4.01/ DYSPHAGIA MANAGEMENT: PANDEMIC LESSONS LEARNED AND FUTURE POSSIBILITIES
40 Min. 10Sec. | May 16, 2022
00:00:13 --> 00:02:23: Bethany Hello and welcome to Clinical Nutrition Notes – a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition – brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals, for education purposes.
I am your host today, Bethany Hopkins, Medical Affairs Manager with Nestlé Health Science.
Today we’ll be talking with 3 guests across the country to follow up on a conversation we first broadcast in January 2021. We’ll pick up on the panelists thoughts on how COVID-19 has impacted dysphagia practice, and discuss key learnings and opportunities they envision for the field moving forward.
I’ll take a moment to introduce our 3 panelists.
Peter Lam is a registered dietitian and credentialed food service executive in Vancouver, British Columbia. Over the past 25 years, he has focused his practice in dysphagia and meal-time management. Peter provides consultation to the healthcare, food service and the hospitality industries and is currently co-chair of the International Dysphagia Diet Standardization Initiative or IDDSI.
Ellen Andrews is an adult medical speech language pathologist with Bruyère Continuing Care in Ottawa, Ontario. Over the past 20 years, she has served patients with complex and chronic health issues which include dysphagia, augmentative and alternative communication and respiratory care. During the pandemic, Ellen has continued her work at St. Vincent Hospital where she joins us today.
Now heading back to the West coast, Janice Duivestein is a combined trained therapist, occupational therapist and physiotherapist, who has worked in eating, drinking and swallowing for 30 years. She currently works for Access Community Therapists providing dysphagia consulting services around British Columbia. She is an associate clinical Professor at the School of Occupational Science and Occupational Therapy and has presented on dysphagia locally, nationally and internationally. Janice is also a member of the IDDSI board and their communications lead.
Thank you all for joining us today.
00:02:25 --> 00:03:27 BethanyAs we previously talked about dysphagia assessment and management has been an area of healthcare nutrition particularly affected by the pandemic. Today, I wanted to pick up that conversation and focus on what's been happening in the dysphagia management space and the opportunities the pandemic has presented for us to both rethink and retool the way we work. While the concept of remote or virtual practice is admittedly not new, it certainly has taken on a new significance and some might say an urgency during the pandemic. And there are also learnings from COVID 19 that we can apply to the future of decision management to improve ways of working and ultimately the care provided to individuals with dysphagia. With that said, let's start the discussion.
The first area or question, I would like each of you to weigh in on centers around what do you believe are some of the key learnings from the pandemic? And if you have any practical nuggets or tips that you can share.
00:03:28 --> 00:08:02 Janice Well, maybe I'll jump in from the start Bethany, and I like that you brought up around tele practice or telehealth as as one of the things that has come to the front of different or new kinds of practices because I think for many of us working in this field, that has certainly been one of the big things that came along.
And you're right, it's not new. I actually can remember which dates me even more like decades ago, it feels like, where a lot of that infrastructure was being put in across Canada through federal grants, and we were all so excited, and here was this new thing. And yeah, it’s great and it has been great. But I think what's happened during COVID is it is actually just sort of parachuted it right up into the stratosphere in terms of the technologies and how we've been able to use them. So I think it was a wonderful thing to have started with, but there were a lot of barriers. It wasn't actually very flexible or very nimble. You couldn't use it in a home setting very easily set to go somewhere. And I think that has allowed us in many ways to, you know, with all the new platforms that have been developed, that's been fantastic. I actually was just looking at a very nice review because it's been around a long time and it's been used a long time and there is actually some really good evidence. And in terms of the fact that this kind of practice is, it's very reliable, it's quite valid. We don't have research so much research on it because in many respects, we've only really just started, you know, using it in such an intensive way.
But Georgia Malandraki and colleagues in March 2021 published a really lovely sort of review and synopsis of that, and I certainly encourage people. There are some terrific resources out there to go and explore and look at, and she really touched on not only the evidence to support the use of it as being it's not, it's not really a second rate thing. This is just, I think it's wonderful. It's another tool in our toolbox. It's something else we can use and it has all its benefits. It's not exactly the same as going in person, but it is another wonderful tool, and I think we're very smart to make use of it and move forward with it and figure out how to do that. I think some of the things can be for people who had never really used it before. Some of the things that are a bit scary are, well, I know for people like me, technology off the top and how do you work with all these things and you need the internet not to break down on you? And you know, how do you get around that? Are there any particular things you need to be careful about in terms of how you use it? There's things like privacy and making sure nobody sort of bombs in onto your session. How do you maintain those things? How do you prepare the people on the other end? And so there's a lot of considerations. And what I'd really encourage people to think about doing this is there's tons of resources out there that have really blossomed in since beginning of COVID. Go and check out on your professional regulatory bodies. You should do that first because there are certain regulations that you need to follow in practices and which you do for an in-person one. You really do need to follow those practices.
Make sure you know what those are. It is your responsibility. So I think that's off the top, you know, go and do that. A lot of these have also developed a lot of places, have developed some nice guidelines and give you really good practical tips.
You know, how do you? Yes, you do need consent. How do you set it up? What platforms do I need? How do I prepare people on the other end? All of those things are important questions to ask yourself this where you go forward. So I've been impressed by the amount of the or the number of resources that I've actually been able to find in terms of how this has come together. So if you think back, really, this has been just over a year and the number of resources and the amount of work that's gone into it and how much this has, you know, just leaped forward is not just quite amazing.
00:08:03 --> 00:08:46 BethanyYeah, it is interesting because as you said, it's it's not new, new, but yet it is for a lot of people. And you know, it's either a new tool or it's sort of getting a tool out at the bottom of the toolbox that may not have been used before. And we're not all I.T. experts. So, you know, working through some of that has been a real learning, and there are learnings, of course, from other people that we can kind of draw on. And I also like your comment too Janice about, you know, checking with regulatory bodies as well just about, you know, if there's any, you know, things people need to be considering around around practice when it comes to sort of working in a virtual environment, I think is is really important as well.
00:08:46 --> 00:13:59 Peter
Well, Bethany I think I’ll just jump in and say Jan, thanks for the comment about aging yourself. I'm not too far behind you and this whole time through COVID and the whole need to parachute into the use of virtual technology. My practice is very much providing support in home and when the COVID hit, there were a lot of people who really didn't want to see us. And so we have to learn very quickly, well, how do we still make ourselves available to people? And so I think one of the first things that is really evident is just as you're watching this broadcast now. It's really quite benign. It's not as intrusive as having an actual person in a home or in an office. And you know, when we were just starting to pull together this broadcast, the panelists all made jokes about, you know, all my little toys here in the back of my credenza. But for a lot of the patients that we support. That actually provides some comfort to them, we see the personal side of you. There is less anxiety involved with this white coat syndrome where the clinician now is just part of the screen and on occasion I actually turn off my video so that it's it's just my name. And so if we're doing a real observation, they don’t see somebody sitting a few feet away from them, watching them intensely. What they see is this electronic device in front of them and half the time a lot of our patients are our clients actually forget we’re even there. So you you do get a more realistic picture of what is happening so often as dysphagia clinicians, we always joke about the fact that when we are there doing the assessment, people are always at their most behaviour. They eat small, tiny, mouthfuls, they eat very slowly they take dainty sips. But this technology has now actually afforded us the ability to be that fly on the wall so we can actually watch what's going on. I think the other thing, Bethany, that actually has really helped here is when we need, again rather than trying to display an image or a motion graphic of some sort, especially when we're trying to illustrate the physiology of a swallow or what might be going wrong with a swallow. We can now just share our screen and they have the full motion graphic in front of them. I always have said, you know, a picture is worth 1000 words, but oh my goodness and motion graphic is worth like 1,000,000 words or more. And so this technology is wonderful because you have it at your fingertips. And having said all of that, the best thing that that has happened is now that we have this ability, you
can pretty much chime in any time. You can really, there's very little preparation, I should say that's involved from that, that the clients end the caregivers end so often when they call, and we say we would like to come and do a visit at your home. People panick because they think, Wow, they have to clean up their house. They have to get everything ready. Sometimes they even think they have to serve as snacks when we come to visit them in their home, whereas again, chiming in on a virtual platform like this is so benign, we can book appointments so much easier. People are so happy to say, oh, you know, we just got half an hour for us. We'll just take it. And so, you know, sometimes a phone conversation or phone call can easily lead right into a virtual consult. Somebody may describe something to you and they say, you know, yeah, the swallow is like this, like this, like this. And you can pretty much say, would you mind if we just set up a really quick video call now? And people are much more open to that idea. So despite all of the craziness that we've gone through, this is definitely one area I think that has been a positive for us coming through COVID.
00:13:57 --> 00:14:39 Bethany It's really interesting to listen to what you're saying, Peter, and think about how you know, when maybe, you know, historically we think of technology as being, something that people aren't comfortable with to really having this opportunity to be less obtrusive and kind of blend into the background, so to speak, both when we're communicating with people or sort of observing what they're doing. And then you also mentioned to that ability then to also use it as a device for education showing those sort of visual aspects as well. So it kind of brings a little bit of richness that way to to some of those interactions, perhaps. Yeah. Thank you.
00:11:47 --> 00:17:42 Ellen
I'm so fascinated hearing the discussion so far because my experience has been entirely face to face. I've been in the hospital setting through the whole thing. And while our organization does run an outpatient service that did eventually move to online, my work never has. I'm in a complex continuing care hospital with medically fragile adults. I work on a tariq and vent program. And so certainly those experiences with remote haven't been my experiences with COVID. But the initial question really about the changes in our practice and those nuggets, we have certainly seen huge changes. And one of them has been the sort of increased isolation even in healthcare. When COVID first started, we stopped having visitors and we stopped having access to outside appointments. So we contract out, for instance, for our instrumental swallowing assessments. So we lost that very important tool we used. And we also lost that face to face of family members at bedside all day who are able to be those those supports.
Fortunately, we've got some of those visitors back, but things are certainly far from normal. And as we’ve moved through COVID, we get in scenarios where we've been in outbreaks and we've really had to adjust our practice. And one of our real learnings is again, which is always for all of us, but about prioritization. Does this need to happen right now, particularly if we're looking at, you know, potential risky things, if there's an infection or there's an issue with PPE or various factors like that? How are we weighing what what we need to do right now?
And a real reminder to us, I think picking up a little bit what Peter said about that. When you're on the remote and sort of getting into people's homes that we're really remembering again how we have to rely on our team members, that an observation from a nurse and observation from another therapist, a conversation with the dietician. It may not be quite what I would have done traditionally as the face to face assessment, but we have to use all of those bits of information to get to build the puzzle, to build the pieces, to understand the needs of our patients.
And certainly, we've had some really challenging scenarios. You know, when we were in outbreak scenarios we often work from, we say from clean to dirty. So you start your day away from COVID patients and we do that at the end of the day.
So a lot of practice structuring that has to happen in those ways, but really finding ways to embrace methodologies. I know we had an amazing situation one day where we had a very complicated conversation with a patient and family around dysphagia, where there was a significant language barrier. So we had a staff member who spoke the language in the room. We had two iPads, one with the family, one the physician and at a certain point we were holding the two iPads up, so the physician and the family could speak directly.
And it was just incredible how chaotic this was, but also this real sort of pioneer spirit of figuring out how to make do and learning those things that it doesn't have to be perfect, but we have to keep moving forward and we have to keep supporting the people we serve.
00:17:42 --> 00:18:55 Bethany You know, it's interesting just listening to what you're saying Ellen, and then also reflecting on what others have said, but it’s, I think people are more accepting of, you know, things happen and we're not all perfect and things don't all always happen in a certain order, you know, best laid plans change. And so it's really, I think, heartening to see people accepting and embracing the sort of this agility and ways of doing things different. And there's a time and a place for things. But getting us to really sort of rethink some of these things and just being, yeah, just sort of more accepting when things aren't the norm. So it's it's interesting to hear that experience. And even though you said you’re face to face, you're doing things with people in the environment where you work, still bringing in that virtual technology aspect where you can and having consultations and family members or interpreters brought into the conversation virtually, which I don't think we would have seen as much of you know, prior to COVID. So there are those other opportunities, even when you're in that sort of face to face clinical environment as well.
00:18:56 --> 00:19:05 Ellen And of course, the face to face looks like this. So it’s a little different than it used to be.
00:19:06 --> 00:21:39 Janice
Face to face has brought in a whole new meaning in many respects.
I think Ellen's description is great, too, because I also we see that now and again, with things becoming a little more flexible in terms some of how you provide the service to people. And I think, as I say, I think we have to look at embracing all the tools in our box, which is just expanded because sometimes a visit may be a need to go in because of, you know, concern over the degree of swallowing difficulty for someone. But I often will work with my dietician colleague and they may come in virtually and I may be the person they are doing it. And we're kind of working together as a team. So it's, you know, it's made it very flexible and nimble in that way. And and I think it does allow you to look at, and as Ellen pointed out, certain circumstances or certain kinds of clinical situations maybe aren't going to lend themselves quite as well to the use of all the technologies in the same way.
On the other hand, we've also opened the doors for providing services, you know, far flung all around the country in many respects. I do a work of a lot of work in outreach where I normally would travel around the province to sort of visit a couple of times a year.
And so now, you know, people living up hundreds of kilometers from from me, I can set up a quick virtual visit and work with a community team there. So it really has, I think, especially for those who don't have access to a lot of the centralized specialized services. It's opened up a lot of opportunities and it's not that they weren't there. It's just that there were a lot of barriers, I think, to getting them. And I think this whole situation has made everybody just have to rethink everything, turn 180 degrees and go, OK, well, maybe it's not so bad to use this platform or that platform and that I think it's been one of the most amazing things at how fast we can all learn to adapt and what things could be created and utilized.
00:16:46 --> 00:22:32 Bethany
So our practices evolved. I mean, the technology itself has evolved at sort of a lightning speed.
It seems like every week there's different capabilities available on platforms like Zoom. It's been really quite amazing to watch, you know, all of this happening. And you know what you were saying, Jan. Just it's just you segued so perfectly into the next area that I wanted to to talk about.
And it was really around opportunities, future opportunities. And how do each of you see, you know, the learnings around what's happened, you know, with the pandemic, how do you see that being integrated into practice moving forward? And you know, just what other implications that that you see?
So I'd like just to get each of you to weigh in on that as well future opportunities for practice.
00:22:32 --> 00:26:03 Peter
Well, I'll jump in first here. I think, you know, just hearing what Jan said about the whole issue of the involvement of the team, that is a new luxury that we now have.
So often it has been so difficult to try to assemble an entire professional team together to discuss the case or to discuss what discharge planning. Now, with virtual technology, the use of mobile devices where people could just chime in for five minutes, the pharmacists can chime in their office. The nurse can chime in from the nursing station. It's actually affords us that ability to now be able to get more wisdom around that table without accumulating huge costs. I remember attending meetings in the past where, you know, this sounds awful, but we wonder, wow, how much does it cost for this meeting to take place with all of these high priced people around the world? I can joke by saying I was probably the cheapest one there, because dieticians don't really make that much money, but now we can set up those types of meetings. And ultimately, it improves the level of care we provide for our patients.
It may sound like a really pro virtual technology and care. Please don't be mistaken. There's still a place for in-person consultations and an assessment. I see us moving to a future where we might have more of a hybrid practice, where once we have perhaps established that initial relationship with a client with the family, then the follow ups may be done in a hybrid type, whether virtual or quick phone follow up. You know, when it comes to, like I said before, setting up a consultation, there's that reduce costs of travel, booking meetings, is so easy these days. It's it's a link. People join in. And I know that the health authorities actually love this because there's not even the need to worry about providing coffee or snacks. Right? You can have your own. So cheers. We're having a lovely chat and you provide your own beverage and a beverage that you like. And so I think that the whole idea going forward, I really do see that, what we have learned to date will provide us with a timely way of addressing issues. And ultimately, it will enhance patient care.
00:26:03 --> 00:26:44 Bethany Yeah, I was thinking as you're talking, Peter as well. And I mean, you're in a, you know, a community based practice and thinking about, you know, Ellen, what you were saying about working in a facility and often hearing clinicians as well talking about sometimes the challenges of, like you said, getting everybody around the table that are working in these different areas geographically, just to talk about things, you know, like discharge planning and continuity of services and that sort of thing. So, you know, you can see how this would really lend itself well to help with some of those, just that one activity in and of itself would be would be so helpful.
00:26:44 --> 00:29:13 Ellen
Yeah, I was so thrilled to hear you, Peter, talking about the increased opportunities for the team to get together. That's absolutely the joy of my career is working with a very strong, interdisciplinary team and knowing those people are available to me and to support the patients in such a holistic manner. So that's wonderful. If the virtual is giving patients the community that same access that patients in facilities often do have. And thinking about, you know, these changes and what's going forward, I'm really finding big health care system changes. Certainly as an organization, we have a new boldness, maybe a new confidence. The things that were years of hemming and hawing are happening. Our ventilator program went from ten to 21 beds, and it's heading towards 30 in the next year because of COVID, and these are long discussions about health care system change.
But finally, somebody made the decision because it was time to make decisions, certainly in-house too. For our practice, we are going to be bringing in instrumental assessment in-house, again a dream of ours, a discussion for many years. And suddenly there was a real realization from a health care system and from the organization that these are things we need the capacity to do to serve our patients. But for me personally, besides those big changes, I think it's been the education opportunities of COVID that have been such a surprise and such a delight. We're so isolated, and I think there's just been this thirst to use this time for connection and for learning.
So the number of webinars and education events I do every week has gone up. I've certainly had the pleasure of getting to know Peter and Jan through this sort of format of doing commitee work with them. And because it's so painless to just meet up with somebody around the country and certainly for myself, you know, I've been able to continue my education in dysphagia. I've had opportunities for learnings that I wouldn't have had before. And also opportunities to share my my knowledge and to be an instructor in those areas, which again has challenged me but also inspired me.
I think as people in health care settings, I used to say I had a job in a hospital before COVID, and now I'm a healthcare worker and I feel very strongly this real change in in my identity. Having gone through this experience and giving myself a certain sort of boldness and confidence and purpose, moving to the next phase of my career when we get through this so interesting times.
00:29:14 --> 00:29:18 Bethany Yes, very much so. Very much so.
00:29:19 --> 00:31:36 Janice
Yeah, Ellen, I like your comments about education because I think that has also become one of the new things. And we certainly, again, all had to pivot a little bit, in terms of, you know, not only sort of being able to, as you say, access courses and now, but also in terms of figuring out, well, how do you deliver education and certainly education to community support workers and others? This is sort of part of the role that Peter and I have in community and we have now gotten our virtual in-services figured out, how to do that, and sometimes we actually get better attendance because, you know, again, you can't get everybody together in a big room, but they can pop in from their own location and participate in that. So it has offered those opportunities, I think, to provide education on a wider basis. I think also, with the use of this kind of support, mentoring is often something I hear from clinicians living in small communities.
Sometimes they're, you know, new practitioners. They've just arrived and then they're supposed to be doing this work, and they're not really sure about how to go about these sorts of things. And you can now provide some of that mentoring support because they can be there and you can be helping and direct them and talk with them and support them in that way. And I think that that has also really started to fill in a gap that has been there for a very long time, and I think certainly something I've heard from a lot of my colleagues around in very remote areas of the province is you now have those opportunities as well, not only for education, but also potentially for some mentoring support in a way that can really help do that. And that can only be better for our healthcare system is people that feel more comfortable, more confident and more knowledge and skills. It's just going to be better healthcare, better care on the ground for all of those people around us. So I think that I think that there are some really bright, exciting opportunities in the future.
00:31:37 --> 00:33:16 Bethany
Oh, that's great to hear.
And, you know, thinking about you add to that continuing professional education. It's, you know, having access is, like you said, is a real challenge for a lot of people and having it to be sort of I'll call it just in time.
You know, the education when you need it, where you need it, how you need it is so important. So it is nice to hear that you're all seeing sort of these opportunities as helping to kind of pave the way for people to have that access, have the ability to participate and that it is something that is adding value to to your practice and then the patients that you're working with as well ultimately. So I want to thank you, Ellen, Peter and Jan for sharing these thoughts and insights, and certainly, you know, the field of dysphagia management looks a little different than we might have imagined a couple of years ago.
And with this pandemic, it has brought these opportunities that you've been talking about to really rethink the way we practice and have these positive influences, as you've mentioned on both ways to collaborate with among each other, and then ultimately, with that goal of improving dysphagia care.
So I do have one last question for each of you before we wrap this up. If you could each choose one thing that you would say was your biggest lesson, your biggest aha moment or opportunity for dysphagia practice coming out of this pandemic.
What would that be?
00:33:17 --> 00:34:24 Ellen Wow, there's been so many big changes, I think we can all agree on that. Certainly, speaking personally, I think I've heard often the lesson about the pandemic is it's really amplified a lot of things and often things we knew before certainly hearing about how my co panelists have been reflecting on to how it's changed their practice and certainly some of the roles, you know, our job was to care and we've had to care more. We've learned to care for our patients. I've also very involved in our health and safety committee and caring for each others. The staff has been so important and for me, it's really reset my comfort meter. Things I was frightened of or nervous, or I had to prepare for a big change. And now again, realizing that through those feelings of disruption and discomfort, that being called to act, being called to serve, being called to be bold and being called to take on new challenges. So I think that's going to be a really amazing lesson as a human being, I'm going to take for it, and also as a clinician, a clinical instructor, an educator and all of those other hats we wear.
00:34:24 --> 00:34:26 Bethany Thank you, Ellen.
00:34:28 --> 00:35:57 Janice
Great, I love that. Go boldly. Kind of a little treky back here, I think warp speed when we talk about how fast things happen. I think for me, one of the most amazing things or just how I've seen it is, is just how things that seemed impossible. I used to remember being so frustrated about how difficult it was to try and set up something to make something work in a remote community because, you know, there was a technology, Oh, no, you couldn't do this because of this reason. And there were there just weren't seem to be barriers every step of the way, and you begin to get just kind of frustrated and a little cynical after a while thinking, Oh my gosh, you know, how come this takes forever to?
Somebody said, you know, decisions actually got made and things move forward. And if I can quote one of my amazing heroes, Nelson Mandela, I have a little fridge magnet, something I hold dear. It's actually on my my filing cabinet.
It is, as it always seems, impossible until it's done. And I just think that the situation we've been through has really brought that to the foray. It did seem impossible and suddenly we've had to do it and we did it.
And I would, I guess I would just say, for me, it's sort of like, you know, got to embrace all these opportunities, the things that were impossible. Now they're done. Now it's time to move forward and take that feeling with us. It's not impossible.
00:35:58 --> 00:38:39 Peter
So Jan, I completely agree with you there. When COVID first hit, there was this worry will I even have a job? Oh my gosh. Like, how do I even see patients? And now that we have this super sharp learning curve, it's amazing to realize we have this ability now to support one individual two individuals, hundreds of people that thousands of people, whether it's in a clinical practice forum or in an education type forum. When we first started out on the work of the International Diet Standardization Initiative. There were some people who sort of smirked at us and said, Oh, good luck. You know, this is just going to be a passing phase. But what COVID has actually has done is propel this to a point where we were forced to use this technology to reach out to international audiences. And we are so excited now with over 40 countries in the world actively implementing.
They have reference groups in place and all of this happened because people were able to connect easier. We had a virtual event where we gathered all the international reference group leaders together just a month ago. And boy, oh boy, was it ever inspiring to hear some of the stories, particularly from areas where they are more resource constrained. But they just really appreciated the opportunity to be able to be with their international colleagues who wouldn't have been able to do that before with the costs of travel and the costs of conferences. And so, yeah, we've been through a tough time, we're going to come out of this, but we've also learned a lot.
And I think it's so amazing that there is a positive lining to all of this, which is we've now learned to do business differently. We've now learned to do business more efficiently, more effectively, and we should continue to embrace this and continue to grow these opportunities.
00:38:39 --> 00:40:03 Bethany
Absolutely. It's interesting thinking about what the three of you said, you know, it is. The excitement around the opportunities and what this has done is great to hear the whole concept of I think Ellen you said: caring more. I hadn't really thought of it quite that way before certainly resetting the comfort meter and the impossible now being possible. And oh, Peter, you've talked about the world being smaller but reach being bigger. All of these things are just, you know, transcend just, of course, dysphagia practice, but certainly do have implications for the
way dysphagia management is going to move forward in the future. And even just thinking about all of us getting together today in this vodcast, you know, this is something that really this format grew out of what we were seeing with the pandemic as well.
So anyway, on that note, I will wrap this up and conclude the podcast today, and I want to just take this opportunity to thank each of you again, Jan, Ellen and Peter for joining us and to thank all of our listeners and viewers.
So this concludes our episode of Clinical Nutrition Notes. For more podcast episodes, you can visit Clinical Nutrition Notes at NestléHealthScience.ca