Watching Weight Trends…Bring in the RD!

Deborah S. Fillman, MS, RD, LD, CDEGreen River District Health DepartmentKentucky Diabetes Prevention and Control Program

Watching Weight Trends…Bring in the RD!

Describe appropriate nutrition assessment and intervention to identify children and adolescents at risk for overweight/obesity and the associated co-morbidities.Identify appropriate food and nutrition programs for children and adolescents.

The question…

Are dietetics professionals (registered dietitians) receiving referrals appropriately?

The scenario…

Siblings, Joe (14 y.o.)(almost 300 lbs) (and Jane (13 y.o.) (greater than 300 lbs)are referred to the local health department registered dietitian.Each child has already seen their pediatrician, endocrinologist, family counselor, and school personnel.School personnel referred to RD.Were in WIC as young children

The scenario continued…

School counselor, therapist, principal, RD, mother, grandmother had joint meetingMissed many school days…with MD excusesBehavior problemsSchool personnel concerned about vending machinesAppointments not kept with RDMother home schoolingFamily knows the “system”

And more…

3 y.o. weighing 75 1/2 lbs. And 40 ¾ inches Sees RD for WIC FU Gained from 57 lbs. To 75 ½ lbs. In 6 months.BMI 31.8Father weighs 300 lbs and has diabetesMother blames fatherSeeing pediatricianNever Breastfed

And more…

3 y.o. weighing 57 ½ lbs. And 38 ¼ inches.BMI 28Lives with 60 y.o. grandmotherReferred to RD via WIC FUSeeing pediatrician.Mom started Breastfeeding, but was incarcerated so breastfeeding limited to one-2 months.

The plot thickens

These are not unusual casesEarlier referral to an RD may help in some casesUsually more than simply a food issue

Pre-RD

Screening and Referral-A supportive system-not a step within the Nutrition Care Process. – An identification step that is outside the actual “care”

and provides access to the Nutrition Care Process.– The Nutrition Care Process depends on an effective

screening and/or referral process that identifies clients who would benefit from nutrition care or MNT.

Screening

“those preventive services in which a test or standardized examination procedure is used to identify patients requiring special intervention”

Accurate Screening

Specificity: Can it identify patients with a condition?Sensitivity: Can it identify those who do not have the condition?Positive and negative predictive

Referral

Referral by physicians, schools and other health professionals is important in connecting RD’s to families needing MNT.

Referral

Poster Session: Community Nutrition and Public Health, September 1999.– Despite evidence that dietary counseling is essential

in chronic disease prevention and management, physicians may not provide adequate counseling or referral of patients to registered dietitians or community nutrition education programs.

Referral

Value-added services that increase physician’s intent to refer patients to an outpatient nutrition clinic., May 1994.– Surveyed almost 400 physicians to identify value added

services that would increase their patient referrals to registered dietitians. Frequency distributions revealed that the services physicians most strongly agreed would increase their referrals were to help patient’s receive reimbursement from third party payers.

American Academy of Pediatrics

“The dramatic increase in the prevalence of childhood overweight and its resultant comorbidities are associated with significant health and financial burdens, warranting strong and comprehensive prevention efforts. This statement proposes strategies for early identification of excessive weight gain by using body mass index, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research.”

AAP Policy Statement on Prevention of Pediatric Overweight and Obesity

“Genetic conditions know to be associated with propensity for obesity include Prader-Willi syndrome, ….In these conditions, early diagnosis allows collaboration with sub specialists, such and geneticists, endocrinologists, behavioralists, and nutritionists, to optimize growth and development while promoting healthy eating and activity patters from a young age.:

KY Department of Education

School Health Services– One of eight components of the Coordinated School

Health Model• Kentucky schools will have readily accessible preventive

services, education, emergency care, referral and management of acute and chronic health conditions.

Screening

BMI – Children older than 2 and adolescents with BMI’s at

or above the 9fth percentile for age and sex are considered overweight and should receive and in-depth assessment

Screening

Children older than 2 and adolescents with BMI’s between the 85th and 95th percentiles for age and sex are considered at risk for becoming overweight and should be screened and evaluated carefully, with particular attention to family history and secondary complications of obesity including hypertension and dyslipidemias.

Screening

Children (older than 2) and adolescents with an annual increase of 3 to 4 BMI units should be evaluated.

Screening

The purpose of screening is to identify children at risk for nutrition problems, to refer children with more severe problems to the next level of care and to provide anticipatory guidance and educational materials to children and their families regarding prevention of nutrition problems.

The RD’s Role

AssessmentNutrition DiagnosisNutrition InterventionMonitoring/Evaluation

ADA Nutrition Care Process and Model (NCP)

A systematic problem solving method that dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe and effective quality nutrition care.

Nutrition Assessment

To obtain adequate information in order to identify nutrition-related problems…initiated by referral and/or screening of individuals or groups for nutritional risk factors.A systematic process of obtaining, verifying and interpreting data in order to make decisions about the nature and cause of nutrition related problems.

Nutrition Assessment Components

Dietary intakeEvaluation of health and disease conditionsEvaluation of psychosocial, functional and behavioral factors related to food access, selection, preparation, physical activity and understanding of health conditionEvaluation of knowledge, readiness to learn, potential for changing behaviorsComparison to standardsIdentification of possible problem areas

ADA NCP

Nutrition Diagnosis– This is not the medical diagnosis; rather, a category

from which to form a specific nutrition diagnostic statement. For example, “excessive fat intake” might be the nutrition issue.

ADA NCP

Nutrition Intervention– A specific set of activities and materials used to

address the problem. – Purposely planned actions designed with the intent

of changing a nutrition related behavior, risk factor, environmental condition or aspect of health status for an individual, target group or the community at large.

ADA NCP

Nutrition Monitoring and Evaluation– The review and measurement of the status at a

scheduled follow up point with regard to the nutrition diagnosis, intervention plans/goals and outcomes.

– The comparison of current findings with previous status, intervention goals or a reference standard.

– Determines the degree to which progress is being made and goals or desired outcomes of nutrition care are being met.

Who’s responsibility is it to Follow Up?

RD?MD?School?Parent?Society?

What programs are available?

Women, Infants and ChildrenFirst StepsHealthy StartHANDSHead StartBuilding Stronger FamiliesSchool Lunch Program

What Programs are Available?

Well ChildExtension ServicesOther?

Barriers?

MoneyAccessKnowledge and awareness of programs and staffOthers?

Overcoming the Barriers

Educate and communicateConsistency in a screening toolAdvocacyWhat else?

Thinking outside the Box

Could we do something totally different that might actually change the lives of our children in a positive manner?– Examples…..

Resources

American Dietetic Association Nationwide Nutrition Network www.eatright.org 1-800-877-1600 ext. 5000– Participation is available at no additional cost to ADA

Members

Resources

Hospitals/Outpatient ClinicsLocal Health DepartmentsRD’s in Private PracticeLocal Dietetic Associations (Part of Kentucky Dietetic Association)

Where do we go from here?

“Nothing will work unless you Do”

Maya Angelou

Thank You!!!