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Effects of risk factors of obesity in childhood and

prevention and intervention strategies: A Literature Review

Angel D. Lee

August 31, 2014

NorthCentral University

Instructor: Dr. D. Franklestein

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Childhood Obesity: A literature review

Obesity in the United States has increased dramatically over the past thirty years as more

children and adults become obese. Obesity is classified as a condition which leads the individual

to weigh 20 percent more than their ideal weight stemming from abnormal or unhealthy storage

of fat tissue (DeAngelo, Kalmuck, & Adlin, 2013). Obesity usually occurs when ingestion of

food regularly exceeds expenditures in which the unused energy is stored as body fat (Moglia

Dell, 2013). According to Kelly (2014) 37 percent of people are more likely to be obese if their

spouses are overweight or obese; 40 percent is if siblings are obese; and 57 percent if friends are

overweight or obese. Surveys have found that 65 percent of Americans are overweight and over

30 percent are obese which has doubled since the 1980’s. Among those individuals, the rate of

childhood obesity has tripled in youth ages 6 to 11 years old (Werner, Tuefel, Holtgave, &

Brown, 2012). Moglia and Dell (2013) claimed that obesity in children occurs when Body Mass

Index (BMI) is greater than or equal to the 95th percentile. Children who are less than the 85th

percentile are considered to be “normal” weight when correlated with their height. In the United

States, it is estimated that 12.5 million children and adolescence are obese (Eyler, Nguen,

Jooyoung, & Yan, 2012). 17 percent of children today are obese compared to the obesity rate of

5 percent in the 1960s. Ethnic minorities (African American youth (24%) and Hispanic/ Latino

youth (23%)) and children from lower economic communities with little access to nutritious

foods and physical activity opportunities suffer from the highest rates of childhood obesity

(Muth, 2008). Previous research has indicated effectively prevent and treat childhood obesity,

one must understand risk factors and consequences of obesity in children. Therefore, the purpose

of this literature review is to examine consequences and risk factors associated with unhealthy

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eating behaviors and the lack of physical activity. This literature review also serves to bring

awareness of childhood obesity and examine potential preventative methods and appropriate

intervention strategies to battle the epidemic of obesity in childhood.

Childhood Development

The period of middle and late childhood contains slow and consistent growth known as

the “calm” before rapid growth during adolescence. During middle childhood years, children can

usually grow approximately two to three inches a year until they reach eleven years of age.

Throughout middle to late childhood from ages 11 to 13, children may gain roughly 5 to 7

pounds a year which is usually caused by increases in the size of the skeletal muscles, muscle

systems, and the size of body organs. Changes in proportion are the one of the most noticeable

physical changes during this stage of childhood as well as the gradual increase in muscle mass

and strength with a decrease of “baby fat” (Santrock, 2011). Children who are well nourished,

healthy, and cared for in their early ages of life are known to have better physical, mental, and

social development (Kartal, 2007). According to Engle and Huffman (2010) children who

experience malnutrition or obesity possess more emotional and social issues as well as learning

deficiencies compared to those who are well nourished and healthy.

Consequences of Obesity in Childhood

Overeating or the consumption of a large amount of food with an accompanying sense of

loss of control over one’s eating has been associated with severity of overweight and

psychosocial morbidity in adults and more recently in children (Levine, Ringham, Kalarchiman,

Wisniewski, & Marcus, 2006). Childhood has also been known to carry over into adulthood.

Werner et.al (2012) found that overweight and children aged 6 years or older carried a 50 percent

probability of becoming obese adults compared to non-overweight children. Werner et.al also

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claimed that health risks also increases as obesity rates are increases. Children ages 5 to 7 years

who suffer from obesity were known to have at least one cardiovascular disease risk factor.

Predictions of long term outcomes of the obesity epidemic include a decline in population health

of disease and disability along with substantial societal and economic costs (Eyler et.al, 2012).

Falker, Lubre, and Schaefer (2010) used data to increase awareness of hypertension

during childhood. The authors used qualitative research methods to describe how factors such as

obesity could contribute to hypertension in children. They acknowledged that sedentary lifestyle

factors, poor dietary nutrition, and poor quality of sleep contribute to the rising prevalence of

obesity. Throughout the article the authors explained adverse consequences of childhood

hypertension and the burden it poses on children, families, as well as the health care systems.

Some of the most serious physical effects of obesity may not become apparent until the child

reaches adulthood such as raised blood pressure and cholesterol, impaired glucose tolerance

leading to Type 2 diabetes which can be identified in children and adolescence.

Hypertension due to obesity could also vary by ethnic group. According to Kelly (2014)

in 2011 the United States Department of Health and Human Services claimed that African

Americans were 1.5 times more likely to be obese than Caucasians and are less likely to engage

in physical activity. African Americans, especially African American women have the highest

rates of obesity, comparing to 80 percent to Caucasian women, with the most weight gain usually

occurring before the age of 50 (Capodilpo, & Kim, 2014). Therefore, Taylor, Maddox, and Wu,

(2009) examined risk factors for the development of high-blood press (HBP) in African

American women as well as determine the extent of genetic precursors for hypertension effect

the genetic environment interaction for HBP in early life. Using a cross sectional research

design, the authors examined if both genetic and environmental lifestyle behaviors could

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contribute to developing hypertension. 108 African American mothers and daughters participated

in a demographic survey, tests of physical activity and sodium intake, measures of BP, height,

and weight as well as collection of Buccal Swabs and genotyping. The findings suggested that

there are some associations between genetic factors and environmental lifestyle variables on BP

in African American mothers and their daughters.

Overweight children may also suffer from some level of psychosocial impact as a result

of their weight. De Sausmarez and Dunsmuir (2011) examined external risk factors for

childhood obesity and clarified if these factors may be assessed throughout the population to

allow for appropriate intervention programs. The authors used qualitative research methods

through reviewing previous research which examined external causes and to develop an

assessment of psychological factors associated with childhood obesity. The findings suggested

that some external risk factors for obesity may include unhealthy parenting behavior, lower peer

status, victimization, and insufficient physical activity. It also suggested that childhood obesity

represents a dynamic process which behavior, emotional regulation, and cognition mutually

interact with each other. Therefore, children who are overweight or obese are also reported to

have a lower perceived self worth, attractiveness, and athletic ability as well as being less

socially competent and often demonstrating behavioral problems.

Probable Causes of Obesity and Weight Gain

Eloranta, et al. (2012) suggested that various eating patterns such as high consumption of

low quality or processed foods, sugar sweetened soft drinks, snacks and sweets, as well as

unfavorable meal patterns such as low number of daily meals, and skipping breakfast have been

related to childhood obesity and weight gain. Moreover adverse eating behavior such as

emotional eating and food responsiveness has also been associated with weight gain. Data from

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the Institute of biomedicine in Kuopio, Finland was used to examine the connection between

eating frequency, eating behavior, as well as the intake of various nutrients with being

overweight, body fat percentage, and waist and hip circumferences in children aged 6 to 8 years

old. Eloranta, et al. (2012) used linear regression to demonstrate the connection between dietary

factors with the risk of being overweight or obese. The findings explained that employment of

food, emotional overeating, and responsiveness to overeating were associated with an increased

body fat percentage in children compared to those who have regulated food patterns. These

results are also in congruence with previous studies which suggested that children’s whose food

intake is unregulated have a higher risk of being overweight.

Problematic eating behavior may also be the cause of weight gain in children. Eating a

decreased variety of foods and avoiding unfamiliar foods are considered a major source of

mealtime distress resulting in disturbances of normal feeding/ eating behavior leading to weight

gain or obesity in children (Orun, Erdil, Centinkaya, Tufan, & Yalcin, 2012). For instance the

African American diet usually consists of meat, fruits, and vegetables, grains as well as dairy.

Compared to women, African American men are usually less concerned with negative

implications of unhealthy eating. They tend to be more pleasure eating often engaging for

convenience, especially outside of the home. African American men are known to have dietary

patterns of consuming large calorie dense foods such as excessive amounts of red meat, eggs,

food higher in sugar, and alcohol; thus, contributing to increasing rates of obesity and mortality

for chronic diseases (Allen, Griffith, and Gaines, 2012). On average African Americans aged 20

years and older are known to consume approximately 2085 calories a day consisting of 76.7

grams of protein, 249 grams of carbohydrates, 81.4 grams of total fat in which 25.9 grams are

saturated, 3,270 grams of sodium and 121 grams of sugar (Evens, 2011). According to Belle

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(2012) many foods that are consumed by African Americans are heavily influenced by the

dominant culture in Western Society which consists of large amounts of fats and sodium and are

based on meat instead of vegetables.

Dietary patterns lower in fruits, vegetables, milk and whole grains contribute to the

disparity between African Americans and many other ethnic groups in the United States

(Scharma, et al., 2009). Scharma, et al. (2009) collected data to characterize diets in lower

income inner-city African Americans and to develop a population specifying quantitative food

frequency questionnaire. This questionnaire could be used to highlight foods and nutrients for a

nutritional intervention program for reducing the risk of chronic disease. Using a cross sectional

survey, the authors examined food consumption and food purchasing habits. 91 low-income

African American between 18 and 74 years old participated in the survey in Baltimore,

Maryland. The findings indicated that African Americans had an increased consumption of

sweetened beverages and foods high in fat. Moreover, their intake of fruit and vegetables were

extremely low. Results are consistent with other studies on the diet of African Americans which

is critical for explain risk factors for the prevalence of becoming obese.

Early life stress is considered to be the exposure to a single or multiple experiences

during childhood which exceeds the child’s coping mechanisms. Some early life stressors may

include verbal or emotional abuse, dysfunction in the home, separation of parents, or social

deprivation (Baker, Williams, Korgaonkar, Cohen, Heaps, & Paul, 2013). Stress has been known

to play a critical role in interfering with appropriate nutritional behavior. Chronic stress releases

the stress hormone Cortisol in which the individual’s appetite may be stimulated during recovery

periods while the individual is experiencing chronic stress. Lipoprotein Lipase which is the

enzyme that aids in the deposit of fat can be activated with the secretion of Cortisol. Emotional

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changes such as anxiety and depression are also associated with chronic stress. These emotional

changes can remove the individual’s self control which usually protects the individual against

overeating leading to increased food intake which can lead to obesity (Montes and Kravitz,

2011). Changes in eating patterns associated with stress may be related to carbohydrate

metabolism and insulin sensitivity. Therefore, stress has been known to promote irregular eating

patterns as well as alter food preferences and that obese individuals are more vulnerable to these

effects through weight in related adaptations in energy regulation and homeostasis (Sinha &

Jastreboff, 2013).

Children’s weight related behavior and cognitions are often influenced by parents and the

home environment. According to De Sausmarez and Dunsmuir (2011) parents are often

classified as a role model for healthy living and often influence attitudes towards weight control

and exercising as well as the psychosocial home environment for healthy eating. Adults who are

obese were more likely to have children that are above normal weight levels. Often models are

portrayed for children from their parent’s own eating habits and behaviors, ranging from foods

they make available to their children and their child’s feeding styles. Parents also create

environments can either promote healthy lifestyle choices or foster the development of bad

eating habits and behaviors. Children who feel teased about their weight by family members may

also have a significantly higher body mass indexes, distorted eating behaviors, low body

satisfaction, self-esteem, and depressive symptoms which can lead to overeating resulting in

obesity.

Huang, Lamza, and Angum (2014) examined developmental trajectories of obesity status

in adolescents and investigated if and how familiar factors are associated with obesity. Specific

data was used from a sample of the 1979 National Longitudinal Survey of Youth to determine if

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children with adverse prenatal exposures could be more prone to adolescent obesity or if the

existence of parental and environmental as well as limited screen time may prolong the risk of

adolescent obesity overtime. Using a hierarchal generalized linear modeling the authors

examined the longitudinal impact of prenatal factors as well as familiar childhood experiences on

developmental trajectory of obesity status in adolescents. A population of 5156 children between

the ages of 10 to 18 years participated in the survey. The findings suggested that higher maternal

weight, maternal smoking, lower maternal education, lack of breast-feeding; heightened media

use as well as negative familial experiences in childhood contribute to elevated risks for

developing obesity during adolescents. This research underscores genetic or lifestyle factors of

the father such as substance abuse or smoking preconception which could also have increased

risk factors for obesity during adolescence.

Peer Influence

Much of a child’s or adolescent’s time is spent in a school environment with their fellow

peers. Peer relationships often play an integral role in psychosocial development in children.

Children who suffer from issues in peer relationships such as having issues making friends; not

being socially accepted; or bullying may develop feelings of depression (Boneberger, von Kries,

Mudle-Busch, Bottle, Rochart, Ruckinger, 2009). Overweight and obese children often also

suffer negative psychosocial interactions with peers such as victimization or bullying through

insulting or exclusion as a result of physical appearance which contributes to depression and

anxiety which may also lead to overeating and obesity. There is significant evidence in which

overweight children may avoid taking part in activities such as sports or physical education to

avoid weight related victimization (de Sausmarez, & Dunsmuir, 2011). Thus, Boneberger, et al.

(2009) investigated the connection between issues in peer relationships and obesity in children.

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Using a cross sectional design study Boneberger, et al. (2009) assessed problems in peer

relationships through issuing the Strengths and Difficulties Questionnaire to parents. Data from a

sample population of 4718 preschool children aged 5 to 6 years was collected at the obligatory

school entry examination in 3 rural counties and 3 cities in Bulvaria. The findings of this

research confer that children with issues with peer relationships have a higher prevalence of

becoming obese or overweight compared to those without such issues.

According to de Sausmarez and Dunsmuir (2011), peers can also demonstrate poor eating

habits which often feed into the belief that an unhealthy lifestyle which may also contribute to

their peer’s adoption of problematic behavior such as overeating and physical inactivity.

Finnerty, et al. (2010) also collected data to explore dietary intake and levels of physical

inactivity of boys and girls as well as investigate any effects of peer relationships on these

behaviors. Using a cross sectional design researchers gathered data from participants who wore

sealed pedometers to measure physical activity, provided measures of dietary intake, and

answered a questionnaire regarding peer influence. A sample of 315 children aged 10 to 13 year

who were full time students in medium to high socioeconomic backgrounds in London. The

results of this study demonstrated low energy intake and physical activity but high saturated fat

intake in all age groups, thus, making a significant connection between peer influence and

physical activity.

Socioeconomic Status

Poverty, exposure to crime, neighborhood stress and other chronic stressors vary with

Socioeconomic status (SES) are tied to poor health. Taylor (2012) explained that children from

poor socioeconomic status experience greater health risks due to such stressors as family discord

and exposure to violence. People with low socioeconomic status typically have low prestige jobs

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which can expose them to greater interpersonal conflict may include psychological distress and

adverse changes in cardiovascular symptoms and other health related outcomes (Taylor, 2012).

Obesity is related to SES but the connection could vary by gender, age, and country. For

example; using cross sectional survey data collected in different population groups across

various countries, Wang and Hyunjung (2012) claimed that in both industrialized and developed

countries SES groups with the greatest access to energy rich foods are more likely to be prone to

obesity which may be different for countries that are underdeveloped or developing. Navalportro,

et al. (2012) however, investigated the relationship between socioeconomic environment of the

area of residence and the prevalence of obesity in Spanish children and adolescents and to

determine if the potential relationship is explained by household socioeconomic circumstances,

by obesity risk behaviors, and by area facilities for physical activity.

Using a cross sectional research design, Navalporto, et al. (2012) used multilevel liner

regression to calculate the relationship between socioeconomic environment based on wealth and

deprivation. A sample population of 4529 Spanish children adolescents aged 6 to 15 years in 50

Spanish provinces participated in the Spanish National Survey of Child Health to gather data.

Researchers of this study found that the prevalence of obesity was 1.45 times greater in

participants who lived in areas of lower wealth than those who lived in higher wealth

communities. Thus, these findings show that obesity is related with socioeconomic environment

of the area of residence which is particularly due to family socioeconomic circumstances,

unhealthy diet, and physical activity.

Children from lower incomes and younger parents have a greater chance of overweight

due to the lack of nutritious foods available to them as well as physical activity opportunities (De

Sausmarez & Dunsmuir, 2011). Data was collected by Kumar, et al. (2011) to explore access to

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chain supermarkets as well as to understand their perceptions on food quality and services and if

these perceptions affected their dietary behavior. Previous research has indicated that compared

to other ethnic groups such as Caucasians, African Americans have a higher mortality rate

resulting from diabetes, heart disease, and cancer due to racial disparities in neighborhood access

to healthy food in the United States. Using a mixed method approach to employ geographic

information systems, focus groups, and surveys the authors examined African American

perceptions of neighborhood nutrition in Pittsburg, PA. 236 African Americans participated in

the survey with an average 2-person household with a mean income of 16,666.50 to 50,000

dollars. The findings indicated that African American living in lower class neighborhoods

perceive lower quality of food and food services compared to neighborhoods with higher mean

incomes. Transportation also played an important role in the results due to the fact that many

African American in these neighborhoods are reliant on public transportation which only provide

access to certain stores. Therefore, they are forced to patronize these stores with poor quality

food services which could be a contributing factor to obesity.

Watt, et al. (2013) used data to identify risk factors associated with childhood obesity

among low-income Hispanic populations. Specific data was used to facilitate the design of a new

child obesity prevention program for clinical patients in southwestern United States. Surveys

were used to examine diet, exercise, social support, food security, stress, infant feeding,

practices, health and demographics in which the authors matched medical record data on infant

weight. A sample of 152 Hispanic women who attended the clinic for their infants 2, 6, or 12

year check-up participated in the survey. The findings indicated that the sample of women had an

infantile profile ranking in the 85th percentile which increased the risk for developing obesity in

childhood. The authors also found that factors such as stress, supplemental nutrition assistance

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programs (food stamps, etc.), poor eating habits, and regular consumption of fast foods, sweets,

and sugar sweetened beverages which may be related to low income levels are also contributors

to obesity in childhood.

Sedentary Lifestyle factors

A major health threat that has recently emerged is excessive sedentary behavior which

can be defined as the amount of time spent seated or in a lying position in which minimum

energy expenditure is required (Conroy, Maher, Elavsky, Hyde, & Doeksen, 2013). Over the past

decades children have also decreased their physical activity and increased their screen time

which can be characterized as the time spent in front of a screen playing video games, working

or playing on the computer and watching television or movies. Increased screen-time is

associated with rates of obesity stemming from increased consumption of high-fat, high-sugar,

and higher caloric foods (Werner et.al, 2012). Ferguson, Contreras and Kilbur (2013) examined

the relative impact of advertizing and fictional media influences on healthy eating choices made

by children. Specific data from children and primary caregivers from a small Hispanic in the

south were examined to determine if exposure to unhealthy eating choices in children; if

exposure to fictional depictions of unhealthy eating choices will have minimal impact on

children’s unhealthy eating choices; if the influence of advertising effects will decline in older

children based on grater sophistication in distinguishing the factuality of information; and if

parental messages regarding healthy eating behaviors could moderate the impact of advertising

experiences.

Using a randomized experimental design, the Ferguson, Contreras and Kilbur (2013)

exposed children to either advertisements or fictional entertainment clips of healthy or unhealthy

food options. A sample of 304 Hispanic children aged 3 to 12 years old were also exposed to

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conditions where parents either encouraged healthy food options or allowed children to choose

foods of their own preferences. The findings suggested that the influence of unhealthy eating

behaviors were developmental. Children 3 to 5 years of age were influenced by the media food

clips whether advertisements or fictional. Children during early adolescence aged 6 to 8 years

were influenced by their parents.

The transition to from childhood to adolescence could be classified as a critical period in

which sedentary behavior is increased. Children 6 to 11 years of age are more prone spend an

average of 6 hours per day engaged in sedentary behaviors compared to adolescence age 16 to 19

years (Mitchelle, Pate, & Nader, 2013). According to Bindle, Petrolin, and Pearson (2014) due to

excessive screen viewing such as television or computer use as well as sedentary socializing and

inactive forms of transport, sedentary behaviors have increased in recent decades. Therefore,

Mitchelle, Pate, and Nader (2013) collected data to examine if the measured total of sedentary

behavior can be linked with change in Body Mass Index (BMI) in children.

Using a prospective observational design study Mitchelle, Pate, and Nader (2013)

enrolled participants in the National Institute of Child Health and Human Development Study of

Early Childcare and Youth development. A sample of 789 boys and girls aged 9 to 15 years

participated in this study which determined that sedentary behaviors were associated with greater

increases of BMI in the 90th, 75th, and 50th BMI percentile. The findings suggested that reducing

sedentary behaviors at a population level may be an effective strategy in public health for the

reduction of the prevalence of childhood obesity.

Prevention of childhood obesity

Childhood obesity is a direct result of an imbalance between the amount of food as well

as what is being consumed and the amount of physical activity. Through improving healthier

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eating habits and increasing a child’s physical activity level, children will avoid the likelihood of

becoming obese as well as maintain a healthier weight (Muth, 2006). Specific nutrients are

needed throughout childhood because of increasing body size and for some children, higher

levels of physical activity. Nutrient needs; such as macronutrients, fiber, and micronutrients, of

young boys and girls do not differ and are grouped together for children aged 8 or 9. The age of

8 or 9; however, marks the beginning of sexual maturation in which boys’ and girls’ bodies

begin to develop differently in response to gender specific hormones (Thomson & Manore,

2009).

Lower body mass index and a positive influence on children’s weight status has been

demonstrated when children consume more fruit and vegetables. Fruits and vegetables are

known to be a good source of essential nutrients such as vitamins, minerals, and dietary fiber.

They also require less energy to consume as well as less energy to burn off (Ohri-Vachapati,

Turner, & Chaloupka, 2012).Whole grains are rich in fiber and also provide essential vitamins

and minerals such as magnesium and iron. Children ranging age between 2 to 3 years old should

consume at least 1 ½ ounces of whole grains per day and children from 4 to 8 years of age

should consume at least 2 ½ ounces per day. The consumption of whole grains can also be

correlated to lower body mass index (BMI) levels and a decrease in obesity (Samples, 2012).

Complex carbohydrates such as those found in whole grains are known to enhance both mental

and physical energy and decrease mental and physical fatigue compared to carbohydrates with a

low Glycemic index (Dammann, Bell, Kanter, & Berger, 2013).

A healthy meal should contain at least ¼ of the plate filed with lean protein; such as

chicken, fish, and other lean meats or beans or legumes, and should be eaten relative to the

child’s body weight (La Barbara, 2012). La barbara (2012) claimed that a diet which contains an

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adequate amount of lean protein can aid in children having the necessary nutrients for the

building of muscles, creating hormones, enzymes, and vitamins, and provide energy for the body

when carbohydrates and healthy fats cannot. Fat intake; however, is necessary for proper growth

and development in childhood. Children need a sufficient amount of dietary fats for development

of the brain and nervous system. It is also known to provide fuel for the body (Gavin, 2012).

According to Thompson and Manore (2009) Children ages 4 to 8 begin to consume total levels

of fat closer to that of adult; approximately 25 to 35 percent of total energy. Fats are also used to

aid in absorbing vitamins such as vitamin A, D, E, and K; which can only be absorbed if there is

fat in the child’s diet. It is known to be the building blocks of hormones and is important for the

insulation of nervous tissue in the body. Fats are also known to aid in curving the appetite which

may allow the child to feel full so they would not consume as much food (Gavin, 2009).

The New nutritional standard for school meals made a requirement that each school meal

should contain either fat-free flavored milk such as chocolate or low-fat or fat-free white milk

(Brown-Riggs, 2012). According to Brown-Riggs (2012) the Dietary guidelines for America

stated that children ages 4 to 8 years of age contain 2 ½ cups of dairy per day while children 9

years or older should consume 3 cups. Brown-Riggs further explained that dairy products

including milk provide children with adequate amounts of calcium, protein, and vitamin A and

D.

Micronutrients should include iron, which is necessary for healthy blood which carries

oxygen throughout the body. Calcium, which is essential in helping children build healthy bones

and teeth. Fiber aids in the production of bowl regularity in children. Vitamin A is responsible

for healthy skin, preventing infections, and adjustment to light in the eyes. Finally, children

should consume Vitamin C which is known to aid in fighting the common cold, holds the cells of

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the body together, strengthens the walls of blood vessels, and aids in healing body wounds

(Bilich, 2011).

According to Wojcicki, and Heyman, (2012) excessive amounts of drinks high in sugar

such as fruit juices, carbonated beverages, and sports drinks are known to contribute to the

increased risk for childhood obesity. Children have increased their daily caloric intake from

sweetened beverages and fruit juices. Toddlers and young children have the highest rate of

consumption of sweetened beverages of all age groups in the United States. Consumption of

drinks high in sugar by children poses the issue in containing high sugar content and lower levels

of fiber which is associated with the reduced risk of obesity in children. The data also suggested

that drinks high in sucrose which is found in fruit juices or high fructose corn syrup in sweetened

beverages can alter the nervous system, energy signaling resulting in feelings of fatigue,

dependence or habituation. Wojcicki, and Heyman further explained that the Instiute of Medicine

suggested limiting children’s consumption of drinks high in sugar to aid in addressing the child

hood obesity epidemic.

Physical Activity

One critical aspect of strategies relating to prevention or treating obesity is physical activity.

Prolonged positive energy balance is one of the most significant causes of obesity which is often

associated with unhealthy eating behavior and physical activity (Morano & Kravitz, 2011).

Recent recommended guidelines for physical activity for children and adolescents have been

developed in which Montes and Kravitz (2011) suggested that children should practice sixty

minutes of daily physical activity and participate in short bouts of intense physical activity

lasting 15 minutes or more. Children and adolescents are also recommended to participate daily

in diverse age appropriate activities which may encourage achievement of optimal health as well

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as performance benefits and should be encouraged to reduce time spent on sedentary behavior.

According to Shirinde, Monyek, Pienaar, and Toriola (2012) physical activity is known to

improve children’s attributes such as high energy concentration and cognitive skills and

increases self-esteem which could also lead to healthier dietary behaviors. Chen and Ludwig

(2013) explained that physical activity could also improve cardioresperatory fitness and

cardiovascular health and metabolic health; muscular strength, bone health as well as a lower

body fat percentage.

Social Support

Support from family members is considered a key factor for implementing proper

nutritional behavior. An adequate level of social support can help improve efforts for

implementing proper nutritional behavior, while a lack of social support can hinder such efforts

(Kieran & Moore, 2012). Taylor (2012) claimed that individuals with social support are more

successful than those with little support. During exercise, social activity and a feeling of

involvement with others can lead to improvement of mood and motivation. For example, the

family members can engage in outdoor activities such as bicycle riding, swimming, or some

form of group exercise which can promote healthy behaviors. Family members could also

support children when it comes to dietary motivation. Taylor also claimed that when all family

members are committed to actively participate in dietary change, it becomes easier for the child

to do so as well. Parents can aid in appropriate eating behavior by changing their dietary

lifestyle. Parents can assist by having family dinners together as a family the table instead of in

front of the television. Parents should also do the grocery shopping for the family to ensure

healthy food choices, as well as ensuring accountability for their children and the rest of the

family that they are staying on track with their healthy lifestyle.

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Since the majority of a child’s time is spent in school, it is the responsibility of healthcare

professionals to implement a plan to provide healthier food options as well as increase the

amount of physical activity in schools. Muth (2006) claimed that childhood obesity is a direct

result of an imbalance between the amount of food as well as what is being consumed and the

amount of physical activity. Through improving healthier eating habits and increasing a child’s

physical activity level, children will avoid the likelihood of becoming obese as well as maintain a

healthier weight. The Institute of medicine recommended that schools serve both fruits and

vegetables on a daily basis, increase the amount of whole grains, only offer low or fat free dairy

products, and limit the amount of grain and meat alternatives (Brown, 2013).

Data from Auburn University was used to evaluate an intergernerational childhood

obesity program referred to as Active Generations. Programs such as these seek to address

obesity among children and adults. Using the Active Generations survey; which assesses

knowledge, skills, and attitudes, the authors examined physical activity levels, nutrition, and

media use also known as screen time. Approximately 760 children in grades 3 to 5 whose ethnic

background included African Americans, Caucasians, Hispanic, American Indian or Asians, as

well as races classified as other participated in the survey. The findings explained that children

who participated in the program increased their self confidence and self knowledge regarding

physical activity and nutritional behavior. Children were also known to increase their daily

consumption of fruits and vegetables and were more likely to engage in physical activity such as

running, bike riding, and exercising compared to when they initially began the program. The

finding s also suggested that children had a decrease in screen time such as video games,

television, and computers after participating in the program. Intergenrerational programs such as

these can play an integral role in the prevention of childhood obesity because of the use of young

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adult volunteers, and community members to heavily influence children on healthy eating

behavior.

Media and Obesity Prevention

Media use could play an important role informing the community regarding public health

issues and presenting supporting and opposing solutions to childhood obesity (Udell & Metha,

2008). The news is an important way of communicating health information to the community

and influences how people can view, understand, interpret, and act on health related issues such

obesity. News coverage of obesity regarding causes and responsibilities has been diverse and had

identified a substantial increase of coverage since 2006 which focused on nutritional and

environmental factors associated with obesity (Espinel, Laws, Bonfigioli, Hardy, & King, 2013).

The use of social networks has increased in recent years as well as ways of finding and

sharing information (Harris, Moreland-Russell, Tabak, Ruhr, & Maier, 2014). Social networks

are groupings of interconnected two-way relationships which involve the use of Web-based

mobile technologies that are commonly used for interaction and communication within networks

(Li., Barnett, Goodmen, Wasserman, & Kemper, 2013). According to Harris, et al. (2014) 72

percent of the population in the United States used social media as of 2013 in which 15 percent

obtained health information from social media sites. Li, et al. (2013) explained that social media

could influence healthy behavior in numerous ways. First, social networks could promote

emotional, instrumental, and informational support as well as support in decision making.

Another pathway of social media is social integration which can increase access to health

information and promote self worth and self care based on societal norms which could aid in the

prevention and treatment of obesity.

Intervention

LeeAPsy6305-8 21

Prevention differs from intervention due to the fact that its main goal is to avoid problems

prior to signs or symptoms of issues and it is also aimed general population groups with various

levels of risk for any problem. Intervention; however, is the process of recognizing warning signs

that individuals may be at risk for potential problems and taking action against factors which

may put them at risk. Basically, interventions serve to help individuals to get better and prevent

existing problems from getting worse (Doyle, 2006).

Due to the increase of obesity in childhood, increasing physical activity levels;

specifically in schools, could aid in the public health objective of treating childhood obesity.

School based physical education classes and recess periods could serve some importance for

getting children to meet federal exercise guidelines which consist of engaging in one hour of

physical activity each day (Chen & Ludwig, 2013). According to Chen and Ludwig (2014)

improvements to recreational infrastructures could be positively correlated with the increase of

physical activity; for instance; engaging in Recess Enhancement Programs (REP). Programs

such as REP seek to enhance physical activity during recess periods through play coaches who

teaches children age appropriate games. Therefore, Chen and Ludwig examined if REPs could be

associated with higher rates of vigorous physical activity in children.

Using a cross sectional research design Chen and Ludwig (2013) examined rates of

physical activity among children on playground during recess comparing schools in and not in

REP. 15 schools in REP and 10 comparison schools not in REP were recruited by convenience

sampling to participate in this study in New York City. The results of this study indicated that the

rate of vigorous activity in REP schools was 52 percent higher than in non REP schools. The

findings also suggested that REP could also provide a low cost method for implementing

LeeAPsy6305-8 22

children’s physical activity during school recess periods which could aid in childhood obesity

interventions.

The Child Health Institute for Lifelong Healing and Exercise (CHILE) is an evidence

based program to prevent obesity in children aged 3 to years enrolled in 16 Head Start centers in

rural communities. Data from the prevention center at the University of New Mexico was used to

examine evidence based programs such as CHILE to improve dietary intake and increase

physical activity in children in rural communities. Using qualitative research methods such as the

socioecological approach the authors defined the program to include a classroom curriculum,

teacher and food training services, family engagement, grocery store participation, and

healthcare provider support. The two ear program was intended or children of preschool age in

which they participated in developmentally appropriate lessons which seeks to establish the

foundation for consumption of more fruits and vegetables and being more physically active. The

findings of this research explained that evidence based programs such as CHILE considered

accountability of recommended foods, the necessity training sessions for teachers and food

services, the need to tailor family events to local needs, consideration of profits and the needs of

grocery stores, and the time constraints of health care providers.

Issue with intervention

Data was used to examine family experiences on attending childhood obesity

interventions. Using qualitative interview methodology the Newson, et al (2013) sought to

highlight recommendations on how to improve attendance at obesity interventions as well as to

inform the development of future local public health strategies to prevent and treat childhood

obesity. A final sample of 11 families, were recruited to participate in the interviews that lived in

an area classified as high deprivation with high obesity prevalence. The findings explained that

LeeAPsy6305-8 23

attending obesity intervention often challenges social and individual identities for some families.

They often may not be perceived as a positive outcome at first. The findings also suggested that

these involved in public health and treatment interventions should aspire to connect people’s in-

group identities and those associated with particular behaviors. Treatment interventions should

address any preconceived negative perceptions by carefully considering how health information

is presented understood and how identity may affect motivation to engage in healthier behaviors.

Summary/ Discussion

Obesity is a condition stemming from abnormal or unhealthy storage of fat tissue and

usually occurs when ingestion of food regularly exceeds expenditures in which the unused

energy is stored as body fat. However, obesity in children occurs when Body Mass Index (BMI)

is greater than or equal to the 95th percentile. Overeating or the consumption of a large amount of

food with an accompanying sense of loss of control over one’s eating has been associated with

severity of overweight and psychosocial morbidity in children which can carry over into

adulthood. Children who suffer from obesity are at risk of suffering cardiovascular disease,

hypertension, Type II diabetes, as well as psychosocial disorders. Unhealthy eating behavior,

sedentary behaviors, parental influence and socioeconomic status, and peer influence are known

to be contributing factors to obesity in childhood. Through improvement of healthier eating

habits and increased physical activity level, children may avoid possibilities of becoming obese

as well as maintain a healthier weight. Factors such as social support from family, peers, and

community members as well as in and out of school intervention programs such as REP and

CHILE can play significant roles in providing appropriate prevention and intervention strategies

to fight of obesity in childhood.

LeeAPsy6305-8 24

After reviewing the literature, it can be concluded that minorities; particularly African

Americans and Hispanics are more prone to obesity compared to Caucasians. This assumption is

partially due to socioeconomic status and the resources that are available to them to provide them

with healthier food choices and physical activity. Another factor aiding in child obesity in

minorities is cultural ideals and values regarding weight and body image. Some ethnicities may

feel that eating healthier food option means giving up some aspects of their culture where they

usually come together and bond over foods that are higher in unhealthy fats and sugars (Belle,

2012). Others may feel that intervention is unnecessary because cultural ideals of body image.

For example, Capodilupo (2014) claimed African American women are generally satisfied with

their body image compared to Caucasian women. This can be due to the fact that African

American women have more positive valuation of their bodies because they are more likely to

embrace a different beauty aesthetic. They are less likely to be motivated by thinness due to

cultural ideals of feminine. They may also use a positive body image as a defense mechanism to

deny tendencies toward overeating and obesity. Therefore interventions may not initially be seen

as a positive outcome.

Issues of validity seem to arise in this review of literature because of the frequent use of

cross-sectional research designs throughout most research. According to Barrat and Kirwan

(2009) cross-sectional research designs are research based on observations that gather data at a

single point in time to examine the relationship between obesity and prevention and intervention

strategies. Even though cross sectional designs are easier to conduct because there is no

manipulation to the environment as well as no long term periods of follow up, this form of

research may not provide definite conclusions regarding the cause and effects of relationships.

Since cross-sectional research only provide a snapshot of what is going on in the environment at

LeeAPsy6305-8 25

a single period of time, important factors such knowing what happened prior to research and the

effects of treatment of treatment after the experiment is not considered thus also prosing issues

with validity. Second, because cross-sectional research is observational this also opens the door

for research bias. Due to the fact that observations are subjective, researchers may base results on

opinion rather than on controlled experimentation, which may put research at a level five for

evidence based practices of intervention which does not produce meaningful outcomes; thus

making causing research to be low in fidelity and validity. They may also conclude that certain

treatments may work for all participants in the experiment without taking into consideration age,

gender, values and norms for particular groups. For instance; relating to nutrition and physical

activity, researchers may not take into consideration aspects of gender in the matter that boys and

girls may have different nutritional needs and different physical abilities at different ages

throughout development. Therefore, intervention strategies should allow for differences in

gender and age regarding treatments for obesity. The lack of a comparison group is also an issue

with research bias in applying interventions to participants due to the fact that researchers may

believe that what may work for one specific group is beneficial for all groups. One possible

assumption for this is due to fact that interventions are short term and there is no follow-up after

research; thus creating issues of validity.

If possible researchers should administer designs such as Randomized Control Trials

(RCT) to understand interventions strategies toward obesity. Stolberg, Norman, and Trop (2004)

claimed that RCTs are known to be the most powerful type of experimental study. The major

strength of these designs, stem from their use of randomization which decreases the chances of

research bias. RCTs are quantitative comparative controlled experiments in which researchers

study two or more interventions by administering them to groups of individuals who had been

LeeAPsy6305-8 26

randomly assigned to receive each intervention. Since RCTs allow for a larger population sample

size, comparison groups, as well as participants having the same chance of being assigned to

each study group, this increases the validity of the study. However, RCTs usually include a

larger sample size, intervention strategies may not be economically feasible and it may be

difficult to implement treatment strategies to diseases such as obesity to all individuals in a given

population.

Conclusion

The most effective form of treating obesity in children is prevention. Prevention can

begin shortly after birth during breast feeding. Children who are breastfed have lower rates of

becoming obese compared to those who were not (Molia & Dell, 2013). Prevention methods

could be carried over in to childhood through parental involvement. Parents are known to be the

child’s primary influence when it comes to maintaining healthy dietary behavior and engaging in

physical activity. Therefore, all it takes is simple lifestyle changes by parents or guardians to aid

in prevention methods for obesity. Prevention methods could also focus on the population as

whole rather than focus on the individual person like intention strategies. Individuals may be

more willing to engage in taking measures to help prevent obesity before it becomes an issue

rather than engage in treatment measures after the issue of obesity arises. For instance, since

issues of body image is so subjective, some may feel that they are fine with their weight and

unhealthy lifestyles and may feel that treatment of this disease is unnecessary. Others may be

willing to engage in treatment of obesity but are unaware of the necessary steps or resources

available to them for intervention. Prevention methods have also been proven to be more

beneficial and cost effective because of its simplicity in making lifestyle changes such as

implementing more fruit and vegetables and reducing the amount of saturate fat and refined

LeeAPsy6305-8 27

sugars in the individual’s diet as well as the reduction of sedentary behaviors such as limiting

screen time (television, computer and video game use) and engaging in physical activity.

Physical activity can be simple as allowing children to go outdoors and engage in active play.

Active play is classified as physical activity; which is usually unorganized and self-directed by

children, that involves symbolic play and includes playground activities, such as ball games

played in the neighborhood as well as backyard games such tag (Janssen, 2014).

Since the majority of children’s time is spent in schools, school based intervention strategies

are proven to be more beneficial than out of school intervention programs other than parental

involvement. The use of successful school based interventions in managing obesity can include

making physical education classes, healthy food choices on student menus, encouraging water

consumption, and the availability of after school programs that encourage physical activity a

priority. One issue for implementing intervention strategies in schools is getting approval from

policy makers to allow for legislation to implement healthier food options and more physical

activity in schools. According to Chin and Ludwig (2014) schools have actually cut back on

physical education programs, decreasing the amount the days per week students are engaged in

physical activity due to budget cuts. Since 2006 only 3.8 percent of public and private

elementary schools required daily physical education classes for all students. Therefore, policy

makers should allow for budget expenditures in schools to increase physical activity in schools.

Legislators should also work closely with schools to assist in implementing dietary and physical

activity programs that may beneficial and appropriate for all students. Another issue of health

based intervention programs in schools is making sure these programs serve all students

regardless of ethnicity, race, and socioeconomic background. Moglia and Dell (2013) claimed

that the key to long term success in prevention and treatment involves awareness and respect for

LeeAPsy6305-8 28

the child’s personal preferences and environments. Decreased sedentary behavior and active

encouragement of free play may be more effective than mandates to exercise and dietary intake.

Lifestyle change will also decrease the negative input on the child’s overall health. Future

research should continue to explore methods regarding how parents, schools, and policy makers

can work to together to aid in the prevention and treatment of child obesity.

LeeAPsy6305-8 29

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