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Medical
Nutrition
Therapy
A Case Study Approach
Sixth Edition
Marcia Nahikian Nelms, PhD, RDN, LD, FAND

Kristen Roberts, PhD, RDN, LD, CNSC
Ohio State University
Australia ● Brazil ● Canada ● Mexico ● Singapore ● United Kingdom ● United States
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Approach, Sixth Edition
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Marcia Nahikian Nelms, PhD, RDN, LD, FAND
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Printed in the United States of America

Print Number: 01 Print Year: 2021
DEDICATION
To my students—past and present—who continue to challenge me, teach me, and guide me as I strive
to enhance dietetic education.
Marcia Nahikian-Nelms
To my husband, who never fails to remind me that I can achieve my dreams.
Kristen Roberts
CONTENTS
Preface ix
Teaching Strategies xiii
Introducing Case Studies, or Finding Your Way Through a Case Study xv
Acknowledgments xvii
About the Authors xix
Unit One
ENERGY BALANCE AND BODY WEIGHT 1
1 Pediatric Weight Management 3

2 Bariatric Surgery 13
3 Malnutrition Associated with Chronic Disease 27
Unit Two
NUTRITION THERAPY FOR CARDIOVASCULAR
DISORDERS 37
4 Hypertension and Cardiovascular Disease 39
5 Myocardial Infarction 51
6 Heart Failure 63
Unit Three
NUTRITION THERAPY FOR UPPER GASTROINTESTINAL
DISORDERS 75
7 Gastroesophageal Reflux Disease 77
8 Gastroparesis 89
vi Contents
Unit Four
NUTRITION THERAPY FOR LOWER
GASTROINTESTINAL DISORDERS 99
9 Celiac Disease 101
10 Irritable Bowel Syndrome 109
11 Inflammatory Bowel Disease: Crohn’s Disease and Short Bowel Syndrome 119
Unit Five
NUTRITION THERAPY FOR HEPATOBILIARY
AND PANCREATIC DISORDERS 131
12 Nonalcoholic Fatty Liver Disease (NAFLD) 133
13 Acute Pancreatitis 143
Unit Six
NUTRITION THERAPY FOR ENDOCRINE DISORDERS 157
14 Pediatric Type 1 Diabetes Mellitus 159

15 Type 2 Diabetes Mellitus: New Adult Diagnosis 173
16 Adult Type 2 Diabetes Mellitus: Transition to Insulin 183
Unit Seven
NUTRITION THERAPY FOR RENAL DISORDERS 195
17 Chronic Kidney Disease Treated with Dialysis 197

18 Chronic Kidney Disease: Peritoneal Dialysis and Renal Transplant 211
19 Acute Kidney Injury 223
Unit Eight
NUTRITION THERAPY FOR NEUROLOGICAL
DISORDERS 231
20 Ischemic Stroke 233
21 Progressive Neurological Disease: Alzheimer’s Disease 245
22 Young Adult Traumatic Brain Injury 255
23 Pediatric Cerebral Palsy 271
Contents vii
Unit Nine
NUTRITION THERAPY FOR PULMONARY DISORDERS 279
24 Chronic Obstructive Pulmonary Disease 281
Unit Ten
NUTRITION THERAPY FOR METABOLIC STRESS
AND CRITICAL ILLNESS 293
25 Metabolic Stress and Trauma: Gunshot Wound 295
26 Sepsis and Morbid Obesity 307
Unit Eleven
NUTRITION THERAPY FOR NEOPLASTIC DISEASE 319
27 Breast Cancer 321

28 Tongue Cancer Treated with Surgery, Radiation, and Chemotherapy 333
29 Colorectal Cancer 345
Appendices
A Common Medical Abbreviations 355

B Normal Values for Physical Examination 359
C Routine Laboratory Tests with Nutritional Implications 361
D Growth Charts for Case 23 363
E Class Activity: Mini-Cases 365
Index 383
PREFACE
In teaching, we seek to promote the fundamental represent the type of patient with which the student
values of humanism, democracy, and the sciences— will most likely be involved. The concepts presented
that is, a curiosity about new ideas and enthusiasm in these cases can apply to many other medical con-
for learning, a tolerance for the unfamiliar, and the ditions that may not be presented here. Furthermore,
ability to critically evaluate new ideas. the instructor can choose a variety of questions from
We wish to provide the environment that will each case, even if he or she chooses not to have the
support students’ metacognition. Metacognition is student complete the entire case. The cases represent
in part the students’ awareness of their own learn- both introductory and advanced-level practice and,
ing processes. The use of the case study is an excel- therefore, use of this text allows faculty to choose
lent tool to allow the student to process the steps for among many cases and questions that fit students’
integration of clinical knowledge and support the varying skill levels.
ongoing development of their critical thinking skills. The cases cross the life span, allowing the stu-
Thus, we strive to develop these “laboratories” and dent to see the practice of nutrition therapy during
“real-world” situations that mimic the professional childhood, adolescence, and adulthood through the
community to build that bridge to clinical practice. care of the older adult. We have tried to represent
The idea for this book actually began more than the diversity of individual patients the Registered
15 years ago in teaching medical nutrition therapy Dietitian Nutritionist encounters today while placing
to dietetic students, and now, as this sixth edition nutrition therapy and nutrition education within the
publishes, we strive for these cases to reflect the appropriate cultural context.
most recent nutrition therapy practice. Entering the The electronic medical record (EMR) provides
classroom after being a clinician for many years, we the structure for each case. The student will seek
want our students to experience nutritional care as information to solve the case by using the exact tools
realistically as possible. We want the classroom to he or she will need to use in the clinical setting. As
actually be the bridge between the didactic knowl- the student moves from the admission or outpatient
edge and the clinical setting. In fashioning one of visit record to the physician’s history and physical,
the tools used to build that bridge, we rely heavily on to laboratory data, and to documentation of daily
our clinical experience and evidence-based practice care, the student will need to discern the relevant
to develop what we regard as realistic clinical appli- information from the medical record. We have
cations. Use of a clinical application or case study is also purposefully integrated interprofessional care
not a new concept; the use of case studies in nutri- throughout as we know team-based care is essen-
tion, medicine, nursing, and many other allied health tial for efficient, optimal care in any health care
fields is commonplace. The case study places the setting.
student in a situation that forces integration of Questions for each case are organized using
knowledge from many sources; it also supports the the nutrition care process, beginning with items
use of previously learned information, puts the introducing the pathophysiology and principles of
student in a decision-making role, and nurtures nutrition therapy for the case and then proceeding
critical thinking—thus, metacognition. through each component of the process. Questions
What makes this text different, then, from a prompt the student to identify nutrition prob-
simple collection of case studies? The pedagogy we lems and then synthesize a PES statement. It will
have developed over the years with each case takes be helpful to begin by orienting the student to the
the student one step closer as he or she moves components of a case. We have provided an outline
from the classroom to the real world. The cases of this introduction below (see “Introducing Case
represent the most common diagnoses that rely on Studies”). Teaching needs to be purposeful. If the
nutrition therapy as an essential component of the faculty member creates an inclusive, supportive en-
medical care. Therefore, we believe these cases vironment from which the student can begin to take
ix
x Preface
responsibility for his or her own successful learning, Furthermore, our reviewers requested that the
it is much more likely that student autonomy will be cases be shortened in length. We have streamlined
the end result. cases so that questions are more precise. Cases have
To be consistent with the philosophy of the text, been changed to better represent the diversity of
each case requires that the student seek information patients that are seen in the United States and better
from multiple resources to complete the case. Many represent the complexity of comorbidities. Finally,
of the articles and online sites provide essential data even within a two- to three-year period, medical and
regarding diagnosis and treatment within that case. nutritional care can change dramatically. These cases
We have found that when students learn how to reflect the most recent research and evidenced-based
research the case, their expertise grows exponentially. literature so that the student moves toward higher
The cases lend themselves to be used in levels of practice.
multiple teaching situations. They fit easily into The sixth edition introduces the following major
a problem-based learning curriculum, and also changes and new cases:
can be used as a summary for classroom teaching
Case 2 Bariatric Surgery
of the pathophysiology and nutrition therapy for
Case 3 Malnutrition Associated with Chronic
each diagnosis. The cases can be integrated into
Disease
the appropriate rotation for a dietetic internship,
Case 6 Heart Failure
medical school, or nursing school curricula.
Case 9 Celiac Disease
Furthermore, these cases can be successfully used
Case 11 Inflammatory Bowel Disease: Crohn’s
to develop standardized patient and simulation
Disease and Short Bowel Syndrome
experiences. In this edition we have created a
Case 14 Pediatric Type 1 Diabetes Mellitus
series of mini-cases that provides a focus on one
Case 15 Type 2 Diabetes Mellitus: New Adult
topic of interest within the case. This provides
Diagnosis
structure for an in-class or small group experience
Case 18 Chronic Kidney Disease: Peritoneal Dialysis
for an in-depth exploration of that topic or for a
and Renal Transplant
specific skill development.
Case 21 Progressive Neurological Disease:
Objectives for student learning within each
Alzheimer’s Disease
case are built around the nutrition care process and
Case 22 Young Adult Traumatic Brain Injury
competencies for dietetic education. This edition has
Case 24 Chronic Obstructive Pulmonary Disease
also assured that the level of each case is appropriate
Case 25 Metabolic Stress and Trauma: Gunshot
for the required graduate level as dietetic programs
Wound
transition to Master’s-level training. The use of these
Case 29 Colorectal Cancer
cases is also well suited for student distance learn-
ing and allows an additional path for nutrition and For the additional cases you will find in this
dietetic faculty to document student performance as edition—although the diagnosis may have been
part of program assessment. included in previous editions—the cases have been
significantly changed to reflect current medical care
with appropriate changes in drugs, procedures, and
New to the Sixth Edition
nutrition interventions. Many cases reflect micro-
Important factors have prompted the changes to this nutrient deficiencies, which are often neglected in
sixth edition. The template for the cases continues to current clinical practice. Multiple cases provide data
use the EMR. Though the EMRs used in clinics, phy- for a nutrition-focused physical examination, al-
sician’s offices, and hospitals vary, these cases capture lowing for the malnutrition diagnostic criteria to be
the primary sources of information that the clinician applied. Incorporation of evidence-based guidelines
will access to provide a thorough nutrition assess- is encouraged throughout each of the cases, and the
ment for her or his patient. The setting for some of questions are designed to not only follow the nutri-
the cases has also been changed to reflect outpatient tion care process but also require the student to
care within the patient-centered medical home. evaluate and apply the most current literature.
Preface xi
Student and Instructor Resources Nutrition Diagnoses for each case is available online
via www.cengage.com/login.
MindTap: A new approach to highly personal-
ized online learning. Beyond an eBook, homework Diet & Wellness Plus: Diet & Wellness Plus
solution, digital supplement, or premium website, helps you understand how nutrition relates
MindTap is a digital learning platform that works to your personal health goals. Track your diet
alongside your campus LMS to deliver course cur- and activity, generate reports, and analyze the
riculum across the range of electronic devices in your nutritional value of the food you eat. Diet &
life. MindTap is built on an “app” model allowing Wellness Plus includes over 75,000 foods as well
enhanced digital collaboration and delivery of engag-
as custom food and recipe features. The Behav-
ing content across a spectrum of Cengage and non-
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your life and guides you through the key steps
Instructor Companion Site: Everything you need to make positive changes. Diet & Wellness Plus
for your course in once place! This collection of An- is also available as an app that can be accessed
swer Guide, Case Questions in Word format, and from the app dock in MindTap.
TEACHING STRATEGIES
You can find cases to emphasize specific topics that Neurological Disease: Alzheimer’s Disease; Case 28
are part of the curriculum for pathophysiology and Tongue Cancer Treated with Surgery, Radiation, and
medical nutrition therapy (a list of cases by topic is Chemotherapy
provided below). Every case has data for a nutrition
assessment and can be incorporated within multiple Dysphagia: Case 3 Malnutrition Associated with
courses for repeated exposure for development of Chronic Disease; Case 20 Ischemic Stroke; Case 21
these foundational skills. We have found that when Progressive Neurological Disease: Alzheimer’s
specific questions are selected for each case, they can Disease; Case 23 Pediatric Cerebral Palsy
assist in the pedagogy for other classes as well.
Fluid and Electrolyte Balance: Case 3 Malnutrition
Surgical Cases: Case 2 Bariatric Surgery; Case 11 Associated with Chronic Disease; Case 11 Inflamma-
Inflammatory Bowel Disease: Crohn’s Disease and tory Bowel Disease: Crohn’s Disease and Short Bowel
Short Bowel Syndrome; Case 25 Metabolic Stress Syndrome; Case 16 Adult Type 2 Diabetes Mellitus:
and Trauma: Gunshot Wound; Case 26 Sepsis and Transition to Insulin; Case 17 Chronic Kidney Dis-
Morbid Obesity; Case 28 Tongue Cancer Treated ease Treated with Dialysis; Case 18 Chronic Kidney
with Surgery, Radiation, and Chemotherapy; Disease: Peritoneal Dialysis and Renal Transplant;
Case 29 Colorectal Cancer Case 19 Acute Kidney Injury; Case 21 Progressive
Neurological Disease: Alzheimer’s Disease; Case 22
Micronutrient Assessment/Nutritional Young Adult Traumatic Brain Injury; Case 24
Supplementation: Case 2 Bariatric Surgery; Chronic Obstructive Pulmonary Disease; Case 26
Case 3 Malnutrition Associated with Chronic Sepsis and Morbid Obesity; Case 29 Colorectal
Disease; Case 5 Myocardial Infarction; Case 6 Cancer
Heart Failure; Case 9 Celiac Disease; Case 10
Irritable Bowel Syndrome; Case 11 Inflammatory Acid-Base Balance: Case 6 Heart Failure; Case 13
Bowel Disease: Crohn’s Disease and Short Bowel Acute Pancreatitis; Case 19 Acute Kidney Injury;
Syndrome; Case 18 Chronic Kidney Disease: Case 24 Chronic Obstructive Pulmonary Disease;
Peritoneal Dialysis and Renal Transplant; Case 19 Case 25 Metabolic Stress and Trauma: Gunshot
Acute Kidney Injury; Case 21 Progressive Wound; Case 26 Sepsis and Morbid Obesity
Neurological Disease: Alzheimer’s Disease; Case 23
Pediatric Cerebral Palsy; Case 26 Sepsis and Morbid Genetics/Immunology/Infectious Process: Case 9
Obesity; Case 27 Breast Cancer; Case 28 Tongue Celiac Disease; Case 11 Inflammatory Bowel Disease:
Cancer Treated with Surgery, Radiation, and Crohn’s Disease and Short Bowel Syndrome; Case
Chemotherapy 14 Pediatric Type 1 Diabetes Mellitus; Case 17
Chronic Kidney Disease Treated with Dialysis; Case
NFPE/Malnutrition Documentation: Case 3 24 Chronic Obstructive Pulmonary Disease; Case 26
Malnutrition Associated with Chronic Disease; Sepsis and Morbid Obesity; Case 27 Breast Cancer;
Case 6 Heart Failure; Case 9 Celiac Disease; Case 19 Case 28 Tongue Cancer Treated with Surgery,
Acute Kidney Injury; Case 21 Progressive Neurological Radiation, and Chemotherapy; Case 29 Colorectal
Disease: Alzheimer’s Disease; Case 23 Pediatric Cancer
Cerebral Palsy; Case 26 Sepsis and Morbid Obesity;
Case 28 Tongue Cancer Treated with Surgery, Hypermetabolism/Metabolic Stress: Case 13 Acute
Radiation, and Chemotherapy; Case 29 Colorectal Pancreatitis; Case 19 Acute Kidney Injury; Case
Cancer 22 Young Adult Traumatic Brain Injury; Case 24
Chronic Obstructive Pulmonary Disease; Case 25
Oral Supplementation: Case 3 Malnutrition Metabolic Stress and Trauma: Gunshot Wound; Case
Associated with Chronic Disease; Case 21 Progressive 26 Sepsis and Morbid Obesity
xiii
xiv Teaching Strategies
Nutritional Needs of the Elderly: Case 3 Malnutri- Nutrition Support: Case 6 Heart Failure; Case 8
tion Associated with Chronic Disease; Case 19 Acute Gastroparesis; Case 11 Inflammatory Bowel Disease:
Kidney Injury; Case 21 Progressive Neurological Crohn’s Disease and Short Bowel Syndrome; Case 13
Disease: Alzheimer’s Disease; Case 24 Chronic Acute Pancreatitis; Case 19 Acute Kidney Injury;
Obstructive Pulmonary Disease Case 22 Young Adult Traumatic Brain Injury; Case
24 Chronic Obstructive Pulmonary Disease; Case
Pediatrics: Case 1 Pediatric Weight Manage- 25 Metabolic Stress and Trauma: Gunshot Wound;
ment; Case 9 Celiac Disease; Case 14 Pediatric Case 26 Sepsis and Morbid Obesity; Case 28 Tongue
Type 1 Diabetes Mellitus; Case 23 Pediatric Cancer Treated with Surgery, Radiation, and Chemo-
Cerebral Palsy therapy; Case 29 Colorectal Cancer
INTRODUCING CASE STUDIES, OR FINDING
YOUR WAY THROUGH A CASE STUDY
Have you ever put together a jigsaw puzzle or taught ●● Chief complaint
a young child how to complete a puzzle? ●● Patient and family history
Almost everyone has at one time or another. ●● Lifestyle risk factors
Recall the steps that are necessary to build a puzzle.
You gather together the straight edges, identify the 4. Review the medical record.
corner pieces, and match the like colors. There is a
●● Examine the patient’s vital statistics and
method and a procedure to follow that, when used demographic information (e.g., age, education,
persistently, leads to the completion of the puzzle. marital status, religion, ethnicity).
Finding your way through a case study is much
●● Read the patient history (remember, this is the
like assembling a jigsaw puzzle. Each piece of the patient’s subjective information).
case study tells a portion of the story. As a student, 5. Use the information provided in the physical
your job is to put together the pieces of the puzzle to examination.
learn about a particular diagnosis, its pathophysiol- ●● Familiarize yourself with the normal values
ogy, and the subsequent medical and nutritional found in Appendix B.
treatment. Although each case in the text is different, ●● Make a list of those things that are abnormal.
the approach to working with the cases remains the ●● Now compare abnormal values to the patho-
same, and with practice, each case study and each physiology of the admitting diagnosis. Which
medical record becomes easier to manage. The fol- are consistent? Which are inconsistent?
lowing steps provide guidance for working with each
case study. 6. Evaluate the nutrition history.
●● Note appetite and general descriptions.
1. Identify the major parts of the case study. ●● Evaluate the patient’s dietary history: calculate
●● Admitting history and physical average kcal and protein intakes and compare
●● Documentation of MD orders, nursing to population standards and recommendations
assessment, and results from other care such as the USDA Food Patterns.
providers ●● Is there any information regarding physical
●● Laboratory data activity?
●● Bibliography ●● Find anthropometric information.
2. Read the case carefully. ●● Is the patient responsible for food
●● Get a general sense of why the person has been preparation?
admitted to the hospital.
●● Is the patient taking a vitamin or mineral
●● Use a medical dictionary to become acquainted supplement?
with unfamiliar terms. 7. Review the laboratory values.
●● Use the list of medical abbreviations provided ●● Hematology
in Appendix A to define any that are unfamiliar ●● Chemistry
to you. ●● What other reports are present?
3. Examine the admitting history and physical for ●● Compare the values to the normal values
clues. listed. Which are abnormal? Highlight those
●● Height, Weight and then compare to the pathophysiology.
●● Vital signs (compare to normal values for
Are they consistent with the diagnosis? Do
physical examination in Appendix B) they support the diagnosis? Why?
xv
xvi Introducing Case Studies, or Finding Your Way through a Case Study
8. Use your resources. not-for-profit organizations, and other

●● Use the bibliography provided for each case. legitimate sites. A list of reliable online
●● Review your nutrition textbooks. evidence-based resources is provided for
●● Access online resources but choose your each case.
sources wisely: stick to government,
ACKNOWLEDGMENTS
We would like to thank the following Ohio State CNSC; and Emily Hill, MS, RDN, LD. We have
University graduate student in medical dietetics who continued to build upon cases from our previous
provided input to the cases and the answer guide: contributors to this text: Georgiana Sergakis, PhD,
Hannah Huffman, MS, RDN, LD. We also have sev- RRT, RCP; Dawn Scheiderer, RDN, LD; Dena
eral contributors to new cases, and we are fortunate Champion, MS, RD, CSO; and Colleen Spees, PhD,
to benefit from the expertise of these outstanding RDN, LD, FAND.
clinicians: Holly Estes Doetsch, MS, RDN, LD,
xvii
ABOUT THE AUTHORS
Marcia Nahikian-Nelms, PhD, RDN, LD, FAND
Dr. Marcia Nahikian-Nelms is currently a professor of clinical health and rehabilitation sciences and the Direc-
tor of Academic Affairs in the School of Health and Rehabilitation Sciences and the Director of Education for
Faculty Advancement, Mentoring and Engagement—College of Medicine at The Ohio State University. She
has practiced as a dietitian and public health nutritionist for over 35 years. She is the lead author for several
textbooks and the author of peer-reviewed journal articles and chapters for other texts.
Her clinical expertise focuses on development and practice of evidence-based nutrition therapy for both
pediatric and adult populations as well as the development of alternative teaching environments for students
within their clinical training.
Dr. Nahikian-Nelms serves as one of the faculty leads for Interprofessional Education (IPE) and has con-
tributed to the design of multiple simulations and IPE experiences within the seven health science colleges at
The Ohio State University. She has received the Ohio State University Alumni Award for Distinguished Teach-
ing, the Governor’s Award for Outstanding Teaching for the State of Missouri, Outstanding Dietetic Educator
in Missouri and Ohio, Outstanding Teacher in Health and Rehabilitation Sciences, and received the PRIDE
award from Southeast Missouri State University in recognition of her teaching.
Kristen Roberts, PhD, RDN, LD, CNSC

Dr. Kristen Roberts is currently an assistant professor of clinical health and rehabilitation sciences and lead for
medical nutrition therapy and clinical nutrition content for the Future Education Model Program. She serves
as nutrition faculty in the Division of Gastroenterology, Hepatology, and Nutrition in the College of Medicine
at The Ohio State University. She has practiced as an RDN for over 15 years and has contributed several peer-
reviewed journal articles and chapters for other texts focused on gastrointestinal nutrition, critical care, and
specialized nutrition support. She is the co-editor for the text Short Bowel Syndrome: Nutritional, Surgical and
Medical Management. Additionally, she has contributed to the Academy of Nutrition and Dietetics Evidence
Analysis Library sections on celiac disease, and has served on various committees within the American Society
for Parenteral and Enteral Nutrition. Dr. Roberts has received the Dietitians in Nutrition Support Distinguished
Practice Award through the Academy of Nutrition and Dietetics.
xix
Unit One
ENERGY BALANCE AND BODY WEIGHT
Case 1 introduces nutrition therapy for treatment of surgery as a treatment method for weight control.
disorders of weight balance and draws our attention This case directs the student to research the surgical
to these major public health concerns in the United options used for bariatric surgery in order to begin to
States. The first case addresses pediatric obesity and understand the progression of nutrition therapy used
can be used as a springboard for a discussion of the and identify potential nutritional complications that
implications of the rapidly rising rate of childhood may occur post-operatively.
obesity. The incidence of childhood obesity has more Case 3 explores the diagnosis of malnutrition. As
than tripled over the past three decades with an es- early as 1979, Charles Butterworth attempted to raise
timated 13.7 million children and adolescents in the awareness of the increasing incidence of malnutrition
United States meeting the criteria for overweight and in the U.S. health care system with his classic article,
obesity. The child featured in Case 1 is representative “The Skeleton in the Hospital Closet.” Unfortunately,
of children ages 6–11. The obesity rate for children the rate of malnutrition is still considered to be
and adolescents aged 2–19 years is approximately significant today—and is associated with increased
18.5%. Pediatric obesity treatment requires complex hospital costs, increased morbidity and mortality, and
interventions to address family, environmental, and decreased quality of life for these individuals. Defi-
economic concerns. This case allows the student to nitions of malnutrition have been proposed by the
explore the current research and the use of evidence- Academy of Nutrition and Dietetics (AND) and the
based guidelines to determine appropriate medical American Society for Parenteral and Enteral Nutrition
nutrition therapy. (ASPEN) in an effort to consistently identify those
Case 2 uses the record of a bariatric surgery individuals who are at risk for malnutrition and who
patient as an opportunity to learn about morbid are malnourished, so that expedient interventions
obesity and the potential nutritional complications may occur. This case uses the most recent literature
of bariatric surgery. Approximately 7.7% of the U.S. to provide the opportunity to assess, diagnose, and
population are considered to be morbidly obese, also develop a treatment plan for malnutrition in an older
referred to as Class III obesity or a body mass index adult. Inclusion of the nutrition-focused physical
(BMI) ≥40.0. Health consequences of untreated exam (NFPE) and a description of usual intake will
morbid obesity include type 2 diabetes mellitus, cor- allow the student to recognize and apply the diagnos-
onary heart disease and hypertension, cancer, sleep tic criteria practice of malnutrition using ASPEN/
apnea, and premature death. According to the 2013 AND guidelines. The minicase found in Appendix E
American Society for Metabolic & Bariatric Surgery, emphasizes the use of the NFPE while allowing the
American Association of Clinical Endocrinologists, instructor to create a quick, hands-on experience in
and The Obesity Society consensus guidelines, those the classroom. Cranial nerve assessment adds a new
individuals with a BMI ≥40.0 or ≥35.0 and who aspect to the NFPE to foster discussion and enhance
meet the medical criteria may consider bariatric RDN assessment skills.
Case 1
Pediatric Weight Management
Jamey Whitmer is taken to see her pediatrician by her parents, who have noticed she appears to stop
breathing while sleeping. She is diagnosed with sleep apnea related to her weight and referred to the
registered dietitian nutritionist (RDN) for nutrition counseling.
Objectives
After completing this case, the student will be 4. Determine nutrition diagnoses and write
able to: appropriate PES statements.
1. Describe the physiological effects of over- 5. Prescribe appropriate medical nutrition
weight/obesity in the pediatric population. therapy.
2. Interpret laboratory parameters for nutri- 6. Develop a nutrition care plan with appro-
tional implications and significance. priate measurable goals, interventions, and
3. Analyze nutrition assessment data to evalu- strategies for monitoring and evaluation
ate nutritional status and identify specific consistent with the nutrition diagnoses of
nutrition problems. this case.
4 Unit One Energy Balance and Body Weight
Whitmer, Jamey, Female, 10 y.o.

Allergies: No known allergies Code: FULL Isolation: None
Pt. Location: University Clinic Physician: Lambert, S. David Appointment Date: 9/22
iStock.com/IPGGutenbergUKLtd Patient Summary: 10-year-old female is here with parents, who describe con-
cerns that their daughter appears to stop breathing while she is sleeping.
History:
Onset of disease: Parents describe sleep disturbance in their daughter for
the past several years, including: sleeping with her mouth open, cessation
of breathing for at least 10 seconds (per episode), snoring, restlessness during sleep, enuresis,
and morning headaches. They also mention that Jamey’s teacher reports difficulty concentrat-
ing in school and a change in her classroom performance. She is the second child born to these
parents—full-term infant with birthweight of 10 lbs 5 oz; 23" length. Actual date of onset for
current medical problems is unclear, but parents first noticed onset of the above-mentioned
symptoms about one year ago.
Medical history: None
Surgical history: None
Family history: What? Possible gestational diabetes; type 2 DM; Who? Mother and grandmother
Demographics:
Years education: Third grade
Language: English only
Occupation: Student
Household members: Father age 36, mother age 35, sister age 5
Ethnicity: Caucasian
Religious affiliation: Presbyterian
MD Progress Note:
General/Constitutional: Well-developed, well-nourished, somewhat tired and irritable.
HEENT: Head: normocephalic and atraumatic
Eyes: anicteric sclera, noninjected conjunctiva
Mouth: oral mucosa pink, dentition in good repair
Throat: pharynx pink without exudates. Tonsillar hypertrophy.
Neck: soft, supple, no palpable masses. No lymphadenopathy.
Cardiac: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.
Pulmonary/Chest: Lungs are clear to auscultation bilaterally.
Abdominal: Abdomen soft, nontender, with normoactive bowel sounds in all four quadrants.
No masses, no organomegaly. No guarding, rebound, or CVA tenderness.
Extremities: Normal range of motion in all four extremities. No cyanosis or clubbing or peripheral
edema. Occasional c/o of nonspecific knee pain.
Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and
symmetrically. No focal neurologic deficit.
Case 1 Pediatric Weight Management 5

Skin: Skin is warm and dry. Patient is not diaphoretic. Rash in skinfolds. No noted ulcerations.
Vital Signs: Temp: 98.5°F Pulse: 85 Resp rate: 27

BP: 123/80 Height: 57" Weight: 115 lbs BMI: 24.9
Assessment and Plan:

10-y.o. female here with parents c/o of breathing difficulty at night. Child has steadily gained weight
over previous several years: >10 lbs per year.
Dx: R/O obstructive sleep apnea (OSA) secondary to obesity and physical inactivity.
Medical Tx plan: Polysomnography to diagnose OSA, FBG, HbA1C, lipid panel (total cholesterol,
HDL-C, LDL-C, triglycerides), psychological evaluation, and nutrition assessment.
SD Lambert, MD
Nutrition:
General: Very good appetite with consumption of a wide variety of foods. Jamey’s physical activity
level appears to be minimal. Her elementary school discontinued physical education, art, and music
classes due to budget cuts five years ago. She likes playing video games and reading. Mother is
5'2" and weighs 225 lbs. Father is 5'10" and weighs 185 lbs. Sister has a weight/height at 85%tile
with BMI at 75%tile.
24-hour recall:
AM: 2 breakfast burritos, 8 oz whole milk, 4 oz apple juice, 6 oz coffee with
¼ c cream and 2 tsp sugar
Lunch: 2 ham and cheese sandwiches with 1 tbsp mayonnaise each, 1-oz pkg Fritos
corn chips, 5–6 Oreos, 8 oz whole milk
After-school snack: Peanut butter and jelly sandwich (2 slices enriched bread with 2 T. crunchy
peanut butter and 2 tbsp grape jelly), 12 oz whole milk
Dinner: Fried chicken (2 legs and 1 thigh), 1 c mashed potatoes (made with whole
milk and butter), 1 c fried okra, 20 oz sweet tea
Snack: 3 c microwave popcorn, 12 oz Coca-Cola
Food allergies/intolerances/aversions: NKA

Previous nutrition therapy? No
Food purchase/preparation: Parent(s)
Vitamin intake: Flintstones vitamin daily

Laboratory Results (Pediatric)

Ref. Range 9/22
Chemistry
Sodium, 10–14 yo (mEq/L) 136–145 142
Potassium, 10–14 yo (mEq/L) 3.5–5.0 4.3
Chloride, 10–14 yo (mEq/L) 98–108 101
Carbon dioxide, 10–14 yo (mEq/L) 22–30 25
BUN, 10–14 yo (mg/dL) 5–18 8
Creatinine serum, 10–14 yo (mg/dL) ≤1.2 0.6
Uric acid, 10–14 yo (mg/dL) 2.5–5.5 3.1
Glucose, 10–14 yo (mg/dL) 70–99 112 !
Phosphate, inorganic, 10–14 yo (mg/dL) 2.2–4.6 3.1
Magnesium, 10–14 yo (mg/dL) 1.6–2.6 1.7
Calcium, 10–14 yo (mg/dL) 8.6–10.5 9.1
Osmolality, 10–14 yo (mmol/kg/H2O) 275–295 302 !
Bilirubin total, 10–14 yo (mg/dL) ≤1.2 0.9
Bilirubin, direct, 10–14 yo (mg/dL) <0.3 0.2
Protein, total, 10–14 yo (g/dL) 6–7.8 6.5
Albumin, 10–14 yo (g/dL) 3.5–5 4.8
Prealbumin, 10–14 yo (mg/dL) 17–39 33
Cholesterol, 10–14 yo (mg/dL) <170 165
HDL-C, 10–14 yo (mg/dL) .45 34 !
VLDL, 10–14 yo (mg/dL) calculated 13
LDL, 10–14 yo (mg/dL) <110 118 !
LDL/HDL ratio, 10–14 yo <3 9.07
Triglycerides, 10–14 yo (mg/dL) <90 65
T4, 10–14 yo (µg/dL) 5.6–11.7 6.1
T3, 10–14 yo (µg/dL) 83–213 79 !
HbA1C, 10–14 yo (%) 3.9–5.2 4.5
Hematology
WBC, 10–14 yo (×103/mm3) 4.0–13.5 4.1
Hemoglobin, 10–14 yo (Hgb, g/dL) 11–16 13.1
Hematocrit, 10–14 yo (Hct, %) 31–43 38
Case Questions
I. Understanding the Disease and Pathophysiology
1. Current research indicates that the cause of childhood obesity is multifactorial. Briefly
outline how genetics, environment, and nutritional intake might contribute to the develop-
ment of obesity in children. Include at least three specific factors in each of the previously
mentioned categories.
2. Describe one health consequence for obese children affecting each of the following physi-
ological systems: cardiovascular, orthopedic, pulmonary, gastrointestinal, and endocrine.
3. How does Jamey’s current weight status affect her risk of developing adulthood obesity?
4. Jamey has been diagnosed with obstructive sleep apnea. What is obstructive sleep apnea?
Explain the relationship between sleep apnea and obesity.
II. Understanding the Nutrition Therapy

5. In general, what are the goals for weight loss in the pediatric population? Are there con-
cerns to consider when developing recommendations for an overweight child who is still
growing?
6. List four recommendations that might serve as goals for the nutritional treatment of
Jamey’s obesity.
III. Nutrition Assessment

7. Assess Jamey’s weight using the CDC growth charts provided (p. 8): What is Jamey’s BMI
percentile? How is her weight status classified? Use the growth chart to determine Jamey’s
optimal weight for her height and age.
8. Identify two methods for determining Jamey’s energy requirements other than indirect
calorimetry, and then use them to calculate Jamey’s energy requirements. What calorie goal
would you use to facilitate weight loss?
Stature-for-Age and Weight-for-Age Percentiles: Girls, 2 to 20 Years

12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in
Date Age Weight Stature BMI*
AGE (YEARS) 76
190
74
185 S
72
180 T
70 A
97 175 T
90
68 U
170 R
75 66
165 E
in cm 3 4 5 6 7 8 9 10 11 50
64
160 25 160
62 62
155 10 155
S 60 60
T 3
150 150
A 58
T 145
U 56
140 105 230
R
54
E 135 100 220
52
130 95 210
50
125 97 90 200
48 190
120 85
46 180
115 80
44 170
110 90 75
42 160
105 70
150 W
40
100 75 65 140 E
38 I
95 60 130 G
50
36 90 H
55 120
25 T
34 85 50 110
10
32 80 3 45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Source: Centers for Disease Control and Prevention
9. Dietary factors associated with increased risk of overweight include increased dietary fat
intake and increased calorie-dense beverages. Identify foods from Jamey’s 24-hour recall
that fit these criteria.
10. Calculate the percent of kcal from each macronutrient and the percent of kcal provided by
fluids for Jamey’s diet recall.
11. Increased fruit and vegetable intake is associated with decreased risk of overweight. What
foods in Jamey’s diet fall into these categories?
12. Use the U.S. Dietary Guidelines to generate a customized daily food plan to plan a 1-day
menu for Jamey.
13. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid and glucose
levels are considered altered (i.e., outside of normal limits) for the pediatric population?
Evaluate Jamey’s lab results.
IV. Nutrition Diagnosis

14. Select two nutrition problems and complete the PES statement for each.
V. Nutrition Intervention
15. Which behaviors associated with increased risk of overweight would you look for when as-
sessing Jamey and her family’s diets? What aspects of Jamey’s lifestyle place her at increased
risk for overweight?
16. You talk with Jamey and her parents, who are friendly and cooperative. Jamey’s mother
asks if it would help for them to not let Jamey snack between meals and to reward her with
dessert when she exercises. What would you tell the family regarding snacks between meals
and rewards with dessert after exercise?
17. Identify one specific physical activity recommendation for Jamey.
18. For each PES statement written, establish an ideal goal (based on signs and symptoms) and
an appropriate intervention (based on etiology).
19. Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey. Based on the Endocrine
Society Practice Guideline, what are the recommendations regarding gastric bypass surgery
for the pediatric population?
VI. Nutrition Monitoring and Evaluation

20. What is the optimal length of weight management therapy for Jamey?
21. Should her parents be included? Why or why not?
22. What would you assess during a follow-up counseling session? When should this occur?
Bibliography Pediatric Weight Management (PWM): Major Recom-

mendations (2015). Academy of Nutrition and
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Baylor College of Medicine Children’s Nutrition /childhood/index.html
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/pediatrics/sections-divisions-centers/childrens
-nutrition-research-center/
Case 2
Bariatric Surgery
Mrs. Turner is admitted for a Roux-en-Y gastric bypass surgery. She has co-morbidities of T2DM,
hyperlipidemia, hypertension, and osteoarthritis. Mrs. Turner has weighed over 250 lbs since age 15,
with steady weight gain since that time. She has attempted to lose weight numerous times but the
most weight she ever lost was 75 lbs, which she regained over a two-year period. She had recently
reached her highest weight of 434 lbs, but since beginning the preoperative nutrition education
program she has lost 24 lbs.
Objectives
After completing this case, the student will be 5. Interpret nutrition assessment data to assist
able to: with the design of measurable goals, inter-
1. Identify criteria that allow an individual to ventions, and strategies for monitoring and
qualify as a candidate for bariatric surgery. evaluation that address the nutrition diag-
2. Research and outline the health risks associ- noses for the patient.
ated with morbid obesity. 6. Understand current nutrition therapy
3. Identify the current surgical procedures guidelines for progression of oral intake
used for bariatric surgery. after bariatric surgery.
4. Describe the potential physiological changes 7. Demonstrate ability to assess for micronu-
and nutrition problems that may occur after trient deficiencies with recommendations
bariatric surgery. for treatment.
13
Turner, Bethany Female, 37 y.o.

Allergies: NKA Code: FULL Isolation: None
Pt. Location: RM 703 Physician: P. Walker Admit Date: 2/23
Patient Summary: Patient is a morbidly obese 37-year-old African American

female who is admitted for Roux-en-Y gastric bypass surgery scheduled for 2/24.
iStock.com/drbimages
Patient has been obese her entire adult life, with highest weight six months ago
at 434 lbs. She has lost 24 lbs while attending the preoperative nutrition pro-
gram at our clinic.
History:
Onset of disease: Lifelong obesity
Medical history: T2DM, hypertension, hyperlipidemia, osteoarthritis
Surgical history: R total knee replacement 3 years previous
Medications at home: Metformin 1000 mg/twice daily; 35 u glargine pm; furosemide 25 mg/day;
Lovastatin 60 mg/day
Tobacco use: None
Alcohol use: Socially, 2–3 glasses of wine per week
Family history: Father: T2DM, CAD, Htn, COPD; Mother: T2DM, CAD, osteoporosis
Demographics:
Marital status: Married
Number of children: 0
Years education: Bachelor’s degree
Language: English only
Occupation: Office manager for real estate office
Hours of work: 8–5 daily, sometimes on weekend
Household members: Lives with husband
Ethnicity: African American
Religious affiliation: Christian-African Methodist Episcopal Church
Admitting History/Physical:
Chief complaint: “I am here for weight-loss surgery.”
General/Constitutional: Well-developed, well-nourished obese female, no acute distress.
HEENT: Head: normocephalic and atraumatic
Eyes: anicteric sclera, noninjected conjunctiva
Mouth: oral mucosa pink, dentition in good repair
Throat: pharynx pink without exudates
Neck: soft, supple, no palpable masses. No lymphadenopathy.
Cardiac: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. Diminished
distal pulses.
Pulmonary/Chest: Lungs are clear to auscultation bilaterally.
Abdominal: Abdomen soft, nontender, with normoactive bowel sounds in all four quadrants.
No masses, no organomegaly. No guarding, rebound, or CVA tenderness.
Extremities: Normal range of motion in all four extremities. No cyanosis or clubbing. Ecchymosis,
abrasions, and pinpoint petechiae present, 2+ pitting edema.
Case 2 Bariatric Surgery 15

Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and
symmetrically. No focal neurologic deficit.
Skin: Skin is warm and dry. Patient is not diaphoretic.
Vital Signs: Temp: 98.9°F Pulse: 85 Resp rate: 23

BP: 135/90 Height: 5'8" Weight: 410 lbs
Nursing Assessment 2/23

Abdominal appearance (concave, flat, rounded, obese, distended) obese
Palpation of abdomen (soft, rigid, firm, masses, tense) soft
Bowel function (continent, incontinent, flatulence, no stool) continent
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color lt brown
Stool consistency formed
Tubes/ostomies NA
Genitourinary
Urinary continence yes
Urine source clean catch
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, clear, yellow
blue, tea)
Integumentary
Skin color WNL
Skin temperature (DI=diaphoretic, W=warm, dry, CL=cool, CLM=clammy, W
CD+=cold, M=moist, H=hot)
Skin turgor (good, fair, poor, TENT=tenting) good
Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae, EC, A, R
R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears,
SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis)
Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae, intact
R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears,
SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis)
Other components of Braden score: special bed, sensory pressure, 15
moisture, activity, friction/shear (>18=no risk, 15–16=low risk,
13–14=moderate risk, ≤12=high risk)

Orders:
Vital signs, Routine, Every 4 hours
CBC with differential, comprehensive metabolic profile; PT/PTT; EKG; Urinalysis
NPO after midnight
Nutrition:
Meal type: NPO
Intake % of meals: NPO
Fluid requirement: 1800–2000 mL
MD Progress Note:
2/24
Subjective: Bethany Turner’s previous 24 hours reviewed
Vitals: Temp: 98.9°F Pulse: 78 Resp rate: 24 BP: 115/70

Urine output: 2230 mL POC Glu: 145
Physical Exam
HEENT: WNL
Neck: WNL
Heart: WNL
Lungs: Clear to auscultation
Abdomen: Obese, soft, some epigastric tenderness +BS × 4
Assessment/Plan:
POD#1 s/p Roux-en-Y gastric surgery—now with positive bowel sounds. Will progress to Stage 1
Bariatric Surgery Diet. If tolerated, discharge to home after nutrition consult. Schedule for postop-
erative visit in one week.
P. Walker, MD

Intake/Output 410 5 186.3636

Date 2/23 0701–2/24 0700
Time 0701–1500 1501–2300 2301–0700 Daily total
IN P.O. 0 60 100 160
I.V. 680 680 680 2040
(mL/kg/hr) (0.45) (0.45) (0.45) (0.45)
I.V. piggyback 0 0 0 0
TPN 0 0 0 0
Total intake 680 740 780 2200
(mL/kg) (3.6) (3.9) (4.2) (11.8)
OUT Urine 700 710 820 2230
(mL/kg/hr) (0.47) (0.47) (0.55) (0.50)
Emesis output 0 0 0 0
Other 0 0 0 0
Stool 0 0 0 0
Total output 700 710 820 2230
(mL/kg) (3.7) (3.8) (4.4) (12.0)
Net I/O 220 130 240 230
Net since admission (2/23) 220 110 230 230

Laboratory Results
Six months
Ref. Range 2/23 1522 post-op
Chemistry
Sodium (mEq/L) 136–145 138 139
Potassium (mEq/L) 3.5–5.1 5.0 4.8
Chloride (mEq/L) 98–107 99 101
Carbon dioxide (mEq/L) 23–29 27 25
BUN (mg/dL) 6–20 15 16
Creatinine serum (mg/dL) 0.6–1.1 F 0.9 0.8
0.9–1.3 M
BUN/Crea ratio 10.0–20.0 16.7:1 20:1
Uric acid (mg/dL) 2.8–8.8 F 5.2 5.3
4.0–9.0 M
Est GFR, non-Afr Amer >60 95
(mL/min/1.73 m2)
Glucose (mg/dL) 70–99 145 101
Phosphate, inorganic (mg/dL) 2.2–4.6 3.9 3.1
Magnesium (mg/dL) 1.5–2.4 2.0 1.9
Calcium (mg/dL) 8.6–10.2 9.5 9.2
Osmolality (mmol/kg/H2O) 275–295 289 293
Bilirubin total (mg/dL) ≤1.2 0.8
Bilirubin, direct (mg/dL) <0.3 0.07
Protein, total (g/dL) 6–7.8 6.8
Albumin (g/dL) 3.5–5.5 4.2
Prealbumin (mg/dL) 18–35 22
Ammonia (µmol/L) 6–47 11
Alkaline phosphatase (U/L) 30–120 118
ALT (U/L) 4–36 21
AST (U/L) 0–35 10
CPK (U/L) 30–135 F 220 !
55–170 M
Lactate dehydrogenase (U/L) 208–378 276
Cholesterol (mg/dL) <200 320 ! 210
HDL-C (mg/dL) >50 F, >40 M 32 ! 45 !
VLDL (mg/dL) 7–32 45 !

Laboratory Results (Continued)

Six months
LDL (mg/dL) 0–99 232 ! 135
LDL/HDL ratio <4.5 7.5 ! 3.0
Triglycerides (mg/dL) <150 245 ! 150
T4 (µg/dL) 5–12 6.1
T3 (µg/dL) 75–98 82
HbA1C (%) <5.7 7.2 ! 6.1
Coagulation (Coag)
PT (sec) 11–13 12
INR 0.9–1.1 0.95
PTT (sec) 24–34 26
Hematology
WBC (×103/mm3) 3.9–10.7 10.2
RBC (×106/mm3) 4.2–5.4 F 5.5
4.5–6.2 M
Hemoglobin (Hgb, g/dL) 12–16 F 12.5 10.5
14–17 M
Hematocrit (Hct, %) 37–47 F 38 35
41–51 M
Mean cell volume (µm3) 80–96 82
Mean cell Hgb (pg) 28–32 29
Mean cell Hgb content (g/dL) 32–36 33
RBC distribution (%) 11.6–16.5 12.3
Platelet count (×103/mm3) 150–350 261
Transferrin (mg/dL) 250–380 F 279 395
215–365 M
Ferritin (mg/mL) 20–120 F 76 19
20–300 M
Iron (µg/dL) 65–165 F 110
75–175 M
Total iron binding capacity (µg/dL) 240–460 269
(Continued)

Laboratory Results (Continued)

Six months
Iron saturation (%) 15–50 F 15
10–50 M
Vitamin B12 (ng/dL) 200–900 450 150 !
Methylmalonic acid (nmol/mL) <0.4 0.2 0.7 !
Folate (ng/dL) 5–25 15 13
25(OH) Vitamin D (ng/mL) 30-100 34 11 !
PTH (pg/mL) 10-65 44 82 !
Urinalysis
Collection method --- clean
catch
Color --- yellow
Appearance --- clear
Specific gravity 1.001–1.035 1.004
pH 5–7 6.1
Protein (mg/dL) Neg Neg
Glucose (mg/dL) Neg Neg
Ketones Neg Neg
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.0 0
Leukocyte esterase Neg Neg
Prot chk Neg Neg
WBCs (/HPF) 0–5 0
RBCs (/HPF) 0–2 0
Bact 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0
Note: Values and units of measurement listed in these tables are derived from several resources.
Substantial variation exists in the ranges quoted as “normal,” and these may vary depending on the
assay used by different laboratories.
Case Questions
I. Understanding the Diagnosis and Pathophysiology
1. Define the BMI criteria for the classification of obesity. What BMI is associated with mor-
bid obesity?
2. List 10 health risks involved with untreated morbid obesity. What health risks does Mrs.
Turner present?
3. What are the standard adult criteria for consideration as a candidate for bariatric surgery?
After reading Mrs. Turner’s medical record, determine the criteria that support her qualifi-
cations for surgery.
4. By conducting an Internet search or literature review, find one example of a bariatric sur-
gery program. Describe the information that is provided for the patient regarding qualifi-
cation for surgery. Outline the personnel involved in the evaluation and care of the patient
in this particular program.
5. Describe the following surgical procedures used for bariatric surgery, including advan-
tages, disadvantages, and potential complications.
a. Roux-en-Y gastric bypass
b. Vertical sleeve gastrectomy
c. Adjustable gastric banding (Lap-Band®)
d. Vertical banded gastroplasty
e. Duodenal switch
f. Biliopancreatic diversion
6. Mrs. Turner has had type 2 diabetes for several years. Her physician shared with her that
after surgery she will not be on any medications for her diabetes and that she may be able
to stop her medications for diabetes altogether. Describe the proposed effect of bariatric
surgery on the pathophysiology of T2DM. What, if any, other medical conditions might be
affected by weight loss?
7. Mrs. Turner’s surgical team uses an enhanced recovery after surgery (ERAS) protocol for
their bariatric surgery patients. What is this and how might this impact Mrs. Turner’s
postoperative recovery?
II. Understanding the Nutrition Therapy

8. How does the Roux-en-Y procedure affect digestion and absorption? Do other surgical
procedures discussed in question #5 have similar effects?
9. On post-op day one, Mrs. Turner was advanced to the Stage 1 Bariatric Surgery Diet. This
consists of water, sugar-free beverages, diluted fruit juices, chicken or beef broth, and
sugar-free gelatin. Instructions are to drink 1-oz portions over 30-minute periods. What is
the rationale for avoiding sugared beverages and limiting the portion sizes?
10. Over the next two months, Mrs. Turner will be progressed to a pureed-consistency diet
with 6–8 small meals. Describe the major goals of this diet for the Roux-en-Y patient. How
might the nutrition guidelines differ if Mrs. Turner had undergone a Lap-Band® procedure?
11. Mrs. Turner’s RD has discussed the importance of hydration, protein intake, and
intakes of vitamins and minerals, especially calcium, vitamin D, iron, and B12. For
each of these nutrients, describe why a deficiency may occur and explain the potential
complications that could result from deficiency. Are there other potential risks for
micronutrient deficiency?
12. Metabolic bone disease has been noted as a long-term complication following bariatric
surgery. Why? How would this be assessed? How can it be prevented?
III. Nutrition Assessment

13. Assess Mrs. Turner’s height and weight. Calculate her BMI and % usual body weight. What
would be a reasonable weight goal for Mrs. Turner? Give your rationale for the method you
used to determine this goal weight.
14. After reading the physician’s history and physical, identify any signs or symptoms that are
most likely a consequence of Mrs. Turner’s morbid obesity.
15. Identify any abnormal biochemical indices and discuss the probable underlying etiology.
How might they change after weight loss?
16. Mrs. Turner’s serum vitamin D level was low post-operatively. What is the potential
etiology for this deficiency? What would be the recommended treatment post-operatively?
17. Determine Mrs. Turner’s energy and protein requirements to promote weight loss. Explain
the rationale for the method you used to calculate these requirements.
IV. Nutrition Diagnosis

18. Select two nutrition problems and complete the PES statement for each.
V. Nutrition Intervention
19. Determine the appropriate progression of Mrs. Turner’s post–bariatric-surgery diet.
Include recommendations for any supplementation that should be prescribed.
20. Describe any pertinent lifestyle changes that you would view as a priority for Mrs. Turner.
21. How would you assess Mrs. Turner’s readiness for a physical activity plan? How does
exercise assist in weight loss after bariatric surgery?
Another random document with
no related content on Scribd:
“Prettiness, as I understand it, is a quality of the personal
appearance which gives to the beholder a pleasurable sensation.”
“Something of the sort.”
“Ah.... Then, what causes it? It is intangible. Let us examine concrete
examples. Let us stand side by side Mary Jenkins, who is said to
possess this quality, and—shall we say?—Mrs. Bogardus, who is
reputed not to possess it. Why is one pretty and the other quite the
opposite of pretty?” He shook his head. “I confess I had never
become consciously aware of this difference between women....”
“What?”
He opened his eyes in mild surprise at the force of her exclamation.
“As a matter of fact,” he said, patiently, “I do not recall taking special
notice of any individual woman.... As to this matter of prettiness—
what constitutes it? What assembling of features and contours
create a pleasant sensation in the beholder, and why?... Perhaps
you noted how I have been scrutinizing you this morning?”
“I most certainly did.”
“Um!... It was for the purpose of determining if your appearance
aroused pleasant sensations in myself.”
“And did it?”
He wrinked his eyes behind his glasses and pushed stiff fingers
through his hair. “It is difficult to determine with accuracy, or to state
in terms the degree of pleasure derived, but I am almost certain that
I derive a mild satisfaction from regarding you.”
“I—I am overwhelmed,” said Carmel, and with abruptness she
passed through the wicket and out into the composing room, where
she sat down in Tubal’s rope-bottomed chair, breathless with
laughter.
“Oh, Tubal,” she said, “what sort of creature is he anyhow?”
“The Prof.?”
She nodded weakly.
“H’m.... The Prof.’s a kind of cabbage that never headed up,” said
Tubal, with finality. “He’s got all the roots and leaves, like that kind of
a cabbage, and, sim’lar, he hain’t no idee how to fold ’em up, or why
he’s a cabbage, nor that cabbages is the chief ingredient of
sauerkraut.”
“Yes,” said Carmel, “that’s it.” And for a long time after that she
continued to think of Evan Pell as a cabbage which had grown to
maturity without fulfilling a cabbage’s chief object in life, which is to
head. “Only,” she said, “he’s really just the opposite. He’s never done
anything but come to head. He’s comatose from his eyebrows to his
toes.”
The second issue of the Free Press had brought faint
encouragement. There had been a slight increase in advertising, due
to Carmel’s solicitations, but her pleasure in this growth was
somewhat dimmed by a guilty feeling that it was not due to any merit
of the paper, or of her solicitations, but to a sort of rudimentary
gallantry on the part of a few merchants.... Perhaps half a dozen
men had lounged in to subscribe, investing a dollar and a half in
curiosity.... But, to put the worst face on it, she had held her own.
She really felt she had improved the paper. The columns of
personals, which had been intrusted to Evan Pell, were full of items.
He had shown an unusual aptitude for observing the minutiæ of the
community. Having observed, he would have reported in the
language of a treatise on sociology, but Carmel referred him to the
files, and admonished him to study the style of the late Uncle Nupley.
This he had done grimly, ironically, and the result was a parrotlike
faithfulness.... He had also read and corrected all the proofs, to the
end that the sensibilities of the community be not offended by
grammatical gaucheries.
He had been offended close to resignation when Carmel insisted
upon running, in inch-tall, wooden type—across the top of the first
page—this query:
WHO IS THE HANDSOMEST MAN IN GIBEON
That was her great idea, born of her interview with Lancelot Bangs.
“If papers run beauty contests for women,” she said, “why not run
handsome contests for men?... Anyhow, it’ll be fun, and I’m entitled
to a little pleasure. Men are vain. It will make talk, and talk is
advertising, and advertising pays.”
Evan inveighed against the scheme as undignified, stultifying, and
belittling to a dignified profession.
“If it brings in subscriptions—and dollars,” said Carmel, “we should
worry!”
Evan closed his eyes in pain. “We should worry!... I beg of you....
That barbaric phrase! The basest argot. Our newspapers should be
the palladium of the purity of the language. If such expressions are
tolerated——” He stopped abruptly because his mind could not
encompass the horrors which would result from their toleration.
“Anyhow, I’m going to do it—and you’ll see. A regular voting.
Coupons and everything. We’ll have a six months’ subscription worth
fifty votes, a year’s subscription worth a hundred votes.”
“But—er—who will they vote for?”
“Just wait,” she said.
Following which she proceeded with enthusiasm. First she printed
the rules of the contest in the Free Press, and then she went to
Tubal.
“I want to stick things up all over the township,” she said, “telling
about it.”
“We got a mess of yaller stock,” he said. “You write it out and I’ll print
it, and we’ll make the Prof. go and paste ’em up.”
So it was done, and on a day Gibeon awoke to find itself placarded
with large yellow notices making it know that the Free Press was in a
fever to discover who was considered the handsomest man in town,
and to read the paper for particulars. Carmel was right—it caused
talk....
In other matters she was feeling her way, and the way was not plain
to her. Of petty news there was aplenty, and this she printed. She
also printed a trifling item about a traveling salesman who had been
“making” the territory for years in a buggy, and who had been
detected in the act of smuggling a few bottles of liquor over the
border in his sample case, thus adding to a meager income.
“There’s your vast liquor traffic,” she said to Evan Pell, “a poor, fat
little drummer with six bottles of whisky.”
“Um!... Who arrested him?”
“Deputy Jenney,” she said.
“There is,” said Evan, “a phrase which I have noted in the public
prints. It is, ‘strangling competition.’”
“What do you mean?”
“Why—er—if you were engaged in a—profitable enterprise, and
some individual—er—encroached, you would abate him, would you
not? That is the ethics of business.”
“Do you infer this drummer was abated as a competitor?”
“Oh, not in the least—not in the least!” He spoke airily, as one who
disposes of a troublesome child.
The incident, small as it was, troubled her. Evan Pell, by his cryptic
utterances, set her thinking.... If her imagination had not tricked her
wholly there was a reticence about Gibeon; there was something
Gibeon hid away from her.... A thing was transpiring which Gibeon
did not wish to be known—at least the powerful in Gibeon.... She
had encountered whisperings and slynesses.... She laughed at
herself. She would be seeing specters presently, she told herself....
But there was the disappearance of Sheriff Churchill. There was the
warning note to herself. There were many petty incidents such as the
one in Lancelot Bangs’s studio. But why connect them with illicit
traffic in intoxicants?... It was absurd to imagine an entire town
debauched by the gainfulness of whisky running.... It were a matter
best left alone.
And so, pursuing her policy of feeling her way, the current issue of
the Free Press was quite innocuous—save for what is known
technically as a “follow-up” on the subject of Sheriff Churchill, and an
editorial in which was pointed out the lethargy of official Gibeon in
assailing the mystery.
As she was leaving the hotel after luncheon that day, she
encountered Abner Fownes making his progress down the street. It
was a slow, majestic progress, and quite impressive. Mr. Fownes
carried himself with an air. He realized his responsibilities as a
personage, and proceeded with the air of a statesman riding in a
victoria through a cheering crowd. He spoke affably and
ostentatiously to everyone, but when he met Carmel face to face, he
paused.
“Um!... A hum!... I have read the paper—read it all.”
“I hope it pleased you.”
“It did not,” said Mr. Fownes.
“Indeed! What fault did you find?”
“You didn’t consult with me.... Told you to consult with me.... Number
of things shouldn’t have been mentioned. Editorial on Churchill—bad
business.... Young woman, you can see past the end of your nose.”
“I hope so.”
“Didn’t I make myself plain?”
“You did.”
“Um!... Hem!... No time for nonsense. After this—want to see every
line goes in that paper.”
“Before it is published?” Carmel was stirred to antagonism, but
forced herself to speak without heat.
“Before it’s published.... I’ll tell you what to print and what not to
print.”
“Oh,” she said, softly, “you will!”
“I own that paper—practically.... I let it live. You’re dependent on me.”
Carmel’s eyes snapped now; she was angry. “I fancied I owned the
Free Press,” she said.
“Just so long as I let you—and I’ll let you as long as you—edit it—er
—conservatively.”
“And conservatively means so long as I print what you want printed,
and omit what you wish omitted?”
“Exactly,” he said. “You’ve kept that schoolteaching fellow after I told
you not to.”
She paused a moment, and then she said, very quietly and slowly, “I
think, Mr. Fownes, that you and I have got to come to an
understanding.”
“Exactly what I’m getting at.”
“Very well, now please listen carefully, and I’m sure you’ll
understand.... At this moment I own the Free Press. Until your
chattel mortgage falls due—and that is two months away—I shall
continue to own it.... During that time I shall edit it as I see fit. I think
that is clear.... I shall ask no advice from you. I shall take no dictation
from you. What I believe should be printed, I shall print.... Good
afternoon, Mr. Fownes.”
She brushed past him and walked rapidly toward the office; Mr.
Fownes stood for a moment frowning; then he turned his round head
upon his shoulders—apparently there was no neck to assist in the
process—and stared after her. It was not an angry stare, nor a
threatening stare. Rather it was appraising. If Carmel could have
studied his face, and especially his eyes, at that moment, she would
have wondered if he were so fatuous as she supposed. She might
even have asked herself if he were really, as certain people in
Gibeon maintained, nothing but a bumptious figurehead, used by
stronger men who worked in his shadow.... There was something in
Abner Fownes’s eyes which was quite worthy of remark; but perhaps
the matter most worthy of consideration was that he manifested no
anger whatever—as a vain man, a little man, bearded as he had
been by a mere girl, might have done....
He peered after her briefly, then, by a series of maneuvers, set his
face again in the direction he had been traveling, and proceeded
magnificently on his way.... Carmel would have been more disturbed,
and differently disturbed, could she have seen into the man’s mind
and read what was passing in its depths. His thoughts had not so
much to do with Carmel as an editor as with Carmel as a woman.
CHAPTER VII
CARMEL entered the office of the Free Press, after her encounter
with Abner Fownes, in a temper which her most lenient friend could
not describe as amiable. It was no small part of Carmel’s charm that
she could be unamiable interestingly. Her tempers were not set
pieces, like the Niagara Falls display at a fireworks celebration. They
did not glow and pour and smoke until the spectators were tired of
them and wanted to see something else. Rather they were like
gorgeous aërial bombs which rent the remote clouds with a
detonation and lighted the heavens with a multitude of colored stars.
Sometimes her choicest tempers were like those progressive bombs
which keep on detonating a half a dozen times and illuminating with
different colored stars after each explosion. This particular temper
was one of her best.
“From now on,” she said to nobody in particular, and not at all for the
purpose of giving information, “this paper is going to be run for one
single purpose. It’s going to do everything that pompous little fat
man, with his ears growing out of his shoulders, doesn’t want it to.
It’s going to hunt for things he doesn’t like. It is going to annoy and
plague and prod him. If a paper like this can make a man like him
uncomfortable, he’ll never know another peaceful moment....”
Evan Pell looked up from his table—over the rims of his spectacles
—and regarded her with interest.
“Indeed!” he said. “And what, if I may ask, has caused this—er—
declaration of policy?”
“He looked at me,” Carmel said, “and he—he wiggled all his chins at
me.”
Tubal thrust his head through the doorway. “What’d he do?” he
demanded, belligerently. “If he done anythin’ a gent shouldn’t do to a
lady I’ll jest ca’mly walk over there and twist three-four of them chins
clean off’n him.”
“I wish you would.... I wish you would.... But you mustn’t.... He gave
me orders. He told me I was to let him read every bit of copy which
went into this paper. He said I must have his O. K. on everything I
print.”
“Ah!” said Evan Pell. “And what did you rejoin?”
“I told him this was my paper, and so long as it was mine, I should do
exactly what I wanted with it, and then I turned my back and walked
away leaving him looking like a dressed-up mushroom—a fatuous
mushroom.”
“A new variety,” said Pell.
“I—I’ll make his life miserable for sixty days anyhow.”
“If,” said Pell, “he permits you to continue for sixty days.”
“I’ll continue, not for sixty days, but for years and years and years—
till I’m an old, gray-headed woman—just to spite him. I’ll make this
paper pay! I’ll show him he can’t threaten me. I’ll——”
“Now, Lady,” said Tubal, “if I was you I’d set down and cool off. If
you’re spoilin’ fer a fight you better go into it level-headed and not
jest jump in flailin’ your arms like a Frenchy cook in a tantrum. Abner
Fownes hain’t no infant to be spanked and put to bed. If you calc’late
to go after his scalp, you better find out how you kin git a grip onto
his hair.”
“And,” said Pell, “how you can prevent his—er—getting a grip on
yours.”
“I don’t believe he’s as big a man as he thinks he is,” said Carmel.
“I have read somewhere—I do not recall the author at the moment—
a word of advice which might apply to this situation. It is to the effect
that one should never underestimate an antagonist.”
“Oh, I shan’t. I’ll cool down presently, and then I’ll be as cold-blooded
and calculating as anybody. But right now I—I want to—stamp on his
pudgy toes.”
The telephone interrupted and Evan Pell put the receiver to his ear.
“... Yes, this is the Free Press.... Please repeat that.... In Boston last
night?... Who saw him? Who is speaking?” Then his face assumed
that blank, exasperated look which nothing can bring in such
perfection as to have the receiver at the other end of the line hung
up in one’s ear. He turned to Carmel.
“The person”—he waggled his thumb toward the instrument—“who
was on the wire says Sheriff Churchill was seen in Boston last
night?”
“Alive?”
“Alive.”
“Who was it? Who saw him?”
“When I asked that—he hung up the receiver in my ear.”
“Do you suppose it is true?”
“Um!... Let us scrutinize the matter in the light of logic—which it is
your custom to ridicule. First, we have an anonymous
communication. Anonymity is always open to suspicion. Second, it is
the newspaper which is informed—not the authorities. Third, it is the
newspaper which has been showing a curiosity as to the sheriff’s
whereabouts—er—contrary to the wishes of certain people....”
“Yes....”
“From these premises I would reason: first, that the anonymous
informer wishes the fact to be made public; second, that he wishes
this paper to believe it; third, that, if the paper does believe it, it will
cease asking where the sheriff is and why; and fourth, that if this
report is credited, there will be no search by anybody for a corpus
delicti.”
“A corpus delicti! And what might that be?”
Evan Pell sighed with that impatient tolerance which one exhibits
toward children asking questions about the obvious.
“It has been suggested,” he said, “that Sheriff Churchill has been
murdered. The first requisite in the establishment of the commission
of a murder is the production of the corpus delicti—the body of the
victim. If the body cannot be produced, or its disposal established,
there can be no conviction for the crime. In short, a murder requires
the fact of a dead man, and until the law can be shown a veritable
body it is compelled, I imagine, to presume the victim still alive. Here,
you will perceive, the effort is to raise a presumption that Sheriff
Churchill is not a corpus delicti.”
“Then you don’t believe it?”
“Do you?”
“I—I don’t know. Poor Mrs. Churchill! For her sake I hope it is true.”
“H’m!... If I were you, Miss Lee, I would not inform Mrs. Churchill of
this—without substantiation.”
“You are right. Nor shall I print it in the paper. You believe some one
is deliberately imposing upon us?”
“My mind,” said Evan Pell, “has been trained for years to seek the
truth. I am an observer of facts, trained to separate the true from the
false. That is the business of science and research. I think I have
made plain my reasons for doubting the truth of this message.”
“So much so,” said Carmel, “that I agree with you.”
Evan smiled complacently. “I fancied you could not do otherwise,” he
said. “Perhaps you will be further convinced if I tell you I am quite
certain I recognized the voice which gave the message.”
“Are you sure? Who was it?”
“I am certain in my own mind, but I could not take my oath in a court
of law.... I believe the voice was that of the little hunchback known
locally as Peewee Bangs.”
“The proprietor of the Lakeside Hotel?”
Evan nodded.
“What is this Lakeside Hotel?” Carmel asked. “I’ve heard it
mentioned, and somehow I’ve gotten the idea that it was—peculiar.”
Tubal interjected an answer before Evan Pell could speak. “It’s a
good place for sich as you be to keep away from. Folks drives out
there in automobiles from the big town twenty-thirty mile off, and has
high jinks. Before prohibition come in folks said Peewee run a blind
pig.”
“He seems very friendly with the local politicians.”
“Huh!” snorted Tubal.
“I don’t understand Gibeon,” Carmel said. “Of course I haven’t been
here long enough to know it and to know the people, but there’s
something about it which seems different from other little towns I’ve
known. The people look the same and talk the same. There are the
same churches and lodges and the reading club and its auxiliaries,
and I suppose there is the woman’s club which is exclusive, and all
that. But, somehow, those things, the normal life of the place, affect
me as being all on the surface, with something secret going on
underneath.... If there is anything hidden, it must be hidden from
most of the people, too. The folks must be decent, honest,
hardworking. Whatever it is, they don’t know.”
“What gives you such an idea?” Evan Pell asked, with interest.
“It’s a feeling—instinct, maybe. Possibly it’s because I’m trying to find
something, and imagine it all. Maybe I’ve magnified little,
inconsequential things.”
“What has all this to do with Abner Fownes?”
“Why—nothing. He seems to be a rather typical small-town magnate.
He’s egotistical, bumptious, small-minded. He loves importance—
and he’s rich. The professional politicians know him and his
weaknesses and use him. He’s a figurehead—so far as actual things
go, with a lot of petty power which he loves to exercise.... He’s a
bubble, and, oh, how I’d love to prick him!”
Evan bowed to her with ironical deference. “Remarkable,” he said. “A
clean-cut, searching analysis. Doubtless correct. You have been
studying him cursorily for a matter of days, but you comprehend him
to the innermost workings of his mind.... I, a trained observer, have
watched and scrutinized Abner Fownes for a year—and have not yet
reached a conclusion. May I compliment you, Miss Lee?”
Carmel’s eyes snapped. “You may,” she said, and then closed her
lips determinedly.
“You were going to say?” Evan asked, in his most irritating,
pedagogical tone.
“I was going to say that you have mighty little to be supercilious
about. You don’t know any more about this man than I do, and
you’ve been here a year. You don’t like him because he hurt your
vanity, and you’re so crusted over with vanity that whatever is inside
of it is quite lost to sight.... He had you discharged as superintendent
of schools, and it rankles.... It’s childish, like that letter of yours....
Oh, you irritate me.”
“Er—at any rate you have the quality of making yourself clear,” he
said, dryly, not offended, she was surprised to note, but rather
amused and tolerant. He was so cocksure, so wrapped up in himself
and his abilities, so egotistical, that no word of criticism could reach
and wound him. Carmel wanted to wound him, to see him wince.
She was sorry for him because she could perceive the smallness,
the narrowness, the poverty of his life; yet, because she felt,
somehow, that his character was of his own planning and
constructing, and because it was so eminently satisfactory to her,
that it was a duty to goad him into a realization of his deficiencies.
Evan Pell did not seem to her a human being, a man, so much as a
dry-as-dust mechanism—an irritating little pedant lacking in all
moving emotions except boundless vanity.
She had taken him into the office, half from sympathy, half because
somebody was needed and he was the only help available. At times
she regretted it. Now she leaned forward to challenge him.
“You’ve boasted about your abilities as a trained investigator,” she
said. “Very well, then, investigate. That’s the business of a reporter.
Gibeon is your laboratory. You’ll find it somewhat different to get at
facts hidden in human brains than to discover the hidden properties
of a chemical or to classify some rare plant or animal.... I haven’t a
trained mind. I wasn’t an infant prodigy. I haven’t spent my lifetime in
educating my brain out of all usefulness, but I can see there’s
something wrong here. Now, Mr. Pell, take your trained faculties out
and discover what it is. There’s investigation worth while.”
“Are you sure,” said Evan, “you will have the courage to publish what
I find?”
She shrugged her shoulders. “There’s no use talking about that,” she
said, “until you find something.”
“What,” he said, provocatively, “do you want me to investigate first?”
“The one thing that cries out for investigation. Find out why nothing is
done to discover what happened to Sheriff Churchill. Find out why he
disappeared and who made him disappear and what has become of
him. Fetch me the answers to these questions and I’ll take back all
I’ve said—and apologize.”
“Has it—er—occurred to you that perhaps Sheriff Churchill
disappeared because he—investigated too much?”
“Are you afraid?” she asked.
He wrinkled his brows and peered at her through his spectacles, and
then, nonplused her by answering, calmly, “I rather fancy I am. Yes,
now I come to give consideration to my emotions, I find I am
apprehensive.”
“Then,” she said, with a shrug, “we will forget about it.”
“You are trying,” he said, “to make me feel ashamed because I am
afraid. It is useless. I shall not be ashamed. It is natural I should be
afraid. Self-preservation dictates fear. The emotion of fear was
implanted in man and animals as a—er—safety device to prevent
them from incurring dangers. No, I am not in the least ashamed....
Fortunately, reason has been provided as well as fear, and,
consequently, if reason counsels a course of action which fear would
veto, it is only natural that intelligence should govern.... Reason
should always control emotion. Therefore, apprehensive as I am of
unpleasant consequences to myself, I shall proceed with the
investigation as indicated.” His tone was final. There was no
boasting in his statement, only the logical presentation of a fact. He
was afraid, but his reason indicated to him that it was worth his while
to subject himself to the hazards of the situation. Therefore he
subordinated fear.
But Carmel—responsibility sat upon her heavily in that moment. She
had ordered or goaded a human being into risking his person,
perhaps his life. That phase of it had not presented itself to her. She
was sending a man into danger, and the responsibility of her doing
so arose stark before her.
“I—I have no right,” she said, hesitatingly. “I was wrong. I cannot
allow you to put yourself in danger.”
“Unfortunately,” said Evan Pell, “you have no vote in the matter. I
have made the decision.... Of course, you may dispense with my
services, but that will not affect my conduct. I shall find out what
became of Sheriff Churchill and put myself in a position to lay before
the proper authorities substantiated facts covering all phases of his
disappearance.”
“But——”
He raised his hand, palm toward her. “My decision is final,” he said,
with asperity.
CHAPTER VIII
GIBEON was so accustomed to Abner Fownes that it took him for
granted, as if he were a spell of weather, or the Opera House which
had been erected in 1881, or the river which flowed through the
town, tumultuously in spring and parsimoniously in the heat of
summer when its moisture was most sorely needed. On the whole,
Abner bore more resemblance to the river than to either weather or
Opera House. He was tumultuous when he could do most damage,
and ran in a sort of trickle when such genius as he had might be of
greater service. On the whole, the village was glad it possessed
Abner. He was its show piece, and they compared him with the show
citizens of adjacent centers of population.
Your remote villages are conscious of their outstanding personalities,
and, however much they may dislike them personally and quarrel
with them in the family, they flaunt them in the faces of outsiders and
boast of their eccentricities and take pride in their mannerisms. So
Gibeon fancied it knew Abner Fownes from the meticulous crust in
which his tailor incased him inward to his exact geometrical center; it
was positive it comprehended his every thought and perceived the
motive for his every action. For the most part its attitude was
tolerant. Gibeon fancied it allowed Abner to function, and that it could
put a stop to his functioning whenever it desired. The power of his
money was appraised and appreciated; but it was more than a little
inclined to laugh at his bumptious pretense of arbitrary power.
George Bogardus, furniture dealer and undertaker, embalmed the
public estimate in words and phrases.
“Abner,” said Bogardus, “figgers himself out to be a hell of a feller,
and it does him a sight of good and keeps his appetite hearty—and,
so fur’s I kin see, ’tain’t no detriment to nobody else.”
Gibeon had its moments of irritation when Abner seemed to take too
much for granted or when he drove with too tight a check rein, but
these were ephemeral. On the whole, the town’s attitude was to let
Abner do it, and then to call him a fool for his pains.
He was a native of Gibeon. His father before him had moved to the
town when it was only a four corners in the woods, and had
acquired, little by little, timber and mills, which increased in size from
year to year. Gibeon had grown with the mills and with the coming of
the railroad. Old Man Fownes had been instrumental in elevating it to
the dignity of county seat. He had vanished from the scene of his
activities when Abner was a young man, leaving his son
extraordinarily well off for that day.
Abner, as a youth, had belonged to that short, stout class of men
who are made fun of by the girls. He was never able to increase his
stature, but his girth responded to excellent cookery. No man denied
him the attribute of industry in those early days, and, as Gibeon
judged, it was more by doggedness and stodgy determination that
he was enabled to increase his inherited fortune than it was by the
possession of keen mental faculties.
For ten years Abner was satisfied to devote himself to the
husbanding and increasing of his resources. At the end of that time,
his wife having died, he discovered to Gibeon an ambition to rule
and a predilection for county politics. It was made apparent how he
realized himself a figure in the world, and tried to live up to the best
traditions of such personages as his narrow vision had enabled him
to catch glimpses of. He seemed, of a sudden, to cease taking
satisfaction in his moderate possessions and to desire to become a
man of commanding wealth. He bought himself garments and
caused himself to become impressive. He never allowed himself an
unimpressive moment. Always he was before the public and
conducting himself as he judged the public desired to see a
personage conduct himself. By word and act he asserted himself to
be a personage, and as the years went by the mere force of
reiterated assertion caused Gibeon to accept him at his own
valuation.... He was patient.
The fact that fifty of every hundred male inhabitants were on his
payroll gave him a definite power to start with. He used this power to
its limit. It is true that Gibeon laughed up its sleeve and said that
smarter men than Abner used him as an implement in the political
workshop; but if this were true, Abner seemed unconscious of it.
What he seemed to desire was the appearance rather than the
substance. It seemed to matter little to him who actually made
decisions so long as he was publicly credited with making them. Yet,
with all this, with all Gibeon’s sure knowledge of his inner workings, it
was a little afraid of him because—well, because he might possess
some of the power he claimed.
So, gradually, patiently, year by year, he had reached out farther and
farther for money and for political power until he was credited with
being a millionaire, and had at least the outward seeming of a not
inconsiderable Pooh-Bah in the councils of his party.
The word “fatuous” did not occur in the vocabulary of Gibeon. If it
had seen the word in print it could not have guessed its meaning, but
it owned colloquial equivalents for the adjective, and with these it
summed up Abner. He possessed other attributes of the fatuous
man; he was vindictive where his vanity was touched; he was
stubborn; he followed little quarrels as if they had been blood feuds.
In all the ramifications of his life there was nothing large, nothing
daring, nothing worthy of the comment of an intelligent mind. He was
simply a commonplace, pompous, inflated little man who seemed to
have found exactly what he wanted and to be determined to squeeze
the last drop of the juice of personal satisfaction out of the realization
of his ambitions.
His home was indicative of his personality. It was a square, red-brick
house with an octagonal cupola on its top. It boasted a drive and
evergreens, and on the lawn stood an alert iron buck. The cupola
was painted white and there was a lightning rod which projected
glitteringly from the top of it. You knew the lightning rod was not
intended to function as a protection against electrical storms as soon
as you looked at it. It was not an active lightning rod in any sense. It
was a bumptious lightning rod which flaunted itself and its
ornamental brass ball, and looked upon itself as quite capping the
climax of Abner Fownes’s displayful life. The whole house impressed
one as not being intended as a dwelling, but as a display. It was not
to live in, but to inform passers-by that here was an edifice, erected
at great expense, by a personage. Abner lived there after a fashion,
and derived satisfaction from the house and its cupola, but
particularly from its lightning rod. An elderly woman kept house for
him.
Abner never came out of his house—he emerged from it. The act
was a ceremony, and one could imagine he visualized himself as
issuing forth between rows of bowing servitors, or through a lane of
household troops in wonderful uniforms. Always he drove to his
office in a surrey, occupying the back seat, erect and conscious,
while his unliveried coachman sagged down in the front seat, sitting
on his shoulder blades, and quite destroying the effect of solemn
state. Abner, however, was not particular about lack of state except
in his own person. Perhaps he had arrived at the conclusion that his
own person was so impressive as to render negligible the
appearance of any contiguous externals.
It was his office, however, which, to his mind, perfectly set him off. It
was the setting for the jewel which was himself, and it was a perfect
setting. The office knew it. It oozed self-importance. It realized its
responsibilities in being the daily container for Abner Fownes. It was
an overbearing office, a patronizing office. It was quite the most
bumptious place of business imaginable; and when Abner was in
place behind his flat-topped mahogany desk the room took on an air
of complacency which would be maddening to an irritated proletariat.
It was an impossible office for a lumberman. It might have been the
office of a grand duke. Gibeon poked fun at the office, but boasted to
strangers about it. It had on its walls two pictures in shadow boxes
which were believed to be old masters rifled from some European
gallery. What the pictures thought about themselves is not known,
but they put the best possible face on the matter and pretended they
had not been painted in a studio in the loft of a furniture store in
Boston. Their frames were expensive. The walls were paneled with
some wood of a golden tone which Abner was reputed to have
imported for the purpose from South America. The sole furniture was
that occupied by Abner Fownes—his desk and chair. There was no
resting place for visitors—they remained standing when admitted to
the presence.
If Abner Fownes, for some purpose of his own, with Machiavellian
intelligence, had set out to create for himself a personality which
could be described only by the word fatuous, he could not have done
better. Every detail seemed to have been planned for the purpose of
impressing the world with the fact that he was a man with illusions of
grandeur, motivated by obstinate folly, blind to his silliness; perfectly
contented in the belief that he was a human being who quite
overshadowed his contemporaries. If he had possessed a strong,
determined, rapacious, keen mind, determined upon surreptitious
depredations upon finance and morals, he could not have chosen
better. If he wished to set up a dummy Abner which would assert
itself so loudly and foolishly as to render the real, mole-digging
Abner invisible to the human eye, he could not have wrought more
skillfully. He was a perfect thing; his life was a perfect thing.... Many
men, possessing real, malevolent power, erect up clothes-horses to
function in their names. It was quite unthinkable that such a man
should set himself up as his own stalking horse.
Abner sat before his desk, examining a sheaf of tally sheets. They
were not the tally sheets of his own lumber yard, but figures showing
the amount of spruce and pine and birch and maple piled in
numerous mill yards throughout the state. Abner owned this lumber.
In the fall he had watched the price of lumber decline until he
calculated it had reached a price from which it could only rise. Others
had disagreed with him. Nevertheless, he had bought and bought
and bought, intent upon one coup which should make him indeed the
power in the lumber industry of the country, which was his objective.
He had used all available funds and then had carried his credit into
the market, stretching it until it cried for mercy. Now he owned
enough cut lumber to build a small city—and the price had continued
to drop. That morning’s market prices continued the decline. Abner’s
state of mind was not one to arouse envy.
The sum of money he must lose if he sold at the market represented
something more than the total of his possessions. Gibeon rated him
as a millionaire. That he was in difficulties was a secret which he had

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Medical Nutrition Therapy: A Case

Study Approach 6th Edition Marcia

(eBook PDF) Medical Nutrition Therapy: A Case-Study

Nutrition Therapy and Pathophysiology 4th Edition

(eBook PDF) Planning Canada: A Case Study Approach

(eBook PDF) Advanced Medical Nutrition Therapy by Kelly

(eBook PDF) Master of Public Health Competencies: A

Infectious Diseases: A Case Study Approach 1st Edition

(eBook PDF) Criminal Investigation: An Illustrated Case

Fractured Minds: A Case-Study Approach to Clinical

Marcia Nahikian Nelms, PhD, RDN, LD, FAND

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Printed in the United States of America

To my husband, who never fails to remind me that I can achieve my dreams.

Teaching Strategies xiii

Introducing Case Studies, or Finding Your Way Through a Case Study xv

About the Authors xix

1 Pediatric Weight Management 3

14 Pediatric Type 1 Diabetes Mellitus 159

17 Chronic Kidney Disease Treated with Dialysis 197

24 Chronic Obstructive Pulmonary Disease 281

27 Breast Cancer 321

A Common Medical Abbreviations 355

8. Use your resources. not-for-profit organizations, and other

Kristen Roberts, PhD, RDN, LD, CNSC

Whitmer, Jamey, Female, 10 y.o.

Whitmer, Jamey, Female, 10 y.o.

Vital Signs: Temp: 98.5°F Pulse: 85 Resp rate: 27

Assessment and Plan:

Food allergies/intolerances/aversions: NKA

Whitmer, Jamey, Female, 10 y.o.

Laboratory Results (Pediatric)

II. Understanding the Nutrition Therapy

III. Nutrition Assessment

Stature-for-Age and Weight-for-Age Percentiles: Girls, 2 to 20 Years

IV. Nutrition Diagnosis

17. Identify one specific physical activity recommendation for Jamey.

VI. Nutrition Monitoring and Evaluation

21. Should her parents be included? Why or why not?

Bibliography Pediatric Weight Management (PWM): Major Recom-

Internet Resources Baylor College of Medicine Children’s Nutrition Research

Turner, Bethany Female, 37 y.o.

Patient Summary: Patient is a morbidly obese 37-year-old African American

Turner, Bethany Female, 37 y.o.

Vital Signs: Temp: 98.9°F Pulse: 85 Resp rate: 23

Nursing Assessment 2/23

Turner, Bethany Female, 37 y.o.

Vitals: Temp: 98.9°F Pulse: 78 Resp rate: 24 BP: 115/70

Turner, Bethany Female, 37 y.o.

Intake/Output 410 5 186.3636

Turner, Bethany Female, 37 y.o.

Turner, Bethany Female, 37 y.o.

Laboratory Results (Continued)

Turner, Bethany Female, 37 y.o.

Laboratory Results (Continued)

a. Roux-en-Y gastric bypass

b. Vertical sleeve gastrectomy

c. Adjustable gastric banding (Lap-Band®)

d. Vertical banded gastroplasty