Childhood Obesity Nursing CE Course

1.0 ANCC Contact Hours AACN Category A

Syllabus

Introduction/Incidence

Childhood obesity has continued to be a significant problem across the globe. According to the Centers for Disease Control and Prevention (CDC, 2018), obesity rates have continued to rise sharply since the data reports from the 1970s. The rates of childhood obesity have tripled. Now the CDC (2018) reports that one in five children are considered obese, and those numbers continue to rise as children move into their teenage years and beyond. The impact of obesity on children is crippling. Lifelong health conditions can start in the childhood years when obesity begins. Heart conditions, atherosclerosis, type 2 diabetes mellitus (DM), and depression can lead to adults who are ill, either acutely or chronically, resulting in disabilities impacting work performance and daily life (Grossman et al., 2017). 

Measurements

When discussing obesity, it is important to know how obesity is measured according to the researchers who report data. The CDC (2010) growth charts are used to help identify growth patterns of children and are based on historical growth data from the US. At well-child appointments, children are weighed and measured. Those measurements are then plotted on standardized growth charts individualized for males and females. Using these growth charts, if a child is greater than or equal to the 95th percentile based on gender and age, they are considered obese, whereas between 85-95% is considered overweight.  According to a study by Cunningham, Karmer, and Nayaran (2014), close to 15% of children were overweight using standard measurements when starting school as kindergarteners, whereas close to 13% were considered obese. These numbers continued to rise as the children reached high school. According to the CDC (2010), the World Health Organization (WHO) has growth charts that are recommended for use in children two years and under. The growth charts from WHO are based on research regarding optimal growth in breastfed infants as opposed to historical data. The WHO has developed initiatives to combat childhood obesity. Utilizing both primary and secondary prevention strategies has been successful globally and should be utilized worldwide. However, the lack of success with the implementation of primary and secondary interventions within the United States has contributed to the epidemic of childhood obesity (Mukhopadhyay, Mondal & Chatterjee, 2019).

Risk Factors and Psychosocial Triggers

Identifying the risk factors associated with childhood obesity can help to decrease the incidence of overweight children. According to Hemmingsson (2018), a variety of risk factors are known to impact the condition of childhood obesity. It was found that obesity rates in children improved in areas of higher socioeconomic areas but continue to be a significant issue in the areas where children are living in lower socioeconomic situations. Furthermore, lower socioeconomic status can impact mental health, leading to depression, anxiety and feelings of self-worth that are also linked to obesity incidence in children. Emotional eating can lead to overeating and poor food choices. Perhaps the biggest impact of lower socioeconomic living conditions is the lack of access to healthy foods and adequate exercise (Hemmingsson, 2018). This is in part due to the lack of grocery stores with adequate fresh vegetables and fruits, as well as the lack of safe playgrounds. In the article by Hilmers, Hilmers and Dave (2012), discussion ensued on the environmental injustice that is seen when neighborhoods do not have the resources to ensure that the community can participate in a healthy lifestyle. While this is seen as an important point in the childhood obesity epidemic, the intervention for this plight is not yet clear.

While low socioeconomic status may be the biggest risk factor, Hemmingsson (2018) discussed the presence of unhealthy family dynamics as another potential risk factor. In families where there is discord and dysfunction, more children are found to be at risk for obesity. This includes situations where there is neglect or emotional abuse. These situations can increase the risk of emotional eating as previously mentioned. Goran (2016), discusses the impact of family life and function on the eating habits of children as well as the activity level of a child. When a child is neglected, they are unlikely to be able to participate in activities that promote cardiovascular health. Children are also not primarily responsible for obtaining and preparing food. The parent or guardian is in control of this part of daily life, which can be negatively impacted in families that are dysfunctional (Goran, 2016). 

In a study by Raver, Blair, Garrett-Peters and Family Life Project Key Investigators (2015), the impact of violence, poverty, and household chaos on young children has been clearly identified as damaging to the internal factors that protect children, such as coping skills, attention, love, and belonging. These factors can protect a child from developing damaging habits such as unhealthy food choices and a lack of physical activity. Coping skills are developed over time, so the early identification of impaired coping skills related to family dysfunction is vital to help with the reduction of obesity related risk factors commonly associated with psychosocial development in children (Raver et al., 2015).

Hemmingsson (2018) identified the impact of stress on the child’s eating habits and psychosocial development. He cited the overuse of junk food to ease the psychological burden often felt in children of dysfunctional homes. Junk food, otherwise known as food with little nutritional value, is easily obtainable and often used to self-soothe when emotions are in turmoil. Once this habit is established, it becomes difficult to change. Therefore, continuing to live in a dysfunctional household will increase the risk for the overuse of junk food. In addition to dysfunctional households, school stress can also affect the child with a tendency to overeat or eat food that is non-nutritious (Hemmingsson, 2018). According to Nga et al. (2019), stress in the school system (deadlines, academic performance, and outside emotional situations) all impact the healthy lifestyles of students from early childhood through adolescence. During a stressful episode, the body will excrete cortisol. When cortisol levels are increased, this causes an increase in appetite and cravings for foods higher in sugar and fat, which then results in food choices that are less nutritious, leading to more weight gain. This overeating affects girls in much greater numbers than boys (Nga et al., 2019).

Hayes, Eichen, Barch and Wilfley (2018) identified that there is a decrease in the executive function in children who are obese. Executive functioning incorporates “inhibitory control, working memory, and cognitive flexibility” (Hayes et al., 2018, p. 11). When looking at control, the child with a high level of functioning can decline appealing food choices that are sugary or otherwise unhealthy. A working memory allows the child to synthesize the knowledge that he/she has gained in education to make the best choice and understand how to develop a dietary or exercise plan that would promote health. Having cognitive flexibility would allow the child to switch between unhealthy temptation and creatively substitute healthier options. Executive functioning has been well researched and leads to the ability to make healthy choices when confronted with unhealthy options. They also found that weight-loss and physical exercise can improve one’s executive functioning (Hayes et al., 2018). 

According to Sahoo et al. (2015), obesity becomes a problem when calories consumed exceed the energy that is expended. Television watching or video game playing often replaces physical exercise. This can occur when the child is withdrawn or depressed and does not interact with peers. They elaborated on the connection between screen time and the overeating of foods that are non-nutritious. Advertised foods are often consumed more than foods that are not advertised, leading to poor food choices. These poor food choices combined with overuse of screen time contributes significantly to the rise of obesity in children (Sahoo et al., 2015).

Goodarzi (2018) addressed the impact of genetics on childhood obesity. Multiple loci, each with different genetic influence, come together to cause the genetic risk of obesity. Genes for obesity correlate with genes for type 2 DM. Ongoing research is looking at birthweight and a potential correlation to obesity (Goodarzi, 2018).

Corica et al. (2018) found that a familial correlation in childhood obesity does exist. This knowledge allows the provider to plan interventions more quickly when there is a strong suggestion of a family history. Familial history is one aspect that is key to the onset of severe obesity, as well as endocrine disorders. An earlier onset of obesity suggests that the child will have significant lifelong weight issues (Corica et al., 2018).

Physical and Emotional Effects of Obesity

Physically, the long-term effects of obesity are significant. According to the CDC (2018), childhood obesity causes immediate conditions as well as those that will continue to be a problem as the child ages. Sahoo et al. (2015) find that the development of endocrine concerns such as type 2 DM and cardiovascular concerns such as coronary vessel disease is directly related to obesity in children. Future issues arise from the initial damage done during childhood, leading to continued endocrine and cardiovascular conditions in adulthood that can be life-threatening. Additionally, adult conditions such as fatty liver disease, musculoskeletal concerns, and sleep apnea are now being seen in childhood as a result of obesity (Sahoo et al., 2015).

Emotionally, the impact of obesity in childhood is significant as well. Sahoo et al. (2015), identified that overweight/obese children have varied levels of psychological impact related to weight gain. Bullying, school-related difficulties, and poor quality of life are all seen in children who are obese (Sahoo et al., 2015).

Prevention

Preventive behaviors are difficult for children to incorporate into their lifestyles if they do not have the support of caregivers. Bleich et al. (2018) highlight interventions that are simple and easily obtainable if there is significant income in the family. It has been said that higher socioeconomic status allows for more successful interventions. Hemmingsson (2018) suggests it is best to focus on social circumstances such as poverty to help with the overall issue of childhood obesity. As one can see, there is not one strategy that fits all the population. 

Hilmers et al. (2018) looked at fast food menu labeling. In this study, specifically the caloric content of menu items was published. While this idea can have enormous impact, the labeling was inconsistent. Further research is needed to improve upon this prevention initiative.  

Nga et al. (2019), identified the need to have teachers engaged in obesity prevention strategies. In the classroom, where children spend most of their time, teachers can be a deciding factor in the activity or health education of the child. First, the teacher needs to review their own feelings regarding obesity. Once done, the teacher can begin to incorporate small opportunities to increase physical activity. Breaking up the day with periods of physical activity such as crunches or running in place can encourage further physical activities and help the child get some form of physical exertion during the day (Nga et al., 2019).

The WHO (2012) published population-based prevention strategies to help with the rising childhood obesity epidemic. Suggestions were to increase funding for health promotion strategies in communities and school systems. They strongly emphasize starting in early childhood education and continuing through adolescence. Incorporating healthy eating and regular physical activity into school curriculum is encouraged. Community programs to improve the knowledge base of healthy eating habits and physical activity for health maintenance is suggested (WHO, 2012).

According to Weihrauch-Blüher et al. (2018), interventions aimed at the school-aged child should improve results. These interventions are best used with younger age groups, primarily those who are preschool and school-age. It is important to note that targeting the child for interventions is not enough. Parents and teachers should be educated on healthy food options and the importance of exercise to help prevent obesity. The older child does well if the plan for education targets the child versus the parent (Weihrauch-Blüher et al., 2018). Junk food is readily available and will continue to be considered an acceptable addiction as opposed to other addictive substances (Hemmingsson, 2018). 

Management and Treatment of Obesity

In a systematic review by Bleich et al. (2018), awareness of childhood obesity as well as healthy eating and exercise can lower obesity rates and improve healthy lifestyles. This includes the limitation or omission of junk food. Interventions are many and need to be well planned to promote healthy eating habits and good physical fitness. Decreasing junk food in school lunches brought from home is one area to explore (Bleich et al., 2018). 

The US Department of Health and Human Services published recommendations for children on the dietary choices that can improve the health of the child (CDC, 2018). It was found that a diet of low saturated fat, reduced intake of sweetened drinks, and increased intake of fruits and vegetables will greatly impact the weight of a child. Furthermore, the incorporation of physical activity can reduce weight gain and improve the cardiovascular health of the child. The recommendations also focus on the parents of younger children, as there is a definite impact when parents are part of the education on dietary changes. Weight loss surgery has not been fully researched for use in children (CDC, 2018).

Xu and Xue (2016) researched the effects of childhood obesity and suggested interventions that can be incorporated in the home and in the general care of the child to decrease and prevent obesity. By far, dietary changes and the introduction of physical activity are the most promising ways to treat/prevent obesity. The use of behavioral counseling and the use of weight loss drugs can enhance the overall process of weight loss. Addressing the behavioral changes needed is an essential part of the process. Making activity and dietary changes without behavior changes can lead to a return of the habits that caused the weight gain initially (Xu & Xue, 2016).  

Conclusion 

Childhood obesity is a serious medical concern with lifelong complications. Early interventions can decrease the likelihood of childhood obesity. Awareness of the incidence of childhood obesity and targeting the risk factors are ways to reduce the rate of obese children. Healthcare providers can make immediate impacts with the right amount of knowledge regarding the issue of childhood obesity. Future research in this area is still needed to help lessen and reduce childhood obesity.

References

Bleich, S. N., Vercammen, K. A., Zatz, L. Y., Frelier, J. M., Ebbeling, C. B., & Peeters, A. (2018). Interventions to prevent global childhood overweight and obesity: A systematic review. The Lancet Diabetes & Endocrinology, 6(4), 332-346. doi: 10.1016/S2213-8587(17)30358-3

The Centers for Disease Control and Prevention, (2010), WHO Growth Charts, retrieved September 13, 2019 from https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Chart

The Centers for Disease Control and Prevention, (2018), Childhood Overweight and Obesity, Retrieved from https://www.cdc.gov/obesity/childhood/

Corica, D., Aversa, T., Valenzise, M., Messina, M., De, L., Wasniewska, M., & Alibrandi, A. (2018). Does family history of obesity, cardiovascular, and metabolic diseases influence onset and severity of childhood obesity? Frontiers in Endocrinology, 9(May). doi:10.3389/fendo.2018.00187

Cunningham, S. A., Kramer, M. R., & Narayan, K. V. (2014). Incidence of childhood obesity in the United States. New England Journal of Medicine, 370(5), 403-411. doi: 10.1056/NEJMoa1309753

Goodarzi, M. (2018). Genetics of obesity: What genetic association studies have taught us about the biology of obesity and its complications. The Lancet. Diabetes & Endocrinology, 6(3), 223-236. doi:10.1016/S2213-8587(17)30200-0

Goran, M. I. (2016). Childhood obesity: Causes, consequences, and intervention approaches. Boca Raton, FL: CRC Press.

Grossman, D. C., Bibbins-Domingo, K., Curry, S. J., Barry, M. J., Davidson, K. W., Doubeni, C. A., ... & Landefeld, C. S. (2017). Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Jama, 317(23), 2417-2426. doi: 10.1001/jama.2017.6803.

Hayes, J. F., Eichen, D. M., Barch, D. M., & Wilfley, D. E. (2018). Executive function in childhood obesity: Promising intervention strategies to optimize treatment outcomes. Appetite, 124, 10-23. doi: 10.1016/j.appet.2017.05.040.

Hemmingsson, E. (2018). Early childhood obesity risk factors: Socioeconomic adversity, family dysfunction, offspring distress, and junk food self-medication. Current Obesity Reports, 7(2), 204-209. doi:10.1007/s13679-018-0310-2

Hilmers, A., Hilmers, D. C., & Dave, J. (2012). Neighborhood disparities in access to healthy foods and their effects on environmental justice. American Journal of Public Health, 102(9), 1644-1654. doi: 10.2105/AJPH.2012.300865

Mukhopadhyay, S., Mondal, S., & Chatterjee, S. (2019). Strategies for prevention of childhood obesity. In Global Perspectives on Childhood Obesity (pp. 299-312). San Diego, CA: Academic Press.

Nga, V., Dung, V., Chu, D., Tien, N., Van Thanh, V., Ngoc, V., . . . Do, D. (2019). School education and childhood obesity: A systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 13(4), 2495-2501. doi: 10.1016/j.dsx.2019.07.014

Raver, C. C., Blair, C., Garrett-Peters, P., & Family Life Project Key Investigators. (2015). Poverty, household chaos, and interparental aggression predict children's ability to recognize and modulate negative emotions. Development and Psychopathology, 27(3), 695-708. doi: 10.1017/S0954579414000935

Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. (2015). Childhood obesity: Causes and consequences. Journal of Family Medicine and Primary Care, 4(2), 187. doi: 10.4103/2249-4863.154628

Weihrauch-Blüher, S., Kromeyer-Hauschild, K., Graf, C., Widhalm, K., Korsten-Reck, U., Jödicke, B., ... & Wiegand, S. (2018). Current guidelines for obesity prevention in childhood and adolescence. Obesity facts, 11(3), 263-276. doi.org/10.1159/000486512

The World Health Organization. (2012). Population-based approaches to childhood obesity prevention. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/80149/9789241504782_eng.pdf

Xu, S., & Xue, Y. (2016). Pediatric obesity: Causes, symptoms, prevention and treatment (Review). Experimental and Therapeutic Medicine, 11, 15-20. doi: 10.3892/etm.2015.2853