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