Diabetes Prevention in Primary School-Age Children

A ngie Fast
BSN, K wantlen U niversity College, 2004

M ajor Paper Subm itted In Partial Fulfillm ent O f
The Requirem ents For The D egree O f
M aster o f Science
In
Nursing
(Fam ily N urse Practitioner)

The U niversity o f N orthern B ritish C olum bia
April 2009
© A ngie Fast, 2009

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Canada

Diabetes Prevention

Abstract
The increasing incidence o f type 2 diabetes among primary sehool-age children is a
rapidly growing problem throughout the world. This project was designed to explore the
research question; in primary sehool-age children, does an alternative nutritional education
intervention reduce the incidence o f type 2 diabetes? A review o f literature related to
nutritional education for this age group yielded three research studies, one systematic review,
and two evidence-based practice guidelines to corroborate alternative nutritional education as
a means for potentially reducing the incidence o f diabetes among sehool-age children. As
part o f this project, Pender’s Health Promotion Model was examined to determine if it would
be a useful framework for implementing an alternative nutritional educational program within
the primary school system in an effort to decrease primary sehool-age onset o f type 2
diabetes. Based on findings from this project, there is evidence that an alternative nutritional
education intervention does reduce the incidence and risk o f type 2 diabetes in primary
sehool-age children.

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TABLE OF CONTENTS
A BSTRA CT............................................................................................................................................2
GLOSSARY OF T E R M S .....................................................................................................................4
CHAPTER O N E......................................................................................................................................
B a c k g r o u n d & N e e d ........................................................................................................................................................6
R e s e a r c h Q u e s t i o n ................................................................................................................................................................ 12

CHAPTER TW O.....................................................................................................................................
S e a r c h C r i t e r i a ........................................................................................................................................................................ 13
R e v i e w o f L i t e r a t u r e .......................................................................................................................................................... 13
S u m m a r y o f F i n d i n g s & I m p l i c a t i o n s ...................................................................................................................2 0

CHAPTER TH R EE.................................................................................................................................
P e n d e r ’ s h e a l t h P r o m o t i o n M o d e l .......................................................................................................................2 4
A p p l i c a t i o n o f M o d e l t o R e s e a r c h Q u e s t i o n ................................................................................................ 26

CHAPTER FO U R ...................................................................................................................................
I m p l i c a t i o n s o f P r o j e c t t o N u r s e P r a c t i t i o n e r P r a c t i c e ................................................................. 3 5
C o n c l u s i o n s .................................................................................................................................................................................3 7

REFERENCES..................................................................................................................................... 38

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GLOSSARY OF TERMS
Alternative nutritional education: Education that focuses on healthy nutrition and has the
goal o f decreasing type 2 diabetes. Children will learn about diabetes and how unhealthy
eating and sedentary lifestyles can contribute to developing diabetes. The education program
is designed specifically to promote learning through lecture, discussion, and visual triggers.
Australasia: A term used to describe Australia and S.W. Pacific Islands.
Cross-sectional study design: “A study designed to observe an outcome or variable at a
single point in time” (Melnyk & Fineholt-Overholt, 2005, p. 586).
Evidence-based practice: “A problem solving approach to practice that involves
conscientious use o f current best evidence in making decisions about patient care” (Melnyk &
Fineholt-Overholt, 2005, p. 587).
Evidence-based clinical practice guidelines: “Specific practice recommendations that are
based on a methodologically rigorous review o f best evidence on a specific topic” (Melnyk &
Fineholt-Overholt, 2005, p. 587).
Lower Mainland: This is a term used to describe portion o f land in British Columbia that is
located between Vancouver and Hope.
Participatory approach: “Research that is participatory in nature” (Melnyk & FineholtOverholt, 2005, p. 591).
Primary school-age children: Children in grades one through seven.
Standardized nutritional education: Nutritional education that is provided to students as
part o f the required school curriculum. Nutritional education that is offered to primary
school-age children in British Columbia is titled “healthy eating” and teaches the four basic
food groups (B.C. Ministry o f education, 2006).

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Systematic review: “A summary o f evidence that uses a rigorous process for identifying,
appraising, and synthesizing studies to answer questions and draw conclusions about the data
gathered” (Melnyk & Fineholt-Overholt, 2005, p. 594).

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Chapter One
BACKGROUND & NEED
Incidence & prevalence o f type 2 diabetes
Type 2 diabetes among primary school children is a problem that is rapidly growing
throughout the world. Rosenbloom (2002) states that until the past decade, type 2 diabetes in
childhood was an unexpected occurrence. There are two main factors that contribute to
pediatric type 2 diabetes: obesity and weight gain (Holt, 2006). “The increased prevalence o f
childhood obesity has reached epidemic proportions in both the developed and developing
world” (Reilly, 2004, p. 6). The most effective way to deal with type 2 diabetes in primary
school-age children is to prevent it and evidence suggests that the best means for doing this is
to provide “intensive lifestyle guidance” (Ritchie, L., Ganapathy, S., Woodward-Lopez, G.,
Gerstein, D., Fleming, S., 2003, p. 192). Ritchie et al. (2003) further state that intensive
nutritional programs should be incorporated into the school system and the interventions
should begin with the young in an attempt to prevent poor eating habits from forming.
Researchers have documented that “type 2 diabetes accounts for 8 to 45 percent o f new
childhood diabetes eases” (Peterson, Silverstein, Kaufman, & Boulton, 2007, p. 658). There
are a number o f reasons that might account for the broad range o f eases, although the author
suspects that location, ethnicity, and increased levels o f poverty in some geographic regions
might account for many o f these cases. Peterson et al. (2007) indicate that type 1 diabetes has
been more common than type 2 diabetes in the pediatric population in the past, but type 2
diabetes is emerging as a significant disease in this population. Huang & Goran (2003) found
that 30 percent o f newly diagnosed diabetic youth between the ages o f 12 and 14 have type 2
diabetes.

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Risk factors, pathophysiology and prevention o f diabetes
Huang & Goran (2003) describe the “increasing prevalence o f obesity in young people”
(p. 39) and subsequent increase in type 2 diabetes in pediatric populations, as an epidemic in
the United States; it was also noted that this epidemic is disproportionately higher in youth
with an ethnic background that is Asian, Indian, or European decent. Early detection and
prevention o f type 2 diabetes in the pediatric population is imperative in order to minimize the
potential for a severe public health burden; untreated prediabetes and diabetic medical
complications at a young age, may lead to further complications including chronic disease at a
young age (Huang & Goran, 2003). Screening children for type 2 diabetes leads to both early
detection and prevention. Screening recommendations apply to both prevention o f diabetes
and follow-up once a diagnosis o f diabetes is determined (Peterson et ah, 2007).
Huang & Goran (2003) further suggest that prevention o f behavioral risk factors such as
poor diet and lack o f physical activity through intensified lifestyle training will reduce
diabetic incidence. Through interactive and intensified nutritional education in primary
school classrooms, there will hopefully be a significant decrease in type 2 diabetes in the
primary school-age population. Education and knowledge are tools toward healthy living;
when individuals are provided with the proper tools they may become healthier.
Cramer (2008) states “in less than a decade, the Canadian diabetic population has
increased by about 60% to 1.3 million people” (p. 45) and further identifies the growing
concern with the number o f children that are being diagnosed with both type 2 diabetes and
prediabetic conditions. Jensen (2004) states the biggest risk factor for diabetes is obesity and
Canada has seen a significant increase in pediatric obesity in the past 10 years, a 20% increase
in boys and a 14% increase amongst girls. Cramer identifies that the increases in both

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diabetes and prediabetic conditions, including obesity are related to lack o f exercise and poor
diet. He indicates the parents o f these children are to blame for the chronic illnesses in their
children related to, and including, type 2 diabetes.
Obesity has a significant role in type 2 diabetes development and it has been identified
that “insulin as the key metabolic hormone o f the body. High levels o f insulin can lead to
excess body fat. When insulin levels become chronically high the body often develops a
resistance to the hormone. This leads to even higher insulin levels and, eventually, full-blown
diabetes” (King, 2006, p. 34). Health issues that can occur in children may be linked to the
diagnosis o f type 2 diabetes that include: high blood pressure, liver disease, sleep apnea, heart
disease, renal disorders, vision problems, circulation failure related amputations, stroke and
nerve damage (Amschler, 2002; Evans, 2003; Landauro, 2005).
Amschler (2002) describes type 2 diabetes as a “condition that occurs when either the
cells in the body become resistant to insulin, when the body does not produce enough insulin
or both. In children, the condition appears related to inappropriate insulin action that leads to
failure o f cells to produce insulin. Individuals are often overweight, have little or no thirst, no
increased urination, and have a strong family history o f diabetes” (p. 39).
Amschler (2002) suggests that girls have a slightly higher risk for type 2 diabetes than
boys related to an increased resistance to insulin action occurring mid-puberty which is
thought to be caused by increased levels o f growth hormones. Obesity is not the only cause o f
type 2 diabetes, as genetics and ethnicity also contribute to the disease (Kiess, Bottner, Raile,
Kapellen, Muller, Galler, Paschke, & Wabitsch, 2003). Furthermore, “lower susceptibility in
Caucasians and higher susceptibility in Asians, Hispanics, and blacks have been noted. There
is a high hidden prevalence and a lack o f exact data on the epidemiology o f the disease in

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Europe. In Australasia, the prevalence o f type 2 diabetes is reportedly high in some ethnic
groups and again is linked very closely to the obesity epidemic” (p. 77). Finally, it has been
suggested that obesity usually occurs hand in hand with type 2 diabetes and state that
worldwide “approximately 22 million children under the age o f 5 years are overweight and
the prevalence o f overweight in the young is increasing” (Kiess et al. 2003, p. 78).
Family history is a contributing factor for the development o f type 2 diabetes in children.
Landauro (2005) states that “childhood obesity is a family problem; children that have obese
parents are more likely to be obese themselves” (p. 6). Brooks (2004) states “most children
with type 2 diabetes have a family history o f type 2 diabetes and insulin resistance” (p. 70).
Intrinsic and extrinsic motivational techniques fo r reducing obesity
Basdevant, Boute & Borys (1999) identify schools as key players in helping to prevent
obesity, which in turn may lead to a decrease in the occurrence o f type 2 diabetes in children.
They conclude that school-based nutritional education is an important part o f preventing type
2 diabetes. “An increasing proportion o f a child’s eating and physical activity is carried out at
school; school doctors may play a key role in identifying individuals at risk for obesity; and
education could keep in check the powers o f the commercial world. Importantly, some
programs that include classroom lessons on nutrition and physical health have been
successful” (Basdevant et al., 1999, p. 10). Most schools in Canada do not have a school
doctor, some have a school nurse, but most rely on public health nursing to meet the needs o f
the children as a group; individual care o f the children is the responsibility o f the family
physician. Public health nurses do not have the time or resources to monitor obesity in the
schools and family physicians do not generally see children on yearly visits, which may make
it difficult to monitor and identify risk factors for childhood obesity.

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Westenhoefer (2002) states that children are interested in nutritional education; however,
to ensure that the nutritional edueation is effeetive, the eorreet stage o f eognitive development
according to the child’s age must be eonsidered. Edueational strategies should eoneentrate on
the importance o f eating a balanced diet, along with encouraging children to trial a variety o f
new foods. Children from 7 to 16 years o f age are interested in “nutrition and better exercise
performance, nutrition and better learning, and nutrition related to different aspects o f beauty”
(Westenhoefer, 2002, p. 22).
Furthermore, Matheson & Springer (2001) identified styles that motivate learning as
intrinsie and extrinsic. Intrinsic motivation is engaging in a behavior that brings internal
pleasure, whereas extrinsie motivation is engaging in a behavior that brings external pleasure
or rewards. Individuals that improve their well-being because o f personal desires to do so are
said to be intrinsic, and individuals that improve their health behaviors to earn praise or non­
health related rewards are said to be extrinsie.
Children are not often motivated by personal desires to improve their wellbeing rather
they are motivated by the intrinsic reward o f having fun; motivating a child to attend
nutritional activities with an element o f fun (e.g. puzzles, computer games, or fantasy play)
will provide an intrinsic pleasure desired by the child (Matheson & Springer, 2001).
Rewarding children with external praise or physical prizes is motivating the child
extrinsically; for example giving out stickers for correct answers to a nutritional question
game.

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Standardized nutritional education in BC
Standardized nutritional edueation is included in the primary school curriculum that
every child attending public or private school receives in British Columbia. Nutritional
edueation is included under the curriculum heading titled “Health” and includes the following
topics: Healthy Living, Healthy Relationships, Safety and Injury Prevention, and Substance
Misuse Prevention (B.C. Ministry o f Edueation, 2006, p. 12). Between 30 & 35 hours per
year is dedicated to Health education. Nutritional teaching falls under the category titled
healthy living, which includes “physical and emotional health, healthy eating practice,
physical, emotional & social changes, human reproductive system, and ways to help prevent
spread o f diseases, including life-threatening diseases such as HIV/AIDS” (B.C. M inistry of
Edueation, 2006, p. 13). Frequently nutritional edueation takes the form o f discussing the
four food groups with little time to more fully discuss healthy food choices. Due to the
amount o f subjects, content required, and the limited amount o f time allotted to Health
edueation, the standardized nutritional edueation provided is not adequate to make significant
lifestyle changes in primary sehool-age children.
Unfortunately, the standardized nutritional education that is included in the BC
curriculum for primary school-age children is lacking as it does not sufficiently emphasize
nutritional education that could potentially decrease the incidence and prevalence o f type 2
diabetes. Based on background information obtained for this project, the author asserts the
following: 1) there is no emphasis on obesity reduction, 2) there is no nutritional teaching
(and counseling) beyond basie food group inform ation provided in the eurrent nutritional

curriculum and, 3) there is no emphasis on the consequences o f poor nutrition such as the
development o f type 2 diabetes. There is clearly the need for alternative nutritional education

Diabetes Prevention

that plaees greater emphasis on establishing healthy eating habits, increasing physical activity,
and identifying foods that increase the risk for developing type 2 diabetes.
The author believes that the growing incidence o f type 2 diabetes among primary
school-age children can be decreased through the alternative nutritional education discussed
throughout this paper. Alternative nutritional education is defined as education that focuses
on healthy nutrition with the goal o f decreasing type 2 diabetes. Children will learn about
diabetes and how unhealthy eating and sedentary lifestyles can contribute to the development
o f diabetes. The education program is designed specifically to promote learning through
lecture, discussion, and visual triggers. If successful, this intervention could be implemented
throughout the region in an effort to decrease this growing, potentially deadly and debilitating
disease.
Research Question
The purpose o f this project is to address the following research question;
1)

In primary school-age children, does an alternative nutritional edueation intervention
reduce the incidence o f type 2 diabetes?

Significance o f the Project
There is significant evidence to suggest that the problem o f pediatric type 2 diabetes is rapidly
increasing around the world. Some countries have begun to take steps towards slowing the
current trends in the number o f children affected by the disease (Ritchie et al., 2003). More
importantly, it is unclear whether Canada has begun to take steps toward reversing this crisis
in its own pediatric populations. As a new nurse practitioner, the author sees a great need to
explore steps towards preventing this disease in primary health care settings. Chapter 2 will
provide the reader with relevant literature related to the research question and this project.

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Chapter Two
REVIEW OF EITERATURE
There is limited research and information regarding type 2 diabetes in children in
Canada; although in Eastern Canada work has been done specifically dealing with the First
Nations populations. More importantly, there was little research identified that discussed the
impact o f nutritional education and/or counseling to reduce the incidence o f type 2 diabetes in
school-age children, particularly in the Eower Mainland where this author’s nurse practitioner
practice will be located.
Search criteria and processes
A systematic and thorough literature review was completed utilizing the databases of
CINAHE, ERIC, Health Source, and Medline. These databases were utilized to glean
information in order to respond to the research question. The keywords utilized in the search
were nutrition, education, and diabetes. The search identified 166 potential resources and
was then further narrowed by adding the keyword child to the search, which resulted in 21
potential articles for review. O f those 21 resources, 6 were selected based on their
relationship to the research question. Those 6 resources included 4 research articles and 2
evidence-based practice guidelines. The search was limited by inclusion criteria only
identifying full-text articles.
Studies highlighting diabetes risk factors and interventions to reduce them
Eibman & Arslanian (2007) identified the following as risk factors for type 2 diabetes in
children: high-risk ethnicity, sedentary lifestyle, insulin resistance genotype, obesity, and
family history o f type 2 diabetes. They also identified guidelines from the American Diabetic
Association recommending screening high-risk children for type 2 diabetes beginning at ten

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years o f age, and every two years thereafter. High-risk is defined as “ehildren with obesity
and 2 o f the following risk faetors: First and seeond degree relatives with type 2 diabetes;
having Ameriean-lndian, Afriean-Ameriean, Hispanie, Asian/Paeifie Islander in ethnie
baekground; signs or symptoms o f insulin resistanee ineluding aeanthosis nigrieans,
hypertension, dyslipidemia, and polyeystie ovary syndrome” (Libman & Arslanian, 2007, p.
25). The latest US guidelines for sereening children and adolescents were also addressed and
these suggest that prevention o f type 2 diabetes in ehildren is a diffieult goal to aehieve.
Faetors to faeilitate prevention in ehildren inelude family-eentered programs involving
lifestyle modifieation, edueation, stress management, emotional assessment, and inereased
physical activities. The strength o f Libman & A rslanian's (2007) work is that it accesses and
presents guidelines and up to date information regarding type 2 diabetes from the American
Diabetic Association. The study identified changing the environment as the key area to target
when attempting to decrease the incidence o f type 2 diabetes in ehildren. The authors
indicated that wide-reaching change must inelude participation o f families o f the targeted
children, schools, the food industry and government. Limitations included the lack o f a clear
research question, the methods used, and results other than the statement indicating more
research is required. Further limitations included the lack o f details and recommendations on
how to proceed within the guidelines, and that the guidelines are from the United States.
Some o f the findings from the guidelines included in the article are applicable to the research
question posed for this project, although the detail regarding nutrition and edueation was
limited. The concept o f participation o f families and sehools in deereasing the ineidenee o f
type 2 diabetes in children is applicable to the research question, however there were no
specific recommendations provided for how to accomplish this.

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Maeaulay, Paradis, Potvin, Cross, Saad-Haddad, MeComber, Desrosiers, Kirby,
Montour, Lamping, Ledue, & Rivard (1997) eondueted a mixed longitudinal and erossseetional study addressing the impaet and possibility o f a eommunity-based type 2 diabetes
prevention program in the Kahnawake sehools, whieh are loeated in a Mohawk eommunity
near Montreal, Canada. The purpose o f the program was to “improve healthy eating and
eneourage more physieal aetivity among elementary sehool ehildren” (p. 779). The study
oeeurred over a 3-year period in whieh the students reeeived health edueation ineluding
information regarding “nutrition, fitness, diabetes, understanding the human body, and
healthy lifestyles” (p. 781). Students between the ages o f 6 and 12 reeeived ten 45-minute
sessions per year o f health edueation. The short-term goal o f the program was to reduee highealorie and high-fat diets, obesity, and sedentary lifestyles among Kahnawake ehildren. The
long-term goal was to deerease the oeeurrenee o f type 2 diabetes in the future. The authors
direeted the partieipants to eomplete 2 questionnaires at the begiiming o f the study and then
again at the eompletion o f the study; one speeifieally questioned the ehildren regarding their
physieal and sedentary aetivities within the previous week, while the other questionnaire
eontained questions about food eonsumption for the previous week. Although no statisties
were reported in the artiele, results o f the study demonstrated that the edueation intervention
inereased healthy eating and deereased sedentary aetivities in the Kahnawake ehildren; it was
reported that girls between the ages o f 6 and 9 and boys between the ages o f 7 and 11
demonstrated improved outeomes as the result o f the intervention. The researeh presented by
M acaulay et al. (1997) is applicable to this project because the main components o f the
program were health edueation elasses eontributing to the sehooTs eurrent eurrieulum,
speeifieally promoting healthy nutrition and type 2 diabetes. The study suggested that

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improved participation in physical activities and eating habits followed healthy lifestyle
training when compared to participation following traditional health education offered in the
current curriculum. The limitation o f this study is that there is no discussion or follow-up
regarding the long-term goal o f decreasing the occurrence o f type 2 diabetes in Kahnawake
primary school children. This would be an important aspect o f the research that more fully
supports alternative nutritional education and its impact on type 2 diabetes in this age group.
In a separate but related study, Paradis, Levesque, Macaulay, Cargo, MeComber, Kirby,
Receveur, Kishchuk, & Potvin (2005) addressed the impact o f a diabetes prevention program
on body size, physical activity, and diet among Kanien’kekaika (Mohawk) children ages 6 to
11 years within the Kahnawake schools. Elementary students in grades 1 through 6 in two
Kahnawake communities received ten 45-minute specialized health lessons each year for an
8-year period. The lessons focused on healthy nutrition, type 2 diabetes, healthy lifestyle, and
physical activity. The authors used a participatory research approach to conduct this
prospective, longitudinal, quasi-experimental study. The purpose o f the study was to
determine if implementing a nutritional education program in the school system would
decrease both the risk factors and the occurrence o f diabetes in Aboriginal children. Data was
collected five times throughout the study. Results throughout the study were not statistically
significant (p=0.1), although there was a reduction in sedentary lifestyle, less television
viewing, and increased physical activity; and there was a decrease in high-fat, high-sugar food
consumption in the first 5 years o f the study. Unfortunately, these changes were not sustained
at the end o f the 8-year study. The short-term results accomplished the goal o f reducing risk
factors for type 2 diabetes in the Mohawk children, but this reduction o f risk factors was not
maintained throughout the study. The study suggested that the introduction o f satellite

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television and new fast food restaurants during the study may have contributed to failure. The
study suggests that nutritional education is a component that reduces risk faetors for type 2
diabetes, but increasing temptations in the community may have contributed to poor results
over time. The authors suggest that more research studying the long-term effects o f this type
o f nutritional education intervention must be conducted. The ideas presented by Paradis et al.
(2005) are applicable to the research question posed in this project because the main variables
being studied included healthy nutrition and type 2 diabetes reduction as aspects o f a
nutritional education program.
Christensen, King, & Prestwich (2000) conducted a cross-sectional study to evaluate
68 children at a 2-week summer camp for diabetes. The purpose o f the study was to
determine whether improvements to diet and nutritional knowledge through time-limited
education sessions would occur in young children and whether or not the education sessions
were correlated with good diabetes control. During the 2-week camp, children attended 4
education classes on self-care management; specifically, education about meal planning, food
contents, and groupings o f foods. At the conclusion o f the camp, each child was given a
written and clinical exam covering the topics discussed in the education classes. Exam results
suggested that only 25% o f the participants improved their knowledge regarding nutrition.
More importantly, it was determined that “correlation calculation between the diabetes
knowledge and the skill to appropriately load portion sizes for a meal was not statistically
significant” (p. 35-36). Specifically, results o f the written exam demonstrated that the
education classes over a 2-week period did not statistically (p=0.132) improve the nutrition
knowledge in most o f the children. The amount o f education provided in the 4 short sessions
was not sufficient for change. The author o f this project believes that a small amount o f

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education introduced over a significant period o f time rather than a large amount o f
information provided in four short sessions might be more effective and could potentially
benefit the nutritional edueation interventions being proposed in a later section o f this project.
This study is applicable to the research question although it demonstrated that a compact and
condensed approach to increasing pediatric knowledge was not an effeetive method for
change in the specified population. The study uses ehildren that already have diabetes as a
diagnosis and have been given some form o f diabetes edueation, although the article does not
indicate how much knowledge each child has, or the length o f time each child has had
diabetes as a diagnosis.
In a study by Trevino, Pugh, Hernandez, Menehaea, Ramirez, and Mendoza (2007), the
Bienestar diabetes risk factor prevention project was implemented to grade-4 students o f
Mexican -A m erican decent living in San Antonio, Texas, in order to increase their knowledge
o f diabetes health. The Bienestar program consisted o f a series o f lessons to be implemented
once per week for 28 weeks. The program was school-based and its primary goal was to
ultimately decrease both dietary intake o f fat and deerease physieal body fat (Trevino et al.,
2007). The lessons focused on “nutrition, wellness, and noneommunicable disease” (p. 63).
Two grade-4 elasses (n=71) and their teachers were involved in the study. The teachers
evaluated the progress o f the students in the following categories: environmental faetors,
personal faetors, behaviors, and outeomes. Questionnaires, written, and physical exams were
administered to determine the effieaey o f the program. Students were divided into two
groups: 46 students who attended greater than 50 pereent o f the elasses; and 56 students who
attended less than 50 percent o f the elasses. The students who attended greater than 50
pereent o f the elasses had a higher knowledge level than those with poorer attendance. The

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program operated for 2 years and results demonstrated that “the program significantly
(p<0.05) decreased dietary fat servings and percent fat total kilocalories, and, significantly
(p<0.05) increased dietary fruit and vegetable servings and diabetes health knowledge” (p.l).
At the eompletion o f the program, however, it was also determined that there was no decrease
in body fat or an increase in exercise among partieipants. Limitations o f the study inelude a
lack o f information available regarding body fat values for Mexican-American youth and the
difficulty in finding a way to reduee the cost o f the program for the children involved
(Trevino et al., 2007). In addition, the specific focus on one culture in the study versus a
study o f North American ehildren may be problematic, as findings may not be generalizeable
to this author’s population o f interest. The results o f this program are important to the
researeh question being evaluated for this project because the study by Trevino et al. (2007)
supports the implementation o f a nutritional program in the sehool system. The fact that a
deerease in body fat was not evident is important to consider as nutritional education alone in
this study was not enough to decrease the participants’ body fat. A combination o f nutrition
and physical fitness in an education plan may be beneficial.
Best practices and treatment guidelines
Peterson, Silverstein, Kaufman & Boulton (2007) offered prevention and edueation
strategies for addressing type 2 diabetes in youth. The authors discussed the most up-to-date
recommendations for sereening youth for type 2 diabetes and recommended monitoring atrisk ehildren for eo-morbid conditions. Recommendations included screening every 2 years
beginning at 10 years o f age, weight management, increasing physical activity, providing
psychosocial support, and incorporating nutritional education in educational programs. The
risk factors identified by the authors were youth 10 years and older with a BMI o f greater than

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the 85* pereentile, as well as any two o f the following: high-risk ethnieity, family history,
hypertension, dyslipidemia, polyeystie ovary syndrome, or aeanthosis nigricans (Peterson et
al., 2007). Healthy eating, increasing exercise, and decreasing obesity and impaired glucose
tolerance will decrease the effects o f risk factors. The nutritional education interventions
discussed within the guidelines for food modification were: developing a meal plan for the
participants to follow; and teaching by dieticians and diabetes educators for the at-risk youth.
One limitation o f the guidelines is the focus on treatment as opposed to prevention. Peterson
and colleagues (2007) suggest that prevention o f type 2 diabetes through education o f young
people is beneficial, however the guidelines they discuss did not focus on specific nutritional
edueation in schools. According to the Canadian Diabetes Association (2009), the current
best practice guidelines for type 2 diabetes in ehildren and adolescents are:
1

)

Edueation regarding active lifestyles and healthy eating to prevent obesity is
recommended (proposed as alternative nutritional edueation in this paper).

2

)

Children at risk for type 2 diabetes should receive regular screening (the frequency of
sereening is not identified).

3)

Consultation with an interdisciplinary pediatric healthcare team should occur with
every type 2 diabetes diagnosis in ehildren.

4)

“Early screening, intervention, and optimization o f glycémie control are essential, as
onset o f type 2 diabetes during childhood is associated with sever and early onset o f
microvascular complications” (p. 13).

Im plication s & sum m ary

All the articles reviewed for this project have a similar theme: they emphasize the
importance o f nutritional edueation as a means for deereasing obesity and risk factors for type

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2 diabetes in school-aged children. Evidence from each article has been presented to establish
that best practice guidelines for prevention o f type 2 diabetes in children should include
interventions that address healthy nutrition. Trevino et al. (2007) indicated that nutritional
education decreases the dietary fat o f grade 4 students, which then decreased the risk of
diabetes. Macaulay et al. (1997) indicated that increased nutritional education decreases the
risk for type 2 diabetes. Paradis et al. (2005) found that nutritional education deereased the
risk factors for pediatric diabetes in the short term; however, the decrease in risk factors was
not maintained over the entire 8-year period. The 2-week study by Christensen et al. (2000)
indicated that intensive short-term nutritional education is not beneficial in increasing
nutritional knowledge in the pediatric population. Further, all the articles reviewed for this
project support the notion that additional education is required to fight the current worldwide
epidemic known as pediatric type 2 diabetes. Although each study did not utilize the same
educational intervention, they all support the need for nutritional education to decrease the
occurrence o f type 2 diabetes in children. Standard nutritional education within the school
system is not adequate as evidenced by rapidly increasing cases o f type 2 diabetes presenting
in the pediatric population.
It is critical to ensure that nutritional edueation addressing type 2 diabetes and foods that
are associated with its cause is presented to targeted pediatric populations. Christensen et al.
(2000) provided nutritional education in a classroom setting at a diabetes summer camp.
Paradis et al. (2005) provided nutritional education in school classrooms consistently every
year for 8 years. Maeaulay et al. (1997) found that primary sehool instruetors were teaching
specific nutritional education regarding diabetes in their classrooms. Trevino et al. (2007)
provided nutritional education in school classrooms for a 9 month period; the curriculum was

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broken into 28 lessons over the 9 month period. Both Petersen et al. (2007) and Libman &
Arslanian (2007) discuss the importance o f educating the primary school-age children on
nutritional topics. Libman & Arslanian (2007) identify the direct need for school involvement
in education; Petersen et al. (2007) did not directly address who should he involved in
educating the children, hut were clear in the fact the children needed to he educated to prevent
type 2 diabetes. The one location common to all primary school-age children is the
classroom.
The risk o f type 2 diabetes is reduced when primary school-age children receive
alternative nutritional education when compared with more standardized nutrition curricula
(Christensen et al., 2000; Macaulay et al., 1997; Paradis et al., 2005; & Trevino et al., 2007).
Based on the evidence reviewed for this project, the best practice to address the research
question is to implement an interactive education intervention in the primary schools that
would include content on health food choices, foods that cause type 2 diabetes, and lifestyle
choices and how they may influence the incidence o f diabetes.
Currently, the British Columbia curriculum encourages teaching primary school-age
children about health using the following learning resources when available: print items,
videos, computer software (B.C. Ministry o f Education, 2006). Resources are limited and
apply to all areas o f health, not specifically referring to nutrition. More importantly,
standardized nutritional education focusing on the four food groups is insufficient to reduce
the risk o f type 2 diabetes in school-age children. The review o f literature for this project was
helpful in identifying which methods o f educating primary school-age children were effective
and which were less effective. Reviewing articles that used similar approaches to answer
similar types o f research questions was useful in providing direction for this author’s own

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nurse practitioner primary care practice. The most successful programs were those that
increased healthy dietary patterns in the children and decreased occurrence o f obesity and risk
o f type 2 diabetes. Chapter 3 discusses Pender’s Health Promotion Model as one possible
approach for beginning the important work o f revising nutritional education in BC as a means
for reducing type 2 diabetes for school-age children.

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Chapter Three
THEORETICAL FRAMEWORK
Overview o f conceptual fram ework
The conceptual framework forming the foundation for this project is Pender’s Health
Promotion Model (HPM). Pender’s model “explores the biopsychosocial process that
motivates individuals to engage in behaviors directed toward health enhancement” (MeEwan
& Wills, 2007, p. 247). The main concepts addressed in this model are; individual
experiences and characteristics, behavioral outcomes, and behavior-specific cognitions and
affect (McEwan & Wills, 2007). In order to improve the health o f a population, health
promotion is a required component. This model uses health-promoting behaviors to bring
about change.
Pender’s HPM identifies that people from all age categories can benefit from health
promotion, including primary school-age children. Health promotion is best delivered in a
place where the target population spends a significant amount o f time. Primary school
children spend a significant amount o f their time in school classrooms, thus suggesting school
is a logical location to implement health promotion interventions. Pender’s model is an
appropriate framework in which to assess the effectiveness o f alternative nutritional education
versus standardized nutritional education in the prevention o f type 2 diabetes in primary
school children.

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Sources and search process
A literature search was undertaken to examine Pender’s HPM. The initial search was
conducted on Medline. The keywords "'health promotion"' and "modeF were used which
resulted in 305 articles. The word "Pender" was added to the search, which narrowed results
to 16 articles. The search was further narrowed by including a combination o f keywords
"models" "psychological" "health prom otion" and "Pender," which then narrowed the
search to 3 articles. A separate search was then conducted within CINAHL. Initially,
"Pender" and "health promotion modeF keywords resulted in 304 articles. The search was
narrowed to include "Pender’s health prom otion modeF which narrowed the field to 78
articles. The search was further refined to include only full-text studies resulting in 19
articles.
A separate search was conducted on the Cochrane database in which "Pender’s health
promotion modeF resulted in zero articles found. The search was expanded to "health
prom otion modeF', again no articles were found. The search was then changed to "Pender"',
1 article was found. The search was expanded to use the phrase "health promotion" and 120
articles were found. The search was narrowed again to combine "Pender and health
promotion," resulting in no articles found. The search was expanded to included "health
promotion and models" which provided 43 articles. To complete the process, a search was
completed using Social Sciences full text, "Health promotion models" triggered 82 articles.
A search o f Electronic Journal Services with the phrase "Pender" yielded 13 articles. A
search o f the Clayton State University: Department o f Nursing - Nursing Theory database
found 3 articles using the word "Pender. ” The articles for this project were included because
they disseminate the most up-to-date information regarding Pender’s health promotion model;

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the articles were identified by including as many keywords into the search as possible. Most
importantly, concepts from the HPM arc consistent general health promotion trends occurring
in Canada including motivation, self-care, and self-awareness.
P ender’s H P M
Pender’s HPM uses behavioral change to positively impact health. Srof & VelsorFriedrieh (2006) describe the health promotion model as “a theoretical perspective that
explores the factors and relationships contributing to health-promoting behavior and therefore
enhancement o f health and quality o f life” (p. 366). Pender (1996) describes the model as “a
framework that serves as a guide for exploration o f the complex biopsyehosoeial processes
that motivate individuals to engage in health behaviors directed towards the enhancement o f
health” (p. 1).
Pender, Murdaugh, & Parsons (2002) stated that the HPM was created based on
assumptions from both behavioral and nursing sciences. It is assumed that individuals seek to
express their unique human health potential through the living conditions they have created.
Humans have the ability for reflective self-awareness and individuals yearn to regulate their
own behavior. People value positive growth and strive for balance between stability and
change. Health professionals compose a part o f the interpersonal environment: self-initiated
changes to ones personal environment are essential for behavior change.
Primary school children meet the assumptions put forward by Pender, Murdaugh, &
Parsons (2002). They are beginning to develop some o f these eharaeteristies, such as
expressing their unique human health potential through living conditions they have created.
Children can change the living conditions within their own environment such as their own
bedroom by keeping the room tidy and free o f garbage, thus promoting health. Primary

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school-aged children are self-aware; they yearn to regulate their own behavior and they strive
for balance. Pender, Murdaugh, & Parsons (2002) further stated that the HPM was based on
the following constructs: prior behaviors and acquired characteristics influence beliefs and
engagement; thereby affecting health-promoting behaviors. People engage in behaviors they
feel will benefit them. Perceived barriers will impact an individual’s commitment to behavior
changes. Perceived competence in a new behavior will increase commitment to action and
decrease perceived barriers. Positive emotions toward a behavior will increase commitment
to action. There is an increase in commitment when individuals model behavior; family,
peers, and health care providers exhibiting the behavior will increase the commitment to
action. Situational influences in the external environment can increase or decrease
commitment to action. Primary school children are easily influenced by the constructs
discussed by Pender, Murdaugh, & Parsons (2002). Children’s behavior is based on their
upbringing, viewed examples, and the belief system that they have developed. In order to
bring about behavioral change in primary children support, behavioral examples, and external
environmental factors are required for positive results.
Tillet (1994) found that the HPM cues individuals to engage in health-promoting
behaviors by specific cognitivc-perccptual components that are transformed by personal,
situational, and interpersonal factors. Pender (1987) describes the importance o f health,
perceived self-efficacy, and perceived control o f health, health definition, perceived status o f
health, and the perceived benefits and barriers o f health-promoting behaviors as cognitiveperceptual factors.

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Diabetes Prevention
Clark (1992) places the health modifying factors into three categories: demographic
characteristics, interpersonal influences, and situational factors. Demographic eharaeteristies
include the influences o f race, age, gender, ethnicity, income level, and education on health
promoting behaviors. Interpersonal influences include expectations o f family members, past
experiences with health care workers, and family health patterns. Situational factors include
all options that are available to the client or in this instance the child.
Galloway (2003) expanded upon HPM modifying factors. Galloway states that
demographic characteristics blend with the concept o f self-actualization within the HPM. For
example a child from a wealthy family is more likely to engage in preventative services than a
child from a poor family. Galloway recognizes that interpersonal influences can either
encourage or discourage behavioral change. For example, being raised in a family that eats
healthy food will encourage a child to change their eating habits towards healthy choices, as
compared to being raised in a family that consumes unhealthy foods. The child living with
the family eating unhealthy food will have a very difficult time making the transition to
healthy choices. Finally, Galloway (2003) describes situational factors as those influenced by
the surrounding environment resulting in behavior changes. For example, lack o f access to
healthy food will negatively impact a child’s behavior even if the child wanted to add fruit
twice a day. Primary school children’s health is affected significantly by demographic
characteristics, interpersonal influences, and situational factors. These can impact the child’s
health in either a positive or negative way. Several groups o f researchers agree that
commitment to a plan o f action leads to engagement in actual health promotion behaviors
(Pender, Murdaugh, & Parsons, 2002; Pender et al., 2002).

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Diabetes Prevention
Pender, Murdaugh, and Parsons (2002) described the HPM as useful in developing
strategies for behavioral change. Pender’s health promotion model is applicable to primary
school children and health promotion. Health education is beneficial in the school system.
An educational intervention grounded in the HPM will reflect its basic trend. Health
professionals can assist primary children to facilitate their unique health potential by assisting
them to regulate their own behavior through reflective self awareness o f their demographic
characteristics, interpersonal influences, and situational factors.
Conceptual fram ew ork concept & form ats
Pender’s HPM has been used in three different formats: as a conceptual framework for
studies, as an outcome to describe health promotion, and as a predictor o f behavior (McEwan
& Wills, 2007). For the purpose o f this project the HPM will be used both as a conceptual
framework and as an outcome indicator. Pender’s HPM has three major concepts: individual
experiences and characteristics, behavior-specific cognitions and affect, and behavioral
outcomes (McEwan & Wills, 2007). All three o f these major concepts are applicable to this
project.
The first major concept is individual experiences and characteristics. Primary school-age
children are individuals; they come with their own personal characteristics and experiences.
These include prior related behavior and personal factors: biological, psychological, and
sociocultural (McEwan & Wills, 2007). Prior related behaviors include their eating habits,
frequency o f meals and snacks, type o f food or drink consumed, and any other activity going
on during the snack or meal time. Personal factors for primary school-age children are their
genetics, sex, ethnicity, race, gender, household income, and past education on health
promoting behaviors.

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The second major concept includes behavior-specific conditions and affect. These
include perceived benefits o f action, perceived barriers to action, perceived self-efficacy, and
activity related to the affect. Also included are interpersonal influences and situational
influences (McEwan & Wills, 2007). A child’s perceived benefits, barriers, self-efficacy and
activity related affect will be very different than those an adult would identify. A primary
school-age child’s interpersonal influences and situational influences are also much different
than an adult would experience. For example a child is being influenced by peers, siblings,
and parents. It would be very difficult for a child to make a significant change in their eating
habits if parents were not supportive. Situational influences can also be a challenge for a
child to overcome. If the family is unable to afford a healthier diet, it will be difficult for the
child to change behavior. Partnerships between local grocery stores and dieticians could be
considered to problem solve with the families and determine healthy choices that are available
within the families budget.
The third major concept is defined as a behavioral outcome. This concept addresses
commitment to a plan o f action and health promoting behavior. A child first must commit to
a plan o f action; in this case, a child must commit to receiving nutritional education.
Following the commitment to the plan o f action, the desired outcome or the health promoting
change should occur. Here, the desired outcome is prevention o f type 2 diabetes in primary
school-age children through an alternative nutritional intervention.
Individual characteristics are inborn features (genetics, gender, age) individuals have,
and along with experience factors can enlighten future behavior (Srof & Velsor-Friedrich,
2006). These background factors (characteristics and experiences) are generally not
transformable. However, it is important to be aware o f them as a plan o f action is developed.

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Srof & Velsor-Friedrieh (2006) deseribe the eategory o f behavior-spécifié eognitions and
affeet as “the target o f most HPM research to date” (p. 367). This eategory ineludes pereeived
barriers and benefits to behavior, affect cues to behavior, and pereeived self-effieaey. Health
behavior that is infiueneed by soeial and environmental factors is situational and based on
interpersonal influenees (Pender, Murdaugh, & Parsons, 2005).
Information about an individual’s interpersonal and situational influences is required
prior to making a plan o f action. It is important to know which influences will impact a
child’s ability to be successful. Knowing what these influenees are and how to address them
will promote an action plan that will be benefieial to partieipants in the project. Exploring
barriers and benefits, along with pereeived self-effieaey, and aetivity related affeet are all
essential when developing a plan o f aetion. For example, children who have a large number
o f barriers to a given planned intervention will not be suecessful and the plan will ultimately
require a different plan o f aetion than those children with a limited number o f pereeived
barriers. Pender (1987) identifies the behavior-specific cognitions and affect as “the primary
motivational meehanisms for aequisition and maintenanee o f health” (p. 1).
The degree o f eommitment to the plan o f aetion can be affected by peers, families, and
health care workers. Individuals are more likely to eommit to an action plan if other
individuals in their soeial network are modeling the behavior, expect the behavior to occur, or
support the individual trying to commit to a behavior ehange (Pender et al, 2002). The higher
the commitment to the action plan, the greater the chanee o f maintaining health-promoting
behavior change over the long-term.
Two important factors play a role in deterring individuals from reaching the goal o f the
health promoting behavior. These are immediate competing demands and preferences.

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Immediate competing demands are factors over which individuals have little or no control.
Preferences are those factors demonstrated when other actions are more desirable than the
plaimed action (Pender et al, 2002). These factors require immediate attention if they develop
during a study.
Applying P ender’s model to this project
Any alternative nutritional education should combine elements previously discussed and
outlined in the articles reviewed. A thorough evaluation component needs to he integrated
into any intervention, in order to determine its effectiveness. For example, pre- and post­
education questionnaires were implemented by several o f the researchers cited in this project
(Christensen et al., 2000; Macaulay et al., 1997, Trevino et al., 2007). In each study
information defining the nutritional knowledge o f each child was collected; following
completion o f the education intervention, a second questionnaire was completed by each
student to evaluate if there was an increase in nutritional knowledge.
For this project, the author proposes incorporating alternative nutritional education
(healthy food choices, foods that cause type 2 diabetes, and reduction o f risk factors
associated with diabetes) into the eurriculum for primary school- age children with the
intention o f increasing the students’ nutritional knowledge specifically related to type 2
diabetes. By incorporating concepts from Pender’s HPM into an alternative nutritional
education intervention, the proposed project may help to reduce the incidence and prevalence
o f type 2 diabetes in sehool-age children.
Potential obstacles and corrective measures
Obstacles that could prevent positive outeomes from oceurring with an alternative
nutritional edueation intervention inelude: laek o f support from the sehool district, lack o f

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support and cooperation from family members, and inadequate finances to fund the project.
There will be costs associated with printing the required questionnaires, hiring a nurse
educator or dietician, as well as costs associated with the training o f classroom teachers to
provide the education to the students. Additional financial and human resource costs may
include time required for compiling and evaluating the completed questionnaires; without
some form o f funding the project may not move forward. Other potential obstacles that may
be encountered are resistance from parents, children, and the school system. Parents may feel
that the study is investigating or pointing fingers at them. Children may feel that the way they
eat or enjoy eating is being threatened. The teachers may not feel they are able to provide
additional classroom time to the alternative nutritional education intervention without
omitting one o f the School Board’s required curriculum components. The school system may
perceive the investigator as an outsider. Studies from a perceived outsider can be threatening
to a community. Thus, support from the school board, the principals, and the teachers would
be required to ensure the nurse educator is able to enter the school and educate the students.
Support and commitment from the parents is necessary, as the children will continue their
learning away from school through discussion with parents and attempting to eat a healthy
diet with food provided by parents; without parental support and participation this would not
be possible. Family support is also critical because children with obesity and / or type 2
diabetes may have parents that are obese and / or have type 2 diabetes. Supportive and
involved families may chose to embrace the changes as a family rather than simply support
the child. Commitment from the students is also necessary to have a successful outcome;
without the students embracing the project, attending the classes, and participating in the
educational sessions the outcome will not be positive. Commitment from the children may

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lead to positive ehanges in families o f the partieipating ehildren. As the ehildren learn and
share nutritional knowledge with their families, healthy lifestyle ehanges may oeeur in the
home with family members as well.
Benefits o f the project
The antieipated outeomes will be that that the students receiving the alternative
nutritional edueation intervention will have increased nutrition knowledge compared to the
students who received only the standardized nutritional education provided by the education
system. With increased knowledge o f nutritional education specifically intended to reduce
type 2 diabetes, this project may assist with decreasing both the risk for and oeeurrenee o f
type 2 diabetes in primary school-age children. The anticipated long-term outeomes are
potential decreases in childhood obesity and type 2 diabetes, and a decreased risk for
developing childhood diseases such as hypertension, cholelithiasis, and atherosclerosis as the
result o f type 2 diabetes. If the proposed project was successful even with a small group o f
children, the author would like to have the alternative nutritional edueation intervention
implemented as a required component o f the curriculum for primary sehool-age ehildren in
the Lower Mainland and, eventually, throughout the province o f British Columbia.

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Chapter Four
CONCLUSIONS
Implications o f project to nurse practitioner practice
Pediatric type 2 diabetes is a significant problem. The prevalence o f childhood obesity
has been described as “reaching epidemic proportions in both the developed and developing
world” (Reilly, 2004, p. 6); childhood obesity is the major contributing factor to type 2
diabetes in children. The most effective way to deal with pediatric type 2 diabetes in primary
school-age children is to prevent it. A significant and large part o f prevention is education.
The easiest and most effective way to educate children is to reach out and meet them in a
place where they spend most o f their time. Children spend the majority o f their daytime hours
in school. School is an effective place to teach children about nutrition and health.
This project will contribute to nursing knowledge by potentially demonstrating an
effective intervention to type 2 diabetes prevention in primary school-age children. It may
also impact the role o f school nurses and enable them to provide nutritional education in
schools contributing to disease prevention and improved health. Success o f such an
educational intervention could provide a precedent to enable nurses to educate students within
the school system about drugs, smoking, proper hygiene, dental care, sex education, safe
sexual practices, safety around the community, and many other necessary topics that children
often do not learn o f in their traditional primary curriculum. If the project proves to be
successful it may open doors to further educate primary school children about healthy living
in circumstances where the traditional curriculum does not have the time or funding to
provide information; for example a nurse practitioner in Agassi, BC has been able to attend
the local high school at the beginning o f each school year to speak with all the grade 9

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students about sexual health and give information regarding the free weekly youth clinic
offered to the high school children in Agassi.
Family nurse practitioners encounter primary school-age children in their practice.
Unfortunately, many primary school-aged children only see their practitioner when there is a
health concern or an acute illness. For these reasons it is difficult for a practitioner to
incorporate continuous teaching and education throughout the primary school-age years. A
primary school-age child may become obese or develop risk factors for type 2 diabetes
without their practitioner’s knowledge. The proposed project permits the nurse practitioner
another mechanism to ensure the primary school-age children in their practice have access to
additional nutritional education that can contribute to decreasing the occurrence o f childhood
obesity, type 2 diabetes and potential risk factors for developing chronic disease related to
type 2 diabetes.
Nurse Practitioners can create the opportunity for learning while their clients wait to
be seen. Nutritional and fitness information can be presented in the form o f brochures,
posters, and reading material displayed in the waiting area. Parents can take home brochures
to learn more about proper nutrition and the importance o f physical activity. Children can be
given take home activity workbooks that have activities promoting healthy eating and
physical fitness. The Nurse Practitioner can set a goal to discuss one health choice with every
client visit. Examples o f healthy choices are: smoking cessation, food choices, exercise,
decreasing alcohol consumption, immunizations, proper care and monitoring o f blood sugars
if the client is at risk for or has diabetes.
Nurse Practitioners can use this project as a tool to move forward into the community
and create partnerships to battle pediatric obesity, risk factors for both obesity and type 2

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diabetes, and the oeeurrenee o f type 2 diabetes in ehildren. Nurse Praetitioners ean eome
together with stakeholders in the eommunity and work towards developing programs that
eombat both obesity and type 2 diabetes. Involving dietieians, fitness faeilities, sehool
boards, eommunity leaders and eommunity praetitioners in planning programs for healthy
ehildren in their eommunity is essential for sueeessful outeomes.
Summary and Conclusions
In the past deeade type 2 diabetes has been infiltrating the pediatrie population, ineluding
primary sehool-age ehildren. An inerease in ehildhood obesity has eontributed to an
alarmingly large pediatrie population with type 2 diabetes. One method used in prevention o f
pediatrie type 2 diabetes is edueation. This projeet addresses whether edueating primary
sehool-age ehildren is an effeetive way to prevent type 2 diabetes in ehildren.
Based on Pender’s HPM, this projeet has explored whether alternative interaetive
nutrition edueation inereases the nutritional knowledge o f primary sehool-age ehildren and
deereases the risk faetors for type 2 diabetes. Long-term evidenee supporting alternative
interaetive nutritional edueation suggests this intervention may help deerease the oeeurrenee
o f obesity and reduee the risk faetors for type 2 diabetes in primary sehool-age children. It is
believed that well-informed individuals ean make informed healthy choices. More
importantly, children need information to make well-informed decisions.

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References
Amschler, D. (2002). The alarming increase o f type 2 diabetes in children. Journal o f
School Health, 72(1), 39.
Basdevant, A., Boute, D., Borys, J. M. (1999). Who should be educated? Education
strategies: could children educate their parents? International Journal o f Obesity &
Related Metabolic Disorders, 23, 10.
British Columbia: Ministry o f Education (2006). Health and career edueation grade 1-7.
Integrated resource package 2006. Retrieved February 6, 2009, from
http://www.bced.eov.bc.ca/irp
Brooks, S. (2004). Type 2 diabetes and ehildren: Using a health at every size approach for
treatment. Health at every size, 18(5), 70-71.
Canadian Diabetes Association (2009). Canadian Diabetes Association 2008 clinical practice
guidelines for the prevention and management o f diabetes in Canada: Executive
summary. Retrieved April 7, 2009, from http://www.diabctcs.ca
Christensen, N., King, E., & Prestwich, L. (2000). Diabetes education evaluation. Topics in
Clinical Nutrition, 75(4), 31-40.
Clark, M. J. (1992). Nursing models for community health nursing. Nursing in the
Community. (2"‘*Ed). Norwalk, CT: Appleton & Lange.
Cramer, D. (2008). Handing down diabetes. Alive: Canadian Journal o f Health &
Nutrition, 313, 45-46.
Evans, J. A. (2003). The new ehildhood epidemie: Diabesity. Prevention,55{\2), 106-158.
Galloway, R. D. (2003). Health promotion: eauses, beliefs and measurements. Clinical
Medicine & Research, 1(3), 249-258.
Holt, P. (2006). Challenges and strategies: W eight management in type 2 diabetes.
British Journal o f Community Nursing, 11(9), 376-380.
Huang, T. & Goran, M. (2003). Prevention o f type 2 diabetes in young people: A theoretieal
perspective. Pediatric diabetes, 4, 38-56.

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Diabetes Prevention

Jensen, K. (2004). Childhood diabetes. Alive: Canadian Journal o f Health & Nutrition, 263,
96-100.
Kiess, W., Bottner, A., Raile, K., Kapellen, T., Muller, G., Galler, A., Paschke, R., Wabitsch,
M. (2003). Type 2 diabetes mellitus in children and adolescents: A review from a
European perspective. Hormone Research, 59, 77-84.
King, B. (2006). M etabolism matters. Alive: Canadian Journal o f Health & Nutrition, 287,
34-35.
Landauro, V. (2005). Childhood Obesity. Junior Scholastic, 107(14), 6-9.
Libman, I. & Arslanian, S. (2007). Prevention and treatment o f type 2 diabetes in youth.
Hormone Research, 67, 22-34.
Macaulay, A., Paradis, G., Potvin, L., Cross, E., Saad-Haddad, C., McComber, A., Desrosiers,
S., Kirby, R., Montour, L., Lamping, D., Leduc, N., & Rivard, M. (1997). The
Kahnawake schools diabetes prevention project: Intervention, evaluation, and baseline
results o f a diabetes prevention program with a Native community in Canada.
Preventive Medicine, 26, 779-790.
Matheson, D., Springer, K. (2001). Content analysis o f the use o f fantasy, challenge, and
curiosity in school-based nutrition. Journal o f Nutritional Education, 33(1), 10.
McEwan, M., Wills, E. (2007). Theoretical basis fo r nursing (2"‘*ed.). Philadelphia, PA:
Lippincott, Williams & Wilkins.
Melnyk, B., Fineout-Overholt, E. (2005). Evidence-based practice in nursing and
healthcare. Philadelphia, PA: Lippincott, Williams & Wilkins.
Paradis, G., Levesque, L., Macaulay, A., Cargo, M., McComber, A., Kirby, R., Receveur, O.,
Kishchuk, N., & Potvin, L. (2005). Impact o f a diabetes prevention program on body
size, physical activity, and diet among Kanien’keha:ka (Mohawk) children 6 to II
years old: 8-year results from the Kahnawake schools diabetes prevention project.
Pediatrics, 775(2), 333-339.
Pender, N. J. (1987). Health promotion nursing practice (2"‘*ed.). Norwalk, CT:
Appleton & Lange.
Pender, N. J. (1996). Health promotion in nursing practice (3‘^‘*ed.). Stamford, CT:
Appleton & Lange.

39

Diabetes Prevention
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002). Health promotion in nursing
practice{A'^ ed.). Upper Saddle River, NJ: Prentice-Hall Health.
Peterson, K., Silverstein, J., Kaufman, F. & Boulton, E. (2007). Management o f type 2
diabetes in youth: an update. American Family Physician, 76, 658-64, 665-6
Reilly, J. J. (2004). Prevention o f obesity in children. Obesity in Practice, 6(1), 6-8.
Ritchie, L., Ganapathy, S., Woodward-Lopez, G., Gerstein, D., & Fleming, S. (2003).
Prevention o f type 2 diabetes in youth: Etiology, promising interventions and
TQCommQnàations. Pediatric Diabetes 2003, 4, 174-209.
Rosenbloom, A. (2002). Increasing incidence o f type 2 diabetes in children and adolescents:
treatment considerations. Pediatric Drugs 2002, 4(4), 209-221
Srof, B. J., Velsor-Friedrieh, B. (2006). Health promotion in adolescents: A review o f
Pender’s health promotion model. Nursing Science Quarterly, 19(4), 366-373.
Tillet, L. A. (1994). Nola J. Pender: The health promotion model. In A. Marriner-Tomey
(ed.). Nursing Theorists and Their Work (3"^^ ed.). St. Louis, MO: Mosby-Yearhook.
Trevino, R., Pugh, J., Hernandez, A., Menchaca, V., Ramirez, R., & Mendoza, M. (2007).
Bienestar: a diabetes risk-factor prevention program. [Electronic version]. Journal o f
School Health, 68(2), 62-7
Westenhoefer, J. (2002). Establishing dietary habits during childhood for long-term weight
control. Annals o f Nutrition & Metabolism, 46, 18-23.

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