Current Childhood Obesity
Obesity is defined as having excess body fat and body mass index (BMI) is a widely accepted screening tool to measure obesity (Centers for Disease Control and Prevention [CDC], 2018). BMI is an individual's weight in kilograms divided by the square of an individual's height in meters (CDC, 2018). The BMI method is only moderately related to direct measures of body fatness but is the chosen method to measure body fat due to its low cost (CDC, 2018). The Centers for Disease Control and Prevention (CDC) recommended that health professionals use BMI percentile when measuring individuals age 2 to 20 years CDC, 2018). A child or young adult's BMI at or above the 85th percentile and less than the 95th percentile is considered overweight and a BMI at or above the 95th percentile is considered obese (CDC, 2018).
The CDC (2018) reported that 1 in 5 school age children (6 - 19 years) had a BMI at or above the 95th percentile for individuals their age and sex, classifying them as obese. Causes of obesity include: genetics, metabolism, community and neighborhood design and safety, short sleep duration, eating and physical activity behaviors (CDC, 2018). Possible immediate effects of childhood obesity include: higher risk for other chronic conditions and diseases that influence physical health (asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease), bullying and teasing, social isolation, depression, and lower self-esteem (CDC, 2018). Possible long-term effects of childhood obesity include: increased likelihood of being obese as an adult, developing heart disease, type 2 diabetes, metabolic syndrome, and many types of cancers (CDC, 2018).
Current Childhood Obesity Prevention Recommendations
The CDC (2018) recommended that multicomponent school-based interventions that addressed nutrition and physical activity, involving parents, caregivers, and other community members were the most effective and should be implemented to combat childhood obesity. The CDC (2018) applied its The Whole School Whole Community Whole Child (WSCC) model to the schools it is partnered with. The WSCC model is student-centered and emphasizes the role of the community in supporting the school and the importance of evidence-based policies and practices (2018). Healthy schools promote: healthier nutrition options and education, physical activity programs and physical education, training on management of chronic conditions, instillation of life-long healthy habits and health literacy, and improved school health services and links to clinical and community resources (CDC, 2018).
A recent study published by a team of CDC researchers consisting of Kenney, Wintner, Lee, & Austin (2017) reported that slightly less than half of the 247 schools included in their survey offered any obesity prevention program. Only 6% reported using a preexisting program and 2% reported using a program with evidence for effectiveness (Kenney et al., 2017). Survey respondents widely reported lack of funding, training, and time as barriers to implementation (Kenney et al., 2017).
The CDC (2017) urged health professionals and researchers to focus on improving support for schools to implement evidence-based obesity prevention programs. A literature search was conducted via various databases including The Cochrane Library, ProQuest, CINAHL, The National Center for Biotechnology Information, Google Scholar, and other resources (federal government websites) for articles examining barriers of childhood obesity intervention.
Key words used in the search included: childhood obesity, barriers, school-based, parental, and health care providers. The articles were examined for common themes of barriers. Ultimately, the final classification of barriers were: home/parental, environmental, health care, and school. The purpose of this literature review is to examine the perceived barriers impeding the implementation of multidisciplinary childhood obesity prevention interventions. It is pivotal to identify the barriers halting implementation of evidence-based multidisciplinary childhood obesity prevention programs in order to understand how to best address the perceived barriers to promote health and wellness.
Lack of knowledge in behavior management techniques is a limiting factor to childhood obesity management at home (Sonneville, La Pelle, Taveras, Gillman, & Prosser, 2009; Staiano et al., 2017; Vittrupp & McClure, 2018). Staiano et al. (2017) stated that parents in their study reported using food incentives to promote healthy behaviors in their children. However, they also reported that their children preferred unhealthy foods, making this a counterproductive technique (Staiano et al., 2017). Rankin et al. (2016) stated that the onset of psychological symptoms is more prevalent in children with obesity.
Psychological comorbidities such as anxiety, stress, attention deficit hyperactive disorder (ADHD), bipolar disorder, and eating disorders complicated obesity behavior management at home (Staiano et al., 2017).
Sonneville et al. (2009) stated that inter-family consistency with the enforcement of behavior management was a barrier. Sonneville et al. (2009) stated that inconsistency occurred with children of divorce or when the children stayed with relatives such as grandparents. Parity among family members was also a reported barrier (Sonneville et al., 2009).
Parents reported feeling that it was unfair to eat unhealthy foods themselves or allow their other children to do so but limit their children with obesity from eating it (Sonneville et al., 2009).
Issues with authority were reported as being a cause for the children's lack of motivation, especially if the person was overweight themselves or did not participate in the healthy behavior that was being enforced (Staiano et al., 2017). This may be especially problematic as The CDC (2018) reported that between the years 2015 “ 2016 there were approximately 93.3 million obese adults in The United States of America (USA), accounting for 39.8% of the total adult population. A child with one obese parent has a 50% chance of being obese (University of California San Francisco [UCSF], n.d.). Whereas a child of two obese parents has an 80% chance of being obese (UCSF, n.d.).
Parents reported lack of time, for both themselves and their children, as the main barrier to obesity management at home (Sonneville et al., 2009; Staiano et al., 2017; Vittrupp & McClure, 2018). Parental work schedules were a reported cause of both lack of time and in turn inability to adequately monitor behaviors (Rodr?guez-Ventura, Pelaez-Ballestas, S??mano-S??mano, Jimenez-Gutierrez, & Aguilar-Salinas, 2014; Staiano et al., 2017).
Cost of healthy food options was another commonly reported barrier (Sonneville et al., 2009; Staiano et al., 2017; Vittrup & McClure, 2018). A study conducted by Harvard School of Public Health (2013) found that it costs approximately $1.50 more per day to eat healthy foods than it does to eat unhealthy foods.
Lack of Knowledge
Accurate parental weight status perception was a barrier discovered (Rodrguez-Ventura et al., 2014; Vittrup & McClure, 2018). Vittrup and McClure (2018) stated that of the 205 parents studied, all of the parents of overweight children and 75% of the parents of obese children incorrectly assumed that their child was not overweight. Rodrguez-Ventura et al. (2014) stated that parents in their study failed to recognize obesity in their children: instead they sought medical attention for acanthosis nigricans, hypertension, asthma, or other health conditions but not for the weight of their children.
Rodrguez-Ventura et al. (2014) also stated that the Latin American participants in their study thought children should eat in abundance to match the rate at which they were growing and that being heavy indicates their growth needs are being met. This is a commonly observed way of thinking in Latin American cultures (Lindsay, Sussner, Greaney, & Peterson, 2011).
Parents also reported being unsure of appropriate portion sizes and physical activity recommendations (Rodrguez-Ventura et al., 2014; Vittrup & McClure, 2018). Parents reported the well-known health risks associated with obesity including diabetes, hypertension, and heart disease but failed to acknowledge risks such as mental health issues (Rodrguez-Ventura et al., 2014; Vittrup & McClure, 2018). Rodrguez-Ventura et al. (2014) reported the lack of parental knowledge regarding associated health risks was due to a lack of explanation from providers or educators in the past.
Each child's individual taste preferences were reported to be a barrier (Rodrguez-Ventura et al., 2014; Sonneville et al., 2009; Vittrup & McClure, 2018). Children's dislike of fruits and vegetables was reported (Rodrguez-Ventura et al., 2014; Sonneville et al., 2009; Vittrup & McClure, 2018). Dislike of fruits and vegetables may be attributed to its unattractive presentation and/or time it takes to prepare (Bren, 2016). Adolescents stated that they would be more likely to choose fruits and vegetables if they were more convenient (Bren, 2016). Preparing vegetables to be convenient and ready on the go may decrease children's dislike (Bren, 2016). While true taste preference is a barrier in some cases, convenience may be the root cause of taste preference against fruits and vegetables (Bren, 2016).
Access to Healthy Foods
The United States Department of Agriculture (USDA) research team of Ver Ploeg et al. (2012) utilized population data from the 2010 Census, current income and vehicle availability data, and a directory of supermarkets to estimate American citizens' access to healthy foods. Ver Ploeg et al. (2012) reported that 9.7% of Americans live in low-income areas (1/2 kilometer-square grids where more than 40% of the population has income at or below 200% of federal poverty thresholds) that are more than one mile from a supermarket. However, only 1.8% of all Americans live more than one mile from a supermarket and do not have a vehicle. Ver Ploeg et al. (2012) stated that estimated distance to the three nearest supermarkets is an indicator of the food choices available and the level of competition among stores. Approximately half of the U.S. population lives within two miles of three supermarkets (Ver Ploeg et al., 2012).
Access to healthy foods is of particular concern in rural communities (Ver Ploeg et al., 2012). The U.S. Census Bureau (2018) defined urban areas as having a population of 50,000 people and defined urban clusters as having at least 2,500 people but less than 50,000 people. Therefore, all remaining populations that are not in the urban category are deemed rural (United States Census Bureau, 2018). Due to the higher number of perceived barriers, the prevalence of obesity is higher in rural communities than it is in urban communities (Bren, 2016). Bren (2016) stated that rural adolescents reported taste, convenience, quickness, craving, and appearance as food choice influencers. Limited access to supermarkets undermined by readily available access to convenience stores constituted for the rural adolescents' food choice trends (Bren, 2016). Rural adolescents preferred the already prepared warm food options that the convenience stores offered (Bren, 2016).
Outdoor Safety / Opportunities
Although the CDC (2018) stated that neighborhood design and safety is a contributing factor to the development of childhood obesity, no significant association has been found between parent perceived safety to play outside and childhood obesity risk (An, Yang, Hoschke, Xue, & Wang, 2017; Datar, Nicosia, & Shier, 2013). However, living in unsafe neighborhoods constituted for a trivial, yet statistically significant increase in body mass index, but no change in childhood obesity risk (An et al., 2017). Interestingly, despite a lack of danger, rural adolescents demonstrated decreased outdoor activity (Bren, 2016). Lack of outdoor physical activity opportunities may constitute for this decrease (Bren, 2016).
Essig (2002) stated that a study of pediatric health care providers, which consisted of 202 pediatricians, 293 pediatric nurse practitioners and 444 dietitians found that the providers were in strong agreement that childhood obesity is a serious medical condition that requires medical treatment but more provider training is needed. The participants identified specific areas for further training inclusive of behavior management strategies, improving parenting techniques, and mediating family conflicts (Essig, 2002). Staiano et al (2017) also reported that trained medical providers and teachers often lack the understanding of how to screen for and access childhood obesity and the importance of regular monitoring of behaviors.
A mixed methods study conducted by Rhee, Kessl, Lindback, Littman, and El-Kareh (2018) also found that healthcare providers recognized the importance of addressing childhood obesity but lacked the proper resources and training needed to do so. The most commonly reported provider-level issues were lack of knowledge and confidence, particularly around effective means of communication (Rhee et al., 2018). Providers reported not feeling comfortable delivering weight management advice and feared that they may offend the parents (Rhee et al., 2018).
Rhee et al. (2018) found that the most commonly reported practice-based/systems barriers were lack of time, poor training, and lack of resources in both the office and community. Providers reported lack of knowledge regarding existing treatments and where to refer their patients (Rhee et al., 2018). Providers expressed interest in having a clinical educator or nutritionist to help deliver an obesity management multidisciplinary approach in the primary care setting (Rhee et al., 2018).
The need for a referral coordinator for treatment administered outside of the primary care setting was expressed (Rhee et al., 2018). Providers expressed the need for clear obesity management guidelines to abide by (Rhee et al., 2018). Suggested guidelines included what labs to order, what referrals to make, and follow up procedures (Rhee et al., 2018). The availability of evidence-based handouts, links to online resources, and a directory of community resources is needed by providers within their practice setting (Rhee et al., 2018). Pre-made documentation templates were also suggested to decrease the time spent on documentation (Rhee et al., 2018).
In order to receive federal reimbursements, school meal programs must offer reimbursable meals that meet federal nutrition standards (School Nutrition Association [SNA], n.d.). In 2010 The USDA updated its nutrition requirements for the first time in 15 years (SNA, n.d.). The updated regulations required schools to offer more fruit, vegetables, and whole grains and limit sodium, calories, and unhealthy fat in every school meal (SNA, n.d.). The USDA also regulates food items sold separate from school meals to meet nutrition standards (SNA, n.d.). These food items include entrees, sides, snacks, or drinks sold during the school day in vending machines, snack bars, and a la carte lines (SNA, n.d.).
Despite these regulations, limitations exist. The USDA nutrition standards do not apply to food and beverages brought from home or sold during non-school hours, weekends, or at off-campus events including concessions during sporting events, otherwise known as competitive foods (SNA, n.d.). As a result of these limitations, nutrition programming in schools is a poorly coordinated effort (Totura, Figueroa, Wharton, & Marsiglia, 2015). Limited opportunity to communicate amongst stakeholders which include food service staff, health educators, and teachers was found to lead to poorly coordinated school-wide nutrition programming (Totura et al., 2015). Tolerating competitive food to be sold via fundraisers or brought in from home are examples of specific factors that are contributing to this lack of school-wide coordination (Patel, 2012). These tolerated practices inherently cultivate fear of negative repercussions of potentially legislating competitive foods (Dodson et al., 2009).
Physical education (PE) is a kindergarten through twelfth grade (K-12) academic subject that provides standards-based curricula and instruction (CDC, 2018). Currently the CDC (2018) estimated that approximately 76.5% of K “ 12 schools required some form of PE and that only 3.7% of these K “ 12 schools actually required daily PE or its equivalent. Of the K “ 12 schools that required some form of PE:
- 76% allowed students to be exempted from PE requirements for one grading period or longer (CDC, 2018).
- 68% allowed students to be excused from one or more PE class periods for additional instructional time, remedial work, or test preparation for other subjects (CDC, 2018).
- 66% prohibited staff from excluding students from all or part of PE to punish them for bad behavior or failure to complete class work in another class (CDC, 2018).
The above statistics suggest that there appears to be a higher value placed on academic achievement and standardized testing versus health among schools nationwide (Langford, Bonell, Jones, & Campbell, 2015; Story, n.d.).
Lack of resources, particularly PE resources, was a recurrently reported barrier amongst school administrators and teachers (Byrd-Williams et al., 2017). Langford et al. (2015) also reported issues with lack of volunteers and food guidelines not being followed were barriers schools encountered. Further resource limitations included competition from other school priorities, lack of time, and financial strains (Kenney, Wintner, Lee, & Austin, 2017; Quelly, 2015; Turner et al., 2013).
Overall, school administrators and staff support the implementation of school-based childhood obesity prevention interventions (Langford et al., 2015; Turner, Slater, & Chaloupka, 2013). Turner et al. (2015) reported that of the 1,070 public schools and 400 private schools in their study, only one-third of administrators agreed that parents were interested in improving nutrition and physical activity practices. Langford et al. (2015) found that the involving families was a challenging aspect of school-based intervention in which illustrates the opportunity for collaboration between families and schools.
Kubik and Lee (2014) stated that minority (non-white) parents, parents that were concerned about their child's weight, and parents whose child was a girl were found to be the most interested in school-based intervention. Berger-Jenks et al. (2016) concluded that caregiver involvement at home may be fostered by transmitting information through children, addressing cultural barriers, and avoiding potentially stigmatizing approaches to delivering intervention.