By: Stephany Singh

While there are more than 160 known food allergens only eight have been considered major allergens and are required to be listed on food labels. But did you know that there are now nine major allergens? As of January 1, 2023, sesame has been added to the list.

You may be wondering why I am giving you this information. At my recent dietetic internship rotation at the Manna Food Center, I was tasked with creating an infographic for the staff in both English and Spanish. After I  developed the infographic, I had the opportunity to provide a 10-minute in-service for those who worked in the distribution center. I was up for the challenge.

 In addition to sesame, the other allergens include peanuts, crustacean shellfish, eggs, wheat, soy, tree nuts, fish, and milk. It is important for the Manna Food Center staff and volunteers to be aware of this information to keep their customers safe. This information is especially important for those who sort the donated foods and pack the specialty boxes.

Food allergy is a potentially life-threatening immune system reaction that occurs soon after eating a particular food. Even a tiny amount of the food causing the allergy can trigger signs and symptoms such as digestive problems, hives, or swollen airways.

Food allergy is a pathological reaction of the immune system triggered by the ingestion of a food protein antigen. For instance, if you have an allergy to cow’s milk, your immune system identifies cow’s milk protein as an invader or allergen. It then overreacts by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction. Food allergy reactions can be mild to severe and, in some people, may cause a life-threatening reaction known as anaphylaxis.

According to the Mayo clinic,, food allergy affects an estimated 8% of children under age 5 and up to 4% of adults. While there is no cure, some children outgrow their food allergies as they get older.

Food allergy is often easily confused with a much more common reaction known as food intolerance. Food intolerance does not involve the immune system and causes less serious symptoms. A food intolerance means either the body cannot properly digest the food that is eaten, or that a particular food might irritate the digestive system. Symptoms of food intolerance can include nausea, gas, cramps, belly pain, diarrhea, irritability, or headaches.

The infographic I developed below gives an overview of the nine allergens and provides a couple of safety tips for the Manna staff and volunteers to follow that may reduce the risk of exposure to an offending food. Additionally, Manna Food Center has a specialty box packing guide which is also useful. For example, if a volunteer is not familiar with celiac disease, the specialty box packing guide instructs them on how to read nutrition labels to ensure they pack items that are gluten-free in the participant’s box. 

The experience of developing this infographic on the Big 9 Food Allergens has empowered me as a future registered dietitian to provide knowledge and education to others in an impactful way. I was able to think freely and strengthen my skill set through the use of a new language. I will lean on this experience to help me make effective social media posts that educate people on common food issues and concerns. My goal for the future is to use impactful infographics like this one to educate others to make sound decisions related to their food choices and overall health.

A Partnership Between a Dietitian and A Speech Pathologist

By: Amber Wall

Reading through multiple clinical notes as a dietetic intern can be overwhelming. There are notes from the nurses, surgeons, occupational therapists, speech pathologists (SLP), and more. I began to question the role of a speech pathologist compared to a dietitian. Prior to this rotation, I thought that only dietitians made suggestions on food consumption. Luckily, I was able to shadow Farlah, a SLP, and her intern to learn more about their expertise. This experience has provided me with a greater understanding of the importance of a second opinion. 

My time with Farlah and her intern, Edith, began with an assessment using a trial tray. A patient on a pureed diet had requested a diet advancement. The purpose of this assessment was to evaluate the patient’s  tolerance to a mechanical soft diet. The meal container included two pancakes and ground sausage. The patient did not like pancakes and consumed only the ground sausage, so the tolerance of the meal he ate was based on the number of times it took to swallow. Also, mouth-clearing and time of mastication were also taken into consideration. Edith placed her pointer and middle finger on the “Adam’s apple” to check for larynx lifting and esophageal closing to allow food passage. The patient appeared to be consuming the food relatively smoothly from just looking at him. Edith informed me that the “Adam’s apple” should rise and fall with ease if the swallow is complete and proper. Improper swallowing, also called dysphagia, may have a pulsing sensation and delayed or reduced motion. While to me the patient seemed to be tolerating his sausage well, Edith noticed a delay and a pattern of multiple swallowing for one mouth full of food. From the surface, this could not be noticed. After pressing my fingers to the patient’s throat, I was able to feel what Edith did.

The results of the physical screen indicated that a  Modified Barium Swallow study (MBS) would be helpful. Farlah, Edith, and I teamed up with radiology to take x-ray videos of the throat cavity.  After being shown by Edith, I was able to set up the barium-coated foods of different consistencies for the patient to eat during the x-ray observation. Barium is used to coat the food, so it is visible in the x-ray. Water was added to the powdered Barium to mimic thin liquids. Barium powder was mixed with applesauce and a fruit cocktail cup to mimic pureed food and a mechanical soft diet, respectively. A whole cookie was topped with barium to mimic a regular diet. From a side profile visual, I was able to witness the patient chewing and swallowing the barium-coated food, which appeared on the screen as a black blob. With the pureed food, the patient was able to clear the throat cavity properly without any signs of aspiration. When the texture increased to the mechanically soft fruit cocktail cup, things changed. I was able to see traces of residue building up in the esophagus and its surrounding cavities. This build-up with each swallow created a small stream of contents going into the airway. When food enters the airway, this is called aspiration. Food in the airway causes choking as the body is trying to remove the particle. As I watched the screen, I could see small and sometimes silent coughs as the patient tried to get down the fruit cocktail. Multiple sips of water were needed to flush down food residues as well. This moment was mind-blowing. Initially, I would have presumed the patient was safe to advance his diet due to him eating his ground sausage without apparent struggle. Internally, the patient’s body was not working properly for him to safely consume his desired food preference at the time. 

Additional screens can be performed by SLP using their “swallow bag”. This bag consists of apple sauce, fruit cups, cookies, thickened liquid, cold water, tongue suppressors, and many other assisting tools. These ingredients and tools can test swallowing ability and help determine a patient’s food consistency level. Muscular capabilities are then tested through an array of small mouth movements. This includes smiling, puckering lips, sticking the tongue out, and more. Dental orientation is also assessed at this time. The experience and array of information were very valuable to me as a dietetic intern. I was able to visit patients with my eyes wide open. I began to pay greater attention to other factors learned from shadowing Farlah and Edith. I was happy to include these factors in my skill box, in addition to assessing for muscle wasting, fat wasting, and edema, which were already a part of my assessment practice.  After performing these exercises, Farlah and Edith made a prediction about the cause of dysphagia and determined if the patient would benefit from seeing other health providers.

Reflecting on my visit with Farlah and Edith, this hands-on experience was very valuable to me. I was able to be more alert as a dietetic intern when providing patient care. I also was able to review notes with a better understanding and appreciation for SLP’s recommendations. I realized that the best patient care comes from multiple eyes and points of view. The end goal is to optimize the health and safety of the patients we are serving. Many tools and resources are utilized to assess and assist in patient care. Getting a second opinion from other professionals, especially from those with slightly different backgrounds, is a powerful asset. Having spent this day with another professional has provided more insight into why second opinions are so important in health care. Since then, with each note I read in the morning, I appreciate it a lot more. I pay deeper attention to each patient and request additional referrals when appropriate. I want to be a second pair of eyes to other practitioners whenever I can.  A second pair of eyes and hands can save lives. Second opinions matter.

By: Haley Flambaum

Staff relief is a challenging time for interns. It’s a chance for them to solidify their knowledge, work independently and reinforce much of what they learned during their main clinical rotation. During their clinical staff relief, most interns are assigned a floor in their hospital and they are responsible for those patients. The preceptor expects them to see between eight to ten patients per day and update their charts. 

That was not the case for my staff relief.

My first week of staff relief started as normal. I was assigned to Floor 7 of my hospital and I was expected to see and chart those patients each day. Floor 7 did not have any specific types of patients, so I was exposed to a wide variety of medical conditions. I woke up on Tuesday morning of my second week of staff relief with a text from my preceptor saying, “Morning… looks like the COVID bug got me finally. I tested positive this morning and so did our Clinical Nutrition Manager (CNM). So when you get in just screen everyone except those in the Intensive Care Unit. Take as many as you can.” My brain was spiraling at this point thinking about how I was going to be the only inpatient “dietitian” there.  Per protocol, one of my preceptors still had to review my notes and co-sign them. This task was given to our outpatient oncology dietitian. My preceptor and CNM texted me saying that they trusted my clinical judgment. 

At first, I wanted to freak out. I took a much-needed deep breath and thought, “This is an opportunity that not many people get.” I decided that I would take this experience and use it as a way to improve my clinical nutrition skills. If my CNM and preceptor had trust in me, then I had to have trust in myself. I knew that I had the knowledge, gained from my undergrad and the previous 7 weeks of the internship, to guide me to a successful experience. 

I started each day by checking our consult list and then moving to screen regular floors to find follow-ups. My goal was to see every consult and follow-up each day. I screened 13 patients on the first day of solo staff relief. Prior to that, my maximum number for seeing and charting patients was 10. I knew I had it in myself to be effective and manage my time in order to see every patient that needed to be seen. After screening, I would make a sticky note of the categories of patients I needed to see. 

The categories were: 

• Total Parental Nutrition (TPN)/Enteral Nutrition (EN): TPN is a method of feeding that is given through a vein. EN, also known as tube feeding, is a way of giving nutrition directly into the gastrointestinal tract. 

• Follow-ups: Depending on the severity of a patient, that individual will need to be seen for a follow-up. A follow-up occurs after the initial consultation with the patient. If a patient is in a more severe nutrition state, per St. Joe’s Medical Center protocol, a dietitian will see the patient three days after the initial consultation. If a patient is in a mild nutrition state, a dietitian could see the patient a week to ten days after the initial consultation. A follow-up is meant to summarize events that have happened since the last time the patient was seen and to update their nutrition interventions.
• Diet Education: Most diet educations I completed were about following a heart-healthy diet or a consistent carbohydrate diet. For each diet education, I would print a handout for the patient, go over the material with them, and answer any questions the patient had.   
• Malnutrition Screening: Another healthcare discipline will fill out a form based on a patient’s nutritional status. The form covers weight loss, inadequate oral intake, open wounds, and more. The disciplinarian will score these categories. If the patient scores a two or higher, the nutrition department is consulted to talk to the patient.  
• Nothing by Mouth (NPO): A dietitian will go talk to a patient if they have been NPO x five days (three if it is on a Friday).
• Other: Other disciplines will consult nutrition services to talk to a patient and assess their nutrition status. For example, a doctor could consult a dietitian to conduct a calorie count if the patient is not eating properly. 

The diet educations were sprinkled all throughout the day. It is important that the patient receives nutrition education before they are discharged to ensure proper recovery at home. I started with TPN/EN because I knew those would take me the longest. I gained confidence in my TPN/EN calculation skills throughout this clinical rotation, so I was excited to be exposed to more opportunities to provide recommendations. I would bring my formulary card when I saw each patient. The formulary card contained all the information regarding my hospital’s enteral nutrition supplements and oral nutrition supplements. I knew this would be a valuable tool if a patient ever had a question about supplements. The formulary card also helped me decide which enteral nutrition formulas would work best for my patients that needed them. 

On average, I would see 10 patients per day. I wouldn’t have had the confidence to handle the situation on my own if I didn’t learn so much during my clinical rotation and gain the trust of my preceptors throughout the rotation. With the help of what I learned in my undergrad and what I have been learning through this internship at UMD, I was able to use that knowledge to help me succeed. By the end of the first week, I was seeing patients on my own and advancing my charting skills. With each completed note, came more confidence in myself and more trust from my preceptors. I was incrementally building my clinical judgment.  This experience taught me so much, especially how to have trust in myself and my nutrition skills. I learned what it would be like to be a clinical dietitian. I learned how to adapt to different situations depending on the patient. I also learned that it is okay to not know everything. This experience taught me the benefits of being flexible and adaptable in the world of dietetics … you never know what is coming your way.

By: Rachel Amsellem

Swallowing, of course, is essential for patients to get the energy, fluids, and nutrients they need. During my rotation at Meritus Medical Center, I learned how speech language pathologists (SLPs) and dietitians work together to assess and manage swallowing problems in patients.  I was extremely interested in seeing a modified barium swallow (MBS) during my clinical rotation at Meritus Medical Center. Over the summer, I had to get a CT scan with contrast. I had no idea what to expect. I was told to drink a barium solution the night before and morning of the CT scan. I now understand that the barium was used as a type of x-ray dye. In a barium swallow procedure, the healthcare team can see the movement of the digestive tract. Radiologists and speech language pathologists (SLPs) are able to visually pinpoint where a patient is having trouble swallowing. They take a series of videos and images using X-rays of the mouth and throat as a patient swallows food and liquid of different consistencies.

I followed the SLP, Angela, to the first floor of the hospital where the patient was already in the X-ray room awaiting the study. We put on lead aprons and prepared different consistencies of drinks and food for the study. In dixie cups, Angela prepared honey-thick, nectar thick, and thin liquid drinks using the barium to mimic liquids with those consistencies.  In addition, she mixed a cookie with a barium pudding to represent soft and bite sized foods and graham cracker with a barium pudding to represent regular foods.

The MBS took around 10 minutes. Angela went one by one and announced which consistency she was giving the patient as I watched the X-ray on the screen and monitored the patient swallowing in real time. After the study, Angela labeled each video segment based on the consistency and if she saw any fluid enter the trachea. Angela was pleased because the evidence in the MBS matched the bedside swallow study she performed previously.

In addition, I was able to see some therapies that SLPs use to help patients with dysphagia, the official term for a swallowing impairment or disorder. Angela encouraged the patient’s swallow capability by implementing a chin tuck method. Reminding the patient about this therapy allowed maximal airway protection.

During this rotation, I also learned about the important role dietitians play for patients with dysphagia. Dietitians plan their menus, ensuring appropriate food textures and fluid consistencies are available while they are in institutional settings. They also counsel clients with dysphasia. In addition to the right consistency, many with dysphagia need guidance on good food choices that will help them get the nutrients and hydration they need. Meritus classifies liquid consistencies into four categories: thin, nectar, honey, and pudding. More facilities are moving towards the International Dysphagia Diet Standardization Initiative (IDDSI). The IDDSI is a framework which describes different food textures and drink thicknesses.  Check out this handout I made below which includes different fluid consistencies and its equivalent in the IDDSI.

In looking at my experiences related to swallowing issues, I think it is beneficial for SLPs and dietitians to know what swallowing techniques and other recommendations they each are providing a patient.  By doing so, they reinforce good swallowing habits and make it easier and safer for patients to swallow. Overall, dietitians and speech language pathologists can provide coordinated, client-centered care when working together.