Monthly Archives: July 2012

Cameroonian Diet and Kwashiorkor

If you watched the Olympic Opening Ceremony in London last night, you might have noticed Cameroon’s athletes and their elaborate attire.

Cameroon’s Olympic Athletes, London 2012

Cameroon has over 30 athletes, in a variety of sports– weightlifting, swimming, boxing, table tennis, rowing, judo, wrestling, track & field, and soccer.   Seeing all of the elaborate costumes and the Cameroon flag reminded me of my trip to Cameroon 6 years ago.  Since this is a blog about nutrition/food, I thought I’d share some of the food I ate while in Cameroon as well as what type of problems the typical Cameroonian diet can cause.

Peeling plantains for 170+ people. Plantains were a main-stay of the diet in Cameroon.

More peeling of the plantains…

Annnnd more peeling plantains. Can you tell it’s a common food in Cameroon?

Peeling carrots. We also used garlic and ginger root in many of the traditional dishes.

Mixing fufu– Water Fufu is made from cassava root, a main staple in the diet in Cameroon. After it is boiled, you can form it into a play-dough like consistency.

Water fufu, aero, and watermelon for lunch. Aero is a type of green. Here it is cooked in a lot of oil– typical of many of the dishes in Cameroon.

Traditional Cameroonian meal of cornchaf

 

Chewing on sugar canes…yum! Pretty much the only “dessert” we had readily available.

A meal ordered at a restaurant in Bamenda: Cheeseburger, carrots, and fried plantains with a glass of D’jino (a fruit-flavored soda). I was craving protein-rich hamburger, what can I say!

Belly distented– an example of a child with Kwashiorkor, a form of malnutrition where there is not enough protein in the diet.

As you can see, the typical diet in rural Cameroon is made of carbohydrates.  We had a lot of corn, cassava root, and plantains, which are all very starchy foods.  The only protein I saw in the typical Cameroonian diet came from beans (a dish called cornchaf, which was basically corn and beans cooked in lots of oil), but there was also chicken, pork, beef, and monkey available for those who can afford it.

In the more rural areas that we traveled, it was not rare to come across many children with Kwashiorkor. Kwashiorkor is a form of malnutrition that results when a person is consuming enough energy (calories) but consuming little or no protein. It usually occurs in individuals who are consuming carbohydrates almost entirely. “Kwashiorkor” is a Ghanian word for the disease that develops when a mother’s child is weaned from protein-rich breast milk to a protein-poor carbohydrate food source (ie: cassava root, corn, rice, and plantains).

Kwashiorkor isn’t common in the US. In fact, in the US it occurs mainly in connection with acute life-threatening illnesses such as trauma and sepsis, where the body’s protein needs are significantly increased.

When a physiological stress is produced, it increases protein and energy requirements at a time when intake is limited. During stress, the body needs extra protein to synthesize additional hormones, immune factors to fight infection, collagen to rebuild damaged tissue and bone, and muscle cells to maintain the physical work of organs.

In children, kwashiorkor can result when poor dietary intake is added to the stress of growth, infections, or other illnesses.  Characteristics of kwashiorkor include significantly decreased serum proteins, pitting edema, swollen abdomen, flaky appearance of the skin, thin muscles but fat is present, “moon face”, and hair which can be easily plucked from the head.  The child may have a well nourished appearance because they are getting enough calories in their diet, but they are still malnourished.  In fact, kwashiorkor can take just weeks to develop and the mortality is high.

The treatment for kwashiorkor is to provide adequate calories and protein for the child/patient.  Carbohydrates may be given first, and then protein slowly added afterwards. The condition can correct itself, but for those who have had kwashiorkor for a long time, permanent physical and mental problems may still exist, such as a child not reaching their full height potential.

It is interesting to see how those in 3rd world countries eat on a day-to-day basis, and how that differs from America.  The athletes from Cameroon may eat their cassava root and plantains, but in order to become top athletes, it’s obvious they had to make sure to get enough protein in their diet, specifically from animal sources such as chicken, beef, and pork.

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Nutrition Intervention for Pressure Ulcers

A pressure sore/pressure ulcer/decubitis ulcer is an injury to the skin and underlying tissue. This happens when the oxygen and nutrient flow to that area of the skin is cut off, leaving the tissue to die.  Sitting or lying in a hospital bed for a long time is a common cause of the formation of pressure ulcers.  In fact, data from the National Nursing Home Survey in 2004 (Park-Lee) published by the CDC in 2009 found that the prevalence of pressure ulcers was 11% of the 159,000 nursing home residents surveyed.

Pressure ulcers are found in different stages, based on the layers of tissue affected. Stage 2 ulcers are the most common, according to the above survey. The NPUAP (National Pressure Ulcer Advisory Panel) has come up with 6 different stages/categories of pressure ulcers.  The follow descriptions were found in the Academy of Nutrition and Dietetics Nutrition Care Manual.

  • Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
  • Stage I:Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
  • Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
  • Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
  • Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
  • Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed.

Stages of pressure ulcers, based on what tissue type is being affected, and common areas for pressure ulcers to develop.

When I read through patients’ charts, there is a section where I see a score from the Braden Scale.  The Braden Scale is a tool used to determine, upon a patient’s admittance to the hospital, their risk of developing a pressure ulcer.  The Braden Scale takes into account:

  • Sensory Perception– Ability to respond meaningfully to pressure-related discomfort. Does the patient have a limited ability to voice pain or discomfort or any sensory impairment?
  • Moisture — Degree to which skin is exposed to moisture.  Is the patient’s skin usually dry, or is there dampness detected on the sheets every time the patient is turned?
  • Activity — Degree of physical activity. Does the patient take frequent walks, or is the patient confined to their bed?
  • Mobility — Ability to change and control body position. Is the patient able to move themselves independently without assistance, or is the patient completely immobile?
  • Nutrition — Usual food intake pattern. Does the patient eat all their meals, 4+ servings of protein per day, or does the patient rarely eat more than 1/3 of the food offered to them?
  • Friction & Shear — Does the patient have sufficient muscle strength to lift completely up during a move, or does the patient slide against the sheets or slide down in their chair and need assistance?

Each of these 6 criteria is assessed and given a point value of 1-4. All of these points, added up, equal that patient’s Braden score.  A score of 15-18 indicates a mild risk for a pressure ulcer, 13-14 indicates moderate risk, 10-12 indicates a high risk, and a score of 9 or less indicates a severe risk for developing a pressure ulcer.

Click here to see a PDF form used to assess pressure ulcer risk: Braden_Scale

Nutrition is a key component in the treatment of pressure ulcers. Here are some things to consider:

Goals of the Registered Dietitian & Support Team:

  • Facilitate wound healing
  • Decrease risk of infection
  • Maintain or replete nutrient stores

Educational Goals:

  • Increase individual’s knowledge of food and nutrition intake needed for wound healing.
  • Increase individual’s awareness of the risk factors associated with pressure ulcer development.
  • Increase individual’s knowledge of dangers associated with over-supplementation of nutrients, especially zinc.

Nutrition Intervention:

  • Maintain adequate nutritional status by providing optimum dietary and fluid intake (Provide adequate energy to maintain or regain any lost weight, and provide adequate protein for positive nitrogen balance and to spare energy).
  • Identify and treat causes of poor nutritional intake.
  • Monitor weight status routinely to detect unexpected or unintentional weight loss.
  • Select nutrition interventions to improve or maintain nutritional status.

Nutritional Needs:

  • Patients should receive adequate nutrient and fluid intake to maximize potential for wound healing
  • Recommended that patients receive 30-50 kcal per kg body weight per day
  • Recommended that patients receive 1.2-1.8 g protein per kg body weight per day
  • Fluid requirements may differ based on what each facility uses, but 30 mL per kg body weight can be used.
  • Patients may also want to meet the RDI of vitamins A, C, and E; the mineral zinc; amino acids arginine and glutamine; and the compound beta-hydroxy-beta methylbutyrate (HMB). These nutrients play an essential role in tissue regeneration and maintaining the health and function of the skin.  If patients are suspected or confirmed to have nutritional deficiencies, a multivitamin including the RDIs of these nutrients may be beneficial.  However, if a patient is not deficient there is no evidence to suggest a supplement will aid in wound healing.  Additionally, further research is needed to make any firm conclusions on the benefit of amino acids arganine and glutamine, and HMB in the area of pressure ulcer treatment.
  • High doses of zinc should be avoided; tolerable upper intake level is 40mg/day.   While zinc does assist in wound healing, high-dose zinc supplementation can adversely affect copper status (copper is an enzyme co-factor for collagen cross-linking) and immune response and may cause gastrointestinal side effects. There is no need to supplement with zinc unless a patient is zinc deficient.

Example:

A 63 year old female, 5’1″ and 140 lbs has a pressure ulcer. What are her kcal, protein, and fluid requirements?

  • 140 lbs = 63.63 kg
  • kcals = 35kcal/kg  x 63.63kg = 2227 kcal/day (female & old, so on the lower calorie range)
  • protein needs = 1.2g/kg x 63.63kg = 76g protein per day
  • OR = 1.8g/kg x 63.63kg = 114g protein per day
  • Fluid requirements: 30mL/kg  x 63.63kg = 1908.9 mL, or 1910 mL fluid (8 cups)

Nutrition Monitoring & Evaluation:

  • The Monitoring and evaluation of patients individualized according to the patient’s nutritional diagnosis.  However, areas that are most relevant to pressure ulcer risk or treatment include:
    • Weight
    • Anthropometrics
    • Laboratory tests (N-balance, electrolytes, glucose)
    • Nutrient intake, quantity and quality (oral, enteral, parenteral)
    • Wound stage/healing
    • Hydration status (I&Os, BUN/Creatinine ratio, Hct)

Recommended Foods:

  • Follow a well-balanced diet with foods from each food group
  • Make sure to eat foods high in protein with each meal (breakfast, lunch, dinner)
  • Keep drinking fluids
Food Groups Recommended Foods
Meat and Other Protein Foods (2-3 servings) Beef, veal, pork, lamb, poultry, fish and seafood, eggs and egg products, tofu, dried beans, peanut butter
Milk and Milk Products (2-3 servings) Whole, reduced-fat, low-fat, nonfat: milk, buttermilk, cheese, yogurt
Grains (6 – 11 servings) Bread, pasta, cereal (hot or cold), cornmeal, crackers, pretzels, rice
Fruit and Vegetables (5-6 servings) All
Fats and oils Oils, margarine, mayonnaise, cream cheese, salad dressings
Beverages Fruit juices, decaffeinated coffee, and tea

Sources: AND Nutrition Care Manual, NPUAP, Photo from eMedicineHealth

Categories: Clinical Nutrition | Tags: , , , , , , , , | 1 Comment

Which Patients See a Dietitian in a Hospital?

Monongalia General Hospital is an 189 bed acute-care community hospital and level 4 West Virginia trauma center.  With only 2 FTE clinical dietitians working each day, it’s impossible (and unnecessary) for a dietitian to visit every patient in the hospital. But who gets to the see a dietitian, and how is that decided? While it may be different at other hospitals, this is the consult system Mon Gen uses:

1- A physician or nurse orders a consult.  This could be because the physician feels the patient needs nutrition education, the patient is high-risk, or any reason they see fit.

2- A system consult is automatically ordered.  On a patient’s chart, there is a section with several boxes of criteria. If one or more of these criteria is met, the charting system automatically orders a consult. The criteria include unintentional weight loss of more than 10 pounds in 3 months, constipation, bed sores, and more.

3- The patient meets nutrition screening criteria. Dietitians can see patients that meet a specific diagnosis and/or treatment with component of nutrition therapy, including but not limited to:

  • Malnutrition, cancer, undergoing chemotherapy, radiotherapy, major surgery, oncology unit patient
  • Newly diagnosed diabetes mellitus, or uncontrolled
  • Unstable chronic renal disease
  • Unstable liver disease
  • GI: Crohn’s disease, ulcerative colitis, short bowel syndrome, GI fistula, small bowel obstruction
  • Failure to thrive
  • CVA (cerebrovascular accident or stroke) with severe dysphagia
  • Significant education needs

When these methods of ordering a consult with a dietitian are used, clinical dietitians are able to use their time wisely to see the patients who need the most help.

You ordered a consult??

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Clinical Nutrition: Edema

So today was the first day of my 2-week clinical rotation at Mon General Hospital. I followed a Registered Dietitian around today, which included going on rounds and speaking to patients referred by a physician or nurse.  One simple clinical term I came across today was edema.  Edema is an abnormal accumulation of fluid in the intercellular tissue spaces or body cavities.  The edema I saw today was present in the feet and ankles, but edema can also be found on other places in the body, such as periorbitally, or around the eyes.  (I didn’t include a photo in this blog, but if you feel like googling “pitting edema,” go right ahead!)

Edema can happen when fluid intake exceeds fluid loss, and can lead to a rapid weight gain. Just a weight gain of 2.2 pounds can mean 1 liter of fluid retention. So if a patient has gained 25 pounds in the last week, it could mean that the patient has retained 11 liters of water in their intercellular tissue spaces or body cavities.

The disease states associated with edema include cardiac failure, hypoalbuminemia (albumin osmotic force- lower albumin releases water into tissue spaces), malnutrition, liver failure, or kidney failure.  These conditions can cause a patient’s body to hold onto excess sodium and water.  In heart failure, renal blood flow is decreased.  This leads to renal retention of sodium and water in order to increase blood flow.  In addition, edema can also be caused by rapid administration of fluids, especially intravenous (IV) fluids.  Edema is treated with diuretics, which can rid the body of excess water. Low-sodium diets can also given to the patients, at 2g or less per day.

Pitting edema is measured on a 4-point scale, with 1+ being the least severe edema and 4+ being the most severe. A physician can press a finger onto the patient’s site of edema and a “pit” will form which will remain indented for anywhere from a brief second to over 30 seconds.  Examples of the 4-point scale are included below:

Pitting Edema – measurement

1+
Barely detectable impression when finger is pressed into skin.   
2+
Slight indentation.15  seconds to rebound
3+
Deeper indentation. 30  seconds to rebound.
4+
> 30  seconds to rebound.

O’Sullivan, S.B. and Schmitz T.J. (Eds.). (2007). Physical rehabilitation: assessment and treatment (5th ed.). Philadelphia: F. A. Davis Company. p.659


1+
2mm depression, barely detectable.Immediate rebound.
2+
4mm deep pit.A few seconds to rebound.
3+
6mm deep pit.10-12 seconds to rebound.
4+
8mm: very deep pit.>20 seconds to rebound.

Hogan, M (2007) Medical-Surgical Nursing (2nd ed.). Salt Lake City: Prentice Hall

Categories: Clinical Nutrition | Tags: , , , , , , , , , , , | Leave a comment

Healthy, Quick, & Inexpensive Recipe: Homemade Hummus

One of my new favorite food items is hummus. I have been loving it with carrots sticks or warm, whole wheat pita bread. For those of you who don’t know much about hummus, or haven’t tried it yet, hummus is a spread made from chickpeas (garbanzo beans), olive oil, and a bunch of other spices. It’s great on top of pita bread, crackers, tortillas, and fresh veggies like carrot sticks, celery, and red pepper.  I like to think of hummus as a lower-calorie and lower-fat alternative to peanut butter.  Another benefit is that I find myself eating a lot more fresh vegetables when I have hummus around! So last week I decided that I should make homemade hummus, because it can be a little pricey to regularly buy hummus from the store, typically Athenos (my favorite) or Sabra.  I used a modified version of the hummus recipe I found in the recipe booklet that came with the food processor.

Homemade Hummus

(makes about 2 cups)

  • 1/3 cup loosely packed Italian parsley leaves
  • 1 garlic clove, peeled
  • 1 can (19 oz) chickpeas, rinsed and drained
  • 2 tablespoons tahini
  • 2 tablespoons fresh lemon juice
  • ¼ cup water
  • ½ teaspoon ground cumin
  • 2 tablespoons extra virgin olive oil
  • 1/8 tsp salt
  • Sprinkle of black pepper
  • ¼ cup roasted red peppers (optional)

Chop the parsley for 5 seconds; remove and reserve. Process garlic until finely chopped, about 5 seconds. Add chickpeas, tahini, lemon juice, water, cumin, black pepper, and reserved parsley to work bowl;  process until smooth, 1 ½ to 2 minutes, stopping to scrape bowl as needed one or two times. With the machine running, add the olive oil in a steady stream and process until the mixture is smooth and creamy. Add any remaining optional ingredients (black olives, roasted red peppers, artichokes, etc) at the end.

The ingredients you’ll need.  Tahini is a sesame seed paste that can be found in most grocery stores. Check the international foods aisle, or in an aisle next to the pickles and olives. When you open the tahini it should have a layer of oil on the top, so be sure to mix it before measuring out the 2 tablespoons for this recipe.

I finally get to use my home-grown parsley! Make sure to wash the parsley with water & dry it on paper towels before use.

Mixing the final product…it’s looking good!  When adding your olive oil, this is where you can experiment a bit. The original recipe called for 1/4 cup olive oil, but I wanted to cut some of the fat out of the recipe, plus I like my hummus to be a little thicker, so I used just 2 tablespoons of olive oil. If you like creamy hummus, you might want to add in an extra tablespoon of olive oil or more.

If you want to make different flavors of hummus, this is where you can add in any optional ingredients. I decided I wanted 1 cup to be basic (parsley, garlic flavor) and 1 cup to be flavored with roasted red pepper. So I scooped out half, and added 1 pepper in to the remaining half. Feel free to add artichokes, green olives, black olives, jalapenos, spinach, pine nuts, sun-dried tomatoes, basil, or other spices.

Final product! About 1 cup basic hummus and 1 cup roasted red pepper hummus. Ready to be eaten with carrots & celery! And just a note: If you decide to make or buy hummus, it should be stored in your refrigerator in an air-tight container.

Nutrition Facts

(serving size = 2 tablespoons)

  • Calories: 59
  • Total Fat: 3g
  • Saturated Fat: 0.4g
  • Cholesterol: 0mg
  • Sodium: 100mg
  • Potassium: 64mg
  • Carbohydrate: 6.8g
  • Dietary Fiber: 1.4g
  • Protein: 1.7g
  • Vitamin A: 2.2%
  • Vitamin C: 6.0%
  • Calcium: 1.9%
  • Iron: 3.4%

Cost Breakdown:

  • 1/3 cup parsley leaves: 0.00
  • 1 garlic clove: 0.05
  • 19 oz chickpeas: 1.32
  • 2 tablespoons tahini: 1.05
  • 2 tablespoons lemon juice: 0.13
  • 1/2 tsp ground cumin: 0.08
  • 2 tablespoons olive oil: 0.29
  • 1/8 tsp salt: 0.00

Total: $2.92 for about 16 servings, which makes out to $0.18 per serving!

As a comparison, store-bought hummus is typically $3.49 for 7 servings, or $0.50 per serving.  The cheapest I’ve seen hummus on sale for was $2.00 for 7 servings, or $0.29 per serving. So by making homemade hummus you’re basically cutting the cost in half!

Categories: Recipes | Tags: , , , , , , , , , | 2 Comments

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