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Childhood obesity: an overview of the existing barriers to the health practitioner’s role in providing effective intervention

Amalia Burca Bouch highlights the latest guidance, and health professional research, on reducing the risks of childhood obesity. She also explores existing barriers to effective intervention and implementation of the guidelines.

The Solihull approach: pros and cons

Amalia Burca Bouch BScN, RN, MSc, SCPHN (HV)

 

Key points:

  • Obese children are at greater risk of developing health issues, including illnesses previously seldom seen in children
  • The emotional consequences of childhood obesity can be severe and lasting l Healthcare professionals are still ineffective at dealing with childhood obesity (Redsell et al, 2013)
  • Health visitors may face difficulties in engaging with obese children’s parents, who may be unwilling to accept their child has a weight issue
  • Preventive strategies need to be implemented while maintaining awareness of cultural and socioeconomic factors
  • Health visitors have the chance to persuade entire families towards healthy nutrition and physical activity.

Abstract

Obesity in children can lead to serious short and long term health problems.

According to the National Child Measurement Programme (NCMP, 2016), over a fifth of reception year children were overweight or obese. In year six, it was over a third. The prevalence of obesity has increased since 2014/15 in both reception and year 6. In reception, it increased from 9.1% to 9.3% and in year 6 from 19.1% to 19.8%.

This paper aims to highlight the latest guidance provided by NICE, NCMP, and the Department of Health to reduce the risks of obesity for 0 to 5 year olds. It also aims to highlight research conducted on the experience of health professionals, including health visitors, and explore the existing barriers to effective intervention and implementation of the recommended guidelines.

Rudolph (2009) and Larsen (2015) indicate that health practitioners can at times demonstrate limited skills and confidence in effective intervention for obese children and their families.  

Proposals for future practice advises that supplementary teaching and guidance should be provided to practitioners on a regular basis. This will augment their skills and knowledge around childhood obesity management based on current best practice recommendations. It is also proposed that ongoing research should be conducted to evaluate the effectiveness of current training, as well as that which might be delivered, and to look more closely at the specifics of the health visitor’s role and child obesity reduction.

Key words: Overweight children, child obesity, parenting skills, health visitors, health practitioners, communication barriers, child obesity management


Introduction

Obesity, with its associated conditions, is a serious risk to public health. The National Child Measurement Programme (NCMP, 2016), states that over a fifth of reception year children were overweight or obese. In year six, it was over a third. The prevalence of obesity has increased since 2014/15 in both reception and year six. In reception, it increased from 9.1% to 9.3% and, in year six, from 19.1% to 19.8%.

As a society, we have come to understand that children who are overweight, or obese, are at greater risk of developing a multitude of health issues. Many illnesses that, previously, were seldom heard of in children – such as Type II diabetes and heart disease – are now being seen. The emotional consequences of obesity in childhood can also be severe and long-lasting, including bullying, low self-esteem and social exclusion. They are also more likely to become obese adults, therefore leading to serious health risks within their life span (Griffiths et al., 2010).

The overall cause of obesity is an energy imbalance.  But it also involves a complexity of factors that influence attitudes around food as well as lifestyle. Such variables are driven by: our own biology, opportunity to be active, omnipresence and easy access to food, our personal feelings and beliefs around food, parental modelling of activity, parental control of children’s diets, and society’s influence over the acceptability of being overweight (Department of Health, 2011).  Children are growing up in an increasingly obesogenic environment, particularly in disadvantaged areas (Lovelace and Rabiee-Khan, 2013), with evidence of a strong relationship between deprivation and childhood obesity. Analysis of data from the NCMP in 2016 shows that obesity prevalence among children in reception year increases with increased socioeconomic deprivation.

Eating and activity habits, including food preferences, are developed early in life. Health behaviours around food and lifestyle, however, also differ according to different religious, cultural and socioeconomic factors, as well as by geography. According to the National Obesity Observatory (NOO) in 2011, unhealthy diets and low levels of physical activity in some minority ethnic groups are known to be of concern. Members of some minority ethnic groups in the UK often have lower socioeconomic status, which is, in turn, associated with a greater risk of obesity in children (NOO, 2011).

According to NICE 2013 guidelines, health care providers are recommended to implement strategies such as: accurate measuring and recording of a child’s height and weight to determine BMI percentile (while using age and gender-specific charts); raise and discuss the issue of weight management confidently and sensitively with families; assist parents and carers in identifying when a child is overweight or obese ; be familiar with the local weight  management pathways and locally approved co-morbidities assessment tools; assess whether referral to a lifestyle weight management programme is appropriate; assess the need for referral to specialist obesity or other specialist services (such as paediatric services); identify suitable lifestyle weight management programmes for children and their families while providing  them with information and ongoing support (NICE, 2013).

According to Rudolf (2009), health professionals report a lack of confidence in working in the realm of obesity, and parents of obese children have reported that conventional measures to obesity management are at times unhelpful (Edmunds, 2005 and Larsen et al., 2015).

There is a need to develop appropriate intervention for very young children and to ensure that health professionals have the skills to support parents and carers.

Preventive strategies around obesity, therefore, ought to be implemented while maintaining awareness about relevant cultural and socioeconomic factors. Giving up to date advice to families on nutritional and activity needs, as well as overall lifestyle, of children under 5 years of age is fundamental to the role of health visitors (DH, 2009).


Barriers to effective intervention

One of the roles of health visitors is to effectively present parents with the most up to date evidence on childhood obesity and interventions. A good way to implement this is through maintaining competence in assessing individual, familial, and community-wide health needs. Health visitors are especially well positioned to intervene since they take on further educational and practical training in the realm of health promotion, child health and developmental assessments, and antenatal assessments. Some factors prove to be a challenge to health practitioners, leading to a tendency to evade dealing with childhood obesity.

Although health professionals, such as GPs and health visitors, have regular contact with families with overweight or obese children, the ways in which the matter is approached differs from one practitioner to another. According to Larsen et al (2015), the reality is that not all of them will consistently provide the necessary and suitable health guidance, or spend much time assessing a child’s nutritional intake while informing parents about healthy diet and lifestyle. The rest will only somewhat bring up concerns when a child’s weight is higher than what it ought to be relative to their height/weight ratio (Larsen et al, 2015). Rapid weight gain or an elevated weight on the growth chart can be often overlooked and not articulated to the parents in a concise manner. Health professionals face a moral and ethical quandary in providing dietary recommendations as they confront a client’s customs, cultural convictions and insights on their child’s size. There is the possibility that addressing the issue may be considered condescending, discourteous, and potentially offensive rather than empowering and beneficial (Larsen et al, 2015).

Factors such as race, ethnicity, lifestyle, genetics, culture, socio-economic status, and the environment tend to have great influence on dietary choices (El-Sayed et al, 2011). Dealing with obesity is thus a multifaceted and complicated process, which involves a broad sociological awareness and understanding. It also requires tactful and compassionate communication skills that can influence behaviour and bring about positive lifestyle changes.

To facilitate this, NICE provided guidance for health professionals, in which a variety of approaches in the prevention of child obesity, including lifestyle management, are set out.

The Healthy Child Programme (DH, 2009) is also an important policy for health visitors to implement in the first five years of a child’s life. The programme’s focal point is early involvement and health endorsement in the varied phases of a child’s life, and it plainly underlines the value of reducing childhood obesity. Education about weight could start as early as the antenatal period so that parents may be informed about healthy weight during pregnancy. This is especially important since many overweight mothers-to-be need to have an awareness that this can cause complications to themselves and their baby (PHE, 2015).

However, despite the guidelines, Redsell et al (2013) states that health professionals are still ineffective at dealing with childhood obesity. This suggests the need to scrutinise the current obstacles to fruitful communication between professionals and families in the context of childhood weight. For this, it is essential to look at the attitudes and beliefs of the parents, and that of the health professionals, to ascertain correct and precise proposal for practice. The barriers have been identified as: lack of parental knowledge and awareness of the dangers of childhood obesity; and lack of health practitioners’ skills, knowledge, and resources in dealing with the topic while fully understanding socioeconomic and cultural factors influencing weight in children (Redsell et al, 2013).


Lack of parental knowledge and awareness of the dangers of childhood obesity

According to Keenan and Stapleton (2010) and Redsell et al (2010), many parents regard large children as cute and healthy. In addition, most parents are unwilling to accept that their child has a weight issue, despite the health professionals’ diagnosis, as they conform to the belief that a big child equals a happy child. Parents of large babies generally do not see a connection between a poor diet, high in calories, and an overall lack of physical activity, and obesity.

The role of physical activity is crucial in the deterrence of obesity both in childhood and adolescence. Redsell et al (2010) stated that parents were finding many obstacles to being active outdoors including lack of safe local play areas or other attractive places. Parents categorise various obstacles to implementing obesity prevention suggestions, regardless of their economic background. However, the main one was opposition to general alterations to the family routine and behaviours (Sonneville, 2009). The Government Change4Life paper (DH, 2011) and website emphasises the importance of healthy weight through the promotion of fun activities and play. The research results of Redsell et al (2010) also highlight a call for extensive professional guidance for carers related to parenting skills and change in behaviour strategies. More often than not, instructive strategies tried to convey nutritional and lifestyle information in a manner that, for many, is not relevant. The purpose of health education is to modify actions and behaviour. Health professionals therefore ought to inspire individuals to establish healthy attitudes, rather than just providing information to change unwanted behaviour. Parents need to be inspired to understand the impact their behaviour has on the development of the eating and lifestyle patterns of their child (Rudolf, 2009).


Lack of health practitioners’ skills, knowledge, and resources in dealing with the topic while fully understanding socioeconomic and cultural factors influencing weight in children

Although both the Department of Health and NICE provided guidance to health professionals related to childhood obesity management, Turner et al (2009) stated that majority of primary care practitioners are uninformed of the existing national guidelines. This was evidenced in their research by the fact that only 10 percent of interviewed practitioners had read the recent NICE obesity guidance. Data collected does indicate that many do not consider it an effective intervention. Many also used justifications such as lack of time, lack of experience in this particular area, or lack of resources.

Turner et al (2009), Edvardsson et al (2009), and Larsen et al (2015) explored the thoughts of healthcare professionals, including health visitors, on research articles. They found that practitioners find it complicated to engage with the parents of obese children. Health visitors perceive it to be quite difficult to make parents recognise and accept the problem of obesity - they are likely to become defensive, in denial of the issue, or even verbally aggressive. Interviewed participants remarked that obesity is a societal, rather than a medical, problem and supervision of this issue ought not to pertain to them alone. It was also remarked by the participants that there is a lack of proficiency, and full understanding, of referral options and of the most valuable and efficient childhood obesity treatments.

Growth charts may provide a useful visual tool when talking about weight with parents. Health practitioners, however, ought first to educate parents as to the significance of the chart percentiles to ensure that they accurately understand their child’s weight. For example, a study from England emphasised that parents deem genetic predisposition to a certain size as important and, in parents’ opinion, growth charts are utilised for assurance of acceptable weight gain, as opposed to a judgment on a child’s weight (Lakshman et al, 2011). Health practitioners, therefore, need to be aware of chart interpretation. UK research papers also indicate that health professionals are not fully aware of the UK growth chart, which sets breastfeeding as the norm rather than formula feeding. Health professionals are again shown to offer conflicting recommendations about the weaning age and quality of food, creating a need among parents to seek guidance from relatives and friends instead. Redsell et al (2010) recommend that there is an urgent requirement to improve infant feeding practice.

If done in a knowledgeable manner, health professionals and health visitors dealing with young children have the possibility to persuade families towards healthy nutrition and physical activity for children and their families. While conducting health promotion activities, health professionals ought to clearly and effectively discuss with the whole family the key actions required for the prevention of overweight and obesity later in life. Main messages to consistently get across are: the reasons for increased duration of breast feeding and the delay of weaning from four to six months, importance of parental role modelling around food and of establishing healthy daily routines, and the benefits of a variety of physical activities. The research results from Edvardsson et al (2009) indicate that parents desire a less authoritarian method, instead preferring a strong practitioner and client rapport when dealing with weight. Health practitioners, however, ought to always sustain their professional guidance with up to date government policies, including the latest recommendation for a balanced diet (Oyebode et al, 2014).


Reccomendations and conclusions

Recommendations

Easy and consistent access to training relating to obesity management might improve the quality of the delivery of the Healthy Child Programme by health visitors and other health care professionals. In addition, such training could be aimed at augmenting and improving health visitors’ understanding of multi-disciplinary work with overweight/obese children.  Existing obesity reduction services such as HENRY have been shown to have a high rate of success (Willis et al, 2014). HENRY is an evidence based programme with an emphasis on helping the whole family make positive changes to their lifestyle, as well as developing healthier communities. HENRY programme is currently working with variety of local partners such as: health trusts, local authorities, public health departments, voluntary organisations and universities.

Health professionals should update their assessment skills to observe the obese child and family, in the wider context of ethnical, cultural and socio-economical concepts in order to communicate effectively and adopt a non-judgemental approach.

More research is required on how to advance communication when dealing with parents’ beliefs. Implementation of research findings, which address parents’ expectation of health professionals, may improve the approach used when addressing obesity. This would hopefully lead to reduced rates of childhood obesity as well as strengthening parents’ experiences of engaging with practitioners.

It could be argued that health visitors are in a significant position to deal with childhood obesity and should be attributed a higher value by the government, and the commissioners, as they add value in the development of a better, fitter and healthier future for the next generation. However, this will require re-evaluation of the current financial support given to health visiting services, addressing the skills shortage, and an investment in additional training.

 

Conclusions

Research findings indicate that health practitioners are not always self-assured or well-informed in overseeing childhood obesity, as they find it complicated to discuss the issue with the families of large children. Neither are all health practitioners aware of the existing national guidelines addressing early intervention to avert the load on health care caused by the obesity epidemic. Some health practitioners also tend to underestimate the importance of referrals and working in affiliation with other disciplines, such as dieticians or paediatricians.

The research has highlighted parental beliefs and behaviours that erect barriers against the successful supervision of childhood obesity. Firstly, dismissal of the weight problem is the most widespread response from parents, as well as their solid convictions that large babies are healthy, and therefore an indication of good parenting. The parents’ vision related to the child’s weight, growth and feeding practices can be far from the DH healthy lifestyle directives. In addition, reports were made by mothers on inadequate and confusing dietary advice from health professionals. Health visitors find it tough to inform parents that they have overweight/obese children due to the above mentioned parental beliefs. Findings also show that health practitioners find it difficult to discuss the issue with parents who are overweight or obese themselves, since they might be insulted. Health professionals who undertake additional training on management of obesity feel more confident to address the weight issue (Larsen et al, 2015). It is worth noting that the influence of culture on beliefs about weight gain, and how socio-economic issues impact nutrition, ought to be included in the training. Training to augment skills and knowledge of childhood obesity management ought to be implemented regularly, especially with new changes to DH and NICE guidelines. It is also proposed that ongoing research should be carried out to evaluate the effectiveness of current training, or suggested training, as well as conduct and assess research around the methods specifically implemented by health visitors, including any other barriers that might exist.


What are the key findings of research?

  • Rudolph 2009 and Larsen 2015 indicate that health practitioners can at times demonstrate limited skills and confidence in effective intervention for obese children and their families. 
  • The barriers have been identified as: lack of parental knowledge and awareness of the dangers of childhood obesity; and lack of health practitioners’ skills, knowledge, and resources in dealing with the topic while fully understanding socioeconomic and cultural factors influencing weight in children (Redsell et al, 2013).
  • Parents of obese children have reported that conventional measures to obesity management are at times unhelpful (Edmunds, 2005) and (Larsen et al, 2015).

References

Department of Health (DH) (2011) Healthy Lives, Healthy People: A call to action on obesity in England. London: The Stationary Office.

Department of Health (DH) (2009) Healthy Child Programme: Pregnancy and the First 5 Years of Life. London.

Department of Health (DH) (2011) Change4Life: Three year social marketing strategy Obesity and healthy eating. London

Edmunds (2005) Parents’ perceptions of health professionals’ responses when seeking help for their overweight child. Family Practice, 22 (3) 287-292.

Edvardsson, K.; Edvardsson, D.; and Hornsten, A. (2009) Raising Issues about Children’s Overweight-Maternal and Child Health Nurses’ Experiences. Journal of Advanced Nursing, 65 (12).

El-Sayed, A.M.; Scarborough, P.; and Galea, S. (2011) Ethnic Inequalities in Obesity Among Children and Adults in the UK: A Systematic Review of the Literature. Obesity Review. 12 (5).

Griffiths, L.J.; Hawkins, S.S.; Cole, T.J.; Dezateux, C.; and the Millenium Cohort Study Child Health Group (2010) Risk factors for rapid weight gain in preschool children: findings from a UK-wide prospective study. International Journal of Obesity. 34, 624-632.

Keenan, J.; and Stapleton, H. (2010) Bonny Babies? Motherhood and Nurturing in Age of Obesity. Health, Risk&Society, 12 (4).

Lakshman, R.; Landsbaugh, J.R.; Schiff, A.; Cohn, S.; Griffin, S.; and Ong, K. (2011) Developing a Programme for Healthy Growth and Nutrition during Infancy: Understanding User Perspective. Child Care, Health and Development, 38 (5).

Larsen, L.M.; Ledderer, L.; Jarbøl, D.E. (2015) Management of Overweight during Childhood: A Focus Group Study on Health Professionals’ Experiences in General Practice International Journal of Family Medicine. Volume 2015, Article ID 248985.

Lovelace, S.; Rabiee-Khan, F. (2013) Food choices made by low income households when feeding their pre-school children: a qualitative study. Matern Child Nutr. 2013 Jan 16 doi:10.1111/mcn.12028.

National Child Measurement Programme (NCMP) (2016) Published 3 November 2016 by NHS Digital, Government Statistical Service.

National Institute for Health and Clinical Excellence (NICE) (2013) Weight management: lifestyle services for overweight or obese children and young people. London: National Institute for Health and Clinical Excellence.

National Obesity Observatory (NOO) (2011) Obesity and Ethnicity. NHS. Solutions for Puclic Health.

Oyebode, O.; Gordon-Dseagu, V.; Walker, A.; Mindell, J. (2014) Fruit and Vegetable Consumption and All-cause, Cancer, and CVD mortality: Analysis of Health Survey for England Data. Epidemiology and Community Health, 10 (1136).

Public Health England (PHE) (2015) Healthy child programme: rapid review to update evidence. London,UK.

Redsell, S.A.; Atkinson, P.; Nathan, D.; Siriwardena, A.N.; Swift, J.A.; and Glazebrook, C. (2010) Parents’ Beliefs about Appropriate Infant Size, Growth, and Feeding Behaviour: Implications for the Prevention of Childhood Obesity. BMC Public Health, 10 (711).

 Redsell, S.A.; Atkinson, P.; Nathan, D.; Siriwardena, A.N.; Swift, J.A.; and Glazebrook, C. (2013) UK Health Visitors’ Role in Identifying and Intervening with Infants at Risk of Developing Obesity. Maternal and Child Nutrition, 9 (3).

Rudolf, M (2009) Tackling Obesity through the Healthy Child Programme: A Framework for Action. Leeds: NHS Leeds Community Health Care; University of Leeds.

Sonneville, K.R.; La Pelle, N.; Taveras, E.M.; Gillman, M.W.; and Prosser, L.A. (2009) Economic and Other Barriers to Adopting Recommendations to Prevent Childhood Obesity: Results of a Focus Group Study with Parents. Paediatrics, 9 (81).

Turner, K.M.; Shield, J.; and Sailsbury, C. (2009) Practitioners’ Views on Managing Childhood Obesity in Primary Care: A Qualitative Study. British Journal of General Practice, 59 (568).

Willis, T.A.; George J.; Hunt, C.; Roberts, K.P.J.; Evans, C.E.L.; Brown, R.E.; Rudolph, M.C.J. (2014) Combating child obesity: impact of HENRY on parenting and family lifestyle. Pediatric Obesity 9: 5, 339-50.

 

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