Thursday, May 4, 2017

Malnutrition

Malnutrition is a major problem within hospitals. As many as 50% of patients enter with malnutrition. This is a statistic of great concern because malnutrition is associated with many adverse outcomes for patients. Malnutrition is associated with increased mortality, morbidity, and length of hospital stay. Inadequate dietary intake can lead to poor functioning of the immune system, damage to the mucosal layer of the gut, increased risk of diarrhea, malabsorption, and infection. Insufficient caloric intake is also associated with muscle wasting. For these reasons it is very important to carefully screen every new patient for malnutrition.
            While there is evidence for the importance of proper nutrition in the inpatient population, it is also necessary to identify patients who may not benefit from aggressive nutritional intervention. Feeding during acute severe illness may be ill-advised. Recent recommendations suggest a low calorie intervention during the first week of critical illness possibly will provide the best outcomes. Unfavorable consequences due to refeeding or early feeding have been reported with interventions occurring too early. It may be that the loss of appetite during illness is advantageous to the patient.
SG 

Schuetz P. Food for thought: why does the medical community struggle with research about         nutritional therapy in the acute care setting? BMC Med. 2017;15(38):1-4. DOI:            10.1186/s12916-017-0812-x.

Iron and PN

For those living with short bowl syndrome, Crohn’s disease, cancer, dysmotility, or other diseases, home parenteral nutrition is a constant, and life sustaining treatment. Many patients with these conditions report low levels of iron. This deficiency is typically due to blood losses and malabsorption. The iron deficiency usually persists in those receiving home parenteral nutrition mostly due to blood losses. Despite this common deficiency, iron in not usually added to PN solutions. This omission is because of the relation to anaphylaxis and other acute reactions that often occur.
Some studies have shown that iron dextran can be added to PN solutions to safely meet daily needs. One such study looked at 185 patients receiving long-term PN at the Mayo Clinic. 32.4% of participants had iron deficient anemia while on PN. The patients were given iron as an infusion, added iron dextran in their PN, or both methods. Those who received the intravenous infusion of iron showed a significant increase in iron status. This study suggests that those who are at risk for iron deficient anemia while on long term PN should consider an infusion of iron.

Hwa Y L, Rashtak A, Kelly D G, Murray J A. Iron deficiency in long-term parenteral nutrition therapy. Jpen-Parenter Enter. 2015;40(6);869-876. DOI: 10.1177/0148607115587329.

SG

Refeeding Adolescent Eating Disorders

Restrictive eating disorders are a serious problem for many adolescents. In some cases, inpatient monitoring is needed for these patients. These individuals are typically severely malnourished with BMIs of 14 or below. During their stay, nutritional support to gain weight back to a healthy range is essential. The current guidelines recommend that patients start at 10 kcal/kg/day. This exceptionally low kcal recommendation is to avoid refeeding syndrome. However, recent research suggests that, in the adolescent population, the starting kcal recommendations does not need to be so restrictive.
            A study performed by Parker, Faruquie, Anderson, et al. assessed the complications of feeding adolescents above the current recommendations. The study looked at 162 adolescents admitted to an inpatient eating disorder program with an average length of stay of 3.6 weeks. The average age was 16.7 years and average BMI on admittance was 80.1% of ideal. They began feeding at 58.4 kcal/kg/day which is much higher than the recommended levels. The average weekly gain was 2.1kg. During this time-frame, none of the patients developed cardiac symptoms indicative of refeeding syndrome or signs of delirium. They did, however, develop decreased levels of several electrolytes. No significant significance was found between the higher caloric intake and the decreased electrolyte balance. This study suggests that a more aggressive feeding schedule may be warranted in adolescents with severe eating disorders.
SG
Parker E K, Faruquie S S, Anderson G, et al. Higher caloric refeeding is safe in hospitalized        
adolescents patients with restrictive eating disorders. J Nutr Metab. 2016:2016;1-9. DOI: 5168978.

Probiotics

An area of interest in medical nutrition therapy that has been growing recently is the use of probiotics.  It has been suggested that alterations to the natural gut microbiome could contribute to several diseases such as diarrhea, constipation, food allergies, certain cancers, and even autoimmune issues such as inflammatory bowel disease. The idea of using probiotics to both treat and prevent these issues is not new. The link between gut health and yogurt consumption has been documented for almost 100 years. However, the supplementation of probiotics is an emerging field of MNT.
            Probiotics have been shown to be beneficial for antibiotic-associated, traveler’s, and infectious types of diarrhea. Gastroenteritis causes diarrhea that typically lasts for several days. Probiotics have been shown to shorten the duration and should be used in combination with oral rehydration therapy. Supplementation of L. plantarum in patients with irritable bowel syndrome have shown significant decreases in abdominal symptoms such as pain, bloating, and flatulence. The cause of inflammatory bowel disease is not clearly understood but one suspected cause is a disturbance in intestinal flora. Probiotic supplementation has been shown to reduce flares and even lowered the need for glucocorticoids in those with IBD.
            Probiotic supplementations has been shown to be beneficial in many disease states. More research is needed to understand the full impact that probiotics can have as a part of medical nutrition therapy.
SG 

Brown AC, Valiere A. Nutrition in clinical care: an official publication of Tufts University. Nutr    Clin Care. 2004;7(2):56-68. PMCID: PMC1482314.

Unconventional Diets in Cancer Care

Dixon, S. (2016). Unconventional Diets in Cancer Care. Today's Dietitian.18(12) 42
http://www.todaysdietitian.com/newarchives/1216p42.shtml

FS

An unfortunate diagnosis of cancer comes with questions and uncertainties regarding medical and nutritional therapy. Oncology dietitians have come with numerous unconventional nutrition and dietary approaches to help aid in overall energy intake that which is secondary to nausea, vomiting, lack of appetite, malabsorption, and constipation can all contribute to declining nutritional status. Ketogenic diets have been approached for patients battling cancer due to the research stating that cancer cells use large amounts of energy derived from glucose. By restricting dietary carbohydrates in cancer patients, there is a secondary force for the body to use fats and ketones for energy which may improve outcomes of cancer. In addition to the ketogenic diet, many dietitians are trying high-carbohydrate and plant-based diets. Dr. Dean Ornish investigated the use of a low-fat vegan diet in men diagnosed with a less aggressive form of prostate cancer. Studies showed that a low-fat vegan diet along with stress management was estimated to help these men either avoid or delay conventional treatment for at least two years by making simple dietary and lifestyle modifications. Its important to realize that there are numerous dietary approaches for individuals battling cancer that patients want to try. Although no one diet has been proven to help all cancer patients, dietitians work to find what works best for each individual in their practice.

Wednesday, May 3, 2017

Certified Dietary Supplements


The U.S. dietary supplement industry has grown into a multibillion dollar industry over the recent years. The Academy of Nutrition and Dietetics indicates that the industry was worth $36.7 billion dollars in 2014. As future Registered Dietitian Nutritionists, it is important to understand the regulatory standards and quality certification programs for dietary supplements to ensure the safety of the public.  Because the Food and Drug Administration (FDA) does not establish standards for dietary supplements, there is very little standardization.  Essentially, anyone off the street can start his or her own supplement company and sell you a powder/pill with their proprietary blend “formulized for maximum potency.”  With this in mind, it is important to opt for dietary supplements with third-party certifications.  The gold standard certifications to be on the lookout for are US Pharmacopeial Convention (USP), NSF International, and ConsumerLab (CL).  All three parties issue standards that require dietary supplements to pass quality, safety, performance, and claim parameters individually set by each governing party.  Regardless of workplace setting, questions about dietary supplements are bound to come up.  RDN’s can help keep the public safe, and informed. 

Akabas, Sharon R. et al. (2016). Quality Certification Programs for Dietary Supplements
Journal of the Academy of Nutrition and Dietetics, Volume 116, Issue 9, 1378-1379.

SM