A Peak into Pediatric Dietetics

Prior to beginning my pediatric rotation at Children’s National Medical Center, I was warned that pediatrics is an entirely different world than general clinical dietetics. Reflecting back on my 2-week rotation, boy were they right! This rotation was my first hands-on experience with pediatric dietetics. I quickly learned that pediatrics has an entirely different way of doing things when it comes to calculations. I had to relearn Ideal Body Weight equations, fluid equations, calorie per kilogram ranges, and recommended grams of protein per kilogram. In addition, this rotation was also my first experience with a diabetes dietitian. I really enjoyed my rotation and learned all about the process a patient and family will go through when diagnosed with diabetes. 


Patients with undiagnosed diabetes may be admitted to the hospital due to symptoms of hyperglycemia or diabetic ketoacidosis. Once the diabetes diagnosis is confirmed, a full day of education ensues. The diabetes team will look at the patient’s labs and work with the patient and family to determine a plan of care. The diabetes team consists of a physician, Certified Diabetes Care and Education Specialist, a dietitian, and a social worker. The education typically begins with a Certified Diabetes Care and Education Specialist. They will educate for about 2-3 hours and go over the basics of what diabetes is, what insulin is, how insulin works, and what their medication regimen will look like. The dietitian then begins providing education, which can take about 1-1.5 hours. This session will consist of determining what the patient’s diet looks like, teaching about the food groups, what foods consist of carbohydrates, what kinds of foods are important to have at each meal, and the timing of meals. One of the most important tips, my preceptor told me, is to have patients keep a scheduled eating routine. This helps with managing insulin regimens and stabilizing blood sugar levels. I also learned the importance of measuring food. Guessing how many carbohydrates are in a meal can be difficult and often leads to poor blood sugar control. This is a long day for the patient and family. They are dealing with the shock of a new medical diagnosis as well as an overload of new information. Luckily, patients and families continue to have support from the diabetes team after discharge. Parents are instructed to call each day following discharge to report blood sugar levels. This allows the team to see how the patient is doing and provide feedback. If a patient has a continuous glucose monitor blood sugar levels can be automatically sent to the team at Children’s.

Patients and families continue to come back to the hospital on an outpatient basis. They schedule appointments to see all the members of the diabetes team. At these appointments, the dietitian can get a picture of how well the patient feels they are doing, what their blood sugars generally look like, and what their diet looks like. The dietitian can then tailor education to their current needs and make health goals with the patient and family.  

Outpatient counseling can consist of general healthy eating tips. I learned to recommend that the entire family eat the way the dietitian recommends so the patient does not feel left out or that they have to eat a “special” diet. The goal is to make sure the patient still feels normal. So, some common topics during an outpatient setting could include tasty ways to cook and season vegetables, how to use an air fryer, and easy carbohydrate-free snacks.

One of the most important tips I learned was tailoring education to the audience. Patients come from a wide range of backgrounds with varying levels of nutrition and diabetes knowledge. Diabetes may run in a patient’s family so the parents are very familiar with the diet education. In that case, education can be focused on areas they need the most help with. Comparatively, patients and families unfamiliar with diabetes may need more time focused on the basics. 

This rotation exposed me to many different areas of clinical dietetics, including pediatrics, inpatient and outpatient diabetes, and general wellness counseling. I learned about the process a patient and family will go through when diagnosed with diabetes. As well as how to assess the educational needs of my patients and their families and gear each session to their needs.

Success in the Post-Op Bariatric Setting

By Jennifer Rivera

For those who are about to undergo bariatric surgery, there is a lot to consider. It’s a procedure that typically reduces a patient’s risk of potentially life-threatening weight-related health problems, but patients must be willing to make permanent changes to lead a healthier lifestyle. People who have struggled with weight loss may turn to bariatric surgery to either limit how much they can eat or reduce nutrient absorption. The treatment plan doesn’t end after the surgery is complete. Patients are encouraged by their medical team to view this as a lifestyle change. 

A recent rotation at the INOVA weight loss (bariatric) surgery clinic allowed me to observe a dietitian who helps keep patients on track before and after bariatric surgery. Here I was able to learn how dietitians help patients improve their health and reach their weight loss goals. While there is a lot of counseling and dietary changes prior to surgery, I want to share what I learned about counseling post-op patients. They begin on a 3-week liquid diet, transitioning into a 6 week “mushy” foods diet, and then advance to regular, everyday foods. Although many elements contribute to successful outcomes in the bariatric setting, four major points were covered at every post-op visit to ensure patients were safely meeting their goals. These include protein intake, optimal hydration, vitamins, and maintenance. 

Protein is a key part of post-op bariatric nutrition. After surgery, every patient’s protein needs vary. Post-op food portions are normally around 2-4 oz per meal. This makes it difficult for patients to eat enough protein. Protein is necessary for maintaining and building muscle, hormones, and enzymes. As my preceptor explained, this is where advising patients on lean protein food sources, protein supplements, and shakes comes into play. In the first few months after bariatric surgery, most patients need protein supplements. I learned how to educate patients on protein supplements and how they can increase their protein intake from food. Once they recover from the surgery and are able to eat enough protein-rich food, they are able to reduce or even eliminate the supplements.

Drinking fluids slowly and keeping up with hydration is the next piece to successful outcomes. I learned to encourage patients to sip on fluids all day long, as it can be difficult to drink normally after surgery. Water helps our bodies do some very important jobs. The dietitian recommends patients drink around 64 oz per day. This is an estimate as fluid needs are individualized case by case. She suggested patients drink water, crystal light, decaf coffee and tea, low sodium broths, low-calorie sports drinks, and protein drinks. I learned patients should avoid drinks such as carbonated beverages, alcohol, sweetened coffee drinks, juices, and sweet tea, as these drinks have the potential to cause feelings of nausea or pain. 

“Vitamins are for life,” the dietitian told her patients during their post-op-visits. This is important because weight loss surgeries require small meal portions. This changes the digestion and nutrient absorption of foods, increasing the potential of having nutrient deficiencies. The dietitian works closely with the other members of the healthcare team to monitor the patient’s vitamin and mineral levels. My preceptor looks for signs of deficiencies and at blood work results so she can advise her patients on which vitamins they need. Some will be permanent, some will be temporary. Common bariatric supplements include a complete multivitamin/mineral, Vitamin B-50 Complex, Vitamin B-12, Vitamin D, calcium, and iron. 

The dietitian’s role in maintenance includes follow-ups, nutrition classes, encouragement, and monitoring for potential post-op complications. Patients are encouraged to participate in physical activity, monitor any unusual symptoms, drink lots of water, eat nutritious foods and seek help when necessary.  I learned that it is necessary for RDs to remind patients that this is their new lifestyle, and following this will help them live their most healthy, confident lives. 

Although success after bariatric surgery is a multifaceted approach, it can be attained by the help of healthcare providers, encouragement, and diligence of a patient. I am thankful to have had the opportunity to rotate at a clinic that aims to better people’s lives by helping them make healthy choices. This rotation highlighted the positive impact dietitians can bring to the table.

New Experiences Leads to Personal Growth

By Anna Ziegler

One of the highlights of my 10-week clinical rotation at the University of Maryland Baltimore Washington Medical Center was spending two weeks in the Intensive Care Unit (ICU) with my preceptor, Amy Hurd, RDN. The ICU is unique because compared to the rest of the hospital they handle extreme cases of tube feeding, which allowed me to explore a more complex yet intriguing part of the field. It’s an ever-changing and fast-paced environment, so I had to learn to be quick on my feet. Here are a few of the many things I learned about the important work of an ICU dietitian and how I grew through these new learning experiences. 

As I began my first day in the ICU, I was nervous; I wasn’t sure if I would remember enough from my medical nutrition therapy class. Amy, like the other preceptors I had during my clinical rotation, pushed and challenged me, which helped me build confidence in myself as I was taking on more clients in the ICU .  I’ve always loved the quote “teamwork makes the dreamwork” and this is exactly what I saw in the ICU. Every morning we started by rounding on the floor with the entire interdisciplinary treatment team. This includes physicians, pharmacists, nurses, social workers, and occasionally surgeons. During rounds the treatment team huddles near each patient’s room and discusses openly about how to best care for the patient. On the first day, Amy told me to pack a snack for rounds, and she was right because rounds would last up to three or more hours because of how thorough they were with each patient and listening to everyone’s input.  It is such a collaborative environment in the ICU and everyone was approachable and helpful in answering questions from others. 

After rounds, we began visiting all of our patients. It was common for Amy to have a new census of patients from day to day because patients may not stay in the ICU for a long period of time. At first, I was anxious because I was not used to interviewing patients that were critically ill and being tube fed. As I observed Amy, I noticed her compassionate approach and how she spoke with all of her patients, even if they were unable to talk back due to their acute disease state. She taught me that engagement with patients is what makes an impactful dietitian.  You have to have the desire to go the extra mile for your patients, even if that means you have to spend twice as long with a patient as you planned.  

Once we visited all the patients, we began charting for each patient. The ICU is unique because unlike the rest of the hospital, they handle extreme cases of tube feeding and a lot of the patients are intubated. Therefore, in the ICU there is more math than diet education. We had to take account of labs, disease state, height/weight history, medications, bowel function, and nutritional needs when deciding what form of nutrition intervention the patient needed. Then calculating each patient’s nutritional requirements and comparing them to what nutrition they’re receiving. At first, I was rusty but with practice, I became confident with my recommendations for tube feeding. It was rewarding that after only a few days in the ICU, the nurse practitioner came to me for my input on what tube feeding formula I would recommend for a patient. 

All of my hard work was paying off and I felt welcomed in the ICU! Every day I met several ICU team members and learned something new from each of them. I was able to meet the ICU speech pathologist and observe her doing a bedside swallow exam on a patient. This was helpful because I was able to understand more clearly how they diagnose dysphagia diets and how they work with registered dietitians. Another one of my favorite experiences in the ICU was being able to observe a bronchoscopy procedure for one of my patients. I was alongside a PA student and PT student as the doctor explained the procedure and answered our questions. It was a great feeling when I noticed how all of the health professionals were always willing to teach one another and were easy to approach for advice. 

As I reflect on my experience, I learned many skills that will carry with me for my future career. The one that will always stick with me is that to be a successful dietitian, you have to be a successful team member. This means being able to actively listen, ask questions, communicate, bring positivity and look at situations from different perspectives. Working together as a team is important when taking care of patients because everyone has their strengths and knowledge to help make the best care plan. In my future career, I will take this skill with me and will remember to not hesitate to seek advice from other health professionals. I greatly value all the advice and skills I took away from my clinical experience. 

Finding the Line Between Promoting Health and Preventing Disordered Eating: Part 2

By Caitlyn Lazorka

Part 2

My Answer

I learned so much practical information by reviewing the literature for best practices and current research. I have summarized my findings into six main points: 

  1. Remove the focus on weight
  2. Avoid moralizing food
  3. Consider the learning development and age appropriateness
  4. Avoid restriction and coercion
  5. Involve the family and divide the responsibility
  6. Ensure adequate duration

Removing the focus on weight

Children experience body changes and a large amount of growth throughout their development. This growth does not look the same for everyone. Interventions focused on weight have the potential to cause unhealthy comparisons, compensatory behaviors, weight stigmatization, and disordered eating. Boutelle’s study showed that overweight adolescents are more likely than their peers to abuse laxatives or use exercise or vomiting to make up for binging. Instead of discussing and focusing on weight, interventions should be focused on knowledge acquisition and changing behaviors (such as being less sedentary), and weight is not a behavior. In one meta-analysis, interventions that focused on behaviors and knowledge rather than weight, and included education geared towards positive body image and self-esteem showed greater success when compared to weight-targeted interventions. 

Avoiding moralization of food

A common theme when educating children about nutrition is to focus on “good” vs “bad” foods. Categorizing foods as either good or bad creates shame around eating certain foods, and a feeling of pride when eating other foods. This can promote disordered eating behaviors. Most adolescents who develop an eating disorder were not previously overweight, however, it is not unusual for an eating disorder to begin with a teenager “trying to eat healthy.” Adolescents and their parents may misinterpret obesity prevention messages and begin eliminating foods they consider bad or unhealthy. Instead of moralizing food, using an all-foods-fit model keeps the tone positive. Educating on the benefits of certain foods rather than the drawbacks of other foods creates a more positive relationship with food. It is very important to avoid creating fear and guilt surrounding food.  


Considering the learning development and age

Cognitive development theory (CDT) suggests that chronological age has a major influence on a child’s ability to categorize, generalize, and think causally. It is not until the formal operational stage, ages 11 to adulthood, that children think more abstractly. This is important to keep in mind when curating nutrition education messages. Many nutrition messages are extremely abstract – ideas such as lower fat and lower sodium are difficult for children to interpret. Telling children some foods are OK in moderation may not be interpreted the same way as it is with adults. Because children think literally, they may think, “If I eat a ‘bad’ food, I’m bad.” Based on this research, I will assess nutrition messaging on portion sizes, red light/green light foods, healthy vs unhealthy foods, and how the food affects the body to determine if it is appropriate for each client or audience. Appropriate nutritional messages for young children could relate to how food is grown, eating a variety of foods, gardening and cooking. 

Avoiding restriction and rewards

Restriction may lead to feelings of deprivation and an increased craving for the specific foods being restricted. Restricting intake or suggesting to restrict intake in the form of dieting has been shown to actually cause an increase of weight gain in the long-term, and does not offer lasting weight loss or health benefits. We want to encourage kids to listen to their internal hunger/fullness cues rather than restrict their eating to fit guidelines. Similarly, coercing or offering rewards for foods also teaches children to ignore their internal cues. Making eating time a game with rewards and/or punishments may create stigmas around eating and can lead to further problems down the line when these children grow up and are in charge of their own food choices. 

Involving the family & dividing the responsibility

Children learn a lot from the people around them, and this is especially true for eating behaviors. Caregivers and family model eating behaviors every day. It is imperative to involve them in nutrition interventions, so that they can reinforce new behaviors. Studies show involving the family in the treatment of both obesity and eating disorders is more effective than focusing solely on the child or adolescent. Engaging caregivers in classes or health fairs, especially when they bring their kiddos with them for cooking, tasting, or nutrition education sessions, is both fun and effective. Another meta-analysis found similar results, concluding that interventions that provide skills and behavior change strategies aimed at parents were associated with healthier preschool children. While providing education to a food secure family, I think it is important to discuss the division of responsibility. In Ellyn Satter’s “Division of Responsibility,” the main point is that in order to help and not harm children, parents and/or caregivers must make providing food for the family a priority, because restricted eating is detrimental to children, and dieting does not work. In this theory, the parent/caregiver is responsible for what, when, and where the child will eat, and the child is responsible for how much and whether to eat the food provided. This prevents power struggles between caregiver and child. Power struggles during meal times can produce unhealthy eating habits and harm the child’s self-esteem and ability to achieve self-mastery and autonomy. Sharing tips for making meal time ‘struggle free’ and calm may help families build healthy eating habits. 

Ensuring adequate duration

Behavior change is a complex process that includes both learning new behaviors and unlearning old ones. This process takes time, therefore adequate duration is an important factor when planning nutrition education and interventions. This includes both dosage and frequency of int. Studies suggest that sessions that last between 30 and 60 minutes long and that are either weekly or biweekly may show significant improvements of nutrition knowledge and healthy eating behaviors. Proper evaluation tools such as questionnaires or quizzes can help gauge whether or not the intervention was an appropriate duration. Evaluation measures should be targeted towards behavior change and knowledge acquisition rather than weight or other numbers.

Conclusion

I learned that developing nutrition education that is age-appropriate and positively worded can lead to better outcomes and help curate a positive eating environment while preventing disordered eating behaviors. Additionally, involving the caregivers and families has been shown to improve outcomes in nutrition interventions. If able, utilizing the division of responsibility can better help children develop into intuitive eaters who have a healthy relationship with food. Avoiding moralizing food and restricting food and/or rewarding food-related behaviors is an important concept for professionals to understand. I believe these concepts will help me develop nutrition education materials that focus on positive food experiences rather than creating a good vs bad mentality. 

Finding the Line Between Promoting Health and Preventing Disordered Eating: Part 1

By Caitlyn Lazorka

Finding the Line Between Promoting Health & Preventing Disordered Eating

This is the first of a two-part series where I explore the line between promoting health and preventing disordered eating, particularly amongst youth. In part 1, I will discuss why this line is important to find and what my plan is to find it. In part 2, I will share my findings and suggest practical ways that educators and families can promote healthy eating patterns while also preventing disordered eating. 

Part 1

The Big Question

Throughout all of my rotations, I keep coming back to the same question: How can I provide nutrition education, especially to children, while also preventing disordered eating? I have become particularly in-tune with sensitizing nutrition information and identifying potentially harmful nutrition education because of my position working at a residential eating disorder facility. The line between promoting health and preventing disordered eating is important to identify when working with children, whose ears and brains are particularly sensitive to this information.

The Problem

In undergrad, I learned about motivational interviewing, medical nutrition therapy, community nutrition, foodservice nutrition, sports nutrition, disease prevention, disease management, weight loss techniques, research techniques, the science behind muscle-building, and how to measure the effectiveness of nutrition interventions. What I did not learn, however, is how to prevent disordered eating. It sounds like such a small idea or skill, but in reality it is critical and, in my opinion, it is not discussed enough. The onset of eating disorders is usually during adolescence, which increases the importance of smart and safe nutrition education. Due to my experiences working at a residential eating disorder facility, I am determined to advance quality nutrition education that both prevents restrictive eating and promotes a healthy attitude toward food and diet. 

My Plan

I decided to answer this question while taking on a research project during one of my rotations at a community site that provides nutrition education to elementary school children. When looking over potential course material for nutrition education classes, I saw a commonly used technique of having children give a thumbs up or thumbs down for various foods. While the intentions of this game are positive – to promote healthy foods and educate on what foods are not health-promoting – I wondered if there is a better way to deliver this information.

My goal of the research project was to identify best practices when teaching children about nutrition, which, to me, means providing positive messages about foods and eating behaviors. After discussing my research observations with my preceptor, she was equally as interested in finding the line between promoting health and preventing disordered eating. Check back to see part 2 of “Finding the Line Between Promoting Health and Preventing Disordered Eating” to read about my findings.