First week on final placement

I'm home for the weekend, allowed to travel south for good behaviour in my first week on placement in GNT. There are three of us students in the department, and we have spent much of the first week together, meeting a large number of dietitians, and starting to find our way around the hospital.

After this first week we will split up, and we have been allocated to various dietetic services according to our preferences. In my case I will be spending a lot of time outside the hospital, which I didn't do on my last placement, and I will have some time in the diabetes service. The other two students will be on the wards more, and focussing on obesity and intermediate care, which is when someone is well enough to leave hospital but not quite well enough to go home.

So last week we spent a day with the hospital catering service, so that we know how meals are prepared and ordered by patients, and how alternative requirements can be supplied. Patients (and ward staff) can select certain options themselves—renal or texture-modified options, for example—and additional snacks can be ordered for people who need extra calories. Unlike my last placement, this system appears to work, and the additional snacks do find their way to the patients on the wards.

Of course, all the notes and recording systems are different in this hospital, and different wards also operate slightly differently, but there seems a little more consistency in what I have seen so far. I've been able to attend a case conference, where a patient's discharge to a residential home with a tube feed was being organised between the community matron, the district nurse, the social worker, the owner of the home, the ward staff and the dietitian.

On Friday, we were sent into town to see the fresh produce markets, which I think was partly a treat to give us a break at the end of the first week, and partly to emphasise the importance of local knowledge. We had a 'task' to complete, comparing prices in the market with supermarket prices. In general, the prices in the market were about the same or slightly higher than the very cheapest 'value' brands in the supermarket, but the quality was much better in the market. We happened to see a stall in the indoor area selling gluten-free produce, giving us some useful inside information about where someone with coeliac disease might shop. It was also interesting to see that despite the introduction of metric measures ages ago, GNT market shoppers and traders still work mainly in pounds and ounces.

The post-graduate centre at the hospital hosts Friday lunchtime lectures, and just by chance this week's was given by a bariatric surgeon, talking about obesity and surgery options. It was fascinating. Again, my last placement couldn't give me any experience of weight management, but this is a major part of dietetic practice in this hospital, and although this isn't on my training schedule (because I have community and diabetes options instead) I hope to learn a lot more.

A point made in the lecture is that it takes only a very little amount of excess food over a long period of time to lead to obesity, and given the large amount of food available to us all, the question is not why some people become obese, but why many people don't. The body's management of energy intake is very finely balanced through production of hormones and metabolic pathways, and we actually have very little conscious control over it, which is why we can do things like fooling ourselves into thinking we have more food by using a smaller plate. Our unconscious systems also tend to 'defend' the highest weight achieved. No wonder it is difficult to restrict energy intake; my own brain is fighting against me.

There are the three options available for 'treating' a patient's obesity: diet, drugs and surgery. Given that the presenter was a surgeon, it is not surprising that his message was clear: diet and drugs don't work when the outcome you want is not only weight loss, but maintenance of that weight loss. Of course it isn't as clear-cut as that, because there are many other ways to 'treat' obesity, the main one being social measures. For example, smoking is as hazardous to health as obesity, but taxation clearly didn't work and psychological and nicotine-replacement therapies may have helped. What has had the greatest effect, I'm perfectly convinced, is the introduction of the smoking ban in public places. I have no idea what measures might apply to obesity, though. It's a hellishly intractable problem.