Edelman, MaryAnn MS, RN, CNS; Ficorelli, Carmel T. MSN, RN, FNP
“MAN, I'M STARVING! I'll have a burger, fries, and a coke, and supersize that for me, please!” Bigger is better, right? That seems to be the American way, but at what cost to our youth?
Affecting children and teens ages 6 to 19, childhood obesity is at epidemic proportions in the United States today. The percentage of obese American children has tripled over the last 30 years and the numbers continue to rise.1
Childhood obesity places young people at great risk for serious chronic illness and even premature death.2 Losing weight isn't easy for many people and can be a sore subject, specifically among teenagers. But, as little as a 5% loss of body weight will decrease the risks of developing heart disease, hypertension, and diabetes, and will greatly improve the quality of life.3 This article addresses the various factors contributing to childhood obesity and discusses what nurses can do to help end the epidemic.
Tipping the scales
Obesity can be defined as excess weight of at least 20% when comparing children of similar height, gender, and age.4 One of the most commonly used measures for identifying overweight and obesity is body mass index (BMI). BMI is calculated by taking the weight of an individual in kilograms and dividing by the individual's height in meters squared. When used in adults, a BMI of 25 – 29.9 is the determining factor in identifying someone who's overweight; a BMI of greater than or equal to 30 classifies an adult as obese.5
In children it's more commonplace to use the CDC Growth Charts, which classify children as either being at risk for overweight/overweight or obese. For example, children and adolescents who range in age from 2 to 19 may be classified as overweight if their BMI is between the 85th and 95th percentile for children of the same gender and age. Children whose BMI is at or greater than the 95th percentile on the charts are classified as obese.6,7 Using the BMI as a tool, experts have determined that approximately 18% of children ages 6 to 17 are currently classified as obese because they're at or above the 95th percentile.7 (See BMI percentiles.)
In the 1980s and 1990s, expert committees recommended that children and adolescents ages 2 through 19 years who were at or above the 95th percentile be considered overweight, and those between the 85th and 95th percentiles be considered at risk for overweight.8 A more recent expert committee recommended that these groups of children be considered obese and overweight, respectively.6,9
Table BMI percentile...Image Tools
A recent survey found that the rates of childhood obesity increased from 14.8% in 2003 to 16.4% in 2007.1 This is a major concern for the CDC and the World Health Organization because childhood obesity statistics show that obese children (especially teenagers) have a 70% chance of becoming obese adults.1 Take a good look around, and you shouldn't be surprised at these figures. The prevalence of overweight and obese teens is overwhelming. There are various reasons why so many teens are obese, some of which are out of their control.
Fitting into those old genes
Genetic propensity for obesity plays a large role in this epidemic. The likelihood of becoming an obese teen is three times as great if one parent is also obese.10 Obesity-related genes have been identified; some control appetite and feelings of satiety secondary to brain chemistry, while others dictate fat deposition in the body. Race and ethnicity can also be factors.11
Teens, like some adults, may also be plagued by food addiction, characterized by periods of compulsive overeating.12–14 These episodes of overeating are followed by weight gain and feelings of shame and low self-esteem. Studies link decreased self-esteem with an increased incidence of feelings of sadness and loneliness.15 Self-medicating with food to eradicate these feelings continues the pattern, leading to obesity and creating a vicious cycle.
Environmental factors such as family lifestyle patterns and poor eating habits, parental control (or a lack of it), family fragmentation, and family attitudes about weight and diet may also contribute to teen obesity. Socioeconomic status may play a role in this crisis too. Healthier food choices may not be an option for lower-income families because these foods tend to cost more. High-fat, processed foods are less expensive and found everywhere, making them easy, inexpensive choices for feeding a family.
Joysticks or bicycles?
These days, it seems as though children and teens have forgotten about the great outdoors. In this age of technology, many of them spend hours inside playing video games, watching the hundreds of TV channels, or surfing the web. This promotes inactivity and a sedentary lifestyle. Snacking often accompanies these forms of recreation, and snacks are most likely to be high-fat, salty foods such as potato chips, not fruits and vegetables.
Teens, in particular, also spend much of their time with peers in activities that often center on eating. It's not uncommon for teens to eat quick-fix, fatty meals on the run. Pizza with four different cheese toppings, burgers, and french-fried potatoes are staples for many teens, who may indulge in such favorites several times a week.
You are what you eat!
Adolescents who make poor lifestyle choices, such as consuming unhealthy food, increase their risk of developing chronic diseases in adulthood. For example, the risk of hypertension increases with obesity and is a significant health issue. Excess weight and hypertension are also components of metabolic syndrome (insulin-resistance syndrome), which can be a predisposing factor for diabetes. Adolescents with a BMI above the 95th percentile are at greater risk for developing type 2 diabetes.6
Partnering for a plan
Nursing interventions should begin with school-age children and must focus on lifestyle changes and modifying behaviors, such as reducing stress eating.9 Emotional or stress-eating behaviors are defined as compulsive eating patterns that may be carried out in an attempt to control mood: food is used as a defense mechanism, as a means of coping. Most often these individuals are eating without feeling hungry. Patterns of stress eating carried out in response to actual or perceived “challenging” situations, if left untreated, may contribute to obesity. Measures that include increasing physical activity, enlisting family and peer support, and motivational counseling are used in an attempt to manage emotional eating and weight gain.13–16 Keep in mind that the topic of weight, particularly among teens, can be a sensitive issue.
A helpful way to kick-start weight loss is to begin with an open discussion to encourage the patient's input and cooperation. Nurses should try to develop a partnership with teenage patients. A strategy for developing a partnership might center on formulating an agreement or contract for a weight loss plan. Before implementing this plan, nurses should obtain a thorough health history, followed by a physical assessment, which includes the patient's height, weight, and percentiles for age, plus BP measurements to determine the risk of hypertension. Blood tests for health-related problems such as diabetes, hypercholesterolemia, and hypertriglyceridemia should also be performed.
Rather than emphasizing the problem of being overweight, stress the goal of health maintenance and preventing the complications of obesity. Providing information that's relevant to the patient is critical for fostering adherence to a program for weight loss. Dieting and/or exercising with a group of supportive friends may lead to greater motivation, self-acceptance, and improved self-esteem. Peer support is a major motivating factor in all aspects of an adolescent's lifestyle, so encourage him or her to join a weight loss program that offers information, guidance, and support in a nonjudgmental environment.
Another strategy for weight loss and/or obesity prevention is to encourage the teen to attend a weight loss camp. High-quality weight loss camps teach children and teens how to eat nutritious foods while incorporating exercise into their routine. In a camp setting, the child or teen is removed from his or her comfort zone (and any associated negative triggers) and surrounded by peers experiencing the same issues.
Because exercising consistently and regularly is an important intervention, be sure to elicit the adolescent's input as to which type of exercise he or she enjoys. If he or she enjoys playing sports, for example, suggest joining a sports team. The goal of an exercise program is to make sure that physical activity becomes part of the patient's life. Developing realistic goals encourages the patient to adhere to a weight-loss program.
Medications such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, and/or diuretics might be prescribed to treat hypertension secondary to obesity if lifestyle modifications are unsuccessful.17
What else can we do?
Nursing interventions should center on supporting the adolescent and his or her family in the overall plan in order to maintain healthy eating patterns at home. Including families in this lifestyle adjustment serves to empower everyone in the self-management and prevention of obesity. Provide patients and families with lists of community resources, such as Overeaters Anonymous, for additional support if neccesary.14
Nurses should also teach parents the importance of sharing family meals that support healthy eating habits, including portion control. Meals should be planned in advance and should incorporate breakfast, lunch, dinner, and healthy snack choices that target the adolescent's food preferences. Healthy snacks include whole-wheat cereals, fresh fruit, and fat-free yogurt. These foods should be within the patient's grasp when he or she is hungry. Soda should be limited and replaced by water.
Explain to parents that they're responsible for finding out what choices are available at school so they can assist their children in making healthy meal choices. A higher consumption of fruits and vegetables should be gradually introduced as a replacement for fried foods and for those that are high in saturated and trans fats.
Educate patients and their families about how incorporating fruits and vegetables and associated vitamins and minerals into the diet reduces the risk of cardiovascular disease and cancer.18
Eating a healthy diet doesn't have to be an impossible task. Even if teens eat “on the go,” they can enjoy various healthy, portable snacks, such as baby carrots, dried fruit, string cheese, wasabi peas, apple or orange slices, and unsalted nuts.
As nurses, we play a key role in assisting adolescents toward achieving and maintaining weight loss goals. It's up to nurses to educate and counsel parents, teens, and children to provide them with the tools needed to maintain a healthy weight for a lifetime.
2. Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC. Childhood obesity, other cardiovascular risk factors, and premature death. N Engl J Med. 2010;362(6):485–493.
8. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA. 2010;303(3):242–249.
9. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.
11. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28.
13. Michels N, Sioen I, Braet C, et al. Stress, emotional eating behaviour and dietary eating in children. Appetite. 2012;59(3):762–769.
15. Nguyen-Rodriguez ST, Chou CP, Unger JB, Spruijt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav. 2008;9(2):238–246.
16. Berkowitz B, Borchard M. Advocating for the prevention of childhood obesity: a call to action for nursing. Online J Issues Nurs. 2009;14(1):1–9.
17. Matoo TK. High blood pressure treatment in children (beyond the basics). UpToDate. 2012. www.uptodate.com
© 2012 Lippincott Williams & Wilkins, Inc.