The Art of Mastering a Nutrition Education

It was 9 weeks ago but I remember it like it was yesterday. My hands were shaking and a glistening sheen of perspiration had appeared on my forehead. I was unable to create any coherent thoughts; I was about to give my first nutrition education to a patient. My first nutrition education was a weight loss education for a 500lb patient. I left this man’s room questioning the effectiveness of my education. Now that I am nearing the end of this clinical rotation, I like to think I’ve become more proficient in delivering nutrition education to patients. Here are a few things I’ve learned to help me in educating patients.

Meet People Where They Are

To put it simply, “meet people where they are” means inferring and understanding how likely they are to make dietary changes in their life. Most of the patients I educated did not seem interested in altering their diets. To meet them where they were, I usually tried and find one easy change they could make to their diet and have them focus their efforts there. In the case of the 500lb man, meeting him where he was involved understanding the difficulties that come with weight loss, his age, and his motivation to actually lose weight. This was a middle aged man who had been carrying extra weight his whole life and he had expressed several times his interest in an outpatient weight loss clinic. To meet this patient where he is, we decided that switching from regular soda to diet soda would be the easiest change to make that would promote weight loss.

Handouts

Handouts can be a very useful tool when providing nutrition education. Some patients are in pain, half conscious, or uninterested in changing their diet, so they may not hear or retain dietary guidance when it is provided; this is where handouts come into play. Many professional organizations offer online nutrition education handouts. I prefer using handouts from the Nutrition Care Manual (NCM). The NCM is a product of the Academy of Nutrition and Dietetics and contains a section on client education with general information about nutrition and varying disease states. Each handout features the relation between nutrition and the disease, foods allowed and foods to avoid, and a sample 1-day menu that follows the prescribed diet, all formatted in a professional manner. The handouts are a great resource for dietetic interns or new dietitians, too, as they can be a prompt for important points to cover with patients.

A sneak peek at the NCM diet education page

Practice, Practice, Practice

As the old cliché goes, practice makes perfect. In my opinion, nothing prepares you for delivering nutrition educations more than practice. At my clinical site, we would receive a fair number of nutrition education consults which allowed for plenty of practice. On days where my floors lacked education consults, I would ask the dietitians on the other floors to send me any education consults they received. Being able to practice has helped me find a balance between simplifying the educations while giving enough detail to highlight what is most important nutritionally for each patient.

Although I am not yet an expert educator, I have learned a lot about providing sound, actionable nutrition education to patients.  I plan to use these three approaches to continue to hone my counselling skills.

Food & Friends Joint Class Day: Building Community to Promote Health

Eating nutritious meals each day is essential for everyone to maintain a healthy body, especially those suffering from critical illnesses. On Monday, March 13, the University of Maryland (UMD) College Park Dietetic Interns joined interns from several other programs in the area for a joint class day at Food & Friends in NE, DC. We all worked together to prepare and package healthy meals for clients who require special meals because of their illness. It was a day filled with learning, collaborating, and volunteering to help those around the community who suffer from critical illnesses receive healthy food.

The Food & Friends website states, “Food & Friends is the only home-visiting nutrition service that delivers hope by the meal -- specialized, fresh, delicious.” Food & Friends is a nonprofit that employs about 50 staff members and benefits from ~9,000 volunteers per year to “foster a community caring for men, women, and children living with HIV/AIDS, cancer, and other life-threatening illnesses by preparing and delivering specialized meals and groceries in conjunction with nutrition counseling.” On our day of volunteering, we were able to actively participate in the kitchen by expediting meals or helping to package groceries-to-go.

Additionally, on our joint class day we had the opportunity to meet two Registered Dietitians (RDs), Priscilla Dhas, Nutrition Services Manager, and Anna Kinard, Community Dietitian. They explained that the dietitians at Food & Friends provide personalized nutrition counseling, develop 11 specific meal plans for each diet need, perform nutrient analyses, instruct cooking classes, create educational handouts, ensure quality control, and participate on various committees.

Our class day at Food & Friends was great because we were able to collaborate with interns from other programs, actively participate in the preparation of food for the clients, and learn from several lectures given by RDs. Joint class days are nice because interns have the opportunity to see other interns, but today was extra fun because we actually got to work side by side with people we didn’t know. At the beginning of the day, everyone was assigned to one of two groups, which prevented us from sticking with our usual partners. The groups took turns volunteering in the kitchen and learning from the lectures. We were also provided a delicious lunch!

Prior to volunteering at Food & Friends, I didn’t know an organization like this existed. However, I do think organizations like Food & Friends are necessary, especially for those who need special diets and have serious nutrition needs or considerations due to their medical therapies! Moreover, this experience was very insightful as I learned that Food & Friends has no requirements for income.  It serves those with life threatening diseases, compromised nutritional status and a limited ability to prepare their own meals. A lot of people don't have a caretaker who can prepare and deliver meals everyday and this area is where Food & Friends really helps. Caretakers typically have to juggle their job, house, and family in addition to now helping their loved ones or in some cases their neighbor or friend go to appointments and receive adequate food. Food and Friends is making a tremendous difference in the lives of both those living with a serious illness and those who are taking care of the patient. Finally, this experience showed me another work option for RDs!

MAND State Legislative Interactive Workshop

On February 8th, 2017, the University of Maryland interns joined forces with members of the Maryland Academy of Nutrition and Dietetics (MAND) in Annapolis to rally for nutrition-related bills. Teams spoke with Maryland Senators, Delegates, and their staff to encourage approval of bills that, if passed, will benefit nutrition professionals and residents alike. Each team leader was equipped with a list of bills to discuss along with related talking points.

My team and me with Maryland Delegate, Alonzo Washington

The bills that we promoted include:

• Health Care Practitioners-Cost Estimate A huge barrier to effective healthcare is the cost. This bill will, in theory, would provide the public with estimated costs of services prior treatment. Unfortunately, sometimes the number of treatments or exactly what insurance will pay (or not pay) is not known in advance as it may change depending on later testing results, insurance reimbursement changes, etc. For this reason, MAND supported the concept, but opposed the bill based on its approach, i.e. its “language”.
• Update of Advisory Board & Councils on Health & Wellness
  With the help of MAND testimony given in January, a bill was approved which allows dietitians to serve on the Council on Health & Wellness. During our visit we thanked legislators for supporting the bill.
• Workgroup on Health in All Policies
  We asked that dietitians have the ability to join this workgroup, as dietitians have a unique perspective on health, wellness, and community that can strengthen the group. The mission of this group is to collaborate to improve health and healthcare accessibility in both the private and public sectors.
• Maryland Farms & Families Act
  With this bill, food-insecure Maryland residents will have double the financial support to buy fresh fruit and vegetables at farmers markets. Although this bill will be financially cumbersome for the state, it will help SNAP and WIC participants by allowing for double the purchasing power and will also help local farmers thrive by promoting farmers markets.

What I took away from the workshop:

Before this interactive workshop, I had minimal interest in state legislation. I now have a new respect for lobbyist and the legislation process at the state level. Each representative that my team spoke to was kind and welcoming. I was impressed by the attention that was given to our quick speech. What I appreciated the most, however, was that each conversation was approached with logic and a touch of empathy--the very combination that drove me to a career in nutrition.

The week before this workshop, I attended a committee meeting as part of my rotation with the Agency on Aging. This committee is dedicated to increasing accessibility of healthcare in the “Health Enterprise Zone,” an area of Maryland that is a healthcare desert. Before the meeting, I knew nothing about the situation but immediately felt a calling to do something. Little did I know that a week later, I would be promoting the “Workgroup on Health in All Policies”  bill, which could help that very situation. My team met with state senator, Joanne C. Benson, who shared our passion for the “Workgroup on Health in All Policies.” She spoke to us about how, if enacted, this bill will improve access to healthcare, especially for those in the Health Enterprise Zone.

This workshop has inspired me to stay informed and active on similar state and local-level nutrition-related bills. It is inspiring to know that I don’t need to a have a career in politics to make a difference.

Nutrition Informatics Interns take on Critical Care

As dietetic interns at the University of Maryland College Park, we have the opportunity to attend joint class days with other internship classes in the area. We recently attended a critical care joint class day hosted by the University of Maryland Medical Center in Baltimore. This day of lectures went in-depth on several critical care topics and really complemented my clinical rotations.

Key points from the critical care lectures:

Nutrition Assessment in Critical Care and Trauma

First, we learned about the starvation and stress responses of the body.  A starvation response occurs in the body when glycogen stores are depleted; this can be reversed by feeding. A stress response occurs when cytokines and counter-regulatory hormones induce a catabolic state; this can be blunted by feeding but cannot be reversed. Nutrition assessment for the critically ill patient includes nutrition status, etiology and severity, and co-morbidities.

Challenges in Enteral Nutrition

Enteral nutrition can be defined as “nutrition support for a patient with a functional and accessible GI tract who cannot or will not meet needs on an oral diet.” Enteral nutrition is strongly preferred over parenteral nutrition, which should only be used when a patient does not have a functioning gut. Although it is preferred over the latter, complications can still arise when using this form of nutrition support. Some complications of enteral nutrition include: high gastric residual volumes, clogged tubes, diarrhea, medication interactions/the need for some medications to be held, hemodynamic instability, refeeding syndrome, and the need for specific formulas based on disease state (e.g. diabetes or chronic kidney disease).

Respiratory Status and Nutrition Considerations

Respiratory failure can be defined as “the failure of the respiratory system to oxygenate or ventilate.” There are two types of respiratory failure: hypoxemic (reduced O2 in the blood), and hypercapnic (elevated CO2 in the blood). For patients experiencing respiratory failure, indirect calorimetry is the best way to estimate nutritional needs. In fact, indirect calorimetry is considered the gold standard for estimating nutritional needs for most patients.

The joint class day at the University of Maryland Medical Center ended with a game of Jeopardy, which was a fun a way of testing what we had just learned.  All internship classes were divided into different teams, allowing us to meet interns from other programs . Overall, our class learned a lot. Even though our program does not have a clinical emphasis, it is still important that we understand complicated conditions that may arise in a clinical setting. We now have a stronger understanding of the nutrition therapy needed for critically ill patients and complicated disease states.