New Rotation – What Does a Clinical Dietitian Do?

This past week I started a new rotation.  This rotation will include the majority of my objectives from Medical Nutrition Therapy II and the Clinical Concentration.  I will be here for about six weeks and am excited to take on a new challenge and get more experience in the clinical setting.

There are a variety of hospitals in the area and many dietitians that I will get to work with over the next few months so that I can experience the greatest diversity in patients and conditions. This first week I primarily spent my time with surgical and neuro patients on the floors and in the intensive care unit (ICU).  Due to the severity of these patients’ conditions, many of these patients required tube feedings, which is also known as enteral nutrition – stay tuned for a post specifically about enteral nutrition! In the weeks to come I will have a chance to work with trauma, pediatrics, rehab, cardiac, behavioral medicine, weight loss, cystic fibrosis, diabetes, transplant, and even the wound clinic!

So before I get too far into this rotation I wanted to provide a little background so you can start to understand what exactly it is that a clinical dietitian does!  A clinical registered dietitian (RD) will typically have following responsibilities:

  • Identify patients at nutritional risk
  • Provide nutrition care using the Nutrition Care Process (see below)
  • Determines the nutritional needs and diet restrictions for patients
  • Plans therapeutic diets and implements preparation and service of meals for patients, which includes tube feedings, parenteral nutrition, and modified texture diets.
  • Instructs patients and their families on healthy eating and/or special diets
  • Participates in interdisciplinary discussions and meetings with other health care providers

What is the Nutrition Care Process?

The NCP is a systematic approach to providing quality nutrition-related care.  It is divided into four separated, but interrelated steps: assessment, diagnosis, intervention, monitoring/evaluation.

  • Nutrition Assessments – obtain, verify, and interpret data to identify nutrition-related problems, their causes, and their significance. Five main domains:
    • Food/Nutrition Related History:
      • Examples include:
        • Allergies, intolerance, special diets
        • How has the patient been eating?
        • Access to food
      • Anthropometric Measurements:
        • Examples include:
          • Height and Weight
          • Calculate BMI, Ideal Body Weight, Adjusted/Feeding Body Weight
          • Any weight changes?
          • NOTE: use this information to calculate calorie, protein, and fluid needs
      • Biochemical Data, Medical Tests, and Procedures:
        • Examples include:
          • Lab values, test results, surgeries
      • Nutrition-Focused Physical Findings:
        • Examples include:
          • Edema, skin breakdown, hair loss
      • Client History:
        • Examples include:
          • Previous health conditions
  • Nutrition Diagnosis – describe nutrition related problem using standardized language
    • Commonly referred to as a PES statements
      • Problem, Etiology, Signs and Symptoms
  • Nutrition Intervention – actions used to remedy a nutrition diagnosis/problem
    • Calculate tube feeding prescriptions
    • Calculate parenteral nutrition prescriptions
    • Recommend nutrition supplements to meet calorie/protein needs
    • Modify diet consistency or texture
    • Provide nutrition education or counseling
  • Nutrition Monitoring and Evaluation:
    • Follow the progress of nutrition goals by monitoring weight, labs, intake and/or diet tolerance.

 

Nutrition Care Process

Nutrition Care Process

 

What patients are seen by the dietitian?

Patients of nutrition risk are seen by the RD – This can be determined by:

  • Admitting diagnosis, condition, or chief complaints.  Common examples include:
    • Bowel Obstruction/Ileus
    • Burns
    • Cancer
    • Celiac Disease
    • Cirrhosis
    • Chronic Kidney Disease
    • Cystic Fibrosis
    • Diabetes, new onset
    • Dysphasia
    • Hepatic Encephalopathy
    • Malnutrition
    • Pancreatitis
    • Renal Failure
    • Renal Transplant
    • Spinal Cord or Traumatic Brain Injury
    • And many more…
  • NPO/Clear Liquid greater than 3 consecutive days
  • New tube feeding (enteral nutrition) orders
  • New parenteral nutrition orders
  • Specific lab values:
    • Low albumin (<2.5 mg/dL)
    • Low prealbumin (<16 mg/dL)
    • High blood glucose (≥200 mg/dL X 3 consecutive results)
    • NICU: Phosphorus (>600 U/L)
    • NICU: Bilirubin (<4.5 mg/dL)
    • NICU: Alkaline phosphatase (> 2 mg/dL)
  • Consults made by MD, RN, Pharm D, ancillary or patient’s family.
    • May include a request for: an assessment, visit, calorie count, tube feeing, parenteral nutrition, or education.

 

References:

http://www.eatright.org/HealthProfessionals/content.aspx?id=7077

http://andevidencelibrary.com/ncp/inc/circle.gif

West Virginia Diabetes Symposium – 2013

These past three days I have my time at the West Virginia Diabetes Symposium that was held in Morgantown, WV at the Waterfront Place Hotel.  This is an annual event that has been in existence for the past 13 years.  This year the conference was entitled “Bridging the Gap with Education.” This conference is attended by physicians, physician assistants, dietitians, nurses, and various other health professionals alike.

On the first day of the conference I attended two sessions:

  • “Diabetes Prevention in the Real World: The Group Lifestyle Balance Program” – Kaye Kramer, RN, DrPH, CCRC
  • “Role of Physical Activity in Diabetes” – Andrea Kriska, PhD

West Virginia has a fairly poor standing when it comes to national health measures. Below are a few statistics to give you a mental representation of the issues this state is facing:

  • 32.4% of the WV adults are obese = 3rd highest in the nation
  • 35.1% of WV adults participate in no leisure-time physical activity or exercise
  • 12% of WV adults have diabetes = 4th highest in the nation
  • 12.3% of WV adults have cardiovascular (heart) disease = 1st highest in the nation

As you can see, West Virginia has a multitude of issues that stem from the high obesity rates in the state.

Are familiar with diabetes? If not, here are few things you should know about diabetes:

  • There are a two main types of diabetes; Type 1 and Type 2.
  • Type 1 Diabetes only accounts for about 5% of all diabetes cases. It is typically diagnosed in childhood or early adulthood.  With Type 1, your body does not produce any insulin.
  • Type 2 Diabetes accounts for the remaining 95% of all diabetes cases.  It can be diagnosed at any time in life. With Type 2, your body produces insulin but your body does not respond to it like it should – this is called insulin resistance.

The lab criteria is the same for any type of diabetes in order to be diagnosed you must meet one of the following criteria:

  • Symptoms of diabetes AND casual plasma glucose of 200mg/dl or above
  • Fasting plasma glucose of 126mg/dl or above
  • 2-hr plasma glucose of 200mg/dl or above during an oral glucose tolerance test
  • Hemoglobin A1c greater than or equal to 6.5%

Exercise can be a huge contributor to overall health!  Remember exercise can be any form of physical activity that gets your body moving.  Exercise has been proven to have a positive impact on:

  • Coronary heart disease (CVD)
  • Cancer (certain types…e.g. colon and breast cancer)
  • Gallbladder disease
  • Bone health
  • Mental health
  • Osteoarthritis
  • Quality of Life/Independence
  • Weight management
  • DIABETES!

While diet will contribute more directly and quicker to one’s weight – it has been stated that one of the greatest predictors of who will keep the weight they lost from coming back is… EXERCISE!

One the second and third day of the conference, I attended the following sessions:

Thursday:

  • “Diabetic Retinopathy” – Muge Kesen, MD
  • “Type 2 Diabetes: A Cardiovascular Disease” – Joel Zonszein, MD, CDE, FACE, FACP
  • “Roles and Strategies of Diabetes Support Group Facilitators” – Joanne Costello, PhD, MPH, RN

Friday:

  • “How to Identify Type 1 versus Type 2 Diabetes, and is There Such a Thing as Type 1.5?” – Brian Ely, MD
  • “Pharmacological Management of Type 2 Diabetes Mellitus: Highlighting the Benefits and Limitations of Each Treatment” – Angel Kimble, PharmD, BCPS
  • “Developing Cultural Competence in Health Care Providers” – Pedro (Joe) Greer, Jr., MD, FACP, FACG

Diabetes wordcloud

References:

– American Diabetes Association, http://www.diabetes.org

– West Virginia Diabetes Symposium & Workshop, http://dsw.ext.wvu.edu/

Final Reflections on WVU Dining Services Rotation

After spending 5 weeks rotating with WVU dining services, working with the dietitian and food service staff, I have a much more complete view of the role of a food service dietitian and a greater appreciation for the work they do.  Over the past five weeks I have been able to: work with food service administration to design staff in-services, wellness programs, and plan employee schedules; work with production staff in multiple dining facilities to learn about cash operations, assist with food preparation, design production schedules, and assist with catering events; conduct temperature, quality, and waste studies; assist with the farmer’s market and hold a student forum to promote local foods; design new meals and put together week-long menus, conduct recipe and cost analysis; and design and conduct a process improvement project on portion control.  In addition to food service activities, I have managed to attend and conduct nutrition counseling sessions, assess body composition, create meal plans, lead and assist with grocery store and dining hall tours, speak with athletic teams, and observe the interactions between the strength and condition staff, athletic coaches and the sports dietitian.  These past five weeks have been busy with a wide variety of activities to ensure that I walk away from this experience fully prepared to tackle the food service industry as a registered dietitian.

My favorite part of the rotation was the week I spent with the sports dietitian.  I had never imagined that I would end up liking sports nutrition as much as I did.  I found it fascinating and very enjoyable to work closely with student athletes.  This was also my first experience with outpatient nutrition counseling and I enjoyed that very much and was surprised how naturally it flowed.  I learned a great deal from the dietitian and listening to her converse with athletes and from her feedback on my counseling skills. (See my previous blog post about this section here!)

I learned so much from each of these activities and how the entire process works together to seamlessly serve thousands of students each day.  I learned the importance of knowing job descriptions in order to be able to contact the correct individual with concerns or consultations. In such a large institution it can seem overwhelming to determine who does what but after my time spent here I realize that that aspect just takes time.  I feel confident in my abilities and my understanding of the role of a dietitian in a food service organization and I can see the need to refill the open position with WVU Dining Services as soon as possible.

I find it very interesting when you think about how many different allergies and diets the staff must accommodate here at Café Evansdale.  This is definitely a skill I need to refine prior to working in a food service establishment.  It is difficult to know exactly which items contain some of the not-so-common allergens.  Part of learning this would come with time and dealing with this on a regular basis and becoming familiar with the food that is served.  I am thankful for having this opportunity to complete this rotation and have learned a tremendous amount of information that has helped me understand food service on a larger scale.

Sports Nutrition with West Virginia University Athletics

This past week I had the privilege of working with the board certified sports dietitian for West Virginia University.  I never thought I would enjoy it nearly as much as I actually did!  I had the opportunity to test body composition, go over the results, conduct nutrition assessments and consultations, help athletes set goals, and even speak with entire teams regarding nutrition. 

Body composition testing and results was the justification for most of our appointments. It is extremely important for athletes to know where they stand and to determine if their body promotes optimal performance for their sport.  While BMI (Body Mass Index) is the most commonly talked about, it is almost never used with athletes.  BMI is really just an over simplified way to assess height and weight.  BMI should not be looked at on athletes because they typically have a large amount of muscle which weighs more than fat.  Instead of BMI, a body composition test will determine the amount of lean body mass (organs, bones, and muscle) and the amount of fat mass an individual has.  A healthy range for females is between 18-28% fat mass but it is not uncommon for athletes to get down below that.  As long as the female is performing well and still menstruating then she may get as low 10%.  Males have a healthy range from 10-20% but it is not uncommon for male athletes to get down to 5% before it is of a serious concern.  

Each sport has different dynamics and different demands.  For example, gymnastics and cross country athletes tend to be leaner where as football players will tend to be much larger.  The sports dietitian will meet with all the athletes at WVU individually to discuss their body composition and works closely with the strength and conditioning staff to help them reach their optimal performance.  In addition to completing individual consults, we completed dining hall tours, grocery store tours, spoke with all the wrestlers and gymnasts as a team, spent time in the weight room with the football players and spoke with the strength staff, and observed the menu planning meetings for traveling sports.  This rotation has greatly improved my confidence and interest in sports nutrition.