Policy from the Ground Up

On March 10^th, Wendy and I had an opportunity to attend the Academy of Nutrition and Dietetic’s 2013 Public Policy Workshop at the Omni Shoreham Hotel in Washington, D.C. At the Public Policy Workshop (PPW), I was able to sit in on lectures focusing on topics such as developing influential messages, sequestration, Older Americans Act, Affordable Care Act, industry etc. Along with being able to attend the workshop, I had an opportunity to work at the Nutrition Informatics Genius Bar during the networking session. Wendy and I provided technology tool presentations on Weebly, Dropbox and Eyejot. For each technology tool we provided information on how nutrition professionals can use these tools in their practice

Weebly is a Web-based software use for the development of a personal or professional website. It is easy to use and you can market yourself while job searching, market your private practice and add weebly.com to your email signature. There is a free and paid version of Weebly but the free version provides almost everything you need to design your own website! You can choose a template from over 70 different designs for your website. Here is an example of my Weebly account:

www.mavisren.com

Eyejot.com is an online video messaging platform that allows anyone to be able to create or receive video messages via email. Eyejot helps to avoid any email misinterpretations and personalizes interactions. The free version provides up to 5 minutes of video and there are no advertisements attached.

http://corp.eyejot.com/

Dropbox is a free online service that allows you to store your photos, documents, videos and folders. After creating a Dropbox account you can easily share files within your Dropbox account to friends, family or coworkers. In addition, Dropbox can be used to store presentation materials or files that are too big for email attachments.

www.dropbox.com

I really enjoyed the Public Policy Workshop! It was definitely a great way for dietetic interns to be involved. 

A Community Setting for Renal Patients

My partner Mavis and I just completed a weeklong rotation in various DaVita Dialysis centers working with patients suffering from kidney disease. I was originally confused that the renal rotation is categorized as a community rotation in the UMD dietetic internship. This was not exactly clear to me before the week began. Surely, a clinic where there is a fully staffed medical team including: doctors, nurses, social workers, and techs classifies as clinical rotation?  I mean labs are being drawn constantly and we are working with patients that have a very serious medical condition.

However, once my rotation began I started to understand that for patients on dialysis, their center is a consistent part of their life. They come 2-3 times every week so it is very important that this clinical setting acts as a welcoming community location to enhance the quality of life for patients and to motivate them to care for themselves. A renal, dialysis dietitian has a very important job monitoring labs including potassium, phosphorus, parathyroid hormone, calcium, and albumin to name a few. They need to provide excellent care to prolong the patient’s life and keep them healthy. But additionally the dietitian has an opportunity to improve the daily happiness in patients. The DaVita clinics Mavis and I visited were working to make their centers more fun and hospitable  by competing among centers in a themed decorating contest they referred to as "The Hall of Fame". The object was to decorate the center with pictures of staff and patients surrounding the theme of diversity. The staff were working diligently in all the centers we visited! Check out the picture of me with last years decoration, Dr. Love!! 

Variability in Energy Needs

By Nikki Bolduc

Energy needs are different depending on the population you are working with, such as if the patient is critically ill, elderly, or an infant.  In addition, the protocol on calculating energy needs for one population may differ between hospitals.  I have experienced the functioning of three different hospitals during my internship and I can appreciate variables in procedure.

I completed my main clinical internship experience at the DC Veteran’s Affairs Medical Center in a 12-week rotation.  A typical patient consisted of a middle-aged male with multiple chronic conditions.  Dietitians most often used Mifflin St. Jeor to estimate resting energy expenditure (REE) plus an energy and activity factor to calculate energy needs.  Protein was calculated using dietary reference intakes (DRI) grams/kg depending on their nutrition status and fluid was often calculated using 1 mL/kcal or per doctors order.

Mifflin St. Jeor (ages 19-78):

REE (female) = 10(weight in kg) + 6.25(height in cm) – 5(age) – 161
            REE (male)    = 10(weight in kg) + 6.25(height in cm) – 5(age) + 5

DRI for protein:

0.5 g/kg = minimal requirement
0.8-1.0 g/kg = normal maintenance
1.5-2.5 g/kg = increased protein demands

Fluid:

1 mL/kcal
per MD orders

This week I completed a two-week rotation at Children’s National Medical Center in Washington, DC.  During my experience, I concentrated on gastroenterology, hematology, and oncology pediatric patients.  Dietitians often used estimated energy expenditure (EER) plus an activity factor and basal metabolic rate (BMR) plus an activity factor to calculate calorie needs.  Protein was calculated using dietary reference intakes (DRI) grams/kg based on pediatric guidelines and fluid was calculated using the Holliday Segar equation.

EER (ranges are further broken down by age)		REE (ranges are further broken down by gender and weight)
Infants (0-35 months)	80-102 kcal/kg/day	Age 1 wk-10 mo	202-593 kcal/day
Boys (ages 3-8)	59-85 kcal/kg/day	Age 11-36 mo	509-816 kcal/day
Girls (ages 3-8)	59-82 kcal/kg/day	Age 3-16 yr	799-1980 kcal/day
Boys (ages 9-18)	36-49 kcal/kg/day
Girls (ages 9-18)	34-42 kcal/kg/day

DRI for protein:

                Infants (0-35 months): 1.05-1.52 g/kg/day
                Boys & Girls (ages 3-8): 0.95-1.05 g/kg/day
                Boys & Girls (ages 9-18): 0.8-0.95 g/kg/day

Holliday Segar:

                1^st 10 kg          -> 100 mL/kg
                2^nd 10 kg         -> 50 mL/kg
                each addtl kg   -> 20 mL/kg (≤ 50 yo)
                                             15 mL/kg (> 50 yo)

It is important to understand the protocol of calculating energy needs at your hospital as well as the reasons why they use what they do.  Dietetics is grounded in scientific research, so although protocols at hospitals vary there most certainly is a reason for each approach.   There are many resources available to dietetic interns, such as the Nutrition Care Manual, the American Society for Parenteral and Enteral Nutrition (ASPEN), and the Evidence Analysis Library.  I hope the above equations will help get you started!

Interns in Annapolis

This past Tuesday, our internship class had the privilege of visiting Annapolis, Maryland’s state capital.  Our day began with an introductory video to the city of Annapolis and a brief refresher on the legislative process (i.e. law making). In the Department of Legislative Services Building we were directed to the Bill Room where bills are printed, assembled and distributed. We learned that each year the Maryland General Assembly acts on around 2,500 bills and approximately 800-900 of those bills make it to law. After the Bill Room, we were escorted to the Maryland State House where we toured historic rooms and chambers dating as far back as 1772. We learned that the Maryland State House is the oldest state capitol in continuous legislative use today. It also served as the nation’s capital for a brief period from 1783 to 1784. In the State House we viewed legislative sessions in the Senate and in the House of Delegates Galleries.  Each year members of the General Assembly gather over a period of 90 days to act on the bills through a series of hearings, readings, debates and voting. After this extensive process, the bills must be presented to the Governor who has the right to veto.

Visiting Maryland’s State Capital was a great way to review the legislative process and actually see it in action. We sat in on a committee hearing and heard testimonies from community members in support and in opposition of bills. We also met with Maryland State Senator Jim Brochin. After this experience I felt more comfortable with the legislative process and even more confident in contacting my state senator.

2013 Intern class with Senator Jim Brochin

Keep Health Literacy in Mind When Working With Patients

According to the NIH, health literacy is “the ability to understand health information and to use that information to make good decisions about your health and medical care.”  This sounds simple enough, however, 1/3 of the US population possesses basic or below basic health literacy skills.  This large population of low health literacy citizens costs the US an estimated $58 billion in healthcare costs each year.  These unnecessary healthcare expenditures occur because those with low health literacy are more likely to be hospitalized, and end up utilizing more expensive healthcare services such as the emergency room.  

For this reason, it is important that healthcare professionals be aware of a patient’s health literacy level and provide appropriate directions and education.  Populations with the highest risk of low health literacy are listed below:

• Older adults (65+)
• Minority ethnic groups
• Unemployed
• English as a Second Language (ESL)
• No high school degree
• Low-Income

As a dietitian, working with low health literacy clients can be challenging, especially when it isn’t quite clear if the client understands the education you are trying to provide.  One great way to help ensure effective communication is to utilize the “Teach-Back” method.  This is where you ask the client to repeat back in their own words what they have just learned from your education.  Another way to help improve patients' understanding is to always present questions at a basic level.  Therefore, opt for questions at a lower health literacy level as opposed to those heavy on medical terminology.  Check out the example below of a dietitian conducting an HDL education. Which questions do you think will create a better conversation with your patients?