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Running head: CHILDHOOD OBESITY 1 Primary Care Nursing for the Prevention and Treatment of Obesity in Children Sarah Richmond University of Central Florida College of Nursing CHILDHOOD OBESITY 2 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 CHILDHOOD OBESITY 3 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). CHILDHOOD OBESITY 4 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). CHILDHOOD OBESITY 5 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 CHILDHOOD OBESITY 6 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 CHILDHOOD OBESITY 7 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 CHILDHOOD OBESITY 8 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 CHILDHOOD OBESITY 9 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). CHILDHOOD OBESITY 10 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 CHILDHOOD OBESITY 11 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 CHILDHOOD OBESITY 12 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. CHILDHOOD OBESITY 13 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 CHILDHOOD OBESITY 14 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: CHILDHOOD OBESITY 15 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 CHILDHOOD OBESITY 16 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. CHILDHOOD OBESITY 17 References Bishop, J., Middendorf, R., Babin, T., Tilson, W. (2005). U.S. Department of Health and Human Resources ASPE research brief: Childhood obesity. Retrieved from http://aspe.hhs.gov/health/reports/child_obesity/index.cfm Caprio, S., Daniels, S.R., Drewnowski, A., Kaufman, F.R., Palinkas, L.A., Rosenbloom, A.L., Schwimmer, J.B. (2008). Influence of race, ethnicity, and culture on childhood obesity: Implications for prevention and treatment. Diabetes Care, 31(11), 2211-2221. doi: 10.2337/dc08-9024 Centers for Disease Control and Prevention. (2013). Overweight and obesity: Data and statistics. Retrieved from http://www.cdc.gov/obesity/data/childhood.html Cox, C.L. (1982). An interaction model of client health behavior: Theoretical prescription for nursing. Advances in Nursing Science, 5(1), 41-56. Daniels, S.R., Jacobson, M.S., McCrindle, B.W., Eckel, R.H., McHugh Sanner, B.S. (2009). American Heart Association childhood obesity research summit report. Circulation, 119, e489-e517. doi: 10.1161/CIRCULATIONAHA.109.192216 Groner, J.A., Skybo, T., Murray-Johnson, L., Schwirian, P., Eneli, I., Sternstein, E. (2009). Anticipatory guidence for the prevention of childhood obesity: Design of the MOMS project. Clinical Pediatrics, 48(5), 483-492. doi: 10.1177/0009922809331799 Haney, M.O., Erdogan, S. (2013) Factors related to dietary habits and body mass index among Turkish school children: A Cox’s interaction model-based study. Journal of Advanced Nursing, 69(6), 1346-1356. doi: 10.1111/j.1365-2648.2012.06126.x CHILDHOOD OBESITY 18 Karnik, S., Kanekar, A. (2012). Childhood obesity: A global public health crisis. Journal of Preventative Medicine, 3(1), 1-7. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278864/ Mathews, S.K., Secrest, J., Muirhead, L. (2007). 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