SCHOOL AGE (5 10 years)

Transcription

1 Section 1. Early Identification SCHOOL AGE (5 10 years) HEAT Clinical Practice Guideline Recommendations and Supporting Evidence BLUE BOXED AREA = Culturally Appropriate Recommendations HISTORY 1. Document and annually update a three-generation family health history, including: overweight, hypertension, diabetes mellitus, gestational diabetes, coronary heart disease (CHD) before 55 years in men and 65 years in women, smoking and passive smoke exposure, gestational age and birth weight of the child, and parent self-report of height, weight, and educational level. a. Pay particular attention to a history of maternal diabetes, including gestational diabetes, because this condition places all exposed children, especially those of Native American mothers, at significant risk of overweight. HISTORY 1. It is important to identify early risk factors and potential co-morbidities (26, 30). Obesity in one or both parent(s) is a risk factor for overweight in children, as is low income status (12, 58). a. Exposure to intrauterine diabetes was a risk factor for the development of obesity and diabetes in Pima Indian children (Culture Ref: 16). MEASUREMENTS 2. Perform accurate height and weight annually; consider more frequent measurement if at risk of or overweight. 3. Perform assessment for risk of overweight: a. Calculate and document BMI on the 2000 CDC growth chart for children. b. Document on the problem list BMI of > 85th%. 4. Perform BP measurement with appropriate size cuff at every well child visit. a. Document BP percentile for age, sex, and height using 2005 NHLBI charts to identify children with BP readings > 90th% (pre-hypertensive) and > 95th% (hypertensive). b. Document on problem list all BP > 90th% (pre-hypertensive) and > 95th% (hypertensive). c. Perform follow-up for elevated BP measurement. 5. Perform a fasting glucose level, total cholesterol, and/or lipid panel to assess for diabetes mellitus, hyperlipidemia, and metabolic syndrome if the child's BMI is > 95%. MEASUREMENTS 2., 3. An accurate height and weight is necessary in order to calculate an accurate BMI. Routine measurement of height and weight in primary care settings has been noted to vary greatly in accuracy (31). It is important to track BMI to ensure early recognition of an increase in weight to linear growth. This monitoring can be facilitated by routine calculation and plotting of BMI (26, 29, 30). 4. Children who have a BMI > 85th% are at risk of having an elevated BP for age and gender. Early detection of elevated BP is important to maintain cardiovascular health (17, 26, 37, 40, 46). 5. Providers must recognize other health-related risks and/or consequences of overweight (26, 30). The prevalence of metabolic syndrome is high among overweight children and escalates with increasing degree of overweight. Biomarkers of increased risk of adverse cardiovascular outcomes are already present in these children (57). SCHOOL AGE PHYSICAL EXAM 6. Perform Sexual Maturity Rating (Tanner Stage) annually. 7. Educate parents about the child s growth pattern, clearly identifying risk status for overweight when BMI > 85th% occurs. PHYSICAL EXAM 6. Early appearance of secondary sexual characteristics is associated with overweight in females before age 8 (1). 7. Increased knowledge by parents about their child s growth status can be a strong motivator. In a recent study, parent awareness of their child s overweight status was significantly related to readiness to change (29, 42). JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S33

2 Section 2. Developmental and Communication Considerations SCHOOL AGE ASSESSMENT 1. Monitor parent/child affect, using the two-question depression screen with both parent and child at every well child visit. During the past month have you been bothered by: a. Feeling down, blue, depressed, or hopeless? b. Feelings of little interest or pleasure in doing things? 2. Document areas of strength and concern. 3. Monitor child s social and emotional development by inquiring about school-related behavior, peer interactions, bullying, activity in and out of school, and academics. 4. Document parent s attitudes, values and beliefs, and spiritual and cultural influences about nutrition, physical activity, and body size and shape; maternal education level; race/ethnicity; religion; preferred language; and preferred type of educational materials. 5. Educate parents about: a. Expected growth and physical, developmental, and emotional changes. b. Changes in growth velocity and implications for appetite and food intake. 6. Educate parents about strategies for effective communication with the developing child: a. Truly listen to the child s verbal and non-verbal communication. b. Respect the child s feelings. c. Respect the child s individuality. 7. Counsel extended family members as well as parents about issues related to the child s health. 8. Refer family as needed to appropriate community nutrition and physical activity resources, including RDs. ASSESSMENT 1. The USPSTF recommends screening for depression among adults, finding the twoquestion screen as effective as longer screening questionnaires. The prevalence of depression is increasing among school-age children. Both overeating and anorexia occur more often among depressed children than among unaffected peers. Providers need to make this assessment so that they can intervene appropriately (4, 21, 38, 49, 59). 2. Health care providers can help families communicate better by identifying specific focal points for intervention. Working with families using strength-based approaches increases the likelihood that parents will follow practitioner recommendations and engage in healthful changes (23, 26, 30). 3. Children with increased BMI are more likely than normal-weight children to report being victimized or bullied by others and bullying others (25). 4. Families are important role models and influence the nutritional and physical activity habits of children (29, 30). Children and parents may have different views of healthy eating and activity (36). 5. Awareness of such issues can aid communication between health care providers, parents, and patients. 6. Data from Melnyk et al. show that parents are likely to be unaware of the worries and needs of their children. Health care providers can help families communicate better by identifying strengths and barriers to good communication (26, 30, 34). 7. Family is of great importance to all children, and is of special relevance in both the Hispanic and African American cultures. Compadres (godparents) play a significant role in the life of the Hispanic child. African American grandparents are greatly involved with the upbringing of their grandchildren. Many Native American households include extended family members (grandparents, aunts, uncles). Promoting healthful eating as well as increasing physical activity was found to be successful if the family of Native Americans was involved. Practitioners are more likely to be successful with their message if the extended family is included in the discussion (Culture Ref: 2, 3, 6, 7, 12, 13). 8. Practitioners are a vital link between families and local community agencies. They can assist families with needs and concerns and can identify and provide referrals to resources for encouraging positive nutrition and physical activity. RDs are a good resource for parents and children who have complex educational and nutritional S34 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

3 Section 2. Developmental and Communication Considerations management needs. Qualified RDs can be located using the American Dietetic Association (ADA) website (51). 9. Educate families and children using culturally appropriate curricula (e.g., the Pathways curriculum developed for Native American families and children). 10.Counsel using MI when parents and children are willing to make positive changes. a. Reinforce all positive health behaviors. b. Identify discrepancies between goals and behaviors. c. Develop a plan of action in partnership with the family. 9. Pathways was a multi-site school-based study that included 1,704 American Indian children in third to fifth grade and was aimed at promoting healthful eating and increasing physical activity. The curriculum includes content that is culturally appropriate for Native Americans. This curriculum can be accessed at (Culture Ref: 9). 10.MI creates a partnership between the parent, child, and professional to address health issues that parents and children can choose to focus on if they wish. The structured MI approach helps the partners address important health issues in a timely way. Some evidence indicates that MI improves the likelihood of positive patient behavior change (7, 35, 50). Section 3. Nutrition Essentials, Optimal Feeding, and Eating Behaviors ASSESSMENT 1. Monitor nutritional intake for consistency with expert recommendations for age, sex, and activity level at each well child visit or at least annually, including: a. Types, amounts, and frequency of foods and beverages. b. Portion sizes. c. Variety of foods eaten in each macronutrient group. d. Types of dietary supplements. ASSESSMENT 1. Expert recommendations are provided by the HHS/USDA 2005 Dietary Guidelines for Americans. Providers need to make this assessment in order to make appropriate suggestions for change to promote healthier eating patterns if needed (29, 56). 2. Monitor and document barriers to healthy eating, such as lack of healthy foods, financial barriers, and lack of knowledge about healthful food choices. 3. Educate parents about recommended nutritional intake for age and about appropriate types, amounts, and portion sizes of healthful foods (see Tables 1 and 2). a. Select whole grain products for at least half of grains eaten. b. Eat 5 or more servings of fruits and vegetables daily (serving = 1 /2 cup). Regularly select vegetables from all subgroups, including dark green, orange, legumes, and starchy vegetables (about 1 /3 of intake should come from each color grouping). c. Choose appropriate types, amounts, and portion sizes of healthful foods (see Table 2). d. Avoid calorie-dense, nutrient-poor foods. e. Limit fast food to no more than twice per week and educate about healthier choices and portion control when eating out. 2. To best assist parents, health care providers must be aware of barriers that families face in making appropriate food choices (52). 3. Excessive calorie intake can be mitigated by focusing on healthy foods, limiting portion size, and limiting foods that are high in calories and low in nutrients (29, 30, 56). c. Because food portions have increased in most foods for children ages 2 18, it is important to limit or teach appropriate portion size, and to help children recognize satiety. Sensations of satiety occur 20 minutes into eating. Therefore it is important to eat slowly enough to allow feelings of fullness to guide intake (3, 29, 30, 39). d. Servings of fruits and vegetables can be substituted for high-fat foods in order to reduce calories and increase nutrient intake (15, 20). e. Consistently eating fast food is associated with an increase in BMI over time (54). SCHOOL AGE JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S35

4 Section 3. Nutrition Essentials, Optimal Feeding, and Eating Behaviors SCHOOL AGE f. Ensure adequate daily calcium intake for age: 800 mg per day between 4 and 8 years of age 1,200 1,500 mg per day between 9 and 19 years of age g. Limit fat intake to 25% 35% after 4 years of age. h. Make healthier choices for types of fat: avoid foods high in trans fats, e.g., cookies, baked goods, doughnuts, french fries use soft margarine rather than butter or stick margarine use low-fat or fat-free dairy products choose polyunsaturated or monounsaturated fats, such as those found in fish, nuts, and vegetable oils i. Provide healthful snacks in appropriate portion sizes and limit prepared snack foods, such as chips, cake, and candy. j. Limit 100% fruit juice to 4 6 oz per day and avoid consumption of fruit drinks and sodas. k. Encourage consumption of water and low or fat-free milk rather than sweetened beverages. 4. Educate parents about how to carry out promising feeding practices, including: a. Recognize changes in growth velocity and associated changes in appetite and need to balance energy intake from food with energy output in physical activity (see Table 1). b. Be a positive role model for healthful eating behaviors. c. Recognize the value of family meals and have them as often as possible to increase quality of nutrition and enhance family connectedness. d. Recognize that parents are responsible for providing healthful food choices at appropriate intervals and settings (what, where, when) and the child is responsible for deciding whether to eat and how much to eat. e. Purchase and prepare only healthful foods and drinks, including snacks. f. Encourage the child to eat a healthful breakfast daily. g. Prepare children to select and prepare healthful foods and drinks. 5. Educate parents about avoiding less optimal feeding practices: a. Avoid use of a clean plate policy. b. Avoid use of food for comfort; recognize emotional triggers for eating and substitute other coping strategies. c. Avoid restrictive and fad diets. f. Lower consumption of calcium and dairy products has been associated with overweight (14, 56). g. i. It is important to limit foods high in refined sugar and saturated fats, as these can lead to increased adiposity. Between 1970 and 2003, Americans increased their daily intake of calories by 23%, fat by 50.5%, intake of refined sugar by 18.9%, and refined grains by 44.3% (26, 56). GuideIndex.htm j. Sweetened drinks and increased weight gain in children are positively associated (22, 24, 32, 56). k. Low- and fat-free dairy products are a nutritious snack option (30, 56). a. Educate parents about changes/increases in appetite associated with onset of puberty (51). b. Recent studies demonstrate that changes in child dietary behavior is strongly supported by positive role modeling by the parent (6, 41, 61). c. When children eat regularly with families, they increase their intake of fruits, vegetables, fiber, and micronutrients from food; consume fewer fried foods, less soda, and less saturated and trans fat; and have a lower glycemic load. Parent role modeling of good nutrition and eating behaviors is associated with both parent and child weight loss (3, 18, 61). d. It is recommended that parents implement this division of responsibility in feeding because it avoids needless and potentially harmful struggles for control. This division of responsibility is supported by the AAP in their on-line and print nutritional resources for parents (14, 29). e. Research shows that many parents do not believe they have control over their child s nutritional choices and buy into the myth of healthy eating as restrictive, expensive, and beyond their reach. Practitioners need to correct these perceptions and support parents in assuming their important role in providing and modeling good nutritional habits (6, 23, 41). f. Eating breakfast helps to ensure a steady metabolic rate throughout the day, increasing the likelihood of avoiding overweight. Eating breakfast also is associated with better school performance and behavior (56). g. Involving children in selecting and preparing foods facilitates their self-care skills and provides useful learning opportunities about good choices at a time when their buying power, decision-making opportunities, and peer influences are increasing (41, 44). 5. Eating a variety of foods is more likely to provide all essential and other biologically beneficial nutrients. It is essential for a healthy lifestyle and is associated with fewer health deficits (15, 20, 28). Research studies show that when parents withhold favorite foods, children crave those foods more and tend to overeat when they do have access to them. The best strategy is to offer only healthful foods and snacks and relatively small portions (16). S36 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

5 Section 3. Nutrition Essentials, Optimal Feeding, and Eating Behaviors 6. Counsel with emphasis on the positive health consequences of good nutrition rather than focusing on the child s weight. 7. Counsel parents to offer traditional foods and not to offer children alternative foods when they refuse traditional foods. Hispanics and Native Americans: beans, corn, tortillas, and vegetables. African Americans: fruits and vegetables. 6. Hispanics: In the Hispanic culture, thinness is often associated with poor health, and there is often the perception that a little extra weight is necessary for children in order to help them recover from illness (Culture Ref: 5, 13). African Americans: African Americans are more tolerant of larger body size and caregivers seldom perceive their children as obese (Culture Ref: 1, 15). Practitioners may be more successful at establishing rapport with Hispanic and African American families if the discussion is initially focused on health, not necessarily weight. 7. Frequent exposure to food is important in developing food preferences and traditional foods tend to be highly nutritious (Culture Ref: 11, 14, 16, 17). Hispanics: School aged children are receptive to family-based activities, and meal preparation helps to reinforce good dietary practices (Culture Ref: 12). Section 4. Physical Activity and Sedentary Behavior ASSESSMENT 1. Monitor at least annually: a. Daily physical activity level, type, and amount. b. Daily types and amounts of sedentary behavior. c. Barriers to performing activity, e.g. safety, access, cost. 2. Counsel with emphasis on the positive health consequences of increased physical activity rather than focusing on the child s weight. ASSESSMENT 1a. Daily, regular physical activity in the school aged child promotes healthful behavior and decreases the risk of co-morbidities associated with overweight (9, 10, 11, 19, 20, 26, 27, 29, 30, 33, 48). b. Sedentary activities are associated with increased incidence of overweight and may limit other opportunities for appropriate social development (3, 5, 20, 25, 26, 30, 31, 45, 46). c. Research has shown multiple barriers associated with engaging in physical activity for children and their families. Awareness of barriers provides an opportunity for practitioner, parent, and child to engage in problem-solving to overcome barriers (23, 43, 55). 2. Hispanics: Average physical activity is lower among Hispanic children than among white children (Culture Ref: 5, 8, 12). African Americans: Statistically, heads of household in this population are less likely to do well with weight loss programs, which decreases their attempts to change their children s weight status (Culture Ref: 15). Native Americans: Native American children are not physically active on a regular basis. A collaborative relationship that involves the Native American community is essential for a program to be successful. Encourage any games that may be traditional for a specific tribe (Culture Ref: 9, 16). SCHOOL AGE 3. Educate parents and children about age-appropriate physical activity and how to incorporate it into daily family routines. a. At least 60 minutes daily of intermittent, moderate to vigorous physical activity. 4. Educate parents about the value of family activities and parent modeling of positive physical activity behaviors. 3. Practitioners may be more successful in increasing the child s activity level for Hispanics, African Americans, and Native Americans if they educate families to participate in the activities together. a. Daily, regular physical activity in the school aged child promotes healthful behaviors and decreases risk of co-morbidity (9, 10, 11, 19, 20, 26, 27, 29, 30, 33, 48, 53). 4. Increased recreational screen time is associated with greater adiposity in children (2, 8, 11, 30, 45, 55, 60). JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S37

6 Section 4. Physical Activity and Sedentary Behavior 5. Educate parents about media influence on health-related behaviors and how to carry out promising screen time practices: a. Turn off TV during meals. b. Limit screen time to no more than 2 hours per day. c. Monitor the child s time to ensure a balance between screen time and physical activity. d. Do not allow a TV in the child s bedroom. 5. Increased recreational screen time is associated with greater adiposity in children (2, 8, 11, 30, 43, 45, 47, 53, 60). Awareness of media influences on food and physical activity choices may improve eating habits. a. Food types and quantities eaten may be influenced by TV watching (2, 45). b. AAP recommendation (30, 45). c., d. Increased TV viewing especially in the bedroom leads to increased inactivity and increased weight gain (13). Section 5. Advocacy SCHOOL AGE SCHOOL AGE CHILDREN 1. Advocate that all foods and beverages sold or served to students in school be healthful and meet accepted nutritional content standards. 2. Advocate for retention of physical education time in schools. 3. Advocate for classroom involvement in school nutrition and physical education activities: Prepare classroom activities to teach origin of foods used in local diet. Prepare a user-friendly resource corner on nutrition for parents and children. Advocate for volunteers to promote supervised physical activity during school recess. Organize fellow students to develop media messages about healthy eating and physical activity for local radio stations and school assemblies. PARENTS AND TEACHERS 4. Perform the School Health Index, a self-assessment and planning tool, on your local school to improve school policies and programs. To order, HealthyYouth@cdc.gov or visit 5. Advocate for daily physical education. 6. Advocate for improved school lunches that: a. Provide a variety of healthy foods from which to select. b. Emphasize appropriate portion sizes. c. Minimize foods high in fat and calories but low in nutrient content. SCHOOL AGE CHILDREN 1. Schools should provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity (Advocacy Ref: 14, 17). 2. Higher student fitness levels are associated with higher performance on standardized achievement tests (Advocacy Ref: 21). A 2000 survey found that only 8.0% of elementary schools, 6.4% of middle/junior high schools and 5.8% of senior high schools provided daily physical education (PE) for the entire school year for all of the students in each grade (Advocacy Ref: 2, 14). 3. The Snack-Wise Nutrition Rating System helps consumers select smarter snack choices through an easy-to-recognize color code of green (best choice), yellow (choose occasionally), or red (choose rarely) (Advocacy Ref: 5). Coordinated changes in the classroom curriculum, the in-school advertising environment, school health services, and after-school programs all offer the potential to advance overweight prevention efforts (Advocacy Ref: 14, 26). PARENTS AND TEACHERS 4. The assessment and planning tool will provide direction for needed changes (Advocacy Ref: 7). 5. Higher student fitness levels are associated with higher performance on standardized achievement tests (Advocacy Ref: 8, 21). 6. Schools should engage students and parents, through taste-tests of new entrees and surveys, in selecting foods sold through the school meal programs in order to identify new, healthful, and appealing food choices. In addition, schools should share information about the nutritional content of meals with parents and students (Advocacy Ref: 26). S38 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

7 Section 5. Advocacy 7. Advocate for restricted vending machine sales and conversion to healthy foods and beverage selections, such as: a. Low-fat snacks. b. Fresh or canned fruits. c. Water and low- or fat-free milk. 8. Advocate for parent and teacher involvement on community and school boards that make decisions on school nutrition and physical education. PROVIDERS 9. Advocate in schools to raise awareness of the importance of physical activity programs and policies. a. Speak out at local schools. b. Take a leadership role in promoting physical education in schools. 10.Educate parents, students, and school staff regarding diversity of children and tolerance and acceptance of all body types and physical abilities. 11.Advocate for the formation of School Health Advisory Committees. a. Practitioners can encourage parents, teachers, other professionals, and youth leaders to join together and assess needs, develop plans, and implement policies related to physical activity and healthy eating in their communities. b. These committees should develop clear, positive physical activity and nutrition messages. 7. By law, in some states, the only beverages that may be sold in school vending machines are water, milk, and 100% fruit juices or fruit-based drinks that are at least 50% fruit juice with no added sweeteners. All other foods sold in schools (including those sold in vending machines, at fundraisers during the school day, and at school functions) must reflect the Dietary Guidelines or meet the USDA standard for a lunch component (Advocacy Ref: 12). 8. Many schools around the nation have reduced their commitment to provide students with regular and adequate physical activity. Low levels of physical activity are consistently linked to overweight in children (Advocacy Ref: 1, 14, 18). PROVIDERS 9. Many schools around the nation have reduced their commitment to provide students with regular and adequate physical activity. Low levels of physical activity are consistently linked to overweight in children (Advocacy Ref: 1, 14, 18). 10.Overweight children often suffer from low self-esteem, depression, and/or fear of being bullied or teased (especially in physical education class). This may lead to avoidance of physical activity or outside activities, which may exacerbate the problem. Stigmatization of obesity is very real. All children want to feel included and competent (Advocacy Ref: 4, 24). 11.Each school should establish and maintain a School Health Advisory Committee (composed of at least one staff member, one school health council member, and possibly a local hospital representative, dietitian or other health professional, recreation program representative, union representative, or employee benefits specialist) that reports to the school health council (Advocacy Ref: 26). SCHOOL AGE JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S39

8 5 HEAT School Age 1/19/06 12:55 PM Page 40 HEAT SCHOOL-AGE Brief Guide EARLY IDENTIFICATION Document family history relevant to risk of overweight and update annually. Measure height and weight at least annually; consider more frequent measurement if at risk of or overweight; document on the CDC growth charts. Perform BMI calculation at least annually and document on CDC growth chart; document on problem list if > 85th%. Perform blood pressure at least annually; identify those with BP >90th% on problem list. Perform and document Sexual Maturity Rating (Tanner Stage) annually. Perform a fasting glucose level, total cholesterol, and/or lipid panel to assess for diabetes mellitus, hyperlipidemia, and metabolic syndrome if the child s BMI is > the 95th%. Educate parent and child about growth pattern, clearly identifying status if at risk of or overweight. DEVELOPMENT AND COMMUNICATION SCHOOL AGE Perform two-question screen for depression on parent and child. Document areas of strength and concern. Monitor child s social and emotional development. Document personal attitudes, values, and beliefs; spiritual and cultural influences about nutrition, physical activity, and body shape and size; race; ethnicity; language and educational preferences. Educate children and parents about expected growth, development, physical and emotional changes. Educate parents and children about effective communication strategies. Refer family, as needed, to free or low-cost community nutritional and physical activity resources, including registered dieticians. Educate families and children using the Pathways curriculum (Native Americans). Counsel using Motivational Interviewing to address areas of concern: Reinforce all positive health behaviors Identify discrepancies between goals and behaviors Develop a plan of action in partnership with the family NUTRITION AND FEEDING Monitor nutritional intake at least annually. Identify barriers to healthy eating. Educate children and parents regarding recommended nutritional intake: Limit portion size BOLD type indicates a strong evidence-based recommendation Red italic type indicates a culturally appropriate recommendation S40 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

9 5 HEAT School Age 1/19/06 12:55 PM Page 41 NUTRITION AND FEEDING Continued Consume 5 or more servings of fruits and vegetables per day At least half of grains consumed should be whole grain foods 3 4 dairy servings per day, fat-free for most; 800 mg calcium/day for ages 4 8 yrs; mg calcium/day for ages 8 12 yrs Limit fast food to no more than twice per week Consume healthful snacks Limit 100% fruit juice to 4 6 oz. or less/day; avoid fruit drinks and soda Limit fat intake; avoid foods high in saturated and trans fats; use soft margarine rather than lard, butter or stick margarine Educate children and parents regarding promising feeding practices: Adapt food intake to match level of physical activity Eat a healthy breakfast daily Eat family meals together regularly Prepare child to select and prepare healthful foods and drinks Educate parents to avoid restrictive feeding practices or use of food for reward or comfort. Counsel parents to offer traditional foods and not alternative foods. PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOR Monitor daily physical activity and sedentary behavior at least annually. Identify barriers to being physically active. Educate children and parents about age appropriate physical activity: No TV in bedroom No TV during meals Parent monitoring of TV ADVOCACY Advocate for retention of physical education in the schools. Advocate for improved school lunches by the National Association of Pediatric Nurse Practitioners (NAPNAP). All rights reserved. JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S41 SCHOOL AGE Engage in at least 60 minutes of intermittent moderate to vigorous physical activity per day Counsel with emphasis on positive health consequences of increased physical activity, rather than child s weight (Hispanics, African Americans). Encourage parents to model healthy physical activity levels, and support child s activity participation. Discuss media influence on health-related behavior, and educate children and parents regarding promising screen time practices: Limit TV and screen time to < 2 hours/day

10 Section 1. Early Identification TEEN (11 21 years) HEAT Clinical Practice Guideline Recommendations and Supporting Evidence BLUE BOXED AREA = Culturally Appropriate Recommendations HISTORY 1. Document and annually update a three-generation family health history, including: overweight, hypertension, diabetes mellitus, gestational diabetes, coronary heart disease (CHD) before 55 years in men and 65 years in women, smoking and passive smoke exposure, gestational age and birth weight of the child, and parent self-report of height, weight, and educational level. a. Pay particular attention to a history of maternal diabetes, including gestational diabetes, because this condition places all exposed children, especially those of Native American mothers, at significant risk of overweight. MEASUREMENTS 2. Perform accurate height and weight annually; consider more frequent measurement if at risk of or overweight. 3. Perform assessment of risk of overweight: a. Calculate and document BMI on the 2000 CDC growth chart. b. Document on the problem list BMI > the 85th%. 4. Perform BP measurement with appropriate size cuff at every well teen visit: a. Document BP percentile for age, sex, and height using NHLBI charts to identify teens with BP readings >90th% (pre-hypertensive) and >95th% (hypertensive). b. Document on problem list all BP >90th% (pre-hypertensive) and >95th% (hypertensive). c. Perform follow-up for elevated BP measurement. 5. Perform a fasting glucose level, total cholesterol and/or lipid panel to assess for diabetes mellitus, hyperlipidemia, and metabolic syndrome if the teen's BMI is >95%. PHYSICAL EXAM 6. Perform Sexual Maturity Rating (Tanner Stage) annually. HISTORY 1. Genetics play an important role in the development of overweight; obesity in one or both parents is a risk factor for overweight in teens, as is low income status (62). Providers must recognize populations and individuals at risk of becoming overweight and be alert for the co-morbidities of overweight (13, 29, 34). a. Exposure to intrauterine diabetes was a risk factor for the development of obesity and diabetes in Pima Indian children (Culture Ref: 16). MEASUREMENTS 2. An accurate height and weight is necessary to calculate an accurate BMI. Routine measurements in primary care settings have been noted to vary greatly in accuracy (35). 3. Early recognition of increases in weight to linear growth can be helped by calculating and plotting BMI routinely (27, 34). Tracking BMI increases provider, teen, and parent awareness of trends in weight. Parental awareness of their child s weight status results in greater readiness to assist the teen in achieving a healthy weight (4, 26, 29, 64). 4. Providers can recognize changes and discuss changes or patterns with parents and the teen as relates to normal growth and BP or movement into at-risk status for overweight or hypertension. Early detection of elevated blood pressure is important to maintain cardiovascular health because it permits early initiation of treatment (18, 29, 41, 44, 49). 5. Providers must recognize other health-related risks and/or consequences of overweight (10, 29, 34). PHYSICAL EXAM 6. Allows for awareness of normal pubertal changes. Early menarche (before age 8) is associated with increased risk of overweight; the onset of menarche varies among ethnic groups (1, 18, 26, 30). 7. Educate parents and teen about teen s growth pattern, clearly identifying risk status for overweight when BMI >85th% occurs. 7. Sharing the information increases parental knowledge about teen s growth status and the potential for the numerous problems associated with overweight. In a recent study of overweight children, parental awareness of their child s overweight status was significantly related to readiness to change (18, 27, 29, 34, 45). TEEN JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S43

11 Section 2. Developmental and Communication Considerations TEEN ASSESSMENT 1. Monitor parent/teen affect using the two-question depression screen at every well teen visit: During the past month have you been bothered by: a. Feeling down, blue, depressed, or hopeless? b. Feelings of little interest or pleasure in doing things? 2. Document areas of strength and concern. 3. Monitor teen s social and emotional development by inquiring about school-related behavior, peer interactions, bullying, activity in and out of school, and academics. 4. Document parent s attitudes, values and beliefs, and spiritual and cultural influences about nutrition, physical activity, and body size and shape; maternal education level; race/ethnicity; religion; preferred language; and preferred type of educational materials. 5. Educate parents and teens about: a. Expected growth and physical, developmental, and emotional changes. b. Changes in growth velocity and implications for appetite and food intake. 6. Educate parents about strategies for effective communication with their changing teen. Teens need parents to: a. Truly listen to their verbal and non-verbal communication. b. Respect their feelings. c. Respect their individuality. d. Teens appreciate a more consultative style of communication, support for increased independence, clear limits. They also have a continued need for time with their parents. 7. Counsel extended family members as well as parents about issues related to the teen s health. This is of special relevance for Hispanics, African Americans, and Native Americans. 8. Refer family as needed to appropriate nutritional and physical activity resources, including RDs. ASSESSMENT 1. Parental depression can affect parent-teen communication and relationships. The USPSTF recommends screening for depression among adults, finding the two-question screen as effective as longer screening questionnaires. The prevalence of depression increases in the teen years. Both overeating and anorexia occur more often among depressed teens than unaffected peers. Providers need to make this assessment so that they can intervene appropriately (5, 22, 42, 51, 63). 2. Health care providers can help families communicate better by identifying strengths and barriers (29, 34). 3. Children with increased BMI are more likely to report being victimized/bullied by others and bullying others (28). 4. Eating and activity behaviors are influenced by changing and developing attitudes and beliefs. Awareness of such issues can aid communication between health care providers and parents and teens (9). 5. Adolescence is period of rapid growth faster than at any time since the first year of life. Therefore increased appetite is normal. Awareness of appropriate portions and healthy food choices may prevent abnormal growth patterns (27, 61). Awareness of variance in eating patterns and normal developmental changes that may influence eating behavior may help promote healthy eating habits (54, 61). 6. Parents need to be aware they continue to be a strong influence in behaviors developing in their adolescent children. Shared physical activity, food shopping, meal preparation, and family meals may promote healthy eating behaviors and provide opportunities for communication (4, 16, 19). 7. Family is of great importance to all children, and is of special relevance in both the Hispanic and African American cultures. Compadres (godparents) play a significant role in the life of the Hispanic child. African American grandparents are greatly involved with the upbringing of their grandchildren. Many Native American households include extended family members (grandparents, aunts, uncles). Promoting healthful eating as well as increasing physical activity was found to be successful if the family of Native Americans was involved. Practitioners are more likely to be successful with their message if the extended family is included in the discussion (Culture Ref: 2, 3, 6, 7, 12, 13). 8. Health care providers need to be aware that families may face barriers in making appropriate food choices (56). Access to appropriate nutritional and physical activity resources may prevent overweight and/or improve general health. Practitioners are a vital link between families and local community agencies. They can assist families with needs and concerns and can identify and provide referrals to resources for encouraging S44 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

12 Section 2. Developmental and Communication Considerations positive nutrition and physical activity. RDs are a good resource for parents and children who have complex educational and nutritional management needs. Qualified RDs can be located using the American Dietetic Association (ADA) website at org (54). 9. Counsel using MI when parents and teens are willing to make positive changes. a. Reinforce all positive health behaviors. b. Identify discrepancies between goals and behaviors. c. Develop a plan of action in partnership with the family. 9. MI creates a partnership between the parent, teen, and professional to address health issues that parents and children can choose to focus on if they wish (53). The structured MI approach helps the partners address important health issues in a timely way. Some evidence indicates that MI improves the likelihood of positive patient behavior change (7, 40). Section 3. Nutrition Essentials, Optimal Feeding, and Eating Behaviors ASSESSMENT 1. Monitor nutritional intake for consistency with expert recommendations for age, sex, and activity level at each well child visit or at least annually, including: a. Types, amounts, and frequency of foods and beverages. b. Portion sizes. c. Variety of foods eaten in each macronutrient group. d. Types of dietary supplements. 2. Monitor and document barriers to healthy eating, such as lack of healthy foods, financial barriers, and lack of knowledge about healthful food choices. 3. Educate parents and teens about recommended nutritional intake for each age (see Tables 1 and 2). a. Eat a variety of foods from all food groups. b. Select whole grain products for at least half of grains eaten. c. Eat 5 or more servings of fruits and vegetables daily (serving = 1 /2 cup). Regularly select vegetables from all subgroups, including dark green, orange, legumes, and starchy vegetables (about 1 /3 of intake should come from each color grouping). d. Choose appropriate types, amounts, and portion sizes of healthful foods (see Table 2). e. Avoid calorie-dense, nutrient-poor foods, such as french fries, chips, and soda. f. Ensure a calcium intake of mg daily (3 4 eightoz glasses of milk daily or the equivalent). g. Limit fast food to no more than twice per week and educate about healthier choices and portion control when eating out. h. Limit fat intake to 25 35% of daily calories. i. Make healthier choices for types of fat: avoid foods high in trans fats, e.g., cookies, baked goods, doughnuts, french fries. ASSESSMENT 1. Providers need to make this assessment in order to make appropriate suggestions for change to promote healthy eating patterns if needed (33, 39, 61). 2. To best assist parents, health care providers must be aware of barriers that families face in making appropriate food choices (56). 3a. c. These are current recommendations to promote good health and appropriate weight gain or management of weight (32, 33, 61). d. Being served a large portion often results in eating a large quantity of food, which increases caloric intake and the risk of overweight (43, 61). e. Calorie-dense foods are associated with overweight and do not add to recommended nutrient intake. Since 1970, Americans have increased their daily intake of fats by 50.5% (61). f. Lower consumption of calcium and dairy products has been associated with overweight and adequate calcium intake is necessary for normal bone development (52, 61, 65). g. Increased intake of foods at fast food establishments is associated with overweight (48, 58, 59). h., i. Lower fat diets have been shown to be effective for preventing overweight and for long-term weight maintenance (48, 57, 61). TEEN JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S45

13 Section 3. Nutrition Essentials, Optimal Feeding, and Eating Behaviors TEEN use soft margarine rather than butter or stick margarine use low-fat or fat-free dairy products choose polyunsaturated or monounsaturated fats, such as those found in fish, nuts, and vegetable oils h. Provide healthful snacks in appropriate portion sizes and limit consumption of prepared snack foods, such as chips, cake, and candy, at home and away. i. Limit 100% fruit juice to 4 6 oz per day and avoid consumption of fruit drinks and sodas. j. Encourage consumption of water and low or fat-free milk rather than sweetened beverages. 4. Educate parents and teens about how to carry out promising feeding practices, including: a. Recognize changes in growth velocity and associated changes in appetite and need to balance energy intake from food with energy output in physical activity (see Table 1). b. Prepare teens for greater independence in selecting a healthful diet, preparing meals, and selecting appropriate portion sizes. c. Serve as positive role models for healthy eating behaviors. d. Recognize the value of family meals and have them as often as possible to increase quality of nutrition and enhance family connectedness. e. Encourage eating a healthful breakfast daily. 5. Educate parents to avoid less optimal feeding practices: a. Avoid use of food for comfort; recognize emotional triggers for eating and substitute other coping strategies. b. Avoid restrictive and fad diets. 6. Counsel with emphasis on the positive health consequences of good nutrition rather than focusing on the child s weight. 7. Counsel parents to offer traditional foods and not to offer children alternative foods when they refuse traditional foods. Hispanics and Native Americans: beans, corn, tortillas, and vegetables. African Americans: fruits and vegetables. h. Snacking has increased among children recently. If they are selected wisely, snacks can be an important source of nutrients and calories, which may promote normal growth and prevent overweight (33, 61). i., j. Unlimited consumption of juice contributes to increased caloric intake and compromises intake of adequate nutrients. Since 1970, Americans have increased their daily intake of refined sugars by 18.9%, while decreasing their dairy intake by 4.2% (24, 36, 38). a. Awareness of normal growth and appetite patterns may influence selection of appropriate portion sizes and food selections to foster normal growth (27, 61). b. Food shopping and meal preparation together may promote healthy eating behaviors (33, 61). c. Parents need to be aware that they continue to be a strong influence on the behaviors of their adolescent children. Parent role modeling of good nutrition and eating behaviors is associated with both parent and child weight loss (39, 64). d. When teens eat regularly with families, they increase their intake of fruits, vegetables, fiber, and micronutrients from food; consume fewer fried foods, less soda, and less saturated and trans fat; and have a lower glycemic load. Eating meals together provides opportunities for parents to be good role models for healthy eating behaviors and promotes psychosocial well-being (16, 19). e. Skipping breakfast is associated with higher BMI and obesity as well as poorer school performance and behavior problems (11, 37, 61). 5. Research studies show that when parents withhold favorite foods, children crave those foods more and tend to overeat when they do have access to them. The best strategy is to only offer healthful foods and snacks and relatively small portions (17). 6. Hispanics: In the Hispanic culture, thinness is often associated with poor health, and there is often the perception that a little extra weight is necessary for children in order to help them recover from illness (Culture Ref: 5, 12). African Americans: African Americans are more tolerant of larger body size and care givers seldom perceive their children as obese (Culture Ref: 1, 17). Practitioners may be more successful at establishing rapport with Hispanic and African American families if the discussion is initially focused on health, not necessarily weight. 7. Practitioners can encourage cultural pride by promoting traditional foods as having high nutritional value. Hispanic teens who are more acculturated are less likely to consume traditional foods (Culture Ref: 10). African American: Fast food has become a favorite chioce because it is quick and easy (Culture Ref: 15, 17). S46 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

14 Section 4. Physical Activity and Sedentary Behavior ASSESSMENT 1. Monitor at least annually: a. Daily physical activity level, type, and amount. b. Daily types and amounts of sedentary behavior. c. Barriers to performing activity, e.g., safety, access, cost. d. Teen sleep behaviors, including amount, patterns, and barriers to restful sleep. 2. Counsel with emphasis on the positive health consequences of increased physical activity rather than focusing on the teen s weight. 3. Educate parents and teens about age-appropriate physical activity and how to incorporate it into daily family routines. a. Recommend at least 60 minutes daily of intermittent, moderate to vigorous physical activity. 4. Educate parents and teens about the value of family activities and parent modeling of positive physical activity behaviors. 5. Educate parents and teens about media influences on healthrelated behaviors and about how to carry out promising screen time practices: a. Turn off TV during meals. b. Limit screen time to no more than 2 hours per day. c. Monitor the teen s time to ensure a balance between screen time and physical activity. d. Do not allow a TV in the teen s bedroom. ASSESSMENT 1.a., b. Providers should be aware of current recommendations for physical activity for adolescents and can recommend changes as needed to improve health, prevent overweight, prevent other chronic diseases, and improve fitness, BP, coronary risk profile, attitudes, and behavior (8, 9, 20, 29, 60, 61). c. Providers need to inquire about barriers and possibly offer solutions so teen can maintain physical activity or become physically active (21, 31, 56). d. Lack of sleep has been linked to overweight (23). 2. Hispanics: Average physical activity is lower among Hispanic adolescents than among white adolescents (Culture Ref: 5, 8, 12). African Americans: Statistically, heads of household in this population are less likely to do well with weight loss programs, which decreases their attempts to change their children s weight status (Culture Ref: 15). Native Americans: Native American children are not physically active on a regular basis. A collaborative relationship which involves the Native American community is essential for a program to be successful. Encourage any games that may be traditional for a specific tribe (Culture Ref: 9, 16). 3. Parental behaviors influence development of healthy eating and activity behaviors in their teenage children (27). a. Regular physical activity can prevent overweight and other chronic diseases as well as improve fitness, BP, coronary risk profile, attitudes and behavior. (9, 29, 45, 50, 60, 61, 64). 4. Parental behaviors influence development of healthy eating and activity behaviors in their teenage children (27). 5. Awareness of media influences on making choices may improve eating habits (25, 55). Parents can discuss with teens influence of content and advertising (14). a. Food types and quantities eaten may be influenced by watching TV (6, 15). b., c. Sedentary activities are associated with increased incidence of overweight and may limit other opportunities for appropriate social development (3, 9, 12, 15, 29, 34, 46, 47, 61). AAP recommendation (34). d. Television in the bedroom is reported to be a strong predictor of greater risk of overweight (2). Section 5. Advocacy TEENS 1. Advocate for partnerships between teens, schools, and the community to develop after-school programs to promote physical activity and improved nutrition. a. Volunteer with a local animal shelter for dog walking and pet care. b. Create opportunities for dance and music through videos and peer educators. TEENS 1. Schools should provide an environment that is consistently conducive to healthy eating behaviors and regular physical activity (Advocacy Ref: 14). a., b. Adolescents who participate in after-school activities have lower BMIs (Advocacy Ref: 10). TEEN JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S47

15 Section 5. Advocacy TEEN c. Develop partnerships with local daycare, Head Start, or after-school programs and have teens help design and work in physical activity programs for children. d. Develop internships with local healthy eating establishments to learn menu planning and food preparation. e. Establish peer group programs to partner with children and youth with special health care needs (CYSHCN) to create opportunities for active play. 2. Advocate for schools to institute and preserve Family and Consumer Science (FACS) classes in the high school curriculum to assist students in developing the knowledge and skills for healthy lifestyle choices in nutrition and physical activity. PARENTS AND TEACHERS 3. Advocate for parent and teacher involvement on community and school boards that make decisions about school nutrition and physical education. 4. Advocate for daily physical education. Physical activity could include non-traditional activities such as dance and movement classes, walking programs, or wall climbing. 5. Advocate for improved school lunches that: a. Provide a variety of healthy foods from which to select. b. Emphasize appropriate portion sizes. c. Minimize foods high in fat and calories and low in nutrient content. 6. Advocate for restricted vending machine sales and conversion to healthy foods and beverage selections, such as: a. Low-fat snacks. b. Fresh and canned fruits. c. Water and low- or fat-free milk. PROVIDERS 7. Advocate in schools to raise awareness of the importance of physical activity programs and policies. a. Speak out at local schools. b. Take a leadership role in promoting physical education in schools. 8. Educate parents, students, and school staff regarding diversity of children and tolerance and acceptance of all body types and physical abilities. 9. Advocate for the formation of School Health Advisory Committees and the adoption of the National Alliance for Childhood overweight must be addressed at the community level. Community programs must interact with school programs to provide opportunities for children to be physically active, both during and after school hours (Advocacy Ref: 13). 2. Coordinated changes in the classroom curriculum and after-school programs offer the potential to advance overweight prevention efforts (Advocacy Ref: 14, 22). FACS National Standards provide guidelines for developing programs that give students the opportunity to acquire knowledge, skills, attitudes, and behaviors for family life, work, and careers (Advocacy Ref: 22). PARENTS AND TEACHERS 3. Coordinated changes in the classroom curriculum, the in-school advertising environment, school health services, and after-school programs all offer the potential to advance overweight prevention efforts (Advocacy Ref: 7). 4. Fostering a teen s sense of competency and fun regarding physical activity may increase participation in vigorous activities, reduce gender differences, and help prevent overweight (Advocacy Ref: 9, 25). 5. All food and beverages sold or served to students in school should be healthful and meet an accepted nutritional content standard (Advocacy Ref: 15, 23). 6. By law, in some states, the only beverages that may be sold in school vending machines are water, milk, and 100% fruit juices or fruit-based drinks that are at least 50% fruit juice with no added sweeteners. All other foods sold in schools (including those sold in vending machines, at fundraisers during the school day, and at school functions) must reflect the Dietary Guidelines or meet the USDA standard for a lunch component (Advocacy Ref: 12). PROVIDERS 7. Many schools around the nation have reduced their commitment to providing students with regular and adequate physical activity (Advocacy Ref: 1, 14, 18). Low levels of physical activity are consistently linked to overweight in children and teens. 8. Overweight children often suffer from low self-esteem, depression, and/or fear of being bullied or teased (especially in physical education class). This may lead to avoidance of physical activity or other outside activities, which may exacerbate the problem. Stigmatization of overweight teens is very real. All teens want to feel included and competent (Advocacy Ref: 4, 24). 9. Each school should establish and maintain a staff wellness committee (composed of at least one staff member, one school health council member, and possibly a local hospital S48 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

16 TEEN Section 5. Advocacy Nutrition and Activity (NANA) Model Local School Wellness Policies on Physical Activity and Nutrition. a. Practitioners can encourage parents, teachers, other professionals, and youth leaders to join together and assess needs, develop plans, and implement policies related to physical activity and healthy eating in their communities. b. Develop clear, positive physical activity and nutrition messages for adolescents and families. 10.Prepare learning sessions on MI techniques for parents and teachers during lunch period or as part of after-school or parent programs. representative, dietitian or other health professional, recreation program representative, union representative, or employee benefits specialist) that reports to the school health council (Advocacy Ref: 25). 10.MI has been shown to be an effective modality in the adolescent population to address problematic behavior. MI creates a partnership between the parent, child, and professional to address health issues that parents and children can choose to focus on if they wish. The structured MI approach helps the partners address important health issues in a timely way (Advocacy Ref: 24). JOURNAL OF PEDIATRIC HEALTH CARE March/April 2006 S49

17 6 HEAT Teen 1/19/06 12:57 PM Page 50 HEAT TEEN Brief Guide EARLY IDENTIFICATION Document family history relevant to risk of overweight and update annually. Measure height and weight at least annually; consider more frequent measurement if at risk of or overweight; document on the CDC growth charts. Perform BMI calculation at least annually and document on CDC growth chart; document on problem list if > 85th%. Perform blood pressure at least annually; document those with BP > 90th% on problem list. Perform and document Sexual Maturity Rating (Tanner Stage) annually. Perform a fasting glucose level, total cholesterol and/or lipid panel to assess for diabetes mellitus, hyperlipidemia, and metabolic syndrome if the teen s BMI is > the 95th%. Educate parent and teen about growth pattern, clearly identifying status if at risk of or overweight. DEVELOPMENT AND COMMUNICATION Perform two-question screen for depression on parent and teen. Document areas of strength and concern. Monitor teen s social and emotional development. Document personal attitudes, values, and beliefs; spiritual and cultural influences about nutrition, physical activity, and body shape and size; race; ethnicity; language and educational preferences. Educate teen and parents about expected growth, development, physical and emotional changes. Educate parents about effective communication strategies with their teen. Counsel extended family members as well as parents about issues related to teen s health. Refer family, as needed, to free or low-cost community nutritional and physical activity resources, including registered dieticians. Engage in Motivational Interviewing to address areas of concern: Reinforce all positive health behaviors Identify discrepancies between goals and behaviors Develop a plan of action in partnership with the family NUTRITION AND FEEDING TEEN Monitor nutritional intake at least annually. Identify barriers to healthy eating. Educate teen and parents regarding recommended nutritional intake: Limit portion sizes BOLD type indicates a strong evidence-based recommendation Red italic type indicates a culturally appropriate recommendation S50 Volume 20 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE