22 annotated bibliographies AMA style

Screeningandmanagementofoverweightandobesityatauniversitystudenthealthcenter.pdf

Home >Applied Sciences homework help >22 annotated bibliographies AMA style

50 The Nurse Practitioner • Vol. 41, No. 7 www.tnpj.com

he high rate of obesity in the United States cur- rently poses a serious threat to the health of college students. Students who are obese face a greater risk

of future chronic conditions, such as type 2 diabetes mellitus (T2DM), coronary heart disease, certain types of cancer, long-term disability, and death.1 In 2013, the American College Health Association (ACHA) reported that one-third (33.7%) of college students self-reported being either over- weight (21.9%) or obese (11.8%), and numerous sources

indicate that most college students are not meeting dietary or physical activity guidelines.2-5

Only 6.3% of students reported eating five or more servings of fruits and vegetables per day, and only 20.0% actually participated in moderate-intensity exercise for 30 minutes or longer, 5 or more days per week.2 Government agencies such as the Institute of Medicine (IOM) recom- mend that all healthcare providers adopt standards of practice (evidence-based or consensus guidelines) for

By Maria Estela Salcido, DNP, APRN and Diane B. Monsivais, PhD, RN, CNE

Screening and management of overweight and obesity at a university

student health center Abstract: This article discusses a quality improvement project focused on developing, implementing,

and evaluating an evidence-based best practice protocol for screening and management of

overweight and obesity in college students in a university-based student health center.

Keywords: overweight and obesity guidelines, quality improvement, student health services, university health promotion

Pe o

P pl

e pp

mImm ag

eege s

//A n

A n

AAAA dr

e dr

er a

C a

ar o

ar ororo

linlinnlinll a

S a

S c

an c

an he

z he

z hehe

G o

GG zanz a

nz aaaa

ezle z

le zz

le z

le / / //i

stis t

is t

is tst oc

k oc

kck ©©©©

Screening and management of overweight and obesity at a university student health center

www.tnpj.com The Nurse Practitioner • July 2016 51

prevention, screening, diagnosis, and treatment of over- weight and obesity in all populations.6

■ Local problem The need for a protocol that met best practices for preven- tion, screening, diagnosis, and treatment of overweight and obesity was identifi ed as a quality gap in the student health center (SHC) at a university in the Southwest Unit- ed States. The students primarily attended on a part-time basis and did not live on campus. Setting apart the adult population on a college campus from the adult population in general was a recommendation from Healthy Campus 2020, which recommends making health promotion a collaborative effort between student health services and campus initiatives.7

In 2010, the obesity prevalence rate for the city where the university is located was 31.2%. Body mass indexes (BMIs) documented for the SHC population were higher than those reported by the 2013 ACHA national survey.2 In the SHC population, 30% had a BMI of 25% to 29.9% (over- weight) and 13% had a BMI greater than 30% (obesity) compared to 21.9% overweight and 11.8% obese from the national survey. These BMI rates underscored the need for an effective protocol to manage overweight and obesity at the SHC.8

■ Intended improvement The PICO question: (P [population or problem]) In pa- tients ages 18 and over with a BMI of 25 or greater, (I [in- tervention]) is the implementation of a clinical practice guideline for initial screening, assessment, and management of overweight and obesity versus (C [comparison]) no stan- dardized guideline or program in place (O [outcome]) a feasible and acceptable option at the SHC? The aim of this project was to identify and implement a best practice protocol for prevention, screening, diagnosis, and treatment of overweight and obesity for patients seen at the SHC. The global aim was to decrease the risk of overweight and obese students developing obesity-related chronic condi- tions, such as T2DM, coronary heart disease, certain types of cancer, and long-term disability. Measurement of the global aim was outside the scope of this quality improvement project.

■ Choosing the guidelines and supporting material To determine the evidence-based, best-practice protocol that would most effectively serve the needs of the student popu- lation, PubMed and CINAHL databases were searched us- ing the following keywords: guideline implementation, evidence-based guidelines for obesity, and college health. Literature focusing on obesity prevention programs for

college populations published in English from 1998-2013 was reviewed.

Several organizations provide information and guid- ance on evaluation and management of overweight and obese patients including the National Heart, Lung, and Blood Institute, the American Obesity Association, the American Academy of Family Physicians, the U.S. Preven- tive Services Task Force (uspstf ), the IOM reports, and the World Health Organization. There were no specifi c guide- lines addressing the college population, and therefore, guidelines and resources for the general adult population were used.

The uspstf recommendations were the best match with the student population at the SHC as well as an initia- tive titled, “Americans in Motion—Healthy Interventions” (AIM-HI).1,9 The uspstf recommends screening all adults for obesity at their preventive health services and to refer all patients with a BMI of 30 or higher to intensive, mul- ticomponent, behavioral interventions.1 The American Academy of Family Physicians, in endorsing this recom- mendation from the uspstf for primary care, developed AIM-HI.

The AIM-HI program uses the multifaceted approach of physical activity, healthy diet, and emotional well-being as the key to prevention and management of many chronic conditions.9 The program was designed to be used for offi ce- based and community interventions, making it ideal for an SHC. The toolkit includes educational manuals for staff and patients, an online module on motivational interviewing, and a fi tness inventory questionnaire (assesses readiness for change behavior, eating pattern, physical activity type and frequency, time spent on computer, and emotional well- being). The questionnaires were developed and normed as part of the entire AIM-HI project, which was evaluated during a 3-year research study.9

Patient outcomes from baseline to 4 months showed decrease in BMI, improved eating habits, improved fi tness, and increased exercise levels.9 Implementation of evidence- based clinical practice guidelines can be facilitated through the use of an algorithm to address key points of care and guide timing of referral to specialty services.10,11 Therefore, the “Prevention and Diagnosis Algorithm” from the Institute of Clinical Systems Improvement was selected for its ease of use and adapted for use with the student population.12

■ Methods Ethical issues. This quality improvement project was ap- proved by the Institutional Review Board at the University and the Director of the SHC. If students met the inclusion criteria of BMI of 25 or greater and were ages 18 and older (and not pregnant) when they presented for preventive

52 The Nurse Practitioner • Vol. 41, No. 7 www.tnpj.com

Screening and management of overweight and obesity at a university student health center

health screenings, they would be provided with an informa- tion sheet describing the quality improvement project. If they agreed to participate, they were given a consent form to sign prior to fi lling out the AIM-HI Fitness Inventory questionnaire. The student could fi ll out the questionnaire anonymously, and the questionnaire was not included in the student’s patient chart but instead was kept in a locked cabinet. Results were presented as aggregate data to protect patient confi dentiality.

Setting. The project setting was a public university in the Southwest area of the United States with a student pop- ulation of 23,003 students. Three providers (one MD and two NPs) at the college health center performed an average of 60 preventive health screenings during the fi rst month of each new semester. Both NPs were female, and the physician was male. Each provider had over 12 years of experience in student health. Because of the small provider group and frequent interaction, no formal survey was carried out prior to the program implementation. Everyone involved ex- pressed enthusiasm for project implementation. Through informal discussion with providers, uninsured students’ inability or unwillingness to pay for any fee-related referrals was the main potential challenge identifi ed.

■ Intervention planning, implementation, and evaluation The intervention was a best practice protocol for prevention, screening, diagnosis, and treatment of overweight and obe- sity in a student health setting. Recommendations from the uspstf and the initiative AIM-HI were used as best prac- tices for this protocol. Outcome measures were as follows: • Documentation of BMI and waist circumference at all

preventive health services • Provider use of the algorithm based on best practice

protocol • Referral of students to campus programs based on the

Fitness Inventory Questionnaire (from the AIM-HI toolkit).

Cullen and Adams’ framework of creating awareness, building knowledge, promoting action and adoption, and pursuing integration and sustained use was used in this project.13 The following sections provide a description of how the steps were implemented.

Step 1: Create awareness. Education and training included all levels of staff, including providers, nursing personnel, support staff, and the nutritionist. From prior experience, the SHC staff prefers small group discussions for educational dissemination, and this was easily accom- plished at the weekly staff meetings on Fridays.

Step 2: Build knowledge. Two weekly in-services were conducted for this project. The staff was introduced to the components of the AIM-HI toolkit, which included online

training for motivational interviewing, evidence-based weight management interventions, and an overview of the Dietary Guidelines for Americans, 2010 (available at http:// health.gov/dietaryguidelines). The second educational ses- sion included education on the calculation of BMI and waist circumference measurements (if BMI was 30 or greater), documentation of these parameters as part of vital signs for all patients, and review of the components of the algorithm. Readiness for change was to be assessed through the use of the fi tness inventory questionnaire.

The campus wellness coordinator was invited to discuss initiatives on campus available for both staff and students. She introduced the staff to the SHAPE (Students Helping Actively Participate in Exercise) Fit Challenge sponsored by a university organization.14 The SHAPE Fit Challenge is a movement to invite others to personally commit to increase their physical activity by exercising 30 minutes a day (or 150 minutes a week) per the recommendations of the U.S. De- partment of Health and Human Services.15 In addition, the campus wellness coordinator provided a list of food venues on campus that offer healthy food choices.

Step 3: Promote action and adoption. The algorithm was posted in the triage area for easy access by all clinic staff and as a reminder of the implementation of the guideline. Easy-tear BMI charts were placed in all exam rooms so patients could record their own BMIs to take with them after the visit. The nutritionist provided her own preferred nutrition record (food diary) to be given to the patient prior to the meeting.

Step 4: Pursue integration and sustained use. Report- ing results of project implementation and revisions based on evaluative data and NP feedback can facilitate addi- tional commitment to sustained use of new practices.13 Practitioners and staff provided feedback that the BMI chart and algorithm posted in the triage area were helpful as a reminder that the BMI for all patients coming in for preven- tive health services had to be calculated and documented. In addition, uninsured patients provided feedback that they did not want to pay the established fee out of pocket for nutritional referrals and counseling. Follow-up consultation fees with the nutritionist were reduced to a more affordable level to encourage continuity of care.

■ Outcome measure documentation Outcome 1: Documentation of BMI and waist circumfer- ence at all preventive health services. Baseline data were obtained from the period of January 3 to 31, 2013 that identifi ed 66 charts with the diagnosis of preventive health services, such as school physical, sports physical, occupa- tional health evaluation, and routine gynecological exam. There were 23 males and 43 females with the age range

Screening and management of overweight and obesity at a university student health center

www.tnpj.com The Nurse Practitioner • July 2016 53

between 20 and 43 years. The information was entered in an Excel spreadsheet created for this project. The categories created for the data collection included BMI, waist circum- ference, age, and gender.

A total of 29 charts fi t the criteria for inclusion (BMI of 25 or greater) in this review. All charts were completed by the NPs. Analysis of the data indicated discrepancies in recording BMIs as part of routine vital signs. Of the 29 charts, 93% (n = 27) had no BMI recorded and had to be calculated retrospectively. Only 7% (n = 2) of the charts had BMI measurements documented. Of these two charts (n = 2), only one was provided a referral to the SHC nutri- tionist, and no screening for comorbid conditions related to obesity was done.

Chart audit 2: Postintervention. Data from a chart re- view in March 2014 were compared to preintervention base- line data from January 2013. Sixty-two charts were identifi ed with the diagnostic code for preventive health services; of these, six were excluded as these consisted of employee oc- cupational health evaluations. Of the 56 charts identifi ed, a total of 24 charts fi t the criteria (BMI of 25 or greater) for inclusion in the review. However, only 18 participants con- sented to complete the anonymous fi tness inventory.

■ Outcome 2: Provider use of the algorithm based on best practice protocol The category “algorithm implementation” was added for the postintervention audit in order to demonstrate algorithm adherence. This category was the consistent use of the clin- ical practice guidelines algorithm by all clinical providers. A total of 53 charts were audited (audit 1 = 29, audit 2 = 24). Descriptive statistics were used to analyze the chart audit data before and after intervention (see Chart audit summary). The difference in the proportion of charts that recorded BMI as part of routine vital signs went from 7% to 100% between chart audit 1 and 2. The proportion of charts identifi ed as consistently using the guideline went from less than 1% in the preintervention group to 100% in the postintervention group.

■ Outcome 3: Referrals to campus programs based on the fi tness inventory questionnaire Fitness inventory questionnaire results: Sixty-seven per- cent (n = 12) of students surveyed spent more than 2 hours per day watching TV or on the computer. Another fi nding revealed that 44.4% (n = 8) were participating in less than 3 days per week of physical activity. According to the latest physical activity guidelines, adults should do at least 150 minutes a week (30 minutes a day) of moderate-intensity physical activity.15 The last fi nding revealed that only 11.1% (n = 2) were eating fi ve or more servings of fruits and veg- etables per day as recommended by the Dietary Guidelines for Americans, 2010.16

The SHC providers found that the fi tness survey pro- vided an excellent starting point for discussion of goals and management of weight loss with the patient and provided a basis from which to make appropriate referrals to campus wellness resources. Clinic personnel followed up with phone calls every 2 weeks for 3 months to assess patient progress.

■ Discussion Low participation in physical activity (documented on the fi tness inventory questionnaire) is an area of concern and suggests that this is a potential area to target in prevention interventions. Since physical activity and nutrition are two of the best modifi able factors to decrease obesity, the recom- mendation was made to refer all students to the SHAPE Fit Challenge to personally commit to increase their physical activity. Enlisting other members of the campus commu- nity, such as the campus wellness coordinator, the SHAPE Fit Challenge created awareness not just for the staff but for the students of the wide range of recreational facilities avail- able on campus for little or no cost.

A wellness fair (once per semester) for the 2014 year was planned as part of the wellness promotion on campus. A wellness fair was held on April 1, 2014. A variety of strategies were utilized to bring the students out, including games with prizes, speaker presentations, and food (prepackaged, healthy choices) as well as home-baked, low-calorie snacks

Chart audit summary

Guideline Preintervention

chart audits (N = 29)

Postintervention

chart audits (N = 24)

Correct Incorrect Correct Incorrect

BMI documentation 2 27 24 0

Algorithm implementation 0 0 24 0

Total chart audits 2 27 24 0

Percentage 7% 93% 100% 0%

54 The Nurse Practitioner • Vol. 41, No. 7 www.tnpj.com

Screening and management of overweight and obesity at a university student health center

with recipes provided. There were 246 attendees, and 41 consented to be screened through the use of BMI. The results of the BMI screening demonstrated that 54% of the students were within the normal of 24.9, 24% were within the range of 25 to 29.9, and 22% had a BMI of 30 or greater. The results correlated with the ones previously seen at the SHC. Of the nine students with the BMI of 30 or greater, two returned to the SHC for further evaluation.

■ Summary This quality improvement project resulted in important practice changes related to screening and management of overweight and obesity at the SHC. The project resulted in consistent documentation of BMI and waist circumference as routine vital signs, implementation of the uspstf recom- mendations for overweight and obesity, identifi cation of risk factors for comorbidities, and referral of students to campus programs based on the fi tness inventory questionnaire com- pleted by the students. Consistent use of screening guidelines is intended to be the fi rst step toward meeting the more global, long-term aim of decreasing the risk of overweight and obese students of developing obesity-related chronic conditions, such as T2DM, coronary heart disease, certain types of cancer, and long-term disability.

■ Limitations Planning for program sustainability became a limitation when the liaisons to the campus wellness programs were unable to continue at their original level of involvement due to competing demands. This meant the number of wellness classes were limited. Another factor that impacted participa- tion was the protocol requirement for participants to com- plete a formal written consent form prior to fi lling out the anonymous fi tness inventory questionnaire. This require- ment may have deterred some students from participating, as there was extra time involved in the visit, and it may have restricted the number of participants who could benefi t from educational resources and referral to campus services.

■ Implications for practice Educational sessions tailored to the needs of the staff, an easily accessible algorithm, and cost-effective campus re- sources for referral resulted in consistent protocol use in the screening and management of overweight and obesity in a college-age population. Health promotion in higher educa- tion should be guided by the principle of facilitating a wide range of campus and community partners for collective action.17

NPs who hold a Doctor of Nursing Practice (DNP) degree are ideally suited to lead this type of initiative. The ability to effectively lead teams for the development, implementation,

and evaluation of practice guidelines is one of the founda- tional skills of the DNP Essentials, with improved patient and population health outcomes as the ultimate goal.18

REFERENCES 1. US Preventive Services Task Force. Screening for and management of

obesity in adults: Clinical Summary of U.S. Preventive Services Task Force Recommendation. 2012. www.uspreventiveservicestaskforce.org/ Page/Document/UpdateSummaryFinal/obesity-in-adults-screening-and- management.

2. American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary. 2013. www.acha-ncha.org.

3. Jaffe R. Confronting the obesity epidemic at community colleges. 2011. http://ctl.laguardia.edu/journal/v5/pdf/InTransit_Spring11_v5_jaffe.pdf.

4. Shah N, Amirabdollahian F, Costa R. The dietary and physical activity habits of university students on health and non-health related courses. J Hum Nutr Diet. 2011;24(3):303-304.

5. University of New Hampshire. College students face obesity, high blood pressure, metabolic syndrome. ScienceDaily. 2007, June 18. www. sciencedaily.com/releases/2007/06/070614113310.htm.

6. National Research Council (NRC). Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. 2012. http://images.nap.edu/ openbook/13275/png.

7. American College Health Association. Implementing healthy campus: MAP- IT framework. 2010. www.acha.org/HealthyCampus.

8. Center for Health Statistics. Texas Behavioral Risk Factor Surveillance System Survey Data. Texas Department of State Health Services. 2010. www. dshs.state.tx.us/Layouts.

9. American Academy of Family Physicians (AAFP). Americans in Motion— Healthy Interventions (AIM-HI). 2013. www.americansinmotion.org.

10. Cincinnati Children’s Hospital Medical Center: Best Evidence Statement (BESt). Initial screening and referral for comorbidities in pediatric obese patients. 2010. www.Endocrinology/Obesity/ComorbidityEvaluation/ BEST073.pdf.

11. Registered Nurses Association of Ontario. Toolkit for implementation of clinical practice guidelines. 2002. rnao.ca/sites/mao-ca/fi les/BPG. Toolkit-o.pdf.

12. Fitch A, Everling L, Fox C, et al. Institute for Clinical Systems Improvement. Prevention and Management of Obesity for Adults. 2013. www.icsi.org/_ asset/s935hy/Obesity-Interactive0411.pdf.

13. Cullen L, Adams SL. Planning for implementation of evidence-based practice. J Nurs Adm. 2012;42(4):222-230.

14. SHAPE: Educate, Advocate & Achieve Fitness & Healthy Living. 2013. http:// utep.edu/cce.

15. US Department of Health & Human Services. Physical activity guidelines for Americans. 2008. www.health.gov/paguidelines.

16. US Department of Agriculture/Department of Health and Human Services. Dietary Guidelines for Americans, 2010. www.health.gov/dietaryguidelines/ dga2010/DietaryGuidelines2010.pdf.

17. American College Health Association. ACHA Guidelines: Standards of Practice for Health Promotion in Higher Education. 2012. www.acha.org/ Publications/docs.

18. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. 2006. www.aacn.nche.edu/ education-resources/essential-series.

Maria Estela Salcido is an advanced practice registered nurse at the Student Health Center, University of Texas at El Paso, El Paso, Tex.

Diane B. Monsivais is the director of the MSN Nursing Education program in the Graduate Nursing Program at the University of Texas at El Paso, El Paso, Tex.

The authors have disclosed that they have no fi nancial relationships related to this article.

DOI-10.1097/01.NPR.0000472251.51574.fd