When I applied to go to Middle Tennessee State University, I did not realize the plethora of experience that I would be receiving. Currently, I am a senior in the Nutrition Food Science Dietetics program. Going to school and studying dietetics taught me many things related not only to food but also medical disease states and counseling skills. Of course, there are many other courses and topics that are interrelated with each other, but those listed previously stuck out to me the most. One assignment in particular put the knowledge I gained from the classes to the test. The objective of the assignment was to provide experience to give, receive, and observe medical nutrition therapy in fifteen minutes.
The class was split into groups of two. Each group was assigned a time to show up to the nursing building to provide a simulated clinical nutrition setting as much as possible. The catch was the roles, registered dietitian (RD) or patient, would not be assigned until right before the simulation started. Since the roles were unknown, my partner and I put together a word document containing all patient information provided by our case study book. The scenario for the simulation was as follows; the patient went for his physical checkup and the physician noted an enlarged liver and elevated liver enzyme and was subsequently diagnosed with nonalcoholic fatty liver disease (NAFLD). The case study book provided all information needed such as doctors’ notes and diagnosis and as well as laboratory results.
Since we were allowed one page of notes and one to two handouts, my partner and I decided to optimize the page with brief information and helpful resources to educate the patient. Although I knew the information, I was very nervous. My partner reassured me that I would be fine and that his gut was telling him that he would be the dietitian. Upon arriving at the building, the professor had two tiny pieces of paper with RD or patient on it within an envelope. Somehow, I was selected to chose the piece of paper. I reached into the envelope and selected the first paper, but my gut told me to switch to the other paper. As I slowly unfolded the paper, my heart was beating rapidly as I read the letters “RD” across the tiny paper. To set the scene, the main room contained two hospital beds and a dummy laying on one of the hospital beds. Next to this room was an area available to control the dummy; however, for the purpose of the simulation, we only needed the voice. A microphone placed in this room allowed the voice to be projected in the other room through the dummy that allowed my partner to simulate the patient. Once my partner was set in that room, that signaled the beginning of the simulation. I had to switch my thinking from dietetic student to future registered dietitian.
Upon knocking and entering the room, I introduced myself to the patient. Although I had my notes with me, I completely blanked on what I had to say next. I calmly took a breath and tried again. I briefly mentioned that the doctor had already explained the diagnosis to him, and that my role as a dietitian was to explain how food lifestyles contained an impact on the development and progression of NAFLD. Next, I went over important lab values that supported his diagnosis such as elevated ALT and AST levels, high cholesterol levels, and high triglycerides levels. Based on his usual dietary intake, there seemed to be a trend with foods that contained fat such as doughnuts, pastries, meats, fries, chips, pie, and cookies. As the patient asked questions, I was able to answer them to the best of my ability. Next on my to-do list was to introduce the possibility of incorporating aspects of the Mediterranean diet into his current diet. I made sure to ask the patient if he has heard of it and what he could tell me about it. While discussing the aspects of the diet, I decided to tell the patient about current dietary choices that are within this diet and how he can incorporate it more into his eating habits. During the session, I forgot to give the patient the handout of the Mediterranean diet, but I did give it to him at the end to take home. Since my time was running out, I quickly addressed how to incorporate exercise into his daily routine. Finally, I provided a recap on NAFLD, how food plays a role, and possible goals and lifestyle modifications that could be made to lessen the signs and symptoms of NAFLD. Compliance is one hundred percent expected.
In the beginning, I would describe myself as nervous and full of anxiety, but by the end I was a confident and knowledgeable dietitian. This simulation has taught me the importance of learning different disease states and how food can impact a person’s quality of life. Giving nutritional advice is not just telling the patient or client what to eat and not to eat. It is a lot about getting to know the person and meet them where they are at. After the simulation was over, I felt like I could do it again! It was nice to get experience on how it would be when I do go out into the crazy and unique world of registered dietitians.
If there is one popular diet that has been at the forefront of research and promoted widely to not only the general public but also within healthcare settings, it would be the Mediterranean Diet. Nearly several decades have gone by since the interest of this dietary pattern began, and within this time span there has been great evidence of its efficacy in reducing cardiovascular disease and promoting longevity. The foundation of this particular diet has an emphasis on increased daily consumption of vegetables, whole grains, and fruits; while consuming moderate amounts of dairy and limiting the intake of red meat.1
Although this dietary pattern is commonly associated with countries bordering the Mediterranean Sea, we also see this pattern -to an extent- amongst those living in other “Blue Zone” areas, such as certain parts of Japan, Costa Rica, and even here in the United States. Blue Zones® (BZ) is a trademarked term for the collection of five distinct areas, Okinawa, Japan; Sardinia, Italy; Nicoya, Costa Rica; Ikaria, Greece, and Loma Linda, California.2 Through the years, those living within the BZ have been extensively studied for their lifestyle patterns (such as diet), social connections, biomarkers, and genetic variations as important factors towards the attainment of remarkable-age also referred to as ‘supercentenarian’ status.
Two years ago, a pre-print (still under peer-review) of S.J. Newman’s study titled “Supercentenarians and remarkable age records exhibit patterns indicative of clerical errors and pension fraud” was released. Within the study, Newman brings to light current evidence that a potential role of errors and operator biases could have been overlooked in previous work.3 His findings showed that illiteracy, high crime rates, poverty, shorter average lifespans, and the absence of birth certificates were included within the data that was used as a predicated factor towards supercentenarian status.3
In this study, Newman’s method of research involved obtaining supercentenarian tables from the Gerontology Research Group that showed the number and birthplace of supercentenarians, those who have attained 110 years of age, in which he had split into subnational units for birth locations.3 Exclusion criteria that were set by Newman included poor subnational resolution of countries with less than 15 total provinces and populations with incomplete subnational birthplace records; dwindling down the useable data to only 25% of the original.3
Using this data set Newman highlighted peculiar trends from the US and in Italy that raises questions as to the validity of the current body of literature on remarkable age reportings of certain populations and individuals.3 When comparing total supercentenarians with the years before and after complete birth registration was implemented in the US (circa 1904), we see a significant drop in the total number of supercentenarians; although during this time there was rapid growth in population and increased life expectancy.3 The significant drop was represented by 82% of the supercentenarian records from the US that happened to predate the state-wide birth certification.3 This data was also reflected when adjusting for total population size per state, as shown in Figure 1.
Figure 1. Number and per capita rate of attaining supercentenarian status across US states, relative to the introduction of complete-area birth registration.
Note. Image adapted from ‘Supercentenarian and remarkable age records exhibit patterns indicative of clerical errors and pension fraud’ by S.J. Newman, pg 7, 2019.
From the years 1880 to 1900, which was the core period in which supercentenarians were surveyed, the population in the US had increased by 150% and the average life expectancy by roughly 20%.3 With such a drastic increase, it would be speculated that there should be a proportional increase in the total number of supercentenarians per capita, but the data showed the complete opposite. With the transition to state-wide birth registration, there was an 80% reduction in the total number of supercentenarians statewide, and a decrease of 69% per capita.3 This raises the question of the validity of those that claimed to be supercentenarians before the complete issuance of birth certificates.
Italy had introduced birth certificates well before the onset of records being kept of supercentenarians and its predictor in the attainment of remarkable age was actually correlated with a short average lifespan.3 When comparing the probability of survival to age 55 with the probability of survival to ages 95, 100, 105, and 110, we see an inverse relation starting after 95 years of age, as shown in figure 2.
Figure 2. Relationship between mid-life and late-life survival across Italian provinces. Note. Image adapted from ‘Supercentenarian and remarkable age records exhibit patterns indicative of clerical errors and pension fraud’ by S.J. Newman, pg 14, 2019.
Within this study, Newman had reported trends of remarkable ages coinciding with a higher prevalence of counter-indicators of health and longevity across many populations and individuals, such as seen with data sets from Japan, France, Costa Rica, as well as here in the US.3
Much of this data is not to negate the fact that the lifestyle and characteristics of those living within the BZ have a positive correlation of health and longevity, but to raise questions as to the validity of the current recorded ‘supercentenarians’ data and to what extent of longevity may be achievable with said BZ lifestyles. With the BZ lifestyle in question, what does that say about the dietary patterns they have and what are the implications towards health in contrast to other dietary patterns in countries outside of the BZ’s? Further research will be necessary to develop a better insight into the relation towards remarkable-age attaintment and its declining trend after the introduction of state-wide birth certificate in the US, as well as the inversed relation between the probability of survival to age 55 and the probability of survival beyond the age of 95 in Italy, as shown in Figure 2.
In conclusion, it is indeed an interesting study that pointed out some conflicting nuances involving a lifestyle and dietary approach that is highly regarded in not only media but in healthcare as a popular dietary intervention. It’s only a matter of time until there has been enough peer-review for this study to be further scrutinized and until then we must ask ourselves, is the Mediterranean diet and the Blue Zone lifestyle that it falls under truly the most optimal for longevity?
Feature image: Created by Doreen Rodo per information in #2 above; April 11, 2021
Need to prepare for the food handler or food manager exam?? Check out these free videos:
Two playlists to choose from: Food manager exam and Food Handler Exam
Starting a private practice is no easy task, but it can certainly be done! The graduate program I enrolled in was “Entrepreneurial” based, meaning I wrote a business plan and was required to take finance classes. The program I graduated from was awesome, and I learned how to be an effective, evidence-based Registered Dietitian… but I was not prepared for how much learning I had YET to do and learn as a business owner! I knew I wanted to start my own private practice before I even started grad school, so I started to learn from my family, friends, the Small Business Association, YouTube, social media, and other RDs. Let me tell you, I was not ready to start my private practice, and I did not feel 100% ready to go. I had picked a date to start, and as that date got closer I got nervous but I started anyway! You may not feel ready or fully confident, but you have to go for it! There are so many moving parts to starting a business, and there is no perfect way to do it. However, there are a TON of resources out there to set you in the right direction!
If you want to have a private practice as an RD, you really do just have to start! I suggest you utilize SCORE through the Small business association (SBA) in your area. SCORE gives you free business mentoring that will help you set up a business plan, develop a marketing plan, offers webinars and classes, and in-person business development. You can connect with the SBA and SCORE before you take the exam if you like. Once you pass the RD exam, check out what licensing you need in your state and town. You will need an NPI number. If you are a member of the Academy of Nutrition and Dietetics, there is group insurance through Mercer/Proliability that has a discounted rate for first year RDs. Once you have your licenses, NPI and insurance, you will want to do the following:
Every day I learn something new. Every day I work on at least one thing to make my business bigger, better and stronger. This is just the tip of the iceberg, but doing these things will help you move forward to owning the practice you deserve!
Jessica’s blog post can also be viewed at: https://jessicadorner.com/2019/08/starting-a-private-practice-as-a-dietitian-how-to-simply-start/
I am a RDN with over 25 years of experience in LTC. Over the past few years, I have been working with students as a preceptor. This led me to create four nutrition presentations that have proven to be helpful to student dietitians and diet technicians. In fact, I have recently updated the videos as a result of some feedback from over 200 students. One had commented, “I wished I had seen your videos at the start of my internship.” In addition, I have written an e-Book that students can purchase for practical information on completing nutrition assessments. Sample patients are included. Overall, these resources are designed to give the student practical advice on how to complete nutrition assessments and plans based on current nutrition scientific evidence.
At some point in your educational career as a dietetics student, you’ll likely serve as an intern in a long-term care facility. Some classes may even require you to gain supervised experience as a student before your dietetic internship begins. I recently had the opportunity to work with my preceptor, Doreen Rodo, in this capacity for one of my classes. This class taught me a lot about what to expect as I enter my dietetic internship, and I hope my insights can be of help to others as they enter clinical rotations.
What Makes a Good Preceptor?
When selecting a potential RDN to work with, interns should consider the qualities that make a successful preceptor. RDNs who choose to serve as preceptors are typically drawn to it because they want to help. A good preceptor has a desire to foster growth and educate future RDNs. Patience is a clear virtue here, as students and interns will likely ask a lot of questions. The RDN may be busy but taking the time to answer questions will produce a better intern by the end of the rotation.
Though an effective preceptor understands an intern is still learning, they will also encourage as much independence as possible. Giving some autonomy whenever possible allows the intern to adapt to a role they may be intimidated by, and this builds confidence over time. The RDN will always review the work of the intern, which offers the chance for feedback and corrections, and also serves as reassurance that the intern is learning under the guidance of an experienced professional rather than going it alone.
How to Be a Successful Student or Intern
It is important for interns to consider the expectations of their preceptors and strive to meet them. As I touched on above, preceptors are typically happy to help students by answering questions, giving insights based on their experience, and offering guidance when judgment calls are needed. When the time comes that a preceptor corrects an intern’s work, a successful student will accept the feedback with appreciation and not defensiveness. It’s important for interns to not be embarrassed or afraid to make mistakes; the RDN doesn’t expect perfection. It follows, then, that the intern should view the RDN’s input as an opportunity for growth rather than criticism.
Asking questions is not only okay, it’s expected of students. An intern who doesn’t ask questions may be perceived as either disinterested or irresponsibly overconfident. However, a delicate balance should be found between being a learner and being an active participant. Interns should find the confidence to assert themselves and take on projects or duties that may lie slightly out of their comfort zone, but that they are capable of. It would serve a student well to remember that they can alleviate some of the RDN’s workload by being productive rather than passively waiting for the RDN to give them assignments.
Finally, all students and interns should remember the basics of being a good employee, especially those with little to no work experience. Always be punctual, dress in a way that’s appropriate for the setting, and be prepared with all of the resources you’ll need. And don’t forget to pack a lunch and some water! Being overly hungry or thirsty can undermine all of your other efforts to succeed.
Maintaining a Positive Preceptor-Student Relationship
Both preceptors and interns can contribute to the success of their relationship by managing expectations. It may be helpful for both parties to discuss their expectations from one another before the rotation starts, to get started on the right foot. When it goes well, this experience can produce a collaboration where the student learns from the RDN and the RDN benefits from having an extra hand with their work and the fresh perspective that a student can bring.
While working with my preceptor in a long-term care facility, I found several resources to be helpful to have on hand. These included a few handy pocket guides, a useful app on my phone, some evidence-based websites, and my go-to textbook. The resources a student or intern finds most helpful will depend on the environment they’re in and personal preferences, but I hope the list below of my own choices serves as a helpful starting point.
*All of these pocket guides are available for purchase, in print or digital form, from the Academy of Nutrition and Dietetics (AND) website at www.eatrightstore.org. Student pricing is available to AND members.
Books and Other Publications:
Effective communication lies at the core of every patient interaction. For RDs and interns in long-term care (LTC) facilities, there are some unique challenges to overcome when communicating with residents. During my time as a student-intern, I learned about these obstacles and saw the unique ways in which they can be overcome.
Factors that affect communication with long-term care residents:
Thankfully, each of these issues can be resolved with the following approaches:
While navigating communication barriers, it is vital that the RD or intern always does so while respecting the resident’s dignity and intelligence. Having a hearing, speech, or memory impairment does not mean a person is of lower intelligence. The RD or intern can show respect by always first assuming that a resident will understand them (and adapting accordingly if they don’t); always addressing the resident directly, until notified that the resident prefers to use a proxy or alternative means of communication; and speaking in a way that is simple, slow, and clear without being patronizing or demeaning.
The time leading up to my initial patient interactions created some anxiety for me. I was nervous about saying the wrong thing, not being able to understand someone or causing confusion or agitation for residents. I quickly found, however, that there was no need for this fear. When an RD or intern approaches each resident interaction with confidence and genuine respect, every barrier can be overcome.
Dietitians in all fields rely on interprofessional collaboration, and this is clearly necessitated in long-term care (LTC) settings. LTC RDNs utilize ongoing relationships with allied healthcare providers to deliver comprehensive and effective patient care. The outline below describes the ways in which these professionals work together.
Foodservice Manager (FSM)
The FSM is the person with whom the RDN works with most closely. The FSM is in charge of all menu planning, ordering and inventory, oversight of kitchen staff and meal service, adherence to special diets, and maintaining care plans as they relate to dietary concerns. The FSM is typically the person who conducts an intake interview to ascertain the basic information upon which the RDN begins their nutrition assessment. They are also the point person for all food-related concerns, so the RDN has many ongoing discussions with them about changes in nutrition status, needs for special diets, and special resident requests.
This includes registered nurses (RNs) and certified nursing assistants (CNAs). The nursing staff are the people who interact with and assist residents with most of their needs. As such, they are often the best sources of information about residents’ recent behaviors, eating patterns, and other pertinent information. The nurses are also tasked with recording vital information like anthropometric measurements, PO intakes, medication and supplement delivery, etc. The RDN relies on the nursing staff to record this information in the EMRs for their assessments and monitoring.
This includes speech-language pathologists (SLPs) and occupational therapists (OTs). The RDN works mostly with SLPs, as they assess and treat speech and feeding issues. If a resident shows signs of dysphagia, the SLPs are the ones to diagnose it. Sometimes the RDN will alert SLPs to a suspected issue, and sometimes the SLPs will alert the RDN.
OTs and RDNs work together less often, but may communicate about residents with motor/movement disorders or mobility issues that affect their feeding abilities. Examples would be a resident with Parkinson’s Disease that needs adaptive silverware, or a resident recovering from joint replacement surgery who needs assistance until their mobility is improved.
Medical Doctors (MDs)
The MDs at a LTC facility are the overseers of all patient care. MDs conduct regular visits with residents to assess, diagnose, and treat a variety of health conditions. When one or more of these health conditions involve nutrition, the MD and the RDN work together to agree on appropriate treatments. Some of these conditions include: diabetes, heart disease, kidney disease, malnutrition, dysphagia, and dementia. As you can see, this covers nearly all of the common conditions found in older adults living in LTC facilities. The RDN gains valuable information about residents’ health by reviewing labs ordered by MDs, and they can also offer guidance to MDs based on their assessment of residents’ weight changes.
Putting It All Together
To provide consistent, comprehensive patient-centered care, the entire healthcare team must work together. One of the primary tools to facilitate this is the Patient-At-Risk (PAR) meeting. At the facility I interned with, this meeting is done on a weekly basis. It includes the resident MD, the head of nursing, the administrator, the foodservice manager, the RDN, the activities director, and a social services manager. Each employee has a turn to review all of the residents currently of concern due to health decline, weight changes, skin/wound changes, falls, behavioral issues, socio-environmental concerns, and more. This meeting is a way to keep all departments abreast of the current happenings of the facility and it guides the team in identifying which residents may need extra attention or monitoring.
As the LTC RDN works to provide quality care to residents, they are never doing so alone. By maintaining relationships with people from every department within the facility, the RDN cements their place as a vital piece of the healthcare system.
Topic 1: The Importance of Meal Rounds in Long-Term Care
Long-term care RDNs rely heavily on observation to identify and address feeding issues in residents. As a student, I was surprised to find just how important meal rounds are. As I assisted my preceptor in meal rounds, I learned a lot about the feeding issues that older adults often face and the various tools an RDN may use to treat them.
Among older adults living in nursing homes, it is estimated that 40-60% experience feeding difficulties.1 This is not surprising, given that an estimated 47.8% of nursing home residents have Alzheimer’s or other dementias.2 Dementia leads to many feeding difficulties, as it often leads to pocketing of food, increased energy expenditure due to pacing, food refusal, agitation, and forgetting to eat.3 What’s more, dementia and other conditions can cause dysphagia, which involves difficulties swallowing food and/or fluids. For residents with motor neuron diseases like Parkinson’s, the physical act of getting food from their plate to their mouth can be laborious. With a population susceptible to unintended weight loss and malnutrition, all of these feeding issues pose a very high risk. This is what makes meal rounds such a powerful tool for RDNs.
By observing residents as they eat, an RDN or intern may notice one of the following situations:
When one of these situations occurs, the RDN may take action by:
When an RDN conducts meal rounds, their primary goal is to help every resident get adequate energy and nutrient intake. The golden rule is, “food first”. If, however, every option above is exhausted and a resident is unable to meet their nutritional needs (as evidenced by significant weight loss or other signs of malnutrition), the RDN has a few other tools to use. First, CNAs and diet aides can be instructed to always offer residents whole or chocolate milk with their meals. The additional calories and protein in milk can make up for deficits caused by feeding issues. If the resident refuses or it isn’t enough, drinks like Ensure or Boost may be warranted. After prescribing one of these nutritional supplements, the RDN will assess the resident’s intake of them at future meal rounds.
Students learn much in their classes about nutrition assessments and nutrition-focused physical exams. Another important tool for RDNs that doesn’t receive as much coverage, however, is meal rounds. During my time as a student-intern, I learned how critical of a practice it is to observe residents as they eat.
Jessie is just completing her undergraduate work at the University of Alabama and will be interning with the University of Delaware this fall.
To prevent the spread of COVID-19, the CDC recommended that the residents eat in their rooms. This was a problem for one of my units with a large dementia population. One resident was so distraught that she couldn’t go out of her room that she threw her food on the floor and also did end up presenting with weight loss. Others were simply not doing well with being out of their routine. Many needed constant cueing, but staffing was an issue. The team met and it was decided that the residents needing assist or cueing would have someone designated to be their assistant for each meal. Upon completing meal rounds, I found that the residents are now being assisted with their meal in a timely manner and we are getting a lot of good feedback on individual preferences. So, just a reminder to all, if you have a dementia population, make an effort to ensure that they are being fed in a timely manner when any situation arises that changes their established routine.
Dementia Mealtime Assessment Tool
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