Gina Smith, MSN, FNP-C & Christina Turbeville, CDM FirstHealth Montgomery County School Health...
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Transcript of Gina Smith, MSN, FNP-C & Christina Turbeville, CDM FirstHealth Montgomery County School Health...
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
Childhood Obesity Prevention: Models of Successful Programs
• 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
Objectives
Obesity Trends* Among U.S. AdultsBRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person))
No Data <10% 10%–14No Data <10% 10%–14%
www.cdc.gov 3
Obesity Trends* Among U.S. AdultsBRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
www.cdc.gov
Prevalence of At-Risk & Overweight Among Children and Adolescents
0
2
4
6
8
10
12
14
16
18
20
1963-1970
1971-1974
1976-1980
1988-1994
1999 2003-2004
Ogden, et al. (2006). JAMA, 295(13), 1549-1555Ogden, et al. (2006). JAMA, 295(13), 1549-1555..
≥ 85%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
1999-2000
2001-2002
2003-2004
2-5 yrs6-11 yrs12-19 yrs
≥ 95%
5
Health Risks of Obesity
• Pulmonary• Sleep disorders• Asthma• Obesity-linked
hypoventilations• Neurologic
• Pseudotumor cerebri
6
Health Risks of Obesity
• Orthopedic– Slipped capital
epiphysis– Tibia vara (Blount’s
disease)– Tibial torsion– Flat feet – Ankle sprain– Fractures
7
Health Risks of Obesity
• Cardiovascular• Hypertension• Dyslidemia• Fatty deposits• Left ventricular hypertrophy• Other• Systemic inflammation
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
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
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.)
Significance of Problem
80% of obese adolescents will becomeobese adults
- NASBHC, 2009
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
FirstHealth of the CarolinasMontgomery County School Health
Centers, East & West
• East & West Middle Schools• Comprehensive, credentialed centers• 670 total registrants
BMI Data Collection 2007-08
• Great partnership with Montgomery County Schools
• Collaboration with school nurses, teachers and students
• SBHC nurses• SBHC Nutritionist• SBHC FNP
BMI DiscoveryPage Street 3rd Graders
2007-08
39%
16%
44%
1%
BMI ≥ 95%
BMI 85%-94%
BMI Normal
BMI < 5%
Page Street Intervention – HEAP“Healthy 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
Week 1 – What to Dump
SODA CHIPSSWEET TEA COOKIESKOOL-AID CANDYLEMONADE DORITOSSUNNY DELIGHT HOT FRIESPOWERADE CHEETOSGATORADE LITTLE DEBBIESFRUITOPIA CAKES &PIESYOOHOO BROWNIESCAPRI-SUN CHOCOLATENABS HONEY
BUNSRICE KRISPY TREATSKLONDIKE BARS
Week 1 – What to Pick Up
1% OR SKIM MILKWATER
CAFFEINE FREE/ UNSWEETENED TEACAFFEINE FREE / DIET SODA
HOMEMADE LEMONADE WITH SPLENDA100% JUICE ONCE A DAY ONLY
LITE MICROWAVE POPCORNCELERY / PEANUT BUTTER
CARROTS WITH LOW FAT DRESSINGPEANUT BUTTER CRACKERS (whole wheat)
APPLES-ORANGES-BANANAS-FROZEN GRAPESSTRING CHEESE
NUTSRAISINS, DRY CHEERIOS, PRETZELS
FROZEN YOGURT
Week 2Week 2WHAT FRUITS TO ADD TO BREAKFAST
BananasRaisinsApples
PeachesCut up fruit to top your waffles versus syrup
Yogurt in place of syrupEat your fruit & vegetables that come with lunch!
FRUITS & VEGETABLES TO ADD TO LUNCH & SUPPER
Carrots & celery sticksCucumber slicesApplesauce cups
Apples, oranges, or bananasBring 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 don’t like it.
Week 2Week 2 – Healthy Eating and Physical Activity Go – Healthy Eating and Physical Activity Go Hand in HandHand in Hand
Exercise can be fun – in fact it’s child’s play!
Make it a family affair
Limit TV viewing time to 2 hours or less/day
Be physically active for 60 minutes every day
Week 3Week 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)
Week 4 – Healthy Meals on the RunWeek 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.
Penny’s Order the small order and stay away from sauces.
BoJangles Grilled chicken, no biscuit. Ask for a bun instead.
Subway Ask for the kid’s meal, salad and no chips.
Results???Results???
BMI – 1% decrease in obese students
from 39% to 38%
Correct answers:
Pretest – 51%
Post-test – 98%
2008 NC Stars Fruit and Veggies Silver Award – Healthcare Division
Page Street 5th Graders 09-10Page Street 3rd Graders
2007-08
41%
14%
45%
0%
BMI ≥ 95%
BMI 85%-94%
BMI Normal
BMI < 5%
Page Street 5th Graders2009-10
39%
20%
41%
0%
BMI = 95%
BMI 85%-94%
BMI Normal
BMI < 5%
47
33.930.6
0
5
10
15
20
25
30
35
40
45
50
Percentage of Obese/Overweight
Montgomery CountySchools
North Carolina United States
Montgomery County Adolescent BMI2007-08
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.
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
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
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
2008-09 BMI TrendsMontgomery County Schools BMI Data
2007-08
26%
19%
53%
2%
BMI ≥ 95%
BMI 85-94%
BMI Normal
BMI < 5%
Montgomery County Schools BMI Data 2008-09
27%
19%
52%
2%
BMI = 95%
BMI 85-94%
BMI Normal
BMI < 5%
2008-09 BMI Trends
47 47
33.9 33.930.6 30.6
0
5
10
15
20
25
30
35
40
45
50
Percentage of Obese/Overweight
Montgomery CountySchools
North Carolina United States
Montgomery County Adolescent BMI
2008
2009
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.
SHC BMI TrendsBMI after 2nd Nutrition Visit
SHC East 2008-09
55%
8%
37%
BMI DECREASED
BMI UNCHANGED
BMI INCREASED
SHC BMI TrendsBMI after 3rd Nutrition Visit
SHC East 2008-09
56%
19%
25%
BMI DECREASED
BMI UNCHANGED
BMI INCREASED
SHC BMI TrendsBMI after 2nd Nutrition Visit
SHC West 2008-09
43%
14%
43%
BMI DECREASED
BMI UNCHANGED
BMI INCREASED
SHC BMI TrendsBMI after 3rd Nutrition Visit
SHC West 2008-09
69%
6%
25%
BMI DECREASED
BMI UNCHANGED
BMI INCREASED
SHC BMI Trends
Overall decrease in BMI of
OB/OW students: 71%
n = 279
2008-09 HEAP Results
Candor 3rd Graders 2008-09 BMI
48%
15%
37%
0%
BMI ≥ 95%
BMI 85%-94%
BMI Normal
BMI < 5%
Candor 3rd Graders 2009-10 BMI
48%
11%
41%
0%
BMI ≥ 95%
BMI 85%-94%
BMI Normal
BMI < 5%
2008-09 HEAP ResultsGreen Ridge 3rd Graders
2008-09 BMI
29%
29%
40%
2%
BMI ≥ 95%
BMI 85%-94%
BMI Normal
BMI < 5%
Green Ridge 3rd Graders 2009-10 BMI
37%
21%
42%
0%
BMI ≥ 95%
BMI 85%-94%
BMI Normal
BMI < 5%
2008-09 HEAP Outcomes
Candor/Green Ridge/Mt. Gilead
Pretest – 58% Correct
Post-test – 93% Correct
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
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
2009-10 SHC BMI Trends
Nutrition Referrals for OB/OWn=261
• BMI ≥ 99% = 19%• BMI ≥ 95-98 = 42%• BMI 85-94% - 36%• BMI <5% or other = 3%
61% obese!!
Additional Efforts
• Present HEAP program to Green Ridge 1st graders – BMI: 33%OB/30%OW
• 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
Childhood Obesity Prevention: Models of Successful Programs
Be Fit, Get Moving
Kara Richards, MA
Meg McHenry, RD, MPH, LDN
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
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
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
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
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
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
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 McDonald’s almost everyday – I would be extremely obese” M, 15
– “One achievement I’m proud of is that I lowered my blood sugar. When I first started this program, it was in the 300s’. Now I’m getting results in the low 80’s.” 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
Process
• Program Structure– Tuesday education seminars and
neighborhood walk/boot camp – Thursday boot camp– Individual nutrition counseling– Individual exercise counseling – Field trips
Dining Out
Eating Out
Physical Activity
Community Support
Contact Information - Wake Teen Medical Services
• Kara Richards, Project Coordinator–[email protected]
• Meg McHenry, Nutritionist–[email protected]
• Telephone: 919-828-0035• www.waketeen.org
Contact Information - FirstHealth Montgomery County School Health Centers
• Gina Smith, FNP, SHC Manager–[email protected]
• Christina Turbeville, Nutrition Educator–[email protected]
• Telephone: 910-428-9392, East;
910-572-1979, West
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
Resources
• NASBHC - http://ww2.nasbhc.org/RoadMap/CONVENTION09/D7_1.pdf
• NASBHC CQI Tool – http://www.nasbhc.org/site/c.jsJPKWPFJrH/b.2719357/k.6312/EQ_Quality_Improvement.htm
• NICHQ – http://www.nichq.org
http://www.nichq.org/documents/coan-papers-and-publications/COANImplementationGuide62607FINAL.pdf
Resources
• Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report http://pediatrics.aappublications.org/cgi/reprint/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
Questions??
Merry Christmas!!