Gina Smith, MSN, FNP-C & Christina Turbeville, CDM

1
Childhood Obesity Prevention Models of
Successful Programs

• Gina Smith, MSN, FNP-C Christina Turbeville,
  CDM
• FirstHealth Montgomery County School Health
  Centers
• Meg McHenry, RD, MPH, LDN Kara Richards, BA, MA
• Wake Teen Medical Services

2
Objectives

• Describe the magnitude of childhood obesity
• Discuss the role of School Health Centers in
  addressing childhood obesity
• Provide examples of successful SBHC programs
  utilizing best practices
• Summarize resources available to providers for
  assisting in implementation of childhood obesity
  programs

3
Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
www.cdc.gov
4
Obesity Trends Among U.S. AdultsBRFSS, 2007
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
www.cdc.gov
5
Prevalence of At-Risk Overweight Among Children
and Adolescents
85
95
Ogden, et al. (2006). JAMA, 295(13),
1549-1555.

6
Health Risks of Obesity

• Pulmonary
• Sleep disorders
• Asthma
• Obesity-linked hypoventilations
• Neurologic
• Pseudotumor cerebri

7
Health Risks of Obesity

• Orthopedic
• Slipped capital epiphysis
• Tibia vara (Blounts disease)
• Tibial torsion
• Flat feet
• Ankle sprain
• Fractures

8
Health Risks of Obesity

• Cardiovascular
• Hypertension
• Dyslidemia
• Fatty deposits
• Left ventricular hypertrophy
• Other
• Systemic inflammation

9
Health Risks of Obesity

• Gastrointestinal
• Cholelithiasis
• Non-alcoholic fatty liver disease
• Gastro-esophageal reflux
• Endocrine
• Insulin resistance/Type II Diabetes
• Acanthosis nigricans
• Menstrual abnormalities
• Polycystic ovary syndrome
• Hypercoricism

10
Health Risks of Obesity Psychological

• Obese children and their parents rate the quality
  of life as similar to pediatric cancer patients.
• Schimmer, Burwinkle, Varni, 2003

11
Health Risks of Obesity Psychological

• Actual and perceived overweight is an important
  risk factor for suicidal behaviors in youth
• Risk factor for suicidality even after
  controlling for alcohol and illicit drug use
• (Swahn, M., Reynolds, M., Tice, M., et. al,
  Journal of Adolescent Health, 2009.)

12
Significance of Problem

• 80 of obese adolescents will become
• obese adults
• - NASBHC, 2009

13
The Role of SBHCs in Addressing Childhood
Obesity

• Leader in child health to emphasize prevention
  and early intervention
• Sensitive to unique needs of children and
  adolescents with the ability to provide
  culturally sensitive, age-appropriate services
• Opportunity for access to students with services
  provided regardless of the ability to pay
• Qualified, highly trained, interdisciplinary
  teams comprised of RD, nutritionist, FNP, RN

14
FirstHealth of the CarolinasMontgomery County
School Health Centers, East West

• East West Middle Schools
• Comprehensive, credentialed centers
• 670 total registrants

15
BMI Data Collection 2007-08

• Great partnership with Montgomery County Schools
• Collaboration with school nurses, teachers and
  students
• SBHC nurses
• SBHC Nutritionist
• SBHC FNP

16
BMI Discovery
17
Page Street Intervention HEAPHealthy Eating
Active Play

• 3rd Graders 39 obese 16 overweight
• Intervention developed RD, Nutrition Educator,
  FNP
• Nutrition Educator as instructor
• 4-week program
• Pretest of knowledge and behaviors
• One 45 minute class/week . Fun activities
  healthy snacks focusing on healthy eating and
  increasing physical activity
• Post-test
• BMIs recalculated

18
Week 1 What to Dump

• SODA CHIPS
• SWEET TEA COOKIES
• KOOL-AID CANDY
• LEMONADE DORITOS
• SUNNY DELIGHT HOT FRIES
• POWERADE CHEETOS
• GATORADE LITTLE DEBBIES
• FRUITOPIA CAKES PIES
• YOOHOO BROWNIES
• CAPRI-SUN CHOCOLATE
• NABS HONEY BUNS
• RICE KRISPY TREATS
• KLONDIKE BARS

19
Week 1 What to Pick Up

• 1 OR SKIM MILK
• WATER
• CAFFEINE FREE/ UNSWEETENED TEA
• CAFFEINE FREE / DIET SODA
• HOMEMADE LEMONADE WITH SPLENDA
• 100 JUICE ONCE A DAY ONLY
• LITE MICROWAVE POPCORN
• CELERY / PEANUT BUTTER
• CARROTS WITH LOW FAT DRESSING
• PEANUT BUTTER CRACKERS (whole wheat)
• APPLES-ORANGES-BANANAS-FROZEN GRAPES
• STRING CHEESE
• NUTS
• RAISINS, DRY CHEERIOS, PRETZELS
• FROZEN YOGURT

20
Week 2

• WHAT FRUITS TO ADD TO BREAKFAST
• Bananas
• Raisins
• Apples
• Peaches
• Cut up fruit to top your waffles versus syrup
• Yogurt in place of syrup
• Eat your fruit vegetables that come with lunch!
• FRUITS VEGETABLES TO ADD TO
• LUNCH SUPPER
• Carrots celery sticks
• Cucumber slices
• Applesauce cups
• Apples, oranges, or bananas
• Bring salad to school
• Supper ½ of your plate should be vegetables
• Try the vegetables your mom makes at least
  three times before you say you dont like it.

21
Week 2 Healthy Eating and Physical Activity
Go Hand in Hand

• Exercise can be fun in fact its childs play!
• Make it a family affair
• Limit TV viewing time to 2 hours or less/day
• Be physically active for 60 minutes every
  day

22
Week 3

• HOW SHOULD YOUR PLATE LOOK?
• One-half (1/2) of your plate should have
  vegetables
• One-fourth (1/4) of the plate should have your
  meat or protein
• One-fourth (1/4) of the plate should have your
  starches (bread, pasta, rice, potatoes)

23
Week 4 Healthy Meals on the Run

• RESTAURANTS CHOICES
• McDonalds 1 milk, mandarin oranges,
• unsweetened tea, apple dippers, or yogurt
  with fruit
• Zenos Grilled chicken, vegetable pizza, salad
• Sir Pizza Salad bar, fruit choices, vegetable
  pizza
• Mazatlan Ask the waiter to take the
  chips off the table when you sit down. Take ½
  of your order home for a later meal.
• Pennys Order the small order and stay away
  from sauces.
• BoJangles Grilled chicken, no biscuit. Ask
  for a bun instead.
• Subway Ask for the kids meal, salad and no
  chips.

24
Results???

• BMI 1 decrease in obese students
• from 39 to 38
• Correct answers
• Pretest 51
• Post-test 98

25

• 2008 NC Stars Fruit and Veggies Silver Award
  Healthcare Division

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Page Street 5th Graders 09-10
Page Street 5th Graders
2009-10
0
39
41
BMI

95
BMI 85-94
BMI Normal
BMI lt 5
20
29
Childhood Obesity Action Network. State Obesity
Profiles, 2008. National Initiative for
Children's Healthcare Quality, Child Policy
Research Center, and Child and Adolescent Health
Measurement Initiative.
30
2008-09 Childhood Obesity Efforts

• Nutritional assessment utilizing HEAP quiz on all
  students enrolled at the SBHCs (EMS/WMS)
• Ht/wt/BMI calculated and plotted
• Early referrals made to SBHC nutritionist for BMI
  ? 85
• Referral to SBHC RD for BMI 95
• 2-3 nutritional counseling sessions 1345
  nutrition visits

31
SHC/school-wide 2008-09 Efforts

• Alignment with MCS system goals Promote a
  child-centered culture of health, rigor, and high
  expectations
• Nutrition educator collaborated with school staff
  in forming after school walking clubs at both
  middle schools 130 miles walked
• Health Eating Every Day (HEED) classes for school
  staff
• BMI data collection for all MCS students grades
  pre-K-12

32
SHC/school-wide 2008-09 Efforts

• HEAP presentations
• Presented to Candor 3rd graders last year were
  most obese in MCS at 41 obese
• Green Ridge 3rd graders
• Mt. Gilead 4th graders
• 176 HEAP students this year

33
2008-09 BMI Trends
Montgomery County Schools BMI Data

2008-09
2
27
BMI

95
BMI 85-94
BMI Normal
52
BMI lt 5
19
34
2008-09 BMI Trends
Childhood Obesity Action Network. State Obesity
Profiles, 2008. National Initiative for
Children's Healthcare Quality, Child Policy
Research Center, and Child and Adolescent Health
Measurement Initiative.
35
SHC BMI Trends
36
SHC BMI Trends
37
SHC BMI Trends
38
SHC BMI Trends
39
SHC BMI Trends

• Overall decrease in BMI of
• OB/OW students 71
• n 279

40
2008-09 HEAP Results
41
2008-09 HEAP Results
42
2008-09 HEAP Outcomes

• Candor/Green Ridge/Mt. Gilead
• Pretest 58 Correct
• Post-test 93 Correct

43
Additional School-wide efforts

• SPARK curriculum in K-8
• www.spark.org
• Fitnessgram software to track BMI
• Healthy Kids/Healthy Communities grant
• School Nutrition Director developing healthier
  menus
• 3 schools received fruit grants

44
2009-10 SHC Efforts

• Nutritional assessment on all SBHC enrollees
• Prevention/early intervention
• 5-3-2-1-Almost None
• Increased nutritional services for SHCS in
  2009-10 by increased nutritional services to 4
  days total/week
• Registered Dietician for students 99
• Actively seek resources/funding for innovative
  methods for addressing childhood obesity

45
2009-10 SHC BMI Trends

• Nutrition Referrals for OB/OW
• n261
• BMI 99 19
• BMI 95-98 42
• BMI 85-94 - 36
• BMI lt5 or other 3
• 61 obese!!

46
Additional Efforts

• Present HEAP program to Green Ridge 1st graders
  BMI 33OB/30OW
• Fasting glucose, lipids, ALT, AST, etc.
• Actively seek resources/funding for innovative
  methods for addressing childhood obesity
• Look for ways to incorporate more physical
  activity into the SHC programs
• Collaborate on a local, state and national level
  in addressing childhood obesity

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48
Childhood Obesity Prevention Models of
Successful ProgramsBe Fit, Get Moving

• Kara Richards, MA
• Meg McHenry, RD, MPH, LDN

49
Wake Teen Medical Services

• Wake Teen Medical Services is a non-profit
  medical service provider for adolescents through
  young adults ages 10 to 23
• Services include
• Primary health care
• Mental health care
• Health education
• Nutrition counseling

50
Wake Teen Medical Services

• Saw 1473 patients in the last year
• Patient demographics
• 975 female, 498 male
• 989 African American, 446 White, 38
  Other/Unidentified
• Over 30 of patients fall at or above the 85th
  BMI percentile
• Wake County obesity prevalence
• For ages 12-17, 21 classify as overweight and
  30 as obese

51
Be Fit, Get Moving

• Kate B. Reynolds-funded multidisciplinary healthy
  lifestyle program that includes
• Health care screening
• Individual nutrition counseling
• Individual exercise counseling
• Mental health counseling (if needed)
• Weekly group educational seminars, exercise
  sessions, and field trips

52
Be Fit, Get Moving

• Target population
• Youth ages 10 through 23
• At or above the 85th BMI percentile
• Highly motivated to make a change
• Program Participants
• Began October 2008 for Wake Teen patients only
• In March 2009, we opened the program to outside
  participants (schools, physician offices, etc.)
• We have served 65 of all participants referred,
  reaching well over 100 teens in Wake County
• 76 are female, 60 African American, 98
  financially needy

53
Intended Outcomes and Results

• Intended Outcomes at 12 months
• Decreased BMI in 65 of participants
• 70 will be active for 20 min/5x/wk
• 85 show improvements in cardiovascular health
• 90 will increase nutrition knowledge
• 85 will eat healthy breakfast 5x/wk
• 90 improve self-perception

• Results at 9 months
• 31 decreased, 50 maintained
• 100 participants increased activity time, 70
  active at least 5xwk
• 55 decreased resting heart rate, 80 decreased
  blood pressure
• 80 increased nutrition knowledge
• 65 eating breakfast daily 100 increased from
  baseline
• 75 increased, 25 maintained or improved
  minimally

54
Measurement Tools Used

• BMI Heights/weights taken at exercise
  appointments CDC growth charts
• Activity Exercise logs/self-report to exercise
  specialist
• Cardiovascular health BP/RHR from exercise
  specialist or medical record
• Nutrition knowledge 20-question quiz developed
  by staff nutritionist
• Healthy breakfast food records/self-report to
  nutritionist
• Self-perception 12-question quiz developed by
  mental health staff

55
Additional Outcomes

• WHR 65 improved from baseline
• Pushups 100 improvement
• Squats 100 improvement
• Qualitative results
• If I had not participated in BFGM, I would still
  be drinking sugared drinks, eating chips all day,
  going to McDonalds almost everyday I would be
  extremely obese M, 15
• One achievement Im proud of is that I lowered
  my blood sugar. When I first started this
  program, it was in the 300s. Now Im getting
  results in the low 80s. F, 18
• Within two weeks of starting the program, I
  noticed my son is more confident he wants to
  ride bikes with other kids, he is more willing to
  be active, and he smiles a lot more. Mother of
  M, 14

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Process

• Program Structure
• Tuesday education seminars and neighborhood
  walk/boot camp
• Thursday boot camp
• Individual nutrition counseling
• Individual exercise counseling
• Field trips

57
Dining Out
58
Eating Out
59
Physical Activity
60
Community Support
61
Contact Information - Wake Teen Medical Services

• Kara Richards, Project Coordinator
• krichards_at_waketeen.org
• Meg McHenry, Nutritionist
• mmchenry_at_waketeen.org
• Telephone [phone]
• www.waketeen.org

62
Contact Information - FirstHealth Montgomery
County School Health Centers

• Gina Smith, FNP, SHC Manager
• rpsmith_at_firsthealth.org
• Christina Turbeville, Nutrition Educator
• cturbeville_at_firsthealth.org
• Telephone [phone], East
• 910-572-1979, West

63
Resources

• USDA Food Guide Pyramid www.mypyramid.gov
• Eat Smart, Move More www.eatsmartmovemorenc.com
• Shield, J. and Mullen, C.M. (2008). Counseling
  Overweight and Obese Children and Teens Health
  Care Reference and Client Education Handouts.
  Chicago, Il American Dietetic Association
• Videos
• Obesity in a Bottle www.learningzoneexpress.com
• Fast Food Survival Guide www.learningseed.com

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Resources

• NASBHC - http//ww2.nasbhc.org/RoadMap/CONVENTION0
  9/D7_1.pdf
• NASBHC CQI Tool http//www.nasbhc.org/site/c.jsJ
  PKWPFJrH/b.2719357/k.6312/EQ_Quality_Improvement.h
  tm
• NICHQ http//www.nichq.org
• http//www.nichq.org/documents/coan-papers-and-pu
  blications/COANImplementationGuide62607FINAL.pdf

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Resources

• Expert Committee Recommendations Regarding the
  Prevention, Assessment, and Treatment of Child
  and Adolescent Overweight and Obesity Summary
  Report http//pediatrics.aappublications.org/cgi/r
  eprint/120/Supplement_4/S164
• CDC BMI Calculator for Children Teens -
  http//apps.nccd.cdc.gov/dnpabmi/
• NC Prevention Partners www.ncpreventionpartners.
  org
• NC Healthy Schools www.nchealthyschools.org

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Questions??
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Merry Christmas!!