Coumadin therapy and vitamin K

Coumadin and vitamin K

Coumadin (warfarin) is a blood thinner that works by interfering with the blood clotting time. It is prescribed for patients with abnormal heart beat, with prosthetics heart valves, people who have had a prior myocardial infarction, patients with or at risk of developing venous thrombosis or pulmonary embolism. Because this medication interferes with K vitamin in blood clotting pathway, the patient has to be educated on the possible interaction and side effects of vitamin K in the diet.

There are over 10 proteins also called coagulation factors involved in blood clotting cascade. Seven of these factors require vitamin K for their post translational modification. The vitamin K dependent factors utilize glutamic acid residues (GLA) to attach to cell membrane surface. With the interference caused by Coumadin, the factors cannot adhere to the phospholipid membrane and the clotting complexes are not formed resulting in defective fibrin formation. Vitamin K is primarily obtained in the diet and some of it is synthesized by colon microbes. Foods high in vitamin K are mainly green leafy vegetables such as kale, spinach, broccoli etc. Most patients on Coumadin have the perception that they cannot have any food high in vitamin K and cannot drink cranberry juice. However this is wrong, and the Academy of Nutrition and Dietetics (AND) has refuted these claims. The patient can have their vegetables as long as they maintain consistency in what they eat. The basis of this principle is that the dosing of Coumadin depends on the INR test. The physician determines the PT (prothrombin time) and the INR (international normalized ratio) of the patient and this is rechecked regularly and the dosage adjusted accordingly. If the patient drastically changes the diet (by avoiding foods with vitamin K) this ratio is affected and this affects the effectiveness of the drug. Therefore the patient must be consistent in vitamin K containing foods consumption and should not have any vitamin supplements without consulting with the doctor. Patients on Coumadin should have abnormal levels of PT and INR, this indicates that the medication is working. The goal of the physician is to maintain a balance between preventing a clot formation and excessive bleeding. However there are other factors other than vitamin K that can affect Coumadin therapy, such as antibiotics, fever, and infection. Dietitians should encourage consumption of healthy diet that includes vegetables to patients on Coumadin therapy according to the nutrition care manual guidelines. Consistency of vitamin K rich foods is vital.

Cardiac ablation

Cardiac ablation

A procedure used to destroy areas of the heart tissue that may be causing arrhythmias that cannot be controlled with medication. Heart arrhythmias are irregular heartbeats caused by improper electric impulses. Most arrhythmias are mild and asymptomatic while others may be deliberating or fatal. Weak arrhythmias can be exacerbated by heart vessel damage and some can be caused solely by the same. Therefore heart-healthy nutrition and lifestyle is important in preventing arrhythmias or making them worse. Medication is the first line of treatment, however when this does not work, cardiac ablations is the second choice for qualifying patients with the goal of reducing arrhythmia-associated morbidity. Common arrhythmias targeted by this procedure include AV nodal reentrant tachycardia, accessory pathway syndrome, AFIB, atrial flutters and ventricular tachycardia. There are several risks associated with the procedure such as valve damage, clot formation, heart attack and atrial fistulas. No particular MNT after surgery other than heart-healthy diet and lifestyle to prevent further damage to the coronary arteries and tissues.

Alpha-1 antitrypsin deficiency

Alpha-1 antitrypsin deficiency:

Apha-1 antitrypsin (AAT) also known as serum trypsin inhibitor is a protease inhibitor  that protects tissues from inflammatory cells enzymes. Its main function is to protect lungs and liver from enzymatic damage. In-born genetic defect causes the deficiency of this enzyme leading to lung and liver damage.  Symptoms of the deficiency manifests in symptoms such as COPD, chronic shortness of breath, liver damage and cirrhosis, weight loss and respiratory failure. Treatment is done by replacing the protein or by liver transplant. Most people with the defect do not develop life threatening symptoms. However in some people, cirrhosis, emphysema and liver cancer develop before the age of 40. The disease cannot be cured but can be managed by slowing its progression by preventing environmental/chemical toxins of the liver or lungs such as smoking, toxin/irritant exposure or excessive alcohol use. AAT replacement is done by infusing purified human plasma containing the protein intravenously, a procedure called augmentation therapy. Medical nutrition therapy is tailored to the patient’s symptoms. Managing and preventing weight loss is paramount to reducing mortality and improving prognosis. Nutrition recommendations include providing high caloric diet with less carbohydrates load to reduce CO₂ production that can exacerbate respiratory distress.

Evidence analysis process

 

Evidence analysis is a process created by the Academy of Nutrition and Dietetics to help dietetic professionals analyse available evidence when scientific evidence is needed to make informed and guided practice. The process consists of 5 steps;

 Step1: Formulating evidence analysis question;

In this step one specifies a question or a recommendation or a hypothesis that is specific to the area of practice. Developing a good question is paramount to generating stronger evidence. To accomplish this, the dietetic has to consider factors that can affect or interact with delivery of intervention and how to work with or confound for these factors. The question is generated using the PICO format. In this format the population (P) of interest is stated, the intervention (I), comparison (C) with other approaches of care and the anticipated outcome (O).

Step 2: This step involves gathering and classifying evidence. This involves a systematic search of peer reviewed literature to gather information related to the question. The material or information gathered is then classified according to its relevance to the original question. To effectively carry out this step, an inclusion/exclusion criterion has to be outlined, use of various databases to search for articles, assessment of abstracts, citations and full articles. A search plan and results table is constructed from the materials gathered.

 

Step 3: Critical appraisal of each article/material gathered: The materials are appraised based on relevance to the question and the original research design used.

Step 4: Summary of evidence: The relevant information gathered is summarized and tabulated.

Step 5: Writing and grading the conclusion: A concise concluding statement is made based on material gathered and reviewed. The reviewers then grade the conclusion indicating the strengths and weaknesses of the information as pertains to the original question. There are five grading levels;

I-                   Strong

II-                Fair

III-             Weak

IV-             Expert opinion only

V-                No evidence.

Interstitial fibrosis

This is a condition where the lung tissue get damaged as a result of injury and abnormal healing process. This makes the tissues to become fibrous, thickened and lose normal elasticity, therefor cannot expand effectively. This can be caused by occupational/environmental factors such as silica dust, bird/animal droppings, asbestos fiber and grain dust. Radiation treatment and medications such as chemotherapy drugs, cardiac medications and some antibiotics such as macrobid can cause the damage. Disorders of unknown cause can lead to the damage and in this case the condition is known as idiopathic pulmonary fibrosis. Common symptoms are shortness of breath and dry cough. Compications associated with this condition include pulmonary hypertension, right-sided heart failure and respiratory failure.

AND scope of practice

AND scope of practice and code of ethics:

                AND scope of practice is a set of rules, activities and regulations under which registered dietitians and other dietetic professionals practice. It focus on food and nutrition services provision to the community in different settings to enhance the populations wellbeing through medical nutrition therapy (MNT), performed by registered dietitian. DTRs work under RD on food and nutrition services in public/community settings to provide nutrition education within the stated scope of practice. The AND scope of practice consists of 3 building blocks;

Block 1: Foundation knowledge.

This block has 5 characteristics;

A)     Code of ethics- professionals follow set code of ethics

B)      Body of knowledge- professionals posses science and evidence-based knowledge.

C)      Education- professionals have met the criteria set for credentialing and have passed credentialing exam and required state licensure.

D)     Autonomy- professionals are independent critical thinkers and are updated on current knowledge and skills that enable them effectively perform their duties.

E)      Service- professionals provide food and nutrition services using nutrition care manual process and model

Block 2: Evaluation resources.

Evaluation resources follows the standards set in the nutrition care process and model and CADE education core competencies.

Block 3: Decision Aids.

Use of AND’s evidence library, nationally-developed AND guides for practice and practice based evidence. Use of decision analysis tree and decision analytical tool for dietetic professionals for use to determine if service requested is within their scope of practice. Also the block provide terms developed by the academy for use by RDs and DTRs.

Food Labels

Food Labels:

At the Mylan healthFair, a lot of people were interested with food claims posted on food packages. Many people do not understand what they mean and if they are reliable. Food labeling is mandatory for most prepared foods such as breads, cereals etc. and voluntary for ‘conventional foods’ such as fruits and vegetables. Labeling is overseen and regulated by FDA. For dietary supplements FDA does not actively regulate the content but only the safety of the product.

We provided handouts with information on food labels and what they mean. Among the food claims information provided were claims on fat, cholesterol, sodium and fiber content. The information was gathered from nutrition care manual and America diabetes association website. However, regulation of organic foods is done by USDA. USDA regulates the standards of the organic farms, harvesting and produce handling in the farms and in the processing. For a product to claim to be organic, it must be produced without any excluding methods such as in genetic engeneering, must be produced as per the national list of allowed and prohibited substances and must be overseen by USDA national organic program (USDA.gov). The label may read 100% organic, organic or made with organic ingredients; all this depends on the extent of the organic product or practices used.

Mylan HealthFair

Today was the first day at a wellness healthFair at Mylan pharmaceuticals. This fair is being held at the Mylan pharmaceuticals facility and is open to all the employees. The nutrition education that I prepared focused on diabetes education, specifically on carbohydrates counting and reading the food labels. People interested in the topic or those diagnosed with diabetes were educated on these areas and given educational materials. Also a handout was prepared as a guide for diabetes patients to use while in fast food restaurants in the area. These handouts listed foods in the restaurants that have not more than 30g of carbohydrates and less than 10g saturated fats.  For the people without diabetes, they were educated on reducing cholesterol and triglycerides in their diets by making health choices. They were also educated on MyPlate, together with demonstrations and education materials. The fair was a good success with a great turnout.

Hypobetalipoproteinemia

Low LDL (Hypobetalipoproteinemia):

Very low LDL is a life threatening conditions that is almost often fatal. This can occur due to 2 inherited disorders of lipoprotein metabolism; abetalipoproteinemia (ABL) and familial hypobetalipoproteinemia (FHBL). Although these people have almost zero chances of developing heart disease, they develop fatty liver and severe vitamin E deficiency. People with this condition exhibit fat malabsorption, acanthocytic RBCs, spinal-cerebral degeneration and growth retardation. Their lifespan is approximately 30 years. With early detection, vitamin E and MCT supplementation, their lifespan may be prolonged and neurological damage delayed. These disorders result from microsomal triglyceride transfer proteins (MTP) and apolipoprotein B (Apo B) mutations during embryonic fetal development.  Non familial forms of these mutations can occur as a result of chronic liver disease, occult malignancy and malnutrition. Although this is a very deliberating condition and infants born with it die due to failure to thrive, it’s a very rare inborn error of lipoprotein metabolism. Clinical manifestation includes failure to thrive, mental retardation, ophthalmological abnormalities and gastroenterological disorders.

In-service training

Production in-service blog

One of my assignments was to give an in-service training for the food service production team. The topic covered was handlingPotentially Hazardous Foods (PHF).The workers were given a handout and a quiz at the end of the lesson. The lesson covered the following areas;

1. What are PHFs?

2. Causes of food borne illnesses

3. Risk factors

4. Cold and hot holding

5. Cooking temperatures

6. Cooling hot foods safely

7. Thawing food safely

8. Safe refrigeration

9. Reheating food safely