Nurses on the Frontlines of the Obesity Epidemic

Nurses On the Frontlines of the Obesity Epidemic

April 8, 2015

On a bright September morning in New York City, Rose Rodriquez ’87 ’06, MS, CPNP-PC, CCTC, is gently talking with a teenage patient about his breakfast cereal. “Do you add milk?” she asks. “What kind do you use?” Matthew, a shy 19-year-old Latino in a Yankees sweatshirt and baggy cargo pants, tells her he pours 2 percent milk on his Cheerios. “Good,” says Rodriguez. “And a good way to cut more calories would be to switch to 1 percent. Some people don’t even notice the difference.

Next they talk about his favorite drinks. When Matthew mentions that he loves juice and fruit punch, Rodriguez is quick with a suggestion. Instead of a full glass of fruit punch, try adding a little to some seltzer water. “It’s like a whole new drink,” she says, with the upbeat enthusiasm of the cheerleader she once was. “It will be flavored with what you like,” she adds, but with a fraction of the calories. Matthew agrees to give it a shot.

At 5 feet 6 1/2 inches and 272 pounds Matthew falls well into the category of obese. This would be concerning in any patient but even more so for someone with Matthew’s medical history. When he was 14, he was diagnosed with cardiomyopathy after he presented with nausea, fatigue, and symptoms of heart failure. Nauseated and weak, he missed two months of ninth grade as his medical providers and family in Brooklyn tried to determine what was wrong. Ultimately, his life was saved by a heart transplant at the Morgan Stanley Children’s Hospital of NewYork-Presbyterian. Rodriguez, who is the chief nurse practitioner for the hospital’s Cardiomyopathy, Heart Failure and Transplantation Program, has been monitoring him ever since.

While Matthew has recovered brilliantly from transplant surgery, his weight now threatens his long-term health. Rodriguez estimates that about 30 percent of her patients are overweight, 10 to 15 percent of whom are obese. “If they are presenting with a high body mass index,” Rodriguez says, “nutrition is a huge component of their health and well-being.” So crucial, that Rodriguez is pursuing a master’s degree in nutrition so that she can bring additional expertise quite literally to the table. She works slowly and carefully with her young patients and their families, mindful of cultural food preferences and putting an emphasis on step-by-step changes to avoid discouragement. “We make suggestions that are approachable instead of trying to radically change what they eat,” she explains. Small steps build the conviction that change is possible; they pave the road to bigger victories against obesity.

It’s virtually impossible to work in 21st-century American health care and not deal with the complex challenges of obesity. According to data from the Centers for Disease Control and Prevention (CDC)published earlier this year, more than a third (34.9 percent) of U.S. adults are obese—meaning that they have a body mass index (BMI) of 30 or more. (For 5-foot-9-inch adult, for example, that means weighing 203 pounds or more.) For non-Hispanic blacks, the prevalence is closer to half—47.8 percent—for Hispanics, 42.5 percent. These racial and ethnic disparities begin in childhood. About 17 percent of American children, ages 2 to 19, are obese, but the figure is 22.4 percent among Hispanic children and 20.2 percent among African-Americans. (For children ages 2 to 18, obesity is defined as having a BMI in the 95th percentile for their age.)

These numbers represent an alarming change from the past. While the child obesity rate appears to have stabilized in recent years, it is nonetheless triple what it was in 1980.As for adults, one recent report calculated that the average American is 24 pounds heavier today than in 1960. The medical implications of these trends are daunting. Excessive weight brings increased risks of diabetes, hypertension, heart disease, liver disease, osteoarthritis, and several types of cancer. No wonder the CDC calculates that the annual medical cost for an obese person is $1,429 higher than for a person at a healthy weight.

Experts generally agree that the causes of the obesity epidemic involve an intricate interplay of individual factors, such as an increasingly sedentary lifestyle; interpersonal factors that include changes in the way families eat and spend their time; environmental influences, such as a landscape brimming with fast food restaurants and heavily promoted processed foods; and government policies, such as federal support for corn producers that led to a food supply awash in high fructose corn syrup. Attacking the epidemic means working at every one of these levels, a concept sometimes referred to as the social-ecological model.

Nurses are, of course, ideally positioned to work at the individual level and interpersonally with families. “We are obtaining height and weight measurements; we are an integral part of that consult, having those delicate conversations about weight and obesity,” says Rodriguez. “We’re really at the crux of making change.”

Nurses are also involved in making changes that influence entire populations. “To be successful in dealing with obesity, we also need action at the interpersonal, community, and policy level,” says Elizabeth Cohn ’09, PhD, RN, adjunct assistant professor at Columbia Nursing, whose research focuses on health disparities, including the impact of policy.

Help an Individual, Help a Family

For most nurses working in clinical care, obesity is a battle fought one patient at a time. Nurses working in bariatric care, such a Dory Roedel Ferraro ‘13 DNP, ANP-BC, CBN, see its worst consequences. Patients who opt for bariatric surgery have reached the end of the line: most are morbidly obese (BMI over 40), diet and exercise have not succeeded for them in a lasting way, and they face multiple health issues. “This is a very medically—and in some cases psychologically—complex population,” say Ferraro, an assistant clinical professor of nursing, who helped pioneer bariatric nursing and currently serves as clinical director of bariatric services at Stamford Hospital in Connecticut. “They are not just obese; they are sick.” Type 2 diabetes typically tops the list, but Ferraro’s patients often have heart disease, asthma, degenerative joint problems, severe sleep apnea, hyperlipidemia, and, among women, polycystic ovarian disease. The American Medical Association recognized obesity as a disease only in June of 2013. Ferraro, among others in the bariatric field, has seen it that way for 20 years.

Stamford Hospital offers four different bariatric procedures, all of which involve altering anatomy in ways that leave the patient with a very small pouch for a stomach. The benefits can be huge but this dramatic and costly intervention requires a tremendous amount of patient education, lasting changes in lifestyle, and lifelong follow-up. Ferraro finds it immensely rewarding to see a patient’s diabetes vanish, blood lipids normalize, and pounds melt away. One of the surprising benefits, she notes, is a “halo effect.” When a patient embraces lifestyle changes after surgery—such as a low-fat, low-carb, high-protein diet and regular exercise, she says, “often we see that it filters down to the rest of the family. There are more nutritious foods in the cabinets, in the refrigerator,and on the table. We see spouses and children start losing weight, along with the patient.” Research has confirmed this halo effect for the families of bariatric patients.

Studies also support a family-based approach to both the treatment and prevention of obesity in children and adolescents. Ideally, that begins at birth (if not even earlier with prenatal nutrition and counseling), says Associate Professor Rita John, EdD, DNP, CPNP-PC, DCC, who directs the Pediatric Nurse Practitioner program at Columbia Nursing. In 2014, John, together with Christen Lefebvre, MS, CPNP, CLC, published a systematic review in the Journal of the American Association of Nurse Practitioners that looked at the relationship between breastfeeding and childhood obesity. In examining 21 studies published between 2005 and March 2012, they found substantial evidence that breastfeeding tends to protect children from becoming overweight or obese, but the relationship falls short of being definitive due to a large number of confounding variables. Basically, says, John, while the review did not show a clear relationship between breastfeeding and obesity protection, mothers should still be encouraged to breastfeed based on evidence showing it offers many advantages for child health.

In the classroom, John teaches her PNP students a technique called motivational interviewing to work with children, families, and adolescents on sensitive issues like weight. The method flips the usual paradigm of health professional- as-expert on its head. Instead, says John, the provider recognizes that “the patient is the expert on his or her own body” and takes cues from what patients feel they can accomplish. “I want you to think about confidence and readiness for behavior change,” she recently told a class of 39 students, assuring them that this will be easier for them to master than it was for her. “I was taught that I’m the expert.”

John used the technique in a pilot study examining whether low-literacy interventions can promote weight loss for obese children, ages 5 to 10, in a low-income community. While she was encouraged by the results, John, like a majority of experts, believes the key to halting the march of American obesity lies in primary prevention. “Treatment is very difficult; getting people to change lifestyle habits is very difficult. The really important thing,” she says, “is to prevent them from getting heavy to begin with.”

Focusing on children less than five years old is critical, since that’s when food preferences and lifestyle habits are established—for better or for worse. John points to a longitudinal study published in the New England Journal of Medicine in January 2014 that found that overweight kindergartners were four times as likely as healthy-weight peers to be obese by eighth grade. Aiming prevention programs at preschoolers and their families is therefore vital, and, there’s evidence that this strategy can work. Earlier this year, the CDC revealed that the obesity rate had declined 43 percent among children ages 2 to 5—from 13.9 percent to 8.4 percent—the first broad decline in any age group and a rare bright spot in the epidemic. Researchers suspect that a variety of factors contributed to the drop: the rising popularity of breastfeeding; improvements in the federally funded Special Supplemental Nutrition Program for Women,Infants and Children (WIC), which distributes food to low-income women; First Lady Michelle Obama’s Let’s Move program, which reaches 10,000 child care centers; and other state, local, and federal policy changes.

The Role of Policy and Community Action

While it’s impossible to say precisely what may be turning the tide on obesity for the country’s youngest citizens, the important lesson is that policy and community programs can make a difference. Elizabeth Cohn ’09, PhD, RN, a Robert Wood Johnson Nurse Faculty Scholar who serves as the director of the Center for Health Innovation at Adelphi University, Cohn believes that the broad reach of public policy makes it the strongest tool for combating obesity and improving public health: “It’s the most powerful thing you can do.” She points to New York City’s decision to ban trans fats from foods sold in the city’s restaurants and the effort under former Mayor Michael Bloomberg to ban the sale of supersized soft drinks. The first eliminated a dangerous additive—one linked to heart disease—from the city’s menus. The second effort was blocked in the courts, but the publicity around it raised awareness about the perilous level of empty calories in jumbo servings of soda. Mexico, the only nation in the world with a higher obesity rate than the U.S., last year approved a national “junk food tax” that adds eight percent to the cost of calorie-dense snacks and sugary soft drinks. Researchers and policymakers around the world are eager to examine whether this policy innovation will help to rein in that country’s runaway obesity.

Those kinds of assessments are critical, since the best intentioned policy doesn’t always work as planned. For example, Cohn has studied the impact of posting calorie content on menu boards in fast food restaurants. Her findings, published in the Journal of Urban Health in 2012, suggest that the posted information demands too much math to be helpful to many consumers. She and her co-authors identify several strategies that would make the postings easier to digest.

Action at the community level is another essential ingredient in the recipe for confronting obesity. Research has long shown that obesity rates are higher in neighborhoods that lack safe parks and recreational facilities, in places where street crime keeps people indoors and where there are few full-service grocery stores selling fresh produce. Central Harlem, which has been plagued by these issues, has an adult obesity rate that exceeds 50 percent; in East Harlem, the figure is even higher.

Cohn, along with others at Columbia Nursing, works in partnership with community organizations and leaders in Harlem to raise awareness about obesity risk factors, good nutrition, and the importance of staying active. One ongoing project supports the Abyssinian Baptist Church (ABC), long a pillar of Harlem, in creating a community kitchen that will offer cooking and nutrition classes to promote healthy eating and primary prevention of obesity. In recent years, the arrival of farmers’ markets and other sources of produce have meant that fresh fruits and vegetables are more available in Harlem than ever before. A lingering challenge, says Cohn, “is what my community partner has termed the bok choy problem”—sure, there are more veggies, “but people don’t actually know what to do with them.” The ABC community kitchen takes aim at that problem.

 

Cohn also serves on the executive team that organizes an annual health walk in Harlem that picks up participants at places of worship throughout the area and finishes with a health fair in Riverbank State Park, where community members can receive nutritional counseling and health screenings. Columbia Nursing is among numerous local partners—including churches, grassroots groups, and nonprofits—involved in the event, which marked its 10th anniversary in September. “Working from within established organizations uses the natural pathways of information flow and incorporates the rhythm and norms of the community,” says Cohn. Community-based approaches, she says, work best when they emanate from the concerns of the community rather than being imposed from on high by experts and authorities. It is, in a sense, parallel to the kind of patient centered counseling that Rita John teaches her students to use in obesity treatment. “In going where people are,” Cohn says, “we can see more easily the environment they are expected to perform in, we can take into account the activities available, and understand better how we can partner for effective and lasting change.”

References

This article originally appeared in the Fall 2014 issue of Columbia Nursing magazine