Child Obesity:  Reflecting on strengths-based approaches to clinical care and looking forward to positive deviance approaches to research

Hooper_PhotoLaura is a 1st year trainee at the University of Minnesota – Twin Cities. She is pursuing a PhD in Nutrition and a doctoral minor in Epidemiology at UMN. Her research is focused on the intersection of obesity and disordered eating in children and adolescents. She is interested in understanding how external factors such as weight stigma and food insecurity impact health outcomes in these populations.

I was thrilled to learn that I would have the opportunity to work as a research assistant on the Positive Deviance Child Obesity Supplement for the MCH Nutrition Training Program here at UMN. What is Positive Deviance you ask? Positive Deviance is an innovative approach to public health research. Traditional research approaches investigate the sick, focusing on a particular disease. They focus on identifying risk factors associated with a particular disease, reducing modifiable risk factors, with the goal to mitigate the population’s risk for developing that disease. Positive Deviance uses a different approach. In Positive Deviance, instead of studying the “sick,” researchers study the “well.” Within an at-risk population, they ask who does not develop the disease? They aim to identify protective factors or protective behaviors within the “well” population. Finally, they aim to promote those protective behaviors within the at-risk population.

For the Positive Deviance Child Obesity Supplement, the condition we are studying is child obesity. We will be looking at 2- to 5-year-old children who are at risk for developing obesity. Our goal is to identify the characteristics that are associated with (and possibly responsible for) not developing obesity. For example, which children do not have accelerated weight gain and what characteristics do they share?

Why am I so excited about this approach, you ask? Well, before I returned to graduate school to purse a PhD, I worked as a MS, RDN for 10 years in child and adolescent obesity clinical programs at Seattle Children’s Hospital. We used a strengths-based approach to clinical care. We partnered with children, adolescents, and their families to help them to see what they were already doing well, then we built upon those strengths as we set SMART goals (Specific, Measurable, Agreed-Upon, Realistic, and Time-Oriented). I saw firsthand how helpful it was to patients and families when our clinical team was able to empower them to feel good about what they were already doing and then make changes based on those strengths. When I was first being trained in this approach to clinical care, one of my mentors used this analogy: “You don’t teach a child to read by listing off all the things they are doing wrong. You start with what they are doing well and then build from there.”

Even though the strengths-based approach to clinical care is not the same thing as Positive Deviance research, they both focus on investigating what is going well rather than investigating what is going wrong. Child obesity is such a complex, multifaceted, layered problem, and previous research approaches have not been able to adequately prevent the condition from developing. It is a puzzle that has yet to be solved. Our research team is currently recruiting participants, and we will be collecting qualitative data this summer. I am very excited for the opportunity to participate in this innovative approach to research and eager to see what we discover!

Reference:

Alex Foster, MD, MPH https://www.youtube.com/watch?v=EOGHqDaiJL0&t=216s

 

Improving CHW’s Work in the Spectrum of Cancer Care Across Minnesota

yetundeYetunde is a 2nd year trainee at the University of Minnesota – Twin Cities. She is currently finishing up her MPH and dietetic internship at the UMN School of Public Health. She earned her Bachelor in Science in Nutrition – Dietetics at Auburn University in 2017. Her interests include maternal and child health, mental health, and nutritional counseling. She hopes to primarily work with women and children of color. 

Community health workers (CHWs) are public health workers that typically come from the same culture, ethnicity and/or socioeconomic background, and speak the same language as the communities they serve. Because they often have similar life experiences as those they assist, they are able to build trusting relationships with their communities and are therefore an important link between health services and the people. CHWs are also involved in a number of other activities that seek to increase the health knowledge of both individuals and the community such as informal counseling, education, support, advocacy, outreach, and providing resources (1).

The Minnesota CHW Curriculum cancer course focuses on the role of the CHW when working with patients with cancer and their families. It places emphasis on understanding cancer, its risk factors, screening for detection and diagnosis, and the types of cancer treatments. It also seeks to understand the emotional factors involved when a cancer diagnosis is made, its treatment, and cultural considerations that must be addressed. Lastly, it helps CHWs in identifying resources and ensuring client access to those resources, as well as aid and support clients and families (2). However, the literature still reveals gaps in cancer training among CHWs in Minnesota.

The goal of my culminating experience (Master’s project) was to better understand the needs and barriers of CHWs and their health care employers as it relates to cancer detection, treatment, and survivorship of clients and their families across the state of Minnesota. Understanding these barriers could improve CHWs’ role in the spectrum of cancer care. I had the privilege of completing this project under the direction of the Program Coordinator of the Comprehensive Cancer Control at the Minnesota Department of Health, the Minnesota Cancer Alliance, and the Cancer Health Equity Network.

After completing a literature review, planning for data collection, and conducting 8 key informant interviews (2 more written responses to the interview questions were received totaling 10 participants), 9 top themes were discovered after thematic analysis: 1. Enrolling clients in screening programs; 2. Providing education; 3. Involvement in the community; 4. Providing culturally appropriate care; 5. Care coordination; 6. Transportation for clients; 7. Integration into the healthcare team; 8. Training for CHWs and 9. Defining the scope of the CHW. Based on the results of the interviews, there are a few recommendations that could be made to help elevate the work that CHWs do in the spectrum of cancer care in Minnesota: 1. Further formal training for CHWs, 2. Integration of CHWs into the primary care team, and 3. Clear scope of practice for CHWs.

CHWs have been shown to play a beneficial role on any interprofessional team, and this also applies to serving clients on the spectrum of cancer care. With further research and implemented recommendations, CHWs have the ability to enhance their work in the spectrum of cancer care in the state of Minnesota.

Through my research project, I acquired the Critical Thinking, Communication, Cultural Competency, and Working with Communities and Systems MCH Competencies.

References:

  1. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf
  2. http://mnchwalliance.org/wp-content/uploads/2012/12/Minnesota-CHW-Curriculum-Outline-Updated-Feb-2015.pdf

UMN Trainee Spotlight: Jessica O’Connell

jessica o'connellJessica is a first-year MPH Nutrition student and dietetic intern in the coordinated master’s program at the University of Minnesota. She earned her Bachelor of Science degree in Biomedical Science with an emphasis in Human Nutrition at Grand Valley State University in Michigan. Jessica has been an MCH Nutrition Trainee since September 2018. As a trainee, she has worked on creating an Infant Feeding brief with ASPHN and the development the University of Minnesota’s Public Health Nutrition Newsletter. As a dietetic intern, Jessica has also had the opportunity to work directly with women and children from low-income and homeless families at Perspectives Inc, which she describes in this post. 

I was paired to intern with Perspectives Inc. in my first semester at the University of Minnesota. Perspectives is a human service agency that provides support to homeless and low-income families in St. Louis Park, Minnesota. My role with the organization included working with women and children in Perspectives’ commercial kitchen/dining classroom. The Kids Café program was designed to increase healthy food consumption by providing hands-on nutrition curriculum and addressing healthy food choices for children and their families. The kids are transported to Perspectives on the bus right after school. Each day, a group of kids help out in the café by preparing, serving and then eating a nutritious dinner with their peers. It’s wonderful to see the kids get excited to try new foods, whether it be parsnip fries or a black bean burger. They also become increasingly confident in the kitchen, as they practice basic cooking tasks like sautéing or chopping vegetables.

Perspectives also provides several opportunities where the mothers are invited to participate in cooking groups at the Café. Through these, they can learn how to cook new recipes or create their own recipes from the ingredients provided. Simply working alongside the mothers and having conversations with them was an integral part of providing equitable support to them through this program. This face-to-face time allowed me to create newsletter articles and other resources for them that were relevant to their needs and goals. I am passionate about reducing barriers to healthy eating, making it both simple and attainable for everyone. Because of this, I’m grateful to be part of an organization that increases access to healthy food and cooking knowledge to those who can benefit so highly.

Using Conceptual Models to Tackle Complex Public Health Problems Affecting MCH Populations

 

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This post is contributed by Junia Brito, MCH Nutrition trainee and PhD student in epidemiology at the University of Minnesota, Twin Cities

An Example of How Structural and Intermediary Determinants of Health Affect Breastfeeding Rates among African American Women

Despite the many known benefits of breastfeeding, a persistent discrepancy exists between African American mothers and mothers of other races who breastfeed. According to the Centers for Disease Control and Prevention (CDC), among all children born during 2010–2013, 64.3 percent of African American women initiated breastfeeding, compared to 81.5 percent for Whites, and 81.9 percent for Hispanics. The percentage point difference in the rate of exclusive breastfeeding through 6 months and breastfeeding at 12 months between African American and White infants was 8.5 and 13.7, respectively. Multiple factors influence a woman’s decision to start and continue breastfeeding. However, certain barriers are disproportionately experienced by African American women.

Using the Word Health Organization’s (WHO) Conceptual Framework for Action on the Social Determinants of Health, I attempt to show you in a simplified manner how structural and social determinants of health shape these lower breastfeeding (BF) rates (i.e., initiation, exclusivity up to 6 months, and duration up to 12 months) among African American women. Following the proposed conceptual model, I briefly explain each construct and how they interact to shape BF rates among African American women.

model

Structural determinants of low BF rates among African American women include (1) the U.S. Federal Employment and Labor Laws (e.g., Family and Medical Leave Act -FMLA), (2) social norms (e.g., embarrassment/ fearful of being stigmatized when they breastfeed in public, sexualizing women’s breasts as objects of male desire, the cultural belief that the use of cereal in a bottle will prolong the infant’s sleep), (3) discrimination, racism, and harassment (e.g., race, religion, appearance), and (4) sexual division of power and labor (e.g., sexual division of labor reduces women’s economic status by distributing wealth in ways that disadvantage caregiving relative to specific forms of productive work, role differentiation leads to unequal parental role expectations and economic opportunity). These structural determinants affect not only occupation and income, but also the following intermediary determinants: (1) material circumstances (e.g., earlier return to work, unsupportive work and childcare environments), (2) psychosocial factors (e.g., poor partner, family and social support, commercial pressures to not breastfeed or stop BF via aggressive marketing campaigns of formula producers), and (3) healthcare system (e.g., inadequate delivery of BF information by providers, lack of access to professional BF support, provision of supplemental feeding to healthy full-term breastfed babies during the postpartum stay, separation of mothers from babies during their hospital stay). Together, these social determinants of health inequities and health shape BF rates in African American women.

Using the WHO’s Framework for Action on the Social Determinants of Health, can you think about any other public health problem that affects MCH populations?

References:

Anstey EH, Chen J, Elam-Evans LD, Perrine CG. Racial and Geographic Differences in Breastfeeding — United States, 2011–2015. MMWR Morb Mortal Wkly Rep. 2017;66(27):723-727. doi:10.15585/mmwr.mm6627a3

Solar O, Irwin AA. A Conceptual Framework for Action on the Social Determinants of Health: Determ Heal Discuss (Policy Pract. 2010:1-79. doi:ISBN 978 92 4 150085 2

UMN Trainee Spotlight: Kalia Thor

 

kaliathorKalia is a second year MPH Nutrition student, MCH nutrition trainee, and a MNLEND trainee. She completed her undergraduate degree in Nutritional Science from Northeastern State University in Tahlequah, OK and her dietetic internship through Iowa State University. She is currently working as a Nutrition Educator for WIC. She has found a passion in helping underserved populations as well as learning more about individuals with neurodevelopmental disorders and helping them with their needs. 

As the semester began in September, I was fortunate enough to have been selected as a trainee in MN LEND which also falls under the MCH bureau. What exactly is MN LEND? MN LEND stands for Minnesota Leadership Education in Neurodevelopmental and Related Disabilities. When I first heard about it, I didn’t know exactly what I was signing myself up for. With my experiences so far as a LEND trainee, it really has allowed me to view things differently from other disciplines outside of nutrition for individuals who may have neurodevelopmental disabilities. During undergrad, one topic that I felt I lacked most in was with those individuals who could possibly a disability and always wondered why their nutrition choices were so limited or why they tend to be so “picky” when it came to meal times. With what I’ve learned so far, I can see a small glimpse of what these individuals see – how their daily activity is affected by their surroundings, what their lens is on their surroundings and their thought process on their surroundings, early signs of developmental delays and more. Being a fellow and with the year continuing, I only hope to continue to learn more about individuals with neurodevelopmental or related disorders. 

As a LEND fellow and working with WIC, I am fortunate enough to be able to work on a project for both organizations. With the project, we hope to identify issues that WIC staff may have in addressing delays with families. We also hope to find partnerships with other programs and helping families find interventions in helping families with identification of possible developmental delays in their young children, often times these delays can be overlooked. This could be as simple as making a referral for other programs that are here in Minnesota known as Help Me Grow or Learn Now, Act Early. With the knowledge I have gained from being a LEND fellow, I have found that the education I learn from MN LEND and working with young children have many benefits and how important this could be in helping families. 

For more information on MN LEND, visit https://lend.umn.edu/.

UMN Trainee Spotlight: Somadee Cheam

IMG_4659 (2)Somadee is a first year MPH Nutrition student in coordinated masters program at the University of Minnesota Twin Cities where she also received her undergraduate degree in nutrition and dietetics in 2018. She began her MCH traineeship in September 2018 and has been working on the development of the University of Minnesota’s Public Health Nutrition newsletter. Somadee is passionate about increasing healthy food access through transformation of the agricultural system to prioritize investments in healthy foods and farms and through the creation of a more transparent supply chain.

For the first semester of my program, I had the privilege of interning at St. Paul Ramsey County Public Health in the Healthy Communities division. During my time spent there, I primarily worked with the Food and Nutrition Commission which is funded and supported by the Statewide Healthy Initiative Partnership grant. I was introduced to the Good Food Purchasing Program and have been working on expanding the partnership between the Twin Cities coalition and the Commission. The Good Food Purchasing Program is a national program with local coalitions working to build relationships with institutions and encouraging them to direct their buying power to source their foods with the consideration of their five core values of nutrition, animal welfare, local economies, valued workforce, and sustainable agriculture.

Public institutions across the country spend billions of dollars on food purchases and have the opportunity to lead the movement for food system change and influence supply chains. Local food procurement through large institutions has been shown to positively impact the food system as it increases transparency throughout the supply chain. Currently the Twin Cities coalition is working with Minneapolis Public Schools and just finished a full assessment of food procurement of the district. With nutrition being one of the core values of the program, it is emphasized within procurement practices. With strategic planning, schools can leverage their purchasing power to provide nutritious food to their students without exceeding their limited budgets. It is very exciting to get involved in this program just as it is starting to gain national momentum. I look forward to continuing to strengthen local and regional food systems through fostering these relationships between producers and consumers and ultimately increasing access to healthy food to communities who need it most.

UMN Trainee Spotlight: Noelle Yeo

IMG957309Noelle is a second-year MPH Nutrition student in the coordinated masters program and an MCH Nutrition trainee at the University of Minnesota Twin Cities. She completed her bachelors of science at the University of Nebraska- Lincoln in nutrition, exercise, and health sciences in 2017 with minors in Spanish and business administration. After graduation in August 2019, Noelle plans to work in school nutrition. 

This summer I had the opportunity to complete one of my dietetic rotations at the Minnesota Department of Education (MDE) working with the School Nutrition Programs team. Over the course of ten weeks, I…

  • assisted with school nutrition program and summer feeding program reviews
  • learned about the USDA School Nutrition Program policies
  • created training materials for school food service directors and workers
  • worked on projects to increase the efficiency and effectiveness of the school nutrition program review process
  • and much more!

One of my favorite projects was creating Visual Portion Size Guides for training food service workers on visually identifying portion sizes of fresh fruits and vegetables as students bring their trays through the lunch line. Many schools in Minnesota have begun implementing salad bars in cafeterias which is great for allowing students more choices and access to fresh fruits and vegetables. However, because students are serving themselves, it can be more challenging to determine if they have taken enough of a fruit or vegetable to meet the meal pattern requirements for a reimbursable meal. The nutrition consultants noticed this issue while visiting schools on reviews and wanted to create something to help.

After discussing with the team, we came up with the idea to take photographs of fresh fruits and vegetables on a school lunch tray in different portion sizes and create life-size photo cards. These cards could then be used for training to become more familiar with the various quantities or even be kept at the registers for reference. We selected common fruits and vegetables, purchased them, cleaned and chopped them, set-up the lighting, and took the photos. There was definitely a lot of questions from other MDE staff in the kitchen area and lots of snacks to pass around once we were done! The final product was cards of 9 fruits and 14 vegetables that showed portion sizes of ¼ cup, ½ cup, and ¾ cup of each.

At the end of the summer, I was able to attend the Minnesota School Nutrition Association annual conference in Rochester, Minnesota. We gave out samples of the visual portion size guides at the MDE booth during the expo and it was really exciting to talk to school food service directors. They all seemed really happy that this resource was available to help train their staff and were excited to use it. Now, the cards are available online on MDE’s website so anyone can print and use them.

Here are some examples of the  cards (not to scale):

grapes

carrot

Full versions can be found at:

Vegetables

https://education.mn.gov/mdeprod/idcplg?IdcService=GET_FILE&dDocName=MDE074461&RevisionSelectionMethod=latestReleased&Rendition=primary

Fruits

https://education.mn.gov/mdeprod/idcplg?IdcService=GET_FILE&dDocName=MDE074442&RevisionSelectionMethod=latestReleased&Rendition=primary