School of Nursing
Online Journal

Childhood Obesity: Growing Up and Growing Out

Zoe Dobbs

Introduction

Obesity rates in New Zealand in all ages, genders and ethnicities have increased over the last 30 years (Ministry of Health, 2016b). The 2015/2016 New Zealand Health Survey identified that one in nine children aged 2-14 years are classed as obese (11% - an estimated 85,000 children): an increase from 8% in 2006/2007 (Ministry of Health, 2016a). In addition to this worrying statistic, Pacific children are nearly four times as likely and Maori children 1.6 times as likely to be obese than their European counterparts (Ministry of Health, 2016a). Increasing rates of obesity are not just an issue faced by New Zealand alone, as the incidence of obesity is increasing in all developed countries worldwide (Gray, 2003). A healthy body size is an enabler for good health and wellbeing, which is why obesity amongst children is so concerning as it is associated with a range of health conditions, including an increased risk for the premature onset of illness, and impacts on the child’s social and mental health (Ministry of Health, 2016a; Ministry of Health, 2016b). Therefore, it is fundamental that all children receive a healthy foundation to reach their full potential in life.

Background

Childhood obesity is a topic that has interested me throughout my school years, and even more so now that I am in my final year of the Bachelor of Nursing Programme. Since doing my primary school speech on the topic in 2005, I have known that childhood obesity is a huge problem in New Zealand. Since 2005, childhood obesity rates have increased from 8% of children aged 2-14 years being obese, to 11% of children of the same age (Ministry of Health, 2016a). Alongside this statistic, is the evidence that overweight or obese children are more likely to be obese as adults (Ministry of Health, 2016a). 2014 statistics also highlight elevated childhood obesity rates amongst the Maori and Pacific Island population, with 15% of Maori children, and 25% of Pacific children classed as obese (Ministry of Health, 2014). These alarming statistics emphasise the growing health disparities between the Maori, Pacific and European populations and the need for better understanding regarding the long-term health problems associated with obesity in children. My reasoning for choosing this clinical issue is due to the existing ethnic disparities and the massive impacts obesity has, not just on families, but on society, the health system, and its resources. Registered nurses, in the primary health care setting, due to the therapeutic relationships they create with clients, are in the perfect position to empower caregivers of children to understand the impact they have on their children’s lifelong habits concerning physical activity and nutrition (Rounsavell, 2005).

Development of Review Question using PECOT

A clinical issue that is raised in New Zealand is the disparity in childhood obesity rates between children of Maori, Pacific Island and European descent. Further exploration of this subject was achieved by asking more questions: why are childhood obesity rates increasing? Which ethnic groups are at increased risk for obesity? And what are the long-term health effects of childhood obesity? Research identified that the prevalence of childhood obesity varies across interethnic groups, with higher rates amongst Maori and Pacific children, and those living in the most deprived areas of New Zealand (Gordon et al.,2003; Ministry of Health, 2016a). The aim of this literature review is to explore the clinical practice issue of childhood obesity within the New Zealand primary health care setting, focussing on the influences obtained from evidence-based practice. These include: influences that create an obesogenic environment, the impacts on obese children’s health, and support measures that registered nurses can provide to families with affected children. Using the PECOT model, I had the ability to refine my search to create a question that would guide my literature review (Whitehead, 2013). By using inclusion and exclusion criteria I was then able to enhance my question. Literature included in my research would be both relevant national and international journal articles, involve children of Maori, Pacific and/or European descent, and the influences and impacts of childhood obesity. Excluded literature from this review included research that included children from other ethnicities, children with acute illnesses or other previously recognised co-morbidities such as type 1 diabetes, intellectual or physical disabilities.

As an outcome of using the PECOT model, I redeveloped my previous search questions into ‘Are children of Pacific Island or Maori descent at increased risk of obesity and its associated long term health effects, compared with children of European descent, and what is the role of the registered nurse in supporting families with affected children?’

Evidence and Findings

Addressing childhood obesity rates is current priority for the New Zealand Government (Ministry of Health, 2016c). New Zealand is a major contributor to the worldwide obesity epidemic, with high body mass (BMI) surpassing tobacco as the leading health risk, contradicting the healthy, outdoor lifestyle that is portrayed globally (Ministry of Health, 2016b; Poppitt, Silvestre & Liu, 2013). It is the fourth highest OECD country for childhood obesity, with 1 in 9 children aged 2-14 years classified as obese, equating to 85,000 children [(11%) (Ministry of Health, 2016a; Stoner, Matheson, Hamlin, & Skidmore, 2016)]. Of particular concern are the existing ethnic disparities, with children of Pacific Island (30%) and Maori descent (15%), having higher rates of obesity than European children using both the conventional World Health Organisation (WHO) BMI limits and other various body composition assessment methods (Poppitt et al., 2013). Statistics also demonstrate that childhood obesity rates are significantly higher amid children living in the most socioeconomically deprived zones (20%), in comparison with 4% living in the least deprived areas (Ministry of Health, 2016a). Therefore, it is imperative that parents, schools and health professionals understand the influences and long-term consequences of childhood obesity (Ministry of Health, 2016c).

There are several influences that contribute to childhood obesity. Obesity is caused by a positive energy balance, where energy consumption is greater than energy expenditure (Ministry of Health, 2012). The family plays a significant role in their children’s health, as they provide the genetic makeup of the child, and shape future dietary and lifestyle behaviours (Hodges, 2003). However, over half of parents whose children are obese cannot recognise that their child is overweight, enabling obesity to become normalised in society (Kelly & Swinburn, 2015; Ministry of Health, 2015). Research into the public’s awareness into influences of the causation of childhood obesity identified: poor parental supervision of diet, over-consumption of unhealthy foods, advertising and modern technology as key influences (Covic, Roufeil, & Dziurawiec, 2007). With socioeconomic and physical environment factors also having a major role in the causation of an obesogenic environment, this creates a need for parents to protect children by creating a healthier household environment (Kelly & Swinburn, 2015).

New Zealand is a multi-ethnic society, with higher childhood obesity rates amongst the Maori and Pacific population (Poppitt et al., 2013). Literature states that this is due to their overrepresentation in lower income bands, and when income becomes limited, household food choices also become constrained (Rush, Puniani, Snowling, & Paterson, 2007; Walton, Signal, & Thomson, 2009). Low-cost energy-dense foods are readily available, and consumers with limited funds often choose energy-dense foods over nutrient value because of affordability, and to ensure the survival of the family (Rush et al., 2007). Therefore, increases in food price is perceived as a barrier to healthy eating for many low-income families (Ministry of Health, 2012). Income therefore affects the type, quality, and quantity of food purchased, whilst also influencing food storage and cooking ability, which again, restricts food choice (Ministry of Health, 2012).

Another common influence on childhood obesity is marketing. Television and food advertising are proven influencers of children’s food choices, with the tendency to promote unhealthy options during peak children television times (Utter, Scragg, & Schaaf, 2006). Various studies have confirmed that junk foods, particularly soft drinks and fast foods, are significant causes of obesity (Utter et al., 2006). Screen time encourages a sedentary lifestyle, snacking and decreased satiety (Water, 2011). Nearly 30% of children, with a greater proportion of this percentage being Maori or Pasifika, watch more than two hours of television a day and are therefore more likely to eat the promoted unhealthy food options, such as soft drinks and fast food (Ministry of Health, 2012). Research has also proven that children from economically-deprived families tend to watch television more frequently, and Maori and Pasifika people are overrepresented at this level (Utter et al., 2006). Regardless of how much parents protect their children from these influences, food advertising is unescapable, and this has prompted requests for greater regulations to help prevent childhood obesity and its long-term health effects (Utter et al., 2006).

Literature shows that childhood obesity has long-term health effects. Short term however, there are effects on the child’s physical and psychosocial wellbeing (Vine, Hargreaves, Briefel, & Orfield, 2013). It is associated with academic and social difficulties, increased feelings of sadness, loneliness, anxiety, negative self-image, and difficulties with social relationships (Water, 2011). Obesity is also linked to the onset of premature and chronic health conditions (Water, 2011). Obese children risk hypertension, cardiovascular disease and depression by the time they are teenagers (Walton et al., 2009). Many children will reach adulthood with obesity that occurred in childhood, and will continue to experience negative health effects, such as type two diabetes, and are expected to have a lower life span than their parents (Vine et al., 2013; Water, 2011). Adulthood cancers, such as renal, thyroid, oesophageal and endometrial, are also linked to obesity (Water, 2011). Obese children also face psychological trauma that results from stigmatism, bullying and prejudice due to their weight (Water, 2011). It is therefore important that children and their families receive adequate support from health professionals.

Implications for Practice

Registered nurses in the primary health care setting are in the perfect position to support the development of children’s dietary and nutrition habits (Rounsavell, 2005). The primary health setting is accessible, available, and patients generally have accessed the health care team previously. It is imperative that nurses have a role in prevention, diagnosis and treatment of childhood obesity, especially as primary health care is focussed on health promotion and disease prevention (Rounsavell, 2005). However, there is a need for nurses to expand their role to include advocacy, demonstrating healthy behaviours through role modelling, and educating families about obesity prevention to successfully promote health (Vines et al., 2013). Nurses also need to be aware of, and address, potential barriers and limitations to practice.

Growth of children needs to be assessed regularly, and for children aged 0-5 years, the WHO Growth Chart is used (Ministry of Health, 2012). Those children, over the age of two years, who chart over the 99.6^th centile, have their body mass index (BMI) calculated using the Well Child weight-height to BMI conversion chart (Ministry of Health, 2012). A child exceeding the 98^th centile is considered obese (Ministry of Health, 2012). Due to the common usage of BMI in the diagnosis of obesity, it is vital that nurses can accurately measure BMI and understand how it is used for children. For children under the age of five, obesity identification is the lowest, compared to older children, with international research showing that many health professionals often rely on clinical impressions to assess for obesity and this has led to reduced identification amongst children (Water, 2011). Therefore, BMI plotting needs to be used consistently within the primary health care setting to identify those at risk and enable preventative measures (Water, 2011).

To enable preventative measures, nurses will require the support of the child’s parents and there is some uncertainty of how to approach this (Water, 2011). Childhood obesity is a sensitive topic due to the attaching of a label to the child and introducing the child to possible stigmatism (Water, 2011). This can also place strain on the therapeutic relationship. Over half of families cannot recognise that their child is overweight, so identifying the issue using sensitive terms and focussing on a healthy lifestyle approach has been proven to be more successful in the long-term (Kelly & Swinburn, 2015; Water, 2011). Helping parents to understand and recognise the problem of obesity whilst working in partnership with them towards treatment and prevention of obesity is complex (Hodges, 2003). For dietary and lifestyle interventions to be commenced and successful, parents need to accept their child is obese (Hodges, 2003). By educating parents about causations of obesity and focussing on the strengths of the family, nurses will be able to better guide parents, and support them in making healthy lifestyle changes for their families (Hodges, 2003).

To best educate parents, nurses need to have adequate knowledge regarding obesity risk factors. The social determinants of obesity in childhood are: socio-economic deprivation, television viewing, an unhealthy diet and sedentary lifestyle, with clear evidence stating that physical inactivity, an unhealthy diet, and excessive weight are three modifiable risk factors that influence early death, illness and disability in New Zealanders (Ministry of Health, 2016c; Water, 2011). Food prices and the cost of living have increased in New Zealand over the years, causing many families to re-evaluate food choices, and choose cheaper, energy-dense foods over nutritional value (Water, 2011). Screen time is a large influence on food choices as nearly 65% of food marketing is for energy-rich unhealthy foods (Utter et al., 2005). It also increases sedentary behaviour and decreases opportunities to participate in physical activity (Water, 2011). Nurses need to understand these barriers and provide healthier alternatives to families that are affordable, and that consider the interlinking factors of the social and physical environment (Vines et al., 2013).

Recommendations

From conducting this literature review, I recommend that interventions need to have a holistic focus on the child and the family. The child should have regular health checks in the primary health care setting, where weight, height and BMI are measured and plotted on the WHO Growth Chart, and the family’s socioeconomic status, health history, lifestyle choices and psychological state are assessed. The nurse can then identify whether the child is overweight or obese and discuss further interventions if required, and by comprehensively identifying the family’s background, can evaluate their readiness, and willingness, to change. This will successfully allow the nurse to support and work in partnership with the family to effectively prevent or treat their child’s obesity.

Interventions require changes to the child’s lifestyle. As this could be potentially difficult for the child, I recommend that nurses encourage parents to model a healthy lifestyle for their children and make it a family target. This is because of the complex nature of childhood obesity and the multiple factors that contribute to the obesogenic environment. By involving the family, nurses can work in partnership with the parents to identify obesogenic factors, and identify possible healthier alternatives. By increasing parental involvement, children are more likely to follow their example of healthier eating and increased physical activity. Nurses could suggest ideas to make implementation of the new lifestyle easier, such as playing sport as a family or cooking all together. They can also set goals and rules together, like only watching a certain amount of television per day to limit food marketing, or watching a movie together at the weekend after doing 30 minutes of exercise every day for a week. By having the whole family involved, the interventions are more likely to be effective as they can motivate each other to succeed.

Conclusion

To conclude, childhood obesity is a serious issue in New Zealand with rates increasing dramatically over the last 30 years (Ministry of Health, 2016b). Childhood obesity is a global problem and needs to be addressed to save children from the associated life-long co-morbidities. To decrease the percentage of obese children in New Zealand society, and improve the future health of children, health professionals need to work in collaboration with parents, schools and communities to create interventions that consider the multiple factors and barriers that create an obesogenic environment. By working in partnership with registered nurses, families can make changes to their current lifestyle that benefit the whole family and give their children a healthy start to life to allow them to reach their full potential.

References

Gordon, F., Ferguson, E., Toafa, V., Henry, T., Goulding, A., Grant, A., & Guthrie, B. (2003). High levels of childhood obesity observed among 3- to 7- year old New Zealand Pacific children is a public health concern. The Journal of Nutrition, 133(11), 3456-3460.

Gray, G. (2003). The voyage to McDonald’s: Short and long term factors in the etiology of obesity in Maori children in Aotearoa. Pacific Health Dialogue, 10(2), 141 148.

Hodges, E. (2003). A primer on early childhood obesity and parental influence. Paediatric Nursing, 29(1), 13-16.

Kelly, S., & Swinburn, B. (2015). Childhood obesity in New Zealand. The New Zealand Medical Journal, 128(1417), 6-7.

Ministry of Health. (2012). Food and nutrition guidelines for healthy children and young people (aged 2-18 years): A background paper (Rev. ed.).Wellington: Ministry of Health.

Ministry of Health. (2014). Annual update of key results 2013/2014: New Zealand health survey. Wellington: Ministry of Health.

Ministry of Health. (2015). Understanding excess body weight: New Zealand health survey. Wellington: Ministry of Health.

Ministry of Health. (2016a). Annual update of key results 2015/2016: New Zealand health survey. Wellington: Ministry of Health.

Ministry of Health. (2016b). Health targets: Raising healthy kids. Retrieved from the Ministry of Health website: http://www.health.govt.nz

Ministry of Health. (2016c). Weight management in 2-5 year olds. Wellington: Ministry of Health.

Poppitt, S., Silvestre, M., & Liu, A. (2014). Etiology of obesity over the lifespan: Ecologic and genetic highlights from New Zealand cohorts. Current Obesity Reports, 3(1), 38-45. doi: 10.1007/s13679-013-0079-2

Rounsavell, A. (2005). Childhood obesity: A review of risk factors, prevention and the role of the nurse practitioner. Retrieved from the Washington State University Libraries website: https://research.libraries.wsu.edu

Rush, E., Puniani, N., Snowling, N., & Paterson, J. (2007). Food security, selection, and healthy eating in a Pacific community in Auckland New Zealand. Asia Pacific Journal of Clinical Nutrition, 16(3), 448-454.

Stoner, L., Matheson, A., Hamlin, M., & Skidmore, P. (2016). Environmental determinants of childhood obesity: A specific focus on Maori and Pasifika in New Zealand. Perspectives in Public Health, 136(1), 18-20.

Utter, J., Scragg, R., & Schaaf, D. (2006). Associations between television viewing and consumption of commonly advertised foods among New Zealand children and young adolescents. Public Health Nutrition, 9(5), 606-612.

Vine, M., Hargreaves, M., Briefel, R., & Orfield, C. (2013). Expanding the role of primary care in the prevention and treatment of childhood obesity: A review of clinic- and community-based recommendations and interventions. Journal of Obesity, 2013, 1-17.

Walton, M., Signal, L., & Thomson, G. (2009). Household economic resources as a determinant of childhood nutrition: Policy responses for New Zealand. Social Policy Journal of New Zealand, 36, 194-207.

Water, T. (2011). Critical moments in preschool obesity: The call for nurses and communities to assess and intervene. Contemporary Nurse: A Journal for the Australian Nursing Profession, 40(1), 60-70.

Whitehead, D. (2013). Searching and reviewing the research literature. In Z. Schneider, & D. Whitehead, Nursing and Midwifery Research methods and appraisal for evidence-based practice (p. 44). Chatswood, NSW, Australia: Elsevier Australia.