US neonatal intensive care unit registered dietitian nutritionists salary description and correlates: results of a survey.

BACKGROUND: This survey described the compensation of neonatal intensive care unit (NICU) registered dietitian nutritionists (RDNs) in the United States and examined correlates of higher salaries within this group. METHODS: A cross-sectional online survey was completed in 2021 by 143 NICU RDNs from 127 US hospitals who reported hourly wage in US dollars (USD). We used initial bivariate analyses to assess the relationship of selected institution-level and individual-level variables to hourly wage; the rank-sum test for binary variables; bivariate regression and Pearson correlation coefficients for continuous variables; the Kruskal-Wallis test for categorical variables. Variables with a compelling relationship to the hourly wage outcome were considered in model creation. Final model selection was based on comparisons of model fit. RESULTS: Median hourly compensation was USD 33.24 (interquartile range [IQR] 29.81, 38.49). Seven variables had a compelling bivariate relationship with hourly wage: cost of living, employer facility with a paediatric residency, employer facility with a neonatal fellowship, NICU bed: full-time equivalents (FTE) RDN ratio, years in neonatal nutrition, having a certification and order writing privileges. In the final adjusted model (R2 = 0.42), three variables remained associated with increased hourly wage: higher cost of living, longer length of career in neonatal nutrition and fewer NICU beds per NICU RDN FTE. CONCLUSIONS: US NICU RDNs earn similar or slightly higher wages than other US paediatric RDNs; they earn substantially less than other NICU healthcare team members. Employers need to improve compensation for NICU RDNs to incentivise their retention and recognise their additional non-clinical responsibilities.

Preliminary content and construct validity of a new model to differentiate research skills from evidence-based practice skills: Core, Evidence Application, Research (CEAR) Model.

BACKGROUND: Research is the scientific basis for the profession of dietetics, as it must be located and applied in evidence-based practice (EBP). EBP is often presented as a foundational skill for research. CEAR - Core, Evidence Application, Research - is a newly proposed model that separates Research and Evidence Application skills into distinct domains, jointly supported by a set of Core skills, thus acknowledging that education and advancement in one domain neither requires nor precipitates education and advancement in the other. The goal was to investigate the content and construct validity of the new CEAR Model. METHODS: A cross-sectional online survey of randomly selected dietitians in the United States was used to collect CEAR domain scores, validated measures of research or EBP skills and self-reported characteristics. Exploratory factor analysis, Cronbach's α and Pearson correlation between various tools and CEAR domains were used to assess validity and reliability. Analysis of variance (ANOVA) and multiple linear regression between CEAR domains and participant characteristics were used to assess convergent and divergent validity. RESULTS: One hundred and fifty-four responses with a valid CEAR score were received and led to a three-factor solution, supporting the theorised differentiation of research from evidence application skills (content validity). Internal reliability for the CEAR Model overall and for each domain was high. The hypothesised correlations between existing research or EBP measurement tools and the relevant CEAR domains were found (construct validity). Known groups analysis demonstrated the expected differences in CEAR domain scores based on participant characteristics. CONCLUSIONS: The CEAR Model demonstrates preliminary validity and internal reliability. It adds to the current literature by acknowledging the separateness of evidence application skills from research skills.

The Role of the Neonatal Registered Dietitian Nutritionist: Past, Present, and Future.

Neonatal registered dietitian nutritionists (RDNs) are critical members of the neonatal intensive care unit (NICU) team due to their unique skillset of growth assessment, nutrition evaluation, and implementation of nutrition best practices. There is a paucity of data on appropriate staffing of neonatal RDNs in NICUs to promote improved patient outcomes. Here, the authors describe current neonatal RDN staffing and responsibilities in the US NICUs.

Interleukin-11 disrupts alveolar epithelial progenitor function.

Background: Interleukin-11 (IL-11) is linked to the pathogenesis of idiopathic pulmonary fibrosis (IPF), since IL-11 induces myofibroblast differentiation and stimulates their excessive collagen deposition in the lung. In IPF there is disrupted alveolar structural architecture, yet the effect of IL-11 on the dysregulated alveolar repair remains to be elucidated. Methods: We hypothesised that epithelial-fibroblast communication associated with lung repair is disrupted by IL-11. Thus, we studied whether IL-11 affects the repair responses of alveolar lung epithelium using mouse lung organoids and precision-cut lung slices (PCLS). Additionally, we assessed the anatomical distribution of IL-11 and IL-11 receptor (IL-11R) in human control and IPF lungs using immunohistochemistry. Results: IL-11 protein was observed in airway epithelium, macrophages and in IPF lungs, also in areas of alveolar type 2 (AT2) cell hyperplasia. IL-11R staining was predominantly present in smooth muscle and macrophages. In mouse organoid co-cultures of epithelial cells with lung fibroblasts, IL-11 decreased organoid number and reduced the fraction of Prosurfactant Protein C-expressing organoids, indicating dysfunctional regeneration initiated by epithelial progenitors. In mouse PCLS exposed to IL-11, ciliated cell markers were increased. The response of primary human fibroblasts to IL-11 on gene expression level was minimal, though bulk RNA-sequencing revealed IL-11 modulated various processes which are associated with IPF, including unfolded protein response, glycolysis and Notch signalling. Conclusions: IL-11 disrupts alveolar epithelial regeneration by inhibiting progenitor activation and suppressing the formation of mature alveolar epithelial cells. Evidence for a contribution of dysregulated fibroblast-epithelial communication to this process is limited.

Survey tools for measuring research or evidence-based practice constructs in dietetics: A narrative review.

BACKGROUND: Exact quantification of research conducted by dietitians and tracking the effectiveness of interventions or training programs to increase either evidence-based practice (EBP) or research behaviours have been hampered by the variety of tools used to measure these constructs. METHODS: In this narrative review, we identified and classified the various tools previously used to measure constructs related to research and/or EBP in the dietetics profession, and to summarise estimates of the constructs measured. RESULTS: We identified and classified 15 scored tools that had been used at least once in the dietetics profession and extracted tool parameter estimates from 22 resulting papers. We also identified six unscored tools and three qualitative studies. The most frequent constructs measured were attitudes and behaviours. Very few tools measured objective knowledge (skills). No objective measures of research outputs were identified. Several tools were closely related to one another. CONCLUSIONS: Even when tools were used across multiple papers, reporting method varied making comparisons difficult. This review should encourage future researchers to utilise existing tools when possible, and encourage the development or adaptation and testing of tools that fill identified gaps. The constructs measured by the tools identified may also provide a starting point for the development of educational interventions aiming to increase research or EBP skills among dietitians. Only by using consistent tools will the dietetics profession be able to track the progress in increasing research conduct and EBP implementation over time.

Academy of Nutrition and Dietetics Nutrition Research Network: Rationale and Protocol for a Study to Validate the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus-Derived Diagnostic Indicators For Adult And Pediatric Malnutrition and to Determine Optimal Registered Dietitian Nutritionist Staffing in Acute Care Hospital Settings.

No systematic, universally accepted method of diagnosing malnutrition in hospitalized patients exists, which may contribute to underdiagnosis, undertreatment, and poorer patient outcomes. To address this issue, the Academy of Nutrition and Dietetics is conducting a cohort study to: assess the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators for the diagnosis of adult and pediatric malnutrition in hospital settings; assess the interrater reliability of the indicators for the diagnosis of adult and pediatric malnutrition; and quantify the level of registered dietitian nutritionist care needed to improve patient outcomes. Up to 60 adult and 60 pediatric hospital sites will collect data to estimate level of registered dietitian nutritionist care, along with patient medical history and Malnutrition Screening Tool (adult) or STRONGkids (pediatric) results. A subset of 600 adult and 600 pediatric patients (∼1:1 screened as high- or low-risk for malnutrition) will be randomly selected for the indicators for the diagnosis of adult and pediatric malnutrition and Nutrition Focused Physical Exam data collection; 100 adult and 100 pediatric patients in this group will also undergo a bioelectrical impedance analysis measurement. Additional nutrition care and medical outcomes (eg, mortality and length of stay) will be collected for a 3-month period after the initial nutrition encounter. Multilevel linear, logistic, Poisson, or Cox regression models will be used to assess indicators for the diagnosis of adult and pediatric malnutrition validity and registered dietitian nutritionist staffing levels as appropriate for each medical outcome. Validation results will allow US clinicians to standardize the way they diagnose malnutrition in hospitalized patients, and the staffing data will support advocacy for available registered dietitian nutritionist-delivered malnutrition treatment to improve patient outcomes.

Changes in US Dialysis Dietitian Responsibilities and Patient Needs During the COVID-19 Pandemic.

OBJECTIVE: This study described the job responsibilities and modalities of care among dialysis dietitians in the United States and their observations regarding the nutrition needs of their patients, during the COVID-19 pandemic. DESIGN AND METHODS: Cross-sectional online survey captures dietitian characteristics and responsibilities, dialysis facility characteristics, and patient needs. We recruited US dialysis dietitians. We used chi-square tests to compare respondent stress and facility-level policies regarding eating/drinking and oral nutrition supplements based on facility ownership type. RESULTS: We received 191 complete or partial survey responses. Sixty-three percent of respondents stated that their center banned eating/drinking during dialysis due to COVID-19 masking policies. DaVita and non-profit facilities were significantly more likely to still allow eating/drinking during dialysis (31% and 29%, respectively) compared to Fresenius facilities (7%). A common theme in open-ended responses regarding nutrition care for COVID-19-positive patients was providing less care to these patients. A majority of respondents admitted to stress from working in healthcare during COVID-19. The majority of respondents indicated that patients were taking precautions such as having a family member or friend grocery shop for them (69%) or going to the store less often (60%). Just over a quarter of respondents indicated that affordability of food was a concern among patients. Seventy-two percent reported that patients were cooking at home more often, 60% had observed an increase in serum phosphorus, and 72% an increase in interdialytic weight gain. CONCLUSIONS: Due to the increased risk of malnutrition and symptoms that can affect dietary intake in COVID-positive patients, and the economic conditions leading to increased rates of food insecurity, dietitians must be proactive in preventing and/or treating malnutrition through adequate protein and energy intake. Eating/drinking bans should not become permanent and dialysis centers should take precautions to allow intradialytic meals and oral nutrition supplement protocols to continue during the pandemic.

Workforce needs and estimated costs/savings for nutrition care in chronic kidney disease-stage 3 through maintenance dialysis.

The role of nutrition in chronic kidney disease (CKD) is well known. However, controversies, misconceptions, and gaps in the literature exist regarding the workforce required to provide nutrition care in CKD. This paper reviews the existing literature on this topic, focusing primarily on the United States. Topics covered in this review include the qualifications and services of the registered dietitian nutritionist (RDN), to which specific patients nutrition care should be provided in CKD and on dialysis, barriers to the utilization of nutrition services, the quantity of nutrition care needed to improve patient outcomes, and the risks of provider burnout. Controversies include whether more staffing is associated with better care and the best measures of staffing. The topics are supported with estimations for the economic impact and practicality of workforce decisions.

Therapeutic Targeting of IL-11 for Chronic Lung Disease.

Interleukin (IL)-11 was originally recognized as an immunomodulatory and hematopoiesis-inducing cytokine. However, although IL-11 is typically not found in healthy individuals, it is now becoming evident that IL-11 may play a role in diverse pulmonary conditions, including IPF, asthma, and lung cancer. Additionally, experimental strategies targeting IL-11, such as humanized antibodies, have recently been developed, revealing the therapeutic potential of IL-11. Thus, further insight into the underlying mechanisms of IL-11 in lung disease may lead to the ability to interfere with pathological conditions that have a clear need for disease-modifying treatments, such as IPF. In this review, we outline the effects, expression, signaling, and crosstalk of IL-11 and focus on its role in lung disease and its potential as a therapeutic target.

Impact of Diabetes Prevention Guideline Adoption on Health Outcomes: A Pragmatic Implementation Trial.

Limited research exists to evaluate nutrition guideline impact on clinical practice and patient health outcomes. In this study we investigate (1) the impact of guideline training on the implementation of the diabetes prevention Evidence-Based Nutrition Practice Guideline (EBNPG), and (2) the relationship between EBNPG congruence and resulting health outcomes in patients with prediabetes. We conducted an implementation study in which registered dietitian nutritionists (RDNs) provided nutrition care with 3-month follow-up to 102 pre-diabetes patients before and after a professional training on the implementation of the Diabetes Prevention EBNPG. Using the RDNs' Nutrition Care Process (NCP) documentation, we measured percent guideline congruence and health outcomes (body weight, waist circumference, fasting glucose, glycosylated hemoglobin), and modeled health outcomes. Guideline congruence improved after training by 4.3% (P < 0.05). However, no significant associations were observed between guideline training, or guideline congruence and health outcomes. Our model showed a reduction in waist circumference (2.1 ± 0.92 cm; P = 0.023), and body weight (-1.78 ± 0.55 kg; P = 0.001) throughout the course of the study. Training of nutrition professionals improved congruence to EBNPG for Diabetes Prevention. Nevertheless, improved guideline congruence did not impact related health outcomes. Standard care including nutrition intervention resulted in body weight and waist circumference reductions. Future research needs to further address the impact of evidence-based guidelines on outcomes in all areas of practice.

Registered Dietitian Staffing in Dialysis: Impact on Quality Ratings in Mandate and Nonmandate States.

OBJECTIVE: Texas is the only state to mandate a patient to full-time equivalent (FTE) registered dietitian (RD) ratio (<125 patients:FTE RD) in dialysis. Little research exists about the relationship between patient:FTE RD ratio and quality. Our objectives were to a) examine the effect of the mandate on patient:FTE RD ratios in Texas facilities compared to similar nonmandated facilities and b) examine the association between patient:FTE RD ratio and the patient rating of staff quality or star rating of the facility. DESIGN AND METHODS: Using data from Dialysis Facility Annual Reports, we excluded facilities with less than 125 patients and matched based on region, chain/profit status, and number of patients, pairing each Texas facility with 2 non-Texas facilities. T-tests for difference of means and chi-square tests were performed to compare facility groups characteristics and assess mandate impact. We used correlation between patient:FTE RD ratio and staff quality linearized score, and ANOVA to compare patient:FTE RD ratios between the star rating levels. RESULTS: The patient:FTE RD ratio was higher in non-Texas than Texas facilities (111.84 ± 40.70 vs 90.80 ± 24.02, P < .01). The Pearson correlation between patient:FTE RD ratio and linearized score rating of the dialysis center staff was essentially nonexistent (r = -0.046). We found a trend of higher patient:FTE RD ratios in facilities with lower star ratings for quality and staff but no statistical significance. CONCLUSION: The mandate effectively lowered the patient:FTE RD ratio in Texas dialysis facilities with over 125 patients, indicating that states considering such a mandate may benefit from implementing it. We found no association between patient:FTE RD staffing and quality, either objectively or via patient assessment. Further research should examine whether dialysis facilities are trending toward smaller patient sizes to circumvent staffing mandates and examine the relationship between other professions' staffing ratios and quality.

TGF-ß activation impairs fibroblast ability to support adult lung epithelial progenitor cell organoid formation.

Transforming growth factor-ß (TGF-ß)-induced fibroblast-to-myofibroblast differentiation contributes to remodeling in chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis, but whether this impacts the ability of fibroblasts to support lung epithelial repair remains little explored. We pretreated human lung fibroblasts [primary (phFB) or MRC5 cells] with recombinant human TGF-ß to induce myofibroblast differentiation, then cocultured them with adult mouse lung epithelial cell adhesion molecule-positive cells (EpCAM+) to investigate their capacity to support epithelial organoid formation in vitro. While control phFB and MRC5 lung fibroblasts supported organoid formation of mouse EpCAM+ cells, TGF-ß pretreatment of both phFB and MRC5 impaired organoid-supporting ability. We performed RNA sequencing of TGF-ß-treated phFB, which revealed altered expression of key Wnt signaling pathway components and Wnt/ß-catenin target genes, and modulated expression of secreted factors involved in mesenchymal-epithelial signaling. TGF-ß profoundly skewed the transcriptional program induced by the Wnt/ß-catenin activator CHIR99021. Supplementing organoid culture media recombinant hepatocyte growth factor or fibroblast growth factor 7 promoted organoid formation when using TGF-ß pretreated fibroblasts. In conclusion, TGF-ß-induced myofibroblast differentiation results in Wnt/ß-catenin pathway skewing and impairs fibroblast ability to support epithelial repair likely through multiple mechanisms, including modulation of secreted growth factors.

Quantifying the Time Used for Renal Dietitian's Responsibilities: A Pilot Study.

OBJECTIVE: The purpose of this study was to quantify how dialysis dietitians spend their time and whether the activities that were most frequent varied based on the ratio of patient to full-time equivalent (FTE) dietitian. METHODS: This study is a cross-sectional, observational, time-and-motion study carried out using the Work Activity Measurement by Activity Timing software/method for time recording. This study was carried out in 14 dialysis centers in and around Cleveland, Ohio. Fourteen registered dietitian nutritionists participated in this study. The mean time/experience of these nutritionists in dietetics was 26.6 ± 8.5 years. Percent of time in direct care (e.g., patient interaction) versus indirect care (e.g., documentation and plans of care, professional communication) versus other responsibilities (e.g., administrative work, education of self or others). RESULTS: The mean number of tasks recorded per 3-hour observation session was 38.3 ± 14.0, including 18.5 ± 7.7 indirect care tasks, 7.7 ± 6.2 direct care tasks, and 9.7 ± 5.4 other tasks. The mean number of unique patients seen per observation session was 6.9 ± 5.4; the mean direct care time per patient encounter was 6.95 ± 4.05 minutes. Indirect care took the highest proportion of observed time, 56.0 ± 22.2%, followed by direct care, 24.9 ± 18.8%. Increasing the ratio of patient to FTE had a moderate negative correlation with the percent of time spent in direct patient care (r = -0.35, P = .21), but there was no relationship between the ratio of patient to FTE and direct care time per patient (r = 0.02, P = .94). CONCLUSION: About 25% of dietitians' time was available for direct patient care. This is much less than that reported in previous studies and may not be sufficient to improve the nutritional status. Limitations of our study include a small sample size from a single region. Further work is needed to understand the balance of responsibilities among renal dietitians and their impact on patient outcomes.