A Collaborative Approach to Nutritional Counseling of the Overweight Child

By Siegel, Jeanne H Parker, Linda M

Collaborative Practice provides a forum for healthcare professionals to share expertise and enhance communication. The health consequences of being overweight are severe and lead to decreased longevity and quality of life. Overweight and obesity have become one of the most prevalent medical conditions affecting the well-being of children. They lead to major health complications, including type 2 diabetes, asthma, heart disease, hypertension, dyslipidemia, metabolic syndrome, orthopedic problems, gastro- esophageal reflux disease, gallbladder disease, sleep apnea, depression, distorted body image, eating disorders, and lowered self- esteem (Eissa & Gunner, 2004; Freedman, Khan, Dietz, Srinivasan, & Berenson 2001; Hassink, 2003; Wang & Dietz, 2002).

In addition, overweight and obesity lead to long-term adult- onset health complications that include atherosclerosis, coronary heart disease, arthritis, liver fibrosis, cirrhosis, and certain cancers (Covington et al., 2001; Eissa & Gunner, 2004; Solomon, 2001). The most serious sequela is the lifetime risk for developing type 2 diabetes, projected to be 30% for boys and 40% for girls born in the year 2000 (Narayan, Boyle, Thompson, Sorenson, & Williamson, 2003).

Adults who experienced childhood obesity have an increased mortality risk when they reach adulthood (Must et al., 1999), in part due to their increased risk of developing type 2 diabetes. As a consequence, the gains in life expectancy and quality of life Americans have realized since 1945 are likely to erode, leading to higher health-related costs and increased economic burden (Centers for Disease Control and Prevention [CDC], 2002; Institute of Medicine [IOM], 2005; Olshansky et al., 2005).

Diet Trends Over the Last 30 Years

Dietary factors play a major part in the development of overweight in children; however, the types of dietary changes and the degree to which these changes influence the development of overweight in children are under debate.

The IOM (2005) has determined that major dietary changes have occurred over the last three decades. These changes include the increased availability of fast foods and sugar-sweetened drinks, increased portion sizes, pressures on families to decrease food costs, less food preparation time, and changes in the composition of diets (IOM, 2005; Rolls, 2003). In addition, other studies have implicated a decrease in eating meals at home, and eating in front of the television as contributors to this epidemic of overweight in children (Gable, Chang, & Krull, 2007).

In a nutritional intake study, Cullen, Ash, Warneke, and de Moor (2002) found that 50% of beverages consumed by fourth to sixth grade students were sweetened beverages, leading to an excess of approximately 330 calories per day. A study that involved school- age children (Ludwig, Peterson, & Gortmaker, 2001) found that for every sugar-sweetened drink consumed there was a significant corresponding increase in body mass index (BMI; 0.24 kg/m^sup 2^) and a higher frequency of obesity in children. In addition, Rolls (2003) found that portion size and the prevalence of overweight have increased in parallel.

Assessment Guidelines

Standards used to assess weight status in children and adolescents utilize BMI percentile for gender and age (Dietz & Robinson, 2005). All children should have their height and weight measured and evaluated for at risk (> 85th percentile) or overweight (> 95%) at least yearly (IOM, 2005). In addition, body fat content should be measured using skin fold thickness, bioelectrical impedance analysis, or alternative techniques. These measures are practical, inexpensive, less invasive than hydrostatic weighing, and accurate when utilized by trained personnel.

Weight Management Recommendations

Successful weight management in children utilizes a multi- focused, collaborative approach that incorporates dietary improvement, increased physical activity, and family participation. Weight management, as opposed to drastic weight loss, is appropriate for children due to their physical growth and development needs. Thus, a philosophy of assisting the younger child to improve diet and activity patterns while maintaining weight as height increases is a reasonable long-term strategy.

A revised meal and snack plan builds upon healthy lower-calorie food choices. Generally lower fat intake, fewer sugar-sweetened beverages, and increased fruits and vegetables are suggested, based on examination of the child’s customary food pattern. Reduced portion size is a key strategy to incorporate for most children. Food portion size may be varied based on energy and growth needs of the individual family members, but no individual family member should be isolated with “diet meals or foods.”

Fad diets are not recommended for use with children due to their limited food choices, which may lack vital nutrients. For example, certain fad diets eliminate all dairy or all fruit foods (Shield & Mullen, 2007).

Pediatric nurses and nurse practitioners may recommend that the child and parent or caregiver schedule an appointment or series of appointments with an outpatient dietitian to assist in understanding and individualizing the care plan. Utilizing current National Institutes of Health (NIH) treatment guidelines (NIH, 1998), the dietitian assists the family to plan healthy menus and snacks that incorporate the child’s food preferences and lifestyle issues. The dietitian suggests personalized behavioral strategies and resources to enhance lifestyle changes (see Table 1). In addition the dietitian will provide a detailed assessment and treatment plan to the referring healthcare practitioner. Referral to a dietitian may be reimbursable through the family’s health insurance plan. A dietitian can be found through the local children’s hospital or from a national online registry (www.eatright.com).

Pediatric nurses and practitioners are powerful influences on patients’ health behaviors. In routine well-child visits, providers can assess weight and diet, providing timely information and advice for follow-up care. Advice provided by the pediatric healthcare provider has been documented to have a “priming effect” to assist the patient and parent/caregiver to initiate healthy lifestyle changes (Kreuter, Chheda, & Bull, 2000).

With the higher prevalence of overweight and obesity, the pediatric practitioner should encourage and assist children and families to successfully address weight issues. Quality resources are available to enhance the practitioner’s knowledge and skills in pediatric weight management (see Table 2). These resources and handouts assist the busy practitioner in providing counseling and encouragement. Helping children and parents/caregivers to develop and sustain nutritious eating goals that are practical and personalized will optimize heath and well-being.

Column Editor: Joseph P. DeSantis

Search terms: Children, diet, dietitian, obesity, overweight

References

Centers for Disease Control and Prevention. (2002). Tables for calculated body mass index for selected heights and weights 2 to 20. Retrieved September 6, 2002, from http://www.cdc.gov/nccdphp/dnpa/ bmi/00binaries / bmi-tables. pdf

Covington, K. S., Cybulski, M.J., Davis, T. L., Duca, G. E., Farrell, E. B., Kasgorgis, M. L., et al. (2001). Kids on the move: Preventing obesity among urban children. American Journal of Nursing, 101(3), 73-75, 77, 79, 81-82.

Cullen, K. W., Ash, D. M., Warneke, C., & de Moor, C. (2002). Intake of soft drinks, fruit-flavored beverages, and fruits and vegetables by children in grades 4 through 6. American Journal of Public Health, 92(9), 1475-1478.

Dietz, W. H., & Robinson, T. N. (2005). Overweight children and adolescents. New England Journal of Medicine, 352, 2100-2109.

Eissa, M. A., & Gunner, K. B. (2004). Evaluation and management of obesity in children and adolescents. Journal of Pediatric Health Care, 18(1), 35-38.

Freedman, D. S., Khan, L. K., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (2001). Relationship of childhood obesity to coronary heart disease risk factors in adulthood: The Bogalusa heart study. Pediatrics, 108(3), 712-718.

Gable, S., Chang, Y., & Krull, J. L. (2007). Television watching and frequency of family meals are predictive of overweight onset and persistence in a national sample of school-aged children. Journal of the American Dietetic Association, 107, 53-61.

Hassink, S. (2003). Problems in childhood obesity. Primary Care: Clinics in Office Practice, 30(2), 357-374.

Institute of Medicine (IOM). (2005). Preventing childhood obesity: Health in the balance. Washington, DC: The National Academies.

Kreuter, M. W., Chheda, S. G., & Bull, F. C. (2000). How does physician advice influence patient behavior? Evidence for a priming effect. Archives of Family Medicine, 9, 426-433.

Ludwig, D. S., Peterson, K. E., & Gorrmaker, S. L. (2001). Relationship between consumption of sugar sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet, 357, 505-508.

Must, A., Spadano, }., Coakley, E. H., Field, A. E., Colditz, G., & Dietz, W. H. (1999). The disease burden associated with overweight and obesity. Journal of the American Medical Association, 282(16), 1523-1529.

Narayan, K. M., Boyle, J. P., Thompson, T. J., Sorenson, S. W., & Williamson, D. F. (2003). Lifetime risk for diabetes mellitus in the United States. Journal of the American Medical Association, 290(14), 1884-1890. National Institutes of Health (NIH). (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. (NIH Publication No. 98-4083). Washington, DC: U.S. Government Printing Office.

Olshansky, S. J., Passaro, D. J., Hershow, R. C., Layden, ]., Carnes, B. A., Brody, J., et al. (2005). A potential decline in life expectancy in the United States in the 21st Century. New England Journal of Medicine, 352,1138-1145.

Rolls, B. J. (2003). The supersizing of America: Portion size and the obesity epidemic. Nutrition Today, 28(2), 42-53.

Shield, J., & Mullen, M. C. (2007). Counseling overweight and obese children and teens: Health care references and client education handouts. Chicago: American Dietetic Association.

Solomon, M. (2001). Eating as both coping and stressor in overweight control. Journal of Advanced Nursing, 36(4), 563-572.

Wang, G., & Dietz, W. H. (2002). Economic burden of obesity in youths aged 6 to 17 years: 1979-1999. Pediatrics, 109(5), 949-956.

Jeanne Siegel, PhD, ARNP

Assistant Professor

Linda M. Parker, DSc, RD, LD

Assistant Professor

University of Miami

School of Nursing and Health Studies

Coral Gables, FL

Author contact: jsiegel@miami.edu, with a copy to the Editor: roxie.foster@UCDenver.edu

Copyright Nursecom, Inc. Jul 2008

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