Carolyn Montoya MSN CPNP Coordinator FNP/PNP Concentrations College of Nursing University of New Mexico Working with Families: Cultural Issues In Pediatric

Carolyn Montoya MSN CPNPCoordinator FNP/PNP Concentrations

College of Nursing University of New Mexico

Working with Families: Cultural Issues

In Pediatric Obesity

April 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 Characteristics

•Strength-based

•Relationship-based

•Evidence-based

•Culturally sensitive

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

Prevalence of childhood overweight

“At Risk for Overweight”Any child ages 2 to 20 years with Body Mass

Index (BMI)-for-age between 85th and 95th percentiles.

“Overweight”Any 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 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.CDC. (2003).National Center for Chronic Disease Prevention and Health Promotion.

BMI = 28BMI Does Not Measure Body Fat

Prevalence of OVERWEIGHT Children 2003-2004

Selected Ethnic Groups –National Health and Nutrition Survey (NHANES)

2006 Journal American Medical Association (JAMA) Article

AGE White

Percent

AfricanAmerica

nPercent

MexicanAmerica

nPercent

2-19y 16.3 20.0 19.2

2-5y 11.5 13.0 19.2

6-11y 17.7 22.0 22.5

12-19y 17.3 21.8 16.3

Citation 1

Prevalence of Overweight Children Trends – Non-Hispanic White

YEARS 2-19y 2-5y 6-11y 12-19y

1999-2000

11.0 8.7 11.7 11.4

2001-2002

13.9 8.7 14.8 15.2

2003-2004

16.3 11.5 17.7 17.3

Ogden, 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 American

YEARS 2-19y 2-5y 6-11y 12-19y

1999-2000

18.8 8.7 19.6 23.1

2001-2002

17.5 8.6 19.9 19.3

2003-2004

20.0 13.0 22.0 21.8


Prevalence of Overweight Children Trends – Mexican American

YEARS 2-19y 2-5y 6-11y 12-19y

1999-2000

20.2 10.9 23.4 23.2

2001-2002

19.5 15.9 20.1 21.1

2003-2004

19.2 19.2 22.5 16.3


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

AGE White

Percent

AfricanAmerica

nPercent

MexicanAmerica

nPercent

2-19y 33.5 35.1 37.0

2-5y 25.0 24.0 32.6

6-11y 36.9 40.0 42.9

12-19y 34.7 36.5 34.3Citation 1

Prevalence of Children AT RISK FOR OVEWEIGHTTrends – Non-Hispanic White

YEARS 2-19y 2-5y 6-11y 12-19y

1999-2000

25.1 21.5 26.0 26.2

2001-2002

27.6 20.0 30.2 28.8

2003-2004

33.5 25.0 36.9 34.7


Prevalence of Children At Risk for OverweightTrends – African American

YEARS 2-19y 2-5y 6-11y 12-19y

1999-2000

34.3 21.2 35.8 39.5

2001-2002

31.8 25.3 31.9 34.5

2003-2004

35.1 24.0 40.0 36.5


Prevalence ofChildren At Risk for Overweight

Trends – Mexican American

YEARS 2-19y 2-5y 6-11y 12-19y

1999-2000

36.6 23.1 38.8 43.3

2001-2002

37.0 30.1 39.4 38.5

2003-2004

37.0 32.6 42.9 34.3


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 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 2001

Strategies for Working withDiverse 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 2001

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


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.


• 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

See Citation #3

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

N=22360% <6yrs42% Male17% Black35% Hispanic42% White 7% Other

20% Overweight19% At risk for overweight

Eckstein, K.; et al. (2006) Parent’s perception of their child’s 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 factor

• Lack of “John Henryism” – need to succeed at all costs

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 childrenKaiser,Lucia; et.al. (2004). Choice of instrument influences relations

between food insecurity and obesity in Latino women. American Journal Clinical Nutrition 80 1372-8.

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.

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

Cultural Considerations ApplicableAll 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?

Cultural Considerations ApplicableAll 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.

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

Cultural ConsiderationsSchool Age &Teens

• Encourage parents to offer traditional foods and not to offer children alternative foods when they refuse traditional foods “No Come Nada”4

Cultural ConsiderationsSchool 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

Envision New Mexico

Pediatric Initiative in New Mexico to deal with the issue of overweight children in this state

http://www.envisionnm.org/

programoverview.html

EnvEnvision New Mexicoision New MexicoOverweight Collaborative AIMSOverweight Collaborative AIMS

To improve health care for children & adolescents who are recipients of Medicaid in New Mexico

To implement significant practice changes in provider offices in order to improve health outcomes and reduce healthcare costs

To offer providers best practice improvement tools

To provide clear and consistent messages for children and families

To facilitate change through improved provider communication skills

To promote collaboration between primary care practices, SBHCs, families, and communities

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

Food and Nutrition InformationCenter

• http://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.”

Alejandro

AndresGabri

elOishansky, S. J., et.al. (2005) New England Journal of Medicine 352 (11) pg. 1143.

Citations1. 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.

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.

Documents

Carolyn Montoya MSN CPNP Coordinator FNP/PNP Concentrations College of Nursing University of New Mexico Working with Families: Cultural Issues In Pediatric