A MultiYear Initiative

1

• A Multi-Year Initiative
• of the National Association of Pediatric Nurse
  Practitioners
• Mary Margaret Gottesman, PhD, RN, CPNP, National
  Chair
• The Ohio State University, gottesman.6_at_osu.edu
  

2
Supported by
and
Gerber Products Company
3
The Steering Work Group
Mary Margaret Gottesman, PhD, RN, CPNP, Ohio,
National Chair Margaret Brady, PhD, RN, CPNP,
California, Resources Chris Calamaro, PhD, RN,
CPNP, Pennsylvania, School-Age Barbara Deloian,
PhD, RN, CPNP, Colorado, Infancy Karen
Duderstadt, RN, MSN, CPNP, California, Advocacy
Bonnie Gance-Cleveland, PhD, RN, CPNP,
Arkansas, Research Lynn Gilbert, PhD, RN, CPNP,
Colorado, Early Childhood Linda Jonides, RN, MS,
CPNP, Michigan, Adolescence Carolyn Montoya, RN,
MS, CPNP, New Mexico, Cultural Appropriateness
4
Why HEAT now?

• Overweight has doubled among 2-5 year olds and
  tripled among 6-18 year olds since the 1970s.
• 1 in 7 US children and teens are obese
• 1 in 10 infants and toddlers are overweight
• Effective reversal of overweight is difficult to
  achieve and seldom long lasting.
• (Foster, Wadden, Matris, et al., 2003 Hedley, et
  al., 2004, Ogden, Flegal, Carrol,
• Johnson, 2002 Summerbell, Ashton, Campbell,
  Edmunds, Kelly, Waters, 2005 )

5
What about their future?

• Leading Causes of Death in the US
• Minino, Arias, Kochanek, Murphy,
  Smith 2002
• Cause of Death Death rate/100,000
• Heart disease 258.2
• Cancer 200.9
• Cerebrovascular disease 60.9

6
How did this happen?

• Actual Causes of Death in the US
• Mokdad, Marks, Stroup,
  Gerberding, 2004
• Actual Cause in 1990 in 2000
• Tobacco 19 18.1
• Poor diet/physical 14 16.6
• inactivity
• Alcohol 5 3.5

7
Whats happening in primary care?

• Time Devoted to Anticipatory Guidance
  during Wellness Visits
• Goldstein, Dworkin,
  Bernstein, 1999
• Average visit length 17.8 minutes
• Average time in advisement 2.4 minutes
• Nutrition 31.7 seconds
• Growth 6.4 seconds
• Exercise 1.6 seconds

8
How well do primary care providers care for
overweight children?

• Routinely include all recommended elements of
• Pediatricians PNPs
• Family history 23.6 24.5
• H P 7.3 8.5
• Lab evaluations 16.5 14.6
• Barlow, Dietz, Klish, Trowbridge, 2002

9
What about today?

• Obesity was a diagnosis in only 0.93 of well
  child visits for children 2-18 years of age,
  despite a 15 occurrence. (NAMCS NHAMCS,
  1997-2000)
• Children with a diagnosis of obesity were 2.5
  times more likely to receive diet counseling and
  more than 3 times as likely to receive exercise
  counseling as children without the diagnosis, but
  it was not 100.
• BP monitoring occurred in only 37 of well visits
  with pediatricians.
• There are disparities in provision of care by
  gender, insurance, and ethnicity.
• Only 36.7 of overweight children, teens, or
  their parents were told they were overweight.
  (NHANES, 1999-2002)
• (Cook, Weitzman, Auinger, Barlow, 2005 MMWR,
  54 (34), 848-849)

10
Life Course Health Development Framework
Time Frames Multiple Developmental
Stages of Life Course Prenatal?Infancy?Childhood
?Adolescence Transitions/Turning Points
Family?Preschool?School?Workplace Crosscutting
Historical, Economic, Political ???????????????
The Context of ? Health
Development Genetic Endowment Physical
Environment Social Environment Family
Environment Psychological Environment
Culture/Policy Environment Health Care System
The Process of Health ? Development Design
Features Strategies Resources chosen
Growth, maturation Health Development
Processes Physiological pathways
Psychological pathways ? Behavioral pathways?
Developmental Health Outcomes Life expectancy
Functional abilities Cognition, mood,
growth, activity Disease, disability School
readiness performance
Regulatory Processes of Health Development Critica
l and sensitive periods Psycho-neuro-endocrine-
immune regulation
Halfon Hochstein,2002
11
Halfon Hochstein, 2002
12
HEAT Mission
To improve child health through
relationship-based, culturally appropriate
interventions enhancing practitioner
effectiveness in working with families to develop
optimal habits in nutrition and physical activity.
13
HEAT Goal

• Prevention of overweight in childhood and
  identification of children at risk for overweight.

14
How did we do it?

• Use of existing meta-analyses and expert
  recommendations
• Institute of Medicine (IOM)
• National Heart, Lung, and Blood Institute (NHLBI)
• American Heart Association (AHA)
• U.S. Department of Agriculture (USDA)
• American Dietetic Association (ADA)
• American Academy of Pediatrics (AAP)
• Cochrane Collaborative
• Two comprehensive literature reviews

15
Our main messages

• Regardless of age, the foundation of good health
  is best achieved by
• High quality nutrition and a physically active
  lifestyle
• A balance between energy intake and energy
  expenditure

16
Major Components of the Guideline

• Introduction
• Four age groups divisions
• Infancy
• Early Childhood
• School Age
• Teen
• Five divisions within each age group
• Early identification
• Development, communication and relationships
• Nutrition essentials
• Physical activity and sedentary behavior
• Advocacy

17
Whats different?

• Focus on the family, not just the individual
• Professional-family partnership
• Developmental context of feeding and physical
  activity
• Advocacy
• Guidance to enhance cultural appropriateness

18
Expert Reviewers

• Michael C. Barth, PhD
• Executive Vice President, IFC Consulting
• National Program Director, Healthy Steps for
  Young Children
• Diane Berry, PhD, CANP
• Assistant Professor
• University of North Carolina at Chapel Hill -
  School of Nursing
• Deborah Cummins, PhD
• Director, Research/Evidence Analysis
• American Dietetic Association
• Scott M. Gee, MD
• Medical Director, Prevention and Health
  Information
• The Permanente Medical Group, Inc.
• Esther Myers, PhD, RD, FADA
• Research and Scientific Affairs
• American Dietetic Association

19
Implementation Resources

• Age-based pre-visit assessment checklist
• Age-based health professional history exam form
• Age-based parent guidance handouts
• Card-sort activity to engage parents, children
  and teens in setting their own goals for
  lifestyle improvement.
• Practitioner cue cards for brief motivational
  interviewing process to support partnership with
  the family for change.
• Practitioner cultural guides
• Additional handouts addressing common problems in
  nutrition and activity to support decisions to
  change.

20
Making implementation happen

• Use of motivational interviewing skills and
  process with family members
• A guideline implementation in practice audit
  checklist
• Use of a rapid cycle improvement processes to
  change practice

21
Next steps

• Testing the guideline in practice
• Primary Aim
• To evaluate the effectiveness of the clinical
  practice guideline in preventing overweight in a
  sample of children birth to 3 years of age.
• Secondary Aim
• To evaluate the effectiveness of the clinical
  practice guideline in changing practitioner and
  parent behaviors.
• Tertiary Aim
• To identify barriers to following the guidelines
  experienced by practitioners and parents.
• Review and critique content of the guideline and
  the supporting materials by parents, children,
  and teens from ethnic minority groups.

22
Where can I learn more?

• Identifying and Preventing Overweight
• in
• Childhood Clinical Practice Guideline and
  Resource Kit
• Please visit http//www.napnap.org
• for more information.