Does referral to and follow up with a registered dietitian affect adolescents’ self-reported patterns of dietary intake, physical activity, or nutritional knowledge: a cross-sectional survey study in children ages 11-17 receiving care at a Federally Qualified Health Center

Abstract

Importance: Few studies have examined the impact of a pediatric dietitian referral on nutrition-related behaviors and no studies to our knowledge have captured the effects of an RD referral on physical activity, nutritional knowledge (e.g., food label use), stage of change, and other factors affecting dietary intake (food insecurity, self-efficacy, body-image, etc.)

Objective: The aim of our study is to assess how a visit with a registered dietitian (RD) not only affects diet and physical activity but also knowledge, and we hope to capture additional variables that may moderate the relationship between RD follow-ups and lifestyle changes such as demographic factors, food insecurity, and body image

Design: This study was a cross-sectional survey study with data gathered from March to November 2022

Setting: Participants were recruited from the Laveen Family Health Care and other Valleywise primary care clinics during both well child checks and sick visits

Participants: Our volunteer sample included adolescents 11 years of age and older; exclusion criteria included referral to a dietitian for a gastrointestinal or genetic disorder

Exposures: We compared the responses of adolescents who were referred to and/or followed up with a dietitian (at least one visits) to a control group who had not been referred to a dietitian

Main Outcome(s) and Measure(s): The Bright Future Survey Tool, a 21-item screening tool developed by the American Academy of Pediatrics, was used to assess dietary intake and physical activity. There were 7 food categories including drinks, grains, vegetables, fruit, meat or meat alternatives, and fats or sweets included in the survey. Each of these categories included checklists with more specific foods. For physical activity, the question was a binary yes or no question (“Did you participate in any physical activity in the past week?) with a follow up question (“If yes, how many minutes per day?”) to elicit a numerical response. Additional items included meal skipping, sharing meals with family, food security, body-image, involvement in food preparation or grocery shopping, fast food consumption, and a gauge of adolescent’s desire to lose weight. The Food Label Quiz is a 5-item nutritional knowledge assessment tool developed by the MOVE! Veteran’s Weight Management Program. The questions include correctly interpreting serving size on a food label, correctly understanding percent daily value of a category, and general nutritional knowledge regarding energy density of fats compared to carbohydrates.

Results: Participants were on average 13.9 years of age (SD of 2). 41.8 % of surveys were completed in Spanish (58.2% in English), and 56.9% of participants were female (42.5% were male). 72.8% of respondents self-identified as Hispanic or Latinx, 13.2% as non-Hispanic, non-Latinx Black or African American, 6.6% non-Hispanic, non-Latinx White or Caucasian, and 3.3% non-Hispanic, non-Latinx Native American or Alaska Native. Children and adolescents who had been referred to a dietitian had a statistically significant reduction in the odds of eating junk food (fats, sweets, sodas, chips). Participants who had been referred to a dietitian were less likely to indicate having consumed fats, sweets, or chips in the past two weeks, with an odds ratio of 3.78 x10-8 compared to participants who were not referred (95% CI of 1.27x10-8 to 1.12x10-7). Additionally, there was a statistically significant decrease in the odds of eating junk food for those children and adolescents who have visited a dietitian 1-2 times by 95% (95% CI of 0.006 to 0.433). No statistically significant difference or further benefit was found for children and adolescents with additional visits (3 or greater). In contrast to our hypothesis, no statistically significant correlations were found between dietitian referral/follow-up and number of sweetened beverages consumed, vegetable consumption, fruit consumption, minutes of physical activity per day, or nutritional knowledge as captured by the Food Label Quiz.

In terms of secondary outcomes, adolescents who have visited a dietitian ≥3 times had a statistically significant increase in the odds of being concerned about their weight by a factor of 27.2 (95% CI 3.27 to 226.23). Visiting a dietitian ≥3 times was also associated with an increase in the odds of being on a diet by a factor of 12.1 (95% CI 2.85 to 51.14). There was no statistically significant difference in weight concerns or dieting for children and adolescents who visited a dietitian less than 3 times or were only referred with no follow-up. Adolescents who had 1-2 visits with a dietitian (compared to 0) had decreased odds of spending 2 + hours of screen time per day by a factor of 0.21 (or 79%) (95% CI 0.047 to 0.913). Interesting, there was no statistically significant difference between children and adolescents with 3 or more dietitian visits compared to those with no visits.

Children and adolescents with food insecurity had a massive increase in their odds (6.21) of having disordered eating patterns—such as binging and/or purging (95% CI 5.03 to 1409.67). Food insecure youth on average obtained nearly 30 minutes less physical activity compared to their food secure counterparts (95% CI -56.21 to -2.88).

In terms of correlations between various demographic factors and primary and secondary outcomes, being female and being Black/African American was associated with increased odds of eating fast food (95% CI 1.12 to 7.95, 95% CI 1.76 to 30.60 respectively). Female youth were also more likely to report appetite problems and had increased odds of being on a diet by 829% (95% CI 3.69 to 128.70, 95% CI 1.56 to 55.39). Additionally, female participants on average reported more than 20 minutes of less physical activity compared to their male counterparts (95% CI -38.88 to -1.77). There were no other statistically significant correlations between gender or race/ethnicity and patterns of dietary intake, disordered eating, food security, or nutritional knowledge.

Conclusions and Relevance: This cross-sectional survey study found that adolescents consulting with a dietitian tended to consume less junk food, with the most significant difference seen in those who had 1-2 dietitian visits. This could be attributed to increased awareness and education provided during these sessions. Notably, there was no significant difference for those with 3 or more visits, possibly due to the small sample size. No other significant correlations were found between dietitian visits and dietary patterns or physical activity, contrary to the initial hypothesis. Regarding secondary outcomes, children with 3 or more dietitian visits were more likely to express weight concerns and be on a diet, possibly linked to education on healthy growth and BMI. Food-insecure participants reported less daily physical activity, possibly influenced by socioeconomic factors such as neighborhood walkability. They were also more likely to report disordered eating patterns, possibly due maladaptive compensatory mechanisms linked to binge eating. In terms of gender, females showed higher odds of appetite problems, dieting, and less physical activity compared to males. Socialization, enrollment in school sports, and societal influences on body image may contribute. The study underscores the importance of clinicians, especially primary care providers, engaging with pediatric patients to address lifestyle choices early and screen for SDOH, food security, and disordered eating.