Dissertation on "Brief Action Plan Applied to Obesity in Pregnancy"

Quoted Instructions for "Brief Action Plan Applied to Obesity in Pregnancy" Assignment:

Can the "Brief Action Motivational Tool" Motivate and Help Maintain Maternal Body Weight (BMI) of Obese Pregnant Mothers with BMI >30 kg/m2 from First Prenatal Visit until Two Weeks Post-Partum?

Abstract

The prevalence of maternal obesity has been increasing, with the general trend from 4% in 1980, to 13% per year since 2000.( Lu, Rouse, & Dubard, et al. 2001). Maternal obesity of Body Mass Index (BMI) >30kg/m2 are becoming more common in the obstetrical setting. Maternal obesity has its own inherent risks factors that can lead to significant increasein maternal and infant morbidities and mortalities. Extrinsic factors such as poverty, limitations nutritional food sources and low physical activity are due to lifestyle. These factors can lead to an increase of gestational weight gain, and increasing BMI.

The purpose of the study is to utilize a client centered motivational technique in the prenatal visits, and then two weeks post- partum period. The goal is to create motivation for the obese mother to create lifestyles changes for herself and her newborn infant.

The structural framework was adapted and simplified from Prochaska & DiClemente Stages of Change Model. (1992) this model has six stages that are cyclical and can be used to identify one*****s readiness for change. The ultra-brief personal action plan (UB-PAP) by Cole, S. Waxenberg, F, D. McCarthy, et al (2008), will be utilized as the motivational interview. (MI). Motivational interviewing has proven to be an effective tool in chronic illnesses and addictive behavior, but there is a gap in knowledge regarding the utilization of UB-PAP upon maternal obesity.Utilizing the UB-PAP for all clients, entering prenatal care, those who*****s BMI > 30kg/m2 identified and open ended question regarding lifestyle changes to maintain BMI throughout each prenatal visit. Anyone who scores a seven or above will have a personal action plan created. BMI adherence, birth outcomes and post-partum BMI will be analyzed through electronic medical records. Quantitative data collection on the EMR can be recorded as well. Time restraints may hinder the collection of data, so that further study and longitudinal data can enhance the quality of the overall effectiveness of the intervention of UB-PAP. Results pending this investigation.

BACKGROUND AND SIGNIFICANCE

The obesity epidemic in the United States (US) and compared globally continues to increase affection approximately six percent of the world*****s population and thirty-five percent of the world*****s biomass. (Walpole et al, 2012). Biomass refers to the product of the population size and the average body mass. Maternal obesity is an independent risk factor for possible adverse maternal and fetal morbidity and mortality. Authors agree that obesity increases the general health problems throughout a woman*****s lifetime. ( Adamo, Ferraro, & Brett 2012; Eckmann-Scholtz, et, al, 2012).

The Healthy people 2010 report from the US Department of Health and Human Serves("Healthy People 2010," 2008), and state wide surveillance data from the Behavior Risk Factor Surveillance System(Kilmer, G, Roberts, H, Hughes, E, et al [BRFSS], 2006, p. 773), are few of these reporting systems, and provide the overall obesity trend. Obesity is increasing rapidly among Americans and worldwide populations. (Spies, C., Scott, D., et al 2012). Health care costs in the United States continue to rise due to obesity and is approaching 300 billion dollars, yet obesity lingers despite the diet and exercise. United States boosts the *****State of the Art***** health care, yet limited access to basic health care for the same continues to fail at combating obesity. (Black, J & Macinko, J. 2009).

Currently in the present young pregnant clients are beginning pregnancy of BMI. 30 kg/m2, and higher. An early study by Lemay et al.(2007) evaluated the change in BMI of adolescent mothers ages fourteen through nineteen in central Massachusetts. The research found through self reporting of intitial BMI and monitoring of BMI found thirty percent increase in BMI from the beginning of prenatal care and two weeks post partum. The most alarming finding of this study found that the children of these adolescent mothers by age two were at risk of obesity and by age three, twelve present were considered obese. These findings were in keeping with the present day trend of long term obesity and a two fold increase in maternal obesity.( Lemay, Elfenbein, Cashman, & Felice,2008).

The population of this study is based in Lowell, MA at the Lowell Community Health Center. The pregnancy demographics and outcomes of this community were last studied in 1989. The population at the time were primarily Cambodian refugees, but now the clinic serve over twenty nine different types of world population, including Portuguese, Burmese, and African ethnicities, some African American, Hispanic, and Caucasian mixed races. The research by Gann, Nighiem and Warner, (1989), found that there was an increase in primary casearian sections, which is an operative procedure done due to the smaller stature of the client and now large birth size of the infant. There has not been a more recent study at the center since 1989.oo

SIGNIFICANCE

The risk of obesity upon pregnancy, along with the medicalization of prenatal care is prevalent. The importance of this study is to focus efforts upon halting further escalation of BMI, by the normalization of pregnancy among the obese pregnant client. Instead of focusing upon clinician desires, the focus will be more client centered. The client will be motivated to change one*****s lifestyle and perhaps, maintain BMI, and normal gestational weight goals, throughout the pregnancy and post partum.

Known adverse outcome related to high BMI in pregnancy are hypertension gestational diabetes, pre-term delivery, induction of labor, increase risk of neonatal death, maternal death, caesarian births, wound infections, hemorrhage, and early spontaneous abortions.(Smith & Lavender, 2011,;Swann, & Davies, 2012).

Pregnancy is not the time to diet; however a great opportunity to begin lifestyles behavior changes. During pregnancy the metabolic demands upon the female body and the growing fetus needs to be met to ensure healthy birth outcomes. According the American College of Obstetrics and Gynecology (ACOG) the ideal weight gain for women who are considered obese is eleven to fifteen pounds throughout her entire pregnancy. This goal may seem unobtainable; however, through head food choices, exercise, and motivation to change years of unhealthy habits are possible. Pregnancy visits are more frequent than primary care visits, from every four weeks in the first and second trimester, every two weeks in the third trimester and from thirty six weeks of gestation, weekly. The routine post partum care is six to eight weeks after delivery, depending upon the mode of delivery. At the Lowell Community Health Center (LCHC), teens are seen at two week, and caesarian section clients are seen at one week post partum. The amount of visits lends itself to opportunities to assess and reassess motivation for lifestyle changes.

According to some authors lifestyle behavior and lack of physical activity contribute to the progression of obesity, and has been studied widely and mentioned in numerous reporting systems. The National Institute of Health (NIH), World Health Organization (WHO) and the Institute of Medicine (IOH) are some of the major reporting systems. The NIH conducted a study which analyzed the treatment of obesity among teen*****s ages eleven through eighteen called the T.E.E.N.S Program. Acronym for teaching, encouragement, exercise, nutrition and support. By utilizing the motivational interview intervention, the researchers found success in the treatment of pediatric obesity.( Bean, Mazzeo, Stern, Bowen, & Ingersoll 2011).

In the literature, researchers state that nutrition plays a critical role in maternal and fetal health, however, research error cannot truly report dietary intake due to the consistent under reporting of energy intake on diet recall and recording. (Nowick, Ritz, et al, 2011).

Exercise guidelines in pregnancy may be given at a prenatal visit, with little

knowledge by the practitioner, and or the lack of funds to attend a local gym by the client are

just two aspect that hinder exercise in our population at Lowell, MA.

Provider input regarding exercise can be beneficial for most expectant mothers and their growing fetus. With the majority of pregnancies, exercise has been proven to be safe and does not contribute to adverse effects. The American College of Obstetrics and Gynecology (ACOG) has basic guidelines for exercise in pregnancy (2002). these set guidelines but do not specify

which exercises would be helpful. Most providers do not know which exercises are helpful, the limitation for maximum benefits of exercise, or modification of exercise for the individual. Clients want to know the specifics of each exercise regime they might choose. In our population culturally, routine exercise programs are not a part of the client*****s lifestyle, however, daily

meditation is routinely mastered.

The Lowell Community Health Center clients consist of a low income, refugee and

homeless population whereby a local gym is beyond their economic means. Their priorities for

survival in this community is paramount over a gym membership. An objective of this study will be to introduce alternative interventions to these woman for example, free access to meditation or exercise space at the center, and modification of exercise for each woman that they can share at home.

According to the National Center for Health and Physical Activity, this is a necessary

component to maintaining a healthy weight and is especially important for obese clients.

(Spies, & Taylor, et. al 2012). One aspect of the study is to tell our clients about specific exercises that are important for her.

Other barriers to maintaining a healthy lifestyle are nutritional barriers which are

addressed by a nutritionist at the center, access to the WIC program (Woman, Infant, Children), and general baseline assessment of nutritional intake at the first prenatal visit. Our limitation to this routine part of our prenatal care is the lack of motivation by the obese client to have an appointment with our nutritionist unless there is some incentive. The center*****s only incentive is punitive. Women are told that if you do not see the nutritionist, you will not get your WIC vouchers. This leads to a quick and less truthful reporting in order to receive the WIC vouchers. This reinforces the results of study by (Norwicki, et al 2010), that errors in reporting nutritional intake are often a barrier to predicting measures in pregnancy. One incentive would be gift cards to our local grocery stores and limit food access to healthy food choices.

At our center, routine prenatal visit for a new obstetrical client consists of a physical, initial blood work, nutritional guidelines, a booklet about medications, common discomforts of

pregnancy and relief measures, warning signs and when and where to call, along with

exercise guidelines. Despite our efforts as health care providers, new obstetrical clients

continue to gain weight with BMI growing to morbid obesity level as she enters labor.

How one broaches the subject of obesity, makes a difference to the client according to

meta-analysis by (Swann, L. & Davies, S.2012). Their study suggested that most obese clients are subjected to punitive and fear approaches to pregnancy verses a joyful time in an important phase of their life. Frequently through practice guidelines, women with BMI > 30kg/m2 are considered at greater risk and therefore, not considered for midwifery care. The purpose of their study was to suggest that the midwifery model of pregnancy care utilizes informed decisions verses the medical model of care for the obese woman. In their study women with BMI >30kg/m2 were either denied midwifery care, or must be co managed by the obstetrician. The medical management of antenatal office visits and labor management reduce these women*****s chances of a normal birth. These authors suggest that midwives treat obese women as individuals, and utilize each visit as a opportunity to problem solve obesity issues with the client. Further research in this area is needed to assess whether or not the midwifery model of health care improves the clients outcome.

Other approaches to motivation needs further study in the realm of rising obesity in women of childbearing years. One approach is a motivation technique created by Cole called the Brief Action Motivational Tool. This tool is an adaptation from guidelines for the medical interview.( Cole, S. & Bird, J., 2000) . This tool assesses one*****s readiness for

motivation. Motivational Interviewing has been utilized in medicine in areas of diabetes, smoking cessation, and substance abuse, however, not been research in obese pregnant clients

. (Miller, W. & Rollnick, S. 1999) ; ( Cole, S. & Bird, J.(2000). Utilization of this tool, in addition to prenatal care can ensure better outcome for pregnant clients, but to her household as well. A change in food choices, the amount of caloric intake, and shopping strategies for good nutritious food, can help to decrease obesity rates. Our nutritionist can assist the client to bring changes in dietary habits to her family. The provider can suggest exercise as part of their daily routines can inspire the pregnant women, their partners or children in their household.

These life changes can make for a healthy family and potentially society as well. A healthy motivated mother can help her children begin with healthy food choices, by breastfeeding, and later by introducing nutritional foods with the help of WIC vouchers. The mother can also begin to introduce children to walking, going to park, afterschool programs which provide rich exercise programs for low income families. Once children see and maintain healthy lifestyles, the intergenerational obesity can be managed, thereby reducing societal costs related to lifetime obesity. Once those children become young adults of childbearing age, the obesity rates will be less, and the co-morbidities of obesity in pregnancy can be reduced.

. With nutritional guidelines, exercise, prenatal care, and motivational

tool, there can be a significant in the reduction of the negative outcomes of obese pregnancies.

With the introduction of the new IPODs, I Pad, and various technology applications, available, mothers can become motivated by the new technology, and access to medical advice. Reminders for appointments, diet recall, and energy intake can be addressed immediately with instant feedback if calorie intake is abnormally high or low. A motivational prompt can be entered by the client. These are just a few ideas that can be done.

Thus far, research has not identified methodologies that work in reducing obesity.

Obesity in pregnancy exists at an alarming rate and the co-morbidities associated, needs further research. Tools are needed to help motivate new mothers. Reduction in their own obesity can lead a new mother to address their own children potential for obesity. This may lead to the

reduction of obesity throughout her lifespan and perhaps break to the cycle of obesity among her young children.

The overall significance of my study is to utilize and an extremely simple tool as the conceptional framework. The goal is to show positive improvements in the obesity rate among

pregnant obese client, have other centers utilize the tool, and reintroduce a basic health

prevention that is cost effective and simple to perform.



References

Cole, S, Waxenberg, F.,McCarthy, D., McClure, T., Majesky, S. J., Lee, F.C. Ultra-Brief

Personal Action Planning (UB-PAP) and motivational interviewing : A Prospective,

Controlled pilot efficacy study of stepped-care health coaching. Abstract presented

At First International Conference on Motivational Interviewing: Interlaken, Switzerland

June 2008.

Lu, G.C., Rouse, D.J., Dubad M. et al, Trends of Maternal Obesity 1980-2000, Am J Obstet

Gynecol (2001).

Prochaska, J. O., & DiClemente, C. C, Trans theoretical therapy: toward a more integrative

model of change. Psychotherapy Research (20) 161-173.(1982)