Nutritional education for management of osteodystrophy (NEMO) trial: Design and patient characteristics,Lebanon

This study aims to determine the effect of a trained dedicated dietitian on clinical outcomes among Lebanese hemodialysis (HD) patients: and thus demonstrate a viable developing country model. This paper describes the study protocol and baseline data. The study was a multicenter randomized controlled trial with parallel-group design involving 12 HD units: assigned to cluster A (n = 6) or B (n = 6). A total of 570 patients met the inclusion criteria. Patients in cluster A were randomly assigned as per dialysis shift to the following: Dedicated Dietitian (DD) (n = 133) and Existing Practice (EP) (n = 138) protocols. Cluster B patients (n = 299) received Trained Hospital Dietitian (THD) protocol. Dietitians of the DD and THD groups were trained by the research team on Kidney Disease Outcomes Quality Initiative nutrition guidelines. DD protocol included: individualized nutrition education for 2 hours/month/HD patient for 6 months focusing on renal osteodystrophy and using the Trans-theoretical theory for behavioral change. EP protocol included nutrition education given to patients by hospital dietitians who were blinded to the study. The THD protocol included nutrition education to patients given by hospital dietitian as per the training received but within hospital responsibilities, with no set educational protocol or tools. Baseline data revealed that 40% of patients were hyperphosphatemics (> 5.5 mg/dl) with low dietary adherence and knowledge of dietary P restriction in addition to inadequate daily protein intake (58.86%± 33.87% of needs) yet adequate dietary P intake (795.52 ± 366.94 mg/day). Quality of life (QOL) ranged from 48-75% of full health. Baseline differences between the 3 groups revealed significant differences in serum P, malnutrition status, adherence to diet and P chelators and in 2 factors of the QOL: physical and social functioning. The data show room for improvement in the nutritional status of the patients. The NEMO trial may be able to demonstrate a better nutritional management of HD patients.     

The role of the dietitian in a multicenter clinical trial of dialysis therapy: the Hemodialysis (HEMO) Study.

The Hemodialysis (HEMO) Study is a randomized multicenter prospective clinical trial, supported by the National Institute of Diabetes, Digestive, and Kidney Diseases of the National Institutes of Health. The trial is designed to assess the effects of a standard versus higher dialysis dose and low versus high dialysis membrane flux on morbidity and mortality of chronic hemodialysis patients. The role of the dietitian in the HEMO Study is to support and maintain the nutritional status of randomized participants. To ensure participant safety, nutritional status is closely monitored by a variety of biochemical and participant-reported parameters. Serum albumin and equilibrated normalized protein catabolic rates are obtained monthly. Appetite assessment and dietary energy and protein intakes using a 2-day diet diary assisted recall are ascertained at baseline and on a yearly basis. Consumption of vitamins, minerals, and nutritional supplements, including oral enterals, tube feedings, and parenteral nutrition, is obtained at least once a year. In addition, anthropometry is performed at baseline and on a yearly basis. Prespecified changes in serum albumin level or body weight trigger action by the dietitian to prevent protein calorie malnutrition. The HEMO Study dietitians play a vital role in carrying out the nutrition program for the trial. The HEMO Study should provide important information about the natural history of the nutritional status of chronic hemodialysis patients and the impact of dialysis dose and dialysis membrane flux on these parameters.     

Medical Nutrition Therapy in Adults with Chronic Kidney Disease: Integrating Evidence and Consensus into Practice for the Generalist Registered Dietitian Nutritionist

Chronic kidney disease is classified in stages 1 to 5 by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative depending on the level of renal function by glomerular filtration rate and, more recently, using further categorization depending on the level of glomerular filtration rate and albuminuria by the Kidney Disease Improving Global Outcomes initiative. Registered dietitian nutritionists can be reimbursed for medical nutrition therapy in chronic kidney disease stages 3 to 4 for specific clients under Center for Medicare and Medicaid Services coverage. This predialysis medical nutrition therapy counseling has been shown to both potentially delay progression to stage 5 (renal replacement therapy) and decrease first-year mortality after initiation of hemodialysis. The Joint Standards Task Force of the American Dietetic Association (now the Academy of Nutrition and Dietetics), the Renal Nutrition Dietetic Practice Group, and the National Kidney Foundation Council on Renal Nutrition collaboratively published 2009 Standards of Practice and Standards of Professional Performance for generalist, specialty, and advanced practice registered dietitian nutritionists in nephrology care. The purpose of this article is to provide an update on current recommendations for screening, diagnosis, and treatment of adults with chronic kidney disease for application in clinical practice for the generalist registered dietitian nutritionist using the evidence-based library of the Academy of Nutrition and Dietetics, published clinical practice guidelines (ie, National Kidney Foundation Council on Renal Nutrition, Renal Nutrition Dietetic Practice Group, Kidney Disease Outcomes Quality Initiative, and Kidney Disease Improving Global Outcomes), the Nutrition Care Process model, and peer-reviewed literature.     

Nutrition support service: role of the clinical dietitian

A study was undertaken to determine: the qualifications necessary to function on a nutrition support team as perceived by clinical dietitians working in this capacity, the actual role of the clinical dietitian on a nutrition support team, the ideal role of the clinical dietitian on a nutrition support team, and the extent to which clinical dietitians perceive differences between the ideal role expectation and actual performance. A questionnaire was developed and sent to a random sample of 300 clinical dietitians listed as members of a nutrition support service. The respondents indicated that the clinical dietitian should have at least a B.S., R.D., and 2 years' prior work experience before assuming responsibility on a nutrition support team. The dietitians indicated that they consistently take and evaluate diet histories and assess energy and protein needs. Moreover, they viewed these tasks as appropriate. They rarely administer or interpret antigen skin tests and do not perceive this as a function of the dietitian. For all other tasks, dietitians indicated that they should perform the duty or responsibility more often. Over half reported that they did not have adequate educational preparation to assume all of the responsibilities of the clinical dietitian on a nutrition support team.     

Response to intradialytic parenteral nutrition

Malnutrition is a major clinical problem in patients receiving maintenance hemodialysis and has adverse effects on survival. Nutritional intervention is indicated, and there is evidence that intradialytic parenteral nutrition can be beneficial. We describe the application of a formal policy regarding the use of intradialytic parenteral nutrition and the beneficial effects on nutrition in the first four patients managed in this fashion. However, the fifth patient did not respond to parenteral nutrition, despite adequate dialysis. This prompted further investigation, and the patient was shown to have extensive gastric malignancy. This report shows that establishing a protocol for intradialytic parenteral nutrition is possible in a medium-sized hemodialysis unit. In these circumstances, nonresponse to this intervention should always be investigated to determine if there is another underlying cause of malnutrition unrelated to renal failure.     

The clinical dietitian as an educator of medical students.

The study of nutrition as it relates to patient evaluation and care is a necessary component of the education of medical students. Although the clinical dietitian is the person best qualified to provide applied nutrition education, this contribution has been made only since the integration of the dietitian into the health care team. Full utilization of the knowledge and expertise of the dietitian in the education of the medical student has yet to occur.     

The clinical dietitian as an educator of medical students

The study of nutrition as it relates to patient evaluation and care is a necessary component of the education of medical students. Although the clinical dietitian is the person best qualified to provide applied nutrition education, this contribution has been made only since the integration of the dietitian into the health care team. Full utilization of the knowledge and expertise of the dietitian in the education of the medical student has yet to occur.     

Nutrition Literacy Tailored Interventions May Improve Diet Behaviors in Outpatient Nutrition Clinics

ObjectivesNutrition literacy examines the intersection of nutrition knowledge and skills; however, no evidence shows interventions tailored to nutrition literacy deficits affect diet behaviors. This study examined the effects of nutrition interventions tailored to individual nutrition literacy deficits on improving diet-related behaviors.MethodsFive outpatient clinics were randomized to 2 arms. The nutrition literacy and diet behaviors of patients were assessed before intervention with a dietitian and again 1 month later. Intervention-arm dietitians received patient nutrition literacy levels and tailored interventions toward nutrition literacy weaknesses. Differences in diet behaviors between arms were analyzed using Mann-Whitney U-tests and within-arms using Wilcoxon signed-rank tests.ResultsIntervention-arm patients improved 10 of 25 measured diet behaviors; control-arm patients improved 6 behaviors. Similarly, intervention-arm patients reported increased green vegetable consumption from baseline to follow-up (z = 2.00; P = 0.04).Conclusions and ImplicationsNutrition interventions tailored toward nutrition literacy deficits may play an important role in improving patient diet behaviors.     

Practice Paper of the Academy of Nutrition and Dietetics Abstract: Oral Health and Nutrition

This paper supports the “Position of the Academy of Nutrition and Dietetics: Oral Health and Nutrition” published in the May 2013 Journal of the Academy of Nutrition and Dietetics. It is the position of the Academy of Nutrition and Dietetics that nutrition is an integral component of oral health. The Academy supports integration of oral health with nutrition services, education, and research. Collaboration between registered dietitian nutritionists (RDNs); dietetic technicians, registered (DTRs); and oral health care professionals is recommended for oral health promotion and disease prevention and intervention. There is a synergistic multidirectional association between diet, nutrition, and oral health. Given that the mouth is the portal of entry into the body, it is essential that RDNs and DTRs include the oral cavity in their assessment for nutritional risk factors and deficiencies. Nutrition assessment is vital to identifying dietary intake and nutritional factors impacting oral health. Conversely, decreased salivary flow, compromised oral integrity, tooth decay, or poor periodontal health can impact an individual's ability to consume an adequate diet. A poor diet can result in limited intake of nutrients crucial to systemic health and well-being. The provision of medical nutrition therapy that incorporates total health, including oral health, is a component of the Standards of Practice for RDNs and DTRs. Inclusion of didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in education programs for both professional groups. The multifaceted interactions between diet, nutrition, and oral health in practice, education, and research in both dietetics and dentistry merit the need for collaborative efforts to ensure comprehensive patient care.     

Nutrient adequacy of a very low-fat vegan diet

This study assessed the nutrient adequacy of a very low-fat vegan diet. Thirty-nine men (mean age=65 years) with early stage prostate cancer who chose the "watchful waiting" approach to disease management, were instructed by a registered dietitian and a chef on following a very low-fat (10%) vegan diet with the addition of a fortified soy protein powdered beverage. Three-day food diaries, excluding vitamin and mineral supplements, were analyzed and nutrient values were compared against Dietary Reference Intakes (DRI). Mean dietary intake met the recommended DRIs. On the basis of the Adequate Intake standard, a less than adequate intake was observed for vitamin D. This demonstrates that a very low-fat vegan diet with comprehensive nutrition education emphasizing nutrient-fortified plant foods is nutritionally adequate, with the exception of vitamin D. Vitamin D supplementation, especially for those with limited sun exposure, can help assure nutritional adequacy.     

Arginine deficiency-induced hyperammonemia in a home total parenteral nutrition-dependent patient: a case report

BACKGROUND: Patients with short bowel syndrome and renal dysfunction with TPN dependence are at high risk for developing hyperammonemia if the TPN does not contain sufficient quantities of arginine. Providing proper nutrition support is essential in the management of these patients. METHODS: We report on a patient with short bowel syndrome, TPN dependence, and normal renal function who developed hyperammonemic encephalopathy due to inadvertent lack of arginine in his TPN. RESULTS: The patient was successfully treated with hemodialysis and an IV arginine infusion to resolve the hyperammonemia. His home TPN was also adjusted such that arginine was added to his subsequent solutions. CONCLUSIONS: Our patient underscores the importance of adequate and sustained arginine supplementation to avoid hyperammonemia in TPN dependent patients with short bowel syndrome.     

Nutrition education in baccalaureate degree nursing schools: 1983 survey results

A mail survey was conducted to clarify the status of nutrition education in baccalaureate degree nursing programs in the United States. Responses from 53% of the 331 schools were classified into 3 groups. Twenty-one percent (36 schools) employed a full-time dietitian, 26% (46 schools) employed a part-time dietitian, and 53% (94 schools) did not have a dietitian on the faculty. Results showed differences within each group and more variability across all groups. In a majority of schools, basic nutrition was a required, three-credit course, taught by a registered dietitian. In one-third of the schools without a dietitian, approximately 15 hours of basic nutrition content was integrated into nursing courses by faculty members who were registered nurses. In most programs, diet therapy was integrated into nursing courses. Teaching responsibilities in the clinical practice area were not always a workload constituent of the full- and part-time faculty dietitians. Several interdependent factors are identified that influence nutrition education in baccalaureate nursing programs. They include and relate to the components of the nutrition curriculum, the implementation plan, and academic preparation of faculty. As the profession of nursing continues to be redefined, revisions in the nutrition component of curriculums will need to be based on present and emerging practice.     

Using the computer as a referral source to find the patient at nutritional risk

The use of the computer-generated reports helped to identify the patient at nutritional risk on the basis of length of stay and diet order and permitted the dietitian to serve the patient in an appropriate and timely manner. Of 572 patients assessed in one year, 265, or 46%, were identified as needing nutrition assessment by the computer reports. As a result of increased visibility and increased medical record entries, awareness of the dietitian's expertise has increased. Several inservice presentations on tube-feeding products, tube-feeding administration, and TPN have been requested and given to medical, surgical, and intensive care nurses. Although specific data were not collected, a decrease in tube feeding wastage was noted. As a result of increased monitoring of tube feedings, a more efficient system of labeling tube feedings was designed. At Fairview General Hospital, use of the mainframe computer-generated patient lists has not only saved the dietitian valuable time in identifying patients with nutrition needs but also has afforded her the opportunity to practice current nutrition assessment on more patients. Possible future applications include microcomputer hook-up with the mainframe computer's data banks to complete nutrition assessment calculations.     

Mass balance: a quantitative guide to clinical nutritional therapy. II. The dialyzed patient.

The concepts of mass balance are extended to the nutritional management of the patient with chronic renal failure on dialysis. The use of these concepts permits estimation of protein catabolism from calculated rates of urea generation, using measurement of blood urea levels. Protein catabolic rate will equal intake in the stable patient (zero nitrogen balance), allowing for accurate nutritional screening in a large dialysis population for whom these values are available without individual dietary surveys. This has resulted in a four-fold reduction in routine monitoring of protein nutrition in such patients, freeing the dietitian to concentrate on specific problems. These concepts also comprise a key aspect of the National Cooperative Dialysis Study which seeks to maintain BUN at different levels in four carefully controlled modes of dialysis therapy. With these methods, the monitoring and control of BUN and protein intake has made the dietitian a pivotal member of this study staff.     

Role of registered dietitians in dysphagia screening

OBJECTIVE: To examine the ability of registered dietitians to identify patients at risk for dysphagia and make appropriate diet/feeding recommendations in comparison with the speech-language pathologist, and to determine screening criteria for the registered dietitian to use for prediction of dysphagia risk. DESIGN: The dietitian and speech-language pathologist performed dysphagia screening on subjects independently through questioning and/or mealtime observation to identify signs and symptoms of dysphagia. Presence of dysphagia risk and diet/feeding recommendations were determined and results from the dietitian and speech-language pathologist were compared. SUBJECTS/SETTING: Thirty-four patients admitted during a 2-month period to a neuroscience unit at an urban teaching hospital were analyzed prospectively. STATISTICAL ANALYSES PERFORMED: kappa Statistics were used to assess agreement between the dietitian and speech-language pathologist. A kappa level of less than 0.4 indicated weak agreement, 0.4 to 0.7 indicated moderate agreement, and greater than 0.7 indicated strong agreement. Logistic regression methods were used to evaluate screening criteria as potential predictors of dysphagia risk. RESULTS: Moderate agreement (0.61) was found between the dietitian and speech-language pathologist in determination of dysphagia risk. The dietitian predicted the ability of the patient to consume an oral diet with strong agreement with the speech-language pathologist (1.0); various diet consistencies with moderate agreement (0.61); and the need for liquid restrictions with strong agreement (1.0). The most significant screening variables for prediction of dysphagia risk (P < .05) were age (P = .018), history of dysphagia (P = .042), difficulty swallowing solids (P = .0007), observed facial weakness (P < .0001), and a change in voice quality (P = .0007). Self-reported screening variables significantly related to dysphagia risk included drooling of liquids (P = .0009) and solids (P = .0080), facial weakness (P = .0006), change in voice quality (P = .0010), and prolonged eating time (P = .0157). APPLICATIONS/CONCLUSIONS: Dietitians can effectively identify patients with dysphagia. Screening for dysphagia can be implemented as part of standard nutrition assessments and may aid in decreasing dysphagia-related complications.     

Nutritional knowledge and attitudes of registered nurses.

Nutritional knowledge and attitudes of hospital nurses in Nebraska and their perceptions of the role of the dietitian in patient care were studied. In general, they had favorable attitudes toward nutrition. Although their knowledge was adequate, they lacked confidence in that knowledge. The nurses perceived dietitians in an educational rather than a service role. Older nurses had more favorable attitudes but were less knowledgeable than younger ones. More knowledgeable nurses had more positive attitudes toward their own role in nutrition education and toward the team approach to health care.