Childhood Obesity: Environmentally Focused Interventions are Key to Combating this Epidemic

Childhood obesity and the health problems that accompany obesity is a growing problem facing American children. The epidemic of childhood obesity in the United States require nurses to consider the family’s belief system and the environment they provide for the child when developing a diet and exercise education plan for the families of obese and high risk children.

Therefore the nurse will assess the parents perceptions of their child's weight and their parenting style and then incorporate behavior modification therapy into the family’s teaching plan.
Parents must learn to identify and address the family behaviors and eating patterns that contribute to the obesity of the child. According to research by Graves, Meyers, and Clark (1998), family centered treatment helped families of the obese child to achieve weight loss and to maintain the healthier weight. Consequently, nurses must educate patients and their families on more than caloric intake and physical activity.
When developing interventions for the family of an obese child, the nurse must assess the parent’s perceptions of their obese child and determine whether or not the parents view their child as being overweight (Hodges, 2003). Pediatric nurses are able to make these assessments during the child's routine health exams. Parents must acknowledge their child as being overweight before they will be able to perceive it as a health problem that requires intervention. In one study, research has shown, “Among 99 mothers of overweight children, 79% failed to identify their children as overweight” (In Hodges 2003; Baughcum, Burklow, Deeks, Powers & Whitaker, 1998). Another study revealed a perception held by mothers enrolled in WIC (a supplemental nutrition program for women, infants and children) is a belief that the higher their child ranks on the growth chart, the healthier the child is and also the belief that this higher rank is equated with better parenting (In Kyung, Delago, Arscott-Mills, Mehta & Davis, 2006; Baughcum, Burklow, Deeks, Powers & Whitaker, 1998). The majority of these parents see their child's weight as

acceptable and not requiring attention or change. If parents hold these perceptions then the nurse must help the family to understand that their child is overweight by explaining Body Mass Indexes and growth charts and how these relate to their child’s weight. The nurse can then educate the family about what defines an obese child and the health risks associated with obesity (Kyung, Delago, Arscott-Mills, Mehta & Davis, 2006).
After the parents have acknowledged their child's weight as a problem that requires them to take action, the nurse must assess the family’s parenting style (Regber, Berg-Kelly, Marild, 2007). In a literature review by Birch & Fischer (1998), it was determined that a child’s eating behavior is directly related to parenting. The reasons given to support this determination are: (a) the parent decides when the child will eat, where the child will eat and what will be eaten, (b) parents model eating behaviors for their children, (c) parents may use food as either a reward or punishment, and (d) parents determine the level of control they are going to exert over their child’s eating patterns. This control, or lack of does not always take into consideration the child's physiological feelings of hunger or fullness, hinders the child’s ability to self regulate and their ability to distinguish between hunger and satiety (In Horodynski & Stommel, 2005; Johnson, 2000). The nurse must identify and understand the family’s parenting style in order to develop interventions designed specifically for the individual family. This understanding will help the nurse teach new parenting techniques in relation to food and to support the family in making changes (Regber, Berg-Kelly, Marild, 2007).
Making changes in a family’s eating patterns requires the family to modify their eating behaviors. The theory of behavior modification, when utilized in the treatment of obesity, strives to increase a family’s understanding of healthy diet and exercise patterns and to increase their ability to identify behaviors incompatible with maintaining healthy diet and exercise

patterns (In Drohan, 2003; Epstien, Roemmich & Raynor, 2001). Behavior modification involves self monitoring, social reinforcement, stimulus control and modeling. Self monitoring involves keeping records of eating patterns, foods eaten and physical activity. As behavior modification therapy progresses, the family can track their successes. (In Drohan, 2003; Epstien, Roemmich & Raynor, 2001). Social reinforcement involves consistent praise directed at specific behaviors and earning privileges (In Drohan, 2003; Epstein, 1996; Epstein et al; 2001). Stimulus control involves helping the child and parents identify elements in their environment that are associated with food consumption and inactivity (In Drohan, 2003; Foreyt & Poston, 1998). Modeling involves parents exhibiting healthy eating and physical activity (In Drohan, 2003; Epstein & Squires, 1998). The nurse can incorporate these principles into the family’s teaching plan. Encouraging the family to track their eating behaviors and helping them develop realistic goals will be part of the nurse’s plan as well as helping the family to acknowledge elements in their home environment that lead to overeating and inactivity ie. eating in front of the television and video games. The nurse must also include in her teaching plan the value of consistent praise when the child makes healthy lifestyle choices and meets weight loss goals as well as the importance of parental modeling of these behaviors. Behavior modification can help the family of an obese child provide a more positive environment for the entire family and maintain control over their lives while achieving weight loss goals.
It is imperative that nurses identify the causative factors that contribute to the obesity of a child. The family behaviors and eating patterns must be integrated into the nurses care plan for the family of an obese child. This understanding will lead to better communication between the family and the nurse and will assist in the development of interventions designed specifically for the individual family.



References:



Drohan, S. H. (2002). Managing early childhood obesity in the primary care setting: A behavior modification approach. Pediatric Nursing, 28 (6), 599-610. Retrieved
January 19, 2007, from Expanded Academic ASAP database.

Hodges, E. A. (2003). A primer on early childhood obesity and parental influence. Pediatric Nursing, 29, (1), 13-17. Retrieved January 07, 2007, from Expanded Academic ASAP database (A98171371).

Horodynski, M. A., Stommel, M. (2005). Nutrition education aimed at toddlers: an intervention study. Pediatric Nursing, 28 (5), 364-381. Retrieved April 18, 2007, from Expanded Academic ASAP database.

Regber, S., Berg-Kelly, K., Marild, S., (2007). Parenting styles and treatment of adolescents with obesity. Pediatric Nursing, 33, (1), 21-28. Retrieved April 18, 2007, from Proquest Database.

Rhee, K. E., De Lago, C. W., Arscott-Mills, T., Mehta, S. D., & Davis, R. K., (2005). Factors associated with parental readiness to make changes for overweight children. Journal of The American Academy of Pediatrics, 116 (1), 94-101, Retrieved October 27, 2006 from http://www.pediatrics.org/cgi/content/full/116/1/e94.








Intervention: The nurse must assess the parent’s perceptions of their obese child and determine whether or not the parents view their child as being overweight then educate the family about what defines an obese child and the health risks associated with obesity.

Disadvantage I: Culturally based views may impede the nurses attempts to educate the parents.

Definitions of obesity differ from culture to culture and these varied attitudes towards body weight and body proportion may contribute to the obesity of the child and the unwillingness of the parents to make changes. In black and hispanic communities women and girls tend to be more satisfied with their body weight, describe themselves as thinner and although they tend to be heavier than their white counterparts, they are less likely to identify themselves as overweight (Cachelin, Rebeck, Chung, Pelayo, 2002). Therefore overweight mothers who do not see themselves as being overweight are likely to view their childs weight as satisfactory and the nurse’s attempts to educate the family are more likely to be dismissed.

Disadvantage II: Increasing the knowlege base of the parent of an overweight child does not result in behavior change.

In a recent study aimed at assessing the effectivness of NEAT: Nutrition Education Aimed at Toddlers (Horodynski & Strommel, 2005), increasing participants knowlege did not change their behaviors. During the six month study parents and caregivers of toddlers were educated on diet and feeding behaviors appropriate for healthy nutrition. Upon completion of this study, the parents/caregivers knowlege was assessed and the results indicated significant increases. However, this did not increase the parents/caregivers ability to change feeding behaviors in the home. The participants in this study were unable to incorporate what they had learned into their everyday lives. Therefore, the nurse must help the family to modify their eating behaviors. To do this, behavior modification must be a part of the nurses teaching plan.




Intervention 2: To help the family of an obese child the nurse must combine patient education with behavior modification therapy.

Disadvantage I: Pediatric practices often do not have guidance and lack the skills required to properly counsel the obese patient and their family.

In a study conducted by Barlow, Trowbridge, Klish and Dietz (2002), it was reported that although medical professionals know what to educate the families of obese children about, they at the same time percieve themselves as lacking the skills to properly educate and motivate the families of obese children. The lack of resources and contiuing medical education in this area contribute to this low skill level. Pediatricians, Pediactic Nurse Practitioners and Registered Dietitians reported an interest in additional training related to patient motivation, behavior change and reinforcement.
The skills required to properly motivate the families of obese children and to help them overcome the emotional obstacles that impede behavior change will help the family live a healthier life.


Disadvantage II: In busy pediatric settings, there is insufficient time and reimbursemnt for interventions aimed at obesity treatment.

According to a study by Story, Neumark-Stzainer, Sherwood, Holt, Sofka, Trowbridge, et al. (2002), interventions aimed at obesity are challlenging due to the level of education required to impart to the patient and family and the implementation of behavior modification therapy. These are time consuming interventions that are often not validated by insurance companies and are therefore not reimbursable. Studies have indicated that more than half of Pediatric Nurse Practitioners and Pediatricians reported that inadequate and/or lack of reimbursement proved as a deterrent when it came to treating obese children. Insurance companies and managed care policies need to make changes because as it stands now, health care providers have no incentive to provide treatment for obese youth. Insurance companies need to be encouraged to cover treatment for both prevention and treatment of this epidemic.




References:


Barlow, S.E., Trowbridge, F.L., Klish, W.,J., Dietz, W.,L. (2002). Treatment of child and adolescent obesity: reports from Pediatricians, Pediatric Nurse Practioners, and register dietitians. Journal of The American Academy of Pediatrics, 110 (1), 229-235, Retrieved October 1, 2007 from http://www.pediatrics.org/cge/content/full/110/1/S1/229.

Cachelin, F.M., Rebeck,R.M., Chung, G. H., Pelayo, E.(2002). Does ethnicity influence body- size preference? a comparison of body image and body size. Obesity Research, 3 (10), 158-165, Retrieved October 2, 2007 from http://www.obesityresearch.org/cgi/content/abstract/10/3/158-166.

Horodynski, M. A., Stommel, M. (2005). Nutrition education aimed at toddlers: an intervention study. Pediatric Nursing, 28 (5), 364-381. Retrieved April 18, 2007, from Expanded Academic ASAP database.

Story, M.T., Neumark-Stzainer, D.R., Sherwood, N.E., Holt, K., Sofka, D., Trowbridge, F.L., Barlow, S.E., (2002). Management of child and adolescent obesity: attitudes, barriers, skills and training needs among health care professionals. Journal of The American Academy of Pediatrics, 110(1), 210-214, Retrieved October 1, 2007 from http://www.pedatrics.org/cgi/content/full/110/1/S1/210.