Teaching Through Stories

By: Erica Parker

Storytelling is a great way to engage an audience, teach a lesson and give people new ideas to consider.  While writing is a great medium to tell stories, it can’t always provide the same impact as stories told by mouth. As future RDs, we can use stories to engage our patients and clients when we give dietary advice. At the end of the day, if your audience isn’t engaged in what you’re saying, they are unlikely to implement or even remember any of the advice you have given them. Storytelling can also be used to help market ideas and yourself!  A popular way to tell stories orally is through podcasts. Luckily, the UMD dietetic  interns get some training and experience creating podcasts, which you can listen to on Soundcloud.  

The podcast assignment requires interns to create two podcasts during the internship, which can be about an internship experience, the intern, nutrition, or an interview with a preceptor or expert. The goal is to create a podcast script that can be read in 2-3 minutes and then record a basic podcast without music, using Audacity or another audio tool that supports mp3 files. The internship’s tech team provides interns with links to many nutrition or dietetics podcasts to help give them an idea of how a podcast works. Interns also get helpful resources that break down the process of creating a podcast and go into great detail on how to tell a story. One of these resources was the “The Ultimate Guide to Storytelling” on the HubSpot blog, which explained what traits make a good story. A good story isn’t just entertaining and possibly educational, it’s organized, has a relatable character, a problem and a solution. The article also explained how to reach specific goals with your story, such as getting people to act, fostering community and educating people.

For my first podcast, I decided to write about personal food budgeting, since it was something my husband and I had been working on for several months. When writing the podcast script, I found the HubSpot blog post very useful because it helped me to write an organized podcast script with a beginning, middle and end. I started the script with how much our monthly food expenses were prior to the budget. I then discussed the method we used to reduce our food expenses by creating a cash envelope budget for the month. Finally, I ended with how the budget method had been working for us so far and provided encouragement to listeners to try the method if they thought it could work for them too. The goal of my podcast story was to educate people and encourage them to try something that worked for me.

Once my script was complete, I practiced reading it to see if it was within the time limits and recorded the podcast using Audacity.  It was easy to do and I was able to edit the recorded version to sound clear and take out any awkward pauses I made while reading it live.  This assignment allowed me to gain a new skill in recording and editing a podcast episode. It also improved the focus of my writing.  I’m glad I got the chance to record a podcast during this internship and I look forward to recording another one in May!

Community Nutrition Program Promotion

By: Zoe Rosner

What does a dietitian do? Most immediately think of in-patient or out-patient clinical dietetic counseling, but not all registered dietitians work in hospitals and provide medical nutrition therapy. The University of Maryland College Park allows for interns to rotate with a variety of organizations and dietitians in the three major areas of dietetics: clinical, food service and community. Within the realm of community nutrition, a dietitian may work for the education system, nutrition assistance programs, food banks or grocery stores. My first community nutrition rotation was spent at Manna Food Center in Montgomery County, Maryland and the variety of activities I completed provided a well rounded experience.

Successful community nutrition program planning begins with a needs assessment. This process identifies the people in need and the types of help that will benefit them. Manna creates a variety of programming, most often involving distribution of shelf stable and fresh food for individuals and families residing in Montgomery County. 

The following programs are already underway at Manna:

  • Food for Families- Distribution of shelf stable items in addition to fresh produce and sometimes meat. 
  • Smart Sacks- Many students received free or reduced meals at school during the week. The program bridges the gap between Friday and Monday and provides food for over the weekend. 
  • Community Food Education- Accessible health education including cooking classes, wellness presentations, and chats with a nutrition expert. 
  • Breaking Bread- A program with the intent to “create space and intentional conversations to nurture dialogue around critical issues, such as race, class, and a culture of dependency, that create or contribute to hunger and food insecurity in our community.”

To provide the most benefit to those in greatest need, Manna analyzes data. This data helps them determine where food pick up locations should be or which schools should be eligible for smart sacks. While at Manna, I was able to compile data to determine which zip codes within Montgomery County are currently facing the largest barriers to food security. The datasets I looked into included the capital area food bank hunger heatmap (shown below), rates of free and reduced lunches amongst elementary, middle and high schools, covid incidence and mortality and lastly the number of individuals Manna is currently serving in the zip code. This data creates support for decisions of which areas to serve.

https://cafb.maps.arcgis.com/apps/webappviewer/index.html?id=a8702d0c6cab44e38688680c86ccf964

Once programs are created, promotion of the programs is essential. Program promotion to participants of Manna and the community is a major step in increasing participation. Promotion to community members, such as medical providers or those in churches/temples/mosques, who can spread the word to those in need is very useful.

Manna allows for providers to refer patients to ensure those in need receive services from Manna. Oftentimes an individual in need may not register for services on their own accord, but with the referral from a provider, they will pursue the programming. Educating providers on how to appropriately refer patients is useful in decreasing food insecurity amongst the patients. My partner, Erica, and I created a brief “How To” video for the providers. The video makes sure patients are being referred correctly and are prepared to receive services. Of note, the University of Maryland College Park dietetic internship has a relationship with an interprofessional education (IPE) clinic that serves patients in Montgomery County. Because the clinic serves many patients experiencing food insecurity, the video was useful to distribute to the IPE team. Creating content that benefits two rotation sites and works to solve a common issue was useful in understanding how community and clinical dietetics are intertwined.

My favorite aspect of the Manna rotation was working through the steps of community nutrition program planning. Learning about the programs currently in place and their goals, locating data for the programs and promoting the programs allowed me to feel confident in my knowledge of community nutrition. I believe having well rounded experiences within each major domain of dietetics is a key aspect of the dietetic internship. Even though I hope to pursue clinical dietetics upon graduation, I now understand how as a provider I can connect patients with community nutrition services.

From Farm to Pantry and Beyond

By: Brandy Leno

When it comes to the dietetics field, my heart belongs out in the community. My previous work and volunteer experiences have shown me that, and my time in this internship reinforced it. So, when I learned what my week with University of Maryland’s Green Dining program would be like, I could hardly contain my excitement. This program is part of UMD’s Dining Services to advance campus sustainability and to achieve UMD’s goals to become carbon neutral by 2025. Green Dining includes programs like Terp Farm, the campus pantry, and the farmers market. My time there may have been short, but it was packed full of experiences that kept me both mentally and physically busy. 

My partner and I kicked off our first day by working on Terp Farm, UMD’s sustainable farm which is located 15 miles from campus. The farm operates in all four seasons and provides produce to the dining halls, catering services and the campus pantry. We received a quick tour of the farm, where we saw what was currently being grown. At the time of our visit, the farm was producing tomatoes, sweet potatoes, and finishing up their okra crop. They were also drying and processing black beans that were grown on site.

After our tour, we went straight to work. Our day was heavily focused on the dried beans, which were still in their pods. We were tasked with using a large machine to sort the dried beans from the rest of the dried plant. Then we used a bucket and a fan to further separate the dried beans from the lighter weight pods. This was hard work that took all day and we barely made a dent in the greenhouse full of dried beans. However, towards the end of the day we were able to harvest some okra, sweet potatoes, and cherry tomatoes to take home!

My partner and I also spent some time at the campus pantry, which serves both UMD students and faculty. The pantry was full of dried goods, canned fruits and vegetables, fresh produce from the farm and even had the dried beans that we helped to process! We observed how the pantry operates and helped to brainstorm ideas for cooking demos and classes that could be held in their new instruction kitchen. 

The rest of our time with Green Dining was spent being active participants in two of their special events: the farmers market and pumpkin painting. At the farmers market we spoke with each of the local vendors and got to buy some goodies to take home for ourselves! The variety of vendors was impressive and catered to the student population. We saw them selling fudge, fresh produce, meat, homemade jewelry and more! The most popular booth was the bread vendor. The line was long for practically the entire market!

The farmers market also featured a cooking demo of a winter squash and black bean soup, which we helped to set up. We served samples when the dish was finished. As you might have already guessed, the star ingredients came straight from Terp Farm. The soup was vegan and free of the big 8 allergens, so everyone was able to have a taste. Next up was the pumpkin painting event. We helped to set up the event by setting up the mini pumpkins to look like a pumpkin patch outside of the dining hall and by portioning paints out on separate paper plates. Once the event started, everyone flocked towards the pumpkins. The plaza quickly filled with students, and we saw so many different creations. It was great to help support a community event using more Terp Farm produce!

I’m grateful I saw how one small two acre farm could help support several sustainability initiatives on campus. In just one week, I saw Terp Farm produce used to provide nutrition education, support a community event and alleviate food insecurity on campus. The Green Dining team is making great strides to uplift the campus community and the environment. I’m happy I experienced being a part of this team for a short period of time.

Bariatric vs. Traditional Weight Loss

According to the Centers for Disease Control and Prevention, 42% of the United States classifies as obese. With the numbers continuing to rise, bariatric surgery proves to be a useful solution for some to achieve a healthier weight. Bariatric surgery is an umbrella of procedures that alter the digestive tract resulting in weight loss. The benefits of bariatric surgery include fast weight loss and a higher success rate of weight loss compared to traditional non-surgical weight loss. The downsides of bariatric surgery include a potentially higher cost (depending on insurance coverage), increased risk of nutrient deficiencies, adverse GI symptoms and higher mortality rate compared to traditional diet and exercise. Traditional, non-surgical weight loss typically has a higher failure rate and takes longer to see results, but also has more flexibility, lower mortality rate and lower risk of complications. I learned about various experiences and motivations for traditional and surgical weight loss at a recent rotation with Inova’s bariatric clinic in Fairfax, VA. 

In order to qualify for bariatric surgery, there must be previous difficulties with weight loss through diet, exercise or medications. Two counseling sessions I was involved with included women who had difficulties with maintaining previous weight loss but had the confidence in themselves to try again and find a method that works for them through the help of the Registered Dietitian (RD). One of those patients had success with short-term diets in the past but did not create sustainable healthy habits. Another patient’s biggest struggle was snacking and grazing throughout the day, with sweet foods as her biggest vice. She was open to change and motivated to alter her habits but did not know where to start. Perhaps these two patients believed in their ability to achieve a healthier weight naturally either due to previous success or self-confidence and just needed accountability to get on the right track. Another patient considered herself a “healthy eater” and described her weight history as always overweight her entire life. Further into the session, she revealed her biggest difficulties included portion sizes, chocolate, pretzels, brownies and high-calorie coffee drinks. Her lack of previous weight loss success despite having high motivation conveyed that she was not confident in the traditional route, but was determined to begin the surgical journey. 

Lack of basic nutrition education is common in people struggling to attain a healthier weight. The education and goal-setting requirements are slightly different for bariatric and traditional weight loss methods. Patients in the bariatric clinic often perceive their typical diet intake as healthy, so instead of asking what their normal daily food intake looks like, the RD asks them to describe what an unhealthy day of eating looks like. This usually depicts the reality of their usual intake more accurately. They may be eating foods considered healthy, but portion sizes may be too large. Once they have the educational tools and a solid plan in place, they may achieve weight loss with an overall healthy diet and exercise. Others seek nutrition education but have difficulty implementing the behavior change for various reasons, such as an emotional or physical condition. For the patients trying the traditional weight loss route to learn nutrition basics, I helped transform a plain, unappealing 20-page diet manual into an engaging, easily digestible manual. This project helped me develop digital design skills by balancing color, fonts and texts. For the patients trying the traditional weight loss route to learn nutrition basics, I helped transform a plain, unappealing 20-page diet manual into an engaging, easily digestible manual. This project helped me develop digital design skills by balancing color, fonts and texts. Some people may understand this basic education yet have difficulties with meal planning, budgeting, meal preparation and cravings. Likewise, their life may feel too stressful to undertake these challenges. One patient I observed in the clinic was a busy gentleman with children, seemed to enjoy following a regimen and was open to lifestyle changes. He knew that if he stayed with the bariatric regimen, he would be successful without worrying about the draining demands of non-surgical weight loss. Bariatric meal plans include daily protein shakes along with small, easy-to-prepare meals. The education with bariatric nutrition is more about following a simple and specific plan, whereas those who undergo natural weight loss follow a more vague and variable plan. This can open the door to “falling off track” and slowly going back to old habits. 

Sample from DIet Manual

Unwanted side effects that occur with nonadherence, such as nausea, vomiting and diarrhea after bariatric surgery incentivize behavior change. One patient I observed during a post-op appointment admitted to eating a bowl of sugary cereal and immediately throwing it up. Even though she knew she shouldn’t eat that sugary cereal, she had a strong difficulty with the impulse control of her strong craving. In this case, the bariatric surgery essentially caused a negative feedback loop to get her back on track by rejecting that food. Due to situations such as this, a handout about behavior change was needed in the bariatric clinic. I created an infographic explaining the stages of behavior change to help patients identify where they are at in their weight loss journey. Furthermore, it gives the dietitian an opportunity to visually show the patient their progress. Some clients struggle with creating practical individual goals, so I created a worksheet to guide patients through setting goals using the S.M.A.R.T method. This stands for specific, measurable, attainable, relevant and time-based. Often if someone tries weight loss without the help of a professional, they may not know where to start. Creating the “Stages of Behavior Change”  and “SMART Goals” handouts enhanced my skills with explaining psychological concepts visually and balancing graphics with white space. 

Although it is not a risk-free solution, bariatric surgery is a great last-resort option to decrease risk of negative health outcomes if all other methods of weight loss, such as medication, diet and exercise were not successful in the past. It may be especially useful if a large weight loss is necessary, such as in the case of needing another medical procedure done. The bariatric team works with each patient to determine if surgery or traditional weight loss is better suited for them. The team considers the patient’s motivations and past experiences, such as previous weight loss attempts, nutrition education, and their stage of behavior change. Transforming a diet manual and creating materials on setting goals and behavior change enhanced my digital design skills while also helping patients at the clinic. Overall, my experience at this rotation was educational and provided me with insight on patients and their readiness for change as well as bariatric weight loss surgery. 

Reference: 

“Adult Obesity Facts.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Sept. 2021, https://www.cdc.gov/obesity/data/adult.html.

Pediatric Obesity: More Than Just a Larger Body

By: Cierra Peterlin

The obesity epidemic is as prevalent as ever in the United States today, and I am not just talking about adult obesity. Childhood obesity is a major problem affecting one in five children worldwide, according to the Center for Disease Control (CDC). During my rotation with Children’s National Hospital’s obesity program, the IDEAL clinic, I was exposed to how childhood obesity relates to health in a physical, mental and social way. Through counseling patients and families, I gained insight into obesity like I never had before. Obesity in adults and children can lead to a long list of associated physical health issues such as diabetes, high blood pressure, gastrointestinal (GI) reflux and GI discomfort, breathing problems, sleeping problems, high cholesterol, heart disease, muscle and joint problems and fatty liver disease. However, it can also lead to mental health problems such as behavioral issues, low self-esteem, depression and anxiety. Obesity is also associated with many social problems as well such as discrimination, stigma and bullying. It was apparent from my first conversation with a patient that childhood obesity is much greater than just a large body size and high BMI.

Childhood obesity is defined as a BMI-for-age that is two standard deviations above the CDC growth chart median range. What does that mean exactly? The growth of children ages 2-20  years old is plotted on growth charts. The growth charts account for height, weight and age and are different for boys and girls. These charts are used to determine if a child is growing adequately. If a child’s weight for age measurement falls within the 5th and the 85th percentile for their age, then their growth is considered normal and healthy. If it falls above the 85th percentile they are considered either overweight or obese. Children are referred to the IDEAL clinic by their primary care physician due to BMIs over the 95th percentile for their ages, which denotes obesity. Most of the patients I saw were at the 99th percentile or above.  

In the IDEAL clinic the dietitian sees patients with either the nurse practitioner (NP) or the physician, whoever is on staff on a given day. Together the pair introduce various interventions for weight loss or weight management. The interventions utilized at the clinic include diet and lifestyle changes, pharmacological interventions and surgical interventions. The dietitian is in charge of implementing diet and lifestyle changes through means of motivational interviewing and goal setting. The NP or physician presents the idea of medications and possible bariatric surgery. 

The acronym IDEAL stands for Improving Diet, Energy, and Activity for Life which was certainly the goal of the obesity program. After observing my preceptor for a few visits she suggested that I lead one of the conversations with a patient and family. This was outside of my comfort zone, as it was still my first day. However, my preceptor knew that I had been preparing and practicing motivational interviewing (MI) and would be able to use the techniques of MI to gather information from the patient and their guardian. By the end of the session, I was able to set goals with the patient that will aid in weight loss and become part of the overall lifestyle change. From the first session I led, I felt comfortable interacting in a manner that was conversational and supportive. I drew upon the skills I had previously learned about MI in my internship and undergraduate education. For the rest of the week I spent at the IDEAL clinic, I led every session, with my preceptor in the room to defer to when needed. The patients I counseled ranged from new consultations to patients who have been following up with the program and even re-operation bariatric surgery patients. Since all of these patients were children or considered “dependent” by the program, they were all accompanied by a parent or guardian. This was at times helpful and at other times difficult to navigate because, depending on the age of the patient, they were more or less apt to be open and truthful around a parent. 

One of the patients I saw was a 7 year old boy who fibbed about his eating habits in terms of sugary beverage intake. However, upon conversation with his mother she informed my preceptor and me that while she kept sugary drinks out of the house his grandparents, who he spent the evenings after school with, would allow him to drink lots of soda and juice. On the other hand, a 13 year old patient struggled with her mother during our session because her mother was not able to understand the patient’s wants and needs as well as the patient’s effort to understand herself as an adolescent. This situation caused the patient to kind of shut down making it difficult to focus on weight management and goal setting. Instead, my preceptor and I needed to guide the conversation into a gentle reminder that dealing with a health concern includes the whole family and can be difficult for each party in different ways. Being able to adapt to different family dynamics as well as bringing out openness and honesty from patients were a big part of each session. I learned that in this setting, the dietitian is the main touch point with the patient which can lead to a lot of emotion, confusion, questions and unloading from the patient and family, especially with such a multifaceted condition like obesity. 

blue tape measuring on clear glass square weighing scale
Photo by Pixabay on Pexels.com

Throughout this experience my understanding of pediatric obesity as well as empathy for those who struggle with it grew ten-fold. I had the privilege of hearing, first hand, the experiences that these children go through in terms of struggles with food consumption, fitting in with friends, managing associated health problems, etc. I also took in how their parents struggle with the stress of a child with serious health conditions associated with obesity, such as prediabetes and high blood pressure, and in many cases a felt sense of responsibility for it. Weight management in children with obesity encompasses much more than setting goals to drink less sugary beverages or go for a walk three times a week. It is accomplished over time when the team:

  • encourages every little positive behavior change the patient makes, even if that change happened once over the past 2 weeks, 
  • supports the child in their own autonomy to know and act upon healthy behaviors, 
  • reassures a strained parent that with true dedication and consistency change can be made, and 
  • knows when to converse more sternly with the child when additional discipline or intervention is needed. 

A continuing epidemic, childhood obesity is an area where the dietitian is without a doubt a crucial practitioner. Getting immersed in the IDEAL clinic allowed me to put my counseling and motivational interviewing skills to work in many sessions. I realized how intimate and necessary work as a dietitian can be to the obese pediatric population. This rotation gave me a glimpse into a side of dietetics that involves more than calories, calculation and menus. I saw the significant impact I can make to a patient’s well-being, as well as the inspiration I can elicit for making changes for better health.

Resource: https://www.cdc.gov/obesity/childhood/causes.html