A Look Into My Time at Children’s National Medical Center

The children at Children’s National Medical Center (CNMC) have something in common besides being adorable; they all need good nutrition to grow and develop. I love kids - I even listed “playing with dogs and babies” as part of my interests in my internship bio.  While I didn’t see any dogs at CNMC, I did see a lot of cute babies.  It took some self-restraint not to give all of them hugs, but I was there in a professional capacity to learn.  The dietitians at CNMC taught me much about helping children meet their nutrient needs.

Having just finished my primary clinical rotation, my mind was still geared towards adult nutrition, so I had to adjust to the fact that children have completely different needs.  Pretty much everything is different, from the feeding formulas to the calculations for nutrition prescriptions.  Bye bye Mifflin St. Jeor! No longer could I calculate calorie needs without barely thinking; I had to take everything step by step again.  When I rotated in general medicine, I used DRI for age to calculate protein and calorie needs.  If the child was falling on their growth curve, though, I used an equation for catch-up growth which involved the DRI for age and ideal body weight, which is also determined quite differently than for adults.  Needs for children in the oncology unit were calculated by REE  (using the WHO or Schofield method) x a weight loss factor of 1.3-2.  Needless to say, this was quite the learning experience.  

The conditions of the children I observed were also very different from the common conditions of my patients at my primary clinical rotation.  I encountered patients with failure to thrive, various neurological disorders, and some other disorders that I had never heard of such as eosinophilic esophagitis.  I participated in the Keto Clinic, where families of children who experience seizures check in with the neurologist and the dietitian regarding the child’s ketogenic diet.  In the oncology unit, I was able to learn so much about childhood cancer and see firsthand the ways cancer can affect nutrition status.  I was fortunate to get training on some very complex cases, which I know will help me be a stronger dietitian.  

Another aspect of CNMC that was different than my primary clinical rotation is that both of the dietitians I shadowed attended rounds every day.  After seeing each patient, the doctors asked the dietitian if she had any comments, opinions, or concerns.  This happens everyday, for every patient.   Children need relatively more nutrition than adults, and in a faster time.  If a child isn’t eating, you can’t wait 5 days before considering alternative nutrition, so the dietitian’s role is extremely important.  In the oncology unit, the RD worked so closely with some families that she knew all the feeding habits and quirks of the child.  This rotation allowed me to see a dietitian working closely with a doctor for the success of a patient, and that was pretty inspiring.

Overall, I was fascinated and blown away by the complexity of caring for children.  I knew I would get a variety of experiences with this internship, but the rotation at CNMC solidified that. I now have finished five rotations, and have been exposed to so many different people and work settings, from food service to corporate wellness, and now to pediatric nutrition.  Working with children at CNMC is an opportunity that many dietetic interns don’t get to experience, and I am very grateful for my short time there.  I got a glimpse into the world of pediatric nutrition, and it is awesome.

Me at my case study presentation on failure to thrive and weight loss in a 6-month old female.

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.

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

On 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.

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.