Michael Kaminski

Medical Nutrition Therapy DIE 3213

Michelle Elkadi, MS, RD, LD/N
November 25, 2015

1. Draw a picture of the GI tract and specify where specific macro and
micronutrients are digested and absorbed.

2. What factors led to inadequate intake in this patient? What

percentage of her UBW has she

lost? What are some other factors that might lead to poor intake in
individuals with CD?
With Crohns disease, the intestine becomes less able to digest and
absorb food nutrients fully due to inflammation. Nutrients, as well as
unabsorbed bile salts, can escape into the large intestine to varying degrees,
depending on how extensively and how severely the small intestine has been
injured by inflammation. 3
Usual weight: 140 lbs.
Weight change: Lost 10 lbs. in the past 3 weeks
(130/140) x 100= 92.8% UBW
100-92.8= 7.2% UBW
The patient has lost 7.2% of her UBW in the past 3 weeks.
Other factors that might lead to poor intake in individuals with CD is
the development of strictures or partial bowel obstruction. These patients
benefit from a reduction in dietary fiber or limited food size. Also patients
with rapid intestinal transit, extensive bowel resections, or excessive small
bowel disease may suffer from malabsorption. 4
3. What specific nutrients might she have difficulty absorbing due to
her ileal disease? Which nutrients might at risk due to drug-nutrient
interactions?
The patient may have difficulty absorbing several nutrients due to the
development of her disease. Protein intake may need to be increased due to
protein losses that occur in areas of inflamed and ulcerated intestinal
mucosa. Supplements for folate, B6, B12,, and minerals are also suggested due
to malabsorption.
Patients receiving intermittent corticosteroids may be placed on
supplementation for calcium and vitamin D.4 Mesalamine side effects may
include abdominal pain, cramps, and diarrhea. Diarrhea can aggravate losses
of zinc, potassium, and selenium. 3, 4
4. What nutrients is she likely to be losing in the diarrhea?
The patients is likely losing zinc, potassium, selenium, and electrolytes,
due to diarrhea.4 Diarrhea also results in the poor absorption of nutrients
including proteins, fats, and carbohydrates. 5
5. What is C-reactive protein and how might it be used in this type of
patient? Which of her biochemical lab values indicate that she is
anemic and why?
C-reactive protein (CRP) is an inflammatory biomarker. CRP is used to
identify the acute hypermetabolic period of the inflammatory response. This

level may be useful to monitor; when decreasing the patient is entering an

anabolic period of the inflammatory response. During this response phase a
more intensive nutritional therapy will be benefit the patient. 4
A few of the biochemical lab values that indicate that the patient is
anemic include hematocrit, ferritin, and hemoglobin. Hematocrit is the
percentage of your blood volume made up by red blood cells. Normal levels
are generally between 36% and 47% for adult women; the patients current
value is 34%. The patient also has a low hemoglobin level of 1.8 g/dL
indicating anemia. The normal hemoglobin range is defined as 12 to 16 g/Dl.
Ferritin is a protein that helps store iron in the body, and a low level of ferritin
usually indicates a low level of stored iron. The patient has low ferritin value
of 6 ng/ml. Normal values for women should be between 12-150 ng/mL. 6
6. Is her nephrolithiasis history related to her CD, and if so, why? Are
there nutritional measures that could help to decrease her risk for
further problems with kidney stones?
Yes, the patients history of nephrolithiasis can be related to her CD.
Nephrolithiasis can be related to CD due to the formation of oxalate stones.
Malabsorption of fat in CD patients leads to increased absorption of free
dietary oxalate that then binds to available calcium ions to form kidney
stones. 7
Nutritional measures that could help to decrease the patients risk for
further problems with kidney stones would be to increase fluid intake. Along
with decreasing intake of sugar, sodium, animal proteins, vitamin C, and
calcium.8
7. What type of oral diet would you recommend for her in the short
term?
Unfortunately there is no single dietary regiment to be discovered for
reducing or decreasing flare ups. A low residue or low-fiber diet should be
followed to reduce the risk of intestinal blockage if you have a narrowed
bowel.9
The patient should also begin to probiotic food and supplements due to its
ability to modify the microbial flora and modulate gut inflammatory
response.4 Finally, the patient should increase fluids due to risk of
dehydration from diarrhea and to help prevent the formation of kidney
stones.
8. Under what circumstances would you consider enteral or parental
nutrition for an individual with Crohns?
The patient should consider enteral or parental nutrition when the
primary goal is to restore and maintain the nutrition status. Diet and specific
nutrients play a supportive role in maintaining nutrition status, limiting
symptom exacerbations, and supporting growth in pediatrics. Children can

also benefit from the use of enteral nutrition with maintaining growth and a
reduction of using steroids that may affect growth and bone disease. PN may
be used in Crohns patients with persistent bowel obstruction, fistulas, and
major GI restrictions that result in SBS where enteral nutrition is not possible. 4
9. Identify an appropriate nutrition diagnosis and write a PES
statement based on the available nutritional assessment data.
Inadequate intake of iron, related to nutrient malabsorption as
evidenced low biochemical lab values; hematocrit, ferritin, and hemoglobin.
10.
What are your goals for this patient, and how would you
monitor the effectiveness of your treatment?
Goals for the patient would include education in foods rich in protein
and iron. The patient should also begin to consume a multivitamin and
mineral to promote low biochemical lab values.
11.

Sample menu and analysis

Breakfast
Grapefruit juice 1
cup,Cereal 3/4 cup,
Skim milk 1 cup,
Scrambled eggs 1,
White toast 2 slices,
Margarine 2 tsp,
Coffee 1 cup,
Water 1 cup

Lunch

Dinner

White meat chicken 2

oz,Wheat bread 2 slices,
Iceburg lettuce 1 cup,
Oil/vinegar dressing 1
Tbsp,
Cantaloupe 1 cup,
Lemonade 1 cup,

Baked haddock 3
oz,White rice 1/2 cup,
Peas 1/2 cup,
Margarine 2 tsp,
Dinner roll 1,
Apple 1,
Animal crackers 16,

Sugar cookie 1,

Water 1 cup

Water 1 cup

Analysis
Calories

1805

Protein

81 gm

Carbohydrates

261 gm

Fat
Sodium
Potassium

51 gm
1821 mg
692 gm

References
1. Clinical Options Website.
http://www.clinicaloptions.com/~/media/InPractice/Oncology/Ch
%2049%20Supportive%20Care
%20Nutrition/SuppCare_Nutrition_figure.ashx.Accessed November 24,
2015
2. The Digestive System. Midlands Tech Website.
http://classes.midlandstech.edu/carterp/Courses/bio211/chap23/chap23.ht
m
3. Crohn and Colitis Foundation of America.
http://www.ccfa.org/resources/diet-and-nutrition-1.html.Accessed
November 24, 2015
4. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food & the Nutrition
Care Process. St Louis: Saunders; 2012
5. http://ibstreatmentcenter.com/digestion-basics/diarrhea
6. Mayo Clinic Website. http://www.mayoclinic.org/diseases-conditions/irondeficiency-anemia/basics/tests-diagnosis/con-20019327.Accessed
November 24, 2015
7. The Washington Manual of Gastroenterology Subspecialty Consult
Website. https://books.google.com/books?
id=zNb1SsSQTDwC&pg=PA175&lpg=PA175&dq=nephrolithiasis+history+
related++CD&source=bl&ots=MqIWT0g8e&sig=BbczOYHTVMKUDY7rxgIkB3A1w78&hl=en&sa=X&ved=0a
hUKEwjGgqri1bHJAhXHyT4KHb5xBmwQ6AEITDAG#v=onepage&q=nephro
lithiasis%20history%20related%20%20CD&f=false.Accessed November
24, 2015
8. GI Care Website. http://gicare.com/diets/kidney-stone-diet/ .Accessed
November 24, 2015
9. Mayo Clinic Website. http://www.mayoclinic.org/diseasesconditions/crohns-disease/basics/treatment/con-20032061 .Accessed
November 24, 2015