Dietitian Mentor
A site for practical nutrition information for student dietitians, DTRs and RDNs…featuring guest blogs from students or RDNs who would like to gain writing experience.
Shine Light on Vitamin D
Written by Stephanie Alvarez, Student Dietitian
The sun has always symbolized Vitamin D. Also known as the Sunshine Vitamin, it stands out to be the only nutrient in the vitamin world chemically produced by humans. Vitamin D comes in two major forms – Vitamin D2 (ergocalciferol) and Vitamin D3 (cholecalciferol). Vitamin D2 is primarily found in plant based and fortified foods. Vitamin D3 is synthesized by our skin when exposed to UV-B rays, and found in animal foods, such as egg yolk, liver, and oily fish. Commercial supplements of vitamin D contain either form.1 These compounds are similar in function, but slightly differ in chemical structure. Although called a vitamin, it is more accurate to identify vitamin D as a prohormone. After dermal synthesis from the sun’s UV-B rays, our liver and kidneys convert vitamin D to its active hormone form – calcitriol, a compound similar in chemical structure to that of hormones. Once available, calcitriol aids in calcium and phosphorus absorption. Increasing and maintaining these levels is critical for bone growth and health. Research has found other vitamin D receptors (VDR) in the cell membranes of the immune system, brain, heart and muscle suggesting it plays multiple roles in human health. Multiple studies have concluded vitamin D may play a role in fighting infections, supporting muscular function, preventing the development of cancer, and reducing the risk of autoimmune disorders, such as diabetes or multiple sclerosis (MS).2
Because of its nature, dietitians among other professionalsrealize achieving adequate levels is a challenge. Reports indicate that vitaminD deficiency and insufficiency affect about 1 billion people worldwide.High-risk groups of vitamin D deficiency include age, pregnant women, breastfedinfants, dark skin color people, and those who live in latitudes greater than37° during the winter months when UV-B rays are poor. 3 The classicexample of vitamin D deficiency is rickets. Most commonly diagnosed inchildren, rickets occurs due to an insufficient mineralization of growing bone.This deficiency is characterized by skeletal deformities in the lower limbs. Otherdeficiencies that may result with low vitamin D levels are osteomalacia and anincrease risk of fractures.
The Dietary Reference Intake for those from 1-70 is 600 IU to promote good bone health.4,5 Dietitians and other health professionals should recommend that clients meet their Vitamin D goals by eating food high in Vitamin D such as fortified milk, other dairy products and egg yolks with supplementation, if blood VItamin D level is below normal limits. In terms of sun exposure, 10-15 minutes of midday sun is recommended, however, the amount depends on age, skin pigmentation, season, and clothing.6 The goal is for health professionals to identify those at risk and come up with an individual plan to promote optimal Vitamin D levels.
- Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Caclium And Vitamin D. Washing (DC): National Academies Press (US); 2011. 3, Overview of Vitamin D. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56051/
- CPE Monthly: Vitamin D – Today’s Dietitian Magazine. Today’s Dietitian. https://www.todaysdietitian.com/newarchives/1216p48.shtml. Accessed May 17, 2019.
- Pfotenhauer KM, Shubrook JH. Vitamin D Deficiency, Its Role in Health and Disease, and Current Supplementation Recommendations. Journal of the Osteopathic Association. 2017;117(5):301-305. doi:10.7556/jaoa.2017.055.
- National Institute of Health. Vitamin D. NIH.gov. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ Accessed May 30, 2019
- eatrightpro.org. https://www.eatrightpro.org/news-center/nutrition-trends/weight-management/risk-for-vitamin-d-deficiency-in-children-and-adolescents. Accessed May 17, 2019.
- Skin Cancer Foundation. Sun Protection AND Vitamin D – SkinCancer.org. https://www.skincancer.org/healthy-lifestyle/vitamin-d/damage. Accessed May 17, 2019.
Nutrition counseling for those on Warfarin
Working in long-term care, I often get questions about what foods to avoid when using the medication, Warfarin, also called Coumadin. People report that they are told to stay away from foods that are high in Vitamin K. Some also have questioned whether or not they could have leafy greens and cranberry juice. According to the Academy of Nutrition and Dietetics, the target should be to have a stable Vitamin K intake.1 A brief was conducted by Leblanc and colleagues who looked at three hundred and seventeen patients, classifying them to three groups, depending on what they were told to do when placed on Warfarin. The groups were: Limit or avoid vitamin K-rich foods, aim for a stable Vitamin K intake or no Vitamin K-related advice. The results were:
- 68% were told to limit or avoid vitamin K-rich foods
- 10% reported that they were instructed to have a stable Vitamin K intake
- 22% did note recall receiving any Vitamin-K related advice
Overall, most warfarin users reported avoiding Vitamin K-rich foods, which has caused them to have a lower than usual Vitamin K intake.1 In a different study, Li et al reported that having 250 mL of cranberry juice daily did not have any significant interactions with warfarin.2 The Academy of Nutrition and Dietetics also cautions Warfarin users to avoid herbal supplements, vitamin E and fish oil supplements as not much is known about the interactions between these items and the drug.1
Many are avoiding green vegetables and cranberry juice and this has raised the question as to whether or not there is a need for better nutrition counseling. The researchers recommend that more studies be conducted, focusing on effective counseling strategies utilizing evidence-based Vitamin K recommendations.2 Until then, RDNs should recommend maintaining a stable Vitamin K intake and avoiding vitamin E, fish oil and herbal supplements.
1) Academy of Nutrition and Dietetics. Vitamin K and Coumadin. https://www.eatrightpro.org/news-center/nutrition-trends/diseases-and-conditions/vitamin-k-and-coumadin. (eatrightPro subscription required) Accessed 5/26/2019
2) Leblanc C, Dube MP, Presse N, et al. Avoidance of vitamin K-rich foods is common among warfarin users and translates into lower than usual vitamin K intakes. J Acad Nutr Diet. 2016; 116(6):1000-1007.
3) Li Z, Seeram NP, Carpenter CL, Thames G, Minutti C, Bowerman S. Cranberry does not affect prothrombin time in male subjects on warfarin. J Am Diet Assoc. 2006;106:2057-2061.
NutriGuide app
Working in long term care for over twenty-five years has been rewarding as well as challenging. I’m actually amazed at how many things have changed since I began. When I started out, I felt that there were no clear guidelines for providing nutrition therapy. It seemed as though most dietitians were doing their own thing. This made it very confusing for many of us. Fortunately, The Academy of Nutrition and Dietetics (A.N.D) realized this and launched its Evidence Analysis Library (EAL) in 2004. Academy members reviewed many studies to come up with practice guidelines for dietitians (RDN’S) and Diet Technicians (DTR’S). The outcomes of the evidence-based reviews were labeled as Strong, Fair, Weak, Consensus, and Insufficient Evidence. (1) It is a great tool for nutrition professionals who want to make sound nutritional recommendations. To make the process easier for RDN’s, the Academy of Nutrition and Dietetics developed a “NutriGuides Mobile” app in 2013 to provide further information. (2) Since today’s world is highly mobile and many students and RDN’s likely have smart-phones, the “NutriGuides” app is an essential tool for practicing utilizing evidenced-based guidelines.
1. Academy of Nutrition and Dietetics (AND). Evidence Analysis Library (EAL). http://www.eatrightpro.org/resources/research/applied-practice/evidence-analysis-library Accessed April 9, 2019.
2. Academy of Nutrition and Dietetics (AND). NutriGuides Mobile.
http://www.eatrightstore.org/product/0F87E78B-4F5F-4F27-BDBD-0803429FC63E Accessed April 9, 2019.
Evaluating Weight Loss
Tips for evaluating weight loss:
- State the % of weight loss and whether it was significant over 30, 90 or 180 days
- Remember that many times residents may lose weight initially after the hospital due to receiving IVF during their stay. So if they are eating 100% and have had a weight loss, this may be the cause. Knowing their UBW can help to identify this.
- Monitor for changes in edema
- Assess for any declines in intake, socialization and look for increased lethargy
- Note any medication changes (look for changes or additions of diuretics, thyroid and diabetic medications, and prednisone etc.)
- Speak to staff and resident (or family member)
- Investigate possible chewing or swallowing problems
- Look for signs and symptoms of malnutrition and dehydration when speaking with the resident
- Come up with a plan to stop the weight loss with the resident, family and/or nurse
- Make recommendations that are appropriate for the individual resident
- State when you will follow-up
- Update the Resident Care Plan
- On next visit: Check to see that the recommendations were written
Nutrition Critical Element Pathway
Click to access CEP-CMS-Nutrition-Critical-Element-Pathway-.pdf
This is a link to the pathway that the surveyors use during the State Survey process. It serves a guide to facilities to ensure adequate nutrition.
New State Survey Process
Starting in the fall of 2017, there will be a new state survey process for LTC. I’m developing a new video on what dietitians need to know about the survey process. Here are a few slides:
Reference:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/New-Long-term-Care-Survey-Process%E2%80%93Slide-Deck-and-Speaker-Notes.pptxhttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/New-Long-term-Care-Survey-Process%E2%80%93Slide-Deck-and-Speaker-Notes.pptx
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DRodoRDN
- Stepping into a Dietitian’s Shoes for Fifteen Minutes By Melany Rivera
- Are the Blue Zone Countries Truly a Hotspot for Longevity? By Michael Nguyen
- Covid-19 Troubleshooting Articles
- Blog Posts on the Long-term Care Internship by Jessie Donaldson
- Food Safety YouTube Playlists
- LTC RD and the State Survey
- Topic 5: What to Expect as a Long-Term Care Intern by Jessie Donaldson
- Topic 4: Helpful Resources for Students and Interns by Jessie Donaldson
- Topic 2: The Art of Communication in a Long-Term Care Setting by Jessie Donaldson, Student Intern
- Topic 3: Interprofessional Relationships in Long-Term Care by Jessie Donaldson, Student Dietitian
Blogs I Follow
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