Friday, October 30, 2009

Community Partnership Involving Dietetic Interns: A Public Health Nutrition Experience


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.


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.

– 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).


Nutrition Services, Population and Public Health

Alberta Health Services - Calgary, AB

Suzanne Galeslott, MSA, RD
T: (403) 943-6752

Annette Li
T: (403) 355-3290

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.


Lindsay Ball, BSc, BASc

Janis Randall Simpson, PhD, RD (advisor)
Unvierstiy of Guelph

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.

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

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.


Wendy Busse, RD, MSc
Red Deer, AB
T: (403) 986-5267