The Varying Shades of "Nutritionist"

Inspired by the ChicagoTribune and my own confusion when I started at the ITPCU, I thought a post on definitions for nutrition counselling was appropriate.  Personally, I field questions on the difference between an M.D. and a D.O. all the time, and I think that Certified Nutrition Specialists and Registered Dieticians can cause similar confusion.

Certified Nutrition Specialist  (CNS):  These practitioners have an advanced degree (Master’s or higher) in nutrition or a related field from an accredited university.  They take certification exams (the Certification Board for Nutrition Specialists, or CBNS) to qualify them to practice as a CNS. Post-graduate study includes many hours of supervised experience in nutrition.  A CNS aims to improve health through science-based nutrition therapy and evidence-based practice.  CNS may work in hospitals, outpatient medicine, or in private practice.

Registered Dietician (RD):  These practitioners have an undergraduate degree or more in nutrition, dietetics, food sciences, or food service management from an accredited college or university.  The Commission on Dietetic Registration of the American Dietetic Association (ADA) registers RDs, requires them to pass a exam by the Commission of Dietetic Registration, and necessitates continuing education requirements in order to upkeep certification.  RDs much also complete a practical internship and have many hours of supervised experience.  RDs are more likely to work in private practice and some go on to get advanced degrees such as a CNS.  RDs also often work in school or hospital cafeterias, nursing homes, or as community educators. 

Note:  Since there are no national guidelines for nutritionists, people can be called a “nutritionist” with varying levels of education and training.  Check for up-to-date certification in any CNS, RD, or anyone else you see for nutrition counseling!  Other nutrition degrees may include Licensed Dietitian/Nutritionist, Registered Dietetic Technician, Certified Clinical Nutritionist, and Certified Nutrition Consultant.  

Food for Fatigue!

Its that time of year where sunlight is rare, the air is cold, and it's a bit more difficult to keep your energy up.  The holiday season - while sparkly and exciting - is also exhausting!  If you're having difficulty with fatigue for whatever reason, these tips are a quick and delicious way to get that energy up!  

Food Remedies for Fatigue: 

·         Squeeze fresh lemon or lime on foods and in drinks.  Lemon and lime are natural “pick-me-ups.”

·         Add garlic to foods.  The stronger the flavor, the more effective it is at improving fatigue.

·         Brown rice balls are an easy “grab and go” snack.  Prepare at home or buy at your local health food store.  Cook one cup of brown rice until sticky and coat by rolling or sprinkling with gomasio or a seaweed gomasio.

·         Barley or wheat grass juice: Drink 1 to 2 ounces of juice per day (available in most health food stores).  If fresh wheat grass juice is not available, you can juice fresh greens or use a premade powder. 

To prepare your own juice:

o   Kale (1 bunch)

o   Spinach (1 bunch)

o   Garlic to taste

o   Beets (especially if you have a low platelet count)

o   Ginger

Directions: Wash well and put through a juicing machine.  For a slightly sweeter taste, add pure fresh apple juice.

·         Use rosemary as a spice.  It particularly helps with mental tiredness.

(all tips are taken from our book, Integrative Strategies for Cancer Patients: A practical resource for managing the side effects of cancer therapy.)    

 

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Another Reason to Stay Up During the Night

The Study:  

 This study looked at coffee consumption and cancer risk in 67,470 females in the Nurses’ Health Study over 26 years.  Originally surveyed in 1980, these women were between the ages of 34 and 59 at the first timepoint.  Coffee consumption was measured in 1980, 1984, 1986, 1990, 1994, 1998, and 2002 through a Food Frequency Questionanire (FFQ) and converted to Cumulative average coffee intake.  Excluded patients include any participants who died, or reported any type of cancer (exceptfor nonmelanoma skin cancer) before 1980, had a history of hysterectomy, and did not complete the 1980 food frequency questionnaire.  Over the study course, participants with missing BMI information, dietary intake information, or had a new diagnosis of cancer or hysterectomy were also excluded.

672 cases of endometrial cancer occurred in the study population.  Fewer than 4 cups of coffee per day were not associated with a change in endometrial cancer risk.  Women consuming 4 or more cups of caffeinated coffee per day had a 30% lower risk of endometrial cancer compared with those who drank less than 1 cup per day.  For decaffeinated coffee, a non-significant inverse association was found among women who had 2 or more cups a day (22% less risk).  Tea consumption was not associated with endometrial cancer risk.

Limitations: 

 FFQs are notoriously at estimating a person’s dietary intake, though this study claims that it is accurate for tea and coffee intake.  The amount of cream, milk, creamer, or sugar was not measured in this study.  Variations in coffee drinks may alter the amount of caffeine and other biologically active compounds in each drink, leading to an incorrect measurement.  While confounders like alcohol intake and smoking were investigated, there may be more confounders such as employment, considering all of the participants were nurses.  Nurses in inpatient settings or overnight shifts may ingest more coffee than other nurses, and increased stress during these shifts may affect the incidence of endometrial cancer; making employment a confounder.  The study did not look at what biologically active substance may cause this decrease in endometrial cancer.

What this Means:   

 High caffeinated coffee intake may lead to a decreased incidence of endometrial cancer.   This association may not be true for decaffeinated coffee or for tea.  More research is needed to determine what substance may cause this decrease in endometrial cancer incidence. 

My Take: 

Good news for female coffee drinkers!  You may have an excuse to drink even more.  You may have trouble sleeping though.

However, this study underlined one point for me – watch what you put in your drinks!  While 4+ cups of coffee a day may be helpful,  4+ servings of cream, sugar, etc. is definitely harmful.  I am known for putting only hot chocolate mix in my coffee, and that would add 420 calories (for 4 envelopes)!  That’s almost 25% of daily recommended caloric intake.   So sip away, just watch what you put in that cup.

ITPCU Media Blitz!

Come look and listen to ITPCU in the news! Many thanks to WABC7 and The Skillful Living Room for such wonderful work!

http://abclocal.go.com/wabc/story?section=news%2Fhealth&id=8459627

http://www.businesstalkradio.net/weekend_host/Archives/tslr.shtml

- click on "Sat, Nov 26" to hear the full podcast!

Acupucture is Largely Safe is Kids…As Long as You Know the Risks

The Study:  

This is a literature review of 18 databases searching for studies on pediatric acupuncture.  The primary reported value was the number of adverse events (AEs) in the pediatric patients who received acupuncture.  Of the 9537 references identified, 450 were assessed for inclusion and a final 37 studies were deemed appropriate for evaluation.  Eligible studies were  (1) contained original patient data published in a peer-reviewed journal, (2) included children from birth to 17 years, inclusively, (3) involved needle acupuncture, and (4) included assessment of AEs in a child.

279 AEs were identified; 25 were serious, 1 was moderate, and 253 were mild.  Of the serious AEs, 12 were thumb deformities, 5 were infections, and 1 of each: cardiac rupture, pneumothorax, nerve impairment, subarachnoid hemorrhage, intestinal obstruction, hemoptysis, reversible coma, and overnight hospitalization.  On review of the severe adverse events, the majority of them may have been secondary to acupuncture technique and not the acupuncture itself.  The mild AEs included pain, bruising, bleeding, and worsening of symptoms. Overall incidence of mild AE In patients was 168 in 1422, or 11.8%.

Limitations: 

This study was limited primarily by the English language.  There may be multiple studies in Chinese or Japanese who were missed or not entered in PubMed due to the lack of translation.  Therefore, the study may be missing multiple of cases with or without AEs.

What this Means:   

Overall, acupuncture is safe in children.  However, acupuncture still has its risks.  Like in Western medical care, it is extremely important to ensure that your acupuncturist has appropriate training and credentials before getting treatment.  It is also important to check that your acupuncturist has experience, uses sterile needles and cleans your points beforehand.  Regardless, you or your child may still experience bruising, bleeding, or pain from the needles. 

My Take: 
Similar to taking a new medication, everyone responds to acupuncture in a different way.  It is important to learn and understand the risks of ANY treatment before you get it, including acupuncture.  Your new acupuncturist should briefly summarize the risks of the treatment and give you a consent form to read and sign beforehand. If you have any questions about the treatment, this educational pause is the time to ask!  Your signature is proof that you understand and accept these risks.

Overall, acupuncture is safe in pediatric populations.  While needle fear is real and understandable, it is important to remember that every medical treatment has risks – even though acupuncture’s risks may be more obvious (like needles in your skin).  I know people who are scared of acupuncture but will pop pills without a second thought.  With either the needles or the pills, it’s important to be clear what you’re treating, if the treatment will help, and what the risks are.  But bleeding, pain, and other risks of acupuncture happen rarely and are largely minor.

I’m excited that this study was published, especially in such a high-impact journal.  Hopefully, the use of CAM will slowly be accepted in the pediatric population. The ITPCU has actually been conducting a study looking at the acceptability and safety of acupuncture in our pediatric oncology population for multiple years.  We’ve presented results from this study multiple times at various conferences, the last one being at the Society for Integrative Oncology (SIO) in 2012.  Sagar, our research assistant, even won the Young Investigator Award for the presentation!  In addition, we’ve published a paper on the safety of acupuncture in pediatric thrombocytopenic patients (patients with low platlets) (1).  Stay tuned for more results of the study…it’s truly great clinical research. 

1. Ladas EJ, Rooney D, Taromina K, Ndao DH, Kelly KM. The safety of acupuncture in children and adolescents with cancer therapy-related thrombocytopenia. Supportive Care in Cancer. 2010;18(11):1487-90.

IT'S HALLOWEEN!

Lady Gaga and her entourage...the lil monsters love her and her needling!

Happy Acupuncture and Oriental Medicine Day!!!

October 24th is Acupuncture and Oriental Medicine Day!!! 

http://www.aomday.org/

The 2007 National Health Interview Survey (NHIS), which included a comprehensive survey of CAM use by Americans, showed that approximately 38 percent of adults use CAM.   Join the growing group of Americans who use CAM in their daily life! 

Today's the perfect reason to try acupuncture, acupressure, reflexology, massage, reiki, or aromatherapy!  

My First Acupuncture Experience and Tips for the Acupuncture-Naive

At my first acupuncture visit, I arrived as the naive patient I was and not as the medical student I’ve been trained to be.  Instead of emulating the perfect patient that I always dream for, I arrived slightly late with incomplete forms and without proper payment methods (cash/check).  I finished the ten pages of forms a few seconds before I was whisked away from my two 3-year students and their preceptor.   Immediately, I was impressed that a student-run clinic actually was functioning on schedule!

The patient interview consisted of some standard Western medical questions interspersed with some questions I definitely didn’t expect, including whether I liked cold or hot beverages and what kind of dreams I had at night.  Rushed, out-of-breath, and slightly sweaty, the students looked at me with concerned eyes and questioned my sleep and energy level.  After feeling my pulse three different ways in both hands, they left to discuss a treatment strategy and left me to relax on the table.

When they returned, I lay as the students “needled” me on my feet, ankles, knees, stomach, sternum, head, wrists – and I’m sure multiple other points that I didn’t even realize.  My treatment was for an immune boost (due to the upcoming cold season), general well-being, and “liver boost”.  After the needles were in, I was left to lie on the table for about 15-20 minutes.  The students came back to remove the needles and asked if I had any pain or new symptoms, and then the visit was done.

Michelle, an acupuncturist here at ITPCU who also teaches at the school, said I “looked great!” after my treatment.  She claimed she witnessed a marked improvement, but my sleepy boyfriend could not.  While I’m not sure if it was the forced relaxation or the actual treatment, but I definitely felt more awake and energized! 

I definitely want to go back, but I want to go back with a concrete complaint.  Therefore, I’ll have a more complete experience with acupuncture treating physical symptoms versus general well-being.

A Few Lessons for the Acupuncture Newbie:

1.   Wear loose and short clothes – points are placed on the ankles, knees, stomach…basically everywhere

2.   Relax as much as possible – falling asleep is fine, especially if you’re getting therapeutic benefit from it

3.   The needles hurt minimally when they’re being inserted at the acupuncture points.  If anything hurts after the initial entry of the needle, let them know!  Acupuncture is NOT supposed to hurt.

4.   Try not to move after the needles have been inserted.  I moved my finger slightly, and I definitely felt my tendon moving against the needle.  Try to stay as still as possible.

5.   Try to relax – you’ll benefit more from the experience if you do.

6.  Bring the right payment method!  Stressful runs to ATMs after treatments is an easy way to ruin your post-needle buzz.

Our Case for Personalized CAM: Aromatherapy Part 2

Inhalation aromatherapy in children and adolescents undergoing stem cell infusion: results of a placebo-controlled double-blind trial. 

Ndao DH, Ladas EJ, Cheng B, Sands SA, Snyder KT, Garvin JH Jr, Kelly KM..  Psychooncology. 2010 Dec 27. http://www.ncbi.nlm.nih.gov/pubmed?term=Inhalation%20aromatherapy%20in%20children%20and%20adolescents%20undergoing%20stem%20cell%20infusion%3A%20results%20of%20a%20placebocontrolled%20double-blind%20tria

The Study:  In a placebo controlled, double blind randomized trial, bergamot inhalation aromatherapy was compared with a pleasant smelling shampoo that did not contain essential oils.  Both were administered around the time of stem cell infusion in 37 children and adolescents undergoing stem cell transplant to both patients and their parents.

Overall, aromatherapy was not found to be beneficial in reducing nausea, anxiety, or pain.   Nausea and pain subsided over the course of the intervention for all children, though nausea remained significantly greater in patients receiving aromatherapy.  As administered in this study, bergamot inhalation aromatherapy may have contributed to persistent anxiety following the infusion of stem cells.  Although no more effective than placebo, parents receiving aromatherapy showed a significant decrease in their transitory anxiety during the period between the completion of their child’s infusion and one-hour following infusion.  These findings suggest the diffusion of bergamot essential oil may not provide suitable anxiolytic and antiemetic effects among children and adolescents undergoing stem cell transplantation. 

Limitations:  The study population was fairly small.  There was a high rate of aromatherapy use pre-intervention, potentially confounding results.  In addition, it was hard to differentiate between treatment- or transplant-related effects including anxiety and nausea.  

What this Means:  This study, in combination with the previous one I posted, provides some opposing evidence for the use of aromatherapy during stem cell transplant.  The difference in study design may explain the differing results, as single blinded or nonblinded trials in general supported the aromatherapy intervention.   In double-blinded studies, both the study leaders and participants do not know what intervention the patient is receiving; they are the gold standard in research since they remove many factors that could alter data. However, the strong emotional link to the sense of smell makes it extremely difficult to control for in research settings.  Since the symptoms measured, primarily anxiety and nausea, are also closely linked to emotions, it is difficult to ascertain any improvement or worsening of symptoms. In addition, this study also showed that essential oils have unknown side effects, possibly nausea and anxiety in this study, that we do not quite understand. 

My Take:  These two studies, in combination, sort of contradict each other.  However, they did use two different essential oils and two different study designs so they are difficult to directly compare.  From personal experience, I’ve seen that other scents may have been more likeable to a pediatric population such as peppermint, grapefruit, orange, and lavender.  However, bergamot, a citrus, has been described as efficacious for pediatric anxiety and nausea in aromatherapy literature  (1,2).  While each essential oil has a clinical indication, the CAM practitioners here at Columbia’s pediatric oncology department mostly go by patient preference.  The scent of smell is so closely related to emotions Often, they find that individual smells “speak” to a certain patient and provide relief regardless of the initial clinical use.  This type of patient-centered treatment allows us more flexibility and better patient care.  In the CAM world, it’s our form of patient-centered personalized medicine. 

1.       Wildwood C. The Encyclopedia of Aromatherapy.  Healing Arts Press: Rochester, 1996.

2.        Price S, Price PP. Aromatherapy for Babies and Children.  Thorsons Publishers: San Francisco, 1996.