2021 Poster Presentations

Thank you to our Poster Presenters for all their hard work this year. Please review each abstract and poster below. You can click the title of the Poster to view a PDF version for more detail.

Esophageal Adenocarcinoma Status Post Transhiatal Esophagectomy: A Case Study

Abigail McMahon, Dietetic Intern

Learning Outcome: To understand the role of medical nutrition therapy status post esophagectomy.

Introduction: Esophageal cancer is the ninth most prominent and the sixth most fatal form of cancer. 80% of patients may develop malnutrition in the setting of dysphagia or unintentional weight loss related to suboptimal intake and elevated energy expenditure. Esophagectomies are considered the cornerstone of treatment though gastrointestinal complications frequently persist after surgery, potentially requiring enteral nutrition (EN).

Case Presentation: A 66-year-old Caucasian male admitted to the Johns Hopkins Hospital for a transhiatal esophagectomy with jejunostomy tube insertion after recent esophageal adenocarcinoma diagnosis, status post neoadjuvant therapy. The patient presented with many risk factors for esophageal adenocarcinoma including sex, race, and age, tobacco use, gastroesophageal reflux disease, and obese BMI.

Nutritional Management and Outcome: The patient was NPO after surgery, and continuous EN was initiated by post-operative day three. He was prescribed a calorically dense formula plus three protein modulator packets daily to promote surgical healing. He remained NPO throughout admission due to oropharyngeal dysphagia and was discharged on cyclic EN. In preparation for potential diet advancement with continued dysphagia treatment, post-esophagectomy education was provided on diet progression and achieving nutritional adequacy while limiting foods that can cause gastrointestinal discomfort.

Discussion: The patient tolerated extended EN well with non-significant 5% weight loss over two months. He was progressively weaned off EN outpatient and advanced to an oral diet. Many patients have delayed ability to eat orally after esophagectomies and, for such patients, EN may be imperative for limiting weight loss and preventing malnutrition.

Funding Disclosure: None.

Complications of End-Stage Renal Disease: A Case Study

Annelise Kohutka, Dietetic Intern

Learning Outcome: To describe medical nutrition therapy interventions in renal function decline and failure in the setting of non-compliance to hemodialysis treatment.

Introduction: End stage renal disease (ESRD) is the final stage of Chronic Kidney Disease and is characterized by the kidneys’ inability to excrete waste, maintain fluid and electrolyte balance, and produce hormones. Dialysis or kidney transplant is required in ESRD. Appropriate nutrition interventions may optimize nutritional status and minimize the risks of associated comorbidities.

Case Presentation: A 70-year-old Black male with type 2 diabetes, hypertension, and ESRD requiring hemodialysis (HD) presented with shortness of breath and weakness. He was subsequently diagnosed with hyperkalemia and metabolic acidosis in the setting of ESRD, complicated by approximately six weeks of missed dialysis.

Nutritional Management and Outcome: The patient was ordered for a renal dialysis diet with no protein restriction, 80 mEq of potassium, 2000 mg of sodium, and Nephro-Vite upon admission. He screened positive for unplanned weight loss (> 10 pounds in 3 months). A Nutrition Focused Physical Exam did not show signs of malnutrition and his intake was >75%. A renal dialysis diet education focusing on reducing potassium, phosphorus, and sodium intake was provided on day 3 with expected fair compliance due to limited health literacy.

Discussion: Even with compliance to dialysis treatment, the mortality rate for ESRD varies from 20-50% over 24 months. This patient was admitted due to noncompliance with dialysis treatments, and with his comorbidities of diabetes, hypertension, and newly diagnosed heart failure and his poor comprehension of the renal dialysis diet, his expected prognosis is poor.

Funding Disclosure: none

Case Study: Decompensated Cirrhosis

Jessica Lawson Goldberg, Dietetic Intern

Learning Outcome: To better understand the pathophysiology and medical nutrition therapy of decompensated cirrhosis.

Introduction: Cirrhosis is the end stage of a variety of chronic liver diseases characterized by impaired liver function and failure as fibrotic scar tissue builds and blood flow is reduced. Common causes of cirrhosis in the United States are hepatitis C, alcoholic liver disease, bile duct obstructions, nonalcoholic fatty liver disease and drug induced liver injury. Complications include portal hypertension, collateral vessels, and gastroesophageal varices, ascites, hepatic encephalopathy, elevated ammonia levels, malnutrition and wasting.

Case Presentation: A 38-year-old male presented to an Emergency Department in critical condition with jaundice, ascites, hypoxia, and general weakness. He was diagnosed with decompensated cirrhosis and malnutrition. The patient reported a history of alcohol use, hypertension, and hypothyroidism.

Nutritional Management and Outcome: A high calorie, high protein diet with sodium (2000mg/day) and fluid (1.5L/day) restrictions, oral nutrition supplements, and vitamin/mineral supplementation was recommended. The patient received education on his diet with expected poor compliance due to lack of engagement. Patient’s needs were estimated in consideration of malnutrition and cirrhosis calculated using his dry weight and determined to be 2310-2695 kcals/day (30-35kcal/kg) and 92-115g protein/day (1.2-1.5g/kg).

Discussion: Medical treatment for cirrhosis focuses on correcting the underlying cause, preventing disease progression, and treating the complications and subsequent symptoms. Medical nutrition therapy for cirrhosis is patient specific but generally aims to avoid or correct protein-energy malnutrition, muscle wasting, fat losses, and electrolyte/ fluid management. The prognosis for patients with cirrhosis depends on the progression of the disease and their overall health.

Funding Disclosure: None

Employee Interest in Participation in a Reusable Container Program to Increase Hospital Cafeteria Sustainability

Jessica Wonn, MS, RD; Joetta Khan, PhD, MPH, RD

Learning Outcome: To evaluate the interest of hospital employees in participating in a reusable container program as a method to improve cafeteria sustainability.

Introduction: Food service establishments generate a large amount of waste from both food and packaging.1 One method to reduce waste is to offer a reusable to-go container program. Prior research on college campuses found individuals were moderately to very-likely to use reusable to-go containers.2, 3 There is limited research investigating the use of these program in the hospital setting. This study aimed to evaluate the interest of hospital employees who eat in the hospital cafeteria in participating in a reusable container program at a large military medical treatment facility.

Methods: An anonymous survey was developed by the nutrition services department to collect demographics, cafeteria usage information (e.g., how often they eat in the facility), and motivation/interest in participating in a reusable container program. The survey was distributed both online via internal network link and in-person via paper in February 2020. Results were analyzed using R Core Team Software.

Results: Of 444 responses, 386 were analyzed; 59 were excluded due to not being employed by the hospital or not using the hospital cafeteria. Over half (61.6%) of respondents reported they would be very likely to participate in the reusable to-go container program.

Key reasons for participating included: the positive environmental impact and increased convenience.

Conclusion: Results demonstrate that based on employee interest, a reusable container program could be utilized to increase the sustainability of food service operations in a healthcare setting. Further, successful marketing of a program should include appealing to the convenience and the positive environmental impact such a program could provide. Disclaimer: The views expressed in the article are those of the authors and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government.

1. Environmental Protection Agency (EPA). 2015. Reducing food waste packaging. United States Environmental Potection Agency. https://www.epa.gov/sites/production/files/2015-08/documents/reducing_wasted_food_pkg_tool.pdf. Accessed June 2020.
2. Barnes M, Chan-Halbrendt C, Zhang Q, Abejon N. Consumer preference and willingness to pay for non-plastic food container in Honolulu, USA. J Env Prot; 2011. 2:1264-1273. Doi:10.4236/JEP.2011.29146

Association Between Dietary Fat and Lipid Values in Traumatic Lower Limb Loss

Brittany Powers and Joetta Khan, PhD, RD

Introduction: Cardiovascular disease (CVD) contributes to 1-in-3 U.S. deaths. Individuals with traumatic lower limb loss undergo pathophysiologic changes resulting in increased risk. Dyslipidemia, a main risk factor for CVD, can be increased by dietary fat intake, however research is varied. This study investigated the association between the ratio of saturated to unsaturated fat, and the ratio of total cholesterol to HDL (TC:HDL) in the traumatic lower limb loss population.

Methods: This sub-analysis of a larger study evaluated baseline data from recruited active duty or retired service members with a traumatic lower limb loss at Walter Reed National Military Medical Center (N=45). Data included anthropometrics, biomarkers, general health data and a 24-hour dietary recall. Cases with missing data were excluded. Shapiro-Wilk's test and Q-Q plot tested for normality and correlation was tested with Spearman rho. A post hoc power analysis indicated that 57 participants were needed to obtain power of 80%.

Results: Participants were 93% males, with mean (SD) age 37 (±15 years), adjusted BMI of 27.8 (±4.5) kg/m2, total of 2,315 (±1015) kilocalories, total fat 85 (±42) grams, saturated: unsaturated ratio and TC:HDL ratio was 1.35 (±1.38) and 3.9 (1.27). The saturated: unsaturated fat ratio and TC:HDL ratio were not significantly correlated, rs(45) = -0.146, p = 0.338.

Conclusion: This was a young, generally healthy sample, with slightly elevated fat intake. Although no correlation was found, results should be interpreted with caution, as this study was underpowered. Future research should include a larger sample size, additional dietary factors, and physical activity.

Pancreatic Adenocarcinoma status post Classic Whipple Procedure

Sarah Szmaciasz

Learning Objective: To discuss medical nutrition therapy for pancreatic adenocarcinoma patients post pancreaticoduodenectomies complicated by delayed gastric emptying (DGE).

Introduction: Pancreatic adenocarcinoma, responsible for 85% of pancreatic cancer cases, is the fourth leading cause of cancer-related deaths in the United States. Surgical resection is the only potentially curative treatment, and for the 20% of those who are candidates, many experience post-operative complications including DGE.

Case Presentation: A 76-year-old Caucasian female presented to an outside medical system with abdominal pain, diarrhea, and weight loss. Work-up discovered pancreatic adenocarcinoma, and the patient presented to Johns Hopkins Hospital for a classic pancreaticoduodenectomy (Whipple Procedure) later complicated by DGE on post-operative day (POD) 6.

Nutrition Management and Outcome: Due to diet regression and inability to tolerate an oral diet, peripheral parenteral nutrition (PPN) was initiated on POD 6 to support the patient’s nutritional needs until her diet progressed on POD 14. After diet progression, post-Whipple diet education was provided with an emphasis on DGE prevention, diet modifications to achieve optimal calorie and protein intake, and pancreatic enzyme replacement adherence. The patient had documented diet and medication compliance one-month post-op and continued to follow nutrition guidelines for pancreaticoduodenectomies.

Discussion: DGE occurs in approximately 18% of classic Whipple Procedures and requires both pharmaceutical and nutritional interventions. Gastric motility agents including metoclopramide and erythromycin promote gastric emptying, and nutrition support provides patients with calories and protein during surgical wound healing. Lastly, nutrition education following diet progression can prevent further DGE complications after patient discharge.

The Impact of Covid-19 and Diabetes Risk Associated with Fast Food Consumption, Among College Students Attending Two Separate Universities

Staci Owens, Kathryn Oates, Keith Bratley, and Michael Kirtsos, MS, RDN, CSSD, LDN

Learning Outcome(s): The aim of this study is to determine the impact of COVID-19 on food behaviors associated with fast food consumption in college students from two neighboring universities and how this may impact their risk for Type 2 Diabetes.

Methods: Participants were provided two electronic distributed survey forms. One self-developed survey regarding fast food consumption lifestyle habits and the American Diabetes Association Diabetes Risk Assessment test.

Participants:The study consisted of 399 Salisbury University (SU) students and 118 University of Maryland Eastern Shore (UMES) students.

Results: There was a significant difference regarding Type 2 Diabetes risk between the two universities (P = <.001), with UMES students having a 56% higher risk of developing Type 2 Diabetes. Increased frequency of purchasing of fast food due to the impacts of COVID-19 and risk for developing Type 2 Diabetes was significantly greater among SU students (P = <.001). Coincidently, 63% of students at SU reported having 6 or more fast-food restaurant options within 5 miles of campus compared to only 20% for UMES students. This coincided with a significant higher prevalence of student’s consumption of fast-food two or more times per day (P = <.001). Both universities ranked convenience as their number one reason for consuming fast food. There was a significant difference in BMI classification, with 61% of UMES students having higher BMI scores of (> or = 25 kg/m2) compared to 54% of SU students (P=.002). Additionally, 16% of SU students had an increase in physical activity compared to UMES students (P = 0.006). The results indicate 31% of UMES students and 21% of SU students had an immediate family member with a diagnosis of diabetes.

Conclusions: UMES students are at a higher risk for Type 2 Diabetes. SU student’s diabetes risk may be more likely related to modifiable behavioral risk factors such as frequency of fast-food consumption and environmental factors such as number and proximity of fast-food options in relation to the campus. Students at SU have three times more fast-food options available to them compared to students at UMES. The risk factors for Type 2 Diabetes among UMES students, although higher, may be more likely due to unmodifiable risk factors such as family history and ethnicity. Funding disclosure: none.

Assessing the Impact of COVID-19 on Food Insecurity and Risk of Developing Type 2 Diabetes on Two University Campuses

Sarah Harbinson, Abbey Kane, Bethany Balentine, and Michael Kirtsos, MS, RDN, CSSD, LDN
Learning Outcomes: The aim of this study is to determine the impact COVID-19 has on food insecurity and risk of incident of Type 2 Diabetes in University of Maryland Eastern Shore (UMES) and Salisbury University (SU) students.

Introduction: Previous research indicates 15 - 19% of college students were food insecure before the pandemic. Recent studies indicate COVID-19 has increased the prevalence of food insecurity 34.5% among college students across the country. Niles et al. also concluded there has been a 32.3% increase in food insecure households since the onset of the pandemic (p <0.001). A large-scale longitudinal study found that food insecure adults were at a 50% increased risk for developing diabetes.

Methods: A 19-question survey was electronically distributed assessing the impact of COVID-19 on food insecurity and risk for Type 2 Diabetes. The survey used a modified USDA Food Security Survey, the American Diabetes Association Diabetes Risk Assessment, and self-developed questions relating to COVID-19. Descriptive statistics were used to analyze the data. Participants: Participants consisted of 167 UMES students and 491 SU students.

Results: The results indicate that 42.5% of UMES students and 39.7% of SU students are at risk for food insecurity (p = 0.05). UMES students have a higher proportion of mild and severe food insecure students while SU students are more likely to be moderately food insecure. The impact of COVID-19 indicated that UMES students had a higher increase in their alcohol intake (p = 0.03) and SU students gained a statistically higher amount of weight (p = 0.02). There was a significant association between food insecurity risk and a decrease in shift work hours for UMES students (p = 0.01). Overall, we found that 6.5% of UMES students were at risk for Type 2 Diabetes compared to only 3.9% of SU students.

Conclusions: In both populations COVID-19 has impacted health and wellbeing by impacting diet and lifestyle factors such as weight gain, increased alcohol intake and a decrease in shift work hours, all of which may be contributing to a statistically higher risk of food insecurity and Type 2 Diabetes in this population with UMES students being at a 2.5 times higher risk for Type 2 Diabetes. Students may benefit from community resources to assist with food insecurity thus decreasing their risk for developing Type 2 Diabetes. Interestingly, both universities currently provide food pantries on their campuses, but only 10.7% of UMES and 5.3% of SU students reported accessing food assistance programs during the pandemic suggesting efforts should be targeted at promoting and educating the use of these resources to the student population. Further research should be conducted to assess other potential impacts of the COVID-19 pandemic on diet and lifestyle risk factors in college aged students.

Funding disclosure: none.

Complications of Autoimmune Hepatitis: A Case Study

Danielle Ziegelstein, Dietetic Intern

Learning Outcome: Provide an overview of autoimmune hepatitis (AIH). Discuss the role of nutrition in the management of complications of AIH in an inpatient setting.

Introduction: Autoimmune hepatitis is a disease in which the body’s immune system attacks the liver, resulting in progressive inflammation of the liver. AIH pathogenesis is secondary to an impaired immune tolerance in a genetically susceptible individual, triggered by environmental factors like infections or medications. Treatment often involves immunosuppressants. In severe cases, liver transplantation may be necessary. Nutritional therapies may be useful to target specific complications.

Case Presentation: A 25-year old woman with sickle cell trait, COVID-19, and AIH was admitted with worsening edema, jaundice, dark urine, and volume overload. Throughout her 49-day hospitalization, the patient developed several complications including CMV viremia and aspergillosis, electrolyte imbalances, kidney injury secondary to septic shock, worsening renal function and acidosis. She required mechanical ventilation and continuous renal replacement therapy. She died on Day 49 from septic shock.

Nutritional Management and Outcome: Medical nutrition therapy included a 2-liter fluid restriction to address hyponatremia and a 2-gram sodium restriction to address anasarca with diet education. For early satiety caused by ascites, it was recommended she eat small, frequent meals. When the patient was intubated and made NPO, enteral nutrition was initiated.

Discussion: Nutritional and medical interventions could not improve the significant complications the patient developed. The immunosuppressants made her more susceptible to developing resistant infections, which prevented re-activation on the liver transplant list. The patient had hypotensive episodes, thought to be exacerbated by long-term diuretic use. She is part of the ~10% of patients with AIH who are treated with prednisone but experience treatment failure.

Funding Disclosure: None

Nutrition Delivery and Complications in Bolus versus Continuous Enteral Nutrition in ICU Patients 

Hailey Hofmann, Taylor Kasoff, Carolann O'Connor, Christy Volovnik, Stacy Pelekhaty

Introduction: Appropriate enteral nutrition (EN) during critical illness is associated with improved outcomes. Equipment shortages reduced continuous EN (CEN) and increased bolus EN (BEN) utilization at this institution. This quality assurance project assessed if EN schedule correlates with differences in delivery or complications.

Methods: Patients age ≥18 years admitted to an adult intensive care unit (ICU) from November through December who received BEN for ≥3 days were included. An equal number of patients from each ICU who received gastric CEN in August were identified. Demographic data collected included age, sex, and body mass index (BMI). The nutrition order (formula, goal volume, protein and/or fiber modulars), documented EN formula and modular infusion, gastric residual volumes (GRV), stool output, emesis, and EN interruptions were recorded. Between-group differences were assessed using the Mann-Whitney-U, Student’s t, or Fischer's Exact test as appropriate.

Results: BEN and CEN groups enrolled 32 patients each. No significant between group differences for age, sex, or BMI were noted. EN was interrupted on 45.8% of CEN days compared to 32.3% of BEN days (P = 0.001). CEN patients received 95.8% (81.8%, 100%) of target EN while BEN patients received 100% (76.3%, 100%) (P = 0.1). Modular delivery rates and median GRV did not differ by feeding schedule. No significant differences in the frequency of emesis or diarrhea were observed.

Conclusion: EN was interrupted more frequently in CEN patients compared to BEN patients; however, this did not result in significant differences in EN delivery. No additional differences in complications were observed.

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