Graduate Seminar: The Effectiveness of Inositol Supplementation on PCOS

As part of my masters plan of study I was required to present a 45-minute presentation for a graduate-level nutrition seminar course (ANNU 696).  The audience consisted of master’s students and professors from the Animal & Nutritional Sciences Department. Below, is the presentation that I created and delivered!

 

 

 

Nutrition Case Study Presentation

It is crazy to think that my rotation is already wrapping up!  I have learned so much information and practical information that will help me to succeed as a dietitian and a health professional.  As a final evaluation of my performance as a dietetic intern I was responsible for identifying a patient to follow for a case study.  After conducting multiple nutrition assessments on my patient for the past few weeks I complied the information I learned into a presentation that I presented to all of the registered dietitians – about 10 of them.

<div style=”margin-bottom:5px”> <strong> <a href=”https://www.slideshare.net/wmthompson/nutrition-case-study&#8221; title=”Nutrition case study” target=”_blank”>Nutrition case study</a> </strong> from <strong><a href=”http://www.slideshare.net/wmthompson&#8221; target=”_blank”>Wendy Thompson</a></strong> </div>

Nutrition Topic of the Week: Parenteral Nutrition

What is Parenteral Nutrition (or TPN)?

As you all know – everyone needs food/nourishment to live!  So… what happens when a person is unable to eat normally or tolerate a tube feeding or cannot get enough intake? That is were parenteral nutrition comes in.  Parenteral nutrition refers to feeding through the vein, or intravenous nutrition.  This is very different from enteral nutrition because it does not enter the digestion pathway.  Parenteral nutrition (PN) bypasses the normal digestion process (ingested food is broken down in the stomach and the intestines, absorbed in the bowel, and carried by the blood throughout the body).  PN in inserted directly into the blood stream via an IV catheter to the vein bypassing the digestive tract.  This is a sterile formula that is mixed in the pharmacy that contains water, amino acids, glucose, *lipids, vitamins and minerals and requires very close monitoring.  Note: it is very common for their to be a lipid (fat) shortage (or a different drug shortage) so at many facilities lipids are only give lipids on Monday, Wednesday, and Friday and in limited quantities.  Since parenteral nutrition may be someone’s only source of intake it is important that all essential nutrients are provided if PN will be used for a long duration. In addition to macronutrients, PN may also include electrolytes (sodium, potassium, chloride, phosphate, calcium, and magnesium) and trace elements (since, copper, manganese, and chromium).  There is currently a shortage on trace elements so they are typically not included unless the patients has been on PN for over 30 days.

Who May Need Parenteral Nutrition?

People of all ages may receive parenteral nutrition and the time may be relatively short or for as long as needed.  Patients may require PN for conditions or diseases that impair food intake, nutrition digestion or absorption. Common examples include: short bowel syndrome, GI fistulas, bowel obstruction, critically ill patients, severe acute pancreatitis, ulcerative colitis, or severe Crohn’s Disease.

How is Parenteral Nutrition Supplied?

An IV catheter (needle) is placed a large vein in either the arm, chest or neck. Common names for these catheters include: PICC, triple lumen, double lumen, single lumen catheter, and ports.  Parenteral nutrition can be supplied continuously over 24 hours or cyclically down to about 12 hours a day.  An infusion pump will control the rate at which the solution is supplied.  Total parenteral nutrition (TPN) will need to be administered through a central access vein such as the chest or the neck and can be supplied in higher concentration to meet the needs of a patient who is relying solely on TPN for nutrition.  Peripheral parenteral nutrition (PPN) is administered in lower concentrations and can be given through a peripheral vein such as through the arm and is mostly used for patients who are also consuming food through another source.  TPN lines will go through a major vein and end at the superior vena cava.

What are the Potential Complications of Parenteral Nutrition?

  • Infection – can be a common complication because of the chronic IV access point. If the infection is severe enough septic shock and death could ultimately occur.
  • Blood Clots – if a blood clot forms in the IV lines but breaks off and enters the lung then death can result from a pulmonary embolism. Patients on long term tube feeds typically receive a Heparin flush periodically to dissolve clots.
  • Liver Damage and Liver Failure – may appear as jaundice
  • Cholecystitis – inflammation of the gallbladder
  • Osteoporosis – bone disease
  • Refeeding Syndrome – characterized by hypokalemia, hypophosphatemia and hypomagnesemia (or low serum potassium, phosphate, and magnesium levels)
  • Hyperglycemia – high glucose levels, can be controlled with insulin

How is Parenteral Nutrition Monitored?

Depending on the facility, TPN will usually be monitored by a nutrition support care team that may include a physician, dietitian, pharmacist, and nursing staff. It is crucial to the patient’s safety that labs be monitored frequently in addition to monitoring weight status. The following labs should be closely monitored so that the order can change as needed:

  • CBC – Complete Blood Count
  • Electrolytes (Sodium, Potassium, Calcium, Phosphorus, Magnesium, Chloride, Bicarbonate)
  • BUN – Blood Urea Nitrogen
  • Glucose Levels
  • Albumin/Pre-Albumin
  • Triglycerides

 

TPN Formula - No Lipids

TPN Formula – No Lipids

TPN Formula with Lipids

TPN Formula with Lipids

PN Routes

PN Routes

References:

http://www.nutritioncare.org/wcontent.aspx?id=270

http://transplants.ucla.edu/body.cfm?id=70

http://www.merckmanuals.com/professional/nutritional_disorders/nutritional_support/total_parenteral_nutrition_tpn.html

Weight Loss Surgery and Lifestyle Changes

This past week I had the opportunity to spend time at a weight loss center, wound clinic, and also in medical telemetry and ICU. I am sure you all have heard of weight loss surgeries (more appropriately called bariatric surgeries) by now and while it may seem like a quick and easy fix… it is far from that.  Even though the majority of these surgeries are preformed laparoscopically, no surgery comes without some risk.  At this particular center the surgeons performed three different bariatric surgeries: Laparoscopic Adjustable Gastric Banding (LABG), Laparoscopic Sleeve Gastrectomy, and Roux-en-Y Gastric Bypass (RYGB).

Bariatric Infograph

 

What is the role of an RD when it comes to bariatric surgeries?

Bariatric surgeries all require a dramatic lifestyle change. Dietitians are responsible for conducting an initial nutritional screening to ensure that the client is suitable for surgery. If the patient is not willing to change their diet then they will not be allowed to undergo surgery due to the danger it could  cause. Dietitians are also used to explain and educate the patient on the bariatric diet prior to surgery and participate in follow-up appointments with patients as needed. Here is just a brief overview of some of the dietary changes one must undergo after surgery.

  • Advance diet as tolerated from clear liquids to puree/soft foods to solids post surgery – this typically takes at least one month.
  • Eat slowly – it should take 20-30 minutes to finish a meal!
  • Always sip liquids, NEVER chug! You should drink about 1 oz. every 15 minutes.
  • Chew slowly and thoroughly before swallowing
  • Avoid sugary foods to prevent “Dumping Syndrome”
  • Limit fat intake – fats slow the digestion process which can lead to nausea
  • REMEMBER the stomach can only hold a few tablespoons immediately after surgery and will eventually hold up to 0.5-1 cup so you will need to eat less
  • Drink at least 64 oz. fluid to prevent dehydration
  • Do not drink fluid with meals – stop drinking 30 minutes before eating and wait until 30 minutes after to drink again
  • Always eat your protein food first to make sure your protein intake is adequate
  • Tolerance of dairy (lactose) may be altered so substitute a lactose-free dairy if needed

What does a typical menu look like for the first month after surgery once you are discharged?

Breakfast – 8:00AM:

  • ¼ cup unsweetened applesauce
  • ¼ – ½ cup non fat cottage cheese

Supplement – 10:00AM:

  • ½ cup skim plus with 1 scoop of protein powder

Lunch – 12:00PM:

  • ¼ – ½ cup blended soup
  • ¼ cup tuna fish with low fat mayo

Snack – 2:00PM:

  • ½ cup sugar free yogurt
  • 1 sugar free popsicle

Dinner – 6:00PM:

  • 1-2 oz. flaked fish
  • ¼ cup puree vegetable

 

References:

http://www.nordbariatric.com/en/articles/infographics/different-wls-compared

http://www.mayoclinic.com/health/gastric-bypass-diet/my00827

Nutrition Topic of the Week: Enteral Nutrition

What is Enteral Nutrition?

As we all know, everyone needs food to survive.  In some cases, individuals are not able to intake any or enough food on their own.  One way to provide nourishment for these individuals is with “enteral nutrition” or more commonly known as “tube feedings.”  Another way to provide nourishment to individuals who cannot orally ingest food is through “parenteral nutrition,” which is providing nutrients through a vein directly into the blood stream.  These two methods are very different and as the saying goes, “use it – or lose it.” In this instance I am referring to the gut and digestive system – if the gut works, then use it!

Tube feeding formulas are in a liquid form that contains protein, carbohydrates, fats, vitamins and minerals.  They are many varieties of formulas to meet different needs and the dietitian performs a variety of calculations to determine which formula will be best for the patient. This formula is given through a tube and then normal digestion can occur in the stomach and intestines.

What Conditions Require Enteral Nutrition?

Any condition that alters a patients’ ability to swallow can lead to the implementation of enteral nutrition as long as the gastrointestinal (GI) system is still working.  Also, if a patient cannot take in adequate nutrition due to impaired nutrient ingestion, digestion, absorption, or metabolism then enteral nutrition can be used.  Common conditions include:

  • Neurological disorders
  • Facial/oral/esophageal trauma
  • Respiratory failure (the need for a ventilator)
  • Traumatic brain injuries
  • Cystic fibrosis
  • Dysphasia (common after a stroke)
  • Major burns, trauma, or wounds

What are the Considerations when Choosing a Formula?

  • Digestibility/availability of nutrients
  • Nutrition adequacy to meet needs
  • Osmolality (fluid needs)
  • Ease of use
  • Cost

What are the Different Formula Categories?

  • Standard – these contain nutrients that are intact (most often used)
  • Elemental – partially or completely hydrolyzed (broken down) nutrients
  • Disease specific – designed for a wide variety of disease states (renal, diabetes, etc.)
  • Modular – allows for the addition of nutrient content

How is the Tube Feeding Supplied?

There are multiple different placements options when considering a tube feed depending on the specific needs of each patient. The greater use of the GI system that can be tolerated by the patient is the route that is used in most cases.  Estimated length of time the feeding tube will be required helps to determine the route.  Another important factor is the risk of aspiration. If there is a high risk for aspiration then the patient will need the tube to continue past the pyloric sphincter.

Short Term (<3 weeks):

  • Orogastric – tube enters through the mouth and goes into the stomach
  • Nasogastric – tube enters through the nose and goes into the stomach
  • Nasoduodenal – tube enters through the nose and goes into the duodenum (first part of the small intestine)
  • Nasojejunal  – tube enters through the nose and goes into the jejunum (second part of the small intestine)

Long Term (>4-8 weeks):

  • Gastrostomy – tube enters directly through the skin into the stomach
  • Jejunostomy – tube enters directly through the skin into the jejunum (second part of the small intestine)

 Enteral Nutrition

What are the Delivery Methods of Enteral Nutrition?

Continuous:

  • Delivered at a continuous/steady rate that is controlled via a feeding pump
  • Most often used when feeding into the small bowel (intestine)
  • Preferred for critically ill patients and those unable to tolerate bolus or intermittent feedings

Bolus or Intermittent:

  • Bolus – last from a few minutes to 20 minutes and given via a syringe
  • Intermittent – last 20-60 minutes and given via a gravity drip
  • Preferred type of feeding for gastric routes (into the stomach) but not well tolerated in the intestine
  • Used for ambulatory patients and patients in their home
  • Fluid ranges between 240-480 mL

Cyclic or Nocturnal:

  • Used as a transition from enteral feedings to an oral (normal) diet
  • Rate can reach up to 150 mL/hour
  • Commonly used for patients in their home
  • They are infused continuously for 10-12 hours (typically overnight) to allow for greater oral intake during the day

What are the Complications of Enteral Nutrition?

While tube feeding is a generally safe option, there are potential risks associate with it.  For example, patients may experience abdominal discomfort, nausea, vomiting, abdominal distention, constipation, diarrhea, or aspiration.  There are ways to reduce this risk that health providers should always abide by.

References:

http://www.nutritioncare.org/wcontent.aspx?id=266

http://patients.gi.org/topics/enteral-and-parenteral-nutrition/