Ace your LTC/Clinical Rotation

I am a RDN with over 25 years of experience in LTC. Over the past few years, I have been working with students as a preceptor. This led me to create four nutrition presentations that have proven to be helpful to student dietitians and diet technicians. In fact, I have recently updated the videos as a result of some feedback from over 200 students. One had commented, “I wished I had seen your videos at the start of my internship.” In addition, I have written an e-Book that students can purchase for practical information on completing nutrition assessments. Sample patients are included. Overall, these resources are designed to give the student practical advice on how to complete nutrition assessments and plans based on current nutrition scientific evidence.

Shine Light on Vitamin D

Written by Stephanie Alvarez, Student Dietitian

The sun has always symbolized Vitamin D. Also known as the Sunshine Vitamin, it stands out to be the only nutrient in the vitamin world chemically produced by humans. Vitamin D comes in two major forms – Vitamin D2 (ergocalciferol) and Vitamin D3 (cholecalciferol). Vitamin D2 is primarily found in plant based and fortified foods. Vitamin D3 is synthesized by our skin when exposed to UV-B rays, and found in animal foods, such as egg yolk, liver, and oily fish. Commercial supplements of vitamin D contain either form.1 These compounds are similar in function, but slightly differ in chemical structure. Although called a vitamin, it is more accurate to identify vitamin D as a prohormone. After dermal synthesis from the sun’s UV-B rays, our liver and kidneys convert vitamin D to its active hormone form – calcitriol, a compound similar in chemical structure to that of hormones. Once available, calcitriol aids in calcium and phosphorus absorption. Increasing and maintaining these levels is critical for bone growth and health. Research has found other vitamin D receptors (VDR) in the cell membranes of the immune system, brain, heart and muscle suggesting it plays multiple roles in human health. Multiple studies have concluded vitamin D may play a role in fighting infections, supporting muscular function, preventing the development of cancer, and reducing the risk of autoimmune disorders, such as diabetes or multiple sclerosis (MS).2

Because of its nature, dietitians among other professionalsrealize achieving adequate levels is a challenge. Reports indicate that vitaminD deficiency and insufficiency affect about 1 billion people worldwide.High-risk groups of vitamin D deficiency include age, pregnant women, breastfedinfants, dark skin color people, and those who live in latitudes greater than37° during the winter months when UV-B rays are poor. 3 The classicexample of vitamin D deficiency is rickets. Most commonly diagnosed inchildren, rickets occurs due to an insufficient mineralization of growing bone.This deficiency is characterized by skeletal deformities in the lower limbs. Otherdeficiencies that may result with low vitamin D levels are osteomalacia and anincrease risk of fractures.

The Dietary Reference Intake for those from 1-70 is 600 IU to promote good bone health.4,5 Dietitians and other health professionals should recommend that clients meet their Vitamin D goals by eating food high in Vitamin D such as fortified milk, other dairy products and egg yolks with supplementation, if blood VItamin D level is below normal limits. In terms of sun exposure, 10-15 minutes of midday sun is recommended, however, the amount depends on age, skin pigmentation, season, and clothing.6 The goal is for health professionals to identify those at risk and come up with an individual plan to promote optimal Vitamin D levels.

  1. Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Caclium And Vitamin D. Washing (DC): National Academies Press (US); 2011. 3, Overview of Vitamin D. Available from:
  2. CPE Monthly: Vitamin D – Today’s Dietitian Magazine. Today’s Dietitian. Accessed May 17, 2019.
  3. Pfotenhauer KM, Shubrook JH. Vitamin D Deficiency, Its Role in Health and Disease, and Current Supplementation Recommendations. Journal of the Osteopathic Association. 2017;117(5):301-305. doi:10.7556/jaoa.2017.055.
  4. National Institute of Health.  Vitamin D. Accessed May 30, 2019
  5. Accessed May 17, 2019.
  6. Skin Cancer Foundation. Sun Protection AND Vitamin D – Accessed May 17, 2019.

Nutrition counseling for those on Warfarin

Working in long-term care, I often get questions about what foods to avoid when using the medication, Warfarin, also called Coumadin.  People report that they are told to stay away from foods that are high in Vitamin K.  Some also have questioned whether or not they could have leafy greens and cranberry juice. According to the Academy of Nutrition and Dietetics, the target should be to have a stable Vitamin K intake.1 A brief was conducted by Leblanc and colleagues who looked at three hundred and seventeen patients, classifying them to three groups, depending on what they were told to do when placed on Warfarin.  The groups were: Limit or avoid vitamin K-rich foods, aim for a stable Vitamin K intake or no Vitamin K-related advice. The results were:

  • 68% were told to limit or avoid vitamin K-rich foods
  • 10% reported that they were instructed to have a stable Vitamin K intake
  • 22% did note recall receiving any Vitamin-K related advice

Overall, most warfarin users reported avoiding Vitamin K-rich foods, which has caused them to have a lower than usual Vitamin K intake.1 In a different study, Li et al reported that having 250 mL of cranberry juice daily did not have any significant interactions with warfarin.2 The Academy of Nutrition and Dietetics also cautions Warfarin users to avoid herbal supplements, vitamin E and fish oil supplements as not much is known about the interactions between these items and the drug.1

Many are avoiding green vegetables and cranberry juice and this has raised the question as to whether or not there is a need for better nutrition counseling.   The researchers recommend that more studies be conducted, focusing on effective counseling strategies utilizing evidence-based Vitamin K recommendations.2 Until then, RDNs should recommend maintaining a stable Vitamin K intake and avoiding vitamin E, fish oil and herbal supplements.

1) Academy of Nutrition and Dietetics. Vitamin K and Coumadin. (eatrightPro subscription required) Accessed 5/26/2019

2) Leblanc C, Dube MP, Presse N, et al. Avoidance of vitamin K-rich foods is common among warfarin users and translates into lower than usual vitamin K intakes. J Acad Nutr Diet. 2016; 116(6):1000-1007.

3) Li Z, Seeram NP, Carpenter CL, Thames G, Minutti C, Bowerman S. Cranberry does not affect prothrombin time in male subjects on warfarin. J Am Diet Assoc. 2006;106:2057-2061. 


Dementia Mealtime Assessment Tool

Kara Lydon

The Foodie Dietitian

Soulful Nutrition

Soulful and Spirit Filled

About a dietitian

My journey and experiences, to help your journey. For the aspiring or accomplished Registered Dietitian.

helping you feel energized with crohn's & ulcerative colitis through nutrition

The Secret Ingredient

The Inside Scoop on All Things Lose It!

NutritionConfidence Blog

Powered by ADSA (Association for Dietetics in South Africa)

Offbeat, unusual, unconventional & interesting career interviews

Research Your Future - Strategic Career Planning for Schools & Colleges

RN Soul

Thoughts and stories of failures, successes, school and life of a registered nurse

Web Dietitian

Debunking myths and uncovering the truth on food and nutrition by a Registered Dietitian

Afshan Hussain

Discovering Myself!

Fox Valley Nutrition Consulting

Nutrition consultations from a registered dietitian

Dietitian Mentor

A site for practical nutrition information for student dietitians, DTRs and RDNs...featuring guest blogs from students or RDNs who would like to gain writing experience.

Healthy Eating on a Budget

Eating healthy no longer means your family has to go broke.

Vegetarian Eating: Delicious and Nutritious

Live well, eat clean, go vegetarian!