Gaining a Community Perspective in Nutrition

By Grace Horgan

One great way to capture someone’s attention is with a sample of free food. I found this to be true with kids and adults during my two week community rotation with FSNE (Food Supplemental Nutrition Education FSNE). FSNE provides nutrition education for Maryland residents that are eligible for SNAP (Supplemental Nutrition Assistance Program) benefits. During this rotation, I first learned all about FSNE and what services they provide in the community. Then I went into the field, helping to provide nutrition education to both students at an elementary school and customers at a food bank. FSNE reaches Maryland residents of all ages.

I was a little nervous walking into an elementary school to teach a second grade class about nutrition and MyPlate. I didn’t really know what to expect. Were they going to know what I was talking about? Would they be interested in what I had to say? The FSNE nutrition educators were each assigned to different elementary schools throughout the state and conducted education sessions once a month. On our first school visit with one of the educators, my partner, Claire, and I taught the students about MyPlate and then made a “MyPlate salsa.” The salsa had components of each food group from MyPlate except dairy; black beans (protein), mango (fruit), tomato salsa (vegetable) and we served it with tortilla chips (grains). Claire and I built the salsa with the students and discussed each ingredient. The students were asked to determine which food group they belonged to.  All the students were required to try one bite of the food that was being served that day. They have a special rule in the classroom called “Don’t Yuck my Yum,” where students are not allowed to say “yuck” after trying the food.

One of the most surprising parts of my visit to the school was that all the students in grades K-2 knew what MyPlate was and were familiar with all the food groups. After our first three class sessions that day, I noticed all of the students in each class also knew the educator by name. I was impressed because they only see the nutrition educator once a month. It appeared their nutrition lessons were something they really looked forward to each month. Thinking back to my grade school experience, I tried to remember when I had learned about basic nutrition and I don’t think it was until Middle School or High School. I think it is extremely valuable that these children are learning practical nutrition information at such a young age. It can build a strong foundation of wellness for their future. Additionally, they can bring some great nutritional information home to their parents or guardians.

During another one of our days at FSNE, we were able to help out at the Howard County Food Bank. Once or twice a month the FSNE educators go to their assigned county’s food bank to provide samples of a low cost recipe. The recipe consists of items that customers can get at that food bank that day. The educators display the food items in the recipe so customers know exactly what is needed. On our day at the food bank, we offered samples of a vegetable crockpot stew. The customers really enjoyed this and some even came back for seconds! I was extremely surprised at how organized and clean the food bank was. There was a wide variety of food, including several frozen items and numerous gluten-free foods.

Claire and I provided samples of crockpot vegetable stew at the Howard County Food Bank.

Overall, I really enjoyed my time with FSNE. The educators were very welcoming and allowed us to get hands-on experience teaching the students and even adding our own twist to things. It was really incredible to see how big of an impact FSNE had on the community. The FSNE programs give children and their families sound nutritional education and encourages them to make healthy choices. 

Behavioral Health Nutrition

By Alexis Mateer

How does substance use disorder relate to nutrition and dietetics? This is the question that I was pondering when walking into Pathways treatment center one recent Tuesday morning. I was in the middle of my eight week clinical rotation at Anne Arundel Medical Center (AAMC), a small community hospital in Annapolis, MD. Pathways, a not-for-profit drug and alcohol rehabilitation treatment facility, is located separate from the main hospital, but is still part of AAMC. Pathways has one dietitian and I was lucky enough to get to spend four days observing and learning from her. Substance use disorder (SUD) and its nutritional implications are not something that I learned about in my undergraduate medical nutrition therapy classes. I started my week feeling intrigued and excited.

Little did I know, there is a thriving, growing knowledge base and workforce of dietitians that dedicate entire careers to working with individuals struggling with SUD. My wonderful preceptor at Pathways, Lise, told me that nutritional care for patients with SUD falls under a practice term known as behavioral health nutrition (BHN). There is a dietetic practice group (DPG) within the Academy of Nutrition and Dietetics packed full of dedicated nutrition professionals working within behavioral health care. BHN is a DPG that Academy members can join in order to become connected to resources, practice tips, research, and other like-minded professionals. Lise also instructed me that Pathways is a treatment facility that is dedicated specifically to those struggling with SUD. Patients with comorbid eating disorders and/or serious mental health issues are not treated at Pathways. However, there are facilities that exist for people with SUD and comorbid eating disorders.

On my first day at Pathways, I toured the new kitchen. 

So What is Behavioral Health Nutrition?

On day one, in addition to going with my preceptor to visit patients in the treatment facility, Lise sat me down and took the time to explain what BHN encompasses. There are three main tracks, or focuses, within BHN: eating disorders, substance use disorder, and mental health. These are three separate focuses, or areas of practice, when it comes to nutrition. However, these also are issues that can overlap within one individual- issues with which one person can struggle. For example, there are people that struggle with eating disorders, people that struggle with substance abuse, and people that struggle with both. So while these two might be separate focuses, or specialties, within the nutrition world, they are certainly not always separate entities or issues in the real world. While this was all very important, relevant information, I still found myself asking the same question as before. How does substance use disorder, and behavioral health more broadly, relate to nutrition and dietetics? Here is what I learned:

Pertinent Nutritional Issues in BHN

  1. Malnutrition – This has to be the largest nutritional issue facing individuals struggling with SUD. Lise told me that people struggling with SUD often prioritize accessing their substance(s) of choice, before getting food. It is clear how protein-energy malnutrition could be an issue, but micronutrient malnutrition is also prominent in this population. Deficiencies of certain vitamins and minerals more commonly present in individuals struggling with SUD than in the general population. Because of this, my preceptor stressed the importance of the nutrition focused physical exam (NFPE). Knowing how micronutrient deficiencies present, and what to look for is a vital skill when working in this setting. I did not get to conduct a NFPE while at Pathways, but I did get information about what some micronutrient deficiencies look like, and which ones are most pertinent, or common, in this setting. The Color Atlas of Nutritional Disorders pictured below is a great resource for learning about the physical presentation of malnutrition and related nutrient deficiencies.
  2. Wounds – I saw a patient with a wound caused by repeated injections into the same site. Wound healing requires micronutrients like vitamin C and zinc, and some people struggling with SUD are deficient in these nutrients.
  3. Diabetes – It is important to remember that patients with SUD often struggle with common medical conditions in addition to their addiction(s). Diabetes is becoming more common in the US, and people struggling with SUD are no exception. I learned that in patients with SUD, diabetes is typically very poorly controlled. This is not surprising since, as I noted earlier, eating meals is not always a priority. Besides the macrovascular disease that occurs over a lifetime of poorly controlled diabetes, extreme highs and lows in blood sugar might be more common in those struggling with SUD, posing a very serious health risk.

A few of the resources from Lise related to behavioral health nutrition.

Activities During my Week at Pathways

On day one, Lise spent a great deal of time talking with me about BHN, exploring the BHN DPG webpage, and discussing nutritional challenges and issues individuals with SUD face. I also got a tour of the facility, including the new kitchen pictured above, and got to sit in on my first, daily team huddle. The daily huddle is an interdisciplinary team meeting, including doctors, nurses, case workers, therapists, and Lise, the dietitian. This team meets every morning, for 30 minutes to 1 hour, to discuss each patient and his/her progress, with each discipline offering pertinent info or findings to the rest of the team. It is a way for each team member to be debriefed on patients’ progress. I got to attend this meeting each morning with Lise, all-the-while learning more about what different disciplines bring to the table in a treatment facility of this nature. Throughout these four days I also got to go see some patients with Lise. She would first look into the patient’s chart, and then go out into the facility to find the patient. At Pathways the patients’ days are scheduled full with activities, so Lise would have to go search for the patient in their groups, the common areas, or even in the cafeteria during meal times. This is very different from how dietitians in the hospital meet with patients; at pathways the patients are rarely in their assigned rooms. Lise would follow up with the patient about his/her progress, provide further nutrition education and support, especially for those patients with diabetes, answer questions, and make recommendations for patients to consume more of certain foods and/or offer supplements. For example, for a patient we saw that had a large, open wound on his hand Lise recommended that the patient use the supplement Juven to support wound healing. For another patient, Lise recommended drinking orange juice with meals because the patient was complaining of sore gums and itchiness. Lise would also often make herself present at meal times, in the cafeteria, to watch what food choices patients make and to see how they are eating, more generally. 

The big project that I was tasked with during this week was creating a finger foods menu, or a safety tray menu, for the upcoming opening of AAMC’s new mental health hospital. All foods must be able to be eaten using no utensils, by hand. One page of this menu can be seen below. Lastly, at the end of this week, I helped Lise prepare for and present the weekly nutrition group lesson and activity. The lesson just happened to fall on Valentine’s Day, so we used the theme: how to fall back in love with your kitchen and with cooking. The patients love listening to music, so we prepared a Valentine’s Day playlist to get everyone excited. Lise bought lollipops and chocolate candies for everyone, and not only presented a fun nutrition lesson, but also made everyone feel welcomed and cared for on this special day. 

This is one page of the Finger Foods Menu that I created for the new mental health hospital.

The Stigma/Treatment Bias

When working with these patients and on a multidisciplinary care team, Lise emphasized that it is important to remember that there is incredible stigma and bias facing patients with SUD. She stressed that SUD, and addiction in general, should be thought of as a chronic disease, similar to diabetes or heart disease, rather than as a choice. I definitely agree, and hope to see more people in the medical field embrace this attitude.

Wrapping it All Up

I ended my four days feeling very excited and uplifted. This was because my preceptor was so kind, positive, and supportive. However, this was also due to the fact that BHN is a growing area of practice for dietitians. I am very excited by this fact and could definitely see this as a possible area of practice for myself in the future. My preceptor made sure that I left Pathways with not just a whole arsenal of BHN resources, but also with a sense of empowerment and excitement. 

Don’t Let the Little Ones Intimidate You

Children’s National Medical Center’s lobby

By: Rachell Burgos

As I started my rotation at Children’s National Hospital, I couldn’t believe how excited I was to put into practice what I had recently learned during my clinical rotation – this time with little humans. I met the challenge of my clinical rotation and left knowing I had accomplished and learned a lot. However, I was a little nervous about starting out at Children’s since this was something completely different than what I had ever experienced. For twelve weeks I had solely focused on adults and for the next two weeks I would be learning and focusing exclusively on children.

About a week before my gastrointestinal inpatient and pulmonary rotations started, my preceptors made sure I was familiarized with some of the most used terminology and concepts.  I was also given case studies which challenged my usual thought process in regards to nutrient needs and tube feeding recommendations; I was beginning to see that children’s needs are much different than those of adults. 

My first day was finally here. To ensure that I would be arriving on time, I left my house at around 6:25am. My partner, Moira, and I arrived an hour early. Since I was nervous, I used this found time to once more review some of my assigned reading materials. Doing this settled my nerves and I was ready to hit the ground running when I met with my preceptor. The stakes seemed higher since I knew I would be working with sick children. 

Slowly, I started getting comfortable with the flow of things. For the next two weeks, I would attend general surgery, pulmonary/adolescent and academic case management rounds. This was very interesting to me because it allowed me to see how different disciplines interact with each other and the importance of each of them during a child’s hospital stay. I also appreciated being part of a teaching hospital where residents, fellows and attending doctors worked closely together to provide the best care possible. 

The kid-friendly hallways

From the very first day, I was encouraged to practice my clinical skills. I had to provide nutrition education to two teenage brothers who had recently had bariatric surgery and were advanced to a clear liquid diet. Nervousness kicked in as this would be my first time speaking to children in a clinical setting. As time went by, I was continually encouraged to speak to patients. Due to this, I was able to retrieve a three-day 24-hour recall for a young girl diagnosed with Crohn’s disease, complete various nutrition assessment and a nutrition screening, complete a follow-up, and speak with a teenager with a possible irritable bowel disease diagnosis.

Must-haves for my nutrition class

One of my most favorite, yet challenging experiences in the past two weeks was conducting two nutrition classes in the behavioral units for adolescents. The eating disorders dietitian, Laura, really needed some help with her workload so my preceptor encouraged me to do it. Throughout the day, the kiddos on these units would attend several classes to stay engaged. As Laura and I were buzzed into the unit, I was nervous. I had little time to prepare, yet I was about to get started. I asked them about their favorite foods, talked about MyPlate, did a MyPlate food group quiz and sudoku, had them come up with lunch meal ideas with all MyPlate food groups and played Pictionary. Most of the kids were respectful and engaged. By the end of the class, they seemed to really enjoy the activities I had chosen for them and connected with my teaching style. As a result, I had gained more confidence as a dietitian-to-be.

Moira and I manning the National Nutrition Month table

Another one of my favorite experiences included manning the National Nutrition Month table with Moira and the outpatient dietitian, Sydney. Throughout this month, we were focusing on the Mediterranean diet and highlighting certain foods weekly. The first week, we highlighted nuts and seeds. We had handouts, erasers, magnets and of course delicious trail mix snacks for people to try. During the second week, olives and hummus accompanied by pita chips were featured. This was such a hit! So many people took handouts and magnets and seemed engaged and interested. This cool opportunity showcased the importance of adapting a healthy lifestyle rather than going on a fad diet.

Overall, I had a great experience at Children’s National. I got to experience what it is like to work in a teaching hospital and how truly valuable pediatric dietitians are in the clinical setting. I was challenged to do things I had never done before and learned so much about pediatric nutritional needs. I really enjoyed learning about the specific caloric needs of babies, Crohn’s patients and cystic fibrosis patients. Learning about the Holliday Segar method, catchup growth equation and calculating enzymes were one of the biggest takeaways of my time at Children’s. I am so grateful for the time I had there and for the preceptors who took time out of their busy days to answer every one of my questions and to ensure I had a well rounded experience.

Clinical Nutrition: It’s like Sports Practice, but Make it in Real Life…

By: Abigail Stultz

Training to be competitive in sports requires many hours every week dedicated to learning new techniques and practicing the skills you have already learned. I have found that mastering the skills required to be a good dietitian also requires much training and practicing. As my track and field coach was instrumental to my success in meets, similarly my clinical rotation preceptors shared with me  their nutrition knowledge, patient interviewing techniques and charting approaches, while providing reinforcement and encouragement along the way. I spent two weeks with each of my four preceptors at my clinical site at Meritus Medical Center in Hagerstown, MD, and then I did a two week staff relief stint. It was difficult entering an environment that I had zero prior experience, but I accepted where I was at and made it my goal to go in with an open mind. My brain has been a sponge for these past (almost) ten weeks as I picked the brains of my “coaches” to absorb all I could and continually build my clinical skills. I bridged gaps in my knowledge through asking questions and I practiced new skills with intentional repetition.

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Prior to my 10-week clinical rotation, the only clinical experience I had was the Medical Nutrition Therapy class I had in my undergraduate coursework. In full transparency, this course was very challenging for me—not because I wasn’t capable of understanding, but because of the mode of delivery. Medical Nutrition Therapy is complicated. Unlike the biochemistry courses I took that involve learning concrete facts, assessing, diagnosing, intervening and monitoring and evaluating nutrition interventions are practical skills that require critical thinking. I had a difficult time piecing things together in a way that would resonate with me because I couldn’t see the big picture yet. The information made sense, but how do I use it?

Week 1-2

I spent my first two weeks learning how to use the EPIC software system and how to chart. I can’t emphasize how foreign this was for me! My preceptor these first two weeks covers the step down floor from the ICU, which I found difficult while I was just getting acquainted with the clinical setting. It sounds silly, but during these first two weeks I felt like I was figuring out the role of what an inpatient dietitian actually does. My preceptor only assigned me one or two patients at a time. I would look up the patient’s medical history in the chart, then discuss my findings with her before we rounded. As we talked through the first few patients, I realized I had no idea what I was actually looking for; I focused on the disease states themselves instead of what nutritionally we needed to do with the patient, if anything. After many repetitions over these two weeks, I found what I call my “lens” for how to see and think about patients as a clinical dietitian. To me, this meant asking myself the question “what can I do for this patient right now, while they’re under my care, to support their healing and not exacerbate their disease state.”

clinical pic

Me with my orientation booklet from my first week– also loved getting to wear scrubs!

Week 3-4

By the end of the second week I had begun to find my groove. I knew what to look for in the chart: patient history, lab values, any recent weight changes, intakes, special diets, GI issues, etc. These  things helped me start to formulate what nutritional support the patient might need and what other information I would need to gather from the patient. During this time, I was able to see between 6 and 9 patients and confidently visit patients by myself.

Week 5-6

Now that I felt comfortable reviewing charts and seeing patients, I really began to think critically about  nutrition interventions for my patients. My preceptor these two weeks helped me think through how disease states impact nutrition and what interventions I could use in different situations. The reps this week helped me feel comfortable about working through the nutrition care process and truly understanding how to utilize it and why it works.

Also during this week, I presented my mini case study to my preceptors to demonstrate my ability to critically think through a patient assessment. I was to choose a patient with a nutrition related issue, complete an initial assessment and follow the patient throughout their length of stay. I chose a young female with uncontrolled diabetes that experienced severely high blood sugar levels. In addition to the assessment, I educated her on how to create a balanced meal to control her blood sugar levels as well as making sure she understood her insulin regimen and how to use her glucometer before she was discharged from the hospital. The “mini case study part” was a comprehensive report on my assessment and interventions during the patient’s stay. 

 

mini case study pic

Me presenting my mini case study.

Week 7-8

I headed to the Intensive Care Unit for these two weeks, and just as I thought I was getting the hang of things the feeling of being unsure crept back. I would be doing a lot with two large concepts in this type of setting: Total Parenteral Nutrition (TPN: providing nutrition to a patient intravenously) and Enteral Nutrition (EN: providing nutrition to a patient via feeding tube). These are things that I was only familiar with in a classroom setting, so it was intimidating when my preceptor assigned me a patient that was on TPN. The ICU is a totally different world where things change at the drop of a hat. My preceptor was thorough as she coached me through how to calculate tube feedings and TPN and use lab values to critically think about changes that need to be made (which, again, were often) and make decisions. I learned to adjust the TPN based on electrolytes and medicines, use energy estimation equations to account for patients in hyper-metabolic disease states or on the ventilator, and much more. These two weeks really challenged my critical thinking skills, but in the end this training helped me bridge gaps in my knowledge and pick up on new things. 

 

clinical materials

References for clinical nutrition guidelines (back left), tube feeding formula rate calculations sheet (top right) and all the nutrition supplements the hospital has with macronutrient percentages (blue sheet). I utilized these a TON over the course of this rotation but definitely got really comfortable using these in the ICU.

Week 9-10

And that brings me here! I begin my first of two weeks of staff relief this week. I feel nervous but also confident in my training—just like an athletic competition. I have learned and practiced many clinical nutrition skills and will continue to have the support of my preceptors. I look forward to putting my skills to the test. It is exciting to see how far I have come and to know there is still more to learn. 

My clinical rotation has shown me that throughout the changes in my life, one thing will forever hold true: repetition breeds success.

You’ll Probably Change Your Mind

By Moira Cain

If I told you that I once almost passed out watching a video of a woman changing her ostomy bag, would you be worried about me during my clinical rotation? Well, that actually happened, and I was very worried. I started my 10 week primary clinical rotation at CalvertHealth Medical Center back in November, and I was terrified. I’m not a huge fan of hospitals, but mostly because I hate bodily fluids. I was convinced that I was going to pass out at some point. 

On the first day, I saw a patient with a nasogastric (NG) tube with intermittent suction, and was not prepared for the color of the bile, or the fact that intermittent suction meant that the bile went back down the tube. That was not the last time I was going to see bodily fluid unexpectedly. 

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I was able to wear scrubs during this rotation, which I took advantage of!

Given my apprehension, I was not expecting to like clinical at all, however, I ended up absolutely falling in love with it. The registered dietitians (RDs) at Calvert are so incredible, and really care about their patients. The RDs are treated as an integral part of the interdisciplinary team of providers at the hospital. Everyday, we would get together and “round” on each patient on the floors. The nurses would explain to the hospitalist, case managers, pharmacists and RDs what was going on with the patient, and then the hospitalist would explain the plan for the day. It was great to be part of the team where you could ask questions and have your voice heard. It was common for the RD to notice a low lab value and request repletion of the nutrient or to notice that a patient hasn’t had a bowel movement for a couple days and request a bowel regimen. 

There are four RDs that work on Calvert’s two floors, the Intensive Care Unit and the behavioral health unit. Instead of working with a dietitian in a particular unit each week, I saw whoever came onto whichever floor I was working on. During my staff relief weeks, I performed many congestive heart failure (CHF) and diabetes educations. This included speaking to a patient about the different foods she should be eating, and things she could substitute to improve what she was eating. This taught me that even in an inpatient setting, as a healthcare provider I need to meet patients where they are. This patient had many questions about her diet and was confused about the different diet recommendations given to her by a variety of providers. It is important to remember that every patient has a different back story; if they are chronically ill, they may have had many different providers manage their diseases. Each provider may differ on how to best treat that patient.The RD must teach the patient how to make nutritionally sound food choices to speed the recovery process, help manage existing diseases, and maintain a healthy lifestyle. The RDs at Calvert were so willing to help me learn. They looked up articles for me in their spare time, including articles about refeeding. They emailed me articles about the effect of hyponatremia and the brain. In my last week of my rotation before staff relief, the dietitian I was working with told me that I was doing great, and the team knew I was ready for staff relief. It gave me a big boost to know that they had confidence in me. I felt so much more sure of myself during my staff relief. I really knew what I was doing as I gave my diet educations and wrote my assessments. 

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The essentials for a clinical rotation.

I am happy to report that I never passed out during the whole ten weeks. I entered this internship without much experience in a hospital and a fear that I wouldn’t be able to handle the exposure to the messy aspects of working in a hospital. I was able to overcome those fears and  am now confident that I will continue to be able to handle hospital work as a dietitian. I was told going into the internship that I might change my mind about a practice area during a rotation; they were right. I did not think that clinical would be the rotation that stuck with me the most, but I was wrong. It taught me so much and I am very happy that I had this opportunity to change my mind.