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.
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.