Alumni Abstracts

Knowledge of and Readiness for Foodborne and Waterborne Bioterrorism of Hospital-based Food Service Directors
Akerlund, E. UMDNJ-SHRP, MS Clinical Nutrition, Newark.

Objective: This study assessed the knowledge of and readiness for foodborne and  waterborne bioterrorism of hospital-based food service directors and determined  relationships among select demographic factors.

Design: A nationwide structured explanatory mail survey was designed and pilot-tested  to hospital-based food service directors. The survey was divided into three parts. The  first section included questions regarding knowledge of foodborne and waterborne  bioterrorism. The second section included question related to disaster readiness and the  last section asked for demographic information. A reminder postcard was mailed two  weeks after the initial mailing to non-respondents; a second survey was mailed to non- respondents one month after the postcard mailing.

Subjects: Surveys were mailed to a random sample of 500 hospital-based food service  directors affiliated with the American Society of Healthcare Food Service Administrators  living in the United States.

Statistical Analyses Performed: Data were analyzed using JMP-IN software version  4.0. Frequencies, means, medians, standard deviations, Wilcoxon rank sum tests,  Pearson Chi-Square and linear regression analyses were performed.

Results: Overall 41.6% (n=208) of surveys were usable. Almost half (n=99, 47.59%) of  respondents had a minimal level of knowledge regarding bioterrorism. One third of  respondents had minimal scores on readiness (n=79, 37.98%). Utilizing another tool  deleting questions regarding adding bioterrorism annual and orientation training for  employees post 9/11, one third of respondents had moderate scores (n=80, 38.46%) on  readiness. There was no significant relationship between food service director knowledge  of bioterrorism and the respondents' age, years of experience, geographic location,  gender, level of education and credentials. There was no significant relationships  between food service director readiness for bioterrorism and respondents' age, years of  experience, level of education and credentials using either readiness scores.  Respondents living inside the 100 mile radius of NYC, Somerset County and Washington  DC had significantly higher readiness scores (6 item and 8 item p=.04) than those  living outside of the 100 mile radius of all three crash sites of 9/11. Females living  within the 100 mile radius of all three crash sites had significantly greater readiness  scores (p = .01) than males. For the population as a whole, males had significantly higher  readiness scores than females (p =.009).

Application/Conclusions: Results of this pilot study indicate that additional research is  needed focused on topics pertaining to knowledge of and readiness for foodborne and  waterborne bioterrorism of food service directors. Results of this survey clearly indicate  a need for greater education of food service directors and food service employees on  topics pertaining to foodborne and waterborne bioterrorism. Foodborne bioterrorism has  occurred in the USA and the increasing likelihood of future large scales attacks is  fathomable in today's day and age. It is imperative that the profession is both ready and  aware. 

A randomized study of gutamine versus placebo administered to patients who receive Taxol Chemotherapy at an Outpatient Cancer Treatment Center in Northern New Jersey.
Albert, T. UMDNJ-SHRP, MS Clinical Nutrition, Newark.

Objective: To determine if there are any differences in symptoms and incidences of neuropathy reported between subjects taking glutamine versus placebo.

Design: A randomized, double blinded, prospective, placebo controlled clinical trial at outpatient clinic in Northern New Jersey. Subjects were consented prior to starting Taxol treatment dosage q 3 week and consumed glutamine or placebo 10 grams T.I.D. on day 1 of treatment until day 5, repeated over three treatment periods.

Subjects/setting: A total of 10 subjects met eligibility criteria, 9 completed cycle 1, 6 subjects completed all three cycles. A general pain score scale was collected for the first 5 days of all three cycles. The general pain score was a sum of subjective neuropathy scores for each day. Six subjects were in the placebo group and three were in the glutamine group.

Results: Overall, the treatment group appeared to have lower general pain scores than the placebo group at all 3 cycles. All three cycles appeared to have a similar pattern, in that the general pain score was highest from days 4 to 5 of the cycle. The results are very tentative due to the under powering of the study.

Conclusions: There was some indication suggesting that glutamine helped to reduce the general pain score. The general pattern in all 3 cycles was that the general pain score increased on days 4-5 of each cycle. Overall, the general pain score was higher in the placebo group than the glutamine group on those days. A larger sample size study is needed to explore this further.

A survey of obesity management practices of pediatricians in New Jersey
Allen, M, RD, UMDNJ-SHRP; Touger-Decker, R, PhD, RD, FADA, UMDNJ-SHRP; O'Sullivan-Maillet, J, PhD, RD, FADA, UMDNJ-SHRP; Holland, B, PhD, UMDNJ/NJMS

The purpose of this study was to examine obesity management practices and variables influencing those practices of members of the NJ Chapter of the American Academy of Pediatrics (1246 pediatricians). Frequency distributions, chi square, Wilcoxan Rank Sum (JMP-IN 4.04), and logistic regression (SAS 8.0) were used with p=.05. Response rate was 424 usable surveys. The three primary reported methods to determine overweight or obese included wt-for-ht (75%), wt-for-age (62%), and visual determination (52%); 27% reported using BMI-for-age. Over two thirds of respondents indicated that, when a child is overweight or obese, wt is discussed with parent and/or child, family, diet, and physical activity histories were taken, diet and physical activity counseling was provided, and patients were referred to RDs. Approximately 50% of respondents reported screening overweight or obese patients for Type 2 Diabetes Mellitus (DM). The top 3 reported barriers to enhancing obesity management in practice were patient compliance (87%), time (75%), and patient interest (51%). The top 3 reported strategies to expand obesity management were better education materials (78%), a seminar on pediatric obesity (65%), and better reimbursement (61%). Respondents identified medical journals (84%), seminars (36%), and conferrals with RDs (35%) as primary sources of nutrition information. Patient compliance had a significant impact on taking diet history (p=0.0011), providing diet counseling (p= 0.0043), and screening patients for Type 2 DM (p= 0.0494); patient interest had a significant impact on use of BMI to determine overweight or obese (p= 0.0117). Nutrition information sources had a significant influence on select obesity management practices. Less than 30% of NJ pediatricians use the BMI to assess overweight or obesity with patients; the majority of respondents view RDs as a credible source of nutrition information. Future studies should explore pediatricians' diet and physical activity histories and counseling practices.

Relationship between indirect calorimetry using different ventilator systems as compared to the Harris Benedict predictive equation
N.A. Amato, RD, CNSD; L. Byham-Gray, PhD, RD, CNSD; R. Touger-Decker, PhD, RD, FADA; J. O'Sullivan-Maillet, PhD, RD; P.B. Matheson, PhD; L.A. Fuentes, RRT

Robert Wood Johnson University Hospital and University of Medicine & Dentistry of New Jersey

ABSTRACT TEXT Critically ill intensive care unit (ICU) patients have specific energy requirements to optimize recovery and improve overall outcome. Two methods of assessing resting energy expenditure (REE) are indirect calorimetry (IC) and predictive equations. This study measured REE from IC using three ventilator systems and compared these results to predicted REE. Thirty ICU patients at a university teaching hospital were enrolled and divided into three equal groups of 10. Group 1 subjects' REE measurements were performed while on the Servo 300 and Puritan Bennett 840 ventilator systems; Group 2 subjects were on the Puritan Bennett 840 and Servo i ventilator systems; Group 3 subjects were on the Servo i and Servo 300 ventilator systems. Predicted REE was estimated in two ways: 1) Harris Benedict (HB) equation with an injury factor of 1.3 (STD IF) and 2) HB with a disease-specific injury factor (DS IF). Paired t-tests compared the differences between measured and predicted REE. There was a within subject difference of 113 +46 kilocalories in measured REE between Group 1 ventilator systems (p=0.04). When predicted equations were analyzed separately, DS IF was significantly higher than measured REE for the total population (p=0.0008) and for the subjects in Groups 2 (p= 0.01) and 3 (p=0.02). Data suggest that predictive equations may not capture the unique metabolic demands of the ICU patient and IC remains as the gold standard for assessing REE among the critically ill. When IC is not available, the STD IF is a reasonable estimate of REE for ICU patients.

FUNDING DISCLOSURE- DNS Researchers Award; American Dietetic Association, Dietitians in Nutrition Support Dietetic Practice Group

Nutrition education in health professions: A survey of program directors
Barracato, JM. UMDNJ-SHRP, MS Clinical Nutrition, Newark.

Objective: The objectives of this study were to determine the perceived needs, curriculum recommendations and expected competencies in nutrition of the graduates of dental (DMD), physician assistant (PA), nurse practitioner (NP) and midwifery (CNM) programs as reported by their program directors.
Subjects: Directors of nurse practitioner programs (n=149), dental schools (n=54), certified nurse midwifery programs (n=42) and physician assistant programs (n=95) in the United States.
Design: A four page nutrition education survey was sent to all program directors from dental, physician assistant, nurse practitioner and midwifery programs nationwide requesting information regarding their perceptions, recommendations and expected competency level of graduates of their programs in nutrition education. A reminder post card then another complete mailing was sent to those who did not respond to the initial mailing.
Statistical analysis: All data analysis was performed using JMP IN software (SAS,1997). Frequencies and non parametric statistics were most frequently used to analyze data. Wilcoxan rank sum and Pearsons Chi-square were used to determine significance among perceptions by program directors for data analysis.
Results: The overall response rate was 81.2% (n=276). Perceived need for competence in nutrition varied by program. The majority of PA, CNM and NP program directors had the same perceptions for competency in nutrition for their graduates. DMD schools differed significantly for perceived need to know how to counsel on a modified diet and how and when to refer to the registered dietitian compared with the other disciplines. At least three quarters of the program directors stated that their graduates were able to screen and assess independently the nutritional status of their patients. About half of the directors stated that their graduates were able to counsel patients on modified diets. Time was selected as the most important factor by the majority of programs that would enhance the provision of nutrition education in these programs. Computer based programs were the most frequently requested education material to enhance the nutrition education component of the their curricula's. Significance was also detected among program directors expected level of competency in nutrition of graduates of their programs.
Conclusion: Program directors indicated that their graduates need to be competent in many areas of nutrition. However, a small amount of time (10-19 hrs) is dedicated to nutrition education in the entire curricula of these surveyed programs which may not be adequate for graduates to be fully competent in nutrition. More time needs to be allocated to nutrition in the curricula of the surveyed programs in order for graduates to be competent in nutrition to provide quality and comprehensive care to patients in their future practice as health care professionals.

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IMPACT OF CONTINUING MEDICAL EDUCATION ON APPROPRIATENESS OF PHYSICIAN PARENTERAL & ENTERAL ORDER WRITING.
Bartel, L., UMDNJ-SHRP, MS in Clinical Nutrition, Newark.

Malnutrition is highly prevalent among hospitalized patients and is associated with negative health outcomes. Timely and appropriate nutrition intervention is important to prevent nutritional depletion among hospitalized patients. Identification of appropriate candidates for nutrition support (NS) therapy and optimal feeding strategies are challenging steps in the proper delivery of NS. The purpose of the study was to assist physicians in the proper identification of candidates who require NS, and promote enteral feeding in a timely manner. A NS continuing medical education (CME) program was provided to physicians at a 206-bed community hospital to determine the impact of CME on appropriateness of physician parenteral and enteral order writing. Data was collected for one month before and after the CME program via medical chart review on all adult patients who received NS therapy. To identify patients who were candidates for and did not receive NS therapy in the pre CME time period, a sample population was randomly drawn from all adult admissions during the study month (n=100 of 600 admissions). In the post CME time period, patients who were candidates for and did not receive NS therapy were identified by the clinical dietitian staff and referred to the principal investigator (n=43 of 900 admissions). Fisher's exact test was used with an alpha level preset at 0.05. Twenty-three and 37 patients received NS in the pre and post CME months, representing 3.83% (of 600) and 4.11% (of 900), respectively (p=0.7880). In the pre CME population, 11 (59%) patients inappropriately received parenteral nutrition (PN). This was not statistically different when compared to the post CME population in which 13 (52%) patients inappropriately received PN (p=0.5567). The average number of days PN was delayed was 13 and 9.5 in the pre and post populations, respectively (p=0.5567). In the pre and post CME populations, 13 (56%) and 21 (52%) patients were candidates to receive enteral nutrition (EN) therapy, respectively. In the pre CME population, 2 (15%) of 13 patients appropriately received EN. In the post CME population, 7 (33%) of 21 patients appropriately received EN. There was no significant difference between the two groups (p=0.4267). There was no statistical difference found in the timeliness of the initiation of EN between groups. The proportion of the sample identified as being at risk for malnutrition (pre CME) was statistically different from the proportion of the population (post CME) identified at risk, therefore these groups were not comparable. CME did not impact the appropriateness of physician parenteral and enteral order writing. This may be a result of the small sample size in each group and/or the limitation of the CME program to a single, one-hour session. However, there were a greater number of patients in the post CME group who received NS therapy and an increase in the number of patients who received enteral feeding. In addition, NS was initiated earlier (1.5 days earlier) in the post CME group. This may be due to an increased awareness among physicians of the need to identify malnutrition and begin nutrition intervention early. This study identified the need for standardization of care for the patients who require NS therapy. Physicians need to document the reason for initiation of NS, the mode of feeding chosen, and the expected length of therapy. A proactive approach to nutrition intervention must begin with clear documentation of the care plan.

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IMMEDIATE GASTRIC FEEDING IN THE CRITICALLY ILL TRAUMA
PATIENT: CONTINUOUS VERSUS BOLUS METHOD.
Bridenbaugh, Jennifer IL. Mosenthsal Anne C., Deitch, Edwin A., Livingston, David H., Passanante, Mahan R., O'Sullivan-Maillet, Julie, Touger-Decker, Riva. UMDNJ-SHRP, MS Clinical Nutrition, Newark and UMDNJ-New Jersey Medical School.

Introduction: The objective of this study was to investigate immediate gastric enteral feeding in the critically ill patient and determine if method of delivery, continuous (C) vs. bolus (B), had an impact on tolerance and effectiveness of immediate gastric enteral nutrition.
Methods: The study design was a prospective, randomized, controlled, clinical trial. Eligible patients were randomized to receive either bolus or continuous feeding upon admission to the Surgical Intensive Care Unit (SICU). The enteral nutrition was initiated within 18 hours of injury.
Results: Six hundred and three patients were admitted into the SICU during an eleven month time period (May 1997 through April 1998). Thirty-six (39%) were consented, randomized and enrolled. Of the enrolled subjects, 22 were randomized to receive continuous feeding and 14 were randomized to receive bolus feeding. There was a significant difference in the ram percent of calorie news met between the bolus and continuous deliveries (day 7: C = 51.5% ± 42.3; I = 87.1% ± 21.5 p = 0.03, Wilcoxon Rank Sum). Comparisons of total calorie and protein delivered as well as mean percent of protein needs met were not found statistically significant (p > 0.05, Wilcoxon Rank Sum). There were remarkable positive trends in nutrient delivery for the bolus method. There wen no significant number of complications identified for either feeding method (p > 0.05, Fishers Exact Test).
Conclusions: Immediate gastric feeding is safe in the critically ill population. Bolus feeding may to advantageous to meet percent of caloric needs sooner after injury. In view of the emphasis for early enteral nutrition in the critically ill, gastric delivery should be considered as the first mode of feeding.

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THE EFFECTIVENESS OF DYSPHAGIA SCREENING BY A REGISTERED DIETITIAN ON THE DETERMINATION OF DYSPHAGIA RISK.
Brody R., Touger-Decker R., VonHagen S. UMDNJ-SHRP, MS in Clinical Nutrition, Newark.

The objective of this study was to examine the ability of the Registered Dietitian (RD) to identify patients at risk of dysphagia and make appropriate diet/feeding recommendations as compared to the Speech-Language Pathologist (SLP). Predictors of dysphagia risk were also determined. Thirty four patients admitted during a two month period to a neuroscience unit at an urban teaching hospital were analyzed prospectively. The RD and SLP screened subjects independently through questioning and/or mealtime observation for signs and symptoms of dysphagia. Presence of dysphagia risk and diet/feeding recommendations were determined. Kappa statistics demonstrated a moderate agreement (0.61) between the RD and SLP's determination of dysphagia risk ( > 0.7 = strong agreement, 0.4 to 0.7 moderate agreement, and < 0.4 weak agreement). The RD predicted the ability of the patient to consume an oral diet with strong agreement (1.0); various diet consistencies with moderate agreement (0.61); and the need for a liquid restriction with strong agreement (1.0). The most significant screening indices for prediction of dysphagia risk (p < .05) were age (p = 0.0181), history of dysphagia (p = 0.0428), difficulty swallowing solids (p = 0.0007), observed facial weakness (p < 0.001) and a wet or hoarse voice ( p = 0.007). Self-reported screening variables significantly related to dysphagia risk included drooling of liquids (p = 0.009) and solids (p = 0.0080), facial weakness (p = 0.0006), wet or hoarse voice (p = 0.0010), and prolonged eating time (p = 0.0157). This study supported the concept that the RD can effectively identify and manage patients with dysphagia. Screening for dysphagia can be implemented as part of standard nutritional assessments and may aid in decreasing dysphagia related complications.

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SUPERINTENDENTS' ATTITUDES, POLICIES, AND PRACTICES REGARDING SCHOOL FOOD AND NUTRITION SERVICES.
Brounstein A. UMDNJ-SHRP, MS in Clinical Nutrition, Newark.

Objective To determine New Jersey public school district superintendents' attitudes, policies, and practices regarding school food and nutrition services, and whether the use of qualified nutrition professionals by New Jersey public school districts has any impact on decisions made. Design Mail survey to population of New Jersey district superintendents, 3 mailings. Subjects/Setting New Jersey district superintendents, or others representing the district that completed the survey (n=587; response rate: 251/587 = 42.76%). Of the 251 surveys returned, 247 were usable. Statistical Analysis Performed Descriptive statistics which examined the frequency of specific attitudes practices, and policies. Correlation coefficients were used to analyze the relationship between each of these variables. x² analysis, Fischer's Exact tests, and ANOVA were used to analyze the relationships between each of the outcome variables and use of a qualified nutrition professional. Results One-half (50.20%) of the districts that responded reported using a qualified nutrition professional. The use of a qualified nutrition professional showed benefit in selling healthier items, however, had little affect on policy-making decisions and attitudes. NJ public school districts had a very positive attitude regarding the importance of having a district-wide food and nutrition policy (89% were in support), however, only 34.82% of districts reported currently have a nutrition-related policy. Over three-fourths (81.82%) of responding districts have access to one or more competitive food venues; only 39% of participants supported having school policies to help reduce the number of overweight or obese students. Applications/Conclusions This study supports the need for districts to implement individual district-wide nutrition-related policies, and employ more qualified nutrition professionals to assist in policy development at local and state levels. This study's findings should be used as a baseline needs assessment for state agencies to help guide each district to create and enforce stricter food and nutrition-related policies and practices.

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REGISTERED DIETITIANS WORKING IN CLINICAL POSITIONS HAVE ACCESS TO SOURCES OF EMPOWERMENT
Buckley, Linda J, Touger-Decker, Riva, O'Sullivan Maillet, Julie. UMDNJ-SHRP, MS in Clinical Nutrition, Newark.

Objective: To determine Registered Dietitian's perceptions of their access to sources of empowerment in the workplace and any demographic factors which may be significantly related to their perceptions of empowerment .

Design: This study was based on the conceptual framework of Kanter's theory of organizational power. The Conditions of Work Effectiveness Questionnaire, developed by Chandler and revised by Laschinger, was used to measure perceived access to sources of power: opportunity, information, support, and resources. Demographic questions were added to the questionnaire to determine factors which may effect perceptions of empowerment.

Subjects: Subjects consisted of clinical RDs employed by ARAMARK, working in acute care settings. Letters were sent to the clinical nutrition managers of all of ARAMARK's acute care facilities asking for their assistance in distributing questionnaires to the RDs working in clinical positions in their departments. Responses were received from 96 managers, and a total of 362 surveys were mailed to them to distribute.

Statistical analyses: The data were analyzed using descriptive statistics. One-way ANOVA was used to identify the difference in empowerment scores based on level of education, years in practice, work setting, and age. Significance was set at p=.05.

Results: Usable questionnaires were received from 230 RDs (92%). On a 5-point scale, scores for opportunity (mean+/-standard deviation [SD]=3.96+/-0.7), access to information (mean+/-SD=3.38+/-1.0), access to support (mean+/-SD=3.39+/-0.9) and access to resources (mean +/-SD=2.79+/-0.6) suggest that RDs perceived themselves to have moderate access to sources of empowerment. Respondents with the longest time in practice (p=.0006), and those in the older age (p=.033) categories had statistically significant higher access to information scores, and their overall empowerment scores were also significantly higher than those in the other categories.

Conclusions/applications: Registered dietitians working in clinical positions can have access to sources of empowerment in the workplace. The structures within the organizations they work in, the administration, and the dietitians themselves all have the potential to enhance their empowerment. These findings will be shared with clinical nutrition managers and the RD respondents who requested the information.

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The Knowledge, Attitudes, Personal Health Care Practices and Patient Care Practices of UMDNJ Faculty Members Regarding Weight Management.
Donna Castellano MS, RD; R. Touger-Decker, PhD, RD, FADA; P. Matheson, PhD; L. Byham-Gray, PhD, RD; J. O'Sullivan Maillet, PhD, RD, FADA. UMDNJ-SHRP, MS Clinical Nutrition, Newark.

Objective: Health care professionals' (HCPs) practices towards obesity treatment might be critical in helping to reduce the international epidemic of obesity. This study aimed to establish the knowledge, attitudes, personal health care and patient care practices of various different health-related professions, and the relationships of these variables regarding the provision of weight management to their patients. Design: A survey was mailed to a random sample of 778 full time faculty appointments of the University of Medicine and Dentistry of New Jersey during the academic year 2004;
Statistical Analysis: Descriptive statistics of knowledge, attitude, personal health and patient care practices scores were analyzed using SPSS (Version II) software with significance set at alpha =.05. Pearson product moment correlation coefficient was used to compare relationships among the variables; independent t-test was used to compare mean total knowledge scores among faculty of the clinical vs. academic settings; one-way ANOVA was used to compare mean scores among the various health professions. Results: The survey yielded a 45.4% (n=353) usable response rate. More than 75 % of faculty could not identify the clinical definition of obesity based on BMI, and 25 % did not know that high waist circumference is associated with increased disease risk. There were no significant differences in total knowledge scores among clinical vs. academic faculty (p=.11). Overall, faculty members agreed that treating overweight and obesity is important and disagreed that treatment of overweight and obesity is futile. They had negative attitudes relating to patients' motivation, ability to lose weight, and that time prevents adequate counseling. Faculty members' personal health care and patient care practices were inconsistent when compared with federal guidelines. Common reasons for faculty members not providing education or referral for weight management were related to it being "not their responsibility" or "outside of their specialty." There were weak but significant correlations among faculty members' knowledge (p=<.01), attitudes (p=.03) and personal health care practices (p=<.01) and their patient care practices. No significant differences were found in mean scores for knowledge (p=.12), attitudes (p=.19), or personal health care practices (p=.93) among the various health care professionals surveyed in this study. Dentists had significantly lower patient care practice scores when compared with physicians (p=.02) and nursing professionals (p=.03). Conclusions: Overall, higher knowledge, more positive attitudes and better personal health care practices were associated with better adherence to evidenced-based patient care practices for weight management. Efforts should be made to improve all HCPs knowledge of screening techniques including use of BMI and waist circumference, as well as educating them to take responsibility for weight management within their own patient population. Improving HCPs attitudes and personal health care practices might also lead to improvements in patient care practices related to weight management.

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