Tuesday, April 17, 2018

MNT for Hypercholesterolemia


MNT for Hypercholesterolemia

Heart disease is the number one cause of death in the United States and costs billions of dollars for treatment each year.  One of the most prominent risk factors for heart disease is hypercholesterolemia, or high blood cholesterol levels.  Medical nutrition therapy (MNT) from registered dietitians is an important part in the improvement and treatment of high cholesterol.
One study by Delahanty et al. compared the effects of MNT from registered dietitians and the usual care from physicians on the impact of cholesterol levels.  The MNT included counseling visits with a registered dietitian for 6 months and those in the physician care group only received advice from their doctor with no interaction with a dietitian.  No one in either group was receiving medication to lower their cholesterol.  Throughout the study, 24-hour recalls were used to assess energy, fat, cholesterol, and fiber intake.
The MNT group for hypercholesterolemia, showed a 7-8% decrease in total fat intake and 4% decrease in saturated fat intake. This group also had a 6% decrease in cholesterol levels compared with no significant decrease in the physician group. The MNT group also showed more weight loss, more physical activity, and more satisfaction with their treatment than the other group. 
During the medical nutrition therapy, the register dietitians were more likely to include handouts, written instructions, recipes, and different counseling strategies in their treatment program.  After the study, about one-third of those who were in the physician group resorted to medications, weight loss programs, or contacting a dietitian.  None of those in the MNT group were prescribed medications following the program.
Medical nutrition therapy is beneficial in decreasing cholesterol levels and reducing risk of heart disease.  Using MNT for healthy lifestyle changes and behavior modification is effective in helping individuals improve their diet and lose weight, which decreases the risk of many future health issues.  Higher patient satisfaction indicates the importance of the quality of treatment and the individualized attention of nutrition counseling.
NT
Delahanty, L. M., Sonnenberg, L. M., Hayden, D., & Nathan, D. M. (2001). Clinical and cost        outcomes of medical nutrition therapy for hypercholesterolemia: a controlled trial. Journal of The American Dietetic Association, 101(9), 1012-1023.

Sunday, April 8, 2018

Diet vs Statins


Diet Vs. Statins

      Atherosclerotic CVD is the leading cause of early death in the United States. Methods to prevent CVD are continuously being discussed and studied. Drugs, such as statins, as well as dietary changes have both been found to be effective in reducing cholesterol levels in the blood.  It is important to understand how statins and dietary changes both individually affect CVD risk.
      Statins are a drug that are used to lower LDL cholesterol. They have been directly linked with decreased risk of heart attack and stroke. Statin dose is determined based upon level of patient risk. The higher the risk, the stronger the statin dose. Statins have been found to be extremely beneficial to many individuals, however, there are side effects to consider, majority being muscle aches and weakness. These side effects are often the cause of an individual stopping the medication. 
      Diet is another effective way to prevent CVD. A heart-healthy diet should be adopted no matter the level of CVD risk. Meeting at least 3 of the 4 healthful lifestyle factors, including, healthful diet, physical activity, nonsmoking, and not overweight, is associated with lower risk of coronary events. The Mediterranean diet has become the standard for heart-healthy diets and preventing CVD. The Mediterranean diet promotes intake of olive oil, nuts and seeds, fruits, vegetables, high fiber, fish, whole grains, beans, and some meat. However, it has inconsistently been defined in studies, therefore, it is difficult to apply findings. The AHA recommends patient/client-tailored intervention to create a diet tailored to specific clients. This form of intervention may also promote adherence and acceptance to the dietary modifications that are necessary.
      Experts say it is difficult to determine whether diet or a statin is necessarily the "best" method for lowering CVD risk. It is recommended that anyone with a 5% or more risk over 10 years use statins alongside dietary changes. While some individuals would prefer to follow a specific diet, others prefer medication and no change in diet. Another issue that is pointed out is that some people may assume any food, including hot dogs and other highly processed, high-fat, high-sodium items, are okay to eat since they are on a statin. 
      Altogether, it is recommended that all individuals make lifestyle modifications to reduce their risk of coronary events. A healthcare provider will help a client determine if they should also include statin therapy in order to reduce risk. Dietitians should be used to help with diet modification.
      I think this is a very important subject for dietitian's to be made aware of. Given the fact that heart disease is the #1 cause of premature death indicates it is a very large issue in our society. Dietitians are the experts when it comes to nutrition therapy for disease. We must be on the forefront of these disease treatments so that we are able to not only show our worth as healthcare providers, but to hopefully reduce the incidence of coronary events. 


SR

Diet vs Statins
By Densie Webb, PhD, RD
Today's Dietitian
Vol. 19, No. 9, P. 26

Safety of Parenteral Nutrition in Newborns

Lapillonne, A, Berleur, M P, Brasseur, Y, & Calvez, S. 2018. Safety of Parenteral Nutrition in Newborns: Results from a Nationwide Prospective Cohort Study. Clinical nutrition (Edinburgh, Scotland), 37(2), 624-629.

Safety of Parenteral Nutrition in Newborns

Neonates born with gastrointestinal difficulties or malformations are at high risk of malnutrition and subsequent physical and neurological impairments. This study is focused on the safety of providing newborn infants with parenteral nutrition within the first hours of life. Parenteral feeds are lifesaving methods of nutrient delivery when the gastrointestinal tract is compromised, but can put strain on organ systems in adults. It is questionable how well a newborn can handle the strain of parenteral solutions in their weak bodies.

This study included 14,167 infants across 119 hospitals, 77% of which were premature (Lapillonne, Berleur, Brasseur & Calvez, 2018). 80.6% of parenteral feeds were administered on the first day of birth. "The incidence of adverse events related to the parenteral nutrition solutions in [the] study was 0.37%" (Lapillonne, Berleur, Brasseur & Calvez, 2018). This very low incidence of adverse effect suggests use of parenteral nutrition is generally safe in neonatal nutrition care.

Conclusions from this study are that parenteral solutions of up to 800 mOsm/L are tolerated well in peripheral veins and ready to use nutrition solutions can safely provide nutrition from the first hours of birth and on (Lapillonne, Berleur, Brasseur & Calvez, 2018).

-CK

Saturday, April 7, 2018

Diabetes, Obesity, & Risk of Pancreatic Cancer

Diabetes Mellitus and Obesity as Risk Factors for Pancreatic Cancer

      Cancer is the second leading cause of death in the United States. About 1/3 of cancer cases are caused by dietary factors. Pancreatic Ductal Adenocarcinoma (PDAC) is the third leading cause of cancer mortality in both men and women, and is only getting worse. Research has found that obesity and type 2 diabetes (T2DM) are both related to PDAC. Although they often coexist, they have found to individually increase risk of PDAC.

      In one study of over 900,000 people, men and women with a BMI >40 were at a significantly increased risk of death from multiple cancers when compared to normal-weight individuals. Although obesity has shown to be a risk factor for many type of cancers, an increased hip-to-waist ratio has shown to increase risk of PDAC by more than 70%. One study found that BMI 30-35 was associated with a 19% increased risk of PDAC development. Studies have shown that weight loss from dietary restriction, increased exercise, or bariatric surgery reduces risk of cancer. 

      There are multiple mechanisms that overlap between obesity and T2DM. These include insulin resistance, hyperinsulinemia (as a result of insulin resistance), and increased insulin-like growth factor (IGF-1). IGF-1 can promote tumor growth. Research has actually found that the significance of insulin and IGF-1 on PDAC comes from the effects of metformin on tumor growth. Metformin lowers insulin and IGF-1 and has been shown to decrease risk of PDAC by actually cancer cell growth. However, these findings were in patients with early stages of PDAC. Metformin did not seem to have any effect on advanced PDAC. 

      Obesity and T2DM have also been classified as systemic inflammatory conditions, which may promote tumor growth. When pancreatic inflammation is targeted using aspirin or targeted blockade of inflammatory cytokines, cancer development/growth seems to be reduced. Weight loss can reduce inflammation which may lead to decreased risk and progression of PDAC. 

      Although dietary factors are difficult to determine based on selection and recall bias, there have been some associations made. When it comes to carbohydrates, One study found that consumption of 2 or more soft drinks per week was linked to an increased risk of PDAC. Another study found that high free fructose intake and/or high free glucose intake were both linked to a significant increased risk of PDAC. However, no associations have been found between glycemic load or glycemic index and PDAC risk. 

    One study found that intake of total fat were associated with increased risk of PDAC, specifically, saturated fat from red meat and dairy. Also, meat cooked at high temperatures was found to increase risk. Another study found that omega 3 polyunsaturated fatty acids were associated with a significantly decreased risk of PDAC. 
      
      No associations have been found between fruit and vegetable intake and PDAC risk. 


      As dietitians, we are on the forefront of obesity and T2DM prevention. Understanding how obesity and T2DM relate to certain cancers can help us reduce risk of all 3 chronic diseases. If we can use diet to reduce obesity, and type 2 diabetes, we may be able to reduce risk of PDAC overall. 


SR


Diabetes Mellitus and Obesity as Risk Factors for Pancreatic Cancer

Eibl, Guido et al.
Journal of the Academy of Nutrition and Dietetics , Volume 118 , Issue 4 , 555 - 567

Wednesday, April 4, 2018

Nutrition Interventions and HIV


Practice Paper of the Academy of Nutrition and Dietetics: Nutrition Intervention and Human Immunodeficiency Virus Infection

Treatment of Human Immunodeficiency Virus (HIV) and Autoimmune Deficiency Syndrome (AIDS) can present many nutritional challenges, especially related to obesity due to treatments that have extended life expectancy for this population. Antiretroviral Therapies (ART)  have shifted nutrition concerns from undernutrition to obesity and cardiometabolic problems. HIV can alter metabolism, resulting in protein-energy malnutrition, anemias, and micronutrient deficiencies. Risks for chronic disease such as cardiovascular disease and diabetes are higher in this population than in the general population, and obesity and overweight incidence is increasing in people affected by this disease. Food insecurity is also higher than average in this population.

RDs should use the nutrition care process and nutrition focused physical exams to identify malnutrition and nutrition diagnoses. Practitioners should be aware of both over- and under- nutrition as forms of malnutrition. RDs should be aware of AIDS related wasting syndrome and the loss of subcutaneous fat, however ART has shown increases in body weight after initial weight loss is regained so RDs need to monitor shifts in body composition. Probiotic supplementation to treat diarrhea associated with wasting has not been fully tested, and there is no current recommendations on probiotic supplementation in this population. Metabolic abnormalities may result from the disease process, medications, treatments, or other infections, but ART may correct some abnormalities in metabolism. Iron stores should be assessed when anemia is present to identify whether it is resulting from chronic disease or nutrient deficiency. Monitoring cholesterol and blood pressure can help prevent CVD and CKD and should occur before and during ART implementation. Blood glucose should be screened periodically, before and after ART initiation.  Hormone levels can also impact CVD risk and other nutrient concerns, and RDs should be aware of transgender patients and how hormonal treatments may impact their nutrition care. Although side effects associated with ART are less common than in older versions of the drug, they may still pose nutrition related problems, such as diarrhea, anemia, and metabolic alterations.

It is recommended that patients see the RD 1-2 times per year if they are asymptomatic, and 2-6 times if they are symptomatic. Counseling and education in patients have proven to be beneficial. Resting energy expenditure tends to be higher in individuals with HIV, creating a need for higher energy intakes, however, with obesity becoming more prevalent, caloric intake should be closely monitored. Osteoporosis, CVD, diabetes, and hypertension are all comorbidities of the disease, and RDs can play a role in treating and preventing these conditions using MNT combined with other forms of medical and pharmaceutical treatment. HIV-positive patients are also more susceptible to foodborne illnesses, thus the RD can play a role in educating on food safety. The RD should also be familiar with complementary and alternative forms of treatment such as echinacea and St. John’s wort because these therapies are often used by patients with this and other chronic diseases.

New studies need to be done to identify acceptable time frames for monitoring and evaluating this population. For children with HIV, growth failure and loss of lean body mass are the most common problems. Children with HIV need very high energy and protein intake from nutrient dense foods, and may require additional supplementation. Women with HIV are not recommended to breastfeed due to the possible transmission of the disease.  For aging patients, the concern is often additional chronic diseases and interactions of drugs. Minorities are disproportionally affected by HIV and treatment outcomes are often not as good. RDs can be conscious of ethnic considerations and disparities in treatment and socioeconomic status.

AC

Academy of Nutrition and Dietetics (2018). Practice paper of the Academy of Nutrition and Dietetics: Nutrition intervention and human immunodeficiency virus infection. Journal of the Academy of Nutrition and Dietetics 118(3). Retrieved from: https://www.eatrightpro.org/-/media/eatrightpro-files/practice/position-and-practice-papers/practice-papers/hivpracticepaper .pdf?la=en&hash=E99F11F549A01371E98C5F4B9EFE52C729C7D396.

Friday, March 30, 2018

NFPE and Nutrient Deficiencies in the Elderly


Detecting Nutrient Deficiencies with NFPE

The process of conducting a Nutrition Focused Physical Exam, or NFPE, begins with an overall observation, head-to-toe examination, functional indicator assessments, and concludes with a patient interview. NFPE can be used to detect malnutrition and nutrient deficiencies, which can be especially useful in the geriatric population. The geriatric population has a unique set of nutritional needs; they require less energy but often the same amount of vitamin and mineral nutrients as a younger population. Other challenging aspects of this population include medications, cognitive impairment, and differences in environment through the lifespan.

For identifying vitamin D and calcium deficiencies, it is important to look at histories and risk factors, such as history of falls, broken bones, muscle weakness, dental caries, hypertension, osteoporosis, cognitive decline, depression, and chronic pain. Dietitians should consider height changes, sun exposure, and dietary intake of these nutrients when assessing for deficiencies. A meta-analysis has found that concentrations of 25-hydroxyvitamin D less than 20 ng/mL (< 20 ng/mL is considered a deficiency) have been associated with falls. Supplementation recommendations for vitamin D vary from 1,000 IUs daily of D3 to 50,000 IUs weekly of D2.

Folate deficiency can present with fatigue, weakness, palpitations, diarrhea, yellow pallor, sore red tongue, impaired concentration, and eventually megaloblastic anemia, and can be caused by medications, dialysis treatment, alcohol abuse, chronic hemolytic disease, celiac disease, and other conditions. When identifying folate deficiencies, use naturally lighting to look for color changes. Biochemical levels of homocysteine should also be assessed, and if homocysteine is high, folate, B12, and B6 should be assessed and supplemented. B12 deficiencies should be ruled out before folate is supplemented so as not to mask a B12 deficiency. Studies have indicated that despite folate fortification in food, the geriatric population continues to be deficient in this nutrient.

B12 deficiency symptoms include hyperpigmentation of the skin, especially at joints and knuckles, vitiligo, angular stomatitis, weakness, gait abnormalities, dementia, loss of appetite, diarrhea, Hunter’s glossitis, edema, pallor, megaloblastic anemia, and other gastrointestinal and neuromuscular symptoms. Some risk factors of deficiency include atrophic gastritis, decreased gastric acid, chronic alcohol consumption, vegan diets, and inability to consume protein foods as good sources of B12. Pigmentation in knuckles and joints should be observed under natural lighting. B12 deficiencies should be treated with supplementation and by correcting the underlying cause, when possible.
Nutrient deficiencies in aging populations should not be accepted as part of the aging process. Dietitians should identify and treat these issues early on to optimize care for this growing population.

AC

Martin, C. (2018). Detect nutrient deficiencies with NFPE. Today's Dietitian, 20(3). Retrieved from: http://viewer.zmags.com/publication/10096222#/10096222/1

Thursday, March 29, 2018

Diet and Alzheimer's Disease


Diet and Alzheimer’s Disease

Alzheimer’s Disease (AD) is a very costly illness for both patient and caregiver. Drugs used to treat this disease may not be very effective or may result in undesirable side effects. Genetics do not account for all variance in the disease, therefore environmental interventions, such as diet and nutrition, may impact the prevention and course of the disease. Dietary interventions are one of the most feasible and effective ways to prevent age related illness, and the Mediterranean diet is thought to be especially protective against AD.

Studies examining the effects of the Mediterranean diet on AD risk must meet certain criteria to be considered sound research. First, the study must consider whether the diet used follows the guidelines of a strict Mediterranean diet (high monounsaturated fat to saturated fat ratio, moderate alcohol, limited dairy and meat products, high fruit, vegetable, cereal, and legume intake). The closer the diet is to a true Mediterranean diet, the more protective it is against AD. The second consideration is how AD is diagnosed. The most accurate method of diagnosis is postmortem histological analysis, but generally clinical studies rely on other tools for diagnosis, such as the Mini-Mental State Exam. This instrument cannot distinguish AD from other forms of dementia, however 80% of dementia cases are typically AD. The final consideration is the limitations of this type of research and confounding factors such as exercise and other lifestyle behaviors that may interfere with the validity of the research. This can be overcome by applying an intervention to a study, such as one study consisting of counseling interventions of the DASH diet, Mediterranean Diet, and MIND diet and its effects on the risk of AD.

Low carbohydrate diets have also been introduced to prevent AD. Similar to the ketogenic diet, it is thought that the low carbohydrate diet may reduce risk factors for AD, such as diabetes, by reducing hyperglycemia. A low carbohydrate diet was not effective in improving cognitive function in mice, however a ketogenic diet was found to increase lifespan and maintain cognitive function in mice. In humans, the ketogenic diet is very difficult to adhere to because of its unpalatability over time, making it difficult to study the effects of this diet on AD. If the diet is strictly followed, it’s biochemical effects on the body make it a potential intervention to protect against AD.

AC

Mobbs, C. (2018). Diet and Alzheimer’s disease. Today's Dietitian, 20(3). Retrieved from: http://viewer.zmags.com/publication/10096222#/10096222/1