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Running Head: DISEASE AND NUTRITION

Final Paper: Disease and Nutrition Kalinda McElroy West Coast University

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C.J. is a 30 year old Jewish, Caucasian female. She is single, with two children, and is currently working five days a week. In her life C.J. stays moderately active and partakes in the Atkins diet. She has a medical history of Crohn's disease and takes 2g of sulfasalazine three times a day (TID) and 1,000mg of calcium each day. Part 1 The Atkins diet is a fad diet plan created in the 1960s that recommends restricting carbohydrate intake and emphasizes the uptake of proteins and fats (Atkins Diet, 2017). The Atkins diet maintains that eating an excess amount of carbohydrates (especially sugar, white flour, and other refined carbohydrates) leads to blood glucose imbalances, weight gain, and cardiovascular problems (Atkins Diet, 2017). The diet therefore restricts carbohydrates and encourages eating more protein and fat. Carbohydrates are composed of carbon, hydrogen, and oxygen (Dudek, 2018). The primary function of carbohydrates is to provide energy to the body’s cells (Dudek, 2018). Examples of high-carbohydrate foods include vegetables, whole fruits, potatoes, and grains (Dudek, 2018). The primary function of fats is to provide fuel to the body, however, other functions include insulating and cushioning internal organs, regulating body temperature, and facilitating absorption of the fat-soluble vitamins A, D, E, and K (Dudek, 2018). High-fat foods include dairy products, avocados, bacon, and sausage (Dudek, 2018). Protein is the major structural and functional component of living cells. It works to promote fluid balance, acid-base balance, transport molecules, and facilitate certain chemical reactions (Dudek, 2018). Examples of high-protein foods include lean meat, eggs, peanut butter, beans, and nuts (Dudek, 2018).

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The proclaimed purpose of the Atkins diet is to initiate and maintain weight loss while boosting energy and improving some health conditions (Atkins Diet, 2017). Neither calorie counting nor portion control is necessary when following the Atkins diet. Instead, it requires tracking an individual’s net carbohydrates (the total carbohydrate content of an item subtracted by the fiber content). As an example, in a serving of Jif creamy peanut butter there is a total of 8g of carbohydrate and 2g of fiber. The net carbohydrate for one serving would thereby be 6g of carbohydrate. Moreover, the diet claims that exercise is not vital for weight loss. However, it does acknowledge that exercise can help to maintain an individual’s weight as well as offer additional health benefits. The Atkins diet has four phases: introduction, balancing, pre-maintenance, and lifetime maintenance. An individual can begin in any of the first three phases depending on their weight loss goals. The introductory phase is the strictest by cutting out nearly all carbohydrate intake. An individual is left with an intake balance of 20g of net carbohydrate per day. Most of these carbohydrates should come from vegetables like asparagus, broccoli, celery, cucumber, green beans, and peppers (Atkins Diet, 2017). During this phase, protein should be eaten at every meal and eight glasses of water should be drunk throughout the day. This phase typically lasts two weeks depending on an individual’s weight loss. The second phase of the Atkins diet is balance. In this phase, an individual will decrease their net carbohydrate intake from 20g to 12g-15g (Atkins Diet, 2017). Foods with added sugar should continue to be avoided. However, some nutrient-rich foods (e.g. berries, nuts, and seeds) can be

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added back into the diet as weight loss continues. This phase proceeds until an individual is roughly 10lbs away from their goal weight. During the pre-maintenance phase an individual is instructed to gradually increase intake of fruits, starchy vegetables, and whole grains (Atkins Diet, 2017). Each week 10g of net carbohydrate can be added to the diet, however if weight loss ceases then carbohydrates must again be taken away from the diet. This phase continues until an individual reaches their goal weight. The final phase of the Atkins diet is maintenance. Once an individual obtains their goal weight, they continue their current diet for life. However, the strict nature of the Atkins diet also affects the availability of micronutrients in the body. Individuals who partook in low-carbohydrate diets were found to be the most deficient in iron, thiamine, folic acid, vitamin C, and magnesium (Gardner et al, 2010). Initially, a deficiency in iron seems contradictory since the Atkins diet allows for the consumption of liberal amounts of red meat. Although red meat is an excellent source of iron, Americans obtain most of their iron intake from fortified cereals and breads (Gardner et al, 2010). Due to the Atkins diet restricting consumption of refined grains, most individuals on this diet will be deficient in iron. Iron is necessary for oxygen transportation throughout the body (Dudek, 2018). The same fortified grains also provide the population of the U.S. with the majority of their thiamine and folic acid as well as iron (Gardner et al, 2010). For the same reason, individuals on the Atkins diet will also have thiamine and folic acid deficiencies. Thiamin (vitamin B1) functions as an enzyme during the metabolism of ATP and promotes normal appetite (Dudek,

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2018). Folic acid (aka folate) is necessary for DNA synthesis; and thereby vital in the synthesis of new cells and transmission of inherited characteristics (Dudek, 2018). Another micronutrient deficiency related to low-carbohydrate intake is magnesium (Fogoros, 2019). Magnesium is found primarily in foods such as pineapple, oat bran, and whole grains (Dudek, 2018). However, these foods are high in carbohydrates and are therefore restricted by the Atkins diet. Magnesium plays a role in the formation of bone and functions as an enzyme in the metabolism of carbohydrates, protein, and fat (Dudek, 2018). The last micronutrient deficiency found in individuals following the Atkins diet is vitamin C. The Atkins diet limits the amount of fruit an individual can partake in, since they are very high in carbohydrates (Gardner et al, 2010). This explains the reason for a lack in vitamin C for individuals on the Atkins diet. Vitamin C plays an important role in immune system functioning, aids in collagen and thyroxine synthesis, promotes iron absorption, and metabolizes certain amino acids (Dudek, 2018). Part 2 Health With any fad diet there are risks and benefits to an individual, and the Atkins diet is not appropriate for everyone. For example, if an individual is on diuretics, oral antidiabetic medication, or insulin, they should consult with their primary care physician before starting on this diet (Atkins Diet, 2017). In addition, individuals with severe kidney disease and those who are pregnant or breastfeeding should not follow the Atkins diet (Atkins Diet, 2017). The Atkins diet claims that an individual following their meal plan can (in addition to weight loss) prevent or improve medical conditions such as metabolic syndrome, diabetes, high blood

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pressure, and cardiovascular disease (Atkins Diet, 2017). The diet also claims that cholesterol levels will improve by lowering triglycerides and LDL, and increasing HDL. While there may be improvements in cardiovascular health, the diet also comes with risks. Drastically cutting carbohydrates can cause severe headache, dizziness, weakness, fatigue, and constipation. Additionally, if carbohydrates are too restricted, nutritional deficiencies may result and prompt constipation, diarrhea, and nausea. Furthermore, restricting dietary intake of carbohydrates to less than 20g per day can bring about ketosis. Ketosis occurs when an individual does not have enough glucose to use for energy, prompting the body to break down stored fat. The process of breaking down fat leads to a buildup of ketones in the body. The effects of ketosis include nausea, headache, fatigue, and halitosis. Disease Process Crohn’s disease is a type of inflammatory bowel disease that causes severe diarrhea, constipation, abdominal pain, and rectal bleeding (Overview of Crohn’s Disease, 2019). Inflammation involves any segment of the gastrointestinal tract, from the mouth to the anus (Lewis, 2017). The stomach and sections of the bowel (duodenum, jejunum, ileum, and colon) are the most commonly affected. Complications involving Crohn’s disease include loss of appetite, weight loss, fatigue, osteoporosis, and delayed growth and development in children (Signs and Symptoms of Crohn’s Disease, 2019). More serious complications such as fistulas, fissures, and strictures can also arise (Signs and Symptoms of Crohn’s Disease, 2019). Inflammatory bowel disease occurs more commonly in people of Caucasian and Ashkenazic Jewish origin (Lewis, 2017).

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Individuals with Crohn’s disease should avoid potential trigger foods, including insoluble fiber (e.g. whole grains and cauliflower), lactose, non-absorbable sugars (e.g. sorbitol and mannitol), sugary foods, spicy foods, high-fat foods, alcohol, and caffeinated beverages (What Should I Eat, 2019). The Atkins diet eliminates almost all carbohydrates from the diet and encourages an individual to increase intake of proteins and fats. While this strategy may help an individual without medical conditions, C.J. has Crohn’s disease. Bowel inflammation can be triggered by foods high in fat, spicy foods, dairy, etc; the same foods that the Atkins diet promotes. If C.J. were to be compliant with the Atkins diet as well as avoid trigger foods, the variety of foods she would be able to consume are even more limited. Crohn’s disease already decreases appetite and the Atkins diet could increase the risk for nutritional deficiencies. Additionally, both the Atkins diet and Crohn’s disease promote weight loss, therefore C.J. would be at risk for malnutrition if she were to continue to follow the Atkins diet. Furthermore, Crohn’s disease can inflict severe diarrhea or constipation on an individual, and known side effects of the Atkins diet also include diarrhea or constipation. With this, the Atkins diet can either relieve or exacerbate the symptoms of Crohn’s disease. If C.J. experiences diarrhea then a low carbohydrate diet will help improve abdominal pain, stool formation, and quality of life (Austin et al, 2009). Moreover, additional risks need to be considered for an individual’s long-term use of the Atkins diet. Complications such as arrhythmias, cardiac contractile impairment, osteoporosis, kidney damage, impaired physical activity, lipid abnormalities, cancer, and death can be linked to long-term restriction of dietary carbohydrates (Bilsborough et al, 2003).

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C.J. is also a Jew, and the laws of kashrut could also impact the foods available in her diet. Kashrut is a set of dietary laws that detail the foods that Jews are permitted to eat and how those foods must be prepared. Some of the laws kashrut specifies are 1) animals that cannot be eaten 2) certain fats and nerves that cannot be eaten 3) slaughter of the animal 4) draining of the blood and 5) separation of meat and dairy products. Criteria of the first law is that land mammals must chew their cud and have a cloven hoof. Any mammal that does not meet both of these requirements is forbidden (Jewish Dietary Laws, 2020). Sheep, cattle, goats, and deer are kosher while camel, pig, and badger are not. All sea dwelling creatures must have both fins and scales (Jewish Dietary Laws, 2020). Thus fish like tuna, carp, salmon, and herring are permitted. However, shellfish, catfish, crab, lobster, and swordfish are not kosher. When it comes to birds, the criteria is less clear. The Torah lists forbidden birds (scavengers and birds of prey) without explaining why. Birds that are permitted include ducks, geese, chicken, and turkeys. All reptiles, insects, amphibians, and worms are forbidden (What Is Kosher?, 2020). The second law requires that the sciatic nerve, as well as the adjoining blood vessels, must be removed before consumption. Additionally, chelev (fat surrounding vital organs) is also forbidden (Jewish Dietary Laws, 2020). Ritual slaughter, known as shechita, must be performed by quickly and unhesitantly moving a perfectly sharp knife across the throat of an unconscious animal (Jewish Dietary Laws, 2020). If not done in this manner the animal cannot be eaten. After the slaughter, the internal organs of the animal are examined for potentially fatal diseases or injuries. Animals that died of natural causes or were killed by other animals are not to be consumed (Jewish Dietary Laws, 2020).

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The fourth requirement is that no blood can be consumed, which applies to only mammals and birds (What Is Kosher?, 2020). The first step begins at the slaughter when the butcher rapidly drains the blood from the animal. Any remaining blood is removed either by broiling or salting the meat (Jewish Dietary Laws, 2020). The last law to be discussed deals with the separation of meat and dairy. The Torah bids Jew not to “boil a kid in its mother’s milk”, which has been interpreted to mean that it is prohibited to eat dairy and meat together (Jewish Dietary Laws, 2020). This separation includes not only the foods themselves, but also the utensils, pots and pans in which the food was cooked, dishes the food was eaten on, the dishwashers in which the dishes are cleaned, and the towels that dry the dishes. This law also requires an individual to wait a significant amount of time (3-6 hours) between eating meat and dairy (Jewish Dietary Laws, 2020). These dietary restrictions, along with the Atkins diet and abstinence of trigger foods, can severely limit the foods available to C.J.. Medications C.J. is currently taking sulfasalazine and calcium. Sulfasalazine is an antiinflammatory agent that also works to inhibit prostaglandins that cause diarrhea, interfere with mucosal transport, and interfere with absorption of fluids and electrolytes. Crohn’s disease increases an individual’s risk for osteoporosis, therefore physicians typically prescribe a calcium supplement as prophylaxis. There are five major classes of medication that are prescribed to patients with Crohn’s disease: 5-aminosalicylates (5-ASA), antimicrobials, corticosteroids, immunosuppressants, and immunomodulators (Lewis et al, 2017). Aminosalicylates decrease inflammation by suppressing proinflammatory cytokines and other inflammatory mediators (Lewis et al, 2017). Examples include sulfasalazine (Azulfine),

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mesalamine (Asacol, Pentasa), olsalazine (Dipentum), and balsalazide (Colazal). If an individual takes iron supplements as well, the absorption of these medications will be altered. “Antimicrobial” is a general term that encompasses antibiotics, antifungals, antiprotozoals, and antivirals. This classification of drugs prevents or treats secondary infections (Lewis et al, 2017). Examples of medications include ciprofloxacin (Cipro), metronidazole (Flagyl), rifaximin (Xifaxan), ampicillin (Penicillin), and tetracycline (Sumycin). Supplemental iron taken at the same time will decrease the absorption of these medications. Corticosteroids are primarily used to decrease inflammation (Lewis et al, 2017). Examples of this classification include prednisone (Deltasone), hydrocortisone (Cortef), budesonide (Entocort), and methylprednisolone (Solu-medrol). Diuretics taken along with corticosteroids will increase the body’s loss of potassium. Examples of immunosuppressants and immunomodulators include 6-mercaptopurine (6-MP), methotrexate (Trexall), infliximab (Remicade), Azathioprine (Azasan), and natalizumab (Tysabri). These drugs fall under both classifications. Immunosuppressants do just as the name suggests, suppress the immune system. Immunomodulators inhibit cytokine tumor necrosis factor and prevent migration of leukocytes from the bloodstream to inflamed tissue (Lewis et al, 2017). Caffeine consumption may decrease joint pain relief that these medications provide. Moreover, when taken with the herbal supplement echinacea, these medications will increase an individual’s risk for hepatotoxicity.

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Part 3 Patient Education and SMART Goals BMI is calculated by dividing an individual’s weight in kilograms by height in meters squared (kg/m2). Established cutoffs identify the parameters of being underweight, normal weight, overweight, obese, and extremely obese (Dudek, 2018). C.J.weighs 135 pounds, which equals 61.36kg (135lb divided by 2.2lb/kg = 61.36kg). C.J.’s height is 67 inches (5’7”); which equals 1.72m (67in divided by 39in/m = 1.72m). Input this information into the BMI formula (61.36kg/(1.72m)2) to receive C.J.’s BMI calculation. Her BMI is 21.1 and indicates that she is at a normal weight (Adult BMI Calculator, 2019). Both Crohn’s disease and the Atkins diet promote weight loss in an individual. If an individual has a BMI of 18.5 or below then they are considered underweight (Underweight Adults, 2017). Being underweight can contribute to a weakened immune system, osteoporosis, anemia, fertility problems, fatigue, nutritional deficiencies, and depression (Underweight Adults, 2017). Goal one: By May 30th , 2020, C.J. will adhere to medical regimens to decrease incidence of acute inflammation. Sulfasalazine works to reduce inflammation in the gastrointestinal lining (Lewis, 2017). If C.J. is compliant with taking her medication, then the symptoms of Crohn’s disease will be better managed. It is important to educate C.J. about why the medication is necessary and the consequences of not taking the medication. Additionally, the medical professional should work with a social worker to determine if C.J. has the ability and financial resources to regularly refill and obtain her medication. Goal two: By June 30th , 2020, C.J. will verbalize understanding of, and avoid potential trigger foods for, Crohn’s disease to decrease acute inflammation. It is important that C.J. understand

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the complications that could arise from her continuing to follow the Atkins diet and the laws of Kashrut, and becoming underweight. It is the role of the medical professional to educate an individual on their disease process, how it will affect their body, and the consequences of any dietary or lifestyle modifications. To achieve this goal, C.J. will have to experiment to determine her specific trigger foods and then promptly avoid them. If C.J. continues to experience diarrhea, she should notify her primary care physician who can then prescribe antidiarrheal agents, such as imodium. A dietitian or nutritionist can help C.J. determine trigger foods. It is also important for C.J. to have the support of family, friends, and other individuals who have the same disease. The medical profession should refer C.J. to different support groups. Goal three: By June 30th , 2020, C.J. will maintain nutritional balance. C.J. is at risk for imbalanced nutrition because Crohn’s disease decreases nutrient absorption and increases nutrient loss through diarrhea. In order to improve intake and reduce the risk of malnutrition, C.J. should identify foods that she enjoys, and consume small, frequent meals. In order for her to maintain dietary compliance, C.J. will need the help and support from those around her. The medical professional should assess C.J.’s support status as well as refer her to different support groups.

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References Adult BMI Calculator. (2019). Retrieved from https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi _calculator.html Atkins Diet: What’s Behind The Claims? (201...