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

Nutrition Counseling Tools: Generational Characteristics and Effective Communication

By: Felix Pan

Born approximately within twenty years of one another, a generation of individuals may share common experiences from events that shape their beliefs, values and characteristics. One of my recent rotations showed me that these generational influences can impact how we learn, how we communicate and even what we eat. I learned that while it is important for healthcare professionals to know about diseases, it is also helpful for them to understand the social impacts from generational experiences. To learn more about diabetes during my rotation at FHI 360, I watched the webinar “A Generational Approach to Healthy Eating for People with Prediabetes and Diabetes,” by Toby Smithson. I gained insight beyond diabetes, learning how world events affect generational characteristics and how to use these characteristics for effective communication and counseling.

At times, different communication styles can be misinterpreted as microaggressions and lead to loss of empathy. As individuals live through shared events and build similar experiences, they may adopt similar traits. During the webinar, Toby explained that these traits may affect their preferred communication style, an influence we should be aware of. The Silent Generation’s strong sense of duty, work ethic and delayed gratification may lead them to trust authority figures more easily, be more involved with their own care, and follow instructions as absolute. Whereas Generation X’s shared traits of skepticism and self-reliance have led many to desire decision-making independence, listen only after trust is earned and consider healthcare interventions as suggestions rather than as absolute. Individuals from either generation may misread the other as judgmental and ill-natured due to contrasting communication styles. We also carry our own generational characteristics with us, making us vulnerable to the same challenge.  I have learned that it is important to “keep our generation at the door” when engaging with clients to allow their generation to fill the space. When working with others, I will consider the effects of generational traits on communication when working with clients and will work on leaving my generation at the door to reduce possible misunderstandings and build rapport.

It can be difficult for people to accept and practice changing recommendations. Highlighting clients’ ability to navigate advancements in disease management is an opportunity to promote self-efficacy. The webinar I watched explained that Baby Boomers’ (born 1945 – 1964) optimism and devotion empowered them to successfully navigate the difficulties of multiple recommendation changes in the exchange system, as well as utilizing carbohydrate counting after its creation. Additionally, Millennials’ (born 1981 – 1996) explorative characteristics enabled them to transition from following strict restrictions while using the exchange system to practicing more flexible care with the advancement of oral hypoglycemic medications. While listening to this information, I recognized that an individual’s resilience toward adopting changing recommendations is an angle that can be used to support self-efficacy.

While generational characteristics can be used to initiate conversation and empathy with clients,  they are not an end-all-be-all for patient-centered care. It is important to recognize that the individual within a generation is not the same as the generation as a whole. To avoid stereotyping clients, generational traits should not be haphazardly assigned to specific individuals. Knowledge of generational habits can be used as a tool to build humility, empathy and rapport with others. Misuse can disrupt quality care and create microaggressions. Just as each generation has its story, each person does too.

Intersections of healthcare technology, world events and lived experiences shape generational traits and communication styles. Each generation builds shared traits from their lived experiences of common events, which dietitians can use to help them build self-efficacy. This webinar has taught me that the knowledge of generational characteristics is a tool that can be carefully used to improve communication and trust with clients of other generations. As I reflect, this webinar has taught me about another consideration that can contribute to biased thinking and actions, which I should be wary of. Knowing this, I will humbly practice creating space for clients’ to fill the session with their generational experience.

Improving Engagement In Data Visualization

By: Felix Pan

“EGGS YOLKS ARE SAFE TO EAT! CAN NUTRITION ADVICE BE TRUSTED?”

Do you ever see headlines like these? Quick, controversial, and tantalizing! How do these headlines ensnare our attention for hours on end? To help us answer this question, we need to understand informatics: the use of data, knowledge, and information to perform actions such as decision making and problem solving. In dietetics, nutrition informatics professionals collect nutrition-related information and use it to make decisions, create content (like the headline), and find evidence-based strategies to address personal and public health challenges. Recently, the Nutrition Informatics Dietetic Practice Group (NI DPG) hosted a webinar “Infographics: A Mental Model To Increase Engagement,” in which Alli Torban, an Information Design Consultant, discussed the importance of identifying the targeted audience for graphics, factors that affect audience engagement, and methods to engage different audiences with data visualization.

Data Visualization

A large part of how we engage with information is how we see it — a field called data visualization. As IBM describes it, “Data visualization is the representation of data through common graphics such as charts, plots, infographics, and even animations.” While these graphics are the most common, other forms can also be used. When there is a lot of data, what is the best format to present it? How can we show all the data cohesively? After all, more information means better decisions… right? Before deciding on a graphical approach, it’s important to check-in and ask “who is the information for?”

Factors Affecting Engagement

People engage differently with data. While some may immerse themselves in graphs and charts, others may simply skim through them. Several factors that can affect one’s level of engagement include: purpose of engagement, interest, focus, time and graphic’s aesthetics. But one factor always diminishes the viewer’s experience: friction, or in other words, the elements of the graphic that interrupt engaging and understanding its content. Have you ever looked at a chart once, twice, or even more and found it difficult to understand? Let’s take a look at an example.

What makes this graphic difficult to read? 

  • Many lines are intersecting and it is difficult to follow a single line through the graph.
  • Sales items are not grouped by any category.
  • Similar colors can intersect (e.g. yellow and darker yellow) making it easy to confuse one line for another.
  • The legend is inside of the graph, making it hard to see points.
  • A lack of gridlines makes it difficult to compare the number of units sold of a particular item with the reference point on the y-axis.

These factors can make the graph harder to read and interpret. As a result, there is more friction to engaging with the graphic and readers are less likely to continue reading. When visualizing data, it is important to consider how friction will affect the audiences’ level of interest and understanding.

Identifying The Target 

Before beginning the data visualization process, it is important to recognize the target audience. Questions such as “What kind of audience do you want to attract and interact with?” or “Do you think our audience needs more incentive to interact with this chart?” can be used to identify the consumer. By defining the readers early on, the data visualization process can be more deliberate and allow the consideration of factors such as the level of detail that needs to be included. 

Types of Readers

From reading a magazine at the laundromat to reviewing monthly reports about a company, people engage with information for different reasons. These reasons affect their levels of interest and focus. This criteria can be used to divide people into four types of readers: 

  • high-interest/high-focus
  • high-interest/low-focus
  • low-interest/high-focus
  • low-interest/low-focus

While interest refers to the relevancy of the topic to the individual, focus describes the effort the individual is willing to exert to learn about the topic’s materials. High-interest/high-focus and low-interest/low-focus groups can be easy to picture: those specifically searching for information and those who look past the information, respectively; however, recognizing the other groups’ characteristics can be more elusive. 

High-Interest/Low-Focus 

High-interest/low-focus individuals can vary in their occupation, but share a similar theme: they manage lots of information. They have limited time to review large amounts of information but are invested enough to seek the knowledge. It’s important for them to consider “What’s in it for me?” For example, a CEO may just want the main message of a chart and is uninterested in the details of data collection and analysis. The data needs to be pertinent and adequately placed to bring their eyes to the center of the diagram. Because they are interested in the information, the visual does not need to be flashy. For example, this line graph clearly shows the trend of sales for three products over twelve months. Graphs like this bar graph should be avoided for this group because it takes longer to read and interpret the trend. 

Low-Interest/High-Focus 

On the other hand, low-interest/high-focus readers may include individuals who are leisure readers where they may not be searching for anything specific. It can be hard for them to find the right topic, but they are hooked once they do! For example, this can be a student searching through the news to find a topic of interest for a school project. When building a graphic, it’s important to make it welcoming with a strong visual introduction. For example, Megan Lautz’s (MS, RD, LD, TSAC-F) website has an effective visual introduction that clearly states how she can help and below it, an easy to understand breakdown of information. 

Diagrams, such as this pie chart, that introduce the reader to the information and invite them to learn more are best. 

Data visualization is a vast field, with many different methods to develop graphics, purposes and audiences. To become immersed, each type of reader requires a tailored visual format based on their level of interest and focus. The process of designing successful, attractive graphics starts with first identifying the target audiences and then creating visual content which meets the needs of those audiences. Identifying who the audience is, what level of information needs to be conveyed, and how the data will be presented can help improve the efficiency and outcomes of the data visualization process. With this in mind, can you guess who the headline at the beginning of this article is trying to reach? Does it engage you?

Nutrition Ed Through Visual Media

By: Anamarie Bergman

To me, being a dietitian entails helping people change their relationship with food or improving their intakes to benefit their health. My rotation at the Frederick County Farm to School Program allowed me to do just that with a video I created for school-aged children. Farm to school (F2S) empowers children to make healthy food choices and gives them access to healthy, locally grown foods in cafeterias. F2S is a movement in the county connecting children to their food, their communities and to farmers. I saw how Alysia, the F2S program director, connected with farmers to provide fresh produce to the schools, while also providing ample nutrition education to the students through different types of media. One example is the engaging video series called “Harvest of the month.”  Harvest of the month videos highlight specific fruits or vegetables in season for each month of the year. This series provides education to students to promote seasonal eating, healthy diets and support the local economy. 

During my two-week rotation with F2S, I spent the majority of my time creating a harvest of the month video on kale. Kale, a green, leafy, cruciferous vegetable is chock full of nutrients and is locally grown, making it an ideal choice. There were many steps involved in creating the video, including writing the outline and script, selecting the educational material and ideas, and filming and editing.

I found developing an outline for the video to be the most challenging aspect of the video production, but in the process I learned how important it is to create a script that resonates with the viewer. The most important steps I learned when writing an outline were identifying the goal, tailoring the video to the audience, selecting the specific topic, defining key takeaways and adding a call-to-action. The purpose of my video was to inform my audience, the students, about how kale grows, the parts of the leaf and the vitamins and minerals it contains. These topics were included to ensure the video was visually engaging, educational, exciting and to emphasize the importance and benefits of vitamins and minerals, in hopes of encouraging children to eat more local vegetables. 

Another vital aspect to the video was inspiring the kiddos to create kale recipes. I did this in two ways. First, I recorded the steps to creating a recipe. Additionally, in order to ensure kids were excited about eating the vegetable and creating the recipe themselves, I provided a kid-friendly recipe in the video they could easily make with their parents. My preceptor emphasized that in addition to my recipe being kid-friendly, it also needed to be safe for kids to prepare. It needed to be executed without using sharp utensils or stovetops and had to contain all three macronutrients – protein, carbohydrates, and healthy fats – so the kids could  see visuals of a balanced meal.  I decided on a simple, tasty kale salad. Since kale has to be massaged and can be torn into pieces with your hands, I knew kids would love making this salad themselves. 

Once I finished writing the script and deciding on a recipe, then I moved on to filming and editing. After learning about different kinds of shots for filming, I filmed half of the content myself at the farms we visited in the county. By using footage from local farms, the students were able to make a connection with the farms in their area and see how the food that is served in the school cafeteria is grown. Furthermore, I learned how to use videos from Canva and to transfer them to Wevideo, the video editing software I was required to use. While I had never used Wevideo before, I learned it quickly and now am proficient using it! One of the tips I learned while editing the video is the importance of switching shots every 8 seconds or less to keep the audience engaged, especially for young children. Adding background music and recording your voice for the script were the final steps in editing. Adjusting your voice to a tone acceptable for students made the video more personal and engaging. 

Producing a creative, educational video is an excellent way of getting kids engaged and excited about nutrition. I learned that creativity is important when developing the outline for the video and choosing the key elements to ensure it is both educational and entertaining. Thus, it’s essential to create the outline before writing the script. If your educational video includes a kid-friendly recipe, ensure the recipe contains all three macronutrients – protein, carbohydrates and healthy fats – so the kids can see visuals of a balanced meal.  When I filmed and edited the video, I worked to connect the content to the audience in order to reach them and keep it concise. Producing an educational video is not an easy task, but it is very rewarding. It’s a great feeling watching the video after it has been completed, knowing it provides nutrition education to the students and promotes local farmers and the farm to school program. When it comes to educating kids on nutrition, an educational video that includes these tips is an excellent choice.  

Check out my educational kale video below. 

Children’s Outpatient GI

By: Candice Danielson

Belly aches, vomiting, constipation, or diarrhea are experiences most kids endure from time to time growing up. Unfortunately for some kids, this is a daily nightmare that causes significant distress and requires reaching out to medical professionals for help. Once diagnosed, dietitians can really help those kids. In early December, I had the opportunity to shadow an outpatient gastroenterology dietitian at Children’s National hospital for two days in the gastrointestinal (GI) clinic and another two days remotely via telemedicine. I felt excited to start because I previously never worked or shadowed anyone in an outpatient setting or with a pediatric population, so it was a little out of my comfort zone. I could tell immediately that the team values the dietitian and the patients she counsels appreciate the recommendations she provides. The patients she sees are typically referred from another provider, and they often see her shortly after an inpatient visit in Children’s Hospital. The dietitian sees a variety of conditions, such as inflammatory bowel disease (IBD), celiac disease, eosinophilic esophagitis, GERD (reflux), allergies and patients struggling with their weight just to name a few. 

I learned how to evaluate a child’s nutrition status by studying growth charts, calculating the rate of growth, and determining the calories, protein and fluid needs for optimal growth. Additionally, as part of the assessment, I learned to ask about the child’s development, behavioral patterns with eating, and the child’s social environment during meal time. One of the biggest concerns in the GI clinic was difficulty gaining weight or growing slowly. The malabsorption, inflammation, and abdominal pain can lead to decreased food intake and therefore nutrient deficiencies and weight loss as a result. 

Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the digestive tract and one of the main disease states treated in the clinic. There is no cure for IBD, but it can be treated with medication, nutrition therapy, and sometimes surgery. Those with this diagnosis often experience weight loss, anemia, slow growth, vitamin/mineral deficiencies, and avoiding certain foods. Nutrition therapy can be used to either manage the disease and induce remission or it can improve symptoms. I was given an assignment to create a handout to show patients the difference between primary diet therapy and nutrition support for IBD. The primary diet therapy to manage IBD is either exclusive enteral feeding or strict therapeutic diets, such as the Specific Carbohydrate Diet or the Crohn’s Disease Exclusion Diet. One of the patients I saw during the rotation completed the Specific Carbohydrate Diet protocol in the past and successfully went into remission. Although it was difficult and it required her whole family to change their diet for some time, she was happy she followed through with it. I learned there are more liberalized diet options that may not manage the disease, but may still improve symptoms and provide the nutrients needed to prevent deficiencies, weight loss, and malnutrition. This type of nutrition support for IBD includes the Mediterranean diet, Low FODMAP diet, Lactose-free/dairy-free/gluten-free diets, general healthy eating, and identifying and avoiding trigger foods. I previously learned about IBD in my undergraduate coursework, but it was really eye-opening to see how much this disease can affect the growth of a child.

Along with the IBD clinic day, there is a Celiac clinic day, where the multidisciplinary team has visits with celiac patients exclusively.  I learned how a specific lab value, the TTG IGA antibody, is used to determine if the patient is accurately following the diet. If the test comes back too high after being on the diet for a few months, it means gluten is still entering the body. In one of the celiac sessions, the dietitian helped a family uncover possible suspects of gluten in the child’s diet, such as school lunches and meatballs. Cross contamination is a main concern the dietitian must cover in these sessions. Additionally, I learned to cover nutrients of concern including fiber, iron, and B vitamins and to educate families on sources of high fiber gluten-free grains. 

I also learned about a disease called Eosinophilic Esophagitis (EOE) during this rotation. EOE is a chronic, immune-mediated inflammatory disease of the esophagus. It usually results from a food allergy and if left untreated, can cause difficulty swallowing. One way to treat this disease is to eliminate potentially allergenic foods from the patient’s diet. I was able to see a patient in the process of the “6 Food Elimination Diet” – this patient completely eliminated dairy, eggs, wheat, soy, peanuts, and tree nuts. The mother was understandably frustrated about the large number of changes in the diet in a small period of time, but by the end of our session with her, she was confident and reassured they would be successful. 

Overall, I learned about a dietitian’s role in an outpatient setting, how counseling sessions are conducted and I expanded my knowledge of nutrition interventions in GI disorders such as IBD, celiac disease, and EOE. I learned how to assess children for malnutrition and adequate growth and, also, how to calculate nutrition needs in the pediatric population.  I enjoyed this setting because of the increased time available to talk in depth with patients about their nutrition and provide solutions to optimize their growth. It seems like a rewarding path working with a pediatric population and I can tell the parents, as well as the kiddos, are quite appreciative of the service. I can definitely envision myself working in this setting in the future and I truly valued my experience at the outpatient GI clinic. 

References: 

https://childrensnational.org/departments/gastroenterology-hepatology-and-nutrition 

​​https://www.seeeoe.com/ 

https://www.ntforibd.org/ 

Photo: https://www.pexels.com/photo/love-people-woman-girl-8460032/