1. Childhood Obesity: A Chronic Problem Ferris State University
Nursing 340
Timothy Amborski, Amy Bradley, Richardia Gibbs-Hook, Rhonda Jones, Robyn Veitch, and Jamie Ziemba

2. Childhood Obesity
1 in 3 adults and 1 in 6 children/adolescents are obese (U.S. Department of Health and Human Services, 2013).
Obesity leads to many chronic preventable diseases such as heart disease, strokes, and diabetes (U.S. Department of Health and Human Services, 2013).
Leading causes of mortality in the United States, Michigan, and District Health Department #10 are from chronic preventable diseases (District Health Department #10, 2011).
In Lake County the obesity rate from 2006 to 2010 was 43.1%. Healthy People 2020 target obesity rate is 30.6%. Lake County ranks the highest in obesity rates in District Health Department #10 (District Health Department #10, 2011).
Sustainable and effective interventions that reduce childhood obesity with primary, secondary, and tertiary prevention measures could lead to a reduction in incidences and mortality of chronic preventable diseases.

3. Analysis of Lake County For 2013
Michigan
Demographics
Population
11,539
9,876,187
% below 18 years of age
18%
23%
% 65 and older
24%
14%
Median household income
$28,971
$45,931
Children eligible for free lunch
85%
41%
Uninsured children 8% 5%
(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

4. Analysis
Lake
County
Error
Margin
Michigan
National
Benchmark*
Rank
(of 82)
Health Outcomes 59
Premature death
7,950
5,713-10,187
7,254
5,317
Morbidity 48
Poor or fair health
14%
10%
Poor physical health days
3.5
2.6
Poor mental health days
3.7
2.3
Low birthweight
7.4% %
8.4%
6.0%
(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

5. Analysis Lake County Error Margin Michigan National Benchmark* Rank
(of 82)
Health Factors 81
Health Behaviors 55
Adult smoking
20%
13%
Adult obesity
32%
26-40%
25%
Physical inactivity
26%
20-34%
21%
(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

6. Analysis 66 Lake County Error Margin Michigan National Benchmark* Rank
(of 82)
Clinical Care 66
Uninsured
21%
18-23%
14%
11%
Primary care physicians**
5,758:1
1,271:1
1,067:1
Dentists**
1,986:1
1,626:1
1,516:1
Preventable hospital stays 62
51-73 70 47
Diabetic screening
89%
78-99%
86%
90%
(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

7. Analysis
Lake
County
Error
Margin
Michigan
National
Benchmark*
Rank
(of 82)
Social & Economic Factors 81
High school graduation**
53%
74%
Some college
45%
36-54%
64%
70%
Unemployment
12.9%
10.3%
5.0%
Children in poverty
48%
37-60%
25%
14%
Inadequate social support
17%
11-27%
20%
Children in single-parent households
38%
29-47%
33%
Violent crime
349
497 66
(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

8. Analysis
Lake
County
Error
Margin
Michigan
National
Benchmark*
Rank
(of 82)
Physical Environment 69
Daily fine particulate matter
9.4
9.9
8.8
Drinking water safety
72% 1% 0%
Access to recreational facilities 9 16
Limited access to healthy foods** 7% 6%
Fast food restaurants
19%
49%
27%
* 90th percentile, i.e., only 10% are better.
**Data should not be compared with prior years due to changes in definition.
Note: Blank values reflect unreliable or missing data
(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

9. Ecological Model
"According to this model, behavior is a result of the knowledge, values, and beliefs of people, as well as numerous social influences"
Social Influences
Relationships
Social support
Community structure
Four levels of influence
Ontogenetic- Individual
Microsystems- Relationships
Exosystems- Community
Macrocultural- Societal
(Harkness & DeMaro, 2012, p.79)

10. Ecological Model for Childhood Obesity
(Birch & Ventura, 2009)

11. Community Strengths & Weaknesses
Limited access to fast food restaurants
Higher rates of children eligible for school lunch programs
Weaknesses
Lower than average household incomes
Higher than average uninsured children
Higher than average adult obesity and physical inactivity
Little access to primary care physicians
No access to recreational facilities

12. Partners for Change Parents Schools Healthcare workers
Encourage change and healthy behaviors at home by being positive role models
Schools
Increase physical education/activity
Take advantage of the school lunch program to provide healthy food
Healthcare workers
Provide education about obesity and the long term effects
Initiate healthy lifestyle programs in the community
Community leaders
Provide more recreational areas for kids to play

13. Problem Statement for Childhood Obesity
Obese children are at risk for heart disease, type 2 diabetes, stroke, several types of cancer, osteoarthritis, and are likely to be obese as adults
Among children and adults in Lake County
Related to onset of childhood obesity
As demonstrated by Lake County obesity rates above the State and National benchmark standards

14. The Childhood Obesity Problem
Children ages 6-11 in the US who were obese increased from 7% in 1980 to 18% in 2010 (CDC, 2013)
About one in three American kids is overweight or obese, nearly triple the rate in 1963 (American Heart Association, 2013)
Overweight is defined as having excess body weight for a certain height from fat, muscle, bone, water, or a combination of these factors
Obesity is defined as having excess body fat

15. Body Mass Index
Graphic from:

16. Lake County Planning
Lake County would have to decide on the following in the planning stage
Funding
Community involvement
Resources
Measurement of Success

17. Planning Goals
Reach
The strategy is likely to affect a large percentage of the target population.
Mutability
The strategy is in the realm of the community’s control.
Transferability
The strategy can be implemented in communities that differ in size, resources, and demographics.
Effect size
The potential magnitude of the health effect for the strategy is meaningful.
Sustainability of health impact
The health effect of the strategy will endure over time
(CDC, 2009)

18. Planning Goals Utility
The measurement serves the information needs of communities enabling them to plan and monitor community-level programs and strategies.
Construct validity
The measurement accurately assesses the environmental strategy or policy that it is intended to measure.
Feasibility
The measurement can be collected and used by local government (e.g. cities, counties, towns) without the need for surveys, access to proprietary data, specialized equipment, complex analytical techniques and expertise, or unrealistic resource expenditure.
(CDC, 2009)

19. Planning Goals
Communities should increase availability of healthier food and beverage choices in public service venues.
Suggested measurement
A policy exists to apply nutrition standards that are consistent with the dietary guidelines for Americans (US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans. 6th ed. Washington, DC: U.S. Government Printing Office; ) to all food sold (e.g., meal menus and vending machines) within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.
Communities should require physical education in schools.
The largest school district located within the local jurisdiction has a policy that requires a minimum of 150 minutes per week of PE in public elementary schools and a minimum of 225 minutes per week of PE in public middle schools and high schools throughout the school year (as recommended by the National Association of Sports and Physical Education).
(CDC, 2009)

20. Planning Goals
Communities should improve access to outdoor recreational facilities.
Suggested measurement
The percentage of residential parcels within a local jurisdiction that are located within a half- mile network distance of at least one outdoor public recreational facility.
Communities should enhance infrastructure supporting bicycling.
Total miles of designated shared-use paths and bike lanes relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.
Communities should enhance infrastructure supporting walking.
Total miles of paved sidewalks relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.
(CDC, 2009)

21. Planning Goals
Communities should participate in community coalitions or partnerships to address obesity.
Suggested measurement
Local government is an active member of at least one coalition or partnership that aims to promote environmental and policy change to promote active living and/or healthy eating (excluding personal health programs such as health fairs).
(CDC, 2009)

22. School Responsibilities and Interventions
Use a coordinated approach to develop, implement, and evaluate healthy eating and physical activity policies and practices.
Establish school environments that support healthy eating and physical activity.
Provide a quality school meal program and ensure that students have only appealing, healthy food and beverage choices offered outside of the school meal program.
Implement a comprehensive physical activity program with quality physical education as the cornerstone.
Implement health education that provides students with the knowledge, attitudes, skills, and experiences needed for lifelong healthy eating and physical activity.
(CDC, 2012)

23. School Responsibilities and Interventions
Provide students with health, mental health, and social services to address healthy eating, physical activity, and related chronic disease prevention.
Partner with families and community members in the development and implementation of healthy eating and physical activity policies, practices, and programs.
Provide a school employee wellness program that includes healthy eating and physical activity services for all school staff members.
Employ qualified persons, and provide professional development opportunities for physical education, health education, nutrition services, and health, mental health, and social services staff members, as well as staff members who supervise recess, cafeteria time, and out-of-school-time.
(CDC, 2012)

24. Community Responsibilities and Interventions
SMART OBJECTIVE FOR CHILDHOOD OBESITY
Smart is an acronym for program objectives that are specific, measurable, achievable, relevant, and time bound (Harkness & DeMarco, 2012).
According to the demographic information concerning Lake County, there is a high unemployment incidence and low income level and 85% of the children are eligible for a free school lunch program. There is a high prevalence of adult obesity and increased physical inactivity. Also, there is no access to recreational facilities presently.

25. Community Responsibilities and Interventions
SMART OBJECTIVE FOR CHILDHOOD OBESITY
Specific-What behaviors, knowledge, skill, change in health status indicators or outcome will result from the program (Harkness & DeMarco, 2012)?
The school children, age 6-10 of Lake County will have healthier nutrition available for the school lunch program.
The Robert Wood Johnson Foundation (RWJF) is to reverse the childhood obesity epidemic by 2015 by improving access to affordable, healthful foods and safe places for children walk, bike, and play in communities across the nation, especially those that are most affected by the epidemic and have the fewest Resources (Govea, 2011).
The Child Nutrition Act pays for school food and other nutrition programs for lower-income children.
Involve parents in nutrition and exercise educational meetings and cooking classes. One of the best stratagies to reduce childhood obesity is to improve the diet and exercise habits of the entire family. Parents are the ones who buy the food, cook the food, and decide where the food is eaten (Mayo Clinic, 2012).

26. Community Responsibilities and Interventions
Measurable: How will the outcome be measured and how will one know if the objective is achieved (Harkness & DeMarco, 2012)?
The BMI of this age group of children would be determined at the beginning of the program, and reevaluated at the end of the school year.
Teaching healthy eating and the five food groups would be added to the school curriculum and tested at the beginning of the program and reevaluated at the end of the school year.
Parental involvement would be necessary and monthly after school meetings would be encouraged to teach healthy eating requirements.
Parents would fill a survey out at the beginning of the school year, half way through the year and at the end of the year to determine areas of change needed. This would also allow for a question and answer period.
Monthly after school family fun nights would be started that would encourage physical activity, such as a nature hike, walking, and swimming.

27. Community Responsibilities and Interventions
Achievable -Appropriate and desired outcome.
Serving 1% or skim milk and water as the drink choices for school lunches.
Serve healthy foods in an attractive way. In a test, children were given identical snacks. One was packaged with a cartoon character and one in a plan package. More than two- thirds said they would choose the snack with the character on the package (Hellmich, 2010).
Serve daily lunch programs at school with healthier food options, implemented by the beginning of the school year 2013.
Provide daily healthy recipe ideas in a weekly parent newsletter, sent home from school with children.
Increase the daily exercise regime requirement to 60 minutes a day/5 days a week. This can be achieved by free play activities, physical education classes, and after school family fun nights.

28. Community Responsibilities and Intervention
Relevant/Realistic - The objective is related to the program's goals and activities (Harkness & DeMarco, 2012)
The plan objectives need to be simple to be able to focus on the 6-10 year old age group, yet involved enough to provide the instruction and information to the parents.
Goals are cost effective related to a lower income population.

29. Community Responsibility and Intervention
Time-bound - What time frame will the objective be accomplished?
The objectives initiated would be reevaluated at the end of the school year, and revised as needed.
According to the survey results that the parents provided three times during the school year, and the BMI results of the children at the end of the school year.

30. Evaluation
Evaluation is the process of collecting and analyzing information and is done in order to learn the value of a health promotion program or intervention (Pender, Parsons, & Murdaugh, 2011).
Evaluation information can be used to improve and implement health promotion programs that provide the most favorable outcomes for communities.
The evaluation plan must be considered during the program development process, as this enables appropriate, accurate information to be collected (Pender, Parsons, & Murdaugh, 2011).
Everyone affected must be involved in the evaluation process, including those benefitting from the interventions as well as those who will be implementing them.

31. Evaluation
Questions that may be answered in a comprehensive evaluation:
What are the intended effects?
What resources are needed to implement the interventions?
Who will benefit from the intervention?
Are those benefitting satisfied?
How can the program or intervention be improved?

32. Approaches to Evaluation
Process Evaluation
Concerned with whether a program or intervention was delivered as intended.
Provides insight into what factors might help or hinder achievement of the program.
Outcome Evaluation
Focuses on the results interventions.
The choice of results to measure is determined by the program goals.

33. Evaluation: How are we doing?
In evaluating whether interventions are effective in Lake County, we will measure how many more children in the 6-10 year old age group are taking advantage of school lunches at the end of the school year, versus the beginning of the school year.
This information is easily quantifiable from school lunch enrollment records.

34. Evaluation: How are we doing?
Survey the community: are the classes on nutrition, cooking, and exercise being attended? Why or why not?
Has the BMI of children in the 6-10 year old age category decreased by the end of the school year?
Test the knowledge: Are families and children more aware of healthy eating habits at the end of the school year compared to the beginning of the school year?
Survey: Have children increased their physical activity to 60 minutes a day 5 days per week? Why or why not?
Survey: Has participation in Family Fun night increased? Why or why not?
Compare: Are the school lunch choices actually more healthful throughout the program? Why or why not?

35. Evaluation
The success of the Lake County program to decrease obesity in children from 6-10 years old will depend on involvement of the community, the family, and the individual children.
Assessing for decreased BMI, school lunch enrollment, and community and school surveys concerning participation in activities and increased knowledge of healthy eating will all assist in evaluation in this program.

36. Conclusion
Lake County obesity rates are higher than the State, County, and National benchmarks and the Healthy People 2020 objectives.
A comprehensive community assessment with a focus on community assets will strengthen building community wide relationship to foster change (Harkness & DeMarco, 2012).
To effectively address childhood obesity issues parents, school administrators, health care professionals, and community leader need to form a collaborative partnership to implement change.
Interventions to reduce childhood obesity rates can lead to a healthier lifestyle which can have a direct impact on the rates of chronic preventable diseases during adulthood and mortality rates.

37. References
American Heart Association. (2013, January 28). Retrieved from Weight Management and Childhood Obesity: hood-obesity_UCM_304347_article.jsp
Birch, L.L., & Ventura, A.K. (2009). Preventing childhood obesity: What works? Preventing childhood obesity. International Journal of Obesity, 33, doi: /ijo
CDC. (2009, July 24). MMWR. Retrieved from Morbidity and Mortality Weekly Report:
CDC. (2012, October 5). CDC. Retrieved from Adolescence and School Health:
CDC. (2013, February 19). CDC. Retrieved from Adolescence and School Health:

38. References
District Health Department #10. (2011) Annual Report. Strong communities through healthy people. Retrieved from:
Govea, J. (2011). Center for Disease Control. Preventing chronic disease. Ethical concerns regarding interventions to prevent childhood obesity. Retrived from
Harkness, G. A., & DeMarco, R. (2012). Community and public health nursing, evidence for practice. Philadelphia: Lippincott Williams & Wilkins
Hellmich, N. (2010). USA today. Cartoon characters tilt kids' food choices. Retrieved from: kidscharacters21_ST_N.htm
Mayo Clinic. (2012). Childhood obesity. Retrieved from:

39. References
Pender, N., Parsons, M., & Murdaugh, C. (2011). Health promotion in nursing practice
(6th ed.). Upper Saddle River, NJ: Pearson
Robert Wood Johnson Foundation, University of Wisconsin Population Health Institute. (2013). County Health Rankings & Roadmaps: A Healthier Nation, County by County. Retrieved from erall/snapshot/by-rank
U.S. Department of Health and Human Services. (2013). Healthy People 2020: Nutrition, physical activity, and obesity. Retrieved from: