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Standardization of the nutritional care for patients with fatty-acid oxidation disorders is lacking. A literature review and national survey of metabolic dietitians describes the range of therapeutic strategies currently employed in the U.S. to treat patients with fatty-acid oxidation disorders. Questionnaire responses provided by dietitians specializing in metabolic disorders evaluated practices used for treatment of fatty acid oxidation disorders, medium-chain acyl-CoA dehydrogenase deficiency (MCAD), very-long-chain acyl-CoA dehydrogenase deficiency (VLCAD), long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHAD), long-chain acyl-CoA dehydrogenase deficiency (LCAD), and Trifunctional Protein deficiency (TFP). This survey reveals a significant lack of evidence supporting the protocols in use. Recent advances in tandem mass spectrometry technology promises an increase in the number of identified patients with fatty-acid oxidation disorders, which reinforces the need for comprehensive, clinical research studies to determine optimal care for patients with these genetic disorders.

As dietetics professionals, rather than debating dietary prescriptions, we must make our priority evaluating whether those prescriptions can be reasonably and consistently translated into food selection and eating patterns. This is nothing new to us. We have long advised physicians about the practicality of diet prescriptions and often recommended that prescriptions be moderated. In my view, we are at our finest when we are advocates for people and their relationships with food rather than arbiters of diets. Rather than emphasizing what people should eat, we must emphasize what is possible and reasonable for them to eat. In my experience, the gap between knowing and doing will continue as long as the knowing is unrealistic. Clinical experience makes it clear that if a diet prescription is unrealistic, it will not do any good. In attempting to apply unrealistic dietary prescriptions, we do not help people. We just make them into dietary cripples. It has been extraordinarily difficult to lighten up on the particular diet prescription of the US Dietary Guidelines. Given the emphasis on preventive nutritional care and the urgency with which the messages are delivered, I and many other dietetics professionals believe our are hands tied: We must go along with the US Dietary Guidelines. If we relax our efforts to persuade people to eat in accordance with the prescription, we have been led to believe we will do them irreparable harm. The data do not support such a threat, either for children or for adults. There is enough inconsistency in the evidence linking dietary fat and heart disease to make prevention a hope, not a guarantee. Before we apply the formulas we love so well (yes, I love them too), we must consider what our attempts to apply a formula will do to people's eating attitudes and behaviors and to the feeding relationships between adults and children. People manage to feed themselves and their children, and they eat the way they do for reasons that grow out of their cultural traditions, preferences, and practicalities. Sweeping changes carry the risk of undermining serviceable foodways, so it is reasonable to recommend such changes only on an individual basis and, for the public, on the basis of compelling evidence. No such evidence exists. Because the scientific evidence for the connection between childhood diet and heart disease is debatable, it is legitimate for us to be advocates for children by recommending doing less, rather than more. "Less" in my view, does not mean doing nothing at all. It means helping families enjoy food and optimize normal eating patterns, rather than attempting to achieve a particular prescription for dietary fat.

Text: The Nutrition Care Process (NCP) provides a standardized yet individualized approach to nutritional care of patients. When the decision was made to implement the NCP into the electronic documentation system at Harbor-UCLA Medical Center, dietitians (RDs) raised two primary concerns: would the briefer method of documentation meet regulatory requirements and would formation of the Nutrition Diagnosis (ND) statement take significantly longer to develop during the initial transition, resulting in decreased productivity? RDs were trained in the NCP over a six month period and the Clinical Nutrition Manager (CNM) worked with Information Systems (IS) to ensure all ND and Nutrition Intervention terminology was included in the Affinity Patient Charting system. The NCP was formally implemented in October, 2007. RD productivity pre-NCP ranged from 1.39 1.81 (average 1.63) inpatients seen per hour. Since implementation of the NCP, productivity has averaged 1.58 (range 1.53 1.67). A minimum of 5 chart reviews are conducted on each RD quarterly to ensure compliance with regulatory requirements as well as assess competency. Chart audit scores prior to NCP implementation ranged from 90.98% to 97.54%. Post-implementation, initial chart audit scores were 95%, increasing to 98.32% the following quarter. In summary, use of the NCP has not resulted in a decreased productivity level, even during the initial learning phase, and chart audit scores have improved to an annual high during the recent quarter. As the staff become more accustomed to the NCP, data will continued to be tracked for further improvement in productivity, competency, and regulatory compliance.

Nutrition screening for this facility is completed via computer search of the admission database completed by nursing. A screening report is generated which includes patient name/location, admission date and time and risk indicators. (% ideal body wt, wt. loss, pressure ulcer present, swallowing/aspiration, pressure ulcer risk scores, high risk diagnoses, albumin, oral intake and geriatric surgical status). The computer enters results under the appropriate risk indicator column and indicates "M" under that indicator if data was missing or incomplete at the time of the search. The missing data component of the report replaced time consuming manual review of records to validate the screening process and provide data for performance improvement. Nutrition Services was able to quickly summarize unit performance and give immediate feedback to nursing on compliance with admission heights and weights, accuracy of reporting actual pressure ulcers and pressure ulcer risk scores. Collaboration with nursing from June 1997 through December 1998 achieved the following improvements in compliance: heights and weights, 58% to 89%; assigning/completing accurate pressure ulcer risk scores, 50% to 85% and reduced reporting other types of skin conditions incorrectly as pressure ulcers, from 50% to 30%. The report is now available in the computer for each nursing unit to review daily. Nutrition Services also used the reports to identify indicator specific populations for monthly tracking. This decreased monthly data collection time by 20%, allowed more timely feedback to individual clinicians and increased time for improvement action and standardizing nutritional care for patients with pressure ulcers.

LEARNING OUTCOME: to assess education and knowledge of registered dietitians' nutrition intervention in hospice patients A survey was constructed to obtain information about the education and practice of clinical dietitians in the nutritional care of hospice patients. It was sent to a random sample of 900 clinical registered dietitians who were members of the American Dietetic Association. The survey contained 10 multiple choice questions about nutrition for the hospice patient and some demographic questions about the respondent's practice and education. There were 461 (51%) respondents of which 390 (85%) had not received any dietetic training specific to hospice patients. Of the 66 (14%) dietitians who had received training, only one reported training in an undergraduate program. In contrast 179 (42%) of the 461 had provided nutritional care to hospice patients. Regarding practice knowledge, 35 (8%) of dietitians surveyed answered all of the ten questions correctly. Thirty-one of the 35 of those respondents who answered all ten items correctly had received formal training. The mean number of correct answers was 6.4. The majority of incorrect responses resulted from inadequate knowledge of symptoms associated with low intake of food and water (56% incorrect), side effects of increased fluids (53% incorrect), symptoms frequently seen in end stage patients (52% incorrect) and complying with patient's preferences (34% incorrect). Incorrect answers suggested that hospice patients are often treated aggressively via oral or enteral feeding, which is the usual traditional nutritional intervention provided by dietitians. With the increase in hospice facilities in this country, the results of this survey indicate the need to provide formal dietetic training regarding specific nutrition principles applicable to the dying patient.

Small frequent feedings are an important part of the Nutritional Care of advanced cancer patients. Evening snacks are routinely planned by the Clinical Dietitian to address the specific problems of anorexia and/or early satiety. Nursing staff are responsible to deliver these planned and prepared snacks. Patient dissatisfaction, diminished intake as well as observation of food items (snacks) being discarded were indicators that the current process was in need of improvement. A multidisciplinary service team made up of representatives from both Nutritional Services and Nursing departments developed a tool which monitored: a) time snack was offered to patient; b) staff member assigned to deliver snacks; c) other,((i.e. change in patient's status, specific food requests, etc.) Initial monitoring of the process indicated 50% compliance. Monthly multidisciplinary meetings were held to review monitoring results and initiate other recommendations to improve the process. These efforts have resulted in an overall improvement in the evening snack delivery with a compliance rate of 97.4%. Other outcomes include: improved patient intake; decrease in number of patient complaints; heightened awareness of the importance of small frequent feedings; improved interdisciplinary communication, improved appreciation of the task responsibilities of each discipline and improved use of available resources: food and labor.

Unchanging patterns of low birthweight deliveries reveal the need for increased emphasis on nutritional management of high-risk neonates. The research of Thompson (JADA 94:400) shows only 38% of the nation's neonatal care centers currently include a dietitian in their intensive care units. The National Institute of Health supports medical nutrition therapy as a "clinical priority" in the management of preterm and low birthweight infants. It is imperative that undergraduate students receive exposure to the specialized field of neonatal nutrition to assist in meeting the urgent need. This project, designed through the Honors Program, provided an educational experience at a leading neonatal care center. Participation in a summer neonatal nutrition fellowship increased interest in specialization and prepared the student for pursuing an advanced-level degree in pediatric nutrition. Commitment of dietetic professionals to create extended educational opportunities for students will be rewarded with a generation of dietitians qualified to meet the demands of providing advanced-level nutritional care. Undergraduate dietetic education will be effectively enhanced both now and in the future.

Guidelines for peer review of clinical dietitians are needed. In this study, two areas relevant to such guidelines, i.e., data useful in assessing nutritional status of patients and written communications of the dietary staff with other health care staff, were explored. Admission height and weight and blood chemistries, as found on dietary cards for 119 randomly selected patients during 1973, were tabulated. In addition, pertinent information on dietary cards and in the medical records was compared. The findings indicated that the biochemical and anthropometric indicators of nutritional status were available in the medical records but were not being utilized by dietitians to the degree expected. The dietary card is the logical focus for peer review, but better documentation is needed in areas of dietary history recording, computation of ideal weights, utilization of laboratory data, and development of nutritional care plans.

Here are documented figures on cost (money) I benefit (improved health) when intensive diet therapy for patients with diabetes was substituted for oral hypoglycemic agents, use of insulin, and minimal nutritional care.

Dietitians are members of the only profession whose sole concern is the nutritional health of people.

The study was designed to identify and to evaluate the interviewing and diet counseling functions of the dietetic technician. Detailed comparisons and analyses were made of data collected from dietetic practitioners and educators and of data from the literature, curriculums, and job descriptions. Competencies were identified for further study. The videotaped performances of dietetic technician students were compared to defined criteria. The interviewing and patient education skills were satisfactory. A majority of the students lacked the counseling skills required for a client-centered approach. Curriculum inferences are presented.

In this second of a three-part series, the authors report on patients’ (consumers’) reactions—expectations, satisfaction, and responses-—to dietary counseling.

Issues which must be addressed by clinical dietitians as participants in their hospitals' quality assessment programs (audits) are defined. Solutions and approaches used at various phases of the audit processes by the clinical dietitians at Brooke Army Medical Center are described. Outcome and process criteria for nutritional care of the patients with maturity onset diabetes mellitus are presented, along with samples of the clinical dietitian's documentation in the patient's record. The impact of "audits" on the quality of nutritional care is exemplified by results of a series of audit studies on diabetes mellitus conducted over the past three years. Other benefits which have accrued from participation in the hospital's audit programs are enumerated.

Public health nutritionists have begun to coordinate efforts toward development of national standards for ambulatory nutritional care by writing and field testing criteria for selected target populations of pregnant women, infants, and children. These efforts have identified problems related to the "state of the art" in both quality assurance and nutrition science. This article reviews the literature on quality assurance in nutritional care and summarizes the current efforts culminating in publication of a preliminary guide on quality assurance in ambulatory nutrition care by the U.S. Department of Health and Human Services.

The results of a study designed to gather information concerning dietitians' charting practices suggest that The American Dietetic Association and hospitals themselves have recognized the importance of dietitians charting in medical records. The results also suggest that dietitians recognize their own adequacies and inadequacies in terms of charting frequency. The identification of lack of time as the factor most often preventing more frequent recording may indicate a need to adjust staffing patterns or to re-order priorities. Achievement of the latter may require more education concerning both the overall importance of charting and the importance of charting some specific categories of information. Due to less exposure to charting during professional programs, dietetic graduates prior to 1966 may need more help to improve their charting than later graduates.

As clinical nutrition has grown, so has the dietitian’s application of knowledge in the nutritional care of patients. Some of the changes over the years are reviewed here.

By observation in ten ambulatory care settings and a literature review, the author found that dietetic service is being delivered by a variety of personnel--trained lay aides, nurses, and physicians, as well as professional dietitians. Employers in such settings agree that nutrition is an important component of total health care but question whether it must necessarily be delivered by dietetic personnel. The dietitian, to survive, must justify on a cost-benefit basis the unique value of her competency to the outcome of patient care. Sixty-eight nutritional care functions, appropriate for dietitians and/or dietetic technicians working in ambulatory care organizations, are identified and listed. In contrast to hospital-based, in-patient care, the author concludes that performance of these functions requires greater interest in helping others and greater flexibility, and she sees such service as the wave of the future.

Usefulness and limitations of liquid formula and chemically defined diets in nutritional care of patients are considered.

Counseling techniques can influence patients’ compliance with therapeutic regimens. Here is a report of strategies currently used by forty-four practicing dietitians in providing nutritional care.

In this, the first of a three-part report on consumers’ (patients’) reactions to dietetic prenatal care, the authors set the stage by describing the clientele and type of counseling provided—as seen by the patients.

Quality assurance criteria developed for six target populations of pregnant women and obese infants, children, and adolescents were field tested in 102 ambulatory care settings to determine whether they were relevant, understandable, measurable, behavioral, and achievable. Field testing identified specific problems in ambulatory nutritional care settings related to documentation and feasibility of using patient care records to provide data to assess quality of care and to determine how statements were formulated. Field test results were used to rewrite the criteria. Findings are consistent with those of other authors.

Educational needs of dietitians were identified by 232 practitioners in Ohio by means of a self-administered questionnaire. Three major knowledge areas--managerial science, nutritional care science, and behavioral, communicative, and socio-cultural science--were covered in 109 questions. The respondents perceived a need for more professional knowledge than for behavioral, communicative, and socio-cultural sciences. Greater need was expressed for skills in technical and human ability than for skills in conceptual ability, and generally for nutritional knowledge rather than application. The findings could form the basis for continuing education programs.

The development of an innovative nutritional care delivery system and its component parts is described.

Interviews were conducted with ninety-two pregnant women who attended the out-patient clinic of a major obstetrical teaching hospital. Information was obtained on the patients' perception of their need for dietary advice during pregnancy and selected demographic, nutritional, and medical care characteristics, as well as their response to, and satisfaction with, the dietary advice and treatment they received. The patients' perceived need for dietary advice appears to be an important factor in the apparent effectiveness of prenatal dietary counseling. Patients who expressed a need for dietary advice were more likely to consider diet important during pregnancy, to have positive feelings toward nutrition services, to have visited the dietitian, and to report making changes in their diet because of the advice received. Little association was observed between demographic and medical care characteristics of patients or more objective measures of need for dietary advice and the patients' own perception of need. It is suggested that patients whose expressed need for counseling is at variance with objective measures are a group requiring special attention.

The basic role of the dietitian is to provide nutritional care. To be effective, however, it must be integrated into all levels of health care, including both those for which governmental agencies must take responsibility and those organized around the health needs of the individual, such as the proposed Health Maintenance Organizations (HMOs).

Existing models for the delivery of child health services, including nutritional care, as well as evolving health care systems, such as national health insurance and health maintenance organizations, are reviewed. Consideration is given to the role of nutrition personnel in emerging health delivery systems and the need for active leadership by the dietetic profession.

Two major factors seem to be contributing to the problem which underlies the need for better nutritional care to clients: clinical dietitians themselves and the system which supports them. It is felt, however, that the burden of responsibility for improvement weighs more heavily on the individual dietitian than on the system, because systems are composed of functionally related individuals working toward a common goal. Few would argue that the goal of the health care system is a positive state of well-being in the population it serves. Even fewer could argue with the primacy of effective nutritional care in the achievement of that goal. If, however, we want clinical dietitians to be more effective nutritional care in the achievement of the goal. If, however, we want clinical dietitians to be more effective in the future, they must be given the time, expertise, and responsibility to provide this improved nutritional care.

Successful nutritional care of individuals and population groups can only be based on adequate and valid data. Both nutritional surveys and surveillance programs are discussed in this light.

A research panel utilized content analysis techniques for quantifying the content of nutritional care plans developed by senior level dietetic students. The content was organized into six subject matter categories relevant to sociocultural and physical factors: cultural, economic, physical, psychological, religious, and social. The average score of six coders was used in determining the content. Content analysis proved to be an effective method of evaluating the content of nutritional care plans and could be further utilized in dietetic education to help dietetic students apply the theories learned in the classroom to actual patient care.

The dietitian is an important member of the health care team in the community and must be competent in the areas of administration, clinical nutrition, patient education, and human relations. Dietary follow-up care is essential in the community to evaluate existing facilities, assess economic levels, disseminate information to residents and sponsors, and ultimately provide good nutritional care to the patients. Responsibilities of the community care dietitian include participation in the initial evaluation of community homes under consideration for veteran placement and in determining the appropriateness of home placement for individual patients. Also, she/he makes follow-up visits to patients living in community residences.