Evidence-based health education model for addressing childhood obesity

  • Abstract

An examination of the extant literature for an educational model to address a complex phenomenon that is childhood obesity and strategies to change the environment that supports obesity include behavioral, policy level, environmental, and familial. For the procedure, an ecological model will be utilized to place the issue squarely in the community’s realm and examine the systemic and phenomenological aspects of childhood obesity. Therefore, a systemwide approach will address the underlying associations of the current childhood obesity epidemic in the United States.

Background

            According to the Centers for Disease Control and Prevention (CDC), childhood obesity is epidemic in the United States (2020). Dietarily, children, and adolescents in the US routinely consume high fat, carbohydrate-rich diet and increasingly live sedentary lifestyles. According to some researchers (Larqué et al., 2019; Ward et al., 2017; Weihrauch-Blüher et al., 2019), this epidemic is growing worse since the mid-2000s. The percentage of overweight children has increased by 200% for ages six through 11 and increased 300% for teenagers (CDC, 2020). The annual national health and nutrition examination survey (NHANES) found that roughly 1/3 of all American children were overweight or in danger of becoming overweight.

Discussion

            Because small children are not the shoppers or the food preparers in either home or school setting, it is not realistic to expect children to discern healthy choices or prepare healthy meals. Therefore, the target population will be the parents and caregivers of children aged 6 to 12 years, utilizing school-based parenting, food preparation, and activities related to reducing childhood overweight and obesity (Misir, 2018). The change type will be individual, environmental, system, and policy-based and will support healthy eating both at home and school (Killian et al., 2020; Kumanyika, 2018). Environmentally, children of this age group need to be supported in physical activity (McLeod, 2017) at the community level through access to physical activities and play in green spaces (Hayes, 2018).

            Several recent studies (Camp et al., 2020; Rao et al., 2020; Veldhuis et al., 2017) found that children of color are more likely to be poor, have a less healthy diet, and be overweight than white children. A recent study found that breastfed infants learn to stop looking for food when milk flow ends and, as a result, are less likely to add extra fat (Yuan et al., 2017) and learn to be satiated easier, as the continuous flow of food for formula-fed babies may create obesity-driven behavior early in life through operant conditioning (Duggal et al., 2020). When children reach toddler age, a healthy diet and obesity prevention are solely in the hands of caregivers; unfortunately, many may not adequately understand the critical importance of nutrition. And while not every parent has access to fresh fruits and vegetables, many choose processed or convenience foods low in protein and fat but high in carbs, sugar (often corn syrup), and salt content (del Rocio et al., 2017; Myers et al., 2017) as these are easier to prepare. For low-income families, especially in inner-city areas, convenient shopping for healthy food can be challenging, if not impossible. Parents often do not know that reducing sugar and high carbohydrate foods like pasta, rice, and baked goods are made with bleached flour (Kim et al., 2018; Ludwig & Ebbeling, 2018; Ma et al., 2017) can be effective in reducing childhood obesity.

Along with reducing size portion, the number of snacks available between meals, and improving school lunch programs that frequently provide cheaply acquired, calorie-dense foods that are easy to make (Kennedy et al., 2020; Miyawaki et al., 2019), a return to a more physical playtime and a reduction in screen time is needed. Historically, children were generally active in previous generations and often needed extra nutrition to fuel their physiological and neurological development (Black et al., 2017). Many were fed a more nutritious and balanced diet. When combined with inadequate nutrition, calorie-dense foods, a sedentary lifestyle, and a poor understanding of nutrition, the wrong kind of food is consumed in a screen-heavy environment. In this setting, carbohydrates and fat intake and metabolic utilization can easily fall out of balance, and carbohydrates that exceed the amount needed for daily activities, metabolism, and development are stored as fat that is often difficult to shed (Davis, 2015). These prolonged periods of caloric imbalance often led to obesity and associated health conditions, including type-two diabetes, metabolic syndrome, hypertension, and cardiovascular issues. Pediatricians today are diagnosing early-onset hypertension, dyslipidemia, high levels of microalbumin, and even fatty liver disease among children and adolescents stemming from these poor diets, inactivity, and excessive weight gain (Davis, 2015; Davis et al., 2018; Sanyaolu et al., 2019). Conditions previously only seen among middle-aged or elderly adults are now seen in children as young as five years of age. Nutritionally, many pediatricians and nutritionists who work with children suggest that insufficient water intake, especially during the school day, is associated with obesity, particularly with a diet of calorie-dense low-quality foods (Stookey et al., 2020). Procedures should be in place to ensure that hydration stations, such as water fountains, are relatively accessible, clean, and well-maintained throughout the school day; this may also include students allowed to carry water bottles during the school day and have access to refilling them.

            Increasing physical activity and encouraging students to participate daily can be done outside, particularly when weather permitting. These activities should include the following characteristics: engage students in physical activity, provide opportunities for physical play during the school day, for example, recess or classroom breaks, and availability of green spaces and large-scale environmental spaces or equipment to make physical activity accessible and to appeal to children (Aubert et al., 2018; Rhode et al., 2019). Educational programs should be introduced that teach and discuss nutrition, building knowledge for children to understand what healthy food is and why it is essential. Vending machines that sell sugary beverages, candy, and potato crisps should be limited or removed from public schools, which will require administrative support from the school and parental consent from the community (Rauzon et al., 2020). While schools routinely employ academic guidance counselors, social workers, and school nurses, they are frequently not equipped to educate on healthy nutrition and exercise beyond a minimal capacity. In this regard, professional health educators are unique in supporting student health and reducing childhood obesity, becoming an epidemic in the United States.

            There is a significant statistical association between early childhood risk factors, to some degree mediated through nutrition counseling and parent support groups for expectant mothers, parents of high-risk infants, and young children, that includes educating on the risks of disorders such as type two diabetes through simple salivary measures of leptin and interleukin-6 (Pîrsean et al., 2019), and understanding the family history of metabolic disorders including how unhealthy eating can lead to type two diabetes and metabolic syndrome (Sladoje et al., 2017). According to many pediatricians, families lack the understanding that proper nutrition and physical activities are both necessary for children to maintain a healthy weight or to lose extra weight and, to promote optimal health physically and mentally (Bond et al., 2017; Hayes, 2018; Vanderwall et al., 2017). Once weight loss is realized, the issue becomes cognitive/behavioral to keep the weight from being regained. Currently, several researchers are examining if temporary change may be associated with more significant weight gain (Hagman et al., 2019).

            Weight loss programs today include several available electronic apps that are tailored to promote behavior change and increase physical activity. These range from intelligent watch applications that trigger water drinking, reminders to get up and move every 15 to 30 minutes that are adjustable, and exercise apps significantly associated with physical activity, mainly outdoor (Chuah, 2019; Jo et al., 2019). Smartwatch and smartphone applications have shown to be effective at altering lifestyle-based behavioral exercises, and children often need reminding to be active, mainly when screen time is available (Fang et al., 2019). Parents need to be aware of the association between inactivity, screen time, and obesity, especially for those who may have comorbid genetic conditions, such as a parent with type two diabetes, a parent with obesity, or a family history of hypertension. Any program that aims to be effective should carefully consider the Center for Disease Control and Prevention’s School Health Guidelines to Promote Healthy Eating and Physical Activity (CDC, n.d.). What is required, therefore, is a coordinated approach in a development evaluation and evolution of healthy nutrition and physical activity policies and practices at every level, a school environment that not only supports but ensures healthy eating and access to physical activity and necessary hydration, provides health education through the intervention of health education professionals to create and implement programs to support healthy nutrition and physical activity, to provide students and faculty with the knowledge, skills, attitudes, and positive experiences for healthy nutrition and healthy activities, by teaching that not only physical but mental health is dependent on both healthy eating, proper hydration, and healthy physical activities. Professional health educators can also introduce the realities of long-term obesity with older children, particularly the development of chronic conditions such as type two diabetes, metabolic syndrome, etc. Partnerships with both families and community members in developing and maintaining intervention programs are crucial. Public health professionals and professional healthcare educators will formulate and construct the intervention programs and be critical in maintaining and evolving the effectiveness of these interventions. Health educators can also inform school staff, including social workers and academic counselors, on the basics of healthy eating and activity; physical education staff, coaches, and cafeteria workers may be somewhat hesitant to adjust current beliefs; however, the success of the program will depend on support from these staff members.

The psychological impact of childhood obesity

            Often society judges the parents of overweight children or blames the children themselves for their weight. Popular literature and peer-reviewed studies are filled with accounts of bullied or teased children, leading to rejection by their peers and ridicule by adults (Davis, 2015; Sagar & Gupta, 2018). Lowering a child’s self-esteem can trigger eating disorders, including bulimia and anorexia (Davis, 2015; McCabe et al., 2019; Sagar & Gupta, 2018; Wong et al., 2019); the social psychology of fast food, super sizing, the ever-present soda and snack food dispensers in schools, added-sugar beverages, and the federal subsidizing of corn syrup are foundational to the childhood obesity epidemic in the US (Bocarsly et al., 2010; Dessbesell et al., 2019).

Biological implications

            Most of the factors leading to overweight and obese children are unfortunately in plain sight and have become a normalized aspect of American life. After-school programs today often involve little physical activity and are more likely to be geared toward videos or video games (Del Rio et al., 2018; Kracht et al., 2020; Oliveira et al., 2020). During playtimes when children once ran around outside and playing sports, today they are more likely to be sitting watching television or surfing the Internet. While there is a psychological element to this, including anxiety and depression, overeating and constant snacking are often used to cope with emotional stress and boredom and negative social interactions.

Intervention strategy

            In addition to the increase in physical activity, decreased screen time, healthy eating at home and school, there are several recognized risk factors for childhood obesity. These include significant maternal weight gain during pregnancy (Leonard et al., 2017) and overfeeding of infants as described (Messito et al., 2020). Along with social determinants of health, including adverse childhood experiences (Davis, 2015), poverty (Min et al., 2018), and a lack of nutritional understanding by parents (Ochoa & Berge, 2017) can lead to a significant imbalance in childhood and family eating. When combined with poor school lunch quality (Ludwig, 2018), and lack of physical activity, childhood obesity becomes endemic. Considering the myriad of associated variables interacting in the maintenance and increase of childhood obesity, a multi-system approach will be needed to address these factors. Using the areas of responsibility for health education practice to help influence and govern these strategies, there are three of the seven accepted areas of responsibility that are applicable here: assessing the needs, resources, and capacity for health education and promotion; planning health education and promotion; implementing health education and promotion.

            A needs assessment and intervention strategy should be conducted, revealing the strengths and weaknesses of available supports, finding the gaps in support, and identifying and recruiting services to help fill these gaps (Gottlieb et al., 2017). When working to improve health on a community basis, once the health needs have been assessed, it is necessary to investigate areas where health knowledge and practice may be suffering due to a lack of resources or education. Once the assessment is conducted, the mode of communication that will best suit both the community and the target population should be utilized, considering socioeconomic and educational factors. This may include using social media, graphic presentations, PowerPoint, or other multimedia methods to inform the population. Budgetary availability, stakeholder attitude, regulations, timeline, and feasibility must be considered when aligning the program’s goals. When the program has been implemented, it should be assessed at 90 days, six months, and one-year intervals so that adjustments or changes to the outcomes or health-related needs of the community can be made. It is necessary to monitor the program’s effectiveness and manage execution at regular intervals to be as successful as possible.

Conclusion

            Childhood obesity is a largely preventable epidemic, but one that is complex and multifaceted. Therefore, programs will need to encourage healthy eating, physical activity, including opportunities for fundamental movement skills during the school day, preferably outside activities, improving the quality of nutrition of food supplied by school lunches, focus on parental support and activities in the home that encourages active movement, nutritious foods, and reductions in screen time activities including television, video games, or computer use. Schools are perhaps most critical in supporting healthy child nutrition and exercise as children spend anywhere from 5 to 8 hours in the custody of the school system five days per week for much of the year and are the primary source of nutrition and physical activity.

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