The Importance of Early Intervention in Weight Management in a Pediatric Setting

By: Skylar Sites

Last month, I had the honor of interning with the IDEAL Weight Management Clinic through Children’s National Medical Center. IDEAL stands for “Improving Diet, Energy and Activity for Life.” This is an outpatient program providing early intervention in children who, based on their BMI-for-age, require either lifestyle interventions, medication or bariatric surgery for weight management. However, surgery is only used as a last resort if lifestyle interventions and medication do not result in weight maintenance or, hopefully, weight loss. Additionally, the clinic sees a select few patients who have a normal BMI for their age but have other complications such as dyslipidemia or prediabetes. In this rotation, I was exposed to a wide range of reasons why a child may struggle with weight management. I believe that weight bias and stigma is such a problem in our healthcare system and country as a whole. I appreciated this experience where the providers emphasized that weight management is more complex than a child’s appetite and physical activity level. There are many physiological reasons that a child may struggle with weight management. Examples include hormonal imbalances involved in PCOS (polycystic ovarian syndrome) or hypothyroidism where an individual’s metabolism is slower than expected.

This was my first rotation after my main clinical rotation, where I saw all adult patients. Transitioning to pediatrics was an adjustment, but one that I really enjoyed. I originally fell in love with nutrition due to the role that it plays in preventative medicine. The nutrition choices we make everyday can impact such a wide range of outcomes whether it is our energy level or lab values and related health outcomes. With the IDEAL Clinic, I connected to that initial allure of nutrition while I got practical experience. I counseled children, along with their families, on how to make small, attainable changes in their daily lives. These small changes will help ensure they can be healthier now and into adulthood. In each appointment, the dietitian and I would discuss how the previous goals that the family set for themselves were going. We would then assess if they were ready for new goals to be set or if we should just “stay the course.” Commonly we set goals for drinking more water daily, eliminating sugar-sweetened beverages, increasing physical activity or including more fruits and vegetables daily.

I assisted the registered dietitian in all visits by filling out the sheet we used to help guide children and families in setting goals.

This rotation also helped to enhance my cultural competency. I talked to several families who did not speak English and required a call-in interpreter. At first, I was concerned that this would make education more difficult for these families. However, the clinic had all the patient handouts written in other languages and the interpreter was able to call in through a video so the translation process went very smoothly.

One of my projects during this rotation was to make a handout that would be beneficial for the clinic to provide to children and their families. Given the time of year, I decided that a predominant issue would be providing ideas on how children can remain active with the earlier sunset as well as cold weather approaching. Most families shared that it has been extremely difficult even in nice weather to encourage their children to remain active during quarantine. Many children are experiencing decreased physical activity due to lack of group sports or in-person gym classes. This combined with a normally decreased level of physical activity in the winter makes this a big concern. Exercise is important for all, but is especially crucial for children who are trying to manage their weight. In this handout, I provided suggestions on how kids can stay active and enjoy it in many different ways, such as trying a dancing video on YouTube or going outside and sledding with their siblings.

Overall, this rotation provided great exposure to working in a pediatric setting, practicing cultural competence and understanding the complexities behind weight management. This was a part of nutrition that I had not previously been exposed to, but I can see myself working in pediatric nutrition in the future.

Behind the Scenes of Maryland Food Bank

By: Rachel Eldering

What do you think of when you hear “food bank”? Maybe you think about large donations or volunteering to sort food. That’s what I thought of before interning with the Maryland Food Bank. My experience, however, showed me an organization that does so much more. My main undertaking while interning at the Maryland Food Bank was to write a preliminary research paper on senior hunger in Maryland. This was my first time creating a research document and presenting it in a professional setting. 

The purpose of this exploratory research was to determine if and where more senior specific nutrition programs are needed in Maryland. My goals were to get a better understanding of where the seniors reside, what senior-specific nutrition services are currently being used and where there are gaps in service.

An example of a CSFP box provided to seniors.

The process of this project was a bit challenging for my type-A personality. Since this was a preliminary project, there wasn’t a strict set of guidelines to follow. Making some assumptions and judgements on my own ended up being a great way to grow my confidence as a novice professional.

The first step in my research was to scour the internet for data on seniors and hunger in Maryland. I sifted through a lot of data looking for solid, specific information on the target population. I found some great information from the Census Bureau and the Maryland Food System Map. Additionally, much of my research came from interviewing employees of the Maryland Food Bank and Maryland Department of Aging. To best complete my research, I needed to talk with professionals who are knowledgeable about the hunger needs in Maryland. Maryland is split into 5 regions: Northern Maryland, Western Maryland, Eastern Shore, Central Maryland and Southern Maryland. Each area has different obstacles and hurdles to address. Maryland Food Bank employs five Regional Program Directors (RPDs), one for each region. It was imperative to speak to each of these RPDs as they are experts in their region’s hunger challenges. By speaking with each RPD, I was able to get a feel for the counties and towns that have a higher senior population and struggle with hunger. Each RPD provided great information and input on where they felt there were gaps in nutrition services in their region. Additionally, I met with a few employees of the Maryland Department of Aging (MDOA). In my research I needed to outline senior nutrition services that are currently in use so I could form a clear idea of what exactly is lacking. The MDOA provided insight on the impact of COVID on their nutrition services and what their funding looked like. This gave me a better view of how services have changed since March and how they are looking as we enter the new year. Finally, I was asked to include a map data visualization to communicate my findings most effectively. The Maryland Food Bank has a hunger map on their website with a plethora of layers. Some of these layers include the population below the federal poverty line, pounds of food distributed by MFB, and population below ALICE. The acronym ALICE stands for Asset Limited, Income Constrained, Employed and is a new method to define families that live above the federal poverty line but still struggle to meet basic needs. I met with the Vice President of Learning, Measurement, and Evaluation two times to help brainstorm what layers could be added to the map to strengthen the research. He worked to put those layers onto the map and later showed them to me so I could use them when I presented to the Senior Vice President of Programs.

The Maryland Hunger Map helps visualize areas of Maryland with high populations below the Federal Poverty Line.

After all my meetings and research, I was able to put together a nine page report on all my findings and present it to the Senior Vice President of Programs. First, I summarized how well the senior hunger need is being met right now. Government funding, like the Coronavirus Food Assistance Program and the CARES act, has increased since COVID in an effort to aid in this crisis. So, hunger needs are being met fairly well at the moment. However, there is concern because a lot of this funding will end at the start of the new year. Members of the MDOA and MFB are unsure how well the need will be met in the coming months. Next, I made a list of hunger hotspots that needed more attention. I made this list based on my conversations with the RPDs and data I found online. The main areas of concern were East Baltimore City, Somerset and Allegany County. Baltimore City has the highest percentage of food insecure individuals in Maryland. East Baltimore, compared to the West side, has fewer partner sites that distribute food to senior programs. Somerset county has the second highest percentage of food insecure individuals and the second highest percent of seniors living below the federal poverty line in Maryland. Allegany county also has a high percentage of seniors living below the poverty line. Furthermore, it is rural and has areas with limited access to affordable and nutritious foods. There also are very few partner sites that distribute food in Allegany County. People can live up to 40 miles away from the nearest grocery store, so creating central food distribution sites is a challenge. 

Finally, I offered some ideas that could potentially aid in senior hunger. One solution to provide more assistance became clear: better transportation. Baltimore City does not have great public transportation and rural areas don’t have a system at all. Additionally, it’s likely that seniors have problems accessing transportation no matter where they live. In order to help seniors there needs to be a better way to either get the food to the client, or the client to the food. 

Overall, I received positive feedback on the completed research paper. I’m hopeful that it will aid Maryland Food Bank as they provide healthy food to seniors, when and where they need it most. I learned so much during my time at the Maryland Food Bank. My biggest takeaway would be the importance of working with others. I learned so much from getting input from knowledgeable stakeholders. It taught me the importance of collaboration and teamwork for producing the best outcome.

“It is All a Part of the Process”

By Linh Nguyen

A former coworker of mine used to say to me, “It is all a part of the process.” I believe those words are a foundational truth that can be applied to almost all aspects of life. My dietetic internship experience started off with my clinical rotation at Sibley Memorial Hospital in northwest Washington, DC. Learning to review a patient’s electronic medical chart, interview the patient, perform an adequate nutrition focused physical exam when necessary, determine the nutrition care process, and finally capture it all succinctly in a note is most certainly an evolving process for me.

Becoming familiar with and adept at utilizing the electronic medical record, Epic, was one of my first important tasks as an intern at Sibley. Overall, I found this cloud-based application to be very customizable and intuitive for users. Fortunately, my preceptor helped configure my Epic account to easily access relevant information and data. Epic stores and displays information in a multitude of ways, and it is just a matter of remembering where and how to access the data you need. I can say learning Epic was the easier aspect of the clinical rotation for me. Learning what pertinent information and data are needed to adequately assess a patient’s status and nutritional needs requires a level of judgement that, with practice, I have developed. Fortunately, my preceptor provided examples of formatted notes that can aid in this process. I initially wrote down a list of information I need on a patient to make sure I am not missing anything, seen here at the bottom, middle part of the picture.

Interviewing the patient and/or family members is another important part of the process. Some patients are easier to interact with than others. I empathize with the fact that many patients are in pain, are scared, do not want to be in the hospital, and are suffering immensely. Other patients are simply unable to physically talk or are not mentally sound so cannot provide adequate information. Still, other patients are happy for the visit and are engaged. In the beginning, I made sure to follow my checklist of information I needed from the patient to ensure I did not miss anything. This approach made me seem undoubtedly robotic to the patients. Observing the preceptors having a conversation with patients while gaining pertinent information helped me see how to interact with patients in a more natural and fluid manner. Over time, the process of interviewing patients has become less effortful and more natural for me. I have become more comfortable gathering the information I need from the patient and believe the interactions are smoother and more comprehensive. Again, this part of the process improved with practice.

The nutrition focused physical exam (NFPE) is an indispensable skill that clinical dietitians need to be comfortable and adept at performing. I was able to perform the NFPE on several patients during this rotation. The first and most important thing about performing an NFPE is gaining the patient’s consent. If a patient would rather not have the NFPE performed on them, I tried to look at the patient from various angles and at different parts of their body to see if I could visually assess for fat and muscle wasting. I typically told the patient what part of their body I would touch before I touch it. A patient’s possible limited mobility, any lines or equipment attached to various parts of the patient, and their body posture in the hospital bed dictates what area of the patient’s body I could assess. Another important aspect of the NFPE is to try to assess what is “normal,” or the baseline body type for a patient before the illness occurred, to be able to determine how the patient’s body has changed over a defined period of time. Documenting evidence and data that are undoubtedly facts about the patient are necessary to diagnose for malnutrition. Two of the resources I used on almost a daily basis are the Nutrition Focused Physical Exam Pocket Guide and the Academy/ASPEN’s criteria to support a diagnosis of malnutrition.

The last part of the nutrition assessment and intervention part of the process is documenting it all in the note. At the start of the rotation, my notes were choppy and not comprehensive. I should have been embarrassed if I knew any better! Throughout the weeks of reading the dietitian’s previous notes and the notes of other healthcare providers, I gained a sense of correct verbiage, acronyms, and data needed to complete a note. I gained a sense of what information I needed to document and in the correct fashion. With time and practice, my note writing skills developed.

Collaborating with other members of the health-care team and revising nutritional needs based on the patient’s clinical course and plan of care are important parts of the process as well. After speaking with the patient, and sometimes the nurse and/or a patient’s family member, I thought I had all the information I needed to create a nutrition care plan and to write the patient’s note. Although, a sudden change in a patient’s plan of care updated from a doctor or nurse may require changing the nutrition intervention as well. (For example, a patient has just been extubated and is no longer receiving propofol, or the doctor no longer plans to initiate tube feeding). It is all a part of the process!

The Do’s and Don’ts of Working From Home: A Dietetic Intern’s Perspective

By: Hannah Lundeen

A year ago, when I envisioned my life as a dietetic intern, I was not expecting to spend much of my time in my house. However, as we all are experiencing, times have changed in ways that nobody could have predicted. With the unfamiliarity of the current COVID-19 pandemic, society has been forced to adapt to a new way of living. Having spent the first two rotations of my internship working from home, I have adjusted and found techniques in order to work as effectively as possible.  

Within the first few weeks of working from home, I determined that it would be important to set up my workspace. I learned some good, practical things from a webinar on staying organized given by a University of Maryland faculty member. I knew implementing some of these new tactics would be crucial in order to be the most productive and efficient dietetic intern possible. For instance, with a few simple modifications I was able to maximize my workspace to make working from home a more comfortable experience. To begin, I elevated my laptop using five textbooks. This helped to maintain posture and kept my computer screen within eye level. Additionally, I purchased a keyboard, mousepad, and mouse, all of which made working from a desk easier.

During my second rotation, I came to understand the importance of sticking to a schedule. For this seven week rotation, I had to sign onto my email by 7:30 AM, and I usually finished work and signed off around 5:30 PM. Having never worked a 9-5 style job before, there were several habits I cultivated early in this rotation that helped me work long hours from home. For example, I learned that sticking to a morning routine was extremely important. When looking to create a new habit, integrating it with something you enjoy can help with adherence. For example, I had to wake up around 6:30 in the morning in order to be ready by 7:30. I mentally connected the act of drinking coffee, which is something I deeply enjoy, with waking up. As such, combining my morning routine with an activity that I look forward to made it easier to uphold. 

Additionally, I came to understand how important maintaining good sleep hygiene is. This, perhaps, is even more necessary when working from home. Sleep hygiene is the practice of creating an environment that helps to foster healthy sleeping habits. Though it doesn’t have to, working from home can hinder one’s sleep hygiene if adequate precautions are not taken. I had to learn this the hard way. Within the first three or four weeks of working from home, I had my desk setup in my bedroom. Not surprisingly, I began to develop insomnia and I think that having my desk situated so close to my bed definitely played a major role. Following the onset of these symptoms, I took steps to improve my sleep hygiene. Most notably, I moved my desk from my bedroom to the basement of my house. This change made an immense difference in my ability to get a restful night’s sleep. As such, I now understand that even if one works from home, there are spaces that should remain work-free.

Upon advice from another University of Maryland faculty member, I learned that getting in regular movement or stretching throughout the workday is very important. During our class days that take place once a week, we generally get up and take a break every 45 minutes. However, on rotation days, it can be easy to fall into the habit of not taking breaks and continue working for long stretches of time. Being able to compare how my body felt at the end of class days versus the end of rotation days was reason enough to implement walking breaks every hour in a half. Now I look forward to walking breaks not only to give my eyes a rest but to see the beautiful fall weather as well.

 In conclusion, the COVID-19 pandemic has drastically changed many aspects of day to day living. Although this may not be what I had anticipated pre-pandemic, I have learned tactics along the way that have made working from home a more productive and pleasant experience. The skills gained during this time can be carried with me throughout my career as a future dietitian — no matter where the setting may be.

A Sustainable Approach to Nourishing Our Bodies and Communities

By Jennifer Rivera

Have you ever wondered where the food on your plate came from or how it got there? My community rotation at Farm to School, an organization that connects local produce to students and their families, taught me so much about where food comes from, the benefits of eating seasonally, and how to eat locally. Farm to School promotes consuming food in a way that supports our health and our communities. During this rotation, I learned not only why it is beneficial to eat seasonally and locally, but also about many ways to make positive changes. I will share with you some online tools that help locate seasonal and local produce, and I’ll share some of my firsthand experiences rotating with an organization that supports this idea.

The Catoctin Mountain Orchard – I had the opportunity to visit during my Farm to School rotation.

There are many benefits to eating seasonally and locally. Seasonal produce, which is sold shortly after it has been harvested, is typically fresher and more delicious. When produce needs to travel great distances, it must be picked before it ripens so that it can survive the journey, but local produce is picked when it is ripe and ready to be harvested. This means local produce tends to be fresher due to shorter storage and transport times. Eating by the season also helps provide a variety of nutrients to our bodies throughout the year. Off-season produce found year-round is still tasty and nutritious, but it’s great to include local and seasonal produce when possible.

While choosing seasonal and local foods is beneficial to our diets, it also supports the communities that we live in. Buying foods that are sourced within our community supports local farmers who compete with large chain grocery stores. This is especially important to note as we navigate through the COVID-19 pandemic. During my time at Farm to School,  I was able to listen in on a conversation regarding the challenges local farmers are facing during this time. Eating locally not only helps your local farmers but also may support other jobs in your community. In addition to buying produce locally, you can check out restaurants in your area that use locally sourced foods.

Knowing where your food is coming from is an added benefit of choosing to consume food this way. During my Farm to School rotation, I had the opportunity to visit Catoctin Mountain Farm in Thurmont, Maryland. Here I was able to see for myself how different fruits and vegetables are grown. I spoke to the farmers about their growing practices and learned how much time and effort goes into the growing process, from start to finish.

Kale growing at the Catoctin Mountain Farm in Thurmont, Maryland.

Choosing to eat local, in-season foods is not only good for your stomach but good for your wallet too. Produce that is in season costs less. Be sure to check that out next time you are shopping for groceries! 

Now that we have explored some benefits of eating this way, learning what is in-season around you is a wonderful way to start. The Seasonal Food Guide is a great online tool that will show you what is in season in your state for any month you choose. Shopping at farmers markets is fun and a great way to support the farmers in your community. Along with doing a simple Google search, the National Farmers Market Directory is an online tool that will show you where the nearest farmers markets are located.

The Catoctin Mountain Orchard selling fruits that are currently in season.

Other tips on eating this way include looking for local labels when you are shopping at the grocery store or planning ahead by preserving what is in season, using creative methods like canning or freezing. 

Interning at Farm to School gave me the opportunity to learn more about this topic. It also encouraged me to eat a variety of food with the intention of caring for the environment and community. Starting slowly and making little changes here and there on how we choose to eat can make a big difference.