Dietitian Working Research Articles

Professional Standards for Renal Dietitian: A Comparison among Different Countries

Dietary therapy plays a key role in the treatment of chronic kidney disease (CKD): it prevents and corrects metabolic need of renal complications, ensures the maintenance or achievement of a good nutritional status and, in the conservative phase, delays the replacement therapy. There are many evidences showing that the nutritional treatment performed by a renal dietitian improves the quality of life of CKD patients, increases the effectiveness of dietary therapy and reduce costs. In the United States there are specific parameters that identify the renal dietitian (RD) and three categories of RD have been identified according to the training degree and acquired competence. In European countries the training of dietitians is very heterogeneous making it difficult to compare it with the USA reality. The European Federation of the Association of Dietitian in recent years, however, has defined academic and professional standards for dietitians and it has identified four roles of responsibility and the related performance indicators. In Italy the National Association of Dietitians has defined its positions on the professional practice of the dietitian working with renal diseases and the Italian Society of Nephrology outlined the profile of the renal dietitian, but no specific academic and professional standards have been yet defined. Dietitians expert in nephrology and nephrologists should work together to define the standards that a dietitian working in a nephrology setting should reach in order to ensure not only high professional competence but also enable uniformity of treatment throughout the country.

Job analysis and satisfaction of dietitians · nutrition teacher in school foodservice by school type in Gwangju and Jeonnam area

The objective of this study was to examine job performance and importance, and job satisfaction of school foodservice dietitians·nutrition teacher in Jeonnam and Gwangju area according to the school types (elementary school, middle school, high school). A total of 646 questionnaires were distributed, 244 questionnaires were analyzed using SPSS 12.0 for a descriptive analysis, t-test and ANOVA. There were significant differences between the school dietitians’·nutrition teachers’ job performance and importance in all areas of the job analysis for all school types. In the foodservice management/evaluation and nutrition education area, elementary and middle school foodservice dietitian·nutrition teacher showed a significantly higher performance, compared to that of high school dietitian·nutrition teacher. Nutrition education was recognized by elementary and middle school dietitian·nutrition teacher to be more significantly important than that of high school dietitian·nutrition teacher. Elementary school foodservice dietitian·nutrition teacher was most satisfied with their job condition. Dietitian working in middle school was least satisfied with the salary and compensation. These results suggest that appropriate curriculum should be structured according to foodservice dietitian·nutrition teacher of the school type for improving the work efficiency. In order to increase the job satisfaction, the employment status of school dietitian should be guaranteed by the government and school officials, especially in the middle and high schools. (Korean J Nutr 2012; 45(3): 274 ~ 282)

충북지역 일부 학교 영양(교)사의 건강기능식품에 대한 인식 및 교육 요구

We investigated perception and educational demand for health functional foods among nutrition teachers and dietitians working in schools. The subjects were 229 nutrition teachers (57.2%) and dietitians (42.7%) working in Chungbuk elementary, middle and high schools. Approximately 67% of the subjects had experience consuming health functional foods. Most of the subjects did not have experience with the side effects after consuming health functional foods. Subjects who were unaware of the legal specifications, classification, and labeling standards for health functional foods (78-91.2%) were much more common than those who were aware of those issues. Most of the subjects perceived health functional foods as a food (45.0%) or as a product between a food and a medicine (44.5%). The subjects recommended themselves (43.1%) or medical doctors/pharmacists (40.8%) as consultation/education specialists for health functional foods. Approximately 66% of the subjects had experience conducting nutritional consultation/education in their schools, but only 3.2% had experience with health functional foods. Only 17.8% of the subjects had experience receiving education on health functional foods. Most subjects (88.2%) demanded education on health functional foods for themselves. The results suggest that an effective education is needed for nutrition teachers and dietitians working in schools for them to play an active role in educating students and their parents about health functional foods in the near future.

Food Science Challenge: Translating the Dietary Guidelines for Americans to Bring About Real Behavior Change

Food scientists and nutrition scientists (dietitians and nutrition communicators) are tasked with creating strategies to more closely align the American food supply and the public's diet with the Dietary Guidelines for Americans (DGA). This paper is the result of 2 expert dialogues to address this mandate, which were held in Chicago, Illinois, and Washington, D.C., in early October 2010 between these 2 key scientific audiences. It is an objective that has largely eluded public health experts over the past several decades. This document takes the perspective of food scientists who are tasked with making positive modifications to the food supply, both in innovating and reformulating food products, to respond to both the DGA recommendations, and to consumer desires, needs, and choices. The paper is one of two to emerge from those October 2010 discussions; the other article focuses on the work of dietitians and nutrition communicators in effecting positive dietary change.

Research Note: PDA Use Is Linked to Dietitian's Work Setting

The purpose of the project was to determine the use of the personal digital assistants (PDA) by dietitians. It was found that those nutrition professionals (n = 76) who worked in medical centers were more likely (p = 0.049) to use a PDA compared to those in other work settings. Calculation of BMI was the most used PDA software by the respondents. Dietitians have become an integral part of medical specialty areas and teams, which necessitates that instant information. A PDA can provide this information.

Job Analysis and Satisfaction of Dietitian of School Foodservice for Job Efficiency

This study conducted task analysis of dietitian working in school foodservice through the job importance and performance and job satisfaction survey in Gwangju and Jeonnam areas. Of 646 questionnaires, 244 cases were analyzed by SPSS 12.0 and frequency, t‐test, ANOVA were performed. In the job performance, there are significant differences in food supplier selection (p=0.013), assessment of number of meals/day (p=0.033) in the food selection and purchase management. In terms of job importance, there are significant differences in assessment of nutritional requirement (p=0.002), analysis of nutrition intake (p=0.037), in the nutrition management and consultation with faculty, students and parents (p=0.001) in the general operation. Elementary school dietitians were the most satisfied with their salary and compensation, work environment and Middle school dietitians were the least satisfied in the analysis of job satisfaction. These results suggest that it is necessary to differentiate the main task of dietitian by the school classification (elementary, middle, high school) in Korea for improving work efficiency.

FROM THE SUPPLEMENT EDITOR

FROM THE SUPPLEMENT EDITOR

Evoking trust in the nutrition counselor: why should we be trusted?

The virtue of trust is often spoken of as central to the work of dietitians working in nutrition counseling, especially in the context of disordered eating/eating disorders nutrition therapy. Indeed, dietitians are purported to be the most trusted source of information on nutrition and food by professional associa- tions such as Dietitians of Canada. Here trust is explored through educational, relational, and virtue theory in order to elucidate trust's meaning and relevance to dietitians' work and interactions with each other, including the general public. If dietitians are to continue to be trusted during times of skepticism in ''expert'' knowledge, reflexivity, active contestation, and moral testing in the context of our socio-political milieu need be employed so that we as a profession may respond to clients in respectful, authentic, meaningful ways; practices worthy of our trust.

What Clinicians Can Learn from Life with Fred

I am a dietitian working in home nutrition support. I know a lot about it because I can assess a patient’s nutritional status and monitor their progress on home enteral or parenteral nutrition. I even know that long-term patients prefer to be called consumers because they aren’t “patients” anymore—home nutrition support is a way of life. That of course is what I thought until I got to know the consumers. Truthfully, I didn’t know about home nutrition support, not really. Technically, yes—but living the life—no. Robbyn Kindle’s article entitled “Life with Fred” details her experiences not only with home parenteral nutrition (HPN) but also with multivisceral organ transplant. Robbyn and other consumers have taught me about the reality of home nutrition support. I cannot remember all of the names nor the nutrition support regimens over time but I can remember the stories and the homes. I remember the retired couple, the husband receiving home enteral nutrition, who were one of my first to visit at home. I provided the information to a family—not just a patient. One gentleman on HPN I met with told me how to refinish a piece of furniture as he had done in his home—that was what he was proud of. My friend Bill, a 26-year veteran of HPN, provides me with the history of HPN because he has been receiving it that long. It is essential that nutrition support practitioners who work with home nutrition support consumers try to understand the challenges of living with home nutrition support. Do you know what it is like to store supplies for enteral or parenteral nutrition at your home? Did you as a clinician figure out a tube feeding formula that is easy to prepare or did you mix two different formulas together along with a modular product? Could you do that at home? Will it be paid for by your consumer’s insurance company? Do the HPN infusion hours meet your consumer’s needs, or could they be changed and improve their quality of life? That is why Robbyn’s article—her story really— is so important. It is the truth about HPN. HPN has been her lifeline as it is for many long-term consumers—that doesn’t mean she has to like it all of the time or that she has to infuse because you the clinician tells her she has to. She and others like her make a conscious decision, every day, to take in nutrition. We are a team—the consumer and the nutrition support practitioner. By working together, we can learn from one another. Ask questions of the consumer, even hard questions. Robbyn says to listen, take time, and understand the reality of home nutrition support. This will benefit us all. Thanks, Robbyn, for sharing your story. Correspondence: Carol Ireton-Jones, PhD, RD, LD, CNSD, Coram Healthcare, 1730 Countryside Drive, Carrollton, TX 75007. Electronic mail may be sent to drcijrd@attglobal.net.

介護保険と訪問栄養食事指導

There are three systems currently used to provide home-visit nutritional and dietary guidance. The first offers home-visit guidance through health care projects for the elderly, the second provides guidance to patients receiving home care through medical care insurance, and the third is provided by an administrative dietitian to homecare patients using long-term care insurance. The amount of home-visit nutritional and dietary guidance decreased after the introduction of the long-term care insurance system, even though the calculated limit of expenditure for care services was increased. The reasons for this decrease may be that the service for which the limit of expenditure was calculated does not meet the needs of users, that nutritional guidance is not exclusively the work of administrative dietitians, and that dietitians are not uniformly distributed among the clinics. Considering the combination of medicine and welfare, which is the purpose of long-term care insurance, the present system attaches too much importance to medical effectiveness and lacks consideration of other issues in the welfare of patients.

The role of the nutritional support dietitian in Europe

The European Community now supports the potential for professionals to practice in any of the member states subject to recognized local standards of education and practice being achieved. However, there is no agreed role for the nutritional support dietitian. This leads to an inconsistent and, sometimes, fragmented approach to the nutritional management of patients throughout Europe. There is a need to develop a common dietetic approach to nutritional support in order to raise awareness and rationalize standards. This will help to optimize care to individual patients by fostering good practice, developing effective communication and encouraging research. Background:The role of the clinical dietitian varies widely throughout Europe — it tends to be more highly developed in some countries than in others, which is a cause for concern among dietitians in ESPEN. This appears to be caused by several factors including education, clinical awareness of the benefits of dietetic support and access to adequate financial resources. The intention of this paper is to focus on the key aspects of the role of the dietitian working in nutritional support. The educational requirements of such a dietitian are outlined and these could be used as a preliminary guide for institutions responsible for delivering undergraduate dietetic programmes. The overall intention is to identify minimum educational standards for practice in this field throughout Europe. However, these should be viewed as a baseline from which to proceed. They should also be perceived as a quality standard for facilitating professional development, sharing clinical practice and enhancing patient outcomes. This paper does not address issues of resource allocation. Recommendations:a) There should be agreement about the key functions of the dietitian working innutritional support; b) There should be a common standard at first degree level for all dietitians; c) There should be an identified programme of post-graduate study (both clinical and academic) leading to specialization in nutritional support; d) There should be an innovative approach to providing clinical support for emerging specialists; e) ESPEN should investigate the potential for developing an accredited and integrated European dietetic standard in nutritional support.

Case Problem: Balancing Nutrition Advice With Dental Care in Patients With Anorexia and Bulimia

Extensive loss of tooth enamel is common in patients with bulimia. Improving their aesthetic appearance often enhances their self-esteem. It would be important for any dietitian working with this patient to reinforce the preventive dental therapy that was prescribed by the prosthodontist. To avert further tooth enamel erosion, the patient was advised to avoid brushing immediately after vomiting, but to use a bicarbonate rinse and to floss daily. To make the teeth more resistant to acid dissolution, a neutral pH sodium fluoride gel was prescribed for daily home use.

A Team Approach to Clinical Dietitian Work Assignments Increases Productivity and Enhances Teamwork

As one of the top 100 cardiovascular hospitals in the United States, as well as the largest cardiovascular program in the state of Illinois, the demand for nutrition services, in particular counseling, is high. In order to more equally divide workload, to provide more diversity in clinical tasks, and to minimize burnout, a team approach to dietitian work assignments was implemented. Four teams were formed: Team 1 maternal child; Team 2 cardiac medical which includes cardiac, critical care, orthopedics, oncology, neurology, surgical intermediate care; Team 3 also cardiac medical which includes general medicine with another intermediate care area, short stay area, psychiatry, and remaining areas of surgery and cardiac; Team 4 is a specialty group of renal, nutrition support team, transitional care and hospice. From a statistical standpoint, the reorganization has increased clinical units of work by 15% while average daily census for the month has been unchanged and clinical dietitian full time equivalents (FTEs) have decreased by 12% due to attrition, while units of work per FTE have increased by 26%. Another benefit of the change is that staff seem more eager to complete the workload as a member of a team. A further advantage is the heightened sense of teamwork, both within and between team members. Yet an additional benefit is more cross-trained staff. Overall staff acceptance of the team approach has been quite positive. By using this method of clinical dietitian work reorganization, productivity can be maintained and perhaps increased while FTE levels are maintained.

An investigation of the face validity of a food intake questionnaire: lessons for dietary advice

Summary Aim: To assess the face validity of a food intake questionnaire (FIQ) by comparison to current dietetic practice exemplified by State Registered Dietitians (SRD) working in the North West of England. Methods: 228 questionnaires were posted to 38 dietetic departments in the North West & North Wales branch of the British Dietetic Association. Dietitians were asked to name foods they considered most important when advising clients on four aspects of healthy eating: lowering sugar intake, lowering fat intake, increasing fibre intake and decreasing salt intake; the foods mentioned by most respondents in each category were ranked 1–10. If an FIQ item appeared in the list of ranked foods and was selected by more than 50% of the sample its inclusion in the FIQ was considered face valid. Results: 56 foods out of the 80 ranked 1–10 in the eight categories appeared in the FIQ. Thirty‐one of these 56 foods were mentioned by more than 50% of dietitians when considering the four aspects of healthy eating; 27 (87%) of these were included in FIQ items. The study also revealed a surprisingly large number of foods to be mentioned by dietitians for each of the four categories. The list of foods mentioned was extensive; for example, 120 foods were mentioned when considering lowering fat intake. Conclusions: The items chosen for the FIQ can be seen to agree closely with the opinions of practising SRDs, confirming its face validity. The results also suggest there is a need to debate the nature of dietary advice which is given to the public. The findings of the study suggest that translating nutritional guidelines into advice about which foods should be eaten is far from simple. The results may provide one reason for public confusion about healthy eating.

Reimbursement of Nutrition Services for Private Practice Dietitians

A survey of 29 Private Practice Registered Dietitians in southwestern Pennsylvania was conducted to learn about the services provided and the methods of receiving payment for their services. Ten surveys (34%) were returned. Two of these Private Practice Registered Dietitians returned to salaried positions and their responses were not included in the survey results. This resulted in a response rate of 28%. The dietitians responding to the survey provided nutrition services to home health agencies, private physicians, long-term care facilities, non-profit agencies, and individuals. Self-referrals accounted for 87% of the clients. Initial visits ranged from 45–60minutes at a cost of $20.00 to $120.00. Follow-up visits ranged from 10–30minutes and cost $10.00 to $120.00 per visit. Only 12% (1) of the dietitians surveyed submitted bills to insurance companies for reimbursement. Eighty-seven percent (7) of the dietitians surveyed requested cash payment for their services. In one instance, a private practice dietitian working with a physician group was paid by the physician group and her services were billed to the insurance company by the physician group. This survey indicated that Blue Cross, Medicare, Pennsylvania Medicaid, Traveler's, and Aetna are being billed for the nutrition services. However, clients normally came to the private practice dietitians to receive counseling in the areas of weight loss, diabetic counselling, and hyperlipidemia/hypercholesterolemia. The majority of dietitians were reimbursed for services by their clients directly.

Commentary and translation: 1994 nutrition recommendations for diabetes

Commentary and translation: 1994 nutrition recommendations for diabetes

The work of dietitians in Great Britain

The work of dietitians in Great Britain

Dietary recommendations for children and adolescents with diabetes: an implementation paper

Summary and recommendationsI General. 1. Children with diabetes mellitus have the same basic nutritional requirements as all other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily life‐style and preferred eating habits. Insulin type, dose and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently, this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special ‘diabetic foods’ are unnecessary. Low‐calorie sweeteners, as used in low‐calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close cooperation with child, parents, diabetes specialist nurse and doctor. n Infancy. 9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula‐feed used. Solids may be introduced from 3 to 6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes.III Under‐fives. 11. After 2 years of age the diet should slowly be changed to one relatively low in fats, with unrefined carbohydrate foods, fitting family customs and meeting energy needs. 12. Fully skimmed cows' milk contains insufficient vitamins A and D, too little fat and therefore energy for the under‐fives. However, semiskimmed milk can safely be included in a nutritionally adequate diet from the age of 2 years. 13. Vitamin supplementation may be given to children aged from 1 month to 5 years according to needs and local practice for all children. There are no specific additional requirements for the under‐fives with diabetes.IV Schoolchildren. 14. Reduction of fat intake, especially of saturated fats, is expected to reduce risk of coronary heart disease, and stroke in later life. After 5 years of age fat intake should be reduced to around 35–40% of total energy. 15. Replacing energy from fat by eating half or more of the daily food energy as carbohydrate, principally from unrefined, fibre‐rich sources, may improve both short‐ and long‐term health. Dietary carbohydrate for the child with diabetes should never be restricted below the usual family intake (usual range 45–50% of calories). 16. Schoolchildren should be encouraged to select their carbohydrate from sources which are rich in soluble fibre with physical structure intact (e.g. whole fruit, oats, porridge, peas, beans and lentils). These have been shown to improve glycaemic control. 17. Consumption of rapidly absorbed carbohydrate in the form of simple sugar such as fruit juice and sweets or refined starch such as mashed potato in isolation, should be discouraged. However, when used in conjunction with other nutrients within a meal, simple sugars and refined starch improve palatability without worsening metabolic control. 18. The use of sugars to prevent or treat hypoglycaemia should be established on an individual basis. 19. The proportion of energy taken as protein should not be increased among children with diabetes compared with their normal peers. 20. Supplements of minerals and vitamins are not required where a good balance of foods is taken. 21. Regular exercise should be encouraged, and insulin dose reduced or extra dietary energy provided as indicated by individual blood glucose monitoring.

Dietary Recommendations for Children and Adolescents with Diabetes: An Implementation Paper

General Recommendations: 1. Children with diabetes mellitus have the same basic nutritional requirements as other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily lifestyle and preferred eating habits. Insulin type, dose, and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special 'diabetic foods' are unnecessary. Low calorie sweeteners, as used in low calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close co-operation with child, parents, diabetes specialist nurse and doctor. Infancy 9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula-feed used. Solids may be introduced from 3-6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes. Under fives: 11.(ABSTRACT TRUNCATED AT 400 WORDS)

Incorporating nutrition into pediatric practice: physicians and dietitians working together to improve children's health.

Clinicians are needed to include nutrition in the routine care of infants and children in office practice. Physicians play an important role in assessing nutritional status, diagnosing nutritional problems, providing a rationale for treatment, prescribing, performing brief counseling, referring to other resources if needed, and following up on the progress of their patients. Registered dietitians are the consultants of choice to assist pediatricians in the care of patients with nutrition-related disorders and are skilled in providing pediatric health promotion and disease prevention information. Consultant dietitians in the community can be found through contacting the local department of health or local hospital outpatient department. The American Dietetic Association also maintains a list of consulting dietitians throughout the United States. Funding mechanisms for engaging dietetic services vary from contracting with dietitians in private practice, local health departments, or hospital outpatient clinics, to employing dietitians on-site to provide counseling services in the office. Availability for third party payment for nutrition services varies with insurance carriers, individual policies, and region of the country. Incorporating nutrition into pediatric practice is important. Together, physicians and dietitians can work together to improve children's health.