Digital Repository Doctoral Projects Fall 2021 Facilitating Change to Adolescent Eating Habits in a Primary Care Setting Marianne Mayo Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Mayo, M. (2021) Facilitating Change to Adolescent Eating Habits in a Primary Care Setting Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Facilitating Change to Adolescent Eating Habits in a Primary Care Setting by Marianne Mayo A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Mary Anne Hales Reynolds PhD, ARN, ACNS-BC_(signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running Head: FACILITATING CHANGE TO ADOLESCENT EATING HABITS 1 Facilitating Change to Adolescent Eating Habits in a Primary Care Setting Marianne Mayo Annie Dee School of Nursing Weber State University December 15, 2021 FACILITATING CHANGE TO ADOLESCENT EATING HABITS 2 Acknowledgments Several people assisted and supported me in completing this Doctor of Nursing Practice project. I would like to thank my faculty mentor, Dr. MaryAnne Reynolds, PhD, RN, ACNS-BC, at Weber State University for the countless hours of edits, phone conversations, and zoom calls. Special thanks to my project consultant, Jana Burningham, MS, FNP-C, and all the staff at Utah Valley Pediatrics Spanish Fork office for their support and patience during project implementation. I am so grateful to the fellow students in my cohort for their ongoing support and encouragement both in person and through our slack channel. Finally, I would like to acknowledge the love and support of my husband, Frank, and our four wonderful children. I appreciate all the dinners, extra chores, chauffeuring, patience, and sacrifices on my behalf. This could not have been done without each of you. FACILITATING CHANGE TO ADOLESCENT EATING HABITS 3 Abstract Healthy eating is important during adolescence (11-18yr), yet poor eating habits are common for this age group and can lead to poor nutrition. Poor nutrition can lead to delayed growth, impaired organ remodeling, preventable chronic diseases, and suboptimal cognitive function. The purpose of this Doctor of Nursing Practice project was to screen and educate adolescents who might be at risk for poor nutrition by introducing routine screening and by providing healthy eating educational resources. Through the implementation of an Adolescent Food Habits Checklist (AFHC) screening tool and educational resources at Utah Valley Pediatrics, adolescents at risk for poor nutrition were identified. Primary care providers were educated on the use of age-appropriate nutritional education and resources, and on how to use the results from the tool to identify and manage those at high risk. After introducing the screening tool, 84% of adolescents presenting for well check visits (n=101) were screened. Of those screened, 78% were identified as moderate or high risk. All, regardless of risk score, received adolescent appropriate healthy eating resources and education. Healthy eating screening and education resources introduced into the primary care setting offer a systematic approach to introduce adolescents to develop healthy eating habits. PCP administered screenings can identify those at-risk and direct providers to manage related undiagnosed problems or deficiencies. Keywords: adolescent, nutrition, screening, influences, and primary care providers. FACILITATING CHANGE TO ADOLESCENT EATING HABITS 4 Facilitating Change to Adolescent Eating Habits in a Primary Care Setting Adolescence is a period of rapid growth and development that requires adequate nutrition to achieve individual full growth potential (Das et al., 2017). In 2012, Utah reported that 88% of the state’s adolescents did not consume at least three vegetables a day, 69% had less than two servings of fruit per day, and 10% of American children (2-17years old) consume zero fruits or vegetables daily (Nielsen, Rossen, Harris, & Odgen, 2014). Forty percent of these daily calories come from empty calories from added sugars and solid fats (CDC, 2019). Good nutrition for adolescence requires intake of specific vitamins and minerals. Poor nutrition precedes nutrient deficiencies that can lead to delayed growth, impaired organ remodeling, and preventable chronic diseases (Das et al., 2017). In 2013, it was estimated that 619 million children and adolescents suffered from iron-deficiency anemia. Micronutrient deficiencies lead to impaired cognitive and physical performance and a lowered immune response (Maggini, Pierre, & Calder, 2018; Hansen, Tveden-Nyborg, & Lykkesfeldt, 2014). It is critical to identify individuals with unhealthy eating habits to facilitate early interventions that promote healthy eating habits during the adolescent period. Interventions tailored to an adolescent learning style can have a positive effect on healthy eating habits (Yeager, Dahl, & Dweck, 2018). The purpose of this DNP project was to identify adolescents at risk for developing poor eating habits, to introduce the importance of eating a healthy diet during this life stage, and to provide resources to facilitate dietary habit changes. Search A web-based internet search was performed using CINAHL and PubMed databases, google scholar, and public health websites. Search terms included healthy eating, adolescent healthy eating, nutrition, healthy eating and brain development, nutrition screening tools, FACILITATING CHANGE TO ADOLESCENT EATING HABITS 5 overweight adolescents, adolescent well checks, adolescent development, young adult development, inactivity, obesity, nutritional interventions, nutritional questionnaire effectiveness, nutrition assessment tools, necessary nutrients, vitamin deficiencies, parental influence on nutrition, and primary care providers. Healthy Eating and Nutrition Healthy eating is a lifestyle pattern that promotes adequate nutrition to the body. A healthy eating pattern describes the individual’s usual way of eating and the combination of foods (and beverages) that follow recommended guidelines (U.S. Department of Health and Human Services (HHS) & U.S. Department of Agriculture (USDA), 2015). By following a healthy eating pattern, an individual maintains a healthy weight, ingests an appropriate level of calories, and gains an adequate amount of nutrition. National guidelines suggest foods should be ingested from all food groups, within individual and age-specific calorie recommendations, to meet nutrient needs (HHS & USDA, 2015). Calories from added sugars and saturated fats, should be limited and sodium intake should be reduced. Food and drink choices should be nutrient dense and come from a variety of food groups. Updated and evidenced guidelines are published every five years to guide professionals in helping individuals and families to consume a healthy diet. While general dietary guidelines include all ages, adolescents have specific requirements and needs (HHS & USDA, 2015). It is recommended that a healthy diet for an adolescent should include protein, carbohydrates, fats, fiber, minerals, and vitamins. During the adolescent stage, rapid physical growth and cognitive development require increased amounts of specific nutrients (Das et al., 2017). Assuring nutrient needs are met in the adolescent period will increase the likelihood of optimal future health. FACILITATING CHANGE TO ADOLESCENT EATING HABITS 6 Adolescence Adolescence is defined by the World Health Organization (WHO) as ages between 10 and 19 years (Das et al., 2017). During this time, many physiological, neurological, behavioral, and sexual changes occur quickly. Adolescents increase in height, body weight, bone mass, and muscle mass during puberty. Major organs including the heart, brain, lungs, liver, and kidney all increase in size. Adolescents often engage in recreational exercise, increasing both their energy and nutrition requirements. Males typically grow taller and heavier and require more calories than females (Das et al., 2017). Brain development during adolescence is evidenced by higher order cognitive functions such as improved memory, learning, reasoning, and information processing (Jamison, et al., 2017). Decision-making autonomy and reliance on peers for acceptance increases (Reicks et al., 2015). Rapid growth and development increase nutritional demands and have important implications to adolescent health. Adolescent Health Adolescents are considered relatively healthy, so most health-related care is preventative (Gawlik, Melnyk, & Teall, 2021). Harris et al. (2006) found that the healthy behaviors and healthy status of young adults tends to decrease after adolescence. Health habits developed at this transitional stage affect future health, thus making this a critical period of intervention (Institute of Medicine & National Research Council, 2015). Most interactions with health care providers happen at yearly visits for routine physicals and preventative health. These visits often take place in pediatric or family practice offices where the primary care provider is critical in adolescent preventative health (ODPHP, 2020). Immunizations, screenings, and physical exams are managed through primary care providers and are fundamental in the preventative health of adolescence. The Center for Disease FACILITATING CHANGE TO ADOLESCENT EATING HABITS 7 Control (CDC) has a recommended schedule for adolescent and adult vaccinations, with recommended between 12-25 years of age (CDC, 2020). Screenings and physical exams performed in primary care provider offices can identify unhealthy conditions and behaviors in asymptomatic patients, facilitating early intervention (ODPHP, 2020). Physical exams aid providers in identifying risks and/or problems that should be addressed. Assessment of the overall health of the adolescent that reflects good nutrition involves monitoring growth and development, laboratory tests, performing a physical exam, identifying risk factors, and providing anticipatory guidance (Sullivan, 2019). Discussions include safety issues, dental hygiene, peer influences, puberty, and lifestyle behaviors (Sullivan, 2019). Lifestyle behaviors include eating and exercise habits, smoking and substance abuse, and sexual behaviors. The National Association of Pediatric Nurse Practitioners recommends measuring height and weight and body mass index (BMI) at every well check visit (Grossman, et al., 2017). Abnormal growth measurement trends or physical exam findings prompt providers to investigate further and to identify risk factors (Sullivan, 2019). While measuring height and weight is a helpful assessment tool in measuring BMI, it does not accurately identify healthy eating patterns (Guo et al., 2004). Screenings in primary care include those for eating behaviors, sexual behaviors, mental health, physical health, tobacco use, and substance abuse. Mental health screenings for depression, suicide risk, and other mental health issues, aid in early treatment (ODPHP, 2020). High cholesterol, high blood pressure, and diabetes screenings allow for early intervention decreasing chances for more serious problems (ODPHP, 2020). Behaviors that are detrimental to health are often initiated during adolescence and are linked to the experimentation and exploration that occur secondary to adolescent brain restructuring (Jamison, et al., 2017). FACILITATING CHANGE TO ADOLESCENT EATING HABITS 8 Behavioral screenings facilitate unhealthy behavior identification leading to educational interventions that promote lifelong healthy behaviors (Jamison, et al., 2017). Screening tools aid in the assessment of good nutrition by providing more specific measurable data and allowing for early intervention and prevention (ODPHP, 2020). Kolodziejczyk, Merchant, Norman, (2012) found that a food frequency questionnaire (FFQ) is a preferred way to gather information about usual food intake and behaviors. FFQs are beneficial in measuring intake of both food groups and nutrient content. A food habits checklist adds to the FFQ by focusing on adolescent choices as a measure of eating behavior (Johnson, Wardle, & Griffith, 2002). Screening outcomes can help identify unhealthy eating habits at this developmental stage and provide critical information that enables change through education, provided resources and specialty referrals (AAP, 2020; Pringle, Doi, Jindal-Snape, Jepson, & McAteer, 2018). Unhealthy eating behaviors can result from the adolescent’s developing independence (Pringle, Doi, Jindal-Snape, Jepson, & McAteer, 2018). Due to the overactive motivational/emotional system of their brain, they are limited in self-control and don’t always focus on long-term consequences (Institute of Medicine & National Research Council, 2015). Adolescent eating behaviors can be detrimental to health as they often include skipping meals and eating convenient foods that lack required nutrients (Reicks et al., 2015). Reicks et al. (2015) found that energy from fast food provided 13% of the adolescent’s total intake. Moreover, adolescents often snack while playing video games or watching TV, leading to increased energy intake because of “mindless” eating. Unhealthy Eating Influences. An adolescent is influenced both positively and negatively by parental modeling, peers, food availability, food preferences, convenience, costs, belief system, mass media, and body image (Das et al., 2017). Eating habits such as “grazing”, FACILITATING CHANGE TO ADOLESCENT EATING HABITS 9 missing meals, eating fast food, eating away from home and dieting contribute to inadequate nutrient intake (Das et al., 2017). Parental influence on eating behaviors includes the availability of foods/beverages, and perceived beliefs and expectations for intake (Reicks et al., 2015). Neumark-Sztainer, Larson, Fulkerson, Eisenberg, & Story (2010) found that adolescents who participated in family meals had improved dietary intake, less disordered eating behaviors, better psychosocial health, and less substance abuse. Promoting a positive body image and providing frequent family meals can help families be involved in the encouragement of healthy eating (John Hopkins Medicine, 2020). Peer culture plays a role in the development of risky behaviors and unhealthy practices (Telzer, Fuligni, Lieberman, Miernicki, & Galvan, 2015). Adolescents rely heavily on peers for acceptance (Reicks et al., 2015). Bruening et al., (2014) conducted a review and found that adolescents ate more healthy foods if their peers ate more healthy foods. In a similar way, Chung, Ersig, & McCarthy (2017) found that adolescent eating and exercise behaviors are influenced by their peers. Unhealthy Eating Consequences. Eating habits established during adolescence will affect the adolescent’s health. These consequences include acute deficiencies, long term consequences, and cognitive impairment. Intake of too many calories may lead to overweight and obesity, however a total intake that falls below the basal metabolic rate can lead to growth stunting, puberty delay, and menstrual abnormalities (Das et al., 2017). Micronutrient deficiencies, such as iron and iodine, lead to both physical and cognitive disorders (Das et al., 2017). Without adequate iron intake, adolescents suffer from iron‐deficiency anemia. In 2013, it was estimated that 619 million children and adolescents suffered from iron-deficiency anemia. Iron deficiency anemia can affect cognitive development and FACILITATING CHANGE TO ADOLESCENT EATING HABITS 10 immunity. O’Neil et al., (2014) found a relationship between unhealthy dietary patterns and poor mental health. Diets that consist of fruits, fish, fiber, vegetables, whole grains, legumes, less sugar, and less processed foods can decrease symptoms of depression (Ljungberg, Bondza, & Lethin, 2020). Without specific nutrient intake, individuals are more susceptible to infection as the immune response is altered. Delayed growth and impaired organ remodeling can be a result of suboptimal nutrition (Das et al., 2017). Malnutrition can lead to whole body stunted growth (de Onis & Branca, 2016). Long term consequences such as chronic diseases are more likely to occur in those with unhealthy eating habits (HHS & USDA, 2015). Poor bone health, cardiovascular disease, high blood pressure, type 2 diabetes, obesity, and some cancers are related to unhealthy eating behaviors. In the last twenty years, thirty three percent of children, ages 2-19 years, measured overweight or obese. Obesity adds risk for more complications such as hypertension, gallstones, gastroesophageal reflux, polycystic ovary syndrome, abnormal lipid profiles, nonalcoholic fatty liver disease, obstructive sleep apnea, asthma, and bone and joint problems (Golden et al., 2016). Among children diagnosed with type 2 diabetes, eighty percent were obese (HHS & USDA, 2015). From 2009-2012, ten percent of children (8-17 yr.) were diagnosed with hypertension disorders. Further, there is evidence that shows a linear dose-response relationship between sodium intake and blood pressure in children. Impaired cognitive performance is a consequence of various nutrient deficiencies (Hansen, Tveden-Nyborg, & Lykkesfeldt, 2014). A vitamin C deficiency affects brain function specifically during development. Micronutrients including omega-3 fatty acids, vitamin B12, folic acid, zinc, iron, and iodine are important for cognitive function (Nyaradi, Li, Hickling, Foster, & Oddy, 2013). Both cognitive function and development are negatively affected by FACILITATING CHANGE TO ADOLESCENT EATING HABITS 11 missing breakfast, emphasizing the detriment of omitted meals. Problems in cognitive ability can influence one’s capacity to learn (Abbaspour, Hurrell, & Kelishadi, 2014). Learning difficulties add unnecessary stressors to adolescent students. While inadequate nutritional intake can impede cognitive function and development, it can also lead to neurological disorders (Tremblay, 2018). Good nutrition and healthy eating are critical in adolescence, making it crucial to identify those at risk and address concerns early (Das et al., 2017; Sullivan, 2019). Primary care providers (PCP) are key to identifying unhealthy eating habits through physical exams and routine screenings during well-check visits. The PCP role is to serve as an educator and provider of preventative treatments (U.S. Department of Health and Human Services; Office of Disease Prevention and Health Promotion. [ODPHP], 2020). PCPs promote healthy behaviors by educating patients on diet, exercise, sleep recommendations, and other healthy behaviors. They use their knowledge to identify asymptomatic individuals as ‘at-risk’ through assessment screening tools. Early identification can aid in distribution of appropriate education and resources (ODPHP, 2020). Further, the undesirable outcomes associated with unhealthy eating can often be prevented (AAP, 2020). Healthy Eating Healthy eating education encourages healthy eating behaviors that promote intake of nutrients required for optimal growth and development (Jamison, et al., 2017). Adolescents need to understand which foods have nutrient value and be educated on how to change behaviors to facilitate better choices. Pringle, Doi, Jindal-Snape, Jepson, & McAteer, (2018) found that healthy eating education may be more effective during early puberty, up to age 14years. Yeager, Dahl, & Dweck (2018) argue that middle adolescence between ages 13 and 17 is the most FACILITATING CHANGE TO ADOLESCENT EATING HABITS 12 effective time of intervention. Nutritional education tailored for the adolescent during this period can promote healthy eating habits and lower the risk of chronic diseases (American Academy of Pediatrics, [AAP], 2020). An adolescent health education focus can promote healthy behaviors and improve health when geared toward adolescent learning styles (Jamison et al., 2017). Adolescent educational interventions work most effectively when individuals can make personal choices that benefit long term future while feeling respected and achieving high status in the short term (Yeager, Dahl, & Dweck, 2018). Interventions toward establishing healthy eating behaviors should include the adolescent’s ability to make their own choices and to provide valuable contributions to a group. Programs that enable individual creation, sharing, and networking, effectively facilitate peer relationships and therefore increase social support (Best, Manktelow, & Taylor, 2014). Programs such as smart phone applications and social media platforms are promising interventions to promote healthy eating behaviors among adolescents. Adolescents are more likely to use smartphones and social media for health purposes and have shown positive clinical and behavioral outcomes (Chau, Burgermaster, & Mamykina, 2018). Because these platforms are popular, it is an easy way to deliver nutrition-related education and to encourage personal behavior logging. Social media platforms that can influence healthy eating choices include blogs, Facebook, Twitter, Snapchat, Instagram, and Food Hero sites. Nutritional phone applications allow the user to log food intake and receive feedback on nutrient content. Several phone applications offer suggestions for meal planning and the ability to set nutrient and vitamin intake goals. Interventions that provide opportunities for self-determination and decision-making processes are most effective (Jamison et al., 2017). Providing choices of reputable FACILITATING CHANGE TO ADOLESCENT EATING HABITS 13 resources for adolescents is an intervention more likely to deliver valid education while maintaining autonomy of choice. Summary Too many adolescents practice unhealthy eating habits and lack adequate nutrition intake during this period of increased growth and development demands (Das et al., 2017). However, changing adolescent eating habits is a complex process. Identifying at risk adolescents is critical in facilitating interventions that promote healthy eating habits (Johnson, Wardle, & Griffith, 2002). Primary care providers play a key role in identifying these unhealthy eating habits through routine visits (Sullivan, 2019). Implementation of a healthy eating screening tool provides objective information on adolescent eating habits and identifies risky behaviors. Once identified, providing educational interventions that include the adolescent’s ability to make their own choices, provide valuable contributions to a group, and support peer relationships are superior choices (Yeager, Dahl, & Dweck, 2018; Best, Manktelow, & Taylor, 2014). As PCPs screen and provide age-appropriate resources/education at routine adolescent visits, healthy eating habits can be developed, thus improving nutritional intake. Healthy habits established during adolescence can promote current and future health. Planning for Change Using Havelock’s Change Theory Havelock’s change theory expands on Lewin’s three step organizational change process theory of identifying a need for change, moving toward the goal, and solidifying the change. Steps that lead to change include building positive relationships, diagnosing the need for change, gathering needed resources, selecting the best option to implement, establishing/accepting the change, maintaining/stabilizing the process, and evaluating outcomes. For this DNP project, Havelock’s theory guides the process of changing adolescent eating behaviors. Initially, FACILITATING CHANGE TO ADOLESCENT EATING HABITS 14 relationships were built upon conversations with the project consultant, and interaction among managers, office staff, and other stakeholders. Unhealthy eating is a well-documented problem among adolescents, but there was not a standard process for the PCP to educate and give resources to healthy adolescents at risk. Necessary resources included healthy eating questionnaire screenings, educational materials, and methods for providing healthy eating information. Office staff were educated on adolescent nutrition, and changes occurred through developing a process to incorporate the intervention into workflow. The DNP role involved ensuring that the intervention was maintained (working properly) and stabilized (sustainable), while confirming that goals were realized, through the introduction of an evaluation process plan. Practice Change Plan Expected Outcomes and Goals The DNP project overall outcome was to improve adolescent nutrition through the development of healthy eating habits. This was accomplished by introducing provider education, identifying unhealthy eating behaviors through routine screening, and providing adolescents and parents with age-appropriate resources. Setting Utah Valley Pediatrics, Spanish Fork office consists of four pediatricians and one family nurse practitioner that collectively see approximately 100 children from birth to 21 years of age daily. Approximately 21-25% are adolescents, 11-18 years old. On a typical day, 33% of patients are seen for sick visits, and 66% for routine well visits. Wintertime hours include a higher percentage of sick patients. FACILITATING CHANGE TO ADOLESCENT EATING HABITS 15 Population Approximately 90% of the adolescents seen attend public or charter schools, and 10% are home schooled. Insured patients make up approximately 85% and are either privately insured or insured through government programs such as Medicaid or the Child Health Program (CHP). Well-visits are composed primarily of yearly well checks, sport physicals, and church physicals. These visits include vision, scoliosis, and depression screenings, growth and vital sign measurements, vaccine and education administration, and developmental marker assessment. Currently, discussions of eating habits, physical activity, hypertension, and type 2 diabetes are part of the well-check visit if BMI percentages measure greater than the eighty fifth percentile. Adolescents at Utah Valley Pediatrics Spanish Fork office are not routinely screened for eating habits and are therefore not completely identified. Lack of identification leads to omittance of critical education and resources that can promote healthy eating behaviors. Those with unhealthy eating habits can lack adequate nutrition needed for development and are also at risk for preventable chronic diseases (HHS & USDA, 2015). Project Plan The DNP leadership role included planning, implementation, and evaluation of a healthy eating process to occur during adolescent well-check visits working with staff, patients, and parents. Planning activities encompassed familiarity of workflow in the primary care setting to identify an effective process for implementation, encountering a reliable screening tool and evidence-based resources to implement, and figuring out how to document and follow up on screening scores. First, a reliable adolescent healthy eating habits screening tool was selected that could identify unhealthy eating behaviors at routine well-check visits. The Johnson’s Adolescent Food Habits Checklist (AFHC) screening tool was selected and is a valid and reliable FACILITATING CHANGE TO ADOLESCENT EATING HABITS 16 tool that measures adolescent healthy eating behavior in situations that adolescents have personal control (Johnson, Wardle, & Griffith, 2002). Measures include adolescent areas of concern such as consumption of fruit and vegetables, energy-dense foods, snacking behavior, and selection of low-fat alternatives. Second, a healthy eating handout was developed using age-appropriate and current resources. The handout was further refined to include lab/referral checkboxes, thus containing education, resources, QR code, and checkboxes on one page. Third, a healthy eating website was created with a corresponding QR code on each resource handout. This electronic resource simplified the process of adding healthy eating apps to smart phones by providing electronic links to the resources. Fourth, a healthy eating process presentation including background, purpose, and office process was organized for presentation to the providers at the implementation site. Fifth, a process education training module was created for office staff. The electronic module introduced the project and included educational background, the work-flow process, staff roles, and scoring training. The project purpose, process, and timeline were then presented to the office providers, allowing time to address concerns and answer questions. The prepared electronic module was sent out to office staff via email, subsequently recording individual completion when concluded. Screening tools, scoring keys, and resource handouts were photocopied and distributed to their corresponding area, while master copies were emailed to a shared office email file. To relieve time burden, all photocopies were organized into file folders in multiple locations, and a scoring template was created. Implementation Implementation began on April 19, 2021. First, to identify unhealthy eating behaviors and create awareness, the front desk staff administered the AFHC screening tool to all 11–18-FACILITATING CHANGE TO ADOLESCENT EATING HABITS 17 year-olds at adolescent well-check visits. Patients were instructed to return the completed tool to the medical assistant upon completion. Second, upon rooming the patient, the medical assistant scored the screening tool, documented the score in the patient chart, and placed the resource handout (with corresponding score) on the door for the provider to collect upon entry. The score determined which prepared handout was given; low, moderate, or high-risk category. Third, providers proceeded into the exam room with the resource handout. All patients screened, regardless of score, were given a resource handout. This sparked conversations about eating habits and any provider concerns or follow up recommendations. Evaluation of the project began the first week of the measurement period and included office process effectiveness observation, data collection, and data analysis. Project Evaluation and Analysis This DNP project was evaluated through chart reviews, parental surveys, provider surveys, and attendance records. Chart reviews encompassed a one-month measurement period beginning April 19th, 2021. Parental surveys responses were collected 1-6 weeks after the adolescent child’s well-check appointment. Provider surveys were collected both prior to and after project implementation. Chart reviews captured measures in adolescent screenings, appointments, resource handout distribution, and additional lab orders and/or referral orders. Adolescent chart reviews showed individual screening scores, or the lack of score, providing data on the number of screened adolescents, and the number of those that received a resource handout. Charts with a documented screening score were reviewed for additional lab orders and/or referral orders, measuring the number of screened adolescents receiving these interventions. Moreover, chart reviews of appointment schedules provided the total amount of adolescent well-checks. FACILITATING CHANGE TO ADOLESCENT EATING HABITS 18 Surveys administered to parents and providers offered measures to evaluate healthy eating education/resource effectiveness, provider satisfaction, and provider confidence. Parental surveys were collected through telephone encounters and included Likert scale responses. Pre and post provider surveys also contained Likert scale responses and were gathered on site. Attendance records provided measures of staff education completion, facilitating evaluation of total office staff trained. Records included a combination of electronic module completion training and in person education/training attendance rolls. Evaluation measures in all areas were obtained and described using descriptive statistics. Results Chart reviews revealed screening scores recorded for approximately 84% (n=84) of all adolescents presenting for well-checks during the measurement period. This reveals an 84% increase prior to implementation. The 101 adolescent visits were comprised of yearly well-check visits, sports physicals, and missionary physicals. Of the eighty-four adolescents screened, approximately 36% (n=30) received high-risk scores, 42% (n=35) received moderate risk scores, and 23% (n=19) scored in the low-risk category. All 84 adolescents screened (100%) received a resource handout, 0.01% (n=1) of screened adolescents received additional diagnostic lab orders and zero were referred to a dietician or other specialist. (See Appendix A.) Office staff training attendance records revealed 100% of providers (n=5) and approximately 87% of office staff (n=15) were educated on the project information and process. The providers and office staff were interested to learn about the process and willing to adjust workflow to accomplish the goals of the project. Pre-implementation provider surveys revealed 40% of providers (n=2) had little satisfaction with current healthy eating educational information given to adolescent patients at well check visits. Post-implementation provider surveys FACILITATING CHANGE TO ADOLESCENT EATING HABITS 19 measured 40% (n=2) of providers were “very satisfied” with the same measure. (See Appendix A.) One provider stated, “I like the program we started!” The handouts help lead into the healthy eating discussion.” Provider confidence in talking to adolescents about eating patterns did not show a significant change. Parental surveys included responses from approximately 30% (n=25) of parents from the 84 adolescents that received healthy eating resources. In the follow up telephone survey, 20% (n=5) of parents agreed that their child’s eating habits had changed after receiving the resource handout, 36% (n=9) agreed that their child had been talking more about eating habits, 68% (n=17) agreed that the information was helpful, and 88% (n=22) agreed that they were confident in talking to their child about his/her eating habits. (See Appendix A.) Overall, the parents were engaged in the healthy eating process and benefitted from the information and handouts. Parental confidence in discussing healthy eating habits and conversations with their adolescent child about healthy eating were impacted. One parent commented that her daughter had the handout on her nightstand and had continued to reference it over the past two weeks. Another parent voiced her appreciation for the verbal information from the provider on healthy eating habits, while another appreciated the printed information and was making goals to increase vegetable content in meals. Healthy eating programs clearly address a health need in the adolescent patient. An assortment of screening tools and age-appropriate resources are easily accessible to primary care providers and can impact adolescent health considerably. Discussion and Recommendations Adolescents are at risk for unhealthy eating habits however the results of this project suggest that implementation of a healthy eating program in primary care offices provides a FACILITATING CHANGE TO ADOLESCENT EATING HABITS 20 consistent avenue to screen and offer age-appropriate resources to this population. The healthy eating screening score alerted providers to high-risk scores, fostering identification of abnormal lab results, and promoting support from specialized members of the interdisciplinary team. Screening tool questions fueled adolescent independence through self-directed completion and created an awareness of personal eating habits. Further, offering age-appropriate, evidence-based, healthy eating resources in a pre-printed handout was a seamless step to providing current healthy eating information and resources while sparking provider/patient discussion. Resource handouts allowed adolescent patients to learn about healthy eating benefits and gather solutions for self-improvement. Premade handouts with the included QR code facilitated access to digital resources and eased process compliance. The provider/patient discussion became a routine part of the well-check visit. Finally, consistency and sustainability in the process were facilitated through successful office staff training. Staff understanding of the screening tool, resource handouts, and the work-flow process were critical to success. Implementing a healthy eating process in primary care settings has major implications to our healthcare system and to nursing practice. A healthy eating program promotes the development of healthy eating habits thus leading to fewer co-morbidities. Healthy nutrition leads to a lower incidence of mental, physical, and cognitive difficulties. Early identification and intervention in those at risk allows adolescents to be more productive in school, experience less mental illness, and reduce the risk of developing obesity and the sequelae of associated co-morbidities. Reducing the occurrence of co-morbidities through healthy eating habits can lessen the burden and cost of healthcare in the future. The completion of this project has led to a reflection on the importance of healthy eating processes within primary care settings. Primary care offices will be impacted with a change in FACILITATING CHANGE TO ADOLESCENT EATING HABITS 21 workflow, accompanying training, and an added cost of supplies. However, as healthy eating screenings, resources, conversations, diagnostics, and referrals become part of the routine well-check, early identification and intervention can occur consistently. These clinical prevention actions can improve health outcomes in communities and throughout the nation. Recommendations for future projects include changes that allow more effective screening score completion, changes to more effectively capture high risk adolescents and changes to successfully evaluate resource effectiveness. A large barrier to screening was inadequate time to score completed surveys prior to the provider visit. This can be solved by use of an electronic screening tool with automatic scoring and EMR uploading. An electronic screening device allows the adolescent to finish the survey in the exam room and have a score uploaded to the chart prior to the provider responding to the room, thus promoting discussion and appropriate interventions. Further, a screening tool sent as a link 24 hours prior to the appointment start time offers a solution. Another identified challenge was the provider misunderstanding of screening tool scores. A large number (36%) of adolescents’ scores fell into the high-risk category however, additional testing/referrals were often neglected. One solution to this problem is to adjust the risk categories on the screening tool to improve accuracy in measuring risk. It is recommended to add a very high-risk category that may elicit provider thought into referrals and/or additional lab orders. Another solution is the development of a protocol providing more specific guidance on recommended interventions. One reason for this discrepancy may have included the adolescent population presenting during the implementation period. Several presented for sports physicals and represented physically fit individuals with normal BMIs. This could be solved by adapting the scale to various circumstances and/or differences. During the global COVID-19 pandemic, FACILITATING CHANGE TO ADOLESCENT EATING HABITS 22 primary care offices saw a significant decrease in routine well check visits, resulting in fewer adolescent visits. Finally, the effectiveness of the resource handouts was not adequately evaluated. While parent surveys gave some insight on this measure, there were no instances of repeat screenings within the measurement period. This problem can be solved by increasing the measurement period to include future screening scores, thus allowing comparison and effectiveness evaluation. Moreover, follow up phone calls to inquire about utilized resources may also add to resource effectiveness measures. The information gathered would provide useful information to facilitate improvements in the resource handout effectiveness and/or utilization. Developing and implementing a healthy eating program is a sustainable approach to addressing unhealthy eating habits and nutritional discrepancies in the adolescent patient. The adolescent well check is the ideal time for the PCP to identify and address concerns, impart nutritional education, and provide age-appropriate resources. Healthy eating program implementation provides a long-term, sustainable solution. Conclusion Identifying unhealthy eating habits and facilitating change during the adolescent period impacts healthcare by decreasing preventable diseases and problems caused by poor nutrition. Primary Care Providers, such as Family Nurse Practitioners, can administer screenings for adolescent eating behaviors, identify those at-risk, and be directed to address and respond to related undiagnosed problems or deficiencies. Screening tools create eating habit awareness among adolescents and their parents while introducing a systematic approach to healthy eating education in the primary care office. Healthy eating educational information offered through FNP/patient conversations and up to date resource handouts provides a consistent avenue that FACILITATING CHANGE TO ADOLESCENT EATING HABITS 23 can ultimately increase adolescent nutritional intake thus decreasing their risk for poor future health. FACILITATING CHANGE TO ADOLESCENT EATING HABITS 24 References Abbaspour, N., Hurrell, R., & Kelishadi, R. (2014). Review on iron and its importance for human health. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 19(2), 164–174. American Academy of Pediatrics. (2020). Healthy eating for school-age kids. 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Perspectives on Psychological Science, 13(1), 101-122. doi:10.1177/1745691617722620 FACILITATING CHANGE TO ADOLESCENT EATING HABITS 29 APPENDIX A-Evaluation Tables Healthy Eating Screening Adolescents seen=101 Adolescent well-check visits Percent Adolescent well-check visits 101 101 100% Screened 84 101 83% Screening Risk Total screened Additional Labs ordered Referral made HIGH risk 30 84 35.7% 1 (.01%) 0 MODERATE risk 35 84 41.6% 0 0 LOW risk 19 84 22.6% 0 0 Parental Responses within 2 months of visit (n=25) In terms of the healthy eating information you received in the clinic… Number of Parent Responses: Strongly Agree and Somewhat Agree Parent Responses: Neutral Parent Responses: Disagree and Somewhat disagree My child’s eating habits have changed 20% 16% 64% My child has been talking more about eating habits 36% 28% 36% Healthy eating information was helpful 68% 8% 24% I am confident in talking to my child about his/her eating 88% 12% 0% FACILITATING CHANGE TO ADOLESCENT EATING HABITS 30 Provider Surveys Pre-Survey: Provider Satisfaction with Current Healthy Eating information (n=5) Providers Percentage Very satisfied 0 0% Moderately satisfied 2 40% Somewhat satisfied 1 20% Little satisfied 2 40% Not at all satisfied 0 0% Post-Survey: Provider Satisfaction with Current Healthy Eating information (n=5) Providers Percentage Very satisfied 2 40% Moderately satisfied 3 60% Somewhat satisfied 0 0% Little satisfied 0 0% Not at all satisfied 0 0% Provider and Office Staff Training Trained Total in office Percent Trained Providers 5 5 100% Office Staff 13 15 87% FACILITATING CHANGE TO ADOLESCENT EATING HABITS 31 APPENDIX B: Johnson’s Adolescent Habits Checklist-Screening Tool NAME:_____________________ Score:______ ADOLESCENT FOOD HABITS CHECKLIST Please tick the box that is right for you most of the time 1) If I am having lunch away from home, I often choose a low-fat option. True False I never have lunch away from home. 2) I usually avoid eating fried foods. True False 3) I usually eat a dessert or pudding if there is one available. True False 4) I make sure I eat at least one serving of fruit a day. True False 5) I try to keep my overall fat intake down. True False 6) If I am buying chips, I often choose a low-fat brand. True False I never buy chips 7) I avoid eating lots of sausages and burgers. True False I never eat sausages or burgers 8) I often buy pastries or cakes True False FACILITATING CHANGE TO ADOLESCENT EATING HABITS 32 9) I try to keep my overall sugar intake down. True False 10) I make sure I eat at least one serving of vegetables or salad a day. True False 11) If I am having a dessert at home, I try to have something low in fat. True False I don’t eat desserts 12) I rarely eat take out meals True False OVER--→ 13) I try to ensure that I eat plenty of fruit and vegetables. True False 14) I often eat sweet snacks between meals. True False 15) I usually eat at least one serving of vegetables (excluding potatoes) or salad with my evening meal. True False 16) When I am buying a soft drink, I usually choose a diet drink. True False 17) When I put butter or margarine on bread, I usually spread it on thinly. True False I never have butter or margarine on bread 18) If I have a packed lunch, I usually include some chocolate and/or cookies. True False I never have a packed lunch FACILITATING CHANGE TO ADOLESCENT EATING HABITS 33 19) When I have a snack between meals, I often choose fruit. True False I never eat snacks between meals 20) If I am having a dessert or pudding in a restaurant, I usually choose the healthiest one. True False I never have desserts in restaurants 21) I often have cream on desserts True False I don’t eat desserts 22) I eat at least 3 servings of fruit most days True False 23) I generally try to have a healthy diet. True False That’s it! Thank you for your time in completing this questionnaire. Johnson’s Adolescent Food Habits Checklist FACILITATING CHANGE TO ADOLESCENT EATING HABITS 34 APPENDIX C: Healthy Eating Resource Handouts FACILITATING CHANGE TO ADOLESCENT EATING HABITS 35 FACILITATING CHANGE TO ADOLESCENT EATING HABITS 36