Community Health and Population Focused Nursing Essay Sample

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Tarrant County, founded in 1849, was named after Edward H. Tarrant, who drove the Native Americans from this area in hopes of preparing land for new settlers. Today, Tarrant County has a total area of 897 square miles: 863 square miles of land, 34 square miles of water. Its neighboring counties are Denton County (north), Dallas County (east), Johnson County (south), and Parker County (west). There are 30 cities within Tarrant County, and four towns. Fort Worth is the county seat. (“Tarrant County history”) According to the 2014 census, Tarrant County’s population is 1,945,360 with a population density of 2142 people per square mile (very high (“State and county”) and is the 3rd most populated county in the state of Texas (out of 254 counties) Fort Worth has the highest population of people in this county, with 803,674, followed by Arlington, with 383,204. Tarrant County lies in the “DFW Metroplex”; an economic and cultural hub of the region known as “North Texas”.

It is considered the largest land-locked metropolitan area in the United States. (“Dallas-Fort Worth Metroplex,”) Tarrant County is known for hot summer months, with mild winters. It gets 34 inches of rain per year, three inches less than average US cities, with an average of only 2 inches of snow. Tarrant County residents see approximately 232 sunny days per year, but the high humidity during the summer months, can make outdoor activities uncomfortable. (“Climate Tarrant County”) Tarrant County sits in the southeast corner of “tornado alley, but has low risk for tornadic activity. In 2000, a tornado hit downtown Fort Worth, Texas, killing 2 people with multiple injuries. (“2000 Fort Worth tornado”) Tarrant County has a wide range of economy, with areas of extreme wealth, and areas of extreme poverty. Opportunity for the residents of wealthy neighborhoods differs greatly from those who live in the areas where poverty prevails. Community

Tarrant County is home to many tourist attractions, such as Six Flags over Texas, AT&T Stadium, (Dallas Cowboy’s Stadium) Texas Ranger baseball stadium in Arlington, Texas, Fort Worth Stockyards, and the Fort Worth Zoo. The arts district is home to the Kimbell Art Museum, Amon Carter Museum of American Art, and many more. Casa Mañana, and the Bass Performance Hall, entertains people with nationally known musicals and plays. Tarrant County is home to Southwestern Baptist Theological Seminary, one of the largest seminaries in the world. DFW International Airport resides in both Tarrant County and Dallas County.

Tarrant County has many colleges and universities, including Texas Christian University, University of Texas at Arlington, Texas Wesleyan University, and Tarrant County Community College. Tarrant County has some of the best hiking and bike trails anywhere in the State of Texas. Fort Worth has over 40 miles of paved trails, known as the Trinity Trails. In the heat of the summer, and even during the winter ice storms, these trails host many walking, running and biking enthusiasts! (Keller, 2010) With the warm climate, and mild winters, area lakes provide an opportunity for swimming, camping, fishing and boating. There are a plethora of restaurants, movie theatres, and shopping centers. Driving between Dallas and Fort Worth gives multiple options for a night out. The median age of residents is 33.8 years, 50.3% male, and 49.7% female. According to, the racial/ethnic groups are: White (50.0%)

Hispanic (27.6%) and
Black (14.9%).
Asian- 4.6%
Two or more races-1.7%
In 2012, the median household Income was $56,859, however, 15.3% of residents live in poverty. Geographical Aggregates
Urban Population – 1,785,730
Rural population – 23,304
Educational Attainment
Age 25 and older, Percent high school graduate and higher- 84.5% Age 25 and older, Percent bachelor’s degree or higher-29.5%
Labor Force: Total for all sectors 141,069-
Retail trade-18, 906
Professional, scientific and technical services-18,412
Arts, entertainment and recreation-12,012
Construction accounts for 9,660.

Top three employers:
AMR Corp. (American Airlines and Envoy Air)
Texas Health Resources Lockheed Martin
Annual Unemployment Rate in 2014- 5%.
Total county income – $52,247,302,144
Per capita income – $28,265

Tarrant County has consistently supported Republican Party presidential candidates in recent decades. (Tarrant County profile)

Religious Affiliation
Evangelical Protestant-30.1%
Mainline Protestant-7.8%
Other-4.2% (Tarrant county, Texas )

Interstates 20, 30, 35W, 820
U.S. Highways 81, 287, 377
State Highways 10, 26, 114, 121, 183, 199, and 360
Bus service- “The T”
The Trinity Railway Express- a commuter train, that takes passengers through many cities of Tarrant County, and Dallas County. This serves close to 2.1 million passengers annually, and is a quick and economical option to get across town. Crime

Violent crime, (murder, rape, robbery, and aggravated assault) on a scale from 1 (low) to 100, is 48, compared to the US average of 41.1. Property crime, burglary, larceny, vehicle theft on a scale from 1 (low) to 100, is 52, compared to the US average of 43.5. (Crime in Tarrant)

Health Care Facilities- Tarrant County has over 40 healthcare facilities, specializing in acute care, rehabilitation, and mental health services. John Peter Smith Hospital, located in Fort Worth, serves as the county hospital. Texas ranks #1 in the US for uninsured residents with 32% of residents without health insurance. According to the 2010 statistics, Tarrant County had 24.4% uninsured residents. A summary of national data by the Congressional Budget Office has identified those with the likelihood of having no health insurance. People living at the poverty level

Young adults, age 19-34
People with part-time work
Individuals in poor health

Health Concern-Adult Obesity
Obesity is defined as abnormal or excessive fat accumulation that may impair health. Body mass index (BMI) is commonly used to determine obesity. It is a measurement of weight for height. A BMI> 30 identifies a person as obese. Obesity arises from the imbalance of intake of calories, and calories expended. According to the World Health Organization, (WHO)

In 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 600 million were obese. Overall, about 13% of the world’s adult populations (11% of men and 15% of women) were obese in 2014. In 2014, 39% of adults aged 18 years and over (38% of men and 40% of women) were overweight. The worldwide prevalence of obesity more than doubled between 1980 and 2014. High-income countries have greater rates of obesity than middle- and low-income countries; however, people in America who live in the most poverty-dense counties are those most prone to obesity. (Levine, 2011) The evidence is overwhelming; obesity places adults at a high risk for a number of health care concerns such as; diabetes, cardiovascular disease, sleep apnea, hypertension, arthritis, and certain cancers. Our
nation’s health care problems will continue to soar, if obesity rates continue to rise.

B2a. Background Information
According to website, “State of Obesity in America,” 39% of American adults are obese, with 40% of American adults between 40-50 years of age are obese Higher percentage of obesity seen in Black adults, (47.8%) Hispanic adults, (42%) compared to White. (32.6%) Nearly 25% of Latino households are considered food insecure, with less access to supermarkets and nutritious, fresh foods, and less access to safe places to be active. (The same is true for low income Blacks) The highest adult obesity rates are in the South and Midwest Twenty states have an adult obesity rate of 30% or higher

The highest rates of type 2 diabetes are in the South
Mississippi and West Virginia have the highest obesity rates (35%) There is a direct correlation between lack of physical activity, healthy food intake, and obesity 28 states have policies regarding the use of school playgrounds, and gyms for community use, with safe routes to school to support physical activity for children and adults. Obesity in the state of Texas has steadily increased since 2000, and is seen in all socio-economic levels. Texas data is similar to that of the US. Texas now has the 15th highest adult obesity rate in the nation; 30.9 percent, up from 25.3 percent in 2004 and from 10.7 percent in 1990. Healthy People 2020, set goals for increasing physical activity, nutritional intake, and decreasing obesity nationwide. A 13.6% in reduction of obese adults, and a 37.5% increase in intake of vegetables is needed to meet the goals of Healthy People 2020. This goal can reduce the probability of co-morbidities such as cardiovascular disease, diabetes, hypertension, and other diseases that increase mortality. (Nutrition, physical activity) B2b. Data Related to Health Concern

The US has seen a dramatic increase in obesity. Obesity-related conditions have increased. Most Americans, do not eat a nutritious diet with decreased physical activity leading to poor health. Vegetable consumption in adults and adolescence is lacking, as well as the amount of physical activity required to maintain optimum health. Physical activity can be positively influenced by the environment, such as safe streets, adequate sidewalks for walking, and bicycling, parks, walking trails, public swimming pools, and availability of these resources. (Physical activity) Hispanics, especially those without a high school education, and those at poverty level are overweight and obese. Food insecurity (the inability to afford nutritionally adequate food) affects one in five in Tarrant County. The number of families in Tarrant County receiving Supplemental Nutrition Assistance Program (SNAP) increased 52% from 2008-2011. Low income individuals are at greater risk for obesity. They face greater challenges with opportunities for physical activity, and access to nutritional food. Some of these nutritional challenges are:

Lack of full service grocery stores- Those without transportation may be forced to purchase food from neighborhood corner stores, where quality fresh produce and low-fat foods are limited. Healthy foods may be more expensive- Families may stretch their budget by purchasing cheap, energy dense, high sugar foods that are linked to obesity. Greater access to fast foods, easy to eat

Fewer opportunities, resources for physical activity, such as sidewalks, safe streets, public pools, safe attractive playgrounds and park Lack of involvement in organized sports due to expense and lack of transportation Limited health care

Often single parent households, with 2 or more jobs (Factors contributing to)

B3. Target Population
Obesity has become an epidemic, and is related to increase co-morbidities such as cardiovascular disease, diabetes, hypertension, and cancer. We have seen a rise of adult obesity, and unfortunately, we are seeing a rise in childhood, and adolescence obesity. A scientific statement from the American Heart Association described an emphasis on obesity prevention in the population at large to prevent the development of obesity in the adults who are still within their normal weight range. (Kumanyika et al., 2008) Also, targeting adults living at a lower socio-economic level may create healthier families, with less risk for co-morbidities in a population that is already predisposed to chronic health conditions.

B3a. Link to Health Inequity and Health Disparity
B3a1. Data
Obesity is costly, and is putting a strain on health care across the United States, causing an increase in related conditions that include heart disease, stroke, type 2 diabetes and certain types of cancer. According to the CDC Adult Obesity facts, “The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight.” (Adult obesity facts) The link between obesity, inactivity, and poverty is very costly, and difficult to ignore. Obesity-associated diseases account for 70% of U.S. health costs. Counties with greatest rates of poverty have greatest diabetes rates. Obesity alone is a substantial risk factor for cardiovascular disease. Obesity is associated with an increased risk of morbidity and mortality as well as reduced life expectancy.

Medical costs associated with obesity and related diseases have risen dramatically and are expected to rise more in the future. (Obesity and cardiovascular, 2006) The estimated annual health care costs of illness related to obesity are close to $190 billion, or 21% of annual health care spending in the US. The US will be paying more for disability due to obesity related illnesses. Many businesses suffer due to obesity-related job absenteeism. (Economic costs of,) According to “Trust for America’s Health Examines States’ Obesity Rates and Related Costs,” current trends in adult obesity: Could exceed 44 percent in every state, and exceed 60 percent in 13 states. Type 2 diabetes, coronary heart disease and stroke, hypertension, and arthritis—could increase tenfold between 2010 and 2020, and then double again by 2030.

The financial cost of treating preventable, obesity-related diseases could increase by more than 10 percent in 43 states and by more than 20 percent in nine states. (Fiester, 2014) Obesity is a problem that affects many Americans. Obesity puts a burden on our health care system, and is responsible for increased morbidity and mortality. The fast food industry also contributes to the obesity problem in the US, including Texas. In a recent University of Texas study on fast food intake, “for every mile the participants lived from the closest fast-food restaurant, there was a 2.4 percent decrease in their BMI.” (BMI, fast food) Fast food restaurants continue to increase in Tarrant County, in spite of many initiatives to eat healthier food.

B4. Resources and Partners
The Get Fit Texas State Agency-Recognizes and rewards employees for meeting required amounts of physical activity. The Texas Mother-Friendly Worksite Program- Recognizes worksites that encourage and support nursing mothers. Tarrant County Food Bank- Area food bank serving Tarrant, and 13 surrounding counties to provide healthy food, and job opportunities for those who live with food insecurity, living in food desserts, and many other underserved. Blue Zones Project- A community-wide well-being initiative for healthier lifestyles in Fort Worth, Texas, such as increasing activity, and increasing fruit and vegetable consumption to promote better health. Healthy Tarrant County Collaboration- A partnership of hospitals, public health organizations, and universities to build healthier communities.

YMCA of Tarrant County- Supports activities in seniors, adults, and the youth of Tarrant County by providing education, and activities to promote healthier lifestyles Tarrant County Obesity Prevention Policy Council- To drive policy, structural and, environmental change in Tarrant County communities to promote healthy eating and physical activity. Tarrant County Health Department- Educate, and inform the residents of health issues such as communicable diseases, immunizations, and work with partners to identify, and address health equity and decrease health disparities. B4a. Fieldwork Interviews

I visited a local Whole Foods store, just a few miles from my home. I must admit, I never shopped at this store; I was sure it was just too expensive. The enormous produce section of the store is there upon entering. It is colorful and inviting. I met with Matthew, from guest relations, and he assured me the prices there are comparable to other stores in the neighborhood, but buyers are assured quality and freshness of all produce. He gave me a tour of the store, and showed me the options for whole grains, nuts, fresh meats, and dairy. There was much less options for chips, candy, and sodas. They have high standards for the food they sell, and feature food that are preservative free, without hydrogenated fats. There is no candy and chips at the check –out.(a tempting place to linger for adults and children) Matthew assured me Whole Foods is dedicated to providing healthier choices, with fresh, high quality foods. Renee Michon , Registered Dietician, for inpatients at Baylor Regional Medical Center at Grapevine, Grapevine Texas, says “portion control is one of the most important aspects of weight management.” She illustrated the “Healthy Eating Plate,” (Figure 2, 3) which divides a smaller size meal plate into food groups; fruits and vegetables, protein, and whole grains.

According to the Healthy Eating Plate,
One-half of your plate should contain fruits and vegetables, (different colors, and varieties ¼ of your plate should have whole grains, such as wheat pasta, brown rice, barley ¼ of your plate should contain healthy protein

Renee believes the culture that consumes fast food is at high risk for obesity. According to “The Journal of Nutrition,” portion sizes at fast food restaurants have increased since the 1970’s, and continue to increase. The term “supersize it” became famous in the 1980’s; and food is estimated to be two-five times larger than two decades ago. Portions of pre-packaged foods, such as potato chips, have also increased over the years. (Ledikwe, Ello-Martin, & Rolls, 2005) Renee is consulted on all inpatients with a diagnosis of Congested Heart Failure, Diabetes, Acute Coronary Syndrome, (MI, Stents) and coronary revascularization. Another dietician, Yasseen Schiller, is the nutritional counselor for the outpatient population at the hospital. Patients are referred by their physician, and clients work with her to lose body fat, and learn healthy eating habits. She works with adults and children, and identifies several barriers in nutritional counseling, such as fast food, and portion control.

Her clients are asked to keep a food diary, and are taught to read labels. Many of her clients have Type II Diabetes, and high cholesterol. Many have cardiovascular disease, and joint dysfunction. Her services are covered by insurance, and she sees patients in a 1:1 setting. She says this service has proven to reduce patients BMI, reduce needs for insulin, and cholesterol medications. I spent time with Richard Feingold, D.O. cardiologist, with Cardiovascular Consultants, Grapevine, Texas. He shared that 30-35% of all of his patients are obese, and close to 50% of the patients in his practice are considered overweight. He acknowledged an increase BMI carries high risks for cardiovascular disease. Many of his patients that are obese also have an obese spouse. He feels many of his obese patients do not fully comprehend the high risk, and treating them can prove to be very frustrating. He also sees many patients with diabetes; many of them who do not have their HgA1C under control.

He used to practice in another hospital in a more underprivileged area, and his practice saw over 50% of the patients with diagnosed obesity. He was very vocal about the need to assist those in underserved areas, and acknowledged the health-care crisis of those without health insurance, and the burden it places on our health care system. I interviewed Linda Fulmer, executive director of Healthy Tarrant County Collaboration, and was introduced to “The Spectrum of Prevention” tool, (Prevention Institution, 1999) as a meaningful way to look at changes. This tool, developed by Larry Cohen, (founder and Executive Director of Prevention Institute) can be used for any prevention initiative. It identifies many levels of intervention, and helps people move away from the thought that prevention can simply be changed with education.

These multi-level ideals, if used together, can produce more powerful outcomes. According to Ms. Fulmer, legislation, and other policy initiatives, gives a “bigger bang for the buck.” In other words, much time and effort are placed on individual knowledge and skill, when many individuals do not have sufficient resources in place to be successful. Many people would appreciate the opportunity to increase activity, but if they reside in a neighborhood that is unsafe, with inadequate sidewalks and activity resources, daily activity may not be reasonable. If there is little public transportation, there may be barriers to access grocery stores that can provide fresh fruit and vegetables. Many areas with the higher rates of obesity in Tarrant County have environmental factors that limit many adults to healthy lifestyles. Ms. Fulmer drove me through some areas in south Tarrant County that struggle with obesity. These areas look so different from the North Tarrant County neighborhoods where I live and work. This area struggles with poverty, and it was clear; increasing access to recreation, and grocery stores, with better police patrol may enhance the healthy lifestyle of the residents.

I spent several hours at the” Hispanic Wellness Fair,” an annual community event geared to the Hispanic community, and their specific issues. Every presenter was bilingual, and all of the fliers and education material was in English and Spanish. They did health screening, (cholesterol, glucose, BMI, blood pressure, skin assessment) with several services represented (Medicaid, food stamps, WIC, health care agencies, YMCA, Diabetes Coalition) There were several stations, each one representing a community need. They offered cooking demonstrations, and had dieticians, life coaches, and exercise specialists. The majority of those in attendance were Hispanics, and there were fun and games for children. This annual event provides education and options for wellness to the Hispanic community, and offers free parking with public transportation.

Each table gives away pens, cups, magnets, toys for children, etc., and draws thousands each year. Another interesting interview was with my friend and colleague, Shelly W., who had bariatric surgery in 2009. S. was 100 pound overweight, and struggled with obesity her entire adult life. She told me she tried Weight Watchers, Nutri-System, and other fad diets, and she would lose weight, only to re-gain it back, and weigh more than before. She was borderline diabetic, and was on medication for high blood pressure. Her biggest complaint was her inability to be active, and her weight kept her from enjoying daily activities. She was embarrassed to go out, and her self- esteem suffered. A year after her surgery, she lost almost 100 pounds, and has kept the weight off. She no longer has high blood pressure, and her glucose is within normal limits. She has become more active, and enjoys gardening, and walking.

I invited four of my colleagues to lunch, to discuss their perception of obese patients, and barriers in caring for them. Each person interviewed shared negative perceptions of obese patients, sighting the physical demands. They said it takes twice as long to do most of the care for an obese patient, and so many cannot do anything to help with their care. They are at risk for falls, pressure ulcers, and the staff is then deemed responsible, and must deal with the consequences of hospital acquired injuries. The high acuity of an obese patient is not considered in making staffing assignments, even though their care is often more time consuming. They also felt our safety was in jeopardy, and know of many who have suffered back and neck injuries caring for obese patients. Many of the obese patients have longer hospital stays, due to the co-morbidities, and the risk of hospital acquired infections is greater. Often, the nursing care can be excellent, but it may still be difficult to prevent hospital acquired injuries.

I also spent the day in cardiac rehab, with the nurse Marla, and the exercise physiologist, Whitney. Patients are referred to cardiac rehab after a cardiac event, such as a Myocardial Infarction, Cardiac Intervention, (stent placement), or Open Heart Surgery. I shadowed both employees for a different perspective. Marla acknowledged, over 50% of her patients, men and women combined were overweight, and almost 30% were considered obese. Many patients did not have an exercise routine, and most admit to an unhealthy diet. Marla stated the population of patient in this area, were not suffering from food insecurities, but ate fast food on a regular basis, and often ate at restaurants. Many in this community have careers, and busy lifestyles, making cooking at home difficult. Marla conducted a complete history and physical exam, including medication lists for each new patient. Whitney, E.P., would then see the patient and discuss the exercise program.

This 26 -36 session program guides patients through exercise while monitoring heart rate, blood pressure and pre and post glucose for diabetic patients. Clients start the program with light exercise, and increase the intensity throughout the program. Patients also have educational classes from a pharmacist, nutritional classes from their outpatient dietician. They are educated on reading labels and identifying high fat, sodium, and sugar contents in food. They are educated on making healthier choices when visiting restaurants. From these interviews, it was very clear that the obesity crisis here in Tarrant County is quite challenging. There are many barriers; both behavioral and environmental issues present.

People with busy lifestyles often eat away from home, and are tempted with tasty, but high calorie fast-foods, with large portions. People don’t often understand the importance of eating a diet based on the Healthy Food Plate, and eat large portions at each meal. “All you can eat” restaurants are very popular, and “supersize it” is a phrase we have all become accustomed to. Unfortunately, many adults in underserved areas face other struggles; living in food desserts, with little access to grocery stores that have quality, affordable, nutritious foods. Many of these neighborhoods do not offer a positive, safe environment for family activities that can enhance a healthy lifestyle. B5. Aspects Not Being Addressed

In my research, and through the field service interviews, I am aware of different problems in different areas of Tarrant County. After speaking with several individuals, it is my opinion that there are two different populations of those struggling with obesity; those who live in underserved areas, and have minimal opportunity in obtaining healthy food and exercise, and those living in areas with an abundance of choices for nutritional food with opportunity for activity. It is a difficult task to implement plans to reduce obesity, when dealing with different needs of people with different lifestyles. The population of people living in food desserts, must have means to get healthy food, and must have an environment for safe activity. Policies are needed to enable this population access to healthier food, and provide safer areas where residents can walk, and play without fear.

In contrast, those living in more affluent areas have opportunity for healthy choices, with a safer environment for activity; yet, obesity is still a major problem. Many here are living the “busy lifestyle,” juggling a career, children in sports, and often have little time to prepare nutritional meals. With the many fast food restaurants available, it has become easy, and almost essential, to get a quick meal, when you are on the go. In my interview with Marla B, RN, manager of Cardiac Rehab at Baylor Grapevine, I asked her opinion of why there is an abundance of obesity in this affluent area. She believes many of the clients she sees, have very busy lifestyles, and seldom cook at home.

She said the majority of the clients acknowledge fast food, and eating away from home, as one of their biggest challenges. Reducing obesity now becomes very complicated. Different populations, (including different rates of obesity within different ethnic groups) within the same county, have different challenges. These challenges can be identified into other sub-groups such as lack of transportation, literacy, education, and poverty. Identifying, educating and providing population specific action plans is the only way to reduce the rate of obesity. C1. Desired Outcomes, Goals for Improvement

Tarrant County, Texas, continues to see an increase in the obesity epidemic, threatening the health of many residents, especially those struggling with poverty, and lack of health care. In Tarrant County, the number of overweight and obese adults continue to rise, and continues to be a priority in health initiatives. Overweight: Adults with a BMI of 25-30 – 414,507 (36.34%)

Obesity: Adults with a BMI>30 – 369,325 (27.80%).
Education, and policy reform is needed to provide all residents with the opportunity for nutritional food, safe environments for activity, and education to promote a healthy lifestyle. Implementing policies for healthier lifestyles may offer the best solutions for decreasing obesity in underserved areas. Obesity rates are higher in families living in poverty. These neighborhoods have been identified as having poor access to healthy foods, (lack of grocery stores offering affordable, fresh fruits and vegetables,) and struggle with safe environments that are not conducive for outdoor activities and exercise.

In my interviews and research, financial resources, and government spending, at many levels, often place priorities and capital on developing large businesses, or the development of new businesses. Educations about healthier fast food choices is necessary for many living in areas with sufficient choices, but are part of a high stressed, fast paced life-style. I have identified several goals to reduce the rate of obesity through nutrition and physical activity. 1. Increase healthy Eating among residents of Tarrant County by, Increasing the number of policy and environmental supports such as; Providing availability of healthy food options to everyone

Increasing breastfeeding amongst new mothers
Reducing fast food consumption
Increasing fresh fruit and vegetable consumption
Reducing disparities by gender, race, socioeconomic class, geographical region 2. Increase physical activity among the residents of Tarrant County by; Increasing the number of policy and environmental supports

Increase activity, such as “moving naturally,”
Providing safe environments for activity
3. Identify those at risk with early intervention
Education and reimbursement to health care facilities
Early screening for health co-morbidities such as diabetes
Community programs for education, screening

3. Encourage physicians to become knowledgeable about community resources and referral services that can assist with the management of overweight and obese patients. 4. Compensate health care providers with federal funding to evaluate all patients for healthy weight, by assessing BMI with each visit, and facilitate weight management for those at risk for obesity. 5. Educate health care providers on providing healthy lifestyle education. (often a very sensitive subject) 6. Early identification of health related co-morbidities such as diabetes, hyperlipidemia with cholesterol and HgbA1c lab work, through health clinics, primary care physicians. 7. Identify and screen all hospitalized patient with BMI >30, for diabetes and hyperlipidemia. 8. Encourage communities to offer free health fairs for screening, and education of risk factors for obesity and health related disparities. 9. Encourage fast food restaurants to provide healthier choices; posting calorie, fat, and sugar contents on menus, and drive through windows.

D1. Nursing Action Plan
Reduce the rate of obesity in the adult population of Tarrant County ten percent by the year 2020 The Community Health Nurse will:
Work with community partners, such as the state and local public health, Obesity Prevention organizations, hospitals and health care providers, community and non-profit organizations, state and local education agencies, transportation, parks and recreation, and faith based organizations Maintain an active voice in policy implementation at a local and state level Maintain current education on health disparities and current evidenced based prevention and treatment, and assist with community education Advocate for those who suffer higher rates of health care concerns due to race, gender, geographic, and socio-economic disparities Promote and set an example for a healthy lifestyle

Encourage collaboration between partners, local and state officials, and population served, in order to maximize opportunities and impact Promote prevention within the community, and empower residents to be proactive with their health

D1a. Population Focused Objectives and Interventions
The Community Health Nurse must identify (assess) and monitor the community health status with data collection, assist in policy development, informing and educating, then evaluate the interventions to ensure they are meeting the community demands. Objective 1

Decrease adult obesity in the Tarrant County by advocating for those living in underserved communities Identifying those at risk by geographical location, socioeconomic class, gender, and race Educate population on healthy nutrition, and to reduce the intake of fast food Advocate for community members by identifying specific needs within a community Collaborate with community partners

Advocate for a safe environment where physical activity can be encouraged

Objective 2
Decrease rate of obesity in communities with plentiful resources Work with community partners for early identification of co-morbidities, health fairs, etc. Encourage intake of healthier food, and less fast food

Educate community on increasing activity, portion control, early identification and prevention of potential risks of obesity

D2. Potential Partnerships
During my field interviews, it became very clear that there are two very specific populations with different health related issues. The underserved communities of Tarrant County struggle with poverty, food insecurities, lack of accessible healthy choices and transportation, education and language barriers with neighborhoods that are generally not conducive for exercise. The Healthy Tarrant County Collaboration is working to partner with many other agencies to reach those in underserved areas, such as health care agencies, lactation specialists, educators, entrepreneurs, businesses, and government agencies. Many of the identified problems cannot be solved with education alone. When I spent time with Linda Fulmer, the Executive Director of Healthy Tarrant County Collaboration, she explained the “Health Impact Pyramid” (see attached picture) and explained the greatest impact for change, is often the hardest to implement.

Sadly, she also said reducing obesity rates, and the health problems that arise from this diagnosis, will most likely take many, many, years. One of the most impressive potential partners I discovered was “The Blue Zones Project” and is a new partner to the City of Fort Worth. The Blue Zones Project is a community well-being improvement initiative designed to make healthy choices easier through permanent changes to environment, policy, and social networks. This idea was started after people discovered certain cities throughout the world had a population of longevity, and minimal illnesses. Studies revealed nine concepts that these cities had in common;

1. Move naturally- No need for gym equipment, the people in these cities, walked, hiked, rode bicycles, mowed their own lawns, and cleaned their own houses.
2. Down Shift-Take time off, relax, and take a vacation,
3. Right tribe- Associate with good people
4. 80% Rule- Stop eating when you are not completely full
5. Plant Slant- Eat a more plant based diet
6. Family First-
7. Wine at 5- many of these cities enjoyed a glass of wine each evening
8. Know your purpose- Why am I here, how can I make a difference?
9. Community- Belong to a group that shares your same values, beliefs

Fort Worth is one of a handful of chosen cities to adopt the philosophy
of living a healthy lifestyle, by following the “Power 9” principles. They have introduced cooking and walking clubs, small community groups, and are working to promote healthier lifestyles by making it easier to make healthy choices. Although still in its infancy in Fort Worth, they have worked with restaurants to provide healthier menus, and plan to implement better opportunities for activity and exercise. The Tarrant County Food Bank is also doing so much in the community to promote healthy eating. They are working with smaller food pantries to encourage community gardens, and helping church based pantries with smaller community needs. They offer culinary classes, offering community member’s employment opportunities, as well as education on healthy nutrition. These two partners are making a big impact on the city of Fort Worth, and with their help, positive change is expected in this community.

D3. Timeline for Interventions
No state met the Healthy People 2010 objective of fifteen percent for obesity rate, and many states had rates higher than twenty five percent. The Healthy People 2020 target is 30.6%; a reduction of 14.3%. This research has shown me that reducing obesity rates is a complex, multifaceted process. In my nursing action plan, my objective was to decrease obesity in Tarrant County by ten percent by the year 2020. (Current obesity rate in Tarrant County: 27.8%; goal 25.0% by 2020) There is so much work to be done to meet this goal. I chose a goal that I felt was attainable, and realistic. E1. Effectiveness of Nursing Action Plan

E1a. Measureable Tools
Tarrant County has strong groups with many newly developed partners and goals. They have made obesity rates and health disparities a priority. Unfortunately, there are many influential people who do not share the same priorities, and wish to see the development of large, profitable business, and increase growth in the county. Ongoing debates regarding budgeted dollars can slow process for implementing new policies in underserved areas. The Behavioral Risk Factor Surveillance System (BRFSS) is a large, ongoing telephone health survey, and reports information to the CDC, state and local health departments, and monitors health risk factors. Information obtained is reported and accessible to all residents.

This continuous monitoring may help influence public leaders to prioritize this issue. Partnering with the health care facilities, may help drive change. The goal of reducing obesity is to promote health, and reduce co-morbidities such as diabetes and cardiovascular disease. These rates are also reported, and can influence a city’s growth success. People want to live in an area where health is a priority. The CDC, and other governmental regulating agencies, monitor health disparities, and require states and cities to have regulations in place to create a healthier population. The National Alliance for Nutrition and Activity, (NANA), advocates for certain programs and policies to promote healthy eating and physical activity, to reduce certain health disparities and health care costs due to unhealthy lifestyles.

NANA works within the legislative and executive branches of government, to educate and promote healthier lifestyles, to reduce health care costs. They have put in place policies to provide healthier food for schools, and child care facilities, support programs that encourage increase in activity, and obesity prevention. (National Alliance for Nutrition and Activity, n.d.) The Community Guide is a website that provides information and reviews programs in place to determine their effectiveness. The Community Preventive Services Task Force, (members include CDC, Partner Agencies and Organizations, Practitioners, Policy Makers, and Researchers) and determines what initiatives are working, and new initiatives that may need to be implemented.

There are many influential organizations providing input in making sure cities and states are meeting initiatives for healthier communities. The community nurse must advocate for her community members, by establishing relationships with city officials, health care workers, and partners. Recording and reporting data within communities will be necessary to show trends of successes and failures. Documentation of reduction of co-morbidities such as diabetes, hypertension, heart attacks, and strokes, will be essential in determining healthier communities.

F1. How my perspective has changed
It is easy to believe obesity is a condition that plagues many individuals due to improper education, lack of willpower, with many genetic
and environmental factors. We are surrounded by fast food restaurants, allowing us to provide a quick filling meal for ourselves, and our families. Our society celebrates almost all events around food, and we have a plethora of amazing restaurants to enjoy these celebrations. In my research of obesity, I was educated on some of the challenges many face with the opportunity to purchase nutritional food, and the many environmental barriers preventing proper activity and exercise. There are populations with the opportunity to buy and make nutritional meals, and live in areas with parks and recreation for activity. Unfortunately, there is a large percentage of people, living in food desserts, with little access to affordable fresh fruits and vegetables, living in neighborhoods that do not provide a safe environment for walking and exercise.

Transportation is another barrier in getting to stores that offer nutritional food. Many families without vehicles, often shop at corner stores; known for foods high in fats, and sugar, with expensive, low quality, fresh fruit and vegetables. I visited a neighborhood just 30 minutes away from my home, and there was only one grocery store within a 10 mile radius. This area had very few sidewalks for anyone to walk. There was no public swimming pool, and the parks were deserted on a warm summer morning. Educating people about nutrition, and activity is good, but providing adequate access to quality food and a safe environment for outdoor activities is essential.

Those is underserved areas are at a much higher risk for developing obesity, and the co-morbidities that accompany this disease. Obesity is seen in all races, and socio-economic groups. However, obesity is seen in epidemic proportions for those living at or below the poverty level. It is essential that we place a priority on providing policies that allows everyone the same opportunity to a healthy lifestyle. The Community Health Nurse plays an important role in identifying, assessing, implementing, and evaluating the health care needs within the community. It is vital to dissect different populations within the community to identify different barriers individuals face.

(Healthy Eating Plate vs USDA’s MyPlate, n.d.)


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