Clinical nutrition experience class 2
インターンシップも２セメスター目になりました。このセメスターは合計３カ所でそれぞれ実習をこなしました。人数も生徒１人につき最低１人の栄養士のもとで勉強させてもらえたので内容がすごく深いものとなりました。
１カ所目はショートタームケアーのブライトンホスピタルでした。この病院はアルコール中毒者や薬物依存症のためにある施設でかなり特殊な場所でした。アメリカでは個人により保険の種類が異なるため充分な治療を受けられないといったことが多々あるようです。これらの中毒になっている患者の入院平均日数は５日から７日です。初めの３日間はDetoxicと言って薬物で薬物を体から取り除く治療をするようです。３日間でほとんどが抜けていくそうですが、勿論精神的依存はまだまだ治りません。この間は栄養士はほとんど何もしません。食事は与えられるそうですが味覚がいつもと違うのか同じモノでもまずく感じるとたくさんの患者さんが言っていました。初めの３日間を終えたときにはほとんどの患者さんが吐き気に襲われたりして食欲はゼロに近い人が多かったです。それから４日ぐらいかけて朝の８時から４時まで心理カウンセリングや栄養学のクラスを受けたりして基本的生活知識をつけるようです。実際このような短期間ではほとんど依存から快復する人はいないようですが、保険がカバーしないからと言ってほとんど強制退院のような感じがしました。
驚かされたのはほとんどのアルコール依存症になっている患者さんの家族の病歴を見ると、彼らの両親または片親が以前にアルコール依存症だった事です。家庭環境がかなり影響しているのでしょうか？
また、コカインやヘロイン中毒の患者さんに対してもほとんどが同じ事が言えると思います。６０歳ぐらいの方になると病歴も長く１０年ぐらいの使用歴の人がたくさんいました。
ここでは特殊な栄養学といったことはなく、退院後にどうやって自己管理を行うかを教えていました。
２カ所目はロングタームの施設だったので老人ホームでした。アンアーバーにあるとても大きな施設でした。そこで働いている栄養士さん２人に順番でス−パーバイザ−としてついてもらいました。その施設の中にはロングタームの老人施設、ホスピス、そしてショートタームのリハビリ施設と３つに分けられていました。 ９０日に一回家族とのケアカンファレンスが開かれ、ナース、OT, PT, RD、ミュージックセラピスト、スピーチセラピスト、必要に応じてドクターも同席して各専門家からの意見や状況報告をします。栄養面からは３ヶ月の体重の動きや血液検査の結果、食欲について話をします。飲み込みが難しい患者さんに対してはスピーチセラピストと話し合って食事の形態を変えていきます。ここでは体重を維持することが一番難しかったです。減らすことよりも増やすことは９０歳を過ぎている人にはかなり難しいようでした。 病気としてはほとんどの人がアルツハイマー、痴呆を持っており、その他にはパーキンソン病や糖尿病が多かったように思います。 毎日アセスメントとケアカンファレスンスに追われていました。ケアカンファレンスでは栄養士以外の専門家とも意見が交換できたりしてとてもよい勉強になりました。
３カ所目は学校になるOffice of Nutrition Serviceというオフィスで実習をしました。主に学生や職員に対して体脂肪率を測ったりカウンセリングを行ったり、学校内にある病院の職員に食に対してのプレゼンテーションを行ったりと様々なアクティビティーがありました。 各サイトでスーパーバイザーに評価を行ってもらい最後に提出となりました。 今回は２セメスター目だったので、各サイトでチャートに慣れるまでが少し時間がかかりましたが、見方が分かればアセスメントの時間もかなり短縮できるようになりました。 いつになってもドクターの書いたハンドライティングが読めません。。。
Clinical Nutrition 2
このクラスは先セメスターの続きで臨床栄養学のクラスです。
各内容ごとにケーススタディーの宿題が与えられ、与えられたチャート（カルテのこと）を見ながらアセスメントをします。症状、病歴、血液検査の結果や食習慣などから情報を拾ってきます。この宿題は実際のインターンで役に立つのでやっていて難しいけれど楽しかったです。
テストは合計３回ありオンラインでした。授業でのテストはADAの試験とほぼ同じレベルだったそうです。クラスで学んだだけではすぐに忘れがちですがインターン先で同じ病気の患者さんに会うと習った通りの血液検査の結果になっていたりして自然と病気に対しての知識がついたように思います。
Life cycle and Nutrition
生まれてすぐの赤ちゃんへの食事から老人への食事まで一生を通しての栄養学についての授業でした。 次のセメスターではWICでの実習が入ってくるのでかなり乳児、幼児、妊婦への栄養学について時間をかけて勉強しました。また、老人への食事の与え方から食器の選び方まで栄養学以外にも勉強できてよかったです。これ以外にも自分の興味のある分野についての栄養学のペーパーを書きました。私のトピックはパーキンソン病と栄養学でした。
NUTRITION FOR PARKINSON'S DISEASE
Introduction
Parkinson's disease (PD) is one of the incurable diseases. There is no cure for this disease. PD is a serious disorder that affects nerve cells (neurons) in the part of the brain controlling muscle movement. There are nearly one million patients who was diagnosed PD in the United States and the number increases by 50,000 every year. There are nearly 120,000 PD patients in Japan. Because it is not contagious and does not have to be reported by physicians, the incidence of the disease is often underestimated. The risk of developing it increases with age, even though there is an alarming increase of patients of younger age. The average life span is getting longer, therefore the number of PD patients is increasing. Actually, it can occurs at any age and in all parts of the world.
My father was diagnosed PD when he was forty-eight years old. When I heard the name of the disease thirteen years ago, I thought that the disease would certainly lead to death. Medical treatment for PD is improving every year, and my father has been having all the treatments. Unfortunately, PD devastated his life, especially in the five years after taking the medications. It was really hard to get along with not only the syndromes from PD but also the side effects from the medications. On the one hand, medical nutritional therapy can reduce disability of eating, prevent of the tragic consequences of malnutrition, reduce hospitalizations, and help for better quality of life.
On the other hand, throughout the course of the disease, I saw him suffering from PD experience nutritional barriers, such as nausea, drug-nutrient interactions, delayed gastric emptying, chronic constipation, dysphasia, choking, gastroesophageal reflux, unplanned weight loss, depression, and many more problems.
In this paper, I would like to present an overview about PD and explain how the nutrition therapy can affect the PD patients by each disease stages and each disability.
Definition of PD
PD is a neurologic disorder in which dopamine-producing neurons in the brain begin to deteriorate and die. "Dopamine is a neurotransmitter responsible for muscular control. The gradual loss of dopamine leads to decreasing muscle control and results in progressively worsening symptoms of PD". ( 1 ) No cure has been found for this disease. Researchers and scientists now believe PD may result form genetic, environment factors, or a combination of them. Certain drugs, diseases and toxins may cause symptoms similar to those of PD. People did not believe that there was a genetic component to PD until 1996. The National Institute of Neurological disorders and stroke (NINDS) found "the special relationship between specific genetic markers and PD in 870 people from 174 families in which more than one person had been diagnosed with the disease". ( 2 ) Five chromosomes have strong susceptible possibility to PD. Another study showed that having two first-degree relatives with PD can increase the risk as much as ten times. Environmental factors also affect to the PD because one study showed that "people with unusual exposure to herbicides and pesticides are three times more likely to develop PD than people who don't have this exposure". ( 3 )
Symptoms
The symptoms of PD can be described in three stages. In the first stage, the symptoms of PD are stiffness, rigidity, tremor, slow movement, impaired balance and difficulty in walking. In the second stage, the symptoms are stooped posture, a soft voice or difficulty in speaking, dementia and depression. In the last stage, further conditions develop, such as food-drug interactions, slow peristalsis, delayed gastric emptying, gastroesophageal reflux, constipation, dysphasia, falls, xerostomia, dry mouth, loss of senses, loss of appetite, fracture bones and unplanned weight loss.
Medication
Drugs such as Levodopa improve the initial PD symptoms, but long-termed, frequent use causes excessive, spasmodic movements and many other side effects. If the syndrome is mild, life style changing, such as diet and exercise would be recommended. The patient might be recommended to get a physical therapy, too. Physical therapy can be extremely helpful for PD patients who are in the early and later stages. Speech pathologist also can help PD patients to improve problems with speaking and swallowing.
Medications are used to help patients with walking, movement, balancing and tremor problems by increasing the brain's supply of dopamine. However, each patient shows different effectiveness and side effects. So, the medication needs to change over time and the drug dosage and timing may require adjustment for each individual. Levodopa, levodopa/carbidopa such as Sinemet, Symmetrel, Selegiline, Deprenyl, COMT inhibitors such as Tasmar, anticholinergics such as Trihexyphenidyl and dopamine agonists such as Parlodel are commonly prescribed for PD. Some of the medication has a strong interaction with diet.
Nutrition for early stage of PD
Some studies showed that PD patients often have lower bone mineral density and they may fall more easily because PD affects the balance and coordination centers in the brain. Therefore, PD patients have greater incidence of osteoporosis and bone fractures.
PD patients need a high calcium diet to prevent osteoporosis in the earliest stages. Consuming 1200 to 1500 mg calcium is suggested per day. Good sources of calcium include food, such as milk, cheese, yogurt and other dairy products. There is a strong interaction between Levodopa, which is the most common PD medicine, and protein in diet, such as meat, beans, egg and so on. If the patient takes the Levodopa, he has to take it 30 to 60 minutes before he eats protein rich foods. Vitamin D is also one of the important nutrients for preventing osteoporosis. Without adequate amounts of vitamin D, calcium cannot be absorbed by the body. Vitamin D supplements (400IU) could help to improve bone density.
Hydration is very important for the human body. First, "Anti-Parkinson drugs are "dry out" the body. It is important to drink water "by the clock", not unlike one would schedule crucial medication". ( 4 ) "Bladder and urinary tract infections are common in older adults and people with PD because they are frequently in a state of mild and prolonged dehydration. This allows bacteria to exist and grow in the bladder and urinary tract, causing infection". ( 5 ) Secondly, water is important to prevent constipation. Some of the PD medications cause constipation as a side effect. PD patients need to drink at least eight glasses of water in a day. Third, dehydrated condition causes dry mouth. "Without saliva, bacteria can breed along the gums and cause decay and loss of teeth, as well as poor digestion of food. Some people report that PD patients often feel thirsty and sometimes of dry mouth, thick or sticky saliva, and dry eyes. This may be due to or aggravated by anti-Parkinson medications; the anti-cholinergic drugs such as Artane or Cagentin used to treat tremor are particularly known to cause such symptoms. Dry mouth may be caused by difficulty swallowing, sleeping with the mouth open, or mouth breathing while awake". ( 5 )
Some medication also cause nausea and vomiting. Fatty food, spicy foods, too much caffeine and nicotine should be avoided to prevent nausea and vomiting.
Nutrition for the second stage of PD
Constipation occurs frequently with PD because of two reasons. One is the medication that is used to treat PD. These medications make the GI tract slow down. The other reason is due to some degeneration of the nerves of the GI tract is caused by PD. Constipation can be an increased risk for colorectal cancer. It is recommended to take 25 to 35 grams of dietary fiber with six to eight glasses of water per day by American Dietetic Association (ADA).
Through the progressive of PD, chewing and swallowing may become difficult. Patients should see a speech pathologist for help in learning safe swallowing techniques. Difficulty with swallowing can lead to a respiratory condition known as aspiration pneumonia. To avoid choking and respiratory problems, eating small and frequent meals are suggested. One bite should be the size of a teaspoon instead of a tablespoon. Boiled milk, mousse, custard, yogurt, ice cream, casseroles, soup, fruit juice, pureed fruit, rice and banana may be easier to swallow. Sitting position also affects the ability of swallowing. Patients should sit with chin down and parallel to the table. When the chin is up, the esophagus is partially closed off and the trachea is more open. This position also increases the risk for aspiration.
One of the most common PD medications is Levodopa. Levodopa is a dopamine precursor, a substance that is transformed into dopamine by the brain. When PD patients start taking this medicine, timing of meals should be carefully considered. Patients need to take Levodopa as much as one hour prior to meals. Levodopa has a very short plasma half-life. It is not absorbed from the stomach, but from the small intestine. Therefore, the contents of the stomach affect the speed of the absorption of the medication. It means the longer the drug stays in the stomach, the more Levodopa will be chemically broken down and less drug will be available for absorption. Protein in the diet also affects the absorption of this medication. Therefore, low-protein diet (less than 0.8 g/Kg /day protein) is sometimes suggested. "Once Levodopa gets from the stomach to the small intestine, it is absorbed into the blood stream. At that time, Levodopa must be transported by attaching to carrier molecules. This carrier system transports the drug from intestine to the blood stream and blood stream to the brain." ( 6 ) The amount for the carrier transport is limited. One type of amino acid, Large Neutral Amino Acid (LNAA) in the diet also uses the same carrier system as Levodopa. A high protein diet contains a lot of LNAA. Therefore, a protein-rich diet can get the space for the carrier system instead of Levodopa. If the patients diet is high in protein, less Levodopa may be sent to the brain and it's absorption can be obstructed.
Nutrition for late stage of PD
Appetite loss and weight loss will be the biggest problem during the last stage of PD. Depression, decreased sense of taste and smell, dementia, use of multiple medications, dysphasia and/ or cognitive impairment are the factors of appetite loss and weight loss. Supplements, fortified foods and liquid supplements are recommended to prevent weight loss and maintain weight. To prevent appetite loss, small and frequent meals and snacks are recommended. High-carbohydrate and low-protein snacks with the ratios of 8:1, 9:1, or 10:1 are sometimes suggested.
Extreme weight loss can cause bed sores. The patient needs extra protein to heal the sore and rebuild lost muscle and tissues although a low protein diet is recommended. If the patient is using Levodopa, be sure that he gets it at least 30 minutes before meals. This will help the Levodopa reach the bloodstream before protein in the meal can block its absorption.
When the patient has difficulty eating at a normal rate, or has chewing or swallowing problems, tube feeding could help the patient to get the food and liquids needed to stay healthy. In this case, tube feeding should start at least 30 minutes after taking Levodopa.
Support
In the early stage, it is particularly important for both patients and caregivers to receive education about bone health, weight maintenance and dietary adjustment. During the middle and the last stage of PD, chewing and swallowing may be difficult. At that time, speech pathologist can coordinate the diet form, such as mechanical alter diet, pureed diet, clear liquid diet or full liquid diet. Timing of meals and medications, food sources of nutrients and adequate fluid intake are all important. Registered dietitian's (RD) can coordinate and give caregivers education about the special diet for PD. Physicians, speech pathologists, nurses, PTs, RDs, caregivers and patients need to work together. All this support can help PD patients and caregivers to maximize strengths, minimize impediments and achieve and maintain full potential. "At present the American Parkinson Disease Association, Inc. sponsors 65 chapters and more than 800 support groups which provide education, counseling, assistance and referrals throughout the United States." ( 7 )
Conclusion
Parkinson's disease is one of the neurologic disorders which needs much support from caregivers and communities. Since PD was discovered by James Parkinson in 1817, many researchers and scientists have been trying to find the cure for the disease. However, the cure has not been found yet. During this time, doctors and specialists discovered many things about PD, such as the mechanism of PD, genetic factors, medications and a variety treatments. There are four major PD treatments which are, medical treatment, surgical treatment, rehabilitation and nutritional treatment. About one million PD patients are having these treatments. Thanks to the progressive treatments, patients can maintain a healthy life longer than before. Although these treatments can slow down the syndrome of the disease, PD patients will develop many complicated syndromes.
Overall, the PD patient needs a variety of therapies. Nutrition is as important as medication because without proper nutrition and diet medication can not have the desirable effect. Not only having these therapies but also involving in PD association are helpful for PD patients and caregivers. Being a member of the association has some advantages, such as getting new information, talking with professionals and sharing feelings and concerns. Many scientists and doctors are still trying to find the cure for PD and they discover new things very frequently. Therefore, all the specialists have to pay attention to the newest discovery and give the patients the best therapy.
Reference
1. Kathrynne H, Valentina R, FADA. Parkinson's Disease: Assessing and managing unique nutrition needs. The American Dietetic Association: 1999
2. National institute of neurological disorders and stroke. Researchers find genetic links
for late onset parkinson's disease: December 2001.
Accessed on February 3, 2003.
Accessed from:www.ninds.nih.gov/news-article-parkinson-genes.htm
3. MayoClinic.com. Parkinson's disease: July 2002
Accessed on February 3,2003. Accessed from: www.mayoclinic.com
4. The national Parkinson foundation, Inc. Nutritional guidelines for Parkinson Patients: 1996-2002.
Accessed on February 3, 2003.
Accessed from: www.parkinson.org/nutrguid.htm
5. Susan C. Parkinson's disease nutrition matters: 1996-2002.
Accessed on February 3, 2003.
Accessed from: www.parkinson.org/mal.htm
6. The national Parkinson foundation, Inc. A special diet for Parkinson's disease: 1996-2002. Accessed on February 3, 2003.
Accessed from: www.parkinsonswellness.org/nut.html
7. American Parkinson Disease Association. Basic information about Parkinson's disease: February 2003
Accessed on February 3, 2003.
Accessed from: www.parkinsonswellness.org/parkinfo.html