Val Palamidy

Nutrition Therapy I
Alireza Jahan-Mihan
November 13, 2014

Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed.
Title: Case 10 Irritable Bowel Syndrome (IBS)
1. IBS is considered to be a functional disorder. What does this mean? How does this
relate to Mrs. Clarkes history of having a colonoscopy and her physicians order for a
hydrogen breath test and measurements of anti-tTG? (3 points)
IBS is designated as a functional disorder, which means a diagnosis is made after ruling out
all possible organic causes of the patients symptoms. Since the patients history has had
negative results of stool cultures and of a colonoscopy, the presence of an active disease has
been ruled out. Although the specific cause of IBS is unknown, some factors may be from
the result of genetic predisposition; small intestinal bacterial overgrowth (SIBO) or an altered
immune response stimulated by food sensitivity. SIBO is described in a significant number
of patients with IBS, therefore, the physicians order for a hydrogen breath test is to confirm
increased sufficient levels of breath hydrogen after a dose of glucose, lactulose, or other
sugars. Measurements of anti-tissue transglutaminase (anti-tTG) are commonly used to
evaluate if the patient has a sensitivity towards to gluten, to make a differential diagnosis of
celiacs disease. 1,2
2. What are the ACG and the Rome III criteria? Using the information from Mrs.
Clarkes history and physical, determine how Dr. Cryan made her diagnosis of IBS-D.
(2 point)
The American College of Gastroenterology (ACG) is an organization that provides a metaanalysis approach to the most recent management of IBS. It provides clinicians with new
information regarding diet recommendation, probiotics, antibiotics, antidepressants, and
recently developed drugs.2 The Rome III Consensus Criteria was developed to interpret and
assess functional gastrointestinal disorders based on a list of clinical symptoms and in order
for IBS to be diagnosed, it is required that patients have had recurrent abdominal pain or
discomfort at least 3 days per month during the previous 3 months. Based on the patients
history/physical, Dr. Cyans assessment on IBS-D (diarrhea predominant) was evidenced by
two or more of the patients following symptoms; persistent abdominal pain, her altered stool
frequency (constipation with diarrhea), and altered stool passage (predominance of diarrhea
several episodes per day).1,3,4
3. Discuss the primary factors that may be involved in IBS etiology. You must include in
your discussion the possible roles of genetics, infection, and serotonin. (3 points)
Irritable bowel syndrome is characterized by chronically recurring symptoms, including
abdominal discomfort and altered intestinal motility. Also commonly included are bloating,
feelings of incomplete evacuation, presence of mucus in the stool, straining or increased
urgency (depending on the type of presentation), and increased GI distress associated with
psychosocial distress. The specific cause of IBS is unknown, but current research is focused
on multiple factors including genetic predisposition; altered immune response stimulated by
food sensitivity and altered microbial environment; an elevated inflammatory response to
gastroenteritis; small intestinal bacterial overgrowth (SIBO); abnormal release, transport, or
recognition of serotonin; and an increased sensitivity of the enteric nervous system that
causes abnormal motility and pain. This condition affects women more than men and occurs

frequently before age 50. 1,2

Other studies have observed development of IBS after infectious enteritis. Specific organisms
that have been documented include Blastocystis hominis, Campylobacter, Salmonella,and
parasites such as Trichinella spiralis. Abnormal cellular immune responses to certain
nutrients have also been documented. 1
Serotonin(alsoknownas5HT4[5hydroxytryptamine])issynthesizedfromtheaminoacid
tryptophan.Morethan95%ofserotoninisfoundwithintheGItract,withtheremaining5%
activewithinthebrain.Serotonincanactivatebothexcitatoryandinhibitoryneuronsinthe
gastrointestinaltract.Serotoninstimulatesboththereleaseofacetylcholine,causingsmooth
musclecontraction,andtheinhibitoryneuronsthatreleasenitricoxide,whichresultsin
relaxationofsmoothmuscle.1,2
4. Mrs. Clarkes physician prescribed two medications for her IBS. What are they and
what is the proposed mechanism of each? She discusses the potential use of Lotronex if
these medications do not help. What is this medication and what is its mechanism?
Identify any potential drugnutrient interactions for these medications. (3 points)
The two medications that were prescribed to the patient were Elavil and Metamucil. Elavil is
a tricylic antidepressant, which helps control anxiety (as noted in her general appearance as
an anxious person) and alleviate the abdominal pain the patient is experiencing. This
medication should be taken once daily, preferably before bedtime to soothe abdominal pain.
The patients history mentions she consumes alcohol of 3-4 times a week, therefore, alcohol
should be avoided so that it does not alter its effectiveness. Metamucil is a fiber supplement
that acts as a bulk forming laxative. Found in a powder form, the patient would need to
dilute it in 8 oz of water, milk, or juice, twice daily. For diarrhea sufferers, the extra fiber
makes the stool firmer and more solid. For constipation sufferers, the extra bulk can make
waste food softer and easier to pass. 5,6
If none of these medications were to help the patients IBS, recommendation of prescribing
Lotronex would be the next step. Lotronex blocks the action of serotonin in the intestines,
which helps slow the movement of bowel movements through the intestines. Generally
prescribed to only women whove had episodes for more than 6 months and no success with
other medications, necessary precautions need to be evaluated prior to prescribing Lotronex
due to its side effects. 7
When taking Elavil, the patient would need to avoid taking it with carbonated beverages or
grape juice since these items decrease its effectiveness. Increased weight gain and appetite,
especially for sweets, are side effects when taking this medication, therefore, the patient
would need to closely monitor her dietary intake to prevent further weight gain. Since the
patients cholesterol (201; normal range 120-199) and triglycerides (171; normal range for
females 35-135) are increased, taking Metamucil would benefit the patient since it decreases
cholesterol and LDL. 8
5. For each of the following foods, outline the possible effect on IBS symptoms. (2 point)
a. lactose : The presence of lactose indigestion does not necessarily mean that it is a cause
of IBS, but certainly the two can co-exist and breath hydrogen test can confirm this.

Symptoms of lactose intolerance mimic those to that of IBS, which include diarrhea, gas,
abdominal cramps and bloating. Additionally, taking a careful diet history relating signs
and symptoms with lactose ingestion or presenting a milk challenge would be other steps
to determine if lactose should be avoided. Generally, elimination of lactose for 12
weeks is adequate to determine the success of this intervention. 1,2
b. fructose : the sugar found in fruits, makes its way into the large intestine where is
fermented by intestinal bacteria. The process can effect GI motility and contribute to
unwanted gas and bloating. For individuals that are sensitive, if large doses are
consumed, symptoms can occur within a short period of time. Fructose malabsorption
may be the result of small intestine bacterial overgrowth (SIBO), which is why fructose is
a component of the FODMAP diet for IBS. 9
c. sugar alcohols : Found as a sweetener in gum and other reduced carbs, thesefoodsarenot
welldigestedandcontributetofermentationpotentiallyleadingtothosespecificsigns
andsymptomsassociatedwithIBS.Simplecarbohydratesthatcausegasareraffinose,
lactose,fructose,andsorbitol(sugaralcohol).Avoidingfoodsthatproducegasand
takingstepstodecreaseswallowedairwilldecreasegasproduction.1,2
d. high-fat foods : As part of the FODMAP diet, foods that are high in fat should be
temporarily avoided to find out if these sources are triggering the symptoms of IBS.
Significant bloating, gas, and abdominal pain have been associated with those suffering
from IBS. 1,2
6. What is FODMAP? What does the current literature tell us about this intervention? (2
point)
FODMAP refers to foods contributing fermentable oligosaccharides, disaccharides,
monosaccharides, and polyols (sugar alcohols). 1 Since it is believed that these sugars can
trigger gastrointestinal symptoms, FODMAPS were created to provide patients a balanced
diet while avoiding these types of sugars. Current research has shown that 75% of the
patients who are on low FODMAP diet have found it to be highly effective in treating
symptoms for IBS. Some patients found that the diet was strict and to hard to follow,
however, 77% were still able to follow it most of the time and showing improvement within
2 to 8 weeks. 10
7. Define the terms prebiotic and probiotic. What does the current research indicate
regarding their use for treatment of IBS? (2 point)
Probiotic: food or concentrate of live organisms that contribute to a healthy microbial
environment and suppress potential harmful microbes. 2
Prebiotic: food, usually carbohydrates or specifically oligosaccharides
(fructooligosaccharides, inulin) from vegetables, grains, and legumes; may also include
resistant starch, soluble dietary fiber, and malabsorbed sugars that are the preferred energy
substrates of friendly microbes in the gastrointestinal tract. 2
The effects of probiotics regarding the management of IBS used in clinical trials has been
promising, however, it has not been consistent due to the different strains of probiotics.
Although, numerous clinical trials have found that the probiotic bacteria Lactobacilli and

Bifidobacteria are important for IBS, other meta-analyses suggest that different strains may
not provide the same benefits for alleviating symptoms of IBS. However, because it low-cost
and can be safe to use, probiotics are seen as an alternative treatment. It is suggested that
patients suffering from IBS use probiotics for a minimum of 4 weeks but must understand
that it may or may not be completely effective. There is still more research needed to fully
understand the use of probiotics and how they can efficiently be utilized as an effective
treatment for IBS. 10
8. Assess Mrs. Clarkes weight and BMI. What is her desirable weight? (3 points)
Weight: 191 lbs, Height: 55 Age: 42 y.o., BMI: 31.8 (obese).
According to the U.S. National Center for Health Statistics for females, the patients
desirable weight for her age and height should be approximately 151 lbs. or between 125 lbs.
(smaller frame) to 159 lbs. (larger frame). 8,11,12
9. Identify any abnormal laboratory values measured at this clinic visit and explain their
significance for the patient with IBS. (3 points)
Abnormal laboratory values seen with the patient include glucose levels at 115 mg/dL
(normal range: 70mg/dL-100 mg/dL), which can means she might have pre-diabetes.
Cholesterol and triglycerides levels were high, with cholesterol at 201 mg/dL (normal range:
120-199 mg/dL) and triglyceride at 171 mg/dL (normal range female: 35 mg/dL-135 mg/dL).
Having a high lipid profile, along with obesity, increases her risk of heart attack and stroke.
The patients protein level was not deficient at 6.2 g/dL, however, it was closer to the low
end of the normal range between 6 g/dL 8 g/dL. Her hemoglobin alpha 1 levels of 6.1%
are higher than the normal range (3.9%-5.2%), which means she is not keeping the diabetes
under control. 1,2
10. List Mrs. Clarkes other medications and identify the rationale for each prescription.
Are there any drugnutrient interactions you should discuss with Mrs. Clarke? (3
points)
Other medications that the patient is taking include 50 mg Omeprazole, 25 mg levothyroxine
and Lomotil prn. Omeprazole (50 mg b.i.d.) is prescribed for gastroesphoageal reflux
disease and should be taken 30-60 minutes before a meal, followed by cool water.
Levothyroxine (25 mg) is prescribed for hypothyroidism and would need to be taken Fe, Ca,
or Mg supplements separately from this drug because they may decrease its absorption.
Decreased absorption has also been reported with soy, soymilk, soy infant formula, walnuts,
cottonseed meal, and high fiber foods. She would also need to take levothyroxine with a full
glass of water on an empty stomach to increase absorption. Lomotril prn is an anti-diarrheal
which needs to be taken with food if GI distress occurs. Due to her persistent diarrhea, she
would need to increase her fluid and electrolyte needs. The patient is also taking vitamin D
and calcium supplements because calcium helps with muscle contraction within the GI tract.
Although she is within the normal range (10.1mg/dL; normal range: 9 mg/dL-11 mg/dL), she
is also supplemented with vitamin D (600 IU), which improves the absorption of calcium. 8
11. Determine Mrs. Clarkes energy and protein requirements. Be sure to explain what
standards you used to make this estimation. (3 points)

By using the Princeton Living Well website, her gender (F), age (42), weight (191lbs), height
(55), and daily activity level (sedentary) were used to calculate her EER, which was 2073.3
total calories per day. 13
According to the RDA, her protein requirements should be 0.8 g/kg/day. Her daily intake
would be approximately 69.4 g of protein per day. 14
1. Weight in pounds divided by 2.2 = weight in kg
191 lbs. / 2.2 = 86.8 kg
2. Weight in kg x 0.8 gm/kg = protein gm
86.8 kg x 0.8 gm/kg = 69.4 g
12. Assess Mrs. Clarkes recent diet history. How does this compare to her estimated energy
and protein needs? Identify foods that may potentially aggravate her IBS symptoms. (3
points)
After assessing the patients diet history and comparing it with her EER and protein needs,
she is exceeding the amount of calories needed on a daily basis while also lacking in protein
needs . Her diet primarily consist of carbs, which may be the root of triggering her
symptoms of IBS. The sugar-free gum she is consuming in order to lose weight contains
sugar alcohols, which is a key component in the FODMAP diet. She would need to
temporarily avoid these foods for a period of 2 weeks and see if any of her symptoms have
improved. 1,2
13. Prioritize two nutrition problems and complete the PES statement for each. (5 points)
1. Altered GI function related to possible dietary carbohydrate intolerance as evidenced by
long history of diarrhea/constipation, food diary, and FODMAP assessment.
2. Excessive energy intake related to undesirable food choices as evidenced by food diary,
high cholesterol/triglycerides and BMI of 31.8.
14. The RD that counsels Mrs. Clarke discusses the use of an elimination diet. How may
this be used to treat Mrs. Clarkes IBS? (2 point)
The purpose of using an elimination diet is to evaluate specific foods that may trigger her
symptoms of IBS. A food record is kept during this phase is to ensure that all forms of
suspected foods have been eliminated from the diet and to evaluate the nutritional adequacy
of the diet. To avoid inadequate vitamins and minerals, a temporary elimination diet should
be personalized, eliminating one or two suspect foods at a time for each 2-week period. Any
food on the list that is suspect or that is eaten more often that once every 4 months should be
substituted with a food that is rarely or almost never eaten. 2
15. The RD discusses the use of the FODMAP assessment to identify potential trigger foods.
Describe the use of this approach for Mrs. Clarke. How might a food diary help her
determine which foods she should avoid? (2 point)
The purpose of using a food diary to is to keep track of the foods that the patient would be
eliminating and to evaluate the nutritional adequacy of the diet. The foods that are identified
as triggering IBS would be eliminated for a 2-week period and reevaluated to see if theres
been any improvement on the patients symptoms. A food diary will also note any vitamins

and minerals that may not be insufficient in the diet, therefore, can be replaced with another
food item if that suspected food were to be eliminated.
16. Should the RD recommend a probiotic supplement? If so, what standards might the RD
use to make this recommendation? (2 point)
Considering the safety and low-cost treatment of using probiotics, the RD should recommend
using a probiotic supplement for a minimum of 4 weeks, especially those that contain
Lactobacilli and Bifidobacterium. After the 4 weeks, the patient would need to be
reevaluated to see if any of the symptoms of IBS have been relieved. Although they may not
be effective for everyone, probiotic supplements can help alleviate abdominal pain, gas, and
constipation. 15
17. Mrs. Clarke is interested in trying other types of treatment for IBS including
acupuncture, herbal supplements, and hypnotherapy. What would you tell her about
the use of each of these in IBS? What is the role of the RD in discussing complementary
and alternative therapies? (2 point)
When recommending other types of treatment such as acupuncture, herbal supplements, and
hypnotherapy, I would suggest that these options are more safe, however, may not always be
effective. With acupuncture, there have been small studies that have suggested it helped
reduce bloating and improve well-being for those who have IBS. Large-scale trials are still
needed to prove its effectiveness. Herbal supplements are another safe option the patient can
try. She can use them in forms such as dried extracts (capsules, powders, and teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). One study found that when
using Chinese herbal medicine, it was able to reduce to the symptoms of IBS. In order to
manage the anxiety within the patient, hypnotherapy could be a beneficial treatment for her.
Several clinical studies have shown relief for patients with IBS in that a series of relaxation
techniques were used to improve well-being, abdominal pain, constipation, diarrhea, and
bloating. 15,16
The role of the RD when discussing the complementary and alternative therapy options is to
ensure that she is provided with the best resources that are safe and available to her. The type
of treatment the patient is interested in would depend on the availability around her local
area, cost, and commitment for each type.
18. Write an ADIME note for your initial nutrition assessment with your plans for
education and follow-up. (5 points)
Assessment :
Patient has had long history of constant diarrhea/constipation and seems to be unaware of
what foods seem to trigger her symptoms. Seen as obese and anxious-appearing female.
Admitted with hypothyroidism and gastroesophageal reflux disease. Current medications
include Omeprazole, Levothyroxine, and Lomotril. Family physician found negative stool
cultures. Colonoscopy negative for active disease.
Labs: glucose 115 mg/dL, cholesterol 201 mg/dL, triglycerides 171 mg/dL, HbA1c 6.1%
Weight: 191 lbs., Height: 55 Age: 42 y.o., BMI: 31.8, EER: ~2073.3 cal/day, EPR: 69
g/day
Diagnosis :
1. Altered gastrointestinal function related to possible dietary carbohydrate intolerance as
evidenced by long history of diarrhea/constipation, food diary, and FODMAP assessment.

2. Excessive energy intake related to undesirable food choices as evidenced by food diary,
high cholesterol/triglycerides and BMI of 31.8.
Intervention :
1. Maintain a low FODMAP diet over a period of 2 weeks
2. Prescribe Elavil and Metamucil.
3. Provide evidence-based information regarding nutritional needs during treatment for IBS
4. Set up dietary plan to focus on weight loss.
5. Practice stress management to reduce anxiety.
Monitoring/Evaluation :
1. Evaluate relief of any symptoms after 2 weeks of low FODMAP diet.
2. If no improvement with Elavil and Metamucil, prescribe Lotronex.
3. Measure weight during each visit to record any weight loss; adjust dietary plan.
4. Ensure patient has reduced levels of stress.

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