Introduction
Food is at the center of our lives; it is the part of our culture, and how we socialize, discipline, and reward our children. However, with childhood obesity on the rise, food can be also recognized as a major problem for some children. With the excessive caloric intake and sedentary lifestyle, weight gain in our children is inevitable. Determining the cause of childhood obesity is essential, so that a preventative plan can be implemented, with an objective to decrease the incidence of childhood obesity; and help children lead a normal healthy life ahead, in the future. Many obesity researchers also believe that preventing obesity, right at the childhood age, is the key to address global obesity epidemic (Heitmann, 2009).
What exactly is Childhood Obesity?
Today, children belong to a world that has changed completely in the last four decades. This can be attributed to longer working hours of parents, changes in food environments, more meals outside the house, changed physical activity pattern – all such things contribute to what they eat, how much they eat, where they eat, and how much energy they spend in a day? Children spend a lot of time everyday glued to television sets, computers, or video games (Heitmann, 2009). All such unhealthy habits lead to obesity. Obesity simply means excess of fat. It is a condition caused by excess fatty tissue that may be associated with several adverse health risks (Whitlock, 2010). Excess body fat puts children at an increased risk for developing certain diseases and medical conditions in the future (Whitlock, 2010). Some also define “overweight” and “obesity” by comparing them to those who appear to have normal weight (provided the children are of the same age and sex) (Whitlock, 2010).
Worldwide, obesity rates have doubled in the last three decades. According to the world health organization (WHO), approximately sixty five percent of the world’s population lives in regions where the death rate from obesity is much more than the death rate from being underweight (WHO, 2011). Adults used to be the only population with overweight issues in earlier times; however, in the last decade, it has been observed largely in children and adolescents (Haboush, 2011). Worldwide, only eighteen million children under the age group of five years in the year 1995 were considered to be overweight, a figure that has now become forty three million (WHO, 2011)!
Risk factors for the disease
For almost all obese children, the condition is due to lifestyle factors; genes are rarely to be blamed (Philips, 2012). Inactivity in the form of watching television for hours or playing video games is an important cause of obesity. Adequate breastfeeding is protective in preventing obesity in later years of life, which means if the child has not been breast fed appropriately, the child may be obese (Philips, 2012). Infants who gain rapid weight in the first year of their life are also at an increased risk of obesity by the time they are close to the age of seven years. Risk also doubles for children from families of social class V to social class I (Philips, 2012).
Overweight or obesity is the result of consuming more calories than necessary coupled with too little physical activity, although this is a highly- simplified overview (Philips, 2012). Childhood obesity is a tangled web of complex factors that include individual decisions made by parents and children themselves in the context of human biology, culture, availability of palatable food, and physical environment like sedentary lifestyle, vehicle use for short distances, and increased screen time (Philips, 2012).
Children at obesity risk
A large study using NHANES data found only sixteen percent nonHispanic White boys and seventeen percent nonHispanic Black boys to be obese as compared to twenty-three percent Mexican-American obese boys, aged 2 to 19 years (Harris, 2006). However, in the same study, prevalence of obesity was highest among nonHispanic Black girls at twenty-four percent followed by Mexican-American (18%), and then nonHispanic White girls (14%) in the 2 to 19 year old age group (Ogden, 2008). Native American boys (39%) were also more likely to be obese as compared to other ethnic groups (10 to 15%) (Harris, 2006). A study by Freedman showed that, among a mixed aged group of 5 to 14 years, sixty five percent of obese White girls and eighty four percent of obese Black girls continued to be obese in their adulthood. Similarly, in the same study, seventy one percent of White boys and eighty two percent of Black boys remained obese (Freedman, 2005).
Importance of screening
There is growing evidence that childhood and adolescent obesity can have a substantial health impact (Must, 1999). However, facts and figures on the general physical and mental health consequences of obesity in children and adolescents are almost solely based upon observations. There is also some evidence that while most obese children will not experience the health consequences of persistent childhood obesity for years later, some of the health consequences can occur much before adulthood sets in. This may particularly be observed in those who are severely obese (Must, 1999). Childhood obesity should be worrying to everyone, the child and the family both, because the extra fat that a child has, often predisposes a child to development of diseases like diabetes, high blood pressure, and high cholesterol (Reilley, 2003). It can also be responsible for mental disorders like depression and a poor self-esteem (Erermis, 2004).
Severely obese children can have a poor quality of life and several other serious conditions such as obstructive sleep apnea, orthopedic problems, and infertility (Reily, 2003). There is a general assumption that if one modifies certain current social, economic, and cultural habits and food patterns, it is of benefit in reducing childhood obesity (Whitlock, 2010). Taking these factors into consideration, screening for the condition at a stage in childhood only, is both important as well as beneficial.
Impact of childhood obesity on individual and population
It should be a surprise that, increased health risks due to obesity do not necessarily lead to increased expenditure (Skinner, 2008). Despite the higher prevalence of health problems in obese children, actual health care expenditures paid by families (including costs of services, devices, and insurance) do not differ between healthy weight, overweight, and obese children, was an observation of a study by Skinner et al. The study authors hypothesized that there are unmet medical needs among obese children, who are disproportionably low-income (Skinner, 2008). The lowest income bracket has a high prevalence of obesity; while those with the highest income levels have the lowest obesity prevalence (Freedman, 2005). Overall, childhood obesity is known to be associated with health issues later in life, which does not only make an individual unhealthy, but also the society at large. Programs can be conducted in healthcare settings to provide information on nutrition, physical activity, behavior-change strategies, coping skills, and relapse prevention (Whitlock, 2009).
Benefits and harm of screening for childhood obesity
According to the US Preventive Services Task Force (USPSTF), there is adequate evidence that if an obese child aged 6 years and older is exposed to moderate- to high-intensity behavioral interventions, it can effectively yield short-term improvements in weight status; however, low intensity interventions are not of much help. According to USPSTF, there is also adequate evidence to show that there is minimal harm of screening (USPSTF statement, 2010).
Screening Tool
According to the USPSTF, body mass index (BMI) is an acceptable measure for identifying overweight or obese children and adolescents. BMI is a tool calculated from the measured weight and height of an individual (USPSTF statement, 2010). For children and adolescents aged 6 to 18 years, the USPSTF defines categories of increased BMI as follows: overweight is defined as an age- and gender-specific BMI between the 85th and 95th percentiles; and, obesity is defined as an age- and gender-specific BMI at ≥ 95th percentile (USPSTF, 2010). There is no specific and appropriate interval for screening. Height and weight, upon which calculation of BMI is done, are routinely measured during health maintenance visits (USPSTF, 2010). It is easy for the physicians to plot BMI percentiles on charts; it can also be calculated by using readily available online calculators (USPSTF, 2010).
Role of a registered nurse (RN)
Screening for obesity is particularly done in schools and primary care settings with an objective of getting a control on the epidemic of childhood obesity. A nurse, particularly, a public health nurse, plays an important role in screening. A nurse can provide nutritional advice to the child, his parents, and his teachers. She can suggest weight management programs that offer advice on decreasing caloric intake and increasing physical activity (Rabbitt, 2012). Nurses should especially try to educate the child’s parents/ family because it is challenging as well as difficult for the obese children alone to change their dietary or physical habits if support from the family is not provided. Overall, a holistic nursing assessment and approach is necessary (Rabbitt, 2012). To assess obesity, the nurse needs to calculate the child’s BMI for which she needs to measure child’s height and weight. This should be a part of routine clinical assessment (Rabbitt, 2012). Based on the calculated BMI, which takes the child’s age and gender into consideration, the nurse will dictate if weight stabilization or weight loss is the goal (Budd, 2006). Nurses should motivate a child to change his habits and change the barriers the child holds to invite a change, such as lack of motivation and the disbelief that he or she is obese. At times, parents may express anger or disbelief that their child is obese (Budd, 2006). In such cases, nurses should explain in a sensitive manner the ill health consequences of obesity later in life. If parents are still unwilling, they should be given a follow-up appointment, to see a possibility of discussing potential changes to their lifestyle (Budd, 2006). The nurse needs to understand that there is no single management program that can help everyone; therefore, management should be tailored to individual and family context (DoHC, 2005). Merely focusing on families may not be sufficient; it is also important to combine educational interventions with population-based approaches (Budd, 2006). Schools can be encouraged to adopt health promotion and physical activity. Thus, a nurse plays a very important role in implementing childhood obesity screening and prevention practices.
Screening Recommendations
Previous USPSTF recommendation (2005) was based on the conclusion that even though there was evidence that overweight children aged 8 years and above are at increased risk of becoming obese adults, there was insufficient evidence to suggest the efficacy of behavioral counseling or other preventive interventions. There was also insufficient evidence to ascertain the magnitude of the potential harm of screening or prevention and treatment intervention (Whitlock, 2010). In 2005, the task force found adequate evidence to determine that BMI was a measure to identify obese children. However, after the 2005 recommendation, there were several systematic reviews and studies to determine what screening tool and its parameters would be used to make a clinical decision. An update and recommendations were provided in 2010. According to the new recommendations, clinicians should screen children aged 6 years and older for obesity and if found to be obese, they should be referred to comprehensive, intensive behavioral interventions to promote improvement in weight status. This is a termed as a “grade B recommendation”. However, the task force did not find any evidence on appropriate screening interval. According to the recommendation, patients should be referred to comprehensive moderate- to high-intensity programs that include dietary, physical activity, and behavioral counseling components (USPSTF, 2010).
Other Recommendations
The American Heart Association (AHA) uses a different approach in that their recommendations focus on making simple changes within your diet routinely that become permanent after some time. The logic behind this is that it causes children to notice less change while helping them to make smarter choices when changing eating habits. Decreasing the amount of calories eaten within a day is the easiest way to implement change . Becoming more active by increasing physical activity is widely recommended; in view of this, an environment that fosters physical activity should be created. Parents' involvement in modifying overweight children's behavior is important . While tackling overweight children, the main emphasis should be to prevent extra weight gain. For many children this may mean limited or no weight gain while they grow taller. The AHA has recommendations to pay careful attention to diet to avoid too many calories .
The American Medical Association (AMA) too has updated their recommendations for childhood obesity and advises that a clinician’s assessment should include a BMI calculation as well as medical and behavioral risks for obesity (Barlow, 2007).
In my opinion, one needs to take into consideration the recommendations given by all the bodies at an individual level as well as at a population level to help combat the epidemic, which leads to ill health later in life.
Nursing Implications
Nurses are at the fore front of any medical treatment. A registered nurse, a public health nurse especially, must take a leadership role in dealing with this epidemic. There is a lot of scientific literature already published and documented; and is known to the population of at least the developed countries; however, a big challenge is the society’s inability to act on that knowledge (Berkowitz, 2009). Nurse should take this factor into consideration and take the opportunity for both advocacy and action in changing the mindset of society. A nurse should always have one thing on mind – “Prevention is better than cure”. Accordingly, she should take steps towards prevention of childhood obesity. She may need to assess the kind of prevention strategy most appropriate for the child, family, and community. Nurses in community-based settings are in a good position to take action of prevention strategies (Berkowitz, 2009)
Conclusion
In conclusion, childhood obesity is an important health problem in many parts of the world, especially the developed western nations. It is a condition that may significantly contribute to conditions such as diabetes and hypertension particularly later in life. Therefore, primary prevention of the condition in childhood itself is essential to prevent development of serious illness later in life. Nurses being at the forefront of healthcare can help the children and their families by providing advice on healthy eating habits and importance of physical activity. To do this, nurses should take a whole – family approach. Recommendations to tackle the problem are provided by many bodies like the USPSTF, AHA, and AMA. All recommendations are aimed at preventing obesity in children and adolescents; and stopping the epidemic from spreading. The recommendations need to be taken into consideration at an individual level as well as population level. Nurses, especially, can play a larger role in achieving this goal.
References
Heitmann, B., Koplan, J., Lissner, L. (2009) Childhood Obesity: successes and failures of preventive interventions. Nutrition Reviews, 67, S89 – 93.
Whitlock, E.P., O’Connor, E., Williams, S., Beil, T., Lutz, K. (2010) Effectiveness of Weight Management Interventions in Children: A Targeted Systematic Review for the USPSTF. Pediatrics, 125 (2), e396-418.
World Health Organization (2011) Obesity and overweight Fact sheet No 311. http://tinyurl.com/ys95a7
Haboush, A., Phebus, T., Tanata, A. D., Zaikina-Montgomery, H., Kindig, K. (2011) Still unhealthy 2009: building community research to identify risk factors and health outcomes in childhood obesity. J Community Health, 36(1): 111-20.
Phillips, F. (2012). Facing up to childhood obesity. Practice Nurse, 42(11), 14-17.
Ogden, C.L., Carroll, M.D., Flegal, K.M. (2008) High body mass index for age among US children and adolescents, 2003–2006. JAMA, 299, 2401-2405.
Harris, K.M., Gordon-Larsen, P., Chantala, K., Udry, J.R. (2006) Longitudinal trends in race/ethnic disparities in leading health indicators from adolescence to young adulthood. Arch Ped Adolesc Med, 160, 74-81.
Freedman, D.S., Khan, L.K., Serdula, M.K., Dietz, W.H., Srinivasan, S.R., Berenson, G.S., (2005) Racial differences in the tracking of childhood BMI to adulthood. Obes Res, 13, 928-935.
Must, A., Strauss, R.S., (1999) Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord, 23 (2), S2-11.
Reilly, J.J., Methven, E., McDowell, Z.C., et al. (2003) Health consequences of obesity. Arch Dis Child, 88 (9), 748 –752.
Erermis, S., Cetin, N., Tamar, M., Bukusoglu, N., Akdeniz, F., Goksen, D. (2004) Is obesity a risk factor for psychopathology among adolescents? Pediatr Int, 46(3), 296 –301.
Skinner, A.C., Mayer, M.L., Flower, K., Weinberger, M. (2008) Health status and health care expenditures in a nationally representative sample: how do overweight and healthy-weight children compare? Pediatrics, 121, e269-e277.
Screening for obesity in children and adolescents: US Preventive Services Task Force Recommendations Statement. (2010) Pediatrics, 125 (2) 361 – 67.
Rabbitt, A., Coyne, I. (2012) Childhood obesity: nurses’ role in addressing the epidemic. British Journal of Nursing. 21 (12).
Budd, G.M., Hayman, L.L., (2006) Childhood obesity: determinants, prevention, and treatment. J Cardiovasc Nurs, 21(6) 437-41.
Getting healthy. (2013) Retrieved April 26, 2013 from American Heart Association: http://www.heart.org/HEARTORG/GettingHealthy/WeightManagement/Obesity/Overweight-in-Children_UCM_304054_Article.jsp
Barlow, S.E.,(2007) Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics, 120(4), S164 –S192.
Berkowitz, B., Borchard, M. (2009) advocating for the prevention of childhood obesity: a call to action for nursing. Online journal of issues in nursing, 14(1), 8.
