Dietetic Internship: Complete!

As of today I am officially done with my 1,200+ hours of dietetic internship rotations!  Once I finish up my coursework, present and defend my thesis I will be finished with my Masters of Science in Human Nutrition and be eligible to take the RD exam to become a registered dietitian!

At the end of May I will be beginning my next journey of beginning PA school at the University of Colorado at Denver to ultimately become a Physician Assistant!

 

excitement

WIC Internship Rotation

These past two weeks I spent the majority of my time in the Monongalia and Marion County WIC offices.  With this rotation I was able to learn all about what WIC has to offer!  WIC represents the Women, Infants and Children Program, which is a federally funded nutrition education and supplemental food program.  This is an excellent opportunity for families that qualify to receive nutrition education, breastfeeding support/education, and assistance with food and other resources.  They are even working with the WIC-ICE program to offer free immunizations for children 0-5 years old!

http://www.monchd.org/wic-enhanced-health-nutrition-services.html

While at WIC I realized that the number of women choosing to feed their baby using formula outnumbered the number of women breastfeeding tremendously! Out of curiosity I ended up looking up the breastfeeding rates for the states of West Virginia and Colorado as well as the national rates.

Data from CDC’s Breastfeeding Report Card, 2013

Breastfeeding Rates

View entire report here!

Source: http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportcard.pdf

Curious to know which state had the highest and lowest rates of exclusive breastfeeding at 3 and 6 months? I was!  I found that the highest rate of exclusively breastfeeding at 3 months came from Idaho with 60.3% and the lowest came from Mississippi with only 17%.  When looking at the those exclusively breastfeeding at 6 months, the highest came from California with 27.4% and the lowest was Tennessee with only 4.1%.  As you can see there are very large discrepancies when comparing each state!

Why is it important to breastfeed vs. formula feedings?

Here are a few of the many wonderful benefits:

  • Reduce the risk of diseases in the infant such as:
    • Necrotizing enterocolitis
    • Lower respiratory infections
    • Asthma
    • Obesity
    • Type 2 Diabetes
    • SIDS
  • Protects the baby from illnesses so they get sick less often
  • Provides benefits to the mother and helps the body return back to ‘normal’ by:
    • Burning extra calories to promoting weight loss
    • Causing the uterus to contract to prevent bleeding
  • It is safe! No need to worry about:
    • Mixing the formula
    • Safety of the water
    • Selecting the right formula
    • Formula safety recalls
  • The cost savings!

One interesting thing I learned at WIC was the cost of formula! Did you know that the average cost of formula for the first year was $1,500 dollars just for basic formula!  This number would sky rocket if an infant required a special formula (very common since formula is harder to digest than breast milk)!  This number also does not include the cost of bottle and supplies!

So, why do so many women chose not to breast feed when it is the best nutrition and supplies of a wealth of benefits for the baby and the mother that will last a lifetime – and not to mention the cost savings?

Breastfeeding
Source: http://www.womenshealth.gov/breastfeeding/why-breastfeeding-is-important/index.html

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>

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/

iCook Session #1

After months of planning, recruiting, and conducting assessments it finally came time to teach session one! We ended up filling about five of our six classes with at least four parent/child groups (also referred to as dyads). Currently, there are three interns who will be teaching the first four sessions and then the other two interns will teach the last two. Remi, Erin, and I alternated teaching the lessons by serving as either Chef, Sous Chef, or an extra helper. We were also lucky enough to have the assistance of three undergraduate students who assisted with note taking, technology, set-up, and cleaning all the dishes.

This first session was entitled “Tools of the Trade.” We covered knife safety skills, physical activity, camera/website use, and an introduction to iCook. The classes had anywhere from four to eight dyads present. This was a great learning experience for the children, parents, and even us! The kids knife skills improved greatly just from the beginning of the class to the end and the parents’ confidence in their kids abilities also greatly improved. While allowing kids (age 8-11) to use a sharp chef knife may seem like an unsafe thing to do, with the right support and monitoring from the parents the kids can accomplish cutting bananas, strawberries, apples, and even kiwi safely! We made it through the entire weekend without any cuts! You can tell which kids had prior experience and which had never even held a knife before. It was fun to work with these kids and I can’t wait to watch their skills improve over the next few months as we move through the sessions!

20130908-191051.jpg

iCook Recruitment CONTINUES!

If there is one thing I have learned these past few weeks it is that recruiting human subjects for any research projects is HARD! No matter how excited the kids are about joining that doesn’t mean that their parents are going to pick up the phone and enroll. We have had to extend the recruitment process for this study and continue to recruit an extra week or two to hopefully meet our target! We are currently about 1/3 of the way there… with only 1 week left IT IS CRUNCH TIME!

We hit the schools yet again and decided to sing a song that Erin Smith and her dad wrote! Here is the video of us with an entire lunch room of 5th graders singing the tune after we have described the iCook study!

 

It has been fun speaking with thousands of 4th and 5th graders but at this point… I am just ready for us to reach our goal and start the actual instruction component of this research study! Below are some silly pictures of Erin and I as we toured the schools!