Prevention of Childhood Obesity 1

Running head: PREVENTION OF CHILDHOOD OBESITY

Prospectus: Prevention of Childhood Obesity
Through Education and Research
Kim Bookout
Julie Dreadin
William Lodrigues
Texas Womans University









Prevention of Childhood Obesity 2
Abstract
Childhood obesity is in epidemic proportions in the United
States (U.S.) (Nemet et al., 2005; WHO, 2000). Many factors are
associated with the rise in childhood obesity such as increased
sedentary behaviors (e.g., time spent watching television and
playing handheld video games) and decreased time for physical
education programs in school. Additionally, families have become
less engaged in fitness activities thereby contributing further
to overweight and obesity. The aim of this educational project
is to address both nutritional and physical fitness components
as they relate to the prevention of obesity in childhood.
Inclusion of the entire family unit is integral to the success
of the program. The methodology utilized for this project is
based on recommendations provided by the Texas Pediatric Society
in conjunction with Texas Department of State Health Services in
Pediatric Obesity: A Clinical Toolkit for Healthcare Providers
(2005). This comprehensive 24-week program includes education
related to nutrition, lifestyle modification, behavioral
modification, increased physical activity, and nutrition/family
counseling. Children (ages 4 to 18) and their families will be
voluntarily enrolled in the program and followed for a two year
period. Outcomes of this program will be based on physical and
cognitive evaluation.
Prevention of Childhood Obesity 3
Problem Statement
Childhood obesity is in epidemic proportions in the United
States (U.S.) and worldwide. And, while recognized as a growing
problem, there is no unified strategy for its prevention or
treatment. Many factors are associated with the rise in
childhood obesity such as increased sedentary behaviors (e.g.,
time spent watching television and playing handheld video games)
and decreased time for physical education programs in school.
Other potential factors impacting the increase in childhood
obesity include the growing demands placed on families related
to both parents working outside the home, decreased after school
supervision, and the reliance on processed foods.
It is recognized that sedentary behaviors lead to increased
body mass index (BMI). And, just as obesity affects children, it
affects adults as well. Families are less engaged in fitness
activities for a variety of reasons. In addition to the
aforementioned barriers, other potential reasons for decreased
physical activity include: busy schedules, lack of motivation
and an overall lack of knowledge related to health and fitness.
However, children are solely reliant on their families for the
purchase and preparation of food as well as determination of
schedules and priorities for the family. Therefore, childhood
obesity becomes a familial problem.
Prevention of Childhood Obesity 4
Prevalence
Childhood obesity has reached epidemic proportions in recent
years. It is considered the most common chronic disease in
pediatrics in our present-day society (Nemet et al., 2005).
Rice, Thombs, Leach and Rehm (2008) report prevalence of obesity
in U.S. children ages seven to 17 years as much as 16% while
another 15% are considered overweight. Prevalence has increased
two-fold in the past two decades. Causality of childhood obesity
is multi-factorial and includes reasons such as lower
socioeconomic status, genetics, parental eating patterns,
decreased physical activity, and consumption of nutritionally
poor foods (Hodges, 2003; Eliakim, Nemet, Balakirski, & Epstein,
2007; Rice et al., 2008).
Aims and Objectives
The aim of this project is to address both nutritional and
physical fitness components as they relate to the prevention of
obesity in childhood. Inclusion of the entire family unit is
integral to the success of the program. Specific objectives
focus on education and research.
Educational Objectives
Participants in this program will increase knowledge related
to nutrition, exercise, and chronic disease prevention.
Prevention of Childhood Obesity 5
Educational knowledge will be measured through pre- and post-
tests prior to classes for both children and adults.
Physical Objectives
Participants will demonstrate improvement in overall
nutritional and fitness status. Measurements of weight, height,
BMI, waist circumference, glucose, lipid profile, liver function
and physical features (i.e., acanthosis) will be carried out at
baseline and intervals over the 2-year study period.
Additional Benefits
The long-term effects of obesity are well understood as
children progress in to adolescence and adulthood. In fact,
obesity in adults is well correlated with risk of development of
hypercholesterolemia, hyperlipidemia, hypertension,
atherosclerosis and cardiovascular disease, and type 2 diabetes
(Ball, Marshall, & McCargar, 2003). Thus, implementation of
early fitness and nutrition programs may have long-lasting
benefits to overall health and wellness of children as well as
adults.
Methods
The methodology utilized for this project is based on
recommendations provided by the Texas Pediatric Society in
conjunction with Texas Department of State Health Services in
Pediatric Obesity: A Clinical Toolkit for Healthcare Providers
Prevention of Childhood Obesity 6
(2005). The toolkit provides information integral to the
implementation of a successful obesity prevention and management
program. Items included are for both patient and provider.
Provider tools are inclusive of evaluation forms, BMI charts,
billing information, resource lists and a weight management
algorithm. Patient tools are available in both English and
Spanish and include handouts related to nutrition guidelines,
sample meal plans, lifestyle guidelines, behavior guidelines and
healthy lifestyle prescriptions.
It is recognized that multiple programs for prevention and
treatment of childhood obesity are demonstrating successful
outcomes (Rice et al., 2008; Summerbell et al., 2005). Small,
Anderson, and Melnyk (2007) identified a younger group (ages
four to seven years) than is often described in the literature.
The authors reviewed 12 randomized clinical trials that were
specific to overweight and obese children ages four to seven
years and were conducted internationally. One-half of the
studies were focused on treatment and one-half focused on
prevention. Sample sizes within the six treatment studies as
well as the six prevention studies were small (n=30 to 65) and
therefore statistical analyses were not conducted.
The authors concluded that findings within the review were
similar to the findings of Summerbell et al. (2005) and urge
Prevention of Childhood Obesity 7
future studies be conducted to develop and test theory-based,
reproducible interventions including patients and parents.
Evidence-based intervention strategies identified within this
review include: nutritional and activity education, cognitive-
behavioral interventions, parent-directed activities, reduction
of sedentary behaviors in children, and reward systems for
milestones.
Program Enrollment
Enrollment in this comprehensive 24-week program is
voluntary. Children and their families will be identified and
recruited during routine well visits as well as problem-focused
office visits from local pediatric practices in the Greater
Lewisville area. Inclusion criteria for the program are children
ages four to eighteen with BMI at 85% or greater, with at least
one active parent or legal guardian. Families will meet weekly
at the clinic for education related to nutrition, exercise and
chronic disease prevention for a 24-week program. Following the
24-week program, periodic surveillance data will be collected at
three and six month intervals for a two year period.
Definition of Terms
Obesity
Obesity is defined as the presence of excess body fat
(Miriam-Webster, 1993, p. 801). It is characterized by a weight
Prevention of Childhood Obesity 8
well above the mean for a childs height and age and a BMI well
above the normal range (95
th
percentile or greater).

Overweight
Overweight is defined as weighing in excess of the normal
for one's age, height, and build (Miriam-Webster, 1993, p.
831). It is characterized by a BMI between the 85
th
and 94
th

percentile.
Body Mass Index
The body mass index (BMI) is a statistical measure of a
persons weight scaled according to his height. BMI is defined
as the individual's body weight divided by the square of their
height. The formulas used in medicine produce a unit of measure
of kg/m
2
. Body mass index may be calculated as follows: BMI =
weight (kg) /height
2
(meters
2
). Another formula for BMI
calculation is: BMI = weight (lb) x 703/ height
2
(inches
2
).
Evaluation
Evaluation of outcomes for this program is two-pronged.
Participants in the program will be evaluated physically and
cognitively. The physical evaluation will consist of
measurements of weight, height, BMI, waist circumference,
glucose, lipid profile and physical features (i.e., acanthosis).
Goals for physical improvement will be developed on an
individual basis and unique to each participant. Cognitive
Prevention of Childhood Obesity 9
evaluation will be assessed with pre- and post-test scores
utilizing a tool provided by the Texas Pediatric Society.
Clinical findings for physical measures will be categorized
into four areas of success; excellent, good, average, and poor.
Participants will be evaluated at the end of successful
completion of the 24-week program. The following criteria will
be utilized to measure program outcomes. An excellent outcome is
defined as >65% of participants demonstrate a decrease in BMI of
2.5%. A good outcome is defined as >40% of participants
demonstrate a decrease in BMI of 2.5%. An average outcome is
defined as >30% of participants demonstrate a decrease in BMI of
2.5%. A poor outcome is defined as 30% of participants
demonstrating a decrease in BMI of 2.5%.
Participants will be entered into a database that will be
updated weekly to include physical findings (i.e., vital signs
and weight), attendance, and verification of participation in
home activities related to the program (i.e., nutrition log and
exercise log). Further program evaluation will include data
related to attendance, attrition rate, and non-compliance. A
successful attendance rate will be defined as 70% weekly
participation with a maximum of two absences over the initial
24-week program. An attrition rate of <5% is considered
acceptable and will be measured only within the initial
treatment program. An additional element for evaluation is that
Prevention of Childhood Obesity 10
of non-compliance. Non-compliance is defined as a participant
that meets attendance obligations but does not comply with home
activities as specified by the program (i.e., nutrition log and
exercise log). A non-compliance rate of <5% is considered a
satisfactory for a successful program. Participants
demonstrating active participation in the program but not
achieving individualized goals for weight loss/BMI reduction may
be referred to appropriate specialists for further clinical
evaluation.
Budget
The implementation of the project will occur in two phases.
The first phases will be the build-out of the clinic in an
established building. The second phase will be the purchasing of
the hardware, equipment, marketing and set-up. The build-out of
the clinic will occupy approximately 2300 square feet in a wing
of a free standing medical office building (Appendix B). The
quoted cost of the build-out will be $85 per square foot. With
2300 square feet of space, the total calculated build-out cost
will be $195,500. This would include architectural design, all
construction cost including plumbing, light fixtures,
electrical, air conditioning and heating, fully functional
kitchen with dishwasher, refrigerator, built-in microwave, and
stove with oven. Also included in the construction costs are
stained concrete floors in the waiting rooms and bath rooms,
Prevention of Childhood Obesity 11
carpet in the exam rooms, office, and hallways, and commercial
recreational carpet for the weight room and activity room. The
clinic will comply with all city and state commercial codes and
the American Disabilities Act codes for access. The time frame
to complete the build-out will be 65 days. All prices were
provided by Brass Key Builders at current market prices. The
initial cost of furniture, equipment, and a computer system with
software is budgeted at $45,000. The computer system will
consist of four laptops, a wireless internet router and software
applications at a cost of approximately $16,500. The exam room
tables and equipment will cost approximately $10,800 and waiting
room and office furniture is budgeted at $3,500. Additional
items such as blood pressure cuffs, scales, and miscellaneous
items will be shared with neighboring clinic space and will not
represent an expense. The equipment proposed for the exercise
room will be four treadmills, four stair climbers, two universal
gym units, free weights, two elliptical machines and 14 mats at
a price of approximately $14,200.
The fulltime staff will consist of one administrative
assistant, two medical technicians, and a nurse practitioner as
the manager. The contracted employees will include one exercise
physiologist, one dietician, and one pediatrician. The
contracted labor will bill directly to the insurance company and
not charge the clinic for any services provided.
Prevention of Childhood Obesity 12
Monies received from the grant will be utilized for the
initial start-up cost and aid in the monthly clinic expenditures
until clientele can be established. The monthly expenses will
consist of rent ($2,500), salaries for fulltime employees
($6,000), clinic insurance ($450), utilities ($550), and
miscellaneous items such as coffee, water, drinks ($250), and
janitorial services ($500). Marketing will be budgeted at $500
per month. The estimated monthly budget for operating
expenditures is estimated at $10,700.00. Additional food items
for use in nutritional counseling demonstrations will be donated
by local merchants.
The clinic will generate sustained income by billing the
insurance companies for services rendered. Services will be
billed using two main evaluation and management codes, 99204
(new patient visit) and 99214 (return patient visit). The
average patient will have 13 clinic appointments, one as a new
patient, and 12 return visits, during the active treatment
phase. The long term maintenance visits will be billed at a
99214 level. The average amount collected for a new patient
visit, 99204, is $164 and $103 for a return appointment coded as
99214. These amounts are based on a current contractual
agreement with Southwest Physicians Associates. During the
active phase of treatment (12 weeks) the revenue from one
patient will be $1297. That will average an income of $432 per
Prevention of Childhood Obesity 13
month per patient in active treatment. In order to meet the
operating expenses ($10,700) of the clinic, the clinic must
maintain 25 patients in the active phase of treatment. An excess
of 25 patients in the active treatment phase plus all patients
in the maintenance phase (12 weeks)of treatment will be profit
for the clinic.
Summary
Childhood obesity is in epidemic proportions in the United
States (U.S.) and worldwide. Causality of childhood obesity is
multi-factorial and includes reasons such as lower socioeconomic
status, genetics, parental eating patterns, decreased physical
activity, and consumption of nutritionally poor foods.
Implementation of early fitness and nutrition programs may have
long-lasting benefits to overall health and wellness of children
as well as adults. A 24-week comprehensive program is planned
for implementation in a suburban setting to include children and
their families who are identified as overweight and obese. Both
the child and his family will participate in nutritional
programs and demonstrations, fitness programs, and lifestyle and
behavioral counseling. While grant monies are desired for the
initial start-up, sustainability of the program is established
through the ability to bill and collect future funds through
contractual agreements with a regional physicians association.
Prevention of Childhood Obesity 14
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activity, aerobic fitness, self-perception, and dietary
intake in at risk of overweight and normal weight children.
Canadian Journal of Dietetic Practice and Research, 66(3),
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Ball, G., Marshall, J., & McCargar, L., (2003). Fatness and
fitness in obese children at low and high health risk.
Pediatric Exercise Science, 15, 392-405.
Eliakim, A., Nemet, D., Balakirski, Y., & Epstein, Y.(2007). The
effects of nutritional-physical activity school-based
intervention on fatness and fitness in preschool children.
Journal of Pediatric Endocrinology & Metabolism, 20(6), 711-
718.
Hodges, E. (2003). A primer on early childhood obesity and
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Prevention of Childhood Obesity 15
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