Jane is a 42-year-old female who presents with acute onset of epigastric abdominal pain associated with nausea and bilious vomiting, poor appetite, and 20-pound (9-kg) unintentional weight loss over the past 3 months. A nutrition consult is requested for assessment of nutritional status and strategies for treating nutritional issues associated with gastroparesis.
Nutrition Assessment
• Past medical history is significant for type I DM, GERD, gastroparesis, hypertension, chronic low back pain, and recent back surgery 3 months ago. Jane was discharged on narcotics, and then was recently hospitalized for similar symptoms that were attributed to diabetic gastroparesis exacerbated by narcotics use.
• Her medications on admission include insulin, Zofran, Prilosec, Reglan, lisinopril, Ultram.
• Oral intake has gradually decreased over the last 3 months to sips of liquids (water, soup, tea), and toast or crackers for the past 2 weeks. Upon further questioning, Jane reports frequent hypoglycemia after meals, early satiety, chronic constipation, and often wakes up in the morning feeling full. She has persistent epigastric abdominal pain accompanied by vomiting.
• Anthropometrics: Ht: 162.5 cm (64 inches); Wt: 72.7 kg (160 lb); BMI : 27.5 kg/m2
• Usual body weight: 81.8 kg (180 lbs); weight change: 11% change in 3 months (significant weight loss).
• Jane’s nutrition-focused physical examination (NFPE) reveals the following: No evidence of muscle loss; stomach is smaller per patient report but otherwise no visible evidence of fat loss; no upper or lower extremity edema. Tongue is beefy red and swollen for the past few weeks (glossitis resulting from possible iron, folate, and vitamin B12 deficiency).
• Functional capacity: Little energy or motivation to do anything for past 3 months. Dizzy and lightheaded for past 1 week.
• Laboratory data: Hb A1C (glycosylated hemoglobin) level: 9.5% (high), blood pressure: 178/95 (high), blood glucose: 293 mg/dl (high)
Nutrition Diagnostic Statements (PES Statements)
• Suboptimal oral intake (P) related to inability to consume sufficient calories (E) as evidenced by report of nausea, vomiting, and persistent abdominal pain (S).
• Unintended weight loss (P) related to altered GI function (E) as evidenced by 11% weight loss over past 3 months (S).
Nutrition Interventions
1) What would you estimate to be Jane’s daily energy and protein requirements?
2) What would you work out with Jane for timing and size of her meals?
3) Would you recommend a trial of oral nutrition supplements?
4) In educating Jane on dietary guidelines for DM and gastroparesis, what would you discuss with her?
5) What concerns would you have related to her use of antiemetics or prokinetic agents.
6) Would you recommend any nutritional supplements for Jane? Which nutrients would concern you?
Nutrition Monitoring and Evaluation
1) What would you monitor during your followup visits with Jane to ensure that her nutrition goals are being met?