School of Nursing
Online Journal

Childhood obesity in the primary health care setting

Melissa Jones

Introduction

A healthy start to life is fundamental to enable children to reach their full potential. The percentage of obese children within New Zealand has substantially increased over the past seven years (Ministry of Health, 2013). Child obesity has become a clinical practice issue, particularly in the primary health care setting. This literature review aims to identify a clinical practice issue from a clinical setting and demonstrate the use of the PECOT model to form a refined search question. It will discuss the implications for practice, based on evidence-based literature and indicate how these implications may impact upon the primary health care setting.

Clinical issue

The topic of child obesity has always interested me throughout my nursing degree. Following brief research of a few articles I came across alarming statistics that intrigued me to want to explore the clinical issue further. The statistics highlight obesity rates amongst Maori and Pacific children are significantly increasing resulting in health disparities between Maori, Pacific and European children. I decided to choose this clinical issue, as obesity is believed to substantially decrease a child’s life expectancy. I wanted to advance my knowledge on child obesity by researching further the influences and health impacts on children and the implications it may have in the primary health care setting.

Search question - PECOT

Through using the PECOT model I have refined my search question of why is child obesity increasing in New Zealand to: “What are the influences on, and health effects as a result of, child obesity and what can registered nurses do to assist affected children and their families?”. Whitehead’s (2013) PECOT model assists the formulation and refinement of the research question to result in a formal searchable question (as cited in Schneider, Whitehead, LoBiondo-Wood, & Haber, 2013). The following table illustrates the process I took to refine my question.

Evidence and findings

Obesity is frequently considered one of the most concerning health challenges of the early 21st century. In New Zealand the reduction of child obesity has become a current health priority for the government and it is essential for parents, health professionals and schools to become aware and understand the influences and health impacts of childhood obesity (Ministry of Health, 2013). By understanding the issues concerning children’s health, it may help to address these issues and improve overall health for children. Following research regarding this clinical issue it shows it is a recognised nationwide problem (Ministry of Health, 2013). Childhood obesity in New Zealand has become a significant clinical practice problem within the primary health care setting. New Zealand Health Survey statistics from 2012/13 reveal there are 1 in 9 children aged 2-14 years classed as obese. This is equal to approximately 11% (85,000) of children compared to 8% in 2006/07. Of these 1 in 4 Pacific children (27%) and 1 in 5 Maori children are obese (19%). Statistics also showed that childhood obesity was much higher amongst children who were living in deprived areas, at 20%, than those who were not, at 5% (Ministry of Health, 2013).

To assess 0-5 year old children for obesity the New Zealand World Health Organisation (WHO) Growth Chart is applied. For children aged 2 years and over who are charted over the 99.6^th centile on the growth chart, body mass index (BMI) is calculated using the Well Child weigh-height to BMI conversion chart. A BMI over the 91^st centile indicates the child is overweight, whereas a child over the 98^th centile is classed as obese (Ministry of Health, 2012).

There are many significant influences that result in childhood obesity. Although family plays a substantial role in the health of their children, the broader sociocultural, economic and physical environment surrounding the household plays an even greater role. Research demonstrates the public’s perception of the influences affecting child obesity is caused by over-consumption of unhealthy foods, modern technology, mass media and parental responsibility (Covic, Roufeil, & Dziurawiec, 2007). There is agreement in research that economic resources are one of the main issues causing childhood obesity. When a household’s economic resource becomes severely limited, there is increased pressure to supply food to ensure the family does not starve. This may take priority over the nutrient value of meals (Walton, Signal, & Thomson, 2009). Likewise, the Ministry of Health (2012) outlines how economic factors influence dietary choices. Income affects the quality, quantity and type of food that is purchased for a household. It also influences the storage facilities and the cooking of the food, which in turn impacts on food choice.

A second common influence on child obesity that is highlighted in numerous studies, is marketing. The media’s impact on influencing the sociocultural aspects of physical activity and food, particularly through advertising, is having a negative impact on children (Ministry of Health, 2012). Advertising of food products is a very powerful tool that can influence individuals’ buying decisions. During children’s television viewing times, advertising is predominately of unhealthy foods. In New Zealand 20% of families were struggling with food security, of those families 50% were Pacific and 30% Maori ethnicity (Ministry of Health, 2012). Concern raised over the contribution of food marketing to childhood obesity has resulted in the WHO calling for greater regulation.

Following wide reading about the health impacts of child obesity, it shows there is a lot of literature and information providing evidence that obesity in young children causes serious health effects. Based on the literature obesity in young children is linked to a variety of cognitive, physical, emotional and social consequences (Water, 2010). Children can suffer from physical problems including: cardiovascular factors such as hypertension and high cholesterol, respiratory factors such as sleep apnoea, and exercise intolerance. Also children who are obese may suffer endocrine problems, for example type 2 diabetes and impaired glucose tolerance. Without intervention these complications may go on to become chronic health conditions as an adult (Water, 2010). 

School aged children in their initial and late stages of education may feel rejected and stigmatised. These effects may result in more complicated behavioural and emotional problems such as adaptation difficulties, personality disorders, and depression (Ministry of Health, 2012). Child obesity is not limited to physical and psychosocial consequences. Poor school performance, development of eating disorders, and absences from school have also been known to occur as highlighted in research (Pizzi & Vroman, 2013).

Implications for practice

Obesity identification is the lowest in children under 5 years of age. In cases where obesity is identified, there are often various barriers for nurses to have the ability to address the issues. Implications for nursing practice consist of, firstly, the inadequate knowledge nurses have of accurately measuring BMI for a child’s age (Larsen, Mandleco, Williams, & Tiedeman, 2006). Nurses should understand how BMI is used for children, as it is the most commonly used indicator of obesity. This is because it is associated with total body fat in most individuals and populations.

Secondly, Registered Nurses (RNs) may have a lack of knowledge on the risk factors such as low socioeconomic status and cultural beliefs that can cause child obesity. Therefore, nurses will require further education on these risk factors. By nurses understanding how low socioeconomic factors can impact on a family’s food choice, they can support them to work around the potential barriers and recommend other options that may be possible (Larsen et al., 2006). Pacifica families believe food portrays the family mana and big babies and children are a sign of good health, well cared for and have good strength (Controller and Auditor-General, 2013). For nurses to recommend other options they will need to have accurate knowledge concerning healthy food and understand individuals’ cultural beliefs. This is essential because it is vital families are aware of limiting their high fat, sugar and salt foods and drinks, and to encourage children to eat regular meals and small snacks during the day choosing healthy food (Ministry of Health, 2012).

Lastly, RNs need to take into account the child’s family. Parents are described as being poor role models for their children with regards to physical activity and eating habits and also lack the basic knowledge about nutrition balance. Research states parents did not appear to be motivated to change the family’s lifestyle (Larsen et al., 2006). Families need to understand obesity and recognise the problem in order to help their child (Hodges, 2003).

The primary health care setting is an ideal setting to address child obesity. It is readily accessible to the general public and patients are generally familiar to the health care team. However, the implications on practice as outlined can affect the primary health care setting. To enable nurses to further their education with regards to childhood obesity, appropriate resources regarding healthy nutrition and how to measure BMI are essential (Larsen et al., 2006). It is important for nurses to continually be up to date on current research so they can better manage and prevent obesity in children.

Interventions to decrease child obesity would be more successful if they were aimed at multiple levels of influence of the determinants of health, rather than directing it solely at the child. I would recommend RNs carry out regular health checks for children. These health checks should assess the child’s BMI and plot on the growth chart, height, weight and blood pressure. By carrying out these checks the nurse is able to assess whether the child is overweight or obese for their age and discuss interventions if needed for the child. Nurses should assess the child holistically, by assessing the family’s socioeconomic status, psychological state and their health history to have an overall understanding of the patient. This will assist the nurse to be able to support them and work effectively to prevent and/or treat the child’s obesity. Lastly, I recommend nurses should engage parents in prevention activities with their child and encourage parental modelling of healthy dietary choices. If the child’s parents are involved the child is more likely to follow what the parent is doing, and therefore will be likely to mimic their healthy eating habits and exercise patterns. Also parents have the ability to set rules in relation to watching television to limit food marketing seen by the child and to encourage physical exercise.

Conclusion

Obesity requires serious attention to begin to decrease the percentage of obese children in today’s society. To successfully make a change to improve the future health status for New Zealand children, parents, schools and health professionals need to work together. It is clear to see from a wide range of research that obesity in children has reached epidemic levels that need to be addressed. Through understanding the influences and health impacts related to child obesity RNs and families are able to make a difference. In addition, for adequate health supervision of children, nurses also must act as advocates in their primary care setting to help overcome the barriers to child obesity prevention.

References

Controller and Auditor-General. (2013). Part 2: Summary of research into community perspectives. Retrieved from http://www.oag.govt.nz/2013/child-obesity/part-2

Covic, T., Roufeil, L., & Dziurawiec, S. (2007). Community beliefs about childhood obesity: Its causes, consequences and potential solutions. Journal of Public Health, 29(2), 123-131.

Hodges, E. (2003). Backup of a primer on early childhood obesity and parentalinfluence. Paediatric Nursing, 29, 13-16.

Larsen, L., Mandleco, B., Williams, M., & Tiedeman, M. (2006). Childhood obesity: Prevention practices of nurse practitioners. Journal of the American Academy of Nurse Practitioners, 18.2, 70-79.

Ministry of Health. (2012, July). Food and nutrition guidelines for healthy children and young people (Aged 2-18 years): A background paper. Wellington, New Zealand: Author.

Ministry of Health. (2013, December). New Zealand Health Survey: Annual update of key findings 2012/13. Wellington, New Zealand: Author.

Pizzi, M. A., & Vroman, K. (2013). Childhood obesity: Effects on children’s participation, mental health, and psychosocial development. Occupational Therapy in Health Care, 27, 99-112.

Walton, M., Signal, L., & Thomson, G. (2009, August). 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. (2010). 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, G. LoBiondo-Wood, & J. Haber (Eds.), Nursing and midwifery research methods and appraisal for evidence–based practice (pp.35-56). Sydney, Australia: Mosby.