Thursday, January 19, 2017

Pediatric Symposium 2017

The dietitians at Children’s National Medical Center know first-hand that big challenges can come in small packages. The University of Maryland Dietetic Interns were given an opportunity to learn this and more at the Children's National Pediatric Nutrition Symposium. The Symposium consisted of a series of lectures presented by the dietitians of Children’s National. The symposium began with the basics of pediatric nutrition care. As the day progressed, the lectures moved on to more specific disease states, such as cystic fibrosis and gastrointestinal disorders. The day ended with breakout sessions on neonatal intensive care, pediatric critical care, and inborn errors of metabolism.

A common theme that appeared during the disease lectures was monitoring the patient’s development on a growth chart. Abnormally low growth chart readings are typically indicative of malnutrition caused by a worsening disease state. With many of these issues, getting enough calories and protein to prevent further loss of lean body mass is critical. The dietitians at Children’s National use creative methods to boost calories in their patients’ meals, such as adding olive oil into dishes or an extra scoop of ice cream into their patient’s supplement shake. These methods may seem to go against the conventional view of dietitians as weight loss coaches; however, they are incredibly important to pediatric care as an imbalance in marco or micronutrients can result in dire consequences.
Dietetic Interns before the start of the symposium
What stood out to me the most from the symposium was the way the dietitians described their work. In a morbid area that sports high levels of burnout, the dietitians of Children’s National Medical Center displayed passion and excitement as they described their experiences with pediatric patients. Nothing but positivity could be found in their body language and their speech throughout the series of lectures. They know they are truly making a difference in so many lives through their work. I believe I speak on behalf of all the interns when I say that the Pediatric Symposium has left me eagerly awaiting my 2 week rotation at Children’s National.

Friday, January 13, 2017

Establishing A Healthier Workplace: Welcome to Wellness Corporate Solutions

Anyone who knows me knows I’m interested in a nontraditional life as a Registered Dietitian. Nutrition is important to me, and fitness is as well. I found out about corporate wellness through my Director, and she gave me the opportunity to experience it firsthand as one of my technology rotations! I just finished my 5-week rotation at Wellness Corporate Solutions (WCS) in Bethesda, MD, and I loved it!

But wait -- what is Wellness Corporate Solutions?
Wellness Corporate Solutions is a state-of-the-art provider of biometric screening services and comprehensive wellness programming. They create customized, high-touch programming that emphasizes health education and promotes lasting behavior change.

What's it like?
When you walk in, the first thing you notice is the white infrastructure highlighted with bright green and blue. The colors pop, the atmosphere is friendly, and the stairs are high. This workplace is really practicing what they preach, complete with treadmill desks, standing desks, and exercise equipment. You don’t just work at WCS -- you walk, squat, lunge, and stretch, too.  WCS encourages their employees to be active at work by wearing workout gear. They have step challenges, salad Fridays, and yoga breaks.

What do Registered Dietitians do there?
Registered Dietitians (RDs) play an essential role in coaching participants to adopt healthy habits that work for them. RDs understand that everyone is different.  They work hard to help the coaching participant create their own unique goals that are specific, measurable, and attainable. The health coaches typically have 30 minute sessions with their participants where they provide support and accountability without pressuring their participants to fit into any one mold. They also write blog posts and create a monthly webinar. They have a robust network of RDs across all 50 states as well as a core group that I worked with at the headquarters in Bethesda, MD.

During my time there, I wrote numerous blog posts on several topics, created a webinar and a seminar, and gained exposure and insight on topics such as motivational interviewing and health coaching to create lasting behavior change.

Why is it important?
Wellness dietitians are changing the culture at work in positive, inspiring ways. They create healthy work programs and implement motivational interviewing based health coaching to establish lasting behavior change!

Saturday, January 7, 2017

NFPE in Action

Nutrition Focused Physical Exams (NFPE) are an up-and-coming set of skills that clinical dietitians can use to identify and help diagnose malnutrition. The exam is a head-to-toe assessment of a patient's physical appearance, focusing on fat and muscle presence and signs of deficiency. NFPE is not widely used in hospitals yet, but I was lucky enough to spend some of my secondary clinical rotation at Calvert Memorial Hospital (CMH) in Prince Frederick, MD where their RDs implement NFPE during each patient's initial assessment.

Image courtesy of Salud Today

The most intimidating part of NFPE, for me, was simply the idea of physically examining a patient. On my first day at CMH, I had that same feeling you get before jumping into a pool of cold water. Once I examined my first patient, the feeling of intimidation was gone. So, for anyone who is curious about using NFPE, here are three things I think are essential for all beginners to know:

  1. It will be awkward at first - No matter how much you read about the process, you will probably fumble around and you will likely forget a step. Most patients will have no idea if it's your first or 50th time unless you make it apparent. Try practicing on fellow students/colleagues to become acclimated with where to feel and what "normal" feels like. In my experience, I found that the exam seemed less awkward when I maintained conversation while examining the patient.
  2. It's not black and white - Unlike diagnostic tests where the results are typically "positive" or "negative,” these results are measured on a broad scale ranging from normal to severe with every step in between. Try to gain as much background information from the medical chart before going to see the patient to get an impression on what to expect. If a patient has a documented 10% weight loss in two months, you can probably expect to find evidence of severe fat/muscle wasting. Then look and feel to see if the physical exam matches your expectation. As example, I had patient with the weight loss described above and, through NFPE, I found that the patient had severe wasting in the temporalis and clavicle/acromion, but all other examined areas were found to have moderate wasting at most.
  3. Include the patient - Just like with most traditional assessments, you'll want to ask the patient about any weight changes and their eating habits. But also ask questions about changes they may have noticed or if they're feeling weaker than normal. For some patients, what may seem like a mild-moderate indicator is normal for their body. While examining the patient, talk to them about what you find and briefly explain why. For example, in the patient I mentioned above I said “Your collar bone doesn’t have a lot of muscle to it--have you noticed it stick out more than normal?” The patient answered “yes,” and I responded that it could be because of the weight loss and encouraged her to eat more protein to help gain the muscle back.
    Although I think I still need much more hands-on practice, I am very glad I was able to have this experience. During my three days with the wonderful RDs of CMH, I was able to feel each degree of subcutaneous fat and muscle wasting. I strongly encourage all interns and current RDs to learn NFPE. NFPE is an excellent tool for RDs to help identify malnutrition, but it also allows patients to recognize the connection between how they eat and how that can affect their body.

Wednesday, January 4, 2017

The Anatomy of a Good Nutrition Note

Writing a good nutrition note in a medical record is an important part of a clinical dietitian’s job. My clinical rotation at Meritus Medical Center helped me develop a good format which is easy to write quickly and easy for others to read and understand. Meritus gave their dietitians freedom to use their own style of nutrition note and I was able to work with several dietitians, which allowed me to take aspects from each of them. Here is what I learned about writing good nutrition notes.

Choose a Good Format

To start writing a note, there has to be a solid format. In my experience, using the ADIME (assessment, diagnosis, intervention, monitor & evaluate) format works best. It just organizes the note so that it flows well and gives a good overview of the patient. The SOAP (subjective, objective, assessment, and plan) format can also be used, but since we were taught ADIME in college, I chose to use that format.

Include All Relevant Information

Relevant information for a nutrition note can include patient history, anthropometrics, medications, lab values, and more. Unfortunately, this information is not always in the same place or easy to find. One of the harder parts about learning to write notes was browsing through the EMR (electronic medical record) system for information for my notes. Not all hospitals use the same EMR software, so learning a new system can take some time. Fortunately, my preceptors were able to help me know what information I needed and where I could go to find it.

Avoid Being Too Wordy

When I first started writing notes, they were relatively wordy and in paragraph form. All the necessary information was there, but it took a while to read them. One of my preceptors pointed out that most doctors don’t have time to read a lengthy, wordy note, and that I should condense the note down into bullet points so that anyone reading doesn’t have to skim through a paragraph looking for relevant information.

Finding the Right Balance

By the end of my rotation, I was cranking out notes pretty quickly. My style had developed into a mixture of descriptive sentences and bullet points that I believed were easy to read and follow. I didn’t start out writing great notes, but there was a definite pattern of improvement, both in quality and efficiency, throughout my rotation.

Thursday, December 15, 2016

REBELLING: A New Approach to Outpatient Counseling

Many tactics people use to lose weight or to become healthier ride right on the edge of an eating disorder. I can specifically remember my freshman year of college, many girls in the dorm were on a diet where they could only eat fruit one day, only vegetables another day, and so on. The problem is that these individuals often have no idea that what they are doing is harmful to their health; they truly believe that restricting calories, cutting out food groups or going to bed hungry will bring them closer to their health goals. With my dietetic training I know that this is not the case. Dietitians understand the metabolic functions of the body and why we need all food groups and adequate calories. Using this knowledge along with good strategies, dietitians can help clients overcome disordered eating.

For my second clinical rotation, I was lucky enough to spend two weeks with the “REBEL dietitians” at Rebecca Bitzer & Associates. They see many different clients for countless reasons, and one of their specialties is the treatment of eating disorders. Their Empowered Eating program focuses on overcoming food struggles related to eating disorders, but I am going to focus on the REBEL theme of their practice.

What is a REBEL dietitian?

At Rebecca Bitzer & Associates, they call themselves REBELS because they break free of traditional dieting plans for clients and focus on the values and goals of each client as an individual. They “REBEL against diets.” There are five pillars that the REBEL dietitians rely on: nutrition, moderation, balance, variety and flexibility. These dietitians know that weight loss from diets is not sustainable and work with clients to create a custom plan that they can maintain.

Why is the REBEL work important?

There are thousands of books, blogs and magazines that have published information about food that is not science-based or factual. For dietitians, this information may seem easy to navigate, because we know general food science and how the body works. For the average person without a nutrition degree, this information can be hard to process. The REBEL dietitians can educate clients and help make sense of the thousands of health claims they have been exposed to and get back to the basics.  Aside from clarifying false information, the dietitians make sure that clients are given a plan they can stick to and that is realistic for their lifestyle.

The Takeaway

Whether a client is struggling with their weight and related health problems, or suffering from an eating disorder, the REBEL dietitians can customize a plan that works for them.  The most compelling thing I have learned from the REBEL dietitians is that even for individuals who do not suffer from an eating disorder, there are many misconceptions surrounding food and bad habits that need to be broken. My time at Rebecca Bitzer’s has given me unique insight into counseling. I learned that every client is different and I need to meet clients where they are so they can gradually improve and eventually meet their goals in a healthy, sustainable way.