The document summarizes a study exploring pediatric healthcare providers' knowledge and attitudes toward guidelines for reducing cardiovascular risk in children. Key findings include: 1) Providers find discussing nutrition and diet most difficult due to sensitivity around weight and family influences. 2) Family culture, socioeconomic status, and perceptions of weight present barriers to implementing guidelines. 3) Recommendations focus on developing culturally-appropriate, action-oriented patient materials that address immediate health benefits and involve family/community influences.

1. Heart of the Matter: Communication about
Reducing Pediatric Cardiovascular Risk
Rebecca R. Moultrie • RTI International, Research Triangle Park, NC
1. Background & Conceptual Model 5. Key Findings
■ Atherosclerosis remains the leading cause ■ In response, the National Heart, Lung, and ■ Cardiovascular risk factors are regarded as Patient Materials
of death in the U.S. Blood Institute (NHLBI) developed cardio­ one of the main health issues for pediatric ■ Parents and caregivers generally do
● rarely manifests in children and vascular health guidelines for pediatric patient populations yet it is not explicitly not request materials from health care
adolescents care providers based on a formal evidence discussed with patients providers
review addressing all the CV risk factors ■ Recommendations related to nutrition and
● yet cardiovascular disease (CVD) has ● Those who do are interested in meal
simultaneously (family hx, tobacco exposure, diet are considered the most difficult to
contributing risk factors and risk plans and menus
nutrition & diet, growth, overweight/obesity, implement with patients and caregivers
behaviors beginning in childhood Materials that providers currently use vary
lipids, BP, physical act., & diabetes). ■
● family culture, limited access to healthy in terms of content and source
food, and lack of parental support play a
large role ■ Only a few providers overall reported offering
NHLBI INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE 1
AGE
their patients materials on healthy lifestyles
RISK FACTOR BIRTH-12 M 1-4 Y 5-9 Y 9-11 Y 12-17 Y 18-21 Y
FAMILY HISTORY — At age 3 y, evaluate Update at each non- Re-evaluate family hx Update at each non- Repeat family hx
■ Providers requested more detail on heart
(FAM HX) OF
EARLY CVD
Fam Hx for early CVD:
parents, grandparents,
aunts/uncles, M ≤ 55 y,
urgent health encounter. for early CVD in parents, urgent health encounter. evaluation with patient.
grandparents,
aunts/uncles,
“A normal child, or like a normal healthy healthy foods
F ≤ 65 y. Review with
parents, refer prn.
M ≤ 55 y,
F ≤ 65 y. child, may look skinny to others…
(+) Fam Hx identifies
children for intensive CV
RF attention.
grandma or grandpa, you know. This is
TOBACCO
EXPOSURE
Advise smoke-free
home; offer smoking
Continue active anti-
smoking advice with
Begin active anti-
smoking advice with
Assess smoking status
of child.
Continue active anti-
smoking counseling with
Reinforce strong anti-
smoking message.
the challenge of trying to say to, to the “The medical part like checking blood
cessation assistance or
referral to parents.
parents. Offer smoking
cessation assistance
and referral as needed.
child. Active anti-smoking
counseling or referral as
patient. Offer smoking
cessation assistance or
referral as needed.
Offer smoking cessation
assistance or referral as
family, “No, your child is normal. He’s pressure, etc. is easy. [Materials needed
not underweight.” And they come and
needed. needed.
NUTRITION/DIET Support breast- feeding Age 12-24 m, may Reinforce CHILD 1 diet Reinforce CHILD 1 diet Obtain diet information Review healthy diet with
include] additional training web-based
say, “Oh, no, he’s underweight. He looks
as optimal to age 12 m change to cow’s milk messages. messages as needed. from child and use to patient.
if possible. Add formula
if breast-feeding
with % fat per family &
pediatric care provider.
reinforce healthy diet,
limitations and provide
on nutrition for kids, ways to approach
pale and my grandma, my mom told me families to help kids with nutrition and
decreases or stops After age 2 y, fat- free counseling as needed.
before age 12 m. milk for all; juice ≤ 4
oz/d; transition to CHILD
1 Diet by age 2 y.
that.” …So it’s always perception that physical activity. Or a list of resources to
GROWTH, Review family hx for Chart Ht/Wt/BMI Chart ht/wt/BMI & Chart ht/wt/BMI & Chart ht/wt/BMI & Review ht/wt/BMI and
OVERWEIGHT/
OBESITY
obesity Discuss wt
for ht tracking, growth
classify wt by BMI from
age 2, review with
review with parent. review with parent and
BMI > 85 %ile, crossing child.
th
review with child and
parent.
norms for health with
patient. you have to be overweight a little bit, give to parents. It can be overwhelming
chart, healthy diet. parent. %iles, intensify BMI > 85th %ile,
diet/activity focus X 6 m. crossing %iles, intensify
If no change RD
BMI > 85th %ile, crossing
%iles, intensify
diet/activity focus X 6 m.
BMI > 85th %ile,
crossing %iles intensify especially in the first three or four years of to pull together all of this information”
diet/activity focus X 6 m. diet/activity focus X 6 m.
referral, manage per
obesity algorithms.
If no change RD
referral, manage per
If no change RD
referral, manage per
obesity algorithms.
If no change RD
referral, manage per
life, that means healthy in some cultures” (family practitioner, Washington, DC)
BMI > 95th %ile, manage obesity algorithms.
(pediatrician, Chicago)
obesity algorithms.
per obesity algorithms. BMI > 95th%ile, manage BMI > 95th %ile, manage BMI > 95th %ile, manage
per obesity algorithms. per obesity algorithms. per obesity algorithms.
1
From the National Heart, Lung and Blood Institute Expert Panel Integrated Guidelines on Pediatric Cardiovascular Health and Risk Reduction Summary Report (Table XV.)
Guideline Implementation
Family Influence ■ Guidelines related to nutrition and diet
■ The following family factors are key barriers are the most difficult to communicate to
2. Study Objectives to the implementation of the guidelines parents and caregivers. Why?
● socioeconomic status (SES) ● the sensitive nature of discussing
● attitudes toward overweight and weight with patients and families
1. To explore pediatric health care providers’
knowledge, awareness, and attitudes obesity ● a family’s socioeconomic status and
toward NHLBI’s Integrated Pediatric ● perceptions of weight including what is lifestyle
Guidelines for Cardiovascular Health considered healthy ■ Other risk factors were deemed easier to
(anticipated for release 2011); ● cultural and familial traditions implement because of their clinical nature
2. To understand providers’ intended (i.e., blood pressure lab tests)
■ Providers acknowledge the importance of
implementation of the guidelines; and parental involvement and modeling ■ Diet was the risk factor discussed most
3. To inform the development of provider frequently with their patients but was also
● Especially the role of extended family
and family materials to support guideline named as the most challenging
implementation.
“Especially in our area… things like their “Physical activity and nutrition and diet
diet is something that they’ve done for would be useful to give as guidelines.
generations. “We’ve, I’ve always eaten this For nutrition and diet there are so many
way. This is the way my family is.” Or,… parents that want to know how much and
3. Methods and Analysis 4. Sample again, even telling someone that they’re amount of milk or food... I don’t think the
overweight,…people here say they’re parents would count their kids calories
■ Qualitative methodology; in­depth in­person ■ Interviews were segmented thick. “That’s not fat, thick.” But it’s fat.… every day. Place emphasis on whole grains
interviews by location and type of health I think they’re, potential barriers is,…is and health foods rather than counting
care provider you’re asking me to be different from the calories. It is nice to give them guidelines
■ 41 Health Care Providers
way, not only I’ve been but the way I was on what they should be doing” (registered
Pediatricians, FPs, RNs, PAs, NPs, and RDs who: ■ A total of 41 interviews
● brought up, the way my grandparents… nurse, Chicago, IL)
60 minutes in length:
◆ Practice in Washington, DC, Chicago, IL or (pediatrician, Greenville, NC)
9 pediatricians, 9 family
Greenville, NC
practitioners, 9 registered
◆ Care for at least 15% of patients are under
nurses, 5 physician’s assistants
18 years of age or nurse practitioners, and
◆ Have the primary responsibility of direct 9 registered dietitians
patient care Average participant had prac­
■
6. Recommendations
■ Reviewed verbatim transcripts of audio­recorded ticed medicine for 17 years
interviews and conducted thematic analysis to ■ 46% practiced medicine in
identify causal and logical statements expressed suburban areas and 27% Patient Materials
by the informant practiced in large cities Materials should be:
■ Culturally appropriate
■ Framed to address immediate benefits to youth as
opposed to long­term benefits
Additional Authors on the Study More Information
■ Focused on healthy lifestyles as well as diet
RTI International *Presenting author:
■ Julia Kish­Doto, PhD, MS Rebecca Moultrie Action Steps
919.541.6696 · munch@rti.org Health care providers should consider:
■ Robert Furberg, PhD, MBA
■ Kenneth LaBresh, MD
RTI International ■ Using existing nutrition­based materials that contain
3040 Cornwallis Road concrete action steps
National Heart, Lung, and Blood Institute Research Triangle Park, NC 27709
■ Assessing existing patient materials prior to use (e.g.,
■ Janet De Jesus, MS, RD Presented at: The International Conference on “don’t reinvent the wheel”; use evidence­based materials)
Communication in Healthcare (ICCH), Chicago, ■ How to involve “influencers” (such as parents, extended
IL, October 16–19, 2011
Presenter Disclosures family members, and local schools and grocers) in
■ Rebecca Moultrie has no relationships to www.rti.org cardiovascular risk reduction
disclose. RTI International is a trade name of Research Triangle Institute. ■ Distributing personalized BMI charts to parents/caregivers