Blog Post

Stefanie Valakas Q & A

Stefanie Valakas Fertility Dietitian

Can you please tell us a little bit about yourself and your career?

I’m a Sydney-based new graduate dietitian. I finished from the University of Sydney at the end of last year and I’ve recently started in private practice in a multidisciplinary health clinic. Throughout my master’s, I started a student dietitian blog called Dietitian to Be, however, I recently relaunched – for obvious reasons – as The Dietologist and I’m interested in private practice, media (you can follow me @the_dietologist) and consulting opportunities.

You have an interest in paediatrics and feeding behaviours stemming back to that Masters. What caused that interest?

I think it was very early on when I decided to go into dietetics, which was in late high school. For some reason, I always had my heart set on paediatrics from that point.

In my mind, I felt that if we could intervene as early as possible in life, we would get the maximal benefit and contribute towards prevention rather than a treatment ideology.

But, of course, any time is the right time to take steps to improve health. For me, I just wondered whether if we get things right younger, could we prevent the chronic diseases that we see later in life?

In terms of feeding behaviours, that probably came a little bit later on when I did a placement at a children’s hospital.

Eating behaviours were something that we discussed in class very briefly, but it wasn’t until I started assessing paediatric patients that it really became an integral part of understanding the environment and the way in which children were fed, not just what they were eating.

This really led to me understanding more about the Ellyn Satter Division of Responsibility model, which states that the parent is in charge of the what and where and when the child eats, but the child is responsible for if and how much they will eat.

Ellyn Satter's Division of Responsibility

I think this model really helps with fussy eating; helping children who are struggling to grow or maybe growing too much. And it ties in really well with infant-led weaning as well, but the good thing about Ellyn Satter’s model is that it can cover anyone from a baby to adolescents, even adults who have issues with food acceptance.

That was really cemented by my research, which centred on feeding behaviours in young children with type 1 diabetes, and it was specifically conducted in a culturally diverse group. But the research is still very early on as it’s a pilot, so I would be keen to see how these findings are validated in a bigger group, which probably will be over the next five years or so.

You said potentially changing behaviours early on when people are young might influence them when they’re older. Have you seen any other research on that or do you know of anything that supports that idea?

There is a lot more research about the first one thousand days of life, but there is also some research about how the first five years of life—the way you eat and the way you’re fed—can set you up for how things go for you into your childhood, into adolescence and even adulthood in terms of how fussy you are, dietary quality, and whether you have a good relationship with food or not. However, these longitudinal-type studies are really difficult to come by, so it’s very theoretical and I guess they do a lot of recall studies. However, there is some idea in the field that if we get it right early, we can set up really great behaviours and habits life-long.

What are some of the key habits to be focusing on?

Stefanie Valakas

I think some of the key habits beyond dietary guidelines and “eat your fruit and veg” are more about creating a very calm and stress-free mealtime environment—making sure that the TV is off, that there’s a family environment wherever possible—which can be really difficult nowadays to actually have more than one person eat at the same time.

The other things to focus on are trying new foods, how they’re presented to the child, making sure they’re willing to try new foods because that lack of food acceptance can really persist throughout life, and it can just be because a parent is too fearful of having their food rejected over and over again. I think there are some key things beyond looking at just pure nutrients.

How should parents present new foods to children?

There are different ways I’ve seen parents do it. One way is you can put the food you want the child to taste on a separate spoon on their plate so that it’s separate from all the other foods, so it doesn’t touch. T

here’s no need to request the child to try the food—it’s up to them whether they touch it, lick it, smell it, throw it on the floor.

Whatever food you’re trying to introduce, whether that be on a spoon or with other foods that they normally eat, try not to introduce lots of new things all at once because that can really be scary for the child as it’s so unfamiliar—just stick to one new food with foods that they regularly eat.

Also, make sure that you’re eating that food too as a parent. Kids are really interested in what you’re eating and often we find that parents are saying that their child won’t eat their vegetables, but when you ask them whether they eat that vegetable, they say no.

It’s important to model the behaviour that you want your child to have. If you want your child to eat lettuce, then you need to eat lettuce in front of your child, or their siblings should also be eating the same thing. It’s all about family meals!

Say in that first instance that you do everything the way you’ve suggested, what do you do if they still turn it down?

You don’t need to do anything really; you just try again. It can take up to 20 to 30 times before a child will even taste food that’s presented to them, which can be really frustrating as a parent because you feel like you’re either wasting food or that you’re not really getting anywhere.

But I would encourage parents to persist—it is important to try and get a wide variety of foods into your child’s diet as they’re learning about food.

It can also get messy, and another important thing about creating that calm and peaceful mealtime is not to freak out about mess, which can be tricky, but it is important because a child may feel like they’re getting in trouble and it might turn them off that new food.

That’s just their way of exploring that new food and learning and it’s a good time in their life to learn about all these new foods. So, let them play, let them make a mess, but keep representing the food. You don’t need to be putting heaps on the plate—just a small taste and model that behaviour for your child as well.

Going back to your Masters research, were there any key takeaways or anything interesting that you found?

Stefanie Valakas

I was involved in the pilot part of the project. The project was determining whether feeding behaviours of culturally diverse one- to five-year-old children with type 1 diabetes had poorer diabetes-related outcomes.

The idea for this study was based on clinical observations by the dietitians who saw that children who were force-fed or who had very stressful mealtimes tended to be of a higher weight and had poorer HbA1c results.

They wanted to really see if they could validate that in a research setting.

The numbers were really small (less than 20), so we couldn’t see anything significant. But what it did for me was it showed me how challenging it is to manage a life-long chronic condition like type 1 diabetes.

There are so many blood glucose checks, insulin injections or managing the pump, carb counting—and then, on top of that, you have the normal child behaviours of fussy eating in that pre-school age group.

It can absolutely send a parent to the brink and they do need that extra support with feeding behaviours as well as nutrition.

I think it’s a very interesting group because the best practice of care is to bolus the insulin before a meal based on the carbohydrates you anticipate the child to eat, but if the child doesn’t finish that carbohydrate portion, it can lead to serious push-feeding, bribery and coercion because the parents are terrified of hypoglycaemia (or low blood glucose levels).

A child may also refuse those foods knowing that if they go into hypoglycaemia, they’re going to get juice or a lolly, or some other kind of treat.

So, they’re associating a medical treatment with a reward, and it can be tricky to try and get feeding behaviours right in that group because there is that medical fear in parents, and as they get older, in the child as well.

It can lead to a lot of overeating, push-feeding and therefore weight gain and poor glycaemic control.

It just showed me that there’s normal fussy eating, but in the context of disease, it’s so much more complicated and I’m really keen to see with the rest of the study if they can show whether they do have worse feeding behaviours than their peers, which is what I started to show, but right now it’s still a little subjective with the tools being used.

Is there a downside that you know of for using insulin after the meal as opposed to before the meal?

There is a type of insulin that works faster and allows you to bolus 30 minutes after the meal. However, I don’t think it’s available in a pump and it’s not very readily prescribed.

It’s one the lesser-known insulins, but I think if we started using that more in this age group, we would definitely see improvements in feeding behaviours.

Another thing that some parents do is bolus some of the insulin before the meal.

Some parents might know 100% that their child is always going to eat their pasta or they’re always going to eat their rice, and then halfway through the meal, they do a top-up bolus for anything extra that their child ate.

You can do it that way, but it can get quite complicated—it can be quite burdensome trying to simplify mealtimes.

Obviously, the goal is to try and get it right the first time without the hypos or not enough insulin. It’s tricky trying to keep the feeding behaviours positive in that context.

What kind of roles do dietitians play in hospitals with infants and what are common cases that you’ve seen?

Dietitians that work in paediatric hospitals see both inpatients and outpatients. They work with children from new-born to 18-year-old adolescents.

You can find paediatric dietitians working on concentrating or diluting infant formula, modifying breast milk, providing specialised paediatric nutrition supplements, counselling on feeding behaviours—especially with children struggling with growth—they tend to be the fussiest eaters or those with excessive weight gain.

They do tube-feeding plans and parental nutrition plans. They can work across a number of speciality areas, including oncology, gastroenterology, nephrology, palate conditions, eating disorders, adolescent medicine; ICU, cardiac babies, cystic fibrosis and other respiratory conditions, food allergies, disabilities or special needs, weight management, neurology and diabetes. Those are just some of the areas!

There is also some more emerging evidence supporting the ketogenic diet in a particular type of neurology patient, especially in children, so there are now emerging dietitians who are specifically trained in these therapeutic diets in the paediatric hospital. Essentially, a dietitian has to be able to work with not just the child, but also with the family and engage with people of all ages.

There can be some very difficult situations that you see in a paediatric hospital. You can see intervention from the government for a particular child—it can be quite emotional at times.

However, I think the vast majority of the experiences that I had at a children’s hospital were positive because you know that the children are going to get better. It’s not as depressing as an adult hospital for me.

There’s a lot more hope and there’s a lot more joy and laughter than the regular hospital, which is really nice, but it can get pretty heavy and serious at times too. And I think that’s just the nature of working in a clinical environment anywhere.

Can you delve a bit deeper into the link between the ketogenic diet and neurology?

They use the ketogenic diet in paediatric refractory epilepsy patients as it reduces the frequency of seizures.

The dietitian on the neurology team is an important part of the team and is another example of how much dietary intervention affects the patient. But in a hospital setting, how the ketogenic diet actually looks is really awful—it’s like three slices of ham and two squares of butter and that’s your lunch.

I don’t want to eat that, let alone a five-year-old or ten-year-old! In the hospital system, the foodservice system is not set up really that well for a lot of specialty diets and you get a lot of ridiculous-looking meals. But it’s hard.

You can say to parents to bring what they want in, but that’s not what’s meant to happen, technically. It’s a difficult diet to implement, and it’s even more difficult when it’s a child who may not understand why they have to eat those particular foods.

There’s definitely work to be done in what the ketogenic diet looks like in a food service setting for children and adults alike.

Is there anything that you wanted to add to wrap up the interview?

I just want to talk a little bit more about feeding behaviours and what they mean and how we define them.

I divide them into two categories. The first is the actual relationship between the parent and the child, or the person that’s primarily responsible for feeding.

The relationship between parent/carer and child must (ideally) be responsive in nature.

That means the parents have to be able to read the cues of hunger and satiety that their child is displaying—whether that be their head-turning away from the screen or shaking their head.

If the parent honours these, that helps to preserve that child’s innate ability to self-regulate their energy intake.

The theory that force-feeding or non-responsive feeding can lead to hunger and satiety cues being overwritten, and therefore when they eat they don’t actually feel satiated and they can’t display that, so they keep eating leading to excessive weight gain in children.

It can be really difficult as a parent to trust the child to be willing to eat. It can seem that they’ve barely eaten anything for a week, but kids are really great at balancing themselves out and will then eat out the fridge the very next week.

As a health professional, at the point where I’m starting to see some issues with feeding behaviours, I would encourage a parent to trust that biology is doing its job, and their child was born with the ability to regulate their food intake.

The second category is the mealtime environment and its structure for when meals are served.

Whether the child sits with family or siblings when eating a meal, whether the TV or iPad is on—what’s the general atmosphere of the mealtime?

Is it stressful and chaotic with lots of “You eat your beans!” or “Can you please try that?” or “No, don’t do that. Why did you drop that on the floor?”

A stressful environment like that versus a calm and relaxed environment can affect how likely a child is to try new foods.

Mealtimes don’t have to be a battle and you don’t want to be battling three times a day to get your child to eat.

Once you’ve provided a nutritious meal in the best environment that you can at the time that you want, your job as a parent is now done. It is your child’s job now to determine if or how much they will eat, and that’s what Ellyn Satter’s model is all about.

If you stress yourself out about that part, you will absolutely lose your mind. The good thing about teaching people this is they feel like, “Okay, I’ve done my job now. I’m happy with that. I don’t need to stress out about how much my child’s eating now.”

Stefanie Valakas
By Aidan Muir

Aidan is a Brisbane based dietitian who prides himself on staying up-to-date with evidence-based approaches to dietetic intervention. He has long been interested in all things nutrition, particularly the effects of different dietary approaches on body composition and sports performance. Due to this passion, he has built up an extensive knowledge base and experience in multiple areas of nutrition and is able to help clients with a variety of conditions. One of Aidan’s main strengths is his ability to adapt plans based on the client's desires. By having such a thorough understanding of optimal nutrition for different situations he is able to develop detailed meal plans and guidance for clients that can contribute to improving the clients overall quality of life and performance. He offers services both in-person and online.