Prevention of Pediatric Obesity
Free CEU from the University of Northern Colorado - School of Nursing

 

Primary Care Prevention of Pediatric Obesity

Hessler, K. L. (2011) ©

 

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Karen Hessler, PhD, FNP-C

University of Northern Colorado

School of Nursing

http://www.unco.edu/nursing

Introduction:

Welcome to the free continuing education program for Nurse Practitioners

This program uses an electronic module online to provide 1 hour of CE regarding prevention of pediatric obesity in the primary care setting. It is important that the busy nurse practitioner be able to keep abreast of the current evidence base and have an opportunity to implement prevention strategies into their every day practice routines. The goal of the progam is to provide nurse practitioners (NP) and NP students with some common sense strategies based on evidence that can be implemented during well child care and other acute problems in current practice settings.

 

Although this is a free CE program, it is also part of a research study investigating how educational interventions with practitioenrs have the potential to increase individual knowledge base and self-efficacy to prevent pediatric obesity. It would be most appreciated if you would take the time to complete the pre-test and post-test as you work on this CE program. Six months after you complete the post-test, you will receive an email with the same survey to measure retention of CE content and provide a 3rd measurement of self-efficacy.

 

Thank you for your participation - we hope to see you back on the UNCO website for more free CE programs coming soon!

 

The entire program including pretest and postest is estimated to take you about 60 minutes to complete and provide 1 credit hour of CE approved by the AANP - these credits are universally accepted as NP continuing education credits.

Please use the link below to access and complete the Pretest. After you are done with the pretest, close that window and use the prompts at the bottom of your screen to view the program.

Primary Care Prevention of Pediatric Obesity - Program Objectives:

At the end of the program, the participant will be able to:

  1. Discuss the past and current statistics of pediatric overweight and obesity for all age groups in the United States.
  2. Define the terms obesity and overweight for the pediatric population.
  3. Discuss current recommendations for screening of overweight and obesity in the pediatric population.
  4. Identify 5 educational pediatric obesity prevention strategies for implementation into the current (practicing NP) or future (NP student) practice setting.
  5. Indicate personal confidence level to prevent pediatric obesity before and after the completion of the program.

 

Please click on the highlighed link to complete the pretest for the program: PRE-TEST

 

 

Definition of Terms

Due to the increasing incidence of overweight and obesity in children, effective strategies for treatment of the condition to prevent adult morbidities are needed. However, research that insures adequate treatment for the problem is not available, and costs of current interventions are high. Therefore, with the present situation, more emphasis must be placed on the development, evaluation, and implementation of primary prevention of pediatric obesity (Koletzko, 2006).

 

Definition of terms:

According to the Center for Disease Control, the following are the current defintions for pediatric overweight and obesity:

The current recommendations for screening children age 2 and older are to use Body Mass Index data. Body Mass Index (BMI) is a child's weight in Kg divided by their height in Meters squared.

Pediatric Overweight

Pediatric Obesity

 

Use of the 95th percentile for the definition of obesity identifies children with a signficiant likelihood of continuing to be obese as an adult (CDC.gov, 2011).

If you would like more information on growth charts, the CDC website below provides some excellent infromation and educational materials for further review (http://www.cdc.gov/growthcharts/cdc_charts.htm):(if you would like to access now, click on the picture below)

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According to the Expert Committee Recommendations set forth in 2007, primary care providers should perform, at a minimum, a yearly assessment of weight status should be appropriately plotted on standard growth charts. These measurements include height, weight, and BMI for age for all children (Barlow, 2007).

Use of skinfold thickness and waist circumference on not recommended measurements for pediatric patients at this time (Barlow, 2007).

 

Prevalence of Pediatric Obesity in the United States

 

Most nurse practitioners (NP) are aware that the rates of pediatric obesity have been increasing over the last 20 years. The following chart has been accessed through the CDC website.

 

Table 1. Prevalence of obesity among U.S. children and adolescents aged 2-19, for selected years 1963-1965 through 2007-2008

Age (in years)1 NHANES
1963-1965
1966-19702
NHANES
1971-1974
NHANES
1976-1980
NHANES
1988-1994
NHANES
1999-2000
NHANES
2001-2002
NHANES
2003-2004
NHANES
2005-2006
NHANES
2007-2008
Total (3) 5.0 5.5 10.0 13.9 15.4 17.1 15.5 16.9
2-5 (3) 5.0 5.0 7.2 10.3 10.6 13.9 11.0 10.4
6-11 4.2 4.0 6.5 11.3 15.1 16.3 18.8 15.1 19.6
12-19 4.6 6.1 5.0 10.5 14.8 16.7 17.4 17.8 18.1

 

Note that the rates of pediatric obesity have risen over the years in all age groups. It is also important to note that the CDC reports that black and hispanic children have significantly higher obesity rates than their non-Hispanic White counterparts (CDC, 2011).

So what children and their parents need counseling about prevention of pediatric obesity?

All children and their parents should receive counseling about prevention of pediatric obesity from their primary care providers. Although the rates are higher for some ethnicities, pediatric obesity is a problem that crosses all ages and races of children. 

 

Strategies for the NP to Prevent Pediatric Obesity

 

In a recent study by McKee, Maher, Deen & Blank (2010), found that the primary care office is an ideal place to introduce healthy lifestyle changes for children and begin to address the pediatric obesity epidemic. Using parents in qualitative focus groups expressed their desire to change behaviors in order to achieve healthier families. Parents in the study wanted their primary care providers to focus more on healthy lifestyle during their child's well-visits.Collaborative goal setting between parents and providers focusing on healthy behavior change with a referral to behavioral change counselor were noted as highly acceptable to the parents in these focus groups. Many NPs may not have access to a behavioral change counselor, and must take on this role themselves. In these cases, it is important to remember parent and child motivation for change. Focusing on small changes over a longer period of time rather than global advice from primary care providers to "be more healthy" can be implemented by families who have ingrained habits and cultural preferences.

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Parents in the McKee study voiced their frustrations with providers who offer advice about necessary behavior change, but then fail to develop a plan of action in order for the family to achieve such change. Simply setting some primary goals with short and long-term completion dates could be a solution to this parent/patient frustration with provider advice.

 

Strategies to Prevent Pediatric Obesity - Infancy

 

There is a vast body of literature regarding pediatric obesity treatment and management. This CEU program will focus only on research based prevention strategies that you can implement within your own practice setting as a NP. Of course prevention begins at a very early age, so the current recommendation is to begin prevention efforts at the earliest well-child visits possible. In fact, studies have shown that encouraging mothers of infants to breastfeed can significantly reduce the likelihood of overweight and obesity in children.Goldfield et al (2006) found that children who were exclusively breastfed for 4 weeks or more (no water, formula or medications) had significant reductions in incidence of overweight and BMI at 6 months and 1 year in comparison to children who were formula fed. In a more recent study, Huh, et al. (2011) found that introduction of solids in babies prior to 4 months who were bottlefed was related to a significant increase in the incidence of obesity at age 3 years (odds ratio of 6.3). In the same study, timing of the introduction of solids in breastfed infants was not found to be asociated with obesity at 3 years. Therefore, the current recommendation is to continue to discourage introduction of solids in infants prior to the age of 4 months, with a debate continuing as to whether introduction should begin at 4 or 6 months of age. Certainly, it is best to encourage breastfeeding, and discourage introduction of solids prior to the age of 4 months to parents at this time.

 

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Expert Committee Prevention Recommendations:

 

If a child ages 2-18 is found to be at or above the 5th percentile and no greater than the 84th percentile for gender specific height/weight/MBMI, the Expert Committee recommendations for the practicing primary care provider are to employ counseling about dietary intake, eating behaviors, and physical activity.

These specific recommendations include:

 

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Some additional thoughts from the Expert Committee:

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Calorie Consumption:

 

One thing is for sure -- you don't need to be a dietician to counsel patients and their families on appropriate eating patterns!

 

 The Expert Committee recommends that primary care providers perform a qualitative assessment of all of their pediatric pateints' dietary patterns at each well child visit for anticipatory guidance.

Qualitative assessment is a general term for verbal questioning of the patient and/or their family members. Included in this assessment should be the following:

 

Expert Committee Qualitative Assessment Recommendations

Suggested Qualitative Interview Questions for NPs

Identification of specific dietary practices

1.    How often does your child/family eat a meal at a restaurant or fast food establishment?

2.    Does your child drink sweetened beverages such as soda/pop, 100% fruit juices, or other sugared drinks? How much and how often?

3.    When your child eats a meal, what portion size does he/she eat?

4.    Does your child/family eat breakfast – how often and what type of breakfast do you typically eat?

5.    What types of snacks does your family/children typically eat (look for responses that indicate excessive consumption of snacks high in energy density, i.e. Junk food)

6.    How many fruits and vegetables does your family/child eat per day?

After questioning, consider if the patient/family needs to consider changes in their dietary practices to embrace a healthier lifestyle:

Self-Efficacy and readiness to change

1.    Does the patient/family feel like they are able to make changes in their current dietary practices?

2.    Do they feel confident that they can make changes and eat a healthy diet?

3.    Is the patient/family ready to make changes for a healthier diet?

 

One strategy to same time during an office visit is to provide the patient/parent or family member accompanying the patient with a handout that addresses the dietary questions to fill out in the waiting room or patient room as they wait for their visit. Then you can review their responses and initiate the self-efficacy for change questions if you believe they are necessary.

 

Energy Expenditure

 

In addition to questionning the patient and/or family about calorie intake, the Expert Committee (2007) also recommends qualitative data gathering about physical activity or "energy expenditure" of the child. This data should be gathered at the minimum during each well-child visit for anticipatory guidance.

The current recommendations are that children engage in:

AND

 

The following provides the specific recommendations and some suggested qualitative questions for the practicing NP:

Expert Committee Qualitative Assessment Recommendations

Suggested Qualitative Interview Questions for NPs

Assessment of levels of physical activity and sedentary behaviors:

 

 

1.    How often is your child able to be physically active?

2.    What types of physical activity does your child like?

3.    Do you feel like you there are things that keep your child from being physically active? (Assessing here for environmental and/or social barriers to being active)

4.    How many hours would you say your child engages in sedentary behavior such as watching TV or DVDs, playing video games, and using the computer?

After questioning, consider if the patient/family needs to consider changes in their physical activity practices to embrace a healthier lifestyle:

Self-Efficacy and readiness to change

1.    Does the patient/family feel like they are able to make changes in their current dietary practices?

2.    Do they feel confident that they can make changes and eat a healthy diet?

3.    Is the patient/family ready to make changes for a healthier diet?

 

As on the previous page - it would be one strategy to add these questions to a written questionnaire as the patient/family is waiting for their visit, review them during the visit and engage any or all of the necessary self-efficacy questions if necessary.

 

Primary Care Providers and Global Change:

Included in the Expert Committee Recommendations is a discussion of how primary care providers can begin to move beyond the practice setting to provide patient advocacy in the prevention of pediatric overweight and obesity. It is currently recommended that:

 

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Conclusions:

It is clear to see from the Expert Committee Recommendations (Barlow, et al, 2007) and other references cited within this educational program that the NP can do quite a bit in their primary care settings to prevent pediatric overweight and obesity. These guidelines can be implemented with little time and could become part of the typical well-visit routine for pediatric patients of all ages.

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It is our challenge as Nurse Practitioners to lead the way in prevention efforts in our current settings. You have the knowledge and power to affect how patients and their families see their current health, and you can be a change agent for these families as the instigator of healthy lifestyle adaptation at the earliest age possible.

Of course, it is important to engage parents or other primary care givers in your prevention strategies. Within this scope - try to encourage parents and remind them that they are their child's primary role model. As such, the parent would do much in the way of preventing obesity in their child by adopting or continuing healthy lifestyle behaviors of their own. Furthermore, encouraging family inclusive exercise options that engage all members of the family are considered optimal for adoption of healthy activity patterns by parents and children (Floriani & Kennedy, 2007).

Praise parents and families that are already engaging in healthy lifestyle, and counsel those on small changes to make in order to reach a family goal to be healthy.

In addition to encouraging parents and other care providers that they are role models for pediatric patients, you as the health care provider also provide a primary role model for not only the pediatric patient, but also their families. Congratulations to those of you who have adopted healthy lifestyle behaviors and continue to make a positive change for your own health. Those of you who have the knowledge to lead a healthy lifestyle but cannot find the time or energy to do so, I encourage you to make one small change a week toward a healthier you.

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Thank you for participating in this program.

It is an honor to be able to offer programs that could potentially impact the health of our nations' children.

 

Please use the link below to complete the post-test. If you have any questions or comments, please do not hesitate to contact:

Karen Hessler, PhD, FNP-C

karen.hessler@unco.edu or (970) 351-2137

 

Please click here for:

POST-TEST

 

(please be certain to fill out address information for receipt of CE Certificate)

 

References:

Barlow, S. E., Expert Committee. (Dec, 2007). Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity. Pediatrics, 120; Suppl 14: S164-192.

Center for Disease Control (2011). Growth Charts. Accessed April 2011 from: http://www.cdc.gov/growthcharts/clinical_charts.htm.

Center for Disease Control (2011). PedNSS Health Indicators. Accessed April 2011 from: http://www.cdc.gov/PedNSS/what_is/pednss_health_indicators.htm.

Center for Disease Control. (June, 2010). Prevalence of Obesity Among Children and Adolescents: United States: Trends 1963-1965 Through 2007-2008. Accessed April 2011 at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm#table1

Floriani, V. & Kennedy, C. (Feb. 2007). Promotion of physical activity in primary care for obesity prevention/treatment in children. Current Opinion in Pediatrics, 19 (1), 99-103.

Goldfield, G. S., Paluch, R. P., Keniray, K., Hadjiyannakis, S., Lumb, A. B. & Adamo, K. (2006). Effects of breastfeeding on weight changes in family-based pediatric obesity treatment. Developmental and Behavioral Pediatrics, 27 (2), 93-97.

Huh SY et al. (2011). Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics; 127:e544. (http://dx.doi.org/10.1542/peds.2010-0740)

McKee, M. D., Maher, S. Deen, D. & Blank, A. (2010). Counseling to prevent obesity among preschool children: acceptability of a pilot urban primary care intervention. Annals of Family Medicine, 8 (3), 249-255.