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Childhood obesity, Nursing education, Obesity, Pediatrics, Staff development.



  1. Rubenstein, Cynthia Dickerson RN, PhD, CPNP-PC


Abstract: Childhood obesity prevention and management is currently a priority health focus in the United States. Graduates of nursing programs and practicing registered nurses must be competent to implement interventions and programs to assess, prevent, and manage childhood obesity in acute care and community settings. This article provides an overview of the scope of the problem and recommendations from relevant health organizations. Nurse and staff educators are provided with specific content and teaching strategies for the prevention and management of childhood obesity for developing the knowledge and skills of nursing students, staff nurses, and advanced practice nurses.


Article Content

As faculty and staff educators continue to adapt educational content to the evolving priorities and health needs of individuals and communities of care, specific attention must be given to the prevention and management of childhood obesity. Nurses in both acute care and community settings are faced with the burden of acute and chronic health problems that obese children face. With the significant numbers of overweight and obese American children, both practicing registered nurses (RNs) and advanced practice nurses (APNs) must be prepared to intervene at the individual, family, and community levels to prevent and reduce the incidence of childhood obesity. The purpose of this article is to provide an overview of childhood obesity and identify specific content and teaching strategies that nurse and staff educators can employ to develop the knowledge and skills of nursing students, RNs, and APNs to address this critical health issue.

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Background and Significance

Reducing and preventing childhood obesity is currently a national public health priority for the federal government and key health organizations. The National Health and Nutrition Examination Survey (NHANES) has tracked obesity rates in children for the past four decades, and the prevalence of childhood obesity has risen steadily to epidemic proportion in our nation (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). The Centers for Disease Control and Prevention (CDC) has defined overweight in children as falling between the 85th and 95th percentile for sex and age on the body mass index (BMI) growth chart. Obesity is defined as exceeding the 95th percentile for sex and age for BMI. The most recent NHANES data identify 38% of preschoolers as overweight and obese, 69% of school age children as overweight and obese, and 65% of adolescents as overweight and obese (Ogden et al., 2010). When these numbers are categorized by ethnicity, a startling disparity is noted. Rates for childhood obesity are significantly higher for African Americans, Native Americans, and Latino/-Hispanic children. For children less than 2 years of age, exceeding the 95th percentile of weight for length is considered a risk factor for childhood obesity. About 10% of children under age 2 years are at risk for obesity (Ogden et al., 2010).


In 2005, the Institute of Medicine (IOM) called for a systems approach to reduce the prevalence of childhood obesity with an emphasis on policy implementation to facilitate changes in local communities, school districts, and children's built environments (IOM, 2005). The White House has developed the "Let's Move!" campaign, which seeks to reduce the rates of childhood obesity through four primary measures. These measures include developing healthier schools, increasing access to affordable and healthy food, increasing children's physical activity levels, and empowering families to make healthy choices (White House, 2010). The CDC has developed recommendations at the federal, state, and local levels to prevent and reverse childhood obesity. The CDC emphasizes early identification, tracking, prevention, and follow-up treatment of chronic diseases including obesity for preschool children (CDC, 2007). The recently revised Healthy People (HP) 2020 goals retain childhood obesity as a priority focus area for prevention. HP 2020 sets objectives for reducing the proportion of children who are overweight or obese and increasing the proportion of daily servings of fruits and vegetables for children (U.S. Department of Health and Human Services, 2011).


Recent literature focuses on obesity risk factors and preventive strategies in children less than 5 years of age. The IOM recently released recommendations to address the gaps in intervention for the youngest children (IOM, 2011a). It recommends policy changes to improve access to nutritious foods, promote continued breastfeeding, increase physical activity levels of young children including infants, improve sleep habits, and eliminate or reduce screen-viewing time. These recommendations are in part a response to research demonstrating that young children have diets that are high in fat and sugar while low in fruits, vegetables, whole grains, and low-fat dairy products (Reedy & Krebs-Smith, 2010). Dietary intake in young children is primarily within the control of parents and child care centers, thus highlighting a need for educating families on healthy foods and policy changes for child care centers for improved nutritional offerings.


Nurses are at the forefront of caring for children and families. Childhood obesity is clearly a pivotal issue in the delivery of care to children. As healthcare continues to shift to a community-based emphasis and nurses are moving from the hospitals to community-based care in greater numbers, it is imperative to prepare those RNs and APNs to meet the needs of these children and their families.


Transtheoretical Model for Integration Into Practice

When integrating specific educational strategies directed at preventing and managing childhood obesity, Prochaska's transtheoretical model (TTM) is ideal as a theoretical foundation. The TTM is widely used for health promotion and includes the behavioral change concepts of stages of change, decisional balance, and self-efficacy (Prochaska & Velicer, 1997). The model recognizes that behavioral change is sequential in nature, occurring as a process rather than an event.


A fundamental principle of the TTM is that distinctive processes of change are applied at different stages of change to facilitate progression through the stages. The model has been widely tested in adult health promotion (Prochaska et al., 2004) and more recently validated with obesity prevention measure for children, teens, and families (Beckman, Hawley, & Bishop, 2006; Hildebrand & Betts, 2009). This model can be used to teach students and nurses a theoretical basis to guide their development of child and/or family specific interventions for obesity-related behavioral change.


Relevance to Nursing and Staff Education

The IOM Report on the Future of Nursing (IOM, 2011b) emphasizes that educators must prepare nurses to be competent as leaders, collaborators, policy advocates, system managers, and in community and public health needs. It is expected that nurses be actively engaged in redesigning the healthcare of the future (IOM, 2011b). In addition, the recently released Master's in Nursing Essentials increase the emphasis on the APN's role in health policy advocacy, mastery of informatics, and a systems level approach to quality improvement (American Academy of Colleges of Nursing, 2011). Both the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP) have policy statements that emphasize strategies for early identification and specific interventions and education to incorporate during health encounters with families (AAP, 2003; NAPNAP, 2009).


Although pediatric health outcomes have dramatically improved in areas such as oncology and neonatology, the prevalence of the chronic diseases associated with childhood obesity has risen for all age groups (Lee, 2007). There are components currently integrated into undergraduate and graduate curricula as well as staff development that can be specifically applied to preventive strategies for childhood obesity. Specific education content for students, nurses, and APNs can be found in Table 1. Therefore, it is necessary for nurse and staff educators to develop the skills of students, nurses, and APNs in the following areas: political activism, assessment and screening, community health, promotion of breastfeeding, evaluation of the built environment, and motivational interviewing. Proficiency in informatics is a necessary foundation for maintaining competency and currency in these areas because nurses need to use technology to search for evidence-based practice recommendations, communicate and educate families, and facilitate interprofessional collaboration.

Table 1 - Click to enlarge in new windowTable 1. Childhood Obesity Education Content

Skills for Improving Childhood Obesity Outcomes

Political Activism

Practicing nurses must be empowered as change agents in the political arena and knowledgeable about health advocacy and activism specific to childhood obesity. Nurses are experts in healthcare and their clients' needs thus political activism should be a natural extension of their roles as advocates for families and communities in their professional lives. APNs must be competent in advocating for changes at all governmental and community levels to reduce barriers to healthy foods, increase opportunities for physical activity, and implementation of other strategies to prevent childhood obesity.


An effective strategy to achieve this is to have students and nurses analyze policy related to barriers to improved obesity outcomes (e.g., low nutrition of school lunches, reduced recess time), and activators of improved obesity outcomes (e.g., community walking/biking trails) and implement a political action plan based on their research (IOM, 2005). A political action plan can include giving oral persuasive arguments, writing to legislators, and participating in other grassroots efforts to change policy-affecting factors linked to childhood obesity (Hahn, 2010). Rubenstein and Graham (2011) found that nursing students had increased political self-efficacy after implementing a political action plan and communicating with legislators and stakeholders about the health policy blog they developed.


Assessment and Screening

Education for nursing students, RNs, and APNs must include an emphasis on screening for obesity in all children and adolescents. Screening parameters include obtaining measurements of height and weight at regular intervals during childhood to monitor growth patterns. During well-child visits and hospital admissions, height and weight are usually recorded but BMI calculations after age 2 are completed less consistently (Klein et al., 2010). Children under 2 years of age should be plotted on the World Health Organization growth charts evaluating weight for length to determine risk for obesity. Children 2 years of age and older should have their BMI calculated and plotted on the age and sex-appropriate growth chart for BMI to determine if they are overweight or obese.


Education for APNs includes further screening recommendations. For those children with a BMI percentile at or above the 85th percentile with two additional risk factors (family history of diabetes, member of an ethnic minority group, or signs of insulin resistance), screening for type 2 diabetes is indicated (American Diabetes Association, 2003). Concurrently, screening for elevated cholesterol and hypertension are advised. Those children exceeding expected growth parameters require further interventions (Barlow & Expert Committee, 2007).


Cultural competency is integral in the effective identification and communication of findings for overweight and obese children. Health screenings of high-risk populations such as Hispanic/Latino and African American children and subsequent education and interventions require cultural sensitivity and competence. For example, Latino mothers typically equate obesity with good health, thus requiring a culturally sensitive approach to screening and educating this ethnic population (Lindsay, Sussner, Greaney, & Peterson, 2011).


Opportunities to apply screening strategies can be provided to nursing students as part of their clinical experience through the use of school screenings, ambulatory care centers, and youth focused health fairs. For graduate students in nurse practitioner (NP) programs, application of screening parameters can be incorporated into primary care settings as well as practicum experiences focused on pediatric chronic health conditions. Practicing RNs should incorporate obesity screening into their standard nursing practice and hospital policies for all units and clinics delivering care to children and adolescents.


A nutrition and dietary assessment also should be obtained at regular intervals for all children and adolescents. Nurses must have knowledge of the recommended nutritional guidelines for infants through adolescents including the importance of breastfeeding, introduction of solid foods, avoidance of energy-dense low-nutrient foods, recommended calcium intake for various ages, and increasing fruit/vegetable intake overall. Currently, only 45% of children ages 2 to 5 years consume two or more fruits each day and only 49% consume three or more vegetables daily (American Dietetic Association, 2008). Other vital factors to assess that contribute to developing childhood obesity include limited family mealtimes, watching television while eating, high intake of convenience or fast foods, and high intake of sugary beverages (American Dietetic Association, 2008). This assessment provides the foundation for nurses to implement family specific education for improving nutrition and eating behaviors (Table 2).

Table 2 - Click to enlarge in new windowTable 2. Family Specific Education for Obesity Prevention

In conjunction with the nutrition assessment is an evaluation of the physical activity level of the child and/or family as well as daily time spent in screen viewing. The AAP recommends that all children get a minimum of 60 minutes of moderate physical activity daily (Barlow & Expert Committee, 2007). This can be both structured and unstructured play activities and can be broken into smaller time intervals (Table 2). Research shows that children become more sedentary as they get older. Although 42% of school age children get 60 minutes of moderate activity daily, only 8% of 12 to 15-year-olds achieve this level of activity daily (Troiano et al., 2008).


Research has consistently associated increased screen time with a sedentary lifestyle, which results in an increased risk for obesity (Spear et al., 2007). "Screen time" is defined as time spent watching television, playing video games, and time spent on computers and other technology devices. Children and adolescents now spend more time engaged with screen time, on average >7 hours daily, than any other activity except for sleeping (Strasburger, Jordan, & Donnerstein, 2010). Nurses need to assess children's screen time at regular intervals. The AAP recommends that children and adolescents over the age of 2 years be limited to 2 hours per day of screen time while it is recommended that children under 2 years do not have any screen time (Strasburger et al., 2010) (Table 2). Education should focus on strategies to reduce screen time by increasing family activities; increasing physical activity levels; and removing televisions, video game systems, and computers from the child or adolescent's bedroom.


Community Health

Many practicing RNs are in community-based positions where they care for children. Schools provide an ideal setting for childhood obesity prevention and reduction strategies since children spend a large proportion of their week attending school. Parents and school nurses agree that schools are an appropriate site for obesity screening, providing education on nutrition and physical activity, and recommending treatment for obesity management (Kubik, Story, & Davey, 2007; Murphy & Polivka, 2007). Yet the amount of time spent in physical education and recess has continued to decline nationwide in school districts due to the 2001 federal policy passage of the No Child Left Behind Act (Ramstetter, 2010). Despite the WIC Reauthorization Act of 2004, which requires schools receiving federal funds to develop wellness policies targeted toward the reduction of obesity (American Dietetic Association, 2008), only 3.8% of elementary schools and 2.1% of high schools provided the recommended daily physical education or its equivalent for the entire school year for students (Lee, Burgeson, Fulton, & Spain, 2007).


RNs and APNs need to be prepared to educate school administrators and school boards on the benefits of physical activity in improving children's and adolescents' physical health as well as cognitive performance and behavior (Ramstetter, 2010). Nurses must be prepared to engage in policy revisions in school districts to restore required quality, daily physical education classes; retain and improve school recess; and expand extracurricular activities that promote physical activity before and after the school day. School nurses must be skilled to collaboratively implement improved nutrition within the school cafeteria and classroom settings, to integrate physical activity into structured classroom activities, and educate children and adolescents on healthy life choices to reduce the risk for obesity.


Promotion of Breastfeeding

Breastfeeding has been correlated in the literature as a factor associated with a reduced risk for developing childhood obesity (Metzger & McDade, 2010). Breastfeeding initiation rates are relatively high in the United States with 75% of new mothers electing to breastfeed at birth. Yet only 13% of mothers are exclusively breastfeeding until 6 months as recommended (CDC, 2011). It is this continued breastfeeding beyond birth that is linked to a reduction in obesity rates for children who were breastfed.


Both RNs and APNs must be competent in providing education prenatally and after birth to support initial breastfeeding success and sustained breastfeeding of the infant. Opportunities must be made available in practice settings for nurses to develop skills in evaluating the breastfeeding dyad to promote effective breastfeeding.


Although laws have changed in support of breastfeeding over the past decade, continued advocacy is needed. Many women who return to work lack space, time, or support for pumping and the laws are not strictly enforced (Li, Fein, Chen, & Grummer-Strawn, 2008). Thus, nurses and APNs have the opportunity to educate and politically advocate for stronger federal and state policies to support breastfeeding. Education for workplaces regarding the law and how breastfeeding can benefit their companies (e.g., breastfeeding mothers have fewer lost work days) can lead to a more supportive atmosphere for breastfeeding mothers.


Evaluation of Built Environments

A discussion of the built environment of children and the relationship to obesity is necessary in preventing and managing childhood obesity from a nursing standpoint. A "built environment" is simply defined as the person's human-made or modified surroundings in which they live, work, and partake in recreation (Renalds, Smith, & Hale, 2010). A child's built environment includes not only the home environment but play opportunities, school, and/or daycare settings, and access to healthy foods.


It is imperative to assess a child's built environment to identify risk factors for childhood obesity and develop family specific interventions to improve dietary intake and physical activity. This evaluation includes assessing for those macrolevel environmental factors that influence dietary choices including the reliance on convenience foods and fast foods, large portion sizes, and the food landscape (Sallis & Glanz, 2006). The food landscape determines access and availability of healthy foods and determines whether families reside in food deserts, resulting in limited access to affordable, healthy foods such as fresh fruits and vegetables.


Additionally, one of the main microlevel factors of the built environment, the home food environment, must be assessed to identify those factors contributing to the development of childhood obesity. This assessment consists of determining the availability and accessibility of fruits and vegetables in the home, the child-feeding practices of the parents, parental role modeling of eating behaviors and dietary intake, and general parenting style (Galvez, Pearl, & Yen, 2010; Rosenkranz & Dzewaltowski, 2008).


In community settings and through established community partnerships, nurses have the opportunity to analyze the built environment of children by completing school or home assessments and windshield surveys of communities. Nurses can then develop specific family and community-based interventions to improve the health of these children. Conditions in many children's communities act as barriers to reducing the risk for developing obesity, thus providing the foundation for change within a community model (IOM, 2009). The IOM recommends that local governments and communities focus on the following six goals: improving access to and consumption of healthy and affordable foods, decreasing access to and consumption of low-nutrient and energy-dense foods, raising awareness of the importance of healthy eating to prevent childhood obesity, promoting greater physical activity for families, reducing sedentary behaviors of children, and raising awareness of the importance of physical activity for children (IOM, 2009).


RNs and APNs can incorporate an evaluation of the built environment in their assessment of well children within primary care settings and educate families on specific, individualized changes within that environment to improve health. Clinical nurse leaders and community health nurses can develop and implement community programs emphasizing these goals while focusing on reducing the community's specific barriers to change.


Motivational Interviewing

The literature identifies that healthcare providers experience a lack of time to provide extensive teaching to parents. According to pediatric NPs, they spend shorter amounts of times counseling parents of preschoolers in decreasing risk factors for obesity when compared to parents of older children. This time limitation for educating families during visits is cited as a significant barrier by nurses (Small, Anderson, Sidora-Arcoleo, & Gance-Cleveland, 2009). Thus, it is imperative that nurse and staff educators ensure that RNs and APNs develop appropriate time sensitive strategies to effectively teach these families.


Nurse and staff educators should incorporate training on motivational interviewing to effectively facilitate change in families with an overweight or obese child. Motivational interviewing is an effective communication strategy used in primary care settings to encourage the parent and/or child to set goals through identification of personal barriers and ways to overcome these barriers to reduce the risk for obesity. Nurses learn to assess current readiness to learn and then adapt the educational session to advance the interventions for behavioral change. It can be easily implemented by nurses in primary care settings and public health clinics who practice under limited time constraints (Levensky, Forcehimes, O'Donohue, & Beitz, 2007) and is readily incorporated into the medical home model. Theoretically, it correlates to the stages of change within the TTM, provides nurses with the knowledge of the parent's current stage of change, and presents an opportunity to facilitate behavioral change by identifying barriers and how to overcome those barriers (Levensky et al., 2007).


Motivational interviewing is effective in that it emphasizes a collaborative approach to behavior change instead of a prescriptive approach (Schwartz et al., 2007). Nurses use open-ended questioning and reflection to encourage the parent or adolescent to share their identified barriers to dietary or activity changes. Once they demonstrate positive comments toward change, the nurse can expand on those comments and provide further support for that change.


In addition to training sessions and case studies, the use of standardized actors portraying parents is an effective teaching strategy for developing skills in motivational interviewing. Staff nurses and APNs can implement individualized, culturally sensitive interventions and teaching within a safe environment. The debriefing session allows the educator to have the participants further elaborate and reflect on the experience and provide recommendations for future encounters. This teaching strategy readily links knowledge to practice.



With the high prevalence of overweight and obesity in children and adolescents, it is critical that graduating nurses and currently practicing nurses are competent to assess and intervene in their practice areas for childhood obesity prevention. Thus nursing and staff education must be adapted to incorporate the content and skills necessary to prevent and intervene with families of children at risk for or experiencing obesity. With purposeful thought, faculty members and staff educators can develop teaching strategies that provide students and RNs opportunities for applying the core concepts and developing competence in the assessment, prevention, education, advocacy, and management of childhood obesity.


Suggested Clinical Implications


* Rates of childhood obesity are high for all ages yet are higher for minority groups requiring nurses to be culturally competent in their screening and education of families about childhood obesity.


* Students, nurses, and APNs need education on specific strategies to effectively identify and manage childhood obesity.


* Current nursing reports and policy recommendations advocate for nurses to have the knowledge and skills to educate families about childhood obesity at all health encounters.


* Students, nurses, and APNs must be competent in screening and assessing growth parameters, nutrition and diet history, physical activity levels, screen viewing time, and a child's built environment to identify specific areas for family teaching.


* Motivational interviewing is an effective communication strategy that nurses can use in all healthcare settings to guide families in setting goals and behavior changes to reduce risks for childhood obesity.



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Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


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