Role of a Dietitian Cassie Bradford RD,LD

About me.. Graduated High School- Marietta, OH 2002 Graduated High School- Marietta, OH 2002 Graduated College- Ohio State 2006 Graduated College- Ohio State 2006 Dietetic Internship Ohio State Dietetic Internship Ohio State Obtained certification of RD Obtained certification of RD Job History-  Ohio State Medical Center  Mount Carmel East 2007-present

Who is a dietitian? Registered Dietitians are the food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living. Registered Dietitians are the food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living. RD / LD RD / LD RD= Registered Dietitian (national) RD= Registered Dietitian (national) LD= Licensed Dietitian (state) LD= Licensed Dietitian (state)

Where can you find a dietitian? Hospitals (30%) Hospitals (30%) Food service operations Food service operations Sports nutrition and wellness programs Sports nutrition and wellness programs Community and public health settings (WIC) Community and public health settings (WIC) Research areas (food and pharmaceuticals) Research areas (food and pharmaceuticals)

What does my job entail? Screening hospital patients for nutritional risk Screening hospital patients for nutritional risk Completing nutritional assessments for those patients with identified risks Completing nutritional assessments for those patients with identified risks Implementing care plans to improve nutritional status and/or prevent further risks Implementing care plans to improve nutritional status and/or prevent further risks Education Education

Who is at risk? Body Mass Index < 16 Body Mass Index < 16 Nutrition support (TF or TPN) Nutrition support (TF or TPN) Chewing/swallowing problems Chewing/swallowing problems Pressure ulcers and nonhealing wounds Pressure ulcers and nonhealing wounds Significant weight changes Significant weight changes Anyone that is unable to meet his or her daily requirements to heal, maintain weight, etc. Anyone that is unable to meet his or her daily requirements to heal, maintain weight, etc.

Malnutrition protein-energy malnutrition--the lack of enough protein (from meat and other sources) and food that provides energy (measured in calories) protein-energy malnutrition--the lack of enough protein (from meat and other sources) and food that provides energy (measured in calories) micronutrient (vitamin and mineral) deficiency (example-obesity) micronutrient (vitamin and mineral) deficiency (example-obesity)  Protein-energy malnutrition (PEM) is the most lethal form of malnutrition/hunger  released on October 14, 2009 by FAO, says that 1.02 billion people are undernourished

Impairments Problems can exist at Problems can exist at any level.

Starting with the swallow.. Some 50 pairs of muscles and many nerves work to move food from the mouth to the stomach Some 50 pairs of muscles and many nerves work to move food from the mouth to the stomach Problems: Problems: Weak tongue or cheek muscles Weak tongue or cheek muscles not being able to start the swallowing reflex because of a stroke or other nervous system disorder not being able to start the swallowing reflex because of a stroke or other nervous system disorder weak throat muscles cannot move all of the food toward the stomach weak throat muscles cannot move all of the food toward the stomach

National Dysphagia Levels Dysphagia diet level 1 for people with moderate to severe swallowing difficulty and have a poor ability to protect their air way for people with moderate to severe swallowing difficulty and have a poor ability to protect their air way allows pureed food (pudding like consistency) that is smooth and easily stays together allows pureed food (pudding like consistency) that is smooth and easily stays together It may be difficult to meet calorie and nutrition needs on this diet. It is important to use high calorie, nutrient dense food such as cheese sauce, gravy and whole or butter milk in this diet. Eating more frequently through the day can also help increase intake. It may be difficult to meet calorie and nutrition needs on this diet. It is important to use high calorie, nutrient dense food such as cheese sauce, gravy and whole or butter milk in this diet. Eating more frequently through the day can also help increase intake.

Continued… Dysphagia diet level 2 step up from the pureed diet. Some chewing ability is required. The level 2 diet is for people with mild to moderate swallowing difficulty. step up from the pureed diet. Some chewing ability is required. The level 2 diet is for people with mild to moderate swallowing difficulty. This diet consists of foods that are moist, soft and easily formed into a bolus (soft wad of food). Avoid foods that are difficult to chew, dry and coarse This diet consists of foods that are moist, soft and easily formed into a bolus (soft wad of food). Avoid foods that are difficult to chew, dry and coarse Meats should be ground or minced and should be keep moist with sauces and gravies. Meats should be ground or minced and should be keep moist with sauces and gravies.

Continued… Dysphagia diet level 3 This diet is a step down from a regular diet and is for individuals with mild swallowing problems. This diet is a step down from a regular diet and is for individuals with mild swallowing problems. This diet consists of all foods, except very hard sticky or crunchy foods. Foods should be moist and should be cut up into bite size pieces. This diet consists of all foods, except very hard sticky or crunchy foods. Foods should be moist and should be cut up into bite size pieces.

Liquids Thin Thin Nectar/Syrup Nectar/Syrup Honey Honey Pudding Pudding

Oral Supplements Ensure Plus- 350 kcal, 13 g protein Glucerna- 220 kcal, 10 g protein Enlive- 250 kcal, 9 g protein

Continued… Magic cup- 290 kcal, 9 g protein Never melts beyond pudding thick liquid

After the swallow… Stomach: Stomach: Gastric Bypass Surgery- (gastrectomy) Gastric Bypass Surgery- (gastrectomy) Diet progression Diet progression Life time changes: Life time changes: Small frequent meals Small frequent meals Low in concentrated sugar and low fat Low in concentrated sugar and low fat Drinking between meals Drinking between meals Vitamin supplementation (iron, calcium, b12, magnesium) Vitamin supplementation (iron, calcium, b12, magnesium)

Gastroparesis Gastroparesis is a condition that affects the ability of the stomach to empty its contents Gastroparesis is a condition that affects the ability of the stomach to empty its contents Gastroparesis occurs when the vagus nerve is damaged and the muscles of the stomach and intestines do not work normally. Food then moves slowly or stops moving through the digestive tract. Gastroparesis occurs when the vagus nerve is damaged and the muscles of the stomach and intestines do not work normally. Food then moves slowly or stops moving through the digestive tract.

Diabetic Gastroparesis People with diabetes have high blood glucose, which in turn causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve. People with diabetes have high blood glucose, which in turn causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve.

Diet 6 small meals day 6 small meals day Low fat Low fat Low fiber Low fiber Soft, easy to digest foods (severe cases may require liquid or pureed diets) Soft, easy to digest foods (severe cases may require liquid or pureed diets)

Inflammation Crohn’s disease is an ongoing disorder that causes inflammation of the digestive tract Crohn’s disease is an ongoing disorder that causes inflammation of the digestive tract can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine Diverticulosis/Diverticulitis Diverticulosis/Diverticulitis low-fiber with low-residue diet or a special liquid diet may be beneficial in minimizing abdominal pain and other symptoms low-fiber with low-residue diet or a special liquid diet may be beneficial in minimizing abdominal pain and other symptoms

Bowel Resections Stomach absorbs 20% of the alcohol ingested, as well as some short-chain fatty acids. Stomach absorbs 20% of the alcohol ingested, as well as some short-chain fatty acids. Duodenum absorbs Vitamins A and B1, iron, calcium, glycerol, fatty acids, monoglycerides, amino acids, monosaccharides, and disaccharides. Duodenum absorbs Vitamins A and B1, iron, calcium, glycerol, fatty acids, monoglycerides, amino acids, monosaccharides, and disaccharides. Jejunum absorbs glucose, galactose, amino acids, glycerol and fatty acids, nonoglycerides, diglycerides, dipeptides, copper, zinc, potassium, calcium, magnesium, phosphorus, iodine, iron, fat- soluble Vitamins D, E, and K, most of the B complex, Vitamin C, and the rest of the alcohol. Jejunum absorbs glucose, galactose, amino acids, glycerol and fatty acids, nonoglycerides, diglycerides, dipeptides, copper, zinc, potassium, calcium, magnesium, phosphorus, iodine, iron, fat- soluble Vitamins D, E, and K, most of the B complex, Vitamin C, and the rest of the alcohol.

Continued… Ileum absorbs disaccharides, sodium, potassium, chloride, calcium, magnesium, phosphorus, iodine, Vitamins C, D, E, K, B1, B2, B6, B12, and most of the water. Ileum absorbs disaccharides, sodium, potassium, chloride, calcium, magnesium, phosphorus, iodine, Vitamins C, D, E, K, B1, B2, B6, B12, and most of the water. Colon absorbs sodium, potassium, water, acids, gases, some short-chain fatty acids metabolized from plant fibers and undigested starch, and vitamins synthesized by bacteria (biotin and Vitamin K). Colon absorbs sodium, potassium, water, acids, gases, some short-chain fatty acids metabolized from plant fibers and undigested starch, and vitamins synthesized by bacteria (biotin and Vitamin K).

Celiac Celiac disease is an inherited, autoimmune disease in which the lining of the small intestine is damaged from eating gluten and other proteins found in wheat, barley, rye, and possibly oats Celiac disease is an inherited, autoimmune disease in which the lining of the small intestine is damaged from eating gluten and other proteins found in wheat, barley, rye, and possibly oats Diet- Gluten Free (composite of two proteins called gliadin and glutenin) Diet- Gluten Free (composite of two proteins called gliadin and glutenin)gliadingluteningliadinglutenin

Following the Diet Reading the label: Especially the list of ingredients Beware of cross contamination

Nutrition Support A.K.A- artificial nutrition A.K.A- artificial nutrition #1 rule- If the gut works… use it #1 rule- If the gut works… use it

Nutrition Support Tube feeding- Tube feeding- Nasogastric (NG) Nasogastric (NG) Nasojejunal (NJ) Nasojejunal (NJ) Orogastric (OG) Orogastric (OG) *Percutaneous endoscopic gastrostomy (PEG) *Percutaneous endoscopic gastrostomy (PEG) *Jejunostomy (PEJ) *Jejunostomy (PEJ) (*long term)

Formulas Fiber/ no fiber- Jevity vs Osmolite Fiber/ no fiber- Jevity vs Osmolite Diabetic- Glucerna Diabetic- Glucerna “Renal”- Nepro “Renal”- Nepro Oxygenation (vented pt)- Oxepa Oxygenation (vented pt)- Oxepa Wound Healing- Pivot Wound Healing- Pivot Elemental- Peptamen Elemental- Peptamen

Nutrition Support TPN (Total Parenteral Nutrition) TPN (Total Parenteral Nutrition) Central Central Central venous catheter- internal jugular, subclavian, femoral veins Central venous catheter- internal jugular, subclavian, femoral veins PICC- peripherally inserted central catheter (placed in the arm and ran up bigger veins until reaches the superior vena cava) PICC- peripherally inserted central catheter (placed in the arm and ran up bigger veins until reaches the superior vena cava) Peripheral Peripheral Tip of catheter is not located at the vena cava site Tip of catheter is not located at the vena cava site

TPN Formula 2 in 1 (run lipids separately) 2 in 1 (run lipids separately) 3 in 1 3 in 1 Protein: provides 4 kcal/g and 15-20% of energy Protein: provides 4 kcal/g and 15-20% of energy CHO: provides 3.4 kcal/g instead of 4 kcal/g and 50-60% of energy CHO: provides 3.4 kcal/g instead of 4 kcal/g and 50-60% of energy Fat: lipid emulsion of oil and lecithin (phospholipids from egg yolk); MCE uses 20% solutions or 2.0 kcal/ml and 20-30% of energy Fat: lipid emulsion of oil and lecithin (phospholipids from egg yolk); MCE uses 20% solutions or 2.0 kcal/ml and 20-30% of energy

Conclusion Dietitians play a key role in the hospital setting with nutritional needs of the patients. Dietitians play a key role in the hospital setting with nutritional needs of the patients. Each diagnosis leads to its own nutritional recommendations. Each diagnosis leads to its own nutritional recommendations. The field is always changing with new research. The field is always changing with new research.

Questions?