National Nutrition Month Campaign

March is National Nutrition Month and it has been a process in the making at developing a campaign for such an important month to the professional of dietetics! As an intern, I have worked with the entire staff at the facility that I am rotating at currently at, and there are a number of events, activities, and education that we have planned for this month.

MyPlate March Madness:
– Employees register for a month-long MyPlate cornhole tournament and particpate during their lunch hour in the multipurpose room within the facility. The winner at the end of the month will receive a healthy cookbook and cooking tips as well!

West Virginia Ramps:
– Nutritional information, cultural background, cooking use, and growth information will be provided to clients, patients, and employees at the facility. I collaborated with another staff member at developing the content.

NNM 2014 Table Tents:
– I developed these table tents with the NNM 2014 logo as well as “Nutrition 101” questions and answers at the bottom of each side of the table tents. Then I put these on display in the facility’s public eating area for everyone to see! This gives this specific population a boost of nutrition knowledge all throughout the month!

March Mediterranean Lunch ‘n Learn:
– This event will incorporate cooking skills, food culture, and nutritional benefits-like heart health. I assisted in the development and implementation of the event and this will take place at the end of the month, as a 1-hour event in a multipurpose room within the facility as well. Participants will learn how to create easy, affordable, and creative appetizers, dips, and spreads. I’ll even give you a hint- kale chips will have a BIG role in this delicious event as well!

NNM VAMC 2014

Continuing Professional Education (CPU)

The Commission on Dietetics Registration (CDR) defines continuing professional education (CPE) as education beyond that required for entry into the profession of nutrition and dietetics. CPE participation is mandatory for maintenance of registration. CDR Credentialed Practitioners engage in lifelong development to maintain and improve knowledge and skills for competent practice. This includes continuous self-assessments to identify professional strengths and learning needs, establishment of short-term and long-term goals for individual professional development and selection of appropriate CPE to meet these goals.

Prior approved activities are individual educational activities for which activity Providers have opted to request continuing professional education (CPE) hour approval on behalf of CDR Credentialed Practitioners prior to the date of the activity.

The documentation for review to the CDR or the affiliated dietetic association should be submitted 4-6 weeks prior to the activity date. The CDR requests at least 4-6 weeks for review and asks that the applicant keeps one copy for their file. Some affiliate dietetic associations share the CPE approval responsibilities with the CDR.

Live Activities
The CDR or State CPE Review Contact will send verification of approval. Activity Providers MUST provide each participant with a certificate of completion verifying completion of the activity. Providers MUST also maintain a list of participants who completed their activity for at least 7 years. The approval status can be effective up to one calendar year from date of approval. Approval status will expire after the 1st of the year, and the entire activity along with documentation must be resubmitted for review prior to the expiration date.

The following must be provided with Prior Approval Requests:
– Educational objectives, describing anticipated outcomes for each session
– A Timing outline, detailing all the time spent in sessions, meals, breaks, testing, etc. All hours are awarded for learning time only
– Info regarding the target audience
– Qualifications of speaker(s)/presenter(s).

Self Study Activities
Request for Prior Approval of Self-Study activities must be submitted to the CDR for review. Providers MUST also maintain a list of participants who completed their activity for at least 7 years. The approval status can be effective up to one calendar year from date of approval. Approval status will expire after the third year, and the entire activity along with documentation must be resubmitted for review prior to the expiration date. The CDR’s Competency Assurance Panel has ruled that Self Study CPE activities, regardless of their format, will be eligible for CPE credit for up to 3 years from the date of their initial publication. PDP (Professional Development Portfolio) policy had until recently indicated that Self Study activities which were not “enduring”, like newspapers and recording of live presentations, would be eligible for CPE credit for only 1 year.

The following must be provided with Prior Approval Requests:
– Access to Self Study activities, including objectives of the activity stated in operational behavioral terms
– A bibliography for reference and further reading. Complete references must be cited. Controversial or disputed issues must be presented as such, with documentation from current and reputable refereed scientific journals
– Three letters from content experts. Letters should attest to the CPE content appropriateness for the CDR credentialed practitioners with specific comments. The letters should also attest to the length of time required to complete the activity. The content experts should not be associated with the Provider in any way. A biography, resume, or CV must be included for each content
– Documentation of the background in test item development of the item writers (participation in class, workshops on item writing techniques including sponsoring organization’s name)

As a part of one of my major projects for my currently rotation site, they have asked me to present a CPE presentation/webinar to be streamed to other affiliated hospitals on the FODMAP diet. The FODMAP diet is currently a presentation assignment/project of mine for my Graduate Seminar class this semester. So, hopefully my Seminar presentation, on March 25th, goes well and I can work out any kinks before I plan on presenting at my rotation site facility. So, be on the lookout for a blog about the FODMAP diet!

cdr cpe

todays dietitian

Intradialytic Parenteral Nutrition (IDPN)

Intradialytic parenteral nutrition is the infusion of an intravenous nutritional formula of hyperalimentation (artificial supplements of nutrients), like amino acids, glucose, and lipids, during dialysis to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality experienced in patients with renal failure or end-stage renal disease (ESRD). The term “parenteral” refers to administration of medication or fluid other than through the digestive tract (intravenous or intramuscular).

Protein calorie malnutrition, typically assessed by measurements of serum albumin, occurs in an estimated 25–40% of those undergoing dialysis and is associated with increased morbidity and mortality. For example, the risk of death is increased more than 10-fold in those whose serum albumin levels are less than 2.5 g/dL, and those with a serum albumin near the normal range have a mortality rate twice as high as those with albumin greater than 4.0 g/dL.

In patients receiving chronic dialysis, the National Kidney Foundation currently recommends a daily protein intake of equal to or greater than 1.2 g/kg in patients undergoing hemodialysis and equal to or greater than 1.3 g/kg in patients undergoing peritoneal dialysis. In hemodialysis, the intradialytic IDPN infusion is administered through the venous port of the dialysis tubing, typically, 30 minutes after dialysis has begun, and continued throughout the remainder of a dialysis session. In peritoneal dialysis, sometimes referred to as intraperitoneal parenteral nutrition (IPPN) or intraperitoneal nutrition (IP), parenteral nutrition is infused into the peritoneal cavity during peritoneal dialysis.

Patients with ESRD on chronic hemodialysis have a high incidence of protein-energy malnutrition (PEM). The reasons for this are multi-factorial and include: inadequate food intake, a catabolic response to systemic illness or chronic inflammation, loss of nutrients through the dialysis procedure, as well as systemic effects of the uremic milieu. IDPN has been supported for the management of malnutrition in hemodialysis patients. The rationale for its use is that patients are unable to increase oral intake to meet their nutritional needs or that the oral or enteral route is not effective in managing malnutrition in this group of patients. Nevertheless, numerous studies using IDPN have failed to demonstrate efficacy conclusively with this very costly mode of treatment.

So, this being said… Today I had the opportunity to witness and assist in the methodology regarding how the Clinical Manager at my rotation site approves or possibly denies a patient request for IDPN. Currently, the cost for this request would approximately be $7,000 per month for a patient to receive IDPN, which is three times per week. So, my job today was to determine if this patient is eligible for the hospital to provide IDPN and how to justify the approval/deny request to hospital administrators as well.

Below are the criteria that I researched which is currently being used for the approval/denial of IDPN:

Patient must demonstrate the following:
– Failed attempt to increase nutritional status with oral nutritional supplements
– Is not a candidate for tubefeeding (where nasogastric or gastronomy feeding is unsafe or impractical)
– Is able to meet greater than or equal to 50% of needs orally

Criteria for Initiation: Patient must meet any three of the following:
– Three month average serum albumin 10% of UBW –or- <90% of IBW
– SGA: score B or C indicating moderate to severe malnutrition
– Diet history showing decrease in:
o Protein <1.0g/kg/d
o Calories <25kcal/kg/d (≤30kcal/kg/d for those with higher kcal requirements)
– Documented diagnosis of a GI disorder (like gastroparesis, malabsorption syndromes, etc.)

Sample IDPN prescription
Initiated after 30 minutes into the dialysis session, through the venous port of the dialysis tubing and given for the duration of the hemodialysis procedure (3.5 hours) at a rate of 150 ml/hour.

Solution:
1. Amino acids: 300 mL of a 15% solution of amino acids (15% Clinisol®; Baxter Healthcare Corp., Deerfield, Illinois, USA) consisted of nine essential AAs (lysine, 1.18 g; leucine, 1.04 g; phenylalanine, 1.04 g; valine, 960 mg; histidine, 894 mg; isoleucine, 749 mg; methionine, 749 mg; threonine, 749 mg; thryptophan, 250 mg) and eight nonessential AAs (alanine, 2.17 g; arginine, 1.47 g; glycine, 1.04 g; proline, 894 mg; glutamate, 749 mg; serine, 592 mg; aspartate, 434 mg; tyrosine, 39 mg).
2. Dextrose: 150 mL of dextrose at a concentration of 50%
3. Lipids: 150 mL of lipids at a concentration of 20% This solution provides 188 kcal/hour or 3.5 kcal/kg fat-free mass per hour for a total of: 45 g of protein and 735 total kcal in 600 mL.

Medicare Intermediary Criteria (2009) for Initiating IDPN in the Presence of a Functional Gastrointestinal Tract
1. Evidence of protein or energy malnutrition and inadequate dietary protein and/or energy intake (for instance: dietary history of decreased intake: protein <0.8 g/kg and/or calories <25 kcal/kg and subjective global assessment (SGA): “C” rating [severe malnutrition])
2. Weight loss greater than 10% of ideal body weight or 20% of usual body weight (no time constraints)
3. Serum albumin <3.4 g/dL (3 month rolling average)
4. Evidence of a comprehensive nutritional assessment and dietary counseling
5. Inability to administer or tolerate adequate oral nutrition, including food supplements or tube feeding
6. Evidence that patient was intolerant of enteral nutrition, or could not meet the individual’s nutritional needs or is not feasible (3 month trial)
7. Evidence that the individual has had the following conditions ruled out or previously addressed:
– Anorexia caused by the uremic state
– Altered taste sensation
– Intercurrent (limited) illness
– Emotional distress or illness
– Impaired ability to procure, prepare or mechanically ingest foods
– Unpalatable prescribed diets
– Catabolic response to a superimposed (limited) illness
– Inadequate dialysis/uremic state
– Gastroparesis
– Constipation

ESRD_Costs_Billions

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esrd

Amyotrophic Lateral Sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS), also known as “Lou Gehrig’s Disease,” is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.

There is early evidence from a small study that people with ALS who are fed a high-kcal, high-carb diet, could potentially see the progression of their disease slowed.
Patients with ALS, who have difficulty swallowing, as did the 24 people in this study, often end up requiring a feeding tube into the stomach in order to receive the adequate amount of nutrition. These patients are usually fed a standard commercially available formula. ALS patient lose weight because they are not able to take in enough calories because of their difficulty in swallowing. As patients lose weight, they are actually burning their own muscle.

Researchers found that a high-kcal, high-carb tube-fed diet was safe and tolerated- better than one designed to main weight or a diet high in fat. Patients on the high-kcal, high-carb diet gained some of the weight they had lost. At the very least, patients should avoid losing weight.

There needs to be larger trials to see if patients should be trying to gain weight. But, until this happens, all patients with ALS should be actively avoiding losing weight.
This study was published in February 2014 and experts report that the results are far from definitive. This study is also much too small to really show a survival benefit from the diets described. A larger trial would be needed to really highlight any problems. Overall, the study, and future studies, would be beneficial if it included more patients.

als

Coronary Artery Disease (CAD)

CAD is the most common type of heart disease. In the United States, it is the #1 cause of death for both men and women. Lifestyle changes, medicines, and medical procedures can help prevent or treat CAD. These treatments may reduce the risk of related health problems. CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and plaque, on the inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can’t get the blood or oxygen it needs. This can lead to chest pain (angina) or worse. Most heart attacks happen when a blood clot suddenly cuts off the hearts’ blood supply, causing permanent heart damage.

A patient seen today was admitted in the intesive care unit (ICU) and was referred to the nutrition staff for support in cardiac care.

Background:
The patient experienced a myocardial infarction (MI) and had coronary artery disease (CAD). He was a male, 85 y/o, and admitted for an MI protocol. He was currently on a cardiac diet with no gastric irritants (NGI). NGIs are foods like juices, chili, and black pepper. He was not experiencing shortness of breathe (SOB), nausea, fever, chills, or vomiting.

Anthropometrics:
Ht: 69 in.
CBW: 195# (88.5kg)
BMI: 28.86 (overweight)
IBW: 160# (72.73kg)

Past Medical History (PMH):
• CAD/Cornoary Artery Bypass graft (CABG)
• Deep Veing Thrombosis (DVT)
• Chronic Kidney Disease (CKD)
• Carotid Stenosis
• Hypertension (HTN)
• Peripheral Vascular Disease (PVD)
• Gallbladder Disease
• Microvascular Decompression (MVD)
• Aortic Atherosclerosis
• Renal Neoplasm
• Cholecystitis
• Stable Angina
• Asbestos Exposure
• B-12 Deficiency

Labs:
Glucose: 132 mg/dl (70-109: normal)
Cholesterol: 144 mg/dl (160-200: normal)
TGs: 205 mg/dl (35-160: normal)
HDL: 36.3 mg/dl (40-60: normal)

Assessment:
TLC Diet
• Limit saturated and trans fats
• Limit cholesterol: less than 200 mg/d
• Limit total fats: 25%
• Consume dietary fiber
• Consume more omega-3 fats
• Consume more plant-based meals

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