THE EVOLVING ROLE OF THE CLINICAL DIETITIAN, WHAT DOES THE FUTURE HOLD? Adrienne Speedy Lead Dietitian, Cleveland Clinic Abu Dhabi

Transcription

1 THE EVOLVING ROLE OF THE CLINICAL DIETITIAN, WHAT DOES THE FUTURE HOLD? Adrienne Speedy Lead Dietitian, Cleveland Clinic Abu Dhabi

2 Disclosure information I have no financial relationship to disclose.

3 Objectives At the end of this presentation participants should be able to: Appreciate how the role and scope of a dietitian has changed overtime and will continue to do so in the future. Identify the benefits of implementing Nutrition Focused Physical Examination (NFPE). Appreciate current research focusing on assessment of lean body mass. Outline potential areas for extended dietetic scope. Consider strategies that you could employ to progress and evolve your dietetic practice

4 History of dietetics 1839 Dunglison Medical Lexicon, described dietetics as a branch of medicine comprising of rules to be followed for preventing, relieving or curing diseases by diet First known diet sheet was circulated in Auckland Hospital, NZ 1889 The term dietitian was first applied to persons who specialized in the knowledge of food. ( ) Sarah Tyson Rorer was the first American dietitian

5 Focus of the first dietitians World War 1 ( ) Role focused on Feeding hospitalized soldiers Planning and monitoring food rationing to prevent food shortages

6 First Dietetic Conference October in Cleveland, USA Main discussion point Dietitians role in the governments food conservation project January 1936 in London, UK

7 Dietetic Scope of Practice Now encompasses roles in Acute, ambulatory/outpatient, home care, and extended health care Business and communications Community and public health Entrepreneurial and private practice. Foodservice systems. Integrative and functional medicine. Military service. Management and leadership. Nutrition informatics Preventive care, wellness, and weight management. Research, Universities and other academic settings. School nutrition. Sports nutrition. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS June 2013 Suppl 2 Volume 113 Number 6

8 Changing work environments

9

10

11 Malnutrition in the Middle East 11

12 Nutrition Focused Physical Exam (NFPE) Included in the Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians Core competencies for dietetic students as per the American Accreditation Council for Education in Nutrition and Dietetics (ACEND) Component of the American Academy of Nutrition and Dietetics (AND) and American Society for Parenteral and Enteral Nutrition (ASPEN) Malnutrition Diagnosis Criteria 2012.

13 What is NFPE Systematic head-to-toe examination of a patient's physical appearance and function to help determine nutritional status by uncovering any signs of malnutrition, nutrient deficiencies, or nutrient toxicities.

14 J Acad Nutr Diet. 2012;112:

15 Malnutrition Diagnosis Criteria Clinical Characteristic Malnutrition in the context of acute chronic illness How do you diagnosis Malnutrition in your practice? Energy intake % of estimated energy needs Interpretation of weight loss Non-severe (moderate) malnutrition < 75% for >7days Illness/injury 1-2% in 1week 5% in 1m 7.5% in 3m Severe malnutrition 50% for >5days >2% in 1w >5% in 1m >7.5% in 3m Malnutrition in the context of Non-severe (moderate) malnutrition < 75% for >1month 5% in 1m 7.5% in 3m 10% in 6m 20% in 1 year Severe malnutrition 75% for >1month >5% in 1m >7.5% in 3m >10% in 6m > 20% in 1year Malnutrition in the context of social or environmental circumstances Non-severe (moderate) malnutrition < 75% for >3months 5% in 1m 7.5% in 3m 10% in 6m 20% in1year Severe malnutrition 50% for >1month >5% in 1m >7.5% in 3m >10% in 6m > 20% in 1year Physical Findings - Malnutrition typically results in changes to the physical exam. Body Fat - Loss of Mild Moderate Mild Severe Mild Severe subcutaneous fat Muscle Mass - Mild Moderate Mild Severe Mild Severe Muscle loss Fluid Accumulation Mild Moderate to Mild Severe Mild Severe severe Reduced Grip Strength Measurably reduced Measurably reduced Measurably reduced Academy/A.S.P.E.N. Clinical Characteristics that the RD can obtain and Document to Support a Diagnosis of Malnutrition.

16 High prevalence of Obesity in UAE European Journal of Clinical Nutrition (2011) 65, ;

17

18 Lean Tissue Imaging Imaging/x-ray attenuation: dual-energy x-ray absorptiometry (DXA) computerized tomography (CT) magnetic resonance imaging (MRI), quantitative magnetic resonance (QMR), quantitative computed tomography (QCT) ultrasound JPEN J Parenter Enteral Nutr. 2014;38:

19 Imaging Techniques JPEN J Parenter Enteral Nutr. 2014;38:

20 Use of CT to define Sacropenia Nutr Clin Pract. 2016;31:40-48

21 Modalities for determining LBM Nutr Clin Pract. 2017;32:20-29

22 Modalities for determining LBM Nutr Clin Pract. 2017;32:20-29

23 Determining LBM in the ICU Bedside ultrasound Need improvement of the ultrasound protocol needed to improve accuracy of determining low muscularity in ICU patients JPEN J Parenter Enteral Nutr. 2017;41:

24 ASPEN CNW 2017 Lean Body Mass (LBM) vs Weight

25 Using LBM.. 25

26 Competency Standards Figure 1 National competency standards and advanced APD competency standards Nutrition & Dietetics 2017; 74:

27 Systematic analysis of Extended Scope Nutrition & Dietetics 2017; 74:

28 Extended Scope of Practice Post-pyloric feeding tube placement in critically ill patients Dietitian trained to place Enteral feeding tubes with Electromagnetically guided technique Post training ~80% success rate placing tubes in average 11mins Yandell, R et (2017), Post-pyloric feeding tube placement in critically ill patients: Extending the scope of practice for Australian

29 Onwards and Upwards

30 Strategies to evolve your practice Reflect on your competencies and skills Self reflection 360degree review Analysis your population and workplace for opportunities Seek knowledge Implementation planning How can I apply my knowledge to my practice Peer learning and peer review Seek expertise Mentorship Strive do better for yourself and for those you work with!

31 Summary Continuous learning and improvement are fundamental traits of the dietetic profession. As the profession has evolved in the last 100 years it will continue to develop in the future to meet the needs of our changing population. Being able to assessment of body composition is vital to refining our ability to appropriately intervene and monitor nutrition support. Challenge yourself to seek new skills and implement evidenced based recommendations into your practice.

32 Further References The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: Revised 2012 standards of practice in nutrition care and standards of professional performance for registered dietitians. J Acad Nutr Diet. 2013;113:S29- S45. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):