Clinical Dietetics Research Articles

Changing the Energy Density of the Diet as a Strategy for Weight Management

A growing body of laboratory-based, clinical, and epidemiological data suggests that low-energy-dense diets are associated with better diet quality, lower energy intakes, and body weight. Dietary energy density can be lowered by adding water-rich fruits, vegetables, cooked grains, and soups to the diet, and by reducing the diet’s fat content. Low-energy-dense diets can be successfully incorporated into clinical dietetics since they help lower energy intake without reducing food volume and thus help individuals avoid feeling hungry and deprived. There are multiple steps that could be taken by nutrition professionals and food manufacturers to encourage the consumption of low-energy-dense diets. The goal is to develop reduced-calorie eating plans that meet personal food preferences and also provide satisfying food portions. Since using energy density to guide food choices leads to food patterns consistent with dietary guidelines, policy level initiatives should be devised to help ensure that low-energy-dense diets are affordable and accessible to all.

What is the “age+5” rule for fiber?

Dietary fiber has important health benefits in childhood and adolescence, especially in promoting regular bowel habits. Intake of dietary fiber may also reduce a child’s risk of chronic disease (eg, cardiovascular disease, cancer, diabetes mellitus) in adulthood ( 1 Nevin-Folino N.L. American Dietetic Association Pediatric Nutrition Practice Group. in: Pediatric Manual of Clinical Dietetics. American Dietetic Association, Chicago, IL2003: 619 Google Scholar ). Therefore, health professionals have sought to determine a method for calculating recommended daily fiber intakes for both adults and children.

A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes

Documentation of clinical services within health care systems has become increasingly significant because greater amounts of information are now required by accrediting agencies, third-party payers, researchers, and others in their evaluation of patient care and because of the increasing emphasis on patient outcomes. Given the multiple users who depend on health care information in the patient record, it is imperative that clinical nutrition practitioners implement a standardized nutrition care process and language to document comprehensively and communicate meaningful information concerning their role in improving patient outcomes. A body of work has led to the development and adoption of a standardized nutrition care process for the dietetics profession. A standardized nutrition care process consistent with the scientific method and a standardized language are two essential components required to articulate a conceptual model for clinical nutrition practice and documentation and distinguish clinical dietetics’ unique body of knowledge. The conceptual model serves as an organizing framework to standardize and guide nutrition practitioners’ clinical judgments or critical thinking processes and document information linking nutrition care to patient outcomes.

The Lenna Francis Cooper Memorial Lecture—The future of clinical dietetics: Evidence, outcomes, and reimbursement

Editor's Note: The following article is a transcript of Marion Franz's 2002 Lenna Frances Cooper Memorial Lecture given on October 23, 2002, at the 2002 Food and Nutrition Conference and Exhibition.

History and evolution of a successful certification program in nutrition support: The CNSD experience

As early as the 1970s, articles were published on the role of dietitians in nutrition support. Both the American Society for Parenteral and Enteral Nutrition and The American Dietetic Association addressed the issues of specialization and certification. Development of a specialty area credential requires a strong demand by practicing clinicians, a unique area of clinical practice with a distinct body of knowledge and the commitment to evolve with clinical practice. Numerous dietitians were involved in the inception, development, and leadership that brought forth certification in nutrition support. This article documents the efforts and participation of a dedicated group of professionals whose common goals resulted in the establishment of a successful, sustaining certification in a specialty area of clinical dietetics: certified nutrition support dietitian. The certified nutrition support dietitian program is now in its 15th year with 2,000 dietitians currently certified both nationally and internationally. A primary focus of the credential is to recognize minimum competency for dietitians practicing in the field of enteral and parenteral nutrition and to provide safe and effective nutrition support therapy. This article provides a framework for persons in other specialty areas attempting to develop certification programs. J Am Diet Assoc. 2003;103:736-741.

Four Years After Enhanced Folic Acid Fortification of the Canadian Food Supply — How Are We Doing?

Four Years After Enhanced Folic Acid Fortification of the Canadian Food Supply — How Are We Doing?

Clinical Dietetics Changes Due to Cost-Reduction Activities in Healthcare Systems

Objective This study was designed to assess changes in clinical dietetics due to cost-reduction activities in healthcare systems. Subjects 1,200 ADA members who indicated that they were employed by acute care hospitals in ADA Area 2 states. Design A questionnaire about changes in clinical dietetics staffing and clinical dietitians’ activities and responsibilities was developed based on qualitative research. Descriptive statistics, t tests, analysis of variance, χ 2 tests, and correlations were calculated. Results A total of 342 usable questionnaires (28.5%) were returned. More than one third (37.9%) of respondents reported reductions in the number of clinical dietitians, and 32.2% reported increases in the number of part-time clinical dietitians. Most respondents indicated that they were more involved with high-risk patient interventions, had limited time for inpatient instruction, and experienced an increased patient caseload. Although 45.4% of respondents reported diminished job satisfaction due to recent changes in healthcare systems, some changes, such as increased high-risk patient intervention and referrals, were positively correlated with perceived job satisfaction. Discussion Thorough review of current clinical dietetics activities/responsibilities and planning before cost-reduction, restructuring activities may maximize staff utilization without decreased job satisfaction of clinical dietetics staff. J Am Diet Assoc. 2001;101:1347-1350.

International perspectives: the profession of dietetics

A survey about the professional characteristics of dietetics practice was mailed to 109 countries and representatives from 61 countries responded. Using the Human Development Index (HDI), a measure that reflects the life expectancy, education, and income of the population of each nation, countries were categorized as high, medium, or low HDI. This allowed comparisons among the HDI scores in the areas of education, professional practice, education, and practice competencies. Responding countries were 36.1% high HDI, 49.2% middle HDI, 8.2% low HDI, and 6.6% were unclassified. Dietetics was a nationally recognized profession in 81% of countries, with most having a professional association that represented dietitians. Clinical dietetics was the most frequently selected area of practice, followed by food service. Undergraduate academic programs in dietetics were available in 79% of countries and 49% offered graduate degrees. Most respondents rated competencies in clinical and community nutrition, along with competencies in professional practice, as important to their work. The results of this study can serve as a baseline as the profession evolves. Leaders in the dietetics profession can use these results to identify areas that need improvement. Collaboration with the United Nations family and sources that fund global initiatives can help in providing resources for the advancement of the profession. When the effectiveness of dietitians is improved, favorable changes in nutritional well-being on the global level can be expected.

Hospital-Based Food Store Is Within the Dietetic Scope of Practice

A new concept for dietetic practice is a hospital-based outpatient food store. Evaluation of the hospital-based food store for inclusion within the scope of practice for clinical dietetics was completed using the model of clinical dietetics as defined by Leyse and Kight in 1993. The data were collected using a group of Registered Dietitians familiar with the model. Results indicated that the hospital-based food store fell within the Domain of Nutraceuticals. The Leyse and Kight model of dietetic practice appears appropriate to evaluate new and emerging areas of dietetic practice such as the hospital-based food store. Such a food store operated by Registered Dietitians would provide a much-needed service to consumers.

Diabetes Training for Dietitians: Needs Assessment, Program Description, and Effects on Knowledge and Problem Solving

Recent changes in management and medical nutrition therapy for diabetes mellitus. have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitian's New Role in Diabetes Management is a 2 1/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (±standard deviation) scores on pre- and posttests of knowledge and problem solving were 69±13% and 86±9%, respectively ( P<.001). The SNAP program needs assessment, training methods, and knowledge/ problem-solving test are relevant to all types of education programs in clinical dietetics. J Am Diet Assoc. 2000; 100:225-228.

Research and the Clinical Dietitian: Some Perceptions of the Research Process, Potential Barriers to Participation, and Routes to Skill Enrichment

The profession of dietetics is rooted in research, and while the philosophical commitment to participating in research has been a part of the profession since its inception, the reality is that clinical dietitians do not often participate in research. Six focus group sessions were held with clinical dietitians in Tennessee (n=35) and 3 sessions were held at the 1998 ADA Annual Meeting (n=18) in order to address this issue. All sessions were facilitated using a structured question format, where similar issues were addressed at each of the 9 separate sessions. Attendees recognized the importance that research findings play in their practice, but barriers to participation were widely realized. Several attendees indicated that they had ideas or questions that would merit research. However, lack of time to pursue such interests was a common concern. Further, low comfort levels with initiating and conducting research were problematic. While many attendees had participated in research projects as a part of their educational and professional preparation for dietetics, these experiences were not generally viewed as applicable to the clinical arena in which they now work. Lastly, seeing clinical dietetics as separate from research dietetics was a primary topic of discussion. Dietitians' perceived needs in order to facilitate involvement in the research process included collaborating with an academic dietitian, thereby fostering a mentoring relationship. Further, having a clinical manager that is supportive of dietetics staff in their efforts to participate in research with other health care professionals was also key. The realities of time and money constraints were pervasive, and while gaining administrative support was seen as a key to surmounting this barrier, few attendees had had success with this strategy. These focus groups provided a snapshot of clinical dietitians' views of their place in the research process. Given that changes in the healthcare environment are going to require increased involvement in the research process by those members of the profession that actively engage in patient care, these findings offer valuable insight into promising ways to address potential barriers.

Changes in Clinical Dietetics Due to Cost Reduction in Healthcare Systems

: Cost reduction in healthcare systems may impact job design of clinical dietitians. Objectives of this qualitative study were to: (1) gather clinical dietetic experts' observations on clinical dietetic job changes, (2) identify visions to improve the professional level of medical nutrition therapy practice, (3) make recommendations on how to prepare students for improved practice, and (4) develop a questionnaire for a quantitative survey. An open-ended questionnaire was designed and sent to nominated clinical dietetic experts in eight states: ND, SD, ME, MN, IA, MO, WI, MI. Responses were sorted into meaningful groups. Selected clinical dietetic experts were interviewed by telephone to clarify their responses.Results indicated changes in staffing and clinical dietitians* activities. In some cases, numbers of clinical dietitians and managers decreased with an increased number of dietetic technicians. In other cases, clinical dietitians' numbers increased to meet increased service needs. Caseloads have changed to include more high-risk patients and outpatients. Results also showed redistribution of activities, efforts to decrease expenses and increase revenue, and changes in department structure and accountability. Suggestions for improving the professional level of dietetic practice included increasing clinical dietitians' capabilities and visibility, proving effectiveness of medical nutrition therapy, and strengthening financial status of dietetic services. Recommendations for educational preparation were increasing student awareness about all aspects of clinical dietitians' jobs (i.e., psychological and behavioral aspects of patients), expanding courses in didactic education, and improving internship programs (i.e., longer duration, more hands-on experiences). Results are the basis for a quantitative questionnaire developed to be field tested with a representative sample of clinical dietitians.

Chicago Dietetic Association Salary Survey

In the summer of 1996, the Chicago Dietetic Association sent 1490 salary surveys to Chicagoland area dietitians. 493 surveys were returned yielding a 33% response rate and of those 84% were available for analysis. 99% of the respondents were female and 1% male. 58.6% had a BS or BA degree as their highest degree. Although there were only six men in the sample, there was a statistically significant difference between their salaries and those of the women in the sample (p=.010). No statistically significant differences were found between whites, Asians, or African Americans with respect to salary (p=.82). A statistically significant difference was found between primary job roles with respect to salary (p<.0005). Dietitians in business/industry or management practice were found to be the highest paid followed by education/research or food service. Lower paid were clinical and consulting/private practice. Lowest paid were community dietitians. Only weak correlations (Spearman's rho 2-21} were found between salary and age group, highest degree earned, years as a practicing dietitian and years in primary job role/position. A statistically significant difference was found between primary job roles and satisfaction with pay (p=.006). The percentages who felt that they were paid adequately for the primary job roles are: business/industry(70%), food service(55%), community dietetics(51%), management(45%), clinical dietetics(43%), consulting/private practice(57%) and education research(30%). As expected, respondents who felt that they were paid adequately had higher salaries than those who did not feel that they were paid adequately (p=.001).

The Application of Interactive Video Patient Simulations to Medical Nutrition Therapy

Dietetic programs are being challenged to enhance clinical reasoning skills in their undergraduate students in an effort to better prepare their graduates for the internship experience. To meet this challenge, an interactive, multimedia simulation was developed on CD-ROM to enhance problem-solving skills. One hundred forty-three senior level students from ten dietetic programs in the United States completed a computerized, interactive, multimedia simulation of three distinct cardiovascular disease patients in which the student interacted as the dietitian. The program was designed to help student dietitians become more comfortable selecting pertinent information from the medical chart in a clinical dietetics setting. As the student asked a question, the patient's response was experienced visually and audibly. The student then had to decide whether to ask the patient additional questions, seek additional information, analyze information gathered and formulate a nutrition care plan. The results of this study indicated that the students’ responses improved, or became similar to the experienced registered dietitians’ responses with each additional patient simulation. Through computer-based instruction a student is given the opportunity to practice nutrition assessment skills, as well as to gain a better understanding of information retrieval and a greater awareness of the more subjective aspects of dealing with real people in a real hospital setting. Computer-based instruction can be integrated into the curricula to enhance clinical-reasoning skills.

Establishing Standard Clinical Nutrition Practice Between Hospitals in the Same System

Staff of food and nutrition services departments at two hospitals began the process of establishing standard practices in January 1998. A clinical design team consisting of staff from both facilities, was formed to eliminate duplication and standardize systems across facilities, and to facilitate the expansion of nutrition services throughout the system. Team members were excited about working together and energized by the opportunity to improve services and efficiency. The team began by analyzing the numerous charges in the charter and prioritizing tasks. The team agreed to search for the best clinical practices rather than focusing on how either facility currently operated. Each member took responsibility for one or more tasks, and a timeline was established. The Manual of Clinical Dietetics was selected as the diet manual, a list of diet orders, patient education materials, and formulary of enteral products was established. A survey addressing inpatient practice was conducted with other hospitals. As a result of the findings, a task force of clinical nutritionists was formed to develop a nutrition screen, levels of care, and an initial assessment form. Through organization and utilization of other staff, the team was able to accomplish their goals, get to know one another, and design new processes that work and everyone likes.

The Evaluation and Development of Standardized Supplementation for Human Milk for Term Infants at High Nutritional Risk

Human milk is uniquely superior for infant feedings. In some instances, even with the assistance of a lactation consultant or occupational therapist to optimize feeding, term infants may not be able to consume or tolerate an adequate volume of milk to meet their needs for growth and development This may occur in infants with congenital heart disease, cystic fibrosis, birth asphyxia, biliary atresia and other medical problems.Human milk fortifiers are marketed to meet the needs of preterm infants but are not appropriate for term infants. Using preterm fortifiers for term infants can result in excess intakes of a number of vitamins and minerals.When supplementing human milk the affect on osmolality, vitamin, mineral and trace element intake, renal solute load, sanitation, cost and accuracy of preparation must be taken into account Recipes must be practical for use in the hospital and home setting, providing reasonable volumes that do not result in wastage of human milk.Standard recipes were developed for supplementing human milk with infant formula powder at varying caloric densities. Guidelines were written for supplementing human milk for home and hospital use and were located on the medical center dietetics computer drive. Clinical dietitians were oriented as to the availability and usage of this information.These guidelines have been well received as a resource by the clinical dietetics staff.

A Study of The Effects of Computerized Multimedia Technology on Anatomical and Physiological Concept Retention

Computerized multimedia educational software has been developed for many disciplines but not for teaching clinical dietetics. The effectiveness of incorporating multimedia technology into lectures on anatomical and physiological concepts was studied using a pre-test/post-test format and cross-over design. Two groups of students (N=44) enrolled in a clinical nutrition class were given a pre-test that included normal and pathological lower gastrointestinal anatomy and physiology. Six consecutive lessons were taught to both groups using the traditional lecture format and identical lesson plans. The experimental group lectures were enhanced with color, sound, and motion using computerized multimedia images, animations, and the Internet. After three lectures, the presentation styles were switched between the groups to complete the cross-over design. A post-test using identical questions from the pre-test was administered after the completion of all six lectures. Significant improvement (p < 0.05) was found in post-test scores and pathological concept scores but not in normal anatomical and physiological concept scores. Additionally, grade point averages and grade in the prerequisite semester of clinical nutrition were highly correlated (p < 0.01) with the learning effect of computerized enhancement. The results indicate that enhanced lectures are effective in teaching difficult concepts involving disease processes, and may have more impact on better prepared students. This reinforces the need for educational software development specifically for the field of clinical dietetics.

Ratings of Food Courses and Culinary Training Components in Dietetics Education

Through the years, dietetics education has decreased its emphasis on food courses. The literature indicates that as directors of dietetics undergraduate programs must decide between essential and nonessential curriculum items, less time is spent on core food courses and courses on quantity food production. Contributing to this change are the fact that role delineation studies have separated entry-level positions into clinical dietetics, foodservice systems management, and community dietetics; clinical dietitians and dietetics practitioners perceive management as less important than clinical tasks; and advances in clinical nutrition emphasize nutrients rather than food (1–6).

A Model for Making Outcomes Research Standard Practice in Clinical Dietetics

In today's rapidly changing health care environment, it is imperative that dietitians demonstrate the importance of their role as health care providers by initiating and participating in outcomes research. Patient care should be based on empirical studies, and clinical dietitians should participate in or be at the helm of such investigations. Nutrition research is usually accomplished and reported by persons with MD or PhD degrees who do not have clinical training in nutrition and does not often address situations encountered by dietitians in clinical settings. This article examines the extent to which clinical dietitians are conducting and reporting outcomes research, their attitudes about such research, and how they think they could best acquire the skills needed to incorporate outcomes research into their practice. Results indicate that clinical dietitians are not writing a substantial percentage of articles and that reports of outcomes research are not commonly included in clinical nutrition journals. Clinical dietitians appear to value the inclusion of research in clinical practice, but they are not spending a great amount of time doing research. Dietitians report being comfortable about participating in research but not about designing, conducting, and reporting research. Results from several surveys were used to develop a model for integrating research in clinical practice. This model includes the research process as a basis for clinical practice. A model for collaborative efforts between clinical and academic dietitians is also proposed and emphasizes the responsibility of academic dietetics training programs in the integration of research and clinical practice. J Am Diet Assoc. 1998;98:451–457.

“Your Way Cafe,”tm a New Pediatric Restaurant Style Hospital Menu–a Partnership Between Clinical Dietetics and an Executive Chef

LEARNING OUTCOME: To demonstrate the development and marketing of a pediatric hospital-restaurant style menu by Clinical Dietetics and an Executive Chef.“Your Way Cafe,”™ a new pediatric hospital-restaurant style menu demonstrates the results of a partnership between clinical dietetics and an executive chef. It features Chefs Specials at all meals in addition to bread basket and dessert specials. For interest, a “Minnesota Fun Lunch” is served in a dinosaur bag. To promote good nutritional intake the daily choices offer familiar foods commonly requested by children and teens. The colorful pediatric hospital logo was the basis of the menu design.Multidisciplinary staff focus groups and pediatric patient/parent feedback were among the driving forces for this menu development. Issues of concern from these groups were: ease of menu selection, favorite pediatric food choices, appropriate portion sizes and visual menu appeal while providing nutritious foods in a cost effective manner.The committee was challenged with writing a menu which resolved issues specific to the pediatric population but also was compatible with the food service for the hospital in general. Nursing staff, Child Life Specialists, patients and parents were surveyed. Restaurant menus, grocery store items and menus from hospitals across the country were reviewed.Marketing and menu promotion plays an important part in the nursing, physician and other medical staff acceptance and support of a menu. Open houses provided the staff an opportunity to preview the menu and sample selections. They responded positively to the menu and foods tasted.Presentations of the menu were given to a parent advocate group, pediatric physician advisory board, multidisciplinary practice group, and medical center administrative staff. The menu has been enthusiastically received. Ongoing surveys and follow-up will continue to assess gains made from this quality improvement process.