Registered dietitian Amanda Kirpitch touches on the challenges of decreased appetite, access to food, what to eat when recovering, diabetes management, how to find a nutrition therapist, and why you absolutely need to stay hydrated.
[JUDITH MEER, HOST] Hello, everyone, I am very excited to have with me here today Amanda Kirpitch, a registered dietitian and diabetes care and education specialist. Amanda, thank you so much for joining me today. Really appreciate it.
[AMANDA KIRPITCH] Thanks, Judith. I'm so excited to be here chatting with you.
[MEER] So let's dive in! As a physical therapist, I look at health through the movement -- through the lens of movement and physical activity, physical fitness. And I know that how we're feeling and how we're fueling ourselves also absolutely impacts our ability or our desire to move. You have almost 20 years of experience as a registered dietician and working with folks dealing with diet and nutrition issues. Can you talk a bit about how and why a hospital state might impact or cause changes to someone's appetite?
[KIRPITCH] Sure, yeah. So appetite regulation and deregulation is actually a fairly complex issue. And we do know that it may be pro-inflammatory, and what that can do is impact the regulatory centers in the brain.
So there are quite a few factors in the hospital stay that would be impacting appetite. So you're looking at things that, you know, from a pro-inflammatory state, you're looking at the disease process itself. So whatever landed somebody in the hospital could potentially be hurting their appetite. You're also looking at the multitude of medications and treatments that someone may have undergone. And so, many medications can actually cause decreased motility, which can actually increase, nausea can increase, you know, appetite changes, just not really wanting to put more food into the body. Being in a sedentary state, so being in a bed can also cause decreased motility, and so similarly impacting that appetite change.
And then certainly hospital food! So people don't always have access to their usual favorites or even their usual intake and so, finding ways to improve the palette, palette, palatability of food can be an issue for hospital patients. And so all of these factors are sort of complex and interplay into each other and cause a lot of issues in terms of appetite regulation. And what we need to do is kind of, you know, when someone comes into the hospital, we first want to treat the acute cause of whatever the reason is that they may be there. And so nutrition is important as it is, is often managed with IV fluids and some dextrose, and so it doesn't come until a few days into the hospital stay that we really start to address the nutrition needs, as we can get by with fluid intake for a few days. And so that can also cause patients to have some decreased appetite because they haven't been eating for a few days.
[MEER] You spoke a little bit about the word motility earlier and you mentioned a couple of times that that might impact someone's desire or their appetite. Could you just explain for everyone in case they haven't heard that word before, or they're not really sure what it means, what that is? What is gut motility?
[KIRPITCH] Yeah, so that's the speed at which food is traveling through our GI tract, our gastro intestinal tract. So stomach, to colon, to all the way through. And so when we use some medications, particularly pain medications, which in the case of a hospitalized patient, pain medications are usually used, those medications actually slow down that whole process. And so the food is not traveling as quickly through the body as it may normally. And so when you have that, there's more food sitting in the stomach for a longer period of time, which obviously can make us feel just a little bit more full, a little bit more uncomfortable. And so that can actually impact appetite.
[MEER] Thanks for clarifying that, and as a physical therapist who focuses a lot on pelvic issues, that is something I'm really excited that you touched on because I absolutely speak to my patients about how we improve their gut motility, how we help things, like how we address things like chronic constipation. I'm going to make sure to include some resources for that, because we certainly don't want people coming home after having a lot of sedatives or medications that may have kind of stopped them up. And you know, we know some great techniques from a physical therapy standpoint that can help people with that. So I'm really excited that you mentioned that.
[MEER] So, Amanda, let's say that someone's home from the hospital. Thank goodness they came back, we're relieved to have our loved ones back with us. But maybe I realize, or or my, my spouse, or my partner or whoever is at home with me, my caregiver, realizes I'm not taking in enough food anymore, that appetite really hasn't come back. How do I get it back? Are there certain foods or food groups that I should focus on or that I should avoid? Once I've had this, any sort of illness but obviously, particularly in speaking about COVID-19 right now is their stuff that we know is better for healing. What would you have to say about that?
[KIRPITCH] Yeah, so all of it is really important. And that really, once someone gets home, nutrition is where we can really make a difference. And so the most important thing is: nourish. And I think, you know, I've talked to a lot of people about this over the last couple of weeks in general. But I think when we get caught up in all the details, we forget that the most important thing is food. We need to get food, and whatever way we can do that is the best way. And so we're in a time where this is completely unprecedented, and I think, you know, getting caught up in "Am I doing the absolute best thing" versus "Am I doing the best thing that I can right now" is really, really important. And so, when we talk about appetite, we can look at it from a variety of scopes.
So basically, what you're looking at is: Can someone get anything in, like, are they able to comfortably eat foods, chew solid food, feel comfortable with that? If not, we're use something liquid. So there is the potential to go with something as simple as a shake. There's, you know, the more formulated products that are more medical based, like Ensure, Boost, a number of other products on the market along those lines. And then there's things as simple as like Muscle Milk and shakes that are over the counter that you can easily get and even the Ensures, you know, go to the pharmacy and pick something up. But what's nice about products that are like this is that they have a mixture of both macronutrients, which are foods we're familiar with: so proteins, fats, carbohydrates. But then they also pick up all the micronutrients, and those are things like your vitamins and your minerals. And all of that is so important for healing. And so what we want to be thinking about is the combination of all of those nutrients is actually going to allow us to get everything we need in a time where eating solid food, accessing solid food, accessing, you know, a multitude of variety of ingredients, these can kind of fill in the gaps or they can provide the entire nutrition, depending on where someone is at with what they can take in.
The other things you really want to be thinking about are probably smaller meals more frequently. Because again, if the stomach is kind of getting filled up really quickly and things aren't moving quite as fast, eating a smaller amount more often gives you the opportunity to get enough nutrition without having it feel super uncomfortable. And then you know, what do people like to eat? So, I'm always 100% on board with what is your favorite food, what is something that you think is going to be appealing to you right now, because that is what you're most likely going to consume enough of. And so just as much as possible getting food in the house that you know is comfort food or comfortable, or you know, something that feels satisfying in the moment, because those are how we're going to get our nutrition.
And then certainly from a healing perspective, you want to get, like I said, the protein and the the vitamins and minerals that you need. So if we are using food, as opposed to a supplement, then you want be thinking about protein sources like animal protein, so eggs, meat, fish, chicken, or vegetarian protein sources. So it's totally fine if what's available right now is beans and lentils, tofu and cheese and eggs, whatever you can kind of fit into the grocery cart is what will work. And so that protein can help with healing. And then fruits and vegetables, in any form. So we'll talk a bit more about that, I think, but really just trying to get as much variety as you can, as much of what you enjoy, and then kind of fill in the gaps with some liquid supplements as needed.
[MEER] Amanda, I love what you said about how comfort food, if that's what someone's gonna eat, that food itself is more important than just the very best, and it's sometimes, I think we can get a little bit derailed thinking about I have to eat exactly the best, most organic, or only I don't know, kale and —
[KIRPITCH] everything, like all the details, I think we need to drop the details right now. Because there's, you know, arguments for probably where the details are more or less important. But right now the importance is getting nutrition. And that comes in food.
[MEER] And you and I had talked about how emotion impacts, impacts diet as well, how we're feeling impacts what we want to put into our bodies. And I want to talk a little bit about that, but also in the scope of COVID-19. Because what we've been seeing is that for some folks, even if they may have not had an extended hospital stay, the disease may have impacted them with a loss of taste or smell. And I'd be curious to hear from you how that loss of taste or smell impacts someone's someone's appetite.
[KIRPITCH] Yeah, so one thing people don't really realize is that about 75 to 95% of our taste comes from our smell. And so when we lose that, we lose our ability to taste food which is a lot of what, what triggers our appetite. So in terms of like what makes us crave a certain food or you know, desire a certain nutrient is the taste, and ultimately the smell. And so when we lose that it becomes harder to enjoy food.
And if we're not enjoying it as much as we want to eat, it may be difficult to get enough nutrition. And so the ways that you can kind of work through that are to sometimes buy foods with stronger tastes and smells. So something that's more acidic or something that has a stronger smell may be more appealing. And again, for some people, the, you know, comfort food, what was familiar from before what is enjoyable, maybe it's the temperature of the food which isn't affected by the smell, that's going to be comforting to you. But trying to navigate, you know, what you can get in, what you can sort of, we don't really want to say force food, but you have to recognize that nutrition is what you need, and not just go with your appetite which may down at this time.
[MEER] Amanda, that was really interesting. I had no idea that 75 to 95% of our taste comes from from our smell, that was really interesting. I wanted to ask you, you have extensive experience working with folks who have diabetes and your impressive credentials include having worked for the Joslin Diabetes Center, which is the world's largest Diabetes Research Center, I believe. We know at this point that having diabetes or some other pre-existing conditions means that someone is at a greater risk of complications from COVID-19. I was wondering if you can talk a little bit based on your expertise, why diabetes might put someone at more risk?
[KIRPITCH] Yeah, I'd love to talk about this. I get this question quite a bit. And so really what we're looking at is when people with diabetes, and really anyone when they get an infection or they get a cold or they get any sort of virus, or any sort of illness, our blood sugars rise in an effort to attempt to treat or to fight that virus. And so in people with diabetes, obviously, if their blood glucose is rising, we need to be managing that with medication. And so, or their own insulin, which often isn't available.
And so what I've really been focusing on with people is making sure that they understand where their current level of glucose is. And if they are getting sick to be checking and monitoring that more frequently, so that they can catch a higher blood glucose level or a higher sugar level and notify their doctors, so that they can get ahead of this so that their glucose levels come into range, so that they're better able to fight the infection.
When that does not happen, so the risk is that when these blood sugars rise, with a patient with an infection, they're at risk for going into very high blood sugars, so at risk for something called diabetic ketoacidosis, which basically means the blood glucose levels rise so high that the body then no longer can do some of its other metabolic functions, and can get patients very sick. If that were to happen, the patients have a very high risk of life threatening complications and so, in conjunction with an already fairly complicated illness like COVID-19. So what we want to do is make sure that patients are getting adequate management early on, so that diabetes doesn't become an additional thing that we're trying to manage alongside this virus.
What that also can mean is that if the blood glucose levels are high, it puts patients at higher risk for infection. And so not only can they get secondary complications, and we're trying to manage these blood glucose levels, but they are having to manage secondary infections. And so if someone were to develop a sore, or some sort of infection in their leg or something like that, while they're laying in a hospital bed, that's going to be harder to heal with higher blood glucose levels. And so the other thing that has come about is obviously when patients are in the hospital, there has been a push for patients to become more self-advocating for themselves. And so one of the things that is so important is checking these blood sugar levels more frequently. And that's difficult to do with our current environment in the hospital where the staff can't be coming in so frequently.
And so one of the things that has been suggested is that patients have sort of a care kit ready to go if they were to be admitted to the hospital with a meter that they could self check their blood glucose levels on. The other thing that has been in high utilization, or is something called a continuous glucose monitor. So those are available to patients at this time, you know, obviously through insurance and such, but it's a tool that a lot of patients are using. And now these are becoming a frequently used method of monitoring glucose in the hospital and actually some of the companies that develop these products are providing these to hospitals around the country to help monitor glucose more efficiently. One of the values of these devices is that it's continuous, as described, so it's monitoring the blood glucose much more frequently anywhere from every five minutes to every 15 minutes. But these levels can be managed remotely. So it doesn't require the staff to be exposed to the patient to know what's going on with those blood glucose levels, which allows us to manage it so much more efficiently. So all of that, but the key really is that the patient and the providers are really on top of these glucose levels. And if we can do that, then the risk and the risk for complications hopefully is diminished.
[MEER] Amanda, I love that you touched upon both how patients should should prepare if they may be going into the hospital, as well as what what their hospital experience might be, why they may have complications like bedsores that aren't healing from being on extended bedrest or or also that they should be monitoring more closely at home because of that added risk of of infection and the difficulty or the the added challenge of fighting off illnesses or infections as they as they arise.
Have you been seeing in the in the folks that you've been working with any challenges they're facing right now? I know that for certain medications that are in high demand at the moment, there are types of patients that can't get easy access to those or unfortunately, with the job loss that's happening right now, folks are losing access to health insurance and potentially, like you said, some of these, these resources are covered by insurance, but someone may no longer have access to those. Are you seeing any particular challenges on the ground as someone who's working with folks everyday dealing with these issues?
[KIRPITCH] Yeah, so as you know, I'm sure there have always been challenges with adequately accessing diabetes medications and any medications with our health care, but certainly that has gone up in recent times. There are many things in place to sort of help these patients because many of these medications are life saving and necessary. And so what has, you know, sort of been helpful if some of the companies that produce these products are offering solutions for patients that are without coverage.
I've been encouraging patients to make sure they have adequate supply to make sure that they're, you know, stocking three months instead of one month, if possible, just so that if things are extended, they are, you know, have the resources they need. The other thing that's been happening is there is legislation happening around the country to allow for better coverage of medications, particularly insulin for patients. And so states are starting to impact it to regulate how what the highest cost would be for a patient out of pocket to afford these medications. But certainly in the times of COVID there are additional pieces of legislation and help from pharmaceutical companies to help patients better access what they need.
[MEER] I want to change tacks just a little bit and ask about the fact that we've all been inundated with these images of empty supermarket aisles and people who are panic buying and just, it's not just toilet paper, they're getting all the canned goods or all the frozen goods, or all of this. As more factories closed down, as we're seeing some food delivery supply chain starting to get impacted with the continued spread of the virus, do you have any thoughts on foods types of foods that people should focus on shopping for or storing? And you know, obviously don't want to encourage people to go out and panic buy and get everything, we need to make sure there's food on the shelves for everyone and we really are in this together and in it for the long haul. But as, from a nutritional standpoint, do we prefer people to eat frozen foods or canned foods? Does it really matter? I know you said any food is good food as long as you're getting into your body and we're looking for those macro and micronutrients, right? But from your perspective, do you have any thoughts on on that?
[KIRPITCH] Yeah. Um, so it's been complicated. Food hasn't been as easy to come by and the way that we are accessing our food have become different. So some people are not going out to the stores and are only accessing food by delivery. Some people are going to stores and you know, the resources that are available at the time that they're able to go are not the usual levels of stock. So it is important, like I said before, you're right, food is what's important, getting enough food is the first step, and once you've got that down, if you have access to think about the additional factors like do you have a protein source? So what are you using for that? Do you have some fruits and vegetables? What are you using for that and do you have some carbohydrates and fat and how are we navigating that.
The fresh, frozen, canned, all of that -- actually all healthy. I think that is one of the things we're learning through this as people are starting to experiment with more, with different items than they may have been using in the past. They're, the fresh produce, if it's available is still perfectly safe. You can rinse it with water and scrub, you know outer skins, but it is safe to consume fresh produce. The cans and the frozen items are going to keep longer. And so if you're stocking up, you're going to want to utilize those resources to have a pantry that's stocked full of stuff in case you are having trouble accessing food throughout this situation. And so if you know if you can find canned items that contain a little less salt or you can rinse the canned items before you use them if salt is a concern for you. Oftentimes, what we forget about canned and frozen items, is they're actually taken right from the field and flash frozen or placed into the cans right away so that food is actually a little more nutrient dense than our fresh food that may have traveled halfway around the world before arriving in our supermarkets.
Certainly today, I think a lot of people are starting to access in different parts of the world as the season warms up some of the local produce. And so certainly supporting local suppliers as much as you can, who are also struggling during this time is important, but I think, you know, food with skin, so citrus fruits, bananas -- bananas don't tend to keep as long but citrus fruits tend to keep a little bit longer. Potatoes, winter squashes, summer squashes tend to last a little bit longer than maybe some salad greens. So those would be things that you could stack up a little heavier on, so that you could get potentially. Most people are trying to get two to three weeks of groceries in the house at a time and so they're not going to the supermarket quite as frequently as they were. But canned beans, canned tomatoes, make delicious soup, stews, you know, kind of cooking in bulk, because it's a lot of work as well and I think a lot of people are experiencing the taxing nature of having to cook three full meals a day for their families, and homeschool, and you know do their jobs and so you know the most you can do to make meal prep simple and kind of bulk it up so that you have these resources to make meals that are reasonably healthy to get through this is really important.
[MEER] And if someone feels like they might need a bit more guidance in terms of their eating habits right now either because they have some sort of medical condition that they're they're struggling in terms of their the access they have food to right now to make sure that they're they're doing right by their body and their health or if they just are a little bit lost because yeah, they used to get better food from takeout or you know, ordering things that may not be an option right now as money and food may be scarce in in some parts of the of the country, or for some folks right now. I've come across the term nutrition therapy and you know, I'm a physical therapist I've spoken as part of this, this series to psychologists as therapists as well, could you explain what a nutrition therapist is? And if someone feels like they might need some more guidance, where would they find these folks? And what sort of certifications or qualifications would be would we be looking for to know that we're in good hands if we're going to take that leap and learn from someone a bit about how to best nourish ourselves and get some some quality, evidence based guidance?
[KIRPITCH] Yeah, um sure. So nutrition therapy is actually part of the term known as medical nutrition therapy and really is a term that describes evidence-based treatment, often following a extensive individualized nutrition evaluation, and really based, primarily used for treating chronic disease, chronic or acute care diseases. So really, the guides of medical nutrition therapy is to help patients navigate nutrition in a reasonable and evidence-based way to manage a chronic condition, or in this case, an acute condition. It is provided by a registered dietitian. And so that is a professional who has a four year undergraduate degree combined with a year long internship and then has passed a qualifying examination.
What it often get sort of confused with is that there are plenty of nutrition professionals as well. And many of them are also qualified, also have a fair amount of, you know, some training, but they are not qualified to provide medical nutrition therapy. And so that's really the distinction. And so certainly, if you're looking for something that's evidence based and dealing with disease management, you really want to be looking for a registered dietician. If you're looking more for just a coach than a nutrition professional, that is not a registered dietitian, may be a reasonable way to go. But if you're looking for something that has a little bit more qualified, evidence-based expertise, then that really is the way you want to go.
You can also, especially if you're looking for specific diseases, I think it's important to potentially look for somebody who has experience in that particular field. So whether it be a certified Diabetes Care and Education Specialist, or be somebody who has a specialist in, a specialized kidney certification, or somebody who specializes in oncology, certainly I don't want to be, you know, as a Diabetes Care and Education Specialist, that's really my specialty. I don't want to be in the hospital providing TPN, or IV nutrition to patients at this point, and nor would you want to be that. But if you're in a hospital, the professionals that you're going to be working with are going to be registered dietitians. So those are the professionals that you come across in that scope. And the way you would find a registered dietician to work with is looking for those credentials, so it's going to have an RD or an RDN following their name and a great place to look for that is the website for the Academy of Nutrition and Dietetics, which is eatright.org And you can find a nutrition professional on that site as well.
[MEER] That was really helpful to know Amanda about the nutrition therapy and where we could find those folks if we need a little bit more guidance, I'm going to make sure that we include that in the resources section on the website. I know that you have to get back to your patients. Do you have anything else to add before I let you go today?
[KIRPITCH] Yeah, I think the only thing that we didn't really touch on would be hydration. It actually is super important that we stay hydrated throughout all of this, particularly if you're ill. And we want to make sure we're flushing out the system, making sure, it also helps with constipation to make sure that you're super well hydrated. That's just going to move things along that much better. Also, if the blood pressure is a little bit low, you've been sitting in bed, just keeping that hydration going is going to be super critical. So even when I was talking about when you're in the hospital, those first few days we may not focus so much on the food nutrition, but we are making sure that we're keeping patients hydrated. So that is just so, so critical. And so especially if blood sugars are high, it's not that they'll actually bring the blood sugars down, but you do get more dehydrated, when your blood sugars are higher. And so it's really important across the board to find good sources of hydration. Obviously water is available and one of the best things that you can do to hydrate but really anything you can find to make sure you're staying well hydrated is really critical.
[MEER] Alright, so we're gonna make sure we're drinking water or any fluid that we can find that is a good source of hydration for the body. Amanda, thank you so much. I really appreciate you take the time today. Be well, stay safe and all the best. Thanks for all the brilliant insights that you provided everybody today.
[KIRPITCH] Yeah, this was great. Thanks.
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