Clinical Nutrition Case Study: Cystic Fibrosis

During the last week of my clinical nutrition rotation, I was required to present a case study to my preceptor, program director, and other clinical dietitians I had worked with.¬† My case study was a 24 year old patient with Cystic Fibrosis and Cystic Fibrosis-Related Diabetes. I chose this patient because I was unfamiliar with the condition as well as the medical nutrition therapy associated with the disease. I learned SO much while researching this topic, and I hope you learn more as well…just click through my PowerPoint presentation below! Enjoy ūüôā



Clinical Nutrition Topic of the Day: Ensure vs. Boost

Two of the most common ‚Äúcomplete‚ÄĚ nutritional supplements on the market are Ensure and Boost.¬† For various reasons listed below, individuals¬†will chose¬†a supplement in order to¬†improve their nutritional status, promote weight gain, or receive nutrients that are not being consumed through food.¬† Ensure and Boost are very similar in nutritional content (shown in the table below) and tend to be¬†used interchangeably in the in-patient setting, however many individuals tend to have a taste preference one over the other. Both products come in 8 oz. plastic containers.

Indications for supplementation include patients with any of the follow:

  • Malnutrition
  • At moderate-high nutritional risk
  • Involuntary weight loss
  • Inadequate oral intake
  • Reduced appetite
  • Anorexia
  • Cachexia

Can’t decide between the two nutritional drinks? Take a look at a little comparison and you make the choice that is best for you!

  Ensure Original
Boost Original
Manufacturer Abbott Nestle
Flavors Vanilla, Chocolate, Strawberry, Butter Pecan, Dark Chocolate, Coffee Latte Vanilla, Chocolate, Strawberry
Price $1.34/each at Walmart as of 9/26/12 $1.25/each at Walmart as of 9/26/12
Calories 250 240
Carbohydrate (g) 40 41
Protein (g) 9 10
Fat (g) 6 4
Fiber (g) 0 0
Vitamins & Minerals Meets a minimum of 25% DV for vitamins and minerals Meets a minimum of 25% DV for vitamins and minerals
Added Benefits Contains 320 mg of ALA (a plant-based omega-3 fatty acid) Contains slightly more Vitamin C, K, D, & E than Ensure
Special Dietary Preferences Halal, Kosher, gluten-free, lactose-free, low-residue Kosher, gluten-free, lactose-free, low-residue
Other Types Ensure Bone Health, Clinical Strength, Enlive!, High Protein, Immune Health, Muscle Health, Plus, Powder, Pudding Boost Glucose Control, High Protein, Kid Essentials (in varying calories), Pudding, Plus

*Represented values are for 8 oz of formula

Dietitians Ranked #3 “Best Career for Saving the World”

One of the main reasons I love being a dietitian is because it is one of the most rewarding experiences.

Please read this article by CNN, who named Dietitians as the #3 “Best Career for Saving the World”!

The Dr. Dean Ornish Program for REVERSING Heart Disease

Dr. Dean Ornish on the cover of Newsweek.

During this week of my clinical nutrition rotation at Charleston Area Medical Center, I have had the privilege to shadow the dietitian who works with the Dr. Dean Ornish Program. ¬†I knew a little bit¬†about the program previously, but I did not fully understand the wonderful health outcomes it truly has, not only in reversing heart disease, but¬†in improving the overall quality of someone’s life.

Who is Dr. Dean Ornish?

Dr. Dean Ornish is a physician and president and founder of the nonprofit Preventative Medicine Research Institute¬†in Sausalito, CA as well as Clinical Professor of Medicine at the University of California, San Francisco. While he was a medical student in the 1970’s, he began conducting research on the prevention of¬†Coronary Artery Disease, which included lifestyle modifications¬†such as a low fat, whole-grain, plant-based diet, smoking cessation, moderate exercise, stress management techniques, and psychosocial support.

For the next 30 years, he has conducted scientific, clinical research proving that his program aids in the reversal of heart disease. He has since written several books¬†and had dozens of television appearances on shows such as The Oprah Show, The Dr. Oz Show, and Larry King Live. He is also a consulting physician for former president, Bill Clinton. After the former president’s bypass surgery, Ornish¬†encouraged him to make similar lifestyle changes and to consume a plant-based diet.¬† Recently, Ornish¬†also published a research article showing that these lifestyle changes can slow, stop, or reverse the progression of prostate cancer. Ornish’s¬†compelling, groundbreaking research has proven that his four-tiered lifestyle changes can¬†actually¬†turn back the hands of time in the development of heart disease.

Dr. Dean Ornish, creator of the Program for Reversing Heart Disease.

The Dr. Dean Ornish Program

There are four main components that comprise the Ornish program: exercise, nutrition, stress management, and group support. All of these components work synergistically to help heal the heart from the inside out.

1. Exercise

Includes moderate exercise such as walking, cycling, and strength training.

  • The program encourages aerobic exercise for a minimum of 30 minutes a day or for an hour every other day for a total of 3-5 hours of aerobic exercise per week.
  • If medically appropriate, participants are also encouraged to engage in strength training exercise 2-3 times per week.

2. Nutrition

The lifestyle change requires a low-fat, whole foods nutrition plan that is high in whole grains, fruits, and vegetables. The diet also requires the elimination of all animal products and fish except for fat-free dairy and egg whites.

  • The composition of¬†the Ornish diet is typically around 70% carbohydrate, 20% protein, and 10% of calories from fat¬†(take note that the average American consumes ~35% of calories from fat). Therefore, the diet is VERY low in fat in order to¬†reduce the “stickiness” of the blood and to improve heart function.
  • No meat, poultry, or fish.
  • No caffeine (with the exception of¬†green tea due to it’s health benefits from polyphenols and antioxidants).
  • No more than 10 mg of cholesterol per day
  • One serving per day of a ‚Äúfull-fat‚ÄĚ soy food. A full-fat soy food is one that contains¬†>3 grams of fat per serving, with none of the fat coming from added fats or oils. Always read the label for portion sizes and ingredient content.
  • Food products with added fat (such as soybean oil or canola oil) is allowed 3 times per day as long as a product has ‚̧ g of fat per serving.
  • Whole grain bread and pasta products with ‚̧ g of fat per serving.
  • There’s no counting calories, however portion control is strongly recommended.
  • Limiting alcohol consumption is encouraged to not exceeding one alcoholic drink per day.
  • The addition of¬†a fish oil supplement and a senior multivitamin is encouraged. Why?? Because fish oil has been shown¬†to reduce¬†the risk of heart disease and a senior multivitamin has no iron and contains¬†more Vitamin B12¬†(which may be¬†lacking in the Ornish¬†diet due to the elimination of meat products) compared to a regular multivitamin.
  • Where’s the protein? Legumes, wheat products, and soy products with ‚̧ g of added fat

The Ornish Diet Food Pyramid.

Ornish Diet Sample Meal Plan


  • 1¬ĺ egg white zucchini frittata
  • 1/3 cup each‚ÄĒblueberries, strawberries, blackberries
  • ¬Ĺ cup non-fat milk
  • 1 slice whole-grain bread
  • 1 cup herbal tea or decaf coffee-alternative


  • 1-7/8 cup mango-beet salad
  • 1-7/8 cup vegetarian chili
  • 1 slice corn bread


  • 5/8 cup green pea guacamole
  • 6 whole-wheat pita bread wedges
  • ¬Ĺ cup red grapes


  • 1-7/8 cup fennel and arugula salad with fig vinaigrette
  • 2 cups whole-wheat penne pasta with roasted vegetables
  • 2-1/3 cup fruit-and-yogurt trifle
  • Glass of wine or sparkling water

Nutrition Analysis of Sample Meal Plan

3. Stress Management

The program is not going to eliminate stress from everyday life, but it teaches participants to better manage their stress. Stress management techniques include stretching, yoga, relaxation, deep breathing, guided imagery, and meditation.

It is recommended for participants to practice stress management techniques for about 60 minutes everyday.

4. Group Support

The participants have regular group meetings where they learn to better their communication skills with one another as well as within their personal relationships. Group support is meant to create a social network who will encourage and support each other along the journey.

Group support sessions are meant to help participants in:

  • Rediscovering inner sources of peace, joy, and well-being
  • Learning how to communicate in ways that enhance intimacy with loved ones
  • Creating a healthy community of friends and family
  • Developing more compassion and empathy for both yourself and others


Does the program actually work? …YES. It’s scientifically proven.

Dr. Ornish¬†has published dozens and dozens of research articles in premier scientific journals proving that this program not only helps participants lose weight, but is the only program that has been proven to REDUCE heart disease without surgery or medications.¬† If you would like more information on Dr. Ornish’s published research¬†articles, click on the link here¬†to read the full versions.

In order to give a general sense of the benefits, here are the latest findings from all of the 3,780 patients who went through Dr. Dean Ornish’s Program for Reversing Heart Disease via Highmark Blue Cross Blue Shield in Pennsylvania, Nebraska, and West Virginia as of October 2011:

  • The average patient lost 13.3 pounds in the first 12 weeks and 15.9 pounds after 1 year
  • Significant reductions in systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, and LDL-cholesterol after 12 weeks were still significant after 1 year
  • Exercise capacity increased from 8.7 to 10.6 METS after 12 weeks (18% increase) and to 10.8 METS after one year (24% increase)
  • Significant reductions in depression and hostility (the emotions most strongly linked with heart disease) after 12 weeks that were still significant after 1 year
  • Hemoglobin A1C in diabetics decreased¬†from 7.4% at baseline to 6.5% after 12 weeks and 6.8% after one year (complications of diabetes such as blindness, kidney failure, heart disease, and amputations can be¬†prevented when hemoglobin A1C is less than 7.0%)
  • 96.5% of patients reported¬†improvement in severity of angina (chest pain) after 1 year

Who can benefit from this program?

  1. Those who are contemplating, or have already had, bypass surgery.
  2. Those with a history of cardiac events or surgery and want to minimize the chance of a recurrence.
  3. Those who have been diagnosed with coronary artery disease or diabetes.
  4. Those with significant risk factors for heart disease, such as: a family history of heart disease, high blood pressure, high cholesterol, obesity, and central or abdominal obesity.

How long is the program?

There are two program options:

1.) The Reversal Program: This is a one-year treatment program. The first 12 weeks are more intensive and include meeting two times per week for four hours each. Sessions include lectures, group exercise, stress management, nutrition education, and group support sessions. As the year progresses, the amount of time committed to on-site sessions decreases.

2.) The Spectrum Program: This is a six-week education-only program based on Dr. Ornish’s best-selling book, The Spectrum, which can be tailored to suit almost anyone who wants to make healthy lifestyle changes.

Okay, so how much will this cost me?

The 1 year program costs over $8,000, BUT luckily most participants have their insurance providers cover 100% of the programs costs! Medicare, Highmark Blue Cross Blue Shield, and PEIA all cover the Ornish program for qualifying individuals.

Where are Ornish program locations?

Most programs are located in Pennsylvania and West Virginia. Go to the website to find specific locations near you!

The Ornish 10-Year CAMC Celebration!

Just last week, Charleston Area Medical Center (located in¬†Charleston, WV) celebrated it’s 10th anniversary¬†of hosting the Dean Ornish Heart¬†Disease Reversal¬†program! Read more about the 10 year celebration in this newspaper article¬†printed in The Charleston Gazette.

Jim Perry and John Linton try some of the healthy food last week at the 10-year celebration of the Ornish¬†program, which is offered¬†through CAMC¬†Memorial Hospital. Perry and Linton were part of the program’s original group that started to reduce the effects of and prevent heart disease.

CAMC had the privilege to have Dr. Dean Ornish speak at the celebration via Skype!

Learn more about the benefits of the Dr. Dean Ornish program in this video!

Factors Contributing to West Virginia’s “BIG” Obesity Problem

West Virginia is the #3 “Most Obese” State in the U.S.

Source: Centers for Disease Control.

Source: West Virginia DHHR Bureau for Public Health. Obesity in West Virginia. 2011

According to the Center’s for Disease Control, nearly two-thirds of West Virginian adults are overweight (BMI>;25) and nearly one-third are obese (BMI>;30). The statistics are alarming, but the data that worries me the most is the rate of childhood obesity. In West Virginia, 14.4 % of children ages 2-5 are overweight (85th to ;95th percentile BMI-for-Age). These numbers stay consistent in kids up to 18 years old.

Obesity in WV is Correlated With Being “Unhealthy”

According to the CDC’s Behavior Risk Factor Surveillance System (BRFFS), the obesity rate in WV has increased by 4.6% since 1989. If obesity keeps growing at this shocking rate, by the year 2018 nearly HALF of all West Virginians will be obese! If this holds true in the year 2018, the Nat’l Board of Economic Research estimates that obesity will cost the state of WV nearly $2.3 billion dollars. But why does obesity matter? Why is obesity such a “big” deal anyway?…Obesity is important because it contributes to an individual’s overall health. In fact, West Virginia is ranked #1 in the U.S. for the prevalence of cardiovascular mortality, diabetes, and hypertension (as shown by the graphs below).

West Virginian residents who were obese were less likely to report their overall health as “Excellent/Very Good”.Source: West Virginia DHHR Bureau for Public Health. Obesity in West Virginia. 2011

Obese individuals have the highest rates of cardiovascular disease and hypertension.
Source: West Virginia DHHR Bureau for Public Health. Obesity in West Virginia. 2011

How does your WV county stack up?

Source: West Virginia DHHR Bureau for Public Health. Obesity in West Virginia. 2011

Factor’s Contributing to West Virginia’s Obesity Epidemic

So the million dollar question is: Why are so many West Virginian’s overweight or obese?

The answer is not a simple one. Obesity is a complex issue that involves both genetic and environmental factors. But what is it about the environment in West Virginia that is making it’s residents SO unhealthy and SO overweight?

1. Fruit and Vegetable Consumption: A healthy diet is probably the most important factor in maintaining a healthy weight. The diet of West Virginian’s, however, is of poor quality. Everywhere you turn there’s a fast food joint offering fatty convenience foods. But, like in any region, the food is just a part of the culture. For example, the pepperoni roll is famous in WV since it was invented in Fairmont, WV around 100 years ago. Good old southern cooking is absolutely delicious…there’s no denying that. But there is also no denying how unhealthy it can be as it’s fried up in butter, fat, and salt.

Not to mention, West Virginian’s aren’t eating enough fruits and vegetables. According to the 2007 CDC BRFFS, fruit and vegetable consumption in this state is very LOW. West Virginian adults consuming 2 or more servings of fruits daily was only 24.9%, compared to a national average of 32.8%. And West Virginian adults consuming 3 or more servings of vegetables daily was only 26% compared to the national average of 27.4%.

2. Access to Healthy Foods: To give a picture of the overwhelmingly easy access to fatty, fried, fast foods…here is another alarming statistic: In Huntington County, WV (which is in the #1 most obese county in the entire country!) there are more pizza joints than there are health clubs available in the entire state!

3. Physical Inactivity: The state of WV used to be bustling with manufacturing jobs, mostly coal mining. In recent years, however, the coal mining industry has been on the downfall and the manufacturing jobs that used to require strenuous labor and physical activity are now not as readily available to it’s residents.

As you can see in the figure below, West Virginian’s are more physically INactive compared to the national average rates. According to the CDC BRFFS, 33.2% of West Virginians reported physical inactivity compared to the national average of 24.2%.

Source: West Virginia DHHR Bureau for Public Health. Obesity in West Virginia. 2011

4. Access to Community Streets/Sidewalks: West Virginia, “Wild and Wonderful”, undoubtedly has the most beautiful landscape of all the U.S. states. Wouldn’t that encourage people to get outside and enjoy the beauty that surrounds them? Well, you would think. But have you ever tried to walk, run, or bike along any streets in WV? It is QUITE a dangerous endeavor. Cars zip by as they swerve around narrow and hilly back-country roads. And there are nearly no sidewalks available for people to use…unless of course you’re willing to get in your car and drive somewhere that has a safer place to walk or bike (but whose going to do that?). In addition, WV has yet to pass the Complete Streets legislation, which aims to ensure that pedestrians, bicyclists, and motorists have safe access to community streets.

5. The Economy: Having a low SES status can sometimes be an indicator of the overall health of an individual. According to a Gallup poll, WV ranked as having the LOWEST score in an economic confidence index.

6. Education: According to the U.S. Census Bureau, WV has the LOWEST rate of attaining a Bachelor’s degree. In WV, only 17.3% of the population will get a college education.

7. Dental Problems: West Virginia has the HIGHEST rate of tooth loss in the U.S. Nearly one-third of adults by the age of 35 have lost at least 6 or more permanent teeth and 42% of WV adults over the age of 65 have lost ALL of their natural teeth.

Having a toothless smile is no laughing matter. Having little or no teeth truly does affect a person’s ability to consume food. After all, would you be able to bite into an apple or chomp on a salad without having any teeth?

8. Disabilities: West Virginia has the HIGHEST rate of disabilities according to the U.S. Dept. of Commerce. The study looked at individuals ages 16-64 years old with disabilities that included functional limitations in physical, mental, and communication disabilities, limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL).

Being physically disabled affects a person’s ability to exercise and burn off extra calories…thus causing more subsequent weight gain.

9. Depression: West Virginia is tied with Mississippi for the HIGHEST rate of depression in the U.S. according to the CDC. Nearly 5.3% of adults in WV meet the criteria for clinical depression.

10. Overall Well-Being: According to a Gallup poll that took into account diabetes, frequency of physical activity, consumption of produce, city optimism, and the uninsured – WV ranked as having the LOWEST score of overall well-being.

11. Lack of Registered Dietitians: According to an article in the Journal of the Academy of Nutrition and Dietetics, WV has the second lowest number of Registered Dietitians (RDs) per capita in the state. With only 17 RDs per 100,000 WV residents, this creates a lack of access to accurate nutrition information and accredited nutrition professionals to combat the obesity problem.


BOTTOM LINE: Needless to say, the state of West Virginia has A LOT of confounding factors contributing to it’s obesity epidemic and Registered Dietitians have A LOT of work to do in the future. So we know the obesity problem exists, but how can we fix it? Well…I’ll have to save that blog post for some other time. ūüôā


West Virginia Department of Health and Human Resources Bureau for Public Health. Obesity in West Virginia. 2011.

Haughton B, Stang J. Population risk factors and trends in health care and public policy. J Acad Nutr & Dietetics. Supp, March 2012.

Clinical Nutrition Topic of the Day: Refeeding Syndrome

Refeeding syndrome is defined as “biochemical changes, clinical manifestations, and complications that can occur as a consequence of feeding a malnourished catabolic individual”. This occurs when feeding is reintroduced after a long period of starvation, resulting in many negative consequences.

Overview of Refeeding Syndrome

During the starvation state, the body decreases the rate of gluconeogenesis in order to preserve muscle and protein stores. This leads to fat, mineral, electrolyte, and vitamin depletion. Insulin levels are decreased and glucagon levels are increased.

Whenever the body is suddenly “refed” after it had been previously starved and malnourished, the body switches from a catabolic state to an anabolic state. In response to high glucose, insulin levels are increased. This causes an increase in fat, glycogen, and protein synthesis. These many metabolic processes require fluid, sodium, potassium, and magnesium…which had previously already been depleted. Refeeding syndrome also increases metabolic rate and decreases the body’s ability to adequately deliver oxygen to other organs, resulting in many negative consequences (presented below).

Source: Z Stanga, et al. Nutrition in clinical practice‚ÄĒthe refeeding syndrome: illustrative cases and guidelines for prevention and treatment: The refeeding syndrome. European Journal of Clinical Nutrition 62, 687-694 (June 2008)

Clinical Manifestations of Refeeding Syndrome

The Features and Manifestations of Refeeding Syndrome

Patients at Risk for Refeeding Syndrome

How Can Dietitians Prevent Refeeding Syndrome??

The key to preventing refeeding syndrome is to begin the feeding, whether enterally or parenterally, slowlythen increase to the goal rate over several days. It is somewhat debated, but the starting calorie range should be somewhere between 15-20 kcal/kg body weight/day.

Source: Mehanna H, et al. Refeeding syndrome–awareness, prevention and management. Head Neck Oncol. 2009 Jan 26;1:4.


Mehanna H, Nankivell PC, Moledina J, Travis J. Refeeding syndrome–awareness, prevention and management. Head Neck Oncol. 2009 Jan 26;1:4.

Z Stanga, A Brunner, M Leuenberger, R F Grimble, A Shenkin, S P Allison and D N Lobo. Nutrition in clinical practice‚ÄĒthe refeeding syndrome: illustrative cases and guidelines for prevention and treatment: The refeeding syndrome. European Journal of Clinical Nutrition 62, 687-694 (June 2008)

A Week of Clinical Nutrition at Teay’s Valley Hospital

I am spending this entire week focusing on clinical nutrition and medical nutrition therapy at Teay’s Valley Hospital.¬† Teay’s Valley Hospital (TVH) is a small, 70-bed, rural hospital located in Hurricane, WV.¬† Associated with Charleston Area Medical Center, TVH is located about 25 minutes outside of downtown Charleston, WV.

I have had the opportunity to work with the on-staff registered dietitian. One of the biggest adjustments I have had to make is the transition from electronic charting to PAPER charting!¬† I have always been used to reading a patient’s medical record electronically, so the process of paper charting was completely Greek to me.¬† But I think it will be beneficial for me to experience how things are run in different types of¬† hospitals.¬† And the paper charting wasn’t as hard as I thought it was going to be…even though it sometimes felt like I was deciphering through hieroglyphics! ūüôā

As the weeks of my clinical rotation roll by, I am slowly beginning to become familiar and comfortable with the daily roles and responsibilities of being a clinical dietitian. And thank goodness, because isn’t that the purpose of the dietetic internship?! Like they always say…practice, practice, practice!

Whole Wheat, Whole What?

Whole grains are being buzzed¬†about all throughout the media, but many Americans do not understand the true definition of what “whole wheat” actually means and the¬†benefits it can provide to your health.

Refined vs. Whole Grain: Whole Grain WINS the Battle Every Time

Refined grains¬†go through a process called milling, which strip the grain of the bran and the germ (refer to the “Anatomy of a Grain” below).¬† Milling removes some of the most important nutrients such as fiber, B vitamins, Vitamin E, and many minerals.¬† Refined grains include white flour, white rice, white bread and degermed cornflower.¬† Refined grains are most commonly used because of it’s thinner texture, taste, longer shelf life, and price.

Whole grains refer to grains that are not refined, or have not gone through the milling process. This leaves the bran and the germ intact and leaves behind all the nutritious “stuff” – the fiber, vitamins, and minerals. Whole grains can either be consumed whole (such as brown rice and my favorite whole grain…popcorn!) or as an ingredient in many foods¬† (such as whole wheat breads and pastas).

Confused about whole grain¬†vs. whole wheat?? …They are¬†exactly the same thing!!

Types of Whole Grains

  • Amaranth
  • Barley
  • Buckwheat
  • Corn – including whole cornmeal and popcorn
  • Millet
  • Oats, including oatmeal
  • Quinoa
  • Rice, brown and wild
  • Rye
  • Sorghum (also called milo)
  • Teff
  • Triticale
  • Wheat – including varieties such as spelt, durum, bulgur, and cracked wheat

Americans Aren’t Getting Enough Whole Grains…Period.

Take a look at the figure below from the 2010 Dietary Guidelines For Americans.

Americans are only reaching 15% of the goal for whole grains and nearly 200% of the limit for refined grains!¬† To put it simply,¬†we aren’t getting nearly enough whole grains in our¬†diet (and this needs to change, stat.)

Health Benefits of Whole Grains

Nutrients in Various Types of Whole Grains

The health benefits of whole grains most documented by repeated studies include:

  • Stroke risk reduced 30-36%
  • Type 2 diabetes risk reduced 21-30%
  • Heart disease risk reduced 25-28%
  • Better weight maintenance

Other benefits indicated by recent studies include:

  • Reduced risk of asthma
  • Healthier carotid arteries
  • Reduced risk of inflammatory diseases
  • Lower risk of colorectal cancer
  • Healthier blood pressure levels
  • Less gum disease and tooth loss

 How Much Should I Be Eating?

The 2010 Dietary Guidelines for Americans, written by the USDA and Department of Health and Human Services, suggests that at least half of grains should be whole grains. Or to make it simpler,aim for about 3-5 servings of whole grains every day.

Source: 2010 Dietary Guidelines for Americans

LOOK AT THE FOOD LABEL – Look at the ingredients list.¬†If the FIRST¬†ingredient is whole grain or whole wheat, then it is likely it’s a 100% whole grain product. If whole grain is not the first ingredient listed, then there are other types of grains (not necessarily whole grains) in the product as well.

Look for the Whole Grain Stamps! There are two…

Food producers have the option of putting a “Whole Grain Stamp” on the front of a food package.¬† There are two types of stamps: a “Basic Stamp”¬†and a “100% Stamp”.

  • Basic Stamp:¬† The food item contains¬†at least 8 g, or half a¬†serving, of whole grain…BUT may also contain some refined grains as well.
  • 100% Stamp:¬† The food item has all¬†of it’s grains from whole grains, or a minimum requirement of 16 g of whole grains (which is a whole serving).

A few words of caution…

Folic Acid¬†– Whole grains are not a natural source of folic acid.¬† Thus, look for items that are fortified with folic acid…the easiest source to find fortified whole grains is ready-to-eat cereals.¬† Folic acid is especially important for pregnant women¬†in order to¬†prevent the birth defect,¬†spina bifida.


“2010 Dietary Guidelines for Americans”. USDA & Dept. HHS.

Clinical Nutrition Topic of the Day: Congestive Heart Failure

Throughout the past 5 weeks of rotating through the acute, in-patient setting, I have been exposed to the dietary implications of a very common disease state: Congestive Heart Failure or CHF (not to be confused with the abbreviation, CF, or Cystic Fibrosis in my previous post).

The general definition of CHF is when the heart is unable to deliver oxygen-rich blood to the rest of the body. This can be due to:

  1. A weakened heart muscle
  2. Stiffening of the heart muscle
  3. Diseases that increase the body’s oxygen requirements that are beyond the capacity of the heart

Signs & Symptoms

  • Fatigue and reduced activity
  • Fluid overload
  • Edema of the legs and/or lungs – This is caused¬†by inadequate blood flow to the kidneys, resulting in aldosterone and antidiuretic hormone secretion…which both act to conserve fluid.¬† Aldosterone acts by increasing sodium resorption and antidiuretic hormone acts by conserving¬†fluid in the distal tubules of the nephron.
  • Shortness of breath – Due to fluid overload of the lungs. Shortness of breath usually worsens at night or at rest.
  • Increased urination
  • Mental confusion, memory loss, anxiety, insomnia – Due to decreased blood supply to the brain.
  • Malnutrition, anorexia, decreased appetite, feeling of fullness, nausea, constipation,¬†abdominal pain – Due to fluid overload of the liver. These are some of the most pertinent symptoms to a clinical dietitian because it leads to many nutritional complications and dietary changes.

Risk Factors

  • Gender – During middle age, men are at a higher risk for CHF than women.¬† However, elderly women are at a higher risk than elderly men.
  • Race – The highest incidence of CHF¬†is as follows: black women > black men > Mexican-American men > white men > white women >¬†Mexican-American women
  • Hypertension
  • Diabetes
  • Coronary Heart Disease
  • Atherosclerosis
  • Obesity
  • Left ventricular hypertrophy (enlargement of the left ventricle of the heart)
  • Myocardial Infarction (a heart attack)
  • Excessive dietary sodium
  • Medication noncompliance
  • Arrhythmias
  • Pulmonary embolism

Nutritional Implications of CHF

Because many CHF patients are malnourished, edema can falsely cause their body weights to appear normal or higher than their true weight. Thus, the dietitian should first determine the dry weight of a CHF patient. Thus, the dietitian should determine a patients weight before eating and before urination at the same time each day.  Other determinants of malnutrition, such as serum prealbumin, albumin, and transferrin may appear low due to dilution of extracellular fluid.

As an overall goal, CHF¬†patients should follow a “heart-healthy diet”. This can either be the DASH diet or a diet that is low in saturated fats, trans fats, and cholesterol, and high in fiber.

Nutrition Prescription:

  • Weigh a patient with¬†CHF regularly – This is to monitor anorexia, weight loss, and excess fluid retention.
  • <2 g or 2000 mg of sodium per day¬†– Sodium is restricted because excess sodium only leads to more fluid retention.
  • Fluid restriction – This is usually determined by the physician, but fluid intake is typically restricted to <2 L/day, <1500 mL/day, or <1 L/day¬†depending on the severity of the disease.
  • Adequate energy intake¬†– One of the common complications of CHF is for patients to lose their appetite quickly or become short of breath, leading to decreased energy intake.¬† The recommendation is to use 31-35 kcal/kg of body weight¬†to determine¬†energy requirements (CHF¬†patients have higher caloric and protein¬†needs due to increases in energy expenditure typical of the body being in a catabolic state). Thus, dietitians need to encourage the importance of¬†consuming adequate calories to prevent cachexia and weight loss.
  • Potassium, Magnesium, Calcium ,and Vitamin D – CHF puts individual at a higher risk for¬†lower levels of these vitamins and minerals due to low activity levels, impaired kidney functioning, and prescription drugs that alter¬†their metabolism.
  • Limit or avoid alcohol – Not only will alcohol add more fluid to the diet, but it also raises blood pressure. If alcohol cannot be avoided, limit intake to <2 drinks/day for men and <1 drink/day for women.
  • Limit or avoid caffeine

Source: AND Nutrition Care Manual

Beverages may be included with meals unless satiety is a problem. Pudding and milk would count toward the fluid intake. If your doctor has limited your fluid intake, the total fluids you drink must be within the amount allowed for the day.

Approximate Nutrient Analysis

Calories: 1,832
Protein: 93g (19% of Calories)
Carbohydrate: 293g (61% of calories)
Fat: 40g (19% of calories), Saturated Fat: 10g
Sodium: 1,525mg
Potassium: 3,750mg
Cholesterol: 80mg

Recommended foods for CHF patients.
Source: AND Nutrition Care Manual

Foods not recommended for CHF patients.
Source: AND Nutrition Care Manual


L. Kathleen Mahan & Sylvia Escott-Stump. Krause’s Food & Nutrition Therapy, 12th Edition

Academy of Nutrition and Dietetics. Nutrition Care Manual.

Clinical Nutrition Topic of the Day: Cystic Fibrosis

Cystic Fibrosis (CF) is a debilitating disease that affects secretory cells that produce mucus, sweat, and digestive juices.  CF is genetically inherited as an autosomal-recessive trait that mostly occurs in the Caucasian population, or about 1 in 3,500 births.  The treatment and early detection of the disease has aided in a drastic improvement in the survival rate (the average life expectancy is 37 years), even though some individuals are not diagnosed until the late teens.  A defect in the CF gene, located on chromosome 7q, causes mucus to become thick and sticky, which plugs up many essential ducts and passageways.  CF predominately alters the proper functions of the lungs and pancreas.

Respiratory Symptoms and Complications

  • Wheezing
  • Coughing up sputum and mucus
  • Shortness of breath
  • Decreased ability to exercise
  • Infections with various different strains of bacteria, which causes many hospitalizations and decreases prognosis

Digestive Symptoms and Complications

  • Pancreatic insufficiency – This is due to the production of thick mucus, which blocks the secretion of digestive enzymes from the pancreas into the small intestine. This leads to the inability of the digestive system to metabolize and break down fat consumed though the diet. Also, pancreatic insufficiency can often lead to Cystic Fibrosis-Related Diabetes (CFRD).
  • Bulky, foul-smelling stools
  • Cramping
  • Poor weight gain and/or failure to thrive
  • Intestinal blockage
  • Constipation
  • Steattorhea
  • Gallstones (blocked bile ducts)
  • Rectal prolapse

Medical Treatments of Cystic Fibrosis

  • Many medications – Antibiotics, mucus-thinning drugs, bronchodilators, inhaled medications, and pancreatic enzymes.
  • Chest physical therapy – Such as a clapper or an inflatable vest that shakes the chest cavity to loosen the mucus.
  • Surgical procedures – Nasal polyp removal, oxygen therapy, endoscopy and lavage, lung transplant, feeding tube.
  • Counseling – Nutritional and/or psychological counseling may be recommended for patients and their families.

Nutritional Implication of Cystic Fibrosis

Due to the GI tract’s inability to break down and absorb fats, CF patients are at a high risk for malabsorption and malnutrition.¬† Because each CF patient manifests the disease differently in terms of the age of the patient, severity of the disease, stage of their treatments, lung function, GI function, and other complications, nutrition interventions are very individualized from patient to patient.

Regardless, the nutrition management of CF patients typically include:

  • Controlling maldigestion and malabsorption with pancreatic enzymes – Digestive enzymes, or enteric-coated enzyme microspheres, are consumed orally and released in the duodenum. The dosage of these enzymes depends on the degree of pancreatic insufficiency and the amount and type of food consumed. The more fat being consumed in a meal will results in a higher dosage of enzymes in order to metabolize the fat.
  • Meeting increased energy needs – Energy needs will vary depending on the patients age, gender, BMR, physical activity, respiratory function, and severity of malabsorption. (Some tips to increase energy and calories are suggested below)
  • Promoting appropriate weight gain – Nutritional supplements are often recommended in order to increase energy intake and promote weight gain.
  • Vitamin/mineral supplementation – Typically, fat-soluble vitamins (vitamins A, D, E, and K) are poorly absorbed in CF patients and may need to be taken as a supplement or a multi-vitamin. Also, osteoporosis is also common because vitamin D aids in the absorption of calcium.¬† Therefore, CF patients may have increased calcium needs.

Scandishakes are a common nutrition supplement recommended by dietitians for patients with CF who have increased energy needs.
Scandishakes contain ~600 calories when mixed with eight ounces of whole milk. That’s a lot of calories in a small volume of fluid, which is great for CF patients trying to gain weight!

Here are some nutrition tips for individuals with CF:

  • Eat as often as possible
  • Prepare foods with, or top foods with, high calorie-condiments such as extra butter, margarine, dressings, gravies, creamy sauces, heaving whipping cream, peanut butter, and whole milk to foods and recipes whenever possible
  • Add dried skim milk powder to add protein to sauces and beverages
  • Add extra cheese to pizza, baked potatoes, soups, pastas, etc
  • Add extra deli meats to sandwiches
  • Top bacon to burgers
  • Milkshakes, milkshakes, milkshakes
  • Add instant breakfast mixes to milk-based drinks
  • Add nuts to cookies, cakes, pancakes,
  • Add nuts, eggs, meats, and creamy dressings to salads
  • Breaded meats and fish adds calories


L. Kathleen Mahan & Sylvia Escott-Stump. Krause’s Food & Nutrition Therapy, 12th Edition