Childhood Obesity

Childhood Obesity MBA 685 Special Topics in Healthcare Dr. Zarina Dawoodbhai Concordia University Wisconsin Katherine Schulz 12/15/10

Childhood Obesity

ABSTRACT: Childhood obesity is increasingly prevalent and has become an epidemic. A vast amount of health problems are associated with the condition, and many of these health problems can be life-threatening and may likely persist into adulthood. Although obesity can largely be associated with genetic composition, other factors contributing to obesity can be almost entirely modifiable on some level. This article examines the physical and psychosocial issues associated with childhood obesity and frames various models for intervention, including parental assistance, motivational interviewing and the transtheoretical model. With the help of parents and medical providers, children may be able to alter their negative habits to live more active lifestyles and shift the paradigm to a healthier society. This could reduce the prevalence of childhood obesity, and consequently it may also reduce the number of obese adults.

The prevalence of obesity has continued to rise over the past few decades. Ten years ago, no state had an obesity prevalence of over 30 percent, but now nine states find that to be the case (Herzog, 2010). Increasing prevalence of obesity in children is especially troubling because studies have shown that obese children and teens are more likely to become obese as adults (Centers for Disease Control and Prevention, 2010) a trend that will only get worse if it is not addressed. Obesity is a complex issue that cannot be pinned down to one single cause, and therefore no simple solutions to the condition exist. Despite rising trends in obesity, negative stereotypes still persist. In addition to psychological effects due the emotional distress of these stereotypes, physical complications are also commonly seen in obese children. Dealing with obesity can become extremely costly to the patient, the hospitals treating them, and also to society. Shifting this paradigm may be far from easy and simple, but it must be done to prevent increased incidence of obesity in the future. In order to do so, various methods must be utilized

Childhood Obesity in connection with one another to focus efforts on overcoming the epidemic of childhood obesity. Identifying overweight and obese children is the first hurdle to overcome in the fight against the epidemic. Body Mass Index (BMI) is a practical measure that is used to determine overweight and obesity. Overweight is defined as a BMI at or above the 85th percentile, while obesity is defined as a BMI at or above the 95th percentile (Centers for Disease Control and Prevention, 2010). The Centers for Disease Control and Prevention reported that between 1976 and 2000 the prevalence of obesity in children and adolescents increased. There was no significant trend in obesity prevalence for any age group from 2000-2008. However, results

from a 2007-2008 survey estimated that 16.9 percent of children and adolescents aged 2-19 years were obese, while only about 5.5 percent were obese in 1976 (Centers for Disease Control and Prevention, 2010). It is not possible to assign one single cause of obesity. Risk factors may include diet, lack of exercise, family history, psychological factors, family factors, socioeconomic factors, as well as cultural traditions and expectations. At an individual level, though, obesity occurs when a child consumes more calories than he uses. That imbalance between calories consumed and calories used can stem from genetic, behavioral, and environmental factors. Although genes can be responsible for a childs susceptibility to becoming obese, the rapid rise of overweight and obesity cannot solely be attributed to genetic factors. The genetic characteristics of the human population have not changed in the last three decades, but the prevalence of obesity has tripled among school-aged children during that time (Centers for Disease Control and Prevention, 2010).

Childhood Obesity Behavioral factors probably have the most influence on whether a child is more likely to

be obese. The rise in popularity of fast food chains and other family restaurants has led to larger portion sizes for food and beverages. More children eat meals away from home and snack frequently on energy-dense foods and consume beverages with added sugar, leading to higher caloric intake. Americans consumed 50 percent of their meals away from home in 1994 and spent close to 50 percent of their food budgets on fast-food restaurants in 1998 (Mason, Crabtree, Caudill, & Topp, 2008). In addition, children have become much less physically active in the past several years. In fact, participation in school physical education among adolescents dropped 14 percentage points over the last 13 years, and only 28 percent of high school students meet the recommended levels of physical activity (Centers for Disease Control and Prevention, 2010). Home, childcare, school, and community environments also influence childrens behaviors related to food intake and physical activity. Parents play a large role in influencing the diet and physical activity of their children because children are likely to develop similar habits to their parents (Mason, Crabtree, Caudill, & Topp, 2008). Childcare and schools have a great opportunity to influence behaviors of children because they often spend up to 40 hours per week at one or the other. If any negative behaviors are acceptable or even encouraged, it may be difficult for parents to mend those habits. Within the community, lack of playgrounds, sidewalks, bike paths and parks may discourage children to go outside and play one of the easiest ways to participate in physical activity. The surge in popularity and advancement of technology also heavily contributes to the sedentary lifestyle of many children today. A study in 2004 suggested that every hour children play video games or watch television may double their risk of obesity (Warner, 2004). While those data may be disputed today, the recommended limit for children is no more than two hours

Childhood Obesity of television watching or videogame playing per day. Some researchers now theorize that it is not the number of hours watching television that matters, but it is how many advertisements for junk food there are. A recent study showed that the association between television viewing and childhood obesity is directly related to childrens exposure to commercials that advertise unhealthy food and that non-commercial viewing, including watching DVDs or educational television programming, had no significant association with obesity (Anderson, 2010).

Regardless of childrens exposure to commercials, more time in front of the television leaves less time to participate in physical activity. In addition, researchers believe that reduced eating in front of the television is at least as important as increasing activity (Dehghan, Akhtar-Danesh, & Merchant, 2005). Childhood obesity can be associated with various health-related consequences. Even though the prevalence of obesity is increasing, the stigma attached to it remains. Obese children often become targets of systematic social discrimination. Obese individuals are judged as unattractive by their peers, and they are treated with disrespect and frequently bullied and teased about their physical appearance. This continual abuse can easily lead an obese child to suffer from low self-esteem and sometimes even depression. Behavior and other learning problems are sometimes associated with obesity as well. In addition to psychosocial risks, numerous physical risks have been linked to obesity. Obese children may find they are unable to perform simple, everyday tasks like walking or taking the stairs. Negative physiologic outcomes of overweight include glucose intolerance, hepatic steatosis, and gallstones, as well as high cholesterol, hypertension, asthma, sleep apnea, orthopedic complications, and polycystic ovary syndrome (Howard, 2007). Young girls may also experience early puberty or menstruation. The incidence of type 2 diabetes is especially

Childhood Obesity concerning. Onset of diabetes in children and adolescents can result in advanced complications such as cardiovascular disease and kidney failure. Children with early-onset type 2 diabetes are extremely likely to become adults with type 2 diabetes. In fact, a recent federal government study warned that the number of American adults with diabetes could double or triple by 2050 between one-fifth and one-third of all adults if current trends continue (Banerj, 2010). All of the complications associated with obesity cost a lot to not only the individual with the condition, but also to the hospitals or clinics treating them and to society as a whole. Recent estimates of the annual medical costs of obesity are $147 billion, which amounts to an average

amount of over $1,400 higher costs each year for persons who are obese than for those of normal weight (Herzog, 2010). For immobile individuals, wheelchairs cost about $150 to $330 for the standard size, but a bariatric wheelchair, which can support a 1,000 pound person, costs roughly $1,500 (Ghose, 2010). Because of all of the medical complications associated with obesity, individuals may also be prone to a reduced lifespan as well. At the basic level, hospitals have to spend more money to treat more diseases associated with obesity due to their increased prevalence, and insurance companies are therefore forced to increase premiums because of the increase in associated costs. Hospitals have also had to make many physical changes in order to accommodate obese patients in their care. Many of the bathrooms are equipped with wall-mounted toilets. The toilets mounted to the wall wont accommodate those larger patients and will literally break off the wall (Ghose, 2010). More than one in three hospitals have been renovated to account for obese patients or are planning to do so in the near future. The Columbia St. Marys Hospital in Milwaukee has roomier rooms and bigger doorways, while Froedtert Hospital in Wauwatosa has retrofitted a couple of the rooms on each floor for bariatric patients. They have spent $300,000 this year on replacing 60

Childhood Obesity rooms with floor-mounted toilets (Ghose, 2010). Hospitals have also had to add wider, stronger wheelchairs, bigger or adjustable beds, stretchers and beds with motors to assist the nurses in maneuvering patients, and waiting room chairs that look like loveseats but can handle someone who is 600 pounds. In addition to those adjustments, high-tech equipment has also had to be upgraded. GE Healthcare has manufactured an MRI machine with a 70-centimeter diameter, rather than the standard 60-centimeter diameter (Schmid, 2009). Societal costs of obesity must not be overlooked. With such rapidly increasing trends in prevalence of obesity, the problem is only getting worse, and society must face all the complications of the epidemic together. Many obese individuals may feel that they do not need to adjust their habits and live healthier lifestyles because everyone is heavier there may be reduced incentive to lose weight if it is the norm to be heavy. In addition, with the current healthcare crisis and insurance obstacles, if a patient cannot pay for his medical care, the costs may be diverted toward the public through increased taxes and higher insurance premiums. Shifting the paradigm to healthier lifestyles will require great effort. There are many obstacles that stand in the way of achieving that goal. People may not wish to or may be afraid of change. Some affected individuals may not even recognize that they need to change their lifestyle because they do not believe they are obese or do not feel that obesity is a problem. Shaking a bad habit is a very difficult thing to do, and weight loss programs take dedication and time to observe results. Fast food is cheap and easily accessible. Americans are increasingly

busy and do not have the time or money to cook healthful meals. Fresh fruits and vegetables are more expensive and not everyone has access to better food because of financial limitations or lack of proximity to the supply. Making excuses is much easier than taking action, and thus, the desired result of a healthier society will require everyone working together to shift the paradigm.

Childhood Obesity

There is not one solution to this epidemic, but many individual pieces that should work in connection with one another to achieve a healthier society. First, adults and parents of children have a responsibility to change their lifestyles just as much as the children do. They must educate children about the risk factors and associated costs in a way that is comprehensible and non-judgmental because children should not be told simply that they must lose weight, but instead the focus should be on healthy nutrition and health activity habits (Perrin, Finkle, & Benjamin, 2007). No-risk recommendations for prevention of obesity through parenting include limiting television and video games, limiting sweetened drinks, and increasing physical activity, especially in children more likely to be overweight. Parents can encourage exercise through playing or participating in organized sports, take away cell phones and control texting for children, and they can enforce sitting down at the table for dinner with the family, limiting time spent eating in front of the television. All of these suggestions promote healthier children by reducing sedentary lifestyles and encouraging more physical activity. Parents are not the only ones who need to be addressing the problem of childhood obesity. Pediatricians and nurses must take every opportunity, no matter how small, to talk with parents about what they can do to encourage healthy lifestyles in their children. They may be able to achieve this goal by practicing motivational interviewing. Motivational interviewing (MI) is a patient-centered style of interaction that facilitates behavior change by helping patients explore and resolve their ambivalence about change (Waldrop, 2006). The first requirement for MI is building a rapport with the patient, which could be easier for a pediatrician who is familiar with the child and his family because of continual treatment throughout the childs life. Collaboration between the patient, who is the expert on his life, and the provider is important in empowering the patient to participate. Empathy and encouragement are required to ensure

Childhood Obesity understanding of what is said or perceived, and intrinsic motivation comes only from within the patient and is required for lasting change. The transtheoretical (TTM) model of health behavior change is a framework that healthcare providers can use to assess readiness for change. It identifies six stages to health behavior change: precontemplation, contemplation, preparation, action, maintenance, and termination (Howard, 2007). These stages can be used as interventions to change other health behaviors as well, including smoking, emotional distress, alcohol abuse, weight loss, and mammography screening (Mason, Crabtree, Caudill, & Topp, 2008). Movement between these stages should be linear, although it is also common to move back and forth between stages before a permanent transition to the next stage and eventual termination is realized (Mason, Crabtree, Caudill, & Topp, 2008). Cognitive approaches, such as consciousness raising, social liberation, self-evaluation, and environmental reevaluation are most effective when individuals have not yet changed their

behavior, such as in the precontemplation and contemplation stages (Mason, Crabtree, Caudill, & Topp, 2008). During the precontemplation stage, the patient does not intend to change their behavior in the next six months. Here, it is necessary to increase awareness, elicit and increase emotion and stimulate thought about the effect of the individuals health behavior on the social sphere. A patient in the contemplation stage is not yet prepared to take action but he intends to change his health behavior in the next six months. He must be guided cognitively and emotionally toward comparing his current self-image to that without the unhealthy behavior and go through self reevaluation (Howard, 2007). Behavioral strategies, such as self-liberation, counter-conditioning, stimulus control, and reinforcement are more appropriate when individuals have initiated or are attempting to maintain

Childhood Obesity

10

new behaviors, such as in the action and maintenance stages (Mason, Crabtree, Caudill, & Topp, 2008). The patient who is actively considering changing his health behavior in the next month is in the preparation stage, and now is the time for self-liberation, increasing social opportunities that support positive health behaviors. An overt behavior change consistent with improved health is taken during the action stage of change. The healthcare professional should reinforce positive or discourage negative health behavior change, encourage supportive relationships, and remove cues that prompt unhealthy behaviors. Maintenance occurs when the patient has changed his health behavior and is working to sustain changes, and termination occurs when he has 100 percent self-efficacy in health behavior (Howard, 2007). Since patients can often move back and forth between stages, it is necessary to monitor these in order to give the appropriate intervention strategy. One example of using MI to help move a patient from precontemplation to contemplation is the case of 13 year old GiGi. She wanted to try out for the junior high dance team, but knew pain was preventing her from practicing the routines. Her BMI was greater than the 95th percentile for her age and height, and she was already on medication for hypertension. MI could be used to help her develop a discrepancy by finding out what her short- or long-term goals were and ask her what connection she sees between her goals and her current behavior. Short-term, she wanted to be on the dance team, and her long-term goal was to become a professional cheerleader. While the ultimate goal of the healthcare provider is for the GiGi to lose weight for health reasons, her goal is to be able to dance. Helping her achieve her goal is a step toward improving her health and possibly may lead to more health-related behavior changes in her future (Waldrop, 2006).

Childhood Obesity Still, physicians feel that they may not be able to treat childhood obesity in the doctors

11

office due to inadequate time to address the problem in the office setting, lack of necessary skills and tools, and inadequate reimbursement for programs targeting obesity (Mason, Crabtree, Caudill, & Topp, 2008). For this reason, a case manager could ideally be utilized to provide a collaborative effort between the obese child and his family, as well as other healthcare team members, such as primary care physicians, nurse practitioners, dieticians, exercise physiologists, psychologists, and social workers. Case management is an effective multifaceted service that can result in significant and quantifiable cost savings in the management of chronic illnesses, and managing that health condition must be individualized to the patients current needs and resources (Mason, Crabtree, Caudill, & Topp, 2008). Childhood obesity is becoming increasingly prevalent in America, and it is an epidemic that needs to be addressed. Not only are there physical and psychological risk factors for the affected individual, but there are extra costs to the patient, the hospitals, and to society. We must shift the paradigm from this increasing trend to promote healthier lifestyles. Change is not easy or fast, and society must work together to address the problem. The transtheoretical model should be used in conjunction with motivational interviewing at the doctors office and with school nurses, parents need to become more involved in encouraging their children to eat better and be more physically active, and they must be good role models for healthier lifestyles.

* This paper was submitted via email. This is the critique I received from my instructor:
Zarina Dawoodbhai <zarina.dawoodbhai@hotmail.com> To: katherine schulz <schulz.katherine@gmail.com> Tue, Dec 14, 2010 at 9:33 PM

Hello Katherine Your paper is excellent, well-written and research based, nice job you received an A, see you tomorrow thanks Zarina

Childhood Obesity References

12

Anderson, S. (2010, February 8). Childhood obesity: It's not the amount of TV, it's the number of junk food commercials. Retrieved December 3, 2010, from UCLA Newsroom: http://newsroom.ucla.edu/ Banerj, M. A. (2010, October 22). One-Third of U.S. Adults Could Have Diabetes by 2050: CDC. Retrieved December 2, 2010, from HealthDay News: http://www.healthfinder.gov Centers for Disease Control and Prevention. (2010, March 31). Childhood Overweight and Obesity. Retrieved December 2, 2010, from Centers for Disease Control and Prevention: http://www.cdc.gov/obesity/childhood/index.html Dehghan, M., Akhtar-Danesh, N., & Merchant, A. T. (2005). Childhood obesity, prevalence and prevention. Nutrition Journal , 4 (24). Ghose, T. (2010, July 17). Hospitals beef up equipment for obese. Milwaukee Journal Sentinal . Herzog, K. (2010, August 3). Nation's obesity rate skyrocketing, CDC reports. Milwaukee Journal Sentinal . Howard, K. R. (2007). Childhood Overweight: Parental Perceptions and Readiness for Change. The Journal of School Nursing , 23 (2), 73. Mason, H., Crabtree, V., Caudill, P., & Topp, R. (2008). Childhood Obesity: A Transtheoretical Case Management Approach. Journal of Pediatric Nursing , 23 (5), 337-344. Perrin, E. M., Finkle, J. P., & Benjamin, J. T. (2007). Obesity prevention and the primary care pediatricians office. Current Opinion in Pediatrics , 19 (3), 354-361. Resnicow, K., Davis, R., & Rollnick, S. (2006). Motivational Interviewing for Pediatric Obesity: Conceptual Issues and Evidence Review. Journal of the American Diatetic Association , 106 (12), 2024-2033. Schmid, J. (2009, April 24). GE Healthcare unveils new medical imaging equipment. Milwaukee Journal Sentinal . Waldrop, J. (2006). Behavior Change In Overweight Patients. Advance for Nurse Practitioners , 14 (8), 23. Warner, J. (2004, July 2). Video Games, TV Double Childhood Obesity Risk. Retrieved December 3, 2010, from WebMD: http://children.webmd.com