Childhood Obesity: A Chronic Problem

Ferris State UniversityNursing 340

Timothy Amborski, Amy Bradley, Richardia Gibbs-Hook, Rhonda Jones, Robyn Veitch, and Jamie Ziemba

1 in 3 adults and 1 in 6 children/adolescents are obese (U.S. Department of Health and Human Services, 2013).

Obesity leads to many chronic preventable diseases such as heart disease, strokes, and diabetes (U.S. Department of Health and Human Services, 2013).

Leading causes of mortality in the United States, Michigan, and District Health Department #10 are from chronic preventable diseases (District Health Department #10, 2011).

In Lake County the obesity rate from 2006 to 2010 was 43.1%. Healthy People 2020 target obesity rate is 30.6%. Lake County ranks the highest in obesity rates in District Health Department #10 (District Health Department #10, 2011).

Sustainable and effective interventions that reduce childhood obesity with primary, secondary, and tertiary prevention measures could lead to a reduction in incidences and mortality of chronic preventable diseases.

Childhood Obesity

Analysis of Lake County For 2013

LakeCounty

Michigan

Demographics

Population 11,539 9,876,187

% below 18 years of age 18% 23%

% 65 and older 24% 14%

Median household income $28,971 $45,931

Children eligible for free lunch

85% 41%

Uninsured children 8% 5%

(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

LakeCounty

ErrorMargin

Michigan NationalBenchmark*

Rank(of 82)

Health Outcomes 59

Premature death 7,950 5,713-10,187 7,254 5,317

Morbidity 48

Poor or fair health 14% 10%

Poor physical health days

3.5 2.6

Poor mental health days

3.7 2.3

Low birthweight 7.4% 5.5-9.2% 8.4% 6.0%

Analysis

(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

LakeCounty

ErrorMargin

Michigan NationalBenchmark*

Rank(of 82)

Health Factors 81

Health Behaviors 55

Adult smoking 20% 13%

Adult obesity 32% 26-40% 32% 25%

Physical inactivity 26% 20-34% 25% 21%

Analysis

(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

LakeCounty

ErrorMargin

Michigan NationalBenchmark*

Rank(of 82)

Clinical Care 66Uninsured 21% 18-23% 14% 11%

Primary care physicians**

5,758:1 1,271:1 1,067:1

Dentists** 1,986:1 1,626:1 1,516:1

Preventable hospital stays 62 51-73 70 47

Diabetic screening 89% 78-99% 86% 90%

Analysis

(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

LakeCounty

ErrorMargin

Michigan NationalBenchmark*

Rank(of 82)

Social & Economic Factors 81

High school graduation**

53% 74%

Some college 45% 36-54% 64% 70%

Unemployment 12.9% 10.3% 5.0%

Children in poverty 48% 37-60% 25% 14%

Inadequate social support

17% 11-27% 20% 14%

Children in single-parent households

38% 29-47% 33% 20%

Violent crime 349 497 66

Analysis

(Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute, 2013)

LakeCounty

ErrorMargin

Michigan NationalBenchmark*

Rank(of 82)

Physical Environment 69

Daily fine particulate matter

9.4 9.2-9.6 9.9 8.8

Drinking water safety 72% 1% 0%

Access to recreational facilities

0 9 16

Limited access to healthy foods**

7% 6% 1%

Fast food restaurants 19% 49% 27%

* 90th percentile, i.e., only 10% are better. **Data should not be compared with prior years due to changes in definition.Note: Blank values reflect unreliable or missing data

Analysis

Ecological Model

"According to this model, behavior is a result of the knowledge, values, and beliefs of people, as well as numerous social influences"

• Social Influences• Relationships• Social support• Community structure

• Four levels of influence• Ontogenetic- Individual• Microsystems- Relationships• Exosystems- Community• Macrocultural- Societal

(Harkness & DeMaro, 2012, p.79)

Ecological Model for Childhood Obesity

(Birch & Ventura, 2009)

Community Strengths & Weaknesses

Strengths• Limited access to fast food

restaurants• Higher rates of children

eligible for school lunch programs

Weaknesses• Lower than average

household incomes• Higher than average

uninsured children• Higher than average adult

obesity and physical inactivity

• Little access to primary care physicians

• No access to recreational facilities

Partners for Change

• Parentso Encourage change and healthy

behaviors at home by being positive role models

• Schoolso Increase physical

education/activity o Take advantage of the school lunch

program to provide healthy food

• Healthcare workerso Provide education about obesity

and the long term effectso Initiate healthy lifestyle programs

in the community

• Community leaderso Provide more recreational areas for

kids to play

Problem Statement for Childhood Obesity

• Obese children are at risk for heart disease, type 2 diabetes, stroke, several types of cancer, osteoarthritis, and are likely to be obese as adults

• Among children and adults in Lake County• Related to onset of childhood obesity• As demonstrated by Lake County obesity rates above

the State and National benchmark standards

The Childhood ObesityProblem

• Children ages 6-11 in the US who were obese increased from 7% in 1980 to 18% in 2010 (CDC, 2013)

• About one in three American kids is overweight or obese, nearly triple the rate in 1963 (American Heart Association, 2013)

• Overweight is defined as having excess body weight for a certain height from fat, muscle, bone, water, or a combination of these factors

• Obesity is defined as having excess body fat

Body Mass Index

Graphic from: www.littlestomaks.com

Lake County Planning

Lake County would have to decide on the following in the planning stage

• Funding• Community involvement• Resources• Measurement of Success

Planning Goals

ReachThe strategy is likely to affect a large percentage of the target population.

MutabilityThe strategy is in the realm of the community’s control.

TransferabilityThe strategy can be implemented in communities that differ in size, resources, and demographics.

Effect sizeThe potential magnitude of the health effect for the strategy is meaningful.

Sustainability of health impactThe health effect of the strategy will endure over time

(CDC, 2009)

Planning Goals

UtilityThe measurement serves the information needs of communities enabling them to plan and monitor community-level programs and strategies.

Construct validityThe measurement accurately assesses the environmental strategy or policy that it is intended to measure.

FeasibilityThe measurement can be collected and used by local government (e.g. cities, counties, towns) without the need for surveys, access to proprietary data, specialized equipment, complex analytical techniques and expertise, or unrealistic resource expenditure.

(CDC, 2009)

Planning Goals

Communities should increase availability of healthier food and beverage choices in public service venues.

Suggested measurementA policy exists to apply nutrition standards that are consistent with the dietary guidelines for Americans (US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans. 6th ed. Washington, DC: U.S. Government Printing Office; 2005.) to all food sold (e.g., meal menus and vending machines) within local government facilities in a local jurisdiction or on public school campuses during the school day within the largest school district in a local jurisdiction.

Communities should require physical education in schools.Suggested measurement

The largest school district located within the local jurisdiction has a policy that requires a minimum of 150 minutes per week of PE in public elementary schools and a minimum of 225 minutes per week of PE in public middle schools and high schools throughout the school year (as recommended by the National Association of Sports and Physical Education).

(CDC, 2009)

Planning Goals

Communities should improve access to outdoor recreational facilities.Suggested measurement

The percentage of residential parcels within a local jurisdiction that are located within a half-mile network distance of at least one outdoor public recreational facility.

Communities should enhance infrastructure supporting bicycling.Suggested measurement

Total miles of designated shared-use paths and bike lanes relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.

Communities should enhance infrastructure supporting walking.Suggested measurement

Total miles of paved sidewalks relative to the total street miles (excluding limited access highways) that are maintained by a local jurisdiction.

(CDC, 2009)

Planning Goals

Communities should participate in community coalitions or partnerships to address obesity.

Suggested measurementLocal government is an active member of at least one coalition or partnership that aims to promote environmental and policy change to promote active living and/or healthy eating (excluding personal health programs such as health fairs).

(CDC, 2009)

School Responsibilities and Interventions

1. Use a coordinated approach to develop, implement, and evaluate healthy eating and physical activity policies and practices.

2. Establish school environments that support healthy eating and physical activity.3. Provide a quality school meal program and ensure that students have only

appealing, healthy food and beverage choices offered outside of the school meal program.

4. Implement a comprehensive physical activity program with quality physical education as the cornerstone.

5. Implement health education that provides students with the knowledge, attitudes, skills, and experiences needed for lifelong healthy eating and physical activity.

(CDC, 2012)

School Responsibilities and Interventions

6. Provide students with health, mental health, and social services to address healthy eating, physical activity, and related chronic disease prevention.

7. Partner with families and community members in the development and implementation of healthy eating and physical activity policies, practices, and programs.

8. Provide a school employee wellness program that includes healthy eating and physical activity services for all school staff members.

9. Employ qualified persons, and provide professional development opportunities for physical education, health education, nutrition services, and health, mental health, and social services staff members, as well as staff members who supervise recess, cafeteria time, and out-of-school-time.

(CDC, 2012)

Community Responsibilities and Interventions

SMART OBJECTIVE FOR CHILDHOOD OBESITY Smart is an acronym for program objectives that are specific,

measurable, achievable, relevant, and time bound (Harkness & DeMarco, 2012).

According to the demographic information concerning Lake County, there is a high unemployment incidence and low income level and 85% of the children are eligible for a free school lunch program. There is a high prevalence of adult obesity and increased physical inactivity. Also, there is no access to recreational facilities presently.

Community Responsibilities and Interventions

SMART OBJECTIVE FOR CHILDHOOD OBESITYSpecific-What behaviors, knowledge, skill, change in health status indicators or

outcome will result from the program (Harkness & DeMarco, 2012)?• The school children, age 6-10 of Lake County will have healthier nutrition

available for the school lunch program.• The Robert Wood Johnson Foundation (RWJF) is to reverse the childhood obesity

epidemic by 2015 by improving access to affordable, healthful foods and safe places for children walk, bike, and play in communities across the nation, especially those that are most affected by the epidemic and have the fewest Resources (Govea, 2011).

• The Child Nutrition Act pays for school food and other nutrition programs for lower-income children.

• Involve parents in nutrition and exercise educational meetings and cooking classes. One of the best stratagies to reduce childhood obesity is to improve the diet and exercise habits of the entire family. Parents are the ones who buy the food, cook the food, and decide where the food is eaten (Mayo Clinic, 2012).

Community Responsibilities and Interventions

Measurable: How will the outcome be measured and how will one know if the objective is achieved (Harkness & DeMarco, 2012)?

• The BMI of this age group of children would be determined at the beginning of the program, and reevaluated at the end of the school year.

• Teaching healthy eating and the five food groups would be added to the school curriculum and tested at the beginning of the program and reevaluated at the end of the school year.

• Parental involvement would be necessary and monthly after school meetings would be encouraged to teach healthy eating requirements.

• Parents would fill a survey out at the beginning of the school year, half way through the year and at the end of the year to determine areas of change needed. This would also allow for a question and answer period.

• Monthly after school family fun nights would be started that would encourage physical activity, such as a nature hike, walking, and swimming.

Community Responsibilities and Interventions

Achievable -Appropriate and desired outcome. • Serving 1% or skim milk and water as the drink choices for school lunches. • Serve healthy foods in an attractive way. In a test, children were given identical snacks.

One was packaged with a cartoon character and one in a plan package. More than two-thirds said they would choose the snack with the character on the package (Hellmich, 2010).

• Serve daily lunch programs at school with healthier food options, implemented by the beginning of the school year 2013.

• Provide daily healthy recipe ideas in a weekly parent newsletter, sent home from school with children.

• Increase the daily exercise regime requirement to 60 minutes a day/5 days a week. This can be achieved by free play activities, physical education classes, and after school family fun nights.

Community Responsibilities and Intervention

Relevant/Realistic - The objective is related to the program's goals and activities (Harkness & DeMarco, 2012)

• The plan objectives need to be simple to be able to focus on the 6-10 year old age group, yet involved enough to provide the instruction and information to the parents.

• Goals are cost effective related to a lower income population.

Community Responsibility and Intervention

Time-bound - What time frame will the objective be accomplished?

• The objectives initiated would be reevaluated at the end of the school year, and revised as needed.

• According to the survey results that the parents provided three times during the school year, and the BMI results of the children at the end of the school year.

Evaluation

• Evaluation is the process of collecting and analyzing information and is done in order to learn the value of a health promotion program or intervention (Pender, Parsons, & Murdaugh, 2011).

• Evaluation information can be used to improve and implement health promotion programs that provide the most favorable outcomes for communities.

• The evaluation plan must be considered during the program development process, as this enables appropriate, accurate information to be collected (Pender, Parsons, & Murdaugh, 2011).

• Everyone affected must be involved in the evaluation process, including those benefitting from the interventions as well as those who will be implementing them.

Evaluation

Questions that may be answered in a comprehensive evaluation:• What are the intended effects?

• What resources are needed to implement the interventions?

• Who will benefit from the intervention?

• Are those benefitting satisfied?

• How can the program or intervention be improved?

Approaches to Evaluation

Process Evaluation• Concerned with whether a program or intervention was delivered as

intended.• Provides insight into what factors might help or hinder achievement of the

program.

Outcome Evaluation• Focuses on the results interventions.• The choice of results to measure is determined by the program goals.

(Pender, N., Parsons, M., & Murdaugh, C., 2011)

Evaluation: How are we doing?

In evaluating whether interventions are effective in Lake County, we will measure how many more children in the 6-10 year old age group are taking advantage of school lunches at the end of the school year, versus the beginning of the school year.

This information is easily quantifiable from school lunch enrollment records.

Evaluation: How are we doing?

• Survey the community: are the classes on nutrition, cooking, and exercise being attended? Why or why not?

• Has the BMI of children in the 6-10 year old age category decreased by the end of the school year?

• Test the knowledge: Are families and children more aware of healthy eating habits at the end of the school year compared to the beginning of the school year?

• Survey: Have children increased their physical activity to 60 minutes a day 5 days per week? Why or why not?

• Survey: Has participation in Family Fun night increased? Why or why not?• Compare: Are the school lunch choices actually more healthful throughout

the program? Why or why not?

Evaluation

The success of the Lake County program to decrease obesity in children from 6-10 years old will depend on involvement of the community, the family, and the individual children.

Assessing for decreased BMI, school lunch enrollment, and community and school surveys concerning participation in activities and increased knowledge of healthy eating will all assist in evaluation in this program.

Conclusion

Lake County obesity rates are higher than the State, County, and National benchmarks and the Healthy People 2020 objectives.

A comprehensive community assessment with a focus on community assets will strengthen building community wide relationship to foster change (Harkness & DeMarco, 2012).

To effectively address childhood obesity issues parents, school administrators, health care professionals, and community leader need to form a collaborative partnership to implement change.

Interventions to reduce childhood obesity rates can lead to a healthier lifestyle which can have a direct impact on the rates of chronic preventable diseases during adulthood and mortality rates.

References

American Heart Association. (2013, January 28). Retrieved from Weight Management and Childhood Obesity:

http://www.heart.org/HEARTORG/gettinghealthy/weightmanagement/obesity/childhood-obesity_UCM_304347_article.jsp

Birch, L.L., & Ventura, A.K. (2009). Preventing childhood obesity: What works? Preventing childhood obesity. International Journal of Obesity, 33, 74-81.

doi: 10.1038/ijo.2009.22CDC. (2009, July 24). MMWR. Retrieved from Morbidity and Mortality Weekly

Report: http://www.cdc.gov/mmwr/pdf/rr/rr5807.pdfCDC. (2012, October 5). CDC. Retrieved from Adolescence and School Health:

http://www.cdc.gov/healthyyouth/npao/strategies.htmCDC. (2013, February 19). CDC. Retrieved from Adolescence and School Health:

http://www.cdc.gov/healthyyouth/obesity/facts.htm

References

District Health Department #10. (2011). 2011 Annual Report. Strong communities through healthy people. Retrieved from: http://dhd10.org/assets/230/2011_Annual_report_final.pdf

Govea, J. (2011). Center for Disease Control. Preventing chronic disease. Ethical concerns regarding interventions to prevent childhood obesity. Retrived from www.gov/pcd/issues/2011/sep/10_0288.htm

Harkness, G. A., & DeMarco, R. (2012). Community and public health nursing, evidence for practice. Philadelphia: Lippincott Williams & Wilkins

Hellmich, N. (2010). USA today. Cartoon characters tilt kids' food choices. Retrieved from:http://usatoday30.usatoday.com/news/health/weightloss/2010-06-21-kidscharacters21_ST_N.htm

Mayo Clinic. (2012). Childhood obesity. Retrieved from: http://www.mayoclinic.com/health/childhood-obesity/DS00698.

References

Pender, N., Parsons, M., & Murdaugh, C. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Pearson

Robert Wood Johnson Foundation, University of Wisconsin Population Health Institute. (2013). County Health Rankings & Roadmaps: A Healthier Nation, County by County. Retrieved from http://www.countyhealthrankings.org/app/michigan/2013/lake/county/outcomes/overall/snapshot/by-rank

U.S. Department of Health and Human Services. (2013). Healthy People 2020: Nutrition, physical activity, and obesity. Retrieved from: http://www.healthypeople.gov/2020/LHI/nutrition.aspx?tab=overview