Nursing Perspective on Childhood Obesity

C H A P T E R

3 Nursing Perspective on Childhood Obesity Carrie A. Tolman, Cynthia Yensel, and Jacqueline Kopetz Section of Endocrinology, Nationwide Children’s Hospital, Columbus, OH, United States

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles [1].

3.1 Introduction It is well-established that childhood obesity has become a global concern, no longer confined to the westernized world. Between 1999–2000 and 2013–14, there was a significant increase in obesity in youth, although there was little change from 2003–2004 to 2013–14. Data from the 2011–14 National Health and Nutrition Examination Survey (NHANES) showed the prevalence of obesity in children and adolescents ages 2–19 years to be 17.0% [2]. The rates are lowest (8.9%) in preschoolers aged 2–5 years old and highest (20.5%) in adolescents aged 12–19 years. Unfortunately, obese adolescents have an 80% chance of being obese as adults, stressing the need for prevention and early treatment to prevent persistent obesity [3]. Nurses have historically been involved in health-promoting activities and preventative care. Current trends in health care have pushed for more preventative care, and the role of the nurse has been driven in this direction [4]. Nurses have a unique opportunity to positively affect outcomes related to obesity in children, as they come into contact with children and families in a variety of settings including outpatient clinics, primary care offices, home health care, hospitals, schools, and other community settings [5]. Nurses must recognize the global scope of the obesity epidemic and how it impacts the children of the world. Being in these various roles, nurses can use their expertise to identify children at risk for becoming overweight, as well as those who are already overweight and obese. This should include screenings for obesity-related comorbidities as well, which requires knowledge of the health consequences related to obesity and their long-term effects. Nurses have awareness of the factors directly influencing the risks for obesity, including environment and socioeconomic issues. Nurses need to have the tools to educate children and families and implement treatment plans. This involves identifying and overcoming barriers for the children, their families, and the nurses themselves. All of this must incorporate cultural and ethnic awareness of the populations with which they work. Nurses also play an integral role in cultivating public policy around the topic of childhood obesity.

3.2 FACTORS INFLUENCING OBESITY The complex interaction between family, genetics, environment, characteristics of the community, and region, culture, and social behaviors has resulted in an energy imbalance. This has led to an increase in obesity rates, especially among children, resulting in an overall negative health impact. To positively impact the rising global obesity problem, these contributing factors need to be identified not only at the local level but also at the international level and addressed by the nursing community.

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3.2.1 Genetics and Family Numerous studies have demonstrated familial tendency for obesity. The presence of parental overweight in one or both parents is seen as a positive indicator for a child’s risk for overweight [6]. When both parents are obese, the child has a 70% chance of becoming obese. If one parent is obese, the chance for the child to be obese is 50%. If neither parent is obese, the child has only a 10% chance of becoming obese [7]. Of obese adolescents ages 10–14 with at least one obese parent, 80% will become obese as adults [8]. Single, overweight mothers have an increased risk of having a child who is overweight or obese [9]. McDonald et al. found the number of overweight Colombian children with an obese mother to be more than three and a half times greater than those children with a nonobese mother [10]. Father’s weight can also be a predictor of the child’s weight as they grow, though this has not previously been considered.

3.2.2 Lifestyle and Environment The built environment, with its endless availability of energy-dense nutrient-poor foods (EDNP), along with a sedentary lifestyle, has had a huge impact on children’s health and well-being worldwide. Known factors that positively affect obesity include sedentary behaviors, skipping meals, and consuming high fat meals, all of which have been seen frequently in teenage girls in Taiwan [4]. Kids eat few fruits and vegetables daily, instead having developed a p-nce for high fat and sugar foods. Foods such as fruits, vegetables, and whole grains common in the diets of many cultures are being replaced by EDNP foods, as seen, for example, in Latin American populations [10]. The intake of high calorie beverages such as juices, soda, and sports drinks is another factor contributing to weight gain in children and adolescents. These toxic food environments surround the child in all areas of life, including school, with access to vending machines and snack shops distributing nutrient-poor food choices [11]. Larger portions, such as super-sizing in the fast food industry, have decreased the awareness of proper portion sizes and contribute to weight gain [12]. Taiwan’s eating patterns have changed due to the invasion of these westernized food preferences, in addition to advertising all types of fast foods and EDNP foods on television [13]. McDonald et al. found that frequency of food consumption in the form of snacking was identified as a positive influence on weight gain in Colombian children [10]. Society today is rich in conveniences that promote inactivity and decreased physical effort. Walking and bike riding have been replaced with cars, buses, or using subway and train systems. Elevators and escalators have reduced the use of stairs. The amount of time spent watching TV, playing video games, and using the computer is another form of inactivity identified in the Taiwanese population [13]. In the United Kingdom, watching TV for more than 3 h daily was a positive risk factor for overweight in 3-year-old children. Adolescents and even younger children frequently spend many hours per day listening to music and talking or texting on a cell phone, resulting in decreased energy expenditure. Parents have cited safety as a newly identified barrier to physical activity. There are fewer safe areas for play in many neighborhoods due to gang activity, drugs, crime, and violence. Racism was also identified as a factor keeping children and families from feeling safe during physical activity. This is increasingly seen in immigrant families experiencing racism as they develop relationships with peers and assimilate into a new community [14].

3.2.3 Cultural Beliefs Cultural and ethnic differences in perception of weight are driving factors in the obesity epidemic. Some countries and cultures consider a person’s larger size a sign of health and status [15]. For instance, in Latino culture, an overweight child is considered to be a sign of health and of the parents’ wealth, thus weight gain is viewed positively [16].It was discovered that more obese boys than girls between the ages of 7–9 in the Northeast region of Thailand, which may reflect the cultural acceptance for boys to have excess weight but not girls. Weight is also affected by the change in diet and activity as families move from one country to another. The prevalence of obesity increases the longer immigrants live in the United States. This has been observed in both Hispanic and Asian Americans born in the United States, as they were twice as likely to be obese compared to their counterparts born elsewhere or newly immigrated. This is evidence that ethnic differences are strongly influenced by environmental factors [17]. In the United States, Davidson and Kanfl found that African Americans did not view obesity as a health concern but found it to be socially acceptable, adding to attractiveness and improving self-assurance [18]. White Americans, on the other hand, viewed obesity as a negative attribute, being seen as unattractive and socially unacceptable, leading to poor body image and negative health consequences. With these factors in mind, the nurse will need to assess cultural perspectives related to obesity, nutrition, and activity when counseling the family and child to positively impact health promotion. It is crucial to explain how these

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factors negatively impact health and the potential for developing comorbid conditions. Families working with nurses who understand their culture and are like them will be more helpful in making changes due to understanding their foods, families, cultures, and lifestyles [19]. Culturally sensitive nurses can be instrumental in helping families become healthier by promoting trust and communication.

3.3 IDENTIFICATION OF AT-RISK CHILDREN Nurses are an invaluable resource when it comes to screening children for overweight or obesity. They provide care in a number of settings where they come into contact with children, giving unique opportunities to conduct important weight screenings. The nurse, however, must be well educated in the tools available for taking this measurement to accurately identify children who are overweight or obese.

3.4 MEASUREMENT TOOLS Body fat can be measured with several tools such as bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DEXA), hydrodensitometry, and skin-fold thickness. Although these tools are excellent for assessing excess body fat, they have limitations, including availability, expense, and lack of pediatric standards. In some countries, the population-specific percentage-weight-for-height (PWH) is used to screen children for obesity. The most widely accepted measure to identify US children and adolescents > 2 years of age who are overweight or obese is the body mass index (BMI) plotted on the Center for Disease Control (CDC) charts [20]. It is easy to use and correlates fairly well with the percentage of body fatness; however, it does not take into consideration lean muscle mass. The BMI may not be a reliable tool to accurately assess children of different ethnic groups due to their body composition [6]. Because a global measure for identification of children who are overweight and obese has been difficult to establish and has not been standardized worldwide, the actual number of children at risk may be underreported [21, 22]. Until a universal, standardized measure is established, BMI is the accepted identification tool. Clinical practice guidelines (2017) from The Endocrine Society recommend this be plotted at least annually, during well or sickchild visits, for children over the age of 2 years [20]. The BMI is not used for children under 2 years of age, instead the gender-appropriate, weight-for-length growth chart is used to follow their growth more accurately. The child’s weight and height should be plotted and evaluated at each office visit regardless of age. Careful inspection of advancing weight trajectory should occur. A weight crossing more than 2 percentiles on the curve should prompt the nurse to screen for behaviors impacting weight, particularly physical activity and nutrition, and to intervene early to slow continued weight gain. It is easier to prevent obesity than to provide the intensive treatment needed once a child reaches an obese level. Categorization of weight based on BMI differs for children and adults. For adults, a BMI > 25 kg/M2 is defined as overweight. A BMI > 30 kg/M2 is defined as obese [23]. For children, the BMI category is based on age and gender. Children with a BMI > 85th but <95th percentile for age and gender are considered overweight. Those with a BMI > 95th percentile are considered obese [24]. Extreme obesity in children is defined as a BMI > 120% of the 95th percentile, or 35 kg/M2 [20]. Nurses can use the BMI in most settings because they will most likely have access to a scale and a way to measure height. Nurses may, however, lack the knowledge and experience to identify obesity. Moyers et al. found that only a third of school nurses used BMI to assess for obesity, with half of nurses using “eyeball analysis”, and four nurses did not screen for obesity at all [11]. When the BMI is not used as part of the child’s evaluation, at-risk children may be overlooked for intervention. Discussing the BMI chart with families can be a useful way for the nurse to help the family understand the seriousness of the child’s weight and how it relates to potential comorbid conditions. The nurse can then discuss lifestyle changes to improve health and decrease the risk for comorbidities. Regardless of the measure used to identify overweight and obese children, the nurse needs to be familiar with the tool being used, understand how to use it accurately and effectively, and include it as part of the child’s evaluation in any setting [11]. They can then facilitate access to health care for treatment. Because children spend the major part of the day in school, this is a primary setting where nurses can positively impact health outcomes [3]. School nurses already share other important health information with families, which make them an ideal resource to share obesity screenings. However, only a third of nurses agree that schools should be responsible for reporting these findings to families [25]. This may be problematic because less than 40% of nurses

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obtain weight, height, and BMI information on all students, as well as follow through with families of at-risk children. The ratio of students to nurses available may also present a barrier to obtaining the required information. Nurses in the pediatric primary care setting play a role in identifying children at risk for being overweight and obese. Nurses in the pediatric office should obtain weight and height, calculate BMI, and plot all measurements accurately on the gender-specific growth chart as part of the well-child visit, as well as most visits in-between, to evaluate for normal growth and development. Frequent assessment of these measures allows for early identification of rapid increases in weight, which can be addressed before the weight gain becomes significant. Educating parents about healthy lifestyles, including age-appropriate portion sizes and physical activity, and using BMI at each well-child visit are important tasks for nurses in primary care. Nurses working in the community are a valuable resource when it comes to screening for overweight and obese children. Churches and community centers are often venues where children participate in activities and could benefit from having a nurse available to do occasional health screenings and provide recommendations for further evaluation of children who fall into at-risk categories. Hospitals have been overlooked by the nurse as a resource for identification of obesity. Many children are hospitalized each year, either in a children’s hospital, on a pediatric unit in an adult hospital, or on a general hospital floor. Regardless of the reason for the admission, there should be an evaluation for obesity risk. In the hospital setting, it is important to identify overweight and obese children to ensure that the best care is provided to them. They may require special-sized equipment, such as a bariatric bed, scale, wheelchair, bedside commode, linens, and gowns to accommodate the weight to make their hospital stay safe and more comfortable. Nurses are in an excellent position to facilitate obtaining the necessary supplies. It is also important to make sure the blood pressure cuff is of adequate size to obtain accurate blood pressure readings during the stay. Having a best practice alert for obese children in the hospital setting may also be an opportune time to address the weight concern and refer them to an intensive weight management program. The nurse may also address any specialized dietary needs during the hospital stay to promote healthy nutrition.

3.5 IMPACT OF CHILDHOOD OBESITY There is a direct correlation between increasing BMI and health risk. Therefore early identification and intervention of obesity and related comorbidities is essential. Obesity is a chronic condition that, if left untreated, increases the risk for comorbid conditions in most obese individuals. If these conditions are acquired during childhood and no intervention for the obesity is provided, there is a greater likelihood that these negative health effects will persist into adulthood, significantly impacting morbidity and mortality [26]. The rise in childhood obesity and obesity-related comorbidities is significantly impacting health care spending. Obesity in children and adolescents has resulted in $1.4 billion more in health care costs than that of their normal weight peers [20]. This will only increase as children are diagnosed with comorbidities at younger ages and require long-term treatment previously seen only in adults. It is crucial that nurses assist in the early identification and treatment of childhood obesity and related comorbidities at much younger ages. As health care professionals, nurses are seeing adult health consequences in the pediatric population. It is critical, then, that nurses and nurse practitioners (NPs) educate themselves on the potentially serious health consequences of obesity in children and prevent these conditions from persisting into adulthood. Basic nurse’s training may include pediatric nursing skills but may not adequately prepare the nurse to address issues unique to the overweight and obese child. Developmentally appropriate care is important when caring for children, despite the fact that they are facing adult health issues [5].

3.5.1 Obesity-Related Comorbid Conditions in Children Children identified as overweight or obese are at increased risk for developing comorbidities [27]. Nearly every system within the body has the potential to be negatively impacted by overweight and obesity, especially if left unidentified and untreated. This brings to light the role of the nurse in identifying children at risk for such comorbidities and intervening at all levels. Many serious health conditions, once thought to be found only in adults, are being diagnosed in children at increasingly earlier ages and at alarming rates. The long-term effects of this have yet to be uncovered.

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Once a child is identified as overweight or obese, the nurse should begin the process of screening for comorbidities associated with the unhealthy weight. Nurses in a variety of settings can participate in gathering the necessary history and physical findings, and may even be able to order diagnostic laboratory studies as further evaluation of comorbidities. A thorough family history of first- and second-degree relatives can identify children at increased risk for obesity and its comorbidities due to familial health conditions such as bariatric surgery, dyslipidemia, type 2 diabetes, liver disease, sleep apnea, and cardiovascular disease, driving the need for additional evaluation [20]. Review of systems in the obese child may also prompt the need for further investigation into comorbidities. The presence of polyuria, polydipsia, irregular menses, or snoring, for example, should prompt additional screening. Advanced practice nurses then play a significant role in performing physical assessments to identify signs indicative of comorbid conditions related to obesity, such as acanthosis nigricans (AN) [24]. The incidence of metabolic syndrome, the clustering of risk factors including hypertension, dyslipidemia, and insulin resistance, has increased significantly in the pediatric population as a result of increased rates of obesity [28]. Cardiovascular disease, a leading cause of death in adults, is being observed in children at very young ages. Dyslipidemia is currently the most prevalent obesity-related comorbidity seen in children. Therefore regular screening by a nurse should be standard in this population. For those with dyslipidemia that does not respond with lifestyle changes, the nurse should refer to a pediatric cardiologist for additional evaluation and treatment [5, 24, 26]. Overweight and obese children are already exhibiting systolic and diastolic hypertension, and should be screened at every clinic visit. To ensure accurate blood pressure readings, it is important for offices to be equipped with blood pressure cuffs of an appropriate size, including extra-long adult cuffs and thigh cuffs [24]. Also disturbing is the presence of insulin resistance, impaired glucose tolerance, and type 2 diabetes in childhood [9]. AN, a sign of insulin resistance, is being observed more frequently in obese children and adolescents of all races and ethnicities. AN is a thickening and/or a darkening of the skin found along the neckline and in the axillae, as well as in flexor aspects of the body, abdominal creases, under the breast line, on the elbows, knees, knuckles, and other skin surfaces. It is related to increased serum insulin levels and can be a precursor to type 2 diabetes [29]. Nurses in many settings can be trained to screen for this sign of insulin resistance and facilitate additional screening for these at-risk children. This provides an opportunity for nurses to educate families about insulin resistance and the increased risk of developing type 2 diabetes in overweight and obese children at a young age. Insulin resistance may be present despite the absence of AN. Therefore a nurse should consider screening laboratory studies that include fasting blood glucose level and lipid profile. Measuring insulin levels is not recommended [20]. Another health concern increasing in children is nonalcoholic fatty liver disease (NAFLD). “Pediatric NAFLD is defined as chronic hepatic steatosis in children (18 years or younger), which is not secondary to genetic/metabolic disorders, infections, use of steatogenic medications, ethanol consumption, or malnutrition” [30]. A large, schoolbased study of obese high school seniors nationwide found NAFLD to be most common in the Latino population [16]. NAFLD, also seen in Caucasian and Asian children, is more prevalent in males. Current guidelines by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommend obtaining an alanine aminotransferase (ALT) level as initial screening. Children with an ALT twice the normal level should be referred to a pediatric gastroenterologist or hepatologist for further evaluation [24]. Lifestyle changes including healthy diet and increased physical activity to promote weight loss are the primary treatment strategy for NAFLD. These include limiting or eliminating sweetened beverages, consuming a balanced diet, and exercising daily [30]. Currently, no medications are recommended to treat the majority of patients. Bariatric surgery is a treatment option to consider for those that qualify. Nurses can provide education to patients on lifestyle changes necessary to improve fatty liver disease. Exacerbation of other gastrointestinal problems, including gallstones and gastroesophageal reflux, is seen in obese children. There is a greater prevalence of gallstones in overweight and obese children, as well as in children experiencing rapid weight loss. Treatment for gallstones and reflux in obese children is no different than that in children of normal weight. It is important, however, for nurses to be aware of the increased presence of these conditions in this young population [24]. Respiratory issues are very common in overweight and obese children. Children with asthma may find it more difficult to be active if asthma is not well controlled. This can exacerbate weight gain and further decrease their level of activity. School nurses especially can work with the child’s family and primary NP to ensure proper asthma management to allow regular physical activity and prevent acute attacks. The occurrence of obstructive sleep apnea is much higher in children who are severely obese and impacts health negatively in a number of ways, including the development of hypertension and ventricular hypertrophy [24]. Nurses should screen for symptoms of snoring with or without apneic periods, restless sleep, and fatigue. The nurse should also assess for signs of obstruction, such as enlarged tonsils, on physical exam. If signs or symptoms are present, a

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referral for a sleep study is recommended. If sleep apnea is identified on polysomnography in an obese child, weight loss is recommended. Treatment of obstruction may include removal of tonsils and adenoids, and/or implementation of continuous positive airway pressure (CPAP) therapy [24]. Other obesity-related comorbidities include pseudotumor cerebri, orthopedic problems, precocious puberty, and polycystic ovarian syndrome [5, 26]. Nurses are instrumental in evaluating and referring children with these conditions to specialists capable of treating these conditions. Overweight and obese children are at risk not only for medical consequences of their weight but psychosocial issues as well. Quality of life is often impaired in these children. Overweight and obese children frequently suffer from depression, anxiety, and low self-esteem [5]. These can lead to lifelong mental health issues if not identified and treated early. Obese children are more likely to be victims of teasing or bullying. They also may perpetrate the bullying, resulting in negative consequences such as punishment at school. To avoid these situations, obese children often isolate themselves socially. School nurses need to be aware of signs of bullying and address it through appropriate channels with the school. These children are also more likely to smoke and engage in high-risk sexual behavior to gain acceptance by normal weight peers. In primary care, the nurse should assess for mental health concerns and offer counseling on high risk behaviors. Sometimes negative feelings come as a result of discrimination experienced due to the child’s size. Inadequate seating to accommodate an obese child may lead the child to pursue home schooling to avoid the embarrassment of not fitting in the regular desks. Driving can be a struggle for some children who do not fit safely in a car. Supplying seatbelt extenders can improve safety. Children of this weight find it difficult to find clothing in fashion in their size. These all lead to low self-esteem and poor self-image.

3.6 NURSE’S ROLE IN PREVENTION AND TREATMENT IMPLEMENTATION With the escalating trend of childhood obesity worldwide, the nurse’s role must not only include identification of at-risk children but the prevention and treatment of obesity as well. Nurses must intervene on the patient level, as well as through community and legislative routes. However, as with many other health care providers, nurses often feel illprepared for this task. A survey of NPs through the National Association of Pediatric Nurse Practitioners (NAPNAP) found that many felt unprepared to effectively prevent and treat overweight and obesity. Larsen et al. [31] found that, although many NPs are aware of the prevention guidelines for pediatric overweight and obesity, very few used BMI for age to target children at risk for obesity [32]. For this reason, it is imperative that nurses in all settings become proficient in providing care for children during this pandemic of childhood obesity. Nursing schools must provide education regarding the worldwide problem of childhood obesity. Curriculum within pediatric nursing should incorporate evidence-based guidelines for identification and treatment of childhood obesity, in addition to overall health and wellness [33]. Beyond early nursing training, nurses should pursue educational opportunities on current health topics such as childhood obesity, nutrition and physical activity. Brief training, for example, on the Healthy Eating and Activity Together clinical practice guidelines offered through NAPNAP, increased practitioner knowledge and confidence in using weight management topics [32]. Education must include strategies for prevention; nutrition education in the prenatal period; treatment through nutrition, physical activity, and behavior modification; and finally, community intervention and political activism to combat childhood obesity.

3.6.1 Prevention Prevention is key to combating childhood obesity, because the likelihood of untreated obesity as a child increases the risk of carrying the excess weight into adulthood. It is easier to prevent children from becoming overweight than it is to correct the problem [34]. Early promotion of healthy lifestyles can prevent or reduce negative health outcomes and establish long-term healthy behaviors [35]. Education on the prevention of overweight and obesity needs to be ongoing, from the prenatal period into late adolescence, and can be facilitated by the nurse in a variety of settings. Three critical periods exist during which factors can influence the development of obesity in children [36]. First of these is during the prenatal period and early infancy. The second occurs from 5–7 years of age, when a rebound of adiposity may occur. Adolescence is the last critical period when obesity may develop. Involving communities, parents, and children for input and feedback on strategies to address health concerns such as obesity is very important to be successful [35].

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Weight and obesity are significantly influenced by availability of nutrients during pregnancy [36]. Nurses caring for pregnant mothers should begin to educate on proper nutrition for the mother and baby. Education should focus on healthy eating and physical activity to ensure adequate, not excessive, weight gain during pregnancy, and the importance of carrying the pregnancy to term. Women who are overweight or obese during pregnancy are at increased risk of gestational diabetes, which can, in turn, lead to infants with excessive birth weight. Excessive birth weight has been identified as a risk factor for overweight or obese during adulthood [37]. Prematurity or low birth weight may lead to childhood weight gain, particularly during the period of adiposity rebound, from ages 5–7 years [36]. Nurses should also provide education on the risk of smoking during pregnancy as this can lead to small for gestational age infants, which then predisposes them to being overweight or obese as they get older [6]. A study of Colombian school children by McDonald et al. found a positive association between maternal BMI and child weight. Children of obese mothers were more than 3.5 times likely to be overweight than children whose mothers were of a healthy weight [10]. When parents received early education regarding healthy nutrition and activity, children were less likely to be overweight or obese at age 3 years [36]. It is well-documented that breast milk is the ideal food for infants. It provides the precise nutrients needed for growth and development during the first 6 months of life [38]. Children who are breast-fed are at much lower risk of becoming obese than children who are formula-fed. Breastfeeding has been shown to have a protective benefit for obesity and overweight, as seen in a cross-sectional study by von Kries et al. in southern Germany [39]. Infants who breastfeed over a longer period have a much lower risk of becoming overweight or obese [36]. The high protein and nitrogen makeup of formula may have an effect on metabolism, causing an increase in insulin and insulin-like growth factor-1 (IGF-1), which may result in increased weight gain. Breast-fed babies may also be more proficient in self-regulating intake as compared to formula-fed babies, who are more likely to overeat [40]. Nurses in prenatal, perinatal, and pediatric settings can influence the likelihood of breastfeeding through proper maternal education. It is important for nurses to promote breastfeeding and provide the necessary support to mothers, even referring mothers to lactation consultants for additional support. As the infant grows, nurses can teach parents feeding strategies that will help the baby grow at a normal rate. Timing of the introduction of solid foods in the first year of life can impact an infant’s risk of becoming overweight or obese as they get older. For each month that solid food introduction is delayed, there may be a 0.1% reduction in the risk of overweight at 3–5 years of age [40]. The American Academy of Pediatrics (AAP) recommends exclusive breast or formula feeding until 6 months of age. Nurses can play a role in educating parents on when to start solid food and the portion sizes appropriate for a child of that age. Because children are often overweight by the time they reach school, parents have identified the need for interventions for healthy lifestyles before the school-age years. Early education regarding healthy lifestyles needs to be directed at parents, as they are responsible for providing healthy nutrition and encouraging physical activity for their children. This can lead to more positive outcomes regarding weight [35]. Nurses can be very effective in addressing these issues with parents at each well-child checkup. As the child grows, feeding behaviors and level of physical activity should be monitored. Nurses can assess that children have adequate physical activity through age-appropriate play, sports, and other physical activities. Adolescents are at high risk for overweight and obesity, which can then lead to negative health consequences longterm. During the adolescent years, children are exploring self-identity and struggle with body image. Risk-taking behaviors such as unhealthy eating habits and sedentary lifestyle contribute to this risk. These lifestyle choices can also lead to psychosocial issues within this population. As they get older, adolescents often move from their pediatric office to a family practice for their primary care. Nurses in either setting need to be aware of the risks of overweight and obesity, and provide preventive education to the adolescent and their parents, if they accompany them to appointments. School nurses are also instrumental in promoting healthy lifestyles with this age group [4].

3.6.2 Treatment Options Moving beyond prevention, nurses should be prepared to educate on treatment options available for children identified as overweight or obese. Treatment will depend on the degree of overweight or obesity, and the presence and severity of comorbidities [26]. The goal for overweight and obese children who have not developed comorbid conditions is to maintain weight or slow weight gain as they grow taller, allowing the BMI to normalize. For those children already exhibiting comorbidities related to weight, weight loss of 1–2 pounds per month is recommended [24, 26]. Before addressing weight loss strategies, the nurse must first assess the family’s and child’s readiness for change. If the family is unmotivated to make the changes needed for weight loss, this will only cause frustration and prevent

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progress. Assessment of motivation can be accomplished through motivational interviewing (MI), the principles of which rely on the notion that changes in behavior are affected more by the level of motivation to make change than by the provision of information regarding the change [41]. MI involves the child and/or parent, depending on the age of the child, and can be used to determine the family’s priorities for weight loss, what goals they would like to set, and how to achieve them [24]. The nurse must recognize that motivation fluctuates over time and should reassess accordingly. MI requires instruction on how to use it effectively and successfully, as well as practice to become proficient, which may be a barrier to using MI.

3.7 LIFESTYLE CHANGES The focus of lifestyle changes for weight loss is energy balance, looking at energy consumed through calories, and energy expended through basal metabolic function and physical activity [38]. Lifestyle interventions need to address not only energy imbalance but other behaviors that lead to unhealthy habits as well [12, 26]. In general, children must consume fewer calories and increase physical activity to lose or maintain weight. It is helpful for the nurse to remind families that even small changes in nutrition and physical activity can impact weight [5]. The nurse should stress that parental role modeling of food selection and activity can positively or negatively affect the weight of a child [42]. Young children often mimic the actions of their parents regarding food and activity [5]. Many times parents and children have a good understanding of what constitutes healthy nutrition and physical activity, but this knowledge is not always put into practice [35].

3.7.1 Nutrition The first component in weight loss intervention is finding ways to reduce calories in the child’s diet without compromising normal growth and development. Nurses can provide basic recommendations regarding nutrition but should refer families to a dietitian for more detailed nutrition guidelines as appropriate. Especially in younger children, the parents heavily influence this, as they are responsible for the food brought into the home and how it is prepared [5]. Nurses can provide information regarding the nutrient value of foods and encourage parents to look for high-nutrient low-energy dense foods. Food models are useful in helping children practice making healthy food choices [37]. Parents need to be educated on simple ways to reduce caloric intake, such as limiting high-calorie beverages like soda and juice. Offering age-appropriate portion sizes is a topic that nurses can quickly review with families at well-child visits. As time allows, nurses can teach parents about reading labels to guide food choices [26]. Nurses can encourage structured meals and snacks, discouraging grazing throughout the day. Having regular family meals is a positive factor in weight management. This provides an opportunity to connect as a family as well as limit outside distractions that could lead to overeating. Keeping a food journal helps families and children be more cognizant of the types and quantity of food being consumed. Parents should be discouraged from using food as a reward for good behavior, as this can create the perception that reward foods are more desirable than healthy foods [36]. Behaviors around food can lead to overweight and obesity. Where food is consumed is an important factor in weight management. Watching television or using smartphones while having a meal or snack can lead to overeating. These act as distractions, overriding the sensation of satiety, causing overconsumption. The nurse should encourage families to eat all meals and snacks in the kitchen without distractions. Food is often seen as comfort or used as a coping mechanism. Children sometimes eat out of emotion, such as happiness, boredom, depression, and stress. Eating as a result of nonphysical hunger cues also leads to overeating and weight gain. The nurse can help the child explore why this type of eating is occurring and, if necessary, make a referral to a behavioral specialist to address underlying psychosocial issues contributing to weight gain.

3.7.2 Physical Activity Physical activity is a critical piece in the weight management strategy. In addition to expending calories, physical activity has many overall health benefits [5]. Exercise has been shown to improve insulin resistance and hypertension in children. It can also improve self-esteem and decrease depression and anxiety [43]. Children who are physically active tend to be more active as adults. Nurses need to define physical activity for parents, as there is often a lack of understanding of how much energy is required to burn off excess calories. Some parents think that any activity, even playing piano, is sufficient to offset

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intake [35]. Physical activity causes an increased heart rate, more than merely playing. It should be scheduled daily and should include parents, depending on the child’s age. It has been found that children’s sedentary activities were closely related to their parents’, reinforcing the need for parental modeling [14]. The latest concern for children today is the amount of daily screen time. This includes time spent watching television, playing videos games, and using computers and cell phones. The American Academy of Pediatrics (AAP) recommends limiting screen time to no more than 2 h per day, except for children under the age of 2 years, who should watch no television [43]. Lanningham-Foster et al. found that replacing sedentary screen time with more active screen time increased energy expenditure more than twofold [44]. Nurses are beneficial in assessing the amount of physical activity and screen time children have daily, and can make recommendations accordingly. Currently, 30–60 minutes of moderate physical activity beyond gym class is recommended most days of the week. The nurse should encourage family participation in activities. Activities that are fun and age-appropriate are more likely to keep children engaged, and can include organized sports and outdoor free play.

3.7.3 Pharmacologic Treatment Options Beyond lifestyle changes and behavioral modification, there are few alternatives available for the treatment of overweight and obesity in children and adolescents. At this time, there are limited options of weight loss medications approved by the Federal Drug Administration (FDA) for use in adolescents. Both the AAP and The Endocrine Society have established recommendations regarding the use of medications for weight loss, including a level of maturity in the child that would allow them to understand the risks and benefits of the use of pharmacologic agents for weight loss. Medications should only be considered when intensive weight management through lifestyle modification has failed. Nurse practitioners in the primary care setting should refer these adolescents to a tertiary center for initiation of these medications. They should also reinforce maintenance of lifestyle changes along with medication to increase the likelihood of success [45]. Weight loss in adolescents using medications was approximately 3 kg more than those with diet alone [24]. Orlistat, which is FDA-approved for use in children 12 years of age and older, acts to inhibit pancreatic and gastric lipases, enzymes responsible for fat absorption. It prevents the absorption of fats by as much as 30%. This mechanism, however, is responsible for the most common adverse effects, including oily stools, abdominal discomfort, and flatulence. Oily stool is most often the reason patients discontinue orlistat. There may also be malabsorption of fat-soluble vitamins. Nurses following patients on orlistat should ensure a daily multivitamin is taken to prevent this. A randomized controlled trial in adolescents found a significant decrease in BMI, waist circumference, and body fat with orlistat compared to placebo.

3.7.4 Surgical Weight Loss Options For adolescents who have been unsuccessful with weight loss through lifestyle changes or medication, bariatric surgery may be an option. Bariatric surgery leads to significant weight loss and often resolves obesity-related comorbidities [24]. There are currently three weight loss surgeries used in adolescents: sleeve gastrectomy, gastric bypass, and adjustable gastric banding. These procedures provide restriction by reducing stomach volume, leading to early satiety. Gastric bypass provides the additional component of nutrient malabsorption in the small intestine. Bariatric surgery is a not a cure for chronic obesity, merely a tool to enhance changes in nutrition, physical activity, and eating behavior. The American Society for Metabolic & Bariatric Surgery Pediatric Committee Bariatric established surgery candidate guidelines [45]. Criteria for the ideal adolescent bariatric candidate, however, vary by institution. Bariatric surgery should be considered if the candidate has a BMI of 35 kg/M2 with the presence of comorbidities, or a BMI of 40 kg/M2 [24, 45]. There also needs to be a significant degree of cognitive and emotional maturity. For this reason, psychological evaluation is very important during the selection process. In the primary care setting, the nurse practitioner can refer patients who may be good surgical candidates to centers performing bariatric surgery. It is important to remember that successful bariatric surgery requires management by a multidisciplinary team, which should include the primary nurse practitioner, both pre- and postoperatively. NPs in primary care should maintain regular follow-up with these patients to manage comorbidities and monitor vitamin levels, especially in the postsurgical patient. It would be helpful for the NP to consult with the bariatric team to determine long-term management needs [45]. The NP should be aware of potential postoperative complications such as

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pulmonary embolus, wound infection or dehiscence, incisional hernia, anastomotic leaks, and vitamin deficiency, and help the patient seek immediate treatment from the surgical team. Ensuring that the patient takes a daily multivitamin and calcium supplement is crucial to prevent vitamin deficiency. They can also assess for adequate daily protein intake. The NP should also continue to monitor for adherence to lifestyle changes for weight loss success.

3.8 NURSES AS ADVOCATES FOR CHILDHOOD OBESITY POLICY Beyond awareness of trends in childhood obesity globally, nurses need to take an active role advocating for public policy regarding this very important issue. Nurses serve as advocates for these young patients who rely on adults to provide an environment that promotes healthy living. Nurses are a trusted group within the community. Using this connection with families and the communities in which they work, nurses can have a significant impact on obesity prevention and treatment [46]. With presence in schools, community health centers, pediatric offices, and hospitals, nurses bring a unique point of view and are poised to influence public policy for the prevention and treatment of childhood obesity [46, 47]. Nurses should stay abreast of current public policy and pending legislation that could potentially affect childhood obesity. Nurses should contact local legislators involved with health care policy and work with professional nursing organizations to push for more awareness of the obesity epidemic and the need for action [48]. With the increasing cost of health care related to obesity and its comorbidities, nurses must advocate for public policy that addresses the prevention of obesity in schools, where children spend the majority of their day. School nurses are wellpositioned to fight for funding for increased obesity screening in schools. They can also advocate to keep physical education in school curricula and to work with communities encouraging physical activity. In collaboration with nutrition services and policy makers, nurses can work to ensure healthy food for school breakfast and lunch programs, which often provide most of a child’s daily intake. Legislation regarding children’s media exposure is also an arena for nurses to tackle. Children are bombarded daily with unhealthy food choices, which can easily influence what they are eating. Limiting a child’s exposure to such potent messages is a critical piece in fighting childhood obesity. Sweden, for instance, prohibits the food industry from using cartoon characters to market food to children [9]. The nurse’s role in the political arena is endless and can be very powerful in influencing policy and legislation.

3.9 BARRIERS TO SUCCESSFUL TREATMENT Many barriers have been identified when addressing obesity issues. Story et al. identified the most common barriers as lack of support services, parent involvement, and patient motivation [49]. Barriers to obesity management exist not only with children and families but with health care providers as well. Overcoming these barriers will be necessary to move forward with prevention and treatment of obesity in children.

3.9.1 Provider Barriers and Health Care Bias NPs have identified lack of time during visits as a barrier, with face-to-face patient time decreasing by half in the past 13 years [50]. Half of the NPs identified lack of reimbursement as a major barrier to addressing obesity. Without sufficient reimbursement for obesity management, NPs are less likely to incorporate this into their care for patients. Practitioners also did not feel proficient when addressing behavioral techniques, family conflicts, or parenting strategies related to childhood obesity. Providing education on these strategies, as well as obesity assessment and training in undergraduate and graduate nursing programs, would be beneficial. Continuing education is a useful tool in obesity management. Not being proficient in motivational interviewing to assess readiness for change is another barrier when addressing obesity. Workshops, seminars, and online training would be useful in managing obesity [49]. Discussing a child’s weight issues with parents can be a difficult conversation. Less than 37% of overweight children were informed that they were overweight by their clinician. Parents of children 2–11 years of age were less frequently informed that their child was overweight, whereas adolescents between 16–19 years of age were more frequently informed that they were overweight [42]. This is troubling because early intervention is instrumental in managing overweight children. Bias held by nurses about obese patients has a negative impact on obesity management. Nurses may view obese individuals as lazy, lacking self-control and motivation for lifestyle changes. Almost 69% of British nurses related obesity to noncompliance with lifestyle changes. This led nurses to feel that obesity management is futile [49, 51]. In one

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study, less than 22% of nurses felt they were effective in helping an individual achieve weight loss. Even bariatric surgery patients reported bias from medical professionals. Nurses need to overcome their biases toward obese individuals and implement behavioral changes in themselves to care for these patients more effectively and compassionately.

3.9.2 Parent Perception of Child’s Weight Parental perception of child’s weight as a health risk and readiness for change are essential for successful weight loss [41]. If they do not understand their child’s weight status and the significance of associated health risks, it may be more difficult for the nurse to address and implement a plan for healthy lifestyle interventions. Parents often underestimate the weight of their child, with girls more frequently identified as overweight than boys. Many times, mothers identified their child’s weight status in reference to physical limitations and social factors, not by the growth chart [42]. WIC providers found that overweight mothers were less likely to view their child as obese [52]. Many families and children are not concerned with weight as the child looks like the rest of the family or feel that being overweight is important. The parent may not have been educated on their child’s weight and the potential for negative health consequences. Clinicians must address the child’s weight status with families at each visit, being sensitive to the family’s perceptions of the weight. Being aware of these perceptions will help the nurse work more effectively with these families. Using the BMI growth chart is an ideal tool to educate families about weight concerns. The nurse should be aware, however, that parents may not want to admit that their child is overweight.

3.9.3 Language and Cultural Barriers As communities become more diverse, a basic understanding of the cultures and their values is critical in caring for these families. It is important to understand cultural perception of weight to address the health risks associated with being overweight or obese. If the family does not believe that their child is overweight, they are less likely to understand the need for lifestyle changes, resulting in a negative impact on the child’s overall health. There is a strong need to have culturally and linguistically competent nurses, even being from the same culture or community, to help facilitate health promotion communication. These nurses are better suited to help families with lifestyle changes to promote weight loss, and can present information on nutrition and physical activity in a culturally sensitive manner [19]. Nurses within these communities can lead by example, such as by preparing ethnic foods in healthier ways or by promoting physical activity through modeling. Culturally sensitive nurses are instrumental in developing tools and strategies to help families of other cultures understand health related consequences and implement healthy lifestyles.

3.10 CONCLUSION With the growing epidemic of childhood obesity, nurses are uniquely positioned to positively impact obesity prevention and treatment. Nurses connect with children in many settings, including schools, primary care offices, and hospitals. They have a responsibility in all settings to identify children who are at risk for becoming overweight or obese, and to ensure families are well-educated regarding health promotion strategies to prevent progression of obesity into the adult years. The challenge is for nurses to educate themselves on current childhood obesity trends and comorbid conditions so they are effective in addressing this issue with families. Understanding the screening tools used to identify overweight and obese children is critical to early intervention and to reduce the likelihood of developing comorbidities related to the obesity. Nurses need to be aware of barriers to treatment and have strategies to overcome these obstacles to positively impact health outcomes. Finally, nurses should take an active role in public health policy to bring awareness to the need for obesity prevention and treatment in children.

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[46] Tao H, Glazer G. Legislative: obesity from a health issue to a political and policy issue. Online J Issues Nurs 2005. Available from: www. nursingworld.org/mainmenucategories/ANAmarketplace/ANAperiodicals/OJIN/Columns/Legislative/Obesity. [47] Sheehan NC, Yin L. Childhood obesity: nursing policy implications. J Pediatr Nurs 2006;4:308–10. [48] Henry LL, Royer L. Community-based strategies for pediatric nurses to combat the escalating childhood obesity epidemic. Pediatr Nurs 2004;30:162–4. [49] Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, Barlow SE. Management of child and adolescent obesity: attitudes, barriers, skills and training needs among health care professionals. Pediatrics 2002;110:210–4. [50] Briscoe JS, Berry JA. Barriers to weight loss counseling. Nurse Pract 2009;161–7. [51] Puhl RM, Heure CA. The stigma of obesity: a review and update. Obesity 2009;17:941–64. [52] Chamberlin LA, Sherman SN, Jain A, Powers SW, Whitaker RC. The challenge of preventing and treating obesity in low-income, preschool children. Arch Pediatr Adolesc Med 2002;156:662–8.

Further Reading [53] Fu WPC, Lee HC, Ng CJ, Tay YK, Kau CY, Seow CJ, Siak JK, Hong CY. Screening for childhood obesity: international vs. population-specific definitions: which is more appropriate? Int J Obes 2003;27:1121–6.

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