1. Carolyn Montoya MSN CPNP Coordinator FNP/PNP Concentrations College of Nursing University of New Mexico Working with Families: Cultural Issues In Pediatric Obesity April 28, 2006

2. National Association of Pediatric Nurse Practitioners Healthy Eating and Activity Together Campaign

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

4. HEAT Key Characteristics Strength-based Relationship-based Evidence-based Culturally sensitive

5. Major Components of the Guideline Introduction Four age groups divisions –Infancy –Early Childhood –School Age –Teen Four divisions within each age group –Early identification –Development, communication and relationships –Nutrition essentials –Physical activity and sedentary behavior –Advocacy

6. Prevalence of childhood overweight “At Risk for Overweight” Any child ages 2 to 20 years with Body Mass Index (BMI)-for-age between 85 th and 95 th percentiles. “Overweight” Any child ages 2 to 20 years with Body Mass Index (BMI)-for-age >95 th percentile. Centers for Disease Control. (2002). Overweight Children and Adolescents: Screen,Assess, and Manage.

7. Measurement of overweight Body Mass Index (BMI) It is a measure of weight for height Correlates well with specific measures of adiposity BMI = Weight in Kilograms (Height in Meters) 2 CDC. (2003).National Center for Chronic Disease Prevention and Health Promotion. BMI = 28 BMI Does Not Measure Body Fat

8. Prevalence of OVERWEIGHT Children 2003-2004 Selected Ethnic Groups –National Health and Nutrition Survey (NHANES) 2006 Journal American Medical Association (JAMA) Article AGEWhite Percent African American Percent Mexican American Percent 2-19y16.320.019.2 2-5y11.513.019.2 6-11y17.722.022.5 12-19y17.321.816.3 Citation 1

9. Prevalence of Overweight Children Trends – Non-Hispanic White YEARS2-19y2-5y6-11y12-19y 1999- 2000 11.08.711.711.4 2001- 2002 13.98.714.815.2 2003- 2004 16.311.517.717.3 Ogden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

10. Prevalence of Overweight Children Trends – African American YEARS2-19y2-5y6-11y12-19y 1999- 2000 18.88.719.623.1 2001- 2002 17.58.619.919.3 2003- 2004 20.013.022.021.8 Ogden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

11. Prevalence of Overweight Children Trends – Mexican American YEARS2-19y2-5y6-11y12-19y 1999- 2000 20.210.923.423.2 2001- 2002 19.515.920.121.1 2003- 2004 19.2 22.516.3 Ogden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

12. 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 AGEWhite Percent African American Percent Mexican American Percent 2-19y33.535.137.0 2-5y25.024.032.6 6-11y36.940.042.9 12-19y34.736.534.3 Citation 1

13. Prevalence of Children AT RISK FOR OVEWEIGHT Trends – Non-Hispanic White YEARS2-19y2-5y6-11y12-19y 1999- 2000 25.121.526.026.2 2001- 2002 27.620.030.228.8 2003- 2004 33.525.036.934.7 Ogden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

14. Prevalence of Children At Risk for Overweight Trends – African American YEARS2-19y2-5y6-11y12-19y 1999- 2000 34.321.235.839.5 2001- 2002 31.825.331.934.5 2003- 2004 35.124.040.036.5 Ogden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

15. Prevalence of Children At Risk for Overweight Trends – Mexican American YEARS2-19y2-5y6-11y12-19y 1999- 2000 36.623.138.843.3 2001- 2002 37.030.139.438.5 2003- 2004 37.032.642.934.3 Ogden, et al. (2006). Prevalence of Overweight and obesity in the United States, 199-2004. JAMA 295(13) pg. 1551.

16. Prevalence of Overweight Children Native American: Rates vary among tribes estimates as high as 39% for boys and 40% girls. Citation 2

17. Questions regarding Strategies for Working with Diverse Populations Do 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 2001www.nap.edu

18. Strategies for Working with Diverse Populations Intracultural 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 2001www.nap.edu

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

20. 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.

21. Cultural Views of What Constitutes an Overweight Child Majority culture places huge emphasis on thinness, youth, and beauty More cultural acceptance of larger body type among African Americans Should the majority culture be held as the ideal? OR VALUE different body types and emphasize health, rather than weight

22. See Citation #3

23. Eckstein, K.; et al. (2006) Parent’s perception of their child’s weight and health. Pediatrics 117 3 681-690. N=223 60% <6yrs 42% Male 17% Black 35% Hispanic 42% White 7% Other 20% Overweight 19% At risk for overweight

24. Eckstein, K.; et al. (2006) Parent’s perception of their child’s weight and health. Pediatrics 117 3 681-690.

25. 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 factor Lack of “John Henryism” – need to succeed at all costs

26. FOOD INSECURITY Definition – food supply or ability to acquire food becomes limited or uncertain Greater food insecurity has been associated with higher prevalence of obesity in low- income Latino women Little 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.

27. ACCULTURATION Traditional foods versus alternative foods Child-led snacking versus setting limits Use of bribes, threats and punishments to encourage eating Kaiser, L.; et.al. (2001). Acculturation of Mexican-American mothers influences child feeding strategies. Journal American Dietetic Association. 101(5) 542-547.

28. ESSENTIAL CULTURAL CONCEPTS When working with Hispanic Families Simpatia – the practice of being respectful Familismo – need for the patient to consult with the family about a treatment plan Personalismo –need to establish a personal relationship Respeto - feeling of being respected

29. Cultural Considerations Applicable All Age Groups – Motivational Interviewing Conviction: How important is this issue of being overweight to the child and family? Confidence: What’s holding the child/family back from making changes?

30. Cultural Considerations Applicable All Age Groups Include extended family members in discussions related to child’s 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 child’s WEIGHT.

31. Cultural Considerations - INFANCY Review 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

32. Cultural Considerations School Age &Teens Encourage parents to offer traditional foods and not to offer children alternative foods when they refuse traditional foods “No Come Nada” 4

33. Cultural Considerations School Age & Teens Hispanics and Native Americans: beans, corn tortillas, vegetables African American: fruits and vegetables Hispanics: 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 Http://hsc.unm.edu/pathways

34. Envision New Mexico Pediatric Initiative in New Mexico to deal with the issue of overweight children in this state http://www.envisionnm.or g/programoverview.html

35. Env ision New Mexico Overweight Collaborative AIMS l To improve health care for children & adolescents who are recipients of Medicaid in New Mexico l To implement significant practice changes in provider offices in order to improve health outcomes and reduce healthcare costs l To offer providers best practice improvement tools l To provide clear and consistent messages for children and families l To facilitate change through improved provider communication skills l To promote collaboration between primary care practices, SBHCs, families, and communities

36. INTERNET RESOURCES VERB™ It’s 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.htm The VERB campaign encourages young people ages 9–13 (tweens) years to be physically active every day. Spanish VERB and Spanish Parent Site

37. Food and Nutrition Information Center http://www.nal.usda.gov/fnic/index.htm l

38. Native American Food Pyramid http://www.nal.usda.gov/fnic/Fpyr/NAmFGP.html

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

40. “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.” Alejandro Andres Gabriel Oishansky, S. J., et.al. (2005) New England Journal of Medicine 352 (11) pg. 1143.

41. Citations 1. 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. 2.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.

42. Citations 3. 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.