The Various Roles of an RD: Community Health Center Dietitian

Different community health centers have different services that they offer patients. Some have dental  and vision offices in addition to their medical practice. Some even have a WIC clinic located within the center. Some will also have a Registered Dietitian or two on staff to provide nutrition counseling.

At the community health center where I was placed during my dietetic internship, there was a bilingual dietitian who saw patients of all ages, from people newly diagnosed with diabetes to new mothers who needed prenatal nutrition counseling. There was also a dietitian on staff who was in charge of a program focusing on reduction of childhood overweight and obesity.

Several health centers run programs similar to this one where there is a case manager who helps the kids find physical activities that they are interested in and an RD who takes care of the nutrition counseling sessions. The nutrition counseling sessions are often done with several members of the family present. When a child is struggling with weight issues, the parents (who are often the ones providing the food) need to be part of the conversation. The counseling sessions would focus on small, realistic steps that the child and parents could make in order to best benefit the child's health. For example, based on the dietary recall the main suggestion may be the cut back on juice. In that case we would explore alternatives that the child might enjoy drinking or ways that the whole family could replace juice with water and still enjoy it - for instance by adding fresh fruit.

The RD in a community health center setting needs to have the ability to remain focused in a potentially hectic environment (for example being able to focus on the conversation with the parent while several siblings are playing loudly in the background) and be flexible when patients do not show up or re-schedule at the last minute. This is different from a hospital setting where patients are a captive audience or a private practice setting where patients may be paying out of pocket and are therefore more motivated to show up for their appointment.

The Various Roles of an RD: WIC Nutritionist

I had the wonderful opportunity to do a rotation in the state WIC office at the Department of Public Health which included one week at a local WIC office. For those who might not be familiar, WIC stands for Women, Infants, and Children and is a nutrition program where pregnant women, moms, and children who meet income requirements are eligible for nutrition education, breastfeeding resources, and supplemental food coupons. Unlike SNAP or Food Stamps, WIC coupons are only good for very specific foods (these vary but the basics are: milk, whole grains, and fruit and vegetables) and the participants must attend nutrition counseling on a regular basis. WIC also highly encourages breastfeeding as it is the best nutrition for newborn babies by offering peer counselors, lactation consultants, and incentives for women who choose to breast feed exclusively.

The role of an RD at the state office differs greatly from that of an RD or nutritionist at a local WIC clinic. Obviously at the state level they are more focused on statewide programs, grants, and overseeing the local clinics, making sure that they are meeting the standards set forth by the state. At the local level, all WIC clinics employ nutritionists, and these may or may not be RDs. Some are LDNs (Licensed Dietary Nutritionists), some are DTRs (Diet Tech, Registered) and some have met other levels of education in order to qualify.

In the day-to-day role of a WIC nutritionist, they will see participants throughout the course of the day either from appointments or on a walk-in basis. These appointments range from pregnant mothers to mothers who have infants to children up until age 5 and they differ slightly based on the type of appointment (initial, low-risk follow-up, high-risk follow-up, etc). When a participant arrives they first have their height and weight taken. Then the nutritionist will sit with them to go over the child’s growth chart and where they fall on the weight for height chart. After that he or she will take a diet recall which might result in the number of ounces of formula per day a baby is drinking or what a toddler eats during the course of the day depending on the participant. Once the diet recall is complete the nutritionist will focus on any problems identified and methods for changing (for example if a child is not drinking the recommended amount of milk per day, they will work with the mom to identify where in the diet to include an extra serving). At the end of the appointment the nutritionist goes over the participant’s “package” which is what specific coupons they receive. Any changes are made based on a few factors such as whether the participant has decreased the amount that they are breastfeeding or whether the participant would rather get whole wheat tortillas instead of whole wheat bread. When the appointment is done the coupons are printed.

There are a wealth of handouts produced by WIC in several languages that are available for the nutritionists to distribute. At the local clinic where I spent the week many participants spoke Vietnamese or Spanish, so there are nutritionists on staff there who speak those languages. WIC also provides referrals to other organizations such as parenting groups, fitness classes, and community activities. WIC is a national program and employs many dietitians, making it a good career option for any RD or RD hopeful across the country.

The Various Roles of an RD: Community/Non-profit Dietitian

There are lots of opportunities for an RD to work in a community setting. Many non-profits employ RDs. This could range from someone working for an organization that delivers healthy meals to people who are chronically ill to someone who teaches urban or low-income teens how to grow vegetables in a city.

I was fortunate enough to be placed at the Greater Boston Food Bank (GBFB) for a rotation and got to see what it might be like to be an RD working under the hunger umbrella. There are actually a few RDs who work at this particular organization and they serve a variety of roles. They help to ensure that all of the food that goes out to pantries and organizations is safe (ie not expired), train people from pantries and organizations in food safety, and help to teach people at these organizations about healthy eating. This may sound a bit abstract so I'll focus mainly on what I did while I was there:

• Design and implement lesson plans about nutrition for kids at a Boys and Girls Club. The GBFB supports a program called Kids Cafe where kids get an evening meal served for free at the Boys and Girls Club. I taught the kids about sodium, calcium, and the importance of fruits and vegetables by playing games and making recipes.
• Create and cook a recipe for a School-based Pantry. These pantries, as well as Mobile Markets, are one way that the GBFB donates food directly to consumers. They set up in a school cafeteria in the community and parents can come and take a variety of foods such as vegetables, fruit, bread, hummus, and yogurt. The day that I went we found out that we'd be handing out acorn squash so I made an acorn squash pasta bake. I handed out samples as well as recipes so that they could make good use of their squash!
• Write nutrition newsletters for different audiences. A few other programs that GBFG implements are the Backpack and the Brown Bag program. Backpack ensures that kids have a bag of shelf-stable food to take home on the weekends and Brown Bag gives bags of groceries to seniors in a supermarket bag to remove any stigma associated with receiving donated foods. Within each bag of food is a nutrition newsletter geared at either the seniors or the kids. These feature a recipe, some cooking tips, and a game.

Working at the food bank is just one example of how an RD can make a difference by working within the community. While it is a very different role from a clinical or counseling position, it is important in the effort to make the community a healthier place!

The Various Roles of an RD: Sports Dietitian

When I started working with two sports dietitians for the counseling portion of my dietetic internship, I wasn’t really sure what to expect. As I learned over the four weeks, there is not a clearly defined role for someone with that specialty. A sports dietitian can wear many different hats and work in a variety of different settings. For example, many college-level and professional sports teams have an RD on staff to help their athletes eat better to perform better. Then there are those who have a private practice and take anyone interested in meeting with an RD but specialize in sports-related issues. Here is a brief snapshot of what two of those roles look like:

Sports Dietitian in a Gym Setting

At this particular facility, the RD was an employee of the gym (rather than just renting out office space within the gym). She had the same responsibilities of other managers there, attending budget meetings, spending one weekend a month as the manager on duty, discussing goals, etc. Her coworkers were personal trainers and group fitness directors.

The clients that she saw consisted primarily of members of the gym who were interested in losing weight. Many of them also meet with a personal trainer to help reach that goal. There were also some clients who needed help managing diabetes, lowering cholesterol, or dealing with a food allergy. Clients can pay out of pocket or if their insurance will cover the visit, the RD bills them and keeps track of which companies have sent her the payments and when (much more time consuming than you might think!). At this gym the RD also does all of her own marketing as well as scheduling. She writes blogs and facebook postings in attempts to educate members of the gym as well as encourage them to come see her. Many of her clients track what they eat using the application MyFitnessPal and she can log into their account between sessions to encourage them or provide suggestions.

The most spots-focused activity that she did during my time with her was to give a talk to the parents of members of the gym’s swim team. She discussed the importance for student athletes of snacking, hydrating, and of course the essential post-race chocolate milk.

Sports Dietitian in a Hospital Setting

In the setting of a hospital, an RD has a much different role as well as different responsibilities. As a staff member at the hospital, her co-workers were doctors and physical therapists who also specialize in sports. She did not do any of her own scheduling or billing since that was done through the hospital system.

This particular RD saw a lot of patients who have eating disorders. Many of these patients were also athletes such as runners or dancers. A number of other patients were dealing with being overweight or had slow-growth or delayed puberty. 

The most sports-focused activity that she did during my time with her was to participate in a clinic for runners where they could come to have their running (and eating)  analyzed by a physical therapist, a podiatrist, an RD, and a gait analysis.

Regardless of the setting or the fact that they both specialize in sports nutrition, my experience with one-on-one counseling was that often the session does not involve a lot of talk about food. Yes it’s covered, but much of the time issues with food and eating extend so much beyond just knowing what you should and should not eat that there is a lot of general therapy happening.

The Various Roles of an RD: Clincial Dietitian

As many of you know, I am currently in the middle of my Dietetic Internship (DI) which is the last step before I'll be certified to take the exam to become a Registered Dietitian (RD). Every DI across the country, whether based out of a college like the one that I got matched to or based out of hospital, has three elements to the rotations: clinical, community, and food service. Some DIs focus more on one particular element, but each program must incorporate each of those elements at some point. It's a great way not only to learn from many different preceptors and prepare us for the big exam that comes at the end, but also to see the varied roles that are out there for an RD once we pass the big exam! So I've decided that as I go through my internship and work with RDs in different settings I'll highlight that career path here. Hopefully this will give you a better picture of what an RD does and the various options available to someone in this field. Keep in mind that these descriptions are based on my experiences with people in these roles but the responsibilities are certainly different in different places.

Clinical Dietitian
A Clinical Dietitian works in a hospital with patients who are admitted as "in-patient" - this is different from someone who might work in a hospital with patients who schedule appointments to see him or her (that would be "out-patient").

At my clinical rotation a typical day for a clinical dietitian would look something like this:

First thing in the morning, print the sheets that tell us everyone who is currently admitted to the hospital including what date they were admitted and what their admitting diagnosis is. Based on their diagnosis, we then figure out when we need to see them. Basically if they are admitted for something nutrition related, we see them sooner. This prioritization is necessary because there isn't enough time to see everyone while they're in the hospital and it would not make sense for us to go see someone who has had hip surgery but has a normal appetite when someone who has stopped eating gets discharged before we have a chance to see them!

Based on their diagnosis, or if a nurse or doctor has requested that we see a patient, we now know who we need to see that day (each day's notes get carried over to the next day so that we can keep track of how many days a person has been here and when we need to see them based on the prioritization). Once you know who you'll be seeing that day you can start to do some research into their past: what is their medical history, have they had weight change recently, have the nurses been recording their appetite, etc. After the background has been researched we head to the floors where the patients' rooms are. We hope that the ones that we need to see are in their rooms and available though often they're off the floor for a test or busy with another medical professional. Once we do get in to see the patient we do our interview to gather information from the patient. Depending on their admitting diagnosis we ask questions such as: What is your normal weight? How is your appetite currently? Have you noticed your pants are feeling looser? Do you typically follow a diabetic/low salt/fat free diet at home? Would you be open to trying a supplement such as Ensure?

Once the interview is over we go off to type our note into their medical file. The note includes information from the interview as well as our nutrition diagnosis. The nutrition diagnosis is written as a PES statement: Problem, Etiology, Signs and Symptoms. Here is an example of a PES statement: Inadequate oral intake related to nausea and vomiting as evidenced by patient report of not eating for 5 days prior to admission. We then address what we're going to do about the nutrition diagnosis such as suggest supplements, educate them on the diabetic diet, etc and how we will monitor their progress (track lab values, weights, how much they're eating).

In addition to repeating that process for all of the patients on the list for that day there are also meetings such as interdisciplinary rounds to attend and patients on nutrition support to follow-up with (tube feeds or total parenteral nutrition).

There is even more that a clinical dietitian does in their day-to-day role in a hospital but hopefully this sheds some light on one very important role that an RD can play!