Updated Lecture II (1).pptx

LECTURE II NUTRITION T H E O RY By Dr Ehab Mohammed ND LEARNING OUTCOMES Identify and utilize different resources for nutrition recommendation. Compare and contrast different Philosophies to select the appropriate intervention. Identify the best opportunities to integrate nutrition practice into t...

LECTURE II NUTRITION T H E O RY By Dr Ehab Mohammed ND LEARNING OUTCOMES Identify and utilize different resources for nutrition recommendation. Compare and contrast different Philosophies to select the appropriate intervention. Identify the best opportunities to integrate nutrition practice into the patient’s healthcare team. Identify the Ethics and the standards of Practice. List of prescription supplements/vitamins approved by CONO Trusted resources for nutrition (check attached video please) • 1- Canada Food Guide • https://youtu.b e/Xp1tgn-wOT4 2- Reading food labels (Video) • https://youtu.b e/vKYdgETc_PI 3NUTRITION TEXTBOOKS Examples Available at CCNM Library (Toronto Campus) NUTRITION TEXTBOOKS Example: Available at Boucher Campus 4- ONLINE ACCREDITED NUTRITION EDUCATIONAL PROGRAMS EXAMPLE: HTTPS://WWW.THENUTRITI ONINSTITUTE.CA/?PARTNER =GO&GCLID=CJ0KCQJW2_ OWBHDQARISAAUNTTG4WQDKHM39RWV-M-Z6LK7B6 UIIHK83IQD7RUVURRPKRV NPV4VMSUAAHKUEALW_W CB 5- Expert opinions NDs MDs Nutritionists Dieticians Philosophies and approaches to nutrition care There are 3 pillars for the philosophy of nutrition practice A- Looking for the best non- biased evidence-based practice in nutrition B- Selecting the most trustworthy and practical evidence for practice C- Clinical assessment, cost benefit and risk calculation Problems with evidence-based practice in nutrition Lack of data filtration when research is posted online . Sometimes, a contradictory research outcomes/findings between different researches makes the public /medical professionals loose trust A N E X A M P L E O F C O N T R A D I C T O RY R E S E A R C H E S Vitamin E was found to reduce cardiovascular disease related deaths (Knekt et al 1994). Further research in 2000 (Yusuf et al) a RCT involving >9000 patients proved no effect of vitamin E on cardiac mortality. However, later on, a research in 2013, Bjelakovic et al in a Meta analysis involving > 135,00 patients proved that vitamin E if given in high doses can be a factor in increasing the cardiac related mortalities. Pillars of evidence-based practice in nutrition 1- Patient’s care 2- Patient’s respect Uncertainty in research-based evidence Weakness of some research projects ( e.g., small number of participants, effect of bias, and weaknesses of the research methodology) Premature data selection / consideration for the clinical practice can negatively influence the practice, on the other hand waiting / looking a better / robust research can be useful for patient’s care RECOGNIZING THE BEST EVIDENCE It depends on the nutritional practice, For therapeutic interventions, the research hierarchy is the determining factor, so the best evidence comes from meta-analysis and systematic reviews, then randomized prospective studies then the observational studies, and the cross-sectional studies On the other hand, for diagnostic interventions the best evidence comes from randomized comparisons of the standard versus the new diagnostic tool RECOGNIZING THE BEST EVIDENCE FOR THE PROGNOSTIC EVIDENCE, A P R O S P E C T I V E O B S E RVAT I O N A L S T U DY I S T H E G O L D S TA N D A R D . UNIQUE SITUATION OF RESEARCH IN NUTRITION PROSPECTIVE RANDOMIZED INTERVENTIONAL STUDIES ARE VERY CHALLENGING FOR MANY REASONS SUCH AS THE HIGH DROP OUT RATES AND THE COST OF THE INTERVENTIONS ON THE OTHER HAND, A PROSPECTIVE OBSERVATIONAL STUDIES TEND TO HAVE MORE PATIENTS ON TRACK AND ARE NOT COSTLY Research evidence is never a replacement for the best clinical judgment • Examples: • A strict sugars/ carbohydrates limited diet is the best evidence-based practice to manage type II DM • However, if your patient is a terminally ill cancer patient with a very limited survival this evidence practice may not be the best for them at this time. Acknowledging patient’s values in EBN (Evidence based nutrition) Taking into considerations the individual’s values, beliefs and social circumstances is very crucial for implementing the right nutrition program for patients For example, a pregnant lady in her 30th with gestational DM and having 2 other children, implementing strict low carbohydrates diet may be challenging in her situation Skills and clinical experience • Diagnostic skills are of paramount significance in EBN, for example if someone has bloating, diarrhea and gases he may have IBS/IBD etc. but doing the right diagnostic test (e.g., serum antibodies for celiac disease) can accurately diagnose his condition (Celiac disease). Skills and clinical experience So, by picking the right diagnosis (celiac) the right nutritional intervention follows (Gluten free diet, and digestive enzymes) . Clinical experience may influence the treatment: e.g., considering patient’s adherence to the treatment, patient’s finances, personal and social values and beliefs can influence the final decision. • The goal(s) of both Naturopathic medical practice and family medicine are parallel: Mainly to maintain the general wellbeing of the public. Integration of Naturopathic practice into the main medical stream Reasons of why people seek ND help • More holistic approach to their problems. • Identifying the root cause(s) of their health issues • Need more time to discuss their issues and elaborate on them. • Lack of response under standard medical care . • Positive outcome from ND care. Reasons why some patients look for an integrative care between their MD and ND Many patients start the care with MDs then shift to NDs so they are under the care of both teams. Co-management of the care between the ND and MD helps achieve the best and optimal care of their health issues. Naturopathic Medical Care can reduce the need for more prescription drugs, and this works in all patient’s favor. Best means to support the collaboration and integration between NDs and MDs • Creation of a professional referral system between both services to secure collateral service delivery and integration. • Respect and trust between the members of each team. • Promoting Naturopathic Services among the main medical stream members. E T H I C S A N D S TA N D A R D S O F P R A C T I C E Naturopathic Medical Profession mandates that all Naturopathic healthcare providers serve the public under a code of ethics that ensures public’s trust and confidence. E T H I C S A N D S TA N D A R D S O F P R A C T I C E NDs should practice under the guidance of their regulatory bodies ( for example, CONO in Ontario), avoiding any practice that may harm patients or impact their health negatively. Refuse any influence on them that may undermine their professional integrity Ethics and standards of practice Treat every patient with dignity and respect Respect patient’s needs and values. Avoid any discrimination on any ground such as age, gender, race or color. Determine only the necessary means for the diagnosis and treatment of their patient’s needs. Ethics and standards of practice • Cooperate and work closely with patient’s family and care givers. • Respect patient’s privacy and avoid any discussion about their health in public. • Continue serving your patients until they wanted to change the practioner and help them get another practioner. • Expand your knowledge and skills with more training and knowledge acquisition to serve our patients well. • Comply with the standards of practice of your regulatory body. Advertising Guidelines • Don’t mention that you TREAT any disease • You are NOT the only practitioner • For example; this Ad doesn’t comply with the guidelines • At Naturopathic Clinic We treat Asthma with Proper Diet and Supplements PRESCRIBING NUTRIENTS As per CONO Guidelines, Prescribing nutrients / supplements is one item of the controlled act Prescribing Dispensing Compounding Selling Prescription requirements • Competency • Meaning that the ND has to satisfy certain requirements to be able to prescribe the nutrients safely and ethically Competency requirements • Completion of a prescribing course approved by the college • Passing a prescribing exam approved by the college • Every 3 years after doing the course and passing the exam, to maintain the competency by a continuous education program Process of prescribing a nutrient/supplement • First : Assessment of the patient’s needs for that supplement and why you prescribe it for that patient Process of prescribing a nutrient/supplement • Formulate a working diagnosis based on subjective and objective assessment before prescribing the nutrients Performance indicators of prescribing • Before prescribing • Full assessment including labs as needed Performance indicators of prescribing • Balance the risks/benefits of prescribing Performance indicators of prescribing • Documentation of the indications and the reason(s) of prescription in the medical chart PERFORMANCE INDICATORS OF PRESCRIBING REVIEW OF PATIENT’S MEDICAL AND SURGICAL HISTORY Performance indicators of prescribing • Prescription should be within the all regulations and permissions approved by the college including the types of the nutrients, dosages, routes of administration and all other specifics Performance indicators of prescribing • ND should give the free choice to the patient to where they should buy the supplements from and NEVER force them to a buy from a specific location/ supplier Performance indicators of prescribing • Should provide a clear written prescription Performance indicators of prescribing • In emergency, you can give a verbal order, but you need to document it in the medical chart Performance indicators of prescribing • Provides the patient with a full details of the nutrient/supplement to the patient: • Why it was administered (main indication (s). • Possible side effects/harm both common and uncommon ones • Contraindications/restrictions • Document all these information in patient’s chart Performance indicators of prescribing • Notification of other healthcare providers (such as MDs, Nurse Practioners, etc.) about the supplement/nutrient prescription after taking patient’s consent Performance indicators of prescribing • Prescription format : • Date • Clearly written patient’s name and address • Name of the supplement, dose, strength, form (capsule, dry herb, tincture or salve) and total quantity. • Directions of use (route, duration, relation with meals and how many refills if any). • Prescriber’s name, address, phone number, signature and college’s registration number Performance indicators of prescribing • After prescribing, the prescriber should monitor patient's response to therapy P E R F O R M A N C E I N D I C AT O R S O F P R E S C R I B I N G After prescribing: Monitor and document any side effects / toxicities of the supplement /nutrient Either to adjust the dosages (increase / decrease) or change the frequency Discontinue the supplement if needed. Consult the other healthcare professionals if needed to support the overall patient’s management. P E R F O R M A N C E I N D I C AT O R S O F P R E S C R I B I N G If the patient was referred to you from another ND and they want to continue their prescribed nutrients/supplements Perform an initial assessment (as patient’s condition/diagnosis may change). Monitor and document patient’s response to the treatment. If the patient returns to their previous healthcare professional, to update them about the current prescription. PR E SC RIPT ION RE C OR D K E EPIN G A copy of the full prescription should be kept In addition to the prescription keep all the labs that are considered relevant to this prescription The names and the addresses of the other healthcare professionals who cared for the patient at the time of the prescription as well, the date of notifying them and the method of notification of them about this prescription. E T H I C S A N D S TA N D A R D S O F P R A C T I C E For full information review the official Website of the College of Naturopaths of Ontario (CONO) https://www.collegeofnaturopaths.on.ca/ Check under registrants then Standards& Guidelines LIST OF VITAMINS THAT NEED A PRESCRIPTION IN ONTARIO ALL THE SUPPLEMENTS AND VITAMINS CAN BE ADMINISTERED AS OVER THE COUNTER PRODUCTS (I.E., DOES NOT NEED A PRESCRIPTION FROM A LICENSED ND) IN ONTARIO EXCEPT FOR CERTAIN VITAMINS SUCH AS VITAMIN D (>2000 IU DAILY) Vitamin D more than 2000 IU daily dose • Regardless of the form (pills, gel capsules, or drops) Example A patient very deficient in vitamin D ( for example 25 ng/ml) they may need 8000 IU daily dose, and this is prescription Vitamin D3 (Brand --) form (drops/gel capsules/pills), 8000 IU once daily AFTER MEALS for 3 months Prescription needed for: Desiccated Thyroid gland Extracts Desiccated Thyroid extracts have an active T3 which can induce hyperthyroidism if given in high doses. Also prescription needed: Bioidentical hormone therapy (Estrogen/progesterone/both) Also, prescription needed: Vitamin A more than 10,000 IU • The precautions/ side effects of high dose of vitamin A administration are: - Possibility of elevation of the liver enzymes - Skin hypercreativities and rashes. - Congenital anomalies if used during pregnancy. P R E S C R I P T I O N N E E D E D : PA N C E R L I PA S E A Digestive enzyme, if you suggest a dose more than 20,000 USP units it should be in a prescription PRESCRIPTION NEEDED: DIGITALIS PURPURA IT IS A CARDIAC STIMULANT THAT IS USUALLY PRESCRIBED FOR PATIENTS WITH HEART FAILURE, AND IT HAS A NARROW THERAPEUTIC RANGE O T H E R S T H AT N E E D P R E S C R I P T I O N Adenosine triphosphate Calcium Chloride (IV form) Calcium Gluconate (IV form). Colchicine (Only as botanical) Dextrose Injection Folic Acid (Only for doses> 1 mg) O T H E R S T H AT N E E D P R E S C R I P T I O N : L-Tryptophan (for oral doses > 220mg or for IV forms). Levocarnitine and its Salts ( only for the treatment of primary or secondary levocarnitine deficiency). Nitroglycerin Pilocarpine and its salts (only botanical form). Podophyllotoxin (only botanical form). Vitamin K1 and K2 ( for doses >0.12 mg) Yohimbine and its salts compounding these products • Desiccated Thyroid Extracts • Bioidentical hormones • Should be done by a compounding pharmacist References • Canada Food Guide online resource • https://food-guide.canada.ca/en/ • College of Naturopath of Ontario online resource • https://www.collegeofnaturopaths.on.ca/ • Fleming S, and Gutknecht N: Naturopathy and the Primary Care Practice, Prim Care. 2010 March; 37(1): 119–136. • Johnston B et al: The Philosophy of Evidence-Based Principles and Practice in Nutrition Mayo Clin Proc Inn Qual Out 2019;3(2):189-199