Monday, March 30, 2015

Omega Fatty Acids and Metabolic Syndrome

Fish and omega 3 fatty acid intake has been an area of interest for the potential protection effect against cardiovascular disease. Metabolic syndrome is one risk factor for Coronary Heart Disease (CHD) and has also been associated with increased CHD mortality and morbidity. Because fish/omega 3 intake may protect from CHD, this study had the objective of determining the effect of intake on metabolic disease prevalence. This study used 3,504 male and female Koreans aged 40-69 from a previous study. Each participant completed a food frequency questionnaire to identify omega 3 intake. Metabolic syndrome incidence was identified by health examinations during a follow up period. The data revealed that fish intake was significantly associated with more acceptable triglyceride and HDL levels. Daily fish intake in males (but not females) also demonstrated a significant decrease in occurrence in metabolic syndrome. The study concludes with the thoughts that a diet high in omega 3 fatty acids and fish was significantly associated with a decrease risk of metabolic syndrome in men, but not women. Further research is needed to determine if fish intake should be encouraged for the purpose of metabolic syndrome prevention.

This study demonstrates the association between specific nutrients and prevention of chronic disease. It is important for dietitians to maintain up to date on nutrition research to assist in prevention of chronic illness through specific MNT and enhance the profession of dietetics.

-LL


Baik, I., Abbott, R. D., Curb, J. D., & Shin, C. (2010). Intake of fish and n-3 fatty acids and future risk of metabolic syndrome. Journal of the American Dietetic Association, 110(7), 1018-1026.

Friday, March 27, 2015

Nutrition Support in Traumatic Brain Injury

In any form of acquired brain injury, your first concerns are stabilizing the patient and preventing further neuronal injury/limiting secondary brain damage. In patients with traumatic brain injury (TBI) many metabolic alterations can occur such as hypermetabolism, hypercatabolism, and glucose intolerance (Wang et al., 2013). The management of such alterations hinges on nutritional support.

Nutritional support is recognized as an “important adjunctive therapy" (Wang et al., 2013) for targeting primary, secondary and long-term effects of TBI. Various prevention strategies have been identified which may reduce mortality, improve outcomes and decrease infectious (i.e., pneumonia/other respiratory tract infections; CNS infection; bloodstream infection/sepsis; urinary tract infection) and feeding-related  complications (i.e., feeding intolerance; aspiration; diarrhea; vomiting; constipation; abdominal distention) (Wang et al., 2013). These include the use of enteral nutrition (EN) and parenteral nutrition (PN) feedings, the use of nasogastric or non-nasogastric EN feedings, and early initiation of feedings. The use of probiotics as well as arginine, glutamine, nucleotides and omega-3 fatty acids also have been investigated.

Decisions regarding choice and delivery of nutrition support in TBI remain controversial - both routes of nutrient administration are effective in improving nutritional status and promoting positive outcomes in post-head injury hypermetabolic states, and both approaches show specific advantages and disadvantages. In any case there are certain parameters that will help determine which will be preferred. Parameters that determine the optimal route of administration include gut functionality, duration of NPO status, symptoms of malabsorption and current energy intake compared to goal energy intake. Patients with severe head injuries should receive early enteral feeding when feasible and when the gastrointestinal tract is functional.
EN is generally the preferred route of nutrition support for patients with TBI; this is due to less risk of infection/noninfectious complications, decreased length of stay and reduced hospital costs. EN supports cell and organ function, gut mass and barrier function; also reduces risk of hyperglycemia or hyperosmolarity (Wang et al., 2013). There are, of course, disadvantages regarding this approach. Such disadvantages include the concern of inadequate delivery of nutrients, obstructions of feeding tubes, GI intolerance to tube feedings, and interruptions in feedings (Vincent et al., 2012; Wang et al., 2013). Delivery of enteral feedings and occurrence of feeding intolerances and interruptions can be the difference between improved clinical outcomes and in-hospital malnutrition. When EN is no longer a feasible option, or is no longer tolerated (<50% of their goal rate by day 7 post-injury) PN should be introduced (Wang et al., 2013).

PN feedings, which are indicated for patients with impaired gastric function, is likely to be beneficial for TBI patients. For TBI parenterally fed patients, PN has the benefit of allowing more nutrient bioavailability and delivering nutrients over shorter time periods without the complications brought about by EN (Wang et al., 2013). For moderately to severe head injured patients, PN might be the optimum route of feeding; however, this route “should not be misunderstood as opposition to the suggestion that EN is preferable whenever possible with functional gastrointestinal tracts” (Zaloga, 2006).
Though PN can be an alternative approach of nutritional support when enteral feeding is not feasible or when a risk of malnutrition is present, it is filled with complications especially when PN is not gradually introduced. Consequently rapid refeeding can lead to the condition known as refeeding syndrome (hypophosphatemia). Refeeding syndrome occurs when aggressive PN particularly carbohydrate (dextrose) is delivered to a patient in a nutritionally compromised state. The sudden administration of dextrose stimulates the release of insulin, which promotes rapid glucose, phosphorous, potassium and magnesium uptake into the cells. The net result: a shift in electrolyte (serum concentration of phosphorous, potassium and magnesium decrease) and fluid balance (insulin secretion associated with high carbohydrate load leads to sodium and fluid retention). This marked shift in electrolyte and fluid balance can potentially be fatal. One potential consequence from fluid retention may be an increase in cardiac workload. Increased cardiac workload due to fluid retention may further increase heart rate and oxygen consumption leading to acute cardiac failure. Increased extracellular fluid volume also can lead to pulmonary edema.

Various studies have demonstrated that non-nasogastric (NNG) feeding has a positive impact on reducing mortality rate and decreasing ventilator days in TBI patients (Escribano et al., 2010; Grahm et al., 1989; Kostadima et al., 2005; Minard et al. 2000). The use of NNG feeding in TBI patients in the ICU setting also promotes EN tolerance, helps avoid overfeeding and prevents aspiration pneumonia (Wang et al., 2103). Supplementation with immune-enhanced formulae post-injury appear to reduce infectious complications; however, more studies are warranted to determine its effect on mortality and functional outcome.
References
Acosta-Escribano, J., Fernandez-Vivas, M., Grau Carmona, T., Catturla-Such, J., Garcia-Martinez, M., et al. (2010). Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Intensive Care Medicine 36(9), 1532-1539.  

Grahm, T., Zadrozny, D., & Harrington, T. (1989). The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery 25(5), 729-735.
Kostadima, E., Kaditis, A., Alexopoulous, E., Zakynthinos, E., & Sfyras, D. (2005). Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. The European Respiratory Journal 26(1), 106-111.

Minard, G., Kudsk, K., Melton, S, Patton, J., & Tolley E. (2000). Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN Journal of Parenteral and Enteral Nutrition 24(3), 145-149.
Wang, X., Dong, Y., Han, X., Qi, X., Huang, C., & Hou, L. (2013). Nutritional support for patients sustaining traumatic brain injury: a systematic review and meta-analysis of prospective studies. PLoS ONE 8(3), e58838.

Zaloga, G. (2006). Parenteral nutrition in adult in patients with functioning gastrointestinal tracts: assessment of outcomes. Lancet 367(9516), 1101-1111.
CP

Thursday, March 26, 2015

AND Works to Expand Medicare Coverage of MNT

The Centers of Medicare and Medicaid Services (CMS) is working to improve outcomes in regards to patient care and lower costs of medical services.  In conjunction with a committee from the Academy of Nutrition and Dietetics, the CMS coverage team hopes to change coverage for medical nutrition therapy for adults over the age of 65.  It is their goal to expand coverage to a broader group of disease states and conditions.  The Academy is supportive of this expansion of Medicare Part B, however as part of this change the AND wants to provide evidence to show the importance of a registered dietitian’s role in primary care practices.  Web based resources, toolkits, and downloadable brochures are just some of the ways RDs can utilize evidence based practice and take advantage of opportunities under the Affordable Health Care Act that can further provide a case to insurance companies and employers for RD nutrition services.

AF

MNT Provider - March 2015. (2015, March 1). Retrieved March 26, 2015, from http://eatright.cld.bz/MNT-Provider-March-2015#2/z.

Racial disparities in diabetes education referral


Racial disparity exists for receiving diabetes education referral


 

            According to research published in The Diabetes Educator, black patients with pre-diabetes and diabetes are more likely to be given an education referral than white patients (14.8% vs. 10%; P < .0001).  A retrospective cross-sectional study was conducted on almost 4,000 patients ages 14-89 from 2008 to 2013 to determine diabetes education referrals based upon race. Black patients had higher rates of diabetes than pre-diabetes (75.8% and 24.2%), while white patients had higher rates of pre-diabetes than diabetes (62.3% and 37.7%). Overall, patients with diabetes were more likely to receive referrals than those with pre-diabetes.

            This study is important for clinical dietitians because every patient should be receiving referrals for diabetes education, regardless of race. Additionally, overall referral rates are too low, especially for pre-diabetes. Providing referrals for patients with pre-diabetes gives them the opportunity to reverse their condition and prevent the onset of diabetes.

-ER

Tuesday, March 24, 2015

Lycopene supplemention and vascular function

Evidence from clinical trials, observational studies and in vitro studies suggest that the active carotenoid component in tomatoes - lycopene - may exert anti-atherogenic activity. Concerning possible implications for the human heart, it has been suggested that the anti-atherogenic activity of lycopene may play a role in vascular function and, in addition, the primary and secondary prevention of cardiovascular diseases. In a recent double-blind, randomized, two-arm, prospective controlled study, the potential anti-atherogenic activity of lycopene was evaluated in vivo by monitoring forearm blood flow (FBF), arterial stiffness, blood pressure, heart rate and cardiac biomarkers.

The study screened ninety participants who had presented at the Clinical Pharmacology Unit: University of Cambridge, United Kingdom. Gajendragadkar et al. (2014) sought to 1. Investigate to which extent oral lycopene supplementation predicts vasculature in patients with (or without evidence of) CVD and 2. To determine the impact of oral lycopene supplementation on efficacy (Gajendragadkar et al., 2014). The researchers proposed that treatment with 7 mg was effective in improving endothelial function in both CVD patients and healthy volunteers.

Only those patients with stable CVD and those individuals who were free of CVD and “active renal, respiratory, neurological or oncological disease” (Gajendragadkar et al., 2014) at baseline and have met all eligibility criteria were randomized. In all, 72 patients met eligibility criteria. Patients were divided into two separate yet parallel arms and later randomized 2:1 to receive either acetylcholine sodium nitroprusside or NG-monomethyl-L-arginine injections. Gajendragadkar et al. (2014) found that administration of lycopene was predictive of cardiac vasculature. Review of data suggest that administration of lycopene results in significant efficacy improvements. Lycopene supplementation of 7 mg improved blood flow and decreased peripheral and central diastolic BP. However this was only demonstrated in CVD patients.
Though further research is needed these findings can help dietitians
  1. Understand how lycopene supplementation can augment endothelial function,
  2. Understand the extent to which lycopene predicts vasculature in patients with CVD to those without CVD, and
  3. Understand the effects of lycopene intervention on systemic markers of inflammation, BP, and arterial stiffness, and markers of oxidative stress.
Gajendragadkar, P., Hubsch, A., Maki-Petaja, K., Serg, M., Wilkinson, I., & Cheriyan, J. (2014). Effects of oral lycopene supplementation on vascular function in patients with cardiovascular disease and healthy volunteers: a randomized controlled trial. PLoS ONE 9 (6), e99070.

CP
New MIND Diet Could Significantly Reduce Alzheimer’s Disease

Nutritional epidemiologist Dr. Martha Claire Morris at Rush University Medical Center in Chicago, Illinois developed the Mediterranean-DASH Intervention Neurodegenerative Delay diet, known as the MIND diet for individuals who are at a higher risk of developing Alzheimer’s.  The diet includes aspects of both the DASH and Mediterranean diets that have been found to be beneficial for cardiovascular disease, stroke and high blood pressure.  The MIND diet consists of ten “brain-healthy food groups” and five unhealthy food groups.  Green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, fish, poultry, olive oil and wine are considered healthy food groups, whereas red meat, butter, cheese, pastries, sweets and fried foods should all be limited.  The MIND diet also places extra emphasis on berries such as blueberries and strawberries because they have been found to be beneficial for brain function.  A research study including 923 participants found moderate adherence to the diet showed a 35% reduced risk for Alzheimer’s and those who strictly followed the diet had a 54% decreased risk.  Although further research is needed, these preliminary results are promising for individuals at an increased risk for Alzheimer’s. 

AF


Whiteman, H. (2015, March 18). New 'MIND' diet linked to reduced risk of Alzheimer's. Retrieved March 24, 2015, from http://www.medicalnewstoday.com /articles/291073.php.

Malnutrition During Hospital Stay


In Today’s Dietitian, registered dietitian Mandy Corrigan highlights the importance of an RD during a patient’s stay in a hospital.  She first approaches the subject by highlighting the 1974 article “Skeleton in the Hospital Closet,” which discusses the incidence of malnutrition in the nations hospitals.   Fast forward 40 years, and we are still dealing with the serious issue today.

It has been found that 1/3 patients enter the hospital malnourished, and if the issue is not addressed within their stay, 2/3 will experience further nutritional decline.  The Academy of Nutrition and Dietetics (AND) and The American Society of Parental and Enteral Nutrition (ASPEN) have addressed and are helping the initiative of preventing and treating malnutrition.  AND and ASPEN have developed a standardized protocol for diagnosing adult malnutrition and use an etiology-based definition that utilizes the relationship between malnutrition and disease.  The collaboration between AND and ASPEN also realize that no single parameter defines malnutrition.  Therefore two out of the six developed criteria points must be present to diagnose malnutrition. 

The following actions can be done by dietitians to successfully treat malnutrition:
·      Work with nursing staff and leaders to provide the best possible nutrition screening.
·      Use the resources available (AND, ASPEN, ect.).
·      Utilize nutrition focused physical assessment in your practice.
·      Use the developed criteria from the AND and ASPEN.
·      Document a minimum of two to support nutritional dx.
·      Identify stakeholders and gain their support.
·      Know the negative effects of malnutrition and be ready to discuss with teammates and patients
·      Be a LEADER (visible and vocal member of the health care team).
·      Make sure nutrition is an ongoing component during the patients stay
·      Use the EMR capabilities to document malnutrition.

Corrigan, M.L. (2014). Hospital malnutrition- Standardized guidelines take center stage. Today’s Dietitian, (16)1. Retrieved from http://www.todaysdietitian.com/newarchives/010614p40.shtml


-DH