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

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Familial Hypertriglyceridemia

Familial hypertriglyceridemia is a common disorder passed down through families in which the levels of triglycerides in a person’s blood are higher than normal. This condition is not associated with a significant increase in cholesterol levels. Recently I had the opportunity to assist in the treatment of a patient who suffered from familial hypertriglyceridemia. I’m glad I had the opportunity to take part in this case because I really learned a lot from this patient, his conditions, and how all of the components in life can affect the rest of your life and health.

The patient was a male, 39 years of age, and was suffering from hypertriglyceridemia. His condition was also exacerbated by his weight, insulin resistance, and alcohol consumption. The patient’s peripheral vascular disease raised suspicion for familial dysbetalipoproteinema. The gentleman was a non-traditional student at a nearby college, majoring in mechanical engineering. He was also married with two daughters. The patient was the main food preparer in the household and was open and willing to learn new ways of cooking (low-fat) for his family.

Here were the patient’s labs values:
Cholesterol: 254 mg/dl (160-200: normal)
TGs: 1029 mg/dl (35-160: normal)
Glucose: 127 mg/dl (70-109: normal)
HDL: 36.3 mg/dl (40-60: normal)

I’ve noticed it’s always important to put the normal range for each lab value because different facilities/healthcare agencies could have different normal ranges, depending on their measuring tools.

The patient’s typical diet consisted of:
Breakfast:
– Once a week
– Breakfast sandwich
– Danish (sometimes)
– Coffee
Lunch:
– 12p-1pm
– Leftovers- dinner
– Salad- chicken, shredded cheese, Ranch/Italian dressing)
– Sandwich- turkey/ham, wheat/rye bread –or- Chicken hoagie with mustard
Dinner:
– Lean chicken breast (grilled/baked)
– Olive oil
– Bread crumbs
– Vegetables (variety)
– Shredded cheese (Mozzarella or cheddar)
Bedtime Snack:
– Pretzels

So after speaking with the patient, learning his diet habits, and hearing about his lifestyle factors, as well as other miscellaneous habits, we developed a few goals for him to strive for.
Goal 1: The patient mentioned that he drinks 2-3 cans of soda a week. So, we asked if he can cut that out of his diet. And he said he could.
Goal 2: The patient mentioned that he’s very tech savvy so we asked if he could keep a food log on through a Smart phone application. And he said he could.

We also gave the patient education materials on:
– Dean Ornish program
– Nutrition Therapy for high TG levels
– High TG Meal Tips
– Fat-Restricted Diet

It was clear to me that the patient was at risk for developing pancreatitis from the amount of pressure that his pancreas was experiencing from the fat in his diet. So, to avoid this, we recommended that the patient restrict his fat intake to 15% of his daily energy intake. This is a good starting point for this patient. This way we can work together to get his fat (and protein) levels down and take those important baby steps towards decreasing his fat intake even more, hopefully, in the future.
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Women’s Heart Health Month Comes to an End

The facility that I am currently rotating at asked me to assist in preparing a women’s heart health event using resources from the facility’s women’s clinic as well as another Registered Dietitian. So, with the help of WVU’s Extension Service Love Your Heart Movement, I prepared a PowerPoint presentation on women’s heart health and the importance of keeping West Virginia’s women healthy.

Of course, on Tuesday, West Virginia was hit with another spell of bad weather. So, not as many participants could attend. But we still had a very good turnout. I led the presentation with the majority of the information coming from another Love Your Heart Movement presentation, but I also incorporated some tables and graphs from the Center of Disease Control and Prevention (CDC) as well as tips from the American Heart Association’s Life’s Simple 7.

Midway through the presentation a Registered Dietitian had an activity showing the differences between healthy fats and unhealthy fats. Some healthy fats that were displayed were walnuts, almonds, and canned tuna fish. Some unhealthy fats that were shown were butter and Crisco. This was done to show the difference between the health risks/benefits between solid fats and liquid fats as well.

We prepared for this presentation for weeks. And I’m really glad that I assisted with it because the women’s clinic at this facility is considered a special population due to the high volume of male patients they attend to. The participants seemed very engaged and willing to make those small steps towards becoming heart healthy!

I’d also like to say thank you to WVU’s Extension Service Love Your Heart Movement for not only providing the supplies, handouts, and supplemental information from one of their Extension Agents but also for providing the magnets and pins we gave the participants as incentives. The participants loved the items and information and we’re hoping for an even bigger event next year!

Facts on Women and CVD in West Virginia

CDC Burden of Chronic Disease in WV

CDC Women and Heart health Awareness

heart health1

Our Fats Demonstration! What's Healthy and What's Not?

Our Fats Demonstration! What’s Healthy and What’s Not?

Gift bags for the participants which included handouts, magnets, pins, and much more!

Gift bags for the participants which included handouts, magnets, pins, and much more!

I made red dress cards for all the participants to write their own personal goal for their health health. Then, we will hang the cards (similar to a clothesline) in the women's clinic lobby area!

I made red dress cards for all the participants to write their own personal goal for their heart health. Then, we will hang the cards (similar to a clothesline) in the women’s clinic lobby area!

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Nasogastric Tube Feedings

A nasogastric (NG) tube is a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving your patient/client extra calories. It’s important to take good care of the feeding bag and tubing so that they work properly, as well as the skin around the nostrils so that it does not get irritated.NG tube feedings incorporate a procedure where a thin, plastic tube is inserted through the nostril, down the esophagus, and into the stomach. Once the NG tube is in place, healthcare providers can deliver food and medicine directly to the stomach or remove substances from it.

NG tube feeding has four distinct advantages:

·         Short-term (<4 weeks)

·         Most commonly used

·         Easiest to place (with a prior patient assessment)

·         Least expensive to administer

Nasogastric tubes are used mainly for short-term support in patients who do not have problems like vomiting, GERD, poor gastric emptying, ileus or intestinal obstruction. Nasogastric tubes can be used for longer term support where other enteral access is not possible or could potentially carry a risk. NG tubes are potentially dangerous in patients who cannot swallow correctly and those who need to be nursed. A patient assessment should always be carried out prior to placement of an NG tube. NG tubes are placed by appropriately trained staff like nurses or doctors.

There is a small risk that NG tubes can be misplaced on insertion or move out of position at a later stage. Position of NG tubes should be verified on initial placement and before each use. It is recommended that a pH <5.5 is consistent with gastric placement. If aspirate cannot be obtained or the pH is >5.5 feeding should not begin. The NG tube should be left in place, the patient’s position changed and the aspirate re-tested in 1 hour. The feed itself can increase the pH in the stomach, so aspiration should take place at least 1 hour after the feed has been stopped.

NG tube

Cancer of the Sigmoid Colon

The sigmoid colon is the terminal section of your large intestines that attaches to the rectum and anus — a sigmoid colectomy is a surgical procedure in which the sigmoid colon is resected. During this procedure, the sigmoid colon is removed and the remaining large intestine is then reattached to the rectum. After the procedure, patients will need to eat certain foods to allow the intestines to heal, as well as to prevent gastrointestinal upset such as diarrhea, constipation and excessive gas.

Patients should follow a low-fiber diet for about six weeks after discharged from the hospital. A low-fiber diet is imperative for post-colectomy patients to decrease the risk of trauma to the intestines and promote healing. After six weeks, slowly introduce fiber back into your diet. Patients can then increase fiber intake by only one serving each day, until they are able to tolerate 20 grams to 35 grams per day, or about five servings. Patients should be sure to drink plenty of water while increasing your fiber. Fiber can be constipating when not complemented with adequate water.

I recently led a follow-up appointment with a patient who was on his third chemotherapy treatment and recovering from a sigmoid colectomy. The patient consistently lost 14 pounds over the last 6 months but gained 10 pounds since his last appointment, which was last month. But, the patient reported that he was slowly gaining his appetite back but could not tolerate smells like he used to. On the SOAP (subjective, objective, assessment, plan) note I developed, I indicated that I educated the patient on the importance of keeping his weight up and maintaining that weight as well. It’s important for patients to maintain their weight after major surgeries like a sigmoid colectomy, in addition to cancer treatment. The stronger the state that the body is in, the more tolerable it will be towards the treatment of cancer. The patient is currently prescribed a vanilla-flavored supplement from the facility and reported that he couldn’t tolerate the taste of it sometimes. So, I educated him on different ways to make his supplement taste better like adding chopped strawberries to his supplement. We talked about what foods he could eat and how we were going to make sure that the patient listens to his body. By listening to his body, I mean if a patient can tolerate a certain food on a Monday- then eat it. But if he can’t tolerate that same food on Tuesday- try something different. The patient reported that he “forces himself to eat”, which is good for patients going through chemotherapy. A number of patients that are going through chemotherapy become easily frustrated. But, RDs are there to remind them that they need to fight through the frustration and aggravation of their senses (taste and smell specifically) changing.

Livestrong

This is an image of a normal colon

This is an image of a normal colon

This is an image before a sigmoid colectomy and highlights the area that will be removed.

This is an image before a sigmoid colectomy and highlights the area that will be removed.

This is an image of how the colon looks after surgery and the shows the section where surgeons re-connected.

This is an image of how the colon looks after surgery and shows the section where surgeons re-connected.

Roux-en-Y Gastric Bypass Surgery and Nutritional Concerns

Bariatric surgery is performed for patients who have chronic problems and difficulties losing weight, in order to be of a healthy body mass index for their individual size and frame. Weight loss surgery is a major surgery, yet it is safe and effective. It is not considered a cosmetic operation. It is considered to be permanent. One particular bariatric surgery, that I have noticed more common compared to other procedures, is the Roux-en-Y Gastric Bypass procedure.

Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. In this procedure, stapling creates a small (15-30cc) stomach pouch. The outlet from this newly formed pouch bypasses most of the stomach and several feet of the small intestine, preventing your body from absorbing all the calories and nutrients from the foods you eat. By combining the smaller stomach and the malabsorption feature, this surgery produces more weight loss than operations that only decrease the intake of food. The malabsorption of nutrients, especially calcium, iron, and Vitamin B12 can be managed through proper diet and vitamin supplements. An excess intake of sugar and fat may trigger a condition known as “dumping syndrome.” The results can be extremely unpleasant and can include nausea, weakness, abdominal cramping, and diarrhea.

Reasons for the procedure

Obesity lowers quality of life. This can result in poor overall health, and contribute to a higher risk for depression. Your doctor may suggest a RYGB surgery if you have a body mass index (BMI) of 40 or more or if you have a BMI of 35 and also suffer from serious obesity-related health problems such as diabetes, coronary heart disease, sleep apnea, high blood pressure, or severe arthritis.

Doctors generally recommend the weight-loss surgery only if you are severely obese. That means about 100 pounds overweight for men and 80 pounds for women. They also usually don’t recommend it unless you haven’t been able to lose a large amount of weight and keep it off through diet, exercise, and changes in lifestyle.

Before the procedure

It’s important that your weight-loss surgery be arranged at a qualified bariatric center, where you will complete an extensive educational and preparatory program before surgery. Your doctor can obtain a referral from the American Society for Metabolic and Bariatric Surgery (ASMBS).

  • Your doctor will typically test you for nutritional deficiencies and prescribe supplements to correct any problems before the operation. Your surgeon may ask you to have tests and visits with other health care providers before surgery such as a dietitian and a psychologist.
  • Because smoking slows recovery and increases risks of surgery, your doctor will suggest you stop smoking for good several weeks before surgery. Tell your doctor or nurse if you need help quitting.
  • You’ll want to check with your health insurance provider to make sure bariatric surgery is covered in your health insurance plan, as many plans will not pay for it.
  • Let your doctor know about any prescription or over-the-counter drugs, vitamins, and herbs you are taking. In the week before surgery you may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and any other blood-thinning drugs. Ask what drugs you can take on the day of your surgery.
  • Let your doctor know if you have had any trouble with anesthesia in the past.

During the Procedure

With either open or laparoscopic RYGB surgery, you will be given general anesthesia for the procedure. Initially your doctors will start an IV and may deliver medications to help you relax. Your anesthesiologist will use a drug or combination of drugs to control pain and make you unaware of the procedure.

When you reach the operating room, your medical team will use routine monitoring equipment throughout the procedure or longer, depending on your health conditions.

The surgery to create the stomach pouch and the bypass usually takes several hours.

After the Procedure

You may stay in the hospital for two to four days after the procedure. You will typically only have liquids or puréed foods for at least three to six weeks after surgery. Rarely, you may have a catheter, or tube, from the larger bypassed part of your stomach that will come out of your side to drain excess fluids from your abdomen for four or more weeks.

Your RD may slowly add soft food and then regular food to your diet about a month after surgery. You will be instructed to chew slowly and completely and not to drink 30 minutes before or after you eat food.

Talk with your doctor, surgeon, and RD about proper wound care, the type of pain-relieving drugs that are safe to take, and when you can resume physical activities. Your surgeon will tell you how often to change the dressing on your incision.

You should inform your doctor immediately if you develop a fever or if your wound becomes painful or hot to the touch or has a foul-smelling drainage. Also look for any coughing or difficulty breathing, vomiting and diarrhea, pain in the abdomen, chest, shoulder, or legs, or any other unusual symptoms.

Your initial weight-loss may occur quickly, so it’s important to get all of the nutrition and vitamins you need as you recover. Your doctor will prescribe certain vitamin and mineral supplements that your body may no longer absorb well from food alone.

Recommendations for the following supplements to prevent nutritional deficiencies after recovery from surgery are:

  • Daily vitamin D and calcium supplements. Vitamin D deficiency is common in people who have had this kind of gastric bypass. Multivitamins containing 1,200 mg of daily calcium citrate and 400 to 800 IU of vitamin D don’t appear to provide enough protection for bone health, studies suggest. Some experts have had success stopping bone loss by increasing vitamin D intake to 1,600 to 2,000 IU daily. Additional calcium supplementation of 1,600 mg daily is also suggested.
  • Multivitamins. You should take a daily multivitamin that contains 200% of the daily values. Wait two hours to take a calcium supplement after your multivitamin.
  • Vitamin B12 supplements. Doctors recommend vitamin B12 supplementation for all weight-loss surgery patients to help prevent bone fractures. You may need to give yourself B12 injections for the rest of your life.
  • Oral vitamin D supplementation if a deficiency is detected. Your doctor may prescribe 50,000 IU of vitamin D2 taken orally once a week for 8 weeks, some people require lifelong vitamin D supplementation.
  • Iron supplements. Research suggests that after RGBY surgery, the amount of iron contained in a standard multivitamin may not be enough to prevent anemia. Teens and menstruating women may require the amount of iron found in two multivitamins, along with 50 to 100 mg of elemental iron a day.

Because nutritional deficiencies are so common after this surgery, RDs recommend that your blood be tested every 6 months for the rest of your life to ensure that you are getting the right amount of vitamins and minerals.

roux

roux en y

What is the Braden Scale?

The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. The scale is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom and the purpose of the scale is to health help professionals assess a patient’s risk of developing a pressure ulcer.

The Braden Scale is a scale made up of six subscales, which measure elements of risk which contribute to both higher intensity and duration of pressure, or lower tissue tolerance for pressure. These subscales are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The lower the score, the greater the risk for a pressure ulcer a patient is at-risk for.

braden scale1

Braden

pressure ulcer

pressure ulcer1

Small Bowel Obstruction in CF Patients

Small bowel obstruction means the small intestine is partially or totally blocked. When this happens, the contents of the intestine cannot properly get out of the body. Stools, fluid, and gas build up inside the intestine. This is a potentially serious condition that requires urgent medical care.

Symptoms

The symptoms for “mechanical” small bowel obstruction include:

          Abdominal fullness and/or excessive gas

          Abdomen feels stretched out more than normal (abdominal distention)

          Pain and cramps in stomach area

          Vomiting

          Constipation (cannot pass gas or stool)

          Diarrhea

          Bad breath

The symptoms of paralytic ileus include:

          Abdominal fullness and/or excessive gas

          Abdominal distention

          Vomiting after eating

          Pain is often less severe than in “mechanical” small bowel obstruction

The diagnosis of a small bowel obstruction is initially performed through a physical exam. The exam will include listening for bowel sounds in your stomach. Very high pitched bowel sounds heard through a stethoscope suggest mechanical bowel obstruction, whereas paralytic ileus often produces no bowel sounds. Your doctor may recommend that you see a gastroenterologist or surgeon depending on the suspected diagnosis. These tests include:

  • CT scan
  • Abdominal ultrasound
  • Abdominal X-ray

For patients with cystic fibrosis, small bowel obstructions are much more common and potentially more dangerous. In cystic fibrosis, the build-up of thick, sticky mucus blocks the ducts leading from your pancreas to your bowel. When this happens, the amount of insulin that your body produces is reduced and digestive enzymes are stopped from aiding your digestion. Without these enzymes, you may not be able to digest enough essential nutrients and you may find it difficult to gain weight. Malnutrition can lead to poor growth, physical weakness and delayed puberty in children. Your feces may contain excess fat making them oily, smelly, large and difficult to flush away.

NYU Langone Medical Center

Bupa Health Center

intestines digital imagesmall bowelpoint of obstructionCF obstruction

Managing Diabetes- It’s App-tastic!

Currently, a steadily increasing amount of people are using their phone as a source of knowledge and information. Honestly, it makes sense though. Your phone is always with you, it’s convenient, and it fits in your pocket. But, more specifically it’s helping people manage diseases like diabetes. Diabetes can be a mountain to manage, unless you have the right tools: knowledge and organization. According to the American Diabetes Association, nearly 19 million Americans, or more than 8% of the population, have diabetes. An estimated 7 million more are living with diabetes and have no idea they have it.

As discussed, with the rapid rising rates of diabetes, managing the condition is more important than ever! By incorporating the digital age of electronic devices, Smartphones, and more importantly phone applications, managing your diabetes can become second nature. So, here is an app that I recently came across that has been generating a substantial amount of “buzz”. Allow me to further investigate the characteristics of the diabetes app….

1.     Diabetes Companion by mySugr

This is the #1 diabetes app in 6 countries. The Companion is a charming, sometimes outspoken diabetes manager. The app is a new-twist on a diabetes logbook. It gives you immediate feedback in a fun package and helps you stay motivated for the long haul. You win points for every entry made which helps tame your diabetes “monster”. The goal is to tame your monster every day. Challenges are available to help you set and attain personal goals. It’s all the diabetes management you’re used to, with a side-order of context to make it meaningful.

You can use photos of your food along with smart searches to help make educated decisions on the go, use tags, notes, and locations to describe the situations and circumstances around your data, and choose from a variety of ever changing challenges to push yourself and your therapy to the next level of diabetes management nirvana.

Cost: FREE

Key Features include:

          Quick and easy logging

          Smart search

          Convenient data analysis

          Neat and clear graphs

          Handy photo functions (multiple pictures per entry)

          Exciting challenges

          Snappy reports (PDF, Excel)

          Smile-inducing feedback

          Secure data backup

           Social sharing functions

          Fast multi-device sync

          Practical glucose reminders

          Registered medical device (which is very important when looking into apps that help manage/regulate health-related diseases/illnesses)

mySugr Diabetes Manager App: The Companion

MySugrdm appdm

Sixty Five Roses

Cystic fibrosis is the most common fatal genetic disorder in North America. The disorder produces thick, sticky mucus secretions that may seriously impair the function of multiple organs in the body. Most notably, these organs are the pancreas and lungs. Just a few decades ago, an infant born with CF seldom survived to adulthood. Today, the outlook is much brighter, with adults reaching their 30’s, 40’s, and some even into their 50’s.

Cystic fibrosis has three major consequences: chronic lung disease, pancreatic insufficiency, and abnormally high electrolyte concentrations in the sweat. Chronic lung disease develops because the airways in the lungs become congested with mucus, causing breathings to be strenuous. As the thick mucus stagnates in the bronchial tubes, bacteria multiply there. Lung infections are the usual cause of death in people with cystic fibrosis.

Cystic fibrosis causes some degree of pancreatic insufficiency in all cases, with about 90% of cases serious enough to require enzyme replacement therapy. With aging, damage to the pancreas deteriorates. The thick mucus obstructs the pancreatic ducts and interferes with the secretion of digestive enzymes, pancreatic juices, and pancreatic hormones. Eventually, the pancreatic cells are surrounded by mucus and are gradually replaced by fibrous tissues. Malabsorption of many nutrients including fat, protein, vitamins, and minerals often leads to malnutrition. Additionally, the secretion of insulin may be affected resulting in glucose intolerance and diabetes.

The therapy of cystic fibrosis aims to promote appropriate growth and development and prevent respiratory failure and complications. Treatment includes respiratory, diet, and drug therapy.

Nutrient losses through malabsorption, frequent infections, rapid turnover rate of protein and essential fatty acids, high protein catabolism, and high basal energy expenditures raise energy needs for people with cystic fibrosis to between 120%-150% of the RDA for gender and age. Extra energy is needed simply to breathe. RDs estimate individual energy requirements based on basal metabolic rate, activity level, pulmonary function, and degree of malabsorption.

Obtaining enough energy can be complicated, but because people with CF frequently experience a loss of appetite that is aggravated by repeated infections, emotional stress, and drug therapy. Coughing to clear the lungs may trigger vomiting or reflux of foods from the stomach. Thus the person with cystic fibrosis finds it difficult to take in enough food energy, protein, and other nutrients to meet needs.

NIH- Cystic Fibrosis

Cystic Fibrosis Foundation

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