Daniel is a 54-year-old man with a recent diagnosis of cancer of the gastroesophageal junction. He has experienced gastroesophageal reflux (GERD) for the past 10 years and had been advised to undergo an endoscopic examination to rule out Barrett’s esophagus, but he never followed up on his doctor’s referral. He lost 30 pounds in the 3 months prior to his diagnosis because of lack of appetite and progressive dysphagia with solid foods. Pre-diagnosis, his diet consisted of drinking “muscle drinks” his son purchased at the local gym. He has been very pleased with his weight loss but knew something was wrong. His medical history also includes hypertension and sleep apnea. Daniel underwent neo-adjuvant chemotherapy and radiation therapy, followed by an esophagogastrectomy 1½ months ago and recalls that he received some nutrition information from the inpatient registered dietitian nutritionist right before he was discharged. Daniel reports that he was anxious to go home and did not pay attention to the diet instruction and could not find the paperwork once he got home. While hospitalized, Daniel received enteral nutrition via a feeding tube, but the feedings were discontinued and the tube was removed just prior to discharge. He has lost an additional 25 pounds in the past month and has been admitted once for dehydration caused by lack of fluid intake and because of symptoms related to ongoing episodes of diarrhea after eating. He has also stopped using his C-Pap because he feels that it is no longer helpful; however, he states he is not sleeping well and never feels rested. His current food and nutrition history includes small meals with a usual intake of approximately 1500 calories daily. He eats three times a day. He reports he does not have the energy to prepare food, so, while his wife is at work, he has started drinking the “muscle drinks” again and is warming canned soup in the microwave. He is also drinking sports drinks because he has been encouraged to increase his fluid intake. He has a sweet tooth, and because eating is difficult, he rewards himself with ice cream or sherbet. His beverages include whole milk, apple juice, and an occasional “finger” of scotch each night. He has been referred to see the outpatient registered dietitian nutritionist.
Biochemical Data
Pre-albumin: 14.0 mg/dl Blood urea nitrogen: 18 mg/dl Creatinine: 0.6 mg/dl Blood pressure: 100/55 Pulse rate of 90
Anthropometric Data
Height: 70” Weight history: Usual body weight: 220 lb, preoperative weight: 190 lb, 1 month postoperative weight: 165 lb Current body mass index: 23
Medications
Metoclopramide (Reglan) 30 minutes before each meal Metoprolol (Toprol) Hydrochlorothiazide Sildenafil (Viagra)
Dietary Supplements One-A-Day for Men Saw Palmetto Lycopene
Nutrition Diagnostic Statement 1
Food- and nutrition-related knowledge deficit related to lack of education and counseling for appropriate medical nutrition therapy as evidenced by food history with inappropriate food choices.
Nutrition Diagnostic Statement 2
Altered gastrointestinal function related to esophagogastrectomy as evidenced by weight loss, dehydration, and dumping syndrome.
Nutrition Diagnostic Statement 3
Inadequate protein and energy intake related to postsurgery recovery as evidenced by decreased food and beverage intake, weight loss, and muscle wasting causing decreased creatinine.
Nutrition Care Questions 1.
What kind of a daily eating plan would you design with Daniel so that he can take in enough food and fluid to meet his nutritional requirements?
2. After reviewing Daniel’s medical, social and physical activity history, what other factors could be contributing to his difficulty with eating and his inability to regain weight?
3. Would you include Daniel’s wife in your counseling sessions? If so, why? If not, why?
4. As Daniel continues to be seen for Survivorship Care at your clinic, what lingering or late-occurring side effects of cancer treatment should you anticipate and continue to monitor? Could any of these side effects affect his ongoing nutritional status? If so, should any laboratory tests be ordered or evaluated? What other factors should be monitored as a part of your nutritional care?
Nutrition Interventions
Nutrition prescription: Small, frequent meals consisting of energy-dense, lower-fat foods and limited simple carbohydrates; majority of fluid consumption between meals (sips during meals okay to aid in chewing and swallowing). Nutrition education: Update Daniel’s knowledge of appropriate nutrition therapy after an esophagogastrectomy. Discuss tolerance of different food groups; sources of protein; energy-dense, easy-to-prepare menu options; and healthy beverage selections, including advising him to discontinue consumption of daily alcoholic beverage; and goal caloric intake needed for slow, steady weight gain. Suggest he consider eating every 2 hours, on the even hour, to create an external reminder to eat. Recommend he review his hypertension medication types and doses with his physicians because his need for medication may have changed with his significant weight loss. At follow-up visits address weight stabilization and weight-gain progress, bowel function, food and beverage intake and tolerance; encourage physical activity (physician approved) starting with short walks to regain muscle strength. Daniel should be accompanied by a friend or family member on these walks. Encourage Daniel to follow-up with his primary care physician to discuss his problems sleeping and that he has stopped using his C-Pap. Nutrition counseling: Coordinate with patient and wife to ensure appropriate foods and beverages are available for consumption. Discuss expected acute and long-term side effects from surgery. Establish slow, steady weight gain and physical activity goals for next 3 months.
Nutrition Monitoring and Evaluation
1. Body weight trends
2. Hydration status
3. Serum pre-albumin levels and creatinine levels (over 3 months)
4. Physical activity
5. Schedule follow-up session in 2 weeks, with optional phone call between visits