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Primary Care Nursing for the Prevention and Treatment of Obesity in Children
Sarah Richmond
University of Central Florida
College of Nursing
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Abstract
Childhood obesity is a growing epidemic in our society. Advanced Practice Nurses working in a
primary care setting will likely be responsible for the prevention, identification, and treatment of
excessive weight gain in children; especially due to the increasing prevalence of childhood
obesity. Primary care providers and the health care community as a whole should be aware of the
risks associated with the development of childhood obesity, including adverse health,
psychosocial, and societal consequences. Advanced Practice Nurses should also understand the
causations associated with childhood obesity, and possess knowledge of effective interventions
to prevent and treat excessive weight gain in children. Nursing theory can help to guide
practitioners in developing effective intervention strategies related to childhood obesity. The
Client Health Behavior Interaction Model is especially effective in determining the relationships
between client singularity, the client-professional relationship, and clinical outcomes as they
relate to childhood obesity. This model takes into consideration the various factors which
contribute to health behavior, and recognizes that nursing intervention and outcome evaluation
vary between individual cases. The application and use of the Client Health Behavior Interaction
Model can assist practitioners both in preventing and decreasing the overall incidence of
childhood obesity in the pediatric population. This model has already been utilized in research
related to excessive childhood weight gain, and can continue to guide research in the future.
Keywords: childhood obesity, adolescence, weight gain, advanced practice nursing,
primary care, nursing theory, client health behavior interaction model, middle range
theory
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Primary Care Nursing for the Prevention and Treatment of Obesity in Children
Introduction and Background
Childhood obesity is an increasing epidemic which affects many, both in the United
States and around the world. In a primary care setting, Advanced Practice Nurses will likely
encounter this issue and be responsible for the prevention and treatment of obesity in the
pediatric population. Therefore, it is imperative that those practicing in a primary care setting
understand the issues and interventions related to excessive weight gain in children, in order to
provide the best care possible for patients. Nursing theory can act as a guide for practitioners in
the primary care setting, allowing for the development of effective intervention strategies related
to childhood obesity. The Client Health Behavior Interaction Model is effective in analyzing
relationships between client singularity, the client-professional relationship, and clinical
outcomes as they relate to childhood obesity; and can help to decrease the overall incidence of
childhood obesity when properly utilized.
Incidence
According the Centers for Disease Control and Prevention (2013), during the last 30
years alone in the U.S., the incidence of obesity has more than doubled for children and tripled
for adolescents; classifying approximately 17 percent (or 12.5 million) of children and
adolescents as overweight or obese in 2010. Certain ethnic groups experience a
disproportionately higher incidence of childhood obesity, including African Americans, Mexican
Americans, and Native Americans (Caprio et al., 2008). In addition to increasing incidence, the
severity of obesity has also increased in recent years. The prevalence of severe obesity in 19992000 for adolescents was estimated at 10 percent in non-Hispanic whites, 20 percent in nonHispanic blacks, and 16 percent in Mexican Americans (Caprio et al., 2008).
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Risks Associated with Childhood Obesity
Obesity and excess weight gain can contribute to a multitude of health issues in children.
According to the American Heart Association’s Childhood Obesity Research Summit Report
(Daniels, Jacobson, McCrindle, Eckel, & McHugh Sanner, 2009):
The increasing prevalence and severity of obesity in children and adolescents have
resulted in a higher prevalence of comorbid conditions, including high blood pressure,
early development of atherosclerosis, type 2 diabetes mellitus, nonalcoholic fatty liver
disease, polycystic ovary disorder, and disordered breathing during sleep. These
complications can occur both in the short-term and in the long-term. Some complications,
such as type 2 diabetes mellitus, previously thought to only occur in adulthood have now
been shown to occur in children and adolescents. This has raised concerns about whether
the obesity epidemic might shorten the lifespan of the current generation of children. (p.
e490)
In addition to experiencing increased health risks early in life, overweight adolescents have
approximately a 70 percent chance of becoming overweight or obese adults, which may increase
up to 80 percent if one or more parent is overweight (Bishop, Middendorf, Babin, & Tilson,
2005). Obesity during childhood is therefore linked to complications of adult obesity including
higher rates of cancer, cardiovascular disease, high blood pressure, diabetes, metabolic
syndrome, and degenerative joint disease (Groner et al., 2009).
There have also been studies related to adverse psychosocial and societal consequences
of childhood obesity including poor school performance, unhealthy or risky behaviors such as
tobacco use, premature sexual behavior, alcohol abuse, and inappropriate diet practices (Daniels
et al., 2009).
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Causation
The development of childhood obesity is often caused by a culmination of contributing
factors. Childhood diet and food preferences are major factors which can affect risk for
excessive weight gain. Children may consume larger portions of food and beverages than
required for energy, and may also choose readily available foods which can include those higher
in sugar and fat (Karnik & Kanekar, 2012). On average, one third of meals are consumed outside
of the home, and often include school or fast foods. These commonly contain an excess of
calories and fat (Vessey & MacKenzie, 2000). Children also tend to prefer foods that are
introduced early to them, and those regularly consumed by their families. In addition, children
may be partial to foods which are used as reward for positive behaviors (Vessey & MacKenzie,
2000). If a child consumes a diet full of unhealthy options, it may lead to the consumption of an
excess amount of calories and weight gain.
Physical activity and exercise also impact weight in children. In the United States the
amount of sedentary time spent by children is on the rise, and time utilized performing physical
activities is declining (Vessey & Mackenzie, 2000). According to Karnik & Kanekar, sedentary
lifestyle is a factor for obesity, as many children spend much of their time watching television,
playing video games, and using computers. Children also tend to snack more while sedentary,
and can be influenced to eat high fat and processed foods advertised on television (2012).
Genetic factors, socioeconomic status, and cultural practices may also influence the
incidence of obesity in some children. Certain genetic patterns affecting metabolism may be
inherited from parents, which can increase a child’s susceptibility for obesity (Karnik &
Kanekar, 2012). Culture can influence a person’s perception related to ideal body size,
understanding of risks related to obesity, development of eating behaviors, food choices based on
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availability and familiarity, and exercise patterns (Caprio et al., 2008). Those children in a lower
economic group may also be at an increased risk for excessive weight gain. The Centers for
Disease Control and Prevention state that in 2010, 1 of 7 low-income, preschool-aged children
was obese (2013). This may be due in part to lower costs of fast food and foods rich in fat, in
comparison to healthier options, which can often be more expensive (Caprio et al., 2008).
Strategies for Prevention and Treatment
Advanced Practice Nurses practicing in the primary care setting should be familiar with
recommended strategies for the prevention and treatment of childhood obesity. Preventing
childhood obesity begins before birth. Controlling the weight of the mother before and during
pregnancy can reduce the risks for gestational diabetes and increased birth weight, which can
increase the risk for later developing childhood obesity (Budd & Hayman, 2006). Breastfeeding
exclusively for the first 6 months of life may also decrease the risk for childhood obesity (Budd
& Hayman, 2006).
When addressing childhood obesity, implementing a family-based plan has been found to
be effective. According to Sorg, Yehle, Coddington, & Ahmed (2013):
The social nature of the family creates an environment that allows for support, which is
crucial in the treatment of obesity. A home life that promotes healthy family habits is
essential to treating the obese child. Behavioral interventions such as dietary
modifications are more likely to become long-term lifestyle changes when presented to
the entire family rather than directed pointedly at changing one individual’s attitudes and
habits. (p. 16)
This emphasizes that addressing the home environment as a whole assists in maintaining positive
lifestyle changes. The inclusion of family members in weight management planning is especially
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important when addressing those with cultural factors which may be contributing to excessive
weight gain (Caprio et al., 2008). Educating children and families together about obesity and a
healthy lifestyle is one of the main strategies which can help to battle excessive weight gain.
Diet is an especially important determinant when addressing childhood obesity.
Preventive measures related to diet include educating parents about balanced diets and
acceptable food choices for their children at various stages of life (Budd & Hayman, 2006). The
inclusion of foods which are lower in fat and high in fiber has also been shown to be beneficial
in the prevention and treatment of obesity (Daniels et al., 2009).
Another prevention and treatment measure to reduce excess weight is promoting the
inclusion of physical activity into the child’s everyday routine (McAdams, 2010). According to
the American Heart Association, “Clinical treatment intervention programs designed to promote
exercise should contain activities structured to the specific physical, emotional, and cognitive
needs of the participants. Exercise for overweight children should be appropriate to their specific
physiological and metabolic condition” (Daniels et al., 2009, p. e495). Reducing time doing
sedentary activities may also reduce the amount of calories consumed because of a decreased
opportunity to snack on unhealthy foods (Bishop et al., 2005).
Regular monitoring of Body Mass Index and the use of lifestyle assessments during
primary care visits are also helpful in detecting risk for obesity in children. Lifestyle assessments
can aid in identifying potential targets for prevention, and can also increase awareness of current
behaviors which may contribute to excess weight gain (Daniels et al., 2009).
Problem Statement
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Obesity or excessive weight gain in children can contribute to a multitude of health,
social, and psychological issues which can extend throughout a lifetime if not properly treated or
prevented.
Significance
Obesity in children is a very clinically significant topic. Obese or overweight children are
at increased risk for many other health issues as previously discussed, which can affect their
quality of life and ability to live a long and productive existence. In addition, obesity related
costs in the United States are extensive. According to the American Heart Association, “Obesityassociated annual hospital costs for children and youth have more than tripled over 2 decades,
rising from $35 million in 1979 to 1981 to $127 million in 1997 to 1999. After adjustment for
inflation and conversion to 2004 dollars, the national healthcare expenditures related to obesity
and overweight in adults alone range from $98 billion to $129 billion annually” (Daniels et al.,
2009, p. e490). Preventing the onset of obesity or treating it early in life can help to decrease
expenditures related to excessive weight gain. Due to the high incidence of obesity in America,
the U.S. Department of Health and Human Services’ Healthy People 2020 initiative also
addresses the importance of decreasing childhood obesity in several major national health
objectives. These objectives include reducing the proportion of children and adolescents who are
considered obese and preventing inappropriate weight gain in youth and adults (2013).
Specific Aims
Primary care practitioners working with the pediatric population should aim to decrease
the overall incidence for the development of childhood obesity and associated comorbidities in
patients. In addition, practitioners should work towards early detection of excessive weight gain
in children, along with prompt and effective intervention. These goals can be achieved by
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measures such as: early education of patients and families about ways to reduce childhood
obesity, encouraging patients and families to adapt a regular exercise regimen and healthy eating
habits, and assessing for lifestyle risk factors and indicators of excessive weight gain, such as
body mass index, during regular scheduled appointments.
Theory
Considering nursing theory can assist Nurse Practitioners in developing effective
interventions and treatment strategies by outlining health relationships and disease in
populations. The Interaction Model of Client Health Behavior, first introduced by Cheryl Cox in
1982, is a practical example of nursing theory which can be applied to the primary care and
prevention of childhood obesity. According to Cox, “The object of the model is to identify and
suggest explanatory relationships between client singularity, the client provider relationship, and
subsequent client health behavior” (1982, p. 46). Essentially, the model recognizes that clients
are capable of making health care decisions, and that those choices are affected by the client’s
singularity, along with specific aspects of the client-provider relationship. The model also states
that it is useful in situations in which the client personal responsibility or health promotion effort
is paramount, at which time the provider becomes less of a health care decision maker and more
of a teacher or counselor (Cox, 1982, p.46). McEwen & Wills suggest that the Interaction Model
of Client Health Behavior (IMCHB), seeks to provide a client-focused theoretical framework of
health behavior, which help to develop interventions specific to the individual person and their
healthcare needs (2007).
Cox states that theoretically, “the elaboration of such a framework and its substantiation
through rigorous research will provide the profession with high-level predictive theory that will
facilitate client care and will further advance nursing knowledge in an orderly manner” (p.42).
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Other theoretical assumptions made by the author include the idea that clients are capable of
making informed and independent decisions about their health care behavior, and that choices
are affected by various aspects of client singularity. The model also makes the assumption that
the client should be given the maximum amount of control in relation to their health care due to
focus on internalization of responsibility for health behavior (Cox, 1982).
The IMCHB falls under the scope of a middle range nursing theory because it fulfills the
requirements for theory in the middle range level. Middle range theories are specific to nursing,
focus primarily on client problems and intervention outcomes, are relatively straightforward and
general, can consider a limited number of concepts, have a particular substantive focus, and are
receptive to empirical testing (McEwin & Wills, 2007). In this case, the concepts are clearly
defined and outlined within the theory, and are within the focus of the nursing discipline. In
addition, the concepts are represented within a model describing the relationships within the
theory, as prescribed by Smith and Liehr (2014). The context of the model is also described by
Cox, in which she states that the model can be used for various health concerns, and in multiple
settings such as in private practices, hospitals, home care settings, and clinics (1982).
Major Concepts
There are several major concepts which are essential to the Interaction Model of Client
Health Behavior. The first element suggested by the IMCHB is the concept of client singularity.
According to Cox (1982), “Client singularity is the term used to describe the configuration of the
client’s background variables, expression of motivation, appraisal of health care concern, and the
affective response to that concern” (p.48). Background variables contributing to interpretation of
the IMCHB may include demographic characteristics, amount and consistency of social
influence, previous health care experience, and environmental resources (Cox, 1982). Motivation
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is also a key component of singularity, which addresses the willingness of the client to comply
with intervention. In addition, competency, self-determinism, cognitive representation of health
care concerns, associated degree of anxiety, and emotional response to health care concerns are
factors associated with singularity (Cox, 1982, p.48-50). The unique combination of these
concepts, which make up client singularity, should be used by the health care professional in
determining effective interventions for the patient and his or her health care goals (Cox, 1982).
The second concept proposed by the IMCHB is the client-professional interaction.
Components making up this interaction include the provision of health care information,
affective support, decisional control, and professional-technical competencies (Cox, 1982). The
provision of health information essentially provides knowledge to the client about the health care
concern, risks associated with the concern, and what can be done to prevent, improve, or rectify
the health care issue. Affective support addresses the client’s emotional response and relates it to
the client’s cognitive appraisal of the health concern. According to Cox, the cognitive appraisal
of the health concern should be congruent with emotional response in order for effective
intervention to take place (Cox, 1982). Decisional control refers to the patient’s expectations of
having the ability to participate in making decisions related to health concerns; and professionaltechnical competencies address the patient’s need for education related to technical skills
necessary for health care intervention (Cox, 1982).
The final component of the IMCHB addresses the elements of client health behavior, and
associated health outcomes. The model defines health outcome as it relates to certain variables,
which include, “The utilization of health care services, clinical health-status indicators, severity
of health care problem, adherence to the recommended health care regimen, and satisfaction with
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care” (Cox, 1982, p. 53). These variables are useful in determining the outcomes related to the
interactions between all of the components of the Interaction Model of Client Health Behavior.
Application of the Theory in the Prevention and Treatment of Childhood Obesity
Although the Interaction Model of Client Health Behavior does not provide specific
interventions related to the prevention of childhood obesity, the theoretical concepts within the
model are applicable to this clinical problem, along with many other primary care concerns.
According to an article by Mathews and Muirhead, “IMCHB model offers NPs a holistic nursing
approach to guide practice that is well suited to primary care and complementary to medical
practice” (2007). As previously described, childhood obesity is caused by a variety of factors
which are addressed in the primary care setting; and the utilization of this model can assist in
identifying the relationships between the practitioner, the client, and healthcare outcomes (Cox,
1982).
The client described in the model would apply to both the family and child in a primary
care setting when relating to the prevention of childhood obesity. In order for a practitioner to
effectively treat or prevent excessive weight gain in a child, identifying the elements of client
singularity, including demographics, family dynamics, resources available to them, and
motivation can assist when developing a plan of intervention (Cox, 1982). As previously stated,
childhood obesity can have a multitude of risk factors and causations including genetics, diet,
exercise habits, cultural influences, family dynamics, and socioeconomic status (Caprio et al.,
2008). In order to effectively treat each patient, a primary care practitioner would need to assess
each case on an individual basis, identifying and targeting the specific risk factors or underlying
causes related to childhood obesity.
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Assessing motivation in the case of both the child and the family for preventing
childhood obesity or intervening in the case of excessive weight is paramount. Childhood obesity
is best addressed as a family unit, as described by Sorg, Yehle, Coddington, & Ahmed, since the
nature of the family creates an environment that allows for support; and a home life that
promotes a healthy lifestyle is crucial in the treatment of obesity (2013). If the family and/or
child are not motivated to pursue a healthy lifestyle, the likelihood of successful intervention or
prevention of obesity would be decreased.
Competency and cognitive ideas or representations related to childhood obesity should
also be taken into consideration when assessing client singularity. For instance, a child or
adolescent may or may not be competent enough to participate in his or her own health care
decision making, which would affect the development of effective intervention strategies. In
addition, the practitioner would need to assess the preconceived ideas related to childhood
obesity that a family might hold. Families may have different perceptions related to ideal body
size, understandings of obesity, and behaviors related to diet and exercise (Caprio et al., 2008).
Identifying misconceptions and ideas related to childhood obesity can allow for proper education
and intervention related to weight gain.
The idea of client-professional interaction is also applicable to primary care of childhood
obesity; more specifically for implementing education and intervention. For instance, providing
health care information related to risk factors associated with childhood obesity, along with
education about the potential complications related to excessive weight gain might help to
motivate families to pursue a healthier lifestyle. In addition, teaching professional-technical
skills, such as familiarization with nutritional tools in this case, may increase the patient’s sense
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of control and competency in regards to their health status (Cox, 1982), and thereby reducing
their risks for excessive weight gain.
Evaluating health outcomes, by identifying client behaviors as they relate interventions in
the primary care setting, is the final component of the theory. Analyzing the relationships
between client singularity, intervention through client-professional interaction, and their
associated outcomes can act to identify effective nursing strategies, and aid in the development
of new interventions (Cox, 1982). Due to the high incidence of childhood obesity in the United
States, understanding relationships between factors associated with excessive weight gain and
the treatment of childhood obesity can help to improve the overall health of the pediatric
population.
The relationship between the Interaction Model of Client Health Behavior and childhood
weight gain has been previously explored. In a study by Robinson & Thomas, researchers
explored the IMCHB as a guide for explaining children’s health behaviors. Measures for client
singularity included demographics, family health, financial difficulty, and parental educational
level. The child’s health perception, food preferences, and feelings towards exercise, along with
other factors were assessed using a modified version of a previously developed Family Profile.
The relationships proposed in the IMCHB were then systematically explored within the data set,
and compared to exercise and diet behaviors. According to the study, The IMCHB was proven to
be a useful framework for the study of children’s diet behavior and physical activity (Robinson
& Thomas, 2004).
Another study which has been done in relationship to the IMCHB model and childhood
obesity was conducted by Haney and Erdogan (2012). This study explored factors related to diet
habits and body mass index among Turkish school children. According to the article:
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The aim of the study was to identify those variables that influence school-age children's
dietary habits and BMI values. Specific objectives were: (1) to use the IMCHB as a
conceptual guide to explain the correlates of children's dietary habits and BMI values; (2)
to determine the contributions of socio-demographic variables, health experiences, family
influence, intrinsic motivation, cognitive appraisal, and affective response to children's
dietary habits and BMI values; (3) to explain the interrelationships among the variables
that contributed to dietary habits and BMI; and (4) to examine the relationship between
gender and dietary habits. (p. 1346)
In this study, the IMCHB was used as a framework that recognized the importance of
background variables and dynamic variables in relation to dietary habits and Body Mass Index
values of children (Haney & Erdogan, 2012).
These examples help to highlight the various ways in which the model can be tested and
utilized in research related to childhood obesity, although it can also be applied to studies in
other areas of practice.
Conclusion and Summary
The goal of primary care nursing intervention for childhood obesity is to prevent or
decrease the prevalence and severity of excessive weight gain in children. Aiming for early
detection and treatment of overweight children may also help to prevent long-term complications
of obesity which can continue throughout adulthood. In addition, identifying effective nursing
interventions through research can facilitate improvement in strategies for increasing physical
activity and providing balanced diets for children, thus decreasing the risk for obesity (Karnik &
Kanekar, 2012). These goals are congruent with the initiatives sanctioned by the Healthy People
2020 program (2013). Nursing theory is a useful tool which can be utilized by Nurse
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Practitioners and other healthcare professionals to improve the outcomes of many health
concerns. The Interaction Model of Client Health Behavior is particularly useful when discussing
the prevention of childhood obesity. The various aspects, including client singularity, clientprofessional interaction, and outcome evaluation are useful in describing relationships between
variables and clinical outcomes. The use of this model can assist practitioners in developing
effective nursing interventions based on the individual patient or family in question. By applying
the IMCHB in practice, practitioners can help to decrease the overall incidence of childhood
obesity in their client population. The theory has already been utilized in research related to
weight gain in the pediatric population, and can continue to guide research in the future. Our
children are the future of our nation. In order to promote the continuation and legacy of our
society, it is imperative that we take all possible measures to ensure the good health of
generations to come. Advanced Practice Nurses are an integral part of an allied health care team
which will help to make this possible.
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