Critical illness or chronic conditions like trauma, injury, burns, wounds, pressure ulcers, major surgery, or sepsis cause a stress response that can result in hypermetabolism, increased catabolism, and loss of lean body mass (LBM). As a result, patients under stress may experience unintended weight loss and protein energy malnutrition (PEM), which contribute to immune impairment, weakness, and increased risk of pressure ulcers. Understanding the reasons why this happens can help practitioners understand how to treat patients under stress.

Metabolic responses during stress or trauma have a dramatic impact on the body. Reactions include increases in resting energy expenditure (REE), breakdown of protein and branched chain amino acids, nitrogen loss through the urine, and conversion of protein to glucose for energy use (1,2).

Proinflammatory proteins called cytokines are released in response to inflammation resulting from stress, tissue damage, or infection. Cytokines stimulate cell growth, cause signs of infection such as fever, contribute to metabolic changes and changes in the gastrointestinal system that can create anorexia and malaise (2). The release of cytokines stimulates an increase in the catabolism of lean body mass. At the same time, counter-regulatory hormones (such as glucagons, cortisol and catecholamines) are released. These hormones mobilize fatty acids, promote breakdown of glucose, and the conversion of dietary protein to glucose for energy. As a result, energy production becomes increasingly dependent on dietary protein, and branched-chain amino acids fuel the muscles (1).

Metabolic stress causes poor utilization of carbohydrate, protein and fat and results in rapid breakdown of lean body mass (LBM). Fat metabolism increases to create energy. This series of events results in an acute PEM in which albumin, transferrin, prealbumin and retinol-binding protein decrease because of inflammation. C-reactive protein may increase during the inflammatory response. A negative nitrogen balance occurs due to rapid loss of LBM, resulting in muscle wasting. Hyperglycemia is also common during stress as the body rushes to produce energy, but simultaneously reduces the production of insulin. At the same time these catabolic activities are taking place, anabolic hormones such as testosterone and growth hormone decrease, resulting in a decrease in tissue synthesis (1).   

In a trauma or acute situation, the stress response typically peaks at 3 to 4 days, and subsides in 7 to 10 days. However, in situations of a chronic nature (i.e. severe wounds, pressure ulcers, and chronic diseases like cancer or COPD), hypermetabolism and the catabolic response may last weeks or even months. Changes in metabolism begin at the time of the injury or acute illness and continue until recovery/healing is complete. Unfortunately, the rate of recovery of LBM is much slower during the recovery stage than the rate of loss during the inflammatory stage. 

Lean body mass makes up 75% of body weight mostly in the form of muscle, bone and tendon, and provides the majority of the body’s protein including visceral protein, collagen, enzymes, antibodies and growth factors. Protein is critical for growth and maintenance, fluid and electrolyte balance, acid-base regulation, blood clotting, enzymatic functions, metabolism, and immune function (3,4). To reverse the catabolic state and promote anabolism, adequate nutrition along with resistance exercise is needed (5).

Nutrition interventions including provision of adequate protein, calories, and fluids can help manage the metabolic effects of prolonged stress by meeting increased needs due to the stress response. 

References:

1. Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper.  National Pressure Ulcer Advisory Panel, 2009.
2. Mahan K and Escott-Stump S, Krause’s Food and Nutrition Therapy, 12^th ed, 2008. Saunders, Philadelphia, PA.
3. Demling R, Involuntary Weight Loss, Protein-Energy Malnutrition, and the Impairment of Cutaneous Wound Healing, Wounds: A Compendium of Clinical Research and Practice; Supplement D. Vol 13, No. 4, July/August 2001.
4. Demling R, DeSanti L, Protein-Energy Malnutrition, and the Nonhealing Cutaneous Wound, 2003.
5. Dimant J, Gruber, et al.  Pressure Ulcer Therapy Companion Clinical Practice Guideline, American Medical Directors Association, Columbia, MD, 1999. 

©2012 Becky Dorner & Associates, Inc.

This article was adapted from materials found in The Complete Guide to Nutrition Care for Pressure Ulcers: Prevention and Treatment, Becky Dorner & Associates, Inc. 2012.

Becky Dorner, RD, LD is widely-known as one of the nation's leading experts on nutrition and long-term health care. Her company, Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for healthcare professionals, sign up for our free membership at www.BeckyDorner.com   

If you have other tips that are effective for determining appropriate approaches to assisting older adults, please take a moment to share it below!

Best wishes,

Becky Dorner, RD, LD

http://www.beckydorner.com/

Approximately 45% of the older adults in the U.S. are affected by sarcopenia, the progressive loss of muscle mass, function, quality, and strength driven by the aging process (1). Sarcopenia can lead to diminished strength and decreased activity levels, and can contribute to mobility issues, osteoporosis, falls and fractures, frailty, loss of physical function and independence (2).

From age thirty to sixty the average adult will gain a pound of weight and lose half a pound of muscle yearly for a total gain of 30 pounds of fat and a loss of 15 pounds of muscle. After the age of seventy, muscle loss accelerates to 15% per decade. Factors that accelerate loss of muscle mass in older adults include decreased physical activity, testosterone and growth hormone deficiency, possibly mild cytokine excess, and the stress response (3). Physiological anorexia, decreased caloric intake and weight loss are all related to aging, which in turn is associated with decline in muscle mass and increased mortality (4,5).

Health care professionals should use a validated nutrition screening tool such as the Mini Nutrition Assessment®-Short Form (MNA®-SF) to identify individuals at risk of malnutrition. Low MNA®-SF scores correlate with decline in functional ability, cognitive impairment, and increased frailty in older adults (6). If the nutrition screening process determines that an individual is at high risk of malnutrition, a referral should be made to the registered dietitian (RD) who should follow the Academy of Nutrition and Dietetics Standardized Nutrition Care Process of assessment, diagnosis, intervention and monitoring/evaluation.

Protein and energy intake are key components along with both resistance and aerobic exercise for the prevention and management of sarcopenia. Older adults historically are at risk for inadequate protein intake below the recommended dietary allowance (RDA) for protein (0.8g/kg/day) for healthy adults. One study of adults over fifty noted that 32% to 41% of women and 22% to 38% of men consumed less than the RDA for protein (7). Metabolic changes in older adults result in the production of less muscle protein than younger adults who consume the same amount of dietary protein. Studies indicate that an amino acid mixture of 30 grams per meal produced protein synthesis similar to younger persons (8). A total protein intake of 1.0 - 1.5 gms/kg/day, with equal amounts of protein consumed at breakfast, lunch and dinner is recommended (9). Paddon-Jones and colleagues noted that whey protein supplementation (15 – 20 gm) increased the muscle strengthening effects of resistance exercise (10). Supplementation of Vitamin D in individuals with low levels increases muscle strength has also shown positive results. 25(OH) vitamin D levels should be measured in all sarcopenic individuals and vitamin D supplementation in doses sufficient to increase levels above 100nmol/L should be given as an adjunctive therapy (9). 

Nearly all older adults can benefit from resistance and strength training to increase muscle strength, improve functional ability, or prevent further decline. There are four components of physical activity that are important for a well-balanced exercise plan. All are important, but resistance exercise has been shown to decrease frailty and improve muscle strength in very elderly adults. Exercise is recommended on most days of the week, but a minimum of three times a week is recommended to slow muscle loss and prevent sarcopenia (11).

• Endurance exercises improve the cardiovascular and circulatory systems (low-impact exercises).
• Strength training to reduce sarcopenia, build muscle, and possibly prevent osteoporosis. Resistance training should be done three times per week.  Alone and in combination with nutritional supplementation, strength training increases strength and functional capacity (12).
• Balance to prevent falls. This may include tai chi, or something as simple as standing on one leg with eyes closed, though older adults may need to hold on to something while doing this.
• Flexibility to recover from or prevent injuries (i.e. yoga or stretching exercises). This may also help prevent falls (13).

Nutrition and exercise together have a synergistic effect that helps combat malnutrition, increase strength, and promote well-being. Health care professionals can help older adults prevent and/or treat sarcopenia by encouraging a proper diet, and physical activity, using age- and ability-appropriate exercises.

References:

1. Janssen I, Shepard D, Katzmarzyk P, Roubenoff R. The Healthcare Costs of Sarcopenia in The United States. Journal of The American Geriatric Society 52:80–85, 2004.
2. Alliance for Aging Research. Aging in Motion: The Facts About Sarcopenia.  http://www.aginginmotion.org/wp-content/uploads/2011/04/sarcopenia_fact_sheet.pdf. Accessed March 19, 2012.
3. Morley JE, DiMaria RA, Amella E. Frailty and the older adult: Features, vulnerabilities, and feeding. Clinical Nutrition Week. January 30, 2005.
4. Morley JE. Weight loss in older persons: New therapeutic approaches. Curr Pharm Des 2007;13: 3637-3647.
5. Visvanathan R, Chapman IM. Undernutriton and anorexia in older persons. Gastroenterol Clin North Am 2009; 38: 393-409.
6. Donini LM, Savina C, Rosano A, et al.  MNA predictive value in the follow-up of elderly patients.  J Nutr Health Aging 2003;7:282-293.
7. Kerstetter JE, O’Brien KO, Isogna KL, Low Protein Intake: The impact on calcium and homeostasis inhumans. J Nutr 2003; 133: 8555-8615.
8. Paddon-Jones D, Sheffield-Moore M, Zhang XJ, Volpi E, Wolf SE, Aarsland A, Ferrando AA, and Wolfe RR. Amino acid ingestion improves muscle protein synthesis in the young and elderly. Am J Physiol Endocrinol Metab 286: E321–E328, 2004.
9. Morley JE, Argiles JM, Evans WJ, et. al. Nutritional recommendations for the management of sarcopenia.  J Am Med Dir Assoc. 2010; 11: 391-396.
10. Paddon-Jones D, Sheffield-Moore M, Katsanos CS, Zhang XJ and Wolfe RR. Differential stimulation of muscle protein synthesis in elderly humans following isocaloric ingestion of amino acids or whey protein. Exp Gerontol Nov 22, 2005b.
11. Dorner B, Diet Manual: A Comprehensive Resource and Guide.  Becky Dorner & Associates, Inc., Akron, OH, 2011.
12. 12. Mead Johnson Advisory Board for Geriatric Health and Nutrition, Recuperative Powers of Nutrition: Resistance, Recovery, Rehabilitation Monograph. Mead Johnson Nutritionals, Mead Johnson & Company, 2003.
13. 13. NIH Senior Health: Falls and Older Adults. http://nihseniorhealth.gov/falls/aboutfalls/03.html. Accessed June 14, 2010.

©2012 Becky Dorner & Associates, Inc.

Authors:

Becky Dorner, RD, LD is widely-known as one of the nation's leading experts on nutrition and long-term health care. She is currently serving as the Academy of Nutrition and Dietetics Speaker of the House of Delegates. Her company is dedicated to improving quality of life for older adults, and is a trusted source of valuable resources for healthcare professionals. Sign up for a free membership at www.BeckyDorner.com and access articles, resources, FAQs, publications, and continuing education programs to make your job easier. Contact us at info@beckydorner.com.

Mary Ellen Posthauer, RD, LD,CD is President of MEP Healthcare Dietary Services Inc. in Evansville, IN.  Mary Ellen was a member of the 2008 Society for Sarcopenia, Cachexia and Wasting Disease expert panel that developed nutrition recommendations for sarcopenia and a contributing author to Nutritional Recommendations for the Management of Sarcopenia JAMDA 2010 article.

For more resources on this subject and other topics related to nutrition and food, please visit www.beckydorner.com and sign up for our free membership for additional free resources and discounts on our products and continuing education programs.

If you have other tips that are effective for determining appropriate approaches to assisting older adults age healthfully, please take a moment to share it below!

Best wishes,

Becky Dorner, RD, LD

http://www.beckydorner.com/

The obesity epidemic challenges health care professionals who care for older adults.

Our next great challenge in working with the nutritional needs of older adults in health care communities will be one that we have not worried about in many years: obesity. In the U.S., the prevalence of obesity in the general adult population is now at 67% (1); among adults over the age of 75 this rate was 26% for men and 27% for women in 2007-8. This may not sound alarming until you realize that this is an increase of 100% and 42% respectively since 1988-1994 (2). It is clear that in the coming years we’ll see more obese residents enter health care facilities for both short-term rehabilitation and long-term stays. 

Obesity and Disease Risk in Older Adults

Along with higher rates of obesity, older Americans are experiencing higher rates of obesity-related diseases. This includes coronary heart disease, type II diabetes, stroke, and several types of cancer. In addition, obese older adults report more limits to activity levels which can lead to further increases in obesity and contribute to metabolic syndrome and/or sarcopenic obesity – age related loss of skeletal muscle mass coupled with obesity which can lead to weakness, frailty and falls.

Benefits of Weight Loss for Obese Adults

At first glance, it is easy to think that weight loss should be the prescribed course of action for all obese older adults. After all, it has been shown that weight loss can help reduce the risk of chronic disease or – for those who already have chronic disease – help control those diseases that tend to be worsened by obesity. Plus, there is some evidence that weight reduction in obese people over the age of 65 has similar health benefits to those at younger ages, primarily related to the reduction of cardiovascular disease risk factors.

The National Health, Lung and Blood Institute summarizes the advantages of weight loss well in their review of the evidence-based research and recommendations (3). In general, weight loss is recommended to:

• Lower elevated blood pressure 

• Lower elevated levels of total cholesterol, LDL-cholesterol and triglycerides

• Raise low levels of HDL-cholesterol 

• Lower elevated blood glucose in obese persons with type 2 diabetes

Is Weight Loss Always the Best Course of Action?

While the benefits of weight loss for healthier older adults may include reduced risk of cardiovascular episodes, reduction in blood cholesterol, blood lipids and blood glucose levels, for more fragile older adults the health risks can outweigh the benefits. For obese older adults, a number of questions must be answered to determine if weight loss is appropriate:

• Will weight loss reduce risk factors for other complications?

• Will weight loss prolong life for the individual?

• What are the risks associated with obesity treatment? (3)

• Will a restricted diet reduce the individual’s ability to consume adequate nutrients to maintain health? 

For individuals who are appropriate for a planned weight loss program, the program must be carefully planned and supervised by trained health care professionals. Proper nutritional counseling and close monitoring of body weight and other nutritional parameters are essential.

For more fragile obese older adults health risks of weight loss include the potential for protein-energy malnutrition, vitamin/mineral deficiencies, and other complications that may follow (such as pressure ulcers, bone loss, weakness, and falls). For these patients a weight loss program may not be appropriate at all. 

“A clinical decision to forgo obesity treatment in older adults should be guided by an evaluation of the potential benefits of weight reduction for day-to-day functioning and reduction of the risk of future cardiovascular events, as well as the patient’s motivation for weight reduction. Care must be taken to ensure that any weight reduction program minimizes the likelihood of adverse effects on bone health or other aspects of nutritional status” (3).

For more resources on this subject and other topics related to nutrition and food, please visit www.beckydorner.com and sign up for our free membership for additional free resources and discounts on our products and continuing education programs.

This information was excerpted from the book The Obesity Challenge: Weight Management in Health Care Communities, authored by Becky Dorner, RD, LD.

References:

1. F as in Fat 2010: How Obesity Threatens America's Future 2010. Trust for America’s Health and Robert Wood Johnson Foundation. http://healthyamericans.org/report/88/. Accessed February 3, 2012.

2. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. National Heart Lung and Blood Institute, National Institutes of Health. http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm. Accessed February 3, 2012.

3. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics. Washington, DC: U.S. Government Printing Office. July 2010. http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2010_Documents/Docs/OA_2010.pdf. Accessed February 3, 2012.

If you have other tips that are effective for determining appropriate approaches to assisting older obese adults, please take a moment to share it below!

Best wishes,

Becky Dorner, RD, LD

http://www.beckydorner.com/

Health care communities are making person-centered dining programs the center of attraction!  

Nursing homes and assisted living facilities alike are embracing the concept of changing their internal culture from institutional-based care to person-centered care where the individual is at the center of making decisions about their daily lives. Dining can be an important part of the transition to person centered care, and can in fact, dining can take center stage in a facility’s culture change movement.

The goals of culture change are to encourage people to thrive in their later years, to live in more home-like atmospheres with fewer people, more privacy, and more control over their everyday lives. Benefits of culture change may include: improvements in quality of care and life, resident, family and staff satisfaction; and reductions in morbidity and mortality, use of restraints, psychotropic medications, unintended weight loss, and staff turnover. With person centered care, the individual is the focus. Individuals are encouraged to follow lifelong habits, rituals, cultural routines, and to make decisions about care and daily activities. Food and dining are a great place to begin making positive changes.

Person Centered Dining Takes Center Stage

Person centered dining often takes center stage since food and dining is something everyone can relate to – and most people look forward to every day. It’s an easy transition because food is part of normal life, socialization, celebrations, and comfort. There are many suggestions for meal service that align with making improvements to enhance quality of life.

Facilities can begin by de-institutionalizing the facility, eliminating things that would not be seen in a home (i.e. food carts, food trays, tray service), and implementing systems that support person centered care such as family style dining, and cross-training all staff to assist with food delivery at meal time, and to assist an individual with their meal set up by helping them to open packages, cut meat, etc. 

Food has social, psychological, ethical and religious connotations, and each individual’s wishes should be respected and catered to. Socialization is an important part of the dining experience. Seating in the dining area can be arranged to foster discussions, develop and nurture relationships, so residents look forward to dining and socialization as a highlight of the day. Dining atmospheres should be visually pleasant, inviting and comforting. Facilities should strive to create a space where people want to spend time – by helping individuals feel welcome and comfortable, encouraging socialization, and assuring that individuals receive the help they need at meal time.

In our own homes, the kitchen is the center of many activities. Food is easily accessible; people eat together and socialize together around the kitchen table. This transfers easily to health care facilities. Food and dining can be incorporated into a normal living setting:

• Family style dining around a dining room table where food is passed on platters and bowls, and people help themselves to what they want.
• Providing access to foods and beverages at any time of day in a small kitchen area.
• Providing choices for foods and beverages at each meal and snack, choices in meal and snack times, choices in dining partners, and dining options such as buffet dining, restaurant style service, room service, and on-demand dining.

In other words, offering individuals more control over who, what, where and when: who they eat with, what they eat, where they eat and when they eat. Menus should be well-planned and should incorporate foods that residents enjoy.

Dining is an Essential Component to Culture Change and Person Centered Care

Health care facilities are embracing culture change and person centered care. You can help your facility and your residents by letting your dining program take center stage with person centered dining. For more resources on this subject and other topics related to nutrition and food, please visit www.beckydorner.com and sign up for our free membership for additional free resources and discounts on our products and continuing education programs.

This information was excerpted from The Person Centered Care Movement in Health Care Communities, authored by Becky Dorner, RD, LD.

If you have other tips that are effective for implementing person centered dining, please take a moment to share it below!

Best wishes,

Becky Dorner, RD, LD

http://www.beckydorner.com/

1. Track Market Trends. Track price increases so you can make changes as needed. Cost of living increases, increased competition for workers, and union increases will affect labor costs. Adjust food purchases and alter menus as needed based on price changes. The Consumer Price Index (CPI) forecast for 2012 predicts that food prices will be slightly above historical averages for the past two decades. Predictions include: All Food Index up 2.5 - 3.5%, Food Away from Home up 2 - 3%, and Food At Home up 3 - 4%. Predicted price increases in various food categories include:

• Meats, poultry, seafood prices up 3.5% overall, with beef/veal up 4.5%, pork and poultry up 3-4%, and fish/seafood up 4-5%.

• Egg prices up 2.5 - 3.5%.

• Cereal and bakery prices up 4.5 - 5.5%.

• Sugar and sweets prices up 2 - 3%.

• Dairy prices (milk, cheese, ice cream, butter) up 3.5 - 4.5%.

• Fresh produce up 3 - 4% overall, with fresh fruit and processed produce up 3 - 4%, and fresh vegetables up 3.5 - 4.5%.

2. Know Your Numbers. Understand your operation’s budget and profit/loss statements. Analyze statements weekly, monthly and quarterly. Your menu drives decisions related to food purchases, labor/skill level needs, food cost, production schedule, equipment needs, customer satisfaction, nutritional value, service needs, and most importantly, your bottom line. Check prices on all menu items to assure costs are within the desired range, and use software systems to take immediate steps to control costs. 

3. Control Labor Costs. Track your meals/labor hour: Total Meals Served/Day ÷ Labor Hours/Day. The average meals/labor hour for hospitals and long term care facilities is 6-12. Track productivity and implement systems to assure efficiencies. Reduce absenteeism, and hold staff turnover to a minimum. For a $20,000/year worker, turnover may cost as much as $10,000 for a turnover rate of 25% (the national average).

4. Avoid Overproduction. The number one cost leak in foodservice operations is over-production! Eliminate as much waste as possible. Ten extra meals a day adds up fast: $3.75 (food/labor/supplies) X 10 = $37.50/day x 365 days/year = $13,687.50/year. Implement controls for preparation, service, and handling leftovers. Adjust recipes for the number of servings actually needed. Use production records to document what and how much food is left, and the plan for use of leftovers. Control portion sizes and use standardized recipes. Train employees on proper portioning and provide the correct measuring utensils and equipment. Conduct a plate waste study to determine which menu items need to be changed, and which portions can be reduced while maintaining customer satisfaction. 

5. Reduce The Price You Pay for Food.  First, join a group purchasing organization (GPO) to save 5 - 10% or more on your food cost. If you are spending $200,000 per year on food, a 5% savings equals $10,000 annually! Next, take these steps:

a. Assure bills are paid on time. It’s like taking out a loan: the longer it takes to pay the bill, the higher the rates will be. 

b. Avoid poor purchasing habits that cause frequent trips to the local store. The average “store run” costs labor time to go to the store, plus the cost of paying someone to do that person’s normal work, and the higher cost of retail goods. 

c. Reduce the number of vendors and deliveries so the vendor can pass cost savings to you. Reducing orders also saves money by saving time to place orders, check in deliveries, put stock away, and process paperwork. 

d. Check in all incoming orders to assure you receive all items on the invoice, and all are in acceptable condition. 

e. Use suitable quality products for each menu/recipe item (Ex. You don’t need Grade A fruit for a fruited gelatin). 

f. Evaluate the true cost of scratch versus convenience foods (include labor and waste in the equation). 

g. Investigate supplement costs. Have physicians write orders for “supplement per dietitian.” Choose the most appropriately priced and well accepted product for your patients and/or residents.

6. Purchase Based on Yield. Use yield price (“as served” or “edible portion” cost) rather than purchase price per unit as your determining factor in choosing a food item. Lower priced products often actually cost more due to lower yield.

7. Eliminate Theft and Pilferage. If you spend $200,000.00/year on food and have a 5% theft rate, it costs your operation $10,000.00 each year (and 5% is on the low side). Have checks and balances in place to decrease risk of theft. 

a. Implement an on-going accurate perpetual and physical inventory system. Keep inventory low and take regular physical inventories. Determine your true food cost: Food cost = Beginning inventory + Purchases- Ending inventory. (Food purchased does not equal usage). Have a supervisor oversee the check-in and storage of all deliveries.

b. Implement “back door policies”: Do not allow employees take food home. Do not allow employees to take breaks or come and go from an outside door near the storeroom/freezer area. Store less tempting items (i.e., thickened juices) by the storeroom door and the more tempting items (coffee packets, cookies) farther away. Use only clear plastic trash bags.

c. Keep storerooms and freezers locked (except when products are being put away or removed). Change locks and keys from time to time and always change them whenever an employee who had access to the keys has left your employment. 

8. Assure financial figures are accurate. When determining cost per meal, factor out extras such as staff meals, nutritional supplements, free coffee, special functions and floor stock. These are not part of the meal cost. Include these “extras” as separate line items, and charge costs to the appropriate financial category.

By taking steps to keep your cost in control can save you thousands of dollars each year without sacrificing quality of food or service. 

This information was excerpted from Cut Your Foodservice Costs Now! Start saving thousands without sacrificing quality, authored by Becky Dorner, RD, LD, and contributing author, Kim Hofmann, RD, LD.

If you have other tips that are effective for controlling overproduction, please take a moment to share it below!

Best wishes,

Becky Dorner, RD, LD

http://www.beckydorner.com/

Becky,

 
Thank you for your kind support of the patients in Haiti. I started a nutrition programme for the spinal patients back in October which consists of protein and milk supplements daily with protein "treats" up to 3 times a week on top of that… Many of my patients on the spinal unit had a BMI that indicated being underweight and in many cases their BMI would be consistent with starvation. As you are aware, having malnutrition to any extent impairs healing of wounds and we were finding that the main reason for our patients staying in the hospital was for treatment of wounds that were failing/slow to heal.

 
Since we started the nutritional programme on the spinal unit we have discharged patients that at one point we had thought might never heal. Edith is a 24 year old girl who sustained a fracture to her cervical spine in a road traffic accident in March 2010 rendering her a C5 Quadraplegic. Edith came to Hospital Bernard Mevs/Project Medishare with a Grade 4 sacral ulcer with comorbidities of systemic infection, severe malnutrition and severe depression. She sustained her wounds from sleeping on hard flooring. She had multiple surgeries to close her wound which failed- mostly due to her poor nutritional status. Following the initiation of the protein supplementation programme Edith's wound healed rapidly and she was discharged home.

I have no doubt that it was the additional nutrition that facilitated Edith's healing and return home. (I have attached photos of Edith's wound and her return home). Edith is one of the patients that we will be presenting at the European Pressure Ulcer Advisory Panel meeting in Porto in August to show how advanced wound care treatment and nutritional support can change practice and lives in Haiti.

At present I am trying to institute a programme for nutritional monitoring form admission to discharge on the spinal unit - I return to Haiti in September for an indefinite period and look forward to continuing the good work that Karen has started with the ICU patients as well as my own projects in the spinal unit and the rest of the hospital.

Best Wishes,

Joanna Cherry MD

The people of Missouri are some of the loveliest individuals you would ever want to meet. They are friendly, kind and understanding. They had to be to allow me to present this topic to them so quickly after this staggering event. The program planner actually broke down and cried when she introduced the topic…and me as the presenter. The presentation began with some photos of the destruction left in the tornado’s path – as we remembered those who had lost their lives, their homes, and everything they had worked a lifetime to build. Imagine…  Some of these people didn’t have to imagine – they had lived through it. I did my best to pack the program with helpful tips and information for planning before, during and after a disaster. Some of the most important information came from disaster survivors sharing their experience and knowledge. After the program, many people told me that even though they felt like they had a disaster plan in place before they attended the program, they realized that they had not done enough to prepare, and had learned numerous ideas that they planned to implement in their facilities. It’s human nature to think “it will never happen to me” but recent events show that nature can unleash its wrath anywhere—from small towns to major cities. If disaster strikes, you do the best you can do for those around you. But wouldn’t it be better to be as prepared as you possibly can?

Because few of the audience participants had disaster menus, I wanted to share ours, along with some other great tools to help you with your planning:

• Webinar: Who Turned out the Lights? Disaster Planning for Dining Services http://www.beckydorner.com/products/224
• Dietary Disaster Plan http://www.beckydorner.com/products/82
• Free 3 day emergency meal plan (log in to our free members only area to access) http://www.beckydorner.com/uploads/disasterplanning-676.pdf

Note: Photo courtesy of Pam Brummit, MA, RD, LD

I just received this note from Karen. It brought me to tears to know that such a small gift actually saved a young girl’s life.

Dear Becky and Jill,

Just wanted to give you guys an update on what is happening with the nutrition. We received your shipment of supplies!! It was just in time, b/c we had again run out for the 4th time since I have been back from Christmas break! It couldn't have come at a more perfect time. 

This week we received a 16 year-old girl who was diagnosed with typhoid and peritoneal TB in November. She was being cared for at a large public hospital here in PAP. She had an exploratory lap on December 17th and developed fistulas. While in the care of the public hospital she received no nutrition after her surgery. She was ordered TPN but Haiti does not have TPN so they were using banana bags instead. She was transferred to us with an abdomen full of fistulas and broken down skin after receiving no protein for almost 3 months. When she came to us she couldn't talk, or move. Today, after receiving tube feeds for four days she was able to feed herself a sucker and drink a chocolate shake. She's talking now, and moving much better. I wouldn't believe it myself if I hadn't seen it with my own eyes! The first night she came to us we were sure she wouldn't survive the night.  

So, I just wanted to say a huge thank you!!! Your generous donation gave her a chance to heal and be a normal kid again. 

Thanks again,

Karen    

Thanks to generous donations from RDs across the country, we have donated funds to provide needed nutrition products for the patients at Port au Prince Hospital. It is hard to believe that in this day and age that this could actually be happening.

If you have an interest in providing donations of any kind (product or financial), please let me know. I’ll be delighted to help coordinate donations. I am working through Karen’s church because they have numerous members that are involved in making sure that the nutrition products get to those in need. Please feel free to email me at becky@beckydorner.com or visit http://www.projectmedishare.org/

The RDAs are developed based on current evidence and variation needed to cover approximately 97.5% of the population’s needs.

RDA for Vitamin D 

The new recommendations increase the RDA for vitamin D to:

·         Ages 1 to 70 years:  600 IU

·         Ages over 70 years: Up to 800 IU

·         Upper level intakes for 9 years and older: 4000 mg per day (higher levels may increase risk for acute adverse affects such as kidney)

·         Pregnancy/lactation: No additional vitamin D is needed

In the U.S., typical dietary intake of vitamin D was approximately 200 IU from food (and it was 300 IU in Canada). However, it is not appropriate to assume that someone has a vitamin D deficiency based on unmet requirements of vitamin D from food/supplements. Sun synthesized vitamin D is contributing substantial amounts as determined by the fact that a large portion of U.S. and Canadian citizens don’t meet the RDA for vitamin D in the diet, but blood levels are still healthy. People may be getting 25-33% of their vitamin D needs from sun. (The committee assumed minimal sun exposure in determining the recommended levels for vitamin D to accommodate the northern-most climates and the use of sun screens that block UV rays).

It is essential to interpret blood values for vitamin D to diagnose an actual deficiency. The lab test for measuring vitamin D in the blood is inexpensive and measures the active form of vitamin D in the body (25-hydroxy). Most labs use 30 nanograms (ng) as the normal level, however, the committee states that if a person has at least 20 ng this is actually adequate for bone health. Vitamin D deficiency is diagnosed when levels are well below 20 ng. (Note: The committee also noted an urgent need to standardize lab tests for vitamin D levels as different research studies used different tests).

Sources of vitamin D:

·         1 cup vitamin D fortified milk provides 100 IU

·         Fatty fish provide some of the best sources: A serving of salmon may provide one day’s RDA

·         Vitamin D fortified milk, fortified milk products (such as yogurt), and fortified cereals are also good sources.

RDA for calcium:

·         Ages 1-3:                                700 mg

·         Ages 4-8:                               1000 mg

·         Ages 9-18:                             1300 mg

·         Ages 19-70:                           1000 mg (women need 1200 mg at age 51+)

·         Ages 71 years and over:     1200 mg

·         Pregnancy and lactation: there is no need for additional calcium. The body becomes more efficient during pregnancy and lactation.

No Additional Benefits Above the RDA

The committee noted that the evidence shows no additional benefits above the recommended levels. In other words, taking additional supplements over and above the RDA has no benefits for the general public.

The recommendations are for total intake of vitamin D and calcium from diet and supplements. Many people can get what they need in the diet, but it is difficult for older people to consume enough vitamin D and calcium from the diet and they may need help in the form of supplements.

It is important to note that these are general recommendations for the public. Medical conditions can impact vitamin D and calcium absorption. Patients with chronic diseases need to work with their registered dietitian (RD) and MD to individualize doses to meet their needs based on their condition and treatment.

Excerpted/adapted from Dorner, B. Diet Manual: A Comprehensive Resource and Guide. Becky Dorner & Associates, Inc. Akron, OH. 2011 Edition.

To read the full report, visit the Institute of Medicine website at http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx or watch the press webcast here http://www.visualwebcaster.com/event.asp?id=74648

DRIs for Calcium and Vitamin D

Released: 11/30/2010

The American Dietetic Association (ADA) held its annual Food and Nutrition Conference and Exhibition (FNCE) in Boston November 6-9, 2010. It was a great meeting with lots of new information! Hot topics  in nutrition care for older adults included the ADA Evidence Analysis Library project on Unintended  Weight Loss in   Older Adults, the new ADA position and practice papers on Nutrition Interventions for Older Adults in Health Care Communities from the Oct. 2010 JADA (we shared the link in our October e-zine); sarcopenia/sarcopenic obesity and the role of nutrition, protein and physical activity; validated nutrition screening tools; and of course Health Care Reform and a whole lot more!

Sue Albrecht, MS, RD, Health Quality Review Specialist for CMS Region 1 and the ADA Dietetics in Health Care Communities (DHCC) CMS contact very graciously shared some important information and fielded many questions on the MDS 3.0. Here are a few key items she shared:

• F371 Sanitation/Food Safety is the number 1 cited tag nationally (again!)
• There are now 14 states using the QIS survey process: Connecticut, Kansas, Ohio, Louisiana, Florida, Minnesota, North Carolina, New Mexico, West Virginia, Maryland, Washington, Delaware, Maine and Vermont. QIS training is scheduled to begin in Georgia and Arizona early this winter.
• MDS 3.0, Care Area Assessments (CAAs) and Care Area Triggers (CATs):
      > CAAs are basically what we used to call “RAPS”, and the CATs used to be what we called the RAP Summary. If anything triggers on the CATs, than you need to do a CAA. In some cases there is no nutrition intervention. In these cases you need to document in detail why there is no nutrition intervention (why you did not intervene).
      > CMS is not mandating that you fill in the CAA checklists that are in the resource section of the MDS 3.0/RAI manual (unless it is your facility’s policy to do so). If you choose to fill them in and they become a part of the medical record, then CMS can certainly use them as part of their review. CAA checklists are there to help you think things through and write the care plan. One audience member noted that the CAA checklists are good learning tools. She found it helpful to fill in the checklists for her own personal use just to learn all the potential issues that you might want to address in your assessment and care plan. Once she learned all the issues, then she didn’t need the checklists any more.
       > The key is to be sure that you document why you did or did not address an issue in the nutrition assessment and/or nutrition notes. Under section V, it is fine to write in “See RD notes”, but if you do that then you must be sure that you documented why you did or why you did not address nutrition issues. In other words, make sure that if you refer them back to your assessment that you thoroughly documented appropriately in the assessment. For example, let’s say the resident’s BMI was >25.9 which triggered for a CAA and you chose not to intervene. Did you document why you chose not to intervene? (An example might be that this resident has been at this same body weight – their usual body weight - for 20 years and the does not want to lose weight.
• Therapeutic Diets:
       > If you are adding anything to increase calories or protein (such as adding extra pudding or cottage cheese to the diet each day), it is considered a supplement and therefore, part of the therapeutic diet.

Please watch our e-zine for upcoming webinar/CEU programs, and feel free to contact me any time if I can be of support.