Nutrition Journal Club: Pediatric Obesity 2017

And we're going to move on to our second article, which will be given by Kristen Fuller. Kristen is the RDN at the Strong for Life clinic and has been with us for several years now. She's board certified specialist in pediatric nutrition, and she's really been a leader in developing innovative education programs for the kids regarding nutrition. And she's going to talk to us today about some of the, the different ways that we can hopefully get some more information for our families, and she's also the quality leader for our program. So, Kristen, we're looking forward to this. Thank you, Doctor Wallace. Um, the article we're going to look at today is, um, an analysis on the features and the content of these mobile apps that use photos for weight loss. And the question is, is a picture truly worth 1000 words? And I think this, um, this article and content area is so relevant to what we've been talking about because the time with pediatricians is so limited that we need them. To be, we need the patients to be able to leave with something, something to work on, something to um Um, connect with so that when they come back they come back with more information for us. It's hard to capture and to get them to open up in a 15 or 20 minute visit. I mean, I find that as well, and I see these patients for a nutrition visit, um, and it helps build rapport and get to know them a little bit better. So as you all know, and you've probably heard me talk about before, this is an area that's very near and dear to my heart. All right. All right, um, as we know, smartphones are being used to access health information and that area is growing rapidly, um, as we can see, 64% of the population owns smartphones, and, um, not only do they use smartphones to access health information. But they're frequently downloading apps to monitor health behaviors and improve health outcomes, um, weight loss being one of the most popular ones. So outside of our offices they're using this technology all the time, but what we don't know is this, is this, is this technology actually helpful, um, although evidence-based behavioral change techniques are proven to support weight loss. There hasn't been any research to see if these techniques are actually incorporated in the programming of these apps, um, and that's what we'll look at today is to see if what we created is actually effective and if it's effective, why are we not incorporating them in our weight loss interventions more often. Um, there are a couple of things that we do know already, and one is that diet tracking is no fun. It's hard to stick with, and um. And it's exhausting. Most people get tired of scanning barcodes and searching for food items, and research has shown that portions are frequently underestimated with this method of tracking. The good news is that adherence and frequency of diet self-monitoring is significantly associated with weight loss and therefore of greater importance than actually the accuracy of the nutritional data tracked. Um. This is really good information to absorb and translate for our patients and families because I think it again emphasizes that consistency is key, but in the in the long term perspective, but not the daily perfection that food doesn't have to be perfect day in and day out it's, it's checking in, it's consistency. Um, other good news is that, um, as we know, most US homes have smartphones and so just in time reporting, which is using those smartphones to take pictures of food. Has been studied and proven to as a valid assessment of dietary intake and um not only in the adult population but also with adolescents. This type of tracking takes away a lot of the typical barriers that we see um with normal diet tracking and makes it much easier for patients to adhere um and check in more frequently. Um, lastly, diet self-monitoring is, um, associated with weight loss with the addition of immediate provision of feedback. Um, many apps and companies are using crowdsourcing as a solution to that. It's cost-effective, easy to use, and reaches the most people. Um. Again, the purpose of this article is to provide a content analysis of the currently available mobile apps for diet self-monitoring via photos and whether these techniques for promoting healthy behaviors, healthy eating behaviors, including self-regulation, are actually targeted. Um, the researchers used a search protocol adapted from previous systematic reviews. Um, they did not include apps that did not target diet tracking, did not include taking or posting pictures of food for the purpose of self-monitoring, and if they weren't written in English, they weren't included. Um, at the end of the study, there were 29, at the end of the search, there were 29 apps that met that inclusion criteria that were downloaded and reviewed and coded by two independent reviewers. Um, the reviewers looked at general information, collected information about behavior, targeted, um, user satisfaction scores, the ability to connect to social media, um, and how feedback on food was then provided to the user. Did they use crowdsourcing or collective feedback, or did they actually have some professional feedback? Um, in encoding these apps, they looked at, um, the different behavior change techniques. They did separate self-regulation from the other behavior change techniques, um, based on previous evidence that shows that self-regulation techniques and more specifically self-monitoring should always be included in programs that are promoting healthy eating habits. Um, There were 2 apps that were quite impressive. Um, 2 of them actually included 11 of the 13 behavior change techniques. One was You Food and the other one is food feedback. These two, were pretty strong in the areas of behavior change techniques, but unfortunately, the other, you know, the rest of the results were not quite as impressive. We looked closely, 18 or 62% of the apps did not provide any feedback at all on posts. And we know that from the slides previous that that's an important part of this success. One of the apps out of the 29 apps only used professionals to provide feedback. Three of them offered an option of professional feedback. 7 of the 29 used only crowdsourcing or collective feedback. And 6 didn't use any of the self-regulation techniques at all, um, which we know are so important in any healthy eating program. Hm Um, for a little more detail on the results, you can see that providing general encouragement, providing information about others' feedback and feedback on user performance were the ones that were found most often in the app. Um, This was a little disappointing to me and to see that the, the behavior change techniques that we value so much in our clinic were, um, were barely found in any of the apps, you know, we focus a lot on specific goal setting, very specific goal setting, um, review of behavioral goals. We do a lot of modeling and demonstrating of behavior. We go through barriers and identify what's getting in the way. Um, we do a lot of follow-up and prompting of follow-ups and intention formation. So, Um, these are things that we really see as the core of our clinic and what really helps, um, us help the patients make change happen. And, um, to see these not included was a little disappointing. Um, overall, I mean, the results were, yes, a little disappointing, but there's plenty of areas of improvement if we look on the positive side. Um, the good news is that these apps are being used and they're out there and they're accessible by a diverse population. Um, they're not hard to get. Most of them are, are cost effective and, um, so we have a tool that people like. The problem is we're not being that effective. What we know works um in professional areas is not necessarily working when they're out on their own. All right, so here comes um a few slides on what we do and um our solution to this issue right now, which wouldn't necessarily work in a general pediatrician's office. And so I guess the next discussion um is how to put these two things, two things together. How do we make this happen, um, in an office where there isn't the time where you don't have the staff to support, um, doing some of this MI around food? Um, in our clinic, we, we discuss food or we collect information about food in three different ways, um, trying to separate it and, and categorize it a little bit to make it less overwhelming. So if you've seen these, a couple of these slides before, um, I like them, they're clear and informative. The, the first one is, we talk about 24 hour recalls or we use 24 hour recalls to identify the schedule of the child, why that, when the child eats, um, any structure around meals and snacks, gives me an idea of parenting and what kind of structure is in the house. Um, we use a photo food log in our clinic as, um, to talk about, um, the quality of the food, the balance in the food groups, and how the people eat. You can see a lot by just looking at their table setting. We do use a written food log more, um, less frequently. We use it more to talk about emotions and feelings with food. Um, but it can be very useful. We just don't do it as much. Here's an example of a before and after plate using the photo food log. Um, this didn't happen in one round of reviews. It was, I'm sure, several. Uh, I can't remember back exactly how many, but I know that it didn't happen, um, instantly. But you can see here that the, the plate has changed a lot. There's a better balance of colors and nutrients, less carbohydrates, um, better cooking methods. Um, when I set up this photo food log with the families, I usually get them very involved in, in how often they want to be sending pictures, how, um, how many pictures per day, so that they can make this fit their lifestyle at home. They would be able to do that with an app, and I want them to be able to do the same thing with this photo food log. Seems to work well um for the family to follow through. Um, here's another example of before and after. Obviously, this is a lot of change, um, and you can see a big difference in colors and nutrients and, and food quality here. Um, in clinic when these patients bring these pictures in. I'm able to sit and pull the pictures up on the computer and talk about food using a lot of motivational interviewing skills. I think this is the most crucial part of This photo food log process and it's probably what we value most about it and this is in-person professional feedback about food photos. This is really the core and the part that's missing from these apps that we saw in that study. They're not able to provide some of this, and we need to figure out how to get this to more people more often. Um, during that MI session of talking about food, you know, I'm able to get the kids involved, talking about food groups using a healthy demonstration of, um, food conversation and, and how to carry out some of these things at home. It brings mom and child back on one team. Mom gets to take responsibility and role of. Um, cooking a little bit differently or better or choosing different foods from the grocery store to help the child out, and the child can take ownership of, of placing the food in the right sections and arranging it and balancing it a little bit better. Um, so that, that part of the sessions and part of the food food blog is, again, what we value most and what I feel is missing, um, from a lot of other technology and instruments that are used to do similar things. Um, this last example is another before and after picture with drastic improvements, and again happened over time. Um, it doesn't happen right away. Um. I think this is a good example of Of some of the MI work we do in clinic as well and demonstration of healthy eating habits and healthy food conversation by not labeling foods as good or bad. We talk about red meat, we talk about refined grains, um, but in the end they all fit into a balanced diet and the child gets to learn a little bit about them. The parent knows how they can make further advancements, further improvements, but, um. Um, we, it's a good example of how not to label foods. All right. So, as well as the photo food logs work in our clinic, um, we still have a lot of barriers to them. We have trouble with people forgetting to take pictures, even though I send out reminder emails and reach out to them. Um, we have kids who eat so fast that they forget to take the picture before they start eating. Um, we have people who are self-conscious about their food and, and start staging pictures in order to, um, make things look a little bit better. And then we have instances where we have continued weight gain and we have these fantastic pictures that um Um, Demonstrate no need for weight gain from food. Um, so we still have areas to improve on, but I definitely, um, you can definitely see where, where the apps or the technology that's becoming so popular is missing, or what, um, features it's missing and where we need to improve upon. Um, we have used the app some in our clinic, but we haven't had as good of results. I think there's something about emailing pictures to your dietitian that, um, is, um, not replaceable by an app. We just have better experience because we have the resources to support, um, that professional feedback and connection. Um, I think this is coming close to the end, yeah, um, but overall, um, I would like to see some way to For pediatricians to be able to use these apps more frequently and so that the patients could have some type of be working on their photo food logs and then um report back in some way to someone um to be working on the behavior change techniques. I don't know the answer to that at this time. Um, if anyone wants to partner with me and make an app, we can do that. Um, but I think, um, it's definitely an area of opportunity. Hey, Kristen, I was great. Thank you. I think, I, I know, I feel very fortunate that you're the dietitian in our program, um, because using some of these innovation, innovative programs and the photo food blogs, I think what surprised me the most about them is how many kids asked to do them again. When you would think, wow, this would be so stressful. But any, any comments about how often you're having to do that, these with families? Um, typically, I think with the most success, we see the families do them about 3 times, because we start to see, um, We work on something small the first time and keep building, so I think it probably takes 3 rounds to really see as big of improvement as we saw in those pictures. Yeah, the, um, the, the changes can be very dramatic, but like you said, you don't, you don't always know, and we've certainly seen our share of staged or off the internet photos too. So, but that allows us again to have a conversation, like you're saying, really use those MI skills to find out what's going on with that family. Um, any issues you run into with photo food logs, like personally or from parents having issues with them, or is everybody usually on board? Um, people are typically on board except for when they're moving very fast at meals, and that gives us a little bit of insight, and Chiel and I can work together on helping this person slow down around food. Why is it, why can we not take a second to remember to take a picture? Um, and so I think. The, the photo food logs that don't work out so well actually bring about bigger issues for us to work on that are, that are not connected, or, you know, that are not food related, um, but are things to work on before we even get to the food. Um, we see a lot of parents, even in photos, we can see some restriction going on, we can see, um, What goes on at home, give us a better insight to the parenting styles as well. We did have a question about how often folks are emailing those to you for feedback, and do you send them feedback immediately, or do you wait until the next clinic visit? Yeah, typically, um. When I talk to parents, we set up a photo food log for about 1 month, and we talk about how often they'd like to send us pictures within that month. If a family seems overwhelmed by 1 month, we back it up to 2 weeks and just focus on completing a goal in that 1st 2 weeks that they're out of the office. Um. Um, they I would say generally, on average, like to send one picture a day, and I typically ask for the meal when they're home as a family together. If not, if they're a teenager that's not home with their family, I just let them connect with me in any way that they can around food. Um, but typically one picture a day for about a month is um. It's a pretty good average, and I typically respond to that person letting them know that I'm receiving the pictures. Sometimes I will send encouragement, but I review and go over the, the pictures, um, in clinic because again that MIP is just, um, something I, I can't replicate over email. Hey Chris, are, are you guys doing any nutrition evaluation or assessments like this? Um, not as much, and I really am, I'd really like to. I, you know, we, we used to do more, um, um, we have not been doing as much, we've kind of fallen off with it, so I'm anxious to get back at it. Alan, how about in your programs, are you using? Some good nutrition assessments or something different? Um, In Maine, we're they're in Orono up with Valerie O'Hara, whom I work with, we're a little old fashioned yet. I don't think we're this advanced, but it certainly looks very promising, and I think it's some immediate friendly productive feedback for the kids and their families. Um, so there are a couple more questions on the chat line. Um, Nancy Ryan was asking if you cover, um, information about the amount of food from the photos, or is it really about the quality that you usually do? We talk a lot about the balance of foods on the plate. I think um that's the part that the kid has most control over is how they set up their plate. And then if there is excess, it's a perfect time to bring in that division of responsibility and talk to parents about why there is so much excess there, why is there so much rice available to the child? Is there anything that you can help them with so that they can set up a better balance and be more in charge of that? Um, so we do talk about volume and quantity, especially some of the families send group pictures where you can see what's being cooked and not just an individual, um, plate set up. Yeah, I thought that was clever to make sure it's the family meal because then you know what everybody's eating and you're not just getting what somebody packed for lunch or, or something. Um, and someone wants to know how much time do you cover. How much time do you have to cover this information during a visit? A typical um 15 to 20 minute follow-up visit. Um, is what I use to go over these photos, but they're so valuable that if I go a little over. Sometimes we give you a little extra time, but you know, again, that gets to how, I mean we're in a specialty clinic where the patients come for a 1 hour, a 2 hour multi-specialty visit as opposed to the pediatrician's office, um, have And I don't know, I know Chris, you said that you're not using something like this. Uh, I don't know, Claudia, is there, is there a way to incorporate technology like this into a practice where maybe even they could be analyzed or looked at offline or do an abbreviated version that isn't quite as intense, but just to give the pediatrician some information or something they can do within the time they have. Uh, Chris, do you, I mean, do you think that's Oh, I, I clearly think there is. I'm, I'm, I'm anxious to hear what Claudia has to say too. We, we typically, um, have patients keep a, a one week's food log. We tell them you can do it on paper. We give them a packet, so it's one page per day, um, and they, the response rate is variable. Um, I will say it's variable. Some kids are really good at it, some kids not so good at it. We have started an incentive program such that if they do return, come back with their food logs, then Um, we enter their name into a drawing to win a prize, whether, whether it's a Target gift card or a basketball or some other gift, and that, that seems to help a little bit, um. It's a, I, I find the, the, the food logs to be a great um teaching tool, and I might just sit with a with a kid and say, so show me one of your days. What do you think of this day? How do you think you did? And um they may say, uh, OK, or great or not, not great, and we'll go through each item. Do you think this was um Good choice, not so great choice. Is there something else at home you could have eaten instead? So it does provide some Um, it, it is a learning tool, I think. And I, and I also, I, I love the idea of the pictures. We have, we, we don't do that generally, um, but have on one or two occasions, and they can be incredibly eye-opening in terms of Um, sort of identifying, oh, so that's what you mean by a bowl of rice. They might be using, you know, really small hands like that, but when you see it in a picture, it's instead could be a really large serving bowl that you would serve a whole family, but that is for one kid. So it, it really, a picture is worth 1000 words. Definitely. And Kristen, tell a little bit more about the education piece that you've, you've done afterwards where the kids sort of, you, you teach them how to sort of grade their own plates later, for lack of a better word. Yeah, we do some sort of scoring method, um, for the patients that, um, can relate to it. Sometimes it's more he sincere, you know, division of responsibility, and in, in some ways the the teenagers can handle, um, starting to grade their own plates a little bit, um, so we set up, we do it based on the my plate method or the balance plate, and we have, um, green stars for, for meeting the, the recommended, um, food groups in that section of the plate. And we have yellow stars and red stars, and it just gives us an opportunity um to not be negative or critical, but to show them how much better they could do and how much more they could advance. Some of them are really ready for that next level of education about nutrition, not all, but the parents as well. Mm mhm The, um Any other nutrition? So yeah, Alan, how in your, in your program that you have with your, with, with your patients, how do you follow the, the nutrition and what's your, what are your, uh, how, how do you approach the food logs? We do some written food logging. And our team at the Weill Clinic up in Orino is, is gradually getting more and more involvement of a dietitian. Most of the pressure previously and still is on the medical providers, the nurse practitioners, and the and the physicians involved. So that's what I said when I watched what Ms. Fuller is doing there. You say, wow, this, this really has potential because it It it is attractive to them, I think. It's something, it's a, these are tools and things that they work with and they create the pictures and then you in a positive and productive way can give them feedback on the feedback on the pictures, much better and much better timing sequence. And once a month or once every 2 weeks and things like that. So I'm taking notes personally. Kristen, I have a question. Are there apps for nutrition that the kids like, even if they're not necessarily great apps from our standpoint? So I see them use calorie counting apps a lot, like MyFitness Power. They come in trying to calorie count using these apps and um I see them be really restrictive with them and then fall off and not be able to stick with it very long. Um, if they're really into the apps, I do try and get them to use those, those ones that we've looked at, um, that, that were such, um, that met all the behavior change techniques was You Food and food feedback. YouFood has been one that some of our kids use, and it's taking pictures of your food. So, um, it's very similar to what we do, um, it's just that they're not emailing them to me, but, um. Um, I try and keep them or steer them away from the calorie counting apps to get them looking at food a little bit differently, but a better relationship with food. Kristen, I, I, I don't know if, just to make sure it was clear for everybody exactly how you do this or the logistics because you're not, you're not using an app, you're using. Basically just pictures and is it texting, is it emailing or you know how do they, what what what are the logistics of how they do it and then how do you just keep track of all these like I actually don't have no idea how you do this, how do you keep track of all these pictures and that's why my mission is to see what I can help with pediatricians come up with because this would never work in a Another, um, in an area that didn't have this resource because I'm able to actually have the kids email the pictures to me through a separate email address and file them and save them in their own folder, um, by their first photo food log, their second one, and their third one, and then in the rooms I'm able to quickly pull up that file folder of pictures and we can review them right there on the screen. So I'm actually getting a whole email account um full of food pictures all day which um in a lot of instances wouldn't wouldn't work for people, um, so it's a lot of organizing and filing but it, you know, I am able to connect with the patients on a daily basis which is nice and I think that's part of um what makes it work so well. Yeah, and how, I mean, like, again, I don't, I know we work together, but I don't know how you do this. Like, how do you get through all those pictures? I mean, does it take you that long to look at them and grade them, or I mean, are you spending a lot of time doing this or is it I don't grade them on the spot. I think the best thing for me to do is respond back to that patient quickly, letting them know that I've, I've seen their. Email I'm seeing that they are um adhering to the goal that they set up. um, I'm, you know, their goal is not to send a perfect picture. The goal is to send me a picture and to connect with me um about their food and so the most important of that is just keeping that rapport, letting them know that I'm here, I'm seeing it. They need to keep up the good work and then um. And I've told the parents this prior to them leaving their appointment is that I won't be giving them a lot of advice. Sometimes if I know the patient well and I'm able to say it's a lot of carbohydrates on one plate, try and tailor that a little differently the next time I can do that. But um. Um, most of the emails are just a quick thank you, keep it up, good work, some encouragement. Kristen, um, I will say as someone who's not a nutritionist and does not like giving nutritional advice because I, I don't really know that much, um, but I think one of the things that's most helpful about it is it seems like it tracks very closely with, um, the My Plate, the the USDA My Plate approach, which, um, I think everyone has access to. And it's very visual and it's very easy to at least give some preliminary suggestions to the family even if you're not, um, you know, a professional, um, and you're not then sort of wading into um nutritional advice which we all know a lot of people think they're experts and they're not, um, so I will say that that has been one benefit even when they show me the pictures, I feel like I can easily look at it and tell here are a couple of things to change. Um, and it, it doesn't always take, um, because I, because I don't necessarily have all the information, but it doesn't always have to take too long. Um, it can be a pretty quick process if, if there's ample room for improvement on the plate. Yeah, um, I agree with that, she thought. It does take more time in the background and before you actually see the patient, it takes looking at those pictures and understanding what you're going to have to talk about, but it does take less time in the room, which is nice. Um, you can get in and out of the, out of the rooms a little bit quicker, um, being able to see it in pictures and go through a food journal. All right, there are two more quick questions. One was about, um, the emails and HIPAAA, and Our our emails are HIPAA compliant, but I guess, was there any other barrier around that? And then, um, did the patient send you any other information about their food, any comments from them, or is it really just a picture? Most of the time, it's just a picture. Um, if the patients are having trouble sending pictures, they sometimes describe their food in the email. Um, I've, I always, um, check with the parent on what email they want to use, if they feel comfortable with the child emailing, um, our system, or if they'd rather have all emails go through the parent. Um, and there's no other identifying information. I never use their, their names or, um, anything else in the emails. It's mostly just pictures. Um. Do you feel like you need to put that in the medical record? I do Sometimes, but I can always access it, um, if I need to. Thank you. Thanks, Kristen. That was great. I think there's so much an easy way, but if we could, we need to make our app. I think that's just the result of this fantastic, yep.