VIEWPOINT
Addressing Childhood Obesity Using a Multidisciplinary Approach with Social Workers Cara Pappas, Amy Ai, and Barbara Dietrick
C
hildhood obesity, measured primarily by body mass index greater than or equal to the 95th percentile for age and gender (Ross, Kolbash, Cohen, & Skelton, 2010), is the most common pediatric nutritional condition leading to significant health and mental comorbidities lasting into adulthood (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007). Among U.S. children, the rate of obesity has tripled over the last three decades (Centers for Disease Control and Prevention, 2012) despite multiple health initiative programs and state mandates on health education. In addition, the prevalence among economically disadvantaged subpopulations such as Latino boys and African American girls is increasing at rates faster than those for their white peers (Ogden et al., 2006). Clinically, health care providers are now faced with the challenge of treating children with diseases that have historically only affected adults. Not only is there the potential to mismanage the mental and physical comorbidities in children, addressing the source of the weight gain and management modalities may never be captured fully. Childhood obesity can be addressed effectively by social workers and nurses in the school setting due to the vast amount of time they spend in that environment. Unfortunately, a critical gap exists within the research literature regarding individual social work interventions, with the exception of one commentary addressing multidisciplinary social work approaches in the medical setting (Eliadis, 2006). META-ANALYSES ON BEHAVIORAL INTERVENTIONS IN REDUCING CHILDHOOD OBESITY
There have been at least five meta-analyses regarding empirical evidence on the efficacy of behavioral
doi: 10.1093/hsw/hlv011 © 2015 National Association of Social Workers
interventions for childhood obesity in the United States. Stice, Shaw, and Marti (2006) gathered data from 64 programs on weight gain prevention involving both children and adults. Larger effects were identified for programs targeting children and adolescents. Yet the design of these programs varied considerably. Young, Northern, Lister, Drummond, & O’Brien (2007) selected 16 studies, restricted to family behavioral treatments for weight loss in children five to 12 years old. Interventions included at least one behavioral or cognitive–behavioral technique (for example, psychoeducation, stimulus control, behavioral awareness and modification, identifying problematic behavior, or behavior change maintenance) to promote children’s physical and eating habits, with at least one parent involved. The effect on the treatment group was significant at follow-up over several months, whereas effect on the control group was not. In the third meta-analysis, Gonzalez-Suarez, Worley, Grimmer-Somers, and Dones (2009) focused on studies of school-based interventions on childhood obesity. They provided convincing short-term evidence on the effectiveness of these interventions in reducing childhood obesity prevalence. The fourth one was most comprehensive, with results of 66 treatment–control comparisons and 59 alternate treatments evaluating lifestyle interventions for overweight children and adolescents (Kitzmann et al., 2010). The authors concluded that such interventions can be effective under a wide range of conditions months after treatment and parents should be actively involved in the treatment. Finally, Seo and Sa’s (2010) analysis of 32 controlled trials showed the benefit of using interventions with multiple components, such as parental involvement and lifestyle modifications, rather than
151
just a few on prevention or treatment of obesity among U.S. minority children. NATIONAL PROGRAMS ADDRESSING CHILDHOOD OBESITY
Particularly worth noting are two programs, Coordinated Approach to Child Health (CATCH) and Planet Health, which have been successful in addressing childhood obesity through randomized controlled trials and have extended into many school districts across the country. CATCH and Planet Health have been successful by building effective multidisciplinary teams, carrying out cost-effective implementation plans, and establishing evaluation methods to measure improvement in weight across several levels of primary and secondary education. The CATCH program began in elementary schools and focused on positive environmental influences toward increased physical activity and healthy eating habits. The intervention was developed by researchers in coordination with multiple disciplines within the school system and parents, resulting in a multilevel program. For instance, school food service changes included providing food lower in fat and sodium; academic curricula addressed healthy eating habits, physical activity, and cigarette smoking; physical education was enhanced to include 40 percent more moderate to vigorous activities; and family participation was encouraged by having various home activity packets with small rewards after completion (Luepker et al., 1996). Results showed a significant increase in time spent (from 40 percent to 50 percent) on physical activity and a considerable decrease in school meals’ fat content (from 39 percent to 32 percent) within the intervention group (Luepker et al., 1996). Longterm positive health effects were also noted, with 73 percent (n = 3,714) of participants from the original study three years prior with a reported diet considerably lower in fat and increased participation in more vigorous physical activities (Nader et al., 1999). Furthermore, the study has been replicated in another U.S. geographic area involving ethnic minority students and has expanded to kindergarten, sixth, and eighth grades as well as after-school programs (Franks et al., 2007). Planet Health was also designed by researchers in collaboration with school health officials toward reducing childhood obesity by increasing physical activity and promoting healthy eating behaviors. The intervention focused on four behaviors:
152
(1) reducing television (TV) viewing, (2) increasing physical activity, (3) decreasing intake of high-fat foods, and (4) increasing daily intake of fruits and vegetables (Gortmaker et al., 1999). Results showed a significant reduction in TV watching for both genders in the intervention group (–0.58 hours girls, –0.40 hours boys) compared with the control group. Obesity rates were also significant for the female intervention group (23.6 percent baseline, 20.3 percent postintervention) compared with the female control group (21.5 percent and 23.7 percent, respectively). Finally, there was a significant increase in fruit and vegetable consumption among girl participants in the intervention group (0.32 increase in servings per day) and less of an increase in daily calories consumed by girls in the intervention group (–575 calories per day). Planet Health is now being implemented in at least 120 schools in Massachusetts, with more than 1,000 teachers trained in the program. In addition, more than 2,000 copies of the curriculum have been purchased across 48 states and 20 countries (Franks et al., 2007). It is somewhat surprising that either program did not use social workers or school nurses in their original trials; however, there may not have been full-time positions for these disciplines in the schools tested. Implementation of CATCH or Planet Health could be efficiently and effectively led by both professionals. COLLABORATIVE EFFORTS IN SCHOOLS USING A MULTIDISCIPLINARY APPROACH
Multidisciplinary teams are a necessary factor when addressing and managing childhood obesity. The practice of working in a collaborative fashion has been successful through increased communication between team members, improved quality of care, and decreased errors when addressing clients’ needs in health and social care (Chan, Pang, Ching, & Lam, 2010). The multidisciplinary team should ideally be made up of social workers, school nurses, educators, administrators, dietetic staff, physical education staff, community members, and families (West et al., 2012). Defining this core group is essential to develop an effective program, meet any potential challenges during implementation, and have an evaluation plan to measure outcomes. Social workers and nurses, in particular, are academically prepared to work collaboratively and lead the team through this process. Both are well prepared to assess
Health & Social Work Volume 40, Number 2 May 2015
the individual, family, and community—including the disadvantaged—in health promotion and disease prevention initiatives while accommodating for various cultures. Social workers and school nurses can collaborate with physical education staff by serving as advocates for change in school committees to maintain or increase physical activity for students. They can also educate teachers by taking part in classes and afterschool activities toward health promotion. In reference to food choices, schools are places where a significant amount of total daily calories are consumed by students (Institute of Medicine, 2009) and, unfortunately, have a vast selection of foods high in fat and sugar (Longley & Sneed, 2009). School nurses and social workers can collectively advocate for healthy food options in vending machines and snack bars (Lawrence, Hazlett, & Hightower, 2010). Promoting healthy eating habits and appropriate portion sizes with the dietetic staff through school campaigns can also be an effective tool. Parents also need to be actively involved and supported in healthy eating habits and increased physical activity for the entire family. Children respond positively to parents’ role modeling behaviors (Rabbitt & Coyne, 2012). In addition, parents, with the assistance of the social worker, can join local community groups for sustaining a lifestyle change. Modifying family behaviors, changing the school environment, and adapting to various cultural practices contributing to weight gain are pivotal toward the sustainable reduction of obesity (Ross et al., 2010). SUMMARY
Childhood obesity can be effectively addressed with behavioral interventions in programs such as CATCH and Planet Health using a multidisciplinary approach. Social workers and school nurses are in close contact with children and youths at risk of obesity and their families within the school setting and are prepared to lead a multidisciplinary team in program planning, implementation, and evaluation related to reducing childhood obesity. REFERENCES Centers for Disease Control and Prevention. (2012). Childhood obesity facts. Retrieved from http://www .cdc.gov/healthyyouth/obesity/facts.htm Chan, E. A., Pang, S.M.C., Ching, S., & Lam, S.K.S. (2010). Interprofessional education: The interface of nursing and social work. Journal of Clinical Nursing, 19, 168–176.
Eliadis, E. E. (2006). The role of social work in the childhood obesity epidemic [Commentary]. Social Work, 51, 86–88. Franks, A., Kelder, S. H., Dino, G. A., Horn, K. A., Gortmaker, S. L., Wiecha, J. L., & Simoes, E. J. (2007). School-based programs: Lessons learned from CATCH, Planet Health, and Not-On-Tobacco. Preventing Chronic Disease, 4(2), 1–9. Retrieved from http://www.cdc.gov/pcd/issues/2007/apr/06_0105 .htm Freedman, D. S., Mei, Z., Srinivasan, S. R., Berenson, G. S., & Dietz, W. H. (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The Bogalusa Heart Study. Journal of Pediatrics, 150(1), 12–17.e2. Gonzalez-Suarez, C., Worley, A., Grimmer-Somers, K., & Dones, V. (2009). School-based interventions on childhood obesity: A meta-analysis. American Journal of Preventive Medicine, 37, 418–427. doi:10.1016/j .amepre.2009.07.012 Gortmaker, S. L., Peterson, K., Wiecha, J., Sobol, A. M., Dixit, S., Fox, M. K., & Laird, N. (1999). Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Archives of Pediatrics & Adolescent Medicine, 153, 409–418. Institute of Medicine. (2009). School meals: Building blocks for healthy children. Washington, DC: National Academies Press. Kitzmann, K. M., Dalton, W. T., Stanley, C. M., Beech, B. M., Reeves, T. P., Buscemi, J., et al. (2010). Lifestyle interventions for youth who are overweight: A meta-analytic review. Health Psychology, 29(1), 91–101. doi:10.1037/a0017437 Lawrence, S., Hazlett, R., & Hightower, P. (2010). Under standing and acting on the growing childhood and adolescent weight crisis: A role for social work. Health & Social Work, 35, 147–153. Longley, C. H., & Sneed, J. (2009). Effects of federal legislation on wellness policy formation in school districts in the United States. Journal of the American Dietetic Association, 109(1), 95–101. Luepker, R.V., Perry, C. L., McKinlay, S. M., Nader, P. R., Parcel, G. S., Stone, E. J., et al. (1996). Outcomes of a field trial to improve children’s dietary patterns and physical activity. JAMA, 275, 768–776. Nader, P. R., Stone, E. J., Lytle, L. A., Perry, C. L., Osganian, S. K., Kelder, S., et al. (1999). Three-year maintenance of improved diet and physical activity: The CATCH cohort. Archives of Pediatrics & Adolescent Medicine, 153, 695–704. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the US, 1999–2004. JAMA, 295, 1549–1555. Rabbitt, A., & Coyne, I. (2012). Childhood obesity: Nurses’ role in addressing the epidemic. British Journal of Nursing, 21, 731–735. Ross, M. M., Kolbash, S., Cohen, G. M., & Skelton, J. A. (2010). Multidisciplinary treatment of pediatric obesity: Nutrition evaluation and management. Nutrition in Clinical Practice, 25(4), 327–334. Seo, D., & Sa, J. (2010). A meta-analysis of obesity interventions among U.S. minority children. Journal of Adolescent Health, 46, 309–323. doi:10.1016/j .jadohealth.2009.11.202 Stice, E., Shaw, H., & Marti, C. N. (2006). A metaanalytic review of obesity prevention programs for children and adolescents: The skinny on interventions that work. Psychological Bulletin, 132, 667–691. West, M. D., Mellin, E. A., Chambers, K. L., Lever, N. A., Haber, D., & Blaber, C. (2012). Challenges to
Pappas, Ai, and Dietrick / Addressing Childhood Obesity Using a Multidisciplinary Approach with Social Workers
153
collaboration in school mental health and strategies for overcoming them. Journal of School Health, 82, 97–105. Young, K. M., Northern, J. J., Lister, K. M., Drummond, J. A., & O’Brien, W. H. (2007). A meta-analysis of family-behavioral weight-loss treatments for children. Clinical Psychology Review, 27(2), 240–249.
Cara Pappas, ND, ARNP, is assistant professor, College of Nursing, and has a courtesy appointment, College of Social Work, Florida State University, Tallahassee. Amy Ai, PhD, is professor, College of Social Work, and has courtesy appointments in nursing, psychology, and social medicine and behavioral science, Florida State University, Tallahassee. Barbara Dietrick is an undergraduate student, Department of Biological Science, Florida State University, Tallahassee. Address correspondence to Cara Pappas, College of Nursing, Florida State University, 98 Varsity Way, #449, Tallahassee, FL 32306; e-mail:
[email protected]. Original manuscript received October 15, 2013 Final revision received December 9, 2013 Accepted March 6, 2014 Advance Access Publication February 18, 2015
154
Health & Social Work Volume 40, Number 2 May 2015
