# Presentation: 502560

## 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@osu.edu                                       

**of the National Association of Pediatric Nurse Practitioners**
**Mary Margaret Gottesman, PhD, RN, CPNP, National Chair****           **
**The Ohio State University, gottesman.6@osu.edu****                                       **
**                                          **

## Supported by

**and**

**Gerber Products Company**

## 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

## 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 )**

## 	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

## 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

## What’s 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**

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

**	****	****	****	****      ****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**

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

## 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)

## 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**
- Critical and sensitive periods    Psycho-neuro-endocrine-immune regulation

**Halfon & Hochstein,2002**

## Halfon & Hochstein, 2002

**Halfon & Hochstein, 2002**

## 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.**

## HEAT Goal

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

## 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

## 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

## 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

## What’s 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

## 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
- Kathy Sawin, DNS, CPNP, FAAN
- Professor and Joint Research Chair in the Nursing of Children
- Children’s Hospital of Wisconsin and College of Nursing, University of Wisconsin-Milwaukee
- Marlene Swartz, PhD
- Rudd Center for Food Policy and ObesityYale University
- Reginald L. Washington, MD, FAAP, FACC, FAHA
- Rocky Mountain Pediatrix Cardiology
- Richard C. "Mort" Wasserman, MD, MPH
- Professor of Pediatrics, University of Vermont
- Director, Pediatric Research in Office Settings, AAP Center for Child Health Research
- Over 175 nurse practitioners

## 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.

## 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

## 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.

## Where can I learn more?

**Identifying and Preventing Overweight **
**in **
**Childhood Clinical Practice Guideline and Resource Kit**
**Please visit**** **_[http://www.napnap.org](http://www.napnap.org/)_
**for more information.**