Makings of a Nurse-Managed Pediatric Weiqht Manaqement Clinic:
Childhood obesity is now a national and public health concern. Between 1999-2000, there has been a 15.5% increase in weight among adolescents 12 to 19 years old and children 6 to 11 years old (Marr, 2004). Obesity and overweight are frequently interchangeable; both signify an imbalance in caloric intake and expenditure. The World Health Organization (WHO) criterion is the global standard for defining overweight and obesity (Levy, 2000). WHO defined the prevalence of obesity in terms of Body Mass Index (BMI). This index, one of the less invasive and approximate calculations of BMI for the pediatric population, is one's weight in kilograms divided by height in squared meter (WHO, n.d.). The U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) uses this method and refers to those at or over the 85th percentile as 'at risk of overweight' and those at or above the 95th percentile as 'overweight.' The CDC does not use the term 'obesity' for children. According to the CDC, 'BMI is a reliable indicator of body fatness for most children and teens,' and that research has shown correlation to direct body fat measures such as underwater weighing and dual energy X-ray absorptionmetry (DXA) (see Figure 1) (U.S. Department of Health and Human Services Centers for Disease Control and Prevention [CDC], 2006a).
Obesity/overweight is the second leading indicator for Healthy People 2010 initiatives (CDC, 2006b) and is a contributing factor to many childhood diseases such as orthopedic disorders, sleep apnea, type Il diabetes mellitus, asthma, high blood pressure and cholesterol, skin disorders, emotional and psychosocial problems (Spigel, 2002), and many more. Childhood morbidity and mortality is expected to rise with the growing obesity rate (American Academy of Pediatrics, 2003).
The causes of obesity range from genetic to environmental, and they are not fully understood. However, the general agreement among researchers is that early intervention and prevention strategies are necessary to curb this epidemic. Parents are the single most important agents in managing obesity in children (Edmunds, Waters, & Elliott, 2001) and also the most important role models (American Obesity Association, n.d.).
A nurse-managed clinic for a pediatrie healthy lifestyle program was developed and implemented. The focus was on families with obese children, ages 8 to 14 years in one of the largest military training facilities in the Western Pacific Okinawa, japan. The objective of this program was to assist the Tri-Service pediatric population in weight management and early development of healthy lifestyle choices. To date, 50 children have benefitted from this program.
Implementation of the Pediatric Healthy Lifestyle Program
Collaborative efforts and strategies at different levels are now being implemented to curb the obesity epidemic among children. The development of a nurse-managed weight management clinic has proven to be a beneficial step in this direction. In initiating such a clinic, the registered nurse who coordinated the effort identified the different disciplines that would be asked to participate: a pediatrician, nutritionist, exercise physiologist, fitness expert, health promotion expert, physical therapist, and families with obese children. The participants were either referred to the program by their primary care provider or self referred.
Using the BMI, the pediatrician referred those at the 85th percentile or greater on the growth chart for age and gender to the program. Those who were self-referred also had to undergo physical assessment by the pediatrician before entering the program. This is a family-centered program, and the parent or caregiver must be present for participation in the program.
The pediatrician ensured assessment of BMI and general health status prior to program participation, and also gave a presentation to the enrolled children and their families stressing the benefits of a healthy lifestyle and weight management. The nutritionist was the cornerstone of the program. She offered information on foods, grocery shopping, eating out, and portion control. The physical therapist assessed posture and made recommendations for proper footwear for physical activities. The exercise physiologist and fitness expert devoted their time on various exercises and engaged the group in 45 to 60-minute exercise sessions during the weekly meetings. Each discipline was able to take workload credit for each session for their respective clinics.
Initial assessment for the program was done based on reports by providers on the number of obese/overweight children seen in the clinic. The steps taken by the nurse to implement the program were as follows:
* Identification of disciplines to participate.
* Designing and determining scope of program required about 4 weeks time.
* Marketing strategies in this case included: flyers, e-mail to providers, television and radio, public service announcement, town hall meetings, and school announcements. The most effective method was through the schools.
* Enrollment and program commencement.
The 6-week program (Mondays from 17:00-19:00) consisted of a day of didactic and physical activity. On Wednesday and Friday, participants could attend optional physical activity from 17:00-18:00. Participants were allowed to only miss one session to remain in the program. There were 25 participants at the beginning of the program and 12 graduated (see Table 1).
Participants brought in snacks and provided their nutritional value. The nutritionist discussed other alternatives as indicated. Participants also had a potluck at the end of the program showcasing delicious, healthy foods that incorporated all they had learned during the program.
The following were identified as benefits of the Pediatric Healthy Lifestyle Program:
* Provided education and structure in assisting families to begin to make healthy lifestyle changes.
* Provided resources and support toward a healthy lifestyle.
* Interdisciplinary approach provided a holistic style in addressing participant needs and influencing behavior toward healthy lifestyle changes.
* Family-centered program that boosted self-esteem and improved psychosocial relationships.
Teamwork and the ability to maximize resources are necessary skills for any intervention program. Nurses are equipped with the leadership skills to assess, identify, and intervene, and are in unique positions to address childhood obesity. School nurses, for instance, can assess, identify, and provide resources for early intervention. A nurse-managed pediatric weight management clinic is a community outreach that is an added benefit to the overall health care system as the demand for obesity-related services increase. At the beginning of this program, participants listed the following personal healthy lifestyle goals that they believed were achieved during the course of the program:
* Better nutrition.
* Lose weight.
* Learn new types of exercises.
* Making healthier food choices.
* Including exercise as a part of daily activities.
* Feeling better about self and self image.
* Cain endurance.
* Calorie counting (what foods not to eat).
A pre-assessment survey questionnaire indicated that 70% of the participants rated their dietary habits and knowledge of physical activity from good to excellent, and engagement in physical activity from fair to poor. The post assessment showed an 80% improvement in both dietary habits and physical activity. The participants expressed their delight and benefits (mostly the changes in nutrition and exercise habits) gained from the program and requested followup on support.
Obesity is not an easily resolved issue, and there is no single intervention that fits everyone; yet the gold treatment of diet, exercise, and lifestyle changes still holds true. The American Obesity Association (AOA) (n.d.) has recommended a healthy eating environment, increased physical activity, and a coalition to effect changes in lifestyle.
Implementation of this pediatric healthy lifestyle program has created a potential for a research study to determine the influence of parental nutrition habits and physical activities on childhood obesity. Findings from such a study could facilitate the development of family-centered interventions toward eliminating childhood obesity.
Acknowledgment: The following are acknowledged for their selfless contributions in making the Pediatric Healthy Lifestyle Program a success: Commander Tina Key (Health Promotions-key supporter), Mr. David Elgar (exercise physiologist), Mrs. Andrea Dean (Health Promotions expert), Dr. Natalie Burman (Pediatrician), and Mrs. Staci Rosen (Fitness expert).
American Academy of Pediatrics (A.A.P.). (2003). Prevention of pediatric overweight and obesity. Pediatrics, 112(2), 424-430.
American Obesity Association, (n.d.). Childhood obesity. Retrieved June 27, 2006, from http://www.obesity.org/subs/ childhood/prevention.shtml
Edmunds, L., Waters, E., & Elliott, E.J. (2001). Evidence based paediatrics: Evidence based management of childhood obesity [Electronic version]. BMj, 323,916-919.
Levy, L. (2000). Understanding obesity: The five medical causes. Buffalo, NY: Firefly Book, Inc.
Marr, L (2004). Soft drinks, childhood overweight, and the role of nutrition educators: Let's base our solution on reality and sound science, journal of Nutrition Education and Behavior, 36(5), 258-265.
Spigel, S. (2002). Childhood obesity. Retrieved June 27, 2006, from http://www.cga.ct.gov/ 2002/olrdata/ph/rpt/2002-R-0529.htm
U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC). (2006a). BMI - Body mass index: About BMI for children and teens. Retrieved November 2, 2006, from http://www.cdc.gov/nccdphp/dnpa/bmi/ childrens_BMI/about_childrens_BMI.htm
U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC). (2006b). Obesity trends. Retrieved June 27, 2006, from http://www.cdc.gov/nccdphp/dnpa/obe sity/trend/index.htm
World Health Organization: Obesity and overweight, (n.d.). Retrieved June 27, 2006, from http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/.
West Virginia Health Statistic Center, (n.d.). Obesity: Facts, figures, guidelines. Retrieved June 27, 2006, from http://www.wvdhhr.org/bph/oehp/obesity/define.htm
Assanatu (Sana) I. Savage, LCDR, NC, USN
Tammy Koch, LT, MSC, USN
Assanatu (Sana) I. Savage, LCDR, NC, USN, is the Division Officer, Pediatric Clinic, USNH, San Olego, CA. She may be reached via e-mail at email@example.com
Tammy Koch, LT, MSC, USN, is a Clinical Dietician, USNH, Okinawa, lapan. She may be reached via e-mail at KochTL@oki10.med.navy.mil