Roanna Martin

"make [food] simple and let things taste of what they are." {Curnonsky}


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Case Study: Anorexia Nervosa

As a culminating experience of my recent clinical rotation, I compiled and presented a case study with the dietitians at the facility.

If you would like to learn more about this critically ill patient that I was able to work with over the course of the rotation, feel free to look through the presentation.

<div style=”margin-bottom:5px”> <strong> <a href=”http://www.slideshare.net/roannamartin/anorexia-nervosa-case-study&#8221; title=”Anorexia Nervosa Case Study” target=”_blank”>Anorexia Nervosa Case Study</a> </strong> from <strong><a href=”http://www.slideshare.net/roannamartin&#8221; target=”_blank”>Roanna Martin</a></strong> </div>


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Vitamin D: An Overview

Vitamins and minerals are a key part of nutrition, and I realized that I haven’t been addressing them a lot here. I lean towards a “whole foods” approach of nutrition. For the average person, it is incredibly time-consuming and therefore, in my opinion, unreasonable to calculate the exact amounts of particular nutrients. It is better to keep the big picture in mind, and “eat food, not too much, mostly vegetables” (to borrow from the tagline of Michael Pollan’s book “In Defense of Food”).

However, vitamins and minerals are key components of healthy nutrition, and it is my job as a dietitian to educate consumers about them.

So, welcome to my version of Vitamin D 101.

Vitamin D is a fat soluble vitamin, and is sort of an outlaw among the vitamins. As most people know, the body can synthesize vitamin D from the sun. And, even though it is called a vitamin, it is technically a hormone because it is a chemical messenger that causes a response in the intestines, kidneys, and bones.

Vitamin D regulates calcium and phosphorus absorption, and is therefore very important for bone mineralization and strength. In addition, research suggests that vitamin D helps to maintain muscle strength, promote a healthy immune system, and help regulate cell growth and differentiation.

Here’s a list of the different diseases and conditions for which vitamin D is perhaps involved in preventing or treating. You will notice that I use the word “perhaps”. Because scientific investigations are constantly expanding and evolving, it is generally not a good idea to use definite words such as “proven” or “will prevent” or “will cure”. It is difficult to nail down 100% definitive answers. But anyways, here’s the list (1):

  • Autism
  • Cancer—best evidence for colon and colorectal cancers
  • Chronic fatigue
  • Chronic pain
  • Congestive heart failure
  • Diabetes—both type 1 and 2
  • Falling and balance problems
  • Fibromyalgia
  • Gum disease
  • Heart disease
  • Lupus/systemic lupus erythematosus
  • Multiple sclerosis
  • Muscle loss and weakness
  • Osteoarthritis
  • Osteoporosis
  • Preeclampsia in pregnancy
  • Rickets resurgence
  • Rheumatoid arthritis
  • Risk of death
  • Stress fractures

You can get vitamin D from food or from the sun. When UV light from the sun hits the skin, it reacts with 7-dehydrocholesterol (a vitamin D precursor made from cholesterol in the liver) to create cholecalciferol (vitamin D3).

This cholecalciferol, and vitamin D from foods, are converted in the liver to 25-hydroxy vitamin D, then sent to the kidney to be converted into 1,25-dihydroxy vitamin D3, the biologically active form.

vitamind1

Several factors that contribute to vitamin D deficiency include: lack of vitamin D in the diet, dark skin, lack of exposure to sunlight, and liver or kidney disease. It is estimated that more than 50% of men and women ages 65 and older in North America are vitamin D deficient (2).

There are not many foods that naturally contain vitamin D. Therefore, in the United States, most dietary vitamin D comes from fortified foods such as breakfast cereals, milk, soy milk, and margarine. Regulations state that all commercially available milk must be fortified with 400 IU/quart (3).

Food sources of Vitamin D include:

  • Salmon (3.5 oz)                          360 IU
  • Mackerel (3.5 oz)                       345 IU
  • Canned Tuna  (3.5 oz)              200 IU
  • Fortified Orange Juice (8 oz)   100 IU
  • Fortified milk (8 oz)                   98 IU
  • Fortified Breakfast Cereals       40-100 IU

The RDA (Recommended Dietary Allowance) for adults ages 19-70 is 600 IU of vitamin D a day, and for adults over 70, the RDA is 800 IU. (For an explanation of RDA, refer to my post on Alphabet Soup). The UL (tolerable upper intake level) for all adults is 4,000 IU (4)

Dark skin, increased age (individuals aged 65 and over generate only 1/4 as much vitamin D as individuals in their 20’s do), and lack of exposure to sunlight inhibit the synthesis of vitamin D from sunlight. Research indicates that people who live above 37 degrees northern latitude have insufficient duration and intensity of sunlight exposure for optimal synthesis (2).

latitude-vitaminD

There is much more that can be said about vitamin D, such as medication interactions, disease states, risks of toxicity, etc. but that’s a bit much to fit into one blog post. I hope you’ve enjoyed learning a little bit about this vitamin!

(1) nutrition411.com

(2) Harvard Health Publications

(3) Nelms, Sucher, and Long. Medical Nutrition Therapy and Pathophysiology.

(4) Office of Dietary Supplements


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Preventive Maintenance

So, this past week brought a bit of extra (unwanted) excited in regards to my mode of transportation.

I drive a 1999 Ford Escort- a basic, run-of-the-mill, get-me-from-point-A-to-point-B type of deal. I try to take good care of it, and regularly check the oil before long trips, get my oil changed every 3000 miles or so, keep plenty of windshield washing fluid inside, wash the outside whenever I’m at my parent’s house and have easy access to a hose, and vacuum it out with moderate frequency.

When I went to get my oil changed this past week, the mechanic called me in to the shop to look at my tires. Much to my chagrin, the inner part of my front tires was worn completely bare. I was aghast, and he informed me that I should probably have my alignment checked. Alignment?! I didn’t know that was part of car maintenance. But alas, apparently it is. So I promptly purchased new tires, and had my tires aligned. The front tires were so badly aligned that it was off the charts. If  the alignment had been checked earlier, I could have saved myself the expense of buying new tires. As an added note, I’m going to make certain to take a quick look at my tires from time to time. Because even I can easily do that, and it would have clued me in to the issue before I went for an oil change.

I felt so, well, STUPID, because I didn’t know that alignment should be checked (every 6,000 miles according to one dealership site, 20-30,000 miles according to another site) with moderate frequency. Obviously, I don’t know much about the world of mechanics and automobiles, so I’m thankful when others can teach me things that I do not know.

I was thinking about how there are likely many people who don’t know about preventive health maintenance. Things that seem obvious to me may not be so obvious to others. As I proceed in the field of dietetics, I need to remember that what seems common sense for health may not be for other people.

This analogy was taken even further in a hospital room at my internship on Friday, when there was a newly diagnosed diabetic who already had several diabetic ulcers on his leg. Ironically, this patient was an auto mechanic.

If he had spoken with a health care professional earlier, regarding his symptoms of increased thirst, increased urination, and blurry vision that accompany hyperglycemia, he may have been diagnosed earlier. At that point, he could have begun to control his blood sugars through diet, exercise, and perhaps medication if necessary. With this preventive care, much like my tire alignment, he could have saved himself the complication of the diabetic ulcers in the same way that I could have saved myself a pair of tires!

Maintaining good health is the best kind of preventive maintenance.

Here are 5 lifestyle habits for health maintenance:

  • Adequate physical activity
  • Good nutrition
  • Decreased tobacco use and exposure
  • Decreased alcohol use
  • Positive thinking

Source


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Medical Ethics

Through my clinical dietetics rotation today, I had the opportunity to attend two medical ethics meetings- a meeting of the Ethics Committee this morning before work, and an “Ethics in the Round” lunch and learn event.

“Medical Ethics” is a term used to refer to the values and guidelines that govern decisions in medical practice. All health care professionals need to be cognizant of the ethical issues that they make each and every day, and dietitians are no exception.

One of the areas that most relates to the work of a clinical dietitian is the use of enteral or parenteral nutrition. Enteral nutrition refers to feeding through the gastrointestinal (GI) tract using a tube, catheter, or stoma that delivers nutrients from a location further down the tract than the mouth (1). Parenteral nutrition refers to administering nutrition directly into the circulatory system (1). Most of the time, being able to use these methods to deliver nutrition to an individual is a wonderful thing that can sustain them while they are recovering from trauma or illness.

However, there are cases in which artificial nutrition will prolong life, but not necessarily promote a high quality of life.

Many of you have likely heard of the Terri Schiavo case. In this case, there was dispute between family members (which lasted from 1998 to 2005) over whether or not to continue feeding through her PEG (percutaneous endoscopic gastrostomy) tube, although doctors declared her to be in a “persistent vegetative state”. Eventually, after the case escalated to a point of federal involvement, the feeding tube was removed for the final time.

An excellent article from Today’s Dietitian addresses the issues related to PEG tube feeding at end of life. Associated risks and indications for placement should be considered prior to using a PEG tube. Although the dietitian is typically not involved in the decision of whether or not to place the PEG, they should be aware of the rationale behind the placement.

Risks include:

  • Potential complications of the surgery to place the PEG
  • Possible infection around the PEG placement site
  • Tube malfunctions (such as a blocked or leaking tube)
  • Intolerance of feeding
  • Possible fluid overload and electrolyte imbalance

 

The most evidence-based and clinically useful indications for placing a PEG tube include:

  • head and neck cancer
  • acute stroke with dysphagia
  • neuromuscular dystrophy syndromes
  • gastric decompression

 

While some practitioners may believe that tube feedings are a level of basic humane care, the wishes of the patient and family must be considered.

One of the best things that can be done is to have advance directives or living wills that clearly spell out your desire to have or not have artificial nutrition placed in case of a medical event.

Other topics discussed today were the use of “bloodless surgery centers”, in order to eliminate the need for blood transfusions during surgery for some religious groups.

As I am diving more in depth into patient cases and medical histories, I am learning so much about the world of health care. I am realizing that I still have a LOT to learn, and I am so thankful for the many things that I am being exposed to over the course of this internship.

(1) Nelms, Sucher, and Long. Nutrition Therapy and Pathophysiology, 2007.


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The Role of the Clinical Dietitian

Many of you may wonder exactly what a dietitian in a hospital does. If you are admitted to the hospital, you may or may not see a dietitian, depending on your diagnosis and what happens to you over the course of your stay.

Here’s a meme which I think does a pretty good job of explaining the role of a dietitian.

 

(Image courtesy of fellow blogger HappyDietitian)

My friends may think I’m all about a perfectly balanced and healthy lifestyle, society may view me as someone who works in the media, patients view dietitians as policemen (the most common joke I hear when I walk into the room and ask if a patient is following any sort of diet at home: “Yeah- I’m on the ‘see-food’ diet. I see food and I eat it!”).

Doctors have a tendency to think of dietitians as food service workers. Although we do work alongside food service to provide nutritionally adequate meals to patients, we are not working in food service. I have a lot of respect for food service workers, to be sure! “Catering assistants” (also called “dietary aides” or other names depending on the facility) are sometimes the friendliest faces of the hospital to many patients, as they come to the room to take menus and bring trays.

And then of course, I like to think of myself as having hours to sit down and counsel patients, helping them to think through how to have optimal health and make changes to improve their dietary patterns.

In all reality, the past week and a half I have spent most of my time reading medical charts and running a calculator to assess the nutrient needs of patients. This week I am working in the ICU, so many of my patients are on tube feedings.

I read through the chart to find out what brought the patient to the hospital. Then I assess the calorie needs for the patient, based on their height, weight, and current condition. For example, patients that have traumatic brain injury have higher energy needs, and those with skin breakdown have elevated protein needs. I had learned the various needs for different conditions through classes, but it is extremely different when you have a real live person for whom you are calculating their nutrition!

Medical nutrition therapy is an integral part of the healing process, and it’s pretty neat to be a part of it.

Contrary to my opinion when I began my dietetic internship, I’m finding some aspects of clinical dietetics to be quite enjoyable. I suppose that is the purpose of this internship- to force myself to be exposed to various opportunities within the dietetics field where I might be able to work.

ps. The power is back on at my house! While I thoroughly enjoyed the “camping” experience, it’s nice to have modern amenities restored 🙂


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The Ornish Spectrum: Sustainable Lifestyle Choices that Lead to Better Health

One of the things that I have noticed in my study of nutrition is that many people are looking for a quick fix. 

A magic food that melts away fat, or a special diet that will be completely composed of desserts but will result in complete and optimal health. But a one-time choice isn’t going to make or break your health. It’s all about the little things. Your character is not defined by how you respond to one event, but in how you respond to the little choices in life.

This concept has been well grasped and even documented by Dr. Dean Ornish, a clinical professor of medicine at the University of California, San Francisco, and the founder of the Preventive Medicine Research Institute. The research and documentation behind his program is what makes it some remarkable- it’s hard to collect solid evidence about lifestyle choices, and this doctor has done it. Patients in a randomized controlled trial lost an average of 24 lbs over one year, and maintained a 12 lb weight loss after 5 years. To read more about Ornish’s approach, take a look at his article published in the New York Times last month.

Dr. Ornish created an intensive lifestyle change program that has been shown to reverse heart disease, and a spin-off of this is the “Ornish Spectrum”, which is available to those who are interested in lowering their risk for developing heart disease.

The program encompasses 4 elements of life:

What you eat

How much activity you have

How you respond to stress

How much love and support you have

The hospital where I am currently interning offers a Dean Ornish Program for reversal of heart disease. This incredible program is covered by major insurance companies, and offers over 100 hours of intensive compassionate care to each participant. Two days a week, participants gather for an hour of exercise, an hour of stress management, an hour of group therapy and relationship building, and an hour of food. 

This evening I was able to participate in the hour of food. It was pretty spectacular. There were a handful of participants enjoying healthful foods that fit within the Ornish guidelines, sharing their personal experiences of purchasing these foods at the grocery store (one woman found a great deal on veggie burgers at Sams club!), and listening to a Registered Dietitian share helpful meal planning and shopping tips.

It was truly a nurturing and supportive environment, and I can see why the program is so effective.

The meal ended on a sweet note- with some fantastic little chocolate cupcakes.

Sweet treats are fine- in moderation 🙂

If you want to know more about the highly structured Dr. Dean Ornish Program for reversal of heart disease, you can check out my friend Mary’s awesome post, or visit the Dean Ornish website.


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Dialysis: The Artificial Kidney

Kidneys are incredibly important for our bodies.

Their function: they filter toxins out of your blood, allowing them to be excreted from the body to maintain health. But for various reasons, including diabetes and hypertension, kidneys sometimes fail to function. A hundred years ago, this would be fatal. But thanks to a young Dutch physician, Dr. Willem Kolff, life can continue despite kidney failure. Dr. Kolff constructed the first dialyzer in 1943, and dialysis has since been called “one of the foremost life-saving developments in the history of modern medicine” (DaVita).

Patients can undergo hemodialysis, in which the blood is taken out of the body and run through a machine. An alternative is peritoneal dialysis, where the dialysis fluid is placed within the peritoneal cavity and toxins are absorbed into the fluid which is then removed from the body. However, renal patients still have to follow a pretty strict diet, limiting sodium, phosphorous, potassium, and water.

If you’re interested in learning a bit more about dialysis, take a moment to check out the presentation that I put together for one of my courses: