Importance of a Diverse Perspective: Behind the scenes of an FNS Dietitian’s Job 

Team working together in the office

By: Stephany Singh

Ever wondered what and how you can advocate for inclusion? This thought has crossed my change-agent mind throughout my life. What would you know, the opportunity truly presented itself in the most unlikely of places. 

I have been provided the opportunity to work with the United States Department of Agriculture (USDA) in their Food and Nutrition Service (FNS) agency. I am currently finishing off my fifth week and have participated in several groundbreaking meetings and sessions. This experience showed me a different way to make the changes I wish to see in this world.

You may be wondering what FNS does? Well, the Food and Nutrition Service (FNS) website explains it best: the FNS, “increases food security and reduces hunger in partnership with cooperating organizations by providing children and low-income people access to food, a healthy diet, and nutrition education in a manner that supports American agriculture and inspires public confidence.” The USDA has a mission to end hunger and obesity through the administration of fifteen federal nutrition assistance programs including Women Infants and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), and Child Nutrition programs such as the National School Lunch Program. As you may have noticed from what I mentioned, FNS plays an integral role in the accessibility of food to a very diverse population with a mission to increase food security and reduce hunger through nutrition education. Numerous programs are administered by FNS such as the Commodity Supplemental Food Program (CSFP), Child and Adult Care Food Program (CACFP), FNS Disaster Assistance, and Food Distribution Program on Indian Reservations (FDPIR), just to name a few.  

Most of the work I was a part of and got to listen to was focused on the Food Distribution Programs that distribute USDA Foods (FDPIR, CSFP, TEFAP, and USDA Foods for Child Nutrition Programs). 

In the essence of time, I will focus on the complex FDPIR program. FNS works hard to ensure from a distribution standpoint that the USDA foods available list for FDPIR reflects what the participants want and can use. Moreover, I was able to join the FDPIR food package review workgroup meeting. The agenda included a vote for new foods to consider based on previous feedback and discussions with the tribes, which led to food being added like those  found on the 2022 FDPIR Foods Available List. You would think that after the work-group votes, the new foods agreed upon would be implemented, right? Well, not quite! The workgroup must first meet with participants to discuss and vote on the potential foods. It is different from that of the meeting agenda votes, these come from the individual FDPIR participants rather than the workgroup. Think community rather than organizational or governmental. For instance, the workgroup met recently and the consensus from that meeting was to add the five foods previously identified and discussed with the tribes. However, the list then needed to move to another agency of USDA, the Agricultural Marketing Service (AMS), of which FNS is in constant communication. AMS conducts market research to identify USDA approved vendors that have the capacity to supply the product based on the volumes needed. All USDA Foods are 100% domestic, so they are grown, processed, and produced in the United States and its territories. Market research ensures that approved vendors can meet the USDA specifications according to what is stated in the  Product Specifications & Requirements and demand before it could  be added to the foods available list. 

In addition, I have gained knowledge by completing the last four weeks learning how government entities work and collaborate with contractors, stakeholders, and organizations, and, more importantly, the role of dietitians. I have analyzed information on how to make FDPIR stronger through the introduction of new food options that are culturally inclusive of the tribes and diverse, I have completed three featured foods for the  FDPIR quarterly e-letter. The featured foods that I was tasked with completing were catfish filets, pollock filets, and canned salmon. The goal of each of these featured food articles was to serve as an introduction to the food item, their nutrient-density, where they are sourced and to provide readers with recipes on how to incorporate these items to their diets. In order to complete this task, I had to read the specifications for each item. The specifications are a five to ten page document that elaborate on how the item is sourced, packaged, labeled and stored, to meet the USDA standards based on AMS research and recommendations.

I am currently in the process of completing two additional tasks which require in-depth research on:

  1. The compilation of recipes and/or cookbooks that are tribe specific for FDPIR staff to use as a resource to incorporate potential nutrition education.
  2. The creation of recipe ideas based on what CSFP offers. 

The goal of the tribe specific recipes is to ensure tribes have the necessary resources to provide their participants through FDPIR, and the goal of the CSFP recipe ideas initiative is to ensure the participants are provided with realistic ways to utilize the foods provided.

With just one week remaining at this rotation, I am eager to learn even more. This experience has shown me a way I can be a change agent in this field, like my preceptor. I have a new diverse perspective on ways dietitians can not only help people eat to sustain good healthy lifestyles, but also make a positive social impact.

Communication Considerations for Healthcare

 By: Julie Henderson

Communication isn’t always easy. However, obtaining good information from patients or residents on the condition of their health, personal preferences concerning their diet, care in general, social circumstances and lifestyle, in addition to a good medical and family history, is crucial to good health. During my recent rotation at Future Care Irvington in Baltimore, MD, I was given many opportunities to engage with residents and I recognized that gathering this information could be challenging for various reasons. This facility cares for people approximately twenty years old and up. Not all residents stay long term, as some go through rehabilitation and are sent home. Either way, I was given opportunities to gather history and dietary information from many residents to better care for each one. To do this, I needed to consider ways to gain the information from individuals who were unable to easily communicate.

First, there are many different types of communication roadblocks when giving information to or receiving information from a resident. 

  • Residents may have vision or hearing problems that affect their ways of transferring information. For hearing considerations, which are heightened while wearing a mask, I asked each resident if they could hear me at my regular tone before continuing to talk with them. 
  • Psychological status, education level, language barriers and readiness to make changes are important factors to consider, too. Some of the residents I worked with had strong accents, but I was able to decipher them by actively listening and repeating what I had heard. 
  • A few of the residents that I encountered had communication struggles due to strokes that caused slurred speech and sometimes muscle weakness in parts of their bodies. I assessed a resident who informed me that he needed assistance with cutting up his food and opening condiment packages because his left side was not functional. I had to listen carefully as his speech was slurred. His deficits could have affected his needed nutrient intake if we hadn’t known to provide assistance. 
  • Encephalopathy, dementia and Alzheimer’s disease, all of which affect memory and hinder reasoning, were common disabilities I witnessed. Therefore, the information I gained from these individuals needed to be supplemented with information already in their records, by direct observation and by checking with those caring for the resident. 

I gained experience working with residents who had challenges with speaking. Some had tracheostomies, others spoke very softly and some were without their dentures. I learned to face those I was talking with, listen carefully, and look for gestures and head nods. I wanted to give every resident the opportunity to share with me what they could.

Researching the resident through their medical records first was helpful. I was able to gain background information about each person and get insight on medications that could have interfered with food and nutritional status before I went to see them. I had a resident tell me he wanted bananas and tomatoes occasionally, but because I saw his medical diagnosis in his records, I was able to explain why he doesn’t get those items in his diet. Until I became more comfortable in my role, I used a list of questions from the nutrition assessment computer format to gather and record information about the residents I met. The team uses that information to guide each resident’s care. I asked questions about chewing and swallowing difficulties, if they had their natural teeth or not, nausea, vomiting, bowel movements, allergies, food and beverage preferences, and about their height and usual body weight.

While considering strategies for communication with residents, I thought of many options to gain the needed information for their individualized nutritional care. When entering any resident room, I learned to give the courtesy of knocking and introducing myself. Afterall, this was their home away from home. I made every attempt to talk to them in person and listen intently. If family members or friends were available in person, I included them in our discussion. They often were helpful with filling in missing or additional details. For example, I entered a resident’s room to find his wife was present. While asking questions to the resident, she informed me that he wore dentures and that he would not have them during his stay at the facility for fear of them getting lost. This was valuable information. I made sure we would provide appropriately textured foods for the patient. Right from initial intake, I learned to consider the residents’ cultural backgrounds, as they may not eat or drink certain things due to their beliefs and religious practices. In addition to the residents and their family and friends, another useful source of information was other staff members. Staff could tell what they heard or witnessed about certain habits, likes, or dislikes of the residents.

When working with residents who were receiving enteral or parenteral feeding, the assessments were geared towards gastrointestinal concerns, labs, and well-being. I had to shift gears when speaking with them for information, since they were not eating by mouth. The formula they received was primarily determined by estimated nutritional needs, and then was adjusted, if necessary, due to health concerns and symptoms from the formula itself or the rate of feeding. Observations of visual physical appearance and measurements were done rather than nutrition focused physical exams due to the fragile nature of the residents in long term care facilities.  I reviewed lab results, bowel movement output records, and any pertinent medical records to look for changes in resident status and provided suggestions for a review. I was asked to give my suggestion for a person who had psychological issues and was opening her tube feeding and letting it drain out onto the floor. She was already on nocturnal feeding to assist, but now it wasn’t helping. I recommended giving her bolus feedings to provide her nutritional needs while under supervision.

To conclude, I have been told many times in the internship to “get comfortable with being uncomfortable.” As an intern, going into a room to visit a resident was intimidating at first, especially without looking over the medical records. Also, I initially felt uncomfortable when residents were unhappy, but listening to them was valuable and they had the right to be heard. By the time I finished my rotation, I found comfort in caring for the residents and finding opportunities to get the information needed to help them. I began building relationships and rapport with residents and staff, which was the highlight of my time at Future Care Irvington. I believe with different experiences throughout the University of Maryland internship, I will continue to learn tricks that work to gain the information that I need to best care for those I serve.

Energy Drink Overload

By: Jerrick Knippel

Can you imagine what it’s like to work 24 hour shifts for a physically demanding job? Many firefighters across the country have morning workouts, calls throughout the day that require heavy lifting, may wake up in the middle of the night to extinguish a burning building and, yet, they still need to stay alert for the next call. This lifestyle may eventually take a toll on a person’s combat readiness if adequate recovery isn’t implemented, which is often the case. This is why firefighters tend to look to caffeine supplementation to help keep them energized throughout the day.

While my preceptor and I were working with Fairfax Fire and Rescue, it was apparent that energy drink consumption was prominent among this population. Some people that we spoke with were consuming two or three energy drinks in a day. Eventually, many of these firefighters started to ask the question: “how many energy drinks can I have in a day?” This question didn’t have an easy answer as there is minimal existing guidance on the topic. This required a deeper look into the latest research regarding caffeine consumption to provide an evidence based answer.

The answer became more complex as I reviewed the research. I learned that higher doses of caffeine consumption can increase a person’s heart rate and blood pressure. This may be especially problematic for firefighters, many of whom suffer from cardiovascular disease. Though people may feel more alert with caffeine consumption, the research revealed that energy drink consumption only benefits cognition in those who are sleep deprived. Also, caffeine metabolism is variable and depends on the genetic makeup of each person adding another element to the answer. Additionally, the caffeine content of the brands of energy drinks available in the market varies from 80mg to 300mg. The last component I learned through research is the consequence of the timing of energy drink consumption with regards to the individual’s bedtime. There is no doubt that sleep is king; it’s an important part of recovery. Consuming caffeine too close to bedtime may alter the individual’s sleep, which may negatively impact the individual the following day. 

So, after completing my research, I realized there is a lot to consider when providing recommendations for consuming energy drinks. I decided a flowchart was the best way to help people navigate the complexities of these considerations. To start, if the individual has cardiovascular conditions, then it’s recommended the individual avoids energy drinks. If not, then the individual needs to consider if sleep deprivation is present or not. The next step is to consider the amount of caffeine the individual has previously consumed and at what time. The FDA recommends consuming only 200mg of caffeine at a time. It’s important for the individual to consider how much caffeine is left in their body before consuming an energy drink as the average half life of caffeine is about 5 hours. The next step is to choose the most appropriate dosage of caffeine as there is a wide range between all of the brands. The final consideration for the individual is the timing of dosage since it can disrupt sleep. It’s important to have a clear and concise message when conveying scientific information. This flowchart provides an easy way for firefighters to navigate the many considerations to determine how many energy drinks are appropriate for them to optimize both their combat readiness and their health.

Newly diagnosed diabetes in the acute setting: through the lens of a diabetes educator

By: Olivia Heinz

Through my clinical rotation at Meritus Health in Hagerstown, MD, I have learned an immense amount of new information on type 2 diabetes mellitus. The registered dietitians at Meritus work closely with Crystal Allison, the certified diabetes care and education specialist (CDCES). Crystal is a registered nurse with a master’s degree in Nursing Leadership and Management. Registered nurses, advanced practice nurses, registered dietitian nutritionists, pharmacists, physicians and other healthcare professionals can get certified to become a CDCES. Due to the extreme prevalence of diabetes, especially in America, it is essential to have qualified diabetes educators.

In the acute care setting, the diabetes educators and dietitians work together when managing patients with diabetes mellitus. Diabetes is a multifaceted disease, and treatment and dietary approaches vary tremendously among patients. Oftentimes, the dietitian screens patients for high blood glucose levels and is in charge of dietary interventions. The diabetes educator provides education and guidance for patients who are newly diagnosed with diabetes, including pump and insulin education. The dietitian and diabetes educators then work together to monitor the patient and any needs for additional education.

I had the opportunity to shadow Crystal during an educational session for a patient with newly diagnosed type 2 diabetes. This was an amazing learning experience, as Crystal is an extremely detail-oriented healthcare professional. She provided the patient with a lot of new information, education and guidance. Crystal explained to me that her sessions vary tremendously depending on the status of the patient. It is important for her to first assess the patient’s previous knowledge of diabetes, talk through any symptoms the patient has been experiencing, explain side effects of hyperglycemia and hypoglycemia, discuss carbohydrates and diet, discuss physical activity and finally discuss medication.

Her approaches to sessions with patients depend mostly on their willingness to make behavioral changes, as well as their engagement with the information she is providing. The patient that we saw together had previously made lifestyle changes and had lost a significant amount of weight through dietary changes and increased physical activity. This patient was very engaged during the session and was receptive to any and all information that Crystal provided. I had not anticipated a session of 45 minutes in length, but Crystal pulled up a chair to the patient’s bedside and got to work. The patient asked many questions regarding diet, caffeine intake and insulin usage. She answered all of his questions and together they set a couple of goals that appeared appropriate given his previous lifestyle changes. She also informed him of the free diabetes classes that the hospital offers.

After shadowing this session, I had not only witnessed exceptional delivery of patient-centered diabetes education, but I had also witnessed excellent bedside manner and rapport-building skills. One aspect of motivational interviewing that I have struggled with throughout the internship and my undergraduate nutrition counseling experience has been providing affirmations. In the examples that I have read, affirmations oftentimes seem forced and awkward. Crystal provided her patient with affirmations in an extremely casual manner, applauding him for the changes that he had already made while pivoting the conversation to additional approaches and meeting the patient at a middle ground.

Below is a video that I took of some of Crystal’s props for visual learners. Crystal created the tubes seen in the video out of tomato paste to simulate the blood at different HbA1c levels. HbA1c is a blood test that is used to help diagnose and monitor individuals with diabetes. It refers to the amount of glucose and hemoglobin molecules joined together in the body at a given time. Hemoglobin is the protein in red blood cells that carries oxygen around the body.  The higher the A1C level, the greater the risk of developing complications, such as problems with your eyes or kidneys. 

People with untreated or unmanaged diabetes are at an extremely high risk for poor circulation throughout their bodies. Crystal wanted a simple way to show that as blood sugar goes up, blood flow is impeded because the elasticity of blood vessels decreases and they narrow. The first tube resembles the blood at an HbA1c of 5.1%, which is normal. The second tube resembles the blood at an HbA1c of 8.5%, which would lead to the diagnosis of diabetes. The third tube resembles the blood at an HbA1c of 15.5%, which is abnormally high. Her catchphrase is “Diabetes? Not really a big deal. It only impacts the organs with blood vessels.”

This pivotal experience allowed me to see a lot of diabetes materials and many skills in action, which I plan to use with clients in the future. I look forward to learning more about the complexities of diabetes through the rest of the internship and my future career.

The Misconception About Fiber Intake with Inflammatory Bowel Disease (IBD)

By Meredith Murdock

During my clinical rotation with Children’s National Medical Center, I was able to work with one of the outpatient gastrointestinal registered dietitians. Through this experience, I attended multiple disease focused clinics and observed the dietitian provide patient education for nutrition management. During the inflammatory bowel disease (IBD) clinic, there was a common misbelief around fiber when it came to diet and disease management. Many patients were under the impression that fiber intake should be lowered or omitted completely to care for IBD symptoms. However, this is not the case. It was informative to hear first-hand about some misconceptions that influence the patients and their families so that I could learn to re-educate them to best improve their health. 

Inflammatory bowel disease (IBD) is an umbrella term for two conditions: Crohn’s disease and ulcerative colitis, which are both characterized by chronic inflammation in the GI tract. The exact cause for IBD is unknown; however, having a weakened immune system is a large contributor because of how it reduces protection against environmental triggers. There is also a strong correlation within IBD and genetics which is being seen more frequently through family history and the development of an ineffective immune response. Common symptoms of both diseases include chronic diarrhea, abdominal pain, weight loss, fatigue and bloody stools or rectal bleeding. 

My preceptor explained that the main difference between Crohn’s disease and ulcerative colitis is the area of damage that occurs within the GI tract. People with Crohn’s disease can have intestinal damage ranging anywhere from the mouth to the anus. The damage is described as patches because of how largely spontaneous it is throughout the GI tract and inflammation from the disease can reach through multiple layers of the gastrointestinal wall. Ulcerative colitis occurs strictly in the large intestine, also known as the colon, and the rectum. Damage is described as continuous because of how it affects the entire area, usually starting in the rectum and spreading into the colon. Inflammation is only present in the innermost layer of the gastrointestinal lining of the colon. 

Inflammation in Crohn’s disease vs ulcerative colitis

During my rotation within the clinic, I commonly heard patients blame fiber for IBD flares and struggles. I can understand why they might think that because, unlike other foods, fiber isn’t digested. However, many studies prove that fiber should not be restricted in patients with an active IBD flare unless they are at risk for obstruction. High fiber foods are filled with vitamins, minerals, phytochemicals and healthy fats. Restricting fiber or aiming for a low-fiber diet could lead patients to choose foods higher in sugar, white carbs, animal fat and ultra-processed foods ultimately leaving nutritional gaps. 

Fiber can be broken down into two major types, soluble and insoluble. Soluble fiber absorbs water as it moves through the digestive tract, adds bulk and is more fermentable than insoluble fiber. These properties of soluble fiber help guard against both diarrhea and constipation. Those with IBD in general should focus more on soluble fiber, which includes foods such as legumes, beans, nuts, seeds, chia, oats, onions and peeled fruit. 

What does someone with an IBD active flare consume? I learned to think more in terms of food’s texture or roughage than fiber content. This is because the rougher the food’s texture is, the more it will irritate the large intestine and increase laxative as well as GI transit time. Therefore, during an active inflammation or for those at risk for obstructing, a low-roughage high fiber diet is used for symptom management. These foods include avocado, banana, peanut or nut butters, hummus, cooked carrots, butternut squash soup, fruit and vegetable smoothies and old-fashioned oats. 

Check out the recipe on the infographic I created to demonstrate an example of a high-fiber, low roughage fruit smoothie!