Nutrition for Older Adults


elderly

For the past few months, I have been working as a Registered Dietitian for two nursing homes in the Pittsburgh, PA area. Because I did not have a long-term care rotation during my dietetic internship, this has been my first opportunity working with the elderly. I have been gaining invaluable experience learning about the nutritional issues and needs of the aging population and applying that knowledge to help residents in a skilled nursing facility.

The golden question I know everyone is wondering is, “Sooooo, exactly how old is…OLD?” Well, according to The Academy of Nutrition and Dietetics, the category of “older adults” includes those aged 60 years and older (or about 1 in every 8 individuals in this country).

Before I have some of my reader’s up in arms about the 60 year “young” marker, I will put a disclaimer out there that I sincerely believe there is a distinct difference between someone’s “chronological age” and someone’s “physiological age”. Someone’s physiological age is a person’s age as estimated from their body’s health, while someone’s chronological age is person’s actual age in years from their date of birth

Regardless of your beliefs, it is hard to ignore the fact that “baby boomers” are now reaching retirement age and the number of older adults is thus “booming” at a rapid pace. From 1990 to 2010, the percentage of Americans 65 years or older increased from 4.1% to an astonishing 13.1% of the total population. Not to mention, with the advancements in healthcare and technology, Americans are now living longer than ever. To illustrate this, I really like this interactive map of the United States, which demonstrates the increased life expectancy over the past 25 years. According to the CDC, the life expectancy is 81.1 years for females and 76.6 years for males. Unfortunately, many of the elderly may end up in a nursing home, skilled nursing facility, or assisted living facility. In the U.S., over 1.5 million residents are living in nursing homes…88% of those are 65+ years old. And these individuals aren’t just staying for a month or two either. According to the 2004 CDC National Nursing Home Survey, the average length of stay is 835 days.

Why does nutrition play such an important role in the health of older adults? To start, nutrition has a major influence on 5 out of the 8 most common causes of death in older adults (see figure below). Secondly, 80% of older adults have at least one chronic disease, with about 50% having 2 or more chronic diseases.  Diet not only plays a MAJOR role in the prevention of chronic diseases, diet also helps to minimize their complications and associated risks (thus having a factor in your physiological age). common cause of death 65

There are many health, physiologic, and functional factors that change our nutritional status and nutritional needs as our bodies age.

1.) Medical/Health Status

  • Presence of chronic or acute illness
  • Medications
  • Sensory changes – taste, smell, appearance, texture
  • Disability and immobility
  • Oral health – Missing teeth and ill-fitting dentures can effect your ability to chew

2.) Physical/Functional Status

  • Physical limitations
  • Balance
  • Physical strength and endurance
  • Physical activity – There are numerous health benefits for older adults. Please refer to the figure below.

physical activity benefits in older adults

3.) Cognition and Mental Status

  • Change in mental status
  • Education level
  • Depression – Nearly 19% of adults 65 years and older suffer from depression.
  • Emotional needs
  • Habitual food intake
  • Health/nutrition-related beliefs
  • Advertising

4.) Environmental Status

  • Living situation – About 29% of non-institutionalized older adults live alone, making it more difficult for them to prepare meals.
  • Economics
  • Cultural beliefs and traditions
  • Religious beliefs and traditions
  • Environment
  • Lifestyle
  • Access to food and proper food storage/preparation
  • Socialization – Living alone versus living with a family member

5.) The Nutritional Needs Of Older Adults

  • Energy – There is about a 15% decrease in calorie needs between age 30 and age 80. With decreasing physical activity, lean muscle mass diminishes and fat mass increases. To estimate calorie needs:

– For men: subtract 10 calories/day for every year of age above 19

– For women: subtract 7 calories/day for every year of age above 19

  • Protein – Evidence has found that dietary intake of protein declines with age, despite the fact that the body’s protein requirements generally stay the same throughout life. (Click here to find out how much protein you should be consuming). It is recommended for adults to consume about 30 grams of high-quality protein at each meal, or a total of 0.8 grams of protein for every kilogram of body weight. Protein malnutrition can lead to other health complications such as muscle wasting, fatigue, and sarcopenia. In long-term care, we measure an individual’s protein needs based on their serum albumin or pre-albumin levels (which is a measure of a visceral protein status or lean muscle mass).
  • Nutrients – Many nutrient needs stay the same throughout the lifespan. Because of decreased energy expenditure and decreased caloric requirements, this makes it difficult for individuals to consume an adequate amount of nutrients while still consuming less calories.
  • Vitamin D and Calcium – These are two important nutrients older adults should be consuming through their diet due to increased risk of osteoporosis. However, many do not consume enough through dietary sources and thus resort to supplementation. Diet daily requirements for calcium and vitamin D are:

Calcium – 1200 mg/day

Vitamin D – Adults 51-70 years old need 10 mcg/day and adults 70+ need 15 mcg

  • Vitamin B-12 – To prevent anemia, older adults should be consuming the RDA of vitamin B-12, which is 2.4 mcg. Older adults are at a greater risk for vit. B-12 deficiency due to malabsorption, lack of intrinsic factor, atrophic gastritis, and poor diet.
  • Hydration – Dehydration can be a major concern for older adults because many do not consume adequate amounts of water.  There are multiple reasons for this, including: decreased perception of thirst, endocrine changes, alterations in cognitive status, side effects of medications,  fear of incontinence, and immobility. An individual’s estimated fluid needs is about 25-30 mL of water for every kilogram of body weight.

 

Lastly, here is an easy and quick tool that I like to use to DETERMINE if someone over the age of 65 is at risk for malnutrition.

Disease – Do you have any chronic illnesses that changes what you need to eat?

Eating poorly – How is your appetite? How many meals a day do you eat? Do you eat fruits and vegetables?

Tooth loss or mouth pain – Do you have problems chewing such as ill-fitting dentures?

Economic hardship – Do you have enough money to buy the types of foods you need?

Reduced social contact – Do you eat alone or with others?

Multiple medications – Do you take 3 or more prescribed or over-the-counter medications?

Involuntary weight loss or gain – Have you lost or gained more than 10% of your body weight over the past 6 months?

Needs assistance – Are you physically able to shop, prepare foods, cook, and feed yourself?

Elderly person – Are you over the age of 80?

 

Sources:

Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness

www.cdc.gov

The Final Two Weeks of Clinical Nutrition


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For the past two weeks, I have had the opportunity to complete my clinical nutrition hours at a small, 80-bed hospital in Morgantown, WV. HealthSouth Mountain View Regional Rehabilitation Hospital specializes in rehabilitating patients who may have had a variety of different conditions.

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HealthSouth treats patients with disease states such as:

  • Stroke
  • Traumatic Brain Injury
  • Amputations
  • Spinal Cord Injury
  • Burns
  • Hip Fractures
  • Arthritis
  • Neurological Disorder
  • Various Injuries/Multiple Trauma

The responsibilities of a dietitian at a rehabilitation hospital is similar to that of a dietitian in an acute care hospital. The overall goal is to evaluate the patient’s nutritional status and determine an intervention to improve their condition in terms of their food. I have really enjoyed working at a rehab hospital because the average length of stay for a patient is 10-14 days, which is much longer than the acute care setting. For this reason, you get to know the patients much better and also have the chance to watch their condition improve.

The other interesting aspect of working at a rehab hospital is participating in a collaboration with many different medical disciplines. The medical team works together to improve the patient’s condition to a point where they can function with minimal assistance in their own home. The dietitian works closely with the speech therapist, physicians, nurses, physical therapists, and occupational therapists.

The DASH Diet ranked #1 Best Overall


As a future dietitian, the number one health question I get asked by friends, family, and patients is: “What is the best diet?”.

“The answer is not so simple”, I tell them, “You have to do what works best for you”.

fad diet

Luckily, health professionals at U.S. News & World Report ranked 29 of the “Best Overall Diets”. The overarching winner?…(drum roll please)…The DASH diet.

The DASH diet recieved a total score of 4.1 out of 5 possible points. The diets were judged based on the following categories: short-term weight loss, long-term weight loss, easiness to follow, nutrition, safety, best for diabetes, and best for heart health. However, not all categories were weighted equally. For example, long-term weight loss was weighted twice as much as short-term weight loss…which I completely agree with (because I believe long-term weight loss is the most imporant factor in determining the success of a diet).

Also known as the Dietary Approaches to Stop Hypertension, the DASH diet was developed by the National Institutes of Health (NIH). The diet is rich in fruits, vegetables, whole-grains, and low-fat dairy and limits foods with added sugar, red meat, and added fats.  Originally, the DASH diet was designed with the purpose of lowering blood pressure and, after several randomized control trials in the 1990’s, it has proved successful at this. In more recent years, the DASH diet is supported by the USDA in promoting overall health and weight loss for the general public.

If you are thinking about following the DASH diet, daily serving suggestions and a sample menu are available below. For more information, the NIH has published a very informative document with complete details about the DASH diet.

dash2

The “Best Overall Diets” according to the U.S. News & World report are ranked as follows:

#1.  DASH Diet

2.     TLC Diet

3.     Mayo Clinic Diet

3.     Mediterranean Diet

3.     Weight Watchers

6.     The Flexitarian Diet

6.     Volumetrics Diet

8.     Jenny Craig

8.     The Biggest Loser Diet

9.    The Dean Ornish Diet

 

 

What is Celiac Disease?


Celiac Disease is the exacerbation of the body’s intolerance to the protein, gluten, which is found in wheat, rye, and barley. The disease is known as an autoimmune disorder because the body’s immune system reacts to gluten by damaging the lining of the small intestine, which leads to the malabsorption of nutrients. In the U.S., about 1 in 133 adults are affected by Celiac Disease, the cause of which is still unknown in the medical profession.

There is a broad spectrum of this disease, meaning the severity of the symptoms varies from person to person. In general, the symptoms of Celiac Disease include:

  • Abdominal pain, bloating, gas, or indigestion
  • Constipation
  • Decreased appetite (may also be increased or unchanged)
  • Diarrhea, either constant or off and on
  • Lactose intolerance (common when the person is diagnosed, usually goes away after treatment)
  • Nausea and vomiting
  • Stools that float, are foul smelling, bloody, or “fatty”
  • Unexplained weight loss (although people can be overweight or of normal weight)

Because the intestines do not absorb many important vitamins, minerals, and other parts of food, the following symptoms may start over time:

  • Bruising easily
  • Depression or anxiety
  • Fatigue
  • Growth delay in children
  • Hair loss
  • Itchy skin (dermatitis herpetiformis) or eczema
  • Missed menstrual periods
  • Mouth ulcers
  • Muscle cramps and joint pain
  • Nosebleeds
  • Seizures
  • Tingling or numbness in the hands or feet
  • Unexplained short height

Diagnosis of Celiac Disease

  • Your doctor can test for certain antibodies in your blood called endomysial (EMA-IgA) and anti-tissue transglutaminase (tTG – IgA and IgG) antibodies. High levels of these antibodies can indicate Celiac Disease.
  • Small intestine endoscopy, medically known as esophagogastroduodenoscopy (EGD).

Gluten-Free Diet

After a person is diagnosed with Celiac Disease, lifelong diet and lifestyle change can help relieve their symptoms. A gluten-free diet requires eliminating all sources of gluten (which is in wheat, rye, and barley).

However, there are still many other grains that do not contain gluten and thus can be included in the diet. These are:

  • Rice
  • Corn
  • Amaranth
  • Quinoa
  • Teff (or Tef)
  • Millet
  • Finger Millet (Ragi)
  • Sorghum
  • Indian Rice Grass (Montina)
  • Arrowroot
  • Buckwheat
  • Flax
  • Job’s Tears
  • Sago
  • Potato
  • Soy
  • Legumes
  • Mesquite
  • Tapioca
  • Wild rice
  • Cassava (Manioc)
  • Yucca
  • Nuts
  • Seeds

Example 1-Day Meal Plan of a Gluten-Free Diet

Breakfast Egg omelet made with low-fat natural cheese, such as cheddar or Monterey jack, and fresh vegetables
Rice cake (check the ingredient list to make sure it is gluten-free) topped with jam, jelly, or preserves
Orange juice
Lunch   Black bean tacos made with corn tortillas, black beans, fresh vegetables, low-fat natural cheese, and topped with fruit salsa (diced tropical fruit, lime juice, cilantro)
Seltzer water with lime
Evening Meal Chicken and fresh vegetables stir-fried in oil and spices
Plain brown rice or plain enriched white rice
Sorbet topped with fresh fruit
Cranberry juice mixed with seltzer water
Snack All natural yogurt mixed with blueberries or another fruit

Approximate Nutrition Analysis

Calories: 1,615
Protein: 67g (17% of calories)
Carbohydrate: 272g (68% of calories)
Fat: 26g (15% of calories)
Cholesterol: 273mg
Sodium: 2,890mg
Fiber: 21g

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 🙂

 

Clinical Nutrition Topic of the Day: Ensure vs. Boost


Two of the most common “complete” 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

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 “full-fat” 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

Breakfast:

  • 1¾ egg white zucchini frittata
  • 1/3 cup each—blueberries, strawberries, blackberries
  • ½ cup non-fat milk
  • 1 slice whole-grain bread
  • 1 cup herbal tea or decaf coffee-alternative

Lunch:

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

Snack:

  • 5/8 cup green pea guacamole
  • 6 whole-wheat pita bread wedges
  • ½ cup red grapes

Dinner:

  • 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 ornish.com 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!

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—the 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
Source: http://www.hopkinsmedicine.org/gim/_pdf/consult/refeeding_syndrome.pdf

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.

Sources:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945646/

http://www.hopkinsmedicine.org/gim/_pdf/consult/refeeding_syndrome.pdf

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—the 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! 🙂

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!

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

Sources:

http://www.medicinenet.com/congestive_heart_failure/page1.htm

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

Academy of Nutrition and Dietetics. Nutrition Care Manual.