Wednesday, December 30, 2009

Intern Research: Surveys Aren’t Easy



As a part of our internship, we experienced the thrill, exhaustion and excitement involved in conducting research. As a three-member team, we completed a research project on the knowledge and comfort level of Registered Dietitians (RDs) in recommending vitamin and mineral supplements.

The first and most difficult task in completing research was hammering out the research question. It was amazing that one question could lead to so many others. For example, our group spent hours discussing what the word comfort meant to each of us. Defining the research question was an important process to go through, and as an added benefit, we learned a lot about fellow group members.

The literature review revealed little research on the topic of our research question. At first, this made us nervous. However, with time, we realized that it was exciting to be the first to help explore a question key to dietetic practice. The next step was to go through the process of getting ethical approval from Fraser Health and from UBC. In other words, “read the fine print”. This was the part where three ‘big-picture’ people ran into trouble and where detail-oriented people (not on our team) would have thrived.


The concept of using a survey to gather information seemed simple, but we learned that it was not. Developing survey questions that asked for the specific information we wanted was very challenging. We discovered that it was extremely valuable to test questions with a focus group as much as possible. We were told (more then once) to avoid double negatives. So, of course, during data analysis we noticed we had still created a question for which the resulting data was a very confusing double negative. Specifically, the result to one of the questions was that ‘RDs are not feeling it was their role to make vitamin and mineral supplement recommendations’. Confused yet?

In our overzealous excitement and eagerness, we ended up asking too many questions that were interesting of course, but did not actually help us answer the research question we had set out to answer or to address our research objectives. For example, our research question
was registered dietitians’ practices in recommending vitamin and mineral supplements. We asked questions about the barriers that prevent RDs from making vitamin/mineral recommendations and what sorts of things would help them improve their comfort level. Although it was very hard to leave some questions out of our results and discussion, having to do so suggested that there are many unanswered questions around this topic.

In general, the research process for our group involved the following things: approximately 10,000 emails, several 1:00 a.m. conference calls, about 100 to-do lists, a couple dinner parties, and a pretty satisfying end-result.


Overall, we found the research component of internship very challenging and interesting. We gained an appreciation for people who contribute to furthering the dietetic profession by completing research, and learned the basics of how to complete a research project from
beginning to end. That being said, the most important things that we learned were how to be effective group members and how not to do surveys.

ACKNOWLEDGMENTS

Karol Traviss, RD for helping us through the process of survey development. Dr. Cathy Morley, RD for helping us find our way out of that huge mess of data. Liz Da Silva, RD and Sian-Hoe Cheong,
RD for being there every step of the way.


Contact

Jaclyn Smith, RD(t)
New Westminster, BC
T: (778) 397-2087
E: Jaclyn.Smith@fraserhealth.ca


Co-researchers:
Damaris Campbell, RD(t) and
Jill Wallace, RD(t)

Thursday, December 3, 2009

Beyond Nutritionism – An Invitation to Critical Dietetics Dialogue

In spring of 2009 a research workshop entitled "Beyond Nutritionism: Rescuing Dietetics through Critical Dialogue" was held at Ryerson University and funded by the Social Sciences and Humanities Research Council. Appropriately, for a springtime gathering, it marked the establishment of a new movement - Critical Dietetics.

At the workshop, leading international theorists, researchers, practitioners, students, and advisors had long-awaited conversations regarding gender, race, class, ability, size, dietetic epistemology, post-structural orientations to dietetic education, art, and poetry in the context of dietetics. The result was an animated, groundbreaking commitment to redefine the profession through Critical Dietetics.

What counts as “knowing” in dietetic practice? How do we, as nutrition professionals, come to know what we don’t know? How does the evidenced-based culture of dietetics give voice? Where does dietetic culture render silence? What is it that we have already accomplished as a profession? In what ways do we continue to evolve? How can we further build upon the rich roots of our profession? What do we envision for the future of our profession? These are but a few of the difficult, essential questions that Critical Dietetics seeks to explore.

Critical Dietetics takes courage as we depart from familiar ways of doing and knowing. Indeed as Simmons (2009) challenged us in an earlier edition of Practice, it is time to “expand” (p.3) our dietetic identities to become more “pluralistic” (p.3), as we move beyond mere nutritionism (Pollan, 2008) in our work.

Critical Dietetics requires conviction for change, comfort with the uncertainty of not knowing, acceptance of the blurry divide between art and science, and a desire for our allies’ knowledge in social sciences, humanities and natural sciences with whom we have much to integrate. We can grapple with the limits of science alongside the imperative to use it, and venture into the vulnerability evoked by the merging of personal and professional ways of knowing.

We are authors of our own experience and supportive witnesses to one another’s growth in the midst of this new terrain.

Critical Dietetics: A Declaration stands as testament to the commitment the initial group has forged. It is extended as an invitation to our colleagues to become companion dietetic explorers in this exciting new movement. Together we can expand the body of knowledge in dietetics and shape the future of our profession.

REFERENCES
Pollan M. (2008). In defense of food: An eater’s manifesto. New York: The Penguin Press.
Simmons D. (2009). Questioning my Dietitian identity. Practice, 46, 3.



Critical Dietetics - A Declaration – June 2009

Dietetics is a diverse profession with a commitment to, and tradition of, enhancing health, broadly defined, through diet and food. We recognize the commitment and hard work undertaken by dietetic professionals of the past and present who continue to innovatively shape and reshape the profession from its roots in home economics to the incorporation of contemporary perspectives on health. While recognizing the multiple meanings of food and its power to nourish and heal, we acknowledge that food is more than the mere sum of its constituent nutrients. We recognize that human bodies in health and illness are complex and contextual. Moreover, we recognize that the knowledge that enables us to understand health is socially, culturally, historically, and environmentally constructed.

Building on the past century of dietetics and the “Beyond Nutritionism”workshop held at Ryerson University June 12-14, 2009, we extend an invitation to individuals in all areas of dietetics education, practice, and research to collaborate on the Critical Dietetics initiative.

Critical Dietetics is informed by transdisciplinary scholarship from the natural sciences, social sciences, and the humanities. By contributing to scholarship, practice, and education, it strives to make visible our assumptions, give voice to the unspoken, embrace reflexivity, reveal and explore power relations, encourage public engagement and diverse forms of expression, and acknowledge that there are no value-free positions. Through these principles, Critical Dietetics will engage with the ever-changing health, social, and environmental issues facing humanity.

Assuming a critical stance means remaining inquisitive and willing to ask and hear challenging questions. Critical approaches grant us permission to imagine new ideas and explore new ways of approaching our practice. Critical Dietetics creates space for an emancipatory (i.e., liberating and socially just) scholarship by drawing upon many perspectives, philosophies, orientations, ways of asking questions, and ways of knowing.

Critical Dietetics derives its strength from supportive relationships, recognizing that it takes courage to step beyond familiar ways of knowing. It invites constructive dialogue and challenges us to discuss, debate, and rethink what we know and how we know it. It is a generative and collective effort which understands that strength comes from diversity and debate. This declaration is therefore a bold invitation that welcomes different ways of thinking and practicing within our own profession and in collaboration with allied fields. We anticipate collectively expanding the body of knowledge in dietetics and continuing the inclusive, scholarly, collective, and pluralistic development of the profession. If you want to contribute to this dialogue and become a signatory of Critical Dietetics, please email your expression of interest to jgingras@ryerson.ca by January 7, 2010.

Sincerely,

Lucy Aphramor (UK) BSc, RD
Yuka Asada MHSc, RD
Jennifer Atkins MHSc, RD
Shawna Berenbaum PhD, RD, FDC
Jenna Brady BA, BASc, MHSc
Shauna Clarke (UK) BA, MA
John Coveney (Australia) MPHEd, PhD
Marjorie DeVault (USA) PhD
Lisa Forster-Coull MA, RD
Ann Fox MHSc, PhD, RD
Jacqui Gingras PhD, RD
Charna Gord MEd, RD
Mustafa Koc PhD
Esther Ignagni MSc
Daphne Lordly RD
Debbie MacLellan PhD, RD, FDC
Elizabeth Manafo MHSc, RD
Catherine Morley MA, PhD, RD, FDC
Dean Simmons MSc(c), RD
Karen Trainoff BASc, RD
Roula Tzianetas MSc, RD
Jennifer Welsh MSc
Kristen Yarker-Edgar MSc, RD

Thursday, November 5, 2009

CINDAR – A Useful Tool for Dietetics Researchers, Practitioners and Students


Have you had an opportunity to use the Canadian Inventory of Nutrition and Dietetic Associated Research (CINDAR) lately? If not, please check it out.

CINDAR is an online resource of dietetic and nutrition research activities. Through this database, researchers can share their work with others and learn who else is doing related research. CINDAR is unique in that it enables users to share updates and to learn about research that is currently in progress. CINDAR also informs practitioners, educators, policy makers, and industry leaders about the nutrition and dietetic research in progress.

CINDAR was developed in 1997 by Dietitians of Canada with funding from CFDR. Currently, both the Canadian Society for Nutritional Sciences and the Canadian Society of Clinical Nutrition also provide their members with access to CINDAR through direct links on their websites.

The value of CINDAR is in the information contributions of the community of dietetics and nutrition researchers in Canada. Researchers input their latest projects and update their progress as they achieve major milestones in their work. The database presents research summaries when users search by investigator or by key words that the researchers themselves have identified. Directions are available to help users profile their research, upload a CV or photo, or simply create a description of their work for the site. The database also allows for direct links to other websites where more information can be found about the researchers and their work.

CINDAR is a useful database of research projects in many practice areas. Currently, there are hundreds of research projects profiled on CINDAR covering a vast array of research projects. Topics include obesity, infant nutrition needs, disease-specific nutrition interventions, dietetics education, and projects enhancing the profession.

CINDAR can be used for a variety of purposes. For example:
  • If you are interested in a particular field of research, you can enter a keyword to find research projects in this area. You might find answers to practice questions.
  • If you want to collaborate with someone on a research project, you can find a researcher who is interested in the same type of research.
  • If you want to find more information about a specific dietetic researcher, you can search on the researcher’s last name to learn about projects they have done.

CINDAR is an excellent resource for dietetics students. Kayla Glynn, MHSc, RD, Internship Coordinator, Division of Food and Nutritional Sciences Graduate Program in Foods and Nutrition at Brescia University College (University of Western Ontario), instructs students on the value of CINDAR. Kayla says, “Our MScFN (Internship Stream) has prepared Guidelines for the MScFN Major Research Project. The guidelines clarify the intern’s responsibilities regarding dissemination of their research. We expect our MScFN interns to submit their research projects to CINDAR. We hope that our graduates appreciate that this aspect of dissemination is a way to give back to the profession while acquiring valuable recognition at the start of their careers.”


For more information on CINDAR, please visit the CFDR website at www.cfdr.ca/cindar.html.


Contact

Isla Horvath
T: (519) 267-0755
E: ihorvath_cfdr@dietitians.ca


Friday, October 30, 2009

Community Partnership Involving Dietetic Interns: A Public Health Nutrition Experience

Background

Partnership is one of the core functions in public health practice. The partnership described in this article arose from a joint commitment of bringing community nutrition and chronic disease prevention work into a community agency, the Patch Project1 (Hull Child and Family Services), whose nutrition programming was focused on emergency food access. This article describes what we did and provides perspectives of different partners including staff of the Patch Project, the University of Alberta Integrated Dietetic Internship Program (UA-IDIP), and Health Agency registered dietitian (RD) preceptors.

What We Did


We took an asset-based approach and conducted an inventory of current community based programming focused on nutrition. The Patch Project advised on the program areas of most relevance to the populations they served. Dietetic interns were key participants in this initial work. During their placements with health agencies they researched the unique needs of the population that the Patch Project served. The work was primarily health agency driven and the outputs included adaptations to the format and delivery of existing resources to address the needs of diverse populations.

The partners had shared values, goals and expectations around accessibility and appropriateness of existing programs and seeking opportunities to model healthy eating in non-health agency programming, rather than seeking initiative funding and/or creating new/temporary resources with limited sustainability. All partners concurred that the goals could be achieved by placing an intern directly with the Patch Project thus optimizing use of preceptors’ areas of expertise while providing dietetic interns with practical experiences in community nutrition work with at-risk populations. The health agency RDs mentored the intern in developing community and public health nutrition competencies including how to appropriately utilize nutrition standards, approaches and resources in working with at-risk populations.


The foundational work spent on building the partnership and the ongoing evaluation led to a decision to pilot a 12-week intern placement at the community agency. Additional components to the established internship placement process were developed including a community agency screening of the intern, intern orientation binder, and scheduled opportunities for partner communication (e.g., weekly meetings, template for weekly intern reflection reports).


Participants’ Reflections


Patch Project, Hull Child and Family Services:

We experienced more nutrition modelling, education, and skill building in our agency programming that clearly stimulated an interest in healthy eating. Nutrition was introduced in practical ways within achievable limits. A challenge is how to manage and sustain the ideas/ programming after the placement ended. Our goal is to integrate nutrition considerations into our practice.


Internship Coordinator (UA –IDIP):

This placement was in a non-traditional setting and was a way to offer hands-on experience for interns in community nutrition. Adding new (non-traditional) placements to the internship increases the number of meaningful placements available to interns and allows them to gain experience in nutrition education, needs assessment, program planning, implementation and evaluation.This particular placement also provided learning opportunities related to food insecurity.


Dietetic Intern (UA –IDIP):
Since I was directly immersed within a low-income, multicultural community during this placement, I was able to appreciate the work that goes into a community development project. I have always been interested in community nutrition and now I have had the opportunity to work on a community garden and to develop a community nutrition program.


Health Agency RDs – Alberta Health Services
(Nutrition Services, Population and Public Health);

Healthy Babies Network, Catholic Family Services:

Placing a dietetic intern in a community agency allowed for a person with nutrition expertise to participate in hands-on work. The shared responsibility of preceptorship and combined perspectives of Dietitians in public health and community nutrition broadened the scope of practice for the intern. This successful pilot placement is seen as a model that can support community level work. Because of the Patch Project’s commitment to health promotion we have been able to consult with them for a community perspective on other initiatives.

Conclusion


The internship placement described in this article is one example of the important role of partnerships in public health nutrition work. We believe that an open and transparent partnership, with common values and goals, where all partnership work is valued and where challenges are addressed from an asset-based approach has been central to the successful outcomes.


1 The Patch Project is a grassroots, community based program serving families that live in subsidized housing units located in high needs communities.



ACKNOWLEDGEMENTS
– Thank you to all partners in supporting this experience: Patch Project (David Wright, Christina Maes, Twyla Mudry, Teresa Rumdit, Stacey McRae, Claire Jackson); UA-IDIP (Carrie Mullin-Innes); UA-IDIP intern (Sandra Paquette); Alberta Health Services (Kathy Cunningham); Healthy Babies Network (Brinda Rao).

Contact

Nutrition Services, Population and Public Health

Alberta Health Services - Calgary, AB

Suzanne Galeslott, MSA, RD
T: (403) 943-6752
E: suzanne.galesloot@albertahealthservices.ca


Annette Li
T: (403) 355-3290
E: annette.li@cancerboard.ab.ca


Friday, October 23, 2009

Assessing Nausea and Vomiting of Pregnancy

My strong interest in pregnancy lead me to study the most common medical condition during this life stage, nausea and vomiting of pregnancy, during my Nutritional Assessment course at the University of Guelph. I was amazed to learn how two symptoms can have such severe consequences in a woman’s pregnancy and life. This article provides information on the nature of nausea and vomiting of pregnancy (NVP), and methods developed to assess symptom severity, nutritional status and dietary intake.


NVP affects almost 80% of all pregnant women (Goodwin, 2002). Although not usually life threatening, it has a negative effect on a woman’s quality of life during pregnancy (Attard et al., 2002). The severity of NVP ranges between mild nausea and uncontrollable vomiting requiring hospitalization. The most severe form, hyperemesis gravidarum, occurs when NVP progresses to severe vomiting and is characterized by decreased dietary intake (Smithells et al., 1977), dehydration, electrolyte imbalance, and weight loss of >5% of body weight (Fairweather, 1968; Emelianova et al., 1999). Symptoms of NVP usually occur during the first trimester, however, some women experience symptoms for longer (Goodwin, 2002). Assessing the nutritional status and symptoms of nausea and vomiting in pregnant women is important to ensure a healthy pregnancy and optimal quality of life. Symptoms can be assessed using clinical assessment instruments, while anthropometric and dietary measures are used to monitor nutritional status.


The severity of nausea and vomiting can be assessed using a validated questionnaire to quantitatively assess the severity of subjective symptoms (Rhodes et al., 1999). The Rhodes Index of Nausea and Vomiting Form-2 (INV-2) is a validated eight-item self-report instrument that measures the physical symptoms and stress caused by NVP (Rhodes et al., 1984). This instrument has been reformatted to a more efficient, reliable and user-friendly version called the Index of Nausea, Vomiting, and Retching (INVR) (Rhodes et al., 1999). Although this instrument is appropriate for clinical assessment and research, it was created and validated with a respondent sample of people experiencing nausea and vomiting in cancer chemotherapy (Koren et al., 2001). The Motherisk Program in Toronto found the INVR instrument cumbersome and time-consuming (Koren et al., 2001). Motherisk developed the Pregnancy Unique-Quantification of Emesis (PUQE), a self-administered instrument with only three items (length of nausea; number of vomits; number of retching episodes) that can be easily performed in all clinical and research settings (Koren et al., 2002). The PUQE scoring system specific to NVP was validated independently (Koren et al., 2005). The major limitation to both the INVR and PUQE scoring systems is that they cover symptoms occurring in the preceding 12 hours and cannot measure NVP severity for a longer period of time (Lacasse et al., 2008). The modified-PUQE is a validated instrument to quantify symptoms occurring from the start of pregnancy (Lacasse et al., 2008). A study conducted by Koren et al. through the Motherisk counselling telephone line showed modified-PUQE scores to be more severe than the 12-hour PUQE. This can be explained by a recall bias produced by a retrospective evaluation of NVP symptoms (Koren et al., 2004).


Anthropometric measures are used to assess pregnancy weight gain with self-reported height and weight and scale measurements. Self-reported height and weight are used to generate an accurate representation of true pre-pregnancy BMI, that is used as a baseline for measuring weight gain (Brunner Huber, 2007). While self-reported weight is usually underestimated and height is usually overestimated in women of reproductive age, Brunner Huber (2007) found that selfreported measurements used to calculate BMIs accurately classified women into a BMI category as assessed through scale/measured values. The Institute of Medicine (IOM) recommended using BMI measurements to assess weight gain during pregnancy (IOM, 1990). Weight measured using a calibrated, electronic scale should be compared to the IOM recommendations for weight gain within a particular BMI category. Weight is an easy measurement; however, it can be affected by time of day, bladder fullness, and clothing choice (Gibson, 2005). It has been reported that BMI is not a better predictor of maternal and perinatal morbidity than body weight alone (Wolfe, 1991). For now, the IOM guidelines are appropriate as the literature shows that adherence to the guidelines will result in low risk of an adverse pregnancy (DeVader et al., 2007).


Energy intake is assessed by a 24-hour recall (Van Stuijvenberg et al., 1995) using a multiple-pass interviewing technique and food models to assist clients to recall their intake, and to accurately estimate portion sizes (Gibson, 2005). The multiple-pass 24-hour recall is so called because interviewers obtain dietary information through ‘multiple passes’ during the interview process using a quick list, detailed description and a final review (Tran et al., 2000). A limitation to using multiple-pass 24-hour recalls with women is that energy intake is often underestimated (Tran et al., 2000). Twenty-four hour recalls are preferred for woman experiencing NVP as they are physically and emotionally unwell, and there is lower respondent burden compared to maintaining (un)weighed food records (Gibson, 2005).


From researching the development of a questionnaire for assessing the clinical symptoms of nausea and vomiting of pregnancy, I have a greater understanding and appreciation for the time and effort that goes into each questionnaire used by health professionals.


REFERENCES available from Janis Randall Simpson.



Contact


Lindsay Ball, BSc, BASc


Janis Randall Simpson, PhD, RD (advisor)
Unvierstiy of Guelph
E: rjanis@uoguelph.ca

Wednesday, October 14, 2009

Self-Running PowerPointTM Presentations –– Part 1


Have you every wanted to be in two places at once? Now you can with self-running PowerPointTM presentations (SRPP). Minimal computer skills and time are required to record your voice into a presentation and create a PowerPointTM show that can run on any computer. This article describes the potential applications and process for developing SRPP.

Applications
The potential applications for SRPP are limitless. I have provided a few examples; use your imagination to come up with more.

Interns: An orientation presentation would introduce interns to the institution/work area. Details on assessment forms, specific wards, names and photos of key employees, etc. could be included. This would significantly reduce the time commitment for preceptordietitians to orient students.

Clients: If you find that you repeat the same information to each client, make a presentation with the repetitive information, and spend more time helping clients integrate the information into their daily lives.

Staff: Getting the staff together for a training session can be a challenge – a SRPP can be watched at one or more convenient times.

Continuing Education: The Art & Science of Food Hypersensitivity – Online Training for Dietitians is an example of how to use SRPP in continuing education. See an example of using this approach at http://www.foodallergynews.com/.

Meetings: If you can’t attend a meeting to present your idea, you can connect with the group by telephone and send an SRPP for the group to watch.

Proposals: A dynamic and creative SRPP can get your ideas across more persuasively than a written document.


Sharing Your Presentation

There are two options for sharing your presentation, either keep the presentation as a PowerPointTM presentation file, and after it is opened, choose slide show view, or save the presentation as a PowerPointTM Show and the presentation will start playing as soon as the file is opened.

If the destination computer does not have the PowerPointTM program installed, a PowerPointTM viewer can be downloaded from the MicrosoftTM website. Recording audio into a presentation greatly increases the file size, making it difficult to e-mail.

SRPPs can be transferred to another computer using a file transfer service, also known as an FTS. There are many services available on the Internet (e.g., YouSendItTM). Generally, files that are under 100MB (approximately 20 minutes of SRPP) can be sent without a charge, but larger files or advanced options require a fee. The process is simple – you upload the file to the Internet and send the recipient the link so they can download the file to their computer. Alternatively, the SRPP can be copied to a disk, memory stick or external hard drive and physically transferred to the destination computer.

Many organizations record live presentations with a video camera for educational purposes. I find creating a SRPP is much more effective because the presenter can read from notes to get the exact wording and animation timing, something that is difficult to achieve with a live presentation. Another advantage is that it is very easy to update one slide with a SRPP.




Developing a SRPP
1. Create your PowerPointTM presentation.
2. Attach a microphone to the computer.
3. From the Slide Show Menu, choose Record Narration. From that dialogue box, click on name and select the quality of recording. ’CD’ is the best quality, but creates the largest file size.
4. Advance your slides and talk into the microphone. When you are ready to stop, press Esc and Save.
5. You can start again from any slide, and individual slides can be re-recorded.
6. When the presentation is in ‘slide show view’, the slides will automatically advance with the presenter’s voice. Note: If the
PowerPointTM file is used for a live presentation, delete the audio (in the custom animations box) and in the Slide Show – Set up Slide Show choose advance slides manually. Practice to make sure the settings are correct or you may have a nasty surprise!
7. Animations will be recorded, but actions during the presentation (e.g., mouse movements or writing with the pen) will not.



Part 2 of this topic in the next issue of Practice will be about techniques to convert a SRPP to video and to upload to the Internet.




Contact

Wendy Busse, RD, MSc
Red Deer, AB
T: (403) 986-5267
E: wendybusse@foodallergynews.com

Monday, September 28, 2009

Vitamin B12 Treatment Options: Supplementation vs. Intramuscular Injections

As a dietetic intern, I (AD) had the opportunity to present an inservice to family physicians and allied health professionals on vitamin B12 deficiency in the elderly during my placement at the Grandview Medical Centre Family Health Team (FHT). As I reviewed the literature, I became passionate about the importance of vitamin B12 deficiency diagnosis and treatment in light of the inconsistent diagnostic criteria and various treatment methods. As a result, I feel strongly that we need to raise awareness among health professionals on the need for more rigorous diagnostic criteria, as well as ‘non-traditional’ treatment methods such as oral supplementation versus intramuscular (IM) injections.


The main area of discussion during the inservice was the effectiveness of oral vitamin B12 supplementation compared to IM injections in light of the high prevalence of malabsorption due to the absence of intrinsic factor (IF) in people with pernicious anemia. IM injections have historically been the preferred treatment for vitamin B12 deficiency, bypassing the active absorption mechanism (where vitamin B12 binds to IF in the terminal ileum prior to absorption). However, the mechanism for absorption of vitamin B12 via the oral route is less commonly understood.


Oral vitamin B12 supplementation relies on free vitamin B12 to be absorbed passively without binding to IF. This accounts for 1–2% of total absorption and is unaffected in patients with pernicious anemia, gastro-duodenal surgical resection, and those with low gastric acidity (Cuskelly, Mooney and Young, 2007). Therefore, when pharmacological doses (>1,000μg) are ingested, approximately 1% of vitamin B12 (about 10 μg) is absorbed by passive diffusion exceeding the Dietary Reference Intake (DRI) requirement of 2.4μg/ day for all adults. Numerous randomized controlled trials have revealed oral vitamin B12 supplementation to be equally effective to IM injections for correcting cobalamin (B12) deficiency (Simone et al., 2005; Butler et al., 2006).


Diagnosis of Deficiency

Unfortunately, there remains no ‘gold standard’ diagnostic criteria of vitamin B12 deficiency. The most common measure for deficiency is serum B12, an unreliable and insensitive measure of vitamin B12 status (Gibson, 2005). Efforts are being made to raise the cutoff value for deficiency to effectively capture those with inadequate levels of cobalamin. For instance, at my FHT placement a serum cobalamin <130μg/l>


Because vitamin B12 deficiency is common and symptoms can be vague and similar to those experienced with aging (e.g., loss of appetite, fatigue, paleness and confusion), it can easily go undetected and untreated (Wolters, 2004). The danger of undetected vitamin B12 deficiency leading to mostly irreversible neurological and psychiatric implications emphasizes the importance of clinicians taking a closer look at vitamin B12 levels particularly among patients over the age of 50 years and those with other risk factors. Registered dietitians should recommend oral cobalamin

supplementation for those with low vitamin B12 status (<250μmol/l).


Benefits of Oral Supplementation

A Canadian cost analysis study reported a potential cost savings of $17.6 million per year by switching from IM injections to oral vitamin B12 therapy (van Walraven et al., 2001). Costs savings are attributed to decreased health care labour. Patient benefits of oral therapy include convenience of home therapy and decreased injection-related anxiety and discomfort.


People not suited for oral treatment are those unable to regularly take medications, those with short bowel syndrome, or those who have active bowel disease.


Conclusion

Following my inservice there is increased awareness at the FHT on vitamin B12 deficiency, the importance for more rigorous diagnostic criteria, and greater physician and dietitian confidence in recommending oral vitamin B12 supplementation. Reflecting on this rich learning experience has allowed me to truly appreciate the influence that research has on directing everyday practice.

I (AD) would like to thank my two preceptors, Michelle Saraiva, RD and April Hoover, RD, for their help and guidance in researching this topic and applying the evidence.


REFERENCES available from Michelle Saraiva.



Contact

Grandview Medical Centre Family Health Team
Cambridge, ON

Andrea D'Ambrosio, MAN, BASc
Masters of Applied Nutrition (MAN) Dietetic Intern
E: adambros@uoguelph.ca

Michelle Saravia, RD, MAN
E: msaraiva@gmchft.ca

April Hoover, RD, CDE
E: ahoover@gmcfht.caa

Tuesday, September 22, 2009

Interprofessional Education: A Dietetic Intern’s Perspective


As part of my dietetic internship, I had the opportunity to participate in an IPE placement during one of my rotations. From this experience, my understanding of IPE is that it is the proposed method for improving the healthcare system in order to provide better patient care. Specifically, I learned that active learning of the roles of health professionals is very effective and resulted in united communication on our team which directly impacted patient care.

The IPE team I was part of was made up of one student each from dietetics, social work, nursing, psychology, and occupational therapy. We met weekly for five weeks with co-facilitators. We discussed our job responsibilities, our interactions within the team, how our roles overlapped and differed, and how we were involved in patient care. We actively learned together rather than through passive observation. It surprised me, for example, that a social work student was not aware of differences between occupational therapy and dietetics. I wondered, wasn’t the difference obvious? We had candid conversations about who does what, when and why. These conversations were stimulating and effective because I knew that I was developing a solid grasp of each member’s scope of practice and that they were developing a solid grasp of mine.

One of our objectives was to discuss a particular patient and work together as a team to discuss his or her care. In our case study, the question arose, ‘is this patient palliative?’ We talked about it with our mentors and learned that palliative care was a confusing issue for everyone. We learned that knowing whether the patient is palliative directly affects each member’s short and long term care plan. The IPE project led us to this level of communication and engaged the team in a valuable discussion about how they each defined palliative care and how they dealt with it both individually and as a team.

Some may argue that understanding the roles of each team member should be intrinsic or that we all eventually learn the roles of the team members just by being on the team. The fact remains that from our IPE placement, the active learning aspect was effective in enhancing our understanding of the roles of team members that resulted in the discovery of team-wide issues affecting patient care. It gave me an appreciation that a new approach towards intern training and education in the health professions overall may be beneficial.

Dietetic internship involves ten months of time, effort and energy to understand the scope of a dietitian’s practice. I believe that interprofessional education can be a beneficial part of internship that complements our training. I trust that the development of interprofessional education within the healthcare setting will help to serve many patients and families and I’m excited to be part of it!

Contact

Teresa Maiorano, Dietetic intern
The Hospital for Sick Children
Toronto, ON
E: teresa.maiorano@sickkids.ca

Monday, September 14, 2009

Promoting Interprofessional Education in Dietetic Education


Although interprofessional education (IPE) has been in the literature since 1978 (WHO, 1978) and identified as an important component of health care
, only recently does it seem to have reached the ‘tipping point’ in Canada (“the levels at which the momentum for change becomes unstoppable”) (Gladwell, 2002). Many will be familiar with the statement from the Romanow report that suggests the necessity of IPE to ensure collaborative practice:

“…in view of… changing trends, corresponding changes must be made in the way health care providers are educated and trained. If health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working arrangement.”
(Romanow, 2002)

Over the past year, I have had the opportunity to work as the Interprofessional Education leader at SickKids Hospital. Reflecting on my experiences has made me think about where dietetic education ‘fits’ in the realm of IPE. With the movement towards explicit IPE initiatives the dietetic community must discuss integration of the concept into dietetic education.

IPE is when “two or more professions learn with, from and about each other to improve collaboration and the quality of care” (CAIPE, 2002), and often involves IPE student placements. IPE is felt to be important to foster effective teamwork, and comprehensive, collaborative practice CIHC, 2009). Outcomes include increased knowledge of others’ roles, the ability to communicate effectively, reflection on practice, trust, mutual respect, willingness to collaborate, and increased patient/family centred care (Cooper et al., 2001; D’Amour & Oandassan, 2004; Oandassan & Reeves, 2005; Robson & Kitchen, 2007). When activities are relevant and realistic interprofessional learners have a positive attitude toward IPE and demonstrate positive changes in behaviour, service and patient care (Hammick et al, 2007).

Dietitians work in collaborative health care models that support our abilities to perform. Although dietitians are not strangers to the benefits of collaboration, the benefits of engaging students explicitly in IPE activities, or empowering them to collaborate, may not be clear. While many of us have cultivated our working relationships to benefit each other and our clients, governments are now dictating that we make this learning explicit for students. In the absence of formal IPE placements, dietetic educators are challenged to think about how to make this explicit for dietetic interns.

It has been argued that in a clinical setting interprofessional rounds and meetings are educational opportunities where interns can learn with, from and about each other. Interestingly, in one of our IPE placements a student suggested that Occupational Therapists (OT) cared for the infants and Physiotherapists (OT) cared for the older children. She learned this by observing who spoke during rounds when patients were discussed. Only by consulting the therapists for our IPE placement did she learn the extensive decision-making process that determines the primary therapist and division of responsibility between OTs and PTs. If students of other disciplines are making incorrect assumptions about the roles of healthcare professionals, dietetic interns may be doing the same. If that is so, when might they have the opportunity to correct these mistakes?

Dietitian-preceptors have unique opportunities to have a lasting impact on the development of budding professionals. We help shape their attitudes and beliefs about dietetics, discuss elements of collaboration amongst professions, and the impact on client care and services. Preceptors have the responsibility to facilitate interprofessional learning and influence the development of IPE competence among their students (Oandassan & Reeves, 2005; Hammick et al, 2007). While influencing learning, we must consider the spectrum of learning (Oandassan & Reeves, 2005). At one end, uniprofessional education (learning with members of one’s profession) is important for competency attainment while at the other end, interprofessional education teaches students to work collaboratively.

Timing is essential as early introduction of IPE may lack relevance, and hinder or delay professional training (Cooper et al, 2001).

With the movement to integrate IPE into undergraduate health care professional curricula we have an obligation to engage dietetic interns in discussions to:
• clarify the roles of other colleagues involved in delivery of patient care and services
• distinguish characteristics and discuss commonalities amongst professions
• make interprofessional communication and collaboration explicit to prevent misunderstandings and misconceptions
• encourage shadowing opportunities with colleagues in other disciplines to increase the relevance of care/ services

These opportunities should be timed well so that we graduate highly skilled dietitians who have trust in others and have the knowledge, skills and attitudes to perform as competent and collaborative healthcare professionals.

Even without explicit IPE placements, we can employ strategies that contribute to the interprofessional learning of dietetic interns.

Contact

Jennifer Buccino, MEd RD CDE
The Hospital for Sick Children
Toronto, ON
E: jennifer.buccino@sickkids.ca


Tuesday, September 1, 2009

How to Use Social Media to Market Your Work


Even if you don’t have a lot of money to market your business, online social networking can be an excellent business-building strategy. Social networking allows you to connect with a large group of people for free with just a small investment of time. In this article, I outline some frequently used social media tools and how to use them to promote your work, to build rapport with potential clients and to promote events.

TwitterTM

TwitterTM is a simple “microblogging” website. Microblog posts on TwitterTM are up to 140 characters. You would be surprised how much information you can squeeze into one ‘tweet’ (a TwitterTM update) especially if you include a link to more information on your blog or website.

You can build up a following on TwitterTM quite easily so long as your tweets provide useful information. You can gain more followers by becoming an active participant in the TwitterTM community, responding to others’ tweets, and following people who look interesting or relevant to the topics you want to address. Once you have followers you can quickly disseminate information and get lots of extra visitors to your website or blog.

Tools to make the most of TwitterTM are:

TwitterGraderTM (
http://twitter.grader.com/search) helps you find top people to follow. Try searching on your city, on professionals you are interested in connecting with (such as ‘dietitian’), or on subject matter you would like to learn about.

TwitterFeedTM (
http://twitterfeed.com/). If you are already writing a blog, TwitterfeedTM will automatically update your TwitterTM account each time you blog with no extra work required.

Facebook


Using this social networking tool to promote your business does not take much more work than what you already do to interact with your friends. The best way to connect with potential clients and other business supporters is to set up a ‘page’ where people can become your ‘fans’. You can use your page to interact with your supporters, to post articles, and to link to your website or blog. You can set up your page to automatically import posts from your blog as ‘Notes’ to save time updating your Facebook profile, and you can use the ‘Events’ feature to spread word about health fairs or workshops, to invite participants, and to track RSVPs.

LinkedInTM

LinkedInTM is a business-focused social media tool and one of the easiest to start up. You simply create your profile (essentially an online resume), then look for people with whom to connect. Once you are connected, ask for recommendations from colleagues or previous clients. These are posted to your profile and build your credibility.

YouTubeTM

If you are thinking that using these tools involves too much writing, you might think about using YouTubeTM. Instead of writing, you can just talk! People watching YouTubeTM postings do not expect professional film quality so you can create a video using a basic video camera, the video feature on your digital camera, or even your cell phone. Your laptop may even have a built-in video camera you can use. To make a film, think about some of the top questions your clients ask you, then film short answers. Once you have a few videos posted, you can create your own ‘channel’ – a YouTubeTM page where all of your videos are collected. Visit
http://www.youtube.com/user/thenutritionexpert to see an example of a dietitian putting YouTubeTM to work.

Bottom Line

Social networking is another form of networking that requires you to interact and to be part of the community, offering valuable content and resources. If done right, the rewards can be great. Some of the outcomes in using these media for me have been that I met journalists, editors, and health writers on TwitterTM who end up publishing my nutrition tips, and a literary agent found me on LinkedInTM and asked if I was interested in writing a book. I even received a nomination for an award from a TwitterTM follower I had never met.

The most important thing when you begin social networking is to be open-minded. You may receive spam (who doesn’t), or have people try to recruit you to sell products. If you do not like what someone says in one of their posts or about one of your posts, it is easy to block or to ‘unfollow’ them. Use these tools to build a real community, and you just never know what opportunities they might bring.

If you are interested in seeing how I use social media, connect with me at:


TwitterTM: http://twitter.com/HealthCastleGlo
Facebook (personal profile):
http://www.facebook.com/gloriatsang
Facebook (business page):
http://www.facebook.com/healthcastle


Contact

Gloria Tsang, RD
Editor-in-Chief
HealthCastle.com
Port Coquitlam, BC