Case Study

Gastroesophageal Reflux Disease

Furwa Haque and Sherene Hudgins

NFS 3250

Winter 2016

3/10/16
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Table of Contents:

Patient Profile and Health History.......3

Overview of Disease5

Nutrition Assessment...8

Medications11

ADIME Note..12

Long Term Plan.....16

Alternative Therapies.18

Answers to Questions19

References..22

Calculations24

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Patient Profile and Health History

The patient is a 48 year old, 215 lb, male of height 5 feet and 9 inches, and his name is

Jack Nelson. The patient is admitted at the University Hospital to be evaluated regarding his

complaints of severe indigestion, which only seem to be increasing. The patient is married to

Mary Nelson, who is in good health, and who he says insisted that he come to the hospital right

away because the pain was so intense that he thought he was having a heart attack. Mary Nelson

is also his primary person to contact in case of an emergency, as well as a source of information

for the patients medical history, although the patient has also provided much of the information.

The patient is the father of 2 sons who are aged 10 and 16, and in perfect health. The patient is

Caucasian and identifies as Protestant. The patients highest education level is that of a Bachelor

of Arts. The patient is currently a retail manager at a local department store, where he works

Monday Friday, consistently in the evenings as well as weekends.

When the patient came in, he said that he consumes Tums, an over the counter antacid,

constantly and still feels very uncomfortable and experiences intense pain. Mr. Nelson said he

has been experiencing increased indigestion over the course of a year. The indigestion and

associated symptoms of discomfort and pain used to only occur at night, however, now they

occur almost constantly, according to the patient. Mr. Nelson also said that he recently hurt his

shoulder while he was coaching his sons baseball team and has been taking Advil, an over the

counter painkiller, to cope with the pain. The patient has been diagnosed with high blood

pressure about a year ago. Mr. Nelson also had a knee arthroplasty on his right knee 5 years ago.

Over the last month, the patient has been taking 50 mg of Atenolol once a day, 325 mg aspirin

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once a day, a One-A-Day Multivitamin for Men once a day, and 500 mg of ibuprofen twice a

day. Mr. Nelson also has a family history of Coronary Artery Disease as his father had it. Mr.

Nelson usually consumes 16-32 fluid ounces of beer a day. He also reported that fried foods

seem to make his indigestion worse. His dietary intake comes from food prepared by his wife

and eating out. It should also be noted that in the Admission Database, its stated that he doesnt

smoke, however in the information listed under patient history states that he is a smoker, hence

the effect of smoking on this patients health have to be considered as well.

The patients diet overall consists of sodas, 16-32 fluid ounces of beer, grain foods, fruits

and vegetables, tea, fast food, and plenty of skim milk and orange juice. He typically starts his

day with 1.5 2.0 cups of dry cereal such as cheerios, bran flakes, or crispix, with 0.5 0.75

cups of skim milk, and 16 32 ounces of orange juice. For lunch the patient tends to eat 1.5

ounces of ham on a whole wheat bagel, an apple or other fruit, 1 cup of chips, and a diet soda.

When he comes home he consumes a snack of either crackers, cookies, or chips, with a diet soda.

For dinner he typically eats 6 9 ounces of meat, usually grilled or baked, 1 2 cups of pasta,

rice, or potatoes, fresh fruit, salad or other vegetable, bread, and Iced tea. Later on, he will eat a

snack of ice cream, popcorn, or crackers. He notes that he consumes about 5- 6 12 ounce diet

sodas every day as well as iced tea. He also notes that lately his familys schedule has been

increasingly busy and hectic which has lead to them ordering pizza or buying and consuming fast

food once or twice a week instead of cooking.

His 24 hour recall reflects his usual dietary intake along with the effects of the

increasingly busy schedule he mentioned. He ate 2 cups of crispix with 1 cup skim milk, and 16

oz of orange juice in the morning. When he was at work he had 3 12 ounce servings of Diet

Pepsi. His lunch consisted of a fried chicken sandwich from McDonalds, small french fries, and

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32 ounces of iced tea. In the late afternoon he consumed a snack consisting of 2 cups of chips

and a beer. His dinner consisted of 1 chicken breast that was fried and from Kentucky Fried

Chicken, 1.5 cups of potato salad, 0.25 cups of a green bean casserole, 0.5 cups of a mixed fruit

salad, 1 cup baked beans, and iced tea. Around bedtime, he consumed a snack of 2 cups of ice

cream with 1 cup skim milk to create a milkshake.

Overview of the Disease

Gastroesophageal Reflux Disease (GERD) is a condition in which stomach content

repeatedly move back up the esophagus, which is the part of the alimentary canal that connects

the mouth to the stomach. This backwards movement is known as reflux. Between the stomach

and the esophagus is a sphincter, essentially a ring of muscles, that loosens to allow contents

from the esophagus to enter the stomach, and tightens to keep the stomach contents from flowing

back up the esophagus. It is important for the LES to tighten up and keep the stomach contents

from moving back up the esophagus because the pH of the stomach is very low making the

contents very acidic, and the esophagus isnt built to handle such acidic conditions, and hence

stomach acid can cause severe damage to the esophagus. Symptoms of GERD include

regurgitating of food, belching, nausea and vomiting, chronic cough, wheezing, sore throat,

hoarseness of change in voice, difficulty swallowing, chest pain, and sour taste (Ehrich, 2015).

Medical treatments for GERD include drugs and surgery. There are four different kinds

of drugs that work to reduce GERD symptoms, Antacids, Alginates, H2-antagonists, and proton

pump inhibitors (PPI). Antacids are available over the counter and there are three different ones,

aluminum hydroxide, combinations of aluminum hydroxide and magnesium hydroxide, and

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calcium carbonate. All three can cause diarrhea and constipation, however calcium carbonate can

cause an increased risk for kidney stones and also nausea, vomiting, and belching. Alginates are

chemically similar to antacids and are often used with them. H2-antagonists work by attaching to

parietal cells in the lining of the stomach and limiting the production of hydrochloric acid. H2-

antagonists can reduce the absorption of vitamin B12 and iron. Known H2- antagonist drugs

include Cimetidine, Famotidine, Nizatidine, and Ranitidine. PPIs work by inhibiting the

production of stomach acid, and can also reduce the absorption of vitamin B12 and iron. Known

PPI drugs include Esomeprazole, Lansoprazole, Omeprazole, Pantprazole, and Rabeprazole

(Armstrong & Marchetti, 2008). Sometimes doctors will recommend surgery for GERD, and the

surgery they recommend is known as a Fundoplication procedure. In this procedure, the fundus

of the stomach, which is basically the top half of the stomach, is sutured around the esophagus to

create pressure at the top, keeping the stomach acid inside the stomach and preventing reflux.

However, it should be noted that according to the U.S. Department of Health and Human

services, drugs can be just as effective as surgery when it comes to treating GERD (Agency for

Healthcare Research and Quality, 2005).

Dietary treatments include a wide range of recommendations and strategies. There are

several triggers for GERD symptoms including carbonated beverages, caffeinated beverages,

alcohol, fried foods and other high fat foods, smoking, chocolate, spearmint, peppermint, acidic

foods and beverages, lying down less than 2-3 hours after eating (Academy of Nutrition and

Dietetics, 2016). While that certainly is a long list of triggers, they are not necessarily all triggers

for someone with GERD. A persons triggers for GERD symptoms are specific to the person,

and dietary intervention works to narrow down the actual triggers that are specific to the person

and then cut those out of the diet and lifestyle. One approach to doing this would be to eliminate

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all possible triggers and then bring them back one at a time to see if they cause GERD

symptoms, and the ones that dont would be fine to continue including in the diet for that person

because they dont actually generate GERD symptoms. A patient can do this by keeping a food

diary and recording their reactions and symptoms along with the meals they eat and activities

they engage in. Other strategies to reduce the occurrence of GERD symptoms include lying

down at least 3 hours after having a meal, and raising the head a good 6-8 inches in bed.

There are also lifestyle changes that can be made to reduce GERD symptoms. If a person

is a smoker, quitting smoking will go a long way towards helping them reduce GERD symptoms.

It also helps to wear loose fitting clothing because it reduces abdominal pressure. Stress can also

be a trigger, so it can also help to look into and explore stress reduction techniques (Ehrich,

2015). Another way to reduce GERD symptoms that has been found to be very, very effective is

weight loss. There have been several studies on the effect of weight loss on GERD that proved

that GERD symptoms decrease with weight loss. In one such study, there were 332 participants,

all adults with GERD, the average age was 46, their body mass index (BMI) values in the

overweight and obese ranges, and they were given a weight loss regimen after which the average

weight loss was about 13 7.7 kg, and they compared GERD symptoms before the weight loss

and after. What they found was that 81% of the subjects experienced a decrease in GERD

symptoms, 65% had complete resolution of GERD symptoms, and 15% had partial resolution of

GERD symptoms (Singh et. al, 2013). Hence weight loss is a very effective lifestyle change for

reducing GERD symptoms. This can be done with the use of a suitable exercise regimen and

dietary intervention.

Prognosis for GERD has to do with early treatment; the earlier GERD received attention

and treatment, the better the outcome. Prevention of GERD is done by essentially reducing ones

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incidence of risk factors. This can be done by maintaining a healthy weight or losing weight to

reach a healthy weight or one is overweight or obese. Another way to prevent GERD is to be

careful with medications that can cause GERD. For example, Nonsteroidal anti-inflammatory

drugs (NSAID) are known to cause GERD if taken long term and without food, calcium channel

blockers taken for hypertension have also been linked to GERD, and some antibiotics can also

increase the risk of developing GERD. Hence, its very important to be informed about the

possible side effects of medication and how to use them properly. Smoking cessation also

reduces the risk of GERD, so one should look into smoking cessation programs. It can also help

to eat smaller meals and avoid lying down immediately after eating, but also to eat healthier,

especially to avoid having a diet high in fat, alcohol, and carbonated beverages. Thus, there are

plenty of lifestyle changes that one can take on to reduce their risk of GERD.

Nutrition Assessment

The patient has an ideal body weight (IBW) of 160 lb 10% which leads to a range of

144 - 176 lb. The patient has stated that he has gained 35 lb since his knee surgery, which makes

his usual body weight (UBW) 180 lb. His BMI is 31.94, which puts him in the obesity category.

His %IBW is 134.4%, his %UBW is 119.4%, and his % weight change is 19.4%. He has stated

that he used to be able to exercise more before his knee surgery, 5 years ago, but after the

surgery he experienced a reduced ability to run and has not yet found a consistent replacement

for exercise. His %UBW and % weight change is high, however it occurred over the duration of

5 years. His being overweight is a major factor that affects his condition, and needs to be

addressed as so. Excessive weight raises abdominal pressure which increases the likelihood of

stomach acid leakage and backflow of partially digested material from the stomach to the

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esophagus, which can damage the esophagus and generate the pain and associated symptoms of

gastroesophageal reflux disease (GERD).

Most of the lab values came back normal, with the exception of some parts of his blood

lipid panel. His total cholesterol level was high at a value of 220 mg/dl. His low density

lipoprotein (LDL) cholesterol level was high as well at a value of 165 mg/dl. His blood

triglyceride level was also high at 178 mg/dl. His high density lipoprotein (HDL) cholesterol

level low at 20 mg/dl. His blood lipid panel shows that his blood lipids are not just far from the

optimal levels, but he has hypercholesterolemia. Furthermore, his LDL/HDL ratio is also not

optimal, as it is 8.25, whereas the optimal level is less than 3.55 for men, which could lead to

more fat being deposited in his blood vessels than being picked up and transported back to the

liver. The fact that he has low HDL cholesterol, high blood triglyceride levels, high blood

pressure (which is controlled by medication), and obesity (which could also include abdominal

obesity, but this is not for certain as a waist circumference measurement was not taken), makes it

possible for him to have metabolic syndrome. Furthermore, he has a high risk of Coronary Heart

Disease (CHD), because he has a family history of cardiovascular disease, his diet is low in

antioxidants, he smokes, his physical activity level is sedentary, he has high levels of stress

coming from his busy lifestyle and work hours, his blood lipid levels consist of high LDL

cholesterol, low HDL cholesterol, and high triglyceride levels, he is obese, he has high blood

pressure, he consumes large amounts of alcohol daily, which increases blood pressure and

triglycerides, and because he could possibly have metabolic syndrome.

Upon physical examination several factors were observed. The patient appeared to be a

mildly obese 48 year old white male in mild distress. The patients body temperature was normal

at about 98.6 degrees Fahrenheit, his heartrate was also normal at 90 beats per minute, and his

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respiratory rate was also normal at 16 breaths per minute. The patients blood pressure was also

normal at 119/75, however it should be noted that he takes medicine to keep it under control.

Furthermore, his heart, head, eyes, ear, nose and throat were normal. The patients rectal exam

showed no hemorrhoids being felt or seen, no signs of an enlarged or soft prostate, however, the

patients stool was found to be slightly Heme-positive. Neurologic evaluation confirmed that the

patient knew who they were, where they were, what date or time it was, as well as recent events.

As for the extremities, the patient did not have any edema, had normal strength, normal

sensations, and normal deep tendon reflex. The patients skin was warm and dry. Lungs were

determined to be clear to auscultation and percussion. The peripheral vascular exam showed the

pulses were full without any bruits. The patients abdomen showed no distention and bowel

sounds were heard in all areas of the abdomen. The patients liver was found to be approximately

8 cm when percussed at the midclavicular line, one finger-breadth underneath the right costal

region. The upper central region of the abdomen was tender but no tensing of the muscles of the

abdominal wall was detected when pressed.

Furthermore, Mr. Nelson also underwent pH monitoring with an intraesophageal pH

electrode and a barium esophagram. These tests determined that he does in fact have

gastroesophageal disease (GERD) and had a negative biopsy for H. pylori. He also had an

endoscopy that revealed no ulcerations or lesions but he did have gastritis.

His dietary intake shows a high intake of fat, which he noted only makes his indigestion

worse, and is a trigger food for GERD. His fat intake is high in saturated fat, which is harmful

for him especially because of his family history of coronary artery disease (CAD) as his father

had it. He also has an excessive intake of alcohol, which could be related to his recent stress

levels, but nonetheless, it is bad for his GERD because alcohol can loosen the lower esophageal

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sphincter (LES). He also consumes carbonated beverages in the form of diet sodas and

caffeinated beverages such as iced tea and soda, which are also bad for GERD and trigger foods

because they can also loosen the LES, further allowing reflux of the stomach contents.

Furthermore, his diet needs an increase in antioxidants and a reduction in his consumption of

simple sugars to lower his risk for heart disease.

Medications

Mr. Nelson was taking several prescription and over the counter medications daily. Atenolol

50mg, 325mg aspirin, 500mg ibuprofen, a multivitamin and antacids when he was admitted to

University Hospital for evaluation per his patient history. Atenolol, a Beta Blocker, is used to

control his essential hypertension. Atenolol decreases cardiac output and the heart rate which

lowers blood pressure by slowing and reducing the force of the heartbeat. Beta Blockers may

cause an increase in serum VLDL and LDL cholesterol and triglycerides as well as decreases in

HDL cholesterol. There is an alcohol interaction. Multivitamin with minerals may decrease the

effects of atenolol. Separate by at least 2 hours. Avoid consumption of large amounts of orange

juice. It could decrease the effectiveness. Licorice may increase blood pressure and counteract

the effects of atenolol

Aspirin is used to relieve pain, reduce inflammation caused by injuries and also to thin the

blood. It can cause stomach irritation. Alcohol worsens stomach irritation. Aspirin could

counteract a beta blocker. Aspirin and NSAIDs should not be taken together because the increase

the chance of stomach irritation. Taking aspirin with food or milk can decrease the chance of

upset stomach and bleeding. Large amounts could cause a loss of vitamin C

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Ibuprofen is used to relieve pain and inflammation. May cause GI tract bleeding, ulcers and

perforation. Alcohol increases the risk of bleeding. May reduce the effect of beta blockers.

Should be taken with food or a magnesium/aluminum antacid. Take with a full glass of water.

Tums (calcium carbonate) can be used to relieve symptoms of stomach upset due to acid

reflux. It is over the counter. It works by neutralizing stomach acid in the body. Avoid drinking

because alcohol will worsen stomach irritation in people who have heartburn. If citrus fruit

drinks trigger symptoms taking them with tums may make the tums less effective. Long term use

of antacids may lower vitamin B12 absorption.

After Mr. Nelsons GERD diagnosis was confirmed by pH monitoring and the barium

esophagram, his doctor started him on lansoprazole 30 mg every morning. Lansoprazole is a

proton pump inhibitor (PPIs). PPIs stop the production of stomach acid. PPIs interfere with the

absorption of iron. Lansoprazole should be taken before eating.

ADIME Note

A: Patient is a 59, 215 lb male, 48 yo.

IBW: 160 lb 10%

BMI: 31.94

%UBW: 119.4%

%IBW: 134.4%

% Weight Change: 19.4%

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Diet History:

Usual Food Intake:

AM: 1 - 2 cups dry cereal (cheerios, bran flakes, Crispix); - cup milk

Lunch:1 oz ham on whole wheat bagel, 1 apple or other fruit, 1 cup chips, diet

soda

Snack when he comes home: Handful of crackers, cookies, or chips; 1-2 16 oz

beers,

PM: 6-9 oz of meat (grilled, baked usually), pasta, rice, or potatoes - cup; fresh

fruit, salad or other vegetable, bread, iced tea

Late PM: Ice cream, popcorn, or crackers

Usual Dietary Intake notes: Drinks 5-6 12 oz diet sodas daily as well as iced tea.

Relates that his familys schedule has been increasingly busy so that they order

pizza or stop for fast food 1-2 times per week instead of cooking.

24-hour recall:

AM: 2 cups Crispix; 1 cup skim milk, 16 oz orange juice

At work: 3 12 oz diet pepsis

Lunch: Fried chicken sandwich from McDonalds, small fries, 32 oz iced tea

Late Afternoon: 2 cups chips, 1 beer

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Dinner: 1 breast, fried from Kentucky Fried Chicken; 1 cup potato salad, cup

green bean casserole, cup fruit salad, 1 cup baked beans, iced tea

Bedtime: 2 cups ice cream with 1 cup skim milk for milkshake

Food Allergies/intolerances/aversions: Fried foods seem to make the indigestion worse.

Labs: Total Cholesterol 220 mg/dl

LDL Cholesterol

Serum Triglyceride

HDL Cholesterol

Medical Tests: pH monitoring and barium esophagram: support diagnosis of

gastroesophageal reflux disease; negative biopsy for H. pylori; Endoscopy indicates no

ulcerations or lesions but generalized gastritis present.

EER: 1875 kcals/day

Protein Needs: 78 - 98 g protein/day

Medical Diagnosis: Gastroesophageal Reflex Disease

Medications: Aspirin, Atenolol, One-A-Day Multivitamin for Men, Ibuprofen,

lansoprazole.

D: P: Altered GI function (NC 1.4)

E: As related to related to consumption of high fat foods, alcohol. carbonated beverages,

and caffeine

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S: As evidenced by indigestion, chest pain, pH monitoring, barium esophagram, and

endoscopy showing gastritis.

P: Inappropriate intake of saturated fats

E: As related to high intake of animal fat

S: As evidenced by total cholesterol level of 220 mg/dl, LDL cholesterol level of 165

mg/dl, serum triglyceride level of 178 mg/dl, and HDL cholesterol level of 20 mg/dl.

I: Recommend 1875 kcals/day

Recommend 78- 98 g protein/day

Recommend avoiding caffeine and carbonated beverages

Recommend avoiding fried foods

Recommend small frequent meals

Recommend saturated fat restriction at less than 15 grams per day

Recommend 30 grams of fiber per day

Recommend reducing intake of simple sugars

Recommend adding monounsaturated fats and polyunsaturated fats to diet

Recommend cessation of smoking

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Recommend Orthopedic consult

Recommend Blood lipid panel

Recommend TLC diet

ME: Monitor blood lipid panel levels

Monitor weight

Monitor digestion for trigger foods

Signed:

Long Term Plan

Motivational Interviewing techniques will be used to determine what his health and fitness

goals are during his first nutrition consultation after his discharge from the hospital. After his

goals have been determined, the issues below will be discussed so that SMART goals can be set.

All of his health and fitness issues need to be addressed, however, setting a few SMART goals

per session will prevent him from feeling overwhelmed so that he will be more successful in his

endeavors.

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Mr. Nelson will be given weight management techniques. He needs to lose weight because

obesity weakens the LES, which contributes to GERD. Until he loses weight, the patient will be

advised to wear loose fitting clothing to avoid stomach constriction. He can achieve his weight

loss goals by reducing the number of calories he consumes per day. In order to lose 1 lb per week

he should consume 1875 kcals. There are several suggestions he can follow to reduce his daily

kcals. He should replace diet soda and iced tea with water and replace chips, ice cream, popcorn,

french fries and crackers with fresh fruits and vegetables. Replacing these items, along with

eliminating processed sugar and grains will not only reduce his daily caloric intake, but also help

reduce his total cholesterol, LDL and triglycerides. Eliminating high fat and fried foods will

decrease reflux because these foods reduce LES pressure and delay stomach emptying, which

increase the risk of acid reflux.

Mr. Nelson can enhance his weight loss by adding daily aerobic exercise. Knee surgery 5

years has decreased his ability to run, which has caused him to gain 35 lbs. Hell be referred to

an exercise physiologist. This exercise professional will help design a long term exercise

program that will help rehabilitate his knee, help with his lose weight efforts as well as address

his recent shoulder injury. Consistent exercise will also help reduce his risk of cardiovascular

disease, strengthen his heart, lower his blood pressure, total cholesterol and LDL-C and raise his

HDL cholesterol.

Eating small, frequent meals and keeping a food diary until any additional food triggers are

realized will also prove helpful. The saturated and trans fat should be replaced with

monounsaturated fatty acids and polyunsaturated fatty acids. The patient should avoid late night

meals and snacks in addition to waiting at least 3 hours after eating to lay down. Mr. Nelson will

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be encouraged to explore smoking cessation methods as well as relaxation techniques to help

with stress reduction.

Mr. Nelson will need to be educated regarding proper food handling techniques because PPIs,

which shut off acid production acid will make him susceptible to foodborne illness. Continued

use of PPIs can interfere with absorption of vitamin B12, iron, calcium, magnesium

folic acid and zinc so lab tests to check levels will be ordered if the patient is using lansoprazole

for more than 3 years.

Alternative Therapies

There are several non-drug therapies that can be used to treat GERD. They include herbs and

acupuncture. The herb licorice may stop NSAIDs from damaging the stomach if used either 1

hour before for 2 hours after a meal. Licorice can interact with some drugs and cause side

effects, so a doctor or pharmacist should be consulted. Chamomile helps to calm the stomach and

eliminate inflammation. It is safe to use unless the patient is allergic to plants in the ragweed

family. Slippery elm and marshmallow provide GERD relief and are safe to use as long as they

are taken away from other medications. Some patients have results and some don't (Heidelbaugh,

Harrison, McQuillan, Nostrant, 2012). Supplements containing vitamins A, C, E, the B vitamins

as well as trace minerals magnesium, calcium, zinc and selenium support the digestive system

(Ehrich, 2015). A clinical trial concluded that using acupuncture along with a proton pump

inhibitor (PPI) gave the same result as using a double dose of the same PPI (Dickman et al.,

2007).

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Answers to Questions

3. What are the complications of gastroesophageal reflux disease?

The complications of gastroesophageal disease include narrowing of the esophagus, ulcers in the

esophagus, and Barretts esophagus. Barretts esophagus is a condition in which the acid from

the stomach causes changes to the cells of the lining of the esophagus, which can also later

become cancerous.

5. Identify the patients signs and symptoms that could suggest the diagnosis of

gastroesophageal reflux disease.

During his physical exam Mr. Nelson had epigastric tenderness without rebound or guarding. His

rectal exam indicated a slight Heme increase which could indicate upper GI bleeding. The

patient is obese and taking blood pressure medication, aspirin and ibuprofen all of which

overtime can weaken the lower esophageal sphincter. Mr. Nelsons constant indigestion and

chest pain are possible GERD symptoms.

7. What risk factors does the patient present with that might contribute to his diagnosis (be sure

to consider lifestyle, medical, and nutritional factors.)

The lifestyle risk factors that might contribute to the patients GERD diagnosis are that the

patient says hes stressed out, he smokes and he hasnt had a regular exercise program since his

knee surgery 5 years ago. Mr. Nelson consumes three large, high fat meals a day in addition to

two high fat snacks per day. He indicated that he eats his food and drinks liquids at the same

time. His food and beverage choices are often fried, highly processed, acidic and carbonated. He

also drinks alcohol which can damage his esophageal mucosa. The medical risk factors that

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might contribute to his diagnosis are the fact that Mr. Nelson is obese. Also, his daily

medications can cause his lower esophageal sphincter (LES) to become weak, which will allow

his stomach contents to flow back into his esophagus.

8. Calculate this patients IBW, %IBW, %UBW, and BMI. What does this assessment of weight

tell you? Could this contribute to his diagnosis?

The patient has an ideal body weight (IBW) of 160 lb 10% which leads to a range of 144 - 176

lb. The patient has stated that he has gained 35 lb since his knee surgery, which makes his usual

body weight (UBW) 180 lb. His BMI is 31.94, which puts him in the obesity category. His

%IBW is 134.4%, and his %UBW is 119.4%. The fact that Mr. Nelson has excess weight

contributes to his diagnosis because excessive weight raises abdominal pressure which increases

the likelihood of stomach acid leakage and backflow of partially digested material from the

stomach to the esophagus, which, in turn, can damage the esophagus and generate the pain and

associated symptoms of gastroesophageal reflux disease (GERD).

10. The MD has prescribed lansoprazole. What class of medication is this? What is the basic

mechanism of the drug? What other drugs are available in this class? What other groups of

medications are used to treat GERD?

Lansoprazole is classified as a proton pump inhibitor. It works by suppressing the molecules that

release stomach acid. Lansoprazole blocks the H+ and K + ATPase enzymes which assist in

HCL production. Other prescription drugs available in this class are esomeprazole (Nexium),

omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex). There are several

other groups of medications used to treat GERD. Histamine H2 blockers, which block stomach

acid production; foaming agents, which coat the esophagus and stomach and prokinetics which

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encourage faster movement of stomach acids along the GI tract reducing the likelihood of acid

reflux occurring. Over the counter antacids, which neutralize stomach acids are also used to treat

GERD.

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References:

Academy of Nutrition and Dietetics. (2016). Gastroesophageal Reflux Disease GERD.

Retrieved From

https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=1937

&ncm_heading=Nutrition%20Care&ncm_content_id=82376#Overview

Agency for Healthcare Research and Quality (2005). Audio News Release Transcript:

Gastroesophageal Reflux Disease (GERD) Effective Health Care Report. Retrieved from

https://wayback.archiveit.org/3920/20131026120019/http://www.ahrq.gov/legacy/news/

erdtrans.htm

Armstrong, D., & Marchetti, N. (2008). Pharmacist-specific guidelines for the medical

management of GERD in adults. Canadian Pharmacists Journal, 141(sp1), S10.

doi:10.3821/1913-701X(2008)141[S10:PGFTMM]2.0.CO;2

Dickman, R., Schiff, E., Holland, A., Wright, C., Sarela, S. R., Han, B. Fass, R.

(2007, September 17). Retrieved from

www.ncbi.nlm.hih.gov/pubmed/17875198

Ehrich, S. D. (2015, September 29). Gastroesophageal Reflux Disease. Retrieved from

http://umm.edu/health/medical/altmed/condition/gastroesophageal-reflux-disease

Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults

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(2013, September) Retrieved from

http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/ger-and-

gerd-in-adults/Documents/gerd_508.pdf

Heidelbaugh, J. J., Harrison, R. V., McQuillan, M. A., Nostrant, T. T. (2013, September).

Gastroesophageal Reflux Disease (GERD). Retrieved from

http://www.med.umich.edu/1info/FHP/practicguides/gerd/gerd.12.pdf

Singh, M., Lee, J., Gupta, N., Gaddam, S., Smith, B. K., Wani, S. B.. . Sharma, P.

(2013). Weight loss can lead to resolution of gastroesophageal reflux disease symptoms:

A prospective intervention trial. Obesity (Silver Spring, Md.),21(2), 284.

doi:10.1002/oby.20279

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 Haque and Hudgins

Calculations:

BMI: 31.94; obese

- height in cm = 69 inches x 2.54 = 175.26 cm

- height in m = 175.26 / 100 = 1.75

- weight in kg = 215 lb / 2.2 = 97.73

- BMI = 97.73 / 1.75

= 97.73 / 3.06

= 31.94

EER = 10(97.73) + 6.25(175.25) - 5(48) 5

= 977.3 + 1095.3 240 5

= 1827.3 x AF x IF

= 1827.3 x 1.3

= 2375.49

2375.49 x 1.0 = 2375.49

Deficit to cause weight loss = 2375.49 - 500 = 1875.49

Round down to 1875 kcals/day

AF = 1.3 (out of bed) IF = 1.0

Protein needs = 0.8 x 97.73 = 1.0 x 97.73

= 78.18 g = 97.73 g

IBW = 106 + (6 x 9)

= 106 + 54

= 160 lb 10%

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 Haque and Hudgins

160 x 0.9 = 144 lb 160 x 1.10 = 176 lb

IBW = 144 - 176 lb

UBW = 215 - 35

= 180 lb

% IBW = ABW / IBW x 100

= 215 / 160 x 100

= 134.4%

% UBW = ABW / UBW x 100

= 215 / 180 x 100

= 119.4%

LDL/HDL ratio = 165 / 20 = 8.25

% Weight Change = [(ABW - UBW) / UBW] x 100

= [(215 - 180) / 180] x 100

= 35 / 180 x 100 = 19.4%

Saturated fat calculation = 1875 x 0.07

= 131.25 / 9

= 14.58

Round up to 15 g saturated fat

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