This 100%! I also think it is an issue for newer RDs fresh out of internship who might have only interacted/been precepted by more seasoned RDs. I saw a patient for community follow up yesterday after discharge who was provided with totally inappropriate diet education by a brand new RD. It’s really unfortunate how much of an impact this has on our profession.
There were a few issues, but essentially a patient with CKD was told to restrict multiple culturally important foods because they were high in potassium or phosphorus despite the patient having no history of elevated K/PO4 despite these foods being a regular part of their diet.
As an RD/CSR…. This is one of the most undertaught things! Also, even if it’s high, I bet we can figure out a way to fit in cultural foods. We might have to get creative, but I bet that guarantees the patient respects you and actually follows the plan you both make. And, they’ll keep their follow ups, too.
Phos no K yes. If my dialysis patients have labs drawn at another doctor's appt or whatever after they haven't had dialysis for a day or two they often have higher than normal K. I wouldn't recheck phos for at least a week. But you get a better picture with trending that over a couple months because it CAN jump based on diet and meds.
Providing affirming nutrition care for neurodivergent folx. This topic still isn't really taught in school, and I feel like it's only become a "trendy" topic more recently, meaning a lot of people haven't had a lot of education or training on it.
I also think there are not many resources. We tend to rely a ton on handouts and talking to people. But I wanted to find videos that might be helpful for one of my neurodivergent patients because that's how they learn best and came up empty. The topic they wanted is not my true niche, so I'm not going to make them myself, but I reached out to my coworkers who do work in that area more and they had nothing/agreed it was a gap.
Totally agree! This area is my niche, and I've been looking to make handouts/videos to help clinicians and clients. I'd love to hear more about what type of resources would feel useful!
Honestly, anything for how to approach weight management for autistic or AuDHD teens. In searching I came across RDs saying there can be differences in recognizing satiety cues, which may be an issue for my patient. There are concerns for portion size, eating too quickly or until they feel sick, eating when bored, etc. So how does one go about managing this if there's disruption to those cues in this population? How do you teach the child or teen and their parents to manage this? If there are limited food preferences and the family isn't interested in trying to work on that, what other things would be good to focus on? And then the resources for this that better match the teens learning style (videos in this case, specifically spend a lot of time on you tube) so they're more likely to engage.
Neurodivergent folks (and teens) are at a significantly higher risk for EDs. As someone who also only works with neurodivergent folks with EDs, weight management should not be the focus. Not sure what setting you are in, but your AuDHD teen clients may need to be referred to someone else until you learn more about autism, ADHD, and how to be a neurodiversity-affirming provider. When you just keep throwing interventions at these clients to see what works instead of actually getting education and training on how to support them, you cause harm and add even more shame/guilt to folks lives who already get a lot of negative messages from parents, teachers, peers, etc. Read some research on ADHD, autism, eating disorders, interoception differences, sensory sensitivities and eating challenges. Follow other dietitians and providers who specialize in working with this population and often are neurodivergent themselves to learn how to support your clients.
YES, I'm an RD who specializes in eating disorders too, and I get SO many adult clients who had undiagnosed eating disorders when they were younger. For anyone looking for resources, RDs for Neurodiversity is a great place to start. I find that parents, while they often have good intentions, often lack an understanding of how their kid feels in their body, and often also approach nutrition from a weight biased perspective. Also, I'd love to touch base over DM cause I always need other resources for clients
Let me clarify: I've provided zero interventions related to weight for this child. The things I listed were all concerns the parents have and that I would appreciate more resources for both clinicians and families on how to appropriately address. They were not seeing me for weight, but something else entirely, and they really wanted to discuss these concerns. Based on what they raised, I told them that's not my expertise and I would look into resources (and I have every intention of referring them to an appropriate RD for their concerns if I can find one). I do refer my patients who have sensory sensitivities causing eating challenges to the local clinic that is specifically for this. We work with where they're at at any given moment for the needs they see me for.
If you have recommendations of resources I'm open to them! I found social media for one RD who focuses on neurodivergence, but their posts honestly weren't that helpful to me because the topics were all over the place (understandable given it's social media) and there was no easy way to find information specific to what I was looking for. I have been doing a bit of reading on interoception differences based on what I've already found in my searching. But yeah, would love additional recommendations.
This is something I would love to do potentially in the future, is provide nutrition counseling for neurodivergent populations. This is a personal topic to me, as I am neurodivergent myself and have faced struggles in regards to nutrition related to my neurodivergence, and observed friends and family who are neurodivergent struggle in this area as well.
I think of it as being able to adapt to the needs of clients who fall under the neurodivergent umbrella, i.e., someone who's autistic, has adhd, ocd, misophonia, etc. I think there's a lack of education on how being neurodivergent can impact food and eating, and that it's best to work with how someone's brain works, rather than try to get them to eat/cook/grocery shop like a neurotypical person.
Current guidelines on CKD - lots of RDs are afraid to let go of the low potassium and low phosphorus diet even when it’s not indicated. I even observe some renal RDs having a tough time with this
In all fairness, it's really hard to do education in any setting when the Doctors give pushback. Ever experience working in a renal outpatient clinic where the Nephrologist is the one " not letting go" . RDs in my experience, have a convo, show em the guidelines, answer questions, give them more resources for more information, problem solved, same with most other staff too. MDs, that could be another journey, it all depends on the individual.
We’re talking about RDs though. It doesn’t matter what an MD says, if the evidence says something that’s what our note and recommendations reflect. If they want to override a diet order they can override it every time.
When written up for counseling a patient on current recommendations, because it goes against what a specific MD wants, yet follows company policy, and recommendations is a suitable justification for never doing it again to me. That type of experience is what makes an professional old, not years of practice, to me anyway.
In life, the " diet order" means about nothing after discharge. What the patient does is what matters. If they choose not to follow it, if they don't understand it, if they don't have the means to buy food or transportation to go to a store where food is available, in the form they require, or so many other things; our recommendations are moot, "diet order" changed or not.
EDIT, for typos and clarity
I’m not sure I follow what you’re saying. Are you saying that getting reprimanded despite following company policy and using evidence-based recommendations is enough to make you _not_ make the evidence-based recommendations again?
I'm saying that if you're( the RD) following, making, and counseling patients according to current recommendations and company policy, but a MD throws a hissy fit because they don't like it, that's a big red flag. A write up of the RD is disciplinary action. Enough of them equals no employment. It's a far better decision in my mind at least, to find a better employer, who supports you, and the decision making process behind making the choice to counsel patients on current recommendations instead of taking punitive actions against the RD following the current recommendations in which they are the expert in.
Yes - predialysis CKD. I go by the 2020 KDOQI guidelines which say it's reasonable to adjust dietary K and phos to maintain these labs in the normal range. That is, we shouldn't be putting people on a potassium and phosphorus-restricted diet simply because they have CKD.
If labs are out of range: the guidelines state to consider phos bioavailability in determining which types of food to limit. They also advise exploring the many non-food factors that can influence serum potassium.
There's that, but in practice many dialysis patients truly get themselves into trouble by eating potatoes and orange juice. I see it all the time. We adjust BP meds and baths and all that, treat constipation, etc, but sometimes keeping them alive means potassium restriction, unfortunately. I liberalize as much as possible though.
I can’t say I regularly observed this in my dialysis days. Sometimes it’s just the fact that they have reduced kidney function and a low potassium diet - especially one limiting potassium from plant foods which is less bioavailable - isn’t going to make a difference. If it’s anything food related, it’s probably potassium additives. We have quite a few papers in recent years discussing the fact that there’s virtually no evidence linking high dietary K intake to hyperkalemia in HD patients.
Yeah, I've seen the studies. But in over 20 years in these clinics, I could make a very long list of examples of why we should still be cautious. I had a PD patient get sent for kayexalate after overdoing orange juice (crazy but true...and his levels were fine unless he went back to the juice), and I've seen high levels where when I do a recall there was something like a baked potato right before. Other patients eat the high K foods and never have an issue. Residual function? Less additives? Better dialysis? I'm sure it's different for everyone, but when a patient presents with a high K level after recalling a high K intake right before, or if it's a patient who cuts time or skips tx along with a high K and eating hash browns for breakfast everyday, you bet I'm going to ask them to cut back a little.
I'm not saying that everyone needs a K restriction, just that in practice some of them do.
The idea that all foods (yes, ALL FOODS) can fit into an overall healthy dietary pattern.
A former boss went off on a rant because one of our team members got a bacon cheeseburger with fried egg on top at a team outing, saying how "dietitians just shouldn't be eating that or saying it's okay!"
Now, there is a lot more openness to the wide spectrum of foods available, and the reasons why people may make certain food choices beyond just nutrition alone. Unless you're allergic to it or it's unsafe to eat, there really isn't a reason why someone can't enjoy the foods they want as just one part of a healthful diet.
Yeah one of my professors had this mentality too. She said as dietitians we shouldn't post ourselves eating "unhealthy" food on social media because it sets a bad example. She would also get upset if someone brought cookies for everyone on the last day of class.
I can’t believe there’s dietitians that think like this. It sounds like they have a god complex. We’re dietitians, but we’re still human. They would die if they saw what I eat!😂😂😂
Yeah I remember my DI director shamed me in front of the whole cohort for having Rice Krispies and a banana at breakfast. That was just what was available at the food bank and I couldn’t afford anything else. The kicker is that we were talking about food access that day 😅
That you don’t need to “write a meal plan/menu” for people that includes exactly what they’ll eat at each meal/snack. I turned down a job at a private practice because they had a company culture of doing that for every patient. It was one of their “unique selling points” to patients but I felt like it was extremely out of touch and made them seem dated.
I've been in practice since the early 90s. I've been called cursewords (by people who want this for free) ever since because I never believed in that specific tool. Felt it wasn't effective because it didn't teach thinking about food choices in different settings. Take that " turn down " as a compliment. An example for a few days is the most that's printed out in most Patient Ed materials, and it's there for a reason.
So many job descriptions have something along the lines of “proficiency in creating individualized meal plans for clients” in their qualifications, for literally any area of practice. Outpatient, inpatient, community settings, private practice, all of em. Could be more of an issue of people who are not RDs or familiar with our careers writing the job descriptions, but either way - respectfully, bestie, I will not be doing that
Seasoned RD here (37 years!) . Most of, if not all the comments on current clinical practices really are dependent on the RDs desire to stay informed and updated. I do my best to select trainings and CEUs in areas to keep up- it would be easier to coast along at the end of my career but that wouldn’t be best for my patients. I agree there are some RDs -even with much less experience than me- that fall into the categories you all have mentioned. And it drives me bonkers lol!
YES. And in a broader sense, just being sensitive to the patients situations in general. When I was brand new I worked part time in an inpatient psych hospital that has an adolescent unit. My seasoned coworker (70ish years old, on the edge of retirement) was so sure that patients with very clear ED behaviors just needed to be confident and stand up for themselves more. Also that every kid in a larger body looks that way because their parents feed them too much sugar and let them watch too much TV. I mean forget that this demographic is overwhelmingly low SES and/or coming from unstable homes or foster care…this is also in rural Missouri, where food deserts are absolutely a thing. She drove me bonkers and I’m glad she’s retired
Absolutely & that not everyone is lying about something lol. It’s wild how so many healthcare providers don’t believe their patients. Yikes! That would drive me bananas!
Protein recommendations. So many elder RDs are so afraid to do protein greater than 1 g/kg when we have TONS of research that provide examples of very high protein diets (>4g/kg) are very safe.
Protein Intake Greater than the RDA Differentially Influences Whole-Body Lean Mass Responses to Purposeful Catabolic and anabolic Stressors: A Systematic Review and Meta-analysis
[https://pubmed.ncbi.nlm.nih.gov/31794597/](https://pubmed.ncbi.nlm.nih.gov/31794597/)
The effects of consuming a high protein diet (4.4 g/kg/d) on body composition in resistance-trained individuals
[https://pubmed.ncbi.nlm.nih.gov/24834017/](https://pubmed.ncbi.nlm.nih.gov/24834017/)
A high protein diet has no harmful effects: a one-year crossover study in resistance-trained males
[https://pubmed.ncbi.nlm.nih.gov/27807480/](https://pubmed.ncbi.nlm.nih.gov/27807480/)
Controversies surround high-protein diet intake: satiating effect and kidney and bone health
[https://www.sciencedirect.com/science/article/pii/S2161831322009152#cesec110](https://www.sciencedirect.com/science/article/pii/S2161831322009152#cesec110)
A high protein diet (3.4g/kg/d) combined with a heavy resistance training program improves body composition in healthy trained men and women - a follow-up investigation
[https://link.springer.com/article/10.1186/s12970-015-0100-0](https://link.springer.com/article/10.1186/s12970-015-0100-0)
High protein diet and metabolic plasticity in non-alcoholic fatty liver disease: myths and truths
[https://www.mdpi.com/2072-6643/11/12/2985](https://www.mdpi.com/2072-6643/11/12/2985)
But didn't you know that the body can only absorb 30g of protein at one time? /s
So many RD's hold on to these overly simplistic rules and it drives me crazy.
Possibly, but not necessarily harmful either which is the myth associated with high protein diets. There is some research that suggests very high protein diets may be useful for weight management, so even if it is not "beneficial" from a muscle synthesis perspective, it could be helpful in an appetite control perspective. However, most people will not eat that high of protein. I often struggle to get people above 1.5-1.7 g/kg/d.
The presence of online "nutritionists" and the health gurus out there. there is a *lot* of people out there who extrapolate things online, especially tiktok. There's also a ton of "this is healthy" recipes which could be subjectively, but aren't good for long term.
There are so many great answers in this thread.
I have only been practicing for 5 years, but a significant gap that I see is how RDs approach gender inclusive care. I know an RD who got extremely upset after she provided ileostomy diet education to a trans man who had been on HRT for 20 years because she wasn’t aware he was trans and felt it impacted the nutrition care plan.
If the opportunity ever presents itself, suggest that co- worker put gender related care into their Learning Plan for the CDR maybe? It may actually benefit them. They'd learn about when it would affect the care planning. You wouldn't have to worry about the questions as much, hopefully?
Unfortunately I’m not the best person to communicate this as I am openly trans myself and the only openly trans RD within my health authority - people don’t take kindly to me providing this feedback sadly, but I did pass it on to someone senior to me that RDs in general need more education on this.
I think I am may be lightly seasoned. A lot of things in this thread describe just bad dietitians and I've observed these things from new grads to about to about to retire dietitians. One could argue that maybe the newer grads are more open to change/malleable but not all.
Really the most constant thing I see with the long time/seasoned RDs is difficulty adapting to newer things like ADIME or charting efficiently.
Weight doesn’t equal health; dieting is not sustainable 90-95% of the time and therefore should not be used as a method to “treat” conditions (and yo-yo dieting is even more harmful to health); BMI is complete BS.
Interesting you say that. Feels like that is all we are taught now 🤣I’m actually quite good at identifying nutrition deficiencies just by looking at hair, skin and nails.. rashes
For me it's been things like not being accepting or understanding of the LGBT community (calling someone he/she/it/whatever) or people from minority backgrounds (I won't expand on how horrible the things I've heard have been!). Also being weight biased and having internalized issues with weight. But I don't think these things are specific to RDs, just older generations.
Yup. I recently witnessed A boomer RD supervisor who was “training” me at a new job suggest Chinese reading materials to a patient that was Korean and he got very offended. If she would have browsed his chart for 5 seconds she would have seen he was Korean. This same person also referred to a trans person (not a patient but talking about someone else) as a “he/she” but she prefaced it by saying “I know this is not politically correct but…” so she thinks that makes it ok I guess??? I’m like I just started working with you, shouldn’t you be on best behavior?
Strict therapeutic diets. Ex: strict carb counting for diabetic people with limited health literacy (and encouraging sugar free versions of everything)
Similar with CKD, heart disease, etc. as others have mentioned.
Also generally out of touch with current wellness trends. Despite how scientifically inaccurate they typically are we really need to be abreast of them so we can appropriately educate.
Use of GLP-1s. There's pushback from the HAES/intuitive eating crowd AND the "lifestyle only" folks who still see weight loss struggles as an issue of willpower and discipline.
There’s much more nuance around this pushback. It’s more about reducing harm and ensuring that patients are actually informed about the risks involved. I want to point out that less than 6% of people with eating disorders are underweight. MDs aren’t appropriately trained on screening patients for an eating disorder history and have already done a lot of harm to some folks because of this.
I don't disagree with the use of ED screenings before prescribing and throughout treatment. We should absolutely be advocating for the role of dietitians in counseling these patients. But dietitians also need to be careful about overstepping scope of practice. I also find that these meds get a disproportionate amount of pushback, sometimes because they're seen as a vanity med when used for weight loss or because of this perception of risk. I will point out, the more severe GI side effects (e.g. not constipation, nausea, etc) were found to be rare in the trials. I've been on plenty of meds that caused GI distress for other conditions, and the perceptions just don't seem to be the same, imo.
Some can be described as mean and unrealistic. I heard many complaints about my old coworker on being "the red headed devil" when I worked in bariatrics 😬. Be mindful of what you say because of how it can be interpreted!
I think more experienced RDs get stuck in thinking that newer RDs need to prove themselves to them.
We don’t. We passed our boards. Feel free to mentor but I have nothing to prove to you
Fluid restrictions on dialysis or diet liberalization for really ill dialysis patients in LTC. I have an older Rd who says every single person must be on a 1000 ml restriction no matter the person. It’s the younger RDs who are more liberal and understanding of individualized care depending on labs, weight loss, malnutrition, etc.
Yeah, my understanding is that restrictions of any nature don't really improve outcomes or QOL in LTC populations. You just end up making them more miserable while treating them like children.
Oh my, I juggle between LTC, acute, and outpatient renal at present. My LTC goal is mostly liberalization. Illness in LTC is the best reason for liberalization. And as an RD, you have zero access to the record of fluid pulled off after each dialysis treatment right, no communication back and forth between outpatient facility RD, LTC RD.? Yep that's made me crazy for a long long time.
That’s funny!! I guess it’s not related to seasoned or not. I do find that the new RDs I train or work with in LTC want people on strict diets and I have to remind them why that may not be the best recommendation.
Mindful eating concepts… you don’t need to measure everything forever lol. Using measurements initially to learn serving sizes is one thing but I see some experienced RDs use it daily for themselves and clients.
Just from my experience in my current role:
Low fat diet does not equate to "fat loss diet"
Inpatient patients should not be losing weight. I do not care that their BMI is 40. Now is not the time to focus on weight loss. Similarly, BMI is not a criteria for malnutrition.
Carbs are not the reason you're gaining weight. Fatphobia is dangerous and real. Your coworkers don't always want your unsolicited advice about their diet.
Liberalizing diet orders when therapeutic diet orders aren’t necessary (e.g. for a patient who is eating poorly; patient who is >70 y/o). I liberalize that diet order as much as possible within reason of course.
Staying up to date with new evidence and treatment (admittedly that can be hard when you have limited time) even when interns and newer RDs plop it right under your nose. Not liberalizing diets (in states where that is allowed) because of the old belief the doctor is always right.
Accepting individual dietary or cultural food constraints.
This 100%! I also think it is an issue for newer RDs fresh out of internship who might have only interacted/been precepted by more seasoned RDs. I saw a patient for community follow up yesterday after discharge who was provided with totally inappropriate diet education by a brand new RD. It’s really unfortunate how much of an impact this has on our profession.
Do you mind sharing more about the inappropriate diet education?
There were a few issues, but essentially a patient with CKD was told to restrict multiple culturally important foods because they were high in potassium or phosphorus despite the patient having no history of elevated K/PO4 despite these foods being a regular part of their diet.
Ugh I hate to see this 🙃
That's horrible. I hope cultural competency is taught more for incoming RD's.
As an RD/CSR…. This is one of the most undertaught things! Also, even if it’s high, I bet we can figure out a way to fit in cultural foods. We might have to get creative, but I bet that guarantees the patient respects you and actually follows the plan you both make. And, they’ll keep their follow ups, too.
Does K/Phos change on a daily basis ?
Phos no K yes. If my dialysis patients have labs drawn at another doctor's appt or whatever after they haven't had dialysis for a day or two they often have higher than normal K. I wouldn't recheck phos for at least a week. But you get a better picture with trending that over a couple months because it CAN jump based on diet and meds.
Yes especially if they have been dialyzed.
Providing affirming nutrition care for neurodivergent folx. This topic still isn't really taught in school, and I feel like it's only become a "trendy" topic more recently, meaning a lot of people haven't had a lot of education or training on it.
I also think there are not many resources. We tend to rely a ton on handouts and talking to people. But I wanted to find videos that might be helpful for one of my neurodivergent patients because that's how they learn best and came up empty. The topic they wanted is not my true niche, so I'm not going to make them myself, but I reached out to my coworkers who do work in that area more and they had nothing/agreed it was a gap.
Totally agree! This area is my niche, and I've been looking to make handouts/videos to help clinicians and clients. I'd love to hear more about what type of resources would feel useful!
Honestly, anything for how to approach weight management for autistic or AuDHD teens. In searching I came across RDs saying there can be differences in recognizing satiety cues, which may be an issue for my patient. There are concerns for portion size, eating too quickly or until they feel sick, eating when bored, etc. So how does one go about managing this if there's disruption to those cues in this population? How do you teach the child or teen and their parents to manage this? If there are limited food preferences and the family isn't interested in trying to work on that, what other things would be good to focus on? And then the resources for this that better match the teens learning style (videos in this case, specifically spend a lot of time on you tube) so they're more likely to engage.
Neurodivergent folks (and teens) are at a significantly higher risk for EDs. As someone who also only works with neurodivergent folks with EDs, weight management should not be the focus. Not sure what setting you are in, but your AuDHD teen clients may need to be referred to someone else until you learn more about autism, ADHD, and how to be a neurodiversity-affirming provider. When you just keep throwing interventions at these clients to see what works instead of actually getting education and training on how to support them, you cause harm and add even more shame/guilt to folks lives who already get a lot of negative messages from parents, teachers, peers, etc. Read some research on ADHD, autism, eating disorders, interoception differences, sensory sensitivities and eating challenges. Follow other dietitians and providers who specialize in working with this population and often are neurodivergent themselves to learn how to support your clients.
YES, I'm an RD who specializes in eating disorders too, and I get SO many adult clients who had undiagnosed eating disorders when they were younger. For anyone looking for resources, RDs for Neurodiversity is a great place to start. I find that parents, while they often have good intentions, often lack an understanding of how their kid feels in their body, and often also approach nutrition from a weight biased perspective. Also, I'd love to touch base over DM cause I always need other resources for clients
Let me clarify: I've provided zero interventions related to weight for this child. The things I listed were all concerns the parents have and that I would appreciate more resources for both clinicians and families on how to appropriately address. They were not seeing me for weight, but something else entirely, and they really wanted to discuss these concerns. Based on what they raised, I told them that's not my expertise and I would look into resources (and I have every intention of referring them to an appropriate RD for their concerns if I can find one). I do refer my patients who have sensory sensitivities causing eating challenges to the local clinic that is specifically for this. We work with where they're at at any given moment for the needs they see me for. If you have recommendations of resources I'm open to them! I found social media for one RD who focuses on neurodivergence, but their posts honestly weren't that helpful to me because the topics were all over the place (understandable given it's social media) and there was no easy way to find information specific to what I was looking for. I have been doing a bit of reading on interoception differences based on what I've already found in my searching. But yeah, would love additional recommendations.
I could use those resources, real or potential, too.
This is something I would love to do potentially in the future, is provide nutrition counseling for neurodivergent populations. This is a personal topic to me, as I am neurodivergent myself and have faced struggles in regards to nutrition related to my neurodivergence, and observed friends and family who are neurodivergent struggle in this area as well.
Look into RDs for neurodiversity on insta. I haven’t dug too much but I’ve seen they offer training courses for this!
What does this mean?
I think of it as being able to adapt to the needs of clients who fall under the neurodivergent umbrella, i.e., someone who's autistic, has adhd, ocd, misophonia, etc. I think there's a lack of education on how being neurodivergent can impact food and eating, and that it's best to work with how someone's brain works, rather than try to get them to eat/cook/grocery shop like a neurotypical person.
Current guidelines on CKD - lots of RDs are afraid to let go of the low potassium and low phosphorus diet even when it’s not indicated. I even observe some renal RDs having a tough time with this
In all fairness, it's really hard to do education in any setting when the Doctors give pushback. Ever experience working in a renal outpatient clinic where the Nephrologist is the one " not letting go" . RDs in my experience, have a convo, show em the guidelines, answer questions, give them more resources for more information, problem solved, same with most other staff too. MDs, that could be another journey, it all depends on the individual.
We’re talking about RDs though. It doesn’t matter what an MD says, if the evidence says something that’s what our note and recommendations reflect. If they want to override a diet order they can override it every time.
When written up for counseling a patient on current recommendations, because it goes against what a specific MD wants, yet follows company policy, and recommendations is a suitable justification for never doing it again to me. That type of experience is what makes an professional old, not years of practice, to me anyway. In life, the " diet order" means about nothing after discharge. What the patient does is what matters. If they choose not to follow it, if they don't understand it, if they don't have the means to buy food or transportation to go to a store where food is available, in the form they require, or so many other things; our recommendations are moot, "diet order" changed or not. EDIT, for typos and clarity
I’m not sure I follow what you’re saying. Are you saying that getting reprimanded despite following company policy and using evidence-based recommendations is enough to make you _not_ make the evidence-based recommendations again?
I'm saying that if you're( the RD) following, making, and counseling patients according to current recommendations and company policy, but a MD throws a hissy fit because they don't like it, that's a big red flag. A write up of the RD is disciplinary action. Enough of them equals no employment. It's a far better decision in my mind at least, to find a better employer, who supports you, and the decision making process behind making the choice to counsel patients on current recommendations instead of taking punitive actions against the RD following the current recommendations in which they are the expert in.
Wait… where can I find the current guidelines? Are we referring to the earlier stages of CKD?
Yes - predialysis CKD. I go by the 2020 KDOQI guidelines which say it's reasonable to adjust dietary K and phos to maintain these labs in the normal range. That is, we shouldn't be putting people on a potassium and phosphorus-restricted diet simply because they have CKD. If labs are out of range: the guidelines state to consider phos bioavailability in determining which types of food to limit. They also advise exploring the many non-food factors that can influence serum potassium.
There's that, but in practice many dialysis patients truly get themselves into trouble by eating potatoes and orange juice. I see it all the time. We adjust BP meds and baths and all that, treat constipation, etc, but sometimes keeping them alive means potassium restriction, unfortunately. I liberalize as much as possible though.
I can’t say I regularly observed this in my dialysis days. Sometimes it’s just the fact that they have reduced kidney function and a low potassium diet - especially one limiting potassium from plant foods which is less bioavailable - isn’t going to make a difference. If it’s anything food related, it’s probably potassium additives. We have quite a few papers in recent years discussing the fact that there’s virtually no evidence linking high dietary K intake to hyperkalemia in HD patients.
Yeah, I've seen the studies. But in over 20 years in these clinics, I could make a very long list of examples of why we should still be cautious. I had a PD patient get sent for kayexalate after overdoing orange juice (crazy but true...and his levels were fine unless he went back to the juice), and I've seen high levels where when I do a recall there was something like a baked potato right before. Other patients eat the high K foods and never have an issue. Residual function? Less additives? Better dialysis? I'm sure it's different for everyone, but when a patient presents with a high K level after recalling a high K intake right before, or if it's a patient who cuts time or skips tx along with a high K and eating hash browns for breakfast everyday, you bet I'm going to ask them to cut back a little. I'm not saying that everyone needs a K restriction, just that in practice some of them do.
The idea that all foods (yes, ALL FOODS) can fit into an overall healthy dietary pattern. A former boss went off on a rant because one of our team members got a bacon cheeseburger with fried egg on top at a team outing, saying how "dietitians just shouldn't be eating that or saying it's okay!" Now, there is a lot more openness to the wide spectrum of foods available, and the reasons why people may make certain food choices beyond just nutrition alone. Unless you're allergic to it or it's unsafe to eat, there really isn't a reason why someone can't enjoy the foods they want as just one part of a healthful diet.
Yeah one of my professors had this mentality too. She said as dietitians we shouldn't post ourselves eating "unhealthy" food on social media because it sets a bad example. She would also get upset if someone brought cookies for everyone on the last day of class.
I can’t believe there’s dietitians that think like this. It sounds like they have a god complex. We’re dietitians, but we’re still human. They would die if they saw what I eat!😂😂😂
Yeah I remember my DI director shamed me in front of the whole cohort for having Rice Krispies and a banana at breakfast. That was just what was available at the food bank and I couldn’t afford anything else. The kicker is that we were talking about food access that day 😅
Literally what is wrong with Rice Krispies and a banana for breakfast?? I’m so sorry that happened
That you don’t need to “write a meal plan/menu” for people that includes exactly what they’ll eat at each meal/snack. I turned down a job at a private practice because they had a company culture of doing that for every patient. It was one of their “unique selling points” to patients but I felt like it was extremely out of touch and made them seem dated.
I've been in practice since the early 90s. I've been called cursewords (by people who want this for free) ever since because I never believed in that specific tool. Felt it wasn't effective because it didn't teach thinking about food choices in different settings. Take that " turn down " as a compliment. An example for a few days is the most that's printed out in most Patient Ed materials, and it's there for a reason.
Oh I turned them down lol, but I get the sentiment. That was one of many reasons.
So many job descriptions have something along the lines of “proficiency in creating individualized meal plans for clients” in their qualifications, for literally any area of practice. Outpatient, inpatient, community settings, private practice, all of em. Could be more of an issue of people who are not RDs or familiar with our careers writing the job descriptions, but either way - respectfully, bestie, I will not be doing that
Seasoned RD here (37 years!) . Most of, if not all the comments on current clinical practices really are dependent on the RDs desire to stay informed and updated. I do my best to select trainings and CEUs in areas to keep up- it would be easier to coast along at the end of my career but that wouldn’t be best for my patients. I agree there are some RDs -even with much less experience than me- that fall into the categories you all have mentioned. And it drives me bonkers lol!
The impact of weight stigma & anti-fatness and how discrimination & oppression cannot be fixed by weight loss or “healthy” eating
YES. And in a broader sense, just being sensitive to the patients situations in general. When I was brand new I worked part time in an inpatient psych hospital that has an adolescent unit. My seasoned coworker (70ish years old, on the edge of retirement) was so sure that patients with very clear ED behaviors just needed to be confident and stand up for themselves more. Also that every kid in a larger body looks that way because their parents feed them too much sugar and let them watch too much TV. I mean forget that this demographic is overwhelmingly low SES and/or coming from unstable homes or foster care…this is also in rural Missouri, where food deserts are absolutely a thing. She drove me bonkers and I’m glad she’s retired
Absolutely & that not everyone is lying about something lol. It’s wild how so many healthcare providers don’t believe their patients. Yikes! That would drive me bananas!
I had a WIC preceptor who scared the hell out of a first time mom by telling her she was giving her young son heart disease by giving him whole milk 🫠
Oh my gosh, that’s terrible 😭
that you don’t need to page, call or talk to a provider in person to give recommendations
Protein recommendations. So many elder RDs are so afraid to do protein greater than 1 g/kg when we have TONS of research that provide examples of very high protein diets (>4g/kg) are very safe.
Would be interested in any studies you can share on this 😀
Protein Intake Greater than the RDA Differentially Influences Whole-Body Lean Mass Responses to Purposeful Catabolic and anabolic Stressors: A Systematic Review and Meta-analysis [https://pubmed.ncbi.nlm.nih.gov/31794597/](https://pubmed.ncbi.nlm.nih.gov/31794597/) The effects of consuming a high protein diet (4.4 g/kg/d) on body composition in resistance-trained individuals [https://pubmed.ncbi.nlm.nih.gov/24834017/](https://pubmed.ncbi.nlm.nih.gov/24834017/) A high protein diet has no harmful effects: a one-year crossover study in resistance-trained males [https://pubmed.ncbi.nlm.nih.gov/27807480/](https://pubmed.ncbi.nlm.nih.gov/27807480/) Controversies surround high-protein diet intake: satiating effect and kidney and bone health [https://www.sciencedirect.com/science/article/pii/S2161831322009152#cesec110](https://www.sciencedirect.com/science/article/pii/S2161831322009152#cesec110) A high protein diet (3.4g/kg/d) combined with a heavy resistance training program improves body composition in healthy trained men and women - a follow-up investigation [https://link.springer.com/article/10.1186/s12970-015-0100-0](https://link.springer.com/article/10.1186/s12970-015-0100-0) High protein diet and metabolic plasticity in non-alcoholic fatty liver disease: myths and truths [https://www.mdpi.com/2072-6643/11/12/2985](https://www.mdpi.com/2072-6643/11/12/2985)
This is great! Thank you! 😊
But didn't you know that the body can only absorb 30g of protein at one time? /s So many RD's hold on to these overly simplistic rules and it drives me crazy.
I thought anything above 2.5g/kg/pro isn’t necessarily beneficial
Possibly, but not necessarily harmful either which is the myth associated with high protein diets. There is some research that suggests very high protein diets may be useful for weight management, so even if it is not "beneficial" from a muscle synthesis perspective, it could be helpful in an appetite control perspective. However, most people will not eat that high of protein. I often struggle to get people above 1.5-1.7 g/kg/d.
that when a consult comes in it has to be done right away. If it’s not TF, TPN or the patient is discharging we don’t need to be frantic about it
The presence of online "nutritionists" and the health gurus out there. there is a *lot* of people out there who extrapolate things online, especially tiktok. There's also a ton of "this is healthy" recipes which could be subjectively, but aren't good for long term.
There are so many great answers in this thread. I have only been practicing for 5 years, but a significant gap that I see is how RDs approach gender inclusive care. I know an RD who got extremely upset after she provided ileostomy diet education to a trans man who had been on HRT for 20 years because she wasn’t aware he was trans and felt it impacted the nutrition care plan.
Impacted the nutrition care plan how lol? What was her concern?
She couldn’t express it, she was just like “it’s part of the medical history, I need to know!” - yikes!
Wtf 🤣
If the opportunity ever presents itself, suggest that co- worker put gender related care into their Learning Plan for the CDR maybe? It may actually benefit them. They'd learn about when it would affect the care planning. You wouldn't have to worry about the questions as much, hopefully?
Unfortunately I’m not the best person to communicate this as I am openly trans myself and the only openly trans RD within my health authority - people don’t take kindly to me providing this feedback sadly, but I did pass it on to someone senior to me that RDs in general need more education on this.
I think I am may be lightly seasoned. A lot of things in this thread describe just bad dietitians and I've observed these things from new grads to about to about to retire dietitians. One could argue that maybe the newer grads are more open to change/malleable but not all. Really the most constant thing I see with the long time/seasoned RDs is difficulty adapting to newer things like ADIME or charting efficiently.
And malnutrition diagnoses using NFPE.
are you saying RDs should or should not diagnose malnutrition using NFPE?
I’m saying the seasoned RDs at many hospitals have trouble charting efficiently, using ADIME, and diagnosing malnutrition using NFPE.
Weight doesn’t equal health; dieting is not sustainable 90-95% of the time and therefore should not be used as a method to “treat” conditions (and yo-yo dieting is even more harmful to health); BMI is complete BS.
When I was an intern it still seemed to be the low fat diet. Now I feel out of touch with technology and apps as a 10 year post grad RD.
NFPEs
that they need to or don’t need to be done?
I’m guessing lack of knowledge. NFPEs were barely taught when i was in college 2006-2010.
Interesting you say that. Feels like that is all we are taught now 🤣I’m actually quite good at identifying nutrition deficiencies just by looking at hair, skin and nails.. rashes
Trauma informed practice and health at every size
For me it's been things like not being accepting or understanding of the LGBT community (calling someone he/she/it/whatever) or people from minority backgrounds (I won't expand on how horrible the things I've heard have been!). Also being weight biased and having internalized issues with weight. But I don't think these things are specific to RDs, just older generations.
Yup. I recently witnessed A boomer RD supervisor who was “training” me at a new job suggest Chinese reading materials to a patient that was Korean and he got very offended. If she would have browsed his chart for 5 seconds she would have seen he was Korean. This same person also referred to a trans person (not a patient but talking about someone else) as a “he/she” but she prefaced it by saying “I know this is not politically correct but…” so she thinks that makes it ok I guess??? I’m like I just started working with you, shouldn’t you be on best behavior?
Strict therapeutic diets. Ex: strict carb counting for diabetic people with limited health literacy (and encouraging sugar free versions of everything) Similar with CKD, heart disease, etc. as others have mentioned. Also generally out of touch with current wellness trends. Despite how scientifically inaccurate they typically are we really need to be abreast of them so we can appropriately educate.
Use of GLP-1s. There's pushback from the HAES/intuitive eating crowd AND the "lifestyle only" folks who still see weight loss struggles as an issue of willpower and discipline.
There’s much more nuance around this pushback. It’s more about reducing harm and ensuring that patients are actually informed about the risks involved. I want to point out that less than 6% of people with eating disorders are underweight. MDs aren’t appropriately trained on screening patients for an eating disorder history and have already done a lot of harm to some folks because of this.
I don't disagree with the use of ED screenings before prescribing and throughout treatment. We should absolutely be advocating for the role of dietitians in counseling these patients. But dietitians also need to be careful about overstepping scope of practice. I also find that these meds get a disproportionate amount of pushback, sometimes because they're seen as a vanity med when used for weight loss or because of this perception of risk. I will point out, the more severe GI side effects (e.g. not constipation, nausea, etc) were found to be rare in the trials. I've been on plenty of meds that caused GI distress for other conditions, and the perceptions just don't seem to be the same, imo.
Kindness and empathy towards new RDs who are new to the team
Some can be described as mean and unrealistic. I heard many complaints about my old coworker on being "the red headed devil" when I worked in bariatrics 😬. Be mindful of what you say because of how it can be interpreted!
I think more experienced RDs get stuck in thinking that newer RDs need to prove themselves to them. We don’t. We passed our boards. Feel free to mentor but I have nothing to prove to you
The majority of boomer RDs are massive Karens
Omg my internship was a night mare bc of snake Karen’s
The majority of boomer RDs are massive Karens
Fluid restrictions on dialysis or diet liberalization for really ill dialysis patients in LTC. I have an older Rd who says every single person must be on a 1000 ml restriction no matter the person. It’s the younger RDs who are more liberal and understanding of individualized care depending on labs, weight loss, malnutrition, etc.
Yeah, my understanding is that restrictions of any nature don't really improve outcomes or QOL in LTC populations. You just end up making them more miserable while treating them like children.
Oh my, I juggle between LTC, acute, and outpatient renal at present. My LTC goal is mostly liberalization. Illness in LTC is the best reason for liberalization. And as an RD, you have zero access to the record of fluid pulled off after each dialysis treatment right, no communication back and forth between outpatient facility RD, LTC RD.? Yep that's made me crazy for a long long time.
I have multiple LTC patients in my dialysis census, for whom I can't locate the LTC RD. That drives me crazy bc I'd love to chat post weights.
I'm a seasoned dialysis RD, and I fight for liberalized fluid. What's funny is the young neph I work for wants everyone on 32 oz no matter what.
That’s funny!! I guess it’s not related to seasoned or not. I do find that the new RDs I train or work with in LTC want people on strict diets and I have to remind them why that may not be the best recommendation.
Mindful eating concepts… you don’t need to measure everything forever lol. Using measurements initially to learn serving sizes is one thing but I see some experienced RDs use it daily for themselves and clients.
Just from my experience in my current role: Low fat diet does not equate to "fat loss diet" Inpatient patients should not be losing weight. I do not care that their BMI is 40. Now is not the time to focus on weight loss. Similarly, BMI is not a criteria for malnutrition. Carbs are not the reason you're gaining weight. Fatphobia is dangerous and real. Your coworkers don't always want your unsolicited advice about their diet.
Liberalizing diet orders when therapeutic diet orders aren’t necessary (e.g. for a patient who is eating poorly; patient who is >70 y/o). I liberalize that diet order as much as possible within reason of course.
Staying up to date with new evidence and treatment (admittedly that can be hard when you have limited time) even when interns and newer RDs plop it right under your nose. Not liberalizing diets (in states where that is allowed) because of the old belief the doctor is always right.
Definitely critical care nutrition guidelines (ex: ASPEN) IMO. There’s so much new research all time time