FDA approves weight loss drug, Qsymia

The FDA has approved yet another weight loss drug, Qsymia.  It is the second diet drug to be approved by the FDA in the past month (along with Belviq).  Qsymia and Belviq are the first FDA-approved drugs in over 13 years.  In a study conducted by the manufacturer Vivus, participants lost an average of 10% of their body weight.  Qsymia seems to be more effective than Belviq.  Participants taking Belviq only lost 4% of their body weight.

Qsymia is a combination of two drugs.  Phentermine, a stimulant related to the amphetamines that suppresses the appetite, and topiramate, a drug used to treat migraines and epilepsy that has weight-loss effects. The side effects of Qsymia are possible heart problems, birth defects, mental fogginess, ad lack of concentration.

What is my personal opinion of Qsymia and weight loss drugs in general? I believe this quote sums it up the best:  “I do think it will help a subpopulation lose weight.  However, I am concerned that mass marketing of this drug will perpetuate the magic bullet approach to weight loss, which is limiting and does not address the root problem,” said Dr. Gerard Mullin, an associate professor at Johns Hopkins School of Medicine.

Enteral Nutrition

“If the gut works…use it.” – This is the theory behind enteral nutrition.

Enteral nutrition, commonly known as tube feeding, is commonly used in patients who can not obtain nutrition or food by swallowing on their own.  Enteral nutrition is a generally safe technique to provide nutrition to individuals who have a well-functioning gastrointestinal system.

Indications for enteral feeding

• Impaired nutrient ingestion – neurologic disorders, facial/oral/esophageal trauma, respiratory failure, cystic fibrosis, traumatic brain injury, anorexia and wasting with severe eating disorders
• Inability to consume adequate nutrition orally – hyperemesis, burns, congenital heart disease, anorexia in congestive heart failure/cancer/COPD, spinal cord injury
• Impaired digestion, absorption, metabolism – severe gastroparesis, inborn errors of metabolism, Crohn’s disease, short bowel syndrome
• Severe wasting or depressed growth – failure to thrive, sepsis, cerebral palsy

Types of feeding tubes

1.) Nasogastric Tube (NG Tube) – An NG tube is passed through the nares (the nostrils) and down the esophagus and into the stomach. NG tubes are typically for short term use (3-4 weeks).

NG Tube

2.)  Nasoduodenal/Nasojejual Tube – This feeding tube goes through the nose and is placed post-pylorically in either the duodenum or jejunum.  This is for patients with gastric motility disorders, esophogeal reflux, or persistent nausea and vomiting.

3.)  Gastric Feeding Tube (G-Tube) –  A tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition (at least 4 weeks).  A specific type  of G-tube is a PEG tube (Percutaneous Endoscopic Gastrostomy), in which a tube is placed endoscopically through the abdominal wall and into the stomach.

4.)  Jejunostomy Feeding Tube (J-Tube) –  A tube surgically inserted through the abdomen and into the jejunum.

J-Tube

Classifications of enteral feeding formulas

Source: http://www.hardingmsn.com/resources/Enteral%20Feeding.pdf

Contraindications to enteral feeding

• Obstruction of the intestines
• Paralytic ileus
• Protracted vomiting/diarrhea
• Acute bowel ischemia with peritonitis
• High-output fistulas
• Acute severe pancreatitis
• If the patient can meet nutritional needs orally

Benefits of enteral nutrition?

• Safer and more cost-effective than parenteral nutrition (intraveneously delivered nutrition)
• Preserves the mucosal integrity of the GI tract
• Immunological effects
• Reduces septic complications

Complications

• Aspiration
• Microbial contamination
• Tube displacement
• Diarrhea/constipation
• Refeeding syndrome
• Malabsorption
• Glucose intolerance
• Pressure ulcers

The Nutrition Care Process

During the past two weeks of my clinical rotation at Mon General Hospital, I have been employing the Nutrition Care Process whenever I am consulted on a patient.  The Nutrition Care Process (NCP) is a systematic approach used in clinical dietetics in order to provide the best care for the patient.  The NCP provides a framework for the RD to assess each patient’s individual nutritional needs and interventions.  There are four steps to the Nutrition Care Process:

1) The Nutrition Assessment – “A systematic process of obtaining, verifying, and interpreting data in order to make decisions about the nature and cause of nutrition-related problems”.  In the nutrition assessment, the RD should obtain as much information about the patients anthropometric data, medical history, diet history, current diagnosis, medications, lifestyle, etc.

Example of data to collect from a patients medical chart:

• Ht, Wt, BMI, Ideal BW, Usual BW, % Ideal BW
• Current diagnosis and current condition
• Medications and possible food-drug interactions
• Family medical history, past surgeries
• Current diet at the hospital
• Meal intake %
• Assistance with meals?
• Bowel movements and bowel sounds
• Functioning of the patient’s GI tract

Examples of questions to ask the patient during the initial assessment:

• Typical diet or any special diet at home
• Have you ever been instructed on any special diet before?
• Food allergies/dislikes/intolerances
• Usual body weight or any weight changes in the last year?
• Do you cook or eat out? Live alone or with anyone?
• 24-hr recall
• Food frequency questionnaire
• Swallowing/chewing difficulties
• Drink alcohol or smoke?
• Typical physical activity and how much
• Vitamin, nutritional, herbal supplements?
• Why typically shops for groceries?
• Do you read food labels?

Determine patient’s nutritional needs:

• Based on the person’s current diagnosis and condition, determine their energy needs using the appropriate equation recommended by the Academy of Nutrition and Dietetics Nutrition Care Manual (ex: kcal/kg, Mifflin-St. Jeor, Ireton-Jones, etc).
• Determine protein, fluid, and any other nutrient needs that are pertinent to the patient.

2) Diagnosis – This is a nutritional problem that the dietitian is responsible for diagnosing and treating.  A formal nutritional diagnosis consists of three components: Problem “related to” Etiology “as evidenced by” Signs/Symptoms. (Or PES Statement for short).

• Problem: A nutritional problem is broken down into 5 different domains, each with several subtopics. The 5 domains are calorie energy balance, oral or nutrition support intake, fluid intake balance, bioactive substances balance, and nutrient balance.
• Etiology: The etiology is the cause or contributing factors related to the problem.
• Signs/Symptoms: These are defining characteristics that provide evidence that the problem exists. These characteristics are usually measurable or quantifiable.

Example PES statement:  Excessive calorie intake (P) related to regular consumption of large portions of high-fat meals as evidenced by diet history & 12 lb wt gain over last 18 mo (S).

Example PES statement:  Altered GI function (P) R/T ileal resection (E) as evidenced by medical history and dumping syndrome symptoms after meals (S).

3) Intervention – “Purposely-planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, a target group, or population at large”.  The nutritional intervention should be quantifiable and obtainable by the patient.  The intervention could include a change of diet (tube feeding or TPN), nutrition education and counseling,increasing the frequency/types of food choices, etc.

Example of Nutritional Intervention: Pt will include at least one nutrient-dense supplement per day in his diet.

Example of Nutritional intervention: Pt will increase energy intake to 1800 kcal per day, complete 3-day food record for analysis of adequacy.

4) Monitoring/Evaluation-The monitoring and evaluation step is meant to determine if the RD’s intervention had a positive outcome on the patient.  Monitoring in an in-patient setting could be anywhere from 3-5 days.

Clinical Nutrition Topic of the Day: Small Bowel Resection

As part of a case study for my Mon General clinical rotation, I chose an elderly patient who had recent bowel resection surgery.  The patient had been having abdominal pains for the past two weeks.  The patient was permitted no food by mouth (NPO) until further notice and may need possible nutrition support (enteral/parenteral feeding) if the patient cannot tolerate food orally in the next couple of days.  So what is bowel resection surgery and what causes it? Here is some general information.

The purpose of small bowel resection surgery is to remove an area of the small intestine that is blocked or diseased.  The procedure can be performed lapar0scopically or an open surgery on any of the three sections of the small intestine: the duodenum, jejunum, or ileum. A small bowel resection is commonly used to surgically treat these types of conditions:

• Crohn’s disease
• Cancer
• Ulcers
• Intestinal obstruction or blockage
• Bowel injuries or trauma
• Precancerous polyp removal

The diseased or obstructed portion of the small intestine is removed.
Source: http://health.rush.edu/HealthInformation/cancer%20center/10/000118.aspx

The healthy segments of the small intestine are then reattached.

There are many concerns a dietitian may have after a patient undergoes a bowel resection.  The first concern is for the patient to gradually start eating post-surgery.  Due to the altered functioning of the GI tract, many people may experience discomfort after surgery including bloating, nausea, diarrhea, and even have a general fear of eating.  It is important for the dietitian to be realistic about the patient’s goals to gradually increase food intake depending on the severity of the patients surgery and current condition. Clear liquids can be introduced into the diet once the bowel is functioning again (signalled by the presence of bowel sounds or flatus).  The diet can be advanced based on the individual’s recovery process.  If the patient is not meeting their energy needs by oral intake of foods, enteral support may need to be initiated.  Some individuals may never be able to consume normal volumes of food and complete adaption of the GI tract can take up to one year post-surgery.

The small intestine is the site of much of the body’s nutrient absorption, with the majority of nutrient absorption in the first 100 cm. Thus, the dietitan next needs to address nutritional concerns of the patient.  Five factors need to be taken into account: (1) the length of the small bowel left, (2) the presence of the ileocecal valve, (3) which section of the small bowel is left, (4) age of the patient, and (5) the presence or absence of disease.  For the most part, the small intestine will compensate in terms of nutrient capacity for the section of intestine that was removed.  However, the jejunum is much more adaptive whereas removal of the ileum would most likely render a patient on lifelong parenteral nutrition, supplemental vitamin B12, and cause fat malabsorption.

Sources:

ADA Nutrition Care Manual

Clinical Nutrition Topic of the Day: Hypothyroidism

Throughout the week of my clinical nutrition rotation, I have noticed several patients suffering from a disorder called hypothyroidism. In fact, it is estimated that approximately 3-5% of the population suffer from hypothyroidism. Thus, I thought I would do some research on the topic.

Where is the thyroid?  The thyroid is a butterfly-shaped organ located in the front of the neck, in front of the windpipe (or trachea) and just below the voice box (larynx).

The thyroid gland.

What is the function of the thyroid?  The thyroid gland uses iodine from food to make two thyroid hormones:  thyroxine (T4) and triiodothyronine (T3). The thyroid gland stores these hormones and releases them as they are needed.  The hypothalamus in the brain regulates the thyroid hormone.  The hypothalamus releases thyrotropin-releasing hormone (TRH), which stimulates the pituitary gland to release thyroid-stimulating hormone (TSH). When the hypothalamus and pituitary are working normally, they sense the levels of thyroid hormone in the body and release the appropriate amount of TRH and TSH to either stimulate or reduce the thyroid’s production of thyroid hormones.

What are the roles of thyroid hormones?

• Regulates the rate at which calories are burned, affecting weight loss or weight gain.
• Can slow down or speed up the heartbeat.
• Can raise or lower body temperature.
• Influence the rate at which food moves through the digestive tract.
• Control the way muscles contract.
• The rate at which dying cells are replaced.

What is hypothyroidism?  A disorder when the thyroid is not making adequate amounts of thyroid hormones.  Chronic hypothyroidism can raise LDL cholesterol and increase the risk of CVD.  It may also cause other problem such as goiter, depression, and damage to the peripheral nerves.

Here are some common symptoms of hypothyroidism:

• Feeling tired, weak, or depressed.
• Dry skin and brittle nails.
• Not being able to stand the cold.
• Constipation.
• Memory problems or having trouble thinking clearly.
• Heavy or irregular menstrual periods.

What are the risk factors/causes of hypothyroidism?

• Older age
• Females>Males
• Severe iodine deficiency
• Autoimmune disease
• Radiation
• Thyroid surgery
• Pregnancy

What types of medications are used to treat hypothyroidism?  Daily use of the synthetic thyroid hormone levothyroxine (Levothroid, Synthroid, others).

What type of dietary precautions should I take while taking thyroid hormone replacements?  Generally, patients should avoid consuming high fiber because it affects the absorption of the thyroid hormone.  Other foods that should be avoided are walnuts, soybean flour, iron supplements, calcium supplements, antacids containing Mg or Al, some ulcer meds (such as Carafate), and some cholesterol-lowering drugs.

 

Sources:

www.webmd.com

www.mayoclinic.com

Clinical Nutrition Topic of the Day: Cholecystectomy

In the past 3 days of my clinical nutrition rotation at Monongalia General Hospital, I have come across several cholecystectomy patients. I have been doing some reading on the condition and the medical nutrition therapy that is appropriate for after the procedure.  For those who aren’t sur what a cholecystectomy is, here is some general information. Then I will delve into the MNT a dietitian should know relating to a patient post operative.

What is a cholecystectomy?  The surgical removal of the gallbladder. The gallbladder is not essential and can generally be tolerated by humans.

Where is the gallbladder located? It is pear-shaped organ just below the liver in the upper right side of the abdomen.

What is the function of the gallbladder?  The gallbladder collects and stores the bile that is produced by the liver. By storing bile in the gallbladder, the bile becomes more concentrated and thus more potent.  The gallbladder mainly aids in fat digestion.  When food containing fat enters the GI tract, it stimulated the release of cholecystokinin (CCK).  The release of CCK stimulates the relaxation of the Sphincter of Oddi and opens the common bile duct between the gallbladder and the small intestine.  The gallbladder can then release it’s bile contents into the duodenum (or small intestine) where it emulsifies fat and aids in the digestion of food.

What is the function of bile?  Bile consists mainly of cholesterol, bilirubin (from hemoglobin), and bile salts.  Bile has two main functions. (1) Breaks down fats from the diet so it can be utilized by the body.  Without adequate bile, a deficiency can result in the fat-soluble vitamins (A, D, E, & K).  (2) Bile aids in the removal of toxins that have been filtered out by the liver.

What are the causes for a cholecystectomy?  The gallbladder may be removed for a number of reasons, but typically to treat gallstones.  It may also be caused by:

• Gallstones in the gallbladder (cholelithiasis)
• Gallstones in the bile duct (choledocholithiasis)
• Gallbladder inflammation (cholecystitis)
• Pancreas inflammation (pancreatitis)

Gallstones are hardened deposits of bile that form in your gallbladder. These stones can create an obstruction into the bile ducts causing abdominal pain and cramping.

What are the risk factors for gallstones?

• Female gender
• Family history
• Pregnancy
• Older age
• Obesity
• Truncal body fat distribution
• Diabetes
• Inflammatory Bowel Disease
• Certain drugs (lipid-lowering medications, oral contraceptives, estrogens)
• Certain ethnicities (Pima Indians, Scandinavians, Mexican-Americans)
• Rapid weight loss (i.e. after gastric bypass or severe calorie restriction)
• Chronic low-grade infections
• High dietary fat intake over a prolonged period of time

What role does the dietitian play in the treatment after a cholecystectomy?

• Most patients after a cholecystectomy are not hypermetabolic or catabolic, and can be assessed at standard nutritional requirements for their height, age, and weight.
• A low-fat nutrition prescription (<30% energy as fat) with a modest protein content may assist in controlling symptoms until surgery to remove the gallstones can occur.
• Consuming a large amount of fat in one meal can overwhelm the bile needed to be produced by the liver. This can cause bloating, gas, and diarrhea due to undigested fat.
• Cholecystectomy patients can advance to a regular diet as tolerated.
• Patients should consume small, frequent meals.
• Foods NOT recommended: high fat foods, fried foods, foods with strong odors, foods that cause gas.

1-Day Menu Fat-Restricted Diet

Breakfast	½ cup oatmeal with 1 cup skim milk 2 slices whole wheat toast with 1 teaspoon margarine and 2 teaspoons jam ½ cup orange juice
Lunch	1 cup chicken noodle soup Turkey sandwich: 2 slices whole wheat bread, 2 oz turkey, and 1 teaspoon   mayonnaise 8 baby carrots 1 apple 1 cup skim milk
Evening   Meal	3 oz lean roast beef 1 cup potato ½ cup green beans 1 whole wheat dinner roll with 2 teaspoons margarine 1 orange ½ cup pudding made with skim milk
Snack	½ cup pretzels

Approximate Nutrient Analysis

Calories: 1,600
Protein: 85g (21% of calories)
Carbohydrate: 259g (63% of calories)
Fat: 29g (16% of calories)
Cholesterol: 107mg
Sodium: 2,191mg
Fiber: 25g

Sources:

ADA Nutrition Care Manuel

Krause’s Food & Nutrition Therapy 12th Ed.

http://www.mayoclinic.com/health/Cholecystectomy/my00372

Do people ACTUALLY read nutrition facts labels?

A recent publication in The Journal of the American Dietetic Association reported that most people tend to overestimate the amount of time they spend looking at food labels.  The authors used eye-tracking technology to discover that the position and location of nutrition information on packaging of food can have an impact on the viewer.  Information at the top of the label was viewed more than at the bottom, and information in center of the screen was viewed more than at the sides.

Bottom line? People have a short attention span when it comes to food labeling.  Therefore, the location and eye-appeal of an item’s packaging and labeling can have a great impact on disseminating nutrition information to the public.

Take a look at this video created by the authors, which summarizes the study and their results!

If you want to read the full scientific report, here is the citation:

Graham DJ, Jeffrey RW.  Location, location, location: eye-tracking evidence that consumers preferentially view prominently positioned nutrition information. J Am Diet Assoc. 2011 Nov;111(11):1704-11.

Clinical Rotation: Day One

Today was the first day of my clinical nutrition rotation at Monongalia General Hospital in Morgantown, WV. I will be spending the first 2 weeks of this rotation doing clinical work and the second 2 weeks doing food service/patient services.  Mon Genearl is a 189-bed acute-care community hospital and Level IV West Virginia Trauma Center.  The hospital offers a full range of services, including General Surgery, Cardiac Surgery, Cardiology, Orthopedics, Imaging and the Hazel Ruby McQuain Birth Center.   Mon General has consistently been rated in the top 10 percentile in the county for patient satisfaction.

Monongalia General Hospital – Morgantown, WV

Today being my first day at the facility, I was oriented and introduced to the general procedures of the dietetic department.  I shadowed an RD throughout the day as she performed dietetic education and recommendations when consulted by a doctor or staff.  I observed her as she educated four different patients on their specific diets (as well as a spouse or family member if present).  She spoke with two post-heart attack or bypass surgery patients who were placed on a cardiac diet, which consists of low-sodium and low-fat intake.  She also spoke with a newly diagnosed renal disease patient about the importance of limiting protein, sodium, and potassium in the diet.  She always asked each patient their satisfaction with the food the hospital had provided them (taste, temperature, etc). For the most part all of the patients were very pleased with their meals.  She also gave the patients educational handouts to take home with them regarding the diets they should continue while they are home.  This usually included a list of recommended foods, foods to avoid, and a shopping list.  I also learned how to record the dietary consult into the patients electronic record or chart.

Overall, I really liked my first day of clinical and look forward to the next two weeks.  It will be a huge learning process, but I am very excited!

A great post by Emily!

Emily Todhunter, WVU Graduate Dietetic Intern

Back in the fall I volunteered at the “Go Red for Women” event at the West Virginia Heart Institute.  Other first and second year WVU dietetic interns and I got to meet 1-on-1 with the women who attended the event and give them nutritional counseling based on their lab values (fasting glucose, cholesterol, blood pressure, weight, BMI) they had recorded and received earlier in the event.  In the beginning, I was very nervous to be giving nutritional advice and answering nutrition questions from strangers, but as the day went on, it was actually a very enjoyable and educational experience.

After talking with each of the women about how they can improve their lab values through changes in their diet, I’d ask if they had any nutrition questions they wanted answered.  The question that came up the most frequently was concerning sea salt.  Some women had been hearing about how sea salt is healthier than table salt, and they wanted…

View original post 406 more words

Healthy Cooking Demonstration

Last week, I had the opportunity to observe a healthy cooking demonstration by Chef Chris Hall.  Chris Hall went to culinary school, worked in several high-end restaurants, and has been a personal chef for clients in the Washington D.C. area.  More recently he has created his own business called MyKitchen.  He has built a licensed commercial kitchen in his home in Morgantown, where he provides cooking lessons and demonstrations.  There are several different types of cooking classes such as Southern Italian, Indian Cuisine, Kids in the Kitchen, Sushi, and a multitude of others.  The class I was able to observe was a 3-hour healthy cooking lesson called “Light, Fast, and Delicious”.  In a class of around 8-10 students, Chef Chris began the lesson by introducing himself and speaking a little bit about his background.  He then began explaining the fundamentals of the kitchen, where to find different types of equipment, and safety procedures.  He then allowed students to pair up and choose one of the eight recipes he had provided.  The recipes were all low-fat, healthy, and quick to prepare.  These recipes included pork Diane, chicken marsala, chicken noodle soup, fruit smoothies, a fish dish, green chile chicken, jumbalaya, and a few others.  I tasted all of the dishes and they were absolutely delicious…definitely not what you would expect from a “low-fat” meal.  Chef Chris was extremely helpful and truly loves teaching others how to cook.  Even if you have never set foot in the kitchen before, he does not mind teaching the basics.  I really liked the atmosphere of MyKitchen.  It felt like I was at my parents or grandparents house learning how to cook a recipe that had been handed down for generations.  And because it was such a small class, everyone got to know each other and got to taste everyone elses healthy creations.

I thought the healthy cooking demonstration was a great learning experience and it inspired me to want to cook more.  I also think that healthy cooking demonstrations should be utilized more in the community nutrition setting.  As a dietitian, we always tell people what to eat…but not how to prepare it.  I think there are major opportunities for educating the public on healthy cooking, just like MyKitchen has been doing.

Chef Chris Hall demonstrating cooking techniques.

The “Light, Fast, and Delicious” class preparing healthy meals in the commercial kitchen.

Check out MyKitchen’s TV commercial at http://www.youtube.com/watch?v=YxQx9ziqds0.