CHILDHOOD OBESITY AN EDUCATIONAL PAMPHLET

By

Kimberley L. Deroo

Abstract

There are over 97 million overweight adults and 5.3 million overweight children in the United States. Children and adolescents globally are being diagnosed with diseases that were reserved for adults in mid-life, such as hypertension, Type II diabetes, respiratory disease, heart disease, orthopedic and psychosocial problems. The purpose of this project was to produce a pamphlet directed at parents and caregivers explaining childhood obesity and proposed risk outcomes directly related to obesity. The conceptual framework used for this project was Orem’s Self-Care Deficit Nursing Theory. This pamphlet on childhood obesity will be evaluated for content validity by two health professionals who are experts in the pediatric field. Due to time constraints, the pamphlet will not be distributed to parents and caregivers of obese children as part of this project.

CHAPTER 1

INTRODUCTION

Over the past 25 years, the prevalence of overweight and obesity in children and adolescents has risen, with the most substantial increases observed in economically developed countries. According to the results of the 2004 Canadian Community health Survey: Nutrition (CCHS), a substantial share of Canadian youth are part of this trend. In 2004, 26% of Canadian children and adolescents aged 2 to 17 were overweight or obese, 8% were obese. For adolescents aged 2 to 17, the overweight/obesity rate of this age group more than doubled, and obesity rate tripled. Since the early 1960’s, the height and weight of a nationally respresentative sample of Americans have been directly measured as part of the National Health and Nutrition Examination Survey. Based on the most recent data (1999-2002), the combined overweight/obesity rate of 2 to 17 year-olds was similar in the United States and Canada, but the American obesity rate was slightly higher (10% versus 8%) (Shields, 2004).

In 1963-1970, 4% of children in the United States were overweight; in 1999-2000, 15% of children in the US were overweight. In Canada, over one-third of children aged 2 to 11 were overweight in 1998-99, and of these, about half could be considered obese (Statistics Canada, 2002).

Children and adolescents globally are being diagnosed with diseases that were reserved for adults in mid-life, such as high blood pressure, diabetes (Type II), respiratory disease, heart disease, orthopedic and psychosocial problems.

There has been a ten-fold increase in the prevalence of newly diagnosed type 2 diabetes mellitus in adolescents from 1982 to 1994 (Sorof & Daniels, 2002). Children were getting so large that their bodies increased demand for insulin was compromised, and exhausted.

Mortality data (Frazao, 2000) for 1994 show that coronary heart disease was the cause of over 480,000 deaths in the United States, nearly two thirds of all deaths from heart disease. The American Heart Association (1997) estimates that as many as 1.1 million Americans suffer a new or recurrent heart attack each year and that over 13.9 million people alive today have a history of coronary heart disease and that someone dies from a heart attack about every minute. These of course are adult statistics, but there are 5.3 million children in America who are overweight. This could suggest that the death rate for coronary heart disease, secondary to obesity could possibly double or triple in the next decade. This researcher believes that in order to prevent the increase of childhood obesity, parents need to be educated and empowered on what they can do to help their children (Frazão, 2000)

At its simplest, obesity is the result of an energy imbalance. Obesity and overweight occur when energy intake exceeds energy expenditure. While it may appear that the solution to obesity prevention amounts to a simple rebalancing of the energy equation at the individual level, there is a much more complex interaction between individuals and their environments that must be examined at the population level (RNAO, 2005)

Statement of Purpose

The purpose of this project is to produce a pamphlet directed at parents and caregivers explaining childhood obesity and proposed risk outcomes directly related to obesity. This pamphlet will suggest to parents and caregivers, strategies they can institute in preventing obesity.

Theoretical Framework

Dorothea Orem’s self care model served as a theoretical framework for this project. Nursing metaparadigm concepts as they pertain to obesity, specifically childhood obesity prevention will be examined.

Person is a self-care agent and self-care is the practice of activities that individuals initiate and perform on their own behalf in maintaining life and well-being. Persons (Hanucharurnkul, 1988) are viewed as having the capacity for self-knowledge and for engagement in deliberate action.

Health is a state of wholeness or integrity of human beings. Orem speaks of physical, psychological, interpersonal, and social aspects of health and noted that they are inseparable. Persons are said to be healthy when they are structurally and functionally sound or whole. The term sound refers to full vigor and strength and absence of signs of disease and morbidity. Whole means nothing has been omitted, ignored or lessened.

Environment is described as a set of conditions that motivate a person to establish appropriate goals and adjust behavior to achieve results specified by the goals.

Nursing is a helping service, an art and a technology; a creative effort of one human being helping another human being. Nursing focuses on individual abilities and requirements for self-care. Assisting persons to sustain self-care on a continuous basis and at a therapeutic level is viewed by Orem as the unique perspective of nurses.

Orem believes that humans can be motivated to establish goals and adjust or modify their behavior to become healthy. Prevention of obesity requires the discipline of children and parents to set goals. Parents are the keepers of their children and need to guide them, in order for them to set goals as adults. Self-care is a learned behavior, and nursing can assist in the education of parents on how to sustain self-care on a continuous basis at a therapeutic level.

Preliminary Literature Review

The epidemic of childhood obesity is a major public health problem in the US, where in 20003-2004, 26.2% of children aged 2-5 years, 37.2% of children aged 6-11 years and 34.3 % of adolescents 12-19 years were at risk for overweight or obesity (Mendoza, Zimmerman & Christakis, 2007). There are over 97 million overweight adults and 5.3 million overweight children in the United States alone (Smolowe, 2002). In Canada, over one-third of children aged 2 to 11 were overweight in 1998-99, and of these, about half could be considered obese (Statistics Canada, 2002). Statistics from 1963 show that 4% of children in the United States were overweight, but despite the research, more children are becoming obese.

Diseases which were only diagnosed in adults are now inflicting children. Until a few years ago, most doctors say surgery or medication traditionally reserved for adults was something they would have never considered for their pediatric population (Sorof & Daniels, 2002). Children between the ages of 2-17 years spend an average of more than 3 years of their waking lives watching television, not including other forms of sedentary entertainment. Television viewing is one of the most easily modifiable causes of obesity (Dowda, Ainsworth, Addy, Saunders & Riner, 2001). In response to the growing problem of childhood obesity and other health issues associated with television viewing, the American Academy of Pediatrics has issued national guidelines for parents to limit their children’s total media time to no more than 1 to 2 hours of quality programming per day for children 2 years of age and older (Mendoza et al., 2007).

Significance and Justification

Childhood obesity is at epidemic proportion. Parents of obese children need to be educated on the debilitating consequences of obesity, be it psychosocial or medical. Parents need to truly understand that their child will develop diseases that have traditionally only affected adults, and potentially may die from those diseases if interventions are not undertaken early.

There is evidence as indicated by Bundred, Kitchiner, and Buchan, 2001, that cardiovascular disease remains one of the principal causes for excess mortality. Body mass index is one of the important risk factors associated with the extent of arthersclerotic lesions in the aorta and coronary arteries in people aged 2 – 39 years of age.

The prevalence of obesity in children as captured by Sorof and Daniels, 2002, grew from 5% to 11% from the 1960’s to the 1990’s. This increase in severity has also translated into an increase in the prevalence of outcomes such as type 2 diabetes and hypertension.

The complications of obesity as stated by Sorof and Daniels, 2002, include hypertension, dyslipidemia, insulin resistance, glucose intolerance, type 2 diabetes, left ventricular hypertrophy and pulmonary hypertension resulting from obstructive sleep apnea. Despite the need for obesity prevention, Jain et al, 2001, suggested that there are multiple barriers to these efforts. They have shown that in mothers without a college education, only 11% of those with an overweight preschool-aged child believed that their child was overweight.

Mothers are critical mediators of obesity prevention as they play a large role in shaping the diet and activity patterns of young children. Some mothers emphasized the need to strengthen a child’s self esteem to buffer the effects of being teased about their weight in the future.

Hospital costs as noted by Wang and Dietz, 2002, may have risen to more than $127 million per year in recent years. Obesity is not a diagnosis, only the complications resulting to obesity are diagnoses, but with healthcare provider awareness, this may change over time. There is a rising disease burden associated with obesity among children. It continues to grow and thus, the increase in healthcare costs. Prevention of childhood obesity is necessary to overcome this epidemic.

Project Objective

The objectives for this project are to:

(1) Conduct an in-depth literature review on childhood obesity.

(2) Design a pamphlet directed at parents and caregivers regarding childhood obesity, describing obesity related consequences.

(3) Evaluate the pamphlet for content validity with two health professionals who are expert in the pediatric field.

Definitions of Terms

The terms unique to this study were defined theoretically and operationally.

Obesity

The theoretical definition: Excessive accumulatin of fat in the body; increase in weight beyond that considered desirable with regard to age, height, and bone structure. (Miller and Keane, 1987)

Operational definition: obesity is a body mass index at or above the 95^th percentile. (Barker, Burton and Zieve’s, 2007)

Body Mass Index (BMI)

The theoretical definition: calculated from a person's weight and height. BMI provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems. (weight/(height²). (CDC, 2008)

Operational definition: The body mass index. A measureable calculation to determine proper weight for height. (Engel, 2006)

Child

Theoretical definition: the human young, from infancy to puberty. (Miller and Keane, 1987)

Operational definition: ``child'' means a person who is less than eighteen years of age (Canada Health Act, 1994).

Pamphlet

Theoretical definition: an unbound printed publication with no cover or with a paper cover. (Merriam-Webster online dictionary, 2008)

Operational definition: short printed publication with no cover or with a paper cover. (Merriam-Webster online dictionary, 2008)

Epidemic:

Theoretical definition: defined as rates of disease significantly higher than the usual frequency. (Valanis, 1999).

Operational definition: the occurrence in a defined population of cases of a particular illness, a specific health-related behavior, or other health-related event, clearly in excess of normal expectancy. (Valanis, 1999).

Limitations

1. The applicability of this tool will be limited to one geographic location.

2. A long-term post evaluation of the integration of this pamphlet’s content into the agency and its educational curriculum will not be completed as part of this project.

3. The childhood obesity pamphlet will be available only in English.

4. Lack of control of medical staff’s previous knowledge on childhood obesity and it’s medical and psychological implications.

Procedure for Data Collection

Following approval from D’Youville College Institutional Review Board (IRB) to conduct the project (see Appendix A), a pamphlet was developed that defines childhood obesity, explores risk factors, comorbidities and explores early prevention strategies to educate parents and caregivers (see Appendix B). Content was based upon an extensive review of the literature. The readability of the childhood obesity pamphlet was assessed using the Flesch-Kincaid Readability Score tool. Two content experts, a pediatric nurse practitioner and a pediatrician, known to the researcher through previous employment, were invited to evaluate the childhood obesity pamphlet for content validity and readability (see Appendix C). Each was contacted by the researcher via letter (see Appendix D) and the purpose of the project was explained. A researcher-developed evaluation tool was provided to each content expert for use in determining content validity (Appendix E).

The evaluation tool included eight Likert-type items that addressed whether (a) the information in the pamphlet was logical and easy for parents of children to understand, (b) the information in the pamphlet was useful to children’s parents, (c) the content adequately addressed what parents need to know about childhood obesity risk factors, comorbidities and early prevention strategies, (d) the content was accurate, (e) the content was comprehensive, (f) the content was current and evidence based, (g) the sources of information were credible, and (h) the material was presented without confusing or missing information. Responses were analyzed, and recommendations were incorporated in the childhood obesity pamphlet as appropriate.

Plan for Protection of Human Rights of the Participants

The proposal was submitted to the D’Youville College Institutional Review Board for an exempt review, as human subjects were not utilized in this project. Two pediatric experts evaluated the pamphlet for content validity and readability.

Plan for the Evaluation of the Effectiveness of the Project

Content validity experts evaluated the childhood obesity pamphlet for content validity and readability. Due to time constraints, the actual distribution of the pamphlet to parents and the evaluation of its effectiveness were not accomplished in this project.

Summary

Chapter I contained the introduction, statement of purpose, conceptual framework, initial literature review, significance and justification, project objectives, definition of terms, limitations, procedure for data collection, plan for protection of human rights of the participants and plan for the evaluation of the effectiveness of the project. Chapter II contains an in-depth review of the literature, while Chapter III presents the methodology outlining the setting, population, delineation of project and plan for protection of human rights of the participants and summary. Chapter IV presents implementation and evaluation of the project, implications for advanced practice, recommendations and summary.

CHAPTER II

REVIEW OF THE LITERATURE

Chapter II presents a review of the literature on childhood obesity incidence, comorbidities, risk factors and early prevention. The literature related to this research was the domains of pediatrics, nutrition/dietetics, medicine, nursing and epidemiology and was guided by Orem’s self care model. The major concepts described in Orem’s self care model provided direction for identifying relevant variables for the project.

Morbidity and Mortality

Obesity in children and adolescents represents one of the most frustrating and difficult diseases to treat. Children begin early to learn dietary and activity habits. Children themselves do not understand the long-term implications of obesity and sedentary lifestyles. You can’t explain to a child and have them understand the health issues that will affect them later in life, or the social isolation and bullying associated with being obese. Morbidities generally restricted to the children who are severely obese which included Pickwickian syndrome, orthopedic disorders such as genu valgum and genu varum and respiratory disorders such as upper airway obstruction (Onis & Blossner, 2000; Sorof & Daniels, 2002; Ludwig, 2002). The most prevalent immediate consequences for obese children are social isolation and peer problems (Birch, 1998).

Dietz (1998) looked at the lack of studies to reflect the difficulties in the maintenance of a cohort for the time necessary for adult diseases to occur. The relative risk of mortality was increased among males, but not females designated as overweight during adolescence. When the mortality risks in men were adjusted for cigarette smoking and adult weight, the mortality risks were only mildly attenuated. In both men and women, rates of diabetes, coronary heart disease, atherosclerosis, hip fracture and gout were increased in those who were overweight as adolescents.

Risk Factors

Parents also have learned how to use food to their advantage as a form of bribery for chores or good behavior. Children do not know how to set limits. They are at the mercy of parents and caregivers. Birch (1998), Baughcum, Burklow, Deeks, Powers, Whitaker (1998), and Jain et al (2001) looked at factors that influence the formation of children’s food preferences. Evidence was presented regarding food preferences, dietary intake and children’s adiposity with an emphasis on dietary fat. Few food and flavor preferences are innate, most are learned via experience with food and eating and involve associative conditioning of food cues to aspects of the child’s eating environment, especially the social contexts and physiological consequences of eating. Parents’ child-feeding practices are central and affect children’s food preferences and their regulation of energy intake. Parents and caregivers require counselling and education to understand the commitment and lifestyle change.

According to Barlow and Dietz (1998), a weight-management program for a parent or an adolescent who is not ready to change may be not only futile, but also harmful because an unsuccessful program may diminish the child’s self-esteem and impair future efforts to improve weight. These authors further state that families who are not ready to change may express a lack of concern about the child’s obesity, believe the obesity is inevitable and cannot be changed, or are not interested in modification of activity or eating.

Research conducted by Whitaker, Wright, Pepe, Seidel and Dietz (1997) concluded that obese children under three years of age without obese parents are at low risk for obesity in adulthood, but among older children, obesity is an increasingly important predictor of adult obesity, regardless of whether the parents are obese. Parental obesity more than doubles the risk of adult obesity among both obese and nonobese children under 10 years of age.

Weight of children among low-income mothers is viewed by some as good parenting and making sure one’s child always has food. Investigation of maternal feeding practices found that mothers believed that a heavy infant was a healthy infant and was the result of successful feeding and parenting. Parents believed that the bigger and faster their children grew, the better their food intake must be and therefore, the better their health must be. (Alaimo, Olson & Frongillo, 2001; Baughcum et al, 1998; O’Loughlin, Gray-Donald, Paradis, Meshefedjian, 2000.

An important theme is that, a bigger infant is a better infant. Low income mothers believe that a heavy infant was a healthier infant and was the result of the successful feeding and parenting given. One mother’s comments were, “if they are overweight, at least I know they are eating. If they are underweight, they are not eating and they are not getting the nutrients they need,” (Baughcum et al., 1998). In addition, the mother’s believed that a heavier baby proved to others that they were effective parents. One mother noted that if their infants were underweight, it might indicate to social service agencies that they did not care properly for their child (Baughcum et al., 1998). The second theme is “my baby is not getting enough to eat”, where the mother would introduce cereal early to the child’s diet and also introduce table food at an early age. Most mother’s did not feel that the formula was enough for them. The mother’s would complain that their child would be up every two hours screaming, and after starting cereal, they would sleep for six hours (Baughcum et al., 1998). This is obviously an educational deficit, as an infant waking every two hours for feeds is normal.

Researchers found that both hunger and obesity occur with an increased frequency among poorer populations in the United States. This can be described as a food insecurity when there is limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable food in socially acceptable ways. Consumption of cheaper foods, which tend to be energy (calorie) dense could result in the person consuming excessive energy and gaining weight (Alaimo et al., 2001).

Environmental Influences

Several studies report that increased television viewing by children is associated with increased obesity, possibly because television viewing is inversely associated with time spent in physical activity (O’Loughlin et al., 2000). Nielsen Media Research (Robinson, 1998) reveals that between the ages of 2 and 17 years, US children spend an average of more than 3 years of their waking lives watching television, not including the time spent watching videos, playing video games, or using a computer. There has been wide spread speculation that television viewing, as part of a sedentary lifestyle, is one of the most easily modifiable causes of obesity. Television is the largest single media source of messages about food. The vast majority of money spent on food advertising comes from branded food manufacturers and fast-food chains, such as McDonald’s, Burger King, Taco Bell and Wendy’s. The presence of television at meals and the number of nights per week parents chose foods for supper are because they are quick and easy to prepare and children eat them without complaining. This suggests a link between television at meals and family behaviors that minimize the work of feeding children. Several studies have documented widespread cultural attitudes in the United States that define vegetables as tasting bad to children, expensive, and trouble for adults to prepare (Coon, Goldberg, Rogers & Tucker, 2001).

Data from the 1997 Youth Risk Behavior Survey indicated that there is a decline in participation in both school and organized sports unaffiliated with schools during high school, especially among females. This may be due to a decrease in accessibility or availability of structured activity. Family income was significantly higher among those children in the non-overweight group compared with the overweight group, suggesting that the obesity rate among lower-income families is higher. Mandatory physical education classes have declined in the United States, which may very well be a cause of the increase in obesity amongst children (Dowda, M., Ainsworth, B.E., Addy, C.L., Saunders, R. & Riner, W.).

Troiano & Fegal (1998) found that only approximately half of all students in grades 9 through 12 reported being enrolled in physical education classes. The decline in physical education participation is particularly troubling because school-based, health-oriented physical education may provide both immediate effects of the activity and sustained effects through encouragement of life-long activity patterns. For physical education programs to contribute to the public health goal of life long activity, they should include activities of moderate intensity and should not focus exclusively on team-oriented sports activities.

At present, Illinois is the only state which requires daily physical education for all students in grades kindergarten to grade 12 (Borra, 2002).

Psychosocial Factors

The Department of Psychology, University of South Florida, looked at teasing by mothers, fathers and peers and how this affected self-esteem and body image, as well as psychological functioning. Adolescents with eating disturbances had a greater history of being teased about their appearance than non-eating disturbed controls. Peers were most often the teasers, but mothers (30%) and fathers (24%) were also frequent perpetrators of appearance related feedback. White and black women were asked if they had been criticized for being overweight during childhood/adolescence by their mother and father. White women reported significantly more instances of teasing than black women (Schwartz, 1997).

Analyses of psychosocial factors in the National Heart, Lung, and Blood Institute Growth and Health Study showed intriguing racial differences in measures of self-perception, particularly in the domains of physical appearance and social acceptance. Although satisfaction with physical appearance was lower with increasing adiposity for both groups, white girls manifested greater response to adiposity than did black girls (Kim & Obarzanek, 2002). Black girls exhibited no variation across the entire spectrum of adiposity, whereas an inverse association between perceived social acceptance and adiposity was seen in white girls. This finding on perceived social acceptance suggests greater tolerance for obesity among African Americans (Kim & Obarzanek, 2002).

In many obese children and adolescents, the most widespread consequences of obesity are psychosocial. Young people are socialized to the importance of appearance early in life. In both boys and girls who perceive themselves to be different from recognized norms, excess weight is a common reason for feeling different. Obese adolescents often experience significant depression and low self-esteem. Obese preschoolers have greater frequency and higher levels of emotional distress and psychiatric symptoms than peers of normal weight (Jonides, Buschbacher & Barlow, 2002).

Klish (1998) states that most children who are obese have a lack of self-esteem, and that about 10% of those children become clinically depressed and would benefit from psychological therapy.

Economic Burden

The increase in the percentage of hospital discharges with obesity-associated diseases may reflect the medical consequences of the obesity epidemic. The increase in obesity related discharges has increased 197%, sleep apnea has increased 436% and gallbladder disease has increased 228% (Wang & Dietz, 2002). During hospital admissions, obesity was usually listed as a secondary diagnosis. One potential explanation for this is that obesity is not generally a reimbursable diagnosis or medical health benefit. Health care payers may not reimburse for hospitalizations for obesity, even when obesity is the disease that causes diabetes, sleep apnea or gallbladder disease. Lack of reimbursement may delay the treatment of obesity and lead to lost opportunities to prevent obesity-associated diseases. The hospital costs associated with obesity have risen to more than $127 million per year. Recent estimates suggest that obesity related morbidity may account for 6.8% of US health care costs (Modkad, A., Serdula, M., Dietz, W., Bowman, B., Marks, J., & Koplan, J., 1999). Medical costs associated with either diabetes and obesity are considerably higher than those for heart disease and cancer, the two leading causes of death in the United States (Frazão, 2000).

The World Health Organization’s International Association for the Study of Obesity (WHO, 2000) states that the costs of obesity to a community and individuals may be divided into the direct costs to the health system and the indirect or social costs to the individual and community; examples would include sick days and individual expenditure on weight loss programs. The direct costs depend in the main part on the diseases caused by obesity and the cost of these diseases.

Healthcare costs are staggering with the treatment of obesity and associated diseases. Healthcare providers have hit a wall. Diseases which were ever only diagnosed in adults are now inflicting our children and are getting worse. Until a few years ago, most doctors say surgery or medications traditionally reserved for adults was something they would have never considered for their pediatric patients. But with childhood obesity growing in both rate and severity, physicians say those measures are now on the table (Sorof & Daniels, 2002).

Childhood obesity is associated with enormous health consequences and costs to society. Immediate action is required to slow or reverse this alarming trend. Programs directed at the treatment of children and adults with overweight and obesity have not been met with much success. In order to have the greatest impact on the health and economic costs associated with obesity, more attention needs to be given to prevention strategies (RNAO, 2005).

Tackling Canada’s childhood obesity problem will require a comprehensive multidisciplinary approach that must be supported by sufficient resources, organizational supports, education and attitudes. Therefore, nurses should advocate that, in addition to those for nursing, the curricula of academic and continuing education programs for allied health disciplines should also include content on this content, as well, nurses need to be informed about and skilled in interdisciplinary and intersectoral practice and collaboration, building and sustaining community coalitions, as well as interdisciplinary and participatory research (RNAO, 2005).

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