What a Week!

It was the first week of a two-week orientation for the Bastyr dietetic internship. We met every day except one with our director in a small classroom on the south side of the building (Bastyr University is essentially one large U-shaped building), far removed from the usual student traffic and looking out onto a walled-in grassy area. Clouds and rain threatened for most of the week, but occasionally the sun would come out to warm and invigorate us.

Without giving away the whole curriculum, we had a number of activities and discussions structured to help us get to know each other and to build our “team.” And of course we discussed the requirements of the internship, went over our rotations, and got a feel for what our year would be like. There were also a couple of field trips, including a "retreat" day at our director’s home with a vegetarian potluck (including some gluten-free and dairy-free options), and a trip to a dialysis center to learn what it’s like to be a renal dietitian. Four of the interns have a special renal rotation, but the rest of us do not so it gave us a nice glimpse into the practice of renal dietetics and dialysis.

In addition to the usual rotations, we have a number of intern projects to complete. We’ll each lead one project, with the other eight interns as resources, and we spent a fair amount of time on the last day planning for the first two projects: a series of cooking/nutrition classes for Bastyr employees, and a research project culminating in the production of a publishable paper, potentially resulting in a published paper with all of our names on it!

As for the nine interns, we are a widely varied group in age, experience, and interests. Personalities run the gamut from irrepressibly exuberant to low-key (that’s me) with many shades of “color” in between. I think everyone liked everyone else, and that we’re going to be a good team for the next 9 months.

Monday starts with a lesson in doing a cooking demonstration. Normally this is taught by the amazing Cynthia Lair, but since three of the interns, including myself, took her course in this very subject in the last quarter of our program, Cynthia turned the class over to us. So three of us will demonstrate how to do a cooking demonstration to the others, then they will have a chance to do a short cooking demo and be evaluated by their peers.

At the end of this first week, I am simultaneously excited and frightened out of my wits about the coming experience. During this week we all expressed some level of trepidation, either about doing or saying something wrong during a rotation, not being able to remember information when it’s called for, and/or public speaking. I’m also fearful of letting down my director or my fellow interns in some way, which would also be letting myself down, but after hearing everyone express these fears I felt somehow better.

Part of being human is to be fearful – fear keeps us vigilant and charged up to meet a challenge. I remember driving to school in the first quarter of my first year of the nutrition program, on my way to doing my first presentation in class. My fear of public speaking is fairly intense, and was even more so then. My heart was racing, my hands were shaking, and my legs were weak. There was absolutely not a happy thought in my heart at that moment and I felt an almost uncontrollable urge to turn the car around and go home.

In that condition, my only recourse is usually to talk myself down from the ledge by finding a new and less scary perspective of the situation. That day, I got past my fear by reminding myself of the purpose of fear. The “fight or flight” response is a programmed reaction to imminent danger. Public speaking is (arguably) not dangerous. That simple logical progression was enough to calm me down and allow me to get to school and do my presentation.

Frankly, I expect to have to “talk myself down” pretty regularly throughout the next year. After two years of practice, it’s a well-developed skill that will help me meet all the challenges of the internship. Now I know that I also have the support of eight others who will be facing the same challenges and who may call on me for support when they feel like they’re out on a ledge.

Last Days of Summer

You know, even though I promised another post about the ADA camp, I just don’t have it in me. Maybe it’s that summer is winding down and I’m getting nervous about the official beginning of the internship. I have a lot of catch-up studying to do, and I’ve been doing a lot of other things over the summer that have kept me from getting all that relaxation time I was looking forward to! So, nothing more for now. The internship starts on September 28th, so stay tuned.

Diabetes Camp: Blood Sugar Control

Kiki trying (not too hard) to get some sleep.

I helped out on midnight checks two nights out of the four I was at ADA camp. Midnight checks were one of the highlights of my experience. It was the one chance I had to directly assess and treat blood sugar levels – under the supervision of the providers, of course. An RD’s scope of practice with diabetes is fairly limited, but in reality that all depends on the provider the RD is working under. One RD told me that we are never allowed to puncture the skin, but I know another RD who is a CDE (certified diabetes educator) and is working on her BC-ADM (board-certified advanced diabetes management) who gives insulin injections, manages insulin pumps and is allowed to adjust insulin doses, so it all depends. One of the ARNP’s admitted to letting high school kids do finger sticks in other venues.

Midnight checks entailed stealth maneuvers through the woods past raccoons and cabins full of sleeping campers, identifying our ADA kids in the dark and wrangling their arms out of their sleeping bags, performing finger sticks on them without making them cry, and administering snacks if their BG was low (<150). Most of these kids were incredible – they’d stick out a hand and fall back asleep while we did our thing. However, if a child had a low BG, it was much more challenging to get him/her to sit up and eat a snack. One of my girls hated the fruit roll-up I gave her so much that she started gagging and crying right there in the top bunk in the dark at midnight with her eyeshade pulled down around her chin. I tried to keep her calm and get her to swallow. Telling her, “the faster you eat it, the sooner you’ll be done,” was NOT the right thing to say and in the end, she had to wash down the half-chewed fruit with some Boost. Within seconds her tears had dried and she had settled back down into her sleeping bag – that's what I love about kids, that ability to move on. Next day we had a little laugh about it together. If faced with that situation again, I think I’d go for the Boost first time around. It’s not a whole food but it’s easy for a groggy child to drink down quickly. The second time I did midnight checks, all three of the kids I checked on had BG’s within normal range so I didn’t have to do anything special but this experience was satisfying in its own way – it meant that we (the ADA staff and the kid) were doing a good job! It also meant that I didn’t have to stay up for 2am checks. Annie and Stefanie, biding their time 'til midnight.

I ended up staying up anyway because Aaron, the provider “on call” that night, was in a teachin’ mood. We (me, Aaron, Stefanie, an RD, and Annie, a dietetics student) took our headlamps and some snacks (dark chocolate and Weinhard’s root beer) and went outside to the picnic area so that our talking wouldn’t wake up the people sleeping in the ADA cabin. We passed a raccoon and her little one rummaging through the garbage just outside – they snacked on camper trash while we sat and talked.

Aaron gave us a lot of insight into the mechanisms behind diabetes, the different kinds of insulin and their best uses, and showed us how he calculates an insulin dose based on the child’s BG, their carb count, their insulin-carb ratio and the insulin correction factor. These last two are calculated from the kid’s total daily dose (TDD) of insulin, which is established by the child’s care team outside of camp based on the child’s weight and insulin sensitivity.

Aaron, diabetes provider AND provider of
delicious snacks and evening entertainment

Dosing the kids at camp was a little different from dosing them at home, because kids tend to be a lot more active at camp. Activity naturally brings down blood sugar, so the insulin doses were adjusted down to account for the increased activity. If a child was on a pump, their basal rate was adjusted when they arrived at camp and as needed throughout camp, and bolus doses to cover meals and high blood sugars were also lower than usual to keep them from going too low between meals and overnight. Children who injected their insulin got a lower dose of Lantus, a long-acting insulin. It was a real balancing act!

I’m sure my explanations are insufficient to describe the whole process that goes on in a provider’s head when deciding an insulin dose. The provider’s judgment is based on the child’s history and TDD, but after a few days at camp and getting to know the kids a little better, I’m guessing that there were countless other small details that influenced the dosing.

So that was what I learned in a nutshell about blood sugar control at ADA camp. It was really a great opportunity to witness the daily challenges of maintaining blood sugar levels for both the kids and the providers.

I still have a few miscellaneous experiences that I’m anxious to write about, so stay tuned for one more post about ADA camp!

Diabetes Camp: Day One

I recently spent five days on an optional rotation at a summer camp with the American Diabetes Association. Here's what day one was like:

Early departure at 6:30 am. I carpooled with Maria, who just finished the Bastyr internship in June and is about to take the RD exam (good luck, Maria!). Besides having Bastyr in common, Maria and I have a connection through a very good friend of mine. Maria's husband is a childhood friend of my friend's husband. Five degrees of separation.

I actually brought my Krause with me because I hadn’t had a chance to read up on MNT for diabetes. When I told Maria I’d brought it she just laughed. She said that the diabetes experience at ADA (American Diabetes Association) camp was barely touching the tip of diabetes, and she should know because besides having done camp before, she’s a Russian-trained endocrinologist with extensive experience with diabetes.

Maria and me at the shoreline

The drive and ferry ride were uneventful, except in how charming and rustic Vashon Island was. We arrived at Camp Sealth just in time for breakfast. And what do you imagine was being served to the Type I diabetics in the dining hall? Belgian waffles with syrupy strawberries and whipped cream (oh, but the syrup was sugar-free!), an assortment of refined cereals like rice crispies and corn flakes, and fresh fruit. The protein was bacon. The fresh fruit was nice, but I had expected there would be a greater attempt at providing more blood sugar-friendly food for our beleaguered little ones.

I should clarify a couple of things before I go on. This was not a camp for diabetics. This was a regular summer camp session with special provisions (i.e., the presence of the ADA staff) for kids with diabetes. We were told at orientation that about 70 kids out of 300 would be Type I diabetics. Secondly, the primary goal of the ADA in this setting was to keep the ADA kids safe while they had a "normal" summer camp experience. Apparently, this included eating the same non-food as the "normal" kids. The only special provision for the kids made by the kitchen was to provide sugar-free syrup for the waffles, and sugar-free canned strawberries for the strawberry shortcake. I hope I don't have to point out the irony of this to you...

Interestingly, special care was taken to provide options for the four vegans/vegetarians at camp, and for the one child in camp with a severe peanut allergy.

The rest of the day was a blur of meeting the ADA staff (most of whom would be replaced the next day by a new crew), getting the lowdown on the life of a camp intern from Misha, another Bastyr intern, and learning to carb count… oh joy! My preceptor would not arrive until late that evening, so Misha’s preceptor, Susie, helped to orient me.

Inside the ADA cabin: tables for checking BS and getting dosed

By mid-afternoon I had a fair idea of what my days at camp would look like:

There would be two ADA staff locations at camp, called “pods.” ADA kids would come to one of the pods before each meal to look at a sample plate of food for that meal, tell us what and how much they were going to eat, and we would count up their carbs. The kids would then do a finger stick and get their insulin dose based on the carbs they planned to eat and their blood glucose level. The insulin dose was decided by the providers, most of whom were nurse practitioners, and administered by nurses or by the kids themselves.

Other than mealtimes, ADA kids would come in if they weren’t feeling well (and go through the same drill except for the carb counting), and at bedtime so that they could get a snack or an insulin dose to take them through the night.

These were my main duties: 1) Prior to every meal, get the menu and do a carb count based on product labels or carb counting books; 2) Plate up reference portions of food for the kids to look at; 3) Write the menu and carb counts on a board; 4) Go through the menu with the kids before each meal, tallying the amount of carbs they planned to eat. Other than that, I would have a chance to supervise the kids doing their finger sticks, participate in midnight blood sugar checks, and wear an insulin pump loaded with saline for a day or two.

Sleeping arrangements: I slept in one of four beds in an area behind a partition at the back of the main room of the ADA cabin. Since this was open to the front of the cabin, I knew there would be no rest for me until midnight checks were done and all the lights were off. I’m a very light sleeper so I always come prepared with ear plugs and eyeshades, but the effects of these were dulled by my racing mind, an awareness of stealthy activity in the next room where staff members were passing the time until midnight checks (more on this later), and SNORING! I counted three different snorers that night, one of them so loud that the noise penetrated my ear plugs (rated for 30 decibels) from a room down the hallway and through a closed door.

Everyone quieted down within a couple of hours and I did eventually fall asleep, but I had a long time to mull over my day and ponder how a snoring person could sleep with such a thunderous sound vibrating through their own skull. ZZZZzzzzzzzZZZzzZ.

First Rotation Done!

I finished my first rotation for my internship yesterday. I actually have two summer rotations, the second of which comes around in another week, and which you will hear all about when it’s over. This first rotation came as a surprise from my director about a week after graduation. She emailed us about the possibility of helping out with two summer food programs in the Auburn School District.

The cool and unusual thing about this rotation is that the internship director’s husband is the Food Service Director for the Auburn School District and I know his reputation for being passionate about whole foods, good nutrition and supporting local farmers. I also know that he started an organic garden and fruit orchard at one of his schools with the hope of bringing fresh food into the cafeteria and teaching the kids about gardening. This rotation would involve working with two different programs in the Auburn school district – the Summer Food Service program and the Summer Food Academy – so I immediately signed up.

The Summer Food Service program is a continuation of the National School Lunch Program, making free lunches available throughout the summer to those families who qualify for free or reduced lunches during the school year. Most school districts, at least in Washington, set up one or two meal sites throughout the district and require the families to bring their kids to the sites every day to get their lunches.

The Auburn School District, on the other hand, literally goes the extra mile by bringing the meals to the communities that need it most. Besides the free meals provided at schools where summer school is in session, there are about 33 other sites where free lunch is served throughout the summer. There are teams of two or three people who prepare the food, pack it into a bus or station wagon, drive out to a neighborhood and literally set up a tray line on the side of the road or in front of an apartment complex so that the kids in the neighborhood can get their free meal. Any child in the neighborhood can come have lunch. Each team goes out to 4-6 sites every day.

As an intern, I participated as part of one of these teams and observed trends in food selection by the kids. They did a pretty good job for themselves! Most of them took both fruit and vegetables, though not many of them knew that the little pinkish-yellow fruit I was offering them was an apricot. They thought it was a peach or a plum, and one kid even said, “I’ll have the mango.” Actually, I think it was the parent who called it a mango.

The Summer Food Academy (days 2 thru 4 of the rotation) is more like a day camp for kids. They enroll in the program ahead of time and pay a fee of $36.00 for a 3-day experience. They help cook breakfast and lunch for the group, and in between meals there are lessons in the organic garden about bugs and plants (and nutrition, now that there are Bastyr interns!) taught by an educator from the FoodSense program.

Part of my responsibility at the Summer Food Academy was to incorporate nutrition “messages” into the curriculum, so I taught a little lesson on “What is a Whole Food?” based on Cynthia Lair’s lesson from the Whole Foods Production course at Bastyr. The kids got really into trying to decide whether or not chicken pot pie was a whole food, and they were absolutely positive that Cheeto’s were NOT a whole food. Guess I did my job there.

The second day I talked to the kids about fiber: what kind of foods have it, what it does for the body… They liked hearing about the 100,000,000,000,000 bacteria (10x the number of cells in the human body) living in their intestines, and how eating fiber feeds the bacteria and keeps them healthy. We also talked about pooping and constipation, not the best topic for breakfast but they took it in stride.

I also did a lesson on “Chip” the compromised corn cob (from Jenn Dazey’s book Naturopathic Gardening -- Jenn teaches organic gardening at Bastyr). Jenn taught us that a plant that successfully fends off bugs and disease or survives a drought has strong genes and a powerful innate immune system that should be preserved by being replanted. The Mayans, famously reliant on corn for food, always kept the seeds from plants that bore Chip-like ears of corn and mixed them in with other corn seeds in a 50:50 ratio, thereby ensuring genetic diversity and a strong crop for the following year.

I learned in a different class altogether that plants that are allowed to defend themselves against adversity (meaning that they aren’t sprayed with pesticides or otherwise artificially protected) actually contain more phytonutrients, the compounds in plants that function as an immune system. This is good to know for those of us who are put off by the imperfect produce at the farmer’s market, or who are used to the uniform and unblemished produce in the grocery store.

I combined these two lessons and taught the kids that the imperfect or blemished fruits and vegetables they see in the store may actually be more nutritious than the perfect F&V. Carey, the garden educator, added a great illustration of this concept by explaining how having chicken pox gives our bodies the tools to fight the virus off and strengthens our immunity.

This was a fantastic experience for me. I found that I instinctively know how to talk to kids despite not having kids of my own, though I need to practice using a louder voice. I tend to start big and loud and end with a whimper. I think I could also practice making a point in two or three different ways, so that the kids who don’t understand a concept the first time around might understand the second time.

I also had some practice in asserting myself (something that is challenging for me), because the people I worked with weren’t sure what I was supposed to be doing and I needed to make sure I fit my assignments into their schedule. I think I did a good job of communicating my needs and also at being flexible about my lesson plans and when and how to offer them. On my last day, Janet, the kitchen manager, told me that I hadn’t been a pain in her butt – this was meant as a compliment. I guess she expected to have to do some hand-holding but I was independent and helpful and didn’t get in the way. Mission accomplished!