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A year ago
Is there a role for supplementation of anti-oxidants in the treatment of individuals with NAFLD?
  What will be an ideal response?

Q. 2

Explain Mrs. Smith's diagnosis: Stage IIB Invasive Ductal Carcinoma T2N1miM0 . Specifically discuss the type of breast cancer and the staging of her diagnosis.
  What will be an ideal response?

Q. 3

What are the risk factors for developing breast cancer? Explain potential genetic and environmental risk factors. Does Mrs. Smith have any of these in her history?
  What will be an ideal response?

Q. 4

Describe the Mediterranean diet and how this eating pattern may support the nutritional goals of treatment of NAFLD.
  What will be an ideal response?

Q. 5

Describe the incidence and prevalence of breast cancer in the United States. How has this changed over the previous decade?
  What will be an ideal response?

Q. 6

Explain the rationale for prescribing a low-carbohydrate diet in the treatment of NAFLD.
  What will be an ideal response?

Q. 7

Write a note for your initial inpatient nutrition assessment with nutrition support recommendations.
  What will be an ideal response?

Q. 8

What factors may affect his tolerance to enteral feeding?
  What will be an ideal response?
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A year ago
Answer to #1

 Vitamin E supplementation has demonstrated positive treatment benefits in the short term (though, longer studies are needed)

Answer to #2

 This means that her breast cancer originated in the mammary ducts and is spreading.
 Stage IIB means that the cancer is either T2, N1, M0 or T3, N0, M0
 The T2 indicates that the primary tumor site is 2-5 cm
 The N1mi indicates that the cancer has spread to 1-3 axillary lymph nodes and are micrometastases (< 2mm)
 M0 indicates that no distant metastasis has been found (via imaging or physical exam)

Answer to #3

 Risk factors for breast cancer:
- Female
- Age (increases with age)
- Adult height (increased risk in taller individuals)
- Larger birth weight
- Family history of cancer
- Late menopause
- Early menarche
- Exposure of radiation to chest (for younger females)
- Hormone replacement therapy (progestin > 5 yrs)
- BRCA1 or BRCA2 gene
- Central adiposity in postmenopausal women
 Yes, Mrs. Smith has some risk factors: family history of breast cancer (mom and sister), female, and older age (61 yrs).

Answer to #4

 Mediterranean diet - high intake of fish and white meat, fruits, vegetables, legumes, and olive oil (main source of fat). Moderate wine consumption is also part of the diet.
- Provides high MUFAs, low saturated fats, a balance of PUFAs (-6 vs. -3), and fiber.
 Antioxidants from fruits, vegetables, and olive oil provide antioxidant components which have been shown to improve the hepatic tissue abnormalities of NAFLD
 Complex carbohydrates and fiber will slow the absorption of carbohydrates and lower insulin response, lowering its effect on lipogenesis.
 The balance of PUFAs prevents the oxidative damage associated with linoleic acid in NAFLD.
 MUFAs from olive oil appears to lower liver enzyme levels and area of fibrosis
 The positive effects from increased antioxidant levels, improved CVD health (lower blood pressure/reduced risk of thrombosis), reduction in blood glucose, cholesterol, triglycerides, LDL, oxidized-LDL, and elevation in HDL lowers the pathological risk factors of NAFLD

Answer to #5

 In 2012, breast cancer was diagnosed in 1.67 million women and 6.3 million women have been living with the diagnosis over the past 5 years.
 1/8 U.S. women will develop invasive breast cancer during their life
 Incidence rates have been declining in the U.S. since 2000 (dropped 7 during the year from 2002 to 2003)

Answer to #6

 High-carbohydrate diets may lead to hepatic insulin resistance by activating carbohydrate responsive element binding protein (ChREBP), inducing glycolysis and lipogenic pathways within liver tissue

Answer to #7

A: 37 yo M
Admitted with SOB now on mechanical ventilation with probable sepsis
PMH: T2DM, HTN, Hyperlipidemia, Osteoarthritis
PSH: s/p Roux-en-Y bariatric surgery 4 months previously, total knee replacement
Meds: lovastatin 60 mg/day (d/c Lantus and metformin 2 months ago)
Skin: warm, dry to touch; ecchymosis, abrasions, petechiae on lower extremities, 2+ pitting edema
Abdomen: obese appearance with rashes under skinfolds; soft, active bowel sounds
I/O: +1430 mL
Labs: K 5.8, CO2 31, Glu 385, Phos 2.1, Pro 5.8, Alb 1.9, Prealb 11, Ammonia 35, WBC 23.5, CRP 110, Ferritin 14, Transferrin 385, Lactate 4.2, Fibrinogen 525, Hgb 12.5, Hct 38, TG 245
Urine: Pro +, Glu +, Ket +, Bact +, WBC +
Diet: NPO
Diet Hx: unable to speak to patient due to mechanical ventilation. Hx of childhood obesity. Patient's highest historical weight was 425 lbs  recent weight loss of 76 after bariatric surgery.
Ht: 5'10 Wt: 325 UBW: 425 UBW: 76 IBW: 166 IBW: 196 BMI: 46.7 kg/m2
EER: 1660-1886 kcal/d (based on 22-25 kcal/kg IBW); EPR: 151-189 (based on 2.0-2.5 g/kg/IBW)
D: Predicted suboptimal energy intake related to induced sedation as evidenced by an order for nothing by mouth and mechanical ventilation status.
I: Goal to meet 100 nutritional needs via enteral feeding.
When medically able, recommend a post-pyloric feeding tube to prepare for enteral feeding.
Within 24-48 hours after hemodynamically stable, initiate Peptamen Bariatric  20 mL/hour. Increase as tolerated by 10-20 mL every 8-12 hours until goal rate of 80 mL/hour (based on 22 hours per day -ICU protocol). This will provide daily 1760 mL total volume, 1760 total kcalories, 164 g protein, and 1478 mL free water. Provide approximately 5 flushes of 60 mL free sterile water throughout the day (ever 4 hours).
Make HOB elevated between 30-45 degrees.
Communicate with team the nutrition support recommendations per above.
M/E: RD to follow patient in ICU.
Monitor weight changes, I/O, abdominal sounds, and GI tolerance.
Monitor BG and suggest insulin therapy if consistently above 180 mg/dL.
Monitor lab trends and risks for refeeding syndrome.
Reassess enteral feeding needs once weaned off of ventilator.

Answer to #8

A number of factors could affect his tolerance, including a worsening disease state (which could affect GI motility). Hyperglycemia and electrolyte imbalances can also impact his response to the enteral therapy. Fluid needs (or fluctuations in fluid status) could also potentially impact tolerance.
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