What? Where? How? Outcome?
Treatment aims
What? Where? How? Outcome?
1 Improve quality of the diet and immune response
GIT (& Immune system)
Decrease sugar, dairy, processed food consumption.
Enhance B12 absorption in the diet.
Identify and avoid food allergens and/or intolerances.
Lower vegetable intake to decrease fibre in the diet (Zhang et al., 2020).
Decreased bloating, fermentation, and inflammation (Zuvarox & Belletieri, 2021).
Better digestion and decreased constipation (Connor et al., 2022).
Enhanced energy levels, decreased fatigue (Tardy et al., 2020)
2 Improve digestion and increase digestive secretion
Upper GI
Increase vagal nerve stimulation and PSNS activation -
--> increase HCl, PE and biliary secretions, glandular secretion and bowel movements (Breit et al., 2018) - eating smaller meals
Balance sIgA production (Pietrzak et al., 2020).
Enhanced breakdown and absorption of food - increased energy and decreased fatigue by signal transmission through the gut-brain axis (Bercik, 2020).
Decreased bloating and constipation (Bercik, 2020).
Reduce fullness and heaviness in the stomach, enhance satiety (Breit et al., 2020).
3 Stress reduction NS, GIT Regulate NT levels:
Increase glutamic acid to increase GABA (Yang et al., 2021).
Increase tryptophan to regulate and increase serotonin levels through SSRIs (Mittal et al., 2017).
HPA axis regulation (Sheng et al., 2021; Tapp et al., 2019).
Reduce bloating and digestive issues (Mittal et al., 2017).
Reduce fatigue, increase energy levels.
Decrease stress in the body by HPA regulation (Stephens, 2012).
Holistic understanding
John, a 45-year-old man is presenting with several complaints which involve his gastrointestinal tract and central nervous system the latter related to his mental state. Upon physical examination, John presented with possible signs of nutrient deficiency demonstrated with vertical ridging on his nails and pale quivering tongue ADDIN EN.CITE <EndNote><Cite><Author>Singal</Author><Year>2015</Year><RecNum>108</RecNum><DisplayText>(Singal & Arora, 2015)</DisplayText><record><rec-number>108</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666676997">108</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Singal, A.</author><author>Arora, R.</author></authors></contributors><auth-address>Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, New Delhi, India.</auth-address><titles><title>Nail as a window of systemic diseases</title><secondary-title>Indian Dermatol Online J</secondary-title></titles><periodical><full-title>Indian Dermatol Online J</full-title></periodical><pages>67-74</pages><volume>6</volume><number>2</number><edition>2015/03/31</edition><keywords><keyword>Matrix</keyword><keyword>nail</keyword><keyword>nail bed</keyword><keyword>nail plate</keyword><keyword>nail unit</keyword><keyword>systemic diseases</keyword></keywords><dates><year>2015</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>2229-5178 (Print)
2229-5178</isbn><accession-num>25821724</accession-num><urls></urls><custom2>PMC4375768</custom2><electronic-resource-num>10.4103/2229-5178.153002</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Singal & Arora, 2015). His BMI was 27.8 which puts him in the overweight range ADDIN EN.CITE <EndNote><Cite><Author>Weir</Author><Year>2022</Year><RecNum>110</RecNum><DisplayText>(Weir & Jan, 2022)</DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666677521">110</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Weir, C. B.</author><author>Jan, A.</author></authors></contributors><auth-address>Michigan State University/Mclaren
Drexel University</auth-address><titles><title>BMI Classification Percentile And Cut Off Points</title><secondary-title>StatPearls</secondary-title></titles><dates><year>2022</year></dates><pub-location>Treasure Island (FL)</pub-location><publisher>StatPearls Publishing
Copyright 2022, StatPearls Publishing LLC.</publisher><accession-num>31082114</accession-num><urls></urls><language>eng</language></record></Cite></EndNote>(Weir & Jan, 2022), and his cardiovascular readings (heart rate and blood pressure) were elevated at 76BPM and 140/90mMHg (hypertensive) ADDIN EN.CITE <EndNote><Cite><Author>Iqbal</Author><Year>2022</Year><RecNum>111</RecNum><DisplayText>(Iqbal & Jamal, 2022)</DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666677701">111</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Iqbal, A. M.</author><author>Jamal, S. F.</author></authors></contributors><auth-address>Oak Hill Hospital, Brooksville, FL
National institute of Cardiovascular Diseases, Karachi, Pakistan.</auth-address><titles><title>Essential Hypertension</title><secondary-title>StatPearls</secondary-title></titles><dates><year>2022</year></dates><pub-location>Treasure Island (FL)</pub-location><publisher>StatPearls Publishing
Copyright 2022, StatPearls Publishing LLC.</publisher><accession-num>30969681</accession-num><urls></urls><language>eng</language></record></Cite></EndNote>(Iqbal & Jamal, 2022).
Johns issues started three years ago when he was diagnosed with gastro-oesophageal reflux disease (GORD) and was prescribed Nexium, a proton pump inhibitor (PPI) which helped his symptoms. It is suspected that the ongoing use of this medication may be linked to his current complaints due to the reduction of stomach acidity ADDIN EN.CITE <EndNote><Cite><Author>Heidelbaugh</Author><Year>2013</Year><RecNum>112</RecNum><DisplayText>(Heidelbaugh, 2013)</DisplayText><record><rec-number>112</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666677826">112</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Heidelbaugh, J. J.</author></authors></contributors><auth-address>University of Michigan, Ypsilanti Health Center, 200 Arnet Suite 200, Ypsilanti, MI 48198, USA.</auth-address><titles><title>Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications</title><secondary-title>Ther Adv Drug Saf</secondary-title></titles><periodical><full-title>Ther Adv Drug Saf</full-title></periodical><pages>125-33</pages><volume>4</volume><number>3</number><edition>2013/06/01</edition><keywords><keyword>antisecretory therapy</keyword><keyword>calcium</keyword><keyword>iron</keyword><keyword>magnesium</keyword><keyword>mineral deficiency proton pump inhibitor(s)</keyword><keyword>vitamin B12</keyword><keyword>vitamin C</keyword><keyword>vitamin deficiency</keyword><keyword>preparing this article.</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2042-0986 (Print)
2042-0986</isbn><accession-num>25083257</accession-num><urls></urls><custom2>PMC4110863</custom2><electronic-resource-num>10.1177/2042098613482484</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Heidelbaugh, 2013). PPIs are a class of drugs that are the standard of care for patients presenting with GORD. They help alleviate the symptoms of GORD by reducing the hydrochloric acid being produced in the stomach ADDIN EN.CITE <EndNote><Cite><Author>Shin</Author><Year>2008</Year><RecNum>113</RecNum><DisplayText>(Shin & Sachs, 2008)</DisplayText><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666677956">113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shin, J. M.</author><author>Sachs, G.</author></authors></contributors><auth-address>Membrane Biology, David Geffen School of Medicine, University of California at Los Angeles, Room 324, Building 113, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA.</auth-address><titles><title>Pharmacology of proton pump inhibitors</title><secondary-title>Curr Gastroenterol Rep</secondary-title></titles><periodical><full-title>Curr Gastroenterol Rep</full-title></periodical><pages>528-34</pages><volume>10</volume><number>6</number><edition>2008/11/14</edition><keywords><keyword>Animals</keyword><keyword>Antacids/*pharmacology</keyword><keyword>Anti-Ulcer Agents/*pharmacology</keyword><keyword>Esophagitis/drug therapy</keyword><keyword>Gastric Acid/metabolism</keyword><keyword>Gastroesophageal Reflux/drug therapy</keyword><keyword>Humans</keyword><keyword>Parietal Cells, Gastric/drug effects/metabolism</keyword><keyword>Peptic Ulcer/drug therapy</keyword><keyword>Proton Pump Inhibitors/*pharmacology</keyword></keywords><dates><year>2008</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1522-8037 (Print)
1522-8037</isbn><accession-num>19006606</accession-num><urls></urls><custom2>PMC2855237</custom2><custom6>NIHMS189138 reported.</custom6><electronic-resource-num>10.1007/s11894-008-0098-4</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Shin & Sachs, 2008). This provides relief to the patient; however, long-term use can cause issues with nutrient digestion and uptake ADDIN EN.CITE <EndNote><Cite><Author>Heidelbaugh</Author><Year>2013</Year><RecNum>112</RecNum><DisplayText>(Heidelbaugh, 2013)</DisplayText><record><rec-number>112</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666677826">112</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Heidelbaugh, J. J.</author></authors></contributors><auth-address>University of Michigan, Ypsilanti Health Center, 200 Arnet Suite 200, Ypsilanti, MI 48198, USA.</auth-address><titles><title>Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications</title><secondary-title>Ther Adv Drug Saf</secondary-title></titles><periodical><full-title>Ther Adv Drug Saf</full-title></periodical><pages>125-33</pages><volume>4</volume><number>3</number><edition>2013/06/01</edition><keywords><keyword>antisecretory therapy</keyword><keyword>calcium</keyword><keyword>iron</keyword><keyword>magnesium</keyword><keyword>mineral deficiency proton pump inhibitor(s)</keyword><keyword>vitamin B12</keyword><keyword>vitamin C</keyword><keyword>vitamin deficiency</keyword><keyword>preparing this article.</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2042-0986 (Print)
2042-0986</isbn><accession-num>25083257</accession-num><urls></urls><custom2>PMC4110863</custom2><electronic-resource-num>10.1177/2042098613482484</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Heidelbaugh, 2013). Nutrients of concern are protein which requires an acidic environment for the enzyme pepsinogen to be cleaved into the active form of pepsin, B12 requires intrinsic factor, folate, zinc, magnesium and iron PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaWVsYTwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Heda et al., 2022; Kiela & Ghishan, 2016). An analysis of Johns 24hr food recall revealed a low intake of zinc (92% RDI), selenium (82% RDI) and magnesium (90% RDI). Johns slightly lowered intake of minerals and poor absorption could explain his ridged nails and elevated blood pressure, furthermore, the result of the Zinc Tally Test points to deficiency PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaW5nYWw8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Champagne, 2008; Singal & Arora, 2015; Zdilla et al., 2016). Another finding of the recall was that ~40% of johns energy comes from fat, this could exacerbate symptoms of GORD as it delays gastric emptying PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXR0bGU8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Jain et al., 2015; McNamara & Almeida, 2019). Johns stool was reported as yellow, which suggests low bile secretion or low bilirubin, this could be due to low cholecystokinin secretion from low HCl in the chyme or another biliary system condition ADDIN EN.CITE <EndNote><Cite><Author>Beckingham</Author><Year>2001</Year><RecNum>120</RecNum><DisplayText>(Beckingham & Ryder, 2001)</DisplayText><record><rec-number>120</rec-number><foreign-keys><key app="EN" db-id="t0zzsvwe8s9wphepfx75dd50tw9p5z9wxzvp" timestamp="1666679359">120</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beckingham, I. J.</author><author>Ryder, S. D.</author></authors></contributors><auth-address>Department of Surgery, Queen's Medical Center, Nottingham, UK. Ian.beckingham@nottingham.ac.uk</auth-address><titles><title>ABC of diseases of liver, pancreas, and biliary system. Investigation of liver and biliary disease</title><secondary-title>Bmj</secondary-title></titles><periodical><full-title>Bmj</full-title></periodical><pages>33-6</pages><volume>322</volume><number>7277</number><edition>2001/01/05</edition><keywords><keyword>Bile Ducts/diagnostic imaging</keyword><keyword>Biliary Tract Diseases/*diagnosis</keyword><keyword>Biomarkers/blood</keyword><keyword>Biopsy, Needle</keyword><keyword>Blood Coagulation Factors/analysis</keyword><keyword>Blood Proteins/analysis</keyword><keyword>Cholangiography</keyword><keyword>Humans</keyword><keyword>Jaundice/diagnosis</keyword><keyword>Liver/diagnostic imaging</keyword><keyword>Liver Diseases/*diagnosis</keyword><keyword>Liver Function Tests</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Tomography, X-Ray Computed</keyword><keyword>Ultrasonography</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan 6</date></pub-dates></dates><isbn>0959-8138 (Print)
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ADDIN EN.CITE.DATA (Bouchoucha et al., 2015; Struyvenberg et al., 2017).
The initial diagnosis of GORD may have been made based on the symptoms of frequent epigastric pain and burning which is shared with other upper gastrointestinal conditions like gastritis, which is also helped with the use of PPIs. John has been referred for an endoscopy which will be able to rule out other causes of his symptoms, for example, helicobacter pylori infection, peptic ulcers, and adenocarcinomas and also test the pH of the stomach to determine whether hydrochloric acid is a problem PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFoZWVuPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Shaheen et al., 2012; Stanciu et al., 2007). Other investigations like food allergy and intolerances are advised to rule them out. These further investigations would help in the determination of Johns underlying pathology and provide better outcomes.
References
Beckingham, I. J., & Ryder, S. D. (2001, Jan 6). ABC of diseases of liver, pancreas, and biliary system. Investigation of liver and biliary disease. Bmj, 322(7277), 33-36. https://doi.org/10.1136/bmj.322.7277.33
Bercik, P. (2020). The Brain-gut -microbiome axis and irritable bowel syndrome. Gastroenterology & Hepatology, 16(6), 322-324. https://www.gastroenterologyandhepatology.net/archives/june-2020/the-brain-gut-microbiome-axis-and-irritable-bowel-syndrome/Bouchoucha, M., Devroede, G., & Benamouzig, R. (2015, Aug). Are floating stools associated with specific functional bowel disorders? Eur J Gastroenterol Hepatol, 27(8), 968-973. https://doi.org/10.1097/meg.0000000000000380
Breit, S., Kupferberg, A., Rogler, G, & Hasler, G. (2018). Vagus Nerve as modulator of the Brain-gut axis in psychiatric and inflammatory disorders. Front. Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00044Champagne, C. M. (2008, Apr-May). Magnesium in hypertension, cardiovascular disease, metabolic syndrome, and other conditions: a review. Nutr Clin Pract, 23(2), 142-151. https://doi.org/10.1177/0884533608314533
Connor, F., Salvatore, S., DAuria, E., Baldassarre, M. E., Acunzo, M., Di Bella, G., Farella, I., et al. (2022). Cows Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review.Nutrients,14(6), 1317. http://dx.doi.org/10.3390/nu14061317Heda, R., Toro, F., & Tombazzi, C. R. (2022). Physiology, Pepsin. In StatPearls. StatPearls Publishing
Copyright 2022, StatPearls Publishing LLC.
Heidelbaugh, J. J. (2013, Jun). Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications. Ther Adv Drug Saf, 4(3), 125-133. https://doi.org/10.1177/2042098613482484
Iqbal, A. M., & Jamal, S. F. (2022). Essential Hypertension. In StatPearls. StatPearls Publishing
Copyright 2022, StatPearls Publishing LLC.
Jain, A. P., Aggarwal, K. K., & Zhang, P. Y. (2015). Omega-3 fatty acids and cardiovascular disease. Eur Rev Med Pharmacol Sci, 19(3), 441-445.
Kiela, P. R., & Ghishan, F. K. (2016, Apr). Physiology of Intestinal Absorption and Secretion. Best Pract Res Clin Gastroenterol, 30(2), 145-159. https://doi.org/10.1016/j.bpg.2016.02.007
Little, T. J., Horowitz, M., & Feinle-Bisset, C. (2007, Sep). Modulation by high-fat diets of gastrointestinal function and hormones associated with the regulation of energy intake: implications for the pathophysiology of obesity. Am J Clin Nutr, 86(3), 531-541. https://doi.org/10.1093/ajcn/86.3.531
McNamara, R. K., & Almeida, D. M. (2019, Mar/Apr). Omega-3 Polyunsaturated Fatty Acid Deficiency and Progressive Neuropathology in Psychiatric Disorders: A Review of Translational Evidence and Candidate Mechanisms. Harv Rev Psychiatry, 27(2), 94-107. https://doi.org/10.1097/hrp.0000000000000199Mittal, R., Debs, L. H., Patel, A. P., Nguyen, D., Patel, K., O'Connor, G., Grati, M., Mittal, J., Yan, D., Eshraghi, A. A., Deo, S. K., Daunert, S., & Liu, X. Z. (2017). Neurotransmitters: The Critical Modulators Regulating Gut-Brain Axis.Journal of cellular physiology,232(9), 23592372. https://doi.org/10.1002/jcp.25518Pietrzak, B., Tomela, K., Olejnik-Schmidt, A., Mackiewicz, A., & Schmidt, M. (2020). Secretory IgA in Intestinal Mucosal Secretions as an Adaptive Barrier against Microbial Cells.International journal of molecular sciences,21(23), 9254. https://doi.org/10.3390/ijms21239254Shaheen, N. J., Weinberg, D. S., Denberg, T. D., Chou, R., Qaseem, A., & Shekelle, P. (2012, Dec 4). Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med, 157(11), 808-816. https://doi.org/10.7326/0003-4819-157-11-201212040-00008
Sheng, J. A., Bales, N. J., Myers, S. A., Bautista A., I., Roueinfar, M., Hale, T. M., & Handa, R. J. (2021). The hypothalamic-pituitary-adrenal axis: development, programming actions of hormones and maternal-fetal interactions. Front Behav. Neurosci. https://doi.org/10.3389/fnbeh.2020.601939Shin, J. M., & Sachs, G. (2008, Dec). Pharmacology of proton pump inhibitors. Curr Gastroenterol Rep, 10(6), 528-534. https://doi.org/10.1007/s11894-008-0098-4
Singal, A., & Arora, R. (2015, Mar-Apr). Nail as a window of systemic diseases. Indian Dermatol Online J, 6(2), 67-74. https://doi.org/10.4103/2229-5178.153002
Stanciu, C., Trifan, A., Mihailovici, S., & Cojocariu, C. (2007, Jan-Mar). Endoscopic diagnosis of Helicobacter pylori in patients with bleeding peptic ulcers. Rev Med Chir Soc Med Nat Iasi, 111(1), 57-64.
Stephens, M. A., & Wand, G. (2012). Stress and the HPA axis: role of glucocorticoids in alcohol dependence.Alcohol research:current reviews,34(4), 468483. HYPERLINK "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860380/" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860380/
Struyvenberg, M. R., Martin, C. R., & Freedman, S. D. (2017, Feb 10). Practical guide to exocrine pancreatic insufficiency - Breaking the myths. BMC Med, 15(1), 29. https://doi.org/10.1186/s12916-017-0783-y
Tapp, Z., Godbout, J. P., & Kokiko-Cochran, O. N. (2019). A tilted axis: Maladaptive inflammation and HPA axis disfunction contribute to consequences of TBI. Front. Neurol. https://doi.org/10.3389/fneur.2019.00345Tardy, A. L., Pouteau, E., Marquez, D., Yilmaz, C., & Scholey, A. (2020). Vitamins and Minerals for Energy, Fatigue and Cognition: A Narrative Review of the Biochemical and Clinical Evidence.Nutrients,12(1), 228. https://doi.org/10.3390/nu12010228Yang, X., Lou, J., Shan, W., Ding, J., Jin, Z., Hu, Y., Du, Q., Liao, Q., Xie, R., & Xu, J. (2021). Pathophysiologic Role of Neurotransmitters in Digestive Diseases.Frontiers in physiology,12, 567650. https://doi.org/10.3389/fphys.2021.567650Weir, C. B., & Jan, A. (2022). BMI Classification Percentile And Cut Off Points. In StatPearls. StatPearls Publishing. Copyright 2022, StatPearls Publishing LLC.
Zdilla, M. J., Saling, J. R., & Starkey, L. D. (2016, Feb). Zinc sulfate taste acuity reflects dietary zinc intake in males. Clin Nutr ESPEN, 11, e21-e25. https://doi.org/10.1016/j.clnesp.2015.11.004Zhang, M., Juraschek, S. P., Appel, L. J., Pasricha, P. J., Miller, E. R., 3rd, & Mueller, N. T. (2020). Effects of High-Fiber Diets and Macronutrient Substitution on Bloating: Findings From the OmniHeart Trial.Clinical and translational gastroenterology,11(1), e00122. https://doi.org/10.14309/ctg.0000000000000122Zuvarox, T., &Belletieri, C. (2021). Malabsorption syndromes. Treasure Island (FL): HYPERLINK "https://www.statpearls.com/" StatPearls Publishing.
Table of ContentsIntroduction
Revised Treatment aim
Discussion of revised treatment aim
Revised 24 hour diet - discussion of key recommendations
Comparison of previous and revised 24 hour diet
Supplement Prescription
Evidence based discussion key nutrient 1
Evidence based discussion key nutrient 2
Dose & instructions
Self reflection of nutritional knowledge
References
Appendices
TOC o "1-3" h z u
Introduction
The purpose of this paper is to develop an evidence-based prescription for John. As discussed in
Revised treatment aim
WHAT? WHERE? HOW? OUTCOME? ACTION? MODALITIES?
What is your overall goal?
What is it that you are seeking to achieve? What tissues or systems are you seeking to work on? How will you achieve this?
What?Via?To?
What is the pathophysiology you are seeking to modify?
What is/are the mechanisms of action you are seeking to alter?
Who will the patient feel? What actions will your therapeutics exert? What modalities are best indicated to achieve this aim?
Improve digestion and increase digestive secretion Upper GI Justification & Discussion of revised treatment aim
Revised 24 hour diet - discussion of recommendations
Comparison of previous and revised 24 hour diet
Diet Change
(nutrient or food group) Old diet Revised diet Rationale
Supplement Prescription (photo of supplement ingredients in appendix)
Supplement Name & Manufacturer/Brand:
Brief rationale of the supplement for John:
Evidence based discussion key nutrient #1
Evidence based discussion key nutrient #2
Dose of supplement to be taken
Instructions for taking supplement
Self-reflection of nutritional knowledge & strategies to address this:
ReferencesOriginal Treatment aims
Foodworks / Foodworks Analysis Reports Revised Diet
Foodworks / Foodworks Analysis Reports Previous Diet (optional)
Nutritional Supplement ingredients
