Watermelon Salsa

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When did I grow up?

I was talking to my friend AJ last night and it was all talk about interest rates and 401K. Oh, and babies. Because he’s officially an uncle. So jealous! I’m trying to get my brother past “flavor of the week” much less a steady relationship, marriage, or children. We can hold a pretty great microbrew conversation, however. Go figure.

When I worked with renal patients, I talked about seemingly silly topics: watermelon, soda, chocolate, beans…

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I’ve mentioned it before, but probably not in much detail. The renal diet for dialysis patients is VERY strict — the most strict “therapeutic” diet there is. My patients had to eat a ton of protein and limit fluids, tomatoes and tomato products, cola beverages (including diet), beans of any variety, potatoes, chocolate, caramel, wheat, melon, cheese, milk, yogurt, ice cream, salt and soup, luncheon meats, hot dogs, bacon, sausage…the list goes on..and on…and on…

With the seasons, the conversation among my patients changed. My topics of counseling changed. While the fall brought about struggles with beans and dairy products (mmm, cheesy casseroles!), the summer offered up the temptation of tomatoes and melon. A group of patients I most recently worked with, LOVED watermelon. It was the one food they missed the most.

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“You don’t have to GIVE UP watermelon as long as we keep a close watch on your fluid gains and potassium levels,” I would explain. They returned with, “But Nicole, we can’t stop at just a little bit of watermelon…we want all ten pounds worth!”

And that, I can understand and respect. I adore watermelon. I thank God every day that I have my health and that I can enjoy things like Watermelon Salsa without jeopardizing my health. It was actually my old patients who inspired me to 1) buy my first watermelon of the season and 2) try watermelon salsa. Wise, wise patients!

This salsa was incredible quick to throw together, though…it doesn’t keep well. Good thing is, it won’t last long enough for that to be an issue! I served this with some homemade baked tortilla chips and it was a great marriage of sweet, juicy watermelon, tart lime juice, and spicy jalapenos. The crystallized ginger added a fun and unexpected twist, too! Backyard barbecues and 4th of July are just around the corner…time to break out the watermelon…and salsa!

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Watermelon Salsa from Bon Appetit, July 2000

1/4 cup fresh lime juice 2 Tbsp (packed) brown sugar 3 cups seeded or seedless watermelon, chopped 1 cup honeydew melon, seeded and chopped 1/2 English cucumber, peeled, seeded, chopped 1/2 cup red onion, chopped 1/4 cup fresh mint, chopped 2 Tbsp crystallized ginger, finely chopped 2 Tbsp jalapeños, seeded and minced

Directions:

Whisk lime juice and sugar in large bowl until sugar dissolves. Add watermelon and all remaining ingredients; toss gently. Season with salt and pepper. Can be prepared 2 hours ahead. Cover and chill.

Yield: 5 1/2 cups (11 servings – 1/2 cup each)

Nutrition Information (per 1/2 cup): 45 calories; 0 g. fat; 0 mg. cholesterol; 6 mg. sodium; 11.3 g. carbohydrate; 1.2 g. fiber; 0.5 g. protein

Result: Sweet, tart, spicy and an overall fun blend of flavors and textures. This comes together in a jiff and is great on chips. I would also love to try this over some grilled cod or halibut, or as a salsa for fish or pork tacos. Mmm! Enjoy!

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Dinner with Donna was incredible. I can’t say it was sad because she is one of those people that I know it isn’t a goodbye…it’s a see you later (and soon!). Some people enter your life and you just know they’ll be in it forever — Donna is one of those people.

I survived night #2 on an air mattress with the snoring princess. I am packing up the car, putting the final touches on cleaning this joint, and we (Lily and I) are leaving Ohio for good. We close on our new home this afternoon. If all goes well, I will be a Michigan resident by 5pm this evening!

I have no idea when internet will be hooked up, so bear with me. I’m sure there’s some wifi close by, but if you don’t hear from me…I’ll be at the beach! :-D

Have a fabulous weekend!

See you in MI,

What I like…and don’t like about being a Renal Dietitian

I have worked as a renal dietitian for the past 2 years. If you’re thinking, “Wait, didn’t you just change jobs in January?”, the answer is yes, but I simply switched companies. Not much about my job duties changed, just location, patient load, and salary.

To start, the word “renal” refers to the kidneys. The kidneys are an organ in the excretory system and perform many vital roles in the body, including: blood pressure regulation, activation of vitamin D, red blood cell production, urine production and fluid removal, the excretion of waste, and so much more! These bean-shaped organs are on the back side of the body and lie just above the waistline.

My work was performed in dialysis units. Dialysis refers to the artificial process of cleaning the blood when the kidneys have failed (most often due to uncontrolled hypertension and complications of diabetes, though there are other causes for kidney failure). Dialysis can be done in-center by exchanging one’s blood through an artificial kidney and large machine, or by way of inserting a sugary fluid into the peritoneum (the space in between all of your organs in your belly) and draining it out. There are benefits and drawbacks to the different types of dialysis and it is up to the interdisciplinary team to help a patient receive the treatment regimen that best fits their needs.

I covered 2 dialysis units (and always have), and in my 24-26 hour work week, I generally cared for about 70-75 patients. The renal dietitian is responsible for completing nutrition assessments on each patient (initial, after 90 days, semi-annually, and annually), assessing each patient’s labs every month and making changes to their diet and recommendations to their prescriptions, dosing their vitamin D, performing nutrition education on the renal diet, monitoring weight status, conferring with hospitals and extended care facilities to meet patient’s needs, referring patients for IV nutrition, charting, and collaborating with the interdisciplinary team by way of physician rounds and attending quality control monthly meetings. My typical work hours were 7-8am to 3:30-4:30pm, though this can vary significantly and is extremely flexible.

Would I recommend renal nutrition to other dietitians? Absolutely…for a period of time. Working as a renal dietitian is such a specialized area of nutrition and it’s not for everyone!

The Good

  1. I got to see the same patients over-and-over. I knew my patients REALLY well. While this can come with plenty of disadvantages, I feel that having that rapport and relationship with patients was invaluable. I knew about their health history, social history, habits, preferences, personalities…I knew them! This made my job more fun and more successful in helping them meet their nutrition goals.
  2. Historically, renal dietitians are part-time employees because most dialysis units can only offer treatment to so many patients (patients run dialysis 3-5 hours, 3 times a week). Again, this comes with positives and drawbacks, but I was able to be very flexible in my schedule. I didn’t have a specific “start time” or “end time”. Some weeks are much busier than others and I could easily adjust my schedule to maximize my time and efforts. I absolutely loved having this flexibility.
  3. I thoroughly enjoyed being a part of a small interdisciplinary team and at the same time, being the only dietitian. If my job didn’t get done or didn’t get done right – I was to blame. Conversely, I didn’t rely on others to get my job done. I enjoyed being able to interact with my coworkers without “sharing” the workload, if that makes sense. I was a one-woman show and I liked it that way. Similarly, the physicians and I built rapport and my suggestions were generally well-accepted.
  4. Nutrition is valued in renal care. Fortunately and unfortunately, lab work that is monitored in dialysis patients is STRONGLY linked to their diet — everything from potassium to calcium to protein to phosphorus to fluid. The role of the dietitian is INTEGRAL to the outcomes of the patients and that is rewarding.

The Bad

  1. Health care is changing and the way physicians approach health care is changing. Because I would see the same patients 2-3 times a week, I would hear about each and every one of their health concerns. While I understand the need to draw lines in the sand as to which health care professional should be “treating” which issue, so many issues affect dialysis outcomes. Due to the changes in reimbursement and thus health care, it is becoming difficult to treat patients as a “whole”. It’s concerning and a disservice to the patient.
  2. It’s hard to see patients so ill and have patients pass away. By the time patients are to the point of requiring dialysis, many of them only live a few short years. It is a blessing that you can live on dialysis a very long time and the kidneys are an organ that can fail and there is treatment other than transplant, but most patients live 5 years or less once starting dialysis. That said, patients who take care of themselves after beginning dialysis can live very fulfilling lives. In the older dialysis population, it is usually a situation of MULTIPLE health complications and conditions that result in death, not the dialysis itself. Sorry so morbid, but it’s a reality.
  3. My job could be very repetitive at times. Draw labs, do assessments, discuss labs and diet changes, chart, calculate dose changes, chart, educate, chart…again, and again. My months all mapped out the same which was nice for planning my schedule, but the work was very predictable and cyclical. I like a bit more variety!

The Ugly

  1. I won’t beat around the bush with this one – 9 out of ever 10 dialysis patients (if not more!) are non-compliant. They are non-compliant with their diet, fluid restriction, coming to treatment, taking medications…you name it. The population can be very trying. Seeing as dietitians are in the business of “change”, non-compliance is a major barrier and hardship to face. As much as you want something for your patients, it always came down to their motivation and follow-through. I think this was the #1 challenge of working in dialysis.

I can honestly say I learned a ton (if you ever want to chat about secondary hyperparathyroidism, I’m your gal!), but my passion is in disease prevention. I want to help diabetics never, ever end up on dialysis. I can speak to the reality of dialysis and outcomes if people don’t change their lifestyle.

I met some AMAZING people – patients and coworkers, and I did enjoy my job. I can’t say I loved it by the end, but I love working with people. I am very excited to open up my next career chapter and bring with me so much of what I learned working in dialysis.

Be well,

Carrot Cake Pancakes with Cream Cheese Glaze

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Does anyone else watch Army Wives? It’s a pretty decent show on Lifetime that airs Sunday nights. It’s about army families and specifically about the wives who have close knit relationships with one another. One of the main characters, Claudia Joy, was diagnosed last season with type 2 diabetes. She began on insulin injections and much of the season focused on her management of the disease. Flash-forward to the most recent episode where she was diagnosed with kidney failure and had to start dialysis.

As I sit there, nearly in tears, it comes to me — this is the life my patients lead. Most of them have diabetes and all of them have been given the news that they will need dialysis (or a transplant) to live. Of course I “know” all this but “seeing it” was eye-opening.

Then today, I was talking with the dietary manager and RD at the long-term care facility I’m teaching at this quarter when we got on the topic of how dialysis patients always end up being told they can’t have their favorite foods and how difficult it is to stick with such a strict diet for the long haul. Sad.

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What the heck does all of that have to do with Carrot Cake Pancakes with Cream Cheese Glaze? Quite a lot, actually!

Sadly, a lot of fruits and vegetables are either high in potassium or phosphorus…or both. Chocolate and caramel are much of the same. As is cheese, milk, and other dairy products. Nuts are a no-no, too. All things considered, this makes (nut-free) carrot cake a good dessert (or breakfast!) choice for my patients. While it’s often hard to find renal recipes, these pancakes made with all-purpose flour (wheat is high in phosphorus) and without nuts would be a great breakfast option. Not only great…but epic.

It’s been awhile, but this is another epic breakfast.

Having my parents in town was motivation to pull out all the stops. Which in the case of breakfast isn’t hard to do. Breakfast…isn’t that what Saturdays and Sundays are designed for? That’s my thinking, anyways. Bonus – these reheated really well for mornings to come :)

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Mr. Prevention SWEARS that I’ve made carrot cake pancakes before. I don’t recall, nor can I find them on my blog. Regardless, they clearly weren’t memorable. After these pancakes, I have awoken every morning since wanting these and nothing else.

While it’s true that carrot cake everything makes me weak in the knees, I just can’t express how perfect these turned out. My dad sings my praises about a lot of things (I am Daddy’s Little Girl), but “my” Carrot Cake Pancakes with Cream Cheese Glaze may be what he brags about to people in the years to come. Obviously the man has excellent taste in food.

My mom…I wasn’t so sure about. I tend to think of her as more of the savory breakfast type, but she surely wasn’t complaining!

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Carrot Cake Pancakes adapted from Cooking Light and Alida’s Kitchen

2 1/4 cups whole wheat pastry flour 1/4 cup brown sugar 2 tsp cinnamon 2 1/4 tsp baking powder 3/4 tsp baking soda 1/2 tsp salt 1 1/2 cups low-fat buttermilk 3 eggs, lightly beaten 1 1/2 Tbsp canola oil 1 1/2 tsp vanilla extract 3 cups carrots, peeled and shredded (about 2 lbs) 1/3 cup walnuts, chopped

4 oz 1/3 less fat neufachtel cream cheese, room temperature 1/4 cup powdered sugar 1 tsp vanilla extract 3 Tbsp skim milk + more, if needed to thin

Directions:

In a medium bowl, whisk flour, sugar, cinnamon, baking powder, baking soda, and salt. Set aside.

In a large bowl, whisk together buttermilk, eggs, oil, and vanilla until combined.

Add dry ingredients to wet ingredients and gently stir until blended. Fold in carrots and walnuts. Let batter sit for 10 minutes.

Microwave the cream cheese for about 15-20 seconds to soften. Whisk the remaining ingredients for the glaze, adding additional milk, if needed, to thin.

Meanwhile, preheat large nonstick skillet or griddle to medium heat.

Pour batter onto griddle using a 1/4 cup measuring cup, spreading the batter with the flat bottom. Flip pancakes when tops are covered with bubbles and edges look cooked (about 2-3 minutes). Cook the other side until set (about 2 minutes). Serve warm with cream cheese glaze.

Yield: 7  servings (2 pancakes each with about 1 1/2 tablespoons glaze).

Nutrition Information (per serving): 365 calories; 12.9 g. fat; 93 mg. cholesterol; 644 mg. sodium; 50.6 g. carbohydrate; 6.4 g. fiber; 7.9 g. protein

Result: Epic! Must make recipe! If you love carrot cake…these are for you! I’m very pleased with the nutrition stats, too — nearly 6 1/2 grams of fiber and only 365 calories…including the glaze! The batter is thick, don’t be alarmed. I like to use a 1/3 cup measuring cup to pour the batter and then use the bottom to spread the batter into a 5-inch pancakes. Enjoy!

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Please be sure to stop by tomorrow…exciting news and celebrations will ensue!

Be well,

Bacon, Eggs, and Asparagus Salad

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Mr. P had a work dinner thing last night, so I was flying solo. My initial thought was leftovers, but when I opened the fridge, I discovered we were all out of leftovers. This never happens and I immediately went into a slight panic.

I mostly panicked because I knew our milk had expired and thus, the ever faithful back-up plan of cereal was a no-go.

What’s a girl to do?

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Then I remembered this meal from Monday night. In short, it knocked our socks off.

It was simple, it was healthy…it was eggs. And eggs, I had on hand. No asparagus or arugula, but I improvised and did not go hungry. No worries there.

Eggs are a daily topic of conversation around my dialysis units. The white of the egg is the best “complete” source of protein in the food supply because contains all of the amino acids and is a very well-absorbed protein. Plus, eggs are cheap and can be prepared many different ways and for any meal. My gal pal Gina the Candid RD just posted about eggs for dinner, too.

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There was nothing about this recipe that would’ve had me throwing it only my meal plan immediately. But my friend Sarah talked this meal up SO much, that curiosity got the best of me. Phew. I would’ve been missing out.

Mr. Prevention asked what was for dinner and I described this meal. I wish I could recreate and/or photograph the look that spread across his face. He made quick decision to add some fish to the grill and throw some sweet potato fries in the oven.

*eye roll*

When I set the plate down in front of him his first response was, “This looks good!” and the second was, “This is way more food than I thought it would be…why didn’t you stop me from making all this other food?”

Well, my dear. Why don’t you just trust and believe that I rarely lead you astray when it comes to food?

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Bacon, Eggs, and Asparagus Salad slightly adapted from Kudos Kitchen by Renee and A Taste of Home Cooking

1/2 tsp Dijon mustard 1 1/2 Tbsp sherry or white wine vinegar 2 Tbsp + 2 tsp extra-virgin olive oil, divided Salt and coarsely-ground black pepper 4 large eggs 1 bunch asparagus spears, trimmed 3 strips uncured turkey bacon 3 handfuls mixed salad greens, rinsed and dried 2 Tbsp pine nuts, toasted

Directions:

To make the vinaigrette, combine mustard, vinegar, and 2 tablespoons oil in a small jar and shake or whisk to blend; set aside.

Preheat the oven to 400 F or preheat a grill. Toss with remaining 2 teaspoons olive oil, salt, and pepper and roast or grill until just cooked through, about 5 minutes.

Cook bacon on a microwave-safe plate with several layers of paper towel beneath the bacon and one layer on top. Check the bacon for doneness every 20-30 seconds. Cooking time will depend on the strength of the microwave.When the bacon is cool, chop it into bits.

In a skillet, cook eggs over-easy, making sure the yolks are still runny.

Toss the salad greens with three quarters of the vinaigrette, and arrange on each of two plates. Add half of the asparagus to each plate, along with 2 eggs each. Scatter the bacon bits and toasted pine nuts over the salad and serve immediately.

Yield: 2 servings.

Nutrition Information (per serving): 446 calories; 33 g. fat; 370 mg. cholesterol; 757 mg. sodium; 12 g. carbohydrate; 5.5 g. fiber; 28 g. protein

Result: Filling, healthy, balanced, loaded with healthy fats, fiber, and protein. This meal is perfect for spring…and those following a lower-carb lifestyle. This meal was ready in about 20 minutes. I do highly recommend grilling the asparagus, but it can most certainly be roasted. If you have a friend or significant other that is willing to take on assisting, one person can be grilling while the other is frying the eggs and then, this meal is ready in NO TIME flat. Enjoy!

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Teaching, then meetings. I hate meetings…

Be well,

National Registered Dietitian Day!

That’s right, today is National Registered Dietitian Day! Being an RD is so much of who I am on and off this blog. More than anything else, I get emails (almost daily!) of people with questions about what RD’s do, if the job market is good, what RD’s like and dislike about their jobs, and what other advice I could give to someone wanting to enter into the field of nutrition.

To begin, there is a difference — a big difference — between a Registered Dietitian and a “nutritionist”. The term “dietitian” is used synonymously with “Registered Dietitian” – meaning, that individual completed a 4-year degree in a CADE- accredited nutrition/dietetics program, went on to complete a CADE-accredited internship, and then passed the RD exam. At that point, someone is an RD. There are a lot of online courses and weekend courses, and even 4-year degrees in nutrition, that do not meet the CADE-accreditation standards for dietetics. These individuals are not eligible to proceed to a dietetic internship or sit for the RD exam. In short, “Registered Dietitians” are recognized as the nutrition professional that is educated and credentialed in nutrition…anyone else is a nutritionist. To take it a step further, anyone, legally, can refer to themselves a “nutritionist” – there is no legal bind to that title, unlike RDs.

Is the job market good? I believe yes. It is a fact that many RD’s-to-be have difficulty matching (being accepted to) internship programs because the demand exceeds the supply at this time. With rates of obesity, diabetes, and other chronic diseases sky-rocketing, preventative medicine WILL come about. I don’t know when and I don’t know to what extent, but I do know that RD’s will play a huge role in helping relieve the obesity crisis our nation faces. And then there’s the aging Baby Boomer population that will increase the need for RD’s in long-term care.

When someone expresses interest in wanting to enter into nutrition, I think it’s only fair to give a realistic look into what many RD’s do because it’s not for everyone. Most RD’s, at least at some point, work in a clinical setting — a hospital, a dialysis unit…somewhere that works with ailing the very ill. With illness comes the need to know many aspects of medicine — medications, medical procedures, lab work, etc. I always like to point out that RD’s have EXTENSIVE training in diseases that many people wouldn’t correlate with the work of dietitians. I believe that one of the main reasons I enjoy my work as an RD is because I love medicine and I love being a part of a health care team. I work very closely with nurses and physicians and pharmacists every day.

I thought I would talk about some of the roles I have now and have had in the past to give an idea of what I do. Yes, I help people eat better to control their weight, diseases, or symptoms and side effects, but there’s certainly much more than that. I think I am blessed to have worked in so many unique and fulfilling jobs so early on in my career and I truly appreciate each opportunity for all that I’ve learned and been able to apply elsewhere.

I worked in a LARGE clinic in the middle of rural Oklahoma seeing patient in an out-patient setting. Our clinic was ambulatory and non-acute. I liked to refer to the clinic as a “one-stop shop” for health care. We had several physicians on staff (along with rotating specialties – podiatry, endocrinology, etc.), a full lab, 2 dietitians, 2 behavioral health counselors, a full pharmacy, radiology, and WIC…all in one big, beautiful clinic. My average day was spent in diabetes clinic where patients first had labs drawn, saw the physician, and then met with a dietitian, every 3 months. Due to the diabetes rates among Native Americans, we had THOUSANDS of patients. It was busy. I would help adjust insulin with the physicians, download and analyze blood glucose readings, and give diabetic nutrition education. On days we did not see diabetics, my schedule would fill with weight loss, fatty liver, hypertension, and other common diagnoses. I also headed the bariatric program at my clinic that was coordinated with the hospital and met with Lap-Band patients every 2 weeks for weigh-ins and diet analysis. If we hadn’t have moved from Oklahoma, I don’t know that I would’ve ever left this job!

I have been working in nephrology (kidneys) for the past 2 years. I work in several dialysis clinics where my patients come 3 days a week, for 3-5 hours, to run dialysis – a process of filtering the blood and removing toxins. The vast majority of my patients have kidney failure due to uncontrolled diabetes and hypertension. Due to the nature of dialysis, lab work is a huge part of what I do. My patients have labs drawn at least once months, and up to 4 times. The renal (kidney) diet is very challenging – my patients require a LOT of meat and eggs, and need to limit many foods, including milk, cheese, yogurt, peanut butter, nuts, chocolate, cola beverages, wheat, beans, potatoes, bananas, tomatoes, and fluid…just to name a handful. I am responsible for helping my patients eat right and control their labs through diet. I work closely with physicians to change medication orders, obtain medications, begin oral and IV nutrition supplementation, and am responsible for dosing their IV vitamin D. I love that I get to know my patients because I see the same individuals over and over, but dialysis can be challenging and sad — many of my patients die. There is a lot of paperwork and documentation involved and our team is responsible for completing full assessments, including nutrition assessments, on a regular basis.

I love teaching and have been teaching since December 201o. I teach nutrition “101″ for nursing and other non-majors, Medical Nutrition Therapy for the diet technician students (this is a 2-part class that goes over every disease state and the medical nutrition involved in treating that disease/condition), Nutrition Care Process for the diet technician students (this class gives an overview on “how to think like a nutrition professional” and the systematical means by which to assess and chart), and as of next quarter, I will be teaching the hands-on practicum for the diet tech students where we go in to long-term care settings and they actually interact with residents. I think practicing dietetics outside of the classroom enables me to share real-life experiences and stories with my students in the classroom. As someone who HATED to public speak, I lecture anywhere between 8 and 13 hours a week…and that’s just the talking! The prep-work involved in teaching is astronomical (though, enjoyable so long as there’s the time)…and I could sure do without the assignment, lab, exam, and quiz-writing and grading…but I guess that’s part of the gig. I feel very “at home” when I teach and I have loved every group of students I’ve had the pleasure of teaching….it is very rewarding.

I have a business partner, Donna, who is one of the most brilliant and tireless women I’ve ever met. Together, we have worked HARD to get a nutrition practice growing. Due to my time restraints, I have not been able to round-up as much private business as I would like, but we have had some great experiences. Last summer we ran an 8-week weight management group with 10 participants that was a huge success. Our main efforts have been tapping into the diabetic and chronic kidney disease populations because Medicare and many insurance companies reimburse for these diagnoses (we are just beginning to hear about weight management being covered by private insurances…you should check with your policy to see if RD services are covered, by the way!). The thing that limits dietitians is the need for a physician referral in order to see patients and this is what makes having a practice nutrition practice so challenging. Despite the many wonderful “connections” Donna and I have in the physician world, we are yet to find a consistent referral base from any physician. When will doctors 1) start referring their patients and 2) care enough to do so?

So, that’s a little bit about my past and present work. I thoroughly enjoy what I do and love feeling like I can make a difference in people’s lives. I have known since the age of 15 what I wanted to be and to be just as happy with that decision 11 years later is a testament to the love I have for nutrition.

If you’d like to show your resident dietitian some love today, please vote for Prevention RD to in the “Best Healthy Eating Blog” through Fitness Magazine. ;)

And Happy RD Day to all the RD’s out there!

Cheers,