Who Knew Diabetes Was So Interesting?

I noticed this morning that the last of the golden leaves are falling from the trees. I didn’t think they would last as long as they did and I’m sorry to see them go, especially because they made my commute for the last two weeks that much more beautiful. I’ve been working with Jennifer Okemah, an RD who has specialized in diabetes and has created a diabetes counseling and education program at Valley General Hospital in Monroe. I know Jennifer from previous volunteer experiences, and from the ADA diabetes camp rotation this past summer.

This rotation was a lot of fun and challenging for me because while I’m a fairly low-key, slow-moving and thinking person, Jennifer is a fireball. She’s always doing three things at once, and probably thinking about twenty. My brain was challenged just by trying to keep track of her movements around the room. Nevertheless, she always had time to answer my questions in detail and to give me guidance when I needed it for an assignment or project.

My hours during the week were shorter to work with Jennifer’s schedule so I was also there on Saturdays to make up the difference. The six-day-week (including Monday seminar) was tough for me but it was certainly nice to get home early every day.

The goal of the diabetes program is to provide people with diabetes with education and counseling to help them manage their diabetes. Jennifer’s partner in the program is an RN/CDE, so they're able to address the patient’s needs from both the medical and the nutrition standpoints – and there is some crossover in each one’s expertise so they complement each other well.

In general, patients have two or three individual appointments with Jennifer and/or her partner and attend a series of four group classes designed to provide more general information about diabetes management. When I first arrived, there was a fairly full calendar of patients to look forward to but every day that I was slated to observe appointments there were several cancellations or no-shows. That was really the only disappointment for me in this rotation, and after the third day of this pattern, I started to feel like I was cursed.

There was a silver lining to this curse. I had more time to ask Jennifer questions, and to work on some of my assignments. During some of this down time, Jennifer let me in on some of the difficult political and bureaucratic issues that an RD faces, both generally and in the position of program coordinator, including the general lack of knowledge that exists around the expertise and scope of practice of an RD. She asked me to sit in on her presentation to the hospital foundation that funds her program (in part) so that I could observe her advocating for herself and the program.

Despite all the no-shows, I did manage to observe several appointments and was astounded (really, I shouldn’t have been surprised) by the level of knowledge and experience that is necessary to truly inform patients about how to manage their diabetes. I was continually reminded of the complexity of the disease, not just medically but in psychosocial terms, especially for the newly-diagnosed. I’m attracted to the idea of specializing in diabetes because I think I would be a better specialist than a generalist, and diabetes is complex enough to be continually engaging for a practitioner.

In the second week, I led a meal plan appointment. I calculated the patient’s energy needs and carb allowance, and explained how to distribute carbs throughout the day. We did some carb education (which foods have carbs in them?) and talked about how diet helps with blood sugar management. That was fun -- not the calculations but the talking to the patient -- though I know I could have done better.

I had lots of opportunities to practice overcoming my greatest fear: PUBLIC SPEAKING (dum da da dummmm). I led parts of two different group classes with lots of backup from my supervisors, taught 6th graders how to look at fat, carbs and sodium on nutrition labels, and did two back-to-back hour-long cooking demos at the YMCA for National Diabetes Month. In the middle of that, I co-taught a cooking demo for people with diabetes through a different outpatient diabetes program with two of the other interns.

I feel like this stage fright should just about be burned out of me by now, but it doesn’t seem to have diminished a lot. What has changed is my ability to deal with the stress of public speaking. I know I have to be prepared (duh). I know I have to have certain parts, especially the intro, scripted out for myself because those parts require some verbal finesse that isn’t always present when I’m nervous. I know now that I don’t have to be perky and perpetually smiling to hold the attention of the audience, even 6th graders, as long as what I’m saying is engaging and makes sense.

Something else I learned was the difference between the CDE (certified diabetes educator) and BC-ADM (board-certified advanced diabetes management) credentials. Jennifer has both credentials and both are useful, though there’s a distinct difference between the two. In short, the main differences are that the BC-ADM requires an advanced degree, the test is harder, and the scope of practice for the BC-ADM is more advanced than a CDE, including “advanced clinical assessment, prioritization of complex data, problem solving, counseling, and clinical intervention and monitoring”. Most diabetes educators are CDEs, some are BC-ADMs and a very small percentage are both.

So that was my outpatient diabetes rotation. I’m sure I’m forgetting something but this will have to do for now –- dinner’s being served. I have another diabetes rotation early next year and I’ve heard that the philosophies and practices are quite different there from what I’ve observed here with Jennifer, so that will be interesting. My next rotation, however, is with WIC. Looking forward to learning more about that program!

Now We're Getting Somewhere

I have two different rotations to tell you about this week.

The first one was not officially a “rotation” but was still a lot of fun and I learned a good deal. For two days I shadowed Michelle Babb, a private practice dietitian who also happens to be an instructor at Bastyr so we knew each other ahead of time (always nice to see a familiar face during a transitional time like this internship). It was fairly leisurely, as she had a couple of no-shows, so we talked a lot about the challenges of private practice, about my plans for the future, and about nutritional approaches to different types of problems and different kinds of people.

For the patients that we did see, I was interested in observing a professionally-run nutrition appointment from start to finish. All the appointments were follow-ups so I missed out a bit on the original intake, but was able instead to witness the positive impact Michelle’s counseling had on these people’s lives. Michelle was very generous in asking for my input during appointments and letting me work with her on charting. It was a great introduction to my rotation the following week at the Bastyr Center for Natural Health, which is where I had done my nutrition counseling shifts in the last year of my program.

I had six four-hour shifts, four with NDs (naturopathic doctors), one with homeopathy and one with acupuncture. All the shifts were fascinating and showed me a bigger picture of complementary medicine than I got on my nutrition shifts at BCNH. The homeopathy shift was the most foreign to me, and I did not have a chance to participate in the patient’s care because of the nature of it. Maybe I’ll write more on this later…

Each shift supervisor had their specialty but the structure was generally the same for each shift: get the bigger health picture for the patient, prioritize the most important issues and treat them, with a follow-up plan to address the other issues later. Treatments ranged from individually-formulated botanical tinctures and teas, to pharmaceutical-grade supplements, to antibiotics for a protracted case of UTI, and referrals for imaging or blood tests. In this context, nutrition issues were often supplanted (and rightly so) by more acute medical problems like head colds, shoulder pain, etc.

However, I did my best to chime in when I thought there were ways to address the priority issues with nutrition, or when I felt that a referral to the nutrition department was called for. Most of my patient contact was very short (1-5 minutes) though I did have a 20-minute conversation with a patient with severe involuntary weight loss during which I intuited a more emotional component to the weight loss, and I shared this with the students, though I will not get to find out what the cause actually was (and therefore find out if my intuition was correct). During the midpoint, I got to do some of my handy-dandy nutrition calculations and reassure the students that the patient was still above ideal body weight, and in the end was able to give the patient some input into how to prevent further weight loss. Very satisfying. And for the last appointment of the last shift, and the highlight of my week, I gave a 30-second lesson in how to make calcium-rich bone broth for a child on a dairy-free diet.

I’d say my biggest surprise in this rotation was that I was able to convey important nutrition messages quickly that fit in with the overall plan for the patient. My other surprise was how grateful patients were for my input.

Over the next two weeks, the gears really start turning. I’m working with an outpatient diabetes program and will be teaching two or three classes, including a couple of cooking demos for National Diabetes Month. I’ll have a lot more to say about that rotation in a couple of weeks.

There's a Revolution Going On

My first rotation was with an organization called Readers to Eaters (also called R2E), a relatively new company that aims to promote food literacy by selling books about food, publishing books about food (starting in 2010), and developing educational programs about food. The owners of R2E are Philip and June Jo Lee – he has a background in radio and publishing, and she is a research consultant to the food industry. To Philip and June Jo, being food literate means having an awareness of what one eats and where food comes from.

My internship director set this rotation up for me because of my background in writing and my special interest in nutrition education in the public school system. I had thought it would be a gentle introduction to the internship, encompassing some writing, some observation of Philip in his daily work, and a little research… as usual, my expectations were quite off the mark (yes, this is an ongoing problem for me).

Instead, my task was to conduct a needs assessment for a food literacy program in the community. Philip’s goal was to create a unique curriculum that fills the gaps left by existing programs. I worked from home, using the Internet to find non-profits, for-profits, school districts and individual schools, and government agencies that are promoting food literacy at some level. Over a two-week period (which was really eight days because we have seminar on Monday), I collected notes on a number of local programs, querying some by email or phone to find out what their staff thought were the unmet needs for food literacy in the community, compiling a resource list for Philip, and writing up my recommendations for a nutrition education curriculum that would answer these unmet needs.

I found some fantastic organizations: Food $ense, Operation Frontline, 826 Seattle, School’s Out Washington, Solid Ground’s Apple Corps (LOVE the name), and Sustainable Table. There were many others; in fact, there are literally hundreds of individuals and programs out there trying to teach kids about food through cooking, gardening, and nutrition education. Everyone I spoke to was passionate about food, interested in the R2E mission, and eager to share information.

I am even more excited now about my long-term goal to get involved in nutrition education in the public schools, though I think it will be more interesting and useful to talk about how to grow, cook and eat real food than to teach the principles of nutrition. These are exciting times, folks, when kids are getting turned on to healthy food by pulling a carrot out of the ground, or by tasting roasted kohlrabi from their own school’s organic garden. Unfortunately, the UK seems to be beating us to the school lunch revolution (thanks in part to Jamie Oliver). Is anyone else out there foreseeing interesting changes in school lunches thanks to the Obamas?

Orientation: Week Two

Week two of orientation is over. We are now so thoroughly oriented that we all point due north. By Friday mid-morning I was utterly wiped out and emptied of most of my questions, except for the big one, “How do I fit all of these rotations, projects and assignments into nine months… AND do a good job?” Ahhh, life... it’s one long series of questions.

Back to my week. Three of us gave a lesson in doing a cooking demo for the interns who hadn’t taken Cynthia Lair’s class last year. We started by describing the elements of a demo, then we showed them what to do by demo’ing Cynthia’s French lentils with sage butter, then showed them what NOT to do (actually Misha showed them what not to do in her inimitable way) in a cooking demo/food safety nightmare skit. Then the other six each did a quick cooking demo for us – they were all so good that you would never know they hadn’t taken the cooking demo class.

We also had a lesson in maternal/child nutrition from an ND, who was such a font of knowledge that she got us excited about our WIC rotations. Later that same day an RD talked to us about WIC and the new food package, which now includes fruits and veggies, whole grains and non-dairy protein options! Hooray! The RD reminded us that the population seen by WIC staff often have higher priorities than nutrition counseling and that we could end up just helping someone figure out how to use their WIC checks, or how to pay their rent that month. No matter, we were still excited about our WIC rotations.

Note to self: Since the WIC population is considered a vulnerable population, working with WIC right out of my internship would qualify me for the loan forgiveness (here's a rather dry description of the program). In other words, if I went to work for WIC, a portion of my student loans would be written off. Hmmm, it's tempting, though the maximum they’ll forgive is $10,000 over five years. (More information on loan forgiveness programs here.)

Wednesday and Thursday were spent working on our group projects in smaller teams. My team finished up our plan for the cooking class we’ll be teaching on white-colored foods. On Friday we basically checked in, talked briefly about our group projects, went over the continued learning portfolio required by the ADA (for RDs, not interns) and then went on our merry ways (my merry way took me home for a nap).

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.