A Weighty Challenge
Nursing resources available to address, prevent overweight in children

By Christina Calamaro, RN, MSN, CRNP
April 25, 2005

Obesity is rapidly becoming the world’s most prevalent nutritional disorder. In the United States, childhood overweight is anepidemic. Nurses must address the problem by educating children and parents about the risks involved and the preventive actions to take. It is important nurses know the issues and the resources available that reflect the most current research on overweight in children.

The U.S. Centers for Disease Control and Prevention recommends childhood overweight be defined as body mass index (BMI) at or above the 95th percentile for age; at risk for overweight is defined as BMI at the 85th to 94th percentile for age.^1,2,3 These definitions were recommended because of the stigma children faced with the prior definitions of obese and very obese, respectively. The definitions also provide a standard for clinical practice to avoid unnecessary treatment.^2,4

Globally, obesity affects more than 310 million people.⁵ Consider that in 1991, only four states reported that between 15% and 19% of their populations were obese. By 2003, 15 states had obesity prevalence rates of 15% to 19%; 31 states reported rates of 20% to 24%; and four states reported more than 25% of their population was obese.⁶ (See “2003 State Obesity Rates.”) Mississippi had the highest rate of obesity (24.3%), and Colorado had the lowest rate of obesity (13.8%).⁸

Serious concerns

Overweight in children can no longer be considered a benign disease because a parallel increase in obesity-associated chronic diseases has emerged in younger patient populations. In adult and pediatric populations in the U.S., obesity is rapidly increasing in prevalence and comorbidities.^8,9,10 Child­hood overweight is now linked to cardiovascular disease, dyslipidemia, impaired glucose tolerance, type 2 diabetes, hypertension, nonalcoholic fatty liver disease, sleep-disordered breathing, social discrimination, and isolation.^11-17 It is a substantial contributor to early morbidity and mortality.

Many factors affect overweight

For most people, obesity still remains preventable. Nurses can help children maintain appropriate body weight as they grow. Measures to decrease the menace of childhood overweight should focus on promoting healthy lifestyle habits in children, such as nutrition and physical activity, rather than on any one aspect responsible for the overweight. Interventions must be culturally sensitive and age-appropriate.

There is noticeable disparity in the incidence of overweight among children of different ethnicities. Most affected are non-Hispanic black and Mexican-American children, who particularly after age 6 exhibit higher incidence of overweight than non-Hispanic white children of the same age range.⁹ (See “Ethnic Disparity: Overweight.”)

Even more important is for the nurse to incorporate resources that build relationships between the parent and child, as well as between the health professional and family members. It is imperative to include both caregiver and child in any discussion focusing on nutrition and physical activity. Educational resources exist that are family-oriented and focused on evidence-based research.

Nursing organization offers solution

One example of a resource being developed is the Healthy Eating and Activity Together (HEAT) Initiative launched by the National Association of Pediatric Nurse Practitioners. NAPNAP is the only nursing organization creating a program focused on preventing childhood overweight. The goal of HEAT is to improve child health through relationship-based, culturally appropriate interventions that include the child, parents, and health care professional. HEAT offers clinical practice guidelines focused on optimal nutrition and physical activity. These guidelines will be available later this year.

“It’s time to begin to identify the causes of the epidemic of overweight in children and to develop innovative and scientifically based ways of preventing it at all developmental stages,” says Richard Ricciardi, RN, MS, CPNP/FNP, president of NAPNAP. “This will take a large-scale effort across all levels of society while focusing on improving dietary habits, reducing sedentary behaviors, and increasing physical activity.”

‘Toxic’ environment

The term “toxic environment” has been used to describe the myriad factors — such as increased portion size, sugar-sweetened beverages, fast food, and decreased physical activity — responsible for overweight in children. The interaction of these factors, in the presence of genetic predisposition to obesity, can increase a child’s risk of becoming overweight.¹⁸ The rapid increase in excessive weight gain in the U.S. cannot be blamed solely on genetics, however. The interplay of environmental factors is the greatest component in this epidemic. Par­tic­ular­ly evident is an energy imbalance in the form of increased energy intake (in the form of calories) or decreased energy output.^18,19

Nurses can assume a leadership role in decreasing the menace of childhood overweight by focusing energies on providing patients and families with information that is realistic for their busy lives, considers ethnicity, and focuses on strengthening family bonds. Only through this approach can there be success in achieving the goal of healthy lifestyles for all children.

Christina Calamaro, RN, MSN, CRNP, is chair of the school-age program for the National Association of Pediatric Nurse Practitioners’ HEAT initiative and a doctoral candidate at the University of Pennsylvania School of Nursing, Philadelphia.

References

1. Barlow SE, Dietz WH. Management of child and adolescent obesity: summary and recommendations based on reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatr. 2002;110(1 Pt 2):236-238.

2. CDC. 2000 CDC Growth Charts. Atlanta: Center for Disease Control and Prevention: National Center for Health Statistics; 2000.

3. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital & Health Statistics - Series 11: Data From the National Health Survey. 2002(246):1-190.

4. AAP. Prevention of Pediatric Overweight and Obesity: American Academy of Pediatrics Policy Statement; Organizational Principles to Guide and Define the Child Health Sytem and/or Improve the Health of All Children; Committee on Nutrition. Pediatr. 2003;112:424-430.

5. International Obesity Task Force website. Available at: www.iotf.org. Accessed February 15, 2005.

6. Obesity Trends. The National Center for Chronic Disease Prevention and Health Promotion website. Available at: www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm. Accessed February 10, 2005.

7. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289(1):76-79.

8. Freedman DS, Srinivasan SR, Valdez RA, Berenson GS. Secular increases in relative weight and adiposity among children over two decades: the Bogalusa Heart Study. Pediatr. 1997;99:420-425.

9. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000.[comment]. JAMA. 2002;288(14):1728-1732.

10. Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology, and demographics. Pediatr. 1998;101(3 Pt 2):497-504.

11. Sokol RJ. The chronic disease of childhood obesity: the sleeping giant has awakened. Pediatr. 2000;136(6):711-713.

12. Johnston FE. Health implications of childhood obesity. Ann Intern Med. 1985;103:1068-1072.

13. Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatr. 1998;102(3):E29.

14. Slyper AH. Childhood obesity, adipose tissue distribution, and the pediatric practitioner. Pediatr. 1998;102(1):e4.

15. Dietz WH, Gortmaker SL. Preventing obesity in children and adolescents. Annu Rev Public Health. 2001;22:337-353.

16. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatr. 1998;101:518-525.

17. Fine JT, Colditz GA, Coakley EH, et al. A prospective study of weight change and health-related quality of life in women. JAMA. 1999;282(22):2136-2142.

18. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002;360:473-482.

19. Goran MI. Metabolic precursors and effects of obesity in children: a decade of progress, 1990-1999. Am J Clin Nutr. 2001;73:158-171.

20. Dietz WH. Overweight in childhood and adolescence. N Engl J Med. 2004;350(9):855-857.