NP-LED OBESITY CLINICS: A NP GUIDED PRIMARY CARE APPROACH FOR
MANAGING OBESITY IN LOW INCOME PRESCHOOL-AGE CHILDREN IN
CANADA
by
Echo Heighes
BSN., Thompson Rivers University, 2006

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING: FAMILY NURSE PRACTITIONER

UNNERSITY OF NORTHERN BRITISH COLUMIA
August, 2012
© Echo Heighes, 2012

UNNERSITYmNORTHERN
BRITISH COLUMBIA
LIBRARY
Prince George, B.C.

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ABSTRACT
Childhood obesity continues to increase at alarming rates despite health prevention efforts to
date. New innovative approaches are needed to help address this public health concern.
Moreover , current literature confirms that early childhood is a fundamental time for establishing
life behaviors that will follow into adulthood; thus, the early years are considered to be an
essential stage for developing both an unhealthy weight and its precursor behaviors. Social
circumstances including socioeconomic status greatly impact health and are notable risk factors
for the development of obesity. Acknowledging sociological influences and working within
these constructs helps to create programs and care plans that are contextual. The purpose of this
paper is to explore the role of nurse practitioners when working with low income families to
address childhood obesity in the preschool-aged population in Canada, specifically within the
setting of a NP-led obesity clinic. Literature to date does not exist for NP-led obesity clinics as
this is a proposed approach to helping combat pediatric obesity. Existing literature regarding
nurse-managed health centers and pediatric weight management programs were utilized to
support the creation of a NP-led obesity clinic. Nurse-managed health centers have established
that NPs are capable of providing appropriate medical treatment with positive health outcomes.
Further, level of patient satisfaction and quality of care provided at nurse-managed health centers
either met or exceeded national benchmarks for care. Pediatric weight management programs
are in the infancy phase in Canada but have demonstrated positive weight management
outcomes. Existing Canadian programs are informally evaluated to provide further support for
the use ofNP-led obesity clinics within the current Canadian health care system. This paper
proposes that NP-led obesity clinics are a novel approach to help address childhood obesity
within the primary care environment.

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ACKNOWLEDGEMENT
I would like to thank Dr. Sue Johnson RN, BSc, PhD Assistant Professor and Undergraduate
Coordinator for the School ofNursing, UNBC and Connie Lapadat BScN, MSN, NP-F Family
Nurse Practitioner, Lead Clinical Faculty, UNBC, and Adjunct Professor, UNBC for all of your
time and patience in working with me to develop this paper. Thank you for imparting your
insight and wisdom to me during this process.

I would also like to thank all of my friends and colleagues for your support and encouragement
in helping me through my educational endeavor. Without your confidence and ongoing
accolades I would not have been able to succeed. Additionally, I would like to thank my fellow
classmates Fran and Michelle for sharing all of our triumphs and tribulations during the fmal
year of the program.

Finally, and most importantly, I would like to thank my wonderful family for all of their help and
emotional support during the course of this program and especially during the development of
this project paper. Specifically, I would like to thank Chris, Ava and Wyatt for the sacrifices that
were made in order for me to complete this degree. As well, thank you mom, dad, Ashley and
Danika for helping me through this process and the countless hours of babysitting the kids while
I worked on my Masters degree. And fmally, thank you Colleen and Dave for taking the kids on
weekends while I worked on this paper. You are all truly amazing members of my life and I
look forward to spending more quality time with all of you.

Echo Heighes

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TABLE OF CONTENTS
SECTION 1: BACKGROUND AND NEED .......... ........ ..... .. .. ..... ..................... .......... ..... .... .... ...... 5

Demography of Childhood Obesity .................... ........ .................. ....................................... 7
Socioeconomic Status ... .................... .... ... ... .. ........................................................... ....... ... 10
Physiology of Obesity and Its Associated Health Effects ................................................. 11
Risk Factors ............... ............ ............................................................. .... ........................ ... 13
Current Interventions and Guidelines ................................................................................ 18
Barriers to Obesity Management ....................................................................................... 21
Implications for Nurse Practitioner Practice ...................................................................... 26

SECTION 2: NP PRIMARY CARE PRACTICES ............. ...... ..... ......... ........ .... ......... .... ............. 28
Nurse-Managed Health Centers ......................................................................................... 28
Pediatric Weight Management Programs ...... ..... ................................. ......... ..................... 37
Programs in Canada ........................................................................................................... 45
NP-Led Obesity Clinics ....... ............................................ ............ .......... ............... ........ ... .. 53

SECTION 3: PRUDENT NP PRACTICE: RESPONSIBILITIES AND CONSIDERATIONS .. 61
Health Equality ................................................................................................................. 61
Accessibi1ity ................ .. ... .......... ... .. ........... .... .. ......................... ... .. ... ................................. 64
Consent .............................................................................................................................. 66
Advocacy .... ...................... ............. ... ........ ............................ ................ .......... ... ................ 71

SECTION 4: IMPLICATIONS, RECOMMENDATIONS AND CONCLUSIONS .................... 74
REFERENCES ....... ...... ................. .................................................................. ... ........... ............. ... 84

APPENDICES ................................... ..... ..................................................................................... 100
Appendix A: Literature Review Search Strategy and Results ......................................... 100

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SECTION ONE
BACKGROUND AND NEED
The United Nations Convention on the Rights of the Child (1989) states under article 24
that all children should have the right to enjoy the highest attainable standard of health and be
provided with access to appropriate health care services. Childhood obesity is reaching epidemic
proportions worldwide and is becoming a public health threat due to its ability to rapidly spread
within the industrialized world. In Canada, 29% of school-aged youths are overweight or obese
and obesity has doubled in 9 out of 10 provinces (Canning, Courage, & Frizzell, 2004). Obesity
related health care costs have tripled and health care professionals are increasingly called upon to
address this national epidemic. Furthermore, adult diseases associated with obesity are
beginning to become more prevalent among youth (Nader et al., 2006) leading to further
reduction in quality of life in the pediatric population. Health promotion and obesity prevention
programs have been implemented across the globe to address this health issue through
government programs; however, many of these interventions fail to include the preschool-aged
population (Campbell & Hesketh, 2007; Nader et al., 2006; Rudolf, Hunt, George, Hajibagheri,
& Blair, 2010). Additionally, literature indicates that obese and overweight preschoolers will
continue to suffer from obesity into school age, adolescence and finally adulthood.
Socioeconomic status (SES) is also reflective of overall health and plays a role in the
development of childhood obesity within the preschool-aged population. Socioeconomic factors
including food security, accessibility to physical activity programs and organized sports, screen
time and geographical location all contribute to obesity (Kumanyika & Grier, 2006). If nurse
practitioners (NPs) are to provide comprehensive care to low income, obese preschool-aged
children, then they must attend to the complex health care needs of this population. NPs have

6

their roots in providing care to underserved, marginalized and vulnerable populations (Browne &
Tarlier, 2008) . Accordingly, they are well situated to improve the health outcomes of this
population through increasing accessibility to preventative and curative health services. These
primary health care initiatives can be achieved through NP-led obesity clinics.
The purpose of this paper is to review existing literature to answer the following
question:

1.) What is the role of the NP when working with low income families to address
childhood obesity in the preschool-aged population in Canada?
This question is divided into the following sub-questions:
a.) What are the prevalence and health consequences of obesity in preschool children in
Canada?
b.) What role does low SES play within the development of childhood obesity?
c.) What current primary care interventions aimed at reducing obesity in the preschoolage population exist and what are the gaps?
d.) What NP-led strategies and interventions might be implemented to address these
gaps?
Background data will be presented and explored to demonstrate the significance of this
health issue to NP practice. The data presented will include a description of the demography,
physiology, health effects and risk factors of obesity. Additionally, the impact of SES on the
development of childhood obesity will be discussed. Current interventions aimed at the
preschool-aged population will be outlined and the barriers primary care providers (PCPs)
encounter in the management and treatment of childhood obesity will be examined. Nursemanaged health centers (NMHCs) and pediatric weight management programs (PWMPs) will be

7

explored and programs in Canada and the United States of America (USA) will be investigated
to present constructive examples of these models of care. Further, NMHCs and PWMPs will
supply evidence and support for NP-led obesity clinics as a potential mode of caring for obese
pediatrics. Finally, prudent NP responsibilities and considerations will be reviewed specifically
pertaining to the care of vulnerable populations and minors. The findings will be synthesized
and critically appraised with identification of the limitations and recommendations recognized by
this integrative review with the goal of exposing future strategies needed to help combat this
national epidemic.

Demography of Childhood Obesity
Obesity is defined as an increase in body weight resulting from an excessive increase in
body fat and is in part the result of caloric imbalance in relation to too few calories expended for
the amount of calories consumed (World Health Organization [WHO] , 2011). Body mass index
(BMI) is a tool used to determine adiposity. BMI is the ratio of weight in kilograms to the
square of height in meters. For children and adolescents, BMI is age and sex specific and is
referred to as BMI-for-age (American Academy of Pediatrics [AAP] , 2011 ; Centers for Disease
Control and Prevention [CDC] , 2011 ; Spruijt-Metz, 2011). A BMI at or above the 85th
percentile but lower than the 95th percentile for age and sex is considered overweight and a BMI
at or above the 95th percentile is considered obese (CDC, 2011).
The World Health Organization (WHO, 2006) has labeled the increasing global epidemic
of obesity as "globesity". In 2004, the International Obesity Taskforce stated that 1 in 10
children were overweight for a worldwide total of 155 million and approximately, 30-45 million
were classified as obese (Lobstein, Baur, & Uauy, 2004, as cited in Spruijt-Metz, 2011). Further,
in 2010, 43 million children under the age of five were classified as overweight (WHO, 2011 ).

8

In Canada in 2004, one in four, or 26 %, of Canadian children and adolescents aged 2-17 years

old were overweight (Lau, Douketis, Morrison, Hramiak, & Sharma, 2007). In addition, the
obesity rate in Canada has increased over the past 15 years from 2% to 10% in boys and from
2% to 9% in girls (Lau et al. , 2007). In British Columbia (BC) in 2004, 20% of children aged 2

to 17 were overweight and 7% were obese (Legislative Assembly of British Columbia, 2006).
BC has the lowest rate of childhood obesity in Canada but is ranked as average for the number of
overweight children within the province compared to the rest of Canada (Legislative Assembly
of British Columbia, 2006).
Obesity rates are continually increasing in Canada and in other countries. The prevalence
of obesity has tripled among children between the ages of 6 to 11 years and increased from 5% to
12% in children aged 2 to 5 years old (Caprio et al., 2008; Cluss, Ewing, Long, Krieger, &

Lovelace, 20 I 0). BMI' s at or above the 95th percentile are becoming more commonplace and
this is even higher among subpopulations of minority and economically disadvantaged children
(AAP- Committee on Nutrition, 2003). This evidence is disconcerting because children tend to

maintain their relative BMI position as they mature; thus, they have greater tendency to become
obese adults with obesity related health conditions. Therefore, as these children age, the obesity
epidemic will lead to increased rates of diabetes, hypertension and cardiovascular disease
(Barlow, Trowbridge, Klish, & Dietz, 2002). The WHO (2011) states that overweight and
obesity are the fifth leading risk for global deaths with 2.8 million adults dying each year.
Overweight and obesity contribute to approximately 44% of the diabetes burden, 23% of
ischemic heart disease and between 7% and 41% of certain cancers (WHO, 2011 ).
Children with a BMI greater than the 75th percentile are at risk of being overweight by
age 12. Similarly, preschool-age children with BMis in and above the 50th percentile are more

9

likely to become overweight by age 12 (Nader et al. , 2006). Evidence is beginning to support
that weight gain in early life, including infancy, is a predictor of later obesity and that lifestyle
behaviors have their roots in early childhood (Rudolf et al. , 201 0). Furthermore, Larsen,
Mandleco, Williams, and Tiedeman (2006) state that once a child becomes overweight treatment
to decrease weight is difficult and often unsuccessful. Hence, the early years are considered to
be a key time for developing both an unhealthy weight and its precursor behaviors (Campbell &
Hesketh, 2007; Legislative Assembly of British Columbia, 2006). Early childhood is a crucial
time to establish lifestyle behaviors that will promote health and mitigate against the
development of both childhood obesity and adult obesity.
The increase in childhood obesity is not only detrimental to individual health but comes
at a significant cost to the public (Spruijt-Metz, 2011). Finkelstein, Trogdon, Cohen, and Dietz
(2009) noted that between 1998 and 2006 the medical cost of obesity increased from 6.5% to
9.1% of annual medical spending and the per capita medical spending for an obese person is
approximately 42% higher than for a normal weight person. A meta-analysis by Katzmarzyk
and Janssen (2004) used a prevalence-based approach to estimate the costs of physical inactivity
and obesity in Canada. They found that the economic burden of obesity in 2001 to be
approximately 4.3 billion dollars. In BC, total obesity costs are estimated at 563 million dollars
and by 2015 these costs will approach 852 million dollars (Legislative Assembly of British
Columbia, 2006). Understanding, preventing and treating childhood obesity is becoming a top
public health priority (Spruijt-Metz, 2009). Additionally, with the increasing prevalence of
childhood obesity, health care professionals must be well educated in the complex nature of this
disease and its associated co-morbidities because health care professionals will undoubtedly

10

encounter children who are overweight and/or obese or are at risk of being obese (Arbesman &
Crespo, 2003).
Socioeconomic Status

Socioeconomic status is often defined as the social standing or class of an individual or
group. Childhood SES is obtained by measuring parental income, occupation or education
(Loucks et al. , 2007). People who have less money suffer substantially shorter life expectancies
and have more illnesses than those who have more wealth. "Being poor is in itself a health
hazard ... " (Canadian Institute for Health Information [CIHI] , 2008, p. 1). The rates of childhood
obesity are alarming in the general population; however, these rates are proportionately higher
among low-income communities (Spruijt-Metz, 2011) with approximately one in seven lowincome preschool-aged children being obese (CDC, 2011). Regardless, for all ages, a social
gradient is evident in which the prevalence of overweight increases from 24% in high SES
neighborhoods to 35% in low SES neighborhoods (Oliver & Hayes, 2005). Low SES negatively
influences many factors that perpetuate and contribute to childhood obesity including eating and
physical activity behaviors, neighborhood safety, local schools and resources, local health food
stores, price of food, watching television (TV) and engaging in sedentary activities. Low SES is
a significant risk factor for the development of childhood obesity (Kumanyika & Grier, 2006;
McAdams, 201 0) independent of ethnicity (Cluss et al. , 201 0). Accordingly, socioeconomic
position and social class greatly impact every aspect of life and often have a cumulative effect on
health status throughout life (WHO, 2003). It is, therefore, judicious that NPs have an acute
understanding of low SES and health equality. As such, these ethical considerations will be
discussed more thoroughly in Section Three of this paper.

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Physiology of Obesity and Its Associated Health Effects

Obesity is the result of positive energy balance. Too many calories are consumed
compared to the amount of calories expended (WHO, 2011 ). Excess calories are stored in fat
cells or adipocytes. Adipocytes secrete several hormones and signaling factors including
adipokines, inflammatory mediators and free fatty acids (Spruijt-Metz, 2011). Adipokines
participate in the regulation of food intake, lipid storage and metabolism, insulin sensitivity and
regulation of energy metabolism. Visceral fat accumulation leads to dysfunction of adipocytes
resulting in alterations of regulation and interaction between hormones and cytokines.
Dysfunction facilitates adipocytes to increase in size; however, when the cells have reached
maximum size, then the cells must increase in number (Spruijt-Metz, 2011).
Neuroendocrine regulation of eating behavior and energy metabolism is controlled by a
signaling circuit or gut-brain axis (Spruijt-Metz, 2011) which acts on the hypothalamus. The
hypothalamus is integral in appetite and metabolism regulation. Several adipokines secreted by
adipose tissue such as leptin contribute to the regulation of food intake. These hormones
circulate in the blood in proportion to body fat mass. With increased levels of these hormones in
the blood, there is increased activation of the hypothalamus resulting in increased promotion of
appetite. Furthermore, obesity leads to a physiological state of chronic inflammation which is
attributed to high plasma levels of inflammatory markers. Chronic inflammation is linked to
several diseases including diabetes mellitus type II and metabolic syndrome. Additionally,
elevated free fatty acid concentrations reduce muscle glucose uptake, increase liver glucose
production and stimulate insulin secretion contributing to a cascade of effects that lead to insulin
resistance (Spruijt-Metz, 2011).

12

Insulin resistance is the failure of insulin to act normally on these targeted tissues leading
to impaired glucose uptake and conversion. Visceral adiposity directly contributes to the
development of insulin resistance. In tum, insulin resistance is related to many diseases
including diabetes mellitus type II, cardiovascular disease and cancer (Spruijt-Metz, 2011). The
development of diabetes mellitus type II increases the risk of acute myocardial infarction,
cerebral vascular accident and/or heart failure to occur prematurely (AAP- Committee on
Nutrition, 2003 ; Hopkins, DeCristofaro, & Elliot, 2011). Hypercholesterolemia, dyslipidemia
and hypertension are common in obese children and are also risk factors in cardiovascular
disease (AAP- Committee on Nutrition, 2003 ; CDC, 2011).
Gastrointestinal disorders associated with obesity include non-alcoholic fatty liver
disease, gallbladder disease, gastroesophageal reflux disease and an altered response to
medications. Furthermore, obesity can lead to asthma and sleep apnea due to mechanical and
inflammatory processes (Hopkins et al. , 2011). Ovarian hyperandrogenism and renal disease can
also occur. Orthopedic conditions associated with childhood obesity include slipped capital
femoral epiphysis, tibia vara, osteoarthritis, osteoporosis and joint disorders (AAP - Committee
on Nutrition, 2003 ; Hopkins et al. , 2011).
Psychosocial problems can arise due to obesity and self-esteem which can lead to
increased prevalence of depression. The psychological stress of social stigmatization of obese
children may be just as damaging as the medical morbidities (AAP- Committee on Nutrition,
2003 ; Spruijt-Metz, 2011). It has been noted that obese children report a low quality oflife
comparable to a child suffering from cancer (Hopkins et al. , 2011) and overweight and obese
children have fewer friends than their normal weight peers (Spruijt-Metz, 2011). Many children
who are obese suffer from teasing, social exclusion, discrimination, prejudice and stigmatization

13

(Wardle, 2005). The impact obesity has in contributing to the development of chronic health
conditions is substantial and these many health challenges greatly impair quality of life.

Risk Factors
There are interactions between genetic, biologic, psychologic, sociocultural, and
environmental factors in the development of childhood obesity. Globally, there has been an
increased intake of energy-dense foods that are high in fat, salt and sugars but are also low in
vitamins, minerals and micronutrients. Simply, overconsumption has led to overnutrition. As
well, there has been a decrease in physical activity as a result of an increasingly sedentary
lifestyle both at home and work, changing modes of transportation and increasing urbanization.
These changes in dietary and physical activity patterns are the result of environmental and
societal changes (WHO, 2011).
Obesity has familial risk factors and it is, therefore, common in families . Monogenic
causes of obesity are being described more frequently. This familial link to obesity, however,
only represents a minority of children with obesity (Registered Nurses Association of Ontario
[RNAO] , 2005). High birth weight, maternal diabetes and obesity in family members are all
factors ; yet, there is likely a combination of multiple genes and a strong interaction between
genetics and the environment that influence the degree of adiposity (AAP -Committee on
Nutrition, 2003). It is found that 70% of the variability ofBMI within the population is
attributed to heritable genetic differences (Wardle, 2005). For young children, if one parent is
obese, then the odds ratio is approximately three for obesity in adulthood, but if both parents are
obese, then the odds ratio increases to more than 10. Additionally, before three years of age,
parental obesity is a stronger predictor of obesity in adulthood than a child ' s weight status (AAP
-Committee on Nutrition, 2003). There are critical periods for development of excess weight

14

gain including extent and duration ofbreastfeeding, early menarche, maternal smoking, birth
weight and metabolism (AAP- Committee on Nutrition, 2003 ; Caprio et al. , 2008; Kumanyika
et al. , 2008).
Environmental influences are also instrumental in the progression of obesity and more
studies are suggesting that environmental change rather than genetic change has contributed to
the dramatic increase in obesity prevalence during the past two decades (Barlow et al. , 2002).
The built environment has recently been recognized as integral in creating the obesogenic
environment. This is an environment that promotes sedentary lifestyles and the
overconsumption of food (RNAO, 2005). Health Canada (2002) defines the built environment
as:
The built environment includes our homes, schools, workplaces, parks/recreation areas,
business areas and roads. It extends overhead in the form of electric transmission lines,
underground in the form of waste disposal sites and subway trains, and across the country
in the form of highways. The built environment encompasses all buildings, spaces and
products that are created or modified by people. It impacts indoor and outdoor physical
environments (e.g. , climatic conditions and indoor/outdoor air quality), as well as social
environments (e.g., civic participation, community capacity and investment) and
subsequently our health and quality of life.
The key influential environments for children are school and home. Therefore, the food
choices available within these areas shape the child ' s appetite for certain foods (Wardle, 2005).
Current family lifestyles manifest abundant energy dense foods with low physical activity levels
and this is particularly significant as physical activity and food intake are the most important
mediators of environmental influences on bodyweight (McAdams, 20 l 0). In today' s society,

15

consumers want more convenient foods and fewer families are eating meals together (Golan &
Crow, 2004). Hammons and Fiese (2011) found that children and adolescents who share family
meals three or more times per week are more likely to have a normal weight range and have
healthier dietary and eating patterns than those who share fewer than three meals together.
Food insecurity may contribute to the inverse relationship between obesity and SES
(AAP- Committee on Nutrition, 2003). Lower SES encourages consumption of low cost, high

energy-dense and nutrient poor foods (Kurnanyika & Grier, 2006). Parental SES poses a barrier
to appropriate nutritional intake by children because of the cost associated with fresh fruits ,
vegetables, lean meats and fiber that are required to ensure a balanced diet that promotes healthy
weights (McAdams, 2010). Children from low SES communities have fewer super market
convenience stores that supply fresh, quality and affordable foods (Kumanyika & Grier, 2006).
As such, low income families are more inclined to shop at comer stores. These stores offer
markedly less healthful foods and the few healthful foods they do stock are pervasively
expensive. Consequently, higher priced foods affect children ' s weight because it is financially
unfeasible for low income families to purchase healthy foods for their children. Additionally,
there has been an increase in fast-food restaurants that are prevalent in low income
neighborhoods and communities. This overabundance in fast-food restaurants leads to poorer
health choices for children who tend to be more susceptible to their intensive marketing
strategies (Kurnanyika & Grier, 2006). As well, soft drinks have become a primary source of
carbohydrates for children and this has been stimulated by the fast-food franchise.
Similarly, activity levels of youth are dependent on environmental features such as access
to recreational facilities , walkability of the environment, low neighborhood crime rates and
neighborhood safety (Spruijt-Metz, 2011). Many parents restrict children ' s time outdoors due to

16

safety concerns (Kumanyika & Grier, 2006). Neighborhoods that have lighted playgrounds, bike
lanes, walking trails, or gated areas foster outdoor activities (McAdams, 2010). Lower SES
communities have limited access to quality housing and live in neighborhoods that do not
facilitate outdoor activities (Srinivasan, O'Fallon, & Dearry, 2003). Hence, children's limited
access to parks and recreational facilities indicates that a child ' s level of fitness is significantly
affected by the availability of physical activity venues. Increasing urbanization has resulted in
the decrease in frequency and duration of physical activity of daily living such as walking to
school or doing household chores (AAP- Committee on Nutrition, 2003). Moreover, society
has begun to view physical fitness as an event that must be slotted into busy schedules; therefore,
competing with work, family and leisure time (Kushi, 2006). Changes in the requirements of
school physical education programs have also led to decreased opportunities for exercise
(Spruijt-Metz, 2011 ).
Furthermore, an article published by Clark (2009) has acknowledged that sport
participation in Canada is declining. Data from the General Social Surveys of 1992 and 2005
has revealed that in 2005, only 51% of children aged 5 to 14 regularly took part in sports.
However, this statistic is steadily decreasing with the most significant decline apparent in boys.
Not only are boys less likely to partake in sports, but those who do compete are involved in
fewer sports. Boys sport participation has decreased from 66% in 1992 to 56% in 2005. Over
the same period, sports participation of girls has remained relatively unchanged from 49% to
45% (Clark, 2009). This reduction in sport activity is influenced by many factors including
household income.
In 2005, 51% of two-parent Canadian households with children spent an average of 579
dollars annually on sports and athletic equipment. This figure does not include other associated

17

costs including facility rentals, transportation, accommodations, club memberships and
competition entry fees . For that reason, sports participation is most prevalent among high
income households (68%) and lowest among children from lower income households (44%)
(Clark, 2009). To help rectify this discrepancy, funding programs are now available to families
and children to help cover the costs of organized sports. For instance, KidSport Canada is a
community-based sport funding program that provides grants to children under the age of 18
years old to participate in a sport session of their choice. The goal of Kid Sport Canada is to help
remove the financial barriers that prevent children from playing organized sport (KidSport
Canada, 2012). Overall, the physical activity levels of youth are declining and this is directly
related to their environment.
Likewise, sedentary entertainment options including TV, video and computer games have
contributed to reduced activity levels. Children who watch four or more hours of TV per day
have a radically higher BMI than those who watch fewer than two hours per day (AAPCommittee on Nutrition, 2003). The average child or adolescent watches an average of three
hours of TV per day and this does not include time spent watching/playing video games or other
media devices (AAP - Committee on Public Education, 2001). Comparably, TV viewing is
exponentially higher in low income households and low income children watch TV for more
hours. These children are exposed to more media than their higher SES counterparts.
Furthermore, children that watch an excessive amount of TV per day are more likely to perceive
advertising as authoritative and helpful in making appropriate health choices. As a result of
increased TV viewing, children are exposed to more food advertising and this advertising
drastically influences food choices and preferences even with brief exposure (Kumanyika &
Grier, 2006).

18

Having a TV in a bedroom is a strong predictor of being overweight even amongst
preschool-aged children (AAP- Committee on Nutrition, 2003). Approximately 32% of2 to 7
year olds have TV sets in their bedrooms (AAP- Committee on Public Education, 2001).
Further, watching TV while eating promotes higher caloric intake and this includes snacking on
high energy foods and drinks (Kumanyika & Grier, 2006; McAdams, 2010). Violent and
aggressive behavior, sexuality, academic performance, body concept and self-image, nutrition,
dieting, and substance use and abuse patterns are influenced by excessive TV viewing (AAPCommittee on Public Education, 2001). Screen time needs to be reduced and more physically
vigorous activities must be encouraged to help compensate for the increase in sedentary
lifestyles.

Current Interventions and Guidelines
As discussed previously, the development of childhood obesity is based on many facets
including personal, environmental, societal and physiological factors. However, most
interventions to date have focused on behavioral change without considering the necessary social
and environmental changes that are needed to enable the desired behaviors (McAdams, 2010).
Likewise, much research to date that examines the determinants of childhood obesity focuses on
the individual without considering the ecological framework that includes family, community
and broader corporate and government influence (RNAO, 2005). Lifestyle modifications
continue to be the cornerstone of treatment of obesity but adherence is poor and success is
limited due to many barriers including low SES (Lau et al. , 2007). Childhood obesity remains an
emerging health issue for which knowledge regarding treatment and prevention is still in the
infancy phase (RNAO, 2005). Seal and Broome (2011) identify that there is continuing need for

19

randomized controlled trials (RCT) that focus on child subgroups which include children in
families with low SES and young children.
Many of the current interventions aimed at childhood obesity involve school-aged
children and adolescents. Hopkins, DeCristofaro, and Elliot (2011) found that children who
began interventions at a younger age and during earlier stages of obesity were more apt to
continue programs; therefore, improving their success at maintaining healthy weights. Since
obesity usually begins in early childhood, this target group needs to be addressed. Research has
shown that " interventions are not usually successful once overweight and obesity have occurred"
(Canning et al., 2004, p. 240). Hedley et al. (as cited in Dontrell, Sherry, & Scallion, 2007)
noted that the current practices aimed at adolescents have demonstrated no signs of the
prevalence of obesity being reduced among the general adolescent population. However, there is
acceleration in the prevalence of overweight among low-income children between the ages of 2
to 5 years old between 1989-1994 and 1995-2000. Based on these data, more preventative
strategies need to be implemented and targeted at this demographic so that preschool-age
children are not reaching the levels of their adolescent counterparts.
This is supported by Dontrell, Sherry, and Scallion (2007) who identified in their
systematic review that few pre-emptive processes are indeed available for this age group. They
isolated only seven interventions directed at 9-70 month old children. This study not only
recognizes the need for preventative practices aimed at this demographic but also that
multicomponent strategies, which are interventions that include more than one change such as
diet and exercise, may be more effective because childhood obesity is multifactorial.
Additionally, Campbell and Hesketh (2007) had similar results with their systematic review of
the literature. In total nine studies were identified as being effective and positively impacting

20

children's body weight from the ages of zero to five years. The majority of these nine studies
included using multicomponent approaches.
In BC there are two provincial initiatives that are committed to the health and well-being
of preschool-aged children. ActNow BC is a cross-government health promotion initiative to
help improve the health of British Columbians through addressing common risk factors and
reducing chronic disease. This strategy also helps to promote healthy living skills in preschool
children (Ministry of Health, 2006). The provincial government invested 2. 7 million dollars to
this project. Another key program is the provincially sponsored Success By 6 program. This
program is a prevention-focused, community based initiative dedicated to children ages zero to
six with the goal of developing the emotional, social, cognitive, and physical activity skills they
need to enter school. Success By 6 is based on a partnership between provincial credit unions,
the United Way, the Ministry of Children and Family Development and local communities
(Legislative Assembly of British Columbia, 2006). Although these two programs are good
examples of provincial plans, there is still an urgent need for more effective strategies.
These studies have illustrated that there are minimal best practice guidelines targeting this
cohort due to the limited research available. As such, guidance involving the preschool years is
restricted and existing clinical practice guidelines are difficult to adapt to pediatric needs. The
National Institute of Clinical Excellence (NICE) Obesity Guidelines are confmed to individuals
over the age of two years. The 2006 Canadian Clinical Practice Guidelines on the Management
and Prevention of Obesity in Adults and Children has 15 recommendations relative to the
pediatric population. Well researched, comprehensive, population-based guidelines to direct
clinical practice and help prevent and manage the complexities of obesity and obesity associated
health conditions are direly needed.

21

Barriers to Obesity Management
PCPs recognize many barriers to preventing and managing childhood obesity. Common
barriers described include time, adequate referral networks, knowledge, and reimbursement for
obesity-prevention services, team-support and practice tools (Boyle, Lawrence, Schwarte,
Samuels, & McCarthy, 2009; He, Piche, Clarson, Callaghan, & Harris, 2010). In spite of the
importance of PCP involvement in pediatric obesity prevention and management, many
providers fail to initiate treatment and report a low proficiency level with pediatric obesity
assessment and treatment (Story et al., 2002). The research has indicated that many PCPs are
insecure in their knowledge about obesity and the requirements necessary to combat this disease
(Boyle et al. , 2009). Moreover, literature posits that providers even fail to regard childhood
obesity as a primary diagnosis or even a true disease (Hopkins et al. , 2011). Equally, parents are
culpable of failing to recognize that their child is overweight or obese (Adams, Quinn, & Prince,
2005). This mutual lack of education is disconcerting and preventative efforts must concentrate
on this noteworthy shortfall.
The obvious disconnect and knowledge deficit between both parents and PCPs requires
rectification; thus, open communication is needed. Appropriate dialogue is necessary to ensure
that health care messages are being interpreted properly. Conversing is the most basic
interaction between people; yet, communication failures within the clinical encounter account for
many missteps in health outcomes. Health care providers must communicate their assessment to
children and parents. Failing to convey the results of assessments has a profound effect on the
health of the child. Approximately one-quarter of parents of overweight children report having
been told that their child is overweight (Perrin, Cockrell Skinner, & Steiner, 2012).
Acknowledging that the child is overweight and/or obese is the beginning of the journey to

22

becoming a healthy weight. This journey cannot exist if health care providers neglect to share
the results of scientific data indicating that their patient is indeed overweight and/or obese.
Therefore, disruptive eating and exercising patterns will continue and the risk of obesity related
co-morbidities will increase. Health care professionals must overcome any feelings of
ambivalence and discomfort when discussing weight. Weight is a sensitive topic for many but it
is worse to remain uninformed of one's overall health status as a result of excess weight.
Of greatest importance in the fight against childhood obesity is ensuring that PCPs are
well educated and confident about the diagnosis of childhood obesity and ensuring that
appropriate preventative, treatment and management strategies are initiated. Boyle, Lawrence,
Schwarte, Samuels, and McCarthy (2009) noted that health care providers "need time, training,
resources, and institutional support to improve their ability to communicate obesity-prevention
messages in both clinical practice and as community policy advocates" (p. S293). There is a
perceived futility in preventing and/or treating childhood obesity that exists in the minds of
providers. This can also be compounded by their own perceptions of body weight and image
(Hopkins et al., 2011).
A study was conducted by Barlow, Trowbridge, Klish, and Dietz (2002) aimed at
identifying interventions that are being utilized by pediatric health providers including
pediatricians, pediatric NPs and dieticians, in the treatment of overweight children and
adolescents to identify provider educational needs. Barlow et al. (2002) identified that for
preschool-aged children, a high proportion of aforementioned pediatric health providers often
recommend changes in eating patterns, limitations of specific foods and a few even advised
modest caloric restriction and low fat diet. All three pediatric health providers did recommend
weight control in preschool-aged children less frequently. However, many pediatric health

23

providers continue to report a lack of proficiency in counseling skills. Many were interested in
additional training with Continuing Medical Education (CME) being the preferred option. This
study supports that encounters with overweight patients are opportunities for assessment and
intervention. Nevertheless, interventions are often challenging within primary care settings
because education of families and patients takes time, behavior change is difficult and the health
consequences of obesity are latent for many children (Barlow et al. , 2002). Thus, addressing
childhood obesity in busy practice settings is often deferred and this is especially true of busy
fee-for-service practices that are not adequately reimbursed for offering these services (He et al. ,
2010; Hopkins et al. , 2011 ; Story et al. , 2002).
The challenge regarding adequate reimbursement for obesity care arose due to the lack of
acceptance of obesity as a chronic disease by health management organizations, private insurers,
and the government. These payers refused to accredit obesity and obesity related treatment.
Historically, reimbursement of obesity has depended on the patient having other health
conditions which are billable. However, efforts have been made to help rectify this downfall in
Medical Services Plan (MSP) billing as obesity is increasing worldwide and is considered a
significant health condition. In BC, the General Practice Services Committee (GPSC) has
established the Personal Health Risk Assessment fee (G 14066) which is a billable service for
physicians to undertake a personal health risk assessment visit with at risk patients. This fee is
part of proactive care which focuses on health promotion and disease prevention.
This fee was created in response to feedback from practicing physicians, and
recommendations from the BC Clinical Prevention Policy Review Committee 2009 report "A
Lifetime of Prevention", the British Columbia Medical Association paper "Partners in
Prevention: Implementing a Lifetime Prevention Plan" and BCs Provincial Health Officer paper

24

"Investing in Prevention Improving Health and Creating Sustainability". Targeted patient
conditions accepted by this fee include smoking, unhealthy eating, physical inactivity and
medical obesity. The value for this fee is 50 dollars in addition to the office visit and it is limited
to 100 patients per year and only one visit annually per patient (General Practice Services
Committee [GPSC], 2012). Obesity reimbursement practices are improving nationally in order
to motivate health care professionals to improve the breadth of services they offer.
Story et al. (2002) also recognize that all members of the interdisciplinary health care
team require more education, not just PCPs. They conducted a study with the primary objective
of evaluating health care professional's attitudes, perceived barriers, perceived skill level and
training needs in the management of childhood obesity. Through their research it was noted that,
of the 293 pediatric NPs, 444 registered dieticians, and 202 pediatricians, all three groups
identified they need additional training on obesity management. Story et al. (2002) noted that
pediatric obesity is a topic that is seldom covered in medical, nursing or dietetic curriculum.
This is also echoed in Canada where He, Piche, Clarson, Callaghan, and Harris (2010) concluded
through their study that Canadian primary health care providers are not sufficiently equipped to
address the pediatric obesity epidemic. This study included 464 family physicians and 396
community pediatricians. It was discovered that ineffective assessment tools, treatment
resources, dissemination of clinical practice guidelines, inadequate undergraduate education and
the infrastructure of the current health care system all impeded practitioners delivery of obesity
related treatment.
Moreover, Larsen et al. (2006) acknowledge that NPs are not exempt from this
inadequacy in educational need. They utilized a convenience sample of 99 family and pediatric
NPs from Texas to evaluate common NP pediatric obesity prevention practices. Through their

25

study they found that 40% of the respondents reported not using any guidelines in their
prevention practices and that half of the sample reported never or rarely utilizing BMI to identify
the rate of excessive weight gain in their patients even though almost 74% reported being aware
of current guidelines for practice. They conceded that specifically NPs need to receive more
instruction on risk factors for childhood obesity. The complexities associated with obesity have
resulted in health care professionals feeling ill-equipped to deal with this escalating public health
concern.
It is evident that further education and skills-training are needed regarding the topic of
pediatric obesity generally and more specifically greater recognition, dissemination and
transparency regarding the interventions and treatments that are available to assist PCPs in
managing their obese pediatric patients. To date most health professionals rely on professional
guidelines and CME courses to help solidify their current practice. Medical training institutions
need to address this inadequacy in childhood obesity education in order to ensure that future
graduates are equipped with the knowledge and skills necessary to make an impact on the rising
levels of obesity world-wide.
Another barrier to the management of pediatric obesity involves accessibility. PCPs are
often not exposed to the preschool-aged population unless they are presenting for episodic health
care needs. It is during these encounters that PCPs must take the opportunity to screen for
obesity and discuss follow-up care with these patients. Other opportunities to approach this
population includes when their parents or guardians are presenting for care and the child is
brought with them. Public health monitors children ' s immunizations, growth and development
during regular scheduled immunization appointments. However, following the 18 month
immunizations, public health often does not have a clinic visit with children again until

26

kindergarten or approximately five years old. During this time, children are not exposed to
health care services, and it is the responsibility ofPCPs to actively seek out opportunities to
evaluate this population. There are many barriers that need to be overcome to assist PCPs in
attending to the health care needs of this cohort.
Implications for Nurse Practitioner Practice
NPs are registered nurses (RNs) who have obtained an expert knowledge base, complex
decision making skills and clinical competencies for expanded practice. NPs in BC are educated
at a Master's level and the education and training acquired through their programs facilitate
autonomous, prudent nursing practice. NPs are equipped with the knowledge base and skills
necessary to diagnose, prescribe medications, refer and consult with physicians and specialists
and ultimately provide an additional point of entry to the health care system for case
management (Browne & Tarlier, 2008). This unique profession functions on the interface of
nursing and medicine. Similar to physicians, NPs utilize clinical practice guidelines and best
practice standards to inform clinical decision making (Tarlier & Browne, 2011). NPs are,
therefore, prepared at a more advanced level than their RN counterparts. NPs are ideal PCPs
able to focus on the complexities of childhood obesity because they are ready to engage in
independent practice, clinical decision-making and are committed to primary care that is
consistent with primary health care (Tarlier & Browne, 2011). This advanced level of training
allows NPs to engage critically with literature, be exposed to cultural safety, embrace primary
health care philosophy, and practice with a profound awareness of how the social determinants
of health affect health and health care inequalities (Tarlier & Browne, 2011).
NPs have their roots in underserved populations. In Canada, outpost nurses were the first
NP type role, and they were established to provide basic primary health care services in rural and

27

remote areas of northern Canada specifically to Aboriginal communities (Browne & Tarlier,
2008). These outpost nurses worked in Aboriginal communities that suffered significant health
care inequities compared to the rest of the Canadian population. These nurses provided essential
primary care whilst working at the community level to address the larger context of socially
determined health disparities and access inequalities (Brown & Tarlier, 2008). As such, NPs are
increasingly called upon to provide care for patients who are facing considerable barriers to
accessing care, including children of low SES.
NPs work with patients of all ages and stages across the lifespan (College of Registered
Nurses of British Columbia [CRNBC] , 2012), including toddlers and children who are suffering
from obesity. As well, NPs are educated and trained in self reflective and communication
strategies that help them create reciprocal therapeutic relationships. This is essential when
working with preschool-aged children and their families within their socioeconomic context.
Further, NPs have the ability to create partnerships with communities and establish opportunities
to connect with this demographic through community functions and events. Creativity and
innovation are the cornerstones for seeking out interactions with children. NPs are educated in
program planning and community engagement and are thus able to employ all forms of skills to
promote health interactions. Therefore, NPs have the capacity to engage in public opportunities
to assess and screen children making the NP role unique and allowing for greater awareness of
the ability ofNPs to navigate through public programs to access children. Subsequently, NPs are
well situated to deliver primary health care services to this population and contribute to the
overall health of children, families and communities.

28

SECTION TWO
NP PRIMARY CARE PRACTICES

The health risks of pediatric obesity have been outlined and specifically the consequences
of low SES have been highlighted in the pediatric populace with emphasis on preschool-aged
children. The implications of childhood obesity on NP practice have been discussed and NPs
have been identified as major stakeholders in the fight against this escalating epidemic. This
section aims to examine the evidence ofNP primary care practices and care within NMHCs, also
known as nurse managed clinics, and PWMPs. The evidence and supporting literature help to
provide the foundation for NP-led obesity clinics within the current health care climate as a
potential option for helping prevent and treat pediatric obesity. The following information
legitimizes the role ofNPs in pediatric obesity within a variety of sites and contexts. NP-led
obesity clinics are an innovative environment in which NPs could thrive and continue to help
combat the pediatric obesity epidemic.
Nurse-Managed Health Centers

NMHCs have existed in the USA for over 30 years but are an emerging area of nursing
practice in Canada. The origin ofNMHCs can be traced to the Henry Street Settlement in the
late 19th century (King, 2008), while the first community-based NMHC in the USA was
established in the 1970s (Clendon, 2003 ; Coddington & Sands, 2008). By the mid-1980s there
was a surge ofNMHCs in academic nursing institutions. These schools of nursing were
interested in increasing focus on faculty practice and research, clinical placements for students
and fulfillment of a community service mission (King, 2008). NMHCs are increasingly utilized
throughout the USA with approximately 250 in operation. Many NMHCs are classified as
academic or community-based health centers. Few NMHCs have gained status as federally

29

qualified health centers (Esperat, Hanson-Turton, Richardson, Debisette, & Rupinta, 2012).
NMHCs in the USA are often located in medically underserved areas including low-income
urban neighborhoods and rural areas (Hansen-Turton, Bailey, Torres, & Ritter, 2010).
In Canada, the Sudbury District Nurse Practitioner Clinics (SDNPC, 2011) became the
first NP-led clinics in the country. The SDNPC (2011) opened its doors to the public in the
summer of2007. The SDNPC (2011) focuses on providing comprehensive primary care with a
team approach. Each patient is registered to the clinics and their care is followed by a NP. The
team is comprised of a physician, pharmacist, registered nurse, social worker and dietician
(Sudbury District Nurse Practitioner Clinics [SDNPC], 2011). The goal of these clinics is to
help mobilize health care for orphaned patients and those who receive sporadic care such as in
walk-in clinics and emergency departments. Continuity of care is important in preventing
overuse of these acute services; thus, patients are partnered with a PCP. These clinics serve
patients of all ages and all backgrounds including obese preschool-aged children of low SES.
The Ontario government announced that 25 NP-led clinics would be established in the province
with the intention of reducing those without a PCP and thereby improving comprehensiveness
and integration of services. The ministry provided funding for six full-time NPs and two parttime consulting physicians who receive a monthly stipend for consultations and are compensated
with fee-for-services for seeing patients in appointments (PRA Inc. Research and Consulting,
2009). The inception ofNP-led clinics in Ontario as a collaborative form of health care coupled
with well educated practitioners has helped to meet the needs of orphaned patients.
NMHCs in the USA and Canada are becoming a dependable health service in many
communities. NMHCs are a cost-effective model of health care delivery that offer health
services within nursing values that emphasize health promotion, disease prevention and

30

education for patients in order to manage their chronic health conditions. NMHCs increase
patients ' knowledge and create a supportive environment for patients to become active members
in their health maintenance (Coddington & Sands, 2008; Coddington, Sands, Edwards,
Kirkpatrick, & Chen, 2011 ). Moreover, an important component of the health services provided
by many NMHCs is community outreach which can extend to the homes of patients who need
more intensive care (Esperat et al. , 2012). NMHCs are settings in which Advanced Practice
Nurses (APN s), most commonly NPs, serve as primary providers, managers and administrators
(Esperat et al. , 2012).
NMHCs have a reputation for providing high quality health services to disenfranchised
and underserved populations. A considerable portion ofNP practice involves treating patients
that would otherwise not receive health management, also known as safety net care. Safety net
providers are health care professionals that deliver a significant level of health services to those
who are uninsured or underinsured (Fiandt, Doeschot, Lanning, & Latzke, 2010). These patients
are given superior medical management regardless of their ability to pay. This is particularly
true in Canada where universal health care ensures that all Canadian citizens have access to
health care no matter SES or ability to pay. However, certain geographical locations remain
secluded from necessary services due to shortages in health care professionals and health
facilities which are evident in rural areas.
According to Fiandt, Doeschot, Lanning, and Latzke (2010) NPs are uniquely qualified to
meet the needs of vulnerable patients due to the nursing skills and background that they bring to
the primary care role. Thus, NP-led obesity clinics are an ideal option for the management of
pediatric obesity in populations with low SES as these individuals are often isolated from
necessary health care services and are essentially an oppressed group. NP-led safety net

31

practices provide a model of care that increases access and improves health outcomes through
attending to social, demographic and other risks (Fiandt et al. , 2010). These practices emphasize
holism and consider the sociodemographic factors that impact wellness. Further, NMHCs are
specifically centered on the family unit and the community. They become a nucleus of the
community and rely on society members and organizations to help create healthier environments
for the entire locality.
There are multiple studies available supporting the quality of care provided by NPs
within interdisciplinary practices; however, there is not extensive research regarding independent
NP practices outside of these multidisciplinary settings (Barkauskas, Pohl, Tanner, Onifade, &
Pilon, 2011). Additionally, although there is a wealth of comparative data available contrasting
NP to physician performance, few studies exist which support the quality of care offered through
a NMHC. Barkauskas, Phol , Tanner, Onifade, and Pilon' s (2011) article aims to describe the
first national collection of quality measures for NMHCs. Nine NMHCs from eight states all
affiliated with universities were recruited to participate in retrospective data collection. Quality
measures related to outcomes for breast cancer screening, cervical cancer screening, diabetes
care, hypertension management and smoking cessation were based on protocols of the
Healthcare Effectiveness Data and Information Set (HEDIS). Through this research, Barkauskas
et al. (2011) discovered that the average percentage of quality goal achievement compared
favorably with HEDIS 50th percentile benchmarks in all cases and the 90th percentile benchmark
for most of the quality measures. The quality outcome for hypertension care exceeded the
HEDIS 90th percentile. These results illustrate that the care delivered by NMHCs either meets or
exceeds the recommended quality benchmarks established by HEDIS. Further, the outcomes for
uninsured patients were similar to insured patients demonstrating that NMHCs are effective

32

safety net providers. This study contributes much needed research about the quality of care
provided by NMHCs.
The concept of high quality of care provided by NMHCs is also echoed in the results of a
study conducted by Coddington et al. (2011). NMHCs administer comprehensive health care
with positive health outcomes and offer a high level of patient satisfaction. Their literature
review revealed that satisfaction surveys indicated that 93% of clients were completely satisfied
or very satisfied with the care they received at a NMHC. Through this research study, they too
found that the quality of health care provided by the NMHC either met or exceeded national
benchmarks of care. This is further supported by Coddington and Sands (2008) who identify that
overall patients are satisfied with the care they receive at NMHCs. Indicators of quality of care
that illustrate specifically the desirable features ofNMHCs include that they remove barriers to
care, improve access and develop lasting therapeutic relationships with NPs. Furthermore,
research to date exhibits that NMHCs improve the use of preventative services, aid in the
promotion of health, compliance of treatment, patient satisfaction and decrease emergency room
visits and hospitalization (Coddington & Sands, 2008). This evidence supports that NMHCs
provide high-quality care and act as a much needed safety net for vulnerable and marginalized
populations.
Badger and Behler McArthur (2003) conducted a study to examine the health outcomes
of patients who utilized an academic nursing clinic staffed by two NPs located in a high-rise
public housing facility for low-income citizens. They found in their study that the NP
therapeutic relationship was a key factor in health outcomes for this population and was critical
in changing patient behavior and compliance. The onsite clinic also removed accessibility
barriers including transportation. Further, the clinic had a significant impact on medical costs

33

and misuse of services. There was a 21 % reduction in paramedic and police calls within the first
year, which represents the behavioral change of the population and the use of the clinic to meet
health care needs as opposed to the emergency department. The fmdings of this study do
concede that the additional cost of running the clinic is an investment in reducing health
disparities. However, the costs associated with such an investment could have an impact on
reducing overall health care expenditure.
Therefore, the most difficult challenge ofNMHCs is achieving financial sustainability
(King, 2008). It is a virtual certainty that a significant proportion of the services provided will
require cross-subsidizing; as a consequence, the fiscal climate for NMHCs is fragile and tenuous
(Esperat et al. , 2012). This is supported by a study initiated by the Independence Foundation, a
private philanthropy, which funded the first NMHCs in Philadelphia, P A. In 2000, the
Independence Foundation initiated a study often of their NMHC grantees to assess their
accomplishments and to identify any challenges encountered by these centers. The study
spanned ten years from 1993 to 2003 and identified the challenges of how these NMHCs could
become fmancially self-sustaining without compromising their mission of providing holistic
health care to underserved populations.
King (2008) utilized these findings from the Independence Foundation and published an
article that presents the themes which emerged from this study with an emphasis on the
challenges encountered by four academic-based centers and how these challenges were
addressed. King (2008) identified that all four Philadelphia based NMHCs were successful in
overcoming their challenges except economic viability. Although these NMHCs were able to
establish effective billing systems, to obtain credentialing from major area payers, to cultivate
trusting collaborative relationships with their communities, to increase their patient base and to

34

operate cost-efficiently, they were not able to achieve fiscal endurability. All of these NMHCs
required a budget subsidy due to difficulties with reimbursement and government legislation.
This article establishes that evaluation data is needed to help ensure that NMHCs receive
monetary support from subsidy programs to guarantee their success.
In the USA, financial resources for NMHCs come from both federal and nonfederal
sources. Federally, a very important source of support and growth came in the rnid-1980s from
funding through the United States Health Resources and Services Administration (HRSA),
Bureau of Health Professions, Division ofNursing' s Special Projects program. Growth of
NMHCs continues to be fueled by support from the HRSA with many NMHCs relying on this
funding. In addition, academic institutions can and do contribute substantial resources to
NMHCs (Esperat et al., 2012; King, 2008). According to Barkauskas et al. (2011), NMHCs are
most often sponsored by schools of nursing. In fact approximately 20%-27% of non-operating
revenue is obtained by subsidies from universities and schools of nursing (Pohl, Tanner, Pilon, &
Benkert, 2011). Nonfederal sources for NMHCs are the National Nursing Centers Consortium
(NNCC) and the Institute for Nursing Centers (INC). Both of these funding sources are nursing
affiliations which promote, encourage, and support NMHCs and independent NP practice.
Finally, private funding has also played a key role in the sustainability ofNMHCs
(Esperat et al., 2012). For example, in 1993, the Independence Foundation designated
community-based nurse-managed health care as one of its primary funding initiatives. Since the
launch of this initiative, NMHCs in Philadelphia have thrived. Accordingly, Philadelphia has
been recognized as a leader in the implementation ofNMHCs and is the foundation for which the
integration of future NMHCs is based on (Bailey et al. , 2009). Reasons for NMHC success in
Philadelphia include establishing federal health center funding, commitment from local funders

35

for instance the Independence Foundation and creating extremely effective NMHC
collaborations such as the NNCC . These three features have cemented the NMHC model of care
in Philadelphia. With continued changes occurring nationally regarding NP practice, the future
is promising for NMHCs. With the passing of the Patient Protection and Affordable Care Act
(201 0) in the USA, more than 30 million Americans will gain access to quality primary care by
2014. Further, this act has resulted in the authorization ofNMHCs, which if the funds are
appropriated for this authorization would provide 50 million dollars to support new and existing
NMHCs (Esperat et al. , 2012; Pohl et al. , 2011). Additionally, NMHCs can now meet the
criteria for consideration by accrediting bodies for formal designation as a patient-centered
medical home and thus be considered for grants and contracts from the Centers for Medicare and
Medicaid Services (Esperat et al., 2012). And lastly, NP care in the USA is now fully
reimbursed by most payers and this includes third-party reimbursement (Buppert, 2010; Phillips,
2012) .
In Canada, however, there remains a lack of consistent public policy regarding long-term
funding ofNPs. There is no defined budget for NP service across the country and the Regional
Health Authorities (RHAs) have the mandate in most parts for identifying population health
needs in their areas and to determine the requisite number, mix and distribution of health care
providers for service delivery (CNA, 2006). Furthermore, a variety of employment models are
used across the country to remunerate NPs. Four employment models have been recommended:
(1) remuneration via an organizational employer; (2) remuneration directly from the Ministry;
(3) remuneration directly from Medicare; or (4) remuneration directly from a physician employer
(CNPI, 2006) . Canada has much progress to make regarding NP funding and to ensure the full
integration ofNPs into the health care system. Looking to our neighbors in the South will help

36

Canada address policy and governing issues and hopefully create a standardized, unified voice
for NPs across the country.
Although NMHCs face unique challenges in making their operations work fmancially,
their success has prevailed due to one common element: the crafting of a comprehensive,
culturally sensitive model of care centered on nursing (Bailey, 2009). Under this model of care
attention is given to unmet health care needs while employing a patient-family centered
approach. This is an important focus of this type of care and it is, therefore, appealing to
patients. Most importantly, the overall contributions NMHCs make to the health care of
vulnerable populations remain substantial and possibly the cost-savings associated with
improving the health status of these populations is enough to facilitate subsidy funding from
academic institutions and/or government grants. Furthermore, the evolution ofNP practice will
continue to stimulate different funding models for NPs in a variety of settings and further help to
ensure the financial feasibility of these services.
In summary, the holistic benefits ofNMHCs far outweigh the economic costs of

implementing these facilities . This is recognized in many countries, including Canada. A
compelling benefit ofNMHCs is their ability to provide quality care at a low cost whilst securing
the long-term continuity of safety nets for suppressed or otherwise orphaned patients. Similarly,
NP-led obesity clinics are able to meet the needs oflow SES children as these patients are often
vulnerable and may not have a PCP. Like NMHCs, NP-led obesity clinics are located within the
communities they serve; thereby, enhancing accessibility. Additionally, NP-led obesity clinics
reflect the health care philosophy embraced by NMHCs place emphasis on health promotion and
obesity prevention. NP-led obesity clinics resemble traditional NMHCs but focus specifically on
the specialty of childhood obesity care.

37

Pediatric Weight Management Programs
There are numerous barriers to providing obesity treatment and management strategies
within the primary care setting. These many obstacles extend far beyond clinical encounters. At
the society level, despite media coverage on the pediatric obesity epidemic and the increased
awareness of the adverse effects associated with excess body fat on health, the existing
preventative and therapeutic measures have not succeeded in abating the prevalence of
overweight and obesity. Additionally, at the individual level, the three pillars of obesity
prevention and treatment- improved diet, increased activity and long-lasting behavior changesare difficult to implement and are failing to meet treatment outcomes (Chanoine, Ball, Hagedorn,
& Morrison, 2009); as a result, more aggressive strategies are needed. PWMPs have become a
more recognized model of care due to their ability to offer intensive weight loss and weight
management interventions.
The prevention and treatment of childhood obesity is evolving to combat the resistant
nature of this chronic disease. The countless variables that facilitate the development of obesity
are difficult to control and efforts to stave off this disease must change accordingly. At this time,
a staged approach is recommended (Spear et al., 2007). There are four stages: (1) prevention
(plus healthy lifestyle changes), (2) structured weight management, (3) comprehensive
multidisciplinary intervention, and (4) tertiary care intervention. Utilizing this approach would
mean that obese children and teenagers who fail to lose a substantial amount of weight with
primary care interventions, which are considered stage one and two interventions, should be
referred to interdisciplinary weight management programs which are stage three interventions.
Stage three interventions consist of approximately eight or more weeks of treatment and focus on

38

moderate to high intensity interventions. Stage four interventions involve aggressive obesity
management including palliative measures, occupational therapy and psychosocial support.
Predominately, PWMPs provide comprehensive, intensive weight reduction interventions
which aim to change children ' s lifestyle through various interactive strategies. These programs
ultimately help children to reach a healthy weight and then manage their healthy weight for the
long-term. The focus is on weight reduction through behavioral counseling, promotion of
physical activity, parent training/modeling and dietary counseling (Grimes-Robison & Evans,
2008; Schroeder, Browne, & McComiskey, 2010; Woolford, Sallinen, Clark, & Freed, 2011).
Behavioral modification techniques are aimed at developing self-regulation skills including goal
setting, self-monitoring and corrective behaviors. Two chief characteristics form successful
PWMPs. Firstly, PWMPs are interdisciplinary. Research has indicated that this form of
collaboration is needed to better meet the needs of the multifaceted components that contribute to
pediatric obesity (Schroeder et al. , 2010; Woolford et al. , 2011). Members of the team include
pediatricians, general practitioners, physiotherapists, registered dieticians, psychologists,
psychiatrists, registered nurses and NPs.
Secondly, PWMPs are family-based . Family-based weight management programs offer
the most opportunity for the prevention of excessive weight gain (Grimes-Robison & Evans,
2008; Holt et al. , 2008; White et al. , 2004; Woolford et al. , 2011). The interplay between social
support and behavior change has been well recognized and even psychosocial theories reinforce
this including the Theory for Planned Behavior and Social Learning Theory. Family is a
significant support network for children and integrating family participation into weight
management programs helps to produce better outcomes. Simultaneously treating both the
parent and the child has benefits for each (Epstein, Paluch, Roemmich, & Beecher, 2007).

39

Accordingly, social support is instrumental in making and maintaining behavior change and this
directly impacts self-efficacy. Without positive self-efficacy and social support, behavior change
cannot occur. Parents act as important role models for forming their children ' s attitudes about
physical activity through predisposing factors (self-efficacy, beliefs and enjoyment) and enabling
factors (environment and physical abilities). Further, parents influence children' s eating
behaviors through both demands or restrictions and through modeling and monitoring (Slusser et
al., 2012). As such, researchers agree that implementing effective behavior methods to reduce
obesity in the pediatric populations requires proficiency in general parenting skills.
Wilson, Latimer, and Mel off (2009) found in their study of the psychosocial determinants
of health behavior change in interdisciplinary, family-based childhood obesity treatment
programs, that children whose BMI decreased more had greater enhancement in social support
and quality of life. Additionally, improvements in quality of life were associated with
improvements in parental social support and self-efficacy. This study supports the relationship
between psychosocial determinants of health behavior change and clinical outcomes. This
connection is part of the reason interdisciplinary, family-based obesity treatment programs are
effective. Interdisciplinary, family-based behavioral obesity treatment programs are not a new
model of obesity care; in fact, these programs were developed 25 years ago. However, over that
time, youth have become more obese and the environment has become more obesiogenic which
influences the efficacy of these programs (Epstein et al. , 2007). Nonetheless, PWMPs continue
to provide intervention programs that focus on these two key elements of obesity management.
Since most of these programs rely on behavioral change as a key characteristic of
ensuring weight management, it is only prudent that self-referral to these programs be necessary.
As noted by Schroeder, Browne, and McComiskey (20 10), a pediatric multidisciplinary team

40

approach assures sensitivity to the unique developmental considerations of the child and family.
This promotes adherence to the commitment of long-term follow-up and weight maintenance
which is necessary to continue to maintain a healthy weight. Specific PWMPs, including the
Packard Pediatric Weight Control Program at the Lucile Packard Children's Hospital at Stanford
in Palo Alto, CA, require that both parent(s) and the child must want to join the program and
parent(s) and the child are required to attend all or almost all sessions. Therefore, many of these
programs prefer that family contact their services instead of health care professionals. It is
recognized that children and their family must be highly motivated and dedicated to the program
to ensure overall success.
Research regarding PWMPs is limited since they are in the formative years. The PWMPs
available have demonstrated modest reduction in BMI; however, few have published outcomes
data and some have even failed to formally evaluate their programs (Woolford, Clark,
Achamyeleh Gebremariam, Davis, & Freed, 2010). There is little to no systematic method of
evaluation throughout the literature to indicate program success (Ball, Ambler, & Chanoine,
2011; Grimes-Robison & Evans, 2008) . In Canada, Ball, Ambler, and Chanoine (2011)
recommend that PWMP leaders allocate resources for evaluation so that data can be compiled to
assess their effectiveness . Once data are generated regarding these programs, then the validity
can be assessed. Thus far, the following table from Grimes-Robison and Evans (2008) lists key
characteristics of successful PWMPs to date based on their literature review.

Table 1: Characteristics of successful weight management programs
Category

Criteria

Quality of care
Weight loss
Motivation

Perceived care rated high by family
Patient met goal weight
Health care team provided verbal or written

41

Positive home environment
Parental involvement
Comprehensive assessment
Group and individual behavior therapy
throughout program
Interdisciplinary approach

Education on diet and physical activity
(Grimes-Robison & Evans, 2008, p. 336).

motivation and feedback to patient
Homework given to engage family and
motivate behavior change
Required family involvement throughout
program including diet and physical activity
Assessment included weight history, current
diet and physical activity records, readiness to
change, etc.
Required component of program
Health care team includes registered dietician,
mental health professional, physician, exercise
therapist
Team communicates regularly about care
Program included education and skill-building
on diet, exercise and decision-making

Despite the benefits of PWMPs, there are marked barriers to their overall success.
Firstly, attrition remains a significant obstacle to PWMPs. Reported reasons for attrition include
insurance/medical coverage, length of the program, lack of adequate transportation, failure of the
program to meet expectations, the children's desire to leave and the inconvenience of
appointment times. Holt et al. (2008) noted in their study that negative interactions with health
care professionals drastically impact dropout rates. Health care professionals failed to develop a
rapport with the child and often their feedback was not perceived as constructive. Alternately,

health care professionals expressed frustration in their interactions with children and parents.
Regardless, the onus is on the health care professional to develop a supportive, empathetic
relationship (Grimes-Robison & Evans, 2008). The high level of patient satisfaction ratings of
NMHCs suggest that this method of health care delivery would be effective at retaining patients
in obesity programs rather than traditional obesity management programs. As well, the ability of
NPs to generate lasting therapeutic relationships with their patients attends to quality of care

42

issues and reduces the potential for negative interactions which have resulted in discord with
other health care professionals.
Another common barrier found in PWMPs involves transportation. Commonly PWMPs
are offered at academic institutions in urban settings; yet, many participants are not members of
the communities in which these facilities are located. Thus, many participants found that travel
to and from these clinics is burdensome (Grimes-Robison & Evans, 2008). Ballet al. (2011)
conducted the first national environmental scan of Canadian programs that offer pediatric weight
management care. In this study, they identified 18 independent PWMPs located in six out of ten
Canadian provinces and three territories. They recommend from their conclusions that there is a
need to translate the obesity-related health services from specialized centers such as hospitals to
the primary care environment. It is within the primary care environment that most family ' s
access care and PWMPs need to be offered in community-based settings (Ballet al. , 2011). As
noted above, NMHCs are often located within the communities they serve and NP-led obesity
clinics are also offered within community-based settings. As such, this helps to address barriers
to transportation.
An additional identified barrier is appropriate referral to PWMPs. Woolford, Clark,
Achamyeleh Gebremariam, Davis, and Freed (20 10) report that the time constraints encountered
within busy primary care practices do not allow for proper counseling, treatment and
management of pediatric obesity. Further, pediatric obesity treatment guidelines and toolkits do
not address the time restrictions that primary care settings contend with. Efforts have been put
forth to help expedite the identification, diagnosis, and treatment of pediatric obesity in primary
care settings. For example, Take ACTION! is a NP practice guide for prevention of childhood
obesity within primary care. It is a toolkit designed to be carried in the NPs pocket or be easily

43

accessible on a desk or a shelf. The toolkit features salient aspects of childhood obesity
including risk factors, diet and activity recommendations and techniques for behavioral
modification counseling. Take ACTION! is intended to promote early recognition of children at
risk and to help improve anticipatory guidance (Chesser The, 2006). The efficacy of utilizing
such a tool in primary care remains to be evaluated, but it is a step f01ward in helping to address
the difficulties of obesity management in primary care. Regardless of these advances, the need
to partner with PWMPs is evident. As a result, the AAP and the American Medical Association
recommend the use of interdisciplinary weight management programs when primary care efforts
have failed to achieve satisfactory results (Woolford et al., 201 0).
As such, referral to PWMPs is required. The referral process should be achieved easily
with the patient's care transitioning smoothly from primary care to specialized care; yet, there
remain challenges inherent in this procedure. Woolford et al. (20 10) found in their study that
referral to PWMPs is often delayed or deferred. Their study examined the factors that might
influence physicians ' referral of obese adolescents to multidisciplinary PWMPs. They surveyed
375 pediatricians and 375 family physicians. The survey explored program availability, referral
history, desired services and when in the course of treatment physicians would transfer care. The
results of their study indicate that physicians would refer when unsure of the next treatment
method after exhausting all other treatment modalities including diet, activity and behavioral
therapies. As well, most physicians would also refer at any time when requested by the child or
parent. Overall, however, physicians tended to delay transfer of care to PWMPs with most
referring after six months of treatment in the primary care setting and if the patient had been
obese for more than two to three years. This postponement has the potential to negatively impact
the course of the patient's condition. Moreover, lack of awareness of the PWMPs available to

44

physicians was a notable shortfall. Approximately one quarter of family physicians did not
know whether there was a PWMP available to them or not. This study reinforces the need for
broadcasting of these programs and resource dissemination so that health care professionals are
aware of the services available in their area. Moreover, this study supports the need for further
communication and attention to PWMPs and the development of guidelines which specify
appropriate referral strategies and timeframes to these necessary services.
Finally, feasibility is paramount to the sustainability ofPWMPs. In general, obesity care
in pediatrics is thought to be poorly reimbursed. Not all portions ofPWMPs offered in Canada,
as in other countries, are covered by the patient's MSP; however, some fees are able to be
covered under extended medical plans. Fortunately, some programs connect with other
corporations or foundations to provide financial assistance to low SES families. The Pediatric
Weight Clinic in Calgary, AB is a private fee-for-service program that has liaisoned with the
Pediatric Obesity Foundation to financially assist families who are unable to afford the program.
These programs are costly, but there are charities and affiliations that are able to contribute
fiscally. In any case, delivering comprehensive obesity care in a primary care or clinical setting
may have negative financial implications for the institutions that support these programs and this
will ultimately affect the longevity and growth of these programs (Woolford et al., 2011).
Likewise, comprehensive PWMPs are most viable at academic centers or hospitals with the
personnel and infrastructure to maintain them. Without the fmancial contribution of academic
institutions or hospitals, it is unlikely that these facilities could be available to all communities.
Many of the programs offered in Canada are affiliated with hospitals and are jointly funded by
health authorities and/or universities. Most of these establishments are located in urban areas, as

45

such, patients and their families often have to travel to these urban centers to receive treatment
and this burden adversely impacts the scope of these programs (Woolford et al., 2011).
NP-led obesity clinics could address fiscal practicability by partnering with academic
institutions for research endeavors. Funding organizations expect providers to demonstrate that
the services offered are indeed cost-effective, that they meet the needs of the target population
and that health outcomes are achieved (Krothe & Clendon, 2006). Therefore, as with NMHCs,
NP-led obesity clinics must participate in data collection and evaluation of programs to ascertain
that the care provided is meeting stakeholder' s expectations. Additionally, academic institution
involvement would allow NP-led obesity clinics to become part of the community they serve and
would facilitate the opportunity of undergraduate and graduate nursing students to obtain
valuable clinical experience. NP-led obesity clinics must lobby the federal and provincial
governments to help compensate them appropriately for the care given to patients within these
specialized settings. Both NMHCs and PWMPs struggle with financial stability; however, the
care which these facilities provide should warrant federal efforts to secure the resources
necessary for their continued success. This has also been echoed by the AAP-Committee on
Nutrition (2003) who identify that there is a need for long-term commitment of funds from many
sources for obesity prevention and for the development and testing of strategies aimed at
reducing obesity.

Programs in Canada
There is a surplus ofPWMPs in the USA . In fact, most children ' s hospitals offer some
form of weight loss clinic and this does not include private clinics available outside of the
hospital setting. Due to the abundance of programs available, the AAP website discusses
pertinent details regarding PWMPs in order to aid parents in choosing an appropriate program

46

for their child. Therefore, it is beyond the scope of this paper to complete an extensive analysis
of the PWMPs available in the USA. Canada, however, is beginning to develop PWMPs and has
a less widespread list. Furthermore, this paper' s focus is on pediatric obesity prevention and
treatment efforts in Canada. As a result, this section will analyze the characteristics of the
documented programs available in Canada in order to ascertain whether these PWMPs model
well-developed PWMPs in other countries, specifically the USA.
The programs selected for analysis are from the Treatment and Research of Obesity in
Pediatrics in Canada (TROPIC) which is a group of Canadian clinicians, researchers, community
members and trainees with an interest in advancing the management of childhood and adolescent
obesity. The goal of TROPIC is to develop collaborations between clinicians and researchers.
Moreover, the focus is to contribute to knowledge transfer and exchange with the Canadian
Obesity Network which has a list of the PWMPs available in Canada. This is the beginning of
efforts to establish a registry. The programs currently registered are not an exhaustive list of the
PWMPs available as each must voluntarily register with TROPIC and the Canadian Obesity
Network. Registration is open to all PWMPs in Canada and a survey must be completed with
registration. The completed survey is then accessible via the website. Currently there are 24
programs registered on the website from seven different provinces across Canada including BC,
Alberta, Manitoba, Ontario, Quebec, New Brunswick, Newfoundland and Labrador (Canadian
Obesity Network, 2012).
The apparent lack of a general registry documenting all the PWMPs in Canada is a
noticeable shortfall and has resulted in a current research initiative. The Canadian Pediatric
Weight Management Registry is a project studying the health of children and adolescents who
are enrolled in a PWMP in Canada. The information obtained from this project will create a

47

national registry to collect the same information regarding body shape and size, medical history,
family history, and lifestyle behaviors from children and adolescents enrolled in five PWMPs
across the country. In the future it is expected that all PWMPs in Canada will be registered
(Canadian Obesity Network, 2012) . This will guarantee straightforward retrieval of the
information necessary to contact and examine these programs and help to aid prospective
research proposals.
Review of the programs listed on this website demonstrates that they consistently focus
on family participation and an interdisciplinary team approach. Moreover, most of the PWMPs
across Canada include a combination of both one-on-one sessions and group sessions where both
the child and parent(s) actively participate. Furthermore, interdisciplinary care is a feature of all
of the PWMPs listed on the Canadian Obesity Network. This is consistent with programs in the
USA. Common members of the multidisciplinary team include pediatricians, general
practitioners, registered dieticians, RN s, psychologists/psychiatrists and physiotherapists, fitness
professionals or kinesiologists . Only two PWMPs identify NPs as members of the team: (1) the
Centre for Healthy Active Living in Ottawa, ON; and (2) the SickKids Team Obesity
Management Program (STOMP) in Toronto, ON (Canadian Obesity Network, 2012). This is
different from the USA where many programs list NPs as members of the weight management
team which could be attributed to the long history ofNP practice in the USA and the relative
novice use ofNPs in Canada. Nonetheless, NPs are beginning to participate in pediatric obesity
treatment within specialized settings in Canada.
Program length ranges from 1-250 weeks and follow-up ranges from 1-728 weeks. Many
of the PWMPs that have follow-up for longer periods of time are participating in research related
activities. Nearly all PWMP interventions concentrate on lifestyle coaching through nutrition

48

and physical activity counseling. Approximately seven PWMPs also include pharmaceutical
intervention and only three PWMPs offer bariatric surgery as an intervention option.
Specifically, STOMP is a program that considers children for bariatric surgery and a surgeon is a
member of the health care team. Children referred to this program must be between 12-17 years
of age and have a BMI greater than the 99th percentile or a BMI greater than the 95th percentile
with a significant co-morbidity. The children that are accessing this particular PWMP have
significant morbid obesity and/or considerable associated health conditions. As such, some of
these children require intense intervention, commonly bariatric surgery (Canadian Obesity
Network, 2012). Of the American programs evaluated, most offer lifestyle coaching with some
offering pharmaceutical and/or surgical interventions. For example, in Baltimore, MD the Mt.
Washington Pediatric Hospital Center for Pediatric Weight Management and Healthy Living is
affiliated with the Johns Hopkins Center for Bariatric Surgery and accepts referral of children
requiring bariatric surgery. Bariatric medicine is a specialty area that is recruiting many different
disciplines to participate in integrated health care for obese individuals. NPs are part of this
multidisciplinary team and are valuable members of the American Society for Metabolic and
Bariatric Surgery. The movement ofNPs into this specialty area is yet another important feature
of the ability ofNPs to provide comprehensive health care to obese patients.
Age parameters are identified by the PWMPs and most address children in the ages of
school-age to adolescence approximately from 5-18 years. Five PWMPs accept children in the
preschool-age cohort including the Child and Teen Outpatient Nutrition Clinic in Toronto, ON,
the Children ' s Exercise and Nutrition Centre in Hamilton, ON, the Healthy Weight for Life
Clinic in Winchester, ON, the Obesity At Risk in Hamilton, ON and the Clinique de Nutrition in
Montreal, QC (Canadian Obesity Network, 2012). Many USA PWMPs incorporate preschool-

49

aged children in their programs including the Pediatric Weight Loss Program at Penn State
Hershey Children ' s Hospital in Hershey, PA, the NEW Kids Program at the Children ' s Hospital
of Wisconsin in Milwaukee, WI, the Mt. Washington Pediatric Hospital Center for Pediatric
Weight Management and Healthy Living in Baltimore, MD and the Pediatric Weight
Management Clinic at the Monroe Carel! Jr. Children ' s Hospital at Vanderbilt University in
Nashville, TN. Despite this, there remains a gap in the services available to preschool-aged
children; yet, these data acknowledge that PWMPs are beginning to incorporate preschool-aged
children into their demographical criteria.
No programs in Canada disclosed that they target specifically low income children.
However, many programs document information regarding their participants ' ethnicity and
immigrant status. This information is important as ethnic and racial disparities are notable in the
development of obesity. Certain ethnic groups, including African-American, Mexican-American
and Native-American, suffer from higher rates of obesity and these groups are often of low SES
(Slusser et al. , 2012). However, in the USA, the University of California at Los Angeles
(UCLA) Fit for Healthy Weight Program in Los Angeles, CA is avidly conducting research
regarding interventions aimed at low income children particularly overweight Latino children.
Dr. Wendy Slusser, an associate professor of pediatrics and public health at the UCLA David
Geffen School of Medicine and the School of Public Health, and director of the Fit for Healthy
Weight Program at Mattei Children ' s Hospital UCLA in Los Angeles, CA, has conducted the
first pilot intervention study that has contributed to reversing weight gain in preschool-aged low
income Latino children. The authors developed the Pediatric Overweight Prevention through
Parent Training Program which combines social learning with evidence-based interventions to
promote healthy nutrition and physical activity. The program was seven weeks in duration and

50

included two additional booster sessions given one month apart. This multi-component parent
training program was then evaluated through a randomized, controlled pilot study. The authors
concluded that combining parent training with promotion of nutrition and physical activity aimed
at low income mothers of Latino children can retract the anticipated curve of increased BMI for
at least one year following the start of the program (Slusser et al., 2012). This study contributes
to the small but growing body of literature examining parental practices and their influence over
children's nutritional status and also supports the need for programs aimed at intervention
measures for low-income children and families. Intervention programs for high-risk populations
need to be introduced well before and during elementary school in order to prevent the
development of pediatric obesity.
Analysis of these PWMPs reveal that the majority of the programs listed are funded by
the hospital and/or health authority and five PWMPs are private and thus funded by private
donors and/or fee-for-service. Under the fee-for-service funding model, the family must absorb
the costs of enrolling their child. The price of these programs is substantial especially for
families who are on a fixed or low-income budget. For example, the Y Kids Fit program in
Ottawa, ON costs approximately 200 dollars for Y-members and 280 dollars for non-Y
members. This fee covers the cost of all instructors and includes a four month access pass to the
YMCANWCA facility for the entire family. As well, the McGill Cardiovascular Health
Improvement Program (CHIP) in Montreal, QC has a 500 dollar initial stipend. However, many
programs offer alternate funding sources to help assist families who are unable to pay. As
discussed previously, the Pediatric Weight Clinic in Calgary, AB has liaisoned with the Pediatric
Obesity Foundation to financially assist families who are unable to afford their program.
Additionally, theY Kids Fit program provides sponsorship for qualifying families and the CHIP

51

programs subsidizes the remaining 75% cost of their program through fundraising and special
grants.
Several PWMPs listed participate in research through grant funding. Certain programs
are affiliated with other organizations or facilities including the YMCA/YWCA, universities,
private donors/sponsors, the Canadian Institute of Health Research, the Women and Children's
Health Research Institute and psychiatry programs. These associations provide support for not
only the program but also research initiatives (Canadian Obesity Network, 2012). Most PWMPs
in the USA are also connected with academic institutions and/or private fee-for-service.
As aforementioned, many PWMPs fail to formally evaluate their programs. This
deficiency was evident- six PWMPs participated in formal evaluation and fifteen did not -but
many did indicate that they plan on evaluating in the future . This insufficiency has contributed
to the limited research on PWMPs and has impacted the literature from which to draw on for a
proper analysis of these programs. Nonetheless, several PWMPs partake in attrition and
satisfaction evaluation. The Canadian Obesity Network (2012) has cited a research study aimed
at examining the cause of high attrition rates. " Should I Stay or Should I Go? Understanding
Overweight Children and Their Families Referred for and Discontinuing Weight Management
Care" is a qualitative, multi-center design that will study the family factors that underlie family's
decision to initiate or continue PWMPs (Canadian Obesity Network, 2012). Ongoing research
will help to validate or revoke the assets of PWMPs. Overall, the goal is to uncover what
intervention strategies produce positive health outcomes for obese children.
In BC specifically there are two PWMPs available through BC Children ' s Hospital in
Vancouver. The Centre for Healthy Weights - BC is a PWMP offered for children and
adolescents. In 2006, the Ministry of Health Services provided funding to BC Children's

52

Hospital to implement the Shapedown program. The Shapedown program was developed by the
School of Medicine at the University of California and is an approach that creates change in
nutrition and physical activity by addressing the underlying causes that promote poor food
choices and physical inactivity. Health care professionals can complete an online referral form
for their patients and a Family Lifestyle Assessment Tool. For families, there is a section for
children aged 2-5 years and it includes tip sheets for promoting healthy weights, active play,
healthy eating and a healthy relationship with food (BC Children's Hospital, 2011).
BC Children's Hospital also offers Healthy Buddies which is a child-centered health
promotion program which addresses attitudes and behaviors regarding physical activity, healthy
eating, healthy beverage consumption, healthy growth and development and healthy body image.
This program focuses specifically on elementary school children. Healthy Buddies was
originally conducted as a pilot study (Stock et al., 2007). It used the concept of buddy teaching
and was peer-led whereby older peers received a healthy living lesson and then had to deliver
that lesson to their younger buddies. The healthy living lesson targeted attitudes and behaviors
about body image, nutrition and physical activity. The data demonstrated that BMI and blood
pressure decreased significantly for the participants in the Healthy Buddies group compared to
the control group. From the results of this study, the authors were awarded a health promotion
and disease prevention grant from the Provincial Health Services Authority and have
implemented the program into 40 BC elementary schools (BC Children' s Hospital , 2012). These
programs are just the beginning of much needed interventional strategies and is the basis for
future PWMPs including NP-led obesity clinics.
The examination of the PWMPs in Canada appears consistent with the PWMPs offered in
the USA. However, this analysis is not extensive and formal evaluation would be beneficial to

53

determine if this is valid. There are many limitations of this assessment including the voluntary
registration ofPWMPs and there is no indication by the Canadian Obesity Network of how
dissemination of this registry was conducted. The process of contacting the existing PWMPs in
Canada is not evident. Therefore, the list available on the website is not an accurate reflection of
all the programs available; thus, signifying the urgent need for a national registry. Nonetheless,
this informal review of PWMPs has provided surface evidence that Canadian PWMPs are not
only available in Canada, but appear to model American PWMPs and utilize strategies supported
by literature within their programs.
NP-Led Obesity Clinics
NP-led obesity clinics are an innovative approach in combating the obesity epidemic
through bridging the successful qualities of nurse-led health centers with PWMPs and utilizing
this approach in a primary care setting. These clinics model the care provided in PWMPs, as
such, interdisciplinary, family-based intervention strategies are utilized. These interventions are
focused on the three pillars of obesity prevention and treatment and also include more intense
interventions such as pharmaceuticals and referral for bariatric surgery. The distinction between
NP-led obesity clinics and PWMPs is the location of the programs. NP-led obesity clinics are
located in primary care settings and offer similar services as PWMPs but are outside the
traditional hospital surrounding. As discussed previously, there is a need to move these
specialized services into primary care where the majority of patients access health care.
Another distinguishing feature ofNP-led obesity clinics is partnering with communities.
NP-led obesity clinics are located not only in primary care settings but within the communities
they serve. The benefit of being located within communities is twofold. First, NP-led obesity
clinics partner with communities to make long-term investments in the health of the entire

54

community. Pomietto et al. (2009) recommend partnerships to meet the needs of families and
children. Establishing methods to identify and partner with schools, programs and resources to
help advocate for optimal care for each patient and ensure mechanisms that facilitate referral to
these resources. PCPs must be cognizant of the resources in their community and refer to these
resources as required. Disconnected health care practices such as practicing in isolation and
being ignorant of community resources hinder optimum patient care. Therefore, NP-led obesity
clinics embrace the philosophy of community orientated primary care (COPC). COPC blends
the principles of public health and primary care. It is a systematic approach to health care that is
based upon epidemiology, primary care, preventative medicine and health promotion (Longlett,
Kruse, & Wesley, 2001). It emphasizes that clinical responsibility goes beyond the individual
and family to the larger community (Pomietto et al., 2009). Creating partnerships with
community programs allows PCPs to reach a greater population and provide more
comprehensive care. Engaging PCPs with community stakeholders also helps to strengthen the
community' s contribution to pediatric obesity and the PCP ' s contribution (Pomietto et al. , 2009).
The concept of collaborating with communities to improve health is not a new
philosophy especially in public health; however, it has gained greater recognition in more
traditional medical settings as health care providers realize that all non-biomedical influences on
health are easily addressed within the clinic setting (Ochoa & Nash, 2009). Krothe & Clendon
(2006) conducted a study of two NMHCs: one in the USA and one in New Zealand. They noted
that a defining characteristic of these NMHCs was that they utilized a community development
model that focused on the achievement of community goals. These NMHCs also regarded the
difference between working with the community and simply working in the community. It was
assumed that interventions without full community participation adversely affect the success of

55

these programs. These NMHCs built and maintained partnerships with key stakeholders through
the use of an advisory board. The Community Advisory Board was comprised of lifelong
residents including patients, representatives from business, education, the faith fellowship and
health and social services. The advisory boards ensured that services were planned and delivered
in an acceptable manner that benefited the community.
Second, placing NP-led obesity clinics in the communities they serve helps to reduce the
travel burden incurred by families when accessing PWMPs. As noted earlier in this paper,
transportation is a distinctive obstacle for patients who live in rural and remote areas and even
those who live in urban areas where access to public transport is limited. Additionally, children
of low SES are faced with the costs associated with commuting to cities to receive treatment.
Addressing the barrier of transportation could also be solved through providing online education
and counseling through various media devices. Computer and media technology has become a
common form of communication within this technological society and is an innovative form of
educating via the internet (Grimes-Robison & Evans, 2008; Woolford et al., 2011).
The primary results of the White et al. (2004) study demonstrate that the internet can be
an effective way to disseminate information and facilitate behavior change. Of course,
depending on the age of the target population there are certainly adaptations that would be
required to meet the patient' s development stage. For example, preschool-aged children may not
yet have the capacity to utilize the internet independently; however, with parental help they
would be able to view online sessions. Further, children of low SES may not have these
electronic devices due to their affordability and this would need to be considered when serving
this population. Nevertheless, utilizing various media to deliver programs is becoming
customary. For example, Small Step Kids is a website sponsored by the US Department of

56

Health and Human Services. This website is an engaging online resource for healthy living that
includes interactive games, videos and downloadable activity books that focus on healthy eating.
As well, TeleHealth which is a real-time, secure video conference is available at most health
centers throughout Canada and patients are able to access this media by connecting with their
local health centre. The Pediatric Centre for Weight and Health in Edmonton, AB offers flexible
services for families who live outside of Edmonton by utilizing TeleHealth. This helps to reduce
the travel burden incurred by families.
Flexibility and ingenuity is needed when caring for children of low SES as financial
constraint is a substantial barrier to health care. Therefore, efforts to mobilize necessary
resources and services to these individuals are required in order to ensure that children of low
SES have the potential to lead healthy lives. A study conducted by Cluss, Ewing, Long, Krieger,
and Lovelace (2010) attempts to overcome this notable barrier and aims to reduce the gap in
knowledge regarding family-based interventions for pediatric weight management in families of
low SES. They enrolled 48 families with 52 overweight/obese children aged 4-12 years from the
Medicaid health plan into an eight week program. The primary objective of this study was to
evaluate the feasibility of adapting and delivering a pediatric weight management intervention
which supports low income parents to become the primary teachers of their children with a focus
on healthy eating and physical activity behaviors.
They utilized the Healthy Eating and Activity for Life Time Habits (HEALTH) for
Families intervention and tailored this intervention to meet the needs of low income families by
adapting program materials for low literacy levels, combining telephone, mailed and in-person
support to reduce participant workload and decrease delivery cost and fmally they focused on
key treatment components. Through the course of their study, their data demonstrates that a

57

pediatric weight management intervention adapted to the needs of low income families is
possible and acceptable to these families and creates excellent program retention (Cluss et al.,
2010). Furthermore, this study illustrates that family-based weight management materials can be
adequately formatted for a low reading level and that using parents as primary change agents
reduces attrition rates because it reduces time and travel burdens placed on families. Thus,
programs should focus on teaching parents, children and other family members to embrace the
philosophy and skills offered by these programs so that all members of the family unit are
improving their own lifestyles and are jointly invested in improving their family's health.
Aspects of care that would differentiate NP-led clinics from current models of PWMPs
are the use ofNPs. NPs are alternate PCPs who have established their capabilities within
medicine over the past 40 years and have a long history of caring for underserved populations.
This lengthy relationship has facilitated a deeper understanding for low income children and
families and has fostered a kinship between NPs and disenfranchised groups. Therefore, NPs are
ideal PCPs for helping to reduce the disparities within the marginalized populace and are able to
bring much needed obesity care through NP-led obesity clinics.
Another noteworthy attribute ofNPs is their conscientious incorporation of integrated
care. NPs are well rounded PCPs that are molded through their graduate education to provide
quality care to their patients. One way in which NPs provide quality care is through holism.
Holism may be defined operationally as an "accumulation of the attributes of all disciplines, and
' nurse practitionering' could be defined as the linkage of all the disciplines into one discipline
that can address all of a patient's health and wellness needs from a holistic perspective" (Nicoteri
& Andrews, 2003, p. 499). NPs are, therefore, holistic practitioners and provide holistic

practices aimed at caring for the patient based on their individual health care needs and context.

58

Thus, care cannot be viewed as standardized but as an evolving entity that is melded to fit the
patient' s context. As such, NPs not only utilize their extensive empirical knowledge but use
inclusive, subjective and creative processes in congruence with empirical evidence. The
provision of salubrious care is recognized as a distinguishing feature in patient decision to utilize
NMHCs (Krothe & Clendon, 2006) and for that reason influences patient's decision to access
other nurse-managed care such as a NP-Ied obesity clinic.
An additional attribute ofNPs is their innate ability to generate a therapeutic relationship
with patients. This too has been documented to be instrumental in patient's decision to access
NP care. Allowing time for trust to build helps to create a safe environment for patients and
facilitates free patient discussion regarding their health issues (Krothe & Clendon, 2006). Open
communication has a profound effect on validating equality within the clinical encounter. The
reciprocity cultivated by NPs ensures that children are less likely to drop out of weight
management programs. As well, the contextual understanding that NPs foster ensures that
patient' s expectations of the program are being met. This is facilitated by individual goal setting
and individualized programs. Utilizing NPs and their unique skill set to generate therapeutic,
reciprocal relationships with this often discriminated and stereotyped population assists in
extinguishing previous negative interactions with other health care professionals (Holt et al.,
2008; Krothe & Clendon, 2006). By attending to these factors, NPs will promote program
attendance which is a primary aspect in successful weight loss for overweight children (GrimesRobison & Evans, 2008).
Like their biomedical colleagues, NPs utilize evidence-based medicine to guide their
practice. Particular attention must be paid to available literature as an extensive evidence base
does not yet exist in the area of childhood obesity (AAP-Committee on Nutrition, 2003).

59

Current recommendations for standards of pediatric obesity care focus on promoting clinical care
that is consistent with scientific evidence and family preferences (Pomietto et al., 2009). As
noted previously, family is yet again mentioned in literature as a valuable resource for childhood
obesity prevention. Specific recommendations to foster evidence-based practices include
utilizing evidence-based algorithms to evaluate overweight and obese children; utilizing
interventions that are population based; supporting families to manage the health care of their
children and collaborating with the patient and their family on their role in the management of
care and setting; and documenting these shared management goals. This provides accountability
of the patient and the family; thereby, increasing commitment to the health care plan. Assessing
readiness to change and providing advice and follow-up that is consistent with the patient and
family ' s readiness to change is essential.
It is imperative that NP-led obesity clinics acknowledge the barriers to medically

supervised PWMPs. As indicated earlier, few PWMPs are formally evaluated and this
discrepancy compromises the potential of these programs. Evaluation and follow-up are
necessary and without this could negatively impact overall success. The information generated
from evaluation facilitates change in the programs to help them continue to provide positive
results for the participants. As well, follow-up allows evaluation of the potential of participants
who may require further interventional strategies to help them continue to manage their weight.
This follow-up creates a supportive environment and thus becomes integral to the participants
support network. Often those who are obese have few friends and are suffering in isolation from
their peers (Holt et al. , 2008). Poor peer interactions are common and group intervention
strategies can enhance peer support. However, group interventions allow participants to interact
with each other and generate a social support network. Maintenance of weight loss is well

60

documented to be a considerable challenge (Woolford et al. , 2011); hence, Woolford et al.
(2011) recommend continued contact with patients following PWMPs. Utilizing standardized
tools such the Child Core Survey which was part of the Consumer Assessment of Health Plan
study have increased the ability to objectively evaluate clinical programs for childhood obesity
(Grimes-Robison, 2008).
NP-led obesity clinics are a feasible model of health care delivery since the economic
consequences of obesity are well noted. In Canada, approximately 4.6-7.1 billion health care
dollars are spent on the direct costs to the health care system and on the indirect costs of
productivity (Public Health Agency of Canada [PHAC] & CllU, 2011). The health care system
both in Canada and internationally will continue to feel the fmancial burden associated with
obesity since the number of obese citizens is increasing. Prevention is vital in order to prevent
the development of obesity. Additionally, treatment of overweight and obesity is also needed in
order to help those who are overweight or obese to establish healthy weights and treat their
associated co-morbidities.
In conclusion, NP-led obesity clinics are an innovative approach to helping combat
pediatric obesity. These clinics are strategically placed within the primary care setting, thereby
increasing access to these programs. Therefore, these clinics not only meet the needs of
vulnerable, marginalized, and disenfranchised populations through attending to the
sociodemographic factors that affect health and well-being, but are also located in the
communities where these populations live, work and play. The utilization ofNPs within these
clinics brings forth favorable attributes which positively influence the health outcomes of
children. Incorporating holism, therapeutic relationship building and evidence-based medicine
ensures that patients are satisfied with the care they receive. Furthermore, these clinics satisfy

61

governments by being both accessible and feasible. These clinics are intended to augment
existing pediatric obesity interventions and specifically provide needed care to underserved
populations such as children of low SES who are identified throughout the literature as being
particularly at risk to the development of obesity. NP-led obesity clinics are a pioneering option
for helping Canada meet the pediatric health care needs of its citizens.

SECTION THREE
PRUDENT NP PRACTICE: RESPONSIBILITIES AND CONSIDERATIONS
Although the NP role involves attending to the biomedical treatment and management of
childhood obesity, it also involves focusing on the greater sociological processes that influence
health. In order to concentrate on health promotion and disease prevention, NPs must address
the root-cause of the obesity epidemic and advocate for policy change at both the provincial and
federal levels of government. NPs, as members of both associations and regulatory bodies, have
the ability to address health inequities. Additionally, NPs must acknowledge the ethical and
legal considerations of caring for minors. These responsibilities and considerations create the
basis for holistic nursing care and are key domains of prudent practice.
Health Equality
The social determinants of health have long been identified as key factors that impact
overall health. Health is not just the absence of disease or infmnity, nor is good health achieved
exclusively within hospitals or medical clinics, health is much more complex. Especially, since
health is susceptible to external stimuli and the environment.
Social determinants of health are the economic and social conditions that influence the
health of individuals, communities, and jurisdictions as a whole. Social determinants of
health determine whether individuals stay healthy or become ill (a narrow defmition of

62

health). Social determinants of health also determine the extent to which a person
possesses the physical, social, and personal resources to identify and achieve personal
aspirations, satisfy needs, and cope with the environment (a broader definition of health).
(Raphael, 2004, p. 1).
It is important to approach health holistically and recognize that there is a social gradient

which exists within countries and between countries resulting in marked health inequalities.
These health inequalities are the result ofunequal distribution of power, income, goods and
services. "In countries at all levels of income, health and illness follow a social gradient: the
lower the socioeconomic position, the worse the health" (WHO, 2008 , p. ii). This unfairness in
people' s lives influences their access to health care, schools, and education; as well as their
conditions of work and leisure, their homes and communities. This discrimination impedes
people from leading flourishing lives; however, this inequality does not have to exist. Changing
these inequalities and the policies and social structures that facilitate them is necessary in order
to achieve a state ofwellness (WHO, 2008).
Similarly, poor social and economic circumstances affect the health of individuals and
populations throughout life. The longer individuals live in stressful economic and social
circumstances, the greater the psychological damage they suffer and the greater the impact on
their physiology leading to chronic health conditions and reduced longevity (WHO, 2003).
Healthy development in the early years provides the necessary building blocks that enable people
to live a flourishing life. Many of the challenges encountered in adulthood have their roots in the
first part of life and this includes the development of obesity (WHO, 2008). Investing in children
is investing in the future. Early childhood development has been recognized as determining
subsequent life chances and health through skills development, education and occupational

63

opportunities (Canadian Nurses Association [CNA], 2005; WHO, 2008). These juvenile years
provide the groundwork for leading healthy lives and this includes the eating and physical
activity patterns of future generations. Reversing the rise in childhood obesity relies on health
promotion strategies and education aimed at creating a healthy environment and ultimately
healthier lifestyles.
Under the United Nations Convention on the Rights of the Child (1989) article 27
recognizes that all children have the right to a standard ofliving adequate for the child's
physical, mental, spiritual, moral and social development. It is the responsibility of parents,
guardians and the government to ensure that children of all social classes receive the basic
necessities of life. The WHO (2008) reaffirms these rights of children and acknowledges that
they need safe, healthy, supporting, nurturing and responsible living environments to ensure that
their potential is attainable. This responsibility falls on all Canadians to help assist those who are
unable to reach an acceptable standard of living such as low SES preschool-aged children and
their families. Canadians will not be able to achieve the health goals that we make as a society
without addressing the social determinants of health (CNA, 2005).
In Canada nursing practice and education focuses on the discourses of social justice; yet,

health inequalities continue to permeate society. Examining these health inequalities through a
critical social justice lens helps NPs to critically reflect on the power dynamics which facilitate
health disparities (Anderson et al., 2009). Furthermore, critical social justice also directs
attention to the root causes of inequalities that affect different social groups (Anderson et al.,
2009; Browne & Tarlier, 2008; Reimer-Kirkham & Browne, 2006). For example, Browne and
Tarlier (2008) state that a critical social justice lens is necessary for NPs to develop in order to
ensure that practice is socially responsive and that NPs aim to achieve greater equality in health

64

and health care. A portion ofNP practice must be aimed at the social and political trends that
influence health inequalities, and advocate for grass-root changes to the medical conditions they
are required to manage (Browne & Tarlier, 2008).
Moreover, Anderson et al. (2009) argue that in order to achieve critical social justice in
practice, NPs must have a greater appreciation ofthe contexts of people ' s lives and to create
health care goals and objectives that are mutually inclusive and work within the patient' s
individual context. NPs must continue to care for the biomedical needs of patients whilst
attending to the social injustices that have created these health care needs. In order to achieve
this goal, NPs require the knowledge necessary to critically analyze the social pathways that
prolong health inequalities (Browne & Tarlier, 2008) such as those experienced by low SES
groups. Overall, adopting a critical social justice lens enables NPs to recognize the health
inequalities that plague low income populations and facilitates contextual patient care.

Accessibility
Canadians often tout their universal health care system; however, accessibility of services
remains a problem (Asada & Kephart, 2007). Low SES populations often experience barriers to
accessing health care services due to many factors including lack of transportation, time, money,
resources and knowledge. The Canadian health care system has striven to remove barriers to
ensure that all Canadians have access to medically necessary health services. Since the
establishment of the Canada Health Act in 1984, which sets out in its mandate accessibility, the
Canadian health care system has attempted to remove financial and other barriers to health care
and embraced the philosophy of equal access for equal need (Asada & Kephart, 2007).
Studies have noted that people of lower SES access health services more often than their
higher SES counterparts (Asada & Kephart, 2007; Kephart, Thomas, & MacLean, 1998) when

65

health care is universal and no co-payment is required. L. L. Roos, Walld, Uhanova, and Bond
(2005) note that a socioeconomic gradient exists with residents of the lowest income
neighborhoods having both more visits and more hospitalizations than higher income
neighborhoods. Therefore, reasonable access to health services does exist for low SES
populations, but the difficulty arises with ambulatory care sensitive (ACS) conditions. L. L.
Roos et al. (2005) define ACS conditions as situations that with timely and effective outpatient
care can help to reduce the risk of hospitalization through either preventing the onset of an
illness, controlling an acute episode of an illness, or by managing a chronic disease. Analysis of
ACS conditions exhibit that patients of low SES are often hospitalized more often for these
disorders compared to higher SES patients. The relationship between ACS conditions and the
SES gradient has established that vulnerable populations often have inadequate primary care
and/or barriers which impede their health and health care access (L. L. Roos, Walld, Uhanova, &
Bond, 2005).
Accordingly, people oflower SES may then access health services more frequently as a
result of their poor health status, not because of the health care they receive. N. P. Roos, Forget,
Walld, and Mac William (2004) also acknowledge this relationship in their article and note this
directly influences an individual's use of hospitals. Conversely, increased physician supply and
use of primary care has aided in reducing hospitalizations within low SES populations;
subsequently, supporting that low SES populations do face barriers to accessing quality health
care. This concept is supported throughout the literature (Asada & Kephart, 2007). N. P. Roos
et al. (2004) state that physicians, and essentially all PCPs, are gatekeepers to hospitals.
Therefore, increasing access to PCPs would help to reduce hospitalizations amongst low SES
populations and instrumentally improve their overall health status. Inherently, the NP role

66

increases the quantity ofPCPs available (DiCenso et al. , 2010; Gould, Johnstone, & Wasylkiw,
2007; Romanow, 2002). As such, NPs are able to attend to the needs of accessibility within the
health care system and provide additional entry to health services (CNA, 2009; DiCenso et al.,
2010).
Consent
Informed consent has developed from the view that people are competent to make
decisions about their own person and that these decisions should be made when sufficient
information is presented to the patient to ensure that their decision is indeed informed. Consent,
itself, must include three necessary components: a demonstrated competence for decision
making, voluntariness, and understanding (Croxton, Churchill, & Fellin, 1988, as cited in
Henkelman & Everall, 2001). For consent to be considered informed it must satisfy four
additional criteria: an indication of choice, the reasonableness of the choice made within the
circumstances, adequate understanding and adherence to a decision that includes evaluation of
the risks and benefits of the treatment process (Tymchuk, 1997, as cited in Henkelman &
Everall, 2001 ). Therefore, informed consent is defined as the "voluntary or intentional
authorization of a medical treatment made by a competent patient or surrogate/representative
who is adequately informed of all relevant information pertaining to the treatment and its
alternatives" (Fisher, 2009, p. 516). It is imperative that all health care professionals obtain
informed consent before initiating medical treatment and for NPs both the Consent Practice
Standard and the Health Care (Consent) and Care Facility (Admission) Act (1996) recognizes
this ethical and legal obligation (CRNBC, 2011).
Working with minors poses some significant ethical considerations. Obtaining informed
consent from children is often difficult and insufficient to meet legal and ethical principles of

67

practice. The ethical principles that provide guidance in the care of adults are unsatisfactory in
the care of children. As such, traditionally, children have not been involved in medical
decisions. While adults are presumed competent - they are considered autonomous, have a
stable sense of self, established values and mature cognitive skills - children are required to
prove their competence because these characteristics are undeveloped or underdeveloped
(Harrison, Kenny, Sidarous, & Rowell, 2009). Moreover, age is used as an arbitrary condition
for consent (Henkelman & Everall, 2001 ). As a result, parents and physicians have made many,
if not all, of the medical decisions on behalf of children.
More recently it has been noted that it is important to respect the developing autonomy of
children and that some children have the capacity and understanding to make health care
decisions regardless of their age: the mature minor. Minors are classified as individuals that are
not adults and are under the age of majority which is generally 18 or 19 years of age. In Canada,
there is no specific legislation denying children the right to consent; yet, children under the age
of 15 are generally assumed to be incompetent to make medical decisions (Henkelman &
Everall, 2001).
There are, however, two areas in Canadian common law that give the right of consent to
the child. The first is the mature minor doctrine which provides for minors to demonstrate their
maturity and competence in making their own medical decisions. To be legally valid, both the
consent and the refusal of medical treatment must be given by a person deemed capable of
making health care choices. Capability is assessed through the person's understanding of the
nature and consequences of the recommended treatment, alternative treatments and nontreatment. If a minor is able to demonstrate their capability, then they are able to make their own
voluntary, autonomous medical decisions. However, if the minor is deemed incapable, then the

68

surrogate decision maker and/or the courts must make a decision on behalf of the minor
(Harrison et al., 2009). The second is the emancipated minor doctrine which refers to minors
who are legally entitled to the rights and duties of adulthood. Emancipation occurs when a
minor voluntarily lives independently ofhis or her parents as a result of marriage, military
service or fmancial independence (Henkelman & Everall, 2001). The emancipated minor is then
no longer under parental authority and is able to make their own decisions.
Despite these two exceptions in Canadian law, there are many circumstances where
determining autonomy of the child and obtaining informed consent is not straightforward. For
example, when both the parent and child are minors, is the parent then considered an adult and
able to make health care decisions for their own child? In these situations, not only is the
capability of the child under scrutiny but also that of the parent. Examining the competence of
the (minor) parent is necessary to determine their decision-making potential. This is dependent
on the age of the (minor) parent and whether the doctrines of mature minor and/or emancipated
minor are relevant. Regardless, the basic paradigm of medical ethics involves individual,
informed, autonomous decisions and as long as these requirements are met then the ethical and
legal obligations of the health care provider will be fulfilled. If conflict arises, the courts are able
to achieve resolution. Many court decisions regarding minors are determined on a case-by-case
basis as the ethical and legal parameters involving children are not transparent.
Preschool-aged children, on which this paper focuses, have no significant decisionmaking capacity and lack the emotional and/or intellectual maturity to meet the requirements of a
mature minor; thus, they cannot provide their own consent (Canadian Pediatric Society [CPS],
2004; Harrison et al. , 2009). In the absence of autonomy, beneficence becomes the most
important value and a surrogate decision-maker must make decisions on the behalf of the child,

69

basing these decisions on the child ' s best interest (Harrison et al. , 2009). This is supported in BC
legislation through the Infants Act ( 1996) which is a key statute that states a minor of any age is
not entitled to consent to treatment unless that child is judged as a capable decision-maker and
the proposed treatment is in the best interest of the infant. In spite of this, preschool-aged
children, and all children, should be involved in health care decision-making.
Involving children in medical decisions is an evolving concept in health care ethics.
Even though it is important to understand the developing autonomy of a child, a family-centered
ethic is best.
A family-centered approach considers the effects of a decision on all family members,
their responsibilities toward one another, and the burdens and benefits of a decision for
each member, while acknowledging the special vulnerability of the child patient.
(Harrison et al. , 2009, p. 31).
A triadic relationship is generated which now occurs when treating children - child,
parent(s) and physician. Incorporating children into the decision-making process helps to
empower children and is a beneficial quality in obesity management as these approaches are only
effective when the participant wants to be part of the program. Therefore, the involvement of
both the child and the parent in the consent process is imperative even if preschool-aged children
do not have decision-making capacity. Empowering children to attend to their health and health
care decisions imparts self awareness, autonomy and accountability for their health choices.
These qualities provide children with the building blocks necessary to ensure they make
appropriate nutrition and physical activity choices independently. Collaborating in health care
decisions encourages children to become active participants in their health and this directly
influences the health promotion behaviors needed to avoid obesity.

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Unfortunately, with all collaborative processes disagreement is inevitable. When there is
disagreement between parent and child, NPs may experience moral discomfort. In these
situations, it is important for NPs to respect both the parent' s and child ' s wishes. However,
ultimately, the NP has a primary duty of care to the patient (Harrison et al., 2009); hence, the
patient's best interests are paramount. NPs may experience moral and ethical issues when caring
for obese preschool-aged children when parent' s refuse treatment for their child. This could
occur because the parent does not feel that the child's weight is of concern, or they do not
believe that certain health conditions occur as a result of obesity, or they do not recognize that
their child is obese. Further, children of low SES may not be able to receive care as a result of
costs associated with travelling for medical care or lack of basic medical coverage.
Legally and ethically, if a rational adult who has received full disclosure regarding the
risks and consequences of not receiving treatment persists in refusal, then the decision should be
respected . Specifically, the patient' s right to refuse even life-sustaining medical treatment is
recognized in Canadian law (Harrison et al. , 2009). Those with parental responsibility are
legally authorized to refuse treatment on behalf of their children; however, they do have a duty to
provide necessary medical treatment under the Child, Family, and Community Service Act
(1996). When there is a conflict between parental refusal and medical support for treatment due
to the child's best interests, then court or provincial child welfare authorities' referral is
necessary to overrule the parent' s decision (Harrison et al., 2009).
The Child, Family, and Community Service Act (1996) further stipulates that if a child or
a parent of a child refuses to give consent to health care that in the opinion of two physicians is
necessary to preserve the child ' s life or prevent serious harm, then they can apply to the court for
an order to override the parents decision. In the case of childhood obesity, if the child's health is

71

suffering substantially from lack of treatment, then the NP has an ethical obligation to appeal to
the courts to decide the best interest of the child if parental refusal persists. At this time, NPs are
not able to give an opinion under the Child, Family, and Community Service Act (1996) but they
must abide by this statute through collaboration with a physician (CRNBC, 2008). Hopefully,
through thorough dialogue with parents and children this can be avoided. Still, the law is there
to help decide cases objectively and ensure that appropriate action is taken in the best interest of
the child.
All nurses are moral agents, but NPs are expected to be leaders in resolving moral
problems and promoting social justice within the health care system. This is a basic tenet of the
central definition ofNPs and therefore ethical decision making is a core competency. NPs will
encounter situations in which public policies and legal guidelines infringe on ethical decision
making. In spite of this, nurses must respect their moral obligations, as set out by the Canadian
Nurses Association (CNA) "Code of Ethics for Registered Nurses" (2008) and ensure that the
care they provide remains ethically grounded and medically appropriate.
Advocacy
The CNA (2009) states that the NP role is not merely clinical, but also incorporates
professional practice which encompasses attributes including advocacy and leadership. NPs are,
therefore, valuable in contributing to community development, organization development,
capacity building and health policy development. An essential characteristic ofNPs is to
demonstrate leadership through the initiation of change to improve patient, organization and
systems outcomes. The efforts ofNPs to mitigate against the development of childhood obesity
is limited by the greater physical, social and economic factors that preclude or undermine these
efforts. The limited success of obesity interventions and the concomitant increase in prevalence

72

has prompted a shift from treatment to prevention. Lack of attention paid to examining the
socio-political constructs that impact health and well-being have fostered an obesogenic
environment. In addition, an acute awareness of the escalating health and social issues have
demanded that NPs take a more active role in policy development. As such, NPs must keenly
advocate for change within all aspects of childhood obesity prevention.
Battling obesity is divided into three main approaches: (1) health services and clinical
interventions that target individuals; (2) community-level interventions to influence behaviors;
and (3) public policies that target the broader social and/or environmental determinants (PHAC
& CIHI, 2011). Most approaches to date have focused on prevention at the individual and

community level, but a NP-led obesity clinic incorporates all three approaches. At the
community level NPs must become more present within childhood settings, particularly schools.
Schools are social institutions where children are most impressionable and interventions within
these environments have been effective. The Public Health Agency of Canada (PHAC) and
Canadian Institute for Health Information (CIHI, 2011) highlight that there is little to no research
on interventions for preschool-aged children and this is consistent with this papers fmding.
Therefore, it is necessary that NP-led obesity clinics partner with early childhood development
programs including preschools, Strong Start BC programs and daycares. Greater integration of
services via school-based health care is occurring with nurse-managed clinics developing as a
subset of this movement (Hansen-Turton et al., 201 0). As a result, there is significant need for
NP approaches within this environment. Further, NPs need to connect and strengthen their
alliance with frontline health care professionals such as public health nurses and work in
partnership with them on identifying children who are overweight and/or obese or who are at risk

73

of being overweight and/or obese. Collaboration is necessary to ensure that children are being
screened and then referred to appropriate health care professionals and programs.
At the policy level, NPs must advocate for affordable healthy foods and recreational
facilities . Particularly, NPs need to campaign for subsidy programs that support healthy eating,
food labeling for all literacy levels, regulation of media marketing to children, land development,
urban planning, and transportation planning that make communities more physically active
through alternative avenues of transportation and recreational facilities (PHAC & CIHI, 2011 ).
Furthermore, families want accessible and affordable physical activity facilities and programs.
Additionally, families want changes to occur within the food industry that would make eating
healthier easier (Holt et al., 2008). The cost of fruit and vegetables is rising making it less
affordable for low income families and even families who are on a fixed budget to eat healthily.
It is crucial that weight management programs and health care professionals connect with
community agencies to lobby for policy changes at provincial and federal levels of government.
These responsibilities and considerations are fundamental to guarantee that NPs function
within their moral imperatives as set out by CNA and that the care offered is not only prudent but
ethically based. Attending to health equality, accessibility and parental consent are all
components of providing appropriate, ethical care to all patients but specifically to obese
preschool-aged children oflow SES. Further, actively pursuing policy change cements nursing' s
contribution to childhood obesity prevention and highlights the ability ofNPs to function both
clinically and professionally through advocacy and leadership. These considerations help NPs
recognize the social structures that create good health and conversely contribute to poor health.

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SECTION FOUR
IMPLICATIONS, RECOMMENDATIONS AND CONCLUSIONS
Health has been defined as a state of complete physical, mental and social well-being,
and not merely the absence of disease. Furthermore, it has been declared in the Declaration of
Alma-Ata that it is a fundamental human right and a significant global concern that will require a
coordinated approach from social, economic and health sectors in order to achieve it
(International Conference of Primary Health Care, 1978). For the first time in history, we are
raising a generation of children with a shorter life expectancy than their parents (Schroeder et al.,
2010). Recently the Health Minister Leona Aglukkaq has stated that the federal government will
invest an additional four million dollars towards new activities to promote healthy eating through
information sharing and informing the public of the consequences of unhealthy dietary lifestyles.
This is in response to the growing rate of obese and overweight children in Canada which has
become the biggest threat to public health in the 21st century (Health Canada, 2012). NPs must,
therefore, continue to bridge the gap between medicine, nursing, and social sciences to help
coordinate interventions and strategies that holistically address the multifactoral components of
pediatric obesity.
The purpose of this project paper was to answer the question of inquiry: What is the role

of the nurse practitioner in working with low income families to address childhood obesity in the
preschool-aged population in Canada? To succinctly and effectively answer this question of
inquiry it was broken into four sub-questions that direct the integrative review: (1) What are the
prevalence and health consequences of obesity in preschool children in Canada? (2) What role
does low SES play within the development of childhood obesity? (3) What current primary care
interventions aimed at reducing obesity in the preschool-age population exist and what are the

75

gaps? and (4) What NP-led strategies and interventions might be implemented to address these
gaps? Current literature has been synthesized to support this question of inquiry.
Through the analysis of the literature it has been identified that pediatric obesity is
increasing at an alarming rate with approximately 1.6 million Canadian children considered
overweight or obese and childhood obesity has even surpassed that of adult obesity (Holt et al.,
2008). It has been ascertained that weight gain in early life is a predictor of later obesity and that
lifestyle behaviors are established in the early years (Campbell & Hesketh, 2007; Rudolf et al.,
2010). As such, interventions need to be targeted at the preschool-aged population who are
beginning to learn healthy lifestyle choices. Further, low SES is a risk factor for the
development of childhood obesity (Cluss et al., 201 0; Kumanyika & Grier, 2006; McAdams,
201 0) and even though existing literature is clear on how to improve pediatric obesity, there is
little direction regarding how to engage lower SES families in family-based efforts to improve
eating and physical activity for their children. NPs have the education and expertise necessary to
teach children the skills they need to manage their weight and recognize the patterns and
behaviors that lead to weight gain.
Over the past decade there has been increasing momentum for the utilization ofNPs
within Canada in a variety of clinical settings, especially the integration ofNPs into primary
care. The CNA (2011) launched a campaign to help educate Canadians on the abilities ofNPs to
help improve access to quality health care. This was in response to the ongoing heavilyburdened and overcrowded health care system. Approximately five million Canadians are
without a PCP (CNA, 2011) and this number will continue to rise with the shortage of
physicians, aging of the population, and concomitant increase in healthcare demands (Gould et
al., 2007; Romanow, 2002). Many PCPs are overwhelmed with the health care needs of the baby

76

boomer generation. As a result, they are inadvertently neglecting the health care needs of the
younger presumably ' healthier' generation. These factors have led to changes in the health care
system and increased reliance on the education and practice ofNPs to help bridge this gap in
care. NPs have been touted as an integral component in reducing health care costs and
increasing health care access (Gould et al. , 2007; Romanow, 2002). BC is in the infancy stage of
role development with the first graduating class in 2005 ; however, there is infinite potential for
growth both within the province and within the profession in Canada. As such, there will be
many NPs involved in primary care and inevitably pediatric obesity care. These NPs will help to
ensure that children of low SES have access to essential obesity management and treatment
interventions within their communities.
The ongoing assimilation ofNPs into the health care system will serve to ameliorate
current gaps and will also facilitate growth within the nursing profession. The CNA (2009)
asserts that the role will enhance nursing' s contribution to the health care system and help to
maximize the nursing workforce. Specifically, NPs practice holistically and employ
interdisciplinary methods in their definition of primary care. According to the CNA (2009), the
role is "derived from blending ' clinical diagnostic and therapeutic knowledge, skills and abilities
within a nursing framework that emphasizes holism, health promotion and partnership with
individuals and families, as well as communities. ' The education and experience ofNPs uniquely
positions them to function both independently and collaboratively in a variety of settings across
the continuum of care" (p. 1).
Furthermore, NP approach to patient care is focused on traditional nursing orientation
which emphasizes a focus on developing relationships with patients and an awareness of the
whole person (Gould et al. , 2007). As such, NP care is considered person-centric. Person-

77

centered care supports people to live intact, meaningful lives and this is a unique contribution
that NPs bring to the health care environment and this model of care is needed as the current
health care system is by design provider-centric (Pogue, 2007) and therefore often fails to
incorporate holism into health care plans. NPs are well equipped with the skills necessary to
educate, counsel, coach, and guide their patients to achieving their desired health outcomes and
goals (Anderson & O' Grady, 2009). NPs have an exceptional ability to formulate reciprocal
therapeutic relationships with patients that is exclusive to the role. This distinctive quality
enhances the mutual patient - health care provider relationship and generates desirable attributes
that improve patient' s health outcomes.
The evidence provided within this integrative review has confirmed that NPs are
academically and clinically prepared to apply their skills proficiently within the facet of pediatric
obesity. NMHCs have helped provide the foundation of independent practice and have carved
the road for future NP-led clinics within other specialty areas. Further, empirically supported
weight management interventions have demonstrated positive short-term and long-term effects.
PWMPs within hospital facilities have produced positive results and are considered a stage three
obesity intervention that must move into community-based settings as it is not readily available
to those who would benefit from it the most (Ballet al., 2011 ; Spear et al., 2007). Moreover, it
has been ascertained that "In the absence of integrated, multi-level, pediatric weight management
strategies, the physical, metabolic, and psychological health consequences of pediatric obesity
will overwhelm existing healthcare system capacity" (Ballet al. , 2011 , p. e60). Therefore, one
essential method in which NPs can help to address pediatric obesity is through NP-led obesity
clinics. NP-led obesity clinics amalgamate the benefits of both NMHCs and PWMPs. Thus,
NP-led obesity clinics provide comprehensive obesity management focusing on long-term

78

weight loss through lifestyle modification that is consistent within the context of the patient's life
and is offered through a community-based setting. NP-led obesity clinics are a proposed
intervention to aid in augmenting current intervention strategies.
At this time, pediatric obesity is a significant public health concern and establishing a
NP-led obesity clinic helps to improve access to all children regardless of age, gender, culture, or
SES. Increasing access to obesity care for vulnerable and disenfranchised children is imperative
as these are the children who are at a greater risk of developing obesity. As with other PWMPs,
NP-led obesity clinics offer health promotion strategies through lifestyle modifications whilst
addressing obesity related health care conditions and the psychological conditions associated
with body image. However, different from other PWMPs, is that NP-led obesity clinics create
partnerships with patients and the community to help establish care that is reflective of the
patient' s context and the greater social constructs that impose unhealthy lifestyles.
Embracing the philosophy of COPC ensures that NP-led obesity clinics do not become
divorced from the broader community environment and the current socio-political climate.
Social justice and health equality are primary aspects of care when working with low SES
populations. For that reason, NPs must remain socially responsive to the factors that stimulate
health inequities and further entrench disenfranchised populations. By remaining abreast of
these constructs, NPs will provide care that is equitable and avoids context stripping.
Additionally, attending to the biopyschosocial aspects of human functioning will ensure
comprehensive, integrated, quality care. Health and illness are merely the tip of the iceberg and
exposing the bottom of the iceberg is required to establish each patient' s state ofwellness.
Without addressing the root-cause of childhood obesity, prevention efforts will fail and curative
care will predominate.

79

Permeability to the external environment is an exclusive feature ofNP-led obesity clinics.
At this time, most stage three obesity interventions are located in hospitals that operate in silo
from their surrounding community. They also serve patients who are not from the immediate
area and are unaware of the circumstances and impediments encompassing urban, suburban,
rural and remote locations. NP-led obesity clinics, therefore, function in harmony with the
communities they serve. This is achievable through physically establishing these clinics within a
variety of neighborhoods. The term community encompasses more than just physical location;
community is where people live, work and play. It includes the entire geographical area where
citizens situate themselves and extends beyond the individual to include the economic,
environmental, social and cultural features of the area. The health of citizens is incumbent upon
the health of the entire community.
Therefore, partnering with communities is essential to ensure that health care plans are
congruent with the unique features of the population. NPs must conduct a needs assessment to
determine the health challenges that the population is facing. Part of this process includes
collaborating with key community stakeholders. NPs need to seek out these stakeholders and
form working relationships with these individuals. Communicating with active members of the
public will facilitate input into salient health issues and barriers which the populace has
identified as being pertinent to the health and well-being of its citizens. Moreover, liaisoning
with community agencies, such as Big Brothers and Sisters and Strong Start programs, to
provide health initiatives jointly will not only promote awareness of the NP-led obesity clinic but
will facilitate rapport with community citizens. Partnering with communities enables community
participation in health care initiatives and this will ensure that the programs developed, such as
the programs provided within a NP-led obesity clinic, meet the needs of the entire community.

80

Furthermore, evaluation of these programs should include community feedback so that this
information can improve future program growth.
Acknowledging the context of the patient's community and the interplay between
individual health and population health ensures that patient care is both individualized and
collective. Thus, the health care plan is designed exclusively to the patient and incorporates
valuable aspects of the biopsychosocial components of the individual ' s context of their disease.
Resultantly, NP efforts focus on improving the health of the community along with its residents
and this symbiotic relationship facilitates better health outcomes. It is, thus, critical that NP-led
obesity clinics evolve with the changing health care milieu and continually diversify its services
in response to the shifting health care needs of children.
The creative nature ofNP-led obesity clinics allows for further exploration into pediatric
obesity management and has the potential to provide promising results in the treatment of
childhood obesity. NP-led obesity clinics are an enhanced venue for delivering therapeutic
treatments to children in a controlled setting. In addition, these clinics nurture necessary
attributes needed to commit to long-term lifestyle changes such as empowerment. Empowering
children to become active team members and primary decision-makers within their health care
compels children to continue to make healthy lifestyle choices. NP-led obesity clinics are in a
position to champion for advances in childhood obesity and present the catalyst for further
pioneering initiatives aimed at the prevention, treatment and management of pediatric obesity.
This integrative review has exposed the lack of successful intervention strategies and initiatives
aimed at curbing childhood obesity and has highlighted the pressing need for new groundbreaking designs and ideas for repealing this public health threat.

81

Limitations of this review are inherent in the lack of literature pertaining to preschoolaged obesity interventions, interventions focusing on children of low SES, PWMPs and retention
rates of PWMPs. PWMPs are in their infancy stage and as such more research is needed
regarding these programs, both in Canada and the USA, and primarily the use ofNPs within
these environments. Data needs to be collected to determine both the benefits of and the barriers
to PWMPs. Limited research has suggested that these programs are influential in helping to
prevent and treat pediatric obesity due to a team approach and incorporating family into the
health care plan. However, there do remain challenges with retention of patients and attrition
rates remain high. Retention rates have not improved and identifying effective retention
strategies is crucial. Program administrators and health care providers remain uninformed about
the factors that influence attrition rates and this directly impacts program success (GrimesRobison & Evans, 2008). It is necessary that NP-led obesity clinics focus on evaluating their
programs to ensure their overall success and to make certain that patients are remaining in the
programs to reap the benefits of them.
Even though there are gaps in existing research, the dearth of literature concedes these
discrepancies and instead incites future NP-led research endeavors. The Canadian Pediatric
Society (CPS, 2008) states that there is limited quality data on the effectiveness of childhood
obesity prevention programs and that there is an urgent need for well designed studies to
examine a range of interventions and their effectiveness so that successful programs can be
generated. A component of the role ofNPs is to engage and participate in research. Nursing
requires more active members to partake in the realm of inquiry concentrating specifically on
nursing methodology. The benefits of inquiry are twofold. Firstly, through the exploration of
research, NPs are able to apply various worldviews and paradigms into their practice. This

82

scientific knowledge inspires methodical, prudent, evidence-based medicine. Secondly, these
clinics present the opportunity for NPs to participate in pediatric obesity research and offer the
environment needed to study intensive interventional strategies aimed at pediatric obesity
treatment and management. The prospective research available provides information that will
help to condense the current gaps in the literature regarding childhood obesity. The data
generated from NP-led obesity clinics has the potential of evaluating the necessary outcome
measures needed to ensure sustainability of these clinics, as well as cementing NPs contribution
to research.
The recognition ofNPs within these specialized settings facilitates needed professional
education propagation. NPs within these sites are considered experts within this field of study
and are, therefore, mentors within the health care community. Thus, NPs within these clinics
have the expertise necessary to educate members of the health care team on pediatric obesity
care. This is vital since many PCPs are interested in obtaining the resources and knowledge
needed to better help them implement comprehensive care plans to this population (Barlow et al. ,
2002). Currently, PCPs feel ill-equipped to meet the needs of this population (Boyle et al. , 2009;
Hopkins et al. , 2011) and NPs can address this through participating in CMEs and other
educational venues which help to equip their colleagues with the resources needed to ensure
positive outcomes for obese children. As well, NPs in these clinics can help to communicate the
importance of stage three interventions for pediatric patients through referral to their clinics and
establish guidelines and protocols necessary to facilitate appropriate expedited referral and
transfer of care. These clinics will also become fundamental to academic institutions by
providing valuable educational placement experiences for students.

83

This paper has supported that NPs are key stakeholders within the health care community
and are ideal PCPs for helping to reduce pediatric obesity. NMHCs have established the efficacy
ofNP autonomous practice within independent practice sites. PWMPs are an emerging entity
for addressing resistant pediatric obesity and provide comprehensive, intensive weight
management interventions. The programs examined in Canada and the USA provides valuable
examples of the breadth of services PWMPs offer. NP-led obesity clinics are an innovative
response to pediatric obesity care where the NP role has a unique opportunity for addressing this
health challenge. NPs are described as disruptive innovators and have the potential to act as a
catalyst for change that will strengthen our collective thinking about nursing and transform our
publically funded health care system in order to sustain it for future generations (Pogue, 2007).
Subsequently, NPs are integral in helping pave the road for clinical endeavors that focus on
pediatric obesity within the current health care climate. Overall, the evolving nature of society
insists that health care professionals continue to become inventive in their approach to access
patients and the benefits to be derived from NP-led obesity clinics is integral to future
generations. Most importantly, NP-led obesity clinics help increase access to children of all ages
and contexts and ensure that appropriate pediatric weight management strategies are being
offered to these patients. Overall, this model of care gives voice to marginalized and
disenfranchised populations who direly need recognition and assistance.

84

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Appendix A: Literature Review Search Strategy and Results
Inclusion and Exclusion Criteria
Inclusion Criteria

Exclusion Criteria

Published in English

Published in a language other than
English

Published between 1990-2012

Published before 1990

Addressed childhood obesity in Canada, the United
States, Europe and Australia. Preference given to
Canadian literature.

Article did not address childhood
obesity in these countries.

Article or literature is peer-reviewed and/or appears
within a credible source.

Article or literature is non-peerreviewed and/or does not appear within
a credible source.

Article or literature is a published or unpublished
government, academic and/or organizational
document.

Article or literature is not from a
recognized governmental, academic
and/or organizational document.

Article or literature addressed at least one of the
following:

•
•

•

•
•

•
•
•
•

Childhood obesity prevalence rates
Causes of childhood obesity
Low socioeconomic status/factors associated
with childhood obesity
Intervention strategies aimed at the preschool
population
Advanced practice nurse/nurse practitioner role
in childhood obesity
Primary care providers role in prevention of
childhood obesity
Barriers to accessing preschool-aged children
NMCs/NMHCs
Pediatric weight management programs

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Keywords and Search Terms
My keywords and search terms pertained to my research question and these terms were
used individually and in combination in order to ensure a comprehensive literature search were
conducted. The following are my keywords and search terms:
•

Childhood obesity/childhood overweight/preschool-aged obesity/overweight/high
BMI in pediatrics/pediatric obesity/overweight

•

Low income families/low socioeconomic status/poor/povershed/health disparities
in Canada

•

Socioeconomic factors/food security/physical activity/screen time/built
environment

•

Obesity interventions/prevention strategies/health promotion strategies/schoolbased programs/community programs/government programs/childhood obesity
guidelines/protocols/management/treatment

•

Accessibility to preschoolers/screening of preschools/use of health care system

•

Barriers to obesity management/treatment/interventions

• NMCs/NMHCs/nurse-led clinics/NP-led clinics/programs
•

NPs/APN s/PNPs working in/with pediatrics

•

Pediatric weight management programs/pediatric weight loss
programs/clinics/stage 3 obesity interventions

•

Pediatric consent/ethical considerations/care of minors

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Search Strategy and Results
Childhood obesity is a complex, multifaceted health issue where research is vast and
evolving. Therefore, to accurately reflect the evolving nature of this research I included
literature from the past two decades. This literature included both primary and non-academic or
grey sources. My initial search strategy began with a hand search of the literature that I have
collected while composing papers for this program. I utilized the aforementioned inclusion
criteria to select material that was primary source literature with relevant grey literature. From
this existing literature, I reviewed the reference pages and highlighted any primary sources and
grey literature that I did not have in my possession and that appeared to meet my inclusion
criteria. I organized these resources into four general streams - multifactoral components of
pediatric obesity/background data; low SES and pediatric obesity; NP pediatric
practice/NMHCs; and pediatric weight management programs. I then began my secondary
search by accessing the University ofNorthem British Columbia (UNBC)'s catalogue and
databases. Specific databases included MEDLINE, CINHAL, OVID and Pub Med. I also
accessed the databases of the American Academy of Pediatrics and the American Academy of
Nurse Practitioners. Once saturation of the search terms was achieved through the primary
sources within these databases, I did a general online search using Google scholar. When
sufficient primary source literature was pulled, I began working on grey literature. I accessed
sources including the Childhood Obesity Foundation, Childhood Obesity Network, TROPIC,
Canadian Pediatric Association, WHO, CDC and Ministry of Health Services- Public Health
Agency of Canada and the Canadian Institute for Health Information. Following saturation
within the literature as indicated by my search terms, I did a third level of review by ensuring
that my literature did indeed meet the inclusion criteria and then placing these resources into my

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multiple themes as listed above. The literature search process resulted in over 101 articles and in
total 64 primary sources, 22 non-academic sources, 3 books and 1 clinical practice guideline
were utilized. Supporting literature was also drawn upon. Through themeing of the literature, I
was able to identify gaps within the literature and select resources that better fit with the four
themes identified.