What its really like being a Registered Dietitian

Thinking of pursuing a Registered Dietitian career? I wanted to share this post about the realities of being a Registered Dietitian.

I had some challenging and upsetting moments this week, in regards to how people perceive my profession, so I thought I would use my little corner of the internet to share a bit of my perspective and maybe help people understand a little better.

The Food Blogger Started It

First, a very popular, highly controversial and generally uninformed food blogger posted a picture on Facebook of an item that a family member had received on his tray during a stay at a local hospital. The item was a “sugar free” ice cream with an ingredient list so long it barely fit on the label. She was appalled anyone could receive such a horrifying item in a place where they are supposed to be getting healthier.

Her followers proceeded to say that this is because hospital “nutritionists” (ie Registered Dietitians, like me) know nothing about good nutrition and promote horrifying unhealthy food for their own financial gain. I am blocked from commenting on this person’s Facebook because I have repeatedly called her out on her idiotic posts, so I was unable to respond directly to the comments. But, this perception about my profession really makes me sad, their comments stuck in my head the rest of the day.

I Know Nothing About Diabetes (Not Really)

Second, I have been having similar struggles with real-life patients who don’t really understand or care about the limitations I have to work with. Earlier this week, we had cinnamon rolls for breakfast at one of my nursing homes. A diabetic patient threw a fit. How dare I serve him a cinnamon roll! Would I ever eat a cinnamon roll? (Yes, I would, and do weekly!) Was I trying to kill him? I clearly know NOTHING about the diabetic diet!! I offered to have something else prepared for him, but he refused to talk to me further, stating he needed to speak to someone with “more power”. Ok then.

So this week I have been beaten down both online and in person. I am not writing this post to defend hospital food service, I think there are A LOT of ways food could be better and healthier. The healthcare system is a mess in so many ways, I am not going to even get into that. But, before criticizing the RD or saying that I know nothing about nutrition, I did want to point out some limitations of my job that maybe you hadn’t considered.

1. My TOP priority is keeping you alive.

Many of my patients are critically ill. They have MULTIPLE medical conditions at the same time. Sometimes, I have to make choices about which condition is likely to immediately kill them in order to make decisions for their care.

Here’s an example, right now I have a patient who is a diabetic but has lost 25 pounds from not eating in the last month. She is in the process of wasting away. All she wants is ice cream and not the fake stuff. Due to her advanced Alzheimer’s and dementia, she is unable to receive any diet education about an ideal diet for diabetes.

In my professional opinion, her weight loss is more important right now than her diabetes. We need to stop her from losing weight. The weight loss is going to kill her, not diabetes. So, I am going to give this lady some ice cream. Actually, I am going to give her as much ice cream as she wants and maybe even try a milkshake to see if she will take that too. We can give her insulin if her blood sugar goes up, but calories are the ONLY thing that will stop the weight loss and therefore prevent death.

These are the types of decisions I have to make on a daily basis. I have to choose which condition is the most important at the time. Many patients are unable to make decisions for themselves, many don’t have family members around either. Therefore, it’s up to me to determine which of these issues is likely to kill them first and prioritize the treatment for that, even if it means serving diabetics enormous quantities of ice cream.

2. Infection control is a BIG issue.

People in the hospital or nursing home are sick. Most have a weakened immune system and are already at high risk for infectious diseases. Then we put them in a building full of other sick people. No matter how good infection control practices might be, it is an ENORMOUS issue. Hospitals and nursing homes spend huge quantities of money and time to train employees to prevent the spread of diseases. But, infections still happen when you are dealing with a compromised population in a situation like that.

I play a big role in infection control by helping to prevent any type of foodborne illness. Part of this is the training of staff to handle food properly, monitoring temperatures in the kitchen, food storage, etc. But, not all my patients eat.

Many receive nutrition via G-tubes, or tubes inserted directly into their stomachs to provide them with 100% of their nutritional needs. When there is literally an open hole in the stomach that is not supposed to be there, this is an INCREDIBLE risk for infection. In addition, these patients are extremely compromised and require intense medical monitoring.

In the hospital or nursing home, there are two companies who supply the tube feeding formulas for these types of patients, Nestle and Abbott. They dominate the market for nutrition products. They do have a lot of research to back up their products, particularly some of the “specialized” ones for certain medical conditions.

But, just a look through the ingredient list of any of these products is a bit of a shock. Usually, one of the main ingredients is corn syrup, followed by a list of chemical names as long as the bottle itself. I am not going to lie, these formulas are not a “health” food by any means. These formulas are designed to provide the basic nutrition needs for life, reduce the risk of infection, and remain stable at room temperature for an extended period of time. They are highly processed to make SURE that no bacteria, virus, fungus, or anything else can grow or live inside them. They are packaged in a manner to prevent contamination of any kind, even when they are at room temperature.

Families or even patients who see these products frequently complain. But, it comes back to my first point, my priority is to keep you alive. A G-tube patient is at extreme risk for infection. Preventing infections will always be my priority for these patients because that is the most critical part of their current situation.

I KNOW the ingredients in these products are less than ideal, but this is what I have to work with. There are other tube feeding formulas on the market that are not covered by insurance and are extremely expensive but are made from real food with high-quality ingredients. Some families do opt for those instead and pay for them out of pocket. I am thrilled when these families come in because the patients really do thrive. But, most cannot afford this. So, until Abbott or Nestle decide to make a “real food” formula, my priority is infection control over “ideal” nutrition.

3. We work hard to make you happy.

Every hospital or nursing home where I have EVER worked really cares about patient happiness. I have had to go to the grocery store multiple times to pick up special requests for patients. One only wanted blue Gatorade, and we only had red or yellow, so I drove to the store to get it for her. Another wanted mushrooms for dinner EVERY NIGHT and although it caused us to exceed our food budget regularly, we got the mushrooms she wanted.

I can’t speak for every nursing home or hospital in the country. I will say the ones where I have worked really try to make the food taste good and look appealing. I eat the food regularly at most of the places I work. It’s not always perfect, but like I said, we are always willing to get you something else.

At the hospital where I delivered both my kids (where I worked for many years), they offer a full menu where you can order whatever you want at any time. This was awesome, especially because I had the “hook up” in the kitchen with all my buddies working down there. I ate like a queen and wasn’t upset when I had to stay longer in the hospital because of my amazing treatment and the fact I could order whatever I wanted anytime!

Room for Improvement

I do think hospital food service is improving. But, I also think patient demands are increasing. Although we could always do better, patients must also consider the limitations placed on the healthcare system. Hospitals must consider cost, I know patients hate to hear this, but it matters. It is expensive to feed people three square meals per day and offer them a large variety of options. We have to work within our budget.

I haven’t even gotten into the government standards about what we are required to provide as a healthcare organization and what is considered a “healthy” meal by these regulations. It is not my job to agree or disagree with the government’s requirements (I mostly disagree), it is my job to make sure they are implemented.

We always have to consider infection control. Like I said, as much as I would love to make you a fresh, organic green juice, the risk of infection with the raw greens, especially for an immuno-compromised patient are enormous. So, for now you will get your boxed cranberry juice, which comes with a low infection risk, until we find a better solution.

We are also trying to please multiple generations of people who see food very differently. Younger people tend to care more about ingredients, organic products, GMOs. Older people tend to want more “comfort” foods. How do we balance that? I know if some of my family members were in the hospital and I served them an organic, vegan meal of kale and tofu they wouldn’t eat. But, if I gave them a hamburger, they would eat it all.

So, before you judge the RD who comes to visit you in the hospital and think they know nothing about nutrition because you got a cinnamon roll for breakfast, consider that this person is working within a system and the limitations that are placed on her job. It’s not that she (or he) doesn’t understand nutrition, she is just trying to provide you the best she can within what the system currently allows.

Ask for what you want (within reason) and know that her priority is to keep you alive and get you out of there as soon as possible. If you want hospital food service to change, the whole system needs to change. But, for now, I am going to leave that up to the politicians, who are clearly doing a great job at that (insert major eye roll).