For Tamara Tanner, RN, BSN, CPN, the impact of the obesity epidemic goes far beyond mere statistics. As a clinical nurse coordinator in a treatment program for obese children in Georgia, she witnesses firsthand the emotional wreckage obesity can leave in its wake.
Tanner recently treated a 9-year-old girl who came with her mother to the Health4Life Clinic at Childrens Healthcare of Atlanta. Her body mass index was above the 95th percentile. When Tanner asked the girl what had brought her to the clinic, she and her mother started crying. The girl made no eye contact as she explained that children at school were teasing her because she was heavy, and she could not keep up with peers in physical education class. Her mother was seriously considering home schooling because her daughter was so unhappy.
Although the individual stories may differ, this girl is not alone. According to the Centers for Disease Control and Prevention, about 17% of children and adolescents ages 2 to 19 in the U.S. are obese, which is defined as a BMI equal to or greater than the 95th percentile. Since 1980, the prevalence of obesity in children has almost tripled, according to the CDC.
Obese children who become obese adults increase their risk for health problems, but Tanner sees many children in the clinic who are suffering the consequences early in life. The patients often arrive with comorbidities, such as type 2 diabetes, high cholesterol, hypertension, joint pain, sleep apnea and a fatty liver. Researchers studied the economic impact of childhood obesity on the medical system and found an elevated BMI in childhood was associated with $14.1 billion in additional prescription drugs and ED and outpatient visits annually, according to a study published in Obesity in 2009.
Despite the daunting statistics, nurses like Tanner have hope because they are seeing children make changes that may have seemed impossible to the children before. One of the keys to success is honing in on what motivates the children, rather than focusing on what they should stop eating, thinking or weighing. These children are given an opportunity to envision how their lives could be different if they had a healthier lifestyle. This lays the foundation for them to choose the changes they want to make to achieve their goals.
They often come here defeated because they have tried Weight Watchers, diet pills or other programs with no success, and its amazing to see them come out of their shells when they realize this is not a weight loss program where we will hand them a diet plan, Tanner said. Instead they get to create goals like being able to keep up with friends on bikes, fit on the swings or roller skate. They come to a realization that they are in control, and by setting small goals, they can have success quickly.
The power of success
The concept of allowing children to create their own goals is one of the fundamental strategies used in the motivational interviewing technique at the Health4Life Clinic, which opened in January. To qualify for the program, children must have a BMI equal to or greater than the 95th percentile, or a BMI equal to or greater than the 85th percentile with a comorbidity, such as hypertension or diabetes. Patients must also demonstrate they are motivated to make personal goals to change their lifestyle to qualify for the program.
Patients, who come to the clinic about once a month, are cared for by a multidisciplinary team that includes nurses, physician, exercise physiologists, registered dieticians and psychologists. The children create their own nutritional and activity goals for the following weeks. In the case of the 9-year-old girl, she decided to consume a sweet beverage once a day and drink water at other times. She also decided to ride her bike outside for 15 minutes twice a week rather than watching TV after school. She returned a month later and said she was enjoying her time outside with friends so much that she was doing it every day.
She was very proud of being able to successfully make these healthy changes and was motivated to continue, Tanner said. Most of the kids we see have this same thing happen. They have success with the small changes, so they stay motivated.
The medical team in the new clinic is collecting data to study the outcomes of the patients, but anecdotally, Tanner said most children stabilize or even decrease their BMI rather than seeing it increase rapidly, as in the past.
When a child is struggling to meet a certain goal, Tanner avoids asking why the child was not able to keep to the plan. Instead, she asks why the child was able to meet the goal the times it did work, and this conversation will usually lead to more troubleshooting.
A lot of times barriers come out that are related to the parents, Tanner said. Ive had kids say they could not get to the gym because their parents did not drive them, so we will come up with other ideas like getting a ride with a friend. Others will say it would be easier not to eat sweets if parents did not keep them in the house.
Gentle weight loss
Meaghan OKeeffe, RN, BSN, a nurse in the preop clinic at Childrens Hospital Boston, started learning more about the childhood obesity epidemic after she started a blog www.thechildhealthblog.com in April 2011 as a forum to explore pediatric health-related issues. After reviewing the literature, she was convinced programs that centered around helping children lose weight had unimpressive results. Like Tanner, she believes focusing on food restrictions and losing weight ultimately will leave children feeling defeated and less motivated to live healthier lives.
In her blog, she promotes the concept of gentle weight loss, which encourages children to pay attention to their bodies and stay away from negative self-talk.
I think the weight loss happens as a byproduct of learning things like how to savor food rather than fearing it, how to eat food only when you are hungry, and how to develop a positive self-image, OKeeffe said.
One way OKeeffe, the mother of two young children, helps her children learn to savor food is by teaching them about the things they eat. When we eat a fruit or vegetable, we look up pictures of it and learn how it grows, she said. This reinforces where food comes from, and I think this helps children develop a sense of what is healthy for their bodies.
OKeeffe, who was raised in a family where women often were striving to lose a few pounds, suggests parents consider the ramifications of their own attitudes about weight. She recently decided to throw away her scale because she did not want her daughter to grow up basing her self-worth on the scale reading.
She tries to promote these positive concepts with patients she sees in the preop clinic. When I see teens coming in for surgery, I weigh them, and 90% of the time they roll their eyes or sigh because they do not want to know how much they weigh, she said. I will often say Hey, be nice to yourself. Would you ever say that to your friend? Many have never had someone say that, so I am planting the seed that maybe weight focus is detrimental.
Terri Lipman, RN, PhD, CRNP, FAAN, has studied barriers to healthy eating and activity among inner-city children and suggests that one of the critical factors required to keep children motivated is an understanding of the community in which they live. In her study, which was published in the January/February 2011 issue of the American Journal of Child/Maternal Nursing, she found parents reported a lack of safety in the environment as the main barrier to exercise for their children.
To find a solution to this problem, Lipman, a professor at the University of Pennsylvania School of Nursing, developed a study in hopes of creating an activity program that would be successful for low-income, inner-city children in West Philadelphia. She formed focus groups and discovered the youth were interested in dance, which could be a safe, culturally relevant, no-cost method of exercise that children could practice at home. Lipman and her nurse practitioner students partnered with a high school and health center to start a weekly Dance For Health program.
Pedometers were provided for the participants. Data showed the students averaged twice as many steps on the days they danced compared to their usual recreational activity. The program was so successful that the children wanted their parents and grandparents to participate in the class, and now Lipman has launched another program for people of all ages. Participants range in age from 5 to 91.
My recommendation to nurses is to get involved in their communities, Lipman said. Nurses in hospital settings often do not have an understanding of the issues that patients face in the community. Getting involved helps nurses gain an appreciation of the health issues and barriers, and together nurses and families can collaborate to develop strategies to achieve healthier lifestyles.