Culture of Health Burlington County, New Jersey Now more than ever, nurses have an opportunity to be involved in advancing and improving health in their communities. With the commitment from The Robert Wood Johnson Foundation and their Culture of Health f

Culture of Health Burlington County, New Jersey
Ogunnubi, O., Phinn, S., Sanabria, L., & Tajudeen, M
Rutgers University
Leadership Practicum
Dr. Mary Johansen

Culture of Health Burlington County, New Jersey
Now more than ever, nurses have an opportunity to be involved in advancing and improving health in their communities. With the commitment from The Robert Wood Johnson Foundation and their Culture of Health framework, nurses have the ability to collaborate with their community stakeholders, local government agencies, and other healthcare professionals to make general wellness more equitable in their communities. Their framework consists of four action areas: making health a shared value, fostering cross-sector collaboration to improve well-being, creating healthier more equitable communities, and strengthening integration of health services and systems. 
Burlington County, New Jersey, is the 2nd largest county, consists of 915.40 square miles and has a population of 448,596. The county is ranked 9th out 21 counties in the state for health outcomes. 28 percent of Burlington County residents battle obesity which is 2 percent higher than other counties in New Jersey. Burlington County also has 4th highest incidences of all cancer types with esophageal cancer having the highest incidence. One of the risk factors of esophageal cancer is obesity. Interestingly, 85% of the residents have access to exercising and only 4% of the residents are limited to healthy foods therefore, suggesting opportunities to improve health outcomes for Burlington residents (Burlington County, 2017). 
The Behavioral Risk Factor Surveillance System (BRFSS) is considered the leading health survey in the world collects health related data through telephone surveys. BRFSS conducts over 400,000 telephone interviews in all 50 states and the District of Columbia therefore their data is considered a reliable tool in advancing health promotion. According to BRFSS, Colorado has the lowest rates of adult obesity 22.6 %, New Jersey ranks at the 41st, and West Virginia has the highest national obesity rates 38.1% (Centers for Disease Control and Prevention [CDC], 2014). 
OBESITY

Obesity is a serious health problem and is increasingly becoming complex to address. It results from a combination of causes and contributing factors ranging from genetics, dietary patterns, and physical activity/inactivity; to medication, education levels, food marketing and promotion. Studies have shown that obesity in adulthood leads to poor mental health, decreased quality of life, and a short life expectancy. Obesity is the leading cause of death worldwide due to co morbidities from diabetes, heart diseases, stroke and some types of cancer (“Overweight and Obesity,” 2018) 
Body mass index (BMI), which is weight in kilograms divided by height in meters squared, is used to identify obesity. For adults, a BMI of 25.0 to 29.9 kg/m2 is defined as overweight and a BMI of 30 kg/m2 or higher is defined as obese (Apovian, 2016).
Morbid Obese patients have a higher comorbidity burden and a shorter life expectancy compared to those of the general population. Obesity has shown to be associated with several risk factors; it influences the development and severity of comorbidities such as hypertension and diabetes. These comorbidities in turn may increase the risk of cardiovascular disease as well as chronic kidney diseases (CKD) which can quickly progress into end stage renal disease (ESRD) (Turgut & Abdel Rahman, 2017).
Cancer is another comorbidity of being obese, a research shows that patients who are obese have an increased risk of cancer. Prospectively collected data from the UK Clinical Practice Research Datalink were evaluated, including BMI values and the prevalence of 22 different cancers for 5.2 million people. The mean BMI of the population was 25.5 kg/m2; 3.8% developed any cancer, and 3.2% developed 1 of the 22 cancers recorded in the study. Thirteen of the 22 cancers were associated with being overweight or obese; 41% of cases of uterine cancer and more than 10% of gallbladder, kidney, liver, and colon cancers were attributable to being overweight or obese. Higher BMI was positively correlated with an increased risk of uterine, gallbladder, kidney, cervical, and thyroid cancers, along with leukemia, and positive associations were seen with liver, colon, ovarian, and postmenopausal breast cancers. A similar relationship between obesity and cancer was observed in cancer-related deaths in the United States. Death from cancer was attributed to being overweight, and obesity ranged from 4.2% to 14.2% for men and 14.3% to 19.8% for women. If people could potentially maintain a BMI under 25 kg/m2, an estimated 90,000 deaths per year from cancer could be avoided (Apovian, 2016).
According to Centers for Disease Control and Prevention (CDC) other consequences of Obesity includes and not limited to depression, lungs and respiratory diseases, joints and lower back pain, Osteoarthritis etc ((“Overweight and Obesity,” 2018)
Palliative Care
The prevalence of obesity in this community has necessitated the initiation of end-of-life discussions with the patients. End of life care discussions involve the transition to the palliative care phase in the life of the affected person. Such discussions usually occur as part of regular conversations between a patient/client, a healthcare professional, and family members.
Provision of the best palliative care across the end-of-life journey is a major challenge especially to the nurses who are key to the care provision. Nurses provide coordination and continuity that promotes optimal care to the patients. Moreover, they work closely with patients and family members in the critical process of making the right decisions. In so doing, and with support from other sophisticated and sensitive communication paradigms, it eases the transformation to the palliative phase when it does finally come (Watts, 2012).
The best way to initiate such conversation is to provide education on general health to the community. Such talks should focus on healthy living, advance directives, and the five best wishes. Having a face to face educative forum is more effective than offering written handouts to the people. A study shows that End Of Life discussions only happened in 1% of encounters in non- palliative family medicine settings. End Of Life discussions should not be limited to terminally ill patients alone, it should be an early and open discussion among non- terminal/healthy patients, families, communities and providers. This study also shows that End Of Life discussion in healthy elderly patients in Japan led to more acceptance of advance directives and less preference of artificial nutrition as the life sustaining measure (Leung et al.,2013)
Burlington County currently has measures set in place to address the growing issue of obesity. The Burlington County Health Department educates the county and promotes healthy living through a variety of different avenues. These avenues range from workshops and seminars to exercise classes and outreach programs (Burlington County, 2018). The residents within the county can also contact the health department and request educational materials and resources (Burlington County, 2018). 
Recently, a campaign was launched in Burlington County to promote healthy living, exercise, stress management techniques, and health screenings (Burlington County, 2018). A major aspect of this campaign was exercise. The residents participated in National Walk at Lunch Day to encourage others to be more active (Burlington County, 2018). This activity was based on the idea that just a couple of minutes a day of exercise can be beneficial to one’s health. Incorporating exercise into one’s daily routines is a great start. 
The PLAAY project, which stands for promoting lifelong activities among adults and youth, was also launched in Burlington County (Burlington County, 2018). This project encourages adults to play or walk for thirty minutes a day and for children and teenagers to play or walk for sixty minutes a day (Burlington County, 2018). Burlington County has many parks and miles of trails available for its residents to use as areas to play or walk (Burlington County, 2018). In addition to this project, Burlington County also offers free fitness classes. The Burlington County Health Department also provides education on the benefits of healthy eating as well as provides samples of healthy recipes (Burlington County, 2018). 
Although there are measures set in place, Burlington County officials continue to strive for better results. The Community Health Improvement Plan (CHIP) of Burlington County is a plan that is updated every few years after the completion of the community health needs assessment (Burlington County, 2018). Results from the most recent assessment identified three key areas that need attention (Burlington County, 2018). Obesity was one of the key areas identified (Burlington County, 2018). The CHIP committee will work to combat the issue of obesity as well as the other issues that were identified. 
Major stakeholders identified include:
Private businesses – grocery/pharmacy stores, nutrition counseling centers, gyms and physical fitness centers;
Healthcare Systems – Kennedy, Cooper, Virtua, Lourdes, and Inspira health systems; 
Health care providers – Federally Qualified Health Center (FQHC), clinicians, primary care providers, patient educators; 
State and local entities – New Jersey Department of Health (NJ DOH), Burlington County Health Department, advisory councils (New Jersey Council on Physical Fitness and Sports);
Organizations /associations – e.g. American Diabetes Association, Obesity Action Coalition (OAC), and the YMCA of Burlington and Camden Counties (YBCC);
Departments of Education – HeadStart programs, K-12 education systems;
Faith- Based and charitable organizations – counseling, church food pantries;
Public health and community social service professionals. 
(The Office of Nutrition and Fitness, 2013)
The New Jersey Department of Health (NJ DOH) identified several strategies used to tackle obesity. The NJ DOH collaborates with the New Jersey Department of Education to support obesity prevention through physical activity and healthy eating programs in school districts (and through curriculum-based physical activity education), New Jersey Safe Routes to School program, New Jersey SNAP-Ed, and the New Jersey Association of Health, Physical Education, Recreation and Dance (NJAHPERD) which conducts professional state and regional meetings of school districts (K-12)where plans are discussed to ensure that schools provide opportunities to choose healthy food choices and physical activity (New Jersey Department of Health, 2013). The Health Corps is another DOH initiative that provides a high school youth coordinator in problematic areas of the county; these coordinators provide high school students guidance in areas of nutrition, health, and fitness by organizing activities such as school gardens and wellness teams etc. (NJ DOH, 2017). 
Pharmacy stores such as ShopRite of Marlton employed a retail dietitian program where consumers and the community are provided with private and group consultations, leading support and weight management groups and counseling the community to choose healthy food options through posters, educational events and ShopRite cooking classes (ShopRite of Marlton, 2018). The YMCA of Burlington and Camden Counties (YBCC) also reaches out to communities, families and individuals by encouraging self-care actions that lead to risk reduction of obesity related complications and provides several health and wellness opportunities available to all ages (New Jersey YMCA State Alliance, 2018). Health systems for example, Kennedy Health System holds focus groups discussions to further understand and address obesity and nutrition needs, and holds free seminars, support groups, and virtual chatting systems where Burlington county residents can discuss weight and obesity issues with experts (Kennedy Health System, 2013).
The Burlington County’s “Health Starts Here” initiative provides free fitness classes for county residents, and an informative online page with a link to an interactive map helps to locate healthy food in the community – http://www.co.burlington.nj.us/1263/Healthy-Eating (Burlington County Health Department, n.d.)

 

References
Apovian, C. M. (2016). Obesity: Definition, Comorbidities, Causes, and Burden. AJMC. Retrieved October 27, 2018.
Burlington County. (2017). County Health Data. Retrieved from http://www.co.burlington.nj.us/1676/County-Health-Data
Burlington County. (2018). Health education. Retrieved from http://www.co.burlington.nj.us/401/Health-Education
Burlington County Health Department. (n.d.). Health starts here – Healthy eating. Retrieved from http://www.co.burlington.nj.us/1263/Healthy-Eating
Centers for Disease Control and Prevention. (2014). About BRFSS. Retrieved from https://www.cdc.gov/brfss/about/index.htm
Kennedy Health System. (2013). Community health needs assessment – Implementation strategy. Retrieved October 3, 2018, from https://www.kennedyhealth.org/sites/default/files/CHNA%202013_0.pdf

Leung, L., Parks, K., Zhang, W., Ashton, S., Dumas, M., French, R., & Haider, A. (2013). End of life discussion in an academic family health team in Kingston, Ontario, Canada. Journal of Family Medicine and Primary Care,2(3), 263. doi:10.4103/2249-4863.120749

New Jersey Department of Health (NJ DOH). (2013). Partnering for a healthy New Jersey: Chronic disease & health promotion plan 2013 – 2018. Retrieved from New Jersey Department of Health website: https://www.nj.gov/health/fhs/chronic/documents/chronic_disease_prevention_plan.pdf
New Jersey YMCA State Alliance. (2018). YMCA of Burlington and Camden Counties – Mt Laurel YMCA. Retrieved October 3, 2018, from https://www.njymca.org/locations/branch/ymca-of-burlington-and-camden-counties-mt-laurel-ymca/
Overweight & Obesity. (2018, March 5). Retrieved from https://www.cdc.gov/obesity/adult/causes.html

Office of Nutrition and Fitness. (2013). Shaping NJ – New Jersey’s state obesity prevention plan. Retrieved from NJ Department of Health website: https://www.nj.gov/health/nutrition/documents/obesity_prevention_plan.pdf
ShopRite of Marlton. (2018). ShopRite dietitian program. Retrieved October 3, 2018, from https://shop.shoprite.com/store/2d59671/shoprite-dietitian-program
State of New Jersey Department of Health. (2017). Nutrition and fitness – school health, nutrition and physical activity. Retrieved October 3, 2018, from https://www.nj.gov/health/nutrition/services-support/schools/schools.shtml

Turgut, F., & Abdel-Rahman, E. M. (2017). Challenges Associated with Managing End-Stage Renal Disease in Extremely Morbid Obese Patients: Case Series and Literature Review. Nephron,137(3), 172-177. doi:10.1159/000479118
Watts, T. (2012, December 29). Initiating end‐of‐life care pathways: A discussion paper. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2011.05924.x/abstract

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