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Abstract
The prevalence of childhood obesity is increasing in the United States and globally. Associated with numerous comorbid conditions, childhood obesity is also recognized as a risk factor for multiple chronic conditions and premature mortality in adult life. Children and adolescents, particularly those from ethnic minorities and rural low income populations, bear an excess burden of obesity and its attendant comorbidities. A major contributor to childhood obesity is a physical and social environment that promotes foods high in fat and calories and minimizes the opportunities for physical activity. Despite the strong environmental influences that encourage overeating and sedentary behavior, weight maintenance is viewed as a personal responsibility. Addressing the obesity crisis requires a paradigm shift away from blaming individuals for the lack of willpower to control their eating and physical activity to one of recognizing the “toxic” or “obesigenic” environment as a primary determinant. This article addresses the obesity crisis from individual, family, local community, and public policy perspectives. Emphasis is placed on the role of nurses and nursing, acting to promote change with individuals and families and acting as advocates for multilevel policy initiatives, in reversing the epidemic and improving the health of future generations.
As the largest group of healthcare professionals, nurses are well positioned to be influential in preventing, identifying, and treating obesity and promoting advocacy efforts for multilevel policy changes necessary to create less obesigenic environments. Public opinion polls indicate that among professionals, nurses garner the most public respect for ethics and honesty (Jones, 2005). To this end, the purpose of this article is to emphasize the role of nursing leadership in reversing a major challenge to the health of the U.S. public, the crisis of obesity. Obesity is currently described as a pandemic (Chopra & Darnton-Hill, 2004) that is responsible for escalating rates of type 2 diabetes (T2DM), hypertension, cardiovascular disease, sleep apnea, osteoarthritis, bone and joint disorders, low self-esteem, cancer (Daniels et al., 2005), and reduced life expectancy in this generation of children (Katz, 2005). The prevalence of obesity is rising for Caucasians and people of color from all socioeconomic levels and geographic areas (Ogden et al., 2006). Finding solutions to this crisis requires concerted action involving the strategic synergistic efforts of science, government, and healthcare (Brownell, 2002; Koplan, Liverman, Kraak, & Wishan, 2006).
Epidemiology
Overweight and obesity result from an imbalance of energy intake and energy expenditure. Body mass index (BMI), the ratio of weight in kilograms to the square of height in meters (kg/m2), is widely used to define weight status. For children older than age 2, the Centers for Disease Control and Prevention (CDC) has standardized the evaluation and description of overweight and obesity with gender- and age-based percentiles intended for use along with height and weight charts (Kuczmarski et al., 2000). The CDC guidelines do not label children as obese but rather use these terms: “at risk of overweight” describes children and adolescents with a BMI between the 85th and 94th percentile for age and gender; “overweight,” describes children at or above the 95th percentile for age and gender. In this article, as in others (Barlow, 2007; Koplan, Liverman, & Kraak, 2005), children with a BMI >95th percentile for age and gender are referred to as obese.
Healthy People 2010 (2000) identified overweight and obesity as leading health indicators and set the goal of reducing childhood obesity to <5% and reducing adult obesity (over age 20) to <15%. In 2004, the Progress Review of Healthy People 2010 addressed nutrition and overweight (Progress Review Diabetes, 2002) and, paradoxically, reported an increase in the prevalence of overweight and obesity for all age groups in the United States. The latest national data indicate that 17% of children are obese (Ogden et al., 2006).
Poverty and education are inversely related to obesity and to a child's BMI (Nesbitt et al, 2004). Both obesity and T2DM disproportionately affect minority populations, especially African Americans and Hispanics of all ages. The problem is more severe in boys and in African American and Mexican American girls (Ogden et al., 2006). Because a primary goal is to eliminate the health disparities that result in unequal treatment (Healthy People 2010, 2000), addressing obesity continues to be a federal priority and becomes a nursing priority as the profession pursues a model of health that encourages disease prevention and health promotion for vulnerable groups.
The ecological framework (Bronfenbrenner, 1986), which proposes that multiple factors act at different levels of influence to promote or enhance the risk of individual development, facilitates understanding the complex nature of the obesity epidemic. Within this paradigm, behavior is recognized as the result of interactions of multiple subsystems over time and across settings and interdependent—rather than independent—of the environment. Individual weight maintenance is influenced by numerous factors at various levels, including family, community, and broader society. Factors that originate from public policy decisions and industry strategies are described as “upstream influences.” Downstream, the “built environment,” or physical locale (including the accessibility to recreation areas and safe walking options, the number of grocery stores, and availability and pricing of foods), influences an individual's potential for achieving energy balance. Figure 1 depicts the numerous factors within the bioecological model for the development of obesity.
 | Figure 1. Bioecological Model for the Development of Obesity |
By and large, Americans feel that individuals are responsible for their own obesity (Schwartz & Brownell, 2005). Almost all cases of obesity are primary, which means that the cause is not due to an underlying disease (Nesbitt et al., 2004), which likely contributes to the common perspective of obesity as a problem under individual control. Estimates are that approximately 30% to 50% of the determination of body shape, patterns of fat distribution, and response to overfeeding can be attributed to genetic factors (Perusse et al., 2005), which predispose individuals at risk to be more vulnerable to gaining weight in a permissive environment. The dramatic increases in prevalence and incidence of obesity over the past 30 years cannot be explained only by changes or mutations in the population gene pool (Nesbitt et al., 2004).
U.S. federal policy, along with the food and diet industry, currently manifests the paradigm of personal responsibility for food intake and physical activity. For example, a major government response to the obesity pandemic is an individual change initiative, coined “small steps” (www.smallstep.gov/ ). The food industry takes a similar attitude, using personal freedom (i.e., responsibility) as a springboard to avoid fast-food regulation or legislation.
Bias against obese individuals is common and often attributed to the belief that obesity is caused by a psychological weakness brought on by lack of willpower and laziness. Children as young as 2 years have been found to discriminate against heavier individuals (Cramer & Steinwert, 1998). As a result, obese persons suffer adverse consequences socially and in education, work, and healthcare (Puhl & Brownell, 2001). Research has documented that obese individuals are likely to evade healthcare, neglect preventive services, and avoid discussions of weight management with healthcare providers (Fontaine, Faith, Allison, & Cheskin, 1998), thereby increasing their risk of chronic conditions associated with obesity.
A child's early experiences in the family environment influence later food preferences and activity levels. Behavioral conditioning through family, cultural, and social cues provides the groundwork for the amount of food and physical activity an individual is likely to pursue (Berkowitz & Stunkard, 2004). Research consistently demonstrates that exposure to high-fat, high-sugar food (e.g., soda pop and fast food) along with large portion sizes increases the intake of these energy-dense foods (Ello-Martin, Ledikwe, & Rolls, 2005).
In the United States, eating meals prepared outside the home has increased 89% since the 1970s (Wang & Brownell, 2005), and the latest data indicate that approximately 46% of Americans eat at least one meal a day outside the home (Guthrie, Lin, & Frazao, 2002). In today's environment, many families find it difficult to eat dinner together; yet the frequency of family meals is positively associated with a healthier intake of fruits, vegetables, and protein (Neumark-Sztainer, Hannan, Story, Croll, & Perry, 2003). Over the past several decades, physical activity patterns also have changed. The result is more sedentary behavior during work, school, and play time (Dietz, 2005). Data from CDC (Eaton et al., 2006) indicate that only 54.2% of students nationwide are enrolled in physical education (PE) classes on 1 or more days of an average school week, whereas 33.0% are enrolled in daily PE classes. Nationwide, only 35.8% of students reported the recommended levels of moderate-to-vigorous physical activity of at least 60 minutes per day on at least 5 days per week. The prevalence of meeting this recommendation was low among all girls (27.8%) and lowest in black female students (21.3%).
The multilevel environmental factors that influence the development and maintenance of obesity have come to be described as “toxic” or “obesigenic” (Brownell, 2002). Within the past 35 years, the number of supermarkets in the United States declined by 15%, whereas the number of convenience stores and fast-food eateries doubled (Schwartz & Brownell, 2005). The cost and portion size of energy-dense, high-sugar, and high-fat foods decreased, which resulted in increased consumption. Healthy foods and fresh produce have been less likely to be found in stores located in poor neighborhoods (Popkin, Duffy, & Gordon-Larsen, 2005).
Children are the primary target of the food industry, because they view about 10,000 food advertisements a year, more than 95% of which are commercials for candy, fast food, soda pop, sugar cereals, and other unhealthy foods (Wang & Brownell, 2005). Toys and familiar characters entice children to purchase unhealthy food products. The marketing of food products in the United States is a multibillion dollar industry that only recently has come under attack (McGinnis, Gootman, & Kraak, 2006). In the 1970s, similar concerns about tobacco prompted federal authorities to prohibit cigarette advertising from television (Schwartz & Brownell, 2005).
Call to Action: The Implications for Nurses and Nursing
Across healthcare and community-based settings, nurses are positioned to advocate for individuals and families in implementing evidence-based activities designed to prevent excessive weight gain for those of normal weight and promote weight loss for the obese. Nursing care involves not only compassionate care for individuals but also advocacy for changes at school, local community, and public policy levels. Campaigning for social changes that promote healthy lifestyles, particularly for vulnerable populations such as children, the disabled, and those living in poverty, is warranted and has been suggested in recent reports and recommendations (Daniels et al., 2005; Koplan et al., 2006).
In direct care, nurses partner with patients in implementing individually tailored strategies for behavior change, including identification of barriers to change, education about behavior modification, skill sets for changing specific behaviors, and strategies for relapse prevention. According to the U.S. Preventive Services Task Force, behavioral counseling on healthy eating and physical activity is recommended at all well-child visits and for obese adults (McTigue et al., 2003). Adults and children should have their BMI measured and charted at every health care visit and should be informed about how BMI is used to assess excess weight. A brief explanation of the BMI parameters, health effects of obesity, and counseling/advice on healthy food and physical activity lifestyle options that are realistic and feasible and based on family resources should be part of such obesity prevention efforts. These activities are optimally implemented across clinical and community-based settings by nurses who are equipped with the necessary knowledge along with the technical and behavioral skill sets.
Often counseling about avoiding obesity is criticized because of the possibility that individuals, particularly females, will develop eating disorders. Recent research, however, did not find any relationship between dieting and eating disorders (Schwartz & Brownell, 2005). The promotion of healthy eating in order to increase the body and mind's strength and endurance with a nutritious diet high in vitamins and minerals from fruits and vegetables, low-fat sources of protein, and whole grains is a universal health message. Eating also should be a positive experience that occurs in a pleasant and unhurried manner. Care should be taken to avoid large portion sizes, especially for children. Recognizing physiological hunger and satiety signals rather than reacting to advertising, smell, or sights of food also should be stressed.
Counseling patients about the importance of physical activity includes education about increasing lifestyle-related activity (i.e., taking the stairs, walking to school and to after-school events and activities). Outside of school, children should not be sedentary, especially in front of the television and computer, for more than 2 hours a day. Alternatively, they should be involved in enjoyable, developmentally appropriate physical activity for 1 to 2 hours daily (Dietz, 2005). Role modeling these behaviors is an important mechanism for change; thus, parents, healthcare providers, teachers, and other individuals should consider being visibly engaged in daily physical activity.
Nurses are in an excellent position to develop parent classes in schools, healthcare settings, and the community. Teaching parents the basics of nutrition, including appropriate portion sizes, label-reading skills, food preparation, and “healthy” grocery shopping, is essential. In doing so, the family's individual preferences and resources must be considered. Behavior modification changes, such as keeping unhealthy foods out of the house and modeling appropriate eating and activity behaviors for children, are helpful. The National Heart Lung and Blood Institute has developed an obesity prevention program for families entitled “We Can.” The curriculum and materials for this 8-week course are available online (www.nhlbi.nih.gov/ ).
Parents and children alike are subject to the marketing techniques used in food advertising (McGinnis et al., 2006). Despite the popularity of the documentary film Supersize Me, which exposed one fast food franchise's unhealthy menus and value pricing strategies, parents may not have heard the health messages that contradict the food and beverage industry advertising. This is not surprising, considering that the food and beverage industry spends 100 times more that the federal government's public campaign for healthy nutrition (Schwartz & Brownell, 2005). Nurses can help families become sensitized to the food industry's strategies. The concept of media literacy is the ability to develop an informed and critical understanding of the nature, technique, and impact of what is seen, heard, or read in the media (McGinnis et al., 2006). Media literacy includes information about the food and beverage industry's advertising ploys and manipulation of consumers, such as the financial incentives for purchasing large amounts of unhealthy foods. Increasing parent's awareness about the marketing tactics used with children and the lack of regulation for such would raise parents' consciousness about the issue.
The school environment is an important setting for population-based approaches to promoting health behaviors, such as nutrition and physical activity (Hayman et al., 2004). The Community Guide to Prevention (www.thecommunityguide.org/obese ) provides a summary of evidence and recommendations for school-based obesity interventions. Schools are also a critical venue for nursing advocacy. Individuals who work with children, especially parents and school nurses, can advocate for changes that would promote healthier eating habits and prevent obesity. Table 1 summarizes appropriate school-based actions.
 | TABLE 1. Advocacy for Obesity Prevention in Schools |
The CDC monitors the physical activity and nutrition behavior of young people through a national surveillance system and provides information on how to improve these behaviors in the CDC coordinated school health and wellness mandate set forth in the 2004 Child Nutrition and WIC reauthorization Act (www.cdc.gov/HealthyYouth/ ). This act requires all schools to develop policies that reflect evidence-based methods for promoting behavior change, such as setting goals for nutrition education, physical activity, and other school-based activities designed to promote student wellness, establishing nutrition standards for all foods that are available in schools, monitoring the implementation of the wellness policy, and involving a broad group of individuals in its development. The mandate poses opportunities for improving school health promotion but is unfunded, which makes it an additional financial burden for schools (Fitzgibbon, Hayman, & Haire-Joshu, 2007).
Opportunities for obesity prevention on the community level include local media campaigns, zoning limits, and nutrition labeling for fast-food restaurants (Koplan et al., 2005). Promoting healthy food choices could mean supporting food cooperatives, farmer markets, and fresh produce in grocery and convenience stores. Recent innovative actions, such as New York City's regulation limiting trans fat, are an example of activism at the local legislative level. Other strategies include promoting the development of community resources, such as infrastructures that encourage walking, biking, and other forms of physical activity. Table 2 provides a summary of family and local community actions.
 | TABLE 2. Advocacy for Obesity Prevention in Families and Local Communities |
Advocacy is needed for obesity prevention at the “upstream” or policy level, because changes at this level are likely to affect the largest number of people. Regrettably, public agencies lack the fiscal resources or authority to institute changes to support a more healthful diet and better parks and trails for physical activity opportunities. Those responsible—the legislators—often have little or no knowledge and expertise in the area. Nurses are well positioned to provide education and information so that elected officials can initiate, promote, and support federal and state policy changes in the food industry, schools, and physical environment. The Center for Science in the Public Interest and the Institute of Medicine highlighted the need for limitations on advertising unhealthy foods to children (McGinnis et al., 2006; Koplan et al., 2005). The protection of children from deceptive advertising and marketing should be a national priority (McGinnis et al., 2006; Schwartz & Brownell, 2005). Restricting commercials aimed at children would require legislative changes because a law prohibiting the Federal Trade Commission from regulating food advertising was enacted after tobacco advertising was withdrawn from television (McGinnis et al., 2006).
An effective method of multilevel changes involves grassroots activism groups. Mothers Against Drunk Driving (MADD) began with two mothers desiring to prevent further deaths from automobile accidents related to drunk driving. MADD's success has resulted in more than 600 community chapters and action teams that passed legislation, educated school children, and increased public awareness (Schwartz & Brownell, 2005). A similar grassroots mechanism for obesity prevention could be driven by nursing and nurses. Professional nursing organizations are a powerful means to influence public policy change. These groups can demonstrate leadership through raising awareness of the need for obesity prevention policies and collaborating with other organizations that share this common goal for social and environmental change. Strategies include agenda setting and developing policy statements on the economic and social costs of obesity. Collaboration among government and community-based, service, and grassroots organizations to explore innovative and interdisciplinary coalitions to promote research and global priorities could foster the needed changes.
Educating and counseling individuals and families about BMI screening and the age-appropriate recommendations for physical activity and healthy nutrition are necessary but not sufficient. Nurse educators should enhance students' understanding of the contribution of weight status and excess adiposity to physical problems documented in acute care settings, the prevalence and magnitude of chronic conditions linked with obesity across the life course, and recognition of obesity-associated healthcare costs. Care should be taken to emphasize the potentially modifiable environmental contributors to obesity. Obese individuals require nonbiased, high-quality care in each and every setting. Consequently, nurse educators should ensure that students avoid negative stereotyping, discrimination, and biased attitudes toward obese individuals and advocate that nurses role model the desired nutrition and physical activity behaviors that patients are encouraged to adopt. Nurse educators and healthcare agencies must ensure that professional and nonprofessional employees receive the training and resources to implement the appropriate physical and psychosocial care.
Nursing research can aid in setting the agenda and advancing the cross-disciplinary science base of obesity prevention and treatment on an individual and population level. The systematic study of particular phenomena of concern relevant to this epidemic and the health of the public are consistent with nursing's emphasis on health promotion, disease prevention, and vulnerable populations. Numerous questions remain to be addressed regarding the potentially modifiable determinants of overweight and obesity in vulnerable families and communities. The urgent need for effective preventive and treatment interventions has been emphasized by numerous expert panels. Nurse researchers are well suited to design and implement small clinical trials (efficacy studies) designed to test innovative approaches for prevention and treatment. Nurses' participation on interdisciplinary obesity research teams addressing obesity prevention and/or the behavioral, pharmacological, and surgical treatment of obesity also will broaden the scope and breadth of the research agenda for nurses and add uniquely to the existing knowledge base.
Conclusion
Multiple environmental factors contribute to the obesity crisis. The serious health risks require that nurses, as the largest group of healthcare professionals, advocate for multilevel policy changes necessary to create and maintain less obesigenic environments. Across professional and personal roles, the mandate to nurses and nursing—as the largest and most ubiquitous group of healthcare professionals—is active involvement in changes designed to improve nutrition and physical activity, thus preventing obesity and promoting the health of the public.
SUGGESTED CLINICAL IMPLICATIONS
ONLINE
Guide to Community Preventive Services www.thecommunityguide.org/obese
CDC's Healthy Schools, Healthy Youth
Federal Small Steps Initiative
Obesity and Physical Activity Information
www.nhlbi.nih.gov/health/public/heart/index.htm
American Heart Association
National Association of County and City Health Officials
Healthy States Initiative
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