1. Watching Weight Trends…Bring in the RD! Deborah S. Fillman, MS, RD, LD, CDE Green River District Health Department Kentucky Diabetes Prevention and Control Program

2. 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.

3. The question… Are dietetics professionals (registered dietitians) receiving referrals appropriately?

4. 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

5. The scenario continued… School counselor, therapist, principal, RD, mother, grandmother had joint meeting Missed many school days…with MD excuses Behavior problems School personnel concerned about vending machines Appointments not kept with RD Mother home schooling Family knows the “system”

7. 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 31.8 Father weighs 300 lbs and has diabetes Mother blames father Seeing pediatrician Never Breastfed

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

9. The plot thickens These are not unusual cases Earlier referral to an RD may help in some cases Usually more than simply a food issue

10. 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.

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

12. 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

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

14. 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.

15. 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.

16. 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.”

17. 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.:

18. 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.

19. 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

20. Screening Children older than 2 and adolescents with BMI’s between the 85 th and 95 th 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.

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

22. 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.

23. The RD’s Role Assessment Nutrition Diagnosis Nutrition Intervention Monitoring/Evaluation

24. 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.

25. 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.

26. Nutrition Assessment Components Dietary intake Evaluation of health and disease conditions Evaluation of psychosocial, functional and behavioral factors related to food access, selection, preparation, physical activity and understanding of health condition Evaluation of knowledge, readiness to learn, potential for changing behaviors Comparison to standards Identification of possible problem areas

27. 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.

28. 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.

29. 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.

30. Who’s responsibility is it to Follow Up? RD? MD? School? Parent? Society?

31. What programs are available? Women, Infants and Children First Steps Healthy Start HANDS Head Start Building Stronger Families School Lunch Program

32. What Programs are Available? Well Child Extension Services Other?

33. Barriers? Money Access Knowledge and awareness of programs and staff Others?

34. Overcoming the Barriers Educate and communicate Consistency in a screening tool Advocacy What else?

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

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

37. Resources Hospitals/Outpatient Clinics Local Health Departments RD’s in Private Practice Local Dietetic Associations (Part of Kentucky Dietetic Association)

38. Where do we go from here?

39. “Nothing will work unless you Do” Maya Angelou

40. Thank You!!!