Nutrition can often be difficult for experienced health professionals to “get right”. Use this podcast to learn how we can support the families we see to be healthier through food and nutrition, whilst keeping an eye on the clock!
In this episode Dr Sam Manger talks to Dr Natassja Billich about healthy growth with healthy diets. Dr Billich is a post-doctoral researcher and paediatric dietitian. She has worked in two tertiary paediatric weight management clinics in Melbourne and Brisbane. Her doctoral research explored approaches to weight management in children with neuromuscular conditions.
Nutrition can often be difficult for experienced health professionals to “get right”. Use this podcast to learn how we can support the families we see to be healthier through food and nutrition, whilst keeping an eye on the clock!
In this episode Dr Sam Manger talks to Dr Natassja Billich about healthy growth with healthy diets. Dr Billich is a post-doctoral researcher and paediatric dietitian. She has worked in two tertiary paediatric weight management clinics in Melbourne and Brisbane. Her doctoral research explored approaches to weight management in children with neuromuscular conditions.
Health and Wellbeing Queensland acknowledges the Yuggera and Turrbal people and the traditional custodians on the lands on which this podcast was recorded and the traditional custodians on the lands of borders on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia's First Nations people.
[upbeat music]
Dr Natassja (Tash) Billich [speaking over music]: So even from a really young age, so, you know, young school children around 5, getting them involved in simple decision making around their lifestyle or around food is really important.
They might not necessarily understand why, and you shouldn't expect them to understand why they're doing that behaviour, but it's more about getting them interested and involved and excited about, say, you know, cooking or growing a herb or, you know, a new activity.
And so, it might be simple questions about what vegetable do you want to try this week or if you're going to do a new activity, is it going to be swimming or did you want to do some other sport like that kind of sort of simple decision making.
Sam: Welcome to the Clinician’s Guide to Healthy Kids, a podcast series for health professionals brought to you by Health and Wellbeing Queensland's Clinician’s Hub. I'm your host Dr Sam Manger and in this series, we'll be diving deep into the topics that matter most in childhood weight management. We'll be talking to Queensland experts across a variety of topics including sleep, disordered eating in higher weight children, prevention and healthy growth with healthy diets.
Let's get started. Today we are going to discuss food and nutrition and healthy diets for healthy growth. We know that most medical or nursing professionals will have not received a huge amount of formal training or education in nutrition, which can make it confusing to know what we should be recommending to our patients. To help us navigate this topic today, we have invited Dr Tash Billich to join us.
Dr Tash is a post-doctoral researcher and paediatric dietitian. She's worked in 2 tertiary paediatric weight management clinics in Melbourne and in Brisbane. Her doctoral research explored approaches to weight management in children with neuromuscular conditions. Thank you so much for joining us, Tash.
Tash: Thanks so much for having me.
Sam: Now please tell us a little bit about yourself and, you know, what you love about this position? You've obviously done a lot of work already. You've worked across Australia so, why?
Tash: I'm a paediatric dietitian, and as you said, I've been a dietitian since 2016 and have worked across a number of different roles in clinical dietetics and in research. And my passion is really paediatric weight management. And I think what I love about it is just the diversity, both in my practice and the patients or clients that I see. So, one clinic can be really diverse in terms of all the different issues that you might face and approaches you might take. So that's what I'm loving about it, and it's a real challenge and you know such a problem in Australia and that's why I'm really enjoying working in this space at the moment.
Sam: And it makes – as we said in the beginning – it can make a major difference to people's lives – and funny that – healthy diet can improve people's lives. So, let's start right at the beginning. What does a healthy diet look like for school-aged children?
Tash: So, for school-aged children, it can look, you know, a little bit different depending on your cultural background or you know your family situation. In Australia we use the Australian Guide to Healthy Eating to guide our practice as a dietitian. And so that's focusing on eating most foods from 5 food groups and limiting those sorts of discretionary or extra foods. And as children get older, the amount of each food group increases and changes. So that's really the core of what we base all of our dietary management on, is the Australian Guide to Healthy Eating. And we dietitians working in weight management, probably all agree with me – that you know it's about including those discretionary or extra foods, but you know, in a balanced way and having a good balance between those core food groups and those extra foods.
Sam: So, you mentioned the 5 food groups there. And there's obviously lots of detail, lots of different types, but what are those 5 food groups?
Tash: So, we have grains and cereals, mostly whole grain, is what would we'd be aiming for, and we have fruits, we have vegetables, we have dairy and alternatives – and so alternatives would be, you know plant-based alternatives to dairy foods and then we have protein foods. So, meat, chicken, fish, legumes and beans.
Sam: And you mentioned right at the beginning, which I thought was a really important point to say early, which is about the cultural diversity – because obviously there is an enormous diversity within a country like Australia, enormous cultural diversity, which is one of the great things about Australia. So how do you approach that, in the sense of you've obviously got the broad categories, but you're always thinking about how can you adapt it accordingly, is that about right?
Tash: Yes, exactly. And I always encourage families to think back to what their traditional foods are and work with those and you know, get excited about preparing those foods. And that might look different. It might look a bit different to our, you know, the Australian Guide to Healthy Eating plate, which you might have seen posters of. So, their diet might look a little bit different to what's on that plate, just because of that diversity in food. Usually, those traditional diets are very good and are based on the principles of the Australian Guide to Healthy Eating anyway.
Sam: When you look at some of the healthiest diets around the world with Okinawan diets or Nordic diets or various other sort of blue zone diets, yes, there's differences in the specifics, but there's definite agreement across the broad categories and whole foods, you know, mostly plants. So, how can parents establish healthy eating habits in their children?
Tash: It really starts from a really young age. So, from the time bub starts solids, it's about introducing variety from that young age and exposing them to as many foods as possible and setting up a really positive food environment at home. One thing that I like to focus on, is when starting solids, of course there's the iron rich foods we know babies need. And then there's introducing allergens, which is another really important thing. But another thing would be introducing vegetables and trying not to mask the taste of vegetables amongst sweet stuff like fruits. Children love sweet foods, so trying to get them used to the taste of vegetables and more bitter, savoury, sort of tasting foods is something that I like to explain to my clients. So, introducing those types of foods from a young age and making sure that they're repeatedly exposed to those new foods is a good first step. I also mentioned setting up a positive food environment and making some family meals together without distractions, without screens, is the norm in their home and trying to make most of the foods available in the house more of those 5 food groups rather than those discretionary foods and making that kind of the norm within the home. I think parents are facing a huge challenge with advertising of discretionary foods all over the place. And so, if they can make their home as positive as possible in terms of the food environment, I think that's a good important step because those outside influences are hard to come up against.
Sam: Yeah, they're very strong, there's no doubt about that. So, you've mentioned a number of things. They're positive food environments and I want to just dig down into that a little bit because it's very interesting. You mentioned around co-created, you know, food. You know, recipes and cooking together and that sort of stuff, but I do wonder about the concept of fun and play, because that's such an important thing for the young. It's important for all people. Adults have forgotten their little bit, so we need to have a bit more fun. But, for example, one thing I find can be a nice little clinical tip, as it were, is to get some of the people's favourite music going, almost like a jukebox, you know, so you know, you, Kevin – the 6-year-old Kevin – and you know you, Shane, the 14-year-old can pick your favourite songs and then dad will pick his favourite song, which is usually pretty embarrassing, and go mum with her favourite song. You know, so you can sort of turn it into an interactive fun time, you know, positive is a great word, but we also remember this – it is actually positive for a reason. You know you actually enjoy doing it. So, I wondered what ideas you had around making it more positive, enjoyable and facilitating that.
Tash: And they're really great points. So, I think shared meals – having all the food in the middle of the table – allowing kids to serve themselves is a really nice way to, not only sort of encourage that kind of sharing of meals, but also for them to regulate their own appetite as well, because they have control of what they're putting on their plate. Understanding where their food is coming from as well, so even if it's growing one pot of herbs, if you're living in an apartment, that's absolutely fine. At least the kids are sort of learning about where food is coming from, how long it takes to grow, how good it can taste if you grow it yourself. So, they're all really positive things. I think schools are doing a really good job as well by introducing school gardens and teaching kids where food comes from and how to grow food. So yeah, it's really great to see all of those things happening in schools as well.
Sam: Yeah, that's some really good tips. I like the idea of engaging the senses. You know that the smells, the sights of different foods, whether it's on the table or you're growing it. I agree. And I could go on a long tangent, I've grown vegetables for about 12 years. The last 12 years. It was actually one of the wellbeing behaviours that got me through my hardest period, you know, intern doctor years. So, you know, knowing where food comes from can be, you know, oh, that's what broccoli looks like. So that can be a great engaging source. You mentioned there around textures, and I do think, I wonder about your insights around young – you know, we're talking young children – letting them just get their hands into it. And you know, the mess can be a bit overwhelming. I understand you're pregnant, so you'll experience this soon, but perhaps it's about embracing that chaos a little bit and letting kids to squeeze the carrot into mush, and that sort of stuff. Are these good behaviours to encourage?
Tash: Yeah, definitely. And that's for children who are not willing to put foods in their mouth and choose them and actually taste them and try them. We definitely encourage as much play as possible and no pressure to put in your mouth and even taste it, as long as they're being exposed to it and they can just look at it, poke it, touch it, squeeze it. All of those types of things are really good.
Sam: Okay, great. And then you mentioned the position of this, you mentioned so many interesting things here that I sadly you know we just want to go down these corridors, but the position of foods to try and offset and negate the macro-environmental circumstances with as you say advertising and all that. So, what recommendations do you make around the kitchen, pantry, fridge or food storage places to optimise that?
Tash: So, I guess empowering families to become a bit of a food detective. So, with all of those claims that you see on television or on the front of packaging, actually look a little bit deeper into that and think about what's actually in that food and try to fill the pantry or the fridge with food in their most natural form. I guess this is one approach to take. So, focusing on those 5 food groups to be predominantly the food within the home. And, trying to limit those kind of extra foods – even if the house doesn't contain many of those extra foods – but you feel like an ice cream one night, so you go out to the shops and you actually make it a bit of a thing where you go out and get an ice cream. And that's absolutely fine. But if it's not available all the time in the house and it makes it much easier to make some healthier decisions around food.
Sam: Yes, I mean that’s one of the things that I can't say I've done for food too much? But it applies for other, let's say, tempting behaviours like the phone or screens, that sort of stuff. I sometimes find putting it in a little box and just saying, you know, treats only, or something and just an extra little barrier can make it a little easier to give people a chance to sort of think, is this really what I want? Is this really what I'm looking for? Now you mentioned a few things there, which I simply highlight and won’t probably ask more questions on, it but is around diversity of foods and ensuring adequate iron because that's really important in young, growing children that they have adequate iron, it's not uncommon see iron deficiencies and allergens. So, exposing those allergens relatively early through that diversity, so that we reduce the chances of later, of sort of atopic conditions, allergic conditions.
So, coming back to your professional role, what does a dietitian do when they see a child and their family for weight management support? And how long does it take, and what would you expect a healthcare professional and primary care to do you know, is it feasible that we can do this also or we'll perhaps talk about a condensed version next?
Tash: For a standard initial consult in a weight management setting for me, it would take 45 minutes to an hour. So quite comprehensive. And so firstly and this may be within a multi-disciplinary setting, or it might be sort of a dietitian led clinic.
So, I would firstly start exploring past medical history and really focusing on any medical history that might have contributed to excessive weight gain or any complications due to weight gain. So, you know all the metabolic complications that we know are well linked with a weight above a healthy weight and so high cholesterol, hypertension and understanding if there are any of those issues there.
Then exploring social history, so family structure. What's school like, what kind of social environment might be impacting on that young person’s ability to participate in activity, or you know eat a balanced diet. I would then assess their growth using growth charts. So, either standard growth charts, or if there's a specific condition that the child has, I would use those as well to assess their overall our weight status. And then I would look into their behaviours in terms of sleep, activity, screen time and understand their routines and the behaviours around those facts. And then I would get into the food lastly.
So, I would dive into a typical day for that young person. So, taking a diet history, I'd be really focusing on some key things. So, portion size, consumption of takeaway food or fast food and sugary drinks. And then I would be looking at the 5 food groups and doing an estimate of how much of each of those food groups they're eating each day. And then I would look at the difference between weekends and weekdays or school holidays and school days and see what those differences are. And I would do that for activity, sleep and screens as well.
I rarely calculate calorie intake or energy intake, or you know, protein or anything like that. In some situations, I would go that far, but usually, I don't need to. It's that more qualitative assessment of their diet. And so yeah, I usually wouldn't do that. And then I would sort of formulate an assessment of what I think has contributed to the weight gain based on all of that information and then work with the family together to set goals that are going to be realistic and that they are both agreeing on as well. So, the clinician and family are agreeing on and making sure they're going to be, you know, effective for weight management or addressing the metabolic health issues or whatever might be actually going on, to be achievable as well.
Sam: I liked how before getting into the specific dietary assessment – because one assumes that one can – well, let's just start with when you first wake up, but you talk more about context. So, the bio-psychosocial content, cultural context and even spiritual context can be relevant first. And then as you see the whole of person factors the different lifestyle domain, and this has your sleep and physical activity because that'll give you an overall picture. But obviously whilst we in a way artificially are doing one episode on, you know, diet, the next one is going to be people are humans, their whole persons and so they will be doing lots of things and these things will feed into each other in some aspect. We'll be back after this short break.
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Sam: And now back to the show. So, lots of healthcare professionals listening today work in primary care and, like me and the GPs, they may be quite sure of time, and if we're lucky, we have maybe 3 to 4 problems to deal with in 15 minutes. So, what are the main things they could ask, and we could ask about diet to help make healthier changes.
Tash: So, I don't even think those working in primary healthcare need to do a full diet history or go into the details of portion sizes and what you know the dietitian would usually do. There's are a few key things that you can focus on. So, the first thing would be sugary drinks, so that's a really good place to start to either cut out sugary drinks altogether, or if that's not feasible, reduce them, or try to transition them away from sugary drinks. The second thing would be takeaway foods and fast food. So, if their family is consuming a lot of takeaway foods or fast food, understanding why that might be, is it because they are time poor? Is it because they don't have very good cooking facilities at home? Is it because they don't know how to cook? So, understanding those barriers and then that might help guide referral pathways in terms of you know the situation.
Then asking about discretionary snacks. So typically, school lunch boxes in Australia have quite a number of discretionary snacks in them. So, you know, it might be bars or chips or sweet biscuits or muffins. So, trying to focus on a discrete item like the lunch box can be really helpful. So, try to remove as much of those snacks as possible and swap them for foods that actually contain some nutritional benefit. So again, focusing on those 5 food groups and trying to put those into the lunch box and take out those extra snacks.
And another thing that is really important for teenagers is regular meals. So many, I would say, most teenagers I see, are potentially skipping breakfast and lunch and are not eating anything until they get home from school, when their body is starving. And wanting to go for those high carbohydrate, refined carbohydrate snacks and then eating a lot in the afternoon, a lot in the evening as well. So regular timing of meals and that might not be a full lunch for someone who's never eaten lunch at school or hasn't for a number of years. It might be just a small snack for lunch as a starting point and building that up slowly. So, I think there's some key things that can be focused on there in terms of diet.
And I think the other important thing is just sort of stepping a bit away from diet, and understanding their family, environment and any psychosocial barriers that there might be to preparing healthy food or accessing healthy food or, you know, participating in physical activity. So, whether there's financial constraints, whether there are stressors happening at home, and understanding those. That can also help guide referral pathways that are targeted and appropriate for that family.
Sam: Great, thank you. There’s certainly the concept of Pareto principle that comes in here for me – what's the 20% we can do that yields 80% of results. And I think there's truth in that, in all my GP listeners, they'll know this feeling well, where we're thinking, what are those high yield questions we can ask. And when it comes to dietary changes, as you said, there's sugary drinks, discretionary spend and discretionary foods – and this is where most of the damage happens, and we can do a lot by targeting those.
You mentioned around then zooming out a little bit, and thinking about the family environment, the social context including their time or what's in their day because of stress and a hungry body will be a body that very naturally seeking high calorie foods. It's not a case of willpower or strength or weakness or anything like that. It's just a case of when you're stressed and when you're hungry you go for high calorie foods and it's hard to control yourself. It’s hard to any for any human to control himself in that situation. So, of course, they're going to go for the less healthy things because they are high calorie, instant foods.
Now clinical guidelines like the Royal Australian College of General Practitioner guidelines encourage the focus to be on healthy behaviour modification to reduce BMI (Body Mass Index) for younger children. But for adolescents, post puberty, how do we support weight loss? So, what would be your focus for older teens or even young adults needing weight loss?
Tash: So, it's really not too different. So, we do focus on gradual weight loss in that older age group, but we're still focusing on the Australian Guide to Healthy Eating, those 5 food groups and all of the, you know, the basic principles that I've spoken about. We're not looking to count calories and reduce them in most situations. Sometimes that's indicated in very particular situations, but it's really the diet quality that we'll still focus on. Ultimately, weight loss happens when there are less calories going in and more calories going out through physical activity, but it's really not that simple. And it's really not as simple as eating less, doing more. There's so many complicated factors that have an influence on weight.
So, what we can do with diet is just focus on trying to reduce discretionary foods as much as possible, understanding you know the differences in, you know, teenage eating habits or young adult eating habits. Do they have a part-time job? Do they access their own money? Do they go out with friends and have more fast food or sugary drinks? All of those sorts of teenage behaviours. Focussing on the age-appropriate developmental stages for that child, would be the main difference between the teenager and a younger school-aged child.
Sam: Yeah, it's a good point you raised there about calories. It's not as simple as calories in, calories out. Sometimes you hear an old myth that all calories are equal. You know, so one calorie of sugar is the same as one calorie of broccoli. Yes, they're both calories in that sense, but the metabolic effects or hormonal effects and neurotransmitter and microbiome effects of those foods are completely different to obviously, the packages of antioxidants and phytonutrients that they come with. So, there's actually a huge difference between ‘different calories’. We need to be very careful about that.
Sam: Now that sort of leads me to my next question, which is then do you – there's always a latest diet – and, this must be one of your banes as a dietitian, but do you ever support diets that get really, you know, quick results like a 6-week intensive calorie restriction or a reduced carbohydrate diet or any other sort of type of diet you know what's out there.
Tash: For 99.5% of the time, no, it's never those types of diets. In some very special circumstances, always with guidance from a paediatrician or a doctor, and the multidisciplinary team we may do a more restrictive diet. If it's clinically indicated, but usually we would never do that for teenagers. And so yeah, we find those kinds of restrictive diets work in the short term, but not in the long term. We also need to think about quality of life, and the psychosocial impact that, you know, restrictive eating might have on a young person, especially when they're going through really challenging time in teenage years, so we'd rarely use restrictive diets or any kind of fad diet. Only under, you know, very exceptional circumstances.
Sam: Yeah, because what matters is the results, right in the sense of short, but medium- and long-term results. And so, you mentioned there are sometimes really restrictive diets. Yes, they can work. Usually, people are very exuberant and excited about it for the first period and then they can be they can be so restrictive as to be prohibitive and hard to adhere to for too long. Then, but then it builds in, as you said, that almost anxiety and stress around certain food groups, which then snowballs into other problems. And we know stress isn't great for healthy lifestyles, full stop. So, we have to be very careful about what we're potentially saying or what's being perpetuated. So, whereas a broad healthy whole food diet within the Australian Guide to Healthy Eating or Mediterranean diet gives a lot of flexibility there for different, you know, culturally appropriate foods, but you have seen –obviously, being a paediatric dietitian for some time – that a good quality whole food, you know, a Mediterranean style diet or whatever cultural variation on that, works in the medium- and long- term.
Tash: Yeah, it does work, but I'm not going to pretend it's easy to implement and there's so many factors working against families, especially when there's also genetic predisposition to weight gain as well. And there are, you know, physiological factors working against certain environmental factors. And so, it's really challenging and it's easier said than done, but it does work and that's what is going to improve health in the long term.
Sam: I think it's important to highlight that it can be challenging, but it's like a lot of things. So, I take obviously the analogy of smoking. Sometimes the average success in smoking cessation occurs at 12 months, and without any support, is about 3 to 5% and people who quit will stay non-smoking at 12 months. But, with the best support, whether that's pharmaceutical support, Quitline, group based supports or stress management, that success rate goes up to about 25% plus. And so just because 75% of people still don't quit doesn't mean it wasn't worth it. You're taking something from 3% to 20%, and it’s an 8-fold difference.
You know that's what we're aiming for here. So, to be realistic about it – and I suppose just accept that we are really trying to help people here and we will help a lot of people – not everyone can change. May they just turn up to the clinic and they're not ready or there are so many social barriers that it's going to take them a much longer investment to do so. So, let's talk about a little bit of the solution and what we can do here.
So, what are some healthy nutrition swaps if we're saying that this can be a challenging thing. We've talked about the different food groups, but now let's get into a bit of fine detail around some of the swaps that you can make in a person's say lunch boxes to, for example, make a huge long-term impact to diet improvement.
Tash: I guess starting with the lunch box, it would be to remove any of the sugary drinks, any of the juice and adding in just water or plain milk as a drink, which would be probably the first swap I would make. And then sticking to the lunch box, those discretionary snacks we spoke about trying to add in, if possible, include putting any type of vegetable into the lunch box would be great. And low- fat dairy foods, grainy, you know, whole grain crackers – swapping things like the white bread for a grainier option, and any kind of processed meats in a sandwich. And even if you're just adding in vegetables to increase fibre, it will increase fulness for longer, and then that's a really good addition.
And then – with the takeaways and fast food – any sort of simple meal that you can prepare instead even if it's super basic eggs on toast, baked beans on toast. You know the handbag chooks that you get from the supermarket. One of those with a salad that's already cut up and some microwave rice – that's going to be much cheaper, much better for you and probably much tastier than a lot of takeaway or fast foods. So even if the cooking skills aren't there or the cooking facilities aren't there, those really simple meal preparations are really important to know and really important for dietitians to have a list of those to give their families so that people are aware that, okay, I'm going to save $10 every day if I can just make some simple things at home.
Sam: Processed food is not as cheap as they try and tell us it is. It's actually quite expensive. So you're right, the money saving there is an interesting point. I learned from my dietitian colleague recently actually, that if you put raw nuts into the microwave for, like, I think it was 30 seconds, and I've been doing this ever since, that you roast them. You know, that quickly. And so, I put a whole bunch of cashews and other things into the microwave the other day, in 30 seconds the flavour came out, and it tasted amazing. Then you throw them into your salad. There's lots of little quick tricks like that. So, as you say, having a handout there can be really helpful and just going through some of those options. And so, what about for kids on the go and snacks? You know, whether that's young kids, but then I'm also in my mind thinking of adolescents, who consume an enormous amount of calories. So, we want some snacks that are off the shelf ready for them to go.
Tash: The nuts are a great one for kids over 5. As long as there's no allergies, of course, and you know, they’re not allowed in pretty much most schools. So nuts are a great one. The unsalted variety. Popcorn. I always encourage snack boxes that give a little bit of variety, so any type of cut up vegetable, a couple of slices of cheese, some rice crackers or some grainy crackers, or, you know, rice wheels. Any kind of dairy foods, so trying to opt for, you know, low fat or the lower, more natural sort of varieties of yoghurt or milk. You know, things like peanut butter and avocado, hummus, tzatziki any of those sorts of dips or spreads on some crackers is a really good thing just to have ready to go or just, you know, some cheese and biscuits are great. At least they’ve got a little bit of protein, a little bit of calcium. It's going to be a bit more satisfying than say a packet of chips.
Sam: And the satisfying point is another important point to raise because satiety is key to everything we're talking about here. So, the foods that will often encourage long term and satisfying satiety are protein foods and fibre-based foods. So, we’ve got the vegetables, the cheeses and some nuts for healthy sources of protein and then people will feel satisfied and full, and they'll have all those beautiful biochemical physiological responses going in their body, which is good for them as a general rule. So, they will make them feel better, give more energy and all that as well. I like to throw in dip there, sometimes it's homemade dip or even store-bought dip as long as it's not a bowl of sugar. But you know some sweet potato or hummus or something like that, which can be a really nice way to spice up their snacks.
One of the little tips which I came across a number of years ago now, which I really liked was having a bowl in the common place in the kitchen or living room or whatever. Just a bowl of chopped vegetables and nuts and other things. Just having it there, people just walk past and put it in their mouth, and it’s sort of incidental behaviour change or passive behaviour change as opposed to saying, ‘make your time to eat this’. It's just like putting them around people's environments. They'll just naturally start eating healthier foods. So, make it a bit easier for us too.
Tash: And sometimes all you need is just something to tide you over until the next meal. You don't need a full snack, but just some cut up vegetables that you can just munch on, and then you're not, you know, ravenous, at the next meal.
Sam: We'll be back after this short message.
[Community Message] Unhealthy weight is one of our greatest public health challenges. Two in 3 Queensland adults and one in 4 children live with overweight or obesity. We need to shift the dial. That's why Health and Wellbeing Queensland has created Clinician’s Hub for you, our clinical workforce. Clinician’s Hub is a digital ecosystem of initiatives, resources and tools, including this podcast series. For multidisciplinary health professionals to support best practice prevention, identification, treatment, and management of overweight or obesity, and it offers a wide variety of clinical tools and training to help you transform health for children, adults and families. Find out how Clinician’s Hub can help you at hw.qld.gov.au/hub
Sam: And now back to the show. Okay. So, what age would you make sure children are involved? We're talking a lot about the behaviour change and choices around food, so, what age do you really encourage children to get involved in that?
Tash: So even from a really young age. So, you know, young school children around 5. Getting them involved in simple decision making around, you know their lifestyle or around food is really important. They might not necessarily understand why, and you shouldn't expect them to understand why, they're doing that behaviour, but it's more about getting them interested and involved and excited about cooking or growing a herb or a new activity. And so, it might be simple questions about what vegetable do you want to try this week? Or if you're going to do a new activity, is it going to be swimming? Or do you want to do some other sport? That is the kind of simple decision making to involve them. Where they're getting involved in their own healthy lifestyle. Obviously, as they get older, then they have a bit more say and they can understand the role of the impact on their health. And but from that young age, I think they can still be involved, but they just may not understand the link between health and that behaviour, but at least it's getting them involved and excited.
Sam: Yes, the point around autonomy is really important to reminding children that, while they're not the bosses of the household, they have autonomy, and they have their own power as well. And so, giving them the right to make choices. So, what should we cook this week? Here's our ingredients. So, define the limits as it were. Here's our ingredients, but you choose within this what should we do? What should we cook and make it a fun exercise.
I've got 3 children and one of my children is 4 turning 5 and she loves getting into the kitchen with mum. It's one of her favourite activities. So, getting the stool up and watching things and just obviously watching your fingers with those knives. But it's, you know, it's still it's quite a lot of joy to see. You mentioned they may not understand their mechanisms, and I agree. But there are also ways around that.
One of my colleagues and friends, Professor Felice Jacka, at the Food and Mood Centre at Deakin University, wrote a book called There's a Zoo in my Poo and that's a really fun kids book about the microbiome and how food interacts with that. And so, I've talked to my children about that and simply said, you know, it's not very good for the bugs, the good bugs in your gut. It kind of hurts them a little bit. And they’re like, oh dear, okay. And I have said she's hit the nail on the head. I think it really relates to children around this idea of good bugs. And we have to look after our little environment and that sort of stuff.
So, what if parents respond though to all of these great ideas and then their kids are fussy and flat out refuse to eat vegetables? That's definitely a reality for all of us, I think, at some point in the career of being a parent or that the parent will give them a less healthy food. Otherwise, the child won't eat anything, so they just give him anything to get some calories in.
Tash: Yeah, and it's tricky and there's not one solution and you do have to just try a list of things and see what works for that individual child or family. And I guess it's important to note that there is a difference between a child who may have very restrictive eating because of something like autism spectrum disorder or obsessive-compulsive disorder or ARFID (avoidant/restrictive food intake disorder). So, it's a little bit different for them. It's not just about giving them food, over and over again. They may refuse it forever.
So, I think, for other children it's potentially just them trying to stamp their authority in the situation and say no to things. Avoiding any kind of pressure to try things or force-feeding practices would be really important to start with, but ensuring that the child is still exposed to those foods over and over again and seeing that everyone else around them is enjoying them, that they can be fun and just allowing them to be exposed in a non-pressuring way.
One sort of approach I take is always providing at least one food that you know the child will eat, one food that they've tried before and is sort of okay with it, and then a new food. So at least you know that there are foods there available for them that they will eat. And then you can avoid trying to compensate with those less healthy foods after the meal because you're concerned that they haven't eaten anything. At least they've eaten something because they’ve got some foods in front of them that they're okay with.
Sam: And I think a lot of what we've said – and listeners might want to listen back – includes loads of tips sprinkled throughout this episode that increase the likelihood that children will engage and be happy with eating vegetables. Because there are various ways you can make healthy eating more interesting, more dynamic, more sensory and more enjoyable. And as you said, we want to identify clearly any eating disorders or related conditions. And then that may need a much more targeted approach – perhaps you need an occupational therapist or a psychologist or a paediatrician involved. But we're talking general rules here, and the point you raised is this – is there an issue you're telling me something about?
As you said, is there a specific disorder for example? Or are you telling me about the dynamic of the relationship? Maybe the child doesn't like the way I'm saying eat your vegetables as an authoritarian, if so, they're just children want to find their own autonomy. So, how can we change that dynamic versus environmental? At least we’re sort of saying do what I say, not what I do. So, are we just telling the kid to do it or are we all on one ship together? So, these are important things to consider.
But what would be red flags for you. So, we talked about eating disorders there. So red flags, if you're seeing a child or adolescent with regards to potential disordered eating or an eating disorder.
Tash: So, I guess obviously like very dramatic weight loss would be a red flag and we'd always investigate what's going on there. Any really drastic changes in the way the young person's eating. So, for example, if they mentioned things like cutting out carbs or counting calories or all of a sudden for no other explanation, they've started eating a vegan diet and cutting out, you know, whole food groups.
If they're using any buzz words you know, clean eating or shredding – those types of buzzwords associated with fad dieting, they would be red flags. You would be trying to explore what's going on and where are they getting their information from? What diet are they trying to follow? Any sort of fixation on weight, such as, weighing themselves daily and being obsessed with the numbers on the scale would be a huge red flag.
Any kind of secretive eating and going through periods of restricting and then bingeing or feeling like they're out of control when they're eating or any secret exercising as well. Also exercising for long, very extended periods especially if it's behind their bedroom door or whatever it might be. And then also sort of physiological signs as well. So, as I said, the big weight loss, any dizziness, fatigue, hair loss, girls losing their period, all those types of things might be red flags if associated with other kind of clinical signs of disordered eating.
Sam: And then purging and those sorts of phases as well. So, follow-up post eating behaviours that are there to compensate in some way. So, when should we refer a person to a dietitian versus feeling like we can just manage this ourselves?
Tash: I think in a lot of situations, a dietitian can be helpful in a weight management context. So, I think the first thing to consider would be, are other family willing to engage at that time? And are they ready to engage or are there too many other things going on and it's just not going to be the right place and time? And that's totally fine. And starting the conversation, at least they know that the options there are a good first step.
And then there might be also other allied health professionals that might be more suited for that family at that time – or psychologists or a social worker – depending what else is going on. But if you feel like you know they're ready to make some changes with diet or they're needing some help in that area, a dietitian referral would be appropriate. In terms of how to go about that, there are public options and community-based options, and depending on where the family lives, then of course private options as well.
So, Queensland's very lucky. There are some really good community-based programs in Brisbane. The Healthy Kids Club is an amazing place to start if they're a local family in Brisbane. A lot of local hospitals do have a dietitian that works in paediatrics as well, so even in the more regional settings there are dietitians who have paediatric experience and who accept paediatric referrals, so looking to local hospitals is a really good place to start for the public system.
And then for private options, the Dietitians Australia website has an option to find an APD (an Accredited Practising Dietitian). You can filter by specialty – paediatrics – and look for people who have interest or expertise in weight management. So, there are a few different options there, and obviously that's different across Australia, but focusing just on Queensland I think there are some options there for referral pathways.
Sam: And you mentioned Brisbane versus other regions? So, what about Queensland – it's a big state – so what about people in rural and remote communities who may not have access to a physical paediatric dietitian?
Tash: So, I guess probably the first place would be looking to the local hospital and seeing who's there and even if it's far away, seeing if they can offer some telehealth or phone consult. And then many private dietitians would be happy to do telehealth consults as well. So, if that's an option for the family, there is an option to see a private dietitian, even if they're living in rural and remote areas, and the private dietitian is based in a major city. At least those telehealth options are there. So yeah, I think there's a couple of options, but it is difficult and then of course if there are telehealth services available and having a local primary healthcare practitioner to be able to assess things like weight and blood pressure, to have that kind of physical examination as well. So having that combination, I think works really well.
Sam: Yes, and this is where there are options to set up things like case conferences under the Medicare item numbers, where you can have a GP and allied health, and a practice. And, you typically have a team of 3 and they can all bill for that, and then it makes it practical at least and reimbursed. So, my final question for today – and it is always a good question to end on – is about the good resources for health professionals, listeners or members of the public that you often use, or you find really useful, whether it's videos or handouts or online courses or all that sort of stuff.
Tash: So of course, the Health and Wellbeing Queensland’s Clinician’s Hub is a really great resource to be able to navigate, in relation to all things in terms of healthy weight for young people. NSW Health also have a similar kind of hub for health professionals. They provide some good resources in terms of how to approach weight in a sensitive way. They've got some good videos on there about having those difficult conversations and they've got some good patient facing resources as well.
I really love all the Good Start resources. The Good Start program is part of Children's Health Queensland. They provide some really good client facing resources tailored to Māori and Pacific Islander families, so they're really useful and really engaging and vibrant and colourful. I really like those.
And then if you've also got an interest in weight management, a good conference to go to would be the Anzos Conference (Australian and New Zealand Obesity Society) which is held annually. I always find that really useful for updates in terms of the weight management space. So yeah, there's lots of resources out there and this is about sort of finding the right ones for your family or for your needs.
Sam: Great. Alright. Well, thank you so much for your time today, Tash. It was excellent to hear your expertise and experience there, and we'll join everyone at the next episode where we will have some questions about physical activity and movement, which is the natural progression of this episode. Thank you so much everyone for listening.
Tash: Thanks for having me.
Sam: Today we've been talking to Dr Tash Billich from The University of Queensland. For more information on today's topics, visit the Health and Wellbeing Queensland website at hw.qld.gov.au. We'll see you next time on the Clinician’s Guide to Healthy Kids.