Role of a DietitianRole of a Dietitian

Cassie Bradford RD,LDCassie Bradford RD,LD

About meAbout me....

Graduated High School- Marietta, OH Graduated High School- Marietta, OH 20022002

Graduated College- Ohio State 2006Graduated College- Ohio State 2006 Dietetic Internship 2006-2007- Ohio Dietetic Internship 2006-2007- Ohio

StateState Obtained certification of RD- 2007Obtained certification of RD- 2007

Job History-Job History- Ohio State Medical Center 2003-2007Ohio State Medical Center 2003-2007 Mount Carmel East 2007-presentMount Carmel East 2007-present

Who is a dietitian?Who is a dietitian?

Registered Dietitians are the food Registered Dietitians are the food and nutrition experts who can and nutrition experts who can translate the science of nutrition into translate the science of nutrition into practical solutions for healthy living. practical solutions for healthy living.

RD / LDRD / LD RD= Registered Dietitian (national)RD= Registered Dietitian (national) LD= Licensed Dietitian (state)LD= Licensed Dietitian (state)

Where can you find a Where can you find a dietitian?dietitian?

Hospitals (30%)Hospitals (30%) Food service operationsFood service operations Sports nutrition and wellness Sports nutrition and wellness

programsprograms Community and public health Community and public health

settings (WIC)settings (WIC) Research areas (food and Research areas (food and

pharmaceuticals)pharmaceuticals)

What does my job entail?What does my job entail?

Screening hospital patients for Screening hospital patients for nutritional risknutritional risk

Completing nutritional assessments Completing nutritional assessments for those patients with identified risksfor those patients with identified risks

Implementing care plans to improve Implementing care plans to improve nutritional status and/or prevent nutritional status and/or prevent further risksfurther risks

EducationEducation

Who is at risk?Who is at risk? Body Mass Index < 16Body Mass Index < 16 Nutrition support (TF or TPN)Nutrition support (TF or TPN) Chewing/swallowing problemsChewing/swallowing problems Pressure ulcers and nonhealing woundsPressure ulcers and nonhealing wounds Significant weight changesSignificant weight changes

Anyone that is unable to meet his or her Anyone that is unable to meet his or her daily requirements to heal, maintain daily requirements to heal, maintain weight, etc.weight, etc.

MalnutritionMalnutrition protein-energy malnutrition--the lack of protein-energy malnutrition--the lack of

enough protein (from meat and other enough protein (from meat and other sources) and food that provides energy sources) and food that provides energy (measured in calories) (measured in calories)

micronutrient (vitamin and mineral) micronutrient (vitamin and mineral) deficiency (example-obesity)deficiency (example-obesity)

Protein-energy malnutrition (PEM) is the Protein-energy malnutrition (PEM) is the most lethal form of malnutrition/hunger most lethal form of malnutrition/hunger

released on October 14, 2009 by FAO,  released on October 14, 2009 by FAO,  says that 1.02 billion people are says that 1.02 billion people are undernourished undernourished

ImpairmentsImpairments

Problems can exist atProblems can exist at

any level.any level.

Starting with the Starting with the swallow..swallow..

Some 50 pairs of muscles and many Some 50 pairs of muscles and many nerves work to move food from the nerves work to move food from the mouth to the stomachmouth to the stomach

Problems:Problems: Weak tongue or cheek muscles Weak tongue or cheek muscles not being able to start the swallowing not being able to start the swallowing

reflex because of a stroke or other nervous reflex because of a stroke or other nervous system disordersystem disorder

weak throat muscles cannot move all of the weak throat muscles cannot move all of the food toward the stomachfood toward the stomach

National Dysphagia National Dysphagia LevelsLevels

Dysphagia diet level 1Dysphagia diet level 1 for people with moderate to severe swallowing difficulty for people with moderate to severe swallowing difficulty

and have a poor ability to protect their air wayand have a poor ability to protect their air way allows pureed food (pudding like consistency) that is allows pureed food (pudding like consistency) that is

smooth and easily stays togethersmooth and easily stays together It may be difficult to meet calorie and nutrition needs It may be difficult to meet calorie and nutrition needs

on this diet. It is important to use high calorie, nutrient on this diet. It is important to use high calorie, nutrient dense food such as cheese sauce, gravy and whole or dense food such as cheese sauce, gravy and whole or butter milk in this diet. Eating more frequently through butter milk in this diet. Eating more frequently through the day can also help increase intake.the day can also help increase intake.

Continued…Continued…

Dysphagia diet level 2Dysphagia diet level 2 step up from the pureed diet. Some chewing ability step up from the pureed diet. Some chewing ability

is required. The level 2 diet is for people with mild is required. The level 2 diet is for people with mild to moderate swallowing difficulty. to moderate swallowing difficulty.

This diet consists of foods that are moist, soft and This diet consists of foods that are moist, soft and easily formed into a bolus (soft wad of food). Avoid easily formed into a bolus (soft wad of food). Avoid foods that are difficult to chew, dry and coarsefoods that are difficult to chew, dry and coarse

Meats should be ground or minced and should be Meats should be ground or minced and should be keep moist with sauces and gravies.keep moist with sauces and gravies.

Continued…Continued…

Dysphagia diet level 3Dysphagia diet level 3 This diet is a step down from a regular This diet is a step down from a regular

diet and is for individuals with mild diet and is for individuals with mild swallowing problems. swallowing problems.

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

LiquidsLiquids

ThinThin Nectar/SyrupNectar/Syrup HoneyHoney PuddingPudding

Oral SupplementsOral Supplements

Ensure Plus- 350 kcal, 13 g Ensure Plus- 350 kcal, 13 g proteinprotein

Glucerna- 220 kcal, 10 g Glucerna- 220 kcal, 10 g proteinprotein

Enlive- 250 kcal, 9 g proteinEnlive- 250 kcal, 9 g protein

Continued…Continued…

Magic cup- 290 kcal, 9 g Magic cup- 290 kcal, 9 g proteinprotein Never melts beyond pudding Never melts beyond pudding

thick liquidthick liquid

After the swallow…After the swallow…

Stomach:Stomach: Gastric Bypass Surgery- Gastric Bypass Surgery-

(gastrectomy)(gastrectomy) Diet progressionDiet progression Life time changes:Life time changes:

Small frequent mealsSmall frequent meals Low in concentrated sugar and Low in concentrated sugar and

low fatlow fat Drinking between mealsDrinking between meals Vitamin supplementation (iron, Vitamin supplementation (iron,

calcium, b12, magnesium)calcium, b12, magnesium)

GastroparesisGastroparesis

GastroparesisGastroparesis is a condition that is a condition that affects the ability of the stomach to affects the ability of the stomach to empty its contentsempty its contents

Gastroparesis occurs when the Gastroparesis occurs when the vagus nerve is damaged and the vagus nerve is damaged and the muscles of the stomach and muscles of the stomach and intestines do not work normally. intestines do not work normally. Food then moves slowly or stops Food then moves slowly or stops moving through the digestive tract.moving through the digestive tract.

Diabetic GastroparesisDiabetic Gastroparesis

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

DietDiet

6 small meals day6 small meals day Low fatLow fat Low fiberLow fiber Soft, easy to digest foods (severe Soft, easy to digest foods (severe

cases may require liquid or pureed cases may require liquid or pureed diets)diets)

InflammationInflammation

Crohn’s disease Crohn’s disease is an ongoing disorder is an ongoing disorder that causes inflammation of the that causes inflammation of the digestive tractdigestive tract can affect any area of the GI tract, from the can affect any area of the GI tract, from the

mouth to the anus, but it most commonly mouth to the anus, but it most commonly affects the lower part of the small intestineaffects the lower part of the small intestine

Diverticulosis/DiverticulitisDiverticulosis/Diverticulitis low-fiber with low-residue diet or a special low-fiber with low-residue diet or a special

liquid diet may be beneficial in minimizing liquid diet may be beneficial in minimizing abdominal pain and other symptomsabdominal pain and other symptoms

Bowel ResectionsBowel Resections StomachStomach absorbs 20% of the alcohol ingested, as well as absorbs 20% of the alcohol ingested, as well as

some short-chain fatty acids.some short-chain fatty acids.

DuodenumDuodenum absorbs Vitamins A and B1, iron, calcium, absorbs Vitamins A and B1, iron, calcium, glycerol, fatty acids, monoglycerides, amino acids, glycerol, fatty acids, monoglycerides, amino acids, monosaccharides, and disaccharides.monosaccharides, and disaccharides.

JejunumJejunum absorbs glucose, galactose, amino acids, glycerol absorbs glucose, galactose, amino acids, glycerol and fatty acids, nonoglycerides, diglycerides, dipeptides, and fatty acids, nonoglycerides, diglycerides, dipeptides, copper, zinc, potassium, calcium, magnesium, phosphorus, copper, zinc, potassium, calcium, magnesium, phosphorus, iodine, iron, fat-soluble Vitamins D, E, and K, most of the B iodine, iron, fat-soluble Vitamins D, E, and K, most of the B complex, Vitamin C, and the rest of the alcohol.complex, Vitamin C, and the rest of the alcohol.

Continued…Continued… IleumIleum absorbs disaccharides, sodium, absorbs disaccharides, sodium,

potassium, chloride, calcium, magnesium, potassium, chloride, calcium, magnesium, phosphorus, iodine, Vitamins C, D, E, K, B1, B2, phosphorus, iodine, Vitamins C, D, E, K, B1, B2,

B6, B12, and most of the waterB6, B12, and most of the water..

ColonColon absorbs sodium, potassium, water, acids, absorbs sodium, potassium, water, acids, gases, some short-chain fatty acids metabolized gases, some short-chain fatty acids metabolized from plant fibers and undigested starch, and from plant fibers and undigested starch, and vitamins synthesized by bacteria (biotin and vitamins synthesized by bacteria (biotin and Vitamin K). Vitamin K).

CeliacCeliac

Celiac disease is an inherited, Celiac disease is an inherited, autoimmune disease in which the autoimmune disease in which the lining of the small intestine is lining of the small intestine is damaged from eating gluten and damaged from eating gluten and other proteins found in wheat, other proteins found in wheat, barley, rye, and possibly oatsbarley, rye, and possibly oats

Diet- Gluten Free (composite of two Diet- Gluten Free (composite of two proteins called proteins called gliadingliadin and and glutenin)glutenin)

Following the DietFollowing the Diet

Reading the label:Reading the label:

Especially the list Especially the list of ingredientsof ingredients

Beware of cross Beware of cross contaminationcontamination

Nutrition SupportNutrition Support

A.K.A- artificial nutritionA.K.A- artificial nutrition

#1 rule- If the gut works… use #1 rule- If the gut works… use it it

Nutrition SupportNutrition Support

Tube feeding-Tube feeding- Nasogastric (NG)Nasogastric (NG) Nasojejunal (NJ)Nasojejunal (NJ) Orogastric (OG)Orogastric (OG) *Percutaneous endoscopic gastrostomy *Percutaneous endoscopic gastrostomy

(PEG)(PEG) *Jejunostomy (PEJ)*Jejunostomy (PEJ)

(*long term)(*long term)

FormulasFormulas

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

Nutrition SupportNutrition Support

TPN (Total Parenteral Nutrition)TPN (Total Parenteral Nutrition) Central Central

Central venous catheter- internal jugular, Central venous catheter- internal jugular, subclavian, femoral veinssubclavian, femoral veins

PICC- peripherally inserted central catheter PICC- peripherally inserted central catheter (placed in the arm and ran up bigger veins (placed in the arm and ran up bigger veins until reaches the superior vena cava)until reaches the superior vena cava)

PeripheralPeripheral Tip of catheter is not located at the vena Tip of catheter is not located at the vena

cava sitecava site

TPN FormulaTPN Formula

2 in 1 (run lipids separately)2 in 1 (run lipids separately) 3 in 13 in 1 Protein: provides 4 kcal/g and 15-20% of Protein: provides 4 kcal/g and 15-20% of

energyenergy CHO: provides 3.4 kcal/g instead of 4 CHO: provides 3.4 kcal/g instead of 4

kcal/g and 50-60% of energykcal/g and 50-60% of energy Fat: lipid emulsion of oil and lecithin Fat: lipid emulsion of oil and lecithin

(phospholipids from egg yolk); MCE uses (phospholipids from egg yolk); MCE uses 20% solutions or 2.0 kcal/ml and 20-30% of 20% solutions or 2.0 kcal/ml and 20-30% of energyenergy

ConclusionConclusion

Dietitians play a key role in the Dietitians play a key role in the hospital setting with nutritional hospital setting with nutritional needs of the patients.needs of the patients.

Each diagnosis leads to its own Each diagnosis leads to its own nutritional recommendations.nutritional recommendations.

The field is always changing with The field is always changing with new research.new research.

Questions?Questions?