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Chair Update . . . . . . . . . . . . . . . . . . . . . . . . . .3

Membership! . . . . . . . . . . . . . . . . . . . . . . . . . .6

More Efficient Delivery of NutritionTherapy Expected with CMS Ruling 42CRF §482.28 . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Feedback Request: ASCEND newEducation Model . . . . . . . . . . . . . . . . . . . . .8

“NCP Corner – HIV” . . . . . . . . . . . . . . . . . . . .9

Back to the Future™: Steering the Way toa Desirable Destination for Nutrition andDietetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Recognition of a DHCC DPG Member by the Academy’s Council onFuture Practice . . . . . . . . . . . . . . . . . . . . . . .16

BEYOND BORDERS: A Vision on DieteticsEducation, Credentials, and Practice . . .17

2014 Public Policy A Success Story . . . .19

News from HOD . . . . . . . . . . . . . . . . . . . . . .21

DHCC Member Awards . . . . . . . . . . . . . . .22

2015 Election Results . . . . . . . . . . . . . . . . .23

Supported, in part, through a restrictededucational grant from Abbott Nutrition,a division of Abbott Laboratories, Inc.

Flavonoids for Health by Christine Rosenbloom, PhD, RDN, CSSD and Sarah Romotsky, RDN

IntroductionRegistered dietitian nutritionists (RDNs) working with community care clientsalready know that fruits and vegetables are good for their clients, but there may beeven more reason to encourage clients to make these foods a part of theireveryday diet. These foods contain flavonoids, a large and diverse group ofcompounds naturally present in a variety of plant-based foods; emerging sciencesupports that their consumption is associated with a range of health benefits.However, recent consumer research reveals low awareness of these potentiallybeneficial compounds. The 2014 IFIC Foundation Food & Health Survey, an onlinesurvey of 1,005 Americans (ages 18-80 years) on issues of food and health, foundthat there is a lack of knowledge of the health benefits associated with diets rich inflavonoids. For example, 78% of survey participants recognized that whole grainspromote heart health, yet only 11% identified flavonoids as heart healthy (1). In a2013 survey on functional foods, individuals identified fruits and vegetables as thetop foods with health benefits, yet when asked about flavonoids almost 60% saythey are not sure they are getting enough to reap the health benefits and out ofthat 60%, 31% of those are above the age of 65 (2).

What are Flavonoids?In the early 1930s, scientists identified and isolated a new compound they called“Vitamin P.” As research advanced, it was clear that this substance was not a vitaminin the classically defined sense, but a unique phytonutrient, a plant-based bioactive(3). Since this time, our knowledge of these plant compounds, also known asphytonutrients has grown substantially. Today, a range of phytonutrients havebeen identified, including a specific group known as flavonoids.

Flavonoids are one of the most common and largest group of phytonutrients foundin the diet and to date, more than 4000 varieties of flavonoids have been identified(3). Flavonoids share a common chemical structure, and in the context of thehuman diet, can be divided into 6 primary sub-classes: flavonols, flavones,flavanones, flavan-3-ols (or flavanols, as simple forms and more complex chainsknown as proanthocyanidins), isoflavones, and anthocyanidins. Though thesesubclasses share common structural features, each class has unique chemical andbiological properties, thus it is important not only to know that a food or beveragecontains flavonoids, but to have information about the forms of these flavonoidsnaturally present in foods. To help examine and characterize the flavonoids in thetypical diet, the United States Department of Agriculture (USDA) has created

ConnectionsVolume 40 • Issue 3 • Winter 2015

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This Symboldenotes thatCPEU credit

is available for the article. Go to www.dhccdpg.orgto take the quiz.

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several comprehensive databases of flavonoids and all of these databases are open access, providing a detailed view ofsome of the most common flavonoid-containing foods in the human diet (4,5,6). As evidenced from these databases,flavonoids are found in a variety of foods including fruits, vegetables, spices, herbs, teas, and even cocoa. Table 1 identifiesthe major classes of dietary flavonoids and some common food sources.

The Health Benefits of Flavonoid IntakeEpidemiological evidence strongly supports that the consumption of at least five servings of fruits and vegetables a day isassociated with lower risk of mortality from a variety of causes (7, 8). While the mechanisms underlying these benefits arenot fully understood, it may be in part due to the flavonoids commonly found in these foods (7, 8). Many studies haveshown that the consumption of higher levels of flavonoids is associated with a range of benefits to human health,including a lower risk of cardiovascular disease mortality and stroke (9, 10).

In the context of a healthy diet, the consumption of flavonoid-rich foods may confer a range of benefits. While the ways inflavonoids may exert their effects on health are still being investigated, there is evidence that flavonoids have anti-bacterial and anti-viral activities, help to reduce inflammation, can improve vascular function, can help reduce bloodpressure, can improve insulin sensitivity, and may even have chemoprotective effects. (3

There is emerging evidence that supports that the consumption of a range of flavonoid-rich foods may also be good foryour brain. Emerging research suggests that flavonoids, specifically those found in berries, may be associated with areduced prevalence of cognitive decline in older adults (11). Between 1995 and 2001, researchers measured cognitivefunction in women in the Nurses’ Health Study to obtain baseline and serial information on maintaining cognitive functionor cognitive decline in the study participants. In 2012, researchers invited women in the Nurses’ Health Study who were>70 years and free of stroke to participate in a telephone study of cognitive function. Using 6 cognitive tests and a 61-itemfood frequency questionnaire, researchers were looking for relationships between dietary intake and cognitive decline.After adjusting for age and income, researchers found that the women with the highest intake of flavonoid-rich berrieshad the slowest rate of cognitive decline. They also found that higher total flavonoid intake was associated with slowerrates of cognitive decline for all the primary outcome measures (11). In addition to berries, frequently consumedflavonoid-rich foods in the women included tea, apples, oranges and onions. The authors believe that a simple publichealth measure of encouraging a flavonoid-rich diet could impact cognitive decline in older women (11).

Fitting Flavonoids into the DietWhile data regarding the potential benefits associated with flavonoids continues to emerge, currently, there are noDietary Reference Intakes (DRI) for flavonoids. Unlike vitamins and minerals, flavonoids do not appear to be essentialnutrients, and as such, are not required to be reported on a product’s Nutrition Facts Panel (12). However, some products,like tea, voluntarily list the amount of flavonoids (or specific sub-class of flavonoids) in the product. So while there is nospecific dietary recommendation regarding the amount of flavonoids to consume daily, by simply encouraging clients toincorporate a variety of flavonoid-rich plant-based foods into their diet, they will not only be getting important vitamins,minerals, and fiber, but also a range of flavonoids that may help to support their health.

As an RDN, helping your clients incorporate flavonoid-rich foods into their diet may depend on the setting in which youwork. For food service, it may be helpful to serve some of the major sources of flavonoids consumed by adults which aretea, citrus fruits and 100% juices (13). Adhering to the Dietary Guidelines is also an easy way to ensure your clients areconsuming flavonoids. Americans consume less than 50% of the recommended intake of fruit and <60% of therecommendation for vegetables (14). The Dietary Guidelines for Americans encourages Americans to make half their platefruits and vegetables with an emphasis on dark green, red and orange vegetables. Citrus fruits, berries, apples, and evencabbage can be particularly rich in flavonoids and can be integrated into a variety of hot and cold dishes. The use of herbsand spices should not be overlooked as a significant contributor to flavonoid intake. The simple addition of spices andherbs like parsley, oregano, and cinnamon can add flavor and flavonoids to your clients’ meals. Finally, both black andgreen tea and dark chocolate are also sources of flavonoids that your clients may enjoy. Given their abundance in plant-based foods, it is not difficult to increase the level of flavonoids in the diet. By simply making small changes in the diet,

Flavonoids for Health continued from page 1

WINTER 2015 CONNECTIONS - PAGE 3

Thanks to DHCC members for making 2014 FNCE inAtlanta, Georgia a huge success!

Thanks to all of our sponsors for the PreFNCE conferenceand the reception:

Abbott NutritionBlue BunnyGeneral MillsGOJO IndustriesLemon-XMerchants FoodserviceNutricia North AmericaNutrition SystemsProvide NutritionPurchasing AllianceSimplified Nutrition Online (SNO)Sysco Thrive Frozen Nutrition, LLC.Wells Blue Bunny

Membership: DHCC added 13 new members duringFNCE. The Membership Committee conducted amembership recruitment program in which members whorecruited new members were entered into a drawing for anI-pad mini. The drawing was held at the pre-FNCEconference. Congratulations Carol Casey!

Resources: The Professional Development committeeintroduced the updated Inservice Manual available as adownload resource. Visit the DHCC website for moreinformation.

CMS Meeting: The Region IV office of CMS is in Atlantaand we invited CMS. We welcomed Angela Williams, RN,who provided an update on survey trends around Diningpractices. The presentation is posted on the DHCC websitein the member-only section, click on resource tab andRegulatory resources.

Sub-Unit: DHCC also introduced the revised sub-unit.Home Care sub-unit has been changed to Transitional Caresub-unit to better reflect the current practice area.

I attended a round-table discussion regarding orderwriting privileges for the RDN. The Federal Register Final

Rule effective July 11, 2014 (http://www.gpo.gov:80/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf) only applies tothe hospital setting but the Academy continues to workwith Centers for Medicare & Medicaid Services (CMS) onextending this authority to RDNs working in long-termcare. This rule is not an automatic green light for RDNs tostart writing orders, the decision is made by each hospital.The rule is a change in a federal regulation and eachhealthcare facility is governed by state rules, statutes andregulations as well as licensure/state practice laws. TheAcademy has researched state legal and regulatoryrequirements and posted the information athttp://www.eatright.org/dietorders/statestatus/. Inaddition, the hospital may require the RDN to obtainprivileges or may require a change in policy or bylawsbefore the RDN can write orders independently. For moreinformation, review the Practice Tips available athttp://www.eatright.org/dietorders/

There are a few things to consider in the long term caresetting that are a challenge. The rule change was based onsaving healthcare dollars and providing timely care.Outcome studies from the hospital setting were providedand this supporting information is lacking in long termcare. Also, many facilities do not have a full-time RDN onstaff which limits the availability of the RDN to write diet orsupplement orders for all residents. It is important torecognize the difference in order scripting and orderwriting. Scripting is writing an order that must be co-signed by physician or other practitioner. Order writing isthe privilege of writing the order without further approval.

NEW YEAR, NEW RESOURCESNow that FNCE tasks are complete, a new project isplanned for the remaining months of my chair term. DHCCwill be enhancing the Member Resource Section of thewebsite. The initial additions will be in BusinessManagement Basics. If you have resources or requests,send them to me. I hope everyone has a wonderful 2015!

Chair Updateby Lisa Eckstein, MS, RD, LD

CONNECTIONS WINTER 2015

not only can you help your clients get the nutrients they need, but also a range of phytonutrients that may help tosupport their health. As you seek to increase flavonoids in the diet, explore the publically-available USDA flavonoiddatabases for ideas on how to make some simple and tasty dietary changes. Applesauce, fruit juices, fruit smoothies, andhot chocolate can meet texture requirements for some clients while delivering some flavonoids. Liberal use of herbs andspices in place of salt can increase flavonoid intake while reducing sodium intake. Table 2 shows some common foods andtheir total flavonoid content.

Another consideration for the RDN is recognition that there are things that can affect the flavonoid content of foods. Inaddition to the impact of food processing (e.g., fermentation, drying, heating) on flavonoid content, common foodpreparation techniques (e.g., peeling, boiling, baking) also reduce flavonoid content.

However, not all processing reduces flavonoid content; some, such as occurs in the manufacture of juices, can raise theflavonoid content, as flavonoids from the skin and seeds of the fruit can be incorporated into the juice. As previouslymentioned, flavonoids are not established nutrients and do not have to appear on the label, so there is no easy way foryour clients to know the actual flavonoid content of a given food. Thus, the best advice for someone looking to increasethe flavonoids in their diet is to choose variety among foods– seek out and enjoy a range of fruit and vegetables, grains,legumes, nuts, spices and plant-based beverages in the context of a balanced diet –everyday. Here are a few points thatmay be useful and are frequently asked by consumers.

• In general, dark chocolate contains more flavonoids than milk chocolate because it is higher in cocoa (cacao) content, and both are higher than white chocolate, which only contains cocoa butter and none of the flavonoids.

• Because the flavonoids in fruit tend to be concentrated near the skin, eating a whole apple or pear will supply more and different flavonoids than applesauce made from peeled apples, or poached pears with the skin removed

• Simply replacing one food for another can be an easy way to get more flavonoids. Red and purple grapes have higher flavonoid content than white grapes. Green and white teas have higher flavonoids than black teas. Whole grains will have more than processed/refined grains. So by making simple substitutions, you can get more of these healthful flavonoids.

• Sometimes you will see advice that buying produce on the top layer of the store will have higher flavonoid content. While it is true that sunlight exposure can trigger an increase in the production of flavonoids, the increase that may occur in the context of grocery store lights is likely to be small.

• Organic produce is not necessarily higher in flavonoids than conventional agriculture practices. There are many reasons to consider buying organic produce, but higher flavonoid content is likely not a key reason for purchasing organic produce.

SIDE BAR: Flavonoid Supplements: A Cautionary TaleFlavonoid supplements are touted as a quick way to get all of the health benefits of these complex plant compounds in apill; however, few of these products have been proven to deliver benefits. While the science on phytonutrients is rapidlyexpanding, the marketing of supplements is often way ahead of the science. Indeed, over 831,000 hits appeared when“flavonoid supplements” was entered into a popular search engine. Trying to distill the bioactive compounds from foodsis a daunting task. Foods contain a wide array of very diverse plant compounds that work synergistically with the othernutrients and non-nutrients in foods (15). So, when it comes to flavonoids, always encourage your clients to eat a balanceddiet which includes a range of fruit and vegetables. Making simple substitutions in the diet, including herbs and spicesfor flavor, consuming tea, and even enjoying dark chocolate in moderation, can be simple and achievable ways to get thenutrition your clients need, with the added benefits of flavonoids.

References1. International Food Information Council. 2014 Food & Health Survey. The Pulse of America’s Diet: From Beliefs to Behaviors. Available at:

http://www.foodinsight.org/surveys/2014-food-and-health-survey. Accessed July 31, 2014.2. International Food Information Council. 2013 Functional Foods Consumer Survey. Available at:

http://www.foodinsight.org/2013_Functional_Foods_Consumer_Survey. Accessed July 31, 2014.


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3. Kumar S and Pandey AK. Chemistry and biological activities of flavonoids: an overview. Scientific World Journal. 2013;2013:1-16. Open Access journal available at: http://dx.doi.org/10.1155/2013/162750. Accessed July 31, 2014.

4. Bhagwat, S., Haytowitz, D.B. Holden, J.M. 2014. USDA Database for the Flavonoid Content of Selected Foods, Release 3.1. U.S. Department of Agriculture, Agricultural Research Service. Nutrient Data Laboratory Home Page available at: http://www.ars.usda.gov/nutrientdata/flav. Accessed July 31, 2014.

5. U.S. Department of Agriculture, Agricultural Research Service. Nutrient Database for the Proanthycyanidin Content of Selected Foods. 2004. Available at: http://www.ars.usda.gov/Services/docs.htm?docid=5843. Accessed August 13, 2014.

6. Bhagwat, S., Haytowitz, DB, and Holden, JM. 2008. USDA Database for the Isoflavone Content of Selected Foods, Release 2.0. U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory Home Page. Available at: http://www.ars.usda.gov/nutrientdata/isoflavAccessed September 10, 2014.

7. Dauchet L, Amouyel P, Hercberg S, Dallongeville J. Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. J Nutr. 2006;136:2588-2593.

8. Wang X, Ouyang Y, Liu J, Zhu M, Zhao G, Bau W, Hu FB. Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ. 2014 Jul 29;349:4490. doi: 10.1136/bmj.g4490. Available online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4115152/. Accessed September 8, 2014.

9. McCullough ML, Peterson JJ, Patel R, Jacques PF, Shah R. Dwyer JT. Flavonoid intake and cardiovascular disease mortality in a prospective cohort of U.S. adults Am J Clin Nutr. 2012;95:454-464.

10. Mink PH, Scrafford CG, Barraj LM, Harnack L, Hong CP, Nettleton JA, Jacobs DR. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr. 2007;85:989-909.

11. Devore EE, Kang JH, Breteler MM, Grodstein F. Dietary intakes of berries and flavonoids in relation to cognitive decline. Ann Neurol. 2012;72:135-143.

12. Gaine PC, Balentine DA, Erdman JW, Dwyer JJ, Ellwood KC, Hu FB, Russell RM. Are dietary bioactives ready for recommended intakes? Adv Nutr. 2013;4:539-541.

13. Zamora-Ros R, Knaze V, Luján-Barroso L, Romieu I, Scalbert A, Slimani N, Hjartåker A, Engeset D, Skeie G, Overvad K, Bredsdorff L, Tjønneland A, Halkjær J, Key TJ, Khaw KT, Mulligan AA, Winkvist A, Johansson I, Bueno-de-Mesquita HB, Peeters PH, Wallström P, Ericson U, Pala V, de Magistris MS, Polidoro S, Tumino R, Trichopoulou A, Dilis V, Katsoulis M, Huerta JM, Martínez V, Sánchez MJ, Ardanaz E, Amiano P, Teucher B, Grote V, Bendinelli B, Boeing H, Förster J, Touillaud M, Perquier F, Fagherazzi G, Gallo V, Riboli E, González CA. Differences in dietary intakes, food sources and determinants of total flavonoids between Mediterranean and non-Mediterranean countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Br J Nutr. 2013;109(8):1498-1507.

14. Dietary Guidelines for Americans 2010: http://health.gov/dietaryguidelines/2010.asp. Accessed July 31,2014.15. Egert S and Rimbach G. Which sources of flavonoids: complex diets or dietary supplements? Adv Nutr. 2011;2:8-14.

Flavonoid Group Food Sources Anthocyanidins Berries, cherries, eggplant, red

onion, red potatoes Flavan-3-ols, flavanols

Dark chocolate, natural cocoa powder, black tea, green tea, cherries

Flavonols Apples, kale, leeks, onions Flavanones Citrus fruits and juices (orange,

grapefruit, lemon) Flavones Celery, cherries, parsley,

strawberries Isoflavones Soybeans, soy flour, soy milk


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Table 2. Flavonoid Content of Common Foods (References 4,5,6)

Food Item Total Flavonoid Content mg/100 g

Total Flavonoid Content Household measure

Cinnamon 8000 320 mg/1 teaspoon Parsley, dried 4800 192 mg/1 teaspoon Oregano, Mexican dried 1500 60 mg/1 teaspoon Blueberries, fresh or frozen 250-350 312-437 mg/1.5 cups Dark chocolate 200 106 mg/2 ounces Green tea, brewed 140 322 mg/8 ounces Black tea, brewed 110 253 mg/8 ounces Milk chocolate 100 53 mg/2 ounces Yellow peach with skin, raw 70 87 mg/1.5 cups Grapes, red whole 60 75 mg/1.5 cups Grape juice, red 48 60 mg/0.5 cup Applesauce, strained 30 37mg/1.5 cups Pinto beans, cooked 26 13 mg/0.5 cup Note: Flavonoids are susceptible to damage under high heat


Each New Year brings an opportunity to reflect on the past and more importantly, to plan for the future. The membershipcommittee has been working on a “strategic” plan to target the most effective ways to reach out to members and non-members of DHCC. One of the principal methods of reaching out to you is via our newsletter, CONNECTIONS. Because it issent to all members and is available electronically on our website, we know it reaches most of you.

Have you checked out our website (www.dhccdpg.org) recently? We are making some changes and have added a shortwelcome video featuring the executive committee talking about what DHCC has to offer its members.

Reaching out to non-DHCC members represents more of a challenge. We are planning to contact dietetic internshipdirectors in order to try to expose dietetic students to the benefits of DHCC. We will continue to reach out to stateaffiliates and corporate nutrition directors promoting DHCC.

Our Facebook page numbers are growing, too! As I write this we have 686 members on our Facebook page whichrepresents DHCC members and non-members, so this is another way we can promote DHCC.

Are you interested in participating on Facebook? LinkedIn? Writing for Connections? Let us know!

As usual, your comments and suggestions are always welcome! Please contact me at [email protected]. Happy NewYear!

Membership!by Patricia Iorio, MS, RD, LDN


The Centers for Medicare & Medicaid Services (CMS) issued a final rule enabling registered dietitian nutritionists (RDNs) inthe hospital setting to become privileged to independently order therapeutic diets. In states where law or regulationslimit appointments to certain categories of practitioners, privileges may still be granted without appointment to themedical staff as long as such privileges are recommended by the medical staff, approved by the governing body, and inaccordance with state law. (Rule Hospital CoP §428.12(c), page 27115). The Academy supported the new rule that willprovide patients with better health care and helps hospitals function more efficiently. CMS concluded, “the addition ofordering privileges enhances the ability that dietitians already have to provide timely, cost-effective, and evidence-basednutrition services as the recognized nutrition experts on a hospital interdisciplinary team”. CMS expects this rule toimprove the efficiency and efficacy of nutrition care and save up to $459 million in annual hospital costs.

CMS issued the rule, published in the Federal Register on Monday, May 12, and it became effective on July 11, 2014. Therule’s intent is for greater flexibility for hospitals and medical staffs to enlist the services of non-physician practitioners toprovide care for which they are trained and licensed. The rule includes language allowing for other types of non-physicianpractitioners to be included on the medical staff (Hospital CoP §428.12(c). Non‐physician Practitioners specificallyincludes Advanced Practice Registered Nurses (APRNs), Physician Assistants (PAs), Registered Dietitians (RDs), and Doctorsof Pharmacy (PharmDs) (Rule, page 27114; Hospital CoP §428.22(a).

CMS follows the Academy’s definition of a therapeutic diet published in 2011. A therapeutic diet is a diet interventionordered by a health care practitioner as part of the treatment for a disease or clinical condition manifesting an alterednutritional status, to eliminate, decrease, or increase certain substances in the diet. Therefore therapeutic diets with thenew ruling will include enteral and parenteral nutrition. Under the ruling, the registered dietitian would be able to writeorders for nutrition support. A registered dietitian writing for labs is a more complex issue since rules and regulations varyby state and also insurance companies. The CMS rule opens the door for this practice. Many other commonly askedquestions are addressed in the Academy’s FAQ available on www.eatright.org.

The CMS ruling does not override state licensing regulations and scope of practice laws. Therefore dietitians will need tobecome familiar with their state regulation to better understand how this new rule affects practice in their state. TheAcademy has assembled information on their website (http://www.eatrightpro.org/resource/advocacy/quality-health-care/consumer-protection-and-licensure/learn-about-the-cms-rule-on-therapeutic-diet-orders) that helps you determineif your state allows for immediate implementation of the rule. The Academy is using a traffic light system (Red, Yellow, andGreen) to help figure out which state you can implement the rule immediately, which needs caution, and which requirechanges in state regulations before implementation can happen. The Academy encourages dietitians in the yellow andred states to work with their local dietetic associations to identify strategies for taking advantage of the new rule and foradvocating for change in state regulation.

I

482.28 Condition of Participation: Food and dietetic services. (b) (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. CMS-3267-F 187 (2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

More Efficient Delivery of Nutrition TherapyExpected with CMS Ruling 42 CRF §482.28 by Quincie Grounds, RD/LD, CNSC - Corporate Dietitian ● Hospital Division - Kindred Healthcare

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Other resources provided by the Academy include Practice Tips: Hospital Regulation - Ordering Privileges for the RDN(http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/practice-tips-hospital-regulation-ordering-privileges-for-the-rdn.ashx), and Practice Tips: Implementation Steps - Ordering Privileges for the RDN(http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/practice-tips-implementation-steps-ordering-privileges-for-the-rdn.ashx). These resources are available at www.eatrightPRO.org.

This regulatory change is a big step in the right direction for millions of hospitalized patients in the US that can nowbenefit from the expertise of the registered dietitian to improve their nutritional status to support healing and recovery ina way that is more direct, timely, and cost effective. However, there still is work to be done in many states to clear the wayfor full implementation of this new CMS rule.References:1. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Federal Register. https://federalregister.gov/a/2014-

10687.2. Academy of Nutrition and Dietetics. PRACTICE TIPS: Hospital Regulation ‐Ordering Privileges for the RDN. July 16, 2014 published.

http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/practice-tips-hospital-regulation-ordering-privileges-for-the-rdn.ashx. Accessed 2.5.15

3. Academy of Nutrition and Dietetics. PRACTICE TIPS – Implementation Steps for Ordering Privileges for the RDN.http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/practice-tips-implementation-steps-ordering-privileges-for-the-rdn.ashx. Accessed 2.5.15.

4. Academy of Nutrition and Dietetics. Frequently Asked Questions. www.eatright.org. Accessed 12.22.14.5. Academy of Nutrition and Dietetics. Therapeutic Diet Orders: State Status and Regulation.

http://www.eatrightpro.org/resource/advocacy/quality-health-care/consumer-protection-and-licensure/learn-about-the-cms-rule-on-therapeutic-diet-orders. Accessed 2.5.15

6. CMS’s RAI Version 3.0 Manual, Chapter 3, K0510 Nutritional Approaches, page K-11; April 2012. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/M DS30RAIManual.html Accessed 1.2.15

More Efficient Delivery of Nutrition Therapy Expected withCMS Ruling 42 CRF §482.28continued from page 7

The Accreditation Council for Education in Nutrition and Dietetics (ACEND) is recommending a new education model forthe future preparation of nutrition and dietetics practitioners based on its environmental scan and data from more than9,500 stakeholders. A copy of the Rationale Document, which details the recommended model and provides results of theenvironmental scan and stakeholder data analysis, can be found on the ACEND website: http://www.eatrightacend.org/ACEND/Standards. Also posted on the website is a Frequently Asked Questions information sheet to address expectedquestions about the recommendations and a recorded webinar that describes the recommended model and the rationalefor proposed changes. ACEND board representatives and staff will be conducting special sessions at the area NDEPmeetings to provide opportunities for educator input. Feedback is encouraged and can be provided at the SurveyMonkey® link: https://www.surveymonkey.com/s/educmodel2015

Feedback Request: ASCEND new Education Modelby Merievelyn Stuber, MS, RD, CPPS, CPHQ - ACEND Chair and Mary B. Gregoire, PhD, RD - ACEND Executive Director


Author’s and Editor’s note: As DHCC strives to provide information that is useful to you in your health care community we must recognize that thereare academic and professional differences in how dietitians apply the NCPT (Nutrition Care Process Terminology now available in electronic formatfrom the Academy of Nutrition and Dietetics as the eNCPT at https://www.eatright.org/shop/product.aspx?id=6442482026).

As you consider how to better incorporate the NCPT into your daily practice, it is best to consider any case study in context of the full body of workrelated to NCPT, using the most recent eNCPT version (available since August 2014) (1). Other resources available through the DHCC and theAcademy of Nutrition and Dietetics including the Nutrition Care Manual (2) and the Academy’s Evidence Based Nutrition Practice Guidelines(available on the Academy’s Evidence Analysis Library), which are the gold standard for directing nutritional care (3). These resources should beutilized within the Policies and Procedures of the institution in which MNT is provided. Nutrition assessment values used are per this writer’s clinicaljudgment; protocols vary per center.

Welcome back to NCP Corner. In this edition of the NCP Corner I share a case study which applies the eNCPT to practice bypresenting the case of an patient living with HIV infection in an inter-city adult medical day care center (AMDC). AMDCsare a relatively new practice setting for me. I found most of the “clients” to be of low nutritional risk. They qualified for theAMDC services in part due to some degree of cognitive decline, and for medical monitor – often daily blood pressureand/or blood glucose monitoring. These clients benefited not only from the nursing oversight but also from receiving adaily meal, socialization and participating in activities including exercise programs. In this particular setting there were afew higher risk clients with the diagnosis of HIV; a diagnosis that we do not get to see much in LTC in this era, so I thoughtit would be an interesting case study to share with the DHCC membership.

As my nutrition related knowledge of HIV was a bit rusty I began by doing some research. I will refer you to the NutritionCare Manual (2) which is an excellent source of information. HIV is the acronym for a human immunodeficiency virus andcauses the disease sequela that leads to acquired immune deficiency syndrome (AIDS). HIV is a retro virus that enters thebloodstream and attaches to cells and incorporates into RNA then DNA, produces and releases new virus, and destroys thehost cell. As the disease progresses, HIV diminishes the immune system and affects regulatory processes throughout thebody. For example, HIV can affect the GI tract which results not only in local disruptions in GI function (diarrhea andmalabsorption), but as the GI tract plays a vital role in immunity, the result is decreased immune response, leaving thedoors open to opportunistic infections. These opportunistic infections can further increase the risk of protein breakdown(catabolism), inadequate nutrient intake and eventually wasting and malnutrition. Wasting syndrome (specific toHIV/AIDS) is defined as a weight loss of at least 10% in the presence of diarrhea or chronic weakness and documentedfever for at least 30 days that is not attributable to a concurrent condition other than the HIV infection itself.(4)

While highly active antiretroviral therapy (HAART), supportive care, and treatment of HIV infection has come a long way,and is effective in slowing down the progression of HIV to AIDS, the side effects of these treatments have nutritionalconsequences such as nausea, vomiting, diarrhea, anorexia and lipodystrophy (redistribution of fat mass). These chronicsymptoms often lead to weight loss, wasting, and malnutrition which increase the risk of opportunistic infections, cancerand mortality. The effect is thus cyclical. HIV treatments can also lead to metabolic disturbances including hypertension,cardiovascular disease, insulin resistance / diabetes, liver and/or renal dysfunction and loss of bone mineral density whichcan further complicate nutritional management.

This case study will present relevant client information (data used for nutrition assessment) followed by a discussion ofnutrition diagnosis, interventions and nutrition indicators for monitoring and evaluation stages. Following the case studyis a sample comprehensive nutrition assessment note demonstrating how this information can be compiled anddocumented in a medical record using the eNCPT.

Patient Presentation:CF is a 52-year-old single Hispanic male who has begun attending an AMDC in a low-income city. His social support islimited and he has history of alcohol and substance abuse. He presents with a medical history which includes: HIV,hepatitis C, and hyperlipidemia and is managed on: Epzicom (a nucleoside reverse transcriptase inhibitor which helpskeep the HIV virus from reproducing in the body) and Ritonavir (a protease inhibitor which help decrease the amount ofHIV in the blood) for HIV; Ribapack and Sovaldi (antiviral medications that prevents hepatitis C virus cells from

“NCP Corner – HIV” by Rena Zelig DCN, RDN, CDE, CSG & Yifat Adler, Nutrition and Dietetics Student, Queens College, NY

continued on page 10


multiplying), and Zocor and Lovaza (statin and omega 3 ) for hyperlipidemia (likely related to HIV medications whichincrease levels of cholesterol and triglycerides in the blood).

Nutrition focused physical examination reveals mouth sores, lipodystrophy (specifically a buffalo hump of fataccumulation behind the neck and upper back), and that he appears thin and frail, especially in his face and extremities(all of which are common side effects of the HIV virus and the medications that are used to treat HIV by slowing theprogression of the virus, including immune suppression and redistribution of fats and lipids). His teeth are intact and hereports no difficulty chewing or swallowing. No gastrointestinal complaints are voiced and no edema is present. CF is ableto ambulate without any assistive devices and eat independently. Nursing reports that he appears tired most of the time,and can often be found sleeping. CF’s height is measured at 60”/152.4 cm and his current weight at 103 pounds/46.8 kg. CF reports gradual weight loss over time and recalls that his weight 6 months ago was ~ 115 pounds, representing an ~10% significant weight loss in this time period which meets the criteria for wasting syndrome – an AIDS defining condition(4). His current weight is at the low end of the Adjusted Ideal Body Weight: 106 +/- 10 (95-116 pounds), and his BMI is 20.1(low end of normal). When questioned on his weight loss, CF reports a lack of appetite that has been worsening over time.While he has always been thin and is comfortable at a low weight, he expresses that he would like to stop losing weightand would ideally like to gain back the ten pounds that he lost recently. CF does not follow any specific diet at present. Hisresources are limited. He receives one meal daily at the AMDC and will eat whatever is available or cheap fast food choices.

No biochemical data were available. Using comparative standards, nutrition needs may be assessed and recommended at:Energy: ~ 1400-1,645 calories (using 30-35 kcal/kg of actual body weight of 47 kg)

~1,500-2,000 Kcal (using Mifflin St Jeor with an activity factor of 1.3-1.4 and injury factor of 1.1-1.2) → use higher end to promote weight gain or lower end + 500 calories to promote weight gain:

= ~ 2,000 Kcal (varies based on your method of calculating energy needs)Protein: ~ 47-56 grams protein (based on ~1.0-1.2 g/kg)Fluids: ~ 2,000 ml (1 ml/kcal)

Case Discussion:Nutrition Assessment:During the nutrition assessment step of the NCP the RD/RDN gathers data for each of the 5 domains/categories – Foodand Nutrition-Related History (FH), Anthropometric Measurements (AD), Biomedical Data, Medical Tests & Procedures (BD),Nutrition-Focused Physical Findings (PD) and Client History (CH). Please see the sample comprehensive initial nutritionassessment note at the end of this article for an example of how the information obtained from the RD/RDN assessmentcan be compiled and documented within a medical record using the eNCPT, as appropriate, for each of thedomains/categories.

Nutrition Diagnosis: After completing the nutrition assessment, the RD/RDN analyzes the information compiled and prioritizes it to arrive at anutrition diagnosis. CF presents with inadequate intake and significant weight loss (~10 pounds/ 10% over the course of 6months) related to decreased appetite and other symptoms of HIV infection (i.e. mouth sores) and medicationmanagement. Appropriate nutrition diagnoses include NI-2.1- Inadequate oral intake, Unintentional weight loss- NC- 3.2,and NI – 5.1 – Increased Nutrient Needs (protein and calories). The RDN may choose to prioritize inadequate oral intake(NI 2.1) as the primary diagnosis and utilize the increased needs as part of the etiology and the unintentional weight lossas a sign and symptom. A sample PES statement may read: Inadequate oral intake (NI 2.1) related to increased nutrient needs due to catabolic physiological condition (HIV infection)and side effects of medication as evidenced by unintended significant weight loss of 10% in 6 months, reports andobservations of suboptimal appetite and intake, and mouth sores. _____________________________________________________________________________________________________

“NCP Corner – HIV”continued from page 9



Nutrition Interventions:In step 3, the RD/RDN chooses interventions and creates a plan for delivery of the individual nutrition prescription. Thereare different acceptable methods for the RD/RDN to use in assessing and calculating nutrition needs. These methods mayvary by facility or as appropriate for specialty practice areas and should be used, documented and referenced accordingly.

The Nutrition Prescription, essentially the diet order, is recommended as ~2,000 calorie cardioprotective diet such as theDietary Approaches to Stop Hypertension (DASH diet), ~ 50 grams protein and ~ 2,000 ml Fluid. Nutrient needs may needto be reached via protein/calorie and vitamin/mineral supplementation.

Nutrition interventions for CF should initially include provision of a protein calorie supplement, multivitamin and mineralsupplement, and calcium and vitamin D supplement to better meet CF’s nutritional needs. The RD/RDN may discuss withthe MD the need for a prescription mouthwash or cream to treat CF’s mouth sores and the consideration of an appetitestimulant such as Megace. These interventions would target the root causes of CF’s barriers to inadequate intake. Nutritioneducation should include food and water safety as people with HIV infection and diminished immune function are moresusceptible to foodborne illness and the principles of a cardioprotective DASH style diet. As the availability of the RD/RDNin the ADMC may be limited it would be appropriate to coordinate the plan of care for this client with the interdisciplinaryteam including nursing and social services and refer this client to community resources such as food assistance programsand an outpatient RD/RDN in the community that specializes in clients with HIV. (3)

Nutrition Monitoring and Evaluation: Before the initial assessment is complete, the RD/RDN needs to determine what outcomes are desired and whichindicators will be monitored.

Given the setting in which this initial evaluation was conducted much of the data was limited. A referral to an RD/RDNspecializing in HIV and practicing in a local clinic is appropriate. According to the Nutrition Care Manual and the EvidenceAnalysis Project on HIV, data to assess, monitor and evaluate as part of a comprehensive plan of care may include (1,2,3): • Anthropometric measurements beyond weight, height and BMI should be included as available including:

o measurements of body compartment estimates, such as circumference measurements (mid-arm muscle, waist, hip and waist-to-hip ratio) or

o measurements of body cell mass and body fat [measured with skinfold thickness measurements, dual energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), or bioimpedance spectroscopy], as fat-free mass and fat mass are altered in people with HIV infection.

• Biochemical data, medical tests and procedures such as: o lipid profile, fasting blood glucose, electrolytes, complete blood count , albumin/pre-albumin, and bone density

measurements as available.• Nutrition focused physical findings should take a holistic approach including:

o Head and neck, cardiovascular, pulmonary and GI function, extremities, skin, nerves and cognition, vital signs and overall appearance.

o Focus on the signs and symptoms of infection (i.e. mouth sores), possible side effects of medications (GI disturbances and lipodystrophy) as well as malnutrition (documentation of muscle wasting).

• Food and nutrition-related history of people with HIV infection should include but not be limited to:o Food and nutrient intake (focusing on energy, protein, fat, fiber, sodium, calcium and vitamin D)o Medications/drugs, herbal/dietary supplements and their potential negative interactions and side effectso Knowledge, beliefs, attitudes and behavioro Factors affecting access to food and food and nutrition-related supplieso Physical activity and functiono Nutrition-related patient and client-centered measures (quality of life)




While the RD/RDN will continue to monitor criteria within the categories of food and nutrition-related history (FN),anthropometric measurements (AD), nutrition-focused physical findings (PD) and biochemical data medical tests andprocedures (BD), only pertinent indicators that relate to the nutrition diagnosis and goal should be listed. Please see thesample comprehensive initial nutrition assessment note at the end of the article detailing specific indicators and criteria tomonitor, as well as how they coincide with the RD/RDN’s goal for CF.

Sample comprehensive nutrition assessment note for CF: *Note: Reference numbers are from the eNCPT and are for reference only. Reference numbers need not be included inprogress notes.

Initial Comprehensive Nutrition Assessment in an Adult Medical Day Care Center (AMDC): Food / Nutrition-Related History (FH):

Food and nutrient intake – suboptimal reports lack of appetite worsening over time Food and Nutrient Administration – Currently on a regular diet Factors Affecting Access to Food and Food/Nutrition-Related Supplies – attends AMDC

where he received 1 meal per day; the availability of other safe food and water is limited Physical Activity / Function – ambulatory without assistive devices, able to feed himself

independently; often appears tired/sleeping Medications – Epzicom, Ritonavir, RibaPack, Sovaldi, Zocor and Lovaza Vitamins and supplements - none

Anthropometric Measurements (AD):

Height: 60 inches ( 152.4 cm) Weight: 103 pounds (46.8 kg) Weight history: Weight down ~ 12 pounds (10%) in 6 months from 115 pounds Ideal Body Weight: 106 pounds +/- 10% (95-116 pounds) Body Mass Index: 20.1 kg/m2

Biomedical Data, Medical Tests & Procedures (BD): Altered nutrition related lab values:

n/a Nutrition-Focused Physical Findings (PD): Non-normal Nutrition Related Physical Findings:

Overall appearance – Thin and frail looking; lipodystrophy (specifically buffalo hump) Oral cavity – teeth intact, mouth sores present Skin – Intact GI – no complaints Cardiopulmonary – no edema

Client History (CH):

Age - 52 years old Race / Ethnicity – Hispanic Gender - Male Medical History – HIV, Hepatitis C, hyperlipidemia Social History – Single, lives alone with limited social support and a history of alcohol and

drug abuse.




Nutrition Diagnosis: P: Inadequate oral intake (NI-2.1*) related to (r/t) E: increased nutrient needs due to catabolic physiological condition (HIV infection) and side effects of medications as evidenced by (AEB) S: Unintended significant weight loss of 10% in 6 months, reports and observations of suboptimal appetite and intake, and mouth sores.

Nutrition Prescription: ~ 2,000 Calorie Cardioprotective Diet (i.e. DASH diet) ~ 50 grams protein ~ 2,000 ml Fluid Nutrient needs will likely need to be met via protein/calorie and vitamin/mineral supplementation

Nutrition Interventions: Food and/or Nutrient Delivery (ND):

1. Modify composition of meals/snacks (ND-1.2*) – cardioprotective diet pattern 2. Medical Food Supplement Therapy (ND-3.1*) – protein energy supplement 3. Vitamin and Mineral Supplement (ND-3.2*) – Multivitamin with mineral, Calcium + D 4. Nutrition-Related Prescription Medication Management (ND-6.1*) – prescription treatment

for mouth sores and appetite stimulation (i.e. Megace) if approved by MD Nutrition Education (E):

1. Survival information (E-1.3*) – food and water safety 2. Recommended Modifications (E-1.5*) – provide diet education on a cardioprotective diet

such as the DASH diet Coordination of Nutrition Care (RC):

1. Team meeting (RC-1.1*): Interdisciplinary meeting to coordinate the plan of care 2. Referral to RD/RDN with different expertise (RC-1.2*) – Refer to RD/RDN in community

who specializes in HIV 3. Collaboration with other providers (RC-1.4*) – specifically the social worker to

coordinate community resources such as food assistance programs, nursing to monitor for continued adverse signs and symptoms of disease progression and medication management and the MD for medication management of mouth sores and an appetite stimulant medication.

Goals:

Adequate intake of meals, snacks and supplements to meet nutritional needs, as evidenced by:

1. Maintain current weight with no further weight loss; gradual weight gain of ½-1# per week to self-stated weight goal of 115 pounds is desirable

2. Improvement in mouth sores and decreased susceptibility to further opportunistic infections

3. Biochemical values within normal limits / at baseline for medical condition




Nutrition Monitoring and Evaluation: Indicator: Criteria: Goals: Outcomes: Food/Nutrient Related History Outcomes (FH):

Energy intake (FH-1.1*) Protein intake (FH-

1.5.2*) Fluid intake (FH-1.2.1*) Supplement Intake

(FH-1.2.1.3)

Meal intake records, meal rounds

Adequate intake of cardioprotective DASH diet ~ 2,000 Kcal, 50 grams protein, and 2,000 ml Fluid

To be determined

Anthropometric Measurements Outcomes (AD): Weight change (AD-

1.1.4*)

Body compartment estimates (AD-1.1.7*) (as available)

Weekly/Monthly weight record (circumferences, skinfolds, DXA, BIA as available)

Maintenance of current weight 103# with no further significant weight loss; gradual weight gain of ½-1# per week to self-stated goal of 115# Maintenance of fat free mass and avoidance of muscle wasting (as available)

To be determined

Biochemical Data, Medical Tests and Procedures Outcomes (BD): Electrolyte and Renal

Profile (BD-1.2*) Glucose, fasting (BD-

1.5.1*) Lipid profile (BD-1.7*) Nutritional anemia

profile (BD-1.10*) Albumin (BD-1.11.1*)

and/or Pre-albumin (BD-1.11.2*)

Standard lab references as available

Biochemical values within normal limits / at baseline for medical condition

To be determined

Nutrition-focused Physical Findings Outcomes (PD): Overall appearance

(PD-1.1.1*) Cardiovascular-

pulmonary (PD-1.1.3*) Extremities, muscles

and bones (PD-1.1.4*) Digestive system (PD-

1.1.5*) Head and eyes (PD-

1.1.6*) Nerves and cognition

(PD-1.1.7*) Skin (PD-1.1.8*) Vital signs (PD-1.1.9*)

Nutrition focused physical assessment/examination as able

Mouth sores to heal To be determined




Learning and understanding the NCP process is a journey that takes time. Learning from each other has great value-evenas we embrace our differences in style. The “NCP Corner” will continue to be a feature in each newsletter to assist DHCCmembers in becoming experts on the NCP and its application to practice. Do you have questions that you would likeanswered in the newsletter? Do you have specific areas of the NCP that you would like discussed in the newsletter? If so,please send your requests to [email protected].

References1. Academy of Nutrition and Dietetics online eNCPT Nutrition Terminology Reference Manual (Can be purchased at http://ncpt.webauthor.com/).2. Academy of Nutrition and Dietetics Nutrition Care Manual - HIV/AIDS – available at:

http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=20149&ncm_toc_id=20149&ncm_heading=Nutrition%20Care (must be subscribed)

3. Academy of Nutrition and Dietetics Evidence Analysis Library – HIV/AIDS – available at: http://www.andeal.org/topic.cfm?menu=5312 (must be subscribed)

4. Centers for Disease Control (CDC). Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. Council of State and Territorial Epidemiologists; AIDS Program, Center for Infectious Diseases. MMWR Morb Mortal Wkly Rep. 1987 Aug;36 Suppl 1:1S-15S [PubMed ID: 3039334]


What will the profession of nutrition and dietetics look like in 2025? Will there be enough RDNs and NDTRs to providenutrition services to those in need? Will we be focused on treatment of disease or the prevention of disease? Will we bereimbursed for providing nutrition services? These are all valid questions that members, RDNs and NDTRs, students, andallied health professionals may be asking themselves. It’s too bad we can’t jump in the DeLorean with Marty and Doc torace Back to the Future™ and see what lies ahead!

Visioning, or thinking into the future, is hard to do, but it is a necessary exercise if we want to navigate and reach ourdesired destination. Visioning is the process of describing the future a group wants to attain. Visioning creates a picture ofthe desired future, affirms the best of what could be, visualizes what excellence looks like, and shows the best scenario forthe time. It is a blueprint for action.

The Council on Future Practice (CFP) has initiated its three-year program of work to describe the future of nutrition anddietetics. The CFP is currently reviewing the literature to identify trends that may affect the future of the profession. Butthe CFP cannot do this alone. The CFP needs your input, as well as the input of external stakeholders, to identify trendsand change drivers affecting the profession. Be prepared to provide your input during the fall of 2015. Further details canbe obtained at http://www.eatrightpro.org/resource/leadership/volunteering/committees-and-task-forces/council-on-future-practice. Please contact [email protected] with any questions or concerns.

Back to the Future™: Steering the Way to aDesirable Destination for Nutrition and Dietetics


We are pleased to announce that Carrie Hamady, MS, RD, LD, received recognition as Top Innovator in Dietetics Educationfor her Innovation in Dietetics Practice and Education display entitled Using Twitter to Enhance Engagement inUndergraduate Nutrition Courses. This display was presented during the Innovations in Dietetics Practice and Educationsession conducted during FNCE 2014 in Atlanta. The abstract for the display can be found on the next page, along with itbeing published in the Supplement to the September 2014 Journal of the Academy of Nutrition and Dietetics.

The Academy’s Council on Future Practice is the organizational unit that sponsors this session during FNCE each year. Inits sixth year, the session recognizes educator contributions to the profession of nutrition and dietetics. Carrie Hamadywas selected by a panel of judges to receive this recognition. We are requesting that you showcase this member of yourDPG as a model for other educators.

The Council on Future Practice sponsors this inspirational session for members to showcase their innovations. The goal ofthe session is to provide an outlet for educators and practitioners to present their best ideas and innovations that willkeep the profession consistently moving forward. Carrie submitted an application and was selected to participate in theevent from 79 applications submitted from all over the cou ntry.

Please join us in congratulating Carrie Hamady for her contribution to keep the profession of nutrition and dieteticsmoving forward into the future. She is a model of excellence for our membership and hope that you will share her story ofachievement.

Using Twitter to Enhance Engagement in Undergraduate Nutrition Courses

Author(s): C.M. Hamady, M. Ludy, D.L. Anderson, N.H. El-Khechen; Bowling Green State University, Bowling Green, OH

Background: Millennial students prefer interactive, technology-infused classroom environments. Twitter is a popular socialmedia platform and microblogging site with 645 million active users. Twitter generates opportunities to communicatewith other professionals, stay abreast with research/news, connect with the public, create business opportunities, andmarket individual brands. With the amount of misinformation generated by non-credentialed individuals, it is particularlyimportant for registered dietitian nutritionists and students to establish their presence as nutrition experts. This project’sgoal was to provide undergraduate nutrition and dietetics students with a hands-on demonstration of responsible,professional social media messaging.

Methods: Undergraduate nutrition and dietetics students (n¼114) from four courses at Bowling Green State Universityparticipated in interactive Twitter chats. These provided extensions of in-class discussions on hot topics in the field (e.g.,2015 Dietary Guidelines and organic vs. conventionally grownproduce). Following the Twitter chats, a seven-question survey was administered and analyzed using paired t-tests.

Results: While 67.5% of students reported using Twitter for personal reasons before class, only 22.8% had used itprofessionally. Participating in class Twitter chats reflected positive attitudinal changes with 62.3% of students ratingTwitter as important to their future occupational success after the activity, compared to 19.3% before (p<0.001).

Conclusions: Exposing undergraduate nutrition and dietetics students to professional uses of social media technologies,such as Twitter, improves the ability of our next generation of credentialed nutrition and dietetics professionals to markettheir expertise. These educational exposures empower students to use social media for communicating evidence-basednutrition information in a consumer-friendly manner.

Funding Disclosure: We received funding from an innovative teaching grant at Bowling Green State University.

Recognition of a DHCC DPG Member by the Academy’s Council on Future Practiceby Becky Dorner, RDN, LD, Chair, Council on Future Practice


IntroductionThe Philippines is made up of 7,107 islands and islets. There are more than 100 dialects, Tagalog, being the nationallanguage. A second language is English (Spanish in the old world) and is the medium of instruction in schools all over thecountry.

Dietetics practice in the Philippines is patterned on the United States. Its formal education was started at the University ofthe Philippines (UP) before WW II by Dr. Presentacion Perez who was educated and had practiced in the US. She wasjoined later by Dr. Ruth Darby and together, they established an exemplary dietetics program. After WW II, otheruniversities offered the dietetics program.

Education, Credentials, and PracticeIn the past, to practice dietetics in the Philippines, one had to complete a Bachelor of Science degree in home economicswith a major in nutrition and dietetics (BSHE-ND) or a Bachelor of Science degree in nutrition and dietetics (BSND) andcomplete a dietetic internship. With the advent of the supervised practice in the United States, dietetic internships werediscontinued for the coordinated programs (CP) in dietetics.

Passing a credentialing examination from the Professional Regulations Commission (PRC) is a requirement to practice aprofession. Dietetics practice, therefore, can only be done after the PRC examination on dietetics. Continuing education isrequired to maintain the credentials (licenses). The Nutritionist-Dietitian Association of the Philippines (NDAP), therecognized organization of dietetic practitioners, provides continuing education and maintains records needed by thePRC.

Having graduated at the UP-Diliman and obtaining the dietetic internship at New York –Cornell Medical Center (now NYPresbyterian) in NYC, I embarked on my dietetic career as a clinical, management, consultant, and entrepreneur, as well asa dietetics educator of NDTRs and RDNs. Active in the profession, I have continued to communicate, share and evenmentor nutritionists-dietitians (RNDs) in the Philippines as well as RDNs in the US. I also facilitated the signing of theDietitian Reciprocity Agreement on RDN examination eligibility between the Professional Regulations Commission (PRC)and the Commission on Dietetic Registration (CDR) on September 29, 1993. The occasion, held at the Academyheadquarters amidst Filipino-American RDNs from various States, had Sanirose Orbeta, RDN, RND representing the PRC.

Balik (Returning) ScientistIn 2011 and 2013, I received the Balik Scientist award. My hosts were the PRC (2013) and the Philippine Women’sUniversity (2011). My program of work included providing consultation; workshops and seminars to professionalorganizations and the lay public; curriculum designs; meetings with university presidents, dean, faculty, and students; aswell as teaching at the university. I also had the opportunity to review hospital foodservice operations, provide foodsafety and sanitation (ServSafe® program) to health care staff as well as present the Nutrition Care Process (NCP) model forthe clinical side of dietetics practice. Meetings with PRC include those related to the pass rates of RDNs taking the NRDexaminations through the CDR.

To meet the challenge of the 2015 ASEAN Economic Community Blueprint which would allow the RNDs to work in Laos,Myanmar, Singapore, Indonesia, Vietnam, Cambodia, Brunei (ASEAN countries) without having to obtain professionallicenses in these countries, I provided timely programs in medical nutrition therapy, foodservice management, andleadership. A seminar on Benchmarking: The Dietetic Profession was a highlight at the First Summit Conference of the PRC.

My workshops and meetings with the public were special - the seniors in Calamba, the teachers and parents of gradeschool children in Loa Banos, and groups in Manila. Thus, being globally competent in the practice of nutrition anddietetics is not only desirable, but needed.

BEYOND BORDERS: A VISION ON DIETETICSEDUCATION, CREDENTIALS, AND PRACTICEby Beatriz Dykes, PhD, RDN, LD, FADA, FAND



ConclusionToday, more than ever, an understanding of dietetics practice around the world is necessary for dietetic practitioners, formembers of the Academy. Sharing one’s knowledge with colleagues and people of other countries through in-house andinstitutional teachings, seminars and workshops, meetings and conferences as well as on-line activities with professionalsand the public is needed.

I am grateful to the Philippine government for the Balik Scientist award through the Department of Science and Technology(DOST), to my hosts - the Professional Regulations Commission (PRC) in 2013 and the Philippine Womens University (PWU) in2011. And a special thanks to the Nutritionists-Dietitians Association of the Philippines (NDAP), the Academy of Nutrition andDietetics (Academy), my amazing colleagues both in the US and the Philippines, without whom, this experience would not havebeen possible. It is special to be counted among the members of the Nutrition and Dietetic Educators and Preceptors (NDEP), theDietitians in Health Care Communities (DHCC), and the Filipino Americans in Dietetics and Nutrition (FADAN). And to beincluded as an honorary member among the many notable ones in NDAP (2015) is truly a highpoint in an international dieteticscareer.

I am equally grateful for the recognition accorded me through the 2014 Wimfpheimer-Guggenheim Fund for InternationalExchange in Nutrition, Dietetics and Management award, the Academy of Nutrition and Dietetics Foundation.

Thank you, all.

BEYOND BORDERS: A Vision on Dietetics Education, Credentials, and Practicecontinued from page 17


As the Academy works on identifying the policy and advocacy priorities for this year, this is a great time to highlight thesuccesses of 2014. My thanks to the Academy’s Policy Initiatives and Advocacy Team for providing me with a listing ofthese accomplishments. This list was previously posted in Eat Right Weekly. As you review these contributions, it isamazing to see the number of consumer, community and professional issues where the Academy staff and members areproviding their expertise.

Agriculture• The 2014 Farm Bill passed in February 2014, including many of the Academy’s recommendations. • Farm Bill implementation: The Academy took part in listening discussions that addressed many opportunities for

registered dietitian nutritionists to get involved.

School Meals• The Child Nutrition Work Group of the Academy’s Legislative and Public Policy Committee convened in preparation for

the Child Nutrition and WIC Reauthorization Act in 2015.• The Academy participated in the School Nutrition Association’s National School Lunch Week, celebrating the work and

dedication of RDNs who lead school lunch programs across the country to provide nutrition education and healthful meals to children.

• The Academy and its Foundation also launched the first annual Kids Eat Right Month in August. As part of the Kids Eat Right initiative, Kids Eat Right Month is a nutrition education, information sharing and action campaign that spotlightshealthy nutrition and active lifestyles for children and families, highlighting the expertise of registered dietitian nutritionists

Food and Nutrition• The Dietary Guidelines Advisory Committee completed its work in December 2014 and will be submitting its report to

the Departments of Agriculture and Health and Human Services for use in drafting the 2015 Dietary Guidelines for Americans.

• Feed the Future: The U.S. Agency for International Development is working to address immediate and underlying determinants of global malnutrition through the Feed the Future initiative. Academy champion and U.S. Rep. Betty McCollum (Minn.) has led bipartisan efforts to pass a bill that would solidify funding for this crucial program that recognizes the need for adequate nutrition and helps build the local agriculture economy.

Diabetes• The Academy was pleased with the United States Preventive Services Task Force’s draft recommendation on screening

for Type 2 diabetes, which resulted from a multi-year effort to expand the scope of individuals who will be screened. The Academy submitted comments, both independently and through the Diabetes Advocacy Alliance, and anticipate the final recommendation to be released in early 2015.

• The Academy also laid the groundwork for strong diabetes legislation in the 114th Congress, with grassroots advocacyefforts on the National Diabetes Clinical Care Commission Act. From August through December 2014, the number of cosponsors rose from 159 to 183 in the House and from 20 to 24 in the Senate.

• The 2015 Consolidated and Further Continuing Appropriations Act (the “Cromnibus”) appropriated $10 million for the National Diabetes Prevention Program. The National Institute of Diabetes and Digestive and Kidney Diseases also received an increase of $5 million from prior budgets.

Older Americans• Funding of Senior Meals on Wheels program is in the 2015 Cromnibus bill.• The Academy is actively involved in planning the White House Conference on Aging, with a webinar coming up in

January 2015.

HIV/AIDS: Ryan White Comprehensive AIDS Resources Emergency Act• The Academy continued its involvement in an advocacy work group focusing on food as medicine and continuing to

promote strong nutrition services and covered RDN-provided services in the Ryan White HIV/AIDS Program.


2014 Public Policy A Success Storyby Karin Palmer, RDN, LD, CDE


Prevention and Public Health• Faces of Austerity, a collaboration with the Coalition for Health Funding, was launched to show the effects of

sequestration on the health professions.

Public Policy Workshop 2014• At PPW, more than 400 RDNs came together to advocate for key policy issues that will improve the food and nutrition

environment. Three pieces of legislation were highlighted: the Treat and Reduce Obesity Act, the Preventive Health Savings Act and the Older Americans Act Reauthorization Act of 2014.

FNCE 2014• During FNCE many activities took place including roundtable discussions, including roundtable discussions, affiliate

meetings, public policy track sessions, and a Nutrition Policy and Advocacy Center. Additionally there was a combinedDPG and MIG Town Hall Meeting. At the meeting attendees received the new grassroots advocacy guidebook for public policy leaders.

As DHCC’s Policy and Advocacy Leader (PAL) and Reimbursement Representative I will keep you informed of public policynews and developments. Your continued involvement and support of food, nutrition, and health policies is necessary forus to achieve our professional and organizational goals.

2014 Public Policy A Success Storycontinued from page 19


It was an honor representing our DPG at the HOD meeting at FNCE!

Lively discussions occurred around the two topics Business and Management Skills and Supervised Practice ExperiencePositions. I shared all the feedback you provided and quite a bit of it was supported by others. Thank you to those whocontributed comments!

The topic of Business and Management Skills was brought forward due to member concerns and supported by the 2006Employer Qualitative Research Study (1).

The report solicited the views of 140 employers of RDNs and DTRs with the focus on entry level practitioners. The majorityof employers identified management skills as a weakness for entry-level RDNs. Employers wanted RDNs who look at thebig picture and think strategically, run and justify programs, understand healthcare as a business, add value and areentrepreneurial. Employers wanted RDNs with the following skills: • ability to work in a team • ability to work across levels/departments in the organization (patients, doctors, nurses, techs, administrators, cooks) • supervision • coaching/mentoring • negotiation • accounting and finance • budget and cost control • inventory control • quality assurance and performance improvement • marketing/selling; • revenue generation • reimbursement, sales, and grant writing

The House meeting opened on October 17th with an update by the President, followed by a panel discussion with a widerange of Dietitians working in the Business world sharing their experiences.

Pearls of Wisdom from the Panel included:1. Find mentors in Business and Nutrition2. There is no such thing as a final plan3. A Masters is important for critical thinking skills4. If something is broke bring and be a part of a solution, Problem solvers at times stand alone and make decisions

others may not agree with - Lead5. Networking is power6. Get involved in the Academy7. Taking Risks is valuable and necessary8. Know the price of your worth and do not compromise/undervalue yourself9. Know your Value equation – How long will it be before they receive a return on their investment in you10. Shed your limiting self-perceptions, realize you are part of a bigger picture and that comes with responsibility andimpacts our overall professional value.Many other speakers provided updates on topics from the foundation, fiscal budget report, to ANDPAC.

Lively discussions occurred around both the Business and Management Skills and the Preceptor and Supervised PracticeExperience topics by dietitians representing education, clinical, foodservice, and management from many industries,resulting in two motions developed and approved by the HOD as listed below.


News from HODby Angela B. Sader, MBA, RD, LD


HOD Motion #1- Business and Management Skills: The HOD requests that the House of Delegates Leadership Teamestablish a task force with representation from DPGs and internal and external stakeholders. The task force will review allof the HOD input from the dialogue session to determine a plan to assist members and students with building, enhancingand utilizing skills and knowledge related to business and management.

HOD Motion #2- Preceptors and Supervised Practice Experience Positions: The HOD requests that the Speakercommunicate all of the input generated by the HOD to ACEND, CDR and NDEP for their consideration in addressing thesetwo critical issues facing the profession. I will keep you posted as information continues to come available!

The HOD will be discussing the mega issue “Engaging Members in the Need to Address Malnutrition Across Nutrition andDietetic Practice Settings” on Saturday, May 2, 2015. The HOD will also discuss the Academy’s corporate sponsorshipprogram on Sunday, May 3, 2015. The HOD Backgrounder and supporting materials on Malnutrition are currently availableat http://www.eatrightpro.org/resources/leadership/house-of-delegates/about-hod-meetings.

HOD Backgrounder material on the corporate sponsorship program is being developed and will be posted soon.

continued from page 21

Do you know an exceptional DHCC member who deserves recognition? DHCC sponsors awards to recognize thesemembers. The application deadline for all is May 1, 2015 unless otherwise noted. Applications may be found on theDHCC Web site www.dhccdpg.org (sign in). Self-nominations are accepted.

Abbott Leadership AwardThe Abbott Leadership Award is one of the highest honors the practice group can grant to members never having servedon the DHCC Executive Committee. The honor is awarded for outstanding contributions to their profession and theclients they serve. Only one Award totaling $1,000 may be made annually.

DHCC DISTINGUISHED MEMBER AWARDThe Distinguished member award may be given annually to a DHCC Member who has made significant contributions tothe profession and organization. Up to 3 Distinguished Member Awards may be selected each year.

DHCC “UP & COMING” MEMBER OF THE YEARThe DHCC Up & Coming Member of the Year award recognizes the competence and activities of members who have beenin practice for 10 years or less and who have been members of Dietetics in Health Care Communities (DHCC) DPG #31 ofthe Academy of Nutrition and Dietetics for at least three (3) years. The purpose of this recognition is to encourage theircontinued participation in DHCC and identify potential leadership for DHCC at the district, state, and national levels.DHCC may recognize one (1) member each year in each of the three (3) following areas:1. Long-term care2. Corrections3. Homecare

DHCC BEST PRACTICE AWARDThe purpose of the “Best Practice Award” is to recognize innovations in practice, communicate practices to the DHCCmembership, and encourage ongoing efforts that improve practice. "Best Practice Awards" will be selected twice eachyear. All recipients will receive $250.00 from DHCC.

DHCC Member Awardsby Jamie Ritchie, MS, RDN, CSG, LDN


DHCC is pleased to announce election results for 2015-16. These officers will begin their terms on June1, 2015. Congratulations – and thanks to all who were on the ballot.

Office ElectedChair-Elect Dana Fillmore, RD, CP-FS (MI)Treasurer Cynthia Wolfram, RD, LD (TX)Nominating Committee Digna Cassens, MHA, RD (CA)

Brady Taylor, RDN (MS)

The Academy Nominating Committee is pleased to report the outcome of the 2015 national elections.The following individuals have been elected from among many excellent candidates. The committeethanks all who participated in the nomination and election processes.

2015 ELECTION RESULTSBoard of Directors• President-elect: Lucille Beseler, MS, RDN, LDN, CDE (FL)• Treasurer-elect: Margaret Garner, MS, RDN, LD, CIC, FAND (AL)• Director-at-Large: Michele Delille Lites, RD, CSO (CA)

House of Delegates • Speaker-elect: Linda T. Farr, RDN, LD, FAND (TX)• Director: Tamara Randall, MS, RDN, LD, CDE, FAND (OH)• At-Large Delegate - Nutrition and Dietetics Technician, Registered (NDTR): Leah Firestone, DTR (PA)

Accreditation Council for Education in Nutrition and Dietetics • Practitioner Representative, Nutrition and Dietetics Technician, Registered (NDTR): Michelle Clinton-

Hahn, DTR, CDM (AODA)

Nominating Committee • Tom Malone, MS, RDN, LD, FAND (TX)• Marisa Moore, MBA, RDN, LD (GA)

Commission on Dietetic RegistrationRegistered Dietitian Nutritionist (RDN): • Coleen Liscano, MS, RD, CSP, CDN, CNSC, IBCLC (NY)• Becky Sulik, RDN, LD, CDE (ID) Nutrition and Dietetics Technician, Registered (NDTR): • Kevin Grzeskowiak, NDTR, FMP (FL)

For more information regarding nominations and elections, visit www.eatrightPRO.org/elections.

2015 Election Results

Chair*Lisa W. Eckstein, MS, RD, LDCanton GA

Chair-Elect*Kathy Weigand, RD, LD/NValrico FL

Past Chair*Pat Dahlstrom, RD, LDVancouver WA

Secretary*Jamie Ritchie, MS, RDN, CSG, LDNRaleigh NC

Treasurer*Lorie Stake, MS, RD, LDNDillsburg PA

HOD DPG Delegate*Angela Sader, MBA, RDWichita KS

Membership CoordinatorPatricia Iorio, MS, RD, LDNClinton MA

Professional Development CoordinatorLaura Goolsby, MS, RD, LD/NKathleen FL

Policy and Advocacy LeaderKarin Palmer, RDN, LD, CDEWalton Hills OH

Sponsorship CoordinatorKaty Adams, MDA, RD, CSG, LDLa Grange TX

Connections (Newsletter)Managing EditorPaula Bohlen, MS, RDN, LDN, LNHASioux Falls SD

Cont. Ed. Editor: Marilyn Ferguson-Wolf,

MA, RD, CSG, CD Seattle WA

Corrections Sub-Unit Marlene Tutt, MS, RDSan Diego CA

Manager DPG RelationsSusan DuPraw, MPH, RDAcademy of Nutrition and

Dietetics800-877-1600 ext 4814312-899-4814312-899-5354 (F)[email protected]

Executive DirectorMarla Carlson2219 Cardinal Dr; Waterloo IA50701-1007319-235-0991319-235-7224 (fax)(Central time zone)[email protected]

Academy Web Page: www.eatright.org

DHCC Web Page: www.dhccdpg.org

Newsletter ReviewersLisa Eckstein, MS, RD, LDPat Dahlstrom, RD, LDSusan DuPraw, MPH, RDMarilyn Ferguson-Wolf,

MA, RD, CSG, CDJamie Ritchie, MS, RDN, CSG, LDNLorie Stake, MS. RD, LDN

*Elected DHCC EC member with voting privileges.

Dietetics in Health Care Communities (DHCC)Executive Committee and Officers 2014-2015

Connections

The quarterly publication ofDietetics in Health CareCommunities (DHCC), a dieteticpractice group of the Academyof Nutrition and Dietetics.

Viewpoints and statements inthis publication do notnecessarily reflect policiesand/or official positions ofDHCC/ Academy of Nutritionand Dietetics.

If you have moved recently, orhad a change of name, pleasenotify Academy MembershipTeam as soon as possible byemailing [email protected] or at the Academy’sWeb site at www.eatright.org“Edit Profile.”

© 2015 Dietetics in Health CareCommunities, a dietetic practicegroup of the Academy ofNutrition and Dietetics.

Paula Bohlen, MS, RDN, LDN, LNHA10915 Highway 18, Apt 203Conneaut Lake, PA 16316

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