childhood obesity

childhood obesity

Childhood obesity: nurses’ role in addressing the epidemic
Aifric Rabbitt and Imelda Coyne

W

orldwide, obesity has more than doubled since
1980 and approximately 65% of the world’s population live in countries where overweight and obesity kills more people than underweight
(World Health Organization (WHO), 2011). Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health (WHO, 2011).Traditionally, obesity has been an adult disorder, however, in the last 10 years, it has increasingly been observed in children and adolescents
(Haboush et al, 2011). In the developed world, it is now the most common health issue affecting children. In 1995, there were 18 million children worldwide under the age of 5 classified as overweight, compared with 2010, when the figure was nearly 43 million (WHO, 2011). Obesity is associated with long-term physical and psychological consequences. It affects relationships with peers, leads to stigmatisation and negative stereotyping, bullying, low self-esteem, and social isolation
(Budd and Hayman, 2006). Childhood obesity pre-stages adult obesity, in that children who are obese are more likely to be obese as adults. Over 60% of children who are overweight before puberty will be overweight in adulthood (WHO, 2007).
At least 2.8 million adults die each year as a result of being overweight or obese. In addition, 44% of the diabetes burden,
23% of the ischemic heart disease burden and between 7% and
41% of certain cancer burdens are attributable to overweight and obesity (WHO, 2011). These are startling statistics and to combat the obesity epidemic and associated comorbidities, childhood prevention is critical.

Taking a whole-family approach
To address childhood obesity, the family must be involved.
The family is central to a child’s care and family-centred care is core to children’s nursing (Coyne et al, 2010). The family may be seen as including anyone related, by birth or not, who is significant to the child. This definition recognises single parents, separated couples, and gay and lesbian couples in addition to the nuclear family. The child is embedded within the family system and, therefore, it is very difficult for obese children to alter their dietary or physical habits if not supported by their families. For this reason, any actions

Aifric Rabbitt is Staff Nurse, King’s College Hospital, Denmark Hill,
London and Imelda Coyne is Head of Children’s Nursing, School of
Nursing and Midwifery, Trinity College, Dublin, Ireland.
Accepted for publication: February 2012

British Journal of Nursing, 2012, Vol 21, No 12

Abstract

Obesity is a significant long-term health problem that is common among children and adolescents in Western countries. Being overweight or obese (extremely overweight) can contribute to type 2 diabetes in childhood and increase the risk of cardiovascular disease in adulthood.
Primary prevention of obesity prevents the development of serious secondary complications in adulthood. Nurses can help parents and children by providing nutritional advice and, through weight management programmes, offer strategies for decreasing caloric intake and increasing physical activity. Nurses’ actions should always take a whole-family approach because it is challenging for obese children to alter their dietary or physical habits if not supported by their families.
Nurses should work with all members of the multidisciplinary team in addressing childhood obesity as it is a major health issue with longterm mobidities.
Keywords: Obesity n Nursing n Strategies n Childhood n Complications of obesity or strategies used by nurses to help obese children should always take a whole-family approach. Changes will only occur if families are motivated and willing to change. Obese and overweight children would benefit from an ecological approach to treatment, which considers the child’s home, routine and family environment when encouraging longterm lifestyle change (Limbers et al, 2008).
Primary prevention of obesity prevents secondary diseases, such as coronary heart disease, type 2 diabetes and osteoarthritis, and reduces psychosocial problems (Haslam et al, 2006; National Institute of Health and Clinical Excellence
(NICE), 2006). This paper will outline the two main clinical complications of obesity; type 2 diabetes and cardiovascular disease. This will provide background for the strategies that nurses can use to help obese and overweight children and their families to reduce the physical and psychosocial consequences of obesity.

Consequences of long-term obesity
Type 2 diabetes
In the past 10–15 years, type 2 diabetes mellitus (T2DM) has increased parallel to the increase in obesity (Soltesz, 2006;
Urritia-Rojas and Menchaca, 2006), with the prevalence of T2DM 2.9 times higher in overweight, then in nonoverweight individuals. Narayan et al (2003) estimate that in the USA, a girl born in the year 2000 has a 38.5% lifetime risk of developing diabetes as compared with 32.8% for boys.
They concluded that females have a higher residual lifetime

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risks at all ages. This finding is striking but Narayan et al do not offer an explanation for the gender difference. This estimation of diabetes prevalence and incidence rates was based on Narayan et al’s (2003) analysis of data from the
United States National Health Interview Survey (19842000) for diagnosed diabetics from birth to 80 years. Narayan et al (2003) also reported that the lifetime risk was higher among minority populations, namely Hispanic females. Thus, gender difference may be linked to the ethnic characteristics and, therefore, these estimates of lifetime gender risk for diabetes must be treated with caution.
T2DM occurs when the body makes insulin, but produces less than required. Glucose homoeostasis is relative to secretion of insulin by pancreatic beta cells, and the sensitivity of surrounding tissues to insulin action. When an imbalance occurs, hyperglycaemia (high blood glucose levels) ensues. Adiposity causes insulin resistance and beta cell failure, resulting in the development of T2DM (Dea, 2011).
Furthermore, adipocytes (fat cells) store excess energy and affect the control of metabolism in surrounding tissues (Shiga and Kikuchi, 2009). Obesity is the most modifiable risk factor for the development of T2DM in children (Yoon et al, 2006;
Tompkins et al, 2009). Owing to the increasing prevalence of T2DM in children, and the associated morbidity and mortality rates, it is imperative for nurses to identify children at risk. Prevention should occur while blood glucose levels are still within normal ranges in order to prevent or delay the onset of the disease (Urrutia-Rojas and Menchaca, 2006).

Cardiovascular disease
In addition to T2DM, childhood obesity increases the risk of heart disease, with an increase of even 1 kg linked to a 1% increase in the risk for heart disease. Lawlor et al (2006) found obese children to have higher blood pressure recordings, greater arterial stiffness and adverse lipid and insulin concentrations, compared with non-overweight children. An elevated body fat percentage poses a greater risk than body weight, as the risk for developing coronary

heart disease, stroke and hypertension are greatly increased with body fat readings above 20% (Pinto et al, 2007;
Pittson and Wallace, 2010). Since obese children are more likely to become obese adults, the link between childhood obesity and cardiovascular disease may predominantly reflect adult heart disease (Celermaajer and Ayer, 2006). The most common diseases of adulthood include ischemia, myocardial infarction, stroke and peripheral artery disease, all complications of atherosclerosis. Atherosclerosis is the main cause of cardiovascular disease and involves the narrowing of blood vessels, or when blood vessels become completely blocked (Department of Health and Children (DoHC),
2010). The development process of atherosclerosis begins in youth (Burrowes, 2010). Additionally, obese children have an increased cardiac workload as a result of changes in the left ventricular mass. Even with a normal ventricular mass, obese children have slight changes in diastolic functioning that impact on future cardiovascular health. An elevated blood pressure measurement is a significant risk factor for heart disease, even in childhood.

Strategies to address obesity
Ensuring a holistic nursing assessment
The prevention and management of obesity requires an understanding of determinant and environmental factors that contribute to the development of the condition
(Aranceta et al, 2009). To help determine health teaching needs, nurses need to assess child and family behavioural and social correlates of weight gain. As a result, a holistic nursing assessment is necessary and the steps are outlined in Table 1.

Body mass index measurement
Body mass index (BMI) measurements are recommended to identify children who are obese or who are at risk for obesity. Children who have a BMI reading at or above the
95th percentile are at high risk for comorbidities associated with obesity (Hughes and Reilly, 2008). BMI must be adjusted to children’s height, age and gender because it is

Table 1: Holistic assessment
ASSESSMENT

RATIONALE

Birth history with the family, antenatal history, birth weight, postnatal history
Developmental history
Weight history
Dieting history
Physical activity/inactivity history
Family history
Psychological history
Medical history
BMI measurement, height and weight
Perform blood pressure recordings, urinalysis, blood tests such as urea and electrolytes, liver functioning tests, fasting glucose and lipids test, exercise stress tests,
ECGs and glucose-tolerance tests

Provide information about mother’s nutrition, pregnancy (gestational diabetes) and birth weight Assess for achievement of milestones
Give an indication of onset, progression of weight gain, and peak weight
Explore previous attempts to lose weight and what worked
Understand the child’s energy expenditure
Reveal if obesity is a family problem and if others suffer from related comorbidities
Explore eating disorders, depression and the psychosocial impact of obesity
Assess for comorbidities, current medications and drug allergies
Assess level of overweight or obesity
Assess for indications of comorbidities of obesity

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childhood obesity not an exact calculation of adiposy (NICE, 2006). Therefore, the National Taskforce on Obesity (2005) recommends that nurses calculate children’s BMI, height and weight as routine clinical assessment. The severity of overweight, the child’s age and the presence of associated comorbidities will dictate whether weight stablisation or weight loss is the goal (Budd and Hayman, 2006).

Health promotion
Sustained lifestyle changes in diet and exercise are the cornerstones of obesity management. A successful weight management programme offers strategies for decreasing caloric intake and increasing physical activity (Budd and
Hayman, 2006; Singhal et al, 2007). Minor changes in food intake and physical activity can have sizeable effects on body weight and obesity (Haerens et al, 2010). Changes in physical activity and diet should be promoted with emphasis on healthy changes. It is important that restrictive diets and over-exercising are not encouraged as they may result in the development of eating disorders and have the potential to be harmful for adolescents and young people (NICE, 2006).

Promoting physical exercise
Nurses should encourage families to partake in exercise they enjoy and reinforce the health benefits of sustained physical activity, in order to improve the likelihood that lifestyle changes will be adhered to and comorbidities prevented (DoHC and Health Service Executive, 2009).
Physical activity is an inexpensive, non-pharmacological intervention for children. Exercise enhances insulin sensitivity by improving the transportation of glucose into muscle cells and also increases the production of muscle glycogen, replacing the amount used during physical activity. Furthermore, physical activity increases fat-free mass and muscle tissue volume, which glucose can then be transported into. This results in long-term enhancement of insulin sensitivity. Insulin sensitivity is greatly enhanced by
40–60 minutes of aerobic exercise daily, but if exercise is not sustained, enhancements in insulin sensitivity are reversed
(Tompkins et al, 2009). Furthermore, exercise is linked to an enhancement in endothelial dysfunction, which contributes to atherosclerosis development. Nurses must emphasise the importance of maintaining physical activity into adulthood, in order to lower the risk of developing cardiovascular disease (DoHC, 2010).
An increase in physical activity helps children to maintain the correct metabolic rate, controls their appetite and improves psychological wellbeing (Ben-Sefer et al, 2009).
Sedentary activities such as watching television and playing computer/video games should be restricted to less than
2 hours per day. Nurses should encourage 60 minutes of physical activity daily (NICE, 2006). If the activity is tailored to the family’s cultural and ethnic preferences and feasible within the resources available, it is more likely to be successful (Budd and Hayman, 2006). For example, choosing an activity the family enjoys, such as dancing, field sports, or family walks, increases the chance of them persisting with it.
Incorporating exercise into daily routine, such as walking to school or cycling to the shops can make it easier for families

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to maintain a level of activity. Families should work towards establishing a regular pattern of activity, gradually increasing their level of activity over time, building up to 60 minutes a day (WHO, 2007). Parents can encourage children by rewarding positive behaviour with praise and agreeing special privileges as rewards for reaching specific goals. Keeping a record of activities with tick boxes or stars can help to motivate each family member to adhere to agreed goals.

Promoting a healthy diet
In addition to physical exercise, a healthy diet should be advised. In the hospital setting, nurses should monitor the food intake of children, considering nutrition as an integrated part of patient care. Portion sizes and energy content of meals should be noted. Health service providers have a responsibility to provide nutritious meals and healthy options for hospitalised children and families. Children admitted for obesity should receive a healthy eating menu or follow a menu prescribed by a clinical dietitian (DoHC, 2009).
Nurses in hospitals and community settings should talk to families about usual consumption for breakfast, lunch and dinner. The size of meals daily should be discussed, with emphasis on the importance of breakfast in the morning and the potential for less calories being served in dinner, providing samples of healthy menus (Mayer and Villaire,
2010). Families should be encouraged to reduce intake of fried food, foods high in fat and those with high sugar and salt content. Excess salt consumption is strongly linked to hypertension, a risk factor for stroke and heart disease. Most salt in the diet comes from processed foods. Daily salt intake is over 50% higher then recommended, with most coming from foods purchased rather then from adding salt in cooking or at the table (DoHC, 2010). Consequently, a family reduction in processed food intake would reduce salt consumption.
Nurses should encourage food that is high in fibre such as peas and beans, and five portions of fruit and vegetables daily
(Department of Health (DH), 2006a; DoHC, 2009). Children should be advised to replace high-sugar drinks with water and replace sweets, cakes and chips with fruit and wholegrain carbohydrates (Budd and Hayman, 2006). Eating more meals together as a family and limiting daily consumption of fast foods could become a family goal. Parents should be encouraged to reward their children’s behaviour when positive changes are made, reinforcing good habits, for example, with the aid of a star chart that leads to a family outing or special reward (non-food treat).

Family practices that influence children’s dietary intake
Parents have a key role in the development of their children’s dietary preferences, that eventually lead to their dietary patterns (Budd and Hayman, 2006; Vereecken et al, 2010).
Parental eating habits are often superimposed on the child, both regarding type and quantity of food. Children are at an increased risk of obesity if their parents are obese. This link is caused by children adapting to an obesogenic lifestyle set by parents who lead a sedentary lifestyle and have a poor diet
(Pittson and Wallace, 2010). Share and Strain, (2008) suggest that the link between obesity and increasing portion sizes and

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poor nutrition indicates a lack of parenting skills with food shopping and estimating appropriate portion sizes. However, there are also societal factors, which have a significant influence on families’ dietary lifestyle. Parents and children may have a sound understanding of what constitutes healthy food but their decisions are influenced by food availability, marketing and cost
(Jones et al, 2008; Nauta et al, 2009). Fast foods containing high levels of sugar and fat, are readily available and are cheaper, discouraging families from purchasing the healthier options
(DH, 2006a). With more parents working as dual earners and less time available for cooking, families are eating less meals together and at home. More families are dining out than in previous years and snacks are consumed frequently as opposed to regular meals (Nauta et al, 2009).

Importance of working with the family
Interventions focusing on education alone are not sufficient in sustaining new health behaviours, so it is important to combine educational interventions with discussions about ways of producing positive behavioural change in the child’s life (Giles-Corti and Salmon, 2007; Pi-Sunyer, 2007). Nurses should provide health promotion advice to the family within a supportive environment that facilitates lifestyle changes.
Interventions should target both parents and child because of parents’ influence in determining food choices and the importance of role-modelling behaviours. Parents need to be aware that they act as role models for their children and are, therefore, encouraged to practice good eating habits and engage in physical activity (Budd and Hayman, 2006). For older children who are obese, nurses must find a balance between involving parents and recognising the child’s own decision-making capabilities (NICE, 2006). Older children should be encouraged to set their own goals and work together with parents to achieve them (Budd and Hayman,
2006). Nurses should also establish children’s motivation and readiness to change, and the barriers to change, such as lack of motivation or disbelief that he or she is obese.

Being sensitive to families’ needs
If parents are unwilling to change their lifestyle, it is a challenge for health professionals to deliver a health promotion message to children. Parents may express denial, anger or disbelief that their child is obese. Nurses should explain in a sensitive manner that obesity is associated with specific health consequences, such as diabetes and heart disease. If families are not ready to make changes, they should be offered a follow-up appointment where they might be willing to discuss potential changes to their lifestyle. They should be educated regarding the health benefits of exercise, dietary changes and maintaining a healthy weight. Nurses should document the discussion with the family and keep a copy of negotiated goals so they can work with families in a sensitive manner (DH, 2006a; NICE, 2006). There is no single management programme that works for everyone and management should, therefore, be tailored to the individual and family context (DoHC, 2005). Advice should focus on individualised activities, which would fit into the family’s life to make it easier for them to adopt new behaviours.

Importance of community support for families
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Interventions focusing on families alone are not sufficient in treating overweight and obesity in children. Thus, it is important to combine educational interventions with population-based approaches (Budd and Hayman, 2006). In the UK, schools are encouraged to adopt a ‘whole-school approach’ as a means of addressing obesity, using both health promotion and physical activity. Changing the food and physical activity environments of schools can promote behaviour change and reduce fat intake. School nurses have an essential role in tackling obesity by monitoring obesity targets in their schools and developing and supporting school interventions according to need (DH, 2006b). However, they need to have adequate resources (Whiting, 2008). They can also provide health promotion advice and support to children and families, and recommend local support groups and amenities. Within the community, nurses should liaise with schools, school nurses and community groups in order to identify children and families at risk of obesity and raise awareness of the associated health risks (Nauta et al, 2009).
In Ireland, where there are few school nurses, public health nurses play an important role in screening for obesity and liaising with schools and primary care centres to promote healthy eating and lifestyle changes.

Conclusion
Since childhood obesity is a major health problem, it is essential that all health professionals, working in hospitals and community health care, are involved in health promotion and health education strategies with families (Mayer and Villaire,
2010). Nurses, along with all members of the multidisciplinary team, must recognise the scale of childhood obesity and, in their daily practice, help children and families deal with the problem. The focus should be on strategies that will promote the health of children within the context of the family, school and community. In addition to the interventions discussed in this paper, broader preventative strategies, in the school setting, community, physical environment and society, are needed to prevent and reduce obesity in childhood (Hughes and Reilly, 2008; Heitmann et al, 2009).
Healthcare staff, providers and policy makers have a responsibility to use the best evidence available to address the obesity problem. Nurses are in a unique position as they interact with families across healthcare and community-based settings and so can help in the prevention and management of overweight and obesity in children and adolescents. The link between childhood obesity and adulthood morbidities has been clearly established. If rates of obesity continue to escalate unabated, future generations will experience premature morbidity, chronic ill health and increased mortality. Childhood obesity represents a serious health and
BJN
economic problem today and for the future.
Conflict of interest: none.
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Key points n The rising levels of overweight and obesity among children and adolescents in Western countries is of major concern as childhood obesity has adverse physical and psychological consequences n Obesity can lead to serious long-term health problems, namely Type 2 diabetes and increased risk of cardiovascular disease in adulthood n Obesity affects relationships with peers and leads to stigmatisation and negative stereotyping, bullying, low self-esteem, and social isolation n Early intervention in childhood is, therefore, critical to stem this rising obesity epidemic and healthcare staff can play an important role n Nurses can help by working with the child and family and combining educational interventions with behavioural and lifestyle changes n Nurses should always take a whole-family approach because it is challenging for obese children to alter their dietary or physical habits if not supported by their families

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Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.