Don't Miss a Beet!!

Maria, a registered dietician, talks about her experience working in the cardiovascular unit at a hospital. She explains that she chose this specialization because there was a need for a dietician in that department. The hardest thing for her was learning the hospital's systems and locations. She emphasizes the importance of understanding the body and how to read blood tests and medications. Maria believes that educating children about healthy eating habits from a young age is crucial in preventing cardiovascular disease. In the hospital setting, patients have limited food choices, but in outpatient settings, individuals can under-report their eating habits. Maria recommends focusing on portion sizes, saturated fatty acids, and LDL levels. She also discusses the benefits of the Mediterranean and DASH diets. She notes that behavior change can be challenging for cardiovascular patients and that fluid restriction is a major difficulty in her unit. Thank you for being here, Maria, and how are you? I'm good. How are you? You're welcome. Nice to be here and see everybody. We are great. Thank you for asking. Today, we'll be talking about your experience as registered dietician, your experience in the cardiovascular unit, and also recommendations you have for the audience. Okay. I'm going to start first. My name is Isia. Hi, Isia. We are going to start with some general information. The first question is, how did you decide to specialize in particular in the cardiovascular unit? Well, it kind of chose me. I've been a dietician for 30 years, and I moved to Miami about two and a half years ago. And when I came to Baptist Hospital, this cardiovascular unit didn't have a dietician. So I was very anxious to get to work. So I just said, okay, I want that floor. Stop orienting me. I just want to work. So I kind of adopted it. Okay. So I guess the following question, what was the hardest thing for you to do when you started to work in this department in particular? The hardest thing really for me to do was to learn where the buildings were and how the computers work and things like that. I mean, being I had been a dietician for so, so many years, you'll see, it's like riding a bicycle. You just, you don't forget. And the longer you do it, the better you get at it, right? It's a learned profession. And I was a clinical dietician in New York at Columbia Presbyterian. Before I came here, I worked in the hemodialysis unit and the renal and liver transplant unit. And then I taught MNT, medical nutrition therapy, and clinical nutrition for 10 and a half years to college juniors and seniors. So then to come back to this after I taught it, it's an interesting chain of events. So it was more like putting in practice that is not even teaching. Teaching, yeah. Well, I have done it in practice, but not for 20 years. And really, I think when you clinical nutrition, you have to love. I am passionate about it. I sincerely love it. And not everybody wants to go into this arm of the profession, right? People want to do community nutrition or food service or people want to do a private practice or a lot of my former students wanted to be sports dieticians, right? You can do none of these things unless you have a solid background in clinical dietitian tests. You have to know how the body works. You have to know how to read a blood test. You have to know how to look into medications somebody is taking. Are there drug nutrient interactions? You really have to understand the person holistically before you can do anything. Thank you so much. And the next question is, you know how health approaches are always changing throughout the time. If there is anything that you would change right now about the health approach to cardiovascular use treatment, what would it be? I would educate children in elementary school about how to eat. Because I don't believe in diet. I don't like that word. I think if we were all taught how to eat and made it a priority to shop for fresh ingredients, to cook at home, to teach the family, the children and all the members how to participate and do all of these things, I don't think we would have cardiovascular disease. Thank you so much. All right. So, hi, Maria. Hi. How are you? I was going to ask the next question. I know you're in the hospital setting. So, I wanted to ask, do you think your treatment of focus on the cardiovascular patients changes when you're in the hospital setting versus being in a now patient setting? That is a good question. So, in the hospital setting, patients here are very sick, as you well know. So, they're also not in their home environment. So, they have limited food selections. And they're really – we kind of impose our will upon them, if you will. We put them on this diet. This is all we have to offer you. In an outpatient setting, it is more – basically, people can under-report what they do if you're looking, especially for cardiovascular disease, right? You'd want somebody to keep a food diary. Because do you remember everything you eat in a day? I know I don't, right? Or you might be watching TV and you're nibbling on a little something. So, when you have to write down everything you're eating and then go back and look at it, it really is quite eye-opening, right? So, in an outpatient setting, you get more of the luxury on having people look at, I think, portion sizes are a big problem in any disease state, right? Saturated fatty acids, because years ago – and I know this was one of your questions – we used to treat cardiovascular disease with a 2-gram sodium diet and a 300-milligram cholesterol diet. That was what we rubber-stamped everybody with. And honestly, we didn't even do fluid restrictions 20 years ago. We really didn't for cardiac patients. Now, the focus is more on saturated fatty acids and the LDL, right? The low-density lipoproteins, because we know that your LDL number is the single strongest indicator of cardiovascular disease, right? So, we try to look at that. Of course, we want everybody to increase their fruits, their vegetables, their nuts, their seeds, their lean proteins, their whole grains. So, as an outpatient, you might focus more on individual dietary components as opposed to an inpatient. You might give them dietary guidance on the Mediterranean diet, right? Because that wins consistently the best overall diet for health, for weight loss. They just did an analysis on 16 studies, and it was published in the Journal of Heart. Because you know, when they create these diets and they test them, it's done mostly on men. You see, I have a lot of women in front of me, right? So, what they did is the Journal of Heart, they looked at the Mediterranean diet as it relates to women. And what they found is if you follow this diet closely enough, it will decrease the risk of heart disease by 24% and decrease the risk of an early death by 23%. So, they looked at this through the eyes of women instead of men. Sorry, Armando. Well, you actually mentioned the Mediterranean diet, and I had a question that touched on that. Okay. So, yeah, I was going to ask if there are specific diets you recommend, because I know the Mediterranean diet is one of them. But I also have the DASH diet. I know about it, so I don't know if you're actually… And that specifically focuses on hypertension, right? And it does have two levels of sodium restriction. And if, you know, the lower the amount of sodium, the better control of the blood pressure. But all of these diets really share the same concept when it comes to food, right? So, no matter what you call it, it boils down to the same thing. And again, diet, I really don't like that word because we have to peacefully coexist with food for the rest of our life. A diet is not sustainable. It's just not. It is not a way to live your life. So, they all have the same concepts, really, right? Yeah, I know what that's going to mean. It's like eating healthy overall. It's more fresh. Prepare it. Do your own cooking, because then you control what goes in there, how it's prepared, and how much you eat. Right? It's not you're in a restaurant, and they're serving you this tremendous plate of food. Yeah, that's right. So, it's me again over here. I like when you're saying, like, it's not good in a diet for patients. But it sounds more like doing, like, behavior modifications. So, my question over here is, do you see the cardiovascular patients complying on the behavior change? Or do you see perceived on them? No, they're definitely resistant because, first of all, they're in a hospital. They're constantly being poked, prodded, woken up. And what is the one thing they can control? It's their food, right? And most of them get here because they are noncompliant, right? And when you talk about diet, if they're constantly told, follow this diet, follow this diet, follow this diet, and their health is getting worse and worse, you'd be like, okay, I'm following this diet, but my health is getting worse. So, why am I following this diet? And you have to understand the unit I work on is heart failure. Any organ failure, there is no cure. Failure is only going one way. So, once one of the organs fails, it's pretty typical to see other organs follow it. And then it becomes many, many dietary restrictions. And it really comes down to, well, you can't have this and you can't have that. So, I always, if I have to educate here and we don't do a lot of education here, it's always, well, tell me about a typical day what you might eat. Oh, well, that's good. You do that, you can keep doing that. It's always good to give them the positive first before you give the negative. All right. I see over here that you try many types of interventions with the patients. But tell us what has been the biggest challenge with the patient in the current unit you have? The biggest challenge I'd say with my patients is fluid restriction. Because when they're in the hospital, you want them to eat, right? So, we really try to liberalize the diet as much as we can. But with fluid, you can't really do that because you are causing problems medically for them. Shortness of breath, edema, they're carrying extra fluid. And that really causes a problem with us, right? How do we estimate protein and calorie needs on a patient that has fluid? They're holding fluid. That's not true weight. So, it really causes us as dieticians when we're doing an assessment, it does throw a lot of things off for us. And somebody with heart failure has a 1,000 milliliter restriction, that's only four cups of liquid. Think about only being allowed to drink four 8-ounce cups of liquids a day. Now, mind you, you have to save some of that liquid for taking your medication. Soup counts. Ice cream counts, right? So, anything that can be liquid at room temperature. So, now, we have a patient who's not eating and we say, okay, let's give you a supplement. What's a supplement? Most of them that we have here are liquids. So, it gets us into a real problem. And they want to, you know, we live in Miami. It's obvious. People want to drink fluids. So, it becomes, you know, and if they're sucking on ice cubes, but I'm only sucking on ice cubes, yes, but that's fluid. So, I'd say that's my biggest challenge is a fluid restriction. So, do you think, like, the MNT for that problem is just introducing different types of, for example, puddings or things like that? Or do you have any? Yes, I do. We do have puddings here, and I think that's great. And we also had a packet of nutrients for wound healing, pressure ulcers, because we see those a lot, too. In people that are in bed for a prolonged period of time. And we needed to give it twice a day for it to work, but it has to be reconstituted with eight ounces of fluid. So, I could never use that for my patients with wounds because it's fluid. So, now we had a lecture, and they have an unsavored packet, which we could now put in the pudding to help with wounds and give them some supplements. So, I'm a pretty happy camper about that. So, as a cardiovascular registered dietitian, what are the average ages or demographics of your patients? And has anything surprised you? And the number of clients, has anything surprised you about it? Actually, it's quite sad. Some of our patients are young. They're in their 40s and their 50s, where we typically shouldn't see that. But I've had patients up to 100, 101. So, it really does, it's a very wide span. I'd say nothing is a typical age because it really is a very wide age range. And I think it's pretty equally spread among males and females. Some days I could have all male patients, and some days I'm like, wow, all these females are here. Just think about it. Females outlive males. So, the older people that I see are a lot of females with heart failure, right? A lot of them. All my 100-year-olds, 99-something, most of them are females in the elderly years. Bad news for you again, Armando. I'm sorry. That's true. We live less than the women. All right. So, let's go to the next question, and it's about the comorbidities. So, do you see there's like common comorbidities with the cardiovascular disease? Yes. Like I said to you before, that typically when one organ fails, we'll see others going in conjunction with that. A lot of our patients do have diabetes, and they do tend to have renal failure, whether it becomes chronic renal failure or acute renal failure. We often see the kidneys go down, too. So, it would be cardiac, it would be diabetes, the pancreas, the kidneys. Sometimes in addition to that, we see the lungs with COPD. So, yes, a wide range of other organs do tend to fail. Hi, my name is Rebecca. Hi. Hi, Rebecca. So, in nutrition education, we mostly talk about like sodium and like its relationship to the cardiovascular and its association with fluid, as you said. So, when you're assessing a patient that's just been admitted, what do you look for in his or her recall of their food? Do you look for like high-sodium food or...? Most of the time, we're not doing a very complete food recall here. Typically, in an outpatient setting, you would do that. Here, you know, you might ask them, what would you eat on a typical day? However, we see very, very ill patients, you know, and you would ask them, what do you eat? Have you ever been educated on this? Do you follow any special diet at home? Have you ever been educated on it? If you have, who did the education? Because recently, we started a program here. We're taking FIU students from the medical school. They're fourth-year medical students, and they have the opportunity to take an elective in clinical nutrition. And so, I asked them, how much nutrition do you get? Two lectures in the first semester. So, if educating a patient, what are they telling them? So, do we have to correct the wrong of what they do? And typically, what I see is they don't cook for themselves. They're eating processed foods. You know, we're all busy. They're working. They don't have the time. Maybe they don't have the financial resources. But a lot of it is coming from processed foods, restaurant foods, and just the American way to eat. That's true. I know most individuals find it hard to, like, follow, like, our healthy diet. They probably think of, like, the marketing strategies as of, like, oh, if it's not organic, it's not good for you. Frozen is... That's not true. Yes. So, your job is to change that perception, right? Because you have to know your audience, right? Psychologically, you have to know who you're speaking to. Do they live alone? How old are they? Do they prepare their own food? Are they retired? Or, you know, maybe they were laid off from the job. There are ways to get in good nutrients. Frozen vegetables can be fine. Beans from a can, again, can be fine if they're rinsed. There are very simple ways to get somebody to consume nutrient-dense foods. You just have to know socioeconomically. You know, you have to change their perception of that. Because, again, we don't have any regulations on what's organic, what's not. I don't think you have to eat organic to be healthy. I agree. I agree. There's most people, like, there are people, there's this trend going around about keto and also calo, and how it differs from heart-healthy. So, like, how would you say those diets impact heart health for those people? Well, paleo, keto, things like that. Well, if you look at the paleo diet, it's really a copy of a heart-healthy diet. Right? Because paleo says don't have processed foods, don't have high-sugar foods, don't have artificial sweetener, nothing with trans fats. Isn't that the dietary guidelines for Americans that they're telling? Yes. Right? Increase your fruits and vegetables, nuts and seeds, we need fish, omega-3s, your vegetable oils. But what they say that's not great is limit your grains, your dairy, and your legumes. Well, they're nutrient-dense foods. What are you talking about? You know, like, really? The ketogenic diet don't even get me started on this. Years ago, we taught that as a treatment for epilepsy. Okay? And that was only meant for epilepsy that would not respond to medication. It was very specific. And it was only supposed to be used for two years for that disease process. So they're prioritizing fat, right? And when we're talking about prioritizing fat, that's about 45% of the diet coming from fat. It has tons of side effects. It can lower your blood pressure, can increase your heart disease risk, cause constipation. None of the things we want to see as nutrition professionals. It also causes nutrient deficiencies. Magnesium, phosphorus, B vitamins, C, selenium, because it increases the excretion of these vitamins, and you're having a decrease in consumption. I don't really, I'm not a fan of anything being used for weight loss, because what happens when you start eating, again, normal portions of food? What's going to happen? Three days. You know, so, I mean, somebody will just take something and run with it. Years ago, it was a cabbage soup diet. You just eat nothing but cabbage soup. Dr. Atkins got very rich, too, with another high-fat and protein and carbohydrate restriction. Balance, moderation, and what balance looks like to people is different. You just can't restrict. Focusing on one nutrient is just not a good approach. We need it all. All right. So, moving away from all the diets, I actually wanted to ask about supplementation. I know Omega-3 is one of the examples that we always talk about, but I want to see if there was any other supplements that you actually recommend to your patients. I do not. I stay away from supplements, because they're not regulated by the FDA, so we don't know purity, dosage, the origin of them, right? Your body likes food best, because the nutrients are more bioavailable to your body. I just think it's wrong to prescribe supplements to people. I do. That's my personal opinion. You know, okay, if you have osteoporosis, yes, it's a good idea to take some vitamin D. Calcium, there's been studies on that. Does it cause heart attacks? And actually, the Academy, which gives us our license, did come out in 2012, and they shot that down and said you could take it. Again, you know, you can find literature on these things for both sides of the argument, right? Food is always best. Now, what if somebody can't take it in? Could they take some supplementation, vitamins, minerals, a multi? Yeah, I'd be okay with that, but all of these CoQ10, Omega-3s, what do they take, too? Milk thistle for the liver. I mean, none of these things were ever studied. There was, in Germany in 1978, there was a Commission E. They were the only people, really, worldwide that would study these. But they're out of business. So, you know, nobody really looks at this. You know, there are a lot of medications in this world. Just look at grapefruit, for example, citrus products. They interact with 60% of all prescribed medications. So you're going to start throwing some supplements, just advising people to take them. How do you know what other kind of medications they're taking and what the interaction would be? I just really don't think we know enough about that to just start throwing blanket recommendations out there. Well, I think oxygen really makes sense. Yeah. Thank you. No. I'll do my job, right? Tell Dana and Mary, keep her there. Do you take supplements on your own? Like, are you completely aware of them? Do I? Yes. I was recently diagnosed with osteoporosis. So, I do indeed. That's something I guess we probably have in common. I was diagnosed a couple of years ago. So every article I can come across, I try to commit to memory. And like you said, the studies are mixed. Is 1,200 too much? Is 750 safe as far as supplementation? And I have a dairy allergy and lactose intolerance. I have a double whammy. So all the plant-based foods I can get in. Right. What I've been reading is geared that plants are extremely beneficial and haven't given enough credit. And I'm so off topic, and I'm sorry. That's okay. No, but you know what, too? I also think, okay, so you have these recommendations. Half the dose from supplements and split the dose morning and night. I think that's reasonable. Yeah. Well, I've been, and I'm so sorry. We're going to hijack your podcast, guys. Just because of upset stomach, I do take it in very small doses throughout the day. But at the end of the day, it is mostly from mineral water, from almond milk or a plant-based yogurt that has calcium fortified. And then I'll pop in a little, if needed, a little bit of calcium. But I wish I could talk to you all day about this. They can give you my contact info. You can talk to me anytime. Just to steer the bus back around, you've touched on it already. I think we know the answer. But just to sum it up for us and our audience, what's the best advice you could give someone to avoid being a cardiovascular patient? Stop for yourself. Fresh. Cook for yourself. Learn to use herbs to season your foods. Because even if you think you're doing yourself a favor and using salt substitutes, they have potassium. And that cannot be your friend, too. Fresh is always best. Cook. Okay. And in general, for the audience members who are future dieticians, what's the best piece of advice you could give for us, please? What can I? Keep an open mind. If you think you might want to have your career go in one direction, don't be set on that. Don't be afraid to try everything. This is a very broad profession. And I think you might be surprised at what you would like and maybe would like to continue with. So just keep an open mind and just try everything. All right. Thank you so much for joining us, and have a great day. Thank you so much. All right. Hey, guys, I'm teaching next Tuesday. It's May. ♪♪