Thursday, November 19, 2015

Inpatient vs. Outpatient Care

During the past two weeks I was given the opportunity to shadow several dietitians within a variety of settings. I shadowed recent UMDCP Dietetic Internship alumni at Franklin Square Medical Center & Surgical Specialists of Anne Arundel Medical Center; inpatient vs. outpatient. Could there really be a clear favorite for dietitians?

Franklin Square Medical Center (photo courtesy
First up was Franklin Square, a hospital that held significantly more beds than my first rotation at Carroll Hospital. I immediately assumed I would be overwhelmed with the influx of patients. Half of my day was spent rounding with resident physicians in the intensive care unit. As a lowly intern and student, I felt like an outcast among the many intelligent physicians surrounding me.  I was brimming with questions and unable to participate due to my lack of knowledge. However, as I was observing the residents interacting with patients, they too struggled to provide answers. I soon realized that everyone is constantly learning, and no one can fully grasp every branch of medical care. The RD was requested for brief education, diet advancement, enteral feeding, parenteral feeding, and supplementation. As the day progressed and we saw more patients, it became apparent that the intention of the RD is to provide immediate nutritional support to warrant better outcomes so patients can go home as soon as possible.

Anne Arundel Medical Center (photo courtesy of
The following days were spent at the Weight Loss and Metabolic Surgery Program of Anne Arundel Medical Center. The switch from an inpatient setting to an outpatient setting made me uneasy. I initially wondered how interesting it could possibly be providing the same lecture to every patient. After coming to the realization that RD’s do more than just lecture, I realized how wrong I really was. RD’s assess patient progress, physically and emotionally gauge patients to determine the most effective motivation strategy and focus on how to reach the goals of their patient. Education was more in depth, focusing on supplements, diet, and exercise throughout the phases of pre- and post-operation.

The real takeaway for inpatient vs. outpatient settings is that no matter what, the delivery of care is tailored towards the patient. Inpatient care is immediate and provides some education when necessary to prevent the patient from returning to the hospital. Outpatient care allows you the opportunity to build relationships with your patient as you educate them to enact lifestyle changes. No matter which setting, the RD is a vital part of a patient’s success.

A Dietitian's Important Role in Bariatrics

INOVA Bariatrics' most popular surgeries are bypass and sleeve,
only one LapBand surgery has been performed in the last year.
Heading to my second hospital rotation, I had mixed feelings about how a dietitian can fit into Bariatric Care. I was mostly excited – I love the out-patient setting. You have the opportunity to get to know patients over a course of visits, receive patient feedback on progress, and tailor nutrition interventions along the way. But in some ways, the position felt backwards. As na├»ve as it sounds, I’m the kind of learning dietitian who believes my job is to help every patient lose weight before they need something as drastic as bariatric surgery. But the fact of the matter is that’s not realistic, and not possible for many patients. Nutrition is just one factor in the treatment of obesity, that is growing so rapidly in this country. Patients have trouble losing weight for reasons much more complicated than “eat more fruits and vegetables” – genetics, diseases, psychological disorders, emotional eating, and unsupportive environments can all play a role in a patient's weight loss journey. After shadowing my first bariatric appointment, it was overwhelmingly clear how important a Dietitian is in this setting.

Here are three of my biggest “shockers” from my 2-week rotation

ONE: Smaller than small portions sizes
It’s hard to imagine, but a starting meal fits into a 2oz plastic cup. Even as a dietetic student, I asked myself what does a 2oz plastic cup even look like? Here at the center, we give condiment containers as a guide. So the little cups you put ketchup in - That’s a meal for a bariatric patient the first 3 months following their surgery. No wonder the weight drops so fast (that is if you’re following the rules!). Portion sizes grow over a year period, but in small amounts and peak at 1 cup per meal for the rest of a patient’s life.
Condiment containers are provided to patients as measuring tools
for meal size.
TWO: No bread, rice, or pasta
This is something I have never recommended for other patients in the past, but eventually made sense to me in the bariatric setting. If you put bread into a cup of water, it absorbs and swells. When a patient’s stomach is reduced to the size of a thumb, a few bites of bread can swell and fill the entirety of the stomach. For many patients, they learn the hard way – they eat the bread they have been craving, and then experience abdominal pain, nausea, or sometimes vomiting. A portion of bariatric patients can tolerate these foods after a year, but still may cause discomfort. All those healthy and vital B vitamins patients are missing out by skipping the grain products are made up through daily supplementation.

THREE: Calories… not really that important
Dietitians are trained to focus primarily on the nutrient content of food when making recommendations, and to not always get caught up in calories. However, our profession revolves around calculating energy expenditure, and knowing that eating less than that estimated number equals weight loss. After bariatric surgery, the stomach acts as a physical calorie counter. And by that, I mean it would be hard for a patient to eat enough calories to exceed their energy expenditure without feeling nauseatingly full.  A stomach after bariatric surgery keeps portion sizes small enough that calories aren’t the major problem. That is why most of diet counseling focuses on what kinds of nutrient dense foods are patients putting into those small meals that help them receive optimal nutrition. 

During my rotation I was able to teach the class
"Eating out after weight-loss surgery" to help
patients learn healthy tips to eat outside their home.
Working in an outpatient bariatric office really gave me an appreciation for how dietitians can get involved in specialized health. Careers for dietitians are vast, and understanding as many career areas as possible is already building my confidence as a soon-to-be professional. Bariatrics definitely took some getting used to, but keeping an open mind gave me the most positive and educational experience possible.

Wednesday, November 4, 2015

M&M Presents the Harvest Festival Theme Meal

Welcome to The Harvest Festival!!

Co-written by UMD Dietetic Interns Mariah Staley & Meredith Dillon (M&M)

Meredith Dillon preparing decorations for the Harvest Festival
  Did you know Harvest Festivals are celebrated all around the world?! For thousands of years countries have celebrated the harvest with ceremonies and traditions. In China there is the Mid-Autumn Festival where they eat mooncakes and light paper lanterns. Many Jewish communities observe Sukkot, a harvest festival in mid to late September, and in Southern India the harvest is celebrated by eating special foods and decorating cattle.  Here in the US, the Harvest Moon and Thanksgiving are main harvest festivals.  With our meal falling on October 30th, we thought it only fitting to celebrate the produce and flavors of fall by bringing the Harvest Festival to Riderwood!

Harvest Festival Meal Flyer
During our time at Riderwood, a retirement community, we developed our menu and recipes, worked with kitchen staff to enhance our culinary skills, and used multiple marketing techniques to advertise our meal to residents and staff.  One way we advertised for our theme meal was by creating a commercial with Riderwood's TV Studio.  Check it out here- Harvest Festival Commercial! Our main focus with this meal was to allow guests the experience of eating foods that use produce that is grown during the autumn season, while incorporating flavors from around the world.  We were able to accomplish this by using pumpkin, squash, apples, and many other produce that are all in season.  Check out this cool link to find out more produce that is in season during the fall!! What's In Season?  Our menu featured items like Roasted Brussels Sprouts with Cranberries & Pecans, Butternut Squash & Mushroom Lasagna, and Spinach & Feta Stuffed Chicken Breast.

Theme Meal Menu
The weeks leading up to our meal were busy and filled with preparing ourselves for the 150+ people we were forecasting to have attend our lunch.  With the help of Riderwood staff, especially their amazing chefs in the Windsor Room kitchen, we were able to pull off a delicious Harvest Festival Lunch for residents and staff!  
Brussels Sprouts before going in the oven


 Have a Happy Harvest Festival!

From the UMD Dietetic Interns Mariah & Meredith

Tuesday, November 3, 2015

Nutritional Supplements

Oral feeding is the most desirable route of feeding; feedings by mouth ensure that gut function is maintained and prevents bacterial translocation. However, for many patients in the clinical setting adequate oral intake is not always feasible. This nutrient deficiency may be caused by their need for increased calories, lack of appetite as a side effect of a disease, altered gastrointestinal function, hatred for hospital food, etc. It is important as a clinical dietitian to ensure that a patient is receiving the appropriate amount of calories for quicker recovery and shorter hospital stays.

Food is more than just a necessity; it represents a comfort for most individuals.

Throughout my short time in clinical I have ordered so many supplements for patients I feel I should be receiving commission from some of these corporations. All joking aside, these products do a lot of good. For example an elderly patient who is suffering from pressure ulcers and requires increased energy and protein needs can receive a protein modular to promote wound healing. A cancer patient that is hypermetabolic can drink high calorie supplements for weight maintenance.

It’s easy to justify why certain patients should receive specific nutritional supplements, e.g. Novasource Renal for a patient suffering from chronic kidney disease. However, when a patient asks you if drink has a medicinal flavor and you have no prior knowledge, a patient is less willing to receive the supplement and/or meet your goals of consuming the supplement.

It was thanks to my preceptors I had the joy of receiving a supplement “buffet”. By the end I had the pleasure of sampling nearly 20 drinks, powders, puddings, and ice cream.

Whether it is through a “hazing” type ritual or simply out of curiosity it is important to sample all of the nutritional supplements before recommending them to a patient. Knowing your products and how they taste makes it easy to assume whether a patient is likely to consume the supplement or not.

Monday, November 2, 2015

A Day in the Diet Office

The diet office of a food service establishment, especially at a large facility like a hospital, can be the brains of the kitchen operations as well as a dietitians best friend. During my first week of clinical rotations at Baltimore Washington Medical Center, I got to spend the day in the diet office to see how meal selection, tray line, and meal delivery works.

At the ripe hour of 6am, I reported to the diet office to meet one of the dietary aides. I observed as she input any last minute meal selections and printed food prep sheets for the cooks and kitchen staff. Then before you knew it, it was 7:30am, breakfast time!

I strapped on my hairnet and joined one of the hostesses to deliver breakfast. The main meal was french toast and syrup, unfortunately not a fan favorite that I thought it would be. As we made our rounds I quickly found how happy the patients were to see the hostess and her cart. For patients that needed some help feeding, the hostess would open containers, cut up the food, and place the tray above the bed. If additional feeding support was needed the hostess would let the nurse or tech know that breakfast had been delivered. Another job of a hostess is to stock the nourishment rooms that have a refrigerator stocked with jell-o's, puddings, beverages, and other snack items patients might ask for.

All meal ordering is done using iPads at BWMC. Dependent on their diet restrictions, patients are able to choose the main meal offered daily, or make modifications of their own. Although a hospital is not a hotel per say- it is a priority for patients to eat, and for the most part enjoy what they are eating. So it is often recommended if a patient finds something on the menu, or something the kitchen offers as an alternative, let the host or hostess know and they can continue to send them that meal.

Weeks following my day in the diet office, the RD's and I continued to keep close contact with the diet office. Whether it be calling the dietary aide for a snack to be delivered to a patient's room, updating food preferences obtained during a consult, or asking if hot dogs are able to be pureed!

If you do get the chance during a clinical rotation, I would highly recommend spending some time in the kitchen, diet office, or on the floor delivering meals.

Friday, October 30, 2015

Food Day at University of Maryland College Park: Supporting Campus Efforts at Sustanability

On Friday October 23, 2015 NFSC Dietetic Internship gathered to assist campus dining services in promoting sustainability in honor of National Food Day this year.

The interns assisted the campus dining sustainability team in urging UMCP students to use "recyclable" take out containers and learn more about campus sustainability efforts.   Visit UMCP Campus Dining Services to learn the many sustainability efforts taking place on campus. 

Interns also served samples of food items being served in the cafeteria -- Marinated Mushroom Sandwich and a less meaty pasta dish.  In the evening for supper dining services served grilled blue catfish.

The event served to enhance intern knowledge about Maryland food-based sustainability issues, gain a great understanding of college student food preferences, and have a great time!

Thursday, October 29, 2015

Experience It: Food and Friends Joint Class Day

I am currently at my information technology rotation in my internship. This part of the rotation is held at IFIC (International Food Information Council). For our first Joint Class day, myself and three of my fellow dietetic interns went to Food and Friends. I had never heard of this organization before coming to my dietetic internship and from what I heard during my internship, I thought it was just a food bank. However, it is more than just your typical ‘food bank’. It distributes specified diet order friendly meals to the DC area. From soft puree to heart healthy, Food and Friends has it. This is a great service and I was happy to learn more about it.

At this great location gathered dietetic interns from two other programs with ours (University of Maryland- Medical Center, & Virginia Tech). Each program was diverse and brilliant in their own right. I met people from both and discovered another side to dietetic internships I hadn’t been exposed to before. I learned that the two dietetic internships had different concentrations -- Virginia Tech’s was leadership while University of Maryland-Medical Center’s was clinical. They had two perspectives that were valuable resources.

After the introductions for the day, we were divided into two groups. My group volunteered in the kitchen first where we put the meals into bags to go out for distribution. Food and Friends had a color coded system for their diet items. There was heart healthy, no fish, vegetarian, diabetic, and soft; just to name a few. They also provided numerous combinations of diets, which was a really nice service. During this time, I was able to learn a lot about the other programs. After we were done packing all the food away, we put stickers on bags and helped them put away the supplies.

We broke for lunch after a small budgeting exercise where we networked with other interns. We had a workshop on strength based leadership which brought a lot of positive response from me. I love psychology and often think about the mindset behind our food choices. This was along the same lines on how to be the best leader you could be with your skill sets. Some dietetic interns were more analytic than creative or more organized than communicative. These qualities do not make you a bad leader, it makes you a different type of leader and that is okay. I concluded that I may be a dietetic intern with an unconventional background but my skill sets are needed in my dietetic internship. I bring something to the table that no one else will.

Our group sat through three lectures, each of them interesting. The first was a lecture on nutrition and HIV which was incredibly informative about the prevalence of the virus in the Washington DC area. There was a motivational interview section where we got to see the different perspectives of the dietetic interns since they tend to focus on different things during their interviews. Some interviews were clinical while others focused in on the emotional well-being of the client. The final topic was food justice and poverty in the DC area. This was eye-opening and shocking since many wards are food deserts. I hope that my contribution to the DC community through Food and Friends has helped make change.

After that, there were some closing remarks and then we were released into the world again equipped with new knowledge. Overall, it was a fun class day where I made new friends and learned many things that I could use for my future as an RD. I am looking forward to the next joint class day!