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Pediatric obesity can lead to chronic cardiovascular and endocrine conditions.
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An effective intervention proven to manage obesity is the implementation of motivational interviewing.
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The motivational interviewing survey tool increases provider awareness of pediatric patients with obesity.
Abstract
The aim of this quality improvement project was to increase the providers’ awareness of pediatric patients with overweight and obesity and initiate change behavior conversations. A healthy weight motivational interviewing survey tool was adapted from the University of Connecticut Rudd Center and was implemented at all well-child visits in patients aged 10 to 18 years at a rural pediatric health care clinic in Alabama. A comparative analysis was conducted on the baseline and postintervention data. The results of the motivational interviewing survey tool indicated that there was an increase from 40% to 90% of patients having their weight status addressed by the health care provider.
American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hour, approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.
Introduction
Pediatric obesity is highly prevalent in the nation, with one-third of the United States children being classified as overweight or obese.
The Centers for Disease Control and Prevention (CDC) defines pediatric obesity as a body mass index (BMI) status at or above the 95th percentile and defines pediatric overweight as a BMI at or above 85th percentile and below the 95th percentile.
indicated that being a child with obesity increases the likelihood of being an adult with obesity. Additionally, pediatric obesity predisposes a child to chronic health conditions, including hyperlipidemia, hypertension, diabetes, and metabolic syndrome.
Furthermore, the health care system and insurance companies are required to spend more money on treatment measures for the comorbidities that accompany pediatric obesity.
These health problems that pediatric obesity exacerbates can add physical, emotional, and financial stressors on the patient and family.
Several studies suggest that increasing physical activity and decreasing caloric intake can result in a healthy weight status for a patient with obesity. However, many studies do not report these methods as being the most effective in establishing a long-term weight management option for the pediatric population.
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
indicated implementing the technique of motivational interviewing (MI) in treating pediatric obesity resulted in improved physical activity and BMI. MI is a family-centered collaborative approach and focuses on the patient and provider to collaborate to determine a plan of care.
Incorporating MI in the care plans of pediatric obesity can empower the patient and family to feel more in charge of their health. Subsequently, patients are allowed to collaborate with the provider to set realistic goals and a step-by-step plan to manage their obesity.
A delay in the identification and treatment of pediatric obesity has been identified as a gap in health care at Wetumpka Pediatrics, a rural health care clinic in Alabama. The rural health care clinic provides primary medical care for children between the ages of newborn to 18 within the surrounding counties. The clinic provides care to most of the surrounding area’s Medicaid population, with approximately 90% of the patients in the practice having Medicaid as a primary insurance. The clinic consists of 4 health care providers and serves approximately 600 to 1,000 patients per month.
Before the project was initiated, a retrospective medical record review was performed weekly for 1 month. The medical record review determined in 1 week, the clinic had 27 well-child visits for patients between the ages of 10 and 18 years. Approximately 48% of those patients were classified as overweight and obese based on their BMI status. However, of those 48% patients classified as overweight or obese, the weight status of approximately 40% of those patients was not addressed during the visit.
A gap analysis performed within the clinic revealed that the providers felt they had a lack of knowledge, resources, and time to effectively start the initial conversation and treatment for the patients with obesity. Approximately 80% of providers feel frustrated with treating pediatric obesity.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
The delay of the identification and treatment of the patients is due to the providers having a lack of resources to effectively start the initial conversation with the patients classified as obese.
This quality improvement (QI) project involved the provider implementing an obesity MI survey tool with patients during well-child visits to identify overweight and obese patients in the clinic and assess the patient’s readiness for change. We used a modified version of the University of Connecticut Rudd Center for Food Policy and Obesity nonprofit research and public policy organization MI survey tool, public domain document.
The MI questions were modified so that it would better adapt to the pediatric population and the comprehension level of the patients. This tool assisted providers in assessing the patients’ readiness to change and initiate the conversation on achieving a healthy weight status.
Literature Synthesis
A search of the PubMed and Cumulative Index of Nursing and Allied Health (CINHAL) databases for peer reviewed articles published within the last 5 years, using the search terms “motivational interviewing and pediatric obesity and healthy weight status,” produced an initial yield of 942 articles. Inclusion/exclusion criteria applied included articles that were full text, peer reviewed, written in English, written within the last 5 years, and pediatric population, reducing the article yield from 942 to 84. The final article yield was reduced to 9 after reviewing the remaining abstracts that included MI techniques within a pediatric population. Two themes emerged from the review of the literature regarding MI techniques: (1) family approach with MI is key to managing pediatric obesity, and (2) behavior change is the best indicator of successful pediatric obesity management.
The literature review recognized that families play an important role in the management of the pediatric patient. Not only is it important for pediatric patients to take control of their health through MI strategies, but for long-term successful behaviors, the family must also provide support.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
Cluster randomised trial of a school community child health promotion and obesity prevention intervention: findings from the evaluation of fun ‘n healthy in Moreland!.
BMC Public Health.2017; 18 (Published correction appears in BMC Public Health. 2017;17(1):736. https://doi.org/10.1186/s12889-017-4625-9): 92
all identified that parents or primary caregivers model behavior for the children, whether that be healthy or unhealthy habits. These authors stressed the importance of families modeling positive health behaviors, such as participating in exercise, having positive attitudes toward food and exercise, and eating a balanced diet.
Therefore, an important part of the MI process is to identify and understand how the parents perceive obesity and treatment options. With the high influence the family has on the child, if the family is not willing to put forth the effort to make healthy changes, the child will not be as likely to manage these changes over the course of their lifetime.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
Families that identified unhealthy behaviors in the life of the child with obesity and made even small changes to correct those behaviors positively affected the BMI status of the child with obesity.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
Cluster randomised trial of a school community child health promotion and obesity prevention intervention: findings from the evaluation of fun ‘n healthy in Moreland!.
BMC Public Health.2017; 18 (Published correction appears in BMC Public Health. 2017;17(1):736. https://doi.org/10.1186/s12889-017-4625-9): 92
all concluded that identifying both the pediatric patient with obesity and the family’s perception of the obesity status, through MI techniques, can increase the success rate for long-term management and treatment of obesity.
Secondly, eliciting behavior change proved to be the best indicator for successful pediatric obesity management. MI interventions on pediatric obesity have been associated with prompt behavior change that can propel the patient to a healthier and more successful outcome. Gourlan et al
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
identified in their articles that MI counseling will encourage patients to think about and express their own reasons for and against change. It also allows patients to address how their current behavior has an impact on their lifestyle and health. This is accomplished through reflective listening by the provider. Gourlan et al
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
found that MI creates an atmosphere where the patient becomes the main advocate for change leading to successful outcomes for the patient. Behavior change was a successful approach to increase physical activity and adherence to a healthy nutrition regimen.
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
supported that once the pediatric patient demonstrates change talk, it will result in positive outcomes on healthy habits and reduction of BMI.
Framework
Pender’s Health Promotion Model (HPM) is the theoretical framework that guided the QI project. The HPM consists of 3 main categories: behaviors and habits, behaviors and interventions, and behavioral actions.
The first category includes how a patient’s past experiences will shape their behaviors and habits. The second category consists of a patient’s cognition process in regard to health behaviors. A patient’s thought process can be altered due to targeted nursing interventions on the patient’s health-promoting behaviors.
The third category includes the action taken to reach a desired behavioral outcome. Specific interventions are implemented based on improving a patient’s self-efficacy and combating barriers to change.
The MI techniques revolve around reshaping the cognition process of the patient to take charge of their own health through interventions by the patient, provider, and family.
Through MI, the provider assesses the patient’s perceived benefits, barriers, self-efficacy, situational influences, and commitment to the plan regarding the weight loss process.
Targeted interventions of nutrition, physical exercise education, and involving the family to support the patient in the health-promoting behaviors are implemented to allow the patient to feel more empowered to take charge of their own health.
The provider can continue with the MI techniques and reassess the patient’s perceived benefits, barriers, self-efficacy, influences, and commitment through the management process and overall BMI status.
Purpose
The purpose of this QI project was to increase the provider’s awareness of a patient classified as obese and to assess the patient’s readiness for change through the use of the obesity MI survey tool. Once patients were identified as overweight and obese, providers used the MI survey tool to assess the patient’s readiness for change. Once the readiness for change was identified, a conversation was initiated between the provider and patient regarding the causes, management, and treatment of obesity. For sustainability of the project, the tool will be used to implement the management and treatment to overall reduce the increasing overweight and obesity rates within the pediatric population at Wetumpka Pediatrics Clinic.
The aim of this QI project was to determine in pediatric patients ages 10 to 18 years whether the use of the obesity MI survey tool compared with usual standard of care was effective in increasing the provider’s awareness of the patient’s classified as overweight and obese and initiate change behavior conversations within 3 months.
Methods
The project received a designation of quality improvement from the University of Alabama at Birmingham (UAB) School of Nursing (SON) QI Review Team. The methodologic framework implemented with the QI project is the Plan-Do-Study-Act (PDSA) cycles. The PDSA cycle is used to implement and test changes within a clinic setting. Implementing the PDSA cycles promotes various levels of evaluation throughout the QI process to ensure best practice is being implemented within the clinic.
The QI project’s plan was the creation of the MI survey tool to increase the provider’s awareness of the patients with overweight and obesity aged 10 to 18 years and initiate change behavior conversations. By identifying these patients and providing the MI survey tool as a resource to the provider, it allows the patient to become aware of their weight status and start the process of change toward a healthy weight status. See Figures 1 and 2 for the healthy weight MI survey tool.
Initially, the providers and nursing staff had a lunch and training session designed to educate them on the statistics of pediatric overweight and obesity rates, the components of MI, and how the obesity MI survey would be distributed with the patients and families. The health care providers had one additional lunch and training session that consisted of how to score the obesity MI survey and included a review of the American Academy of Pediatrics’ (AAP) nutrition and exercise handouts for patients and families.
Do
The “do” phase outlines the actual implementation portion of the plan.
The nursing staff was responsible for providing the patient and/or family with the 1-page obesity MI survey at the start of the well-child visit for patients between the ages of 10 and 18 years. The survey was administered to all patients with appointments for well-child visits between ages 10 and 18 years for consistency within the clinic. The inclusion criteria included English-speaking patients, well-visit appointments, all BMI statuses, both sexes, all races, and all insurances. Exclusion criteria included age <10 years, age >18 years, sick appointments, and non–English-speaking patients.
After the patient completed the survey, the health care provider scored the survey and reviewed results with the patient and/or family. If a patient had a BMI ≥85th percentile, which is calculated based on the patient’s height and weight by the electronic health record (EHR) system, the health care provider began the discussion of assessing the patient’s readiness for change in regard to their weight and lifestyle. The provider offered the identified overweight or obese patient and/or family the AAP’s healthy children’s “Educational Healthy Habits” handout on nutrition and exercise at the conclusion of the visit. These handouts serve as a resource and reference that the patient and family can use at home.
Study
The “study” phase reviews the data gathered during the do phase.
During the study phase, data were gathered on the MI survey tools administered to each patient aged 10 to 18 years with a well-child visit. Data were also gathered on the identification of weight status based on the patient’s BMI status. An outcome measure for the project was for 80% of pediatric patients between the ages of 10 and 18 years to be screened through the obesity MI survey evidenced by the comparison of the number of surveys administered to patients and those patients not administered the survey. Data were collected on each well visit for all 4 providers to determine the number of patients identified as overweight or obese compared with the number of patients seen for each month of implementation. For each patient that was classified as overweight or obese, data were collected on whether the patient was administered the MI obesity survey tool. Data were also collected on the ratio of ethnicity, age, sex, and religion of the patients classified as overweight or obese. Data collected from each well-child visit from June 1, 2020, to August 31, 2020, were recorded via an Excel spreadsheet (Microsoft) and then transferred to SPSS software (IBM Corp) via the identified random code generator. Descriptive statistical analysis was performed via SPSS.
Act
Lastly, the “act” phase encompasses the adaption, adoption, or restart based on the results of the study phase.
For the QI act phase, the results reported an increase in identification of overweight and obese patients within the clinic. An adaption of the MI survey tool can be implemented into the clinic. After 3 months of implementation, another PDSA cycle will be conducted if any revisions to the plan should be made.
Results
There were 288 well-child examinations of patients aged 10 to 18 years performed from June 2020 to August 2020, and 260 patients received the MI survey tool during the well-child visits; resulting in a 90% rate of administration. For the 3 months of implementation, 39 patients were classified as overweight, and 89 patients were classified as obese. This totaled 15% of patients identified as overweight and 37% of patients identified as obese (Figure 3).
Figure 3Percentage of body mass index (BMI) status.
Descriptive statistics were performed on the ratio of ethnicity, age, sex, and insurance provider of the patients identified as overweight or obese. The mean was 13.5 years, and the BMI was 95% of the analyzed sample. The patients identified as overweight and obese included 79 boys and 60 girls. For race/ethnicity, 48.2% were African American, 48.9% were White, 0.7% were Asian, and 2.2% were Hispanic (Table 1). A total of 91.4% patients had Medicaid, 2.9% All Kids, 5% Blue Cross Blue Shield, and 0.7% TRICARE (Table 2).
Table 1Race/Ethnicity for Identified Overweight and Obese Patients
The literature suggests the effectiveness of treating pediatric obesity with MI techniques. However, a crucial step in using MI interventions is incorporating the primary care provider to conduct the interventions and support the families and patients. Resnicow et al
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
addressed that primary care providers did not believe they had the sufficient skills needed to engage and motivate patients and families.
In the study, 80% of the providers reported feeling frustrated treating pediatric obesity. Primary care settings are crucial for preventative care and being first line to addresses any problems or concerns within the pediatric population. Therefore, the healthy weight MI survey tool equips the primary care health care providers with the resources and knowledge needed to begin the conversations on identifying and addressing overweight and obesity within the pediatric population. Once identifying the patient as overweight or obese and making the patient aware of the weight status, the provider had the opportunity to discuss the patient’s responses to the MI survey tool with the patient and/or family. Also, the provider had the AAP’s handouts on healthy habits to review and provide to the patient so the patient and/or family could use these as a reference at home. These tools and resources allowed the provider to open the communication on establishing healthy habits and formulate a plan with the patient to achieve a healthy weight status.
Before the QI project was implemented within the clinic, only 40% of patients classified as overweight and obese were having their weight status addressed and being made aware of the weight status by the health care provider. After the QI project was implemented, 90% of the patients being classified as overweight and obese were having their weight status addressed and discussed by the health care provider. Additionally, of the 90% of patients classified as overweight and obese, 100% of the patients were administered the healthy weight MI survey tool at the clinic’s well visit. Additionally, 100% of the providers were reviewing the MI survey tool with the patients and using the AAP’s healthy habits resources to discuss the patient’s weight status. Of the 288 well-child visits aged 10 to 18, 28 patients did not complete the MI survey tool at the clinic. This was due to patient and/or family refusal or the nursing staff did not provide the healthy weight MI survey tool at the beginning of the well visit.
Limitations
One limitation to the QI project was the coronavirus disease 2019 global pandemic. The QI project began implementation in June 2020, which was during the initial shutdown of states and stay at home orders. This negatively affected the primary health care clinic’s daily patient census. The clinic had to delay some well visits, start telehealth visits, and had an increase in no-show rates and cancellations. Therefore, the primary care health care clinic’s monthly patient census reduced from approximately 1,100 patients per month to approximately 600 patients per month during the implementation phase.
Conclusion
The implementation of the healthy weight MI survey tool in the rural primary care pediatric health care clinic produced positive results of increased provider awareness of patients with overweight and obesity between the ages of 10 and 18 years. This increased rate of awareness allowed the providers to start behavior change conversations with each of the patients with overweight and obesity. The MI survey tool prompted health care providers to discuss with parents and/or patients how to help the patients meet their healthy weight status. Making available MI techniques in the treatment of pediatric obesity can result in a healthier lifestyle for the patient. The charge to pediatric health care providers is to further investigate MI counseling techniques and fully implement those interventions into the treatment plans of pediatric obesity.
References
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Cohen D.
Pribis P.
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Nutrition education and body mass index in grades K-12: a systematic review.
Motivational interviewing as a way to promote physical activity in obese adolescents: a randomised-controlled trial using self-determination theory as an explanatory framework.
Advances in motivational interviewing for pediatric obesity: results of the brief motivational interviewing to reduce body mass index trial and future directions.
Cluster randomised trial of a school community child health promotion and obesity prevention intervention: findings from the evaluation of fun ‘n healthy in Moreland!.
BMC Public Health.2017; 18 (Published correction appears in BMC Public Health. 2017;17(1):736. https://doi.org/10.1186/s12889-017-4625-9): 92
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