Nursing Evidence-Based Practice for Childhood Obesity Management

Introduction and Current Nursing Practice

Nursing encompasses the skills and knowledge required to assist patients with health maintenance, recovery from illness or injury, and treatment. Nurses develop care plans for patients, sometimes in collaboration with physicians or therapists. This paper discusses a current nursing practice in which intervention is needed and proposes an evidence-based approach to change.

Description of the Current Nursing Practice

Children of all age groups are facing a grave and growing problem: obesity. Childhood obesity is a major risk factor for future health problems and a significant public health concern, as the available research literature makes clear. The literature thoroughly documents the risk factors and multifaceted contributors associated with childhood obesity and overweight that threaten public health.

According to the Centers for Disease Control and Prevention (CDC), children above the 85th percentile body mass index (BMI) are at risk of being overweight, with overweight defined as a sex- and age-specific BMI at or above the 95th percentile cut points from the CDC Growth Charts developed in 2000. Childhood overweight prevalence data for ages 6 to 19 years is provided by the National Center for Health Statistics (NCHS) Chartbook, Health, United States (2007), based on national studies conducted from the 1960s through 2004. Data for racial and ethnic subgroups are available from the 1980s to 2004, and within each subgroup, prevalence of childhood overweight has increased steadily since the 1980s (CDC, 2007).

Childhood overweight is even more common in younger children. Nelson, Chiasson, and Ford (2004) increasingly document evidence of elevated overweight prevalence in children aged two to three years. According to Patrick and Nicklas (2005), overweight prevalence in children aged 4 to 5 years rose from 5% to 10.4% between 1976 and 2000. Overweight children aged 4 years have a 20% risk of the condition persisting into adulthood, whereas the risk for teenagers stands at 80% (Thorpe et al., 2004). Overweight prevalence is greater in 4-year-olds than in their younger counterparts, indicating that prevention efforts should begin early in childhood (Walker & Avis, 1999).

Why the Practice Needs Change

The current practice needs to change because the dramatic increase in childhood weight poses serious health risks. Among the chief reasons for child obesity are lack of exercise and insufficient time spent on physical activities. Today, children are more likely to use laptops and video games than to play outdoors with friends. A striking illustration of this shift is that fewer than 5% of school children now cycle to school, compared with more than 80% approximately twenty years ago (Clark, 2004, p. 29).

School nurses, as well as those working in hospitals or other health units, should be equipped to perform primary health care tasks such as weight management for obese children, with treatment lasting three months or more. The various treatment stages of childhood obesity represent a progressive increase in the level of counseling, supervision, and intervention. Nurses and other clinicians involved in treatment interventions have reported several obstacles to obesity treatment in children, including lack of clinician time, support services, available treatment skills, and clinician knowledge. Reimbursement for obesity-related management services is typically poor. According to one study on a tertiary weight management program, obesity treatment receives reimbursement at a rate of only 11%, forcing related programs to seek substantial financial support from external parties for long-term viability. The variation in reimbursement among various programs ranges from 0% to 100% (Story et al., 2002; Tershakovec et al., 1999). These factors clearly explain the need for change in nursing practice.

Nurses should be able to use their critical thinking skills for better diagnosis and the development of treatment plans. A weight management program could be devised to determine whether weight in obese children is controlled and how much change is observed. Results can then be compared to a no-intervention group so that a clear comparison can be made between nurse-led weight management and no intervention. A three-month check would also ensure an adequate measure of the effect of any particular intervention strategy.

Weight management interventions in adolescents were studied to investigate the efficacy of school nurse weight management (Pbert et al., 2013, p. 182). Six high schools were sampled, from which eighty-four obese adolescents in grades 9 through 11 were selected and asked to complete behavioral and psychological assessments. Follow-ups at two months and two three-month intervals revealed that nurse intervention helped control weight. The obese adolescents were able to reduce their intake of cola and fast foods once per week, demonstrating measurable health improvement.

Another study examined the effects of providing weight management education to children, adolescents, and their parents with the goal of reducing BMI. The foundation of this project was the Primary Care Healthy Choices Intervention Program for Overweight and Obese School-aged Children and Their Parents (Jenike, 2013, p. 15). Remote methods were used to improve knowledge about healthy nutrition and physical activity. A seven-week, one-group pre-/post-test design was employed. Results showed that the project was informative for both children and parents through remote methods such as telephone counseling. A decreased BMI percentile was observed alongside increased understanding of physical activity and the benefits of a healthy diet.

Health Consequences and Prevalence of Childhood Obesity

Obesity presents serious risks beyond weight itself. It has been demonstrated that childhood obesity promotes the development of biomarkers for critical health conditions later in life. For instance, Hispanic children are predisposed to type 2 diabetes due to overweight or obesity combined with genetic susceptibility (Neufeld et al., 1998). According to Poston et al. (2003), Mexican-American individuals have an increased likelihood of developing serious atherogenic body fat distribution patterns and upper-body weight gain due to obesity. Obese children also risk developing joint problems, asthma, elevated cholesterol, anxiety, and depression.

Severe to moderate overweight can lead to psychosocial and physical effects including accelerated growth during puberty followed by stunted growth, obstructive sleep apnea, early onset of puberty in females, hyperlipidemia, gallbladder disease, pancreatitis, polycystic ovary syndrome, hypertension, and long-term cardiovascular damage (Barlow and the Expert Committee, 2007). According to Myers and Vargas (2000), based on the 20-year Bogalusa epidemiologic study, the major heart disease atherosclerosis has its roots in early childhood. Poorer endurance performance and impaired development of gross motor skills are also associated with childhood obesity (Graf et al., 2004).

According to Action for Healthy Kids (2004), absenteeism and decreased scholastic performance have been associated with childhood obesity in multiple studies. Strauss (2000) links overweight in children to mental health conditions, finding that obese children with decreasing self-esteem experience loneliness, sadness, and nervousness, and are more likely to use substances such as alcohol and cigarettes compared to obese peers whose self-esteem is increasing.

Obesity is considered a chronic disease when weight gain reaches a dangerously elevated level that poses health risks. The raised body mass is of increasing concern in schools, which are now sending notices to parents to address their children's diets and enlisting school nurses for intervention aimed at reducing childhood obesity. An effective strategy must be formulated to alleviate the effects of obesity in children. Such a strategy involves contact with children and parents regarding dietary and general health education, as well as increased physical activity (Clark, 2004, p. 29). Strategy implementation requires the involvement of health professionals, particularly school nurses. In recent studies, four research studies were examined to measure reductions in child obesity due to nurse intervention; only two showed positive results in intervention groups compared to control groups (Berkowitz & Borchard, 2009, p. 4).

Key Stakeholders in Practice Change

The key stakeholders who would be part of the proposed change are nurses, doctors (including physicians and therapists), top management of healthcare units or hospitals, school management, and parents and children.

Nurses

The role of nurses is to provide comprehensive care to obese children using expert clinical thinking and specialized knowledge. The roles of nurses in childhood obesity include, but are not limited to, the following:

• Advocating for governmental policies that increase physical activity in obese children
• Engaging families in prevention efforts and activities geared toward managing childhood obesity
• Encouraging parenting styles that facilitate enhanced physical activity in obese children while minimizing sedentary behaviors
• Encouraging parental modeling to promote healthy dietary choices
• Prevention, early detection, and effective treatment of childhood obesity
• Participation in health education and health promotion programs
• Provision of appropriate nutritional advice to parents, the general public, and policy-makers (Sheehan & Yin, 2006)

Doctors

Doctors assist and support nurses in completing their care tasks, as nurses often work in collaboration with physicians and therapists. Doctors provide the following services in obesity management programs:

• Education and partnership with parents to monitor progress and offer recommended treatments
• Provision of patient-centered treatments
• Diagnosis and the carrying out of clinical tests
• Coordination of childhood obesity treatments and provision of appropriate drug prescriptions

Therapists

Therapists help deliver treatments based on therapeutic modalities such as obesity behavioral therapy, which encompasses exercise, nutrition, and counseling. Exercise specialists and behavioral counselors assist with behavior modification and physical activity, respectively.

Dietitians

Dietitians develop customized diets that suit the unique needs of each obese child to support recovery. They work together with nurses to advise parents on the best healthy lifestyles and dietary plans for their obese children.

Top Management of Healthcare Units

Healthcare unit management also plays a critical role in childhood obesity interventions by granting nurses the autonomy needed for effective weight management and by creating policies aligned with the requirements of the proposed change. Management ensures that nurses have all the resources necessary to provide obese patients with proper treatment. They are also the decision-makers in all matters related to nursing practice within the organization (Sheehan & Yin, 2006).

School Management

Since children spend the majority of their time in school, teachers and fellow students need to be involved in a school-based program supported by school management. School management can establish policies and provide support to nurses for implementing an effective weight management program. It can also participate in nutritional education, improvement of healthy behaviors, and promotion of positive changes in children's dietary habits (Sheehan & Yin, 2006).

Parents

Children need the support of their parents and families to make healthy behavioral choices. Parents take charge of family-based programs for the successful prevention and treatment of childhood obesity. They serve as their children's role models and foster conditions that help children make the right choices regarding their health. Through sound family functioning and the adoption of appropriate parenting styles, parents help cultivate healthy lifestyles and habits in their children (Sheehan & Yin, 2006).

Obese Children

Ultimately, children are the primary beneficiaries of the proposed change. They stand to gain from consistent, uninterrupted nurse-led treatment, and their parents can expect to see meaningful progress in weight loss and the development of a healthier lifestyle (Sheehan & Yin, 2006).

References

Action for Healthy Kids. (2004). The learning connection: The value of improving nutrition and physical activity in our schools. Retrieved from www.actionforhealthykids.org/

Barlow, S. E., & Expert Committee. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120, S164–S192.

Berkowitz, B., & Borchard, M. (2009). Advocating for the prevention of childhood obesity: A call to action for nursing. The Online Journal of Issues in Nursing, 14. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No1Jan09/Prevention-of-Childhood-Obesity.html

Centers for Disease Control and Prevention National Center for Health Statistics. (2007). Health, United States (PHS, 2007-1232, GPO Stock Number: 017-022-01604-4). Washington, DC: U.S. Government Printing Office.

Clark, A. (2004). The role of school nurse in tackling childhood obesity. Nursing Times, 100. Retrieved from http://www.nursingtimes.net/Journals/2012/12/07/p/u/c/040608the-role-of-the-school-nurse-in-tackling-childhood-obesity.pdf

Collins, P. M., Golembeski, S. M., Selgas, M., Sparger, K., Burke, N. A., & Vaughan, B. B. (2007). Clinical excellence through evidence-based practice model to guide practice change. Topics in Advanced Practice Nursing eJournal, 7. Retrieved from http://www.medscape.com/viewarticle/567682_2

Graf, C., Koch, B., Kretschmann-Kandel, E., Falkowski, G., Christ, H., Coburger, S., et al. (2004). Correlation between BMI, leisure habits and motor abilities in childhood. International Journal of Obesity, 28, 22–26.

Jenike, L. R. (2013). A primary care intervention for overweight and obese children and adolescents (A Capstone Project). Retrieved from http://scholarworks.umass.edu/cgi/viewcontent.cgi?article=1027&context=nursing_dnp_capstone

Kelishadi, R., & Azizi-Soleiman, F. (2014). Controlling childhood obesity: A systematic review on strategies and challenges. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 19(10), 993–1008.

Myers, S., & Vargas, Z. (2000). Parental perceptions of the preschool obese child. Pediatric Nursing, 26, 23–43.

Nelson, J., Chiasson, M., & Ford, V. (2004). Childhood overweight in a New York City WIC population. American Journal of Public Health, 94, 454–458.

Nemet, D., Barkan, S., Epstein, Y., et al. (2005). Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics, 115, e443–e449.

Neufeld, N. D., Raffel, L. J., Landon, C., Ida Chen, Y. D., & Vadheim, C. M. (1998). Early presentation of type II diabetes in Mexican-American youth. Diabetes Care, 21, 80–86.

Patrick, J. H., & Nicklas, T. A. (2005). A review of family and social determinants of children's eating patterns and diet quality. Journal of the American College of Nutrition, 24, 83–92.

Pbert, L., Druker, S., Gapinski, M. A., Gellar, L., Magner, R., Reed, G., Schneider, K., & Osganian, S. (2013). A school nurse-delivered intervention for overweight and obese adolescents. Journal of School Health, 83(3), 182–193. DOI:10.1111/josh.12014

Phillips, K., Wood, F., & Kinnersley, P. (2014). Tackling obesity: The challenge of obesity management for practice nurses in primary care. Family Practice, 31(1). DOI:10.1093/fampra/cmt054

Poston, W. S., Reeves, R. S., Haddock, C. K., Stormer, S., Balasubramanyam, A., Satterwhite, O., et al. (2003). Weight loss in obese Mexican-Americans treated for 1 year with orlistat and lifestyle modification. International Journal of Obesity Related Metabolic Disorders, 27, 1486–1493.

Ross, M. M., Kolbash, S., Cohen, G. M., & Skelton, J. A. (2010). Multidisciplinary treatment of pediatric obesity: Nutrition evaluation and management. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition, 25(4), 327–334. http://doi.org/10.1177/0884533610373771

Sheehan, N. C., & Yin, L. (2006). Childhood obesity: Nursing policy implications. Journal of Pediatric Nursing, 21(4), 308–310.

Skelton, J. A., DeMattia, L. G., & Flores, G. (2008). A pediatric weight management program for high-risk populations: A preliminary analysis. Obesity (Silver Spring), 16, 1698–1701.

Sparger, K., Selgas, M., Collins, P. M., Lindgren, C., Massieu, M., & Castillo, A. (2012). The EBP rollout process. Nursing Management, 43(5), 14–20. DOI:10.1097/01.NUMA.[redacted].72966.f4

Spear, B. A., Barlow, S. E., Ervin, C., et al. (2007). Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics, 120(suppl 4), S254–S288.

Story, M. T., Neumark-Sztainer, D. R., Sherwood, N. E., et al. (2002). Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals. Pediatrics, 110(1 pt 2), 210–214.

Strauss, R. S. (2000). Childhood obesity and self-esteem. Pediatrics, 105, 1–5. Retrieved from http://pediatrics.org/cgi/content/full/105/1/E15

Swan, J., & Evans, N. (2016). Childhood obesity. Wild Iris Medical Education. Retrieved from http://www.nursingceu.com/courses/520/index_nceu.html

Tershakovec, A. M., Watson, M. H., Wenner, W. J., & Marx, A. L. (1999). Insurance reimbursement for the treatment of obesity in children. Journal of Pediatrics, 134, 573–578.

Thorpe, L. E., List, D. G., Marx, T., May, L., Helgerson, S. D., & Frieden, T. R. (2004). Childhood obesity in New York City elementary school students. American Journal of Public Health, 94, 1496–1500.

Vine, M., Hargreaves, M. B., Briefel, R. R., & Orfield, C. (2013). Expanding the role of primary care in the prevention and treatment of childhood obesity. Journal of Obesity, 2013, 172035. Epub 2013 Apr 28.

Vos, R. C., Wit, J. M., Pijl, H., Kruyff, C. C., & Houdijk, E. C. (2011). The effect of family-based multidisciplinary cognitive behavioral treatment in children with obesity: A study protocol for a randomized controlled trial. Trials, 12, 110. Epub 2011 May 6.

Walker, S., & Avis, M. (1999). Common reasons why peer education fails. Journal of Adolescence, 22, 273–277.

Whitlock, E. P., O'Connor, E. A., Williams, S. B., Beil, T. L., & Lutz, K. W. (2010). Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Pediatrics, 125, e396–418.

Zhu, D. Q., Norman, I. J., & While, A. E. (2013). Nurses' self-efficacy and practices relating to weight management of adult patients: A path analysis. International Journal of Behavioral Nutrition and Physical Activity, 10(131). DOI:10.1186/1479-5868-10-131