friendly and cooperative. Jamey’s mother asks if it would helpfor them to not let Jamey snack between meals and to reward her with dessert when she exercises. Whatwould you tell them?•Snacks between meals are acceptable as long as they are healthy snacks.oFruits and vegetables would be ideal.•Instead of using dessert as a reward,Jamey’smother should offer to do some kind of activity like going tothe park or shopping withher—anything that will encourage physical activity.18.Identify one specific physical activity recommendation for Jamey.•If it’s nice out, Jamey and her mother could go out for a walk in the evenings.•Ininclement weather, Jamey and her mother could play the latest motion video game.IV.Nutrition Diagnosis19.Select two nutrition problems and complete PES statements for each.Following are possible PES statements. It may be helpful for students to initially write more than two nutritiondiagnoses and then prioritize as to the ones most likely to have immediate nutrition interventions.Clinical:•Overweight related to physical inactivity and excessive energy intake as evidenced by BMI of 24.9 (>95%)Intake:•Excessive energy intake related to snacks and meals consisting of calorically dense foods and beveragessuch as whole milk, regular sweetened sodas, and fried foods as evidenced by typical daily caloric intake ofapproximately 4400 kcal compared to recommended daily intake of 1800-2000 kcal(Students could also write a similar PES using "Excessive oral food/beverage intake" as theproblem.)

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Behavioral/Environmental:•Physical inactivity related to overweight, fatigue,and limited PA at school as evidenced by usual activitieslimited to playing video games and reading•Undesirable food choices related to knowledge deficit and low intake of fruits and vegetables as evidencedby frequent intake of juices, whole milk, sweetened beverages, refined carbohydrates, fried foods, andhigh-fat meals•Food and nutrition knowledge deficit as evidenced by Jamey’s mother inquiring about the use of foodrewards to motivate an increase in physical activity and exercise (in this case an etiology may not benecessary)V.Nutrition Intervention20.For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriateintervention (based on etiology).Clinical:•Overweight related to physical inactivity and excessive energy intake as evidenced by BMI of 24.9Ideal Goal:BMI within normal range and less than 85thpercentileIntervention:Nutrition counseling with focus on behavioral modification (refer to specific interventionsassociated with the intake and behavioral problems defined below).Intake:•Excessive energy intake(or oral food/beverage intake)related to snacks and meals consisting of caloricallydense foods and beverages such as whole milk, regular sweetened sodas, and fried foods as evidenced bytypical daily caloric intake of approximately 4400 kcal compared to recommended daily intake of 1800-2000 kcalIdeal Goal:Average daily kcal intake within recommended range of 1800-2000 kcalIntervention:Nutrition education to develop alternative foods and beverages that are nutrient dense.Modify distribution, type,and amount of foods within meals and snacks to include:•Reduced-fat milk•Water for thirst instead of sweetened colas•Decreased portion sizes•Increase of fruits, vegetables, and whole grainsBehavioral/Environmental:•Physical inactivity related to overweight, fatigue and limited PA at school as evidenced by usual activitieslimited to playing video games and readingIdeal Goal:Increase in physical activity (can specify an amount or type if desired)Interventions:In this case, interventions may not necessarily be directed at the etiologies as defined but bedesigned to lessen signs and symptoms; therefore, nutrition counseling would use the strategies of goalsetting, rewards and reinforcement (not foods), and social support to promote physical activities that arerealistic and appropriate for both Jamey and her parents. Students should include in their answer the needfor exploring a variety of options that are fun and non-competitive.•Undesirable food choices related to knowledge deficit and low intake of fruits and vegetables as evidencedby frequent intake of juices, whole milk, sweetened beverages, refined carbohydrates, fried foods, andhigh-fat meals.Ideal Goal:Even though this PES statement is quite similar to the intake example noted above, the goalswould be defined slightly differently. Instead of a specific caloric goal, goals for this PES would be basedon the amount and type of foods described in the signs and symptoms, such as “no more than 4 oz of fruitjuice daily” or “limit fried foods to one time weekly,” etc.Intervention:A similar intervention as noted above is appropriate as well.

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•Food and nutrition knowledge deficit as evidenced by Jamey's mother inquiring about the use of foodrewards to motivate an increase in physical activity and exerciseIdeal Goal:Jamey’s mother providing appropriate non-food rewards to motivate an increase in physicalactivityIntervention:Nutrition education stating the purpose and use of family counseling theory and strategiesthat include problem solving, social support, and goal setting.21.Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli (orlistat). What would youtell them?No pharmacological agents for weight loss have been approved for use in children under the age of 12.22.Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey.Using the EAL, what are therecommendations regarding gastric bypass surgery for the pediatric population?TheExpert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child andAdolescent Overweight and Obesity2include the following criteria for adolescents being considered for weight-loss surgery:•Failure of at least six months of organized weight-loss attempts as determined by their primary careprovider•Severely obese (BMI 40 or greater) with serious obesity-related medical complications or have a BMI of 50or more with less-severe co-morbidities•Co-morbidities related to obesity that might be resolved with durable weight loss•Attainment of a majority of skeletal maturity (generally at least 13 years of age for girls and at least 15years of age for boys).•Demonstrate commitment to comprehensive medical and psychological evaluations both before and afterweight-loss surgery•Capable and willing to adhere to nutritional guidelines post-operatively•Able to decide and participate in the decision to undergo weight-loss surgery.•Have a supportive family environment•Evaluated by a multi-disciplinary team involved in patient selection, preparation,and surgery as well asimmediate and long-term post-operative follow-up carePotential candidates should be referred to centers with multi-disciplinary weight-management teams that haveexpertise in meeting the unique needs of obese adolescents. Surgery should be performed in institutionsequipped to meet the tertiary needs of severely obese patientsthatcollect long-term data on the clinicaloutcomes of these patients.VI.Nutrition Monitoring and Evaluation23.What is the optimal length of weight management therapy for Jamey?•Nutrition counseling should include goal-setting, self-monitoring, stimulus control, problem-solving,contingency management, cognitive restricting, use of incentives and rewards, and social supports•MNT should last at least 3 months or until initial weight-management goals are achieved•Weight control is often a life-long condition and it is critical that a weight management plan beimplemented after the intensive phase of treatment•More contact betweenthepatient and RD may lead to more successful weight loss and maintenance24.Should her parents be included? Why or why not?2Sarah E. Barlow and the Expert Committee. Expert Committee Recommendations Regarding the Prevention,Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report.Pediatrics,2007;120;S164-S192. (P. S185).

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•Family counseling is very important and improves weight management outcomes.•Parents need to be ready to make lifestyle changes to support the child/adolescent with cognitive behaviorstrategies.•Components include:onutrition education on lifestyle behaviors and their relationship to chronic disease developmentomodification ofthehome/school environment to enable the adolescent to make wise food choicesoself-monitoring and motivation to change by modeling behaviors and contracting25.What would you assess during this follow-up counseling session?•Accurate measurement of height and weight, plottedon CDC Growth Chart•24-hour recall with either FFQ or food record•Identify areas that have been changed and can be changed•Patient’s and parents’ motivation to change•Physical activity record/recallotype of physical activity adolescent participates inotype of physical activity parents participate inotime spent watching TV, video games, or on computer•Real or perceived limitations•Body image•Ethnic or religious practices and beliefs related to food•Use of vitamins, supplements, and alcohol or drugs by patient

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Answer Guide forMedical Nutrition Therapy: A Case Study Approach4thed.Case 2–Bariatric Surgery for Morbid ObesityI.Understanding the Disease and Pathophysiology1.Discuss the classification of morbid obesity.•Body mass index (BMI) is usually used as a common method for determining if someone is obese since itis easy and quick.BMI>30 is considered obese.•Obesity can be defined as a fat percentage greater than >25% fat in females and >33% in males. However,this requires tools and skill so BMI is more commonly used even though BMI does not factor in bodycomposition.•BMI>40 is considered morbidly obese for both men and women.•For children, obesity is defined using the CDC growth charts that provide BMI for age data.≥the 95thpercentile is considered an obese classification.•TheDietary Guidelines for Americanshave different classifications for obesity. Class 1 is a BMIof30-34.9;class 2, aBMIof35-39.9;and extreme obesity (class 3),a BMI≥40 kg/m2.•Waist circumference canbe used to determine mild obesity but it is a poor indicator of morbid obesity.Awaist circumference >40in. men or>35in. in women indicates obesityor increased risk for CVD. This isbased on the fact that central adiposityis thought topropose a higher risk for CVD than gynoid obesity.2.Describe the primary health risks involved with untreated morbid obesity. What health risks does Mr.McKinley present with?Risks with untreated morbid obesity include:•Type 2 diabetes: 3asprevalent among obese persons compared to those with normalweight•Hypertension (high blood pressure):3more common in the obese•Dyslipidemia (abnormal lipid profile, high cholesterol, low HDL, high LDL, high triglycerides)•Gallstones: 6greaterrisk for gallstones among persons who are obese•Non-alcoholic fatty liver disease: central adiposity is a risk factor for NAFLD•Cancer:•Men are at an increased risk for esophageal, colon, rectum, pancreatic, liver, and prostate cancers•Women are at an increased risk for gallbladder, bile duct, breast, endometrial, cervix, and ovariancancers.•Coronary heart disease•Myocardial infarctions (heart attacks)•Angina (chest pain)•Sudden cardiac death•Sleep apnea (inability to breathe while sleeping or lying down)•Asthma•Reproductive disorders:•Men: gynecomastia (enlarged mammary glands in males), hypgonadism, reduced testosterone levels,and elevated estrogen levels•Women: menstrual abnormalities, polycystic ovarian syndrome•Metabolic syndrome•Premature death: obese individuals have a 50-100% increased risk of premature death compared to healthy-weight individuals.•Bone health: obesity can increase chances of osteoporosis or decreased bone mineral densityHealth risks Mr. McKinley presents with:•Osteoarthritis•Type 2 diabetes•Hyperlipidemia•Hypertension

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•Mr. McKinley has been obese his whole life, which puts him at an increased risk for type 2 diabetes,hyperlipidemia, hypertension, and osteoarthritis.3.What are the standard adult criteria for consideration as a candidate for bariatric surgery? After reading Mr.McKinley’s medical record, determine the criteria that allow him to qualify for surgery.•The patient should be morbidly obesewith a BMI ≥40 or...•...The patient should be obese with a BMI≥35 and display a co-morbidity such as cardiovascular disease,sleep apnea, or diabetes.•Surgery is a resort used when the patient has failed to lose weight by other,less invasive means.•However, often times, physicians require that a patient lose some weight prior to the operation todemonstrate thathe or she iswilling to followthrough with lifestyle changes relating to exercise and diet.•Mr. McKinleyis a candidate for surgery because he is morbidly obese with a BMI of 59 (BMI >40) and hehas several co-morbidities including: type 2 diabetes, hypertension, and hyperlipidemia.4.By performing an Internet search or literature review, find one example of a bariatric surgery program.Describe the information that is provided for the patient regarding qualification for surgery. Outline thepersonnel involved in the evaluation and care of the patient in this particular program.Internet search information is taken from:http://www.obesityhelp.com/forums/vsg/about_vertical_sleeve_gastrectomy.htmlQualification information: for low-BMI individuals that should consider this procedure:•Those concerned by long-term complications of intestinal bypass•Those who are concerned about a lap-band, or inserting a foreign object into the abdomen•Those who have other medical problems that prevent them from having weight-loss surgery such asanemia, Crohn’s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and othercomplex medical conditions•People who need to take anti-inflammatory medications;VSGpresentsa lower riskfor developmentofulcers after taking anti-inflammatory meds after surgeryPersonnel involved:•Laparoscopic Associates of San Francisco (LAPSF)•Obesityhelp.com•“In more than 700 patients, there were no deaths, no conversions to open and a leak rate of less than 1%.”(obesityhelp.com)•Study showed that two-year weight-loss results from the vertical gastrectomy were similar to the roux-en-Y.•57% weight loss using the vertical gastrectomy compared to41% forthe lap-band procedure.•This case is associated with a team of several doctors from LAPSF.5.Describe the following surgical procedures used for bariatric surgery including advantages, disadvantages,and potential complications.a.Roux-en-Y gastric bypassDescription:•Most common restrictive-malabsorptive procedure.•A small pouch is created at the top of the stomach, which restricts food intake by increasing satiety.The jejunum is cut at the distal end and is attached to the small pouch at the top of the stomach, whichbypassesthe rest of the stomach, the duodenum, and the first part of the jejunum in order to restrictdigestion and absorption.•The proximal end of the jejunum that is draining the stomach is surgically connected to the lower endof the jejunum, allowing for secretions from the liver, gallbladder and the pancreas to enter thejejunum to aid in digestion and absorption.

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Advantages:•Weight loss is achieved through this procedure by decreasing food intake, increasing satiety,anddeceasing absorption.•Dramatic improvements in diabetes, sleep apnea, hypertension, cancer,and cardiovascular disease risk.•Potential 40% reduction in mortality.•laparoscopic procedure, which is minimally invasive.Disadvantages:•Vitamin and mineral deficiencies;may need lifelong supplementation.•Cannot take NSAIDs after surgery.•Emotional and physical stamina are needed to be willing to make the necessary dietary and lifestylechanges.•Nutrient deficiencies are more common because it is a restrictive-malabsorptive procedure, especiallyforfat-soluble vitamins (A,D,E,K),vitamin B12, folate, iron,andcalcium.oThe stomach is being bypassed, whichresults in loss ofintrinsic factor, which is necessary for B12absorption.oThe stomach provides acidity for iron absorption, which may be impairedfollowingthisprocedure.Potential complications:•Development of gallstones, anemia, metabolic bone disease, osteoporosis•Ulcers if patient smokes after surgery•Nausea/vomiting if too much food is consumed•Dumping syndrome (diarrhea, nausea, flushing, bloating from decreased transit time and from eatingrefined carbohydrates)b.Vertical sleeve gastrectomyDescription:•Up to 85% of the stomach is removed but leaves the pylorus intact and preservesthe stomach’sfunction.•There is a tubular portion of the stomach between the esophagus and the duodenum, restrictingremaining stomach’s holding capacity to 50-150mL.•The surgeon places two rows of staples through both walls of the stomach and then cuts through bothwalls of the stomach between the lines of the staples, separating the stomach into two sections.•The section attached to the esophagus and duodenum is removed.•Procedure causes a decrease in food intake by restricting the stomach’s capacity and is considered arestrictive procedure.Advantages:•Minimal nutrient malabsorption.•Removing part of the stomach results in a loss of the hormone ghrelin, which further enhances weightloss because ghrelin plays a role in hunger.•Dumping syndrome is usually avoided by leaving the pylorus intact.•Effective for weight loss in high-BMI candidates.•Laparoscopic, which is minimally invasive.Disadvantages:•Weight regain is more possible because it does not involve intestinal bypass. Instead, it relies on adecrease in food intake.•Procedure is not reversible.•High-BMI candidates will most likely need a second procedure further down the road to aid in furtherweight loss. VSG acts as a beginning surgery.Potential complications:Leaks related to the stapling procedure may occur.c.Adjustable gastric banding (Lap-Band®)

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Description:•Silicone ring or band is laparoscopically introduced into the abdominal cavity and secured around theupper part of the stomach to create a small pouch with a narrow opening at the bottom of the pouchthrough which food passes into the rest of the stomach.•The band restricts the stomach’s capacity to as little as 30mL.•As time goes on, the band can be adjusted to increase the capacity of the stomach.•The band is inflated with saline, which narrows the opening at the bottom of the pouch. This delaysgastric emptying, allowing the patient to feel full longer.•Most common restrictive procedure.Advantages:•Complications are least likely to result from AGB compared to other bariatric procedures.•Hospital stay and post-op recovery are shorter thanforthe other procedures.•Band can be adjusted to suit patient’s caloric needs.•Simple and the least invasive of the procedures.Disadvantages:Patients lose weight at a slower rate thanafterrestrictive-malabsorptive procedures such asthe roux-en-Y gastric bypass procedure.Potential complications:Risk of tear in the stomach during the operation; potential for nausea, vomiting,heartburn, and abdominal pain. The band may slip, which would require additional surgery.d.Vertical banded gastroplastyDescription:Upper portion of stomach is stapled with a one-centimer hole at the bottom of the pouch thatallows for a very slow passage of food into the lower portion of the stomach. This procedure restrictsoverall oral intake due tothe stomach’sdecreasedcapacity, aiding in weight loss.Advantages:•Simple, non-invasive.•Procedure is reversible.•Does not change the normal digestive pathways.Disadvantages:•Weight regain is possible because it does not involve intestinal bypassand the pouch may stretch overtime. Instead, it relies on a decrease in food intake•Breaking of staples.•Nausea and vomiting if excessive amounts of food are consumed.•May have difficulty digesting high-fiber foods.Potential complications:Possible complications associated with surgery, infection,etc.e.Duodenal switchDescription:•Portion of stomach removed to reduce stomach’s capacity and thus food intake.•Pyloric valve stays intact to maintain normal digestion of nutrients.•The intestinal pathway is re-routed to separate the flow of food from the flow of bile and pancreaticjuices to inhibit absorption ofenergy-yielding nutrients.•The pathways are then re-joined before the large intestine, bypassing a lot of the absorption in thesmall intestine.Advantages:•Keeping the pyloricvalveintact reduces the risk for dumping syndrome.•Significant weight reduction.Disadvantages:•More aggressive procedure, which means more complications associated with the procedure.•Heavydietary restrictions.

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Potential complications:•Leaks•Blood clots•Bowel obstruction•Abscesses•Kidney failure•Bleeding•Pneumonia•Infection•Osteoporosis•Anemia•Deficienciesofvitamin A, calcium, vitamin D, and proteinf.Biliopancreatic diversionDescription:•Often performed with a duodenal switch•Restrictive-malabsorptive procedure•Least frequently performed•Laparoscopically performed vertical sleeve gastrectomy•Bypass of food through the intestine, resulting in more weight loss•Distal part of the small intestine is surgically attached to the stomach•Secretions from the liver, gallbladder, and pancreas are re-routed so they can eventually enter the smallintestine to aid in digestion and absorption.Advantages:Greatest amount of weight reductionDisadvantages:Usually only performed on patients with BMI >50Potential complications:See complications for duodenal switch6.Mr. McKinley has had type 2 diabetes for several years. His physician shared with him that after surgery hewill not be on any medications for his diabetes and that he may be able to stop his medications for diabetesaltogether. Describe the proposed effect of bariatric surgery on the pathophysiology of type 2 diabetes. What,if any, other medical conditions might be affected by weight loss?•Weight reduction is part of the management of diabetes because it aids in gaining blood glucose control.•Bariatric surgery restricts food intake to a small portion of food at each sitting, which increases satiety andhelps prevent hyperglycemia.•The controlled food intake helps with keeping blood glucose levels from becoming too high.•Weight reduction alsoreducesinsulin resistance. Receptors become more sensitive to insulinwhenanindividual is in a more normal weight range. The chronic inflammatory stateassociated with obesityhinders glucose uptake into the cells.•Other conditions that may be affected by weight lossincludecardiovascular disease. If hyperglycemia canbe controlled, it may reduce the damage to the blood vessels,which aids in reducing risk of cardiovasculardisease.•Sleep apnea will be improved with weight reduction,as there isless mass around the respiratory muscles.•Hyperlipidemia can be improved. As the patient eats more consistently with a decreased capacity, lipidprofiles may begin to normalize as the patient loses weight.•Blood pressure can be lowered with weight reduction, aiding inresolvinghypertension.II.Understanding the Nutrition Therapy7.On post-op day one, Mr. McKinley was advanced to the Stage 1 Bariatric Surgery Diet. This consists ofsugar-free clear liquids, broth, and sugar-free Jell-O. Why are sugar-free foods used?•Sugar-free foods are used to prevent dumping syndrome.

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•Dumping syndrome ischaracterized bynausea, vomiting, bloating, and diarrhea and is caused byhyperosmolar foods, which are usually simple carbohydrates.•The hyperosmolar foods cause water to be pulled into the intestine. This occurs because part of the intestineis bypassed in the roux-en-Y procedure, which gives less surface area and transit time for absorption.•In order to prevent dumping syndrome, theNutritionCareManualrecommendsavoiding simplecarbohydrates such as fruit juices or other foods high in sugar.8.Over the next two months, Mr. McKinley will be progressed to a pureed-consistency diet with 6-8 smallmeals. Describe the major goals of this diet for the Roux-en-Y patient. How might the nutrition guidelinesdiffer if Mr. McKinley had undergone a Lap-Band procedure?•Since roux-en-Y is a restrictive-malabsorptive procedure, it is important to consume very small meals,usually 2-4 Tbspat one time,to decrease the risks of dumping syndrome. 6-8 small meals are neededbecause the stomach has a very limited capacity.•Other major goals of the diet include:oProtein-dense foods (at least 60 g of protein per day);protein helps with the healing process aftersurgery and it helps with satiety sothepatient can recognize thathe/she isfull before eating too much.Protein should be consumed first at the meal.oAvoid high-sugar beverages and foods.oLiquids should be consumed between meals to avoid dumping syndrome. Hydration is important (6-8cups of low-calorie liquid per day).oEat slowly to avoid blockage or nauseaoStop eating when full. This willpreventnausea/vomiting.oVitamin/mineral supplementation is probably warranted.oIf Mr. McKinley had a lap-band procedure,his risk forvitamin and mineral deficiencieswould belowerbecause a lap-band procedure is restrictive but not a restrictive-malabsorptive procedure. A lap-band procedure simply reduces the size of the stomachwithoutbypassingintestinal absorption.oIn addition, the lap-band procedure is adjustable, so food intake can be suited to meet the patient’sneeds.9.Mr. McKinley’s RD has discussed the importance of hydration, protein intake, and intakes of vitamins andminerals, especially calcium, iron, and B12. For each of these nutrients, describe why intake may beinadequate and explain the potential complications that could result from deficiency.•Calcium:Sincemost of the stomach is bypassed, there isareduction in thegastric acidity that aids incalcium absorption, causing potential deficiencies andrisk of osteoporosis.•Iron:Iron is mostly absorbed in the duodenum of the small intestine. It also needs the acidity from thestomach, which is mostly bypassed in the roux-en-Y procedure,to aid in absorption. Therefore, iron maybe malabsorbed and an iron deficiency may occur. Iron deficiency may lead to iron-deficiency anemia.•B12:B12is absorbed in the ileum, but it requires intrinsic factor, which is released from the stomach. Thestomach is mostly out of commission, so the absorption of B12is affected.B12deficiency may lead topernicious anemia and a folate deficiency.•Protein:Since the stomach’s capacity is very limited, a the patient must restrict their food intake to about2-4 Tbspper meal. Protein should be taken first to help with satiety and to aid in healing after surgery. Incase a person cannot tolerate the whole meal, it is important for protein-dense foods to be consumed so theperson does not break down lean body mass when losing weight. Protein malnutrition may also lead tofurther edema and other micronutrient deficiencies.•Hydration:Hydration is key but liquid should be consumed between meals to minimize dumpingsyndrome. Hydration goes hand in hand with protein intake. With risk of dumping syndrome, excess watercould be lost from diarrhea, so it is important to stay adequately hydrated to prevent dehydration. Inaddition, as one loses weight, water weight will be lost,making hydration very important.III.Nutrition Assessment10.Assess Mr. McKinley’s height and weight. Calculate his BMI and % usual body weight. What would be areasonable weight goal for Mr. McKinley? Give your rationale for the method you used to determine this.

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•BMI=703410lbs/70in./70in.= 59•% UBW=(410lbs/434lbs)100= 95% UBW•A reasonable weight goal would be to lose 30-35% of body weight within 1-2 years post-op.0.3410= 123lbs, 410-123lbs= 287lbs.0.35410= 143.5lbs.,410-143.5= 266.5 lbs.Therefore, since research shows that most patients lose about 30-35% of their weight, it would bereasonable for Mr. McKinley to lose between 123 and 267lbs.within the first year or two.•Studies also show that 60% of patients typically maintain weight once weight is lostpost-surgery.•Another goal would be to get Mr. Mckinley’s BMI below 30,sinceevidence shows a significant reductionin the risk for co-morbidities associated with obesity when BMI is less than 30.This is equivalent to a goalweight <209 lbs.11.After reading the physician’s history and physical, identify any signs or symptoms that are most likely aconsequence of Mr. McKinley’s morbid obesity.•Elevated blood pressure (135/90mmHg): more strain on the blood vessels due to obesity•Pitting edema•Skin rash (impaired blood flow to the skin due to obesity)•Elevated respiration rate: hard to breathe with excess weightcompressinglungs and other respiratorymuscles12.Identify any abnormal biochemical indices and discuss the probable underlying etiology. How might theychange after weight loss?•Potassium (high):Serum potassium levels may be elevated post-surgery or could be an acid-baseimbalance. Weight loss may improve levels but it is probably a side effect of the surgery more than obesity.•CPK (high):CPK is an inflammatory marker. This could be due to surgery and destruction of tissue fromthe roux-en-Y surgery. In addition, individuals with chronic obesityoften exhibitchronic inflammation,which may result in higher CPK values. In this case, it is probably due to surgery. Once healing occurs, theCPK value should be improved;weight loss may also help.•Glucose(high):Because ofuncontrolledtype 2 diabetes. Obesity contributes to uncontrolled blood glucoselevels and obesity is a major risk factor for type 2 diabetes. Glucose values willprobably decrease withsignificant weight loss.•HbA1c(high):Average blood glucose over 8-12 weeks. High due to uncontrolled diabetes. High bloodglucose allows for more hemoglobin to be glycated with glucose. May improve or be lowered with weightloss as glycemic control can be helped by weight reduction.•HDL (low):Obesity is positively associated with dyslipidemia, which would explain low HDL levels. HDL(high density lipoproteins)remove cholesterol from the body tissues and bring it back to the liver.•LDL (high):Obesity is associated with hyperlipidemia, which is why the cholesterol or lipid profilenumbersare out of range.An alteration in lipid metabolismoccursin obesity, which may decrease theactivity of the lipogenic enzyme that down-regulates LDL receptors. Lipid profiles tend to be normalized asindividuals reach a more optimal weight.•Triglycerides (high):An excess amount of fat or obesity contributes to high TG levels. Most of the fatfrom food is consumed in triglyceride form.•Cholesterol (high):Same reasoning as LDL and other lipid profile values. Value will probably decreaseonce weight loss is achieved.13.Determine Mr. McKinley’s energy and protein requirements. Explain the rationale for the method you usedto calculate these requirements.•Mifflin-St. Jeor used to calculate energy needs according to theNutritionCareManual under “bariatricsurgery.”•RMR(men)= (9.99actual weightin kg) + (6.25heightincm)–(4.92age) + 5wt.= 410lbs.or 410lbs./2.2=186 kg; ht. = 70 in.2.54 = 177.8 cm

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(186 kg9.99)+ (6.25177.8cm)–(4.9237 years) + 5= 1858 + 1,111–182 + 5= 2792 kcal1.3(sedentary)= 3630 kcal.•TheNutritionCareManual used actual body weight. However, due toa limited capacity of the stomach,ideal body weight could be used to lower calorie amounts.IBW = 166 lb. or 166/2.2 = 75 kg20-25kcal per kg of body weight75kg= 1500-1875kcal.(I would use 20-25kcal/kg body weight,asMifflin St.-Jeor’s estimation seems very high.)•Protein: Higher proteinintakes may be warranted to help with the healing process after surgery. The RDAis 0.8g/kg,or1.0-1.2g/kgfor post-surgery until healed: 1.0-1.2IBW= 75-90g protein/day.IV.Nutrition Diagnosis14.Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.•Nutritional problem post-surgery:After surgery, vitamin and mineral deficiencies are very common sincethe absorptive function of the GI tract is being altered by the roux-en-Y procedure.oInadequate vitamin intake (B12) (NI-5.9.1) relatedtodecreased absorption as evidenced by reports ofadequate vitamin B12sources in diet with low serum levels.•Another nutritional problem is the fact that the patient is obese.oObesity related to excessive energy intake as evidenced by BMI of 59 (BMI >30).•Another post-surgery problem may be that the patient may have a hard time consuming adequate proteinbecause the stomach capacity is reduced but the protein needs are increased.oInadequate protein intake related to recent altered absorption and digestion from recent surgery asevidenced by increased estimated protein needs of 75-90g/day.oNutrition-related knowledge deficit related to changes in diet due to recent RYGB surgery asevidenced by patient reports.V.Nutrition Intervention15.Determine the appropriate progression of Mr. McKinley’s post-bariatric surgery diet. Includerecommendations for any supplementation that you would advise.Post-bariatric surgery progression would probably look like this:•Phase 1: Clear liquid diet (in hospital only)•Sugaryclear liquids should be avoided to prevent dumping syndrome•Includes water, broth, unsweetened beverages such as sugar-free apple juice•Stomach capacity is at about 30mL maximum at eachmealof clear liquids•N/V may occur initially post-surgery•Phase 2: Full liquid diet (1-2 weeks)•Drink liquids slowly.•Drink 6-8 cups of water between drinking high-protein beverages such asBoost,Ensure.•May need to enhance beverages with non-fat powdered milk to increase protein intake if lactoseintolerance is not a problem.•Phase 3: Pureeddiet (2 weeks)•All foods are blended to baby food-like consistency.•Drink low-fat milk or water (6-8 cups) between pureed meals (30min.-1 hour post-meal).•Phase 4: Soft diet (2 weeks)•May behelpful to use smaller plates and smaller utensils, such as baby spoons,to avoid too much foodconsumption since stomach capacity is limited.•Avoid sweets.•Phase 5:Regular diet (after 1-2 months)•Slow progression of regular food is necessary to prevent the onset of early and late dumping syndrome.•Patient should eat small, frequent meals to avoid dumping syndrome symptoms.•Patient should consume liquids between meals and be consuming 6-8 cups per day to maintainhydration status. Liquids should be consumed 30min.-1 hour afterameal.

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•Insoluble fiber should be avoided but soluble fiber is okay to help to delay gastric emptying (educationonhigh-fiber foods will be necessary).•Patient may need to lie down after mealsto help delay gastric emptying.•As the stomach expands, may change to 3 meals/day plus two high-protein snacks in between.•In addition, high-protein diets would be enhanced,which may include supplementation using protein-enhanced drinks such asBoost orEnsure when patient is in the full liquid and pureedstages.•The anti-dumping diet will also be a part of post-surgery progression. Patient will need to restrict foodshigh in sugar and substitute sugar-free foods that will aid in avoiding symptoms of dumping syndrome.•If patient is lactose intolerant,he/she shouldavoid dairy products.•If progression to solid foods is not working, patient may need nutrition support via enteral nutrition.•Vitamin and mineral supplementation will be necessary due to analteration in absorptive capability of theGI tract as a result of surgery:•Liquid multivitamin initiated to meet the DRIs.•Vitamin B12injections since B12absorption is impaired due to lack of intrinsic factor.•Calcium, folate, and ironsupplementation may be necessary since these nutrients are of major concernwhenacidity of the stomach is lost from surgery, which affects theirabsorption.16.Describe any pertinent lifestylechangesthat you would view as a priority for Mr. McKinley.•Incorporating physical activity into hisdaily routine will help with weight loss and will aid in correctinghislipid profile.•Hemay need to changethetypes of foodshe eats.oSweets will need to be avoided post-surgery.oSmaller,more frequent meals mayrequirea change in lifestyle/eating habits, since pt. will be eating 6small meals rather than 3.oThepatient will need to learn how to read the signalsindicatingfullnessand stop eating to avoidnausea and vomiting.He must adjustto a very small stomach capacityand the decreased food intakethis necessitates.oOncehisstomach expands, lifestyle measures will need to be taken to practice control over servingsizes. Stomach stretches to size of a cup in about a year.oFollow up with physicians, registered dietitians,etc.oAvoid pregnancy.oMay have excess skin or other skin problems so subsequentprocedures may be a option toconsider.17.How would you assess Mr. McKinley’s readiness for a physical activity plan? How does exercise assist inweight loss after bariatric surgery?•Mr. McKinley should adhere to an exercise routine that he enjoys.•To assess readiness, see what he is willing to do and establish goals. Goals should be attainable, realistic,and concrete.•Strenuous exercise should be avoided until he is healed, but walking should not be avoided.•Physician should be consulted to discuss exercise options that are appropriate.•Exercise will help maintain weight loss over time because after the weight is lost, Mr. McKinley will haveto changehislifestyle to maintain weight loss.•Exercise will help with chronic conditions such as obesity, hypertension (reduces BP),and diabetes. Thereis evidence that exercise improves insulin resistance.•Onceanexercise program is in place, Mr. McKinley will still have to followup withaphysician orexercise specialist to assess any medical problems associated with exercise such as chest pain, dyspnea,etc.VI.NutritionMonitoring and Evaluation18.Identify the steps you would take to monitor Mr. McKinley’s nutritional status post-operatively.•Determine calorie needs post-surgery and adjust as stomach expands. Monitor how much patient isconsuming or % of energy needs using a 24-hour recall or food diary. Volume should also be assessedsince stomach capacity is reduced.

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•Assess sugar intake. Patients should avoid sweets post-surgery, as it increases the risk of dumpingsyndrome.•Determine if patient is complying with rules such as drinking liquid between meals instead of with meals.•Assess any signs/symptoms of dumping syndrome that may be present, such asN/V, bloating, cramping,abdominal pain,ordiarrhea.•Determine protein needs and make sure protein-dense foods are being consumed. Encourage high-proteinsnacks or supplements since protein is a major part of the healing process.•Assessforvitamin and mineral deficiencies, particularly calcium, iron, B12. B12injections should be givenand multivitamin supplementation is typically required for life.•Assess weight loss per week. Patient should be recording changes in weight. Physical changes in skin andbody contour should be evaluated. This is a big change in weight and patient will have to adjust clothing,etc. on a weekly basis to keep up with the weight loss. Calculations include: % weight loss, % IBW.•Monitor diabetes, such as self-monitoring blood glucose practices, HbA1cvalues to see if they are improvedwith weight loss.•Monitor lipid profile to evaluate any improvements orotherchanges in cholesterol, TG, LDL, HDL afterweight loss. These are all risk factors for CAD, so these values should be closely monitored.•Evaluate potassium levels;sudden changes in potassium can cause cardiac arrest and since his value washigh, this may be something to monitor.•Evaluate hydration status. Patient should consume 6-8 cups water or low-calorie beverages/day. As weightloss is dramatic, it is important for patient to stay hydrated becausehe islosing water weight in addition tofat mass.19.From the literature, what is the success rate of bariatric surgery? What patient characteristics may increasethe likelihood for success?•Most patients lose about 30-35% of weight in 1-2 years.•Successful maintenance of weight loss isachieved byabout 60% of patients who undergo bariatric surgery.•Dramatic improvements in diabetes, sleep apnea, hypertensions,and CVD risk.•RYGB surgery study showed that there was a 40% reduction in mortality from causes like CAD, diabetes,and cancer.•Patient willingness and motivation to adhere to lifestyle changes help with weight loss and maintainingweight loss.•Willingness to incorporate exercise and stick to exercise routine.•Weight loss prior to surgery shows a commitment to lifestyle change.20.Mr. McKinley asks you about the possibility of bariatric surgery for a young cousin who is 10 years old.What are the criteria for bariatric surgery in children and adolescents?In children/adolescents, the following are criteria to be considered as a candidate for bariatric surgery:•Failure to meet weight loss goals for greater than six months (goals areusuallyset up with primary carephysician).•Severely obese with a BMI >50, presence of co-morbities that could be improved with weight loss, andhave attained a skeletal maturity for the most part (age 13 for girls and 15 for boys).•Showswillingness to adhere to nutritional guidelines post-op.•Undergonepsychological evaluation that showshe/shecan handle the emotional effects of surgery.•Must possess decision-making capabilities.21.Write an ADIME note for your inpatient nutrition assessment with initial education for the Stage 1 (liquid)diet for Mr. McKinley.2-23-2012 (1:30pm)–Roux-en-Y gastric procedure nutrition follow-upChris McKinleypt. admitted for gastric roux-en-Y surgery.A: 37 YOWM,Dx: morbidly obese, candidate for bariatric surgery, PMH: type 2 diabetes, hypertension,hyperlipidemia, osteoarthritis

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Meds: Metformin 1000 mg/twice daily; 35 u Lantus pm; Lasix 25 mg/day; Lovastatin 60 mg/daySkin: warm, dryAbdomen: Obese, rash present under skinfoldsI/O: + 2200,-2230mL, net:-30mLLabs: HbA1c(high), glucose (high), LDL (high),HDL (low), TG (high),cholesterol (high),K+(high),CPK—inflammation marker (high),urinalysis: WNLHt.= 5’ 10” (70in.),Wt.: 410 lbs. (actual),highest wt.:435lbs.,% UBW: 95%,BMI: 59 (severely obese)EER: Determined by 20-25kcal/kg (1500-1900kcal)Protein: 1.0-1.2g/kg= 75-90g proteinDiet Hx: Not given, clear liquids,restrictive diet,post-surgical diet.D: nutrition-related knowledge deficit related to diet changes from recent roux-en-Y gastric bypass as evidencedby patient reports.I: Goals:Restrict calorie intake to accommodate for decreased stomach capacity to facilitate weight loss.oPhase 1: Clear liquid diet (in hospital only)•Sugaryclear liquids should be avoided to prevent dumping syndrome.•Patient should consume water, broth, unsweetened beverages such as sugar-free apple juice.•Stomach capacity is at about 30mL maximum at eachmealof clear liquids.oPhase 2: Full liquid diet (1-2 weeks)•Drink 6-8 cups of water between drinking high-protein beverages such asBoost,Ensure.oPhase 3: Pureeddiet (2 weeks)•Patient maydrink low-fat milk or water (6-8 cups) between pureed meals (30min.-1 hour post-meal).oPhase 4: Soft diet (2 weeks)oPhase 5:Regular diet (after 1-2 months)•Slow progression of regular food is necessary to prevent the onset of early and late dumping syndrome.•Patient should eat small, frequent meals (6-8).•Patient should consume liquids between meals and be consuming 6-8 cups per day to maintainhydration status. Liquids should be consumed 30min.-1 hour after meal.•Insoluble fiber should be avoided but soluble fiber is okay to help to delay gastric emptying (educationonhigh-fiber foods will be necessary).•Patient may need to lie down after meal to help delay gastric emptying.•As the stomach expands, may change to 3 meals/day plus two high-protein snacks in between.Patient will begin exercise regimen after consultation with physician or exercise specialist.•Patient will engage in physical activity for 150 min./week after healed from surgery.•Activities should be ones that patient enjoys and is committed to engage in.M/E: follow-up appointment will be scheduled with physician and dietitian.Monitor weight loss percentage and the rate of weight lossPt. will keep record and weigh himself once per weekMonitor lipid profile: LDL, HDL, TG, andcholesterolPatient should report any discomfort, pain,or other complications from surgeryMonitor patient’s adherence to exercise regimenFollow-up HbA1ctest 8-12 weeks post-surgery

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Answer Guide forMedical Nutrition Therapy: A Case Study Approach4thed.Case 3–Malnutrition Associated with Chronic DiseaseI.Understanding the Disease and Pathophysiology1.Outline the metabolic changes that occur during starvation that could result in weight loss.•inadequate nutrient supply•decrease in basal metabolic rate to conserve energy (decreased thyroid function leads to decreased BMR)•liver glycogen stores used up in first 12-24 hours (glycogenolysis)•energy from fat storage (lipolysis) provides >90% of kcal (ketones as primary energy source)•energy from protein/lean mass provides <10% of kcal for gluconeogenesis to provide glucose for obligateusers (brain)•increased need for alanine and glutamine (from muscle) to stimulate gluconeogenesis•protein losses significant during first 7-10 days (1-2kg lean body mass lost over first 7 days;skeletalmuscle catabolized, muscle synthesis decreased)•organ function changes in GI tract result in loss of mass, decreases in villi, decreased enzyme secretion,impaired motility,andbacterial overgrowth, which lead to maldigestion and malabsorption•decreased protein synthesis in liver•muscle function decreases;breakdown of intercostal muscles can lead to decreased respiratory function;breakdown of cardiac muscle can lead to hypotension, bradycardia, decreased cardiac output•immune function decreases to spare protein•decreased growth2.Identify current definitions of malnutrition in the United States using the current ICD codes.ICD-9-CM Diagnosis Code 260-Kwashiorkor•Protein-calorie malnutrition: nutritional edema with dyspigmentation of skin and hair (predominantlyprotein depletion)ICD-9-CM Diagnosis Code 261-Nutritional marasmus•Protein-energy malnutrition: nutritional atrophy, severe calorie deficiency, severe malnutrition (energydepletion/ reduced fat stores out of proportion with lean body mass loss)ICD-9-CM Diagnosis Code 262-Other severe protein-calorie malnutrition•Nutritional edema without mention of dyspigmentation of skin and hair3.Current definitions of malnutrition use biochemical markers as a component of the diagnostic criteria.Explain the effect of inflammation on visceral proteins and how that may impact the clinician’s ability todiagnose malnutrition.The body downregulates albumin synthesis so that needed positive acute-phase proteins for the immune system(antibodies, complement, cytokines, C-reactive protein), clotting (fibrinogen),and wound healing can be made.Production of cytokines like IL-1, IL-6, and tumor necrosis factor (TNF) is increased, which altershormonesecretion to favor a catabolic state, increasing muscle catabolism, gluconeogenesis, and lipolysis.Thesecytokinesalso inhibit protein synthesis (albumin, prealbumin, transferrin, retinol-binding protein) and musclerepair.Extracellular fluid is expanded (due to edema),causing biochemical tests to be diluted andresults toappearlow.Resting energy expenditure is elevated/increasedandprotein requirements are increased, making energy andprotein needs difficult to accurately determine.

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If the cause of metabolic stress is severe or prolonged, nutrition intervention alone will not prevent muscleprotein loss in inflammation if nutritional intake is inadequate.Therefore, measurement of albumin/ prealbuminis not an accurate measure for diagnosis of malnutrition when inflammation is present.4.What does the ADA evidence analysis indicate regarding the correlation of albumin/prealbumin with visceralprotein status and risk of malnutrition during periods of prolonged protein-energy restriction?According to the ADA EAL, in the four models of prolonged protein-energy restriction (anorexia nervosa, non-malabsorptive gastric partitioning bariatric surgery, calorie-restricted diets,or starvation), there was nocorrelation between serum albumin/ prealbumin and weight loss.This evidence is rated Grade II for albumin (fair supporting evidence) and Grade III for prealbumin (limitedsupporting evidence).5.Read the article: Jensen et al. Adult starvation and disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee.Clinical Nutrition29 (2010) 151–153. Explain the differences between malnutrition associated with chronicdisease and malnutrition associated with acute illness and inflammation.Malnutrition associated with chronic disease-this includes chronic diseases or conditions that have sustainedmild to moderate inflammation (organ failure, pancreatic cancer, rheumatoid arthritis, diabetes mellitus,metabolic syndrome, chronic kidney disease, etc.)•Loss in lean body mass is gradual and can eventually reach significant depletion over time (severalmonths).With nutritional intervention, lean body mass loss is slowed or potentially reversed.•Positive response to nutrition intervention also requires successful medical treatment of underlying disease.Malnutrition associated with acute illness and inflammation-this includes acute diseases or injury states withacute and severe inflammatory responses (major infection, burns, trauma,or closed head injury)•Significant depletion of lean body mass occurs over a short period of time (<1 month) without nutritionalintervention.With nutritional intervention, lean body mass loss is slowed, but stilloccursif inflammationpersists.•Priority of nutrition intervention is to provide nutrients to support organ system functions and preserveimmune function while acute medical treatment is provided.II.Understanding the Nutrition Therapy6.Mr. Campbell was ordered a mechanical soft diet when he was admitted to the hospital. Describe themodifications for this diet order.•This diet consists of foods that are mechanically altered by blending, chopping, grinding,or mashing sothat they are easy to chew and swallow.•Use gravies, sauces, vegetable/ fruit juice, milk, half & half,broth,or water from cooking to moisten foodswhen mechanically altering and serving.•Casseroles or salads are served moist and without large chunks of meat or vegetables.•Soups are served with small pieces of easy to chew and swallow meats and vegetables.•Vegetables are cooked tender enough to be easily mashed with a fork.•Bread products are mixed with sauce, gravy,or syrup until the bread product begins to dissolve into aslurry.•Sticky and chewy foods such as peanut butter and caramel are not served.•Nuts;seeds;overly dry foods;and tough, fibrous,or stringy foods are avoided.7.What is Ensure Plus? Determine additional options for Mr. Campbell that would be appropriate for a high-calorie, high-protein beverage supplement.Ensure Plus is a 1.5 kcal/mL high-calorie, high-protein beverage supplement.It contains 350kcal, 11g fat,50g carbohydrate, and 13g protein per 8-oz serving. It is a good source of 24 essential vitaminsandminerals

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(948mL/ 1422 kcalneeded to meet 100% of RDIs).Ensure Plus iskosher, halal, and gluten free.It is okaytouse in patients who are lactose intolerant but contraindicatedin patients with galactosemia. It is notappropriatefor parenteral nutrition, but can be used as oral or enteral nutrition.Additional option examples: Whole milk milkshake (can add peanut butter, dry skim milk powder, etc.toincrease protein and calories), Resource 2.0 (2.0kcal/mL, 21g protein/ 8 fl oz supplement), Resource Shake(2.0kcal/mL, 15g protein/ 8 fl oz supplement), Carnation Instant Breakfast (260 kcal/ 14g protein per bottle,or use mix)III.Nutrition Assessment8.Assess Mr. Campbell’s height and weight. Calculate his BMI and % usual body weight.Height: 6'3" (190.5 cm), weight: 156# (70.9 kg),UBW: 220#BMI = 70.9 kg / 1.905 m2= 19.5 kg/m2(BMI 18.5-24.9 considered normal weight;however,his BMI hasdecreased from 27.5 to 19.5 in 1-2 years,which is a significant decrease, and he is nearing underweight BMIstatus)% UBW = 156# / 220#100 = 70.9% UBW (severe unintended weight loss in 1-2 years)9.After reading the physician’s history and physical, identify any signs or symptoms that support the diagnosisof malnutrition.•feelings of weakness, lack of energy•decreased temperature•cachectic appearance, appears older than years•noted temporal wasting•dry mucous membranes with petechiae (nose), dry mucous membranes (throat)•reduced strength on neurologic exam•decreased muscle tone in extremities, noted loss of lean mass in quadriceps and gastrocnemius, +1 pedaledema•dry skin with ecchymoses•shallow respirations (decreased muscle tone in diaphragm), increased respiratory rate10.Evaluate Mr. Campbell’s initial nursing assessment. What important factors noted in his nutritionassessment may support the diagnosis of malnutrition?•abdominal appearance: flat•palpation of abdomen: soft•dry skin•tenting skin turgor•skin condition: ecchymosis, dry, tearing•mucous membranes: dry, petechiae11.What is a Braden score? Assess Mr. Campbell’s score. How does this relate to his nutritional status?A Braden score is an assessment of a patient's risk of developing pressure ulcers.TheBraden score looks at 6criteria: sensory perception, moisture, activity, mobility, nutrition, and frictionandshear.Mr. Campbell's Braden score is 17. This indicates that he is currently at mild riskof developing pressure ulcers.Nutrition relates totheBraden score because it is one of the 6 criteria involved.Poor nutrition can lead to poorwound healing, poor skin turgor, decreased mobility/ activity,anddecreased sensory perception and increasesthe risk of the patient developing a pressure ulcer.Poor nutrition also makes it more difficult for pressure ulcersto heal.

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