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childhood obesity

Childhood obesity: nurses role


in addressing the epidemic
Aifric Rabbitt and Imelda Coyne

orldwide, obesity has more than doubled since


1980 and approximately 65% of the worlds
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 childs care and family-centred
care is core to childrens 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, Kings College Hospital, Denmark Hill,


London and Imelda Coyne is Head of Childrens 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 childs 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 1015 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 als (2003) analysis of data from the
United States National Health Interview Survey (19842000) for diagnosed diabetics from birth to 80years. 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 childrens 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 mothers 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 childs 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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British Journal of Nursing, 2012, Vol 21, No 12

childhood obesity
not an exact calculation of adiposy (NICE, 2006). Therefore,
the National Taskforce on Obesity (2005) recommends that
nurses calculate childrens BMI, height and weight as routine
clinical assessment. The severity of overweight, the childs
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
4060 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 familys 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

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

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 childrens 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


childrens dietary intake
Parents have a key role in the development of their childrens
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 childs
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 childs 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 childrens 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 familys 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

735

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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.