Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists.

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.

Etiology Intervention Link Predicts Resolution of Nutrition Diagnosis: A Nutrition Care Process Outcomes Study from a Veterans' Health Care Facility.

In this article, we evaluate relationships between Nutrition Care Process (NCP) chain links and improvement or resolution of the nutrition diagnosis. We conducted a retrospective record review for 12 months in a single Veterans Health Administration health care system using the Veterans Health Administration-specific monitoring and evaluation terms, NCP terminology, and its etiology categories to evaluate outcomes. Logistic regression analysis revealed that the strongest predictor for diagnosis improvement was the etiology-intervention link. The odds of improving the nutrition diagnosis were 51.43 times higher when the etiology-intervention link was present. The odds of improving the nutrition diagnosis were 19.74 times higher when the evidence-diagnosis link was present and 9.46 times higher when the intervention-goal link was present. For every added nutrition visit by the registered dietitian nutritionist, the odds of improving the nutrition diagnosis increased by 32.5%. For every increased point on the NCP audit score, the odds of resolving or improving the nutrition diagnosis increased by 37.7%. When applying the NCP, the presence of the etiology-intervention link significantly improves the odds of resolving the nutrition diagnosis in a Veterans Health Administration population. For the first time, we show evidence that the NCP works as designed. Also, we demonstrate that the quality of NCP documentation impacts resolution of the diagnosis, and we describe the methodology for how to evaluate NCP outcomes. Registered dietitian nutritionists are encouraged to critically evaluate links of the NCP chain, assess NCP documentation for quality, and pursue follow-up visits to improve resolution of nutrition problems.

Evaluation of dietary supplement, functional food and herbal medicine use by dietitians during the COVID-19 pandemic.

OBJECTIVE: The current study was conducted to evaluate the dietary habits of the dietitians who had a leading role in this regard during the pandemic and their use of dietary supplements, functional food and herbal medicines. DESIGN: A cross-sectional study. An online questionnaire was used as a data collection tool to identify the participants' socio-demographic characteristics, health statuses and dietary habits and their use of dietary supplements, functional foods and herbal medicines. SETTING: Turkey. PARTICIPANTS: The study population was 550 dietitians. RESULTS: In the current study, the participants' average age was 30·6 ± 9·1 years, and most of them (88·2 %) were women. More than half of the participants (88·9 %) thought that adequate and balanced nutrition would positively affect the course of COVID-19. To avoid COVID-19, 94·5 % of the dietitians used dietary supplements, 46·1 % herbal medicines and 34·9 % functional foods during the pandemic. The most commonly used dietary supplement was fish oil (81·9 %), functional food was vegetables and fruits (80·5 %) and the herbal medicine was cinnamon (63·5 %). Women's consumption of functional foods was approximately twice higher compared with men (95 % Cl: 1·048, 4·165; P < 0·05). The findings showed that the longer the dietitians were in their careers, the more functional foods and herbal medicines they used. CONCLUSION: During the pandemic, dietitians' use of foods with protective effects against diseases increased depending on their academic knowledge and experience in nutrition. The findings obtained in the current study suggest that an expert's opinion should be obtained before using dietary supplements and herbal medicines.

Retail Nutrition Programs and Outcomes: An Evidence Analysis Center Scoping Review.

As nutrition-related diseases contribute to rising health care costs, food retail settings are providing a unique opportunity for registered dietitian nutritionists (RDNs) to address the nutritional needs of consumers. Food as Medicine interventions play a role in preventing and/or managing many chronic conditions that drive health care costs. The objective of this scoping review was to identify and characterize literature examining Food as Medicine interventions within food retail settings and across consumer demographics. An electronic literature search of 8 databases identified 11,404 relevant articles. Results from the searches were screened against inclusion criteria, and intervention effectiveness was assessed for the following outcomes: improvement in health outcomes and cost-effectiveness. One-hundred and eighty-six papers and 25 systematic reviews met inclusion criteria. Five categories surfaced as single interventions: prescription programs, incentive programs, medically tailored nutrition, path-to-purchase marketing, and personalized nutrition education. Multiple combinations of intervention categories, reporting of health outcomes (nutritional quality of shopping purchases, eating habits, biometric measures), and cost-effectiveness (store sales, health care dollar savings) also emerged. The intervention categories that produced both improved health outcomes and cost-effectiveness included a combination of incentive programs, personalized nutrition education, and path-to-purchase marketing. Food as Medicine interventions in the food retail setting can aid consumers in navigating health through diet and nutrition by encompassing the following strategic focus areas: promotion of health and well-being, managing chronic disease, and improving food security. Food retailers should consider the target population and desired focus areas and should engage registered dietitian nutritionists when developing Food as Medicine interventions.

Are Dietitians Documenting Malnutrition Based on Subjective Global Assessment Category?

Purpose: This study reports on dietitian use of the Nutrition Care Process Terminology (NCPT) diagnosis of malnutrition based on Subjective Global Assessment (SGA). Methods: Nutrition assessment reports for adults in medical, surgical, and cardiac units in 13 Canadian hospitals were retrospectively examined for a 6-week period in 2014. Reports with a SGA and NCPT diagnosis were included regardless of why the patient was seen by the dietitian. Results: Of the 932 nutrition assessment reports, 857 (92%) included an SGA. Based on SGA, the prevalence of mild to moderate malnutrition (SGA B) and severe malnutrition (SGA C) was 53.4% (n = 458) and 10.0% (n = 86), respectively. When categorized as severely malnourished, the most common NCPT diagnoses were "malnutrition" (n = 55, 72.4%), "inadequate oral intake" (n = 11, 14.5%), and "inadequate protein-energy intake" (n = 10,13.1%). Among those with SGA B and C, the assignment of the NCPT malnutrition diagnosis was 19.8% (n = 95). Conclusions: Dietitians play a key role in the prevention, identification, and treatment of malnutrition in the hospitalized patient and are well positioned to take a leadership role in improving its documentation. Ongoing audits, staff support, and training regarding NCPT use may improve the application of the malnutrition diagnosis. Future research examining dietitian barriers to using the malnutrition diagnosis would be valuable.

Dietetic Staffing and Workforce Capacity Planning in Primary Health Care.

The addition of Registered Dietitians (RD) to primary health care (PHC) teams has been shown to be effective in improving health and economic outcomes with reported savings of $5 to $99 New Zealand dollars for every $1 spent on nutrition interventions. Despite proven benefits, very few Canadians have access to dietitians in PHC. This paper summarizes the literature on dietetic staffing ratios in PHC in Canada and other countries with similar PHC systems. Examples are shared to demonstrate how dietitians and others can utilize published staffing ratios to review dietitian services within their settings, identify gaps, and advocate for additional positions to meet population needs. The majority of published dietetic staffing ratios describe ranges of 1 RD: 15 000-18 500 patients, 1 RD for every 4-14 family physicians, or 1 RD for every 300-500 patients with diabetes. These staffing ratios may be inadequate as surveys report ongoing issues of limited access to dietetic counseling, under-serviced populations, and a shortage of dietitians to meet current population needs in PHC. Newer projection models based on specific population needs and ongoing workforce data are required to identify professional practice issues and accurately estimate dietetic staffing requirements in PHC.

Sex and seasonal variations of plasma retinol, alpha-tocopherol, and carotenoid concentrations in Japanese dietitians.

AIM: To clarify sex and seasonal variations of plasma antioxidant concentrations among middle-aged Japanese. SUBJECTS AND METHODS: We investigated sex and seasonal variations of plasma antioxidant concentrations, including retinol, alpha-tocopherol, and carotenoids (alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein and lycopene), in 55 middle-aged dietitians (46 women and 9 men) in Aichi Prefecture, Central Japan, who took no supplements from autumn 1996 to summer 1997. Reversed-phase high performance liquid chromatography was used to measure plasma antioxidant concentrations in overnight-fasting blood samples. RESULTS: Plasma levels of alpha-tocopherol, alpha-/beta-carotene, b-cryptoxanthin and lutein were significantly influenced by sex, being significantly higher for women than men in each corresponding season; retinol and lycopene, however, showed no such difference. For women, winter values of alpha-tocopherol, alpha-/beta-carotene, lutein and lycopene were significantly lower than corresponding summer values, and had reached their annual lowest. Retinol failed to show any significant seasonal variation, whereas the winter value of beta-cryptoxanthin had reached its annual highest. For men, beta-cryptoxanthin exhibited significant seasonal changes and was also highest in winter. Winter values of alpha-tocopherol, alpha-/beta-carotene and lycopene were lower compared with other seasons, but not statistically significant, probably due to the small sample size. CONCLUSIONS: The findings indicate that sex and seasonal variations of plasma antioxidant concentrations should be taken into account in nutritional epidemiologic studies.

Registered dietitian prescriptive practices in hospitals.

The objective of this cross-sectional study was to describe the level of prescriptive authority and explore barriers to obtaining prescriptive authority of registered dietitians in acute health care facilities. A sample of 1,500 clinical nutrition managers was electronically surveyed; data from 351 respondents (23% response rate) were analyzed using descriptive statistics and chi(2) tests. Many (54%) respondents reported no prescriptive authority, 36% reported dependent prescriptive authority, and 10% reported independent prescriptive authority. Most (95%) respondents with no prescriptive authority and (89%) with dependent prescriptive authority valued independent prescriptive authority. The two most commonly listed barriers to independent prescriptive authority were opposition (52% no prescriptive authority, 48% dependent prescriptive authority) and liability (40% no prescriptive authority, 48% dependent prescriptive authority). Forty-five percent of respondents with independent prescriptive authority reported the route to independent prescriptive authority was via clinical privileges. Based on the responses of this sample, the authors conclude the majority of respondents do not have, but value, independent prescriptive authority. The issue of liability as a barrier to independent prescriptive authority might need further study to determine reasons why liability is perceived as a barrier to independent prescriptive authority.

Herbs and other dietary supplements: healthcare professionals' knowledge, attitudes, and practices.

CONTEXT: Herbs and other dietary supplements (H/DS) are frequently used by the public. They have significant health implications, yet little is known about health professionals' knowledge, attitudes, or clinical practices related to H/DS. DESIGN: Cross-sectional survey of clinicians prior to participation in an Internet-based educational program on herbs and dietary supplements. PARTICIPANTS: The 537 participants included 111 physicians (MD), 30 advanced practice nurses (RN), 46 pharmacists (PharmD), and 350 dietitians (RD). In addition to demographic information, participants were asked about their knowledge, attitudes, and practices related to H/DS. RESULTS: Most participants were involved in direct patient care (85%), in practice or on faculty (84%), and from outside our local institutions (76%); 66% reported receiving professional education about H/DS in the past year. There were statistically significant differences between professional groups, with RDs scoring better than others, but even their average scores were less than 60% of possible. The average score on knowledge questions was 10/20; the average confidence score was 4 out of 10 possible, and the average communication score was 1.4 out of 4 possible. Most respondents knew the most common clinical uses of echinacea and St. John's wort, and felt confident that they knew more than their colleagues about H/DS. Key deficits were in knowledge about adverse effects, confidence in reporting side effects, routinely communicating with patients about H/DS, and recording H/DS information in the medical record. CONCLUSIONS: Despite significant interest and previous training in H/DS, these clinicians had substantial room for improvement in knowledge, attitudes, and clinical practices about H/DS. Educational interventions and institutional policies are needed to improve the quality of patient care regarding H/DS, and such interventions should be rigorously evaluated to ensure that continuous improvements occur.

Treatment of child and adolescent obesity: reports from pediatricians, pediatric nurse practitioners, and registered dietitians.

OBJECTIVE: The primary aim of this study was to identify interventions used by pediatric health care providers in treatment of overweight children and adolescents to identify provider educational needs. A secondary aim was to examine the association of certain provider characteristics with recommended evaluation practices. STUDY DESIGN: A random sample of pediatricians, pediatric nurse practitioners, and registered dietitians (RDs) received questionnaires about their diet, activity, and medication recommendations for overweight patients and about referrals to specialists and programs. Results were examined for adherence to published recommendations and for associations with certain respondent characteristics. RESULTS: A total of 940 providers responded (response rate: 19%-33%). The majority recommended "changes in eating patterns" and "limitations of specific foods." Half or more used "low-fat diet" and "modest calorie restriction" in adolescents. Less than 15% used "very low-calorie diet." Fewer RDs recommended more restrictive diets. More than 60% of all groups followed recommended eating interventions for school-aged children and adolescents. More than 80% followed recommended physical activity interventions for all age groups. In each group, about 5% sometimes recommended prescription medication and herbal remedies for adolescents. None recommended surgery. Two thirds of pediatricians and pediatric nurse practitioners often referred to RDs. Approximately 20% referred to child/adolescent weight programs, but for 27% to 42%, these programs or pediatric obesity specialists were not available. No consistent associations between respondent characteristics and adherence to recommended interventions were identified. CONCLUSIONS: The providers generally promoted healthy eating and activity with minimal use of highly restrictive diets or medication to control weight.

Ethical issues in nutritional sciences for the next century: nutrition research and counseling of nutraceutical supplementation and disease

Ethical issues pertaining research and counseling in nutritional sciences will be arising in this new century. This issue will be of great importance especially in the area of nutraceutical supplementation and disease (pharmacological nutrition). Steps to insure bioethical correctness are discussed in this paper.

Physician and dietitian prescribing of a commercially available oral nutritional supplement.

We examined whether a policy change transferring prescribing privileges for oral nutritional supplements to dietitians resulted in fewer inappropriate outpatient prescriptions. This was a pre/post study design using a retrospective review of physician and dietitian prescribing for ambulatory patients during two separate time periods: physician prescribing, October to December, 1994; dietitian prescribing, April to June, 1995. Inappropriate prescriptions during each period were defined as those given to patients with normal nutritional status or with a contraindication to a high-energy, electrolyte-containing solution. The study was conducted in outpatient clinics at a Veterans Affairs teaching hospital. We found that dietitians gave fewer prescriptions to outpatients who were not malnourished or to outpatients who had a contraindication to receiving a supplement (11% vs 34%; P = 0.002). In addition, dietitians more often completed relevant laboratory assessments (75% vs 43%; P = 0.001) and more frequently arranged follow-up dietetic evaluations (84% vs 30%, P < 0.001) for ambulatory patients receiving supplements. We conclude that transferring nutritional supplement prescribing privileges to dietitians led to fewer inappropriate outpatient prescriptions and to more comprehensive nutritional assessments, as measured by relevant laboratory use and dietetic follow-up. Physicians more frequently prescribed supplements to outpatients who were not malnourished or who had contraindications to receiving supplements. Our results suggest that physicians would benefit from assistance with and/or education concerning oral nutritional supplements.

Decision making in health care institutions: the health care practice paradigm.

Based on research reported in the health care literature, this paper adapts Blake and Mouton's (1985) two dimensional Managerial Grid to develop a model called the Health Care Practice Paradigm. The paradigm postulates two primary dimensions to represent the behavior of health care providers and practitioners: (1) patient orientation and (2) task orientation. To illustrate the usefulness of this approach, a study of the decision making processes of dietitians with respect to a new product was conducted. Based on a national sample of dietitians, the findings suggest that health care orientation of the dietitians is a better predictor of attitudes toward trying a new product than traditional demographic factors such as hospital size. Key implications for health care providers targeting new products toward hospitals and other health care institutions are highlighted.