This essay will focus on the prevention of obesity in
primary school children in Cornwall as
an aspect of health promotion. The prevalence of childhood obesity in Cornwall,
the UK and in Europe has increased tremendously in the last decade. The
rationale for choosing to investigate childhood obesity lies behind the huge
costs the NHS, society and individuals face in terms of illness, lost
productivity through illness and premature death. The causes of childhood
obesity are deep rooted and arise as a result of health inequalities. This
essay will examine the various interventions that individuals and populations
can take to combat obesity. It will analyse the various health promotion models
and theories and the role of the nurse. Finally, the essay will focus on
how nurses can work collaboratively to form
partnerships with other professionals and the local community to help to
diminish the ticking time bomb of childhood obesity.
Worldwide over 41 million children under 5 are either
overweight or obese (WHO 2017). The UK has one of the highest
rates of childhood obesity in Europe (National Obesity Forum 2015). Lee et al. 2006 state
obese children are twice as likely to develop type-2 diabetes. Obesity causes
30,000 deaths in the UK each year-it
increases the risk of colon cancer threefold and the risk of developing
hypertension 2.5 times (Gov.uk, 2017). It
also causes early puberty, menstrual irregularities, polyscystic ovary
syndrome, steathohepatitis, sleep apnea, asthma, benign intracranial
hypertension , muscoskeletal disorders and psychological issues (Reilly et al.
2003). In 2014-15 the cost of
obesity to the NHS was £5.1 billion (Scarborough 2011)
childhood obesity costs £51 million annually. In 2012 the Chief Medical Officer
for England claimed the long term costs were £588-686 million (Strelitz 2013). Obesity is also
identified as both a cause and a consequence of a number of psychological
disorders, such as anxiety, poor self-esteem, poor body image and eating
et al. 2009 and National Obesity Observatory , 2011). Griffiths et al. (2011) said
that obese children are also more likely to have behavioural issues. Childhood obesity
affects all sectors of society and across all ‘life courses’ there is also a
‘cumulative effect of negative experience’ in that it not only leads to health
issues in childhood but also beyond thus causing irrevocable damage (Anda et al.
2009) to the health of the individual and also to society .
By looking at a target population it helps to build a
more comprehensive understanding of communities and their needs it also helps
to identify where resources should be targeted with the aim of improving health
and redressing health inequalities. Measuring a child’s BMI is slightly more
complicated than measuring it for an adult as children grow at different rates.
If a child is between the 85th
and 94th centile they are overweight and anything over the 95th
centile is categorised as obese. The new BMI charts from the Royal College of
Paediatrics and Child Health have caused some controversy as they class children
as overweight, but a year or so later they become classed as ‘normal’ (Haslam and Cook 2016).
The National Childhood
Measurement Programme NCMP) monitors trends
in children’s BMI(Body Mass Index) at a population level in England. 95% of
eligible children were measured in 2015/16. Body Mass Index (BMI) is the most
common tool used for measuring Obesity (Phillps 2012).
Health Survey for England also collects data relating to
childhood obesity covering all 2-15 year olds , as a sample it has much lower
coverage than NCMP therefore we can have
less confidence in the results. Only 20%
of parents said that they received constructive feedback and support as a
result of the NCMP so some question the value of the initiative (Health and Social Care Information Centre
2015 and Public Health England 2015). The
NCMP method only weighs children in reception class and in Year 6- ideally they
should be measured annually to be able facilitate a more accurate trend
In 2015, 27% of reception class children in Camborne
Redruth and Pool (CRP) were overweight or obese(REF). In Year 6 this figure was
an astonishing 36% for children in CRP( NCMP) the figure was 17.3 % for
Cornwall and 19.8% for England (REF). A
detailed look at the social determinants of health and health inequalities will
go some way in explaining why the figures for CRP are so bad.
The Barton and
Grant Health Map (2006) looks
at the social determinants of wellbeing
and how these factors affect the likelihood of a child becoming obese.
Overall 10 areas in CRP are in the 20% most deprived (Department for Communities and Local Government). 14.6% of
CRP lives in fuel poverty and 17.9% of children live in low income families (Department for
Energy and Climate Change (2014) and HM Revenue and Customs (2014)).
There is a correlation between poverty and obesity. The poorer the parent is
then the more likely their children will be obese and if the income inequality
is greater the more pronounced the obesity ( Robertson et al. 2007).
Between 2013 and 2015, 256 children aged 5 in CRP needed
tooth extraction (Smile, 2016) this is linked to
poverty – this may be due to poor diet, lack of oral hygiene education, poor
role models in the home, lack of dentists locally and parents being unable to
afford transport to the dentists.
30.2% of adults in CRP are physically active this is well
below the UK average this means that
children in CRP have very poor role models (PHE, 2015). Children are more likely to play in
cyber land than they are outdoors. 47% of UK primary school children walked to
school in 2012, (Department for Transport, 2013) compared to 80%
in 1971 (Shaw et al. 2013). .
The population of CRP is expected to increase by 16% by 2025 compared to
9% for the rest of Cornwall thus putting additional pressure on health services
and green spaces making it increasingly difficult for children in CRP to exercise.
There is strong evidence that most excess weight in
children is gained before the age of 5 (Gardner et al.,
2009). Harrington et al., 2010 believe that the first 2 years of a
child’s life is a critical period. Once a child becomes obese it is very
difficult to rectify the condition and its effects (James
2008). Treating obese
teenagers is not very successful (Epstein et al,
Tackling and preventing obesity in the early years of a
child’s life is easier than doing it later on as parents are more receptive to
support at this stage of a child’s life and the child will be developing their
food preferences and lifestyle habits in these early formative years ( Skouteris et al, 2011).
Many families realise the importance of healthy eating
but cannot afford fresh foods as junk foods are cheaper-the credit crunch meant
higher food prices which hit the poorest
the hardest ( Roberts, Cavill,
Hancock and Rutter 2012) resulting
in many single parent families switching to cheaper alternatives (Griffith et al. 2013). Many people make unwise food choices as they find them
It is becoming
widely accepted that the obesogenic environment plays a part in obesity. Obesity
is multifarious and not one nation has managed to conquer it (The Foresight Review 2012).
It’s not just a question of individual responsibility the
food indtry is also to blame. Forty years ago the American food industry
started to use high-fructose corn syrup- sweetener – it is cheaper than sugar
and inhibits the hunger controlling hormone leptin thus further fuelling
obesity (The Guardian, 2012).
If the social
determinants of health are tackled then thus should go some way in reducing
health inequalities. It is important to realise it is not just poor children
who end up becoming obese as nobody is immune to obesity. Marmot argued giving
each child the best possible start in life is the best way to reduce such
inequalities (Marmot, 2010). Society needs to look at
the root causes of obesity so that preventative policy interventions are taken upstream
rather than waiting to address it downstream (RCN, 2012).
The Spirit Level- Wilson and Pickett (2009) states that everyone would benefit
from a more egalitarian distribution of income.
Peter Sanders dismisses this and argues that their assumptions are
fundamentally flawed and based on statistically invalid claims. He states that
social ills are in fact worse in countries that have a more equal income
distribution (The Guardian, 2010).
Naidoo and Wills (1998)
state that nurses can use health promotion models to help them better understand
the complexities of the different strategic choices that they face. Ewles and Simnett (2003) argue that there is not one single
correct way in which to approach health promotion. Tannahill’s Health Promotion
Model is too simplistic to deal with childhood obesity, Beattie’s Health
Promotion Model is a better model –it gives nurses a structural analysis of
health promotion,. It is based on 4 paradigms-Health Persuasion-nurses take the
lead and directs it at the child. It is unlikely to be effective in the long
term as it does not address why children engage in unhealthy habits.
Legislative action-here the government sets up rules and resources aimed at
obesity such as the sugar tax. Personal Counselling –is a process of active
listening and reflection –this helps the child to become empowered and to
become better equipped to make choices. Community development encourages those
in a similar situation to change their environment for example The BHF Healthy
Hearts programme in The Heartlands, Pool, Redruth.(REFF)
Nurses can use Beattie’s model to
analyse health promotion strategies-it focuses the nurse’s attention on the
roles they themselves and acts as a tool which can be utilised to improve
health promotion strategies and to develop new ones (Wills and Earle,
2007). Tannahill (2009)
warned against the dangers of focusing on only one element of health promotion-Beattie’s
model recognises that in order to tackle an issue as complex as obesity then
there needs to be many different organisations with many different approaches
in each of the four quadrants.
The Health Belief Model (HBM) looks at
how an individual’s specific health beliefs ( i.e. how serious a child
perceives their obesity to be ) and their preferences (what the child sees as
being the benefits of engaging in treatment) and then their own experiences of health professionals and education as will affect
their level of knowledge. These factors
will affect what health behaviours they choose to adopt (Goodman, 2015). The HBM has limited value in tackling addictive
deep rooted behaviour such as childhood obesity-it lacks insight into the
complexity of health beliefs.
The HBM looks at demographic and psychological
variables-some of these factors the nurse, the obese child and their parents
will not be able to change but the nurse might be able to advise how the
physical environment impacts upon on obesity (Dolinksky, Siergaria,
Perri and Armstrong 2011). How much imparting of knowledge the nurse
does will depend on how the child perceives their susceptibility and the
severity of their obesity (HBM 2010 and Hayden 2009).
The nurse will have to look at how they can get the child ready to change their
behaviours and lifestyle (HBM 2010, Hayden 2009).
Nurses will need to work with children to help them overcome some commonly
perceived barriers such as the notion that weight is an easy issue to fix and parents
labelling obese children as having only puppy fat (Lewitt and Gillison
Nurses must ensure that patients have
the confidence in themselves that they can change their behaviour (HBM 2010). Criticisms
of the HMB model include the fact that it can be seen as victim blaming, it’s
hard for habitual behaviours –these might be better addressed separately, it is
good for short term behaviour change for a specific goal but may be less
effective in achieving long term change for conditions such as obesity (ReCAPP).
Tones and Tilford’s Health Action Model(
HAM) 2001 further
builds upon the Health Belief Model to focus on why individuals knowingly
choose to act in an irrational manner –e.g. why do children still lounge around
on sofas and eat junk food when they know the link to obesity? (Goodman, 2015). Despite the obese
child wanting to change-whether or not they do so will depend on a plethora of
factors. Mitcheson 2008 argues that HAM looks more complex, it focuses
on all areas of change, such as social situation, personality variables and
individual life skills. There are a number of ways in which nurses can involve
children and their families in managing their own care by working with the
whole family this has more success than just targeting the child (Staniford, Breckon and Copeland 2012). The way the nurse
communicates with the child is important and they will have to look at the
development stage of the child. If children have an internal locus of control (Rotter 1966) they will feel much more in control of their
lives and therefore be more empowered to seek help and make the necessary
The HAM places great emphasis on
empowering the child this will have the knock on effect of positive health
behaviours. Nurses need to make sure that Every Contact Counts a good approach
would be to ask the child questions, advise the child and act upon what the
child has said . Nurses need to work collaboratively with the child and parents
to create a SMART action plan- they also need to look at the level of support
available to the child, signpost the child where relevant, show them where they
can access information from. Most importantly the nurse needs to tell the child
how to recover from a relapse . A particular strength of Prochaska and
Diclemente’s Transtheoretical Theory of Change Model (1982 (TTCM) is
that it analyses many aspects of the human mind. It also explains the stages
that individuals will have to work through in order to stop being obese and to
maintain food health.). Critics of TTCM say it can be time consuming and may
not be suitable for busy clinical environments (Evans, Coutsaftiki
and Fathers 2017).
Partnerships in health promotion are key in
focusing on the determinants of health which in turn helps to address health
inequalities. Effective partnership working requires the following elements
leadership and vision, organisation and involvement, strategy development and
co-ordination, learning and development, resource (Audit Commission, 1998;
Pratt et al., 1998).
Nurses may wish to use motivational
interviewing (Rollnick et al. 2008) this recognises that people feel resistant to change and it helps
children to become more autonomous and to take charge of their obesegenic
Year Forward View (NHS England, 2014) states
that patients are the experts of their long term conditions and therefore they
must play a role in managing their own health (Evans, Coutsaftiki and Fathers 2017).
Hibbart and Gilburt 2014 state that -if children have a high level of activation then they
will feel more confident in dealing with their obesity effectively and as a
result they will demonstrate more positive health behaviours (Evans,
Coutsaftiki and Fathers 2017).
There have been a number of successful partnership
projects that have assisted children with obesity. HENRY(Health, Exercise,
Nutrition for the Really Young) a national charity which aims its interventions
at 0-5 year olds and their families recognises that merely providing advice
about healthy eating and exercise is unlikely to change people’s behaviours. HENRY uses partnership working approaches. As a result OF the HENRY approach- there has
been increased fruit and vegetables and water consumption, less junk food,
increased family meal time frequency, less time watching television and more time exercising (Willis et al, 2014). The HENRY approach had some
problems. A lot of practitioners have
issues tackling weight and lifestyle issues with parents as they feel somewhat
out of their comfort zone-and they are not certain if their efforts are effective ( Edmunds et al, 2007; Redsell et al, 2013). Henry developed a 2 day training
programme in response to this. Obesity is largely attributable to poverty (HSCIC, 2013) and HENRY had to overcome barriers that
different socioeconomic and ethnic groups face. HENRY increases empowerment and
resilience so children can better withstand the pressures of the obesogenic
There are a number
of subgroups within the population whose needs may not be met by universal
care. Cornwall has a high migrant workforce therefore them and their children
may well experience language barriers, their customs may also conflict with the
health promotion message. Traveller communities tend to have poor levels of
education, and due to their transient lifestyle this hinders the health
promotion message and GCSE achievement for Gypsy Children is worse any other
ethnic group (Dept of Education 2005).
The above groups will need a somewhat
different approach if they are to be successfully targeted. One approach that
nurses could use with say the Gypsy community is to appoint a well respected
member of their community and impart information to this person so they can
then go back and cascade this information and peer teach fellow gypsies. Also
nurses need to look to see if they can explain it in different way by using different approaches
such as team teaching, using the internet to teach using videos etc and making
sure that language is appropriate.
essay had demonstrated some of the many complexities surrounding childhood
obesity, which leads to deep-seated emotional and psychological consequences
for the child, their family, society and an already beleaguered NHS. As
mentioned what happens prior to conception and in the early years of a child’s
life is crucial, as it is a window of opportunity, which has to be seized upon
if society is to effectively combat childhood obesity. The current financial
crisis and the burden of providing baby boomers with care means that treating
obesity is more important now than it has ever been. The HENRY approach has
shown that by using an holistic approach-society can make real head way in
combatting this global epidemic, surely those questioning whether or not
society can afford to fund obesity prevention programmes should be asking
themselves if they can afford the social, personal and financial costs of burying
one’s head in the sand