Role of a Dietitian

1
Role of a Dietitian

• Cassie Bradford RD,LD

2
About me..

• Graduated High School- Marietta, OH 2002
• Graduated College- Ohio State 2006
• Dietetic Internship 2006-2007- Ohio State
• Obtained certification of RD- 2007
• Job History-
• Ohio State Medical Center 2003-2007
• Mount Carmel East 2007-present

3
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.
• RD / LD
• RD Registered Dietitian (national)
• LD Licensed Dietitian (state)

4
Where can you find a dietitian?

• Hospitals (30)
• Food service operations
• Sports nutrition and wellness programs
• Community and public health settings (WIC)
• Research areas (food and pharmaceuticals)

5
What does my job entail?

• Screening hospital patients for nutritional risk
• Completing nutritional assessments for those
  patients with identified risks
• Implementing care plans to improve nutritional
  status and/or prevent further risks
• Education

6
Who is at risk?

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

7
Malnutrition

• 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)
• 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

8
Impairments

• Problems can exist at
• any level.

9
Starting with the swallow..

• Some 50 pairs of muscles and many nerves work to
  move food from the mouth to the stomach
• Problems
• Weak tongue or cheek muscles
• 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

10
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
• 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.

11
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.
• 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.

12
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 consists of all foods, except very hard
  sticky or crunchy foods. Foods should be moist
  and should be cut up into bite size pieces.

13
Liquids

• Thin
• Nectar/Syrup
• Honey
• Pudding

14
Oral Supplements

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

15
Continued

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

16
After the swallow

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

17
Gastroparesis

• 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.

18
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.

19
Diet

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

20
Inflammation

• Crohns 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
• Diverticulosis/Diverticulitis
• low-fiber with low-residue diet or a special
  liquid diet may be beneficial in minimizing
  abdominal pain and other symptoms

21
Bowel Resections

• 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.
• 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.

22
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.
• 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).

23
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
• Diet- Gluten Free (composite of two proteins
  called gliadin and glutenin)

24
Following the Diet

• Reading the label
• Especially the list of ingredients
• Beware of cross contamination

25
Nutrition Support

• A.K.A- artificial nutrition
• 1 rule- If the gut works use it ?

26
Nutrition Support

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

27
Formulas

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

28
Nutrition Support

• TPN (Total Parenteral Nutrition)
• Central
• 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)
• Peripheral
• Tip of catheter is not located at the vena cava
  site

29
TPN Formula

• 2 in 1 (run lipids separately)
• 3 in 1
• 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
• 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

30
Conclusion

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

31
Questions?