Healthy eating and activity together (HEAT): Weapons against obesity☆☆☆

Home contributors to obesity 

Obesity is the result of many factors, including heredity. However, as Goran (2002) points out, the rapid rise in childhood obesity cannot be attributed to changes in genetic inheritance. The rise is far too precipitous to be accounted for by genetic mutations. The increase is almost certainly due to changes in environmental factors influencing energy intake and physical activity levels.

Here is a sampling of the numerous changes around food consumption and physical activity that have occurred since 1985, when childhood obesity rates began their dramatic climb. A study involving a large national sample of over 16,000 boys and girls reported by Gillman et al. (2000) found that the number of children eating dinner with their families every day plummeted from 43% among 9-year-olds to only 30% among 14-year-olds. Children who ate with their families consumed more fruits and vegetables, fiber, and micronutrients such as iron, and consumed less soda pop, fried foods, and foods high in fat. Most families spend well over 35% of their food budget on these high calorie, fat-laden foods eaten outside the home and this percentage is still rising (Lin, Frazao, & Guthrie, 1999).

Over 40% of children do not eat breakfast every day. Yet eating breakfast is associated with better academic performance and school attendance, and a lower likelihood of being overweight (Devaney & Stewart, 1998). Another undesirable change is the enormous increase in soft drink consumption, which has more than doubled among 13-18 year-olds since 1977. Shockingly, 16% of all children's diets meet none of the Food Guide Pyramid guidelines, and only 1% of children meet all of its recommendations (Munoz, Krebs-Smith, Ballard-Barbash, & Cleveland, 1997). McCrory et al. (1999) found that higher body mass index (BMI) was related to increased consumption of carbohydrates, snacks, condiments, and sweets, while lower BMI was associated with increased consumption of fruits and vegetables.

Data suggest that 20% of children do not perform more than 2 hours of vigorous physical activity per week (Andersen, Crespo, Bartlett, Cheskin, & Pratt, 1998). At the same time that obesity rates have risen, so has amount of time spent watching TV, with 33% of 10-15 year olds watching more than 5 hours of TV per day (Dietz, 2002). Gortmaker et al. (1996) found that watching 5 hours of TV or more each day was associated with a 4.6 times greater likelihood of being overweight. In 1998, Robinson estimated that children 2-17 years of age would spend 3 years of their waking time watching TV. This does not even include other forms of sedentary activity, such as playing video games or surfing the Internet.

School contributors to obesity 

The picture doesn't look much better at school. The Center for Disease Control and Prevention's (CDC) School Health Policies and Programs Study in 2000 found that required health education for children from elementary through high school grades included no more than 5 hours of nutrition information per year. Over 60% of the teachers who provided this education had not had any nutrition in-service in the preceding two years. Less than 10% of schools require certification for school-level food service managers and only 40% of school district food service directors have an undergraduate degree. Twenty percent of schools offer brand-name fast foods to students and only 12.4% prohibit junk foods.

Between 1991 and 1999, the percentage of students participating in daily physical education classes dropped from 42% to 29% (Freedman, Dietz, Srinivasan, & Berenson, 1999). While many school districts have justified decreasing physical activity time in the name of improving test scores, research shows that increased physical activity time in school consistently results in higher math scores and better in-class behavior (Shephard, 1997; Symons, Cinelli, James, & Groff, 1997).

Intervening 

Prevention of overweight is without question better than treatment (Dietz, 2002). Ideally, it starts during the prenatal period as the PNP assists parents in understanding their powerful role as models of healthy behavior and the need to extend the healthy behaviors of pregnancy into the post-birth period. Anticipatory guidance throughout childhood can help parents anticipate the challenges of their children's behavior, arming them with sound information and healthy coping strategies, and helping them to avoid strategies that create new problems (Bethell, Peck, & Schor, 2001). For example, warning parents of upcoming toddlers about picky eating and food jags can help them relax when their child exhibits these behaviors, confident that by continuing to offer healthy choices and avoiding power struggles, their child will indeed thrive.

Warning parents of potential pitfalls is an important part of providing anticipatory guidance (Satter, 2000). Introduce this information indirectly by saying, for example, “Most parents want their children to eat well and often encourage them to clean their plate or empty that last half-ounce from their bottle. We now know that it's important to help children obey their feelings of fullness and to stop eating when they are full.” In addition to control issues around food and activity and the use of food for reward or withholding food for punishment, parents should avoid negative comments on a child's appearance, weight, or lack of athletic ability (Dietz & Stern, 1999).

All wellness visits include measurement of growth in height and weight, providing the basic information needed for nurse practitioners to calculate body mass index (BMI) to identify children who are overweight (BMI of 25 to 29.9kg/m2) and those who are obese (BMI of ≥ 30 kg/m2) (Kuczmarski, Carroll, Flegal, & Troiano, 1997). In light of the data about the health risks associated with obesity and the difficulty of losing weight, the sooner intervention begins to address poor habits in nutrition and physical activity, the better (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). Data show that as many as 35% of parents of obese children do not recognize their child's weight problem (Baughcum, Chamberlin, Deeks, Powers, & Whitaker, 2000). Therefore, practitioners should not wait for parents to identify the problem, but rather should avoid any blame or embarrassment to the child or the parent by approaching the issue with sincere concern for the child's health and readiness to spend the time necessary to develop a plan of action and provide the support for its execution (National Heart, Lung, and Blood Institute [NHLBI], 2002; Resnicow, 2002).

Figure 1 offers a structured assessment form to guide practitioners in a thorough evaluation of overweight children based on the recommendations from the landmark Bogalusa Study (Valdez, Greenlund, Wattigney, Bao, & Berenson, 1996).

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Fig. 1. Health care provider assessment checklist for evaluation of overweight children.

Assessing readiness to change is a key to success (Prochaska & DiClemente, 1982; Rollink, Heather, & Bell, 1992). Begin the intervention process by exploring these issues (NHLBI, 2001):

Family meals and activity for fun and enjoyment are the heart of the health message. Gradual, small changes that involve the child and provide a benefit to the parent work best. For example, eating meals prepared in the home decreases food costs and allows parents more budget flexibility. Walking together after dinner provides exercise to the child and stress relief to the parent. Reinforce each small step forward with praise. Figure 2 provides a parent handout on healthy ways to begin improving diet and activity in the home.

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Fig. 2. Parent handout for encouraging better nutrition and physical activity at home.

When obesity has reached classes II and III with BMI ≥ 35.0, referral to an obesity specialist should be considered. Additional interventions with appetite suppressants and surgery are possible choices for management of extreme obesity when traditional strategies of improved nutrition, behavioral strategies to limit food intake, and increased physical activity have failed (Trent, 2002).

Heat it up 

Pediatric nurse practitioners are ideal for assuming a leadership role in stemming the rise of childhood obesity. With our forté in wellness and anticipatory guidance, we have the opportunity to assist parents in avoiding feeding strategies that are often harmful to child health and in adopting better strategies, including avoidance of sedentary activity. Our efforts can extend beyond our practices as we support our school districts in raising funds and making wise choices to enhance physical education time, improve health instruction, and avoid selling junk food to students. Our efforts can also extend beyond our own communities to our state as legislators decide among budget priorities.

In the coming years, NAPNAP will work diligently to give life to the priorities regarding obesity in children identified by the International Life Sciences Institute. These include setting an agenda through evidence-based research for what works and does not; identifying and demonstrating ways to improve intervention efforts within health care, school, and the community; and raising awareness of childhood obesity issues through advocacy efforts at the local, state, and national levels (Hill, 2002). Through the HEAT Campaign, as an association dedicated to the health of children, NAPNAP will use our resources in members and talent to make a difference through efforts in education of PNPs, parents, and children on this issue, through advocacy efforts on Capitol Hill and support of our chapters' efforts at the state level, and through evidence-based research. In the coming months NAPNAP will actively solicit sponsorship from industry and seek partners in other disciplines to join us in “HEATing” up efforts to stem this epidemic that holds lifelong consequences for health.