Carolyn Montoya MSN CPNPCoordinator FNP/PNP ConcentrationsCollege of Nursing University of New MexicoWorking with Families: Cultural Issues In Pediatric ObesityApril 28, 2006

National Association of Pediatric Nurse Practitioners

Healthy Eating and Activity Together Campaign

HEAT Focus Prevention of overweight in childhood and identification of children at risk for overweight as well as its physical and psychological morbidities.

HEAT Key CharacteristicsStrength-based

Relationship-based

Evidence-based

Culturally sensitive

Major Components of the GuidelineIntroductionFour age groups divisionsInfancyEarly ChildhoodSchool AgeTeenFour divisions within each age groupEarly identificationDevelopment, communication and relationshipsNutrition essentialsPhysical activity and sedentary behaviorAdvocacy

Prevalence of childhood overweightAt Risk for OverweightAny child ages 2 to 20 years with Body Mass Index (BMI)-for-age between 85th and 95th percentiles.

OverweightAny child ages 2 to 20 years with Body Mass Index (BMI)-for-age >95th percentile.

Centers for Disease Control. (2002). Overweight Children and Adolescents: Screen,Assess, and Manage.

Measurement of overweightBody Mass Index (BMI)It is a measure of weight for heightCorrelates well with specific measures of adiposityBMI = Weight in Kilograms (Height in Meters)2CDC. (2003).National Center for Chronic Disease Prevention and Health Promotion.

Prevalence of OVERWEIGHT Children 2003-2004 Selected Ethnic Groups National Health and Nutrition Survey (NHANES) 2006 Journal American Medical Association (JAMA) ArticleCitation 1

Prevalence of Overweight Children Trends Non-Hispanic WhiteOgden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

Prevalence of Overweight Children Trends African AmericanOgden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

Prevalence of Overweight Children Trends Mexican AmericanOgden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

Prevalence of Children AT RISK FOR OVERWEIGHT 2003-2004 Selected Ethnic Groups National Health and Nutrition Survey (NHANES) 2006 Journal American Medical Association (JAMA) Article

Citation 1

Prevalence of Children AT RISK FOR OVEWEIGHTTrends Non-Hispanic WhiteOgden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

Prevalence of Children At Risk for OverweightTrends African AmericanOgden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

Prevalence ofChildren At Risk for Overweight Trends Mexican AmericanOgden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

Prevalence of Overweight Children

Native American: Rates vary among tribes estimates as high as 39% for boys and 40% girls.

Citation 2

Questions regarding Strategies for Working withDiverse PopulationsDo health communication campaigns influence health behavior? Do health campaigns specifically aimed at diverse groups work?

Speaking of Health Assessing Health Communication Strategies for Diverse Populations 2001. Institute of medicine of the National Academies. The National Academies Press. Washington, D.C. www.nap.edu 2001

Strategies for Working withDiverse PopulationsIntracultural Variation

Stereotyping

Speaking of Health Assessing Health Communication Strategies for Diverse Populations 2001. Institute of medicine of the National Academies. The National Academies Press. Washington, D.C. www.nap.edu 2001

Cultural Views of What Constitutes an Overweight Child Being overweight not necessarily associated with being unhealthy among African American and Hispanic familiesThinness often associated with poor health

Cultural Views of What Constitutes an Overweight Child One study found that Hispanic mothers believed a little extra weight would help children recover from illnesses. Thin children tended to be more likely to develop disease.

Crawford, Patricia, et.al. (2004). Counseling Latina mothers of preschool children about weight issues: suggestions for a New Framework. Journal of the American Dietetic Association. 104(3) 387-394.

Cultural Views of What Constitutes an Overweight ChildMajority culture places huge emphasis on thinness, youth, and beautyMore cultural acceptance of larger body type among African AmericansShould the majority culture be held as the ideal? ORVALUE different body types and emphasize health, rather than weight

See Citation #3

Eckstein, K.; et al. (2006) Parents perception of their childs weight and health. Pediatrics 117 3 681-690.N=22360%

Eckstein, K.; et al. (2006) Parents perception of their childs weight and health. Pediatrics 117 3 681-690.

Does the Hispanic Paradox Exist?Even though risk factors may be elevated for Hispanics for diseases such as coronary heart disease, some national data indicates lower mortality rate for Hispanics.May be that spirituality, adaptive coping behaviors provide a certain protective factorLack of John Henryism need to succeed at all costs

FOOD INSECURITYDefinition food supply or ability to acquire food becomes limited or uncertainGreater food insecurity has been associated with higher prevalence of obesity in low-income Latino womenLittle to no research on the impact of food insecurity may have on overweight Latino children

Kaiser,Lucia; et.al. (2004). Choice of instrument influences relations between food insecurity and obesity in Latino women. American Journal Clinical Nutrition 80 1372-8.

ACCULTURATIONTraditional foods versus alternative foodsChild-led snacking versus setting limitsUse of bribes, threats and punishments to encourage eatingKaiser, L.; et.al. (2001). Acculturation of Mexican-American mothers influences child feeding strategies. Journal American Dietetic Association. 101(5) 542-547.

ESSENTIAL CULTURAL CONCEPTS When working with Hispanic FamiliesSimpatia the practice of being respectfulFamilismo need for the patient to consult with the family about a treatment planPersonalismo need to establish a personal relationship Respeto - feeling of being respected

Cultural Considerations ApplicableAll Age Groups Motivational InterviewingConviction: How important is this issue of being overweight to the child and family?

Confidence: Whats holding the child/family back from making changes?

Cultural Considerations ApplicableAll Age GroupsInclude extended family members in discussions related to childs health (may not be necessary with older teen)Encourage appropriate physical activity Focus on positive health Consequences of good Nutrition and increased Physical activity rather than Focusing on the childs WEIGHT.

Cultural Considerations - INFANCYReview normal patterns of infant growth and closely monitor rate of weight gain especially in the first 6 months of life. Additional guideline specific for Native American infants: Assess infant for intrauterine exposure to diabetes and promote breastfeeding

Cultural ConsiderationsSchool Age &TeensEncourage parents to offer traditional foods and not to offer children alternative foods when they refuse traditional foods No Come Nada4

Cultural ConsiderationsSchool Age & Teens Hispanics and Native Americans: beans, corn tortillas, vegetablesAfrican American: fruits and vegetablesHispanics: Encourage parents to involve school age children in the preparation and serving of meals. Native Americans: Provide information on the Pathways curriculum Http://hsc.unm.edu/pathways

Envision New MexicoPediatric Initiative in New Mexico to deal with the issue of overweight children in this statehttp://www.envisionnm.org/programoverview.html

Envision New MexicoOverweight Collaborative AIMSTo improve health care for children & adolescents who are recipients of Medicaid in New MexicoTo implement significant practice changes in provider offices in order to improve health outcomes and reduce healthcare costsTo offer providers best practice improvement toolsTo provide clear and consistent messages for children and familiesTo facilitate change through improved provider communication skillsTo promote collaboration between primary care practices, SBHCs, families, and communities

INTERNET RESOURCESVERB Its what you do. is a national, multicultural, social marketing campaign* coordinated by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/youthcampaign/index.htmThe VERB campaign encourages young people ages 913 (tweens) years to be physically active every day. Spanish VERB and Spanish Parent Site

Food and Nutrition InformationCenterhttp://www.nal.usda.gov/fnic/index.html

Native American Food Pyramidhttp://www.nal.usda.gov/fnic/Fpyr/NAmFGP.html

http://www.napnap.org/index.cfm?page=198&sec=220&ssec=486

Unless effective population-level interventions to reduce obesity are developed, the steady rise in life expectancy observed in the modern era may soon come to an end and the youth of today may, on average, live less healthy and possibly even shorter lives than their parents. The health and life expectancy of minority populations may be hit hardest by obesity, because within these subgroups, access to health care is limited and childhood and adult obesity has increased the fastest.AlejandroAndresGabrielOishansky, S. J., et.al. (2005) New England Journal of Medicine 352 (11) pg. 1143.

Citations Ogden, C.; Carroll, M., Curtin, L.; McDowell, M.; Tabak, C.; Flegal, K. (2006). Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295(13) 1549-1555.Story, M.; Stevens, J.; Himes, J.; Stone, E.; Rock, B.H.; Ethelbah, B.; Davis, S. (2003). Obesity in American-Indian children: prevalence, consequences, and prevention. Preventive Medicine 37 S3-S12.

Citations3. Sherry, B.; McDivitt, J.; Birch, L.L.; Cook, F.H.; Sanders, S.; Prish, J.L.; Francis, L. A.; Scanlon, K.S. (2004). Attitudes, practices, and concerns about child feeding and child weight status among socioeconomically diverse white, Hispanic, and African-American mothers. Journal of the American Dietetic Association. 104(2) 215-221.

4. Garcia, Richard (2004). No Come Nada. Health Affairs. 23(2) 215-219.

Reasonably good evidence that health communication campaigns can influence health behavior Little evidence on the enhanced impact of health campaigns that are planned with special attention to addressing the needs of diverse audiences.Striking lack of data available to answer essential questions about diversityIntracultural variation-change and variation within a cultural group- occurs constantly. These variations occur among individuals in the same setting, across generations, between genders, across geographic and rural urban settings, and so on. Often assumed that peoples behavior is locked in by their culture, an assumption that is incorrect and often resented as stereotyping.

Often assumed that peoples behavior is locked in by their culture, an assumption that is incorrect and often resented as stereotyping.

Crawfor, P. B., et.al. (2004). Counseling Latina Mothers of Preschool Children about Weight Issues: Suggestions for a New Framework. Jouranl of the American Dietietic Association Vol. 104 No. 3 pg. 387-394.

In these households, women reduce their own food intakes in an attempt to spare both the adult males and young chidren from experiencing hunger. Fodd insecurity in Latino huseholds is associated with significantly lower howehold supplies of fruit and veetables. In times of food insecurity, Latino households of Mexian descent rely heavily on traditional foods, including corn tortillas, beans, rice, potatoes, egggs, tomatoes, and child peppers. Children who are allowed to opt out of trying traditional foods such as beans, corn tortillas, or dishes containg vegetables, may grow less accepting of these foods over time.Mexican-American parents tend to be ambivalent about the need to limit child led snacking. Simpatia appearing to understand and agree with the advice of the practitioner even though they may neither understand nor intend to comply with the treatment

Barron, Florencia; Hunter, Anita; Mayo, Rachel; Willoguhby, Deborah. Acculturation and Adherence: Issues for Health Care Providers Working with Clients of Mexican Origin. Jouranl of Transcultural Nursing. Vol. 15 No. 4, October 2004. Pg. 331-7