Sunday, February 19, 2017

Takeaways from my time in Outpatient Diabetes


While many associate type 2 diabetes with obesity, eating a poor diet can lead to type 2 diabetes regardless of weight status. During my outpatient diabetes rotation, I counseled patients to practice mindful eating and get regular physical activity to prevent or delay Type 2 diabetes.  My training taught me also to explain how the body reacts to the food we eat.
 
At the clinical sites where I completed my diabetes rotations, I had the opportunity to learn techniques on how to counsel and educate people with pre-diabetes and diabetes. I learned that diabetes affects 1 in 14 people, and once it is diagnosed it becomes a chronic condition. It cannot be cured, although it can be managed with diet, exercise, and in some instances, with medicine. The good news is that preventive screening can identify people at risk, and with proper intervention, those people can prevent or delay a diabetes diagnosis.
One of the most important things I learned is that, in addition to educating people on what to do or what steps to take towards changing their lifestyle, it is also important to explain how the body reacts every time we eat food. Keeping the explanation simple and to the point was the best way to convey the message and to educate the patients.  The following is an example of a simple explanation to patients about glucose metabolism:
Everything we eat gets converted into glucose, body’s main source of energy. In people without diabetes, glucose stays in a healthy range, because insulin is released at the right time and in the right amount to help glucose enter the cells (I think of insulin as “the door man.”) In diabetes, blood glucose build-up occurs for several possible reasons:
  • Too little insulin is made
  • The liver releases too much glucose
  • Cells can’t use insulin well = insulin resistance
Of particular importance is the last bullet – insulin resistance – and helping patients to understand how they can help themselves improve their body’s ability to use insulin:
  • Exercise: This is the biggest one! If lack of time is an issue, try to exercise first thing in the morning or schedule it as part of your daily routine. Be active in any way you can: take stairs, take a brisk walk, cut your lunch time in half and go for a walk the remaining time.
  • Lose some central body fat: Fat deposition around the waist and the mid-portion of the body is a risk factor for type 2 diabetes.
  • Healthy eating: Choose foods high in fiber (non-starchy vegetables and whole grains), which are more complicated for our bodies to break down, and thus, are more satisfying.  Eat vegetables first, and then protein so you will not be as hungry when eating starchy foods.
  • Portion size control: your plate should look like this:             
½ of your plate filled with vegetables, ¼ with starch and ¼ with protein.

After taking part in the counseling sessions, I realized how overwhelming this new diagnosis must be for patients. They need to change their eating habits, add exercise into their daily routine, and test their blood glucose after their meals.  I also learned that what often worked best for patients is to help them set two or three manageable goals at a time, then help them to think through any challenges that might prevent them for reaching these goals. It is important also to convey to them the importance of flexibility and consistency – it’s OK if one of the goals can’t be reached initially. They can keep that goal on their longer range plan and, in the short term, move on to the next goal to try to reach it. The most important piece of guidance is to help them recognize that taking charge of their health is a work in progress and a lifestyle change. Rome wasn’t built in one day, and, it’s important to help patients remember that.
It would be good for most of us, those diagnosed with diabetes or not, to make healthier choices. We can really make a positive impact  on our health if we set attainable goals and incorporate reasonable changes into our way of living.

Monday, February 13, 2017

Sustainability at UMD


This January I had the opportunity to spend a week interning with the sustainability department for the University of Maryland (UMD) Dining Services. I had an idea about what sustainability was, but never had a chance to really dive into the details of it, so I was looking forward to learning as much as I could in a week. My preceptors here did a great job of scheduling activities for us around campus and on the Terp Farm so I could get a good idea of what sustainability is.
Sustainability
Sustainability is the practice of producing foods, such as fruits and vegetables, in a manner that has a protects the environment, wildlife, public health, and communities. The Sustainable Agriculture Research and Education Program, a leader in sustainability, has a website detailing both the philosophy and practical aspects of sustainable agriculture. It lists three primary goals of sustainable agriculture: environmental health, economic profitability, and social-economic equity. To accomplish these goals, farms use methods of growing and harvesting that promote soil health, reduce water use, and lower pollution levels. These methods can include crop rotation, using organic material to retain soil moisture, and composting.





The Terp Farm

The Terp Farm is a sustainable farming operation managed by UMD’s Department of Dining Services, College of Agriculture and Natural Resources, and Office of Sustainability. It is located about 15 miles from UMD’s College Park campus, where many of the crops are delivered and used to produce meals for students.

I had the opportunity to spend a day at the Terp Farm and assist with the harvesting of several crops, including rainbow chard, Siberian kale, red Russian kale, and cilantro. Once harvested and bundled, I assisted with the washing, sanitizing, packing, weighing, and loading. These crops were used the same day by Dining Services, which is common practice for the Terp Farm. Because of the short distance from campus, it is not uncommon for foods to make it from the farm to a person’s plate in only a few hours.

The short travel distance and use of a small van reduces the Terp Farm’s transportation costs. This, coupled with reduced water consumption and use of organic fertilizers, among other things, allows the Terp Farm to keep financial costs low and remain profitable.


Campus Pantry

C:\Users\Michael\AppData\Local\Microsoft\Windows\INetCacheContent.Word\pantrypic2.pngC:\Users\Michael\AppData\Local\Microsoft\Windows\INetCacheContent.Word\pantrypic1.pngOn one of my last days, I got to volunteer at the Campus Pantry. The Campus Pantry is working to eliminate food hardships at the UMD College Park campus. It provides good quality, nutritious foods to students, faculty, and staff. Some food products are purchased with department funding, which is possible due to the economic profitability of the department’s other projects, but the great majority of foods are donated by the local communities. In this way, the Campus Pantry completes the third goal of sustainability, promoting social and economic equity. Those that have the ability to provide additional resources donate to the Pantry, which allows the pantry to offer low-cost foods and personal products to those that would otherwise go without.  

At the moment, the campus pantry is located in the basement of the Campus Health Clinic, but there are plans to move to a larger facility that will allow for cold-storage. During my time volunteering there, I helped to unpack recent donations, screen items for expiration dates and quality, and sort items into their respective categories. The Campus Pantry organizes foods based on the type, such as grains and pasta, beans and soups, and vegetables. They even have a gluten-free section!


Overall, I really enjoyed my time working with Campus Dining’s Sustainability department at UMD. I learned a lot about sustainable agriculture and how it strives to protect the health of the environment. Sustainable farming practices also attempt to reduce resource consumption and then give back to the community to promote social and economic equity.  Sustainability allows the current generation to meet its needs while protecting future generations’ ability to do the same. The work they are doing at UMD seems to be doing just that.


Monday, February 6, 2017

From Class to Clinical: What I Didn’t Expect at My Clinical Rotation

Prior to starting a clinical rotation, it’s not uncommon for interns to feel intimidated.There’s so much information to know at such a detailed level that it can be overwhelming. Preparation can make the rotation easier but, you can’t prepare for everything. Here are a few things I learned during my clinical rotation:



  1. There’s no such thing as a textbook patient. In MNT classes, case studies are typically focused on one specific disease that is being covered, such as stage 4 chronic kidney disease. Students learn how to create a diet for a patient with that disease. In the hospital, though, you’re more likely to see a patient with multiple health issues, such as chronic stage 4 kidney disease with uncontrolled type 2 diabetes and a stage IV pressure ulcer. With the guidance of my preceptors, I have learned how to prioritize the nutritional needs for each disease a patient has in order to create a diet that best fits their immediate needs.
  2. Oral Nutrition Supplements for the Obese. A common long term goal for obese patients is weight loss, however this is not the goal for these patients while in the hospital. They often have higher needs than normal because they are experiencing some level of stress. To meet these increased needs, many obese patients will receive oral nutrition supplements. While weight loss would be beneficial in the long run, patients need to have a healthy weight loss. Developing malnutrition can only worsen their condition.
  3. Alcohol for withdrawal. Alcohol addiction is not uncommon in clinical patients. Addiction can further complicate a patient’s treatment, especially if they go through withdrawal. The policy for handling alcohol addiction varies from facility to facility. The hospital where I am currently rotating uses the pharmacological approach to reduce the side effects of withdrawal. In contrast, a hospital that I shadowed at during my undergraduate studies served alcohol to patients with alcohol addiction. The hospital kept a bottle of every type of alcohol - vodka, wine, brandy, etc. The patient would be served their drink of choice with their meals to prevent withdrawal from occurring.
  4. Doctor’s Orders! Another thing that varies between facilities is who writes tube feeding, parenteral nutrition and diet orders. In some facilities dietitians write recommendations for these orders while in other facilities they write the actual orders. This policy can also vary between doctors at the same facility. Some doctors take the opportunity to be certified to write TPN and maintain their certification by completing continuing education credits. This is beneficial in ensuring the doctors and dietitians are communicating and working together for the patient’s nutrition!

Clinical rotations have much more to teach interns than just about different disease states and appropriate nutrition. Dietitians work with the rest of the health care team to make decisions that best meet the patient’s needs. How these decisions are made will differ between facilities, but the goal is always to give the best care to each patient.

Monday, January 30, 2017

Eat the Rainbow: My Experience Teaching a FSNE Nutrition Education

Early nutrition intervention in a child’s life may be the optimal window for promoting the development of healthy eating behaviors. FSNE has several nutrition education programs geared toward school age children for this reason. During my time at the University of Maryland Extension’s Food Supplement Nutrition Education Program (FSNE), I had the opportunity to not only observe, but also teach a few nutrition education sessions. The curriculum we used is called ReFresh. It focuses on encouraging 4th and 5th grade students to eat more fruits, vegetables, and whole grains through hands-on activities, food demonstrations, and tastings. ReFresh integrates nutrition education into different subjects already in the schools curriculum like math, art, science, English, technology, engineering, and social studies.

We began the lesson by asking the students some questions. What are some “all the time” foods? Why are fruits and vegetables healthy? What in them makes them healthy? The kids knew the answer we were looking for: the vitamins and minerals in fruits and vegetables are what make them healthy.

My partner, Ben, and me teaching a ReFresh Lesson.

We then played an interactive grocery store game to teach the kids which vitamins are in the different colored fruits and veggies. For example, we read a short passage about a pilot needing to eat his orange fruits and veggies in order to have great vision. One student from each table then ran over to the grocery store and put an orange fruit or vegetable in their bag. We repeated this with three more colors: red protects against cancer, purple is good for memory, and green for bones and muscles. This was a fun and hands-on way to get the kids interested in different vitamins and minerals and to get them moving.

The second activity we did with the class was “cook” a recipe together. The recipe was for a pasta salad called confetti spaghetti. The recipe included cooked pasta, mozzarella cheese, dressing, and vegetables of various colors: carrots, red cabbage, cauliflower, spinach, and red bell peppers. The tables were given a bowl of cooked pasta and handfuls of each vegetable. The students worked together to cut up the vegetables and put them in the pasta. We then added dressing and cheese for the students that wanted it. They then shook up the container and served each other. FSNE has a rule called “don’t yuck my yum.” The kids are not supposed to say “yuck,” “ew,” “gross,” etc. to allow their classmates who enjoyed the tasting to continue eating. They are asked to try at least two bites.


Overall, confetti spaghetti was a big hit. The majority of the class liked the recipe, and many of the students told me they tried at least one new vegetable. The tasting was a great way to get the students excited about some nutrient-rich foods.  I was pleasantly surprised to see how many students wanted the recipe cards to take home to their parents. I am grateful for this experience of teaching children and making an impact on their lives.  

Wednesday, January 25, 2017

O.A.R.S for Outpatient

Using O.A.R.S. to steer counseling sessions can help move patients forward, motivating them to make positive changes.
O= Open Ended Questions
A= Affirmations
R= Reflective Listening
S= Summarizing
I had the exciting opportunity to use O.A.R.S. with real patients in the outpatient setting of my clinical rotation. Motivational interviewing techniques such as O.A.R.S. use a client based approach. Just like oars help a rower steer a boat, O.A.R.S. help the dietitian direct the counseling session, while the patient chooses the destination (the goal, such as weight-loss, healthy eating habits, etc.). There might be a few barriers in the water, but the dietitian guides the patient around them to successfully reach the desired destination.

Here is how O.A.R.S. can help you guide your clients to their destinations:

Open Ended Questions- these are what help you gather information from clients to get a better idea of why they came to see you. You can find out tons of information about their past experiences, feelings, thoughts, and beliefs by letting them explain their story. You want to ask questions that go beyond  a simple “yes” or “no” response so they provide you with details. Try asking them “how did you do this” or “what made you do that,” rather than “did you do this?” Remember that you hold the “oars” and your questions are what guide the session.

Affirmations- these are small statements or actions that acknowledge your clients’ efforts in achieving their goals. This is important in improving clients’ self efficacy, which is their beliefs of their own ability to succeed in tasks. The more positive they feel, the more motivated they will be to reach their goal. Some examples of affirmations are eye contact, relaxed facial expressions, and feedback, such as “It is great that you want to find a way to accomplish this.”

Reflective listening- this is when you listen to what clients have to say and reflect on what is pertinent to the counseling session. For example, if he or she wants to lose weight, but explains eating a dozen cookies everyday and then stepping on a scale after eating them, you might want to respond with “So you’re feeling a bit guilty every time you eat too many sweets.” They might agree or disagree with your interpretation, but this shows the client that you are trying to understand their situation.

Summarizing- this is when you summarize your clients’ thoughts in order to keep the session organized and lead to transitions or closures. It might start with something like “Earlier you explained wanting to make your diet healthier... maybe now we can think of some goals to help you accomplish that.” Summarizing information can also help clients decide when to schedule follow-up appointments

O.A.R.S tremendously helped structure my counseling sessions. By following the steps of O.A.R.S, I helped patients become more aware of their barriers and create achievable goals. Some of the patients' goals involved weight-loss, weight-gain, and overall healthy eating habits. I had a great learning experience and am excited to do more nutrition counseling in the future-- I’ll remember to bring my oars!

Practicing on my fellow intern/roomie, Alyssa!


Sunday, January 22, 2017

Nutrition, Communication and Information Management Area Internship Class Day Conference

What do the Maryland WIC Program, nutrition informatics, sugar sweetened beverage research, social media, and dialog communications training all have in common? These topics were part of the University of Maryland’s Dietetic Internship 2017 Joint Class Day Conference agenda, where area dietetic interns and program directors learned various ways to enhance their communication skills and harness the power of social media and information management. In addition to exploring communications skills through the lectures, dietetic interns from Johns Hopkins, NIH, NOVA/Virginia Tech, Sodexo, UMD, UMMC, and WIC also networked and got to know one another through interactive sessions.

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Joint Class Day - held at Harbor Hospital in Baltimore
The topics, while varied, helped interns know more about the Maryland state affiliate groups and hone their communication skills.  Two of the speakers are graduates of the University of Maryland Dietetic Internship who specialize in communication and information management. The interns were engaged and asked many follow-up questions. Presentation PowerPoints are available on our website. Here is a sampling of what was covered in the lectures:
  • information about the Maryland EBT (Electronic Benefit Transfer) card, which is currently being implemented for Maryland WIC recipients,
  • what it takes to implement a successful program to limit sugar intake,
  • the basics of nutrition informatics, and
  • which are the most relevant social media platforms for RD communicators.


2017 Joint Class Day Agenda

The final speaker, Lynn Rubin from the Maryland Food Supplemental Nutrition (FSNE/ SNAP-Ed) program, led an interactive training session on dialogue learning for groups.  The interns learned practical ways to engage a group of clients and bring about positive behavior change.


Three things came together to make this Nutrition, Communication and Information Management Area Internship Class Day Conference a success: a solid agenda, compelling and knowledgeable presenters, and engaged interns. We would like to thank those who helped make this a fantastic learning experience.


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UMD interns pose for a silly picture




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.