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Preventing childhood obesity: establishing healthy lifestyle habits in the preschool years

      Childhood obesity rates have more than doubled in the past two decades, now affecting 15% of children and adolescents (

      Centers for Disease Control (CDC). Prevalence of overweight among children and adolescents: United States. (1999-2000). Retrieved from http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight99.htm.

      ). As the prevalence of childhood overweight increases, primary health care providers more frequently see overweight children in their practice, providing an excellent opportunity for assessment and intervention with the families. However, many barriers to effective intervention exist. Behavior change counseling is challenging and time-consuming, and health care providers may develop a sense of futility after repeated, unsuccessful efforts. In particular, barriers in intervention practices identified among health care professionals include lack of parent involvement and motivation, lack of behavior management strategies, and lack of support services. Current research recommends increased training opportunities for health care providers that address behavior management techniques and patient motivation in childhood obesity prevention and treatment (
      • Story M.T.
      • Neumark-Stzainer D.R.
      • Sherwood N.E.
      • Holt K.
      • Sofka D.
      • Trowbridge F.L.
      • et al.
      Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals.
      ). Training programs need to improve skills and provide educational materials to help providers better address the needs of overweight children and their families (
      • Barlow S.E.
      • Trowbridge F.L.
      • Klish W.J.
      • Dietz W.H.
      Treatment of child and adolescent obesity: Reports from pediatricians, pediatric nurse practitioners, and registered dietitians.
      ).
      The present report describes the background theory and content of an on-site training program for primary health care providers entitled “Take Charge of Your Family's Health” (“Take Charge”). The title of the training program and aspects of the training content were modeled after the social marketing campaign messages in the “Take Charge of Your Health” promotion model developed by the Georgia Department of Human Resources (
      • Hammond S.L.
      • Green V.
      • Trainer A.
      • Volansky M.S.
      ). The goal of the training is to assist health care professionals in their ability to educate families of preschool children on prevention of overweight and development of healthy lifestyle habits. A freestanding “flip chart” was created to use in an exam room for parent education; parent/child booklets were designed as well. In particular, these tools and materials should prove useful for Pediatric Nurse Practitioners (PNPs), who often spend considerable time with parents of young patients discussing feeding issues and concerns (
      • Satter E.
      Feeding dynamics: Helping children to eat well.
      ). The Childhood Obesity Prevention team at Children's Healthcare of Atlanta (Children's) developed the training and educational tools. The Georgia Indigent Care Trust Fund (ICTF Grant 07258) provided grant funding to support the project.

      Getting beyond “eat less and move more”

      The conventional intervention response to change the behavior of overweight children is to restrict or control food. Yet intervention efforts that reinforce positive boundaries around eating behaviors and patterns will be more useful for the family than the conventional food restriction or “diet” approach. In essence, this approach demonstrates that children will eat what they like and leave the rest without adult interference (
      • Satter E.
      Feeding dynamics: Helping children to eat well.
      ,
      • Birch L.L.
      • Johnson S.L.
      • Fisher J.A
      Children's eating: The development of food-acceptance patterns.
      ). If foods are restricted and parents attempt to control a child's eating behaviors, then a child is likely to eat too much, too rapidly, and begin to hide, sneak, or crave those foods that are under tight control. A harmful cycle ensues with parents continued attempts to control a child's actual eating behaviors. Breaking the cycle involves setting clear boundaries around exactly what the parents and the child can control and what they cannot control. This involves establishing a healthy and positive feeding dynamic where a division of responsibility exists. Parents are responsible for planning meals and snacks, preparing the food, and providing a supportive atmosphere and maintaining limits on grazing between meals and snacking. Children are responsible for whether they eat and how much they eat of the food provided by the parent (
      • Satter E.
      Internal regulation and the evolution of normal growth as the basis for prevention of obesity in children.
      ).
      Allowing children to control their own eating behaviors also includes teaching families to understand that the regulation of food intake is a highly individualized internal process for each person. Evidence shows that early experiences in the feeding relationship contribute to the development of these patterns, namely that “in the absence of adult coercion, young children eat what they like and leave the rest” (
      • Birch L.L.
      • Johnson S.L.
      • Fisher J.A
      Children's eating: The development of food-acceptance patterns.
      ). Often the internal cue of fullness is overpowered by feelings that accompany struggles around food ingestion.
      The American Academy of Pediatrics (AAP) (
      • American Academy of Pediatrics (AAP)
      Prevention of pediatric overweight and obesity.
      ) outlined evidence for recognizing the detrimental effects of overcontrolling parental behavior on children's ability to self-regulate energy intake, including maternal restraint, verbal prompting to eat at mealtime, attentiveness to noneating behaviors, and perception of daughter's risk of overweight. Parents should be educated about health risks and step-by-step behavior changing strategies. Discussions should include ways that parents can intervene with their child in a nonjudgmental, blame-free manner so that unintended negative impact on the child's self-concept is avoided. Teaching children how to develop healthy eating behaviors begins with teaching parents how to develop healthy feeding practices. This involves establishing a positive parent-child relationship around food and developing consistent mealtime habits (
      • Satter E.
      Feeding dynamics: Helping children to eat well.
      ,
      • Satter E.
      Internal regulation and the evolution of normal growth as the basis for prevention of obesity in children.
      ). Additionally, teaching children how to develop physical activity habits begins by increasing the amount of physical activity for the entire family (
      • Epstein L.
      • Goldfield G.
      Physical activity in the treatment of childhood overweight and obesity: Current evidence and research issues.
      ). Clearly, parenting skills are the foundation for successful intervention efforts.
      “Take Charge” content embraces the need to avoid restrictive approaches in eating behaviors, since such approaches may actually increase future obesity risk (
      • Field A.E.
      • Austin S.B.
      • Taylor C.B.
      • Malspeis S.
      • Rosner B.
      • Rockett H.
      • et al.
      Relation between dieting and weight change among preadolescents and adolescents.
      ,
      • Birch L.L.
      • Johnson S.L.
      • Fisher J.A
      Children's eating: The development of food-acceptance patterns.
      ,
      • Birch L.L.
      • Fisher J.A.
      Development of eating behaviors among children and adolescents.
      ). Physical activity guidelines are based on research demonstrating that regular physical activity is associated with both immediate and long-term health benefits. Literature supports the notion that active children are more likely to become active adults (

      Centers for Disease Control (CDC). Prevalence of overweight among children and adolescents: United States. (1999-2000). Retrieved from http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight99.htm.

      ) and that promoting physical activity among patients is an essential role for health care professionals (
      • Patrick K.
      • Sallis J.F.
      • Long B.
      • Calfas K.J.
      • Wooten W.
      • Heath G.
      • Pratt M.
      A new tool for encouraging activity.
      ).

      From theory to practical tools: what can professionals say or do in ten minutes?

      Recognizing the limited time professionals have for educating patients, the “Take Charge” project consists of a series of five behavior change modules (Box). Each module describes specific steps families can use to develop healthy lifestyle habits and help prevent childhood obesity. Each module may stand alone or be used in combination with other modules and be taught to the family in less than ten minutes. Perhaps most importantly, the behavior recommendations in each module are appropriate for all families. Providers can, in less than 10 minutes, help the family set realistic health-centered rather than weight-centered goals regardless of a child's size. Ultimately, the goal is to help all family members learn to eat and exercise in healthful and positive ways, to feel better about themselves, and to feel good about their bodies (
      • Satter E.
      Childhood obesity demands new approaches.
      ).
      “Take Charge of Your Family's Health” content modules
      Take Action: Developing practical ways to become physically active.
      Take Charge of Eating: Establishing the roles of parent and child in regard to food and eating.
      Picky Eaters: Listing the Do's and Don'ts for mealtime management.
      Water/Hunger-Fullness: Increasing water and decreasing fruit juice and sweetened beverage consumption and preventing overeating.
      Take Down Screen Time: Decreasing sedentary activities for everyone.
      Reproduced with permission of Children's Healthcare of Atlanta.
      A freestanding eleven-inch square flipchart houses the five modules, allowing the provider or family to choose what topic they are interested in. The flipchart can stand-alone (like a small easel) in an exam room or waiting room. All five modules are separated by dividers and consist of a series of two-sided laminated pages. The front side of each page, viewed by the parent, has simple, yet clear behavior change messages for parent and child depicting colorful, culturally diverse, age-appropriate photographs of families promoting the recommended behaviors. The flip side of each page, viewed by the provider, contains more detailed information on the same topic for use in counseling the family.
      In Figure 1, Figure 2, Figure 3, sample pages from the “Take Charge of Eating” module demonstrate the “Parent” page with a photo of a father preparing food and a preschool-age daughter feeding herself at the table. The message above the photos says: “When it comes to food, parents have jobs and children have jobs.” The message is based upon the notion that children need to be able to trust their internal processes and parents need to be able to relax and trust their children and those processes (
      • Satter E.
      Feeding dynamics: Helping children to eat well.
      ). The “Provider” side of the page contains the more detailed explanation of the parent and child jobs: “3 Ps” and “3 Cs.” In essence, parents have the “3Ps” jobs to plan, prepare, and provide scheduled meals and snacks. The “3 Cs” of the child's job are to choose to eat, choose what to eat, and choose how much to eat from the foods provided. In addition to the flip chart, parent booklets and children's interactive workbooks were designed to match the major sections of each module and were given to the providers for use in family education (see Figure 2, Figure 3).
      Figure thumbnail loc1
      Figure 1Sample pages from Take Charge of Eating module. Reproduced with permission of Children's Healthcare of Atlanta.
      Figure thumbnail loc2
      Figure 2Sample pages from the Children's workbook. Reproduced with permission of Children's Healthcare of Atlanta.
      Figure thumbnail loc3
      Figure 3Sample page from Parents' workbook. Reproduced with permission of Children's Healthcare of Atlanta.
      Figure 4 contains sample pages from the “Hunger-Fullness” teaching demonstration. The parent side of the page contains a series of “smiling and frowning faces” to demonstrate how a child feels when they are too hungry, hungry enough to eat, just right, full enough, and too full. On the provider page, there are a number of detailed tips to help the family understand how to use these “faces” when learning to trust their child's sense of hunger and fullness. Instructions include advice for parents to respect when the child needs to stop eating, to slow down the eating process, and to turn off distractions (such as television during mealtimes) so that everyone can truly pay attention to eating and listening to the body cues. Providers may choose to use a few tips at a time when assisting families and may always return for additional reinforcement of the messages. Combining the hunger-fullness tips along with the P's and C's is a very useful combination since it is often challenging for parents to trust the child in making food choices.
      Figure thumbnail loc4
      Figure 4Sample pages from the Hunger-Fullness module. Reproduced with permission of Children's Healthcare of Atlanta.

      Getting the word out

      In 2002, six health care provider sites pilot tested the “Take Charge” curriculum. On-site educational seminars occurred during an extended lunch-hour period taking 60-90 minutes. Training included the theory behind key behavior change concepts, use of motivational interviewing techniques, and engaging the family in simple goal setting. A total of 98 providers participated in the “Take Charge” training and received all of the materials. Of those trained, 42 were nurses and nurse practitioners, 9 physicians, 29 dieticians, and 18 allied health care workers. Providers were then given an opportunity to take part in a follow-up survey two months after using the materials, and 47% responded.
      Figure 5 provides results from the two-month follow-up survey. Based on these responses, over one-third of providers indicated using the materials daily or weekly. In addition, nearly all of the providers agreed that the messages were presented clearly and that the families understood the information and found it appealing. Moreover, the materials made a good addition to current provider resources and many providers expressed interest in further in-depth training. The most frequently cited reason for using the materials infrequently or not at all was a lack of time. However, other comments were more positive and included: “very professional materials at a good reading level”; “I thought the material was wonderful”; “The material was of high quality, wonderful for parents wanting to make changes.”
      Figure thumbnail loc5
      Figure 5Three-month follow-up survey. Reproduced with permission of Children's Healthcare of Atlanta.
      A majority of the providers trained indicated an enhanced capacity and comfort level in their ability to work with families in establishing healthy eating and physical activity patterns. Providers appreciated the on-site training opportunity and indicated they would like further training. In conclusion, it is possible to provide behavior-change techniques in a usable format for providers and families. However, the challenge continues for the provider to find adequate time to spend with families to provide education and counseling. Since 2002, with the continuation of ICTF grant funding, Children's has been able to train over 600 health care providers with the “Take Charge” curriculum and materials.

      Applications for nurse practitioners

      With childhood obesity rates at epidemic proportions and rising, it is clear that health care professionals must intervene with families. The reality is that many barriers exist, including time constraints, lack of knowledge, and a scarcity of usable tools and information for families. The American Academy of Pediatrics policy statement on prevention of pediatric overweight states: “Families should be educated and empowered through anticipatory guidance to recognize the impact they have on their child's development of lifelong habits of physical activity and nutritious eating” (
      • American Academy of Pediatrics (AAP)
      Prevention of pediatric overweight and obesity.
      , p. 427). Pediatric Nurse Practitioners are among the most significant primary health care providers who educate and interface with families at critical developmental junctions. Awareness of and practices consistent with appropriate intervention techniques and tools are paramount to successful intervention to prevent and limit childhood obesity. Indeed, as NPs work with parents and children of all sizes in their offices and clinics, they need effective strategies and tools for promoting healthy weight and lifestyle patterns. The “Take Charge of Your Family's Health” training and associated materials assist health care professionals to effectively intervene with families at an early stage of children's development in establishing those healthy habits which may prevent childhood obesity.

      References

      References

        • American Academy of Pediatrics (AAP)
        Prevention of pediatric overweight and obesity.
        Pediatrics. 2003; 112: 2-4
        • Barlow S.E.
        • Trowbridge F.L.
        • Klish W.J.
        • Dietz W.H.
        Treatment of child and adolescent obesity: Reports from pediatricians, pediatric nurse practitioners, and registered dietitians.
        Pediatrics. 2002; 110: 233-240
        • Birch L.L.
        • Johnson S.L.
        • Fisher J.A
        Children's eating: The development of food-acceptance patterns.
        Young Children. 1995; 50: 71-73
        • Birch L.L.
        • Fisher J.A.
        Development of eating behaviors among children and adolescents.
        Pediatrics. 1998; 101: 539-549
      1. Centers for Disease Control (CDC). Prevalence of overweight among children and adolescents: United States. (1999-2000). Retrieved from http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight99.htm.

        • Epstein L.
        • Goldfield G.
        Physical activity in the treatment of childhood overweight and obesity: Current evidence and research issues.
        Official Journal of the American College of Sport Medicine. 1999; 31: 553-558
        • Field A.E.
        • Austin S.B.
        • Taylor C.B.
        • Malspeis S.
        • Rosner B.
        • Rockett H.
        • et al.
        Relation between dieting and weight change among preadolescents and adolescents.
        Pediatrics. 2003; 112: 900-903
        • Hammond S.L.
        • Green V.
        • Trainer A.
        • Volansky M.S.
        Take charge of your health: Using social marketing to plan and implement a nutrition and physical activity campaign for low-income Georgians. Georgia Department of Human Resources, Nutrition Section, 1996
        • Patrick K.
        • Sallis J.F.
        • Long B.
        • Calfas K.J.
        • Wooten W.
        • Heath G.
        • Pratt M.
        A new tool for encouraging activity.
        Physician and Sports Medicine. 1994; 22: 45-52
        • Satter E.
        Feeding dynamics: Helping children to eat well.
        Journal of Pediatric Health Care. 1995; 9: 178-180
        • Satter E.
        Internal regulation and the evolution of normal growth as the basis for prevention of obesity in children.
        Journal of the American Dietetic Association. 1996; 96: 860-862
        • Satter E.
        Childhood obesity demands new approaches.
        Obesity & Health. 1991; 5: 42-43
        • Story M.T.
        • Neumark-Stzainer D.R.
        • Sherwood N.E.
        • Holt K.
        • Sofka D.
        • Trowbridge F.L.
        • et al.
        Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals.
        Pediatrics. 2002; 110: 210-214