Role of Nurses in Implementing Nutritional and Physical Activity Interventions for Obese Children

Abstract

A literature review was conducted to answer the question, how important is nutritional and physical activity intervention in the nurse’s role regarding eliminating childhood obesity? Evidence was examined that discussed the extent of the childhood obesity issue in terms of nutrition and physical activity (PA). Studies that explored the effectiveness of nutritional and PA intervention suggested that nutrition was the more important of the two. Other studies suggested that the nurse is in an ideal position to correct the ignorance and indifference of both adults and children toward healthy nutritional and PA behaviors. 

Role of Nurses in Implementing Nutritional and Physical Activity Interventions for Obese Children

Because nurses are one of the primary points of contact for patients, it is important to have a broad and thorough knowledge of common health concerns. One of the most troubling and increasingly common health concerns in the United States is obesity. Nurses are confronted with the issue of obesity in a number of ways on a daily basis, but when a patient asks for help in dealing with it, that is when a nurse stands to do the most good. In particular, identifying, countering, and ultimately preventing obesity in children are some of the most significant health concerns today and an area of nursing that cannot afford neglect. This review will focus on potential interventions by nurses in the areas of nutrition and physical activity for children.

Obesity rates among children, and the reasons for those high and growing rates, have been extensively researched. There is no shortage of information about this problem, nor is there a shortage of studies conducted in the interest of correcting it. Roughly 30% of North America’s children are either overweight or obese (Adamo, Rutherford and Goldfield, 2010, pg. 806) and healthcare costs attributed to obesity in children and adolescents increased by over $90 million in the United States from 1979 to 2000 (Northrup, Cottrell and Wittberg, 2008, pgs. 28-29). Eisenmann et al. (2011) identified “Poor nutrition, physical inactivity and obesity” to be “the most pressing health issues in pediatrics and child health” (pg. 1). These troubling findings from researchers combined with the nurse’s role on the frontline of healthcare makes childhood obesity a primary concern for nurses.

The literature chosen for this study was selected based on how recently it was conducted or updated, the age range of participants, application to potential interventions, and relevance to a discussion of nutrition and physical activity. Many studies have been conducted that include these components, but specific attention was given to studies that either directly compared the use of nutritional and physical activity interventions or specifically focused on one or the other. The question to be answered is, how important is nutritional and physical activity intervention in the nurse’s role regarding eliminating childhood obesity?

Literature Review

Lowry et al. (2008) examined and analyzed the results of the Youth Risk Behavior Surveys (YRBS) from 1999, 2001 and 2003 to identify “patterns of weight-related behaviors among female and male students who reported trying to either to lose weight or stay the same weight” (pg. 418). This study was useful for identifying problem behaviors in terms of this review’s primary outcomes, nutrition and physical activity (PA).

Three stages were used to determine sample groups. Initially, counties were chosen from among 16 different strata identified by urbanization and minority student variables. Schools within those counties were chosen based on enrollment size with higher sampling of schools with larger minority student populations. The third stage was random selection of individual and intact classes from mandatory subjects. Nonresponse rates were determined insignificant to the outcome. Data was gathered with anonymous survey questionnaires, which were administered by trained data collectors. Individual data was entirely self-reported. Only data from students who reported that they were trying to lose or maintain weight was incorporated into the analysis (Lowry et al., 2008, pg. 419).

The sample sizes from the three different years ranged from 13,601 to 15,349 and the overall response rate ranged from 63% to 67%. The population of students attempting to lose or maintain weight was 77.4% of female students and 48.2% of male students. Among those females, only 8.8% were overweight compared to 23.9% of eligible males. Females were more likely to be trying to lose weight (77.9% compared to 57.9%), more likely to control their calorie intake (69.7% compared to 47.7%), and more likely to keep television viewing to less than two hours per day (63% compared to 56%). Males were more likely to use physical activity for weight management (75.5% compared to 63.6%) and only 21.6% of males and 31.5% of females used all three methods to control their weight (Lowry et al., 2008, pg. 420). These findings suffered from the limitations of self-reported data. Though they would not have been incorporated into a study if they had been deemed unreliable, it is difficult to know how much faulty reporting occurred in the key data point of whether a student was trying to lose or maintain weight which may have thrown off the sample group of the study. The higher representation of females interested in managing their weight combined with the lower incidence of actually being overweight suggest that females are a more critical target group for intervention in terms of psychological health, though that is outside the scope of this review. The findings also suggest that males are in greater need of intervention because of their greater incidence of being overweight and fewer healthy behaviors.

Though studies have shown that increased intake of fruits and vegetables and a decreased intake of fatty foods are significant contributors to weight loss, Lowry et al. (2008) found that only 21.3% of females and 24.7% of males used this technique. Adequate consumption of fruits and vegetables was independently associated with physical activity and low fat and calorie intake as well as limited television viewing for female students (pg. 422). These findings suggested that healthy behaviors were comprehensive when the most fundamental behavior, eating an adequate amount of fruits and vegetables, was present, but this particular behavior was lacking in the majority of subjects. Based on this finding, an intervention geared toward communicating the importance of consuming adequate fruits and vegetables would be the most beneficial between nutrition and PA.

In a study purely devoted to the comparative efficacy of different approaches to PA, Adamo, Rutherford and Goldfield (2010) explored the efficacy of stationary cycling as an interactive video game component compared to stationary cycling combined with music (pg. 805). This study would prove useful both for the identification of more or less favorable methods of PA intervention and for the overall effects of PA intervention regardless of method. 30 out of 150 families with a consenting child between ages and 17 were determined eligible for this study at the Children’s Hospital of Eastern Ontario through the Endocrinology clinic. To be eligible, the youth had to have a BMI above the 95th percentile, a BMI above the 85th percentile combined with glucose levels indicative of heart risks or a first degree relative with type 2 diabetes or heart disease. Excluding factors included the use of performance enhancing or body composition altering medications, recent weight change greater than or equal to 5% of body weight, recent or planned participation in an exercise program, or disorders including eating disorders, depression and substance abuse (Adamo, Rutherford and Goldfield, 2010, pg. 806). The specific characteristics of the study group were evidently geared toward intervening for youths with heart risks, something a nurse would be eminently qualified to identify in his or her own patients which makes this a study relevant to the types of patients a nurse is likely to be treating.

The youths were randomly and evenly distributed between the experimental group and the comparison group with gender stratification to account for the generally higher rates of physical activity observed in boys.  Four participants dropped out, evenly among the study, leaving seven males and six females in each group. Both groups used the same GameBike for the cycling component, to increase consistency of results. The experimental group had access to a Sony Play Station 2 and 42” flat screen TV with a selection of racing games that they were free to choose from. The comparison group was allowed to listen to their choice of music on the radio, CD or on a personal listening device. All participants did two 60-minute sessions per week and were allowed to freely take breaks and bike at whatever resistance and rate they chose (Adamo, Rutherford and Goldfield, 2010, pg. 807). As a means of intervention, this study technique would be applicable to implementation in the general population. Mandatory PA programs are already limited in schools, leaving voluntary PA programs as the only alternative. Identifying what makes a voluntary PA program successful is absolutely necessary to successful PA intervention.

The comparison group demonstrated a higher adherence to protocol than the experimental group, attending 92.3% of sessions vs. 86.1%, which was inconsistent with a study conducted on adults (Adamo, Rutherford and Goldfield, 2010, pgs. 808, 810). This result seems counterintuitive and warrants further study before it could be considered decisive as it may be a symptom of the small sample size. Adamo, Rutherford and Goldfield (2010) observed that cycling to music resulted in more time spent at vigorous intensity, which was defined as 80% to 100% of maximum heart rate, than the video game group, 44% vs. 25% of total time spent pedaling. No significant differences were observed in energy expenditure during the study or aerobic fitness at the end of the study, suggesting no difference in effectiveness between the two groups (pg. 810). The results of this study provided little insight into the best methods of PA intervention, except to suggest that any form of PA is statistically as good as another for children that adhere to the physical parameters of this study. If this is the case, it would be reasonable for any PA intervention that successfully engaged the children to be worth implementing, regardless of specifics. This is an important finding for nurses who might otherwise struggle trying to convince parents or children to pursue certain kinds of physical activity when the findings of this study suggest any kind will do.

A study by Northrup, Cottrell and Wittberg (2008) provided a brief history of the Lifestyle Improvement in the Family Environment (LIFE) project which was aimed at identifying and countering the increase in cardiovascular risk factors observed in fifth grade children (pg. 28). This study was specifically dedicated to a developing intervention program focused on nutrition and PA for children. The success of the program makes the findings of this study highly relevant to a review of intervention methods with an aim toward practical implications.

The study spanned five years of the LIFE program from its early, more limited form that operated for three years through the fourth and fifth year in which it was larger, more focused and better funded. Screenings in the early years were conducted at school in the early morning and were open to any family member. The screenings identified lipid profiles, fasting glucose levels, BMI, blood pressure, and inspections for acanthosis nigricans (AN) on the neck (Northrup, Cottrell and Wittberg, 2008, pg. 29). This data was gathered to identify the extent of risk factors present and to track the progression of those risk factors during the life of the program.

The LIFE program was two-pronged, requiring both screening and intervention. A variety of voluntary intervention programs were made available to educate families about healthy nutrition and activity and to provide opportunities to apply what they had learned (Northrup, Cottrell and Wittberg, 2008, pg. 30). The positive response of families toward both the screening and the intervention suggested that the growing obesity problem was one caused by ignorance and convenience as much as any deliberate intent on the part of adults to neglect the health of themselves and their children. This would be encouraging for nurses seeking to implement intervention practices as they would likely be well-received, if properly presented. The success of the first three years of the LIFE program led to widespread implementation and further funding. The present version of LIFE was expanded to cover three grades and increased the role of school nurses in both screening and intervention (Northrup, Cottrell and Wittberg, 2008, pg. 30). This particular finding was important to this review because it indicated the importance of nurses to both children and parents. Nurses are more respected than teachers, in matters of health promotion, more personable than pamphlets or other forms of passive educational material, and more readily available than doctors, making them the perfect agent of intervention for an everyday health concern like nutrition and PA.

Northrup, Cottrell and Wittberg’s (2008) study screened kindergarten, 2nd, and 5th grade students for BMI and AN and provided the families vouchers for lipid and fasting glucose testing at local hospitals. Blood pressure information was gathered for 5th grade students on the screening day and for kindergarten and 2nd grade students at a later date. Families could choose to withhold their child from the screening, but only 49 of the 2,844 screened students were withheld by request or because of other limiting circumstances. School nurses were entirely responsible for educating the students about the screening and conducting the screening itself, both on the screening day and on later days for those who required it (pg. 31). By taking the full burden of the screening and intervention process onto themselves, the school nurses that participated in the study demonstrated their importance to the process and ability to make it entirely their responsibility.

The results of Northrup, Cottrell and Wittberg’s findings were promising, despite the short timeline of the study. In year 4, the first year of the second version of LIFE, 14.8% of kindergarten students, 19.8% of 2nd grade students, and 23.2% of 5th grade students were identified as having a BMI at or greater than the 95th percentile. AN was detected in 1.5% of kindergarten students, 2.8% of 2nd grade students, and 5.3% of 5th grade students (pg. 31). The study results indicated that from year 4 to year 5, there were 1.1% fewer students at or above the 95th percentile of BMI in the 2nd grade group and 2.4% fewer students in the 95th BMI percentile in the 5th grade group. Detection of AN was also lower by 1.4% and 3.6% respectively in these groups as well as 0.4% less in the kindergarten group (Northrup, Cottrell and Wittberg, 2008, pg. 32). The study would have to be extended to present truly credible results, but the preliminary findings were enough to secure future funding for the LIFE program so more findings will be available in the future.

Nurses worked with physical educators to develop intervention throughout this phase of LIFE and incorporated it into the school curriculum. As part of the intervention in year 4, 20 of the 27 school districts in the study offered physical activity programs separate from the required physical education that was part of the basic curriculum. A correlation study found that BMI was not affected by gender or the free/reduced meal program that is typically used to measure socioeconomic status of students. The correlation study also found that fitness level, but not strictly BMI, was a determining factor for academic performance (Northrup, Cottrell and Wittberg, 2008, pgs. 32-33). Nurses were shown to have considerable influence in convincing students and families to become educated about health concerns and intervention to promote healthy behavior. The data gathered by the LIFE program will serve to improve the program itself and to help school nurses to better identify the health behaviors they need to focus on.

The Eisenmann et al. (2011) study examined the effectiveness of Project FIT in improving nutrition and physical activity behaviors of children through increased education and opportunities to implement healthy behaviors. The groups studied were students in five low-income, urban elementary schools. The Project FIT program relied heavily on social marketing to encourage adherence to the nutrition and activity policies it advocated. In the four intervention and one control schools selected, 434 of the 768 3rd to 5th grade students participated (pg. 2). This study was in its preliminary stages and only baseline data was available. It did, however, further indicate problem areas for both children and adults, in terms of nutrition and PA, and it identified areas of interest adults reported having for improving their own knowledge about nutrition.

The baseline results for the study found that 30% of students in both the control and intervention schools engaged in the recommended 60 minutes of physical activity each day and watched an average of 5.3 hours of television per day on the weekends and 75% of students in both groups viewed more than 2 hours of television per day in total.  The baseline results also reported that students ate an average of 73% of the entrée, 61% of the fruit, 36% of the vegetable, 63% of the grain, and 29% of the milk in their school lunches. 17.4% were identified as overweight, 25.1% were identified as obese, and 6% were identified as severely obese (Eisenmann et al., 2011, pg. 7).  These results suggested that in addition to inactivity, the majority of children do not consume anywhere near the recommended amount of recommended nutritional components, particularly vegetables and milk.

Results of the adult subjects shed some light on the possible reasons for the inactivity and disinterest in nutrition observed in the child subjects. Eisenmann et al. (2011) found that 53.1% of the parent respondents engaged in the recommended amount of aerobic and strength activity each week. 50% of the parent respondents reported that they engaged in physical activity with their child 1 to 2 times per week and 27% reported doing no physical activities with their children. 11.5% reported physical activities with their children 3 to 4 times per week and 11.9% reported doing so almost every day. 90% of adult respondents reported consuming less than 5 servings of fruit and vegetables per day while 53.1% reported satisfaction with their fruit and vegetable consumption (pg. 7). These statistics suggested that adults were not setting a healthy example for their children. The relatively high amount of satisfaction about fruit and vegetable consumption compared to the high incidence of inadequate consumption also suggests a poor example, but one caused by ignorance about what behavior would be healthy. This kind of knowledge is precisely what a nurse is positioned to share with patients.

Eisenmann et al. (2008)’s study found that reported barriers to healthy behaviors were inadequate time for 25.5% of respondents, not knowing how to prepare healthy foods for 24.7%, and too expensive for 19.9%. Interest in the education Project FIT could provide was mostly oriented toward learning how to prepare healthy food, according to 43.6% of respondents. 32.3% wanted to learn more about how long and how often to exercise and 29.9% wanted to learn about different types of exercise to do (pg. 7). Though a nurse is not able to create time for patients or make food suddenly cheaper, it is possible to teach patients more time and cost-effective methods for healthy food preparation. It would also be possible to emphasize the importance of healthy eating behaviors, which many adults seemed interested in learning about along with healthy PA behaviors, which might encourage adults to more highly prioritize healthy eating and activity and so pass that value down to their children.

In a research review conducted by Luttikhuis et al. (2009) 64 studies, 54 of which were focused on diet and physical activity, were examined and analyzed to identify effective interventions that have been previously studied and determine possible directions for future study (pg. 2). Only studies with baseline and post-intervention measures gathered by trained data collectors, not self-reported information, were considered. BMI standard deviation score and percentage overweight were the primary data points considered, but body fatness as measured by dual energy X-ray absorptiometry or bioelectrical impedance analysis were also included. Other outcomes included in the review were body fat distribution or waist and hip circumference, metabolic indicators including lipid profile and glucose/insulin metabolism, behavioral changes related to nutrition and physical activity, participant perception of the study and of themselves, potential risks of the intervention and cost effectiveness of the intervention. The studies included in the review were identified using three methods. Experts in the fields of nutrition and exercise science as well as information scientists with experience reviewing nutrition and exercise studies were consulted, several databases were searched in the date range of 1985 to 2001 and the list of references from two other reviews were examined for additional suggestions. Updating the review from its original version to its present version was done with similar methods (Luttikhuis et al., 2009, pg. 4). These exhaustive methods were intended to minimize as much as possible the limitations of the review, since it inherently adopted the limitations of each individual study. The overall review considered many more types of interventions than this review is concerned with so only the analyses that focused on diet and PA will be considered.

Two thirds of the 54 lifestyle studies were conducted among children with an average age below 12 and one third included adolescents, an average age at or above 12, in the study group. Dietary, physical, and behavioral therapy where the three kinds of interventions included in this group of studies (Luttikhuis et al., 2009, pg. 10). It was found among four studies that focused on dietary intervention that making healthy food choices and reducing unhealthy foods like fast foods, as two separate groups, both resulted in improvement to the children’s weight status, but the making healthy choices group had greater effects in the long term. It was also found that specific dietary intervention was more effective than general health information. Results for physical activity interventions demonstrated no significant differences in different methods, only a general and comparable improvement to BMI over the course of all methods of intervention (Luttikhuis et al., 2009, pg. 11). These findings heavily favor a focus on dietary intervention since the results suggested that focused information was most effective.

Direct effects on weight status were not the only positive effects results associated with lifestyle interventions. Luttikhuis et al. (2009) found that lifestyle interventions demonstrated very little risk of adverse effects and improvement to negative dietary behaviors like disordered eating (pg. 13). All these factors considered, supported by the systematic review process that makes these findings more credible than those of any single study, it is strongly suggested that a lifestyle intervention focused on education about healthy dietary practices would be the most effective way for a nurse to positively influence obese patients, particularly obese child patients.

Discussion

The literature reviewed strongly supported lifestyle intervention for positively affecting the nutritional and physical activity behaviors of children. Nurses in particular were found to be in a position to effectively screen, educate and intervene in the lives of children who are either ignorant or unmotivated regarding their health. Though it was found that both physical activity and nutritional interventions had an effect on childhood obesity, the greater of the two was decisively nutrition. Physical activity was identified as being important, but only in a general way and a nurse would not be needed to implement any specific PA intervention (Adamo, Rutherford and Goldfield, 2010, pg. 810 and Luttikhuis et al., 2009, pg. 11). Nutrition, on the other hand, was found to be much more effective. Both reducing unhealthy dietary behaviors and increasing healthy ones were independently identified by the research as methods for improving the weight status of children (Lowry et al., 2008, pg. 422 and Luttikhuis et al., 2009, pg. 11).

Because nutrition is a poorly understood science, as evidenced by the studies that found both children and adults to be ignorant of healthy dietary practices (Lowry et al, 2008, pg. 422 and Eisenmann et al, 2011, pg. 7), it is critical for nurses to know how to communicate the importance of diet to patients. It is also necessary for nurses to be able to identify the warning signs of obesity before it develops. The success of interventions implemented by nurses in the early years of the LIFE program (Northrup, Cottrell and Wittberg, 2008, pg. 31-32) demonstrated that nurses have the authority in the eyes of both children and parents to educate about nutrition and PA behaviors.

Implications for nursing practice based on these conclusions are a matter of both education and implementation. Nurses need to know what health behaviors are and they need to know how to tell when patients are either not aware or not implementing healthy behaviors. Nurses also need to be educated in the role of teachers so they can effectively communicate nutritional and PA knowledge to patients. In terms of implementation, nurses need to be empowered to speak out when they identify unhealthy behaviors. It is their role as healthcare providers to intervene in situations of immediate medical importance and the vast body of evidence that has indicated a serious weight crisis in North America (Adamo, Rutherford and Goldfield, 2010, pg. 806 and Northrup, Cottrell and Wittberg, 2008, pgs. 28-29 and Eisenmann et al., 2011, pg. 7) poses a serious argument that obesity is a situation of immediate medical importance.

Maximizing the effectiveness of nurses in this role would require further research. Though it is never too early for a nurse to start teaching his or her patients about healthy diet and activity behaviors, the evidence that found focus was more effective than general knowledge (Luttikhuis, 2009, pg. 11) suggested that identifying precisely what knowledge is most helpful would be the most efficacious form of intervention. This might manifest regionally since foods and PA opportunities are likely to be different from area to area. General studies that identify the foods most lacking in children’s diets as well as those nutritional behaviors most essential to eliminating childhood obesity would be helpful across the nation and also serve as starting points for localized studies that could determine how to compensate for regional limitations. 

References

Adamo, K. B., Rutherford, J. A., & Goldfield, G. S. (2010). Effects of interactive video game cycling on overweight and obese adolescent health. applied physiology, nutrition and metabolism, 35, 805-815.

Eisenmann, J. C., Alaimo, K., Randall, S., Mayfield, K., Holmes, D., Pfeiffer, K., et al. (2011). Project FIT: Rationale, design and baseline characteristics of a school- and community-based intervention to address physical activity and healthy eating among low-income elementary school children. BMC Public Health, 11, 1-10.

Lowry, R., Lee, S. M., McKenna, M. L., Galuska, D. A., & Kann, L. K. (2008). Weight management and fruit and vegetable intake among US high school students. Journal of School Health, 78(8), 417-424.

Luttikhuis, H. O., Baur, L., Jansen, H., Shrewsbury, V. A., O'Malley, C., Stolk, R. P., et al. (2009). Interventions for treating obesity in children (Review). The Cochrane Library, 1, 1-174.

Northrup, K. L., Cottrell, L. A., & Wittberg, R. A. (2008). L.I.F.E.: A school-based heart-health screening and intervention program. The Journal of School Nursing, 24(1), 28-35.