In Practice: Reflections from NPs and PAs

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

“Your BMI puts you in the obese category. You need to limit weight gain to 10 pounds this pregnancy.”

As the obstetrician’s words sunk in, I was overcome with embarrassment. Sure, I knew I was overweight, but I was pregnant. And according to my BMI, I have been “obese” for years. But this was the first time a provider had actually called it to my attention, at least in such a blunt manner.

Sitting in the patient’s seat made me think about the best way to counsel families of pediatric patients about obesity. I have had plenty of practice discussing diets with people, but now I wondered — was I being sensitive to people’s feelings while also making the necessary lasting impression? The first time I had to educate a family regarding obesity, it wasn’t fun, but my preceptor broke the ice. Here’s what happened:

I had a patient in the 99^th percentile for weight and BMI. He was only 7 and visibly obese. My preceptor counseled me before the appointment, educating me on why this was an important issue and how it would affect his life for years to come. He couldn’t stress enough how the family needed a provider to be “real” with them. I walked into the patient room and politely started asking about diet and exercise. After about 5 to 10 minutes of dancing around the subject, my preceptor barged into the room and said, “What she’s trying to say is, your son is overweight.” Though his approach was abrupt, it got the point across and got us all down to business. My preceptor asked me to show the family my patient’s growth charts and really explain, without beating around the bush, how serious the subject was. So, there I sat, showing charts and talking about the importance of exercise as well as avoiding juice, candy, soda, and the like. My patient left with a plan to change his diet and follow up in a few months.

My clinical training took place in an area where not every neighborhood is safe, and many of my patients were of low socioeconomic status. This complicated things when counseling them about diet and exercise. How does one encourage physical activity when there is no safe place to play? Similarly, with money scarcity, buying fresh fruits and vegetables in lieu of fast food was not always possible or a priority, especially in families where parents were working two jobs just to make ends meet. In these situations, a parent would often tell me that time and money were pretty influential in guiding meal choices. A box of macaroni and cheese is not only much cheaper but can feed a lot more people than a head of lettuce.

Hearing this story over and over again, I began to realize that although clinicians can do a lot to educate parents regarding childhood obesity and promote healthy eating, we must first understand the context of our patients’ lives — neighborhood safety, access to healthy foods, income level — to be most effective. By validating these hardships prior to suggesting solutions, I found that families were much more receptive to change.

After being on the receiving end of obesity counseling, I started to suggest rules for my patients’ families to follow. I picked up several of these from a physician I shadowed for a number of months, and now I use them all the time (in my home as well). Here they are:

• First and foremost, diet and lifestyle changes need to happen now.
• Always eat breakfast, and make sure this meal has protein in it, as some evidence shows that people who eat breakfast with protein eat fewer calories throughout the day. (I have personally found this to be true.)
• No juice, soda, or other drinks high in sugar
• And lastly, try not to eat in front of the television. If you are hungry, sit at the table or assigned family eating place and eat without distractions. This will hopefully keep you from consuming food mindlessly past the point of satiation.

In regard to my last pregnancy, I am proud to say that I only gained 12 pounds and gave birth to a 9+ pound baby! I made exercising a priority and followed a healthy eating plan. It was much easier to lose the weight after already having these practices in place. Was it fun? Not really; there were definitely days when I struggled. But I did it, and I am thankful for my provider’s transparency.