Application of Clinical Research: Improving Provider Knowledge to Decrease Pediatric Obesity Dr. Susan Farus-Brown, DNP, CNP, FNP-BC Assistant Professor of Nursing Ohio University

Background of the Problem Twenty three million children in the United States are obese or overweight (Green, Riley, and Hargrove, 2012). Global occurrence of overweight and obese children increased from 4.2% in 1990 to 6.7% in 2010, and will likely reach 9.1%, or 60 million children by 2020 (Raj, 2012).

Background of the Problem Global obesity rates more than tripled since 1981 (WHO, 2012). There are a greater number of adolescents from families living in poverty that are obese (23%), compared with those families of a higher socioeconomic status (14%) (The Health Policy Tracking Service, 2008).

Significance of the Problem to Provider Practice Fifty one percent of nurse practitioners surveyed believed that children sometimes outgrow their overweight/obesity (Hessler and Siegrist, 2012). Being overweight or obese in childhood leads to obesity as an adult (Goran, 2001) and the most reliable predictors of overweight at age 11 was being overweight at age nine (Dwyer, et al, 1998).

Significance of the Problem to Provider Practice Studies have found that most medical schools are not adequately preparing their students for discussing weight management with their patients (Peters, Bird, Ashraf, McNamee, & Ng, 2013). Forty percent of 99 NPs surveyed reported not using any guidelines in their prevention practices. More than half the NPs sampled reported never or rarely using BMI to identify rate of weight gain their patients (Larsen, Mandleco, Williams, and Tiedemann, 2006).

Significance of the Problem to Provider Practice Twelve percent of 256 pediatricians reported high confidence levels with managing obesity. However, nearly all respondents reported that they were in need of better counseling tools (Miller-Perrin, Flower, Garrett, & Ammerman, 2005).

Significance of the Problem to Provider Practice Physician’s reported a low confidence level in the management of pediatric obesity. Twenty percent (249) of 1,243 physicians rated themselves as not at all or slightly comfortable in treating pediatric obesity (Jelalian, Boergers, Alday, and Frank, 2003).

Significance of the Problem to Provider Practice Reasons for poor management of pediatric obesity may be more personal for the provider. It may be the personal characteristics of the providers such as one’s own weight, eating habits, and exercise patterns (Freedman and Stern, 2004).

Application to Clinical Practice

Project Purpose The purpose of this project is to increase NP knowledge of prevention, recognition, and treatment of pediatric obesity. Once providers are confident with their own abilities to address pediatric obesity they were more comfortable utilizing prevention and treatment strategies (Jelalian, Boergers, Alday, and Frank, 2003).

About the Tool Kit The tool kit was developed by BlueCross BlueShield of New Mexico (2013) in collaboration with The American Academy of Pediatrics, The American Diabetes Association, and the U.S. Centers for Disease Control and Prevention. The tool kit is titled “Prevention and Treatment of Pediatric Obesity and Diabetes” The tool kit includes education on general risk assessment, physical risk assessment, behavioral risk assessment, and discussion of common diseases related to childhood obesity.

Project Sample The participants were selected by convenience sampling. The sampling criterion includes nurse practitioners that practice in an ambulatory care setting. The sample size was between 15-20 participants spanning from two different districts located with Southeastern Ohio (7-8 clinics).

Project Design The design consists of assessing NP knowledge both pre and post-intervention utilizing a questionnaire.

Project Design Following the completion of the pre-intervention questionnaire, a power point presentation was offered discussing the significance of pediatric obesity, as well as, participant education on the use of tool kit. Post-intervention knowledge was measured after the participant utilized the tool kit for a two-month period by completing the same questionnaire utilized in the pre-intervention.

Instrumentation The project utilized the Assessment of Overweight in Children and Adolescents (AOCA) tool, developed by Story and others (2002). The AOCA is a likert-scale instrument and contains two sections, the first focusing on the experiences and attitudes of the healthcare professional and the second on the assessment and actual treatment of the overweight child.

Chosen Methodology Given the small sample size and unequal number of pre and post-intervention respondents, the best nonparametric test is the Mann-Whitney U-Test. When changes in the mode or median were noted, the Mann-Whitney U-Test was utilized to determine significance between pre and post-intervention responses.

Results

Barriers to Effective Treatment Pre-intervention responses indicated that participants perceived that their clinical knowledge (“sometimes”) and treatment skills (“sometimes”) were occasional barriers to effective treatment. Post-intervention scores demonstrate participants increasingly believed lack of clinician knowledge (“often”), and lack of clinician treatment skills (“often”) were the most serious barriers to treatment of pediatric overweight/obesity.

Barriers to Effective Treatment The increase noted for lack of clinician knowledge and lack of clinician treatment skills were both noted to be statistically significant (p< 0.05).

Sources for Information Pre-intervention responses indicated that participants were most likely to rely on past experiences (“often”) to inform practice. Post-intervention scores demonstrate less reliance on past experience (“sometimes”) and increased reliance on more appropriate sources such as information from nursing/graduate school, professional journal articles (p < 0.05), seminars/CME courses, computer programs/websites (INF3D), and pharmaceutical companies (p < 0.05).

Skill Proficiency Participants pre and post-intervention rated their proficiency in behavioral management strategies, modification of diet/eating practices, modification of physical activity, and guidance in parenting techniques as “moderate.” The participants rated their proficiency in assessment of degree of overweight in children and adolescents as “moderate” pre-intervention and “high” post-intervention.

Addressing Overweight and Providing Recommendations About Weight Pre-intervention, respondents reported “never” making recommendations for weight management for children aged 5 years or less. Respondents were more likely to make recommendations regarding weight control (“sometimes”) for both school-aged children and adolescents.

Addressing Overweight and Providing Recommendations About Weight Post-intervention responses remained unchanged for infants, school-aged children, and adolescents. However, respondents were significantly more likely (p <0.05) to make weight control recommendations for pre-school aged children. These results may suggest that the NPs are now aware that children are not likely to outgrow their overweight and the problem needs to be addressed when it is identified.

Methods to Assess Excess Weight Pre-intervention the participants were more likely to use their clinical impression (“sometimes”) to judge excess weight. They stated that they “rarely” used weight for age percentile, change in weight velocity (crossing percentiles), and body mass index percentile to assess excess weight gain.

Methods to Assess Excess Weight Post-intervention the participants were more likely to use multiple methods to assess weight. Participants reported they would use weight for age percentile (“sometimes”), weight for height percent (“often”), change in weight velocity (“sometimes”), waist-hip ratio (“sometimes”) and BMI percentile (“most of the time”).

Methods to Assess Excess Weight Further reliance on clinical impression and increase use of waist-hip ratio were noted to be statistically significant (p <0.05). Change in the directionality of the responses seem to suggest that respondents began to use multiple assessment measures. NP’s clinical impression seems to persist as the dominant response post-intervention.

Implications for the Future The relationship between obesity and mental health would be a potential direction. Additional research needs to be completed to better assess which component proceeds: obesity or poor mental health. Does the mental disorder lead to obesity or does obesity lead to poor mental health in the pediatric population? Begin changing the conversation that we have with our patients and families: Explore the relationship to pediatric obesity and early antibiotic use.

Application of Project in Other Settings The project could easily be utilized in a family or pediatric practice with little modification. The project could be adapted to a preventive treatment strategy for new parents beginning as early as when they are seeking prenatal care.

Application of Project in Other Settings Findings of this project suggest applying it to the graduate curriculum for the advance practice nurse and the medical student. Discussions on this subject should extend far beyond simply limiting screen time, increasing physical activity and diet changes. Providers should be armed with knowledge and skills to help them confidently address issues of childhood obesity.