Dietitian's Journal

"Do not let your patients starve....[feed] by the safest, simplest, most effective route"

2013-03-20T22:18:34Z

Hello, all. This is a surprise to you as much as me: posting two days in a row. I've decided to follow my impulse and begin featuring the resources listed in the previous entry.

First, a resource commissioned by the National Institute for Health and Clinical Excellence (U.K.) in 2006:

National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults - Oral nutrition support, enteral tube feeding and parenteral nutrition. National Collaborating Centre for Acute Care, London (PDF)

Although this resource is several years old, I discovered it only this past January while I was searching the literature on enteral nutrition delivery topics (e.g., methods, schedules, transitions).

As the Foreward states (and we dietitians know so well):

Malnutrition is both a cause and a consequence of ill-health. It is surprisingly common in the UK [Canada, too, I would add - ee], especially in those who are unwell. Many older people and those with any long-term medical or psycho-social problems are chronically underweight and so are vulnerable to acute illness. Even people who are well-nourished eat and drink less if they are ill or injured and although this may only be short-lived as part of an acute problem, if it persists the person can become undernourished to an extent that may impair recovery or precipitate other medical conditions (page 2).

Also from the Foreward:

The aim of these guidelines is to improve the practice of nutrition support by providing evidence and information for all healthcare professionals, patients and their carers so that malnutrition whether in hospital or in the community, is recognized and treated by the best form of nutrition support at the appropriate time....

[M]any of the recommendations in this guideline are derived from a combination of clinical evidence, clinical experience and expertise. Many are also quite general, applying to all patients with malnutrition whatever their disease or care setting. However, all healthcare professionals who have contact with patients should find the recommendations relevant for we believe that they contain an obvious, simple message:

'Do not let your patients starve and when you offer them nutrition support, do so by the safest, simplest, most effective route.’

Other versions of this guideline, including a quick reference guide (PDF), are available on the NICE Nutrition Support in Adults Web page.

If you are a clinician working with malnourished patients or clients, I highly recommend you add this valuable document to your library. I've found it to be a practical -- and necessary -- complement to the key A.S.P.E.N. documents I refer to in everyday practice, including the 2009 Enteral Nutrition Practice Guidelines.

Favourite Enteral Nutrition Resources

2013-03-19T22:16:50Z

Hello, all. Welcome to my first post of 2013 -- just in time for the Vernal Equinox. Much as I love to blog, I've had to set aside this activity to create time and mental space for another series of workshops at which I'm a presenter.

As part of my preparation, I've been digging deep into the literature. (And yes, I'm still digging in the garden -- more on this soon). I've added new resources to my frequently used favourites and would like to share some of them with you now.

Enteral Nutrition (Tube Feeding)

Key references for guidelines, standards and safe practices

American Society for Parenteral & Enteral Nutrition (A.S.P.E.N.) Professional Resources

Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J and A.S.P.E.N. Board of Directors. A.S.P.E.N. Enteral Nutrition Practice Recommendations. JPEN J Parenter Enteral Nutr. 2009;33:149-167.

National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults - Oral nutrition support, enteral tube feeding and parenteral nutrition.

Ethics

Blackmer J. Artificial feeding post-stroke: A medical and ethical perspective. 2010. [Presentation slides in PDF format. Available for download from the Champlain Regional Stroke Network Web site]

Fluid & electrolyte balance

Basic Principles of Fluid and Electrolyte Balance (free e-book available on the ESPEN site.)

Dickerson RN, Brown RO. Long-term enteral nutrition support and the risk of dehydration. Nutr Clin Pract. 2005;20:646-653.

Whitmire SJ. Nutrition-focused evaluation and management of dysnatremias. Nutr Clin Pract. 2008;23:108-121.

Gastroenterology

Matarese LE. Nutrition and fluid optimization for patients with short bowel syndrome. JPEN J Parenter Enteral Nutr. 2013;37:161-169.

University of Virginia School of Medicine, Articles in Practical Gastroenterology, Enteral Nutrition

Home Tube Feeding

The OLEY Foundation - Founded in 1983 by Lyn Howard, MD and her patient, Clarence "Oley" Oldenburg, the Oley Foundation is a national, independent, non-profit 501(c)(3) organization that enriches the lives of patients dependent on home intravenous (parenteral ) and tube feeding (enteral ) through education, outreach, and networking. The Foundation also serves as a resource for consumer's families, clinicians and industry representatives, and other interested parties.

Coping Well with Home Enteral Nutrition: Words of Wisdom from Resilient Adult Consumers - The Utah Dietetic Association developed this self-help manual. “Resilient HEN consumers who participated in a research study provided the majority of the information and strategies. They offered suggestions and insights based on their personal experiences." This document is stored on Lucy's Real Food for the Tube, another site worth exploring.

An Honest Kitchen #5: "Seasonal Desserts"

2012-11-10T15:16:06Z

house is beautiful not because of its walls,
but because of its cakes.

~ Old Russian saying

here is a place for dessert, even in the healthiest of diets and to be honest, without the occasional dessert, life would be blander, paler and a lot less sociable.

~ An Honest Kitchen, Seasonal Desserts
by Kathryn Elliott & Lucinda Dodds

Because I wholeheartedly agree with the "old Russian" and believe Kathryn and Lucy have created something very special with Seasonal Desserts, I've purchased two copies of this e-Magazine to give to two very lucky Greens & Berries readers.

And I'm going to keep this post short and sweet.

Simply stated, Seasonal Desserts makes my cooking tastier, healthier and more creative. Here's why:

1) Nutrition savvy: Kathryn Elliott writes in an engaging, sensible, positive way on how to eat well without feeling deprived.
2) Warmth and beauty: Lucy's gorgeous film photographs are visual comfort food.
3) Reliability: Recipes have been triple-tested recipes to ensure consistent results.
4) Honesty: Recipes consist of basic, wholesome ingredients and clearly-explained methods.
5) Deliciousness: The creative ingredient combinations please the palate.
6) Value: The 60-page (PDF) e-Magazine features ten seasonal recipes, many more healthy eating and food preparation tips, seasonal food guides and a wise reflection on the benefits of "a cup of tea", which I highly commend to myself as much as you, dear readers.

Berry and Hazelnut Cranachan

Chocolate Date Honey Balls

Disclosure: I was a recipe-tester for two recipes in this issue; you can see the results from my test kitchen in the preceding photographs. But I'm also a dietitian and try to be a critical, honest, fair evaluator. I followed the recipes exactly and the results were delicious and, in real life, much prettier. (My kitchen doesn't have the best light and I'm not a skilled food stylist.) The photographs, however, are truthful and authentic, which is in the spirit of An Honest Kitchen.

How to win a copy of Seasonal Desserts? Just leave a comment here. You're welcome to simply say "hello, count me in." But I'd love if you shared a story about how a dessert made a special or everyday occasion sweeter, brighter and more sociable.

You can double your chances of winning by going to my newish blog, More Greens & Berries, and leaving a comment on any post.

And though I have my biases about recipes, cookbooks and food bloggers I will be completely unbiased when selecting the two winning entries. Each comment will be assigned a number in consecutive order, based on its time stamp, and I'll use an online random number generator to select winners. (You can read more details in the fine print, below.)

Good luck to all!

An Honest Kitchen links:

An Honest Kitchen (new web site)
Limes & Lycopene (Kathryn Elliott's Web site)
Nourish Me (Lucinda Dodd's Web site)

The fine print about the give-away: Excluding my immediate family, any dessert-lover in the world -- and beyond -- can enter! I will be purchasing two copies of the e-magazine, Seasonal Desserts, and sending the download link to two randomly selected commenters, one commenter on Greens & Berries, and one commenter on More Greens & Berries. I will be assigning each comment a number in chronological order based on the time stamp of the comment; i.e., the first commenter will be #1, the second #2, etc. I'll be using a random number generator to select the winners. Contest closes at midnight (2400 hrs, PST) Friday, November 16th.

I'm back with a give-away....

2012-11-06T14:57:00Z

Details in the next post but here's a hint about the give-away item.

And if you're curious about my whereabouts and whatabouts during the past few months, I've balanced a very busy 5 months of work with gardening, long walks with Piper to favourite places, and a few weekends in the country.

Away for a while...

2012-04-25T16:24:56Z

...but I hope to be back here soon.

Despite all the gardening posts on this blog, you did know I'm a clinical dietitian at a large, acute care hospital, yes?

Vancouver General Hospital remembers 100 years: Private ward dinner tray, 1933

And now my mind, energy, and time are focused on this work as well as preparing for an upcoming educational event. This is my latest "excuse" for why I'm unable to spend time on my -- or your -- blog.

See you soon, I hope. I miss my online time with you all.

(The photo has very little to do with my day-to-day work -- or present day reality -- but I do love this glimpse into history.)

Resources for people with dysphagia & those who care for them (collection #2)

2012-02-18T22:52:00Z

Here are three more dysphagia resources I recommend for basic information and practical tips on eating safely and with enjoyment.

Dysphagia - This web page from the National Institute on Deafness and Other Communication Disorders in the U.S. provides a basic, easy-to-understand overview of dysphagia in a question and answer format. It also includes a clear diagram of anatomy involved in swallowing.

A Manual for People Living with ALS - ALS stands for Amyotrophic Lateral Sclerosis (ALS), the most common form of Motor Neuron Disease (MND). A Manual for Living with ALS is available as a free PDF from the ALS Society of Canada. It includes a section on adapting to swallowing problems and maintaining good nutrition (pages 36 through 41) and a page of recommended cook books (page 81) as well as a section on maintaining oral health (pages 55 through 57).

Although some of the manual's information is region-specific (e.g. community resources), the content on food and nutrition will be helpful no matter where one lives.

Puréed Foods for Swallowing Problems (PDF) - Wendy J. Dahl, PhD RD, developed this clear, concise resource that describes the characteristics of the ideal pureed food and explains how to prepare it as well make meals tasty and appealing. Dr. Dahl also is the author of Textured Modified Foods: A Manual for Food Production for Long Term Care, 2nd Edition.

Plum Crisp

2012-01-29T21:22:47Z

My contribution to a pot-luck dinner hosted by a colleague. The other items on the menu: an apéritif made with homemade ginger syrup and soda water, white bean & kale soup, a rustic loaf of wholegrain bread, and a salad of mixed baby greens, sweet bell peppers and pecans. Did we eat with abandon? No, I wouldn't say that. But we did eat with freedom, enjoyment and gratitude.

Plum Crisp, adapted from a recipe for berry crisp in "Food to Live By", The Earthbound Farm Organic Cookbook

Plum Crisp

Makes one 1-quart crisp

FOR THE FILLING:

2 cups frozen, pitted plums, thawed and cut in quarters
1 cup frozen apple-and-pear sauce, thawed
2 tablespoons cornstarch
2 tablespoons Turbinado sugar (use more or less depending on sweetness of fruit and your taste preference)
2 tablespoons maple syrup

FOR THE TOPPING:

1/3 cup unbleached all-purpose flour
1/2 teaspoon cinnamon
1/8 teaspoon salt
1/4 cup firmly packed dark brown sugar
1/3 cup old-fashioned rolled oats
3 tablespoons unsalted butter

1. Make the topping. Place flour, cinnamon, salt and brown sugar in a medium-size bowl. Stir together until blended. Add the butter in small chunks. Work the butter into the dry mixture with a fork or your fingers until it is in small, sweetlet pea-like bits. {Make mental note to self to try Heidi's recipe for crumb topping next time.} Add the rolled oats and stir to combine.

2. Set topping aside. {Take a break to give some love and a treat to any pet who knows some kitchen goodness is happening, a crumb or two may fall, and so is leaning heavily against your lower legs while you stand at the sink.}

3. Position a rack in the centre of the oven and preheat it to 375 degrees Fahrenheit.

4. Make the filling. Place the plums and apple-pear sauce in a large bowl. In a small bowl, combine the cornstarch and sugar until blended. And the cornstarch and sugar to the fruit. Toss gently to combine. Transfer the fruit mixture to a shallow baking dish. {I used a quiche/flan pan.} Drizzle the maple syrup on top of the fruit.

5. Sprinkle the topping over the fruit but do not pack it down.

6. Bake the crisp until the fruit juices bubble up around the edges of the baking dish and the topping turns golden. {In my convection oven, this took about 30 minutes.} Let the crisp cool slightly before serving it warm.

Adapted from a recipe for Summer Berry Crisp, Food to Live By: The Earthbound Farm Organic Cookbook, page 346.

Resources for people with dysphagia (collection #1)

2012-01-29T21:05:37Z

Maple Custard, a nourishing, tasty, easy-to-swallow food

Last November, an intern's question prompted me to update my inventory of education material for people with dysphagia. Keen, energetic interns never fail to inspire me, but when we're so busy collecting and discussing new information, I don't have much time to refine my notes into a publishable blog post. You may have heard me lament I don't write quickly. You also may recall last week I vowed to finish some of the things I've started, blog posts being one of the main unfinished things.

This morning I pulled out the draft post where I'd compiled dysphagia resources, re-visited each site to refresh my memory about its content, and decided, yes, each one is well worth sharing. Here now, with brief commentary, are three resources.

Please note: Not every tip or recipe in these resources will be appropriate or safe for people with specific types of swallowing disorders who must limit their intake to a particular consistency for solids (e.g., pureed) and liquids (e.g., honey-thick). Though people who can eat soft and minced/finely chopped foods usually also can eat pureed foods, the reverse is not necessarily true.

Meals for Easy Swallowing (PDF)

This is a publication from the ALS division of the Muscular Dystrophy Association (U.S.). An ALS clinic coordinator, registered dietitian, nurse & speech-language pathologist compiled recipes "derived from our patients and their creative spouses who translated their caring into foods that look good, taste good, are easy to chew and to swallow, and minimize discomfort." In addition to recipes for beverages, soups, breads, entrees, sauces, vegetables, and desserts there are helpful tips on food preparation, service, menu-planning. Most recipes are suitable for a pureed diet but there are some recipes for soft and minced textures, too.

A separate Nutrition Issues page discusses related topics such as maintaining weight, hydration, choking and feeding tubes.

WebWhispers Laryngectomee-Friendly Recipe Collection

WebWhispers is an international Internet group that provides information and support to laryngectomees and those with laryngeal cancer as well as more diverse group of persons with other head and neck cancers, permanent tracheostomies, caregivers and health care providers.

To help its members eat safely and with enjoyment, the website's library includes recipes "specifically tailored to laryngectomees at various stages or abilities." The Food-Nutrition-Recipes section also includes books and articles, practical tips for managing eating problems and more recipe links.

Easy to Swallow

Food stopped being a pleasure and instead became a chore.

~ Claire Wade

And so Claire Wade, a young woman with Myalgic Encephalomyelitis (Chronic Fatigue Syndrome), took steps to restore her joy in eating. She collected recipes from renowned chefs, who included Nigella Lawson, Graham Kerr and Sophie Grigson, and published them on her site, Easy to Swallow. There are recipes for soups, main meals, vegetables, sauces, desserts and drinks.

Though the site hasn't been updated since September 2006, the content remains timely as well as tasty with helpful tips and creative, appealing recipes. I've picked a few to test including the Pumpkin & Ricotta Rotolo and the vegetable mashes and purées.

20.10.5.1

2012-01-20T22:43:40Z

I'm facing up to the numbers. And they're spurring me into action.

Twenty days into the new year. Ten months since my last published Dietitian's Journal post. Five drafts partly completed. And one piece of advice (but not the only one) I'm going to try live by this year:

"Finish what you start" by Irina Troitskaya | Advice to Sink in Slowly http://advicetosinkinslowly.net

Yes, wise words, though I think in this case, it's advice to apply quickly.

Celebrating food, farms & gardens

2011-03-14T21:46:54Z

Nutrition Month may be officially over but I forgot (!) to publish this post last week, so here it is now, a little late but still timely.

That all people in the community, at all times, have access to nutritious, safe, personally acceptable and culturally appropriate foods, produced in ways that are environmentally sound and socially just.

Richmond Food Security Society's Mandate

To help my knowledge keep pace with my passion for food security & environmental sustainability, on March 12th I attended the Richmond Food Security Society's Conference where I listened to stories that inspired and informed me.

After the sessions, I did some research to learn more about the speakers & their projects. If you're interested in food security and sustainability issues or setting up a healthy school lunch program or school garden project, I encourage you to check out the following resources:

Food For All – Making Food Security more Inclusive (Jelica Shaw, Claudia Li, Cease Wysse)

Oskayak Garden Project

Shark Truth

Farm 2 School & Food Gardens: How to advocate for healthy food in our schools (Joanne Bays & Michael Wolfe)

Farm to School

Food Gardens in Richmond - School Year Garden Toolkit