The 117th Running of the Boston Marathon

It's Friday of marathon weekend and I approach the expo hall with the usual mixture of excitement and dread. Excitement to interact with tens of thousands of marathon runners and their families and friends, and dread at how I know, from several years of experience, my body will feel by Sunday night. Over the next several days I spend hours on my feet handing out samples of Clif Bars, talking to runners about when they should use Shot Bloks versus Shot Gel, and answering the question over and over again: are any of our products gluten-free? (The answer: wheat free but not oat free so they may contain trace amounts.)

By Sunday afternoon I'm ready to finally sit down, so I head to the other side of the hall where I finish out the weekend by volunteering at registration, which is where runners come to pick up their bib number. I have several friends who volunteer with me and we all smile while family members take our picture as we hand the number to their runner, answer questions about where the runner needs to be in the morning to catch the shuttle to the start, and help calm nerves about the race that at that point is only a little over 15 hours from starting. This is my sixth year volunteering (that's every year but one since I ran the marathon in 2006) and I absolutely love it. During one point when I don't have any runners at my station a couple of students from Suffolk University approach and ask if I would mind answering some questions for them. They set up the camera and ask me whether or not I think the marathon is a good thing for Boston. Of course! I answer. It brings in people from all over the world, it increases tourism to Boston, everyone is out and about and seeing what a great city we have here full of active people. Next question: do I think that the marathon is a good thing for people in Boston to see happening. Definitely! Anything that might encourage people to get active and inspire them is a great thing, especially since people need to move more in order to increase health.

At 6:30pm on Sunday night I leave the expo hall having just spent what feels like every waking minute of the last three days there. I fall asleep on the couch after eating dinner but wake up in the morning feeling refreshed and ready for what many consider the best day of the year in Boston: Marathon Monday. My boyfriend lives on the course, so we have friends over and we alternate between watching outside on the street and coming inside to watch the finish line on TV. We cheer for some of the fastest people in the world as they stream by, just a few feet from his front door. It happens every year and yet every year it feels so special.

Today's Boston Marathon, the 117th running, will forever be remembered for the senseless loss that occurred when two bombs exploded at the finish line and to be honest I'm not sure that I'll ever have another weekend like the one I just described. I think that today's events will have a lot of people asking the same question that I was asked by the students yesterday: is the marathon good for the city? But now more questions will be added to that one: can we ever have another Boston Marathon? Will other running and sporting events everywhere be affected by today's violence?

My heart goes out to the people hurt today and their families. It also goes out to every runner and every spectator, both today and in the future, for what today's events might mean for us and our healthy, active, supportive lifestyles that were threatened today in an unimaginable way.

The Various Roles of an RD: Community Health Center Dietitian

Different community health centers have different services that they offer patients. Some have dental  and vision offices in addition to their medical practice. Some even have a WIC clinic located within the center. Some will also have a Registered Dietitian or two on staff to provide nutrition counseling.

At the community health center where I was placed during my dietetic internship, there was a bilingual dietitian who saw patients of all ages, from people newly diagnosed with diabetes to new mothers who needed prenatal nutrition counseling. There was also a dietitian on staff who was in charge of a program focusing on reduction of childhood overweight and obesity.

Several health centers run programs similar to this one where there is a case manager who helps the kids find physical activities that they are interested in and an RD who takes care of the nutrition counseling sessions. The nutrition counseling sessions are often done with several members of the family present. When a child is struggling with weight issues, the parents (who are often the ones providing the food) need to be part of the conversation. The counseling sessions would focus on small, realistic steps that the child and parents could make in order to best benefit the child's health. For example, based on the dietary recall the main suggestion may be the cut back on juice. In that case we would explore alternatives that the child might enjoy drinking or ways that the whole family could replace juice with water and still enjoy it - for instance by adding fresh fruit.

The RD in a community health center setting needs to have the ability to remain focused in a potentially hectic environment (for example being able to focus on the conversation with the parent while several siblings are playing loudly in the background) and be flexible when patients do not show up or re-schedule at the last minute. This is different from a hospital setting where patients are a captive audience or a private practice setting where patients may be paying out of pocket and are therefore more motivated to show up for their appointment.

Got Vitamin D in Your Milk? Got Fat?

You may have a negative association with fat - when there is extra on your body you might not be happy so you may attempt to avoid it when you hear the term associated with your food. And it is definitely a healthy choice to avoid meat that has a lot of fat, foods that are deep fried with fat soaking into every crevice, and other foods that slide down nice and easy because they're coated in the stuff (ie: pizza, nachos, anything else smothered in cheese).

If you have some basic vitamin knowledge, you probably also know that we need some dietary fat in order for our bodies to absorb the fat soluble vitamins which you can remember using the image of a deck of cards: ADEK. Other vitamins are water soluble so our body doesn't have a very hard time absorbing them and also any excess that we have in our body comes out in our urine, just as excess water does that is not needed by the body. But back to our friends ADEK.

I learned early on that these vitamins need fat in order to be absorbed. That's all well and good. Many foods containing these vitamins are naturally often served with fats (A and K found in veggies might either be sauteed in oil or served with a dressing for example). But it took a rotation during my dietetic internship for a lesson to really sink in about vitamin D.

A little bit of quick back story: I grew up in Wisconsin, drinking milk with meals. Because my parents were health conscious, the milk that I grew up drinking was skim milk. It has calcium, protein, and 0% fat - healthy, right? Well, mostly right.

Vitamin D, the sunshine vitamin, can be hard to find in natural dietary sources. Those places you can find it, like some types of fatty fish or beef liver, also have a lot of fat. But one of the main sources of vitamin D for many people, especially in the winter, is in milk where it has been added. It makes sense to add vitamin D to milk because it helps with calcium absorption. And if you drink a delicious, refreshing glass of skim milk, which has 0% fat, or your pour some skim milk into your fat free cereal, or you get a latte made with skim milk, you're not able to absorb any of that good vitamin D that has been added to your milk for your health benefit!

This is why just about any dietitian that you talk to will likely recommend that you switch from skim to 1% milk unless you have a weight issue. If you often drink your milk with meals that contain fat, you can also stick with the skim stuff. But if you tend to consume your milk either on it's own or with a meal or snack that doesn't contain fat, the bottom line is: switch it up and treat yourself to 1% milk. After all those years of drinking skim, trust me, it'll taste decadent!

Clever companies use the science behind fat-soluble vitamins as a marketing tool. This salad dressing's label reads: "Naturally helps better absorb vitamins A&E from salad with the oils in [the dressing]"

The Various Roles of an RD: WIC Nutritionist

I had the wonderful opportunity to do a rotation in the state WIC office at the Department of Public Health which included one week at a local WIC office. For those who might not be familiar, WIC stands for Women, Infants, and Children and is a nutrition program where pregnant women, moms, and children who meet income requirements are eligible for nutrition education, breastfeeding resources, and supplemental food coupons. Unlike SNAP or Food Stamps, WIC coupons are only good for very specific foods (these vary but the basics are: milk, whole grains, and fruit and vegetables) and the participants must attend nutrition counseling on a regular basis. WIC also highly encourages breastfeeding as it is the best nutrition for newborn babies by offering peer counselors, lactation consultants, and incentives for women who choose to breast feed exclusively.

The role of an RD at the state office differs greatly from that of an RD or nutritionist at a local WIC clinic. Obviously at the state level they are more focused on statewide programs, grants, and overseeing the local clinics, making sure that they are meeting the standards set forth by the state. At the local level, all WIC clinics employ nutritionists, and these may or may not be RDs. Some are LDNs (Licensed Dietary Nutritionists), some are DTRs (Diet Tech, Registered) and some have met other levels of education in order to qualify.

In the day-to-day role of a WIC nutritionist, they will see participants throughout the course of the day either from appointments or on a walk-in basis. These appointments range from pregnant mothers to mothers who have infants to children up until age 5 and they differ slightly based on the type of appointment (initial, low-risk follow-up, high-risk follow-up, etc). When a participant arrives they first have their height and weight taken. Then the nutritionist will sit with them to go over the child’s growth chart and where they fall on the weight for height chart. After that he or she will take a diet recall which might result in the number of ounces of formula per day a baby is drinking or what a toddler eats during the course of the day depending on the participant. Once the diet recall is complete the nutritionist will focus on any problems identified and methods for changing (for example if a child is not drinking the recommended amount of milk per day, they will work with the mom to identify where in the diet to include an extra serving). At the end of the appointment the nutritionist goes over the participant’s “package” which is what specific coupons they receive. Any changes are made based on a few factors such as whether the participant has decreased the amount that they are breastfeeding or whether the participant would rather get whole wheat tortillas instead of whole wheat bread. When the appointment is done the coupons are printed.

There are a wealth of handouts produced by WIC in several languages that are available for the nutritionists to distribute. At the local clinic where I spent the week many participants spoke Vietnamese or Spanish, so there are nutritionists on staff there who speak those languages. WIC also provides referrals to other organizations such as parenting groups, fitness classes, and community activities. WIC is a national program and employs many dietitians, making it a good career option for any RD or RD hopeful across the country.

The Various Roles of an RD: Community/Non-profit Dietitian

There are lots of opportunities for an RD to work in a community setting. Many non-profits employ RDs. This could range from someone working for an organization that delivers healthy meals to people who are chronically ill to someone who teaches urban or low-income teens how to grow vegetables in a city.

I was fortunate enough to be placed at the Greater Boston Food Bank (GBFB) for a rotation and got to see what it might be like to be an RD working under the hunger umbrella. There are actually a few RDs who work at this particular organization and they serve a variety of roles. They help to ensure that all of the food that goes out to pantries and organizations is safe (ie not expired), train people from pantries and organizations in food safety, and help to teach people at these organizations about healthy eating. This may sound a bit abstract so I'll focus mainly on what I did while I was there:

• Design and implement lesson plans about nutrition for kids at a Boys and Girls Club. The GBFB supports a program called Kids Cafe where kids get an evening meal served for free at the Boys and Girls Club. I taught the kids about sodium, calcium, and the importance of fruits and vegetables by playing games and making recipes.
• Create and cook a recipe for a School-based Pantry. These pantries, as well as Mobile Markets, are one way that the GBFB donates food directly to consumers. They set up in a school cafeteria in the community and parents can come and take a variety of foods such as vegetables, fruit, bread, hummus, and yogurt. The day that I went we found out that we'd be handing out acorn squash so I made an acorn squash pasta bake. I handed out samples as well as recipes so that they could make good use of their squash!
• Write nutrition newsletters for different audiences. A few other programs that GBFG implements are the Backpack and the Brown Bag program. Backpack ensures that kids have a bag of shelf-stable food to take home on the weekends and Brown Bag gives bags of groceries to seniors in a supermarket bag to remove any stigma associated with receiving donated foods. Within each bag of food is a nutrition newsletter geared at either the seniors or the kids. These feature a recipe, some cooking tips, and a game.

Working at the food bank is just one example of how an RD can make a difference by working within the community. While it is a very different role from a clinical or counseling position, it is important in the effort to make the community a healthier place!

The Various Roles of an RD: Sports Dietitian

When I started working with two sports dietitians for the counseling portion of my dietetic internship, I wasn’t really sure what to expect. As I learned over the four weeks, there is not a clearly defined role for someone with that specialty. A sports dietitian can wear many different hats and work in a variety of different settings. For example, many college-level and professional sports teams have an RD on staff to help their athletes eat better to perform better. Then there are those who have a private practice and take anyone interested in meeting with an RD but specialize in sports-related issues. Here is a brief snapshot of what two of those roles look like:

Sports Dietitian in a Gym Setting

At this particular facility, the RD was an employee of the gym (rather than just renting out office space within the gym). She had the same responsibilities of other managers there, attending budget meetings, spending one weekend a month as the manager on duty, discussing goals, etc. Her coworkers were personal trainers and group fitness directors.

The clients that she saw consisted primarily of members of the gym who were interested in losing weight. Many of them also meet with a personal trainer to help reach that goal. There were also some clients who needed help managing diabetes, lowering cholesterol, or dealing with a food allergy. Clients can pay out of pocket or if their insurance will cover the visit, the RD bills them and keeps track of which companies have sent her the payments and when (much more time consuming than you might think!). At this gym the RD also does all of her own marketing as well as scheduling. She writes blogs and facebook postings in attempts to educate members of the gym as well as encourage them to come see her. Many of her clients track what they eat using the application MyFitnessPal and she can log into their account between sessions to encourage them or provide suggestions.

The most spots-focused activity that she did during my time with her was to give a talk to the parents of members of the gym’s swim team. She discussed the importance for student athletes of snacking, hydrating, and of course the essential post-race chocolate milk.

Sports Dietitian in a Hospital Setting

In the setting of a hospital, an RD has a much different role as well as different responsibilities. As a staff member at the hospital, her co-workers were doctors and physical therapists who also specialize in sports. She did not do any of her own scheduling or billing since that was done through the hospital system.

This particular RD saw a lot of patients who have eating disorders. Many of these patients were also athletes such as runners or dancers. A number of other patients were dealing with being overweight or had slow-growth or delayed puberty. 

The most sports-focused activity that she did during my time with her was to participate in a clinic for runners where they could come to have their running (and eating)  analyzed by a physical therapist, a podiatrist, an RD, and a gait analysis.

Regardless of the setting or the fact that they both specialize in sports nutrition, my experience with one-on-one counseling was that often the session does not involve a lot of talk about food. Yes it’s covered, but much of the time issues with food and eating extend so much beyond just knowing what you should and should not eat that there is a lot of general therapy happening.

The Various Roles of an RD: Clincial Dietitian

As many of you know, I am currently in the middle of my Dietetic Internship (DI) which is the last step before I'll be certified to take the exam to become a Registered Dietitian (RD). Every DI across the country, whether based out of a college like the one that I got matched to or based out of hospital, has three elements to the rotations: clinical, community, and food service. Some DIs focus more on one particular element, but each program must incorporate each of those elements at some point. It's a great way not only to learn from many different preceptors and prepare us for the big exam that comes at the end, but also to see the varied roles that are out there for an RD once we pass the big exam! So I've decided that as I go through my internship and work with RDs in different settings I'll highlight that career path here. Hopefully this will give you a better picture of what an RD does and the various options available to someone in this field. Keep in mind that these descriptions are based on my experiences with people in these roles but the responsibilities are certainly different in different places.

Clinical Dietitian
A Clinical Dietitian works in a hospital with patients who are admitted as "in-patient" - this is different from someone who might work in a hospital with patients who schedule appointments to see him or her (that would be "out-patient").

At my clinical rotation a typical day for a clinical dietitian would look something like this:

First thing in the morning, print the sheets that tell us everyone who is currently admitted to the hospital including what date they were admitted and what their admitting diagnosis is. Based on their diagnosis, we then figure out when we need to see them. Basically if they are admitted for something nutrition related, we see them sooner. This prioritization is necessary because there isn't enough time to see everyone while they're in the hospital and it would not make sense for us to go see someone who has had hip surgery but has a normal appetite when someone who has stopped eating gets discharged before we have a chance to see them!

Based on their diagnosis, or if a nurse or doctor has requested that we see a patient, we now know who we need to see that day (each day's notes get carried over to the next day so that we can keep track of how many days a person has been here and when we need to see them based on the prioritization). Once you know who you'll be seeing that day you can start to do some research into their past: what is their medical history, have they had weight change recently, have the nurses been recording their appetite, etc. After the background has been researched we head to the floors where the patients' rooms are. We hope that the ones that we need to see are in their rooms and available though often they're off the floor for a test or busy with another medical professional. Once we do get in to see the patient we do our interview to gather information from the patient. Depending on their admitting diagnosis we ask questions such as: What is your normal weight? How is your appetite currently? Have you noticed your pants are feeling looser? Do you typically follow a diabetic/low salt/fat free diet at home? Would you be open to trying a supplement such as Ensure?

Once the interview is over we go off to type our note into their medical file. The note includes information from the interview as well as our nutrition diagnosis. The nutrition diagnosis is written as a PES statement: Problem, Etiology, Signs and Symptoms. Here is an example of a PES statement: Inadequate oral intake related to nausea and vomiting as evidenced by patient report of not eating for 5 days prior to admission. We then address what we're going to do about the nutrition diagnosis such as suggest supplements, educate them on the diabetic diet, etc and how we will monitor their progress (track lab values, weights, how much they're eating).

In addition to repeating that process for all of the patients on the list for that day there are also meetings such as interdisciplinary rounds to attend and patients on nutrition support to follow-up with (tube feeds or total parenteral nutrition).

There is even more that a clinical dietitian does in their day-to-day role in a hospital but hopefully this sheds some light on one very important role that an RD can play!