Thursday, May 5, 2016

Resting metabolic rate (RMR) equations; what's the story?



Finding the RMR for your client or pt is a crucial first step in diagnosing adequate energy requirements; without this basic info, we can't very well proceed with the NCP. RMR is defined as the energy required for vital bodily functions at rest. The most accurate way to get this number is through indirect calorimetry. This is both way to expensive and time consuming for the daily routine of RDs. For this reason, prediction equations using basic, easy to get data such as, age, weight and height are used. There are a lot of these equations, and some debate as to which one is the most accurate.

The study set out to test the accuracy of the Harris-Benedict, WHO, Mifflin-St Jeor, Nelson, Wang equations and three meta-equations of Sabounchi. Both group and individual accuracy were tested. There was also the element of RMR to fat free mass (FFM) introduced as a critical relationship when discussing energy requirements.

The envelope please...

For group accuracy the award goes to Harris-Benedict and WHO. The Mifflin-St Jeor was most accurate for individuals, but it had a tendency to undervalue the energy needs. All of the equations became less accurate with increasing FFM. Overall RMR equations should continue to be undertaken with caution. As usual, more research is needed. Until then, go with  the Harris-Benedict.

Journal of the AND. Cross-Validation of Resting Metabolic Rate Prediction Equations. 2016

FD

Implementing the Care Plan for Patients Diagnosed with Malnutrition—Why Do We Wait?



The implementation of a nutrition care plan (NCP) for malnourished patients in ICU and peri-operative protocols is fairly straightforward. The problem, waiting to implement the NCP, is more evident in the medicine units where integration of the plan with the overall clinical care plan may not be as straightforward. With the prevalence and problems related to malnutrition in hospitalized patients finally recognized and standardized diagnostic criteria available for early identification, there should not be any doubt that implementation of a NCP is a clinically and morally appropriate course of therapy.

Early and adequate intervention of well-documented nutritional deficits may be delayed for a number of reasons. There may be a focus on medical diagnosis first then later on the patients nutrition needs. The care team may be waiting for the pt to regain appetite or have improved symptoms. Many times, a pt may be scheduled for testing that requires a NPO situation, then the testing is delayed and then delayed some more.

These are not simple cut and dry scenarios that can be solved by the book. There are ethical issues involved; what is best for the patient and when. There is a call to develop policies and protocols to alleviate ambiguity related to delaying or proceeding with the NCP. The question "Why wait?" needs to be answered.

Journal of the AND, Implementing the Care Plan for Patients Diagnosed with Malnutrition—Why Do We Wait? 2016.

FD

Cystic fibrosis patients with diabetes; the origin of the contemporary diabetes diet?




As patients with cystic fibrosis (CF) are living longer, incidence of glucose intolerance (insulin resistance) and type 2 diabetes have increased. Previously, glucose monitoring with CF patients was not addressed due to the fact that patients weren't expected to live long enough to develop the added complications of chronic diabetes. The typical diabetic diet style and insulin regimen can not be applied to the energy requirements needed with the CF patient.

With diabetics, diets will have restricted energy, simple sugars and fats following a consistent meal schedule. The CF related diabetic has increased energy needs, and the diet will be higher in fat energy and higher in carbohydrates. This diet also requires a more flexible pattern to accommodate the ever changing needs of the CF patient. More frequent glucose monitoring and different insulin requirements are part of the CF diabetic daily routine. Carbohydrate counting is the key to creating a more flexible diet for the CF pt. Monitoring grams of CHO instead of energy simplifies the meal planning and insulin dose.

Note the date of this article (1994). This type of diabetic diet was a new approach to the MNT of diabetes at the time. The one element missed in this older version is the importance of protein. This is curious because protein is a crucial part of the CF diet. It begs the question; was this the origin of what we consider common MNT for diabetes today?



 

Journal of the AND, Management dilemmas in the individual with cystic fibrosis and type 2 diabetes, 1994

 

FD

Wednesday, May 4, 2016

New Cystic Fibrosis malnutrition screening tool




A malnutrition screening tool was recently evaluated for pediatric patients diagnosed with Cystic Fibrosis (CF). Up to now there has not been a nutrition screening tool for CF patients that considers all relevant clinical variables. The idea is to promote earlier detection of clinical risk.

The tool assigned a score of 1 or 2 to 10 risk factors for malnutrition with a maximum malnutrition score of 14. Risk factors included BMI, pancreatic insufficiency, weight gain less than minimum, dietary intake less than 100%, CF related diabetes and albumin < 3.5 mg/dL.

It is important to note wt. and % intake. CF patients require a high Kcal diet due to their systems constant battle against disease related factors.Serum albumin is normally not considered an indicator when diagnosing malnutrition status. However, in the case of CF, albumin level is an indicator of serum protein reserves and can reflect acute visceral protein depletion. Albumin has also been associated with severity of pulmonary involvement because it is a potent pulmonary antioxidant.

When assessing level of malnutrition, this new tool includes a mild or low category. Out of the 14 total points max, < or = 3 is low, 4 - 7 is moderate and > or = 8 is high. Is this a new trend creeping into malnutrition screening tools?

Journal of the AND,Validation of a Nutrition Screening Tool for Pediatric Patients with Cystic Fibrosis, 2016 

FD

Daily Blueberry Consumption Improves Blood Pressure in Postmenopausal Women with Hypertension

Johnson, S., Figueroa, A., Navaei, N., Wong, A., Kalfon, R., Ormsbee, L., Feresin, R., Elam, M. (2015).   Daily blueberry consumption improves blood pressure and arterial stiffness in      postmenopausal women with pre- and stage 1-hypertension: A randomized, double-blind,   placebo-controlled clinical trial.  Journal of the Academy of Nutrition and Dietetics, 115(3), 370-377.

 

            Blueberries have earned the reputation as a disease-fighting superfood because they are packed with nutrients.  One cup of blueberries provides protein, fiber, vitamin C and vitamin K and minerals such as manganese as well as iron, potassium and copper.  Anthocyanins, the purple pigment found in blueberries, is a phytochemical that also offers health benefits.

            An eight-week study on blood pressure and arterial stiffness was performed on postmenopausal women with hypertension to assess the effectiveness of blueberries on reducing hypertension.  Postmenopausal women have a high rate of hypertension, thus increasing their risk of cardiovascular disease. 

             Blueberry consumption is known to increase the production of nitric oxide, possibly increasing vasodilation.  This eight-week study showed improved arterial stiffness in postmenopausal women with hypertension.  The results of the study would suggest that blueberries consumed regularly could potentially reduce the occurrence of hypertension and reduce the risk of cardiovascular disease.  It is not currently known if increasing the amount of blueberries or the duration would improve results. 

VS

Saturday, April 30, 2016

Hyponatremia


Reinagel, M. (2016, March/April). Who is affected by hyponatremia? Food & Nutrition. Page 14.


Hyponatremia is a life threatening condition that occurs when blood sodium levels drop below 135 mmol/L.  Excessive amounts of sodium are lost through urination, perspiration, vomiting or diarrhea, resulting in hyponatremia.  Overhydration, medications or certain health conditions, such as congestive heart failure, kidney disease, and syndrome of inappropriate anti-diuretic hormone can also cause dilutional hyponatremia.  Athletes, specifically female athletes who participate in long-duration sports most often experience hyponatremia.  Certain medications such as diuretics may deplete the body of electrolytes and therefore sodium, leading to low levels in the blood. Children and the elderly who receive intravenous administration of hypotonic fluids in excessive quantities or speeds can cause dilutional hyponatremia.  It’s also important to closely monitor patients who receive parental nutrition in effort to maintain proper fluid and electrolyte balance.

-AC

Friday, April 29, 2016

Should You be Counting Macronutrients Instead of Calories to Lose Weight?

Barnes, Z. (2015).  Should you be counting macronutrients instead of calories to lose weight? Womens Health.  Retrieved from http://www.womenshealthmag.com/weight-loss/tracking-macronutrients.

Should You be Counting Macronutrients Instead of Calories to Lose Weight?

“If it Fits Your Macros” (IIFYM) diet is a diet that claims that you can have your cake and lose weight. Meeting your macronutrient requirements (carbohydrates, proteins, and fats) is the most important in losing weight according to this diet.  As long as the food fits in your daily allowance of macronutrients, you are allowed to eat it.
Before starting the diet the basal metabolic rate (BMR) must be determined.  The BMR is the amount of energy your body uses at rest.  A registered dietitian will be able to give you a more accurate estimate.  An activity factor is considered that ranges from 1.2(sedentary) to 1.8 (very active) and the BMR is multiplied by this factor.   This gives you your estimated daily calories. The IIFYM diet requires that 40% of your calories come from carbs, 40% from protein, and 20% from fat.   Standard requirements for daily calories are about 50% from carbs, 30% from fats and 20% from proteins.
With this diet you must be able to determine the nutrient contents of every food you eat in order to know if you have satisfied your macronutrients requirements.  You will need to know how many grams of carbs, proteins and fats are required each day. The diet is more restrictive due to the calculations and tracking necessary.  People on this diet will tend to eat the same meals day in and day out because they know those particular foods fit their macros.  If you are eating the same meals week after week,   you may not be receiving adequate nutrients.
This diet may work initially because the person is paying more attention to what they are eating.  However, due to the amount of calculations required (something, we as dietetic students are accustomed to) and the strictness of meeting each macronutrient requirement, the plan is difficult to maintain.  With this diet the amount of carbs (40%) and fat (20%) required are not adequate in keeping the body energized and the protein (40%) is too high, which could cause problems long-term.  The diet does not specify that you should eat a variety of foods but only that you meet the macronutrient requirements, which could potentially cause malnourishment.

Eating a well-balanced diet, controlling portion sizes, and exercising regularly is the best way to lose weight.  IIFYM is yet another diet that will eventually lose its appeal.

VS