Ongoing RD Exam concepts, 2015

1. Medicare’s Intensive Behavioral Counseling for Obesity Benefit:

• Effective November 29, 2011• For screening and intensive behavioral counseling for obesity • Key elements of coverage:

– Furnished by Primary Care Providers (PCPs), or by auxiliary personnel– Furnished in primary care settings for Medicare beneficiaries with BMI >30 kg/m2

• PCPs to offer or refer pts with BMI >30 kg to intensive, multi-component behavioral interventions to include:

– Behavioral therapy activities (e.g. goal setting)– Nutrition counseling– Increasing physical activity– Addressing barriers to change– Self-monitoring– Motivation– Strategizing how to maintain lifestyle changes

• Limit of 22 times in initial 12-month period, counted from date of 1st

claim; can be repeated annually

• 1x/week, face-to-face, during 1st

month

• 2x/month...every other week…months 2-6 (intensive)

• 1x/month for months 7 – 12… but only IF

– Patient loses >3 kg (>6.6 lbs) in months 2 – 6

– Wt loss in months 2 – 6 to be documented in MR for reimbursement of visits in months 7 – 12

• Consistent with 5-A framework for behavioral-based therapy– Assess, Advise, Agree, Assist, and Arrange

Billing requirements

– Benefit must be furnished in primary care setting by:– Qualified primary care physician (PCP), or – Qualified non-physician practitioner (mid-level), or

– BUT, per Center for Medicare/Medicaid Services (CMS), benefit may be covered if also furnished by PCP’s auxiliary personnel

– RDs consider auxiliary personnel to furnish benefit “incident to” PCP’s services• Approved places of service (POS) and POS codes:

11 = Physician’s Office 22 = Outpatient Hospital 49 = Independent Clinic 50 = Federally Qualified Health Center 71 = State or Local Public Health Clinic 72 = Rural Health Center

• Telehealth IBT for OB As of Jan. 1, 2013, can be furnished via telehealth; must meet all CMS

requirements

Eligible PCPs/Licensed Providers that RDs can billed under of “incident to”:– 01 = General Practice– 08 = Family Practice– 11 = Internal Medicine– 16 = Obstetrics/Gynecology– 37 = Pediatric Medicine– 38 = Geriatric Medicine– 50 = Nurse Practitioner– 89 = Certified Clinical Nurse Specialist– 97 = Physician Assistant

2. 2012 Diagnostics for Diabetes

Source: Adapted from American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(Supp 1):S12, table

3. Pregnancy Wt Gain Guidelines for Singleton

Twins: 35-45 # Triplets: 50#

4. Types of Data

a. Qualitative:i. Nominal: categorical like gender, race, or sport

ii. Ordinal: also categorical but can be ordered, like small, medium largeb. Quantitative:

i. Discrete: can only take specific values, like number of births or number of daysii. Continuous: can be any numerical value on a scale, like BMI (32.1, 32.2, 32.3)

5. Measures of Association (stats)

RELATIVE RISK The ratio of the risk of disease (or death) among people who are exposed to the risk factor, to the risk among people who are unexposed. This is synonymous with risk ratio. Alternatively, relative risk is defined as the ratio of the cumulative incidence rate among those exposed, to the rate among those not exposed. To estimate a relative risk, you need a cohort study, from which incidence can be calculated. An RR of 1.0 means that the two incidence rates are equal so the factor has no effect. An RR of 2 would indicate that the exposed people were twice as likely to get the disease; an RR of 0.5 means they were half as likely, so the factor protected them from the disease.

ODDS RATIO. The term "odds" is defined differently according to the situation under discussion, but it is the ratio of the probability of occurrence of an event to that of non-occurrence. If 60 smokers develop a cough and 40 do not, the odds of developing the cough are 60:40 (or 1.5). [Note that the probability of developing a cough is 60/100, or 0.6].

The odds ratio expresses the association between a risk factor and a disease by comparing the likelihood of disease under two circumstances, such as the risk of a cough among smokers compared to non-smokers. The ratio of the two odds is closely related to the concept of relative risk, but the very useful feature is that the odds ratio can be calculated from a case-control study, and does not require knowing incidence rates. The odds ratio is calculated as:

Exposed Not exposed

Got the disease a b

Did not get the disease

c d

Odds Ratio = ad / bc

RATE DIFFERENCE. (Incidence rate of disease among those exposed) - (incidence among those not exposed). This is useful in showing the excess morbidity due to the exposure (the "Attributable risk"), which, in turn, can be used to indicate the health benefit of removing the exposure.

6. Fats: Random Facts Nut/seeds with highest omega 3: flaxseed, chia seeds, butternuts, walnuts (highest in alpha-

linolenic acid, or ALA). o Note: food high in the other omega 3 ( eicosaentaenoic acid, or EPA, and

docosahexaenioc acid, or DHA) are fatty fish). Nut/seeds with lowest omega 3: pine nuts, pecans, soybeans Nut/seed with highest omega 6: pine nuts, walnuts Nuts/seeds lowest in omega 6: sunflower seeds, macadamia nuts, chestnuts Latest AHA recs on fat intake:

o For adults who would benefit from lowering their LDL cholesterol, the American Heart Association recommends:

Reducing saturated fat to no more than 5 to 6 percent of total calories. For someone eating 2,000 calories a day that’s about 11 to 13 grams of saturated fat.

Reducing the percent of calories from trans fat.o The American Heart Association’s Nutrition Committee strongly advises these fat

guidelines for healthy Americans over age 2:

Eating between 25 and 35 percent of your total daily calories as fats from foods like fish, nuts, and vegetable oils.

Limiting the amount of saturated fats you eat to less than 7 percent of your total daily calories. That means if you need about 2,000 calories a day, less than 140 calories (or 16 grams) should come from saturated fats.

Limiting the amount of trans fats to less than 1 percent of your total daily calories. That means if you need about 2,000 calories a day, less than 20 calories (or 2 grams) should come from trans fats.

For good health, the majority of fats you eat should be monounsaturated or polyunsaturated.

About omega 6 and Omeg 3 omega 3 ratio: Harvard School of Public Health and AHA:

o Omega 6:

Most people should consume at least five to ten percent of their total daily calories from omega-6 fatty acids.

Replacing saturated fats with polyunsaturated fats, which are natural sources of omega-6, may help reduce heart disease risk. Saturated fats are found in meat, full-fat dairy products, and tropical oils, such as coconut and palm oil.

Higher intakes of omega-6 may improve insulin resistance, reduce diabetes risk and lower blood pressure.

There has been debate as to whether omega-6 fatty acids lead to arterial inflammation, a marker for heart disease. The advisory explains why omega-6 fatty acids are in fact heart-healthy and are not pro-inflammatory.

Omega-6 fatty acids lower LDL cholesterol (the “bad” cholesterol) and reduce inflammation, and they are protective against heart disease. So both omega-6

and omega-3 fatty acids are healthy. While there is a theory that omega-3 fatty acids are better for our health than omega-6 fatty acids, this is not supported by the latest evidence. Thus the omega-3 to omega-6 ratio is basically the “good divided by the good,” so it is of no value in evaluating diet quality or predicting disease.

o Omega 3:

Omega-3 fatty acids are essential fats that your body doesn't make but needs to function properly. Omega-3 fatty acids, particularly EPA and DHA, have been shown to benefit the heart. They can decrease the risk of arrhythmias (abnormal heartbeats), decrease triglyceride levels, slow the growth rate of atherosclerotic plaque and lower blood pressure

Omega 6:3 ratio NIH in 2002 statement :The importance of the ratio of omega-6/omega-3

essential fatty acids. Several sources of information suggest that human beings evolved on a diet with a ratio of omega-6 to omega-3 essential fatty acids (EFA) of approximately 1:1 (current recommendatino) whereas in Western diets the ratio is 15/1-16.7/1.

7: Vit D/Calciums: Random Facts:

8 oz milk: 300 mg Ca, 100 IU Vit D

Table 1: Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health* [1]nmol/L**

ng/mL* Health status

<30 <12 Associated with vitamin D deficiency, leading to rickets in infants and children and osteomalacia in adults

30–50 12–20 Generally considered inadequate for bone and overall health in healthy individuals≥50 ≥20 Generally considered adequate for bone and overall health in healthy individuals

>125 >50 Emerging evidence links potential adverse effects to such high levels, particularly >150 nmol/L (>60 ng/mL)

8. DRI: explained:

Intake reference values for nutrients are provided in the Dietary Reference Intakes (DRIs) developed by the Food and Nutrition Board (FNB) at the Institute of Medicine of The National Academies (formerly National Academy of Sciences) [1]. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and gender, include:

Recommended Dietary Allowance (RDA): average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy people.

Adequate Intake (AI): established when evidence is insufficient to develop an RDA and is set at a level assumed to ensure nutritional adequacy.

Tolerable Upper Intake Level (UL): maximum daily intake unlikely to cause adverse health effects [1].

9: Campinha-Bacote Model

The Process of Cultural Competence in the Delivery of Healthcare Services: Know the 5 components:

10: dialectical Behavior therapy:

Often a popular form of cognitive- behavioral   psychotherapy for eating disorders , it was developed in the late 1980s by psychologist Marsha M. Linehan to help better treat borderline personality disorder. Since its development, it has also been used for the treatment of other kinds of mental health disorders.

The word "dialectical" refers to the concept of being able to hold onto two seemingly different ideas at once.

Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

Dialectical behavior therapy (DBT) is a therapy designed to help people change patterns of behavior that are not helpful, such as self-harm, suicidal thinking, and substance abuse. [1] This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions. DBT assumes that people are doing the best they can but are either lacking the skills or influenced by positive or negative reinforcement that interfere with their ability to function appropriately.

DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, andmindful awareness largely derived from Buddhist meditative practice

11. Acceptance-commitment Therapy

According to https://contextualscience.org/act, Acceptance and Commitment Therapy (ACT) is a unique empirically based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. Psychological flexibility means contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.

This is a common therapy used in eating disorder

12. Food Safety Temps:

13. Menu Pricing/Menu engineering

http://jan.ucc.nau.edu/~jtm/ha355/class/overview/menu/lesson1-3-1.html

Menu Engineering

Menu engineering is a method of analyzing sales to determine the effectiveness of the restaurant's menu. Each menu item is reviewed to determine its margin per meal and sales volume mix. The following matrix shows how menu items are analyzed and categorized:

Another version of this chart seen below: