The Role of Nursing in Pediatric Lifestyle Medicine

Abstract

Lifestyle medicine is a critically important part of optimizing holistic health across the life course of individuals. For children and adolescents, lifestyle medicine with the focus on developing healthy lifestyle behaviors, is initiated early in life and emphasizes multidisciplinary, multisectoral efforts. Central to these efforts is primordial prevention, with an emphasis on developing and maintaining healthy patterns of lifestyle behaviors. Viewed within a socio-ecological model of health and behavior, contexts including families, schools, and communities interact to influence and impact the health of children and adolescents. Nurses and nursing organizations and societies promote pediatric lifestyle medicine with the aim of promoting optimal health and development for all children.

“Schools, including preschools, are viewed as a critically important context for primordial and primary prevention for children with opportunities to extend to families as a unit of intervention.”

Introduction

Lifestyle medicine has emerged as a critically important part of health care across the life course and health care and community-based settings. Pediatric lifestyle medicine emphasizes efforts designed to promote optimal health beginning early in life. Central to these efforts is primordial prevention, preventing the development of risk for adverse health conditions and primary prevention, designed to reduce adverse health factors and behaviors with the aim of preventing incident disease. Nurses, including advanced practice nurses and nurse practitioners, form the largest group of health care professions in the U.S. and have important roles in promoting and advancing lifestyle medicine as part of holistic care for children and adolescents and their respective families. The purposes of this article are to underscore the importance of promoting healthy lifestyles beginning early in life, provide an overview of the pillars of pediatric lifestyle medicine, highlight contributions of nurses and nursing in pediatric lifestyle medicine, and provide direction for future innovations in the field with the goal of optimizing ideal health for all children and adolescents.

Significance of a Healthy Start

Substantial clinical and epidemiologic data document the associations of adverse levels of health factors and health behaviors with less-than-optimal developmental processes and health early in life. With cardiovascular diseases (CVD) as major causes of morbidity and mortality in women and men in the U.S. and worldwide, decades of research have focused on the early origins with a goal of developing timely, targeted preventive interventions. ¹ Of note, most children are born with ideal cardiovascular health as operationalized by Lloyd Jones and colleagues. ² Central to this concept of ideal cardiovascular health are health behaviors including patterns of physical activity, dietary intake, sleep, and nicotine exposure. Emphasized in pediatric lifestyle medicine, these behavioral patterns are established early in life, track over the life course, associate with health factors (body-mass index, blood lipid and glucose levels and blood pressure) and are important in maintaining health and preventing emergence of chronic conditions.

The Pillars of Lifestyle Medicine and Life’s Essential Eight

The pillars of lifestyle medicine ³ are consistent with the American Heart Association’s (AHA) Presidential Advisory, Life’s Essential Eight (LE8) ⁴ with emphasis on health behaviors and primordial prevention. Specifically, AHA advanced the concept of ideal cardiovascular health in Life’s Simple Seven (LS7), ² published in 2010 which was based on substantial data illustrating that adults who reach middle age without traditional established risk factors have remarkably lower morbidity and mortality from CVD and overall better quality of life and well-being. ⁵ Life’s Essential Eight (LE8) ⁴ differs from Life’s Simple Seven ² with the addition of sleep as well as consideration of the foundational context of health with an emphasis on the social determinants of health, including the socioeconomic and structural determinants that affect an individual’s or a community’s ability to optimize cardiovascular health. ⁴ Psychological health and well-being are also viewed as a critical context in LE8 based on evidence indicating there are multiple pathways by which psychological health and well-being may influence cardiovascular health and risk for CVD. The LE8 metrics for capturing the health behaviors (diet, physical activity, nicotine exposure, sleep) and health factors (BMI, blood lipids, blood glucose, blood pressure) are stratified by age and allow for more sensitivity of scoring to inter-individual differences and changes over time in individuals and populations. ⁴ Important in this context is that ideal levels for health behaviors and health factors for children and adolescents are based on respective current evidence-based guidelines. The pillars of lifestyle medicine, ³ like LE8, and consistent with socio-ecological models of health, underscore the need for and benefits of focusing on contexts/systems in promoting health and well-being beginning early in life and extending across the life course. ⁴

Nutrition

Dalal and colleagues (2022) ⁶ argue persuasively that lifestyle medicine practitioners including nurses and nurse practitioners, should encourage parents to introduce lifestyle medicine in early infancy because of the importance in establishing lifelong, healthy practices. Nutrition and feeding practices, a key pillar, begins with maternal dietary intake and practices because this influences the health and development of the developing fetus. Relatedly, breastfeeding is highly recommended by the American Academy of Pediatrics ⁷ as well as other agencies and organizations. The numerous benefits of breastfeeding for mother and offspring are well established with more recent evidence indicating that maternal dietary intake during breastfeeding also influences a child’s food preferences. De Cosmi and colleagues ⁸ observed that length of breastfeeding and foods consumed while breastfeeding were strong predictors of children’s later food consumption. As children transition from breastmilk or formula as primary food source, the complementary food introduced offers opportunities for exposure to a variety of flavors. Nurses and other lifestyle medicine practitioners have important roles in facilitating transition to complementary food sources when children are developmentally ready (4-6 months of age).

The pattern of dietary intake recommended for optimal health in the pillars of lifestyle medicine ³ and LE8 ⁴ are similar. Both emphasize consumption of appropriate energy intake for age, developmental processes and with consideration of energy expenditure. The pillar places more emphasis on consumption of plant-based foods than LE8. Both emphasize consumption of whole grains, vegetables, fruits, fiber, nuts and minimizing consumption of sugar, fats (particularly saturated fats), and salt.

The child’s family is a major context for development of healthy patterns of dietary intake with foods made available in the home environment and role-modeling by parents/caregivers. ⁹ Evidence indicates that beginning early in childhood role-modeling by parents/caregivers results in imitative and vicarious learning of selected behaviors including dietary intake. ⁹ Parental modeling of healthy eating behaviors is associated with higher intake of vegetables and fruits and lower intake of saturated fat. Of note, the physical as well as the behavioral components of the shared family environment affect the acquisition and maintenance of healthy behaviors. As suggested in socio-ecological models of health, the physical environment encompasses availability of resources for nutrient-rich healthy foods. The community in which the family resides is an important context and there is considerable variation between U.S. communities in availability of and access to resources essential to promote health in childhood, adolescence, and across the life course of individuals and families. This is exemplified in the ongoing epidemic of obesity with substantial evidence underscoring that children from marginalized communities bear an excess burden of obesity and its comorbidities. ¹⁰ A major risk factor for CVD and other chronic conditions, obesity aggregates in families. Taken together, this evidence and anecdotal observations underscore the need to focus on the social determinants of health in primordial and well as primary prevention and with the family as a unit of intervention. Nurses, nurse practitioners and nursing societies have and continue to advocate for assessing the social determinants of health in well-child visits and other encounters with health care providers, and follow-up with referrals to appropriate sources of support. ¹¹

Physical Activity

Emphasized in both the pillars of lifestyle medicine ³ and LE8, ⁴ physically active lifestyles are viewed as a central component of primordial prevention. The physical, psychosocial, and emotional benefits of physical activity for children, adolescents and adults are well established. Evidence-based guidelines indicate that children should have 60 minutes of moderate-to-vigorous-physical activity (MVPA) daily. ¹² Equally important is the evidence-based recommendation to restrict sedentary time to no more than 2 hours per day for older children and discouraging screen time for children younger than 2 years of age. ¹² As with patterns of dietary intake, parents/caregivers and the family environment are important in helping children adopt and maintain physically active lifestyles. Evidence indicates that physically active parents are more likely to have children who are engaging in recommended levels of physical activity. ¹³

In clinical and community-based settings including preschools and schools, nurses advocate for and support developmentally appropriate physical activities for children. ¹⁴ Counseling parents/caregivers as part of well-child visits, nurses and nurse practitioners incorporate recommendations for physical activity and suggest strategies for enabling a range of activities in the home environment.

Sleep

The quality and quantity of sleep affects physical and mental/psychological health in childhood and across the life course. Based on accumulated evidence, as noted above, the AHA added sleep health as a new component of cardiovascular health and provided metrics for capturing optimal sleep in LE8. ⁴ Of note, sleep is viewed as a multidimensional construct with overlapping components including duration, timing regularity, efficiency, satisfaction, and impact on daytime alertness. ⁴ Evidence indicates that healthy patterns of sleep in childhood are associated with optimal learning, attention, behavior, and mood. ⁶ Parents/caregivers have important roles in promoting healthy sleep patterns beginning early in life. Sleep is a modifiable health behavior and establishing family sleep routines including a consistent bedtime for children (and parents) as well as creating a home environment conducive to optimal sleep is recommended in the pillars of lifestyle medicine. Indeed, the home and family environment are important contexts for development and maintenance of healthy sleep patterns; however, children and families residing in under-resourced communities with adverse social determinants may not have the resources to support healthy patterns of sleep. Community-based nurses making home visits have opportunities to work with parents/caregivers in developing realistic and feasible strategies to promote optimal sleep for children and the family unit. Engaging appropriate community-based agencies as well as pediatric societies in these processes is also recommended. Nurses and nurse practitioners functioning in clinical settings also have opportunities to assess and promote optimal sleep behaviors and hygiene particularly during well-child visits.

Nicotine Exposure/Risky Substances

The adverse effects of nicotine and nicotine exposure including second-hand smoke have been well documented, merited a scientific statement from the AHA, ¹⁵ and evidence-based preventive and treatment (smoking cessation) interventions in guidelines issued by expert groups and pediatric societies. ¹⁶ At well-child visits and other health care encounters, nurses and nurse practitioners assess tobacco exposure including second-hand smoke and provide information and advice regarding the importance of smoke-free home environments. With the increase in prevalence of vaping/e-cigarette use in children, adolescents and adults, information, provided in several formats, regarding the adverse effects is strongly recommended. The AHA has supported several projects, currently in progress, that will provide innovative approaches to prevent vaping as well as promote cessation. ¹⁷ Given the multifaceted, multisystem adverse effects of nicotine, a highly addictive substance, initiating anti-smoking and vaping counseling early in school-age years is recommended. Equally as important are efforts focused on parents/caregivers since role-modeling of these behaviors and other substances is associated with likelihood of experimentation and uptake in children and adolescents. For adolescents, emerging adults as well as parents/caregivers, assistance with cessation including counseling, telephone helplines, communal cessation programs, and pharmacotherapy is recommended. ¹⁶

Psychological Health and Well-Being

Psychological health and well-being is now recognized as foundational in the AHA’s Life Essential Eight (LE8). ⁴ Pillars of lifestyle medicine ³ emphasize stress management and the importance of positive social connections. Indeed, both acute and chronic stress emanating from several sources have adverse effects on health in early life and across the life course. Important to note is that stress and responses to stressors demonstrate considerable inter-individual variability. The COVID pandemic, for example, and the school, work, home, and societal changes that continue currently have been sources of stress for children, adolescents, and families. Learning to manage and cope with everyday stressors (daily hassles) and major life events in positive ways is critically important. Suggestions should be offered beginning early in life. Dalal and colleagues ⁶ remind us of beginning the conversation about mindfulness in the first year of life. Infants are believed to be born to be mindful ⁶ but lose this ability in environments filled with constant stimuli, including the effects of interactions with electronics. Play, characterized as the work of childhood, with traditional toys as opposed to video toys is suggested and has been shown to improve language skills. ⁶

Lifestyle medicine practitioners, including nurses, have the potential to influence parents/caregivers’ choice of play activities that are developmentally appropriate and encourage creativity and mindfulness. Parents/caregivers can also teach self-regulation skills to toddlers and older children using the mnemonic “ABC.” As defined by Dalal and colleagues, ⁶ A stands for awareness of emotions; B stands for breathing, and, C stands for calming. Recommendations for increasing awareness of emotions include having a chart with different emotions depicted and illustrating through facial expressions the range of emotions. As suggested by the American College of Lifestyle Medicine (ACLM), ⁶ simple breathing techniques, can be used to manage feelings of anger and other such emotions. For example, “square box breathing” is suggested whereby children are asked to trace the shape of a box and for each side, 4 seconds inhale/breathe in, 4 seconds hold breath, 4 seconds exhale. All is done while tracing a box. Older children can be taught the 5 senses grounding tool to promote mindfulness. This includes thinking of 5 things you can see, 4 things you can feel, 3 things you can hear, 2 things you can smell and 1 thing you can taste. ⁶

Important to emphasize is the influence and impact of parents/caregivers in functioning as role models demonstrating effective methods for dealing with stress and maintaining a sense of equanimity and calm. Nurses and nurse practitioners, knowledgeable about the child’s and family’s challenges, needs, and resources and equipped with the appropriate “toolbox” for stress management are essential members of multidisciplinary teams prepared to address and support the psychological health and well-being of children, adolescents, and families.

Pediatric Lifestyle Medicine in Clinical Settings: Contributions of Nurses and Nursing

Nurses and nurse practitioners functioning in clinical settings including hospitals, outpatient clinics, pediatric and family practices are instrumental in supporting patterns of lifestyle medicine focused on promoting optimal health and development for children, adolescents, and emerging adults. ¹⁸ As highlighted above, providing information, advice, and counseling on adopting healthy patterns of dietary intake, physical activity, sleep and smoke-free lifestyles and environments have been part of nursing practice for decades.

Schools: A Population-Based Venue for Pediatric Lifestyle Medicine

With 95% of U.S. children attending schools, it is an appropriate venue for promotion of pediatric lifestyle medicine. School-based research focused on healthy lifestyle behaviors and reduction of risk for CVD and chronic conditions has been implemented and supported by the National Institutes of Health (NIH) and other sources since early 1990s. ¹⁹ Results have been mixed with some well-designed and rigorously implemented multicomponent interventions demonstrating short-term modifications in levels of physical activity in school-aged children. ¹⁹ A multicomponent behavioral-lifestyle intervention in preschools (Heathy Start) ²⁰ resulted in significant short-term modifications in dietary intake and reduction in atherogenic lipids. Taken together, collective results from school-based research and programmatic initiatives underscore the promise and potential of preschools and schools for promotion of lifestyle medicine including primordial prevention. The critical importance of policies that affect the food and physical activity environments of schools cannot be over-emphasized. ¹⁴ Indeed, this is an opportune time for health professionals and child health advocates to support funding of safety net programs designed to provide healthy foods in schools. For example, the National School Lunch Program (NSLP), administered by the Food and Nutrition Service of the U.S. Department of Agriculture, is a federally assisted meal program operating in public and nonprofit private school and residential child care institutions. The NSLP must meet Federal requirements regarding child nutrition and meal patterns. ²⁵

Nurses provide behavioral-lifestyle assessments and advice and counseling in schools. With the changes and challenges in the nursing workforce attributed in part to COVID and retirements, and the ongoing shortage of school nurses, time targeted for such efforts is less than optimal. ²¹ The National Association of School Nurses ²¹ and like-minded organizations continue to advocate for additional resources and supports for school nurses with recognition of the potential to contribute to the health and well-being of U.S. children.

Summary and Future Directions

The importance of establishing healthy behaviors and lifestyles early in life is well established and endorsed by ACLM, ³ AHA, ⁴ the Society of Behavioral Medicine (SBM) ²² pediatric societies including the American Academy of Pediatrics (AAP) ²³ and nursing organizations including the National Association of Nurse Practitioners ²⁴ and National Association of School Nurses. ²¹ Nurses and nurse practitioners functioning in clinical and community-based settings promote pediatric lifestyle medicine, providing evidence-based information, advice, counseling on development, maintenance or change in patterns of behavior and referral to appropriate additional sources of support. Families are viewed as critically important contexts for lifestyle medicine with engagement of parents/caregivers in individualized plans designed to promote healthy lifestyles for children and the family as a unit. When setting realistic and feasible goals for children and families, nurses, and other lifestyle medicine practitioners must consider families’ social determinants of health, socio-cultural backgrounds and availability, accessibility, and affordability of health care, and outlets for physical activity and nutrient-rich foods that influence and impact lifestyles. Schools, including preschools, are viewed as a critically important context for primordial and primary prevention for children with opportunities to extend to families as a unit of intervention. While progress has been made in recognizing and promoting the significance of lifestyle medicine and health within pediatrics, much more remains to be accomplished in effectively and efficiently implementing evidence-based guidelines and practices. Exemplified in the epidemic of overweight and obesity, individuals from under-resourced, marginalized families and communities bear an excess burden of this condition, ¹⁰ a major risk factor for diabetes, CVD, and other chronic conditions. Relatedly, innovative methods for incorporating lifestyle medicine in clinical and public health practice particularly in prevention of overweight and obesity in early life and across the life course are urgently needed.

Viewed within the socio-ecological model of health and behavior, innovative initiatives require changes in policies.^26,27 This is exemplified in the substantial decrease in cigarette smoking in the U.S. over past several decades, attributed in part to implementation of smoke-free policies in workplace, school, and community environments. Substantial evidence is needed to guide and inform those policies and advocacy for implementation. Nurses, nursing, and pediatric health care professionals are well positioned to advocate for allocation of resources and multilevel policies designed to promote optimal health for all children and adolescents.