ARTICLE IN PRESS Nurse Education in Practice (2008) xxx, xxx–xxx

Nurse Education in Practice www.elsevier.com/nepr

The childhood obesity pandemic: Promoting knowledge for undergraduate nursing students Ellen Ben-Sefer

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Faculty of Nursing, Midwifery and Health, University of Technology, Lindfield, NSW 2070, Sydney, Australia Accepted 25 July 2008

KEYWORDS

Summary The rise in childhood obesity is acknowledged as a major health problem in many countries. Health issues directly related to the childhood obesity pandemic are numerous as are the risk factors in its development. No single strategy is likely to be effective in reversing this alarming trend, rather, nurses need to work with children and families by providing education, guidance, and support to promote a change in the many lifestyle factors that have helped to create this health problem. Curriculum, teaching practices and assignment topics based on contemporary health issues of relevance to nursing practice support the importance of educating nursing students on this worrying health issue. The use of a creative strategy to help students learn about the childhood obesity problem can also be utilised to encourage lateral thinking in students. Thus, an assignment can have two significant goals in the development of knowledge and understanding of childhood obesity but also personal discovery of creative ability to design a method that engages children in learning about this health problem and what they can do to avoid its development. c 2008 Elsevier Ltd. All rights reserved.

Childhood; Obesity; Pandemic



The disturbing trend of overweight and obesity in Australia has risen at significant rates in the last 20 years (Nathan et al., 2005). This is no different from a number of industrialised countries however, the issue has become a major public health concern with particular worry regarding the excessive weight problem among children.

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The current rates in children are among the highest in the developed world with approximately 25% of children considered to be either overweight or obese, a dramatic rise from the 5% that was identified in the 1960s (www.abs.gov.au–– Australian Bureau of Statistics). This growing trend appears to be on the rise since the number of overweight children in Australia has doubled since 1995, indicative of the prevalence rates rapidly rising with little reason to believe that this will not continue to be a trend (Waters and



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Baur, 2003). The health issues that relate to this troubling occurrence include both physical and emotional health consequences that include hypertension, type 2 diabetes, shortness of breath, obstructive sleep apnea, and musculoskeletal problems due to increased pressure on muscles and joints (Waters and Baur, 2003). Additionally, obesity has been linked to several adult cancers including cancer of the breast, colon, kidney and esophagus (Chronic Disease Notes and Reports, Centers for Disease Control and Prevention, 2005). Overweight and obese adults develop conditions that further decrease quality of life which include arthritis, respiratory problems and infertility. Such fundamental health problems are not only costly in terms of health resources but also contribute to absence from work, a further drain to the economic system (NSW Summit on Childhood Obesity, Background Paper, 2002). The world-wide gravity of this health crisis is reflected in data from a number of countries and the impact of childhood obesity on both physical and emotional health. One study in the United States indicated a significant decrease in self-esteem that was apparent in both boys and girls by age 13 years ( Strauss, 2000). Lowered self-esteem has been associated with increasing rates of sadness and loneliness and as a further consequence, such children were found to be more likely to engage in high risk behaviour including smoking and drinking alcohol ( Strauss, 2000), compounding the health problems of these children and adolescents. The stigma of obesity is apparent even among young children. Zametkin et al. (2004) observed that when shown drawings of children with varying body shapes, obese figures were selected as the least desirable playmates. While large number of adults also suffer from overweight and obesity, the focus on children is fundamental not only for contemporary society but for future populations since it precludes the potential for a reduction in lifespan due to medical complications such as cardiovascular disease at a much younger age as well as the financial implications for the health care system. The global trend of increasing childhood obesity makes this a health issue of concern to nurses throughout the world. Crisis level has been reached in a number of European countries with 10–30% of European children between the ages of seven and eleven years already overweight or obese, while up to 25% of adolescents are considered to be overweight or obese as well (Lobstein and Frelut, 2003). This is mirrored in the Middle East, with

18%t of all children overweight and 7% obese (Lobstein and Frelut, 2003). In addition to the data previously cited for Australian children, the problem is equally troubling in New Zealand where 20% of children between the ages of five and fourteen years are overweight, and another 10% obese; 31% of the Maori and Pacific Islander sub-population are affected (Baur, 2006). Brazilian statistics provide an example of the scope of the problem in Latin America with a finding that an additional 0.5% of all children became overweight each year (Lobstein et al., 2004). Clearly, this is an issue of global import that can be considered the ‘‘millennium disease’’, a term employed by Baur (2006). Considering the trend towards obesity in children and the many health implications, it is reasonable to regard the issue as an epidemic that requires serious, long term planning. Such planning can only be addressed through recognition of the many factors associated with the current problem.

Factors associated with obesity Numerous factors have been identified as causative links between incidence of overweight and obese children. In Australia, prevalence of such children is greater in children who come from homes of either European or Middle Eastern background, and children from lower socio-economic status (Gliksman et al., 1990). The lack of energy expenditure has also been cited as significant. The prevention of obesity has far too often been linked to children taking responsibility for their food choices with their parents held ultimately responsible thereby compounding guilt over their child’s appearance. However, it is clear that the troubling issue of childhood obesity is not only a matter of personal choice, as tempting and simplified as that approach may appear, but rather a fundamental health issues that crosses all boundaries of society including social class and culture. Environment plays a crucial part in the trend towards obesity. Access to safe public transport and parks are fundamental in encouraging both adults and children to engage in physical activity. McMurray et al. (2000) has noted that the level of fitness in children in industrialised countries has continued to decline which has been associated with growth of technology and access for children thereby encouraging a sedentary lifestyle. This lifestyle, compounded with a lack of role modeling by parents who are often sedentary as well.

Please cite this article in press as: Ben-Sefer, E., The childhood obesity pandemic: Promoting ..., Nurse Educ. Pract. (2008), doi:10.1016/j.nepr.2008.07.006

ARTICLE IN PRESS The childhood obesity pandemic: Promoting knowledge for undergraduate nursing students Furthermore, if television viewing can be seen as an environmental factor since it shapes the choices children may make. From a young age, they are bombarded with food advertisements that primarily consist of fast food, high sugar content cereals and sweets. According to the Canadian Paediatric Society, most food advertising on children’s TV shows is for fast foods, candy and pre-sweetened cereals. Commercials for healthy food make up only four percent of those shown, (http://www.media-awareness.ca/english/parents/ television/tv_impact_kids.cfm). Similar advertising content is paralleled in Australia. Clearly such media messages can have a significant influence on children’s food preferences, purchases and ongoing consumption. In a recent study (Matheson et al., 2004) it was determined that a significant amount of the daily food intake of children was consumed while watching television with higher fat foods prevalent on weekend. Furthermore, the ability to recognize food advertised on television was associated with the amount of food ingested after exposure to them (Halford et al., 2004). Their conclusions strongly suggest that it is not only the sedentary lifestyle that contributes to the rise in childhood obesity, but the exposure to food advertisements. Furthermore, the children in their study all ate more after viewing ads. The influence of advertising on children’s food choices has been well known for a number of years. In 1984, Brody et al. determined that young children who had viewed food advertisements and accompanied parents while food shopping were more likely to influence parental purchase, with particular emphasis on the advertised product. This is particularly troubling as findings in Australia indicate that such advertising to children not only fails to support recommended dietary intake, but manipulates children (Egberts and Riley, 2004). Television viewing, then, is associated with obesity and interventions must begin in early childhood (Viner and Cole, 2005). This is supported by Padez et al. (2005) in a study of Portuguese children. While other factors play a significant role in the obesity problem, data suggests that education about nutrition and energy expenditure must be implemented much earlier in families who are identified as high risk. If that is so, clearly the need to introduce health promotion targeted at children and parents must begin from the earliest stages of childhood. In order to be effective, such strategies must include the use of media rather a critique of its influence. This paper aims to discuss one strategy for helping students to learn about the issues highlighted

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and their subsequent evaluation of a related assignment.

Initiatives in the education of undergraduate nursing students Considering the import of this global problem in children’s health that has long term repercussions, it follows that nursing students should receive educational information that will allow them to work with children and families to identify those already at risk and help them to create active solutions to the problem. In the United States, the National League for Nursing (2005) noted that Faculty must base their curriculum decisions, teaching practices, and evaluation methods on current research findings supporting the chosen assignment topic for undergraduates as significant to their practice. Likewise, nurses can be active in health programs that aid children in maintaining appropriate weight and activity levels as part of an overall concern for general health and well-being. There are a number of ways that this philosophy can be achieved in the undergraduate curriculum. Traditional lectures and tutorials with supplementary readings can be useful in ensuring that students are aware of this global contemporary problem. However, providing opportunities for students to engage with the issue of childhood obesity can be achieved in other ways. At University of Technology, Sydney, a three year program in undergraduate nursing, all second year students are required to undertake Children’s Nursing. This subject includes care of sick children as well as care of children in a community setting. One hour of lecture content per week is devoted to providing students with a solid understanding of growth and development through the various ages and stages of childhood to enable them to appreciate the cognitive, fine motor and gross motor abilities as well as development of morality through the lifespan of children and adolescents. Consequently, any nursing subject at another institution that contains similar foundational content may be able to adapt the assessment within parameters that relate to the childhood obesity problem in another country. Since working with children requires some creativity, flexibility and at times, a challenge to the status quo, a creative assignment was designed to help students learn about the health problems associated with childhood obesity but to also challenge their own sense of creativity and encourage lateral thinking. The assignment was also designed to encourage nursing students to seek appropriate

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ways of promoting health in young children. Such an approach may also be seen as a means of helping students achieve excellence in a challenging, and different manner that is related to developing creative thinking. Excellence also implies being unwilling to accept the status quo. Individuals who strive for and expect excellence question and challenge the status quo by asking why things are done the way they are, examining the assumptions that underlie existing practices, and offering thoughtful and realistic alternatives for how things could he done in other ways. Clearly, creative thinking is linked to the achievement of excellence, thinking beyond traditional solutions. An assignment that involves a creative approach in this manner is also significant for students who struggle with academic writing and have difficulty mastering this skill. Therefore, students were assigned a traditional essay in which they were to discuss the problems of childhood obesity which included a theoretical rationale supporting the choice of a project undertaken and designed. They were also required to submit a ‘‘creative strategy’’ or project to teach children about the problem as a form of health promotion. The strategy is marked on the basis of color, safety, and accordance with growth and development principles. Consequently, the assignment endeavours to apply theory to practice which is of importance since many students have not had previous contact with children. The creation of a project to be used to teach children about the vital importance of healthy diet and exercise provides a concrete learning experience for them. It is also designed to enable students to gain insights into the world of children. Thus, the assignment combines both critical and creative thinking. While critical thinking is seen as selective and analytical (Miller and Babcock, 1996), creative thinking is a complementary approach that can be useful to nurses when they are confronted with situations that do not fit predictable situations. Creative thinking is likely to produce ideas and most useful in situations when routine approaches have not worked. It is likely that both types of thinking need to be employed by nurses who may shift back and forth between the two. Therefore, it is vital that students are given the opportunity to engage in assessments that encourage both types of thinking. After initial puzzlement, students take to the assignment with enthusiasm. Academic staff discusses the assignment during class and provide some examples that would be suitable for the creative activity. Students have submitted numerous creative strategies including storybooks, game boards, original songs composed for children,

activity packs, video recordings of puppet shows they have scripted and performed, interactive CDs, card games, and many other strategies that would be suitable for children. In an effort to promote both learning and physical activity, some students included instructions in their work, such as ‘‘hop on one foot three times’’ at various places on the game boards. Many of the pieces of work contained instructions for parents with advice on how to best use the activity designed thereby fostering family participation and parental educational as well. It was important to stress to students that creative work submitted for marking need not be professional in presentation, ‘‘stick-figure’’ hand drawings in a book would accrue equal marks to a more professional presentation, that is, the concept with sound rationale of growth and development principles would be the underlying factor in marking. One example of this was a handmade ‘‘karaoke’’ device created from a carton and paper towel rollers with simple paper that contained drawings and lyrics that the child could easily roll enjoying text and pictures while singing the lyrics of the song. The assessment was submitted prior to commencing clinical practicum and a significant outcome was observed by clinical facilitators as a direct result of the assessment. Facilitators noted that during the practicum, many students discussed their ability to focus more attention on children’s eating behaviours and attitudes towards food, as well as noting their body shape and type of activity undertaken during a play period. This suggests that they have internalised the important aspects of the assessment and will continue to incorporate the knowledge learned through the assessment process.

Students’ evaluation of the assignment in terms of learning All students were invited to complete an evaluation of the assessment in class and all were willing to do so. While these evaluations cannot be considered to be research, they are anonymous and ask students to address questions that enable them to identify areas of import in their learning. The teaching staff also benefits from the evaluations as they can be utilised to refine such assessments in the future from student feedback. A number of students used the process of evaluation to reflect on their learning experience in terms of creativity.

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ARTICLE IN PRESS The childhood obesity pandemic: Promoting knowledge for undergraduate nursing students An overwhelming number of students, 185 out of a cohort of 207, believed that the assignment allowed them to extend their understanding of the many issues surrounding childhood obesity. The student evaluation helps to validate the choice of assignment topic as well as the format chosen to facilitate their learning and indicates indeed, that the assignment served its purpose of creating a learning experience for students. Approximately half of the cohort, 118 students felt that creative activities of this sort should be retained in the subject. This can be explained by some of their comments in which they discussed both the positive and negative aspects of the assignment. For the most part, the negative aspects cited by students centered on the amount of time required to complete the assignment. Others felt there was expense involved despite being given explanations that the activities submitted did not need to be professional in appearance nor should cost become a factor. Two students out of the cohort felt that the assignment was not relevant to nursing despite all the explanations given that emphasised the importance of appreciating growth and development in children and one stated that it was based on craft skills rather than knowledge. One hundred and eighty-five students had positive comments to make about the assignment thereby revealing that it also achieved its goal of encouraging students to think in a more creative way. More than half the cohort, 110 students, agreed that the assignment fostered a different thought process and encouraged them to extend their thought processes and further consider ways in which creative interventions could be included their future practice as nurses. One student expressed this change of approach in the following: It was a unique assignment and it allowed the development of creative thought; it tapped into thought processes that are rarely utilised in nursing theory-ie creativity. Other students also felt strongly about flexibility in project choice. Any suitable sort of creative project that was appropriate to age and stage of a child was acceptable, thereby giving students considerable scope in choosing a format to present the issues to a child as part of their work. It was more interesting and thought provoking that the usual assignments. I had a choice in the project format, not just a straight essay.

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Although not considered part of the purpose of the assignment, several students commented that the assignment became personally meaningful by providing insights into their own behaviour as well as their family members. It opened my eyes to all the junk I eat and children eat. My sister is overweight. I learned from this assignment not to get angry with her and force her to lose weight. A better way would be to encourage healthy eating, exercise with her and make it fun. It was a relevant topic, in the media all the time, I like that I could contribute something to society. Clearly, the format of this assignment cannot satisfy all students, however, the vast majority, as evidenced by 185 students out of a cohort of 207, found it stimulating and a learning experience. They found the assessment to be thought provoking and a way of encouraging their thinking processes to develop in a more creative way without neglecting critical thinking skills in the essay portion of the assignment. The academic staffs are also challenged by the assessment, but find it an enjoyable task. The considerable variety of work submitted by students ensured that staff likewise found the assessment marking an engaging task. Staffs have been impressed by the quality of students’ efforts and in some cases have approached them for permission to display their work in the campus library. This has fostered further self-esteem, particularly for those students who have had difficulty with the traditional assignments and has motivated them in subsequent assessment tasks. The students’ evaluation is significant in terms of nursing education. Simpson and Courtney (2002) purport that creative thinking is strongly linked to the development of critical thinking skills: an essential skill for contemporary nurses. Creative thinking however differs in its combination of both knowledge and imagination that allows the learner to seek new approaches and explore ideas. Furthermore, creative processes can make work and therefore assignments more interesting. Teaching methods that enhance such thinking need to include ways to open minds while integrating theory and practice (Bittner 7 Tobin 1998). Gilmartin (2001) noted that educators must be flexible while creating assignments that will also challenge students. While a number of students purport that poor academic performance is a direct result of personal characteristics, such a view may also reflect a failure to engage them in deep learning. Such a result defeats the purpose of education; therefore it is

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acceptable and appropriate to utilise multiple forms of assessments (Hufton et al., 2002). Ideally, assessments that engage students in creative thinking should promote the integration and assimilation of fundamental ideas and concepts in nursing and assist them in applying such processes in the clinical field. For the most part, students’ evaluation of the assignment is in accord with current theories of nursing education; that they welcome the opportunity to engage in creative thinking, find the assignment challenging and appreciate that these thought processes are applicable to their clinical practice. While such an approach to the assignment design may not always be feasible, practical or even suitable, with judicious application, such an educational strategy may be beneficial to both nursing educators as well as their students. While this assessment is appropriate to students within the curriculum at University of Technology, Sydney, it may not necessarily be suitable for other programs. However, the concept of utilising a creative approach that is similar to the one employed may be adaptable. One of the benefits in encouraging students to be creative and design a project to engage children that is both developmentally and topically relevant is that it may provide students with an understanding of personal responsibility as nurses who provide care for children. While most students understand that nurses in general have a collective interest in this alarming health problem and appreciate the global import in a variety of implications that include long term health problems and economic consequences as examples, many are not able to engage their understanding on a personal level. To address the problem of childhood obesity, nurses, along with other health professionals and parents, must take collective and personal responsibility. Their understanding at this personal level is reflected in the above responses as they evaluated the assessment.

Conclusion From the student evaluations, it can be seen that creative activity and assessment can be helpful in developing a life-long learning for nursing students who will go on to practice for many years as registered nurses. Furthermore, such assessment provides a justifiable alternative to traditional assessment methods and can be adapted to other subjects. Finally, the assignment topic provided an important means of educating students about a significant public health issue concerning children

that has far reaching implications for their adolescent and adult lives.

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ARTICLE IN PRESS The childhood obesity pandemic: Promoting knowledge for undergraduate nursing students Viner, R., Cole, T., 2005. Television viewing in early childhood predicts adult body mass index. Journal of Pediatrics 147 (4), 417–418. Waters, E., Baur, L., 2003. Childhood obesity: modernity’s scourge. Medical Journal of Australia 178 (9), 422–423.

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Zametkin, A., Zoon, C., Klein, H., Munson, S., 2004. Psychiatric aspects of child and adolescent obesity: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 43 (2), 134– 150.

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