Training Program for International Dietitians
Clinical Nutrition Services
St. Jude Children’s Research Hospital
Memphis, TN, USA
Terezie Tolar Mosby, MS, RD, LDN
Virginia Carney, RD, IBCLC, RLC, LDN
Carla Cartwright, RD, CNSD, LDN
Lucille Fletcher-Pope, MS, RD, LDN
Kristy Gibbons, MS, RD, CSP, LDN
April Gollihugh, MS, RD, LDN
Kay Hall, RD, CLC, LDN
Whitney Orth, MS, RD, COS, CNSD, LDN
Karen Ringwald-Smith, MS, RD, LDN
Harriet Surprise, MS, RD, CNSD, LDN
International outreach and/or "twinning" programs are common in pediatric oncology, promoting sharing of knowledge and resources between hospitals from high and low income countries. Traditionally these programs involved medical doctors, and most recently, involve nurses. Many hospitals now recognize the importance of a multidisciplinary team and utilize other health care disciplines in care for pediatric oncology patients. There are many training opportunities for medical doctors, but fewer for other members of the multidisciplinary team, such as dietitians, pharmacists, speech pathologists, physical therapists, child-life specialists, and social workers.
Because of the nature of the disease, nutrition in cancer treatment is extremely important. In pediatric cancer patients, nutrition status is crucial for the success of treatment, the child’s physical and psychological development, tolerance to infections, and quality of life. While it is challenging to maintain appropriate nutritional status of pediatric oncology patients in hospitals from “high income” countries, in hospitals from “low income” countries it can be particularly difficult. In low income countries, many children are already malnourished at the time of diagnosis. Improving or maintaining nutritional status of children during the treatment becomes a challenging task that may be complicated by side effects of treatment, hospital resources and, in many countries, by scarcity of food.
Since childhood cancer is a rare disease worldwide compared to diseases of infectious etiology, many low income countries have only a limited number of hospitals specializing in treatment of pediatric cancer patients. In many hospitals in low income countries there are no dietitians available and nurses or medical doctors cover the work usually done by dietitians. In fact, in many countries, there are only a handful of dietitians working in this narrow field of expertise. There is a shortage of training for dietitians in pediatric oncology in high income countries and almost non-existent training for dietitians in low income countries. This new program is a way to support dietitians from around the world working in this narrow field, share information and knowledge, and participate in the research.
International Outreach Program for Dietitians
The Clinical Nutrition Department and the International Outreach Program at St. Jude Children’s Research Hospital initiated a training program for pediatric oncology dietitians from around the world in 2005. Since that time, St. Jude has hosted dietitians from Mexico, Brazil, the Czech Republic, Turkey, and Guatemala. The purpose of this program is to share information and foster cooperation. In the 3-week program, dietitians have a chance to observe St. Jude dietitians working in hematology, leukemia, solid tumors, neuro-oncology, and the bone marrow transplantation unit. Food Service and Infectious Disease rotations can be accommodated upon request.
The curriculum includes identifying patients at risk, pediatric nutrition assessment, establishment of nutritional goals, interventions, nutrition during palliative care, and prevention.
Continuation of the program after dietitians return to their home countries is accomplished via webcast through Cure4Kids (www.cure4kids.org). The Clinical Nutrition Department and International Outreach Program may provide assistance for air travel, hotels, and meals in cases when it is necessary. The main obstacles we have identified in our efforts are financial problems, language barriers, and differences in job descriptions.
In conclusion international collaboration is feasible and enriches the professional life of participants from low and high income countries. The ultimate beneficiaries of this program are the patients from the countries involved. Participating dietitians from low income countries may gain additional knowledge and evidence-based practice regarding management of pediatric oncology patients. Dietitians from high income countries may gain cultural competency. In an increasingly multicultural and multiethnic country, such as the United States, it is important for dietitians to be culturally competent to meet the needs of multiethnic patients and caregivers. Personal experience, which is secured by this exchange, is optimal. In the future it will be ideal to be able not only to have dietitians from low income countries in our department but also to be able to send dietitians from our department to developing countries to work side-by-side with local dietitians to fully understand the needs of that particular clinical nutrition department and patients.
Initiation of International Outreach for Dietitians
Any hospital with an expertise in a certain area of nutrition can implement an international outreach program or a "twinning program." The dietetic department can collaborate with an already established medical international outreach program or it can start its own collaboration. The collaboration can have different forms. For example: informal exchange of information via Email or phone, providing books or journals for the department, formal and regular online meetings (using Skype, Horizon Wimba, etc.), training and observation of dietitians’ work, and exchange. Some of these forms of collaboration need more financial support but some do not. Usually the only thing necessary to start such collaboration is personal enthusiasm and dedication.
Role of Terezie Tolar Mosby in the Program
Terezie Tolar Mosby serves as the coordinator of the project. Because she is originally from a low income country and has worked and lived in several low income countries, she recognized the need for such a program. St. Jude Children’s Research Hospital (SJCRH) already had an established international outreach program for medical doctors and for nurses. The Clinical Nutrition Department of St. Jude Children’s Research Hospital, together with International Outreach Program (IOP) from SJCRH, decided to also support international dietitians. Terezie chooses qualified candidates and discusses with them what they would like to accomplish during their stay in SJCRH. Applicants then apply through the IOP program by filling out an online application. Terezie then helps to arrange travel and accommodation on St. Jude campus. When the candidate arrives, a detailed schedule is made depending on the candidate’s needs and requirements. Usually the candidate spends time with a variety of dietitians from the clinical nutrition department in different services including solid tumor, neuro-oncology, leukemia, and transplant. One PowerPoint presentation from the candidate is required for the department to discuss the candidate’s work, challenges and possible research. Terezie also coordinates online lectures using the Cure4kids website, which offers 2-way communication for existing groups.
Statements from Past Participants
Katja Stein, PhD
Dietitian, Pediatric Hematology/Oncology Department
"Including dietitians in the International Outreach Program raises the awareness of the fundamental importance of nutritional support in pediatric cancer care. Being involved in the evaluation of any patient as well as in research increases the body of knowledge about cancer and nutrition. My participation in the Clinical Nutrition Services International Outreach Program for Dietitians of the St. Jude Children’s Research Hospital in Memphis gave me the opportunity to gain experience and update my knowledge about optimal nutrition care in children with cancer. Our purpose is to improve the patient care and realize investigations together in the field of nutrition and cancer."
Derya Biçakli Hopanci
"I participated in this program in June 2009 for 3 weeks. I took an opportunity for observation about oncology-specific nutrition. I experienced working with pediatric oncology dietitians in the USA, where I saw many differences from Turkey. I benefitted a lot from this program. My colleagues who work in the Clinical Nutrition department at St. Jude Children’s Research Hospital were very friendly, helpful and well-versed in oncology. I loved them and this was a great experience in my professional life. Thank you."
Ana Lucía Molina Linares
"Thanks to this experience I met wonderful people not only professionally. Personally, I made many good friends. It gave me the opportunity to promote research to improve nutritional interventions for our patients and improve their tolerance to treatment."
Claudia Paola Medina Jiménez
"I am proud to have gone to the hospital with the highest level of expertise in its genre, and I am delighted to have shared the workplace with people whom I lived with this time. I not only had a good experience working with knowledge of clinical nutrition services and other services in the hospital, but I found good friendships as well. I am willing to do further exchanges of professional interest."
Maria Claudia Bernardes Spexoto
"I found it a very stimulating experience. I certainly learned and brought some new strategic changes back to my home country and hospital. I also had a remarkable experience at research opportunities."
"Finally, I found what the job description of a dietitian should be and what competencies a clinical dietitian should have. In my country, nothing like that exists yet. Based on my experience, I started a training program for our dietetic students. I established a new position for one dietitian to be designated only to pediatric oncology. I also went back to school to pursue an additional degree in nutrition. None of that would have happened if I had not had the experience at St. Jude."