- Email: [email protected]
A Weight Management Program Within a High School Health Center
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
A Weight Management Program Within a High School Health Center Laura O. Smith, PhD, FNP-BC a b s t r a c t Keywords: adolescent obesity school-based health center weight management
A program for helping adolescent students manage their weight was implemented within a school-based health center to promote evidence-based practice and identify barriers to successful weight management. Voluntary student participation included 6 visits with an advanced practice registered nurse. Body mass index screenings (n ¼ 702) and system variables for case-managed students (n ¼ 41) were examined to identify treatment gaps. Despite a high number of eligible students (n ¼ 250), a low percentage of students (16%) enrolled in case management services. Building effective and sustainable approaches for weight loss in this population requires adequate staffing and community resources. © 2019 Elsevier Inc. All rights reserved.
The public health obesity crisis in adolescence requires an identification of deficits and promotion and implementation of effective strategies. There is a positive association between adolescent health behaviors and adult health outcomes,1 with societal costs projected to exceed $145 billion.2 Obesity is a chronic condition that requires a comprehensive assessment, evaluation, and treatment plan that includes documentation of prior health conditions, physical examination, family stability, and the students’ social environment. Weight reduction efforts for adolescents will likely benefit from interventions provided in a school-based environment. The school-based health center (SBHC) offers a health promotion milieu where ease of access to students is a key component. Traditionally, high-risk communities have difficulty accessing quality health care, and a SBHC located on the school property closes this gap.3 The SBHC service delivery models vary, and sound management practices are necessary to ensure sustainability. The setting is ideal for engaging students in efforts to improve their health outcomes and thereby academic success.4,5 Resources to promote healthy lifestyles in youth within the SBHC include personnel and medical equipment. Although these resources are necessary for treatment of obesity, there is a heavy behavioral health component for successful and sustained weight loss that requires additional resources,6 and SBHC data validate successful outcomes treating obesity.7 Resources in an SBHC environment can be limited and may reduce nurses’ effectiveness in managing obesity. These limitations include knowledge deficits of best practices related to obesity management and prohibitive workloads for successful care coordination.4 Communication between the SBHC and the community health care provider (medical home) is necessary for improved health outcomes and requires time.8 This process is necessary for https://doi.org/10.1016/j.nurpra.2019.08.025 1555-4155/© 2019 Elsevier Inc. All rights reserved.
reducing treatment duplication and cost, and it provides the primary care provider updates that improve patient outcomes in chronic disease management.9 A case management project for treatment of adolescent obesity was implemented in a SBHC located in a metropolitan public high school in the Southeastern United States providing free health care services to the 1,677 students attending the school. In the academic school year before project implementation, 852 unduplicated students visited the SBHC. These students identified themselves as 40% minority and 53% economically disadvantaged. The project was initiated to examine the process for treating obesity, promote evidence-based practice, and identify barriers to successful weight management of students in the high school setting. Methods Setting and Eligibility The SBHC is on the school campus and staffed by a family nurse practitioner (NP), a licensed practical nurse, and a medical assistant. Parental consent is necessary to receive health services, and teachers provide students with permission (hall pass) for an SBHC visit. Students with consent who had a body mass index (BMI) value > 25 kg/m2 were invited to participate. Procedure The project was approved by the Florida Department of Health Institutional Review Board. The assessment and management plan is summarized in an algorithm (Figure 1) and was adapted from the American Academy of Pediatrics’ guidelines for management of childhood obesity.10 The BMI was used to establish, a pathway for
e2
L.O. Smith / The Journal for Nurse Practitioners xxx (xxxx) xxx
BMI > 85%
Measure height and weight Calculate BMI and plot Classify weight (LPN)
Readiness assessment (Student)
NO
Ready for change?
BMI = 5 - 85% YES
Support healthy eating and activity Engage student in 5-2-1-0 behaviors (APRN)
Re-evaluate weight annually (CNA)
Review contract letter with student (APRN)
F/U 6 -12 months (Student)
Nutritional assess and PE (APRN)
Encourage group participation Reinforce BMI (APRN) YES
Family hx DM, CAD or abnormal PE?
NO
Develop SMART goals and continue treatment plan (Student & APRN)
Consent for lab?
NO
Assess depression levels and ACE scores (APRN)
NO
NO
YES
Contact parent to report PE findings and request lab (APRN)
Weight loss?
YES
YES
Obtain labs (LPN) and review (APRN)
Abnormal Findings?
Treatment or refer to specialist (APRN)
Figure 1. Process used for weight management. ACE ¼ adverse childhood experiences; APRN ¼ advanced practice registered nurse; BMI ¼ body mass index; CAD ¼ coronary artery disease; CNA ¼ certified nursing assistant; DM ¼ diabetes mellitus; F/U ¼ follow-up; hx ¼ history; LPN ¼ licensed practical nurse; PE ¼ physical examination; SMART ¼ specific, measurable, attainable, relevant, and time-bound.
management. Students who were of normal weight were provided instruction on the 5-2-1-0 (eat 5 or more servings of fruits and vegetables, limit of 2 hours or less of recreational screen time, engage in 1 hour or more of physical activity, and limit sugary drinks; drink more water and low fat milk) prevention strategies and reinforcement for healthy behaviors.11 Students with a BMI > 85th percentile were encouraged to discuss their intention to participate with their parent and schedule their first of 6 visits with the SBHC receptionist. On the initial visit, a plan of care was developed with the NP that included a nutritional assessment (Figure 2) and an assessment of readiness to change activity and dietary behaviors.12 After this evaluation, students developed a specific, measurable, attainable, relevant, and timebound (SMART) goal. Subsequent visits included a follow-up at 2 weeks, and the remaining 4 visits were scheduled at monthly intervals with the NP. The student completed a questionnaire at each appointment. Questions included: 1. 2. 3. 4.
What changes to diet and activity were made since the last visit? Are you pleased with your progress and if not, why not? What challenges were encountered in making changes? What might have been done differently?
confidence to sustain the behavior modification. After this achievement, the NP encouraged and assisted students to identify another SMART goal. Results Of 702 students who were screened, 452 (64%) had a BMI < 85th percentile. The remaining 250 students having a BMI > 85th percentile were encouraged to participate. Forty-one students (16.4%) who met eligibility enrolled in the program and completed the initial assessment. Additional demographic information for the participants is provided in the Table. Project measures included the number of students who returned after the initial assessment (n ¼ 33 [80%]) and the number of visits per student (mean, 3.51). Ten students (30%) completed all 6 visits. In addition, the length of the visit (mean, 40 minutes), number of students who indicated a positive family history for obesity or another comorbid condition on assessment (n ¼ 26 [63%]), and students’ readiness scores were recorded. Although 35 participants (85.4%) indicated they were in the action or maintenance stages for changing diet and exercise behaviors, overall reduction in the BMI was minimal. Discussion
The NP reviewed strategies at each visit, and students were guided in developing new goals. Education and health promotion discussion continued until the adolescent reported a high level of
Every student who sought services at the SBHC had a BMI screening; thus, 42% of the entire school population received care
L.O. Smith / The Journal for Nurse Practitioners xxx (xxxx) xxx
e3
WEIGHT MANAGEMENT Name
DOB
Contact phone
Guardian phone
Referred by
Healthcare providers
Current weight
Told previously of unhealthy BMI weight? BMI % Are you concerned about your height or your weight? Why or Why not?
Date
Current health status
Do any family members have a weight concern? Y/N WHO? On the line below, indicate how important is it to you to develop a more healthy lifestyle including losing weight and becoming more physically active? 1 5 Can you identify things in your day to day life that you know need to change?
10
What things in your life might interfere with making changes? (stress, unsafe environment, money, depression, anxiety, family worries) Circle factors below that apply to student: Free lunch Parent Divorce Parent death
Domestic violence Did you eat breakfast today? Y/N Yesterday? Y/N Do you like to cook? Y / N Skip meals to lose weight? Y / N Who grocery shops in your home?
Neighborhood Substance Incarceration of Familial mental violence/gang abuse family member illness Lunch today? Y/N Yesterday? Y/N Dinner? Y/N Yesterday? Y/N Have you been on “diets” in the past? Y / N Who cooks or prepares food in your home?
How many Fruit? Vegetable? Diet soda? Water? Milk? Sports/sweet Juice? serving a day drinks? What is a snack food for you? How often do you buy your food already prepared (fast food)? Do you participate in the school meal program? Yes No Sometimes Do you buy food at lunch? Yes No Sometimes Have you binged/vomited to control weight? Y/N Diet pills? Y/N Other medications? Y/N How many hours a day do you Play video Surf web? Social networking? Homework? watch TV? games? What do you do for exercise? Frequency/wk and amount of time for each/day Walking Dancing Sports Running Other: How many hours a night do you sleep? FEMALES ONLY: Date of LMP: Irregular? Y / N OCP? Y/N Figure 2. Nutritional assessment developed for project completed orally by students with advanced practice registered nurse. BMI ¼ body mass index; DOB ¼ date of birth; LMP ¼ last menstrual period; N ¼ no; OCP ¼ oral contraceptive pills; Y ¼ yes.
during the project period. Students who use the SBHC typically seek physical examinations for participation in extracurricular activities or have an acute or chronic health care need. Students who have a medical home are likely to receive services by their primary provider. The need for a weight management program was supported because 35% of students screened could have benefited from the program. However, student participation was low, at only 16% at
Table Select Student Demographic Characteristics Characteristic
Number (%) (N ¼ 41)
Body mass index 26 to 30 kg/m2 31 to 35 kg/m2 >35 kg/m2 Sex Female Male Race/ethnicity African American/black Hispanic White Other Class level Freshman Sophomore Junior
10 (24.4) 12 (29.3) 19 (46.3) 26 (63.4) 15 (35.5) 16 9 11 5
(39) (22) (26.8) (12.2)
13 (31.7) 12 (29.3) 9 (22)
initiation and 13% at follow up. Several factors were identified that likely contributed to low participation. Participation and encouragement from parents have been shown to improve outcomes in weight reduction rates.13 During this project, the NP contacted parents via phone only when laboratory work was indicated, primarily because parents have limited availability during the school day. The Health Insurance Portability and Accountability Act requirements make alternative methods, such as telehealth, email, and text messaging, difficult because the software needed for these vehicles require platforms that exceed the in-home capability of most parents.14 The school cloud offers a secure and possible mechanism for providing parents educational opportunities and to obtain data that could reduce duplication of health services, but families would need a remote connection placed on their devices. Another important factor for a successful weight management program is assistance in establishing students with a medical home. This patient-centered care model is a holistic approach to health care delivery that includes a primary care provider, collaborating health providers, integration of technology to improve access, and a delineated payment structure that reflects its value.15 Most of the students recalled a previous medical encounter when they were advised to lose weight; however, they could not name their health care provider or a prescribed intervention or treatment. Efforts to communicate their condition and transmit medical records was time intensive even when students had an established medical provider. For example, students who had recent laboratory evaluations done by their medical home needed a
e4
L.O. Smith / The Journal for Nurse Practitioners xxx (xxxx) xxx
Health Insurance Portability and Accountability Act release via a parent signature and had to return the document before a fax could be sent to the provider’s office requesting the needed information. A large percentage of students did not return with the documents, which meant staff intervention measures taken up to that point, as well as student motivation, were lost. Student participation in physical activity was a priority. If the SBHC had established community resources for students that included accessible recreational activities with training components, outcomes might have improved.6 Students reported an inability to afford sport activities or they had no reliable transportation, or both. Furthermore, students expressed spending after-school hours engaging in sedentary activity but verbalized an interest in an employment or volunteer opportunities. Providing these nontraditional treatment measures strengthens the SBHC as a valued referral source, offers students alternative coping strategies, and provides opportunities that may sustain behavior changes. The NP has an opportunity to identify community partners and communicate with them to substantiate a need for student participation. In addition, the NP can offer workshops or speak at community events to detail available resources for children and adolescents. This effort may ultimately benefit the organizations and build collaborative partnerships that can improve adult health, thereby strengthening communities.
Limitations This weight management program has limitations. Staff was not provided training in motivational interviewing techniques, which might have improved enrollment numbers. In addition, recording dietary and activity data in a software application could enhance personal intervention and weight loss, thereby motivating students to remain in the program. Finally, limited parental participation and conflicting student schedules likely contributed to low participation rates. Conclusion The associated health risks students will face as adults will decrease only when opportunities for screening, educating, and intervening are available to them. SBHCs seem like the ideal place to host such programs, but they face significant challenges. School nurses can be guided by APRNs and other providers to use effective evidence-based strategies for addressing obesity. Overcoming inadequate communication between parents and providers of the students’ medical homes, in addition to finding additional resources for incentives and technology, are worthwhile efforts for engaging students in weight loss efforts through the SBHC.
References 1. Hargreaves DS, Elliott MN, Viner RM, Richmond TK, Schuster MA. Unmet health care need in US: adolescents and adult health outcomes. Pediatrics. 2015;136:513-520. https://doi.org/10.1542/peds.2015-0237. 2. Sonntag D, Ali S, De Bock F. Lifetime indirect cost of childhood overweight and obesity: a decision analytic model. Obesity (Silver Spring). 2016;24:200-206. https://doi.org/10.1002/oby.21323. 3. Knopf JA, Finnie RK, Peng Y, et al. School-based health centers to advance health equity: a community guide systematic review. Am J Prev Med. 2016;51: 114-126. https://doi.org/10.1016/j.amepre.2016.01.009. 4. American Academy of Pediatrics Council on School Health. Role of the school health nurse in providing school health services. Pediatrics. 2016;137: e20160852. https://doi.org/10.1542/peds.2016-0852. 5. Vinciullo FM, Bradley BJ. A correlational study of the relationship between a coordinated school health program and school achievement: a case for school health. J Sch Nurs. 2009;25:453-465. https://doi.org/10.1177/ 1059840509351987. 6. Sussman AL, Montoya C, Werder O, Davis S, Wallerstein N, Kong AS. An adaptive CBPR approach to create weight management materials for a school based health center intervention. J Obes. 2013;2013:Article ID 978482. https:// doi.org/10.1155/2013/978482. 7. Schroeder K, Travers J, Smaldone A. Are school nurses an overlooked resource in reducing childhood obesity? A systematic review and metaanalysis. J Sch Health. 2016;86:309-321. https://doi.org/10.1111/ josh.12386. 8. Schroeder K, Smaldone A. What barriers and facilitators do school nurses experience when implementing an obesity intervention? J Sch Nurs. 2017;33: 456-466. https://doi.org/10.1177/1059840517694967. 9. Baker D, Anderson L, Johnson J. Building student and family-centered care coordination through ongoing delivery system design. NASN Sch Nurse. 2017;32:43-49. https://doi.org/10.1177/1942602X16654171. 10. Barlow SE; Expert Committee. Expert committee recommendations regarding prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4): S164-S192. 11. Golden NH, Schneider M, Wood C. Committee on Nutrition; Committee on Adolescence; Section on Obesity; AAP Committee on Nutrition. Preventing obesity and eating disorders in adolescents. Pediatrics. 2016;138:e20161649. https://doi.org/10.1542/peds.2016-1649. 12. Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport. 1992;63:60-66. https://doi.org/ 10.1080/02701367.1992.10607557. 13. Niemeier BS, Hektner JM, Enger KB. Parent participation in weight-related health interventions for children and adolescents: a systematic review and meta-analysis. Prev Med. 2012;55:3-13. https://doi.org/10.1016/ j.ypmed.2012.04.021. 14. Anderson KE, Byrne C, Goodyear A, Reichel R, Le Grange D. Telemedicine of family based treatment for adolescent anorexia nervosa: a protocol of treatment development study. J Eat Disord. 2015;3:25. https://doi.org/10.1186/ s40337-015-0063-1. 15. Bernstein KM, Manning DA, Julian RM. Multidisciplinary teams and obesity: role of the modern-centered medical home. Prim Care. 2016;43:53-59, viii. https://doi.org/10.1016/j.pop.2015.08.010.
Laura O. Smith, PhD, FNP-C, is an assistant professor at Nova Southeastern University, Tampa, FL, and can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
A Weight Management Program Within a High School Health Center Laura O. Smith, PhD, FNP-BC a b s t r a c t Keywords: adolescent obesity school-based health center weight management
A program for helping adolescent students manage their weight was implemented within a school-based health center to promote evidence-based practice and identify barriers to successful weight management. Voluntary student participation included 6 visits with an advanced practice registered nurse. Body mass index screenings (n ¼ 702) and system variables for case-managed students (n ¼ 41) were examined to identify treatment gaps. Despite a high number of eligible students (n ¼ 250), a low percentage of students (16%) enrolled in case management services. Building effective and sustainable approaches for weight loss in this population requires adequate staffing and community resources. © 2019 Elsevier Inc. All rights reserved.
The public health obesity crisis in adolescence requires an identification of deficits and promotion and implementation of effective strategies. There is a positive association between adolescent health behaviors and adult health outcomes,1 with societal costs projected to exceed $145 billion.2 Obesity is a chronic condition that requires a comprehensive assessment, evaluation, and treatment plan that includes documentation of prior health conditions, physical examination, family stability, and the students’ social environment. Weight reduction efforts for adolescents will likely benefit from interventions provided in a school-based environment. The school-based health center (SBHC) offers a health promotion milieu where ease of access to students is a key component. Traditionally, high-risk communities have difficulty accessing quality health care, and a SBHC located on the school property closes this gap.3 The SBHC service delivery models vary, and sound management practices are necessary to ensure sustainability. The setting is ideal for engaging students in efforts to improve their health outcomes and thereby academic success.4,5 Resources to promote healthy lifestyles in youth within the SBHC include personnel and medical equipment. Although these resources are necessary for treatment of obesity, there is a heavy behavioral health component for successful and sustained weight loss that requires additional resources,6 and SBHC data validate successful outcomes treating obesity.7 Resources in an SBHC environment can be limited and may reduce nurses’ effectiveness in managing obesity. These limitations include knowledge deficits of best practices related to obesity management and prohibitive workloads for successful care coordination.4 Communication between the SBHC and the community health care provider (medical home) is necessary for improved health outcomes and requires time.8 This process is necessary for https://doi.org/10.1016/j.nurpra.2019.08.025 1555-4155/© 2019 Elsevier Inc. All rights reserved.
reducing treatment duplication and cost, and it provides the primary care provider updates that improve patient outcomes in chronic disease management.9 A case management project for treatment of adolescent obesity was implemented in a SBHC located in a metropolitan public high school in the Southeastern United States providing free health care services to the 1,677 students attending the school. In the academic school year before project implementation, 852 unduplicated students visited the SBHC. These students identified themselves as 40% minority and 53% economically disadvantaged. The project was initiated to examine the process for treating obesity, promote evidence-based practice, and identify barriers to successful weight management of students in the high school setting. Methods Setting and Eligibility The SBHC is on the school campus and staffed by a family nurse practitioner (NP), a licensed practical nurse, and a medical assistant. Parental consent is necessary to receive health services, and teachers provide students with permission (hall pass) for an SBHC visit. Students with consent who had a body mass index (BMI) value > 25 kg/m2 were invited to participate. Procedure The project was approved by the Florida Department of Health Institutional Review Board. The assessment and management plan is summarized in an algorithm (Figure 1) and was adapted from the American Academy of Pediatrics’ guidelines for management of childhood obesity.10 The BMI was used to establish, a pathway for
e2
L.O. Smith / The Journal for Nurse Practitioners xxx (xxxx) xxx
BMI > 85%
Measure height and weight Calculate BMI and plot Classify weight (LPN)
Readiness assessment (Student)
NO
Ready for change?
BMI = 5 - 85% YES
Support healthy eating and activity Engage student in 5-2-1-0 behaviors (APRN)
Re-evaluate weight annually (CNA)
Review contract letter with student (APRN)
F/U 6 -12 months (Student)
Nutritional assess and PE (APRN)
Encourage group participation Reinforce BMI (APRN) YES
Family hx DM, CAD or abnormal PE?
NO
Develop SMART goals and continue treatment plan (Student & APRN)
Consent for lab?
NO
Assess depression levels and ACE scores (APRN)
NO
NO
YES
Contact parent to report PE findings and request lab (APRN)
Weight loss?
YES
YES
Obtain labs (LPN) and review (APRN)
Abnormal Findings?
Treatment or refer to specialist (APRN)
Figure 1. Process used for weight management. ACE ¼ adverse childhood experiences; APRN ¼ advanced practice registered nurse; BMI ¼ body mass index; CAD ¼ coronary artery disease; CNA ¼ certified nursing assistant; DM ¼ diabetes mellitus; F/U ¼ follow-up; hx ¼ history; LPN ¼ licensed practical nurse; PE ¼ physical examination; SMART ¼ specific, measurable, attainable, relevant, and time-bound.
management. Students who were of normal weight were provided instruction on the 5-2-1-0 (eat 5 or more servings of fruits and vegetables, limit of 2 hours or less of recreational screen time, engage in 1 hour or more of physical activity, and limit sugary drinks; drink more water and low fat milk) prevention strategies and reinforcement for healthy behaviors.11 Students with a BMI > 85th percentile were encouraged to discuss their intention to participate with their parent and schedule their first of 6 visits with the SBHC receptionist. On the initial visit, a plan of care was developed with the NP that included a nutritional assessment (Figure 2) and an assessment of readiness to change activity and dietary behaviors.12 After this evaluation, students developed a specific, measurable, attainable, relevant, and timebound (SMART) goal. Subsequent visits included a follow-up at 2 weeks, and the remaining 4 visits were scheduled at monthly intervals with the NP. The student completed a questionnaire at each appointment. Questions included: 1. 2. 3. 4.
What changes to diet and activity were made since the last visit? Are you pleased with your progress and if not, why not? What challenges were encountered in making changes? What might have been done differently?
confidence to sustain the behavior modification. After this achievement, the NP encouraged and assisted students to identify another SMART goal. Results Of 702 students who were screened, 452 (64%) had a BMI < 85th percentile. The remaining 250 students having a BMI > 85th percentile were encouraged to participate. Forty-one students (16.4%) who met eligibility enrolled in the program and completed the initial assessment. Additional demographic information for the participants is provided in the Table. Project measures included the number of students who returned after the initial assessment (n ¼ 33 [80%]) and the number of visits per student (mean, 3.51). Ten students (30%) completed all 6 visits. In addition, the length of the visit (mean, 40 minutes), number of students who indicated a positive family history for obesity or another comorbid condition on assessment (n ¼ 26 [63%]), and students’ readiness scores were recorded. Although 35 participants (85.4%) indicated they were in the action or maintenance stages for changing diet and exercise behaviors, overall reduction in the BMI was minimal. Discussion
The NP reviewed strategies at each visit, and students were guided in developing new goals. Education and health promotion discussion continued until the adolescent reported a high level of
Every student who sought services at the SBHC had a BMI screening; thus, 42% of the entire school population received care
L.O. Smith / The Journal for Nurse Practitioners xxx (xxxx) xxx
e3
WEIGHT MANAGEMENT Name
DOB
Contact phone
Guardian phone
Referred by
Healthcare providers
Current weight
Told previously of unhealthy BMI weight? BMI % Are you concerned about your height or your weight? Why or Why not?
Date
Current health status
Do any family members have a weight concern? Y/N WHO? On the line below, indicate how important is it to you to develop a more healthy lifestyle including losing weight and becoming more physically active? 1 5 Can you identify things in your day to day life that you know need to change?
10
What things in your life might interfere with making changes? (stress, unsafe environment, money, depression, anxiety, family worries) Circle factors below that apply to student: Free lunch Parent Divorce Parent death
Domestic violence Did you eat breakfast today? Y/N Yesterday? Y/N Do you like to cook? Y / N Skip meals to lose weight? Y / N Who grocery shops in your home?
Neighborhood Substance Incarceration of Familial mental violence/gang abuse family member illness Lunch today? Y/N Yesterday? Y/N Dinner? Y/N Yesterday? Y/N Have you been on “diets” in the past? Y / N Who cooks or prepares food in your home?
How many Fruit? Vegetable? Diet soda? Water? Milk? Sports/sweet Juice? serving a day drinks? What is a snack food for you? How often do you buy your food already prepared (fast food)? Do you participate in the school meal program? Yes No Sometimes Do you buy food at lunch? Yes No Sometimes Have you binged/vomited to control weight? Y/N Diet pills? Y/N Other medications? Y/N How many hours a day do you Play video Surf web? Social networking? Homework? watch TV? games? What do you do for exercise? Frequency/wk and amount of time for each/day Walking Dancing Sports Running Other: How many hours a night do you sleep? FEMALES ONLY: Date of LMP: Irregular? Y / N OCP? Y/N Figure 2. Nutritional assessment developed for project completed orally by students with advanced practice registered nurse. BMI ¼ body mass index; DOB ¼ date of birth; LMP ¼ last menstrual period; N ¼ no; OCP ¼ oral contraceptive pills; Y ¼ yes.
during the project period. Students who use the SBHC typically seek physical examinations for participation in extracurricular activities or have an acute or chronic health care need. Students who have a medical home are likely to receive services by their primary provider. The need for a weight management program was supported because 35% of students screened could have benefited from the program. However, student participation was low, at only 16% at
Table Select Student Demographic Characteristics Characteristic
Number (%) (N ¼ 41)
Body mass index 26 to 30 kg/m2 31 to 35 kg/m2 >35 kg/m2 Sex Female Male Race/ethnicity African American/black Hispanic White Other Class level Freshman Sophomore Junior
10 (24.4) 12 (29.3) 19 (46.3) 26 (63.4) 15 (35.5) 16 9 11 5
(39) (22) (26.8) (12.2)
13 (31.7) 12 (29.3) 9 (22)
initiation and 13% at follow up. Several factors were identified that likely contributed to low participation. Participation and encouragement from parents have been shown to improve outcomes in weight reduction rates.13 During this project, the NP contacted parents via phone only when laboratory work was indicated, primarily because parents have limited availability during the school day. The Health Insurance Portability and Accountability Act requirements make alternative methods, such as telehealth, email, and text messaging, difficult because the software needed for these vehicles require platforms that exceed the in-home capability of most parents.14 The school cloud offers a secure and possible mechanism for providing parents educational opportunities and to obtain data that could reduce duplication of health services, but families would need a remote connection placed on their devices. Another important factor for a successful weight management program is assistance in establishing students with a medical home. This patient-centered care model is a holistic approach to health care delivery that includes a primary care provider, collaborating health providers, integration of technology to improve access, and a delineated payment structure that reflects its value.15 Most of the students recalled a previous medical encounter when they were advised to lose weight; however, they could not name their health care provider or a prescribed intervention or treatment. Efforts to communicate their condition and transmit medical records was time intensive even when students had an established medical provider. For example, students who had recent laboratory evaluations done by their medical home needed a
e4
L.O. Smith / The Journal for Nurse Practitioners xxx (xxxx) xxx
Health Insurance Portability and Accountability Act release via a parent signature and had to return the document before a fax could be sent to the provider’s office requesting the needed information. A large percentage of students did not return with the documents, which meant staff intervention measures taken up to that point, as well as student motivation, were lost. Student participation in physical activity was a priority. If the SBHC had established community resources for students that included accessible recreational activities with training components, outcomes might have improved.6 Students reported an inability to afford sport activities or they had no reliable transportation, or both. Furthermore, students expressed spending after-school hours engaging in sedentary activity but verbalized an interest in an employment or volunteer opportunities. Providing these nontraditional treatment measures strengthens the SBHC as a valued referral source, offers students alternative coping strategies, and provides opportunities that may sustain behavior changes. The NP has an opportunity to identify community partners and communicate with them to substantiate a need for student participation. In addition, the NP can offer workshops or speak at community events to detail available resources for children and adolescents. This effort may ultimately benefit the organizations and build collaborative partnerships that can improve adult health, thereby strengthening communities.
Limitations This weight management program has limitations. Staff was not provided training in motivational interviewing techniques, which might have improved enrollment numbers. In addition, recording dietary and activity data in a software application could enhance personal intervention and weight loss, thereby motivating students to remain in the program. Finally, limited parental participation and conflicting student schedules likely contributed to low participation rates. Conclusion The associated health risks students will face as adults will decrease only when opportunities for screening, educating, and intervening are available to them. SBHCs seem like the ideal place to host such programs, but they face significant challenges. School nurses can be guided by APRNs and other providers to use effective evidence-based strategies for addressing obesity. Overcoming inadequate communication between parents and providers of the students’ medical homes, in addition to finding additional resources for incentives and technology, are worthwhile efforts for engaging students in weight loss efforts through the SBHC.
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Laura O. Smith, PhD, FNP-C, is an assistant professor at Nova Southeastern University, Tampa, FL, and can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.