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.

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.