Building Skills to be an RD: Counseling as the Key between Nutrition Knowledge and Patient Outcomes

Imagine a busy weekday: maybe you’re running late and quickly grab something out of the fridge for breakfast. You go to the cafeteria for lunch and pick out the chef’s special, chips, and an orange juice. On the way home, you make a last-minute stop at your favorite fast food restaurant since you have soccer practice and will be short on time.

Now imagine you have type I diabetes. Do you know how many grams of carbohydrate were in each of your meals, and would you be able to figure it out before you ate them? How many servings were in that bottle of orange juice? What is a carb, anyway? Would you be able to check your blood sugar 4+ times per day, and give insulin accordingly? These are the questions I began asking myself during my recent rotation in the Children’s National Medical Center (CNMC) Endocrinology and Diabetes Clinic. Would I be able to perform the same tasks that we were asking of children and their families?

This past month, I had the opportunity to work for two weeks alongside the endocrine and diabetes pediatric outpatient dietitian at CNMC. Most patients that I saw had type I diabetes, and self-management is a 24/7 job with both nutrition and insulin. Patients and their families undergo a crash course in type I diabetes and how they can manage it at home.

Think back to the scenario of a busy week day. Imagine all the changes you would need to make in your day to be successful and make sure that you’re eating the correct amount of carbohydrates at each meal, and that you have your meals at the right times. After working with the children and their families at CNMC, I learned that these skills are part of the everyday job of managing type I diabetes. Imagine, too, that you were newly diagnosed.

Trying to learn all this new information, especially if you don’t work in either nutrition or the healthcare field, is considerably overwhelming. During my rotation, I learned how a dietitian can counsel a child and family to help them manage diabetes factoring their own lifestyles, needs, and wants. Some families were ready to count carbohydrates and look at blood sugar trends, while others may prefer focusing on food groups and portion sizes. This was demonstrated by two families that I saw. The first family was a new diagnosis at the age of 8, and the second family was for a follow-up with a 15-year-old. The first family wanted to learn everything they could to count carbs, time meals, and manage blood sugar levels during exercise. The second family was experiencing “diabetes fatigue” after having been diagnosed 11 years ago. Their fatigue came from managing diabetes on a daily basis for so long, and so the instruction was simpler to help get them back on track for success. The big take-away for me was that I need to meet my patients where they are so that I can assist them in creating achievable goals.

Before starting this rotation, my goal was to gain clinical knowledge in pediatrics. I achieved this goal and so much more. I also acquired valuable counseling skills, which are needed for meaningful visits with patients and their families. Just calculating patients’ nutrient needs and telling them what they need to do isn’t enough. To really have a strong impact, I will need to use those counseling skills to clarify what patients are telling me, gather important information from them, provide them with information on their conditions, and train them so that they can make positive lifestyle changes and adhere to their treatments’ protocols.


Not all families are ready to count carbohydrates down to the gram in the foods they’re eating. At times, the better approach is to give simpler instruction on portion sizes and following the “MyPlate method.” Families need to feel successful in their management and slowly build more skills from there. An important part of counseling is meeting a patient where they are and tailoring your nutrition advice to what fits their life and needs.

Pediatrics adds another level to counseling as often not only are you counseling the child, but you are counseling their caregiver as well. Understanding the different obstacles between age groups of children is important too. Counseling a six-year-old will look very different from counseling a sixteen-year-old. The teen years add new obstacles as children look to gain independence and are no longer under the full care of their parents.

This was my first experience working in an outpatient setting to understand the interaction between a dietitian and their patients using counseling and education. The skills I gained from this rotation are applicable anywhere I go in clinical dietetics. It is always important to listen to your patient and be able to judge at which level they are ready to receive information. It’s important that the goals a patient makes are achievable, and it’s the small steps along the way that can add to big changes.

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