1. Bill Berlin and Sarah Gurd Ferris State University
Childhood Obesity
Bill Berlin and Sarah Gurd
Ferris State University

2. Objectives After this presentation, the learner will:
Identify the significance of childhood obesity to nursing.
Explain 2 main causes of childhood obesity
Identify 3 issues caused by childhood obesity
Explain what strategies nursing can implement to help prevent and reduce the rate of childhood obesity

3. Why is Childhood Obesity a BIG Deal?
17% of children between 2 and 18 are considered obese
Complications of obesity- Diabetes, hypertension, cardiovascular disease and many more!
Nurses work to promote health and prevent disease
17% of children in the US are considered obese. This is triple the rate of childhood obesity from the previous generation. With the many health complications associated with obesity, Babyatzky et al states that this may be the first time in 200 years that the current generation of American children has shorter life spans than their parents. As healthcare professionals, it is our responsibility as nurses to educate, empower and expose at risk children and their parents to healthy lifestyle choices.

4. Assessment of the Healthcare Environment- the pros
•Reaching out to children and their families:
– Primary Care Provider – well visits, sports physicals, acute care visits
– School nurses - focus on keeping students healthy and promoting health.
– Community Based or Public Health Nurse
In looking at the healthcare environment, let’s start with what we as health care workers are doing right regarding childhood obesity:
*The primary care provider is directly involved in patient care from birth thru adolescence thru well visits, sports physicals, and acute care visits. Height and weight are taken to calculate BMI, educational resources for parent/patient
*School nurses can help to address some of the nation’s most pressing health concerns while delivering quality, cost-effective health care. School districts that restructure revenue streams can use these dollars to support the delivery of health services, which ultimately will help to eliminate or reduce health-related barriers to learning and improve academic achievement. The school nurse role has focused on keeping students healthy and promoting health.
*To support community prevention efforts, the Affordable Care Act provides funding to advance activities that improve nutrition and increase physical activity, promoting healthy lifestyles and reducing obesity-related conditions and costs; programs in which school nurses are often involved. Under the ACA, states may have the ability to receive reimbursement for school health services and activities related to community-based prevention.

5. Assessment of the Healthcare Environment- the cons
Childhood obesity – a difficult subject to talk about.
Stigma surrounding childhood obesity – judgmental attitude
Lack of continuity in healthcare providers
Time Constraints during appointments
Medical Expenses: over a lifetime childhood obesity costs $19,000 per child (Duke Medicine, 2014)
The list of what’s wrong regarding healthcare and childhood obesity? Well…It’s much longer. Focus has increased on educating the population about the risks of childhood obesity. Healthcare professionals play a large part in helping parents address issues regarding their child's weight, Childhood obesity is a sensitive subject.
*This begs the question, healthcare professionals adequately trained to approach this topic with the parents and patient in a non-judgmental way?
*Due to the changes in healthcare delivery, patients do not always see their family doctor, but may see a nurse practitioner or physician assistant. This shuffling of providers does not provide the relational continuity to feel comfortable talking about sensitive issues.
*Primary care doctors' appointments are typically scheduled in 15-minute increments. For primary care doctors, time is money. Unlike specialists they do not generate payments for procedures. The fee for service payment model, of most health insurance companies, rewards doctors who see more patients. Short visits take a toll on the doctor-patient relationship. This makes it even more difficult to broach a sensitive subject like a child's obesity. (Rabin, 2014)
*Also, obesity is expensive. According to a study by Duke Medicine, childhood obesity comes with an estimated price tag of $19,000 per child when comparing lifetime medical costs to those of a normal weight child, according to an analysis. When multiplied by the number of obese 10-year-olds in the United States, lifetime medical costs for this age alone reach roughly $14 billion .

6. The Great Debate: Genetics vs. Environment
Studies have found that certain loci are strongly associated with childhood obesity.
Currently, we have no way to alter these traits
Environment
Research has shown that poor diets and lack of physical activity are risk factors for childhood obesity.
Modifiable factors
There are many causes of obesity, but the two biggest contributors are believed to be genetics and the environment
In a systematic review done in 2011, researchers examining information gathered from genome-wide association studies found that several loci, or the specific location of a sequence of DNA on a chromosome are linked to obesity in children and adolescents.
In 2012, data collected from the Healthy Youth Survey conducted by the state of Washington found that school districts which implemented an obesity prevention program that included nutritional standards for meals, healthy living campaigns, farm-to-school programs and participation in health groups saw a greater reduction in obesity rates than those districts that did not.
Because more research needs to be conducted on the function of the identified genes as well as their effect on obesity, modifiable factors such as diet and physical activity will be the focus of this presentation.

7. Root Cause Analysis Factors affecting food choices:
Unhealthy food and drink choices served in schools, childcare centers and homes
Marketing of unhealthy food and drink choices
Expense associated with healthier food options
Increases in portion size and intake of processed foods
The typical American diet, which features large portions of high-fat, high calorie and processed foods, is a large component of obesity in the United States. 55 million children are enrolled in schools throughout the US, over half of which still serve sugary drinks and unhealthy food choices. Sugary drinks are the largest source of added sugar, and contribute to large amounts of caloric intake in children. High levels of consumption of these drinks are associated with obesity, and the CDC found that 80% of children drink them on a typical day.
Children view over 10,000 commercials a year for fast food, soft drinks and unhealthy snacks all marketed specifically at their demographic (Kaneshiro, 2012). Processed foods are cheaper to produce, and therefore less expensive for consumers to purchase. Over time, portion sizes, particularly of unhealthy food and drink options have increased throughout grocery stores and restaurants throughout the US. Finally, as more parents work outside the home, more processed foods are consumed in the household, which tend to be higher in calories and have lower nutritional density. (CDC,2013).

8. Root Cause Analysis cont’d
Factors affecting physical activity:
Daily physical activity programs not available in all school systems.
Difficulty to find safe, positive environments for children to take part in regular physical activity.
Overuse of television and media
Inactivity is a major contributor to childhood obesity. Most adolescents fall short of the recommended 60 minutes of physical activity a day. In fact, in 2007 only 18% of high school students reported meeting this recommendation. A daily, quality physical education program in schools could help reach this goal, but only 1/3 of students participated in daily physical education classes. For many children, safe routes for walking or biking to school or playgrounds may not exist. Half of children in the US do not have a park, community center or sidewalk in their neighborhood. In fact, only 27 states have policies regarding community-scale design. Children between the ages of 8 and 18 spend an average of 7.5 hours on electronic media per day (CDC, 2013).

9. Root Cause Analysis cont’d
Other factors leading to obesity
Learned behaviors
Lack of breastfeeding support
Medications
Medical conditions
These are some other factors that can lead to childhood obesity. Learned behaviors such as children being rewarded with food, having to eat all the food on your plate or using food as a source of comfort lead to overeating. Children tend to model their parents behavior, therefore are more likely to be overweight if their parents lead inactive lifestyles and having poor eating habits.
Studies have shown that breast feeding can protect against childhood obesity. Although 75% of mothers in the US breastfeed their newborns, only 13% are exclusively breastfeeding at 6 months of age.
Medications like anti-depressants or birth control can also cause weight gain, as can some medical conditions such as hypothyroidisms (CDC,2013).

10. Inferences and Implications
Self assessment
Primary medical care needs to be transformed.
Community approach to prevention of childhood obesity
Health Promotion Strategy
Prevention Interventions
Protection Interventions
Lifestyle changes
Now that we have looked at the information, what should we do next?
*The nurse should examine his or her own feelings about obesity. It is important to be aware of one’s negative beliefs and attitudes. Nurses owe it to themselves and those in their care to solidify strengths and identify areas for growth.
*There is currently a Medicare Demonstration Project called the Michigan Primary Care Transformation (MiPCT). RN Care Managers are embedded into the medical practice. This is a three-year multi-payer project aimed at improving health in the state, making care more affordable, and strengthening the patient-care team relationship. MiPCT is state-wide in scope and is the largest Patient-Centered Medical Home (PCMH) project in the nation. Approximately 400 primary care practices and 1900 primary care physicians and mid-level providers affiliated with one of 35 physician/physician hospital organizations are currently receiving payments. In addition to Medicare, Blue Care Network and Priority Health are also paying for the care management services. The RN Care Manager is able to spend more time with the patients, at less cost than the physician. He/She is able to have multiple contacts with the patient/family in order to develop the trust relationship necessary to discuss sensitive topics like childhood obesity. Billing codes are added based on the service – for example telephone contact vs. face to face contact. The program is being reviewed for continuation.
A community-based approach will require a community-readiness assessment. For example: Union County a rural county in the State of Oregon used the Community Readiness Model to 1) identify the counties' state of readiness to prevent childhood obesity, 2)Identify Community members with expertise or interest in children's nutrition and/or physical activity who were willing to serve on a prevention coalition, 3)Engage these community members in developing strategies to increase the county's level of readiness, and 4)Establish qualitative data on community strengths and barriers that facilitate or hinder the development of an obesity prevention program (Findholt, 2007). In order to facilitate change at the community level, Berkowitz and Borchard (2009) indicate the nurse should:
1)Advocate for the federal government to increase physical activity promotion.
2)Support efforts to preserve and enhance parks as areas for physical activity, to develop walking and bike paths and to promote families' use of these activities.
3)Engage families with parental obesity in prevention activities. A long term study with a ten-year follow up showed that success factors for childhood obesity interventions included involvement of at least one parent as an active participant in the weight loss process (Berkowitz & Borchard, 2009).
4)Encourage parenting styles that support increased physical activities and reduce sedentary behaviors.
5)Encourage parental modeling of healthy dietary choices
A prevention interventions are behavior changes at the individual, family, or community level that promotes positive health improvements) - Literature is consistent that prevention is more successful than most forms of corrective action. Literally, an ounce of prevention is worth a pound of cure. A key area for prevention is targeting preschoolers and their parents which has shown to be successful (Berkowitz & Borchard, 2009)
A protection strategy (behavior change at the individual, family, or community level that actively avoids poor health) for example - pop machines will not be located within the school.
*-studies have shown that children will prefer and consume the foods they are most routinely exposed to (Berkowitz & Borchard, 2009). Focus on increasing intake of healthy foods like fruits and vegetables is more effective than focusing on decreasing fat and sugar.
In order to reduce childhood obesity, there must be a change in the way people live. The average American consumes almost 3 pounds of sugar a week. The World Health Organization recommends the average American consume less than 25 grams a day. Obesity rates will only be reduced with a healthy balanced diet and adequate physical activity, neither of which the average American has.

11. Inferences and Implications cont’d
The Three E’s
Educate
Expose
Empower
In order to modify behaviors, nurses must work closely with both parents and children.
Learning should focus on the importance and benefits of increased physical activity and proper nutrition. By teaching the significance of eating a healthy balanced diet, minimizing processed food and sugary drink intake while eating more fresh produce will help children get the nutrients they need for proper growth and development. Increasing physical activity will help to burn calories, build muscle and bone density, as well as developing balance and coordination.
Participating in cooking classes and athletic programs that encourage exercise can help build confidence and develop lasting, healthy habits. If adults and their children feel comfortable in preparing nutritious dishes that are appetizing, they may be more likely to cook these kinds of meals rather than serving processed ones. Making physical activity part of a daily routine would make it easier for children to get the exercise they need, instead of making it seem like a punishment.
Finally, parents need to feel enabled to push for changes in the community, like farm-to-school programs or providing safe areas for their children to play. If it takes a village to raise a child, then it also takes one to make them healthy. Generating community support for healthy lifestyles would make it easier to live them.

12. Solution GET INVOLVED!!!! Build Relationships Raise Awareness
Take Action
Nurses can work within the community in many different ways to affect the changes necessary to prevent childhood obesity. Networking with government officials, school administrators and business executives can help raise funds for community programs, and generate support for obesity reduction initiatives.
Advocating for changes that support healthy lifestyles in the community, such as bike lanes, neighborhood gardens or healthier food choices in schools promotes public health.
Finally, direct action, such as leading nutrition seminars, forming walking groups or teaching cooking classes help both parents and children learn healthy lifestyle behaviors.

13. Solutions cont’d Strategies to encourage a balanced diet
Offer incentives to grocery stores
Reduce access to sugary, processed food and drinks
Model healthy eating
Strategies to encourage physical activity
Limit time spent using electronic devices
60 minutes of play per day!
Make activities accessible
Although there are many ways to go about this, the solutions listed here are relatively simple. Offering grocery stores tax breaks for establishing businesses in low income areas and for offering more fresh, healthy foods will make these foods more accessible.
Offering more free drinking water and nutritious snacks while removing processed snacks like chips and sodas from schools will encourage children to consume healthier food options while limiting the availability of foods with low nutritional value.
If children see their parents eating a healthy diet, they will be more likely to do the same. Good habits can be formed in the exact same way bad ways are, by doing the same things repeatedly.
Restricting how much time children spend playing video games or watching TV will help encourage them to be more active by limiting time spent on sedentary activities. The CDC recommends that children get 60 minutes of physical activity a day, focusing on aerobic conditioning, muscle building and bone strengthening. This could include traditional physical training exercises, like push-ups, sit-ups and running, playing sports such as basketball or soccer, participating in gymnastics or free play on a neighborhood playground. Finally, by providing bike lanes, walking paths and safe places to play, children will have more opportunities to be active.

14. Summary Childhood obesity is a major issue
Leads to multiple health issues
Costs BIG BUCKS
Can be mitigated through better nutrition and regular exercise
In conclusion, childhood obesity is a huge problem faced by our society. Although there many causes for it, the two most modifiable issues are diet and lack of exercise. Obesity leads to many health issues, and costs millions of dollars in medical care a year. In order to reduce the rate of obesity, children need to eat reasonable, balanced meals and get adequate physical activity daily.

15. References
Babyatzky, J., Kim, J., Kramer, S., Radday, A., & Stanzler, C. (2011). Childhood Obesity Prevention. Social Issue Report, May 2011, 1-6. Berkowitz, B and Borchard, M. (2009). Advocating for the prevention of childhood obesity: a call to action for nursing. The Online Journal of Issues in Nursing 14(1). Retrieved from CDC (2013). A growing problem, what causes childhood obesity? Retrieved from Centers for Disease Control and Prevention. (2011, May 16). Overweight and obesity. Retrieved from Duke Medicine (2014, April 7). Over a lifetime, childhood obesity costs $19,000 per child. Retrieved from: htm Findholt, N. (2007). Application of the community readiness model for childhood obesity prevention. Public Health Nursing 24(6) DOI: /j x
We want to thank everyone for tuning in. If you haven’t already, please check out the links posted to the related readings and questions posted in the discussion board, and we look forward to hearing your feed back.

16. References cont’d
Kaneshiro, N. (2012, August 1). Causes and risks for obesity - children. Retrieved from htm Kern, E., Chan, N., Fleming, D., & Krieger, J. (2014). Declines in student obesity prevalence associated with a prevention initiative-King County, Washington, Morbidity and Mortality Weekly Report, 63(07), Rabin, R.C. (2014, April 21) 15-minute visits take a toll on the doctor-patient relationship. Retrieved from doctor- visits.aspx Zhao, J., & Grant, S. (2011, April 6). Genetics of Childhood Obesity. Journal of Obesity, 2011,1-9. doi: /2011/845148