Wednesday, August 4, 2010

Predictive Energy Equations: Which One to Use?

Dietetic interns challenge us to keep our practice current. The question of what predictive energy equation to use in clinical practice was a recent example of how our roles as educators linked to our need to keep current. Fraser Health (FH) interns recognized their preceptors had different approaches to calculating estimated energy needs for their patients and wondered how something so core to dietitians’ daily activities could be so varied in practice. A poll of Canadian dietitians and a literature review provided perspectives on the use of predictive energy equations.

Indirect calorimetry (IC) is the ‘gold standard’ for calculating energy requirements. Several barriers prevent routine measurements on patients including lack of a metabolic cart or personnel to operate equipment, and the impracticality of completing repeated measures on every patient who requires an energy calculation. Consequently, dietitians rely on predictive energy equations to estimate patients’ energy needs.

Over 200 predictive energy equations have been published in efforts to accurately predict energy needs (MacDonald and Hildebrandt, 2003; Ireton- Jones, 2005). No equation has consistently proven to be accurate in hospitalized individuals in acute or critical care. Inaccuracies are introduced due to controversy over which weight to use, the limited number of validation studies done, and the homogeneity of reference populations used when establishing the formulae, amongst other variables (Frankenfield et al., 2005; Fabiono et al., 2009; Walker and Heuberger, 2009).

An e-mail poll in October 2009 to members of the Dietitians of Canada (DC) Clinical Nutrition Managers’ Network yielded a list of the equations used by at least one dietitian at each of the 16 responding sites: 13 sites used Harris Benedict (HB); eight used the American College of Chest Physicians’ equation (25kcal/kg); six used Mifflin-St Jeor; five used one of the Ireton-Jones’ equations; and two used one of the Penn State equations. These results were consistent with practices worldwide (HB remains the most frequently-used formula (Fabiono et al., 2009)), and the varied practices that the FH dietetic interns had noticed.

The e-mail poll also yielded information on which weight (actual, ideal, or adjusted) is used in energy calculations. Four sites used actual weight only and 12 sites used either actual or adjusted weight depending on the individual case. Most sites adjusted body weight using a 25% factor (based on a 1984 American Dietetic Association publication as referenced in Krenitsky, 2005). Other sources recommended a 50% factor (Barack et al., 2002; Krenitsky, 2005). The use of adjusted body weight is not well supported (Barack et al., 2002; Ireton-Jones, 2005; Krenitsky, 2005).

The following points summarize the support for the predictive energy equations with graded evidence-for-use in clinical practice:

Harris-Benedict (Harris and Benedict, 1919): Not sufficiently accurate to be used in the critically ill (Grade I evidence) (Frankenfield et al., 2007) Use actual body weight (Walker and Heuberger, 2004; Krenitsky, 2005).

American College of Chest Physicians (Cerra et al., 1997): Use 25-30 kcal/kg actual body weight for the nonobese critically ill (Grade IV and V evidence). Use 11-14 kcal/kg actual body weight or 22-25 kcal/kg ideal body weight for the obese critically ill (Grade III evidence) (McClave et al., 2009).

Mifflin-St Jeor (Mifflin et al., 1990): Best predictor of energy needs in healthy nonobese and obese adults (Frankenfield et al., 2005). Use actual body weight (McClave et al., 2009). Not recommended in the critically ill (Grade V evidence) (Frankenfield et al., 2007).

Ireton Jones et al. (1992): Most accurate in young and obese adults compared to other populations. Insufficient data to reject the equation (Grade III evidence supporting its use) (Frankenfield et al., 2007; Walker and Heuberger, 2009)

Penn State 1998 and 2003 (Frankenfield et al., 2004): May use 1998 equation for obese, critically ill ventilated patients (Frankenfield et al., 2005). May use 2003 equation for nonobese critically ill patients (Walker and Heuberger, 2009) (Grade III evidence) (Frankenfield, et al., 2007; Walker and Heuberger, 2009).

Swinamer (Swinamer et al., 1987): May use for nonobese critically ill patients (Grade III evidence) (Frankenfield, et al, 2007; Walker and Heuberger, 2009).

Even with an accurate predictive equation, obtaining goal intakes is often hindered by delays in establishing feeding access, enteral feed intolerances, and feedings that are held for tests. Our efforts should go toward achieving goal tubefeeding rates and maximizing oral intake regardless of what equation is used. Further, monitoring markers of feeding adequacy including laboratory measures, weight, ventilator weaning, and wound healing allow us to adjust energy goals as appropriate.

Based on the results of our survey and literature review, we can have confidence in reporting to our interns that there is more to learn before setting standards for estimating energy needs in hospital inpatients. We use these teaching moments as opportunities to discuss the concept of evidence-based practice using best available research, clinical expertise, and a patient-focused approach to guide decision-making to provide the best possible patient care.

A summary chart of the origins and evidence on predictive energy equations is available on request.


Tamar Kafka, RD, MSc
Dietetic Internship Coordinator/Research Dietitian
Fraser Health
New Westminster BC

Wednesday, July 21, 2010

My Food Service Experience as an Intern

When I began the internship component of the Masters of Science in Foods and Nutrition program in May 2009 I was excited to start with my Food Service (FS) rotation. I felt confident in my skills in this area and was ready to apply what I had learned about Patient FS while at school. On the first day of the placement my preceptor told me that my major project was in retail. WHAT? Yes, that was exactly my reaction. Of course, I appeared calm and tried not to show my emotions. I had no experience in retail and had been prepared for projects in Patient FS…. what was I to do?

My project was to revamp the menu for the summer and include nutritional analyses of the items so that customers could make better food choices. Being unsure how to go about this, I decided to look at survey returns from cafeteria customers. These revealed interest in the nutritional content of foods offered, and in healthier entrees. To increase revenue and attract more customers, we decided to include entrees that were less expensive so that those who brought lunch from home would consider purchasing a cafeteria meal instead. I created a three-week summer menu with healthier entrees including low-value entrees, and high-end entrees to meet the varying needs of customers who were mainly hospital staff. We completed nutritional analyses of all entrees to identify those that could be labelled low fat (less than 10 g/serving), low sodium (less than 500 mg/ serving), or as a source of fibre (2 g or more/serving). I identified top selling items on the existing menu to retain, searched for lighter, summer-type foods, and explored trends in the food industry (e.g., the Mediterranean influence).

While working on this project, I realized that the experience and knowledge I gained would be the same whether developing a patient or cafeteria menu. Synthesizing the items into a 21-day menu cycle was the most critical part of this project. I made sure there was variety and that there were vegetarian choices, that side items (vegetable and starch) would look and taste good with the entrees, and I considered the labour available at lunch versus dinner. I also worked on eliminating my own biases when choosing the recipes, realizing that people have different tastes and preferences.

I had to determine who was going to be involved in this project, to whom I could delegate tasks, whose help I would need, who would be affected by the changes, and how we could promote the summer menu. I learned there are many parties involved. The Purchaser had to change ordering and search for new items through Sysco. I worked with her to determine items we had, items to discontinue, possible substitutes, and amounts to order. I also worked closely with the cafeteria Team Leader to determine labour needed to produce the new recipes. We worked on cost and selling prices and promoted the new menu through posters, newsletters and samples.

Educating the cooks on the importance of following the recipes was interesting. Not following recipes would change the nutritional value of the menu items, and invalidate the health symbols I had created for each item. I realized I had to slow down and work one-on-one with each cook. I identified a champ, one of the cooks who was supportive and motivated to make changes. He was key to getting the other cooks onboard. Two activities that helped encourage the chefs to follow the recipes were a “Chef of the Day” signature spot on the daily menu where the day’s cook signed off that the items met the nutrition criteria, and having a weekly Chef’s Special. They loved signing off the menu, particularly those who loved being ‘out front’ and showing off their talents and names. The Chef’s Special provided opportunities for the cooks to showcase their creativity and passion for cooking.

I learned that networking and talking to colleagues is one of the greatest sources of information since there is not much literature pertaining to Food Service Administration. Thanks to Dianne Steele, the Food Service Manager at Trillium Health Centre (THC) and my preceptor during the placement, I had the opportunity to learn about menu planning and implementation. Thanks also to John Del Prado, the cafeteria Team Leader, who was a great asset. I got to see how everyone’s roles in the nutrition department, Aramark, and the overall organization fit together. This was the ‘big picture’ that sometimes, as interns, we don’t get to see.


Dahlia Abou El Hassan, BASc, MScFN (C)
Master of Science in Foods and Nutrition program (Internship Stream)
Brescia University College - University of Western Ontario
London ON

Monday, July 12, 2010

Studying Food Skills: A Public Health Perspective

Why are food skills important?

Food skills are necessary for the provision and preparation of foods for ourselves and our households. As dietitians, we speak the language of food skills in our professional work. In Practice - Fall 2007, Christine Chou asked "Where have all the foodies gone?", noting prophetically that focus on the science and therapeutic role of food could be at the expense of its soul. Well, I am grateful to see more foodie dietitians baring their souls and moving "beyond nutritionism" (Practice - Winter 2009). Without food skills, I believe people surrender many choices for what they eat, becoming increasingly dependent on what the food industry provides. In Canada, our food supply is the primary driver of our nation's growing prevalence of obesity, afflicting ever-younger individuals in the population (Slater et al., 2009). Everyone, from an early age, needs to develop good food skills, to be competent and self-reliant, able to follow Michael Pollan's good advice to "eat food, not too much, mostly plants" (2008).

Focus on food skills in Ontario

In the Ontario Public Health Standards (2008), Health Units are required to provide ‘opportunities’ for food skill development among priority populations. There is however, no published research available that describes the level of food skill among individuals within our communities, though many of us, in addition to the media have bemoaned the ‘de-skilling’ of our population. In Fall 2008, Region of Waterloo Public Health had the opportunity to include two pages of questions about food skills and food activities in the Waterloo Region Area Survey conducted by the University of Waterloo Survey Research Centre. The results of this cross-sectional, random survey from 703 adult respondents aged 18 years and over gave us a snapshot of self-reported food skills and kitchen activities within the general adult population of Waterloo Region. The research findings were presented on January 20, 2010 via a Fireside Chat through CH-NET entitled "Food Skills of Waterloo Region Adults" - the slides and podcast are available at A report by the same title is now available on our Public Health website at (under Resources - Reports and Fact Sheets; topic-specific - Food). While there will certainly be differences between communities, I believe this data provides a baseline description of Ontarians' (perhaps Canadians'?) reported food skills.

Food skills of Waterloo Region Adults

Based on responses to 13 food skill questions, the prevalence of ‘good’ food skills for everyday kitchen activities ranged between 64.6 - 93.5%, with fewer adults reporting ‘good’ skill in food preservation (freezing/ canning). Data were analysed to examine differences in skills by gender, age and household incomes. Information was also compiled about the amount of time taken to prepare the ‘main meal’ in the home, the frequency of ‘from scratch’ cooking, and the relationship between gardening and food preservation skills.

How shall we proceed?

The challenge for us as dietitians remains; we must regard our own skills with food as an important continuing education activity, and we need to consider what we know about the food skills and food activities of our audience/ clients as we plan programs and services. Some of the questions we can ask are: WHO might benefit most from developing their food skills?; HOW do we facilitate the provision of opportunities for food skills in our communities?; WHAT is the best way for the target learners to learn; and WHERE and WHEN would this happen? Certainly, we can all begin in our own homes. Children need to learn and develop skills with food from an early age. When people develop food skills, they increase their eating choices, relying less on industrial processing or restaurant offerings. To promote health, to stem the rising tide of obesity and the increased burden on healthcare systems, everyone needs food skills - how to choose it, how to prepare it, and how to eat it.

For more information and discussion about food skills and our research at Region of Waterloo Public Health, check out the posted materials and/or contact us.


Ontario Ministry of Health Promotion (2008). Ontario Public Health Standards. Available at: program/pubhealth/oph_standards/ophs/index.html

Slater J, Green CG, Sevenhuysen G, Edginton B, O’Neil J, Heasman M. (2009). The growing Canadian energy gap: More the can than the couch? Public Health Nutrition, 12(11): 2216-24.

Pollan M. (2008). In defense of food: An eater's manifesto. The Penguin Press: New York, NY.


Pat Vanderkooy, MSc, RD
Public Health Nutritionist
Waterloo ON

Monday, July 5, 2010

From Field to Table Spring Supper in Manitoba

Most, if not all, Canadian dietitians know that March is Nutrition Month. Sometimes we start planning activities months ahead of time; sometimes we begin preparations later than is ideal. This year at the end of February, a group of rural dietitians in southern Manitoba (MB)* were inspired to jointly plan a community-minded supper that would showcase local foods in keeping with the 2010 theme From Field to Table.

The seed was planted when two of us attended the session From Farm to Cafeteria at the Growing Local, Getting Vocal Conference in Winnipeg in February 2010 ( and started to dream. We quickly rallied interest in other dietitians, and began to develop vision and structure for the event. The first priority was identifying a venue. Although we live in four different communities, we agreed to focus our energies and pick one town to host the supper. Luckily, determining the site proved easier than anticipated as a number of venues had limited or no availability. As we were interested in partnering with a chef, when we contacted the chef and the food manager at the local golf and country club in Morden (a fairly new building with country charm and a fabulous view), they were very receptive and enthusiastic. They had been talking about doing something similar for a while! They were on board from the beginning, willing to provide a lower plate cost than their standard price, and brought their event planning expertise and support staff as part of the package. This was a no-muss and less-fuss solution that was particularly enticing given the short timelines.

Local food champions in surrounding communities and other stakeholders were invited to participate in the initial planning meeting. The meeting was also advertised on a public community website. Two dietitians agreed to share the leadership role. The three-fold purpose of the event was identified right from the start: To create awareness of local food opportunities and issues in south central MB; to build local food partnerships within the area; and to celebrate Nutrition Month.

We divided into sub-committees: Promotion; Program; Menu/Food; and Vendor/ Producer Booths. We finalized the date (March 25) early to optimize promotion opportunities and to secure program participants, vendors, and volunteers. Due to time constraints, the lead dietitians developed committee work plans for key tasks and timelines prior to the first meeting. Two of the committees (Promotion; Program) were comprised of dietitians only. The Menu/Food committee included the chef, food manager, and a lead dietitian; the Vendor/Producer committee work was executed by two dietitians and a community person. The core planning group met three times prior to the event including a brief meeting on the day prior to the supper.

Key components of the event included: 1) A simple yet elegant menu accompanied by donated fresh breads; 2) local food producers or suppliers set up at stations around the dining area with additional displays from Manitoba Agriculture, Food and Rural Initiatives; Dietitians of Canada; and Food Matters Manitoba (FMM); 3) MC duties by a representative from FMM; she also shared information and quizzed diners for prizes; 4) harp and cello music; 5) open microphone session; and 6) door prize tickets.

We charged $20 per meal in advance and $25 at the door (only seven people paid at the door!). Attendance was 145 people, almost 50% more than the food manager had predicted based on past experience. We went over-budget by about $300, mainly due to printing costs, a large number of complimentary and discounted meals (to volunteers and producers), and under-estimating revenue in the door prize area.

A contingency plan in place prior to the event ensured that the loss was covered.

The following groups of participants expressed high levels of satisfaction with the evening:

  • Dietitians: Through great teamwork and focusing on a shared goal, we attained a feeling of accomplishment and community.
  • Vendors/Producers: Although we did not permit sales on site, the presence of the producers in the banquet room facilitated a lot of interest and interaction from diners. The key times for visiting the booths were during the appetizer course and at the end of the meal. Many said the evening far exceeded their expectations.
  • Restaurant: The food manager and chef expressed keen interest in partnering again to plan a similar evening.
  • Master of Ceremonies: She noted the supportiveness of our community and the breadth of our local resources.
  • Diners: Many individuals took time to compliment us on all aspects of the supper.

What conditions were favourable? Since there has been limited promotion of local foods in area restaurants or other foodservices, this was a unique event that captured community interest. Being in a rural community may have eased some planning obstacles. Most of all, the main element of success was the drive and commitment of the dietitians involved. Everyone thought that others were working harder than themselves (always a good sign!). The main challenges encountered related to the tight planning timelines.

Recommendations for future events

The following points represent our successes and lessons learned from the planning and implementation processes.

  • Due to the amount of work involved and seasonality of produce, the ideal time to start planning would be at least six months prior to the event. This would support the foresight needed to freeze and preserve summer and fall harvest foods.
  • Define ‘local’ foods and related parameters, as not everyone involved will have the same context! Decide what proportion of the menu and whether condiments will be ‘local’.
  • When choosing a date for the event, ensure that your event is not competing with other high profile events.
  • Add a sub-committee focused on ticket sales and door management to spread out the workload.
  • Identify a charitable group (or groups) to receive any proceeds/profits from the event.
  • Try to tap into the myriad of existing groups and activities that support the evening’s theme and find ways to include them in the process. They are your champions!
  • Utilize the various strengths of your planning group. For example, we depended on one creative dietitian with excellent graphic arts skills to finalize signage, the written menu, and vendor/ producer flyer.
  • Establish clear roles and menu expectations with the chef from the outset of planning.
  • Promote, promote, promote! Use media – posters, radio spots, newspapers and newsletters, church bulletins, interest group listservs, and local web resources such as town sites and events calendars. We suggest using the Dietitians of Canada press releases as a reference format.
  • Include schools and youth in various aspects of planning and implementation.
  • Use the opportunity to showcase local successes. Involve the farm community as much as possible
  • Be aware of potential for conflict between the various interests represented by mainstream farmers and industry, and smaller independent farmers (the latter often focus on local, sustainable agriculture and may lean towards organic and/or non-genetically modified production). Strive for a balanced perspective.
  • Provide clear direction and expectations for those in supportive roles on the evening of the event.
  • Consider asking attendees to bring an item for the local food bank.
  • Recognize and reward your volunteers and donors.
  • Have fun!

Further details on the event, including menu, press release, promotion poster, and vendor/producer guidelines can be found at:

A copy of the committee work plans and vendor/producer promotion flyer are available upon request. For general event planning basics, we recommend ‘Event Planning Suggestions’ (Morley, Practice #17, p. 7, 2002) available at:

* Aimee Cadieux, Candice Comtois, Katharina Froese, Kim Knott, Adrienne Penner, Amanda Nash, Michelle Turnbull, Diane Unruh


Kim Knott RD, CDE

Winkler MB

Michelle Turnbull MScCH, RD, CDE

Morden MB

Diane Unruh RD, CDE

Carman MB

Tuesday, June 8, 2010

Using Simulation and Video Feedback to Enhance Dietetic Interns’ Counselling Skills and Confidence

The transition from dietetic intern to registered dietitian involves a tremendous amount of adaptation over a relatively short time. Interns must acquire the knowledge, practical skills, and critical thinking processes that underpin dietetic practice. In addition, interns must move through a socialization process where they internalize the values, attitudes and behaviours that define how dietitians conduct themselves in the workplace.

Evidence suggests that student nurses, medical interns and other trainees (including dietetic interns) experience ’Transition Shock’ (Duchscher, 2008) and struggle with feelings of anxiety, insecurity, inadequacy and instability as they move from the known role of student to the less familiar role of health care practitioner (Kramer, 1974; Duchscher, 2008). Simulations have been identified as a strategy to combat Transition Shock, and can be used to provide a skills-based clinical experience in a safe and secure environment (Fowler-Durham and Alden, 2007). Exposing students to activities that mimic those occurring during practicum training is thought to decrease anxiety and promote skill development.

Role the tape!

In September 2008, simulation suites based at the University of Alberta (UA) Health Sciences Education and Research Commons (HSERC) began operations. The suites, constructed to resemble clinical interview or examination rooms, allow students to be discreetly videotaped while engaged in practice-based activities with mock patients. The process used to tape simulated patient care activities at the HSERC is novel. While both the student and the mock patient consent to being videotaped, they have limited awareness of a camera in the room as cameras are disguised as light fixtures and controlled by a teaching assistant from a hidden monitoring room. Video footage of the simulation is saved to a secure website that students can access. Students can only access their own footage. They can do this from home if they wish and can view the footage repeatedly to identify strengths and areas for skill development.

The first cohort of dietetic interns participated in simulated patient interviews in the Winter of 2009. The simulations were structured to expand on a basic nutrition assessment and interviewing framework taught in NUTR 466: Introduction to Professional Practice. NUTR 466 is a classroom-based course designed to transition interns into professional life. The interns were asked to interview a mock patient diagnosed with either uncomplicated type 2 diabetes or hyperlipidemia. They were to assess the patient’s nutritional requirements, develop a simple care plan, and provide basic nutrition education. In addition, interns were asked to demonstrate their ability to manage the interview by taking time to develop rapport, set one to three simple goals, and to respond to questions. Intern feedback was extremely positive. They commented that they appreciated being able to ‘see’ how they did while engaged in the interview; many indicated that they had a clearer idea of skills to develop.

The simulated interviews are now a dedicated part of the NUTR 466 curriculum. Each intern completes at least two videotaped interviews and additional sessions can be arranged for those who are struggling or who want extra practice. Feedback from interns continues to be positive. Informal feedback from preceptors and interns (once interns are in placements) suggests that simulation use along with the other practical teaching methods used in NUTR 466 have increased intern confidence and readiness to engage in patient interviews.

Cut the tech

No simulation suite – no problem! It is possible to reap the benefits of videotaped simulation in ways that are relatively simple to organize:

  • Ask interns to invite a friend, family member or colleague to act as their mock patient.

  • Set up a mock interview room by arranging a table and two chairs in front of a clean wall. Place a video camera on a tripod in front of your set.

  • Position the intern and the mock patient in the chairs in front of the camera and begin recording.

  • After the interview, download the footage and share it by email or save to a disk or data stick.

All interns experience some degree of “Transition Shock” as they enter the health workforce. However, novel teaching strategies like simulation and video feedback may help to lessen this effect and make the experience enjoyable for both interns and preceptors.


Duchscher JB. (2009). Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5): 1103-1113.

Fowler-Durham C, and Alden KR. (2008). Enhancing patient safety in nursing education through patient simulation. In Patient Safety and Quality: An evidence-based handbook for nurses: Vol. 3. Available at

Kramer M. (1974), Reality Shock - Why Nurses Leave Nursing. St. Louis: Mosby.


Heidi Bates, MSc, RD
Director, University of Alberta Integrated Dietetic Internship
Edmonton AB

Friday, June 4, 2010

The H1N1 Pandemic: A Shot at an Extraordinary Learning Opportunity

Interning with Public Health Services in the Capital District Health Authority, Nova Scotia during the H1N1 pandemic was a whirlwind experience. Public Health was my first rotation as an intern. I was privileged to witness both its health promotion and health protection roles during my community rotation. In the late summer, my preceptor alerted me that I would be starting my rotation with Public Health earlier than anticipated in hopes that I would miss an H1N1 pandemic that was forecasted to begin in January. This change did not go as planned as cases of H1N1 arrived earlier than predicted.

In the last week of October I could sense that the Public Health team was feeling the heat; it was ‘crunch time’ to prepare for mass immunization clinics as the vaccine had finally arrived. I was fortunate to experience two immunization clinics; once when the vaccine eligibility criteria was restricted to high risk groups and once when the vaccine was available to all. However, I was not involved with clinics every day as I had to complete other competencies unrelated to this unique experience.

While the nutritionists were at the clinics, I provided day care directors with verbal and written feedback on their menus, integrated dialogue from several meetings into notes, kept a journal, inputted an online survey, and worked on my research project. Because everyone was occupied with H1N1 related activities in the community, I was working in a ‘ghost town’ office complete with empty cubicles and lunches eaten in solitude. This contrasted my earlier experiences when I had had lunch with at least 10 others and would always hear someone typing at their computer. I began to feel a sense of isolation.

Before my internship, I anticipated that I would receive ample amounts of direction as an intern. My expectations became apparent during the pandemic as my contact with the team was limited. I was nervous that the work I was completing was not sufficient and I had few opportunities to ask for guidance. This unavoidable situation forced me to become more self-directed in my work. I knew I had to finish the projects and that it was time for me to trust my instincts and myself. This was the only way for me to accomplish the projects. Reflecting on this, I realized that I was afraid to believe in myself and that sometimes I have to be bold and take risks, even if it is uncomfortable. I had to trust my capacity and knowledge. I tended to forget that I am in a learning environment where I will make mistakes but will also celebrate successes. I realize that being pushed outside of my comfort zone in this supportive learning environment was integral to preparing me for the future as I continue to encounter experiences with unknown outcomes. My advice to future interns is to embrace learning opportunities and to engage in these experiences as much as possible - even if you feel thrown into the dangerous ‘deep end of the pool’ instead of what feels to be the ‘safe shallow end’.

In December when the immunization clinics came to an end, I was invited to participate in a closing discussion that involved Public Health employees who acted as clinic leaders. This discussion group of about 40 employees amazed me. I realized the honesty and mindfulness that this group of public health professionals possessed. I learned from the many stories told, and was touched and motivated by their enthusiasm and dedication. That evening I participated in a mass immunization clinic and confirmed my perceptions of this working group. I got to see the clinic staff (including volunteers, students, and public health employees) in action.

My participation in this experience was extraordinary! I believe that fate led me to Public Health during a time when I could experience first-hand health protection and health promotion, two of the core functions of Public Health. I did not learn about the functions of the health care system during times of crisis while at university. Owing to my immersion I feel better prepared for the possibility of involvement in a pandemic in my career.

I encourage future interns to seek rotation opportunities in public health, and suggest that internship programs provide and promote opportunities encouraging interns to experience community rotations in public health.

My sincere thanks to the staff members at Capital District Health Authority’s Public Health Services that made this an invaluable learning experience possible. A special thank you to my supportive preceptor, Rita MacAulay.


Melissa Koch, Dietetic Intern
Capital Health
Halifax, NS

Rita MacAulay
Keely Fraser

Public Health Nutritionists
Capital Health
Halifax, NS

Northern Reflections – My Experiences During An Allied Health Placement

In the summer of 2009, a program offering placements to nursing in northern communities was extended to allied health practitioners at University Health Network. This program, funded by the Ontario Ministry of Health, allowed clinicians to travel north for approximately four weeks to engage in education networking as well as clinical care delivery opportunities. The purpose of this program is to foster collaboration, to exchange knowledge, and to provide an enriched experience among health care practitioners. The opportunity appealed to my adventurous side and on August 24, 2009, I began my northern experience.

The bulk of my five-week placement was on Moose Factory Island located on the Moose River just south of James Bay. The island has a population of approximately 2700 individuals who are predominantly of Cree First Nation descent. The nearest town is Moosonee that is so remote that it has no road access. Travel to Moose Factory Island involves a flight or train to Moosonee followed by a boat, helicopter or car ride across the Moose River depending on the season and the stability of the ice road in winter.

My placement was based out of Weeneebayko General Hospital – a hospital that had been without an inpatient dietitian for two years. Part of the challenge with this placement was etching out how to best utilize my time and resources while I was there. Some of the responsibilities I undertook included assessing and implementing nutrition care plans with inpatient and outpatient consults, preparing community presentations on a variety of nutrition topics, and assisting in various clinics. I also had the opportunity to fly to the coastal community of Kashechewan to assess the nutritional status of women at the prenatal clinic.

The challenges were numerous and overwhelming, and my brain was stretched with the magnitude of nutritional issues that this community faced. Food insecurity, substance abuse, isolation, poverty, and the prevalence of nutritionally relevant illnesses seemed to be more the norm than the exception. In addition to these challenges, there was the education level of the clientele (many could not read English or Cree), the lack of other allied health professionals to which I had become so accustomed (e.g., speech language pathologists), my unfamiliarity with some of the foods (e.g., bannock bread), and the research into nutritional issues that I would not typically see on my general internal medicine unit in Toronto.

It was sometimes hard to know what to say to the 20 year old mother of three who told me that she could not afford to eat healthy food when four litres of milk was $13.59 and a five pound bag of potatoes was $10.69. It was difficult to remain unmoved by the elderly gentleman on hemodialysis who was too tired to cook, had no family, and for whom there were neither home care services nor home meal delivery services to provide assistance. There was also the challenge of trying to advise young mothers against feeding their babies evaporated milk and convincing them that it was nutritionally incomplete (even though it was what their mothers had done for them). Food availability did not make it any easier. If you were well accustomed to the grocery store delivery schedule, you could get the pick of the best and freshest groceries available. In-between deliveries, you would be lucky to find half-decent fresh fruits and vegetables, if available at all. One evening when I went to pick up milk, I found that the entire island was sold out until the next delivery.

Provision of dietetic services up north is unique in both the needs of the clientele and the retention of professional services. However, despite all of the challenges – maybe even because of them – I found dietitian work in the north to be truly satisfying. Overcoming the seemingly insurmountable hurdles produced a sense of achievement. Dietetics in the north is rewarding and fulfilling; I would encourage you to consider the many opportunities that abound in northern Ontario. I also encourage you to embrace every opportunity you get to immerse yourself in other cultures! Cultural competence is an ongoing process that is developed through familiarization of oneself with and in diverse cultural backgrounds. By better understanding cultural norms and mores, nutrition professionals can tailor nutrition counselling to best meet client needs. For the vast majority of my placement, I was working outside my ‘comfort zone’, and it was a great way to grow, both personally and professionally. I was grateful to be part of such a collaborative initiative that exposes health care staff to unique educational opportunities.


Tiffany Krahn, RD
University Health Network
Toronto Western Hospital
Toronto, ON

Wednesday, May 5, 2010

Necrotizing Enterocolitis and the Preterm Infant

Necrotizing Enterocolitis (NEC) is an inflammatory bowel disease affecting three to ten percent of neonates in intensive care units (ICU) (Bisquera et al., 2002: Guthrie et al., 2003) and results in necrosis of the intestinal tissue and possible perforation of the bowel (Kafetzis et al., 2003; MedlinePlus, 2009). NEC predominantly affects low birth weight (LBW) and very low birth weight (VLBW) neonates (Kafetzis et al., 2003; Martin et al., 2008) and plays a significant role in the morbidity and mortality (rates reported between 13%-25%) of these infants (Guner et al., 2009; Henry et al., 2009; Lambert et al., 2007). A Canadian survey of 18,234 infants, in 17 neonatal intensive care units (NICU), reported the incidence of NEC among VLBW infants ( less than 1500g ) as 6.6 percent (Sankaran et al., 2004).

The etiology of NEC (with severity classified on a scale of I (mild) to III (severe, including GI hemorrhage and septic shock) (Bell et al., 1978)) is multifactorial. Many pathogenic factors play a role, including, immaturity and ischemia of the gastrointestinal (GI) tract, and changes in commensal gut microflora (normal, indigenous bacteria) accompanied by increases in pathogenic bacteria as well intestinal inflammation (Hsueh et al., 2003; Panigrahi, 2006; Thompson et al., 2008). Treatment includes medically and surgically invasive procedures such as intravenous fluids, orogastric and peritoneal drainage and laparotomy (Panigrahi, 2006; Thompson et al., 2008). It is therefore important to prevent and manage the disease so that this already vulnerable population is not placed under even greater risk for complications.

Are There Alternative Treatments?

Reviews of the use of probiotics (defined as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host” (FAO/WHO, 2001, pg. 5)) for the treatment of acute and antibiotic associated diarrhea and atopic dermatitis in infants have suggested that for these conditions, probiotics are tolerated well, and are beneficial and safe for infants (Kullen et al., 2005; Saavedra, 2007).

Although not as extensive, research regarding administration of prophylactic probiotics to VLBW neonates shows a decrease in the incidence a nd severity of NEC. The rationale for supplementation of probiotics for prevention and management of NEC in infants is that the bacteria will restore microbial balance to the immature gut by competing with pathogens, thereby improving the gut barrier and decreasing inflammatory responses (Costalos et al., 2003; Cucchiara et al., 2002; Martin et al., 2008).

Relevance to Practice

Clinical trials conducted in NICUs using various probiotics are promising. Dani et al. (2002) conducted a prospective, multi-centre, double-blind, randomized study of VLBW preterm infants. The probiotic group (PG) received a dose of 6 x 109 colony-forming units (CFU) of Lactobacillus GG each day (in pasteurized breastmilk or infant formula) until discharge. The incidence of NEC was lower in the PG (1.4 compared to 2.8 percent) but not significant. Bin-Nun et al. (2005) conducted a blinded randomized trial using a different probiotic supplement (ABC Dophilus: Bifidobacteria infantis, Streptococcus thermophilus and Bifidobacteria bifidus at a dose of 1.05 x 109 CFU per day added to breastmilk or enteral formula). Incidence of NEC in the PG was significantly lower (4 percent) than the placebo group (16.4 percent; p=0.03), as was the severity. Two randomized controlled trials, using Infloran (Lactobacillus acidophilus and Bifidobacterium infantis; dosage of 125 mg/kg per dose of 109 CFU twice daily added to breastmilk or formula) on VLBW infants, demonstrated a significantly lower incidence and severity of NEC in the PG (Lin et al., 2005; Lin et al., 2008). Lastly, a historic control group was compared to a newborn PG (treated with Lactobacillus acidophilus and Bifidobacterium infantis, 250 x 106 CFU, in sterilized water or 5 percent dextrose, via orogastric tube or drops into the mouth) admitted to the ICU during one year. Although the dose was smaller than other studies, this trial demonstrated a significant reduction in NEC (Hoyos, 1999). No significant adverse reactions were reported in these studies.

Probiotics are potentially beneficial in preventing NEC in neonates. However, evidence is lacking to recommend the most beneficial probiotics, the best time to initiate prophylaxis, the optimal dose, or the duration of treatment. A predictive model using United States NEC statistics estimated an increase length of stay (where surgical NEC infants exceeded controls by 60 days and medical NEC infants exceeded controls by 22 days), and an additional $6.5 million in hospital charges per year, or $216,666 per NEC survivor (Bisquera et al., 2002). As technology and health care practices improve, survival of VLBW neonates will increase possibly increasing the incidence of NEC. This should be taken as a call to action. The ‘cost’ of NEC on the neonatal community (financially for the health care system, and emotionally for parents aware of the bleak statistics) is arguably far greater than the ‘price’ of using health care dollars to research best practices for the use of probiotics for the prevention of NEC in neonates.

REFERENCES available from Andrea Buchholz.


Deborah Van Dyke
4th year student (visiting from U of A)

Andrea Buchholz, PhD, RD
Faculty Advisor
Dept of Family Relations and Applied Nutrition
University of Guelph

Tuesday, April 20, 2010

Vitamin K in Bone Health

Phylloquinone (vitamin K1) is in foods of plant origin, especially leafy greens and soybean, canola, and olive oil. Menaquinone (vitamin K2) includes multiple forms found in cow’s liver, some meats, and products of bacterial fermentation such as cheese, natto, and miso. Little is known about the contribution of menaquinones to vitamin K status and while initially thought that 50 percent of the daily requirement for vitamin K was provided by intestinal flora, there is insufficient evidence to support this (Booth, 2003).

The different vitamin K entities have tissue-specific distribution. Liver, the main storage site, contains longchain menaquinones (MK-7 through MK-13) and a minor amount of phylloquinone. In plasma and bone, the major forms are phylloquinone followed by short-chain menaquinones MK-4 through MK-8.

The only known biochemical role for vitamin K is as a cofactor in carboxylation of specific glutamate residues in certain proteins. Finding vitamin K-dependent proteins in the skeleton lead to the hypothesis that vitamin K has a role in bone (Booth, 2003). Furthermore, α–carboxyglutamyl residues in these proteins provide mineral binding properties. There are at least three vitamin K-dependent proteins in bone and cartilage; osteocalcin, matrix gla protein, and protein S. Osteocalcin, the best understood of the three, is synthesized by osteoblasts during bone matrix formation. Its hydroxyapatite-binding capacity is associated with α-carboxylation of glutamate residues 17, 21 and 24; carboxylation of residue 17 is required for the conformation that allows binding of osteocalcin to hydroxyapatite.

Percent undercarboxylated Osteocalcin (ucOC) is a marker of vitamin K status. However, an inverse relation exists between serum 25(OH)vitamin D and ucOC. Thus, controlling vitamin D status is important when assessing the impact of vitamin K on bone health (Booth, 2003). Until recently, supporting evidence of a role for vitamin K in age-related bone loss was largely based on associations between dietary intakes or biological markers of vitamin K status and bone mineral density (BMD) or hip fracture. Randomized controlled trials (RCT) attempt to determine whether vitamin K1 has a role in the prevention or treatment of osteoporosis.

This article summarizes four key RCTs of vitamin K1 with dose ranging from 200 ug to 5000 ug per day (1-4). Three trials studied postmenopausal women while the fourth studied older women and men; these studies controlled vitamin D and calcium intakes (previous Vitamin K1 trials have not always done so). Furthermore, subjects started with comparable vitamin K status in all studies and vitamin D status in three of the studies. All studies followed BMD; unfortunately only one also monitored fracture incidence.

Giving vitamin K1 at 200 ug and 5000 ug per day appeared to have a positive effect on bone (1,2). Subjects treated with 200 ug showed a continuous significant increase in BMD over 6 months at the ultradistal radius. Fracture incidence was lower with a 5000 ug vitamin K1 treatment despite no effect on bone density. Vitamin K’s effect may have been on bone microarchitecture. However, since very few subjects had fractures, the observed difference in fracture rate may have occurred by chance. In a third study (3) where vitamin D status was not assessed, 1000 ug of vitamin K1 had no effect on BMD. Finally in a fourth study (4), 500 ug vitamin K1 had no effect on BMD. Larger trials including a range of K1 doses. with fracture as an endpoint and side effect monitoring, are needed.

Implications for Counselling Patients:

In my work at the Osteoporosis Program I am seeing an increasing number of patients taking calcium supplements including vitamin K with marketers stressing its importance in bone health. The typical dose of 50 ug/tablet is so paltry that I feel obliged to explain that a serving of leafy green vegetables provides 200 – 300 ug vitamin K along with many other nutrients and health benefits. I clarify how little their supplements provide in relation to the levels being tested in RCTs.

I also see patients taking anticoagulants who have the misconception that they should avoid all leafy greens because their vitamin K content will interfere with anticoagulation. I recommend to them the need for reasonable consistency in intake of leafy greens from day
to day rather than avoidance.


Binkley N, Harke J, Krueger D, Engelke J, Vallarta-Ast N, Gemar D, Checovich M, Chappell R, Suttie J. (2009). Vitamin K treatment reduces undercarboxylated osteocalcin but does not alter bone turnover, density or geometry in healthy postmenopausal North American women. Journal of Bone and Mineral Research. 24:983-991.

Bolton-Smith C, McMurdo M, Paterson C,Mole P, Harvey J, Fenton S, Prynne C, Mishra G, Shearer M. (2007). Two-year randomized controlled trial of vitamin K1(phylloquinone) and vitamin D3 plus calcium on the bone health of older women. Journal of Bone and Mineral Research. 4: 509-19.

Booth S L. (2003). Dietary vitamin K and skeletal health. In: Nutritional aspects of bone health., The Royal Society of Chemistry: Cambridge, UK.

Booth SL, Dallal G, Shea MK, Gundberg C, Peterson JW, Dawson- Hughes B. (2008). Effect of vtamin K supplementation on bone loss in elderly men and women. Journal of Clinical Endocrinology and Metabolism. 93: 1217-1233.

Cheung A, Tile L, Lee Y, Tomlinson G, Hawker G, Scher J, Hu H, Vieth R, Thompson L, Jamal S, Josse R. (2008). Vitamin K supplementation in postmenopausal women with osteopenia (ECKO Trial): A randomized controlled trial. Public Library of Science Medicine. 5(10): 1461-1471.


Debbie Reid, MSc, RD
BC Women's Hospital and Health Centre
Vancouver, BC

Wednesday, April 7, 2010

From Meal Trays to Dining Room…

Sunnybrook Health Sciences Centre houses Canada’s largest veteran population, providing long term and complex continuing care to approximately 500 elderly veterans. In June of 2007, six Nursing Home units, representing 204 beds in the Veterans Centre, were converted from tray meal service to a bulk meal service dining room to align with the Ontario Ministry of Health and Long Term Care Dietary standards. The project presented a unique opportunity, not only because of the size of the population involved, but because most other long term care facilities offering bulk meal service have done so from the time of opening and rarely undergo a change in service model.

As dietitians working in food services our priorities are meeting nutrition standards, menu planning, meeting fiscal responsibilities, and patient/resident satisfaction. To evaluate that we met our objectives fo r this project, we retrospectively collected data pre – and post-implementation looking at nutritional parameters (e .g., weight, nutritional risk level , diet), financials, and food satisfaction. Converting to a bulk meal service did not appear to impact the residents’ nutritional status parameters, we were able to operate within our financial objectives, and our third party food satisfaction survey showed that changing the meal service model had no sustained impact on residents’ satisfaction with food. Despite achieving our food service objectives, the food serv ice team spent the majority of time addressing the unforeseen social outcomes of this change.

Adjusting to anything new takes time. The bulk meal service model had many benefits for residents, however, asking anyone to change their daily routine, especially around meals, inevitably results in some resistance. The new daily social interaction among residents at meal times allowed many relationships to flourish but also opened the door for conflict among others. Who sits with whom in the dining room was not an easy puzzle to put together. Waiting for tables to be served exposed residents to wait times that were previously less obvious when they ate in their rooms. Dietary restrictions were more visible to tablemates, and suddenly, residents started asking for specific food items of which they had not previously been aware. This phenomenon stimulated discussion among the care team about liberalizing the resident menu.

Despite the fact that forecasting, preparation, and production were done separately for each seating, having a ‘second seating’ at meals gave some residents the perception that ‘first seating’ received preferential treatment, and that those seated second were getting leftovers. Education with staff, residents and family members was necessary to dispel this myth.

The bulk meal service was implemented in phases bringing on one nursing unit per week over four weeks so that we could focus on the particular needs of each unit. Unique challenges surfaced when the implementation took place on the Cognitive Unit. Continuity is important for these residents; they may not be able to recall yesterday’s events but adapt well to routines. One resident, when offered a choice of two entrées replied, “I don’t want either, I just want my lunch tray”. Where family members previously made menu selections for residents with the tray service, some residents appeared overwhelmed having to shift to making seemingly simple food choices three times a day. Over time, the bulk meal service became routine and these challenges now seem to be non-issues. All of our experiences during the implementation prompted good discussion between our department and the care team about dining room philosophy and creating a home-like environment. Dining ‘ground rules’ for processes and conduct for both staff and residents continues to be a work in progress to improve the quality of the dining room experience.

Resident satisfaction with the bulk meal service was of high importance for both our department and for the organization in evaluating the success of the project. Despite the fact that there does not appear to be a difference in resident satisfaction over the long term, it is important to note that the satisfaction survey primarily assessed operations and food services para meters (e.g., quality, timeliness, temperature ). The potential impact of a dining environment and mealtimes on other factors related to quality of life cannot be discounted.

Lessons learned from this project:

1. Get to know the population and consider the social impact of the change for the residents and families;

2. Consider a broader survey tool to evaluate the impact of changing the meal service model on residents’ quality of life;

3. Recognize the value of ongoing communication with the residents and families; and,

4. Be patient!


Alexa Edmonstone, RD
Clinical Dietitian

Ann Robertson, RD
Director, Food Services

Sunnybrook Healthcare Food Services