NURSE PRACTITIONER USE OF A FAMILY CENTERED CARE APPROACH TO
MANAGE CHILDHOOD OBESITY IN THE PRIMARY HEALTH CARE SETTING

by
Colleen Patenaude

B.S.N., University College of the Cariboo, 2004

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

THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA
September, 2012
© Colleen Patenaude, 2012

UNIVERSITY of NORTHERN
BRiTISH COLUMBIA

LIBRARY
Prince George, B.C.

11

Abstract
Childhood obesity rates are rising at an alarming rate. Obesity has a negative impact on health
and well being as well as social development. Obese children have a higher incidence of
morbidity and mortality. Current clinical practice guidelines recommend practitioners use a
family centered approach to managing childhood obesity. The purpose of this project is to
examine the use of a family centered care (FCC) approach in managing childhood obesity in the
primary health care setting and determine how best to incorporate it into managing childhood
obesity in nurse practitioner (NP) practice. The principles of FCC are reviewed. NP use of
existing nursing models such as the McGill model of nursing for guidance in incorporating
family centered care into practice is examined and discussed. The research obtained during the
literature review indicates using a FCC approach to disease management is effective and can be
achieved in the primary health care setting. As a result of the findings, a five step approach to
assessing and managing childhood obesity is recommended for NPs practicing in the primary
health care setting.

111

Table of Contents
Abstract

11

Table of Contents

111

List of Tables

v

Glossary

Vl

Chapter One

Chapter Two

Introduction

1

Impact of Obesity on Health and Well-Being
Social impact
The Role of the Nurse Practitioner
Purpose

2
3
4
5

Background and Context
The Complexity of Childhood Obesity
Classification of Overweight and Obesity in Children
Risk Factors for Developing Childhood Obesity
Genetic and biologic
Sleep disturbances
Ethnicity
Social determinates ofhealth
The Role of the Nurse Practitioner in Childhood Obesity
Management
Family Centered Care
McGill Model ofNursing
Elements of the Model
Health
Person
Environment
Nursing

7
7
7

8
8

11

12
12
15
16
18

20
20
21
22

22

Chapter Three

Approach and Research Methods

24

Chapter Four

Findings
Literature Review
Current Clinical Practice Guidelines
The Use of Family Centered Care in the Management of
Childhood Obesity
The relationship between family centered care and weight loss
Effect of family centered care initiatives on long-term weight
loss

30
30
30
32
33
36

IV

The use of family centered care in managing severe obesity
The use of family centered care in primary health care settings

40
42

Chapter Five

45
Discussion, Conclusions and Implications
Implications and Recommendations for Nurse Practitioner Practice 46
Areas for Further Research and Study
49
51
Summary and Conclusion

Bibliography

53

v

List of Tables

Table 1: Key Principles of Family Centered Care

17

Table 2: Inclusion and Exclusion Criteria for Selection of Research Articles

24

Table 3: Keywords Used in Electronic Database Search

25

Table 4: Results of the Database Search

26

Table 5: Results ofEBP Search

27

Table 6: Using the McGill Model to Facilitate Family Centered Care into Practice

47

Table 7: Assessment and Management of Childhood Obesity in the Primary Health Care
Setting

50

Vl

Glossary
Body Mass Index (BMI): Body mass index (BMI) is a measure of body fat based on height and
weight. BMI provides a reliable indicator of body fatness for most people and is used to screen
for weight categories that may lead to health problems (Centers for Disease Control and
Prevention [CDC] n.d.).

Cholesterol: A monohydric alcohol ; a sterol widely distributed in animal tissues and occurring
in egg yolks, oils, fats, the nerve tissue in the brain and spinal cord, the liver, kidneys, and the
adrenal glands. In most individuals, elevated blood cholesterol levels increases the risk of
developing coronary heart disease (CHD) and stroke (Taber & Thomas, 1997).

Dyslipidemia: Elevated total or low-density lipoprotein (LDL) cholesterol levels, or low levels
ofhigh-density lipoprotein (HDL) cholesterol. Dyslipidemia is an important risk factor for
coronary heart disease (CHD) and stroke (Fodor, 2011).

Energy expenditure: Calories burned off in physical activity (Daniels et al. , 2005).
Energy intake: Calories consumed in food and beverages (Daniels et al. , 2005).
Ethnicity: Ethnicity is a term used to categorize populations on the basis of shared
characteristics. These characteristics include culture, shared language, ancestry, religious
tradition, dietary preferences and history. Although ethnic groups can share a range of
phenotypic characteristics due to their shared ancestry, the term is typically used to highlight
cultural and social characteristics instead ofbiological ones (Caprio et al. , 2008).

Family centered care: A way of caring for children and their families within health services
which ensures that care is planned around the whole family, not just the individual child/person,
and in which all the family members are recognized as care recipients (Shields, Pratt & Hunter
2006).

Vll

Globesity: A swelling global tidal wave of obesity and diet-related diseases (World Health

Organization [WHO] , 2011).
Hepatic Steatosis: The initial stage of non-alcoholic fatty liver disease (NAFLD): one of the

most important effects caused by obesity on children and adolescents' health (Duarte & Silva,
2011).
Hyperglycemia: Increased blood sugar, as in diabetes (Taber & Thomas, 1997).
Hyperlipidemia: An increase oflipids [fats] in the blood (Taber & Thomas, 1997).
Hypertension: A condition in which the patient has a higher than normal blood pressure (Taber
& Thomas, 1997).

Morbidity: 1: State of being diseased. 2. The number of sick persons or cases of disease in

relationship to a specific population (Taber & Thomas, 1997).
Mortality: The death rate; the ratio of the number of deaths to a given population (Taber &

Thomas, 1997)
Nurse practitioner: Nurse practitioners are health professionals who have achieved the

advanced nursing practice competencies at the graduate level of nursing education that are
required for registration as a nurse practitioner with CRNBC. Nurse practitioners provide health
care services from a holistic nursing perspective, integrated with the autonomous diagnosis and
treatment of acute and chronic illnesses, including prescribing medications (CRNBC, 2011 ).
Overweight: Children with a BMI that is (~85th to < 95th percentile) when plotted on the

growth charts of the US Centers for Disease Control and Prevention (CDC). Charts can be
accessed from: http://www.cdc.gov/growthcharts/clinical.chm1s.htm#Setl )

Vlll

Obesity: Children with a BMI that is (;:::95th percentile) when plotted on the growth charts of
the US Centers for Disease Control and Prevention (CDC). (Charts can be accessed from:
http://www.cdc.gov/growthcharts/clinical.charts.htm#Setl).
Primary health care: Primary health care refers to an approach to health and a spectrum of
services beyond the traditional health care system. It includes all services that play a part in
health, such as income, housing, education, and environment. Primary care is the element within
primary health care that focuses on health care services, including health promotion, illness and
injury prevention, and the diagnosis and treatment of illness and injury. Primary care serves a
dual function in the Canadian health care system: direct provision of first-contact services (by
providers such as family physicians, nurse practitioners, pharmacists, and telephone advice
lines); and a coordination function to ensure continuity and ease of movement across the system,
so that care remains integrated when Canadians require more specialized services (with
specialists or in hospitals, for example) (Health Canada, n.d.).
Primary care provider (PCP): Primary care providers are health professionals who take primary
responsibility for an established group of patients for whom they provide longitudinal person-focused
care; comprehensive care for most health needs; first contact assessment for new health care need
and referral and coordination of care when it must be sought elsewhere. A primary care provider is
ideally chosen by an individual to serve as his or her health care professional to address a wide
variety of health issues including health promotion, illness and injury prevention, and the
diagnosis and treatment of illness and injury (CRNBC, 2010).
Social Determinants of Health: The social determinants of health are the conditions in which
people are born, grow, live, work and age, including the health system. They are shaped by the
distribution of money, power and resources at global, national and local levels which are
influenced by policy choices. The social determinants of health are mostly responsible for health

lX

inequities- the unfair and avoidable differences in health status seen within and between
countries (WHO, 2011).

1

Chapter One
Obesity can be defined simply as "the result of an energy imbalance" (Canadian Medical
Association [CMA], 2006; Registered Nurses Association of Ontario [RNAO], 2005), this means
that obesity and overweight occur when energy intake exceeds energy expenditure. For a
problem that seems to have such a logical explanation it stands to reason that the successful
treatment of obesity would amount to a simple rebalancing of the energy equation at the
individual level: fewer calories consumed and more energy expended. However, the reality of
obesity is much more complex and multifactoral. Obesity is a chronic condition caused by long
term positive energy balance and is influenced by social, environmental and genetic factors. It
can also result from pathology in the metabolic feedback between energy intake, and expenditure
(Daniels et al., 2005).
Obesity affects all races, all ages, and is a global epidemic. Once considered a problem in
high income countries, overweight and obesity are now on the rise in low and middle-income
countries, particularly in urban settings. According to the World Health Organization (WHO)
(2011) worldwide obesity has more than doubled since 1980. In 2008, 1.5 billion adults, 20 and
older, were overweight. In 2010 nearly 43 million children under the age of five were
overweight. Close to 35 million overweight children are living in developing countries and eight
million in developed countries (p. 1).
The World Health Organization (WHO) has labelled this epidemic "globesity'' (WHO,
n.d.). In Canada in 2007, the self-reported rate of adult obesity (age 18+) was 17%; researchers
estimate that the actual rate of obesity is likely much higher, closer to 25% (Public Health
Agency of Canada [PHAC], 2009). Obesity has developed into a leading cause of morbidity and
mortality worldwide (Maziak, Ward, & Stockton, 2007). Between 1985-2000, over 57,000
deaths in Canada were attributed to overweight and obesity (Katzmarzyk & Ardem, 2004).

2
Perhaps even more alarming than the staggering rates of obesity among Canadian adults
is the strong evidence showing that the prevalence of overweight and obesity among Canadian
children and adolescents is increasing more rapidly than in the adult population (Willms,
Tremblay, & Katzmarzyk, 2003). In 2004, 26% of Canadian children and adolescents were
considered overweight; 8% were obese. Increases in overweight and obesity rates over the past
25 years in Canada have been notable. During this time the number of adolescents considered
overweight has more than doubled, and the obesity rate among adolescents has tripled (Shields,
2005).
The seriousness of childhood obesity is related to its association with major health risks:
breathing difficulties, increased risk of fracture, hypertension, early markers of cardiovascular
disease, insulin resistance, and metabolic syndrome (Biro & Wien, 201 0). Childhood obesity
negatively influences children's quality oflife impacting their physical, social and psychological
functioning (Maziak et al., 2007). Childhood obesity is also associated with a higher risk of adult
obesity, certain cancers, disability and premature death in adulthood, and is now the leading
cause of morbidity and mortality worldwide (World Health Organization [WHO], 2011).

Impact of Obesity on Health and Well-Being
The rising rates of childhood obesity in Canada and worldwide are of major concern due
to the immediate and long term health consequences associated with childhood obesity (Jonides,
Buschbacher, & Barlow, 2004). Experts in the field of childhood obesity warn that children will
have a shorter lifespan than their parents if current practices aimed at the prevention and
treatment of childhood obesity fail (Davis et al., 2007; Hopkins, DeCristofaro, & Elliott, 2011).
Obese children are developing the same complications as obese adults long before they reach
adulthood. In a population-based study of obese children conducted by Freedman, Dietz,

3

Srinivasan, and Berenson (1999), approximately 60% of those studied had at least one risk factor
for cardiovascular disease (hyperlipidemia, insulin resistance, or elevated blood pressure) and
25% had two or more such risk factors. Obese children are also at risk for developing type 2
diabetes, a disease previously thought of as only occurring in adults (Arslanian, 2002). Earlyonset type 2 diabetes in children is associated with severe and early onset microvascular
complications including nephropathy, retinopathy and neuropathy. These irreversible
microvascular complications can lead to renal failure, vision impairment and blindness and
eventually premature death (Eppens et al. , 2006; Krakoff et al. , 2003).
Childhood obesity increases the overall risk for morbidity and early mortality
(Katzmarzyk, Janssen, & Ardem, 2003 ; Must & Strauss, 1999). Obese children are also at risk of
becoming overweight adults and the presence of obesity during adolescence is the best single
predictor of adult obesity (Dietz & Gortmaker, 2001). Freedman et al. (2005) found that
childhood BMI is associated with adult adiposity and that the magnitude of this association
depended on the relative fatness of children: the greater the BMI, the greater the risk of adult
obesity. The risks of obesity related morbidity and mortality only increase as overweight and
obese children reach adulthood, as obesity is also associated with metabolic syndrome,
osteoarthritis, certain cancers and left ventricular hypertrophy (Hopkins et al. , 2011 ; Institute of
Medicine [10M], 2004).
Social impact.

Childhood obesity can negatively impact social, academic, and economic outcomes in
childhood and adulthood (Gortmaker, Must, Perrin, Sobol, & Dietz, 1993). Maziak et al. (2007)
explain that children are not equipped to handle the prejudice and stereotyping associated with
obesity and are at risk of developing serious social and emotional health consequences related to

4

their weight status. Negative behaviors such as anger, depression, and suicidal ideation have
been noted (Carpenter, Hasin, Allison, & Faith, 2000). There is significant stigma associated
with being obese that can lead to shame, self-blame, and low self-esteem. This stigma can
negatively affect academic performance, socialization and employment opportunities into
adulthood (IOM, 2004; Lobstein, Baur & Uauy, 2004). Severely obese children and adolescents
have reported a low health related quality of life, equal to that of children with cancer (Hopkins
et al. , 2011; Lee, 2007).

The Role of the Nurse Practitioner
Seal (20 11) states the "global epidemic of obesity in children and adults is one of the
greatest challenges in public health today." The myriad of factors that contribute to obesity
makes the prevention and treatment of obesity especially challenging (p. 65). Nurse practitioners
(NPs) working in primary health care settings in Canada can play a crucial role in the fight
against childhood obesity as "each healthcare encounter with children or adolescents and their
parent/guardian inherently provides an opportunity for NPs to screen for evidence of risk factors,
overweight status or sequelae to overweight" (McAdams 2011 , p.463). Wald, Moyer, Eickhoff,
and Ewing (20 11) suggest children are more likely to visit to primary health care clinics during
childhood for well child exams and for common childhood illnesses. This provides NPs the
opportunity to recognize obesity and intervene early on, and early intervention is more likely to
result in long term change.
A recent study published by the Organisation for Economic Co-operation and
Development (OECD) found that one in four Canadian children are overweight, which is among
the highest rates in developed countries. The Health at a Glance report, which combines health
statistics from 34 OECD countries to give a comparative picture of health care systems around

5
the world, showed only Italy and the United States scored higher on the childhood obesity index
(OECD, 2011). Primary health care providers will be seeing more overweight and obese children
in practice. Thus an understanding of the factors that influence obesity, why it is important to
address and how childhood obesity can be effectively managed in family practice is necessary.
Current NP literature (Hopkins et al., 2011) advocates the use of family based
intervention to address childhood obesity however, there are no clear guidelines that support the
implementation of family centered care or NP use of a holistic family centered approach in
managing childhood obesity.
Purpose
The purpose of this project is to examine the use of a family centered care approach in
managing childhood obesity in the primary health care setting and determine how best to
incorporate FCC into managing childhood obesity in FNP practice. The following question of
inquiry was used as a guide in completing this project: "How can the nurse practitioner
incorporate family centered care into practice in the assessment and management of childhood
obesity in the primary health care setting?" The question was answered through an integrative
review of the literature on family centered care and childhood obesity.
Chapter Two provides background data on obesity as a global epidemic. It also examines
the physiology, pathophysiology and more specifically the effects of obesity on the health and
well being of children and youth ages 6 to 18. It describes the role of the NP in Canada and
introduces family centered care. It also looks at the McGill Model ofNursing as a framework to
assist practitioners to incorporate FCC into practice. Chapter Three outlines the approach to the
project and research methods. In Chapter Four the literature is critically analysed. This chapter
examines the use of FCC in managing childhood obesity in the primary health care setting. In

6
Chapter Five analysis of the literature will be disseminated with regards to how NPs can draw on
the principles of FCC and the McGill Model when managing childhood obesity in primary care
settings. Areas for further research and study are also reviewed. Finally, specific
recommendations for nurse practitioner practice are provided.

7
Chapter Two
Background and Context
The Complexity of Childhood Obesity
Rapidly rising rates of childhood obesity cannot be reduced to the simple equation of "too
much food, not enough activity" theory (Swinbum & Egger, 2004). In reality, there are a myriad
of factors that influence the development of obesity in the pediatric population. While increased
caloric intake and decreased energy expenditure are major contributors other factors include
genetic, behavioral, social, psychological, technological, environmental, economic, and cultural
(PHAC, 2011). As researchers continue to study obesity, it will be necessary for primary health
care providers to remain aware of current and emerging literature regarding the prevention and
management of childhood obesity.
Classification of Overweight and Obesity in Children
Current Canadian clinical practice guidelines on the management and prevention of
obesity in adults and children (CMA, 2006) recommend measuring body mass index (BMI;
weight in kilograms divided by height in metres squared) in all children and adolescents (aged 2
years and older). They also recommend using the growth charts of the US Centers for Disease
Control and Prevention (CDC) for BMI to screen children and adolescents for overweight. Once
BMI is determined it is plotted on the appropriate CDC growth chart. Overweight is defined as a
BMI that when plotted on the growth chart is ;:::85th to < 95th percentile. Obesity is ~5th
percentile (p. 6)
Percentiles are measurements that show where a child is compared with others. On the
CDC growth charts, the percentiles are shown as lines drawn in curved patterns. When a child's
BMI is plotted on the chart, the measurements land on a percentile line. The higher the percentile

8

number, the bigger a child is compared with other children of the same age and gender. The
lower the percentile number, the smaller the child is. For example, if an 8-year-old boy's BMI is
in the 1Oth percentile it means that 10% of boys that age weigh less than he does and 90% of 8year-old boys weigh more.
There has been some debate as to whether or not these growth charts were appropriate for
use in Canadian aboriginal populations. Currently the CDC promotes one set of growth charts for
all racial and ethnic groups. The Canadian Paediatric Society (Canadian Paediatric Society
[CPS] , 2004) does not recommend the use of racial and ethnic charts because studies support the
premise that the differences in growth among children of various racial and ethnic groups are the
result of environmental rather than genetic influences (p. 478).

Risk Factors for the Development of Childhood Obesity
Genetic and biologic.
The risk of obesity is increased when an individual has relatives who are obese. When
one parent is obese the risk of obesity in their children increases three-fold; if both parents are
obese the risk increases by ten times or greater (Dietz 1998; Ogden et al., 2006; Whitaker,
Wright, Pepe, Seidel, & Dietz, 1997). Obesity is "not inherited in families in a predictable
pattern like other genetic diseases, such as cystic fibrosis, but rather demonstrates a complex
"polygenetic" pattern, meaning that multiple genes are involved" (Seal, 2011). Seal (2011)
further suggests that although each of the obesity genes has only a marginal affect on commonly
measured obesity related phenotypes ( BMI, waist circumference, percentage fat mass, and body
weight) collectively they play a major role in determining how an individual responds to
environmental factors such as nutrition and physical activity (p. 63).

9

Other biologic factors found to be involved in the regulation of food intake and thus obesity
include leptin (LEP), LEPR, ghrelin, pro-opiomelanocortin (POMC), MC4R, and the enzyme
pro-hormone convertase-1 (PC I) (Seal, 2011 ).
Banning (2005) describes leptin as a hormone produced by adipose tissue that modifies
the function of cerebral nerve cells. Leptin regulates a broad variety of processes and behaviours
such as blood pressure, bone mass, fat cells, muscle cells and immune function as well as
regulating multiple intracellular signalling mechanisms which are thought to be associated with
leptin resistance and obesity. The genes PMO and POMC have both been associated with the
onset of obesity although the related mechanism and trigger are unclear (p. 164).
Ghrelin is a hormone that has been recognized as having a major influence on energy
balance (Klok, Jakobsdottir, & Drent, 2006). Ghrelin is secreted by the stomach, gastrointestinal
tract, pancreas, ovaries, and adrenal cortex. It is also secreted in the brain (page 24). Ghrelin is a
fast acting hormone that signals the hypothalamus when an increase in metabolic efficiency is
necessary. Research conducted by Cummings, Frayo, Marmonier, Aubert, and Chapelot (2006)
showed that increases in ghrelin levels before meals correlated with increased hunger scores in
healthy humans. This occurred regardless of usual consumption patterns and food related cues.
They concluded that ghrelin seems to function as a meal initiation signal for short term
regulation of energy balance.
Insulin is a hormone secreted by the pancreas in response to high levels of blood glucose.
Higher levels of circulating insulin signal the body's cells to absorb glucose. Insulin and
specifically insulin resistance plays a role in obesity (Chiarelli & Marcovecchio, 2008). Insulin
resistance is a state in which a specific amount of insulin produces an inadequate biological
response. It is characterized by a decrease in the ability of insulin to stimulate the uptake and use

10

of glucose by muscle and adipose tissue and to suppress hepatic glucose production and output
(page S69). The development of insulin resistance is believed to be influenced by both genetic
and environmental factors including obesity, ethnicity, gender, perinatal factors , puberty,
sedentary lifestyle and diet (p. S69). Insulin resistance in obesity is related to the development of
hypertension, dyslipidemia, impaired glucose tolerance, and hepatic steatosis. It is also related to
higher lipolytic activity of visceral fat when compared with subcutaneous or total body fat. The
combination of these factors is called metabolic syndrome (p. S70). Insulin resistance in
childhood obesity is the best predictor for the development of impaired glucose tolerance and
type 2 diabetes mellitus, a progressive disease with a gradual increase in insulin resistance
associated later with a decline in insulin secretion with fasting hyperglycemia (Chiarelli &
Marcovecchio, 2008).
Stress is also linked to obesity. In obesity, cortisol levels are abnormally elevated.
Maglione-Garves, Kravitz, and Schneider (2005) describe cortisol as a steroid hormone that is
produced in the adrenal cortex. Cortisol production is a normal metabolic process. Fasting, food
intake, exercise, awakening, and psychological stressors all cause the body to release cortisol.
Energy regulation and mobilization are the two most critical functions of cortisol. Cortisol
regulates energy by selecting the right type and amount of stored energy in the form of
carbohydrate, fat or protein that is needed by the body to meet physiological demand. Cortisol
mobilizes energy by moving the body' s stored fats triglycerides, from one location to another or
delivering it to working tissues such as muscle. Under extreme stress cortisol can provide the
body with protein for energy through glucogenesis, the process of converting amino acids into
useable carbohydrate (glucose) in the liver. Chronic stress causes body tissues to be exposed to
high levels of cortisol for extended periods of time. This leads to the relocation of fat stores and

11
excess circulating fat to be relocated and deposited deep in the abdomen, which can lead to the
development ofhypertension, hyperlipidemia, and hyperglycemia (p.22). Cortisol aids immature
fat cells to grow into mature fat cells. Cortisol may also act as an anti-inflammatory agent,
suppressing the immune system during times of physical and psychological stress (p 21 ).
Children who are overweight have a greater stress-elicited change in cortisol secretion than
individuals of normal weight (page 345). The research regarding cortisol levels and childhood
obesity is still preliminary, however current findings support the significance of psychological
stress as a potential contributor to childhood obesity (Dockray, Susman, & Dom, 2009;
Gunderson, Mahatmya, Garasky, & Lohman, 2010; Koch, Sepa, & Ludvigsson, 2008).
Sleep disturbances.

Sleep deprivation and short sleep duration may increase the risk of obesity in children
and adolescents (Bell & Zimmerman, 201 0; Canadian Obesity Network [CON] , n.d.). Both
insulin and glucose metabolism are negatively affected by lack of sleep resulting in slower
glucose clearance, lower insulin response to glucose, a lower disposition index and lower insulin
sensitivity. Sleep deprivation also results in lower levels ofleptin and higher overall levels of
ghrelin. It has an effect on what people are hungry for and the amount that they consume. Sleep
deprivation causes people to become hungry for fattier and more calorically dense foods which
can lead to weight gain and obesity (CON, n.d.). Sleep deprivation also affects cortisol levels,
which have also been shown to be higher in sleep-deprived persons (Bell & Zimmerman, 201 0;
CON, n.d.).
Obesity itself also contributes to sleep dysfunction. Many obese children develop sleep
apnea, a condition in which sleep is disrupted by irregular breathing patterns. When obese
children develop sleep apnea they have fragmented sleep causing secondary sleep deprivation.

12
This occurs as a result of constant waking during the night due to ineffective oxygenation. For
obese children, the risk of sleep apnea increases by 12 percent for each kg/m2 increase in BMI
(CON, n.d.).
Ethnicity.

The prevalence of obesity varies across ethnic groups in Canada with the lowest
prevalence amongst East-Southeast Asians, while Aboriginal Canadians living off the reserve
have the highest prevalence (Katzmarzyk, 2008). In Canada, 41% of young people of Aboriginal
origin living off reserve are overweight or obese (Katzmarzyk, 2008; Tjepkema, 2002). Data
collected in the First Nations Regional Longitudinal Health Survey (2003) found the prevalence
of obesity is also particularly high among on-reserve First Nations children: 36.2% of children
(age 2-11) and 14.0% ofyouth (age 12-17) were considered obese (Sheilds, 2005). High obesity
rates among First Nations people have both genetic and environmental roots. Aboriginal people
have a genetic make-up that made energy storage a priority which was ideal in their ancestors '
feast-famine environment. However, in today' s ' feast-feast' environment, the body stores
energy as fat and puts this population at high risk of obesity and related disease, such as diabetes.
Loss of traditional lifestyles and lack of access to affordable healthy food choices also exacerbate
the problem (Harris et al. , 2011).
Social determinants of health.

Swinbum et al. , (2011) state the most obvious social determinant ofhealth (SODH) for a
population to develop obesity is sufficient wealth. They also point out that although increasing
wealth enables obesity the level of prosperity does not have to be high for obesity to manifest.
Economic prosperity brings with it several transitions: a changing demographic from younger to
older population distribution, rural to urban dwelling, fewer infectious diseases, more non

13
communicable diseases, low to high mechanization and motorization, and a change in diet from
traditional foods to more processed energy dense foods (p. 806). These changes eventually lead
to the development of the obesogenic environment such the one we are living in with the
developed world.
As Golan and Crow (2004) explain, an "obesogenic environment [is one] that idealizes
thinness and stigmatizes fatness, but paradoxically encourages excess food intake and quick
approaches to weight loss". Other contributing factors are children and their families living
sedentary or less active lifestyles, overeating, and consuming high-fat, high-calorie foods (Golan
& Crow 2004; Kumanyika, Jeffery, Morabia, Ritenbaugh, & Antipatis, 2002; Lobstein et al.,

2004; Young & Nestle, 2002).
Out of the global context and within developed countries the relationship between income
and obesity changes dramatically and an inverse relationship between wealth and obesity exists.
As wealth and levels of education increase, obesity levels decrease. Low socioeconomic status
and low levels of education negatively influence a variety of the SDOH that contribute to obesity
in children and adolescents including eating and physical activity behaviours, neighbourhood
safety, local schools and resources, local food stores offering healthy food choices, cost of food,
screen time and other sedentary activities, and access to exercise facilities (McAdams, 2010).
In Canada the influence of socio-economic status is clear. For example, young people in
households where no members had more than a high school diploma were more likely to be
overweight/obese than were those in households where the highest level of education was postsecondary graduation. The prevalence of poor health or unhealthy behaviours is less common at
every step up the socio-economic scale (PHAC, 2011). Current NP literature recommends
targeting environmental influences on the risk factors for childhood obesity is critical in obesity

14
management strategies and suggests a "thorough knowledge of the factors that impact the
environment associated with overweight in children and adolescents will augment the holistic,
ecological perspective" (McAdams, 2010, p. 466).
Genetics and SDOH play a large role in the rising rates of childhood obesity, but there
are other contributing factors. Researchers have found other modifiable and non-modifiable
factors that may contribute to the development of the disease. These risk factors for childhood
obesity include: gestational diabetes, maternal smoking during pregnancy, fetal growth
retardation, and bottle-feeding of infant formula (Hopkins et al., 2011; RNAO, 2005).
Brophy et al. (2009) suggests infant feeding influences the development of childhood
obesity (p. 467). Breastfeeding of infants has been found to be protective factor against the
development of childhood obesity as breastfed babies seem to be better able to regulate their food
intake and thus are at lower risk for obesity in later life (Moreno, 2011; Twells & Newhook,
2010). Both the WHO and PHAC recommend exclusive breastfeeding of infants for the first six
months oflife because "it provides all the nutrients, growth factors and immunological
components a healthy full term infant needs" (WHO, 2004).
A study conducted by Brophy et al. (2009) found that feeding solids before 3 months of
age is associated with higher BMI!obesity at age 5 and subsequent unhealthy feeding behaviour.
Currently the PHAC recommends solid foods be introduced in the infant's diet beginning at six
months of age. Delaying the introduction of solid foods may be protective against the
development of childhood obesity in later childhood (p. 472). Clearly childhood obesity is
complex with multiple contributing factors including biologic, quality of sleep, ethnicity, and
SODH. The complexity of this issue poses a challenge for NPs working with obese children and
their families in primary health care settings.

15

The Role of the Nurse Practitioner in Childhood Obesity Management
The trend toward incorporating NPs into primary health care is not a new phenomenon
and has been evolving over the past several decades (Browne & Tarlier, 2008). Browne and
Tarlier (2008) describe NPs as nurses educated at an advanced level, typically a Master's degree
in nursing and as having scope of practice that incorporates activities that were traditionally
undertaken exclusively by physicians including diagnosing, prescribing medication, referring
patients to other professionals. NP's provide a direct point of entry to the healthcare system for
case management, as well as diagnose, treat, advocate health prevention and promotion (p. 83).
In Canada, integrating NPs into the health care system has been proposed as a key
strategy in reducing healthcare costs and increasing healthcare access (Gould & Wasylkiw, 2006;
Laurant et al., 2004; Nurse Practitioner Association of Ontario [NPAO], 2006). Since the
introduction ofNPs into the Canadian healthcare system in the 1970's, Browne and Tarlier
(2008) state the "trend towards preparing, recognizing and valuing NPs as autonomous
healthcare providers [has] continue[ d) to gain steady momentum" (p. 84).
NPs registered as family or primary health care NPs typically work in community
settings such as community health centres, primary care offices, and long term care facilities and
focus on health promotion, preventive care, diagnosis and treatment of acute illnesses and
injuries, and monitoring and management of chronic diseases. NPs also provide advanced
nursing care in acute care settings for patients are acutely, critically or chronically ill with
complex conditions in clinical areas such as emergency, oncology, and cardiology (Dicenso &
Bryant-Lukosius, 2010).
Nurse practitioners work as autonomous health care providers. They provide many of the
same health care services as their physician colleagues. The role of the NP is not to replace the

16

family physician rather to collaborate with allied health care to increase access to healthcare for
all patients. Although NPs practice diagnosis and prescribe treatments using the medical model
as a framework they are different from family physician in that their nursing education has a
unique theoretical foundation from that of other health professions. NP's are first and foremost
nurses. Nurses "view the world and their role in it from a theoretical perspective that is built on
four fundamental concepts: person or client, the environment, health and nursing" (Kozier et al.,
2004). The person or client who receives care from a nurse may be an individual, family group,
community or population. Nurses take into consideration the environment and both the social
and physical factors that may affect the client (Thome, 2003). Nurses focus on health, which has
many facets including degree of wellness, well-being and quality of life that the client
experiences. Nurses are also concerned with the broader determinants of health including
economic, social and environmental conditions that influence the health of individuals,
communities and jurisdictions as a whole (CNA, 2007). Caring for families has long been
inherent in nursing practise. A background in nursing combined with newly obtained knowledge
and skills make NPs well suited to provide family centered care.
Family Centered Care
Family centered care promotes and supports the well-being and health of families and
family members in different phases of life. NPs have the opportunity to use a family nursing
approach to help families manage their resources and cope with different health problems. In
family nursing individuals are considered independent and yet part of a family unit. Using a
family centered approach the nurse regards the whole family as clients. Establishing goals and
promoting health means involving the entire family (Haggman-Laitila, Tanninen, & Pietila,
201 0). Key principles of family centered care are outlined in Table 1.

17

Table 1

Key Principles of Family Centered Care
1. Acknowledges the family as the constant in a child's life
2. Builds on family strengths
3. Supports the child in learning about and participating in his/her care and decision making
4. Honours cultural diversity and family traditions
5. Recognizes the importance of community-based services
6. Promotes an individual and developmental approach
7. Encourages family-to-family and peer support
8. Supports youth as they transition to adulthood
9. Develops policies, practices, and systems that are family-friendly and family centered in all
settings
10. Celebrates successes
Adapted from: Arango, (2011)

The core concept of FCC is the creation of a partnership in which families and
practitioners work together for the child. It is "a way of caring for children and their families
within health services which ensures that care is planned around the whole family, not just the
individual child/person, and in which all the family members are recognized as care recipients
(Sheilds et al., 2006). Arango (2011) describes FCC as assuring "the health and well-being of
children and their families through a respectful family-professional partnership; [FCC] honours
the strengths, cultures, traditions and expertise that everyone brings to this relationship" (p. 97).
For the family/practitioner partnership to succeed each member is expected to respect the skills
and expertise the other partners bring to the relationship. Arango (2011) describes the FCC
relationship as based upon trust, open communication, mutual decision making and a willingness
to negotiate as needed (p 97). Further, participation in FCC is reported to be a positive

18
experience for families as FCC is associated with improved access to health care, higher
satisfaction, more appropriate utilization of services, and improved health and functional status
(p. 97).

Family centered care one important concept in the management of childhood obesity
because it has been shown to result in sustained weight loss in children over time while
improving the health and well being of the entire family. Family based management strategies
are recommended in current evidence based guidelines regarding childhood obesity (Berry et al. ,
2004). NPs can take advantage of their nursing knowledge and look to existing nursing models
such as the McGill Model of Nursing for guidance in incorporating family centered care into
practice. The McGill Model includes many of the elements of family centered care as described
by Arango and incorporates other factors that influence health such as environment and SDOH.
Because of this, it can be utilized by NPs to manage childhood obesity in primary health care
settings.
McGill Model of Nursing

The McGill Model ofNursing was developed at the McGill School of Nursing under
the guidance of Dr. Moyra Allen. Dr. Allen envisioned nurses taking a unique, active and
complementary role in providing health care. Gottlieb and Rowat (1987) describe that within
the model:
The central goal of nursing is to maintain, strengthen and develop the [client' s] health
by actively engaging him or her in a learning process. Because health is a learned
phenomenon and the family is considered the primary socialiser in this learning, the
family is the focus of nursing. The nurse strives to structure a learning environment
that enables the patient to participate as fully as possible. The nurse and the patient

19
together set goals and, building on the patient's strengths and resources, devise means
of achieving them. (p. 51)
Over the years, the McGill Model has been developed, refined, tested and
implemented in various practice settings and has gained widespread acceptance in Canada and
elsewhere as a useful framework for nursing practice. The McGill Model of Nursing,
previously known as the Allen Model, the Developmental Health Model and the Strength
Model, is a dynamic model that evolves today with the continued efforts of faculty members
and students at McGill University (The McGill Model ofNursing, 2012).
There are several major assumptions that provide the underpinnings for the McGill
Model. Perhaps the most important and fundamental of these is the belief that health is a
nation's most valuable resource. Lalonde (1974) points out that "good health is the bedrock
on which social progress is built. A nation of healthy people can do those things that make life
worthwhile ... and good physical and mental health is necessary for the quality oflife to which
everyone aspires." Obesity is a major health threat, and is one of the leading preventable
causes of morbidity and mortality in all ages (McAdams, 2010). Overweight and obesity in
children is a key predictor of obesity in adolescence and adulthood (Wald et al., (2011 ).
Obese child children experience psycho-social problems and discrimination in addition to
substantial medical co-morbidities that adversely affect their quality of life (p.l 01 0).
The second major assumption of the model is that individuals, families and
communities strive for and are motivated toward better health. Further is the assumption that
within each individual there is the potential to develop and achieve this goal. Finally, health is
best achieved through active learning, involvement and personal discovery. Wald et al. (2011)

20
describe primary care as an appropriate environment in which to influence large numbers of
overweight children and their families.
Based on these assumptions the McGill Model describes that the fundamental task of
nursing is to "assist families in developing their potential for health by engaging them in an
active learning process" (Feeley & Gerez-Lirette, 1992). Further, "the unit of concern to the
nurse is the family, since the family is the context in which learning occurs and health situations
exist" (Allen, 1983). In order achieve this nurses must have a broad knowledge base, one
grounded in the sciences and the humanities. Skills of analysis and synthesis are also essential
prerequisites (Gottlieb & Rowat, 1987). NPs working with families are well situated to
address the problem of childhood obesity as children are seen more frequently for
preventative care and treatment of common childhood illnesses during their early years.
Treatment during early childhood may be more likely to yield long-term change (Wald et al.,
2011).
Elements of the Model
Health.

Health is the central component and the focus of nursing practice in the McGill Model.
Gottlieb and Rowat (1987) explain that health and illness in the McGill Model are viewed as
separate entities that coexist. Health is conceptualized as a "dynamic, multidimensional
construct encompassing a number of processes" (p. 54). Two processes that are salient in the
model are coping and development. Coping refers to the effort of the individual and their
family to deal with a problematic situation by problem solving. Problem solving activities
include: identifying the problem, finding alternative actions and evaluating these alternatives.
Development involves acts of recognizing, mobilizing, maintaining and regulating the

21
potentials and resources that reside within the individual, family and the larger social context.
Gottlieb and Rowat (1987) describe that coping and development are both learned within the
context of the family. They are viewed as dynamic, evolving over time and interconnected.
Further, mastery of these processes enables the individual or family to function at a perceived
maximum capacity and to achieve a high level of satisfaction with life (p. 54).
Person.

The second element of the model is person. The McGill Model recognizes that health
is learned within the context of the family and thus person encompasses the entire family.
Even though the family is the unit of concern, the individual is considered. Within the model
the influence of the family on the individual and the effect of the individual on the family are
recognized.
The McGill Model of Nursing recognizes that all individuals and families possess
strengths, potentials, and resources. Within the model four different types of strengths are
described that enable individuals and families to cope with life challenges, to change and to
develop (Feeley & Gottlieb, 2000). The four strengths include: traits that reside within an
individual or a family (e.g., optimism, resilience), assets that reside within an individual or a
family (e.g., finances), capabilities, skills or competencies that an individual or a family has
developed (e.g., problem-solving skills), and qualities that are more transient in nature than a
trait or asset (e.g., motivation) (p.12). Potentials are described as precursors that could be
developed into strengths. Resources include assets that are external to the family, such as the
social network or the services that exist in the broader community (Feeley & Gottlieb, 2000).
Assisting families to manage their own inherent resources is referred to as resourceenhanced family nursing (Haggman-Laitila et al., 2010). The goal of resource-enhancing family

22
nursing is to help families use the resources of individual members and of the family unit as a
whole, as well as external resources to the family system. The McGill Model of nursing provides
nurses with the framework and knowledge to assist families to determine their own resources and
support them to develop themselves and solve their own problems (Gottlieb & Gottlieb, 2007;
Haggman-Laitila et al., 201 0). To facilitate resource-enhanced family nursing, the nurse's role is
to establish a co-operative relationship with the family wherein the family's expertise is
appreciated and trusted. The nurse listens, respects and takes family members seriously. Once a
trusting relationship has been established, the NP employs three strategies: identifying resources
and providing feedback, developing resources, and calling for resources (Haggman-Laitila et al.,
201 0). The end goal is to support families to see that they have alternatives and possibilities to
improve their situation.
Environment.

In the McGill Model the environment is viewed as the context within which health and
healthy behaviors are learned. Gottlieb and Rowat (1987) state that although health is learned
primarily within the context of the family, learning also occurs in varied settings such as acute
care units, community health centers, long-term care institutions, schools and work places (p.
56). The person and the environment are in constant interaction, each influencing and being
influenced by the other. As a result of this interchange learning occurs. Thus, nurses can
facilitate the creation of new environments or manipulate existing ones in order to assist the
individual or family in learning.

Nursing.
According to the McGill Model the primary goal of nursing is health promotion. As
health is a learned process, the goal of the nurse in the McGill Model is to engage the individual

23
or family in the process ofleaming about and participating in healthy living. The nurse does this
by including the individual and family as an active participant and collaborator in the health
promotion process. Negotiation, collaboration and coordination are prominent features of the
nurse-patient relationship.
The development of professional practice based on nursing models such as the McGill
Model and others like it has had a significant impact on care delivery, nursing knowledge and
practice and has led to the concept of family centered care (FCC) as a standard of nursing
practice (Arango, 2011; Feeley & Gerez-Lirette, 1992). In the context of childhood obesity,
NPs can use the McGill Model as a framework to develop family centered care plans that support
families to identify their own strengths, develop coping mechanisms and achieve success. In
doing this they have the potential to facilitate a positive change in the overall health and well
being of the entire family.

24
Chapter Three
Approach and Research Methods
The approach to the Nurse Practitioner project consisted of an in-depth review of current
academic literature on childhood obesity and family centered care. The literature search was
conducted in order to obtain evidence to answer the question; "How can the nurse practitioner
incorporate family centered care into practice in the assessment and management of childhood
obesity in the primary health care setting?" The search process involved consultation with a
research librarian and a systematic plan to search the literature including keywords used in the
search and detailed inclusion and exclusion criteria was drafted and reviewed. The search
strategy consisted of an initial web search, electronic database search, a search of evidence based
practice (EBP) literature, a web site search, a search of archives of five top rated pediatric,
obesity, family nursing, and nurse practitioner journals, and a search of reference lists. Inclusion
and exclusion criteria are presented in Table 2.
Table 2

Inclusion and Exclusion Criteria for Selection ofResearch Articles
Inclusion criteria
Exclusion criteria
•
•
•

•
•

Published in the English Language, EBP
guidelines from within North America
Peer reviewed research papers, studies,
systematic reviews or dissertations
Relevant to treatment in a primary care
setting and within the scope of the NP
Studies examining childhood obesity and
or management of the disease
Studies focused on treatment of obesity
using a family centered care approach

•
•
•

•
•

Not published in English, EBP guidelines
from outside of North America
Non research editorials, book reviews,
news releases, or opinion statements
Studies focusing on the treatment of
obesity in the acute care setting (bariatric
surgical centers, hospitals, centers for
eating disorders)
Studies aimed solely at prevention,
identification, or screening for the disease
Studies focused on other methods of
treatment (anti-obesity drugs, surgical
interventions, psychiatric treatment for
over eating disorders)

25
In consultation with the research librarian it was decided that limits would not be placed
on publication dates. This was done because of the limited number of studies and research
available on the use of family centered care in the management of childhood obesity and to
ensure that seminal works in this field would not be excluded. Family nurse practitioners practice
primarily within primary health care settings, so search parameters were focused in this clinical
area.
The following data bases were searched: Cumulative Index to Nursing and Allied Health
Literature (CINAHL), Health Source Nursing/Academic, Medline (Ovid), Pubmed Central,
Psych Info, and Social Work Abstracts. Keywords were entered into each data base. MeSH and
CINAHL headings were then used where appropriate to obtain relevant literature. The key words
used in the search are shown in Table 3.
Table 3

Keywords Used in Electronic Database Search
• Obesity (age limit 6-12,
• Childhood obesity (age
13-18)
limit 6-12, 13-18)
• Treatment
• Management

•

Morbid obesity (age limit
6-12, 13-18)
Intervention

•

•

Family centered care

•

Family based care

•

Patient centered care

•

Nurse Practitioner

•

Pediatric Nurse
Practitioner

•

Primary health care

The literature search was initiated by combining like terms from the list of keywords with
the Boolean operator "or". This resulted in thousands ofhits. The searches oflike terms were
than combined using the Boolean operator "and". This action limited the articles found to more
manageable numbers. The title and abstract of each article found in the search was reviewed and
articles were selected for further review based on the relevancy to the project and research
question. The search included the terms Nurse Practitioner and Pediatric Nurse Practitioner but

26
research conducted and published by and about other health care providers was included due to
the limited availability of research conducted about NP practice and by NPs. Results of the
database search are presented in Table 4.
Table 4

Results of the Database Search
Database
Results

Articles selected for review

CINAHL

30

19

Health Source
Nursing/Academic
Medline Ovid

2

1

1

0 (Duplicate article)

Pubmed

18

2

Psych Info

0

0

Social W ark Abstracts

0

0

The search of the EBP literature was completed using Dicenso, Bayley, and Haynes'
(2009) "Hierarchy of Pre-Processed Evidence" as a guiding framework. The Hierarchy of PreProcessed Evidence is a tool that assists clinicians in appraising evidence. The tool is a pyramid
depicting a hierarchy of pre-processed research evidence. The highest level of synthesized
evidence is 'systems', followed by summaries, synopses of syntheses, syntheses, synopses of
single studies, and finally single studies. The original and ongoing intent of classifying evidence
in this way is to encourage decision makers to begin their search for evidence at the highest level
of the pyramid, which is the most synthesized form of evidence, as opposed to beginning their
search at the bottom of the pyramid, representing the least synthesized form of evidence. The
pyramid can be used to guide decision makers in accessing the highest level of synthesized

27
evidence and only moving to lower levels in the pyramid when no evidence exists at a higher
level (Robeson, Dobbins, DeCorby, & Tirilis, 2010).
Databases searched included (in hierarchical order) Clinical Practice Guidelines and
Protocols in BC, CNA Standards & Best Practices, CMA InfoBase, National Guideline
Clearinghouse, TRIP Database, DARE, Cochrane Database of Systematic Reviews, and Johanna
Briggs Institute Database of Systematic Reviews. Articles were selected for review based on
inclusion and exclusion criteria. The title and abstract of the remaining articles were reviewed
and each article was selected or rejected based on relevancy to the project. Results of the EBP
search are presented in Table 5.
Table 5

Results ofEBP Search
Database

Results

Articles selected for review

Clinical Practice Guidelines
and Protocols in BC
CNA Standards & Best
Practices
CMA InfoBase

0

0

1

1

National Guideline
Clearinghouse
TRIP Database

40

2

2939

12

Cochrane Reviews

4

0

Johanna Briggs Institute

32

3

1

Websites from government health agencies and leading health organizations that were
searched include: Public Health Agency of Canada (PHAC), Statistics Canada, Center for
Disease Control and Prevention (CDC), Obesity Canada, and the World Health Organization.

28
Specific articles were not retrieved during the initial literature search however specific data was
retrieved later during the process of writing the project paper.
Finally, during the process of analyzing the content of the articles found during the
literature search, the reference list of each research paper was manually searched. Any research
article titles that did not appear in the initial literature search and appeared relevant to the project
were selected. The articles were then obtained from electronic journals or the library for review.
The total number of articles and guidelines chosen for analysis was limited by the length
of this project. Of the 41 articles selected for review, 20 were retained after initial analysis to be
included in the project. The clinical practice guidelines were included because they are the most
current recommendations available for use in NP practice. The remainder of the articles were
selected for review based on; analysis of the use of family centered care in the management of
childhood obesity, publication date within the last 10 years (although seminal works in the field
were not excluded based on date of publication), and relevancy to NP practice in Canadian
primary health care settings. Seminal works were identified by means of citation analysis.
During the review of the reference lists of the articles retrieved from the data base search it was
noted that one key research article was referenced numerous times. A subsequent search using
the Web of Science database to search cited references was completed. Epstein, Valoski, Wing
and McCurley (1990) was found to have been cited 334 times. Based on these findings, the
article was included in the literature review as it is considered a seminal work in the field.
Sixteen research articles, one systematic review, one meta-analysis and two clinical
practice guidelines were included in the review of the literature. Two of the 16 research articles
(Arango, 2011 ; Shields et al. , 2006) provide insight into the concept of FCC, and seven of the 16
research articles are referenced in the discussion regarding the use of the McGill Model of

29
Nursing as a framework for providing FCC (Allen, 1983; Feeley & Gerez-Lirette, 1992; Feeley
& Gottlieb, 2000; Gottlieb & Rowat, 1987; Gottlieb & Rowat, 2007; Haggman-Laitila et al.,

2010); Lalonde, 1974). The remaining seven research articles, systematic review, meta-analysis,
and two clinical practice guidelines are analyzed in Chapter Four.

30
Chapter Four
Findings
The Literature Review
Current clinical practice guidelines regarding the management of childhood obesity
provided a starting point for examining the literature on the management of childhood obesity.
Peer reviewed clinical practice guidelines are used by primary health care providers including
nurse practitioners to guide decision making in clinical practice. They are often the first research
that clinicians access when researching a practice query. Therefore, an analysis of two clinical
practice guidelines is included in the review. The use of family centered care (FCC) in the
management of childhood obesity in the primary care setting is the second major focus of this
chapter.
Current Clinical Practice Guidelines
Evidence based clinical practice guidelines provide clinicians with relevant, peer
reviewed information on assessment, screening and strategies to manage childhood obesity once
it has been identified in clinical practice. The first step during the literature review process was
to look at current clinical guidelines and examine current recommendations regarding the
management of childhood obesity in the primary health care setting.
They are the most relevant to NPs and family physicians practicing in BC. There were
several American guidelines that were also relevant however Barlow (2007) was mentioned most
often in the childhood obesity literature. It was also the subject of a recent article on childhood
obesity in a leading peer reviewed NP publication (Hopkins et al. 2011) and was selected based
on these two factors.

31
The current Canadian clinical practice guidelines regarding the treatment of childhood
obesity were developed by the Canadian Medical Association (CMA) in collaboration with
Obesity Canada. They were published in 2006. The recommendations in the guideline provide a
solid foundation on which a PCP can initiate treatment. They support the use of family orientated
behaviour therapy. The CMA also endorses the use of lifestyle intervention including a
comprehensive weight management program as the preferred method of treatment for childhood
obesity. They suggest the role of the health care provider in facilitating a weight management
program is to provide appropriate education, support, and therapy.
Barlow (2007) provides a step by step approach to childhood obesity management and
thus may be helpful to NPs who have limited experience caring for obese children. This
guideline promotes the use of four stages of intervention in the treatment of childhood obesity;
prevention plus; structured weight management; comprehensive multidisciplinary intervention;
and tertiary care intervention. The first two treatment stages would be appropriate to a primary
health care setting although more intense treatment stages will generally occur at a tertiary care
facility.
Both guidelines provide information on initiating treatment of childhood obesity as well
as treatments that may be initiated in tertiary care centers including pharmacotherapy and
surgical intervention. They suggest the first step in treating childhood obesity is implementing a
family centered program focused on lifestyle modification such as healthy eating and exercise.
Although the guidelines provide evidence based recommendations for managing childhood
obesity it is up to primary care providers to apply them to practice. This could be potentially
difficult for some practitioners depending on their experience and education regarding family
centered care. The research gathered during the literature search sheds some light on what FCC

32
is, its efficacy in reducing BMI in overweight and obese children and how practitioners can
incorporate it into family practice.

The Use of Family Centered Care in the Management of Childhood Obesity
The review of the literature on the use of FCC in the management of childhood obesity is
discussed below. First, the research focusing on why the use of FCC is appropriate in the
management of childhood obesity is examined. The relationship between the use of FCC and
weight loss in children is explored and long term weight loss reviewed. Finally the use of family
centered care in severe obesity and the primary health care setting is analysed.
Three research articles regarding the use of FCC were reviewed and analysed to
determine why the use of FCC is appropriate in the management of childhood obesity. Family
centered care is important in the context of childhood obesity management because the home
environment and the family is the most influential setting for shaping children's eating and
physical activity behaviours (Goran, 2006). The use of FCC in treating childhood obesity is
relevant because dynamic influences on obesity include the family environment, social
determinates ofhealth, and both parents' and children' s knowledge and attitudes about healthy
lifestyles (Tyler & Homer, 2008). Children learn from their environment, beliefs about what is
healthy or unhealthy are communicated through family conversations as well as the actions and
choices of individual family members, these actions and choices are influenced by the
environment and SODH (p. 196).
Tyler and Homer (2008) suggest incorporating FCC into practice can be a positive
experience for both the family and primary care provider. Practitioners who recognize and
address the impact of the family environment on children's health and advocate the use of the
guiding principles of FCC when managing childhood obesity in primary health care can make

33
meaningful differences in lifestyle behaviours ofthe family, and therefore the child (p.196). Use
ofFCC can also lead to improved health-related quality of life, reduced health risks and overall
well being for the entire family (Cifuentes et al., 2002).
Although the literature supports the use of FCC in primary health care adopting FCC into
primary health care practices for the purpose of obesity management can be challenging for
providers. Obesity can be a difficult topic to discuss and conflicts can arise during discussions
about changing lifestyle behaviours (Tyler & Homer, 2008). Understanding the key principles of
FCC can assist care providers in establishing a successful family/professional partnership.

The relationship between family centered care and weight loss.
One meta-analysis and a systematic review were selected because they specifically
address the relationship between the use of FCC and weight loss in obese children. The metaanalysis was completed by Young et al. (2007). The objective was to evaluate the effect of a
family-behavioral component in weight loss treatments for children. Studies published in the
English language evaluating family-behavioral treatment for weight loss in children aged 5 to 12
years were eligible for inclusion. The intervention family-behavioral treatment was defined as
the use of at least one named behavioral or cognitive-behavioral technique to encourage children
to pursue and maintain healthy physical and/or eating habits. At least one parent or guardian had
to be involved in the treatment of the child.
Young et al. (2007) found family-behavioral treatments carried a statistically significant
reduction in mean percentage overweight. The reduction in percentage overweight with familybehavioral treatments remained significant at follow up averaging four months. The effect of
other treatments on weight reduction was not significant. They concluded that weight-loss

34

interventions that include a family-behavioral component are associated with a significant weight
reduction, which was maintained in some studies beyond 24 months.
Limitations ofYoung's meta-analysis were as follows; only studies published in English
were considered which might have introduced a language bias. The potential influence of
publication bias was not considered. No quality assessment of the included studies was reported;
the potential impact of methodological flaws in the primary studies upon the reliability of the
review findings cannot, therefore, be assessed. Not all of the studies reported follow up data.
Although this is a strong study it was conducted in a psychology clinical setting and thus
applying these findings to NP practice may not yield the same results. Finally the fact that the
authors conclusions are based on a relatively small number of studies and participants mean
conclusions must be viewed with caution.
Young et al. (2007) provide strong evidence that weight loss interventions involving
FCC approaches can result in significant short term weight loss. Their definition of family
behavioral treatment does not indicate that any of the key principles of FCC were considered or
practiced during interactions with families . These findings are significant as modest weight loss
has been associated with significant health improvement and a reduction in overall risk of
morbidity and mortality in obese children (Garipagaoglu, Sahip, Darendeliler, Akdikmen, &
Kopuz, 2008). Young et al. (2007) also demonstrated that weight loss achieved using family
based management strategies is achievable and can be maintained short term. Even short-term
weight loss is important as small successes can have a profound impact on health status (Wing et
al. (2011). Families who achieve successful weight loss early in treatment are more likely to
have long-term success (Goldschmidt et al., 2011).

35
The systematic review was conducted by Berry et al. (2004). Their objective was to
assess family centered interventions for childhood obesity. The authors reviewed randomized
controlled trials (RCTs) that followed participants for a minimum of 6 months and studies of
family centered interventions for childhood obesity that used nutrition, exercise or behavioral
methods for weight reduction were included. Family centered interventions were defined as
those targeting the child and at least one parent. Studies involving pharmacotherapy or bariatric
surgery were excluded as were studies not published in English and non-randomized clinical
trials. Participants were obese children ranging in age from 5 to 17 years old.
The reviewers concluded that behavioural modification interventions that targeted
children and parents together or separately were successful in improving weight-loss outcomes in
both parents and children. Behavioural therapy interventions targeting children and parents
together or the parents of children separately improved weight outcomes. Problem solving
interventions that targeted parents of children showed improved weight outcomes for their
children but weight outcomes did not improve when problem solving was used with both parents
and children together or children alone.
Although Berry et al.'s (2004) findings support family centered intervention as a
successful method of managing childhood obesity there were several limitations. Limitations of
the systematic review were that the review was limited to studies published only in English, no
attempts were made to find unpublished studies thus there was potential for both publication and
language bias. One study included in the review did not meet the inclusion criteria for study
design. The number of studies included in the study was small and generally "methodologically
inadequate" (p. 443). Researchers did not elaborate as to how information was delivered to
families just that interventions had to target the child and one parent to meet criteria for

36
inclusion. There was no mention of principles of FCC or how therapeutic relationships were
established. The reviewers also pointed out that 70% (n=9) of the studies reviewed did not report
either the socioeconomic status or ethnicity of the participants. Of the studies that did report, the
participants were predominately Caucasian and from middle to upper socioeconomic groups.
This is of concern as research has shown a strong association between ethnicity, socioeconomic
status and obesity.
While the evidence suggests that managing childhood obesity using FCC is effective in
Caucasian participants of middle to upper socio-economic status, Berry's systematic review has
failed to include research that addresses the influence of ethnicity on health and obesity. This
brings into question the relevance of the findings to specific ethnic populations with higher rates
of childhood obesity such as Canadian Aboriginal youth living off reserve. Primary care
providers working with specific ethnic and minority populations such as Canadian First Nations
youth may want to view the findings with caution. Research has shown that childhood obesity is
influenced by the environment and SODHs. Models such as the McGill Model ofNursing
suggest practitioners support families within the context of their environment and SODH.
Despite this, researchers have failed to address the effect of the environment and SODH on
obesity and successful management of childhood obesity in this systematic review.

Effect of family centered care initiatives on long-term weight loss.
The following two research studies address the long-term outcomes of the use of FCC in
managing childhood obesity. The first study examines the effects of FCC on long-term weight
loss in children. The second evaluates the effect of FCC on both short and long-term weight loss.
A ten-year follow up study by Epstein et al. (1990) was included in this literature review
as it is considered a seminal work in this field. The purpose of this study was to examine the

37
effects ofbehavioural family centered management on percent overweight and growth over 10
years in obese 6 to 12 year old children. Researchers used a prospective, randomized, controlled
design with an intervention described as a diet, exercise and behaviour management training
program. Seventy-six obese children aged 6 to 12 years and their parents were assigned
randomly to one of three treatment groups, 1) child and parent target; 2) child target; and 3) nonspecific target. Group one reinforced parent and child behaviour change and weight loss, group
two reinforced child behaviour change and weight loss and group three reinforced families for
attendance. All treatment groups met weekly for 8 weeks and approximately once per month for
6 months. Children and parents were given US $5 for every visit at which the parent and child
lost weight. Follow-up data were collected at 21 months, 60 months and 120 months. The
percentage change in weight for height, age and gender was the primary outcome variable.
The results of the study found significant weight loss (p<0.05) shown at both 5 and 10
years with children in group one. Children in groups two and three showed an increase in percent
overweight from baseline to 5 and 10 years. Strengths of the study include the duration of the
study, and that it followed children who had obese parents. The study concluded that using
behavioural family centered management to focus on healthy eating, exercise and behavioural
skills training can result in long term sustained weight loss. It also concluded that children with
obese parents who participated in such programs were able to maintain significant weight loss
over time.
Limitations of the study are that it only included middle class, Caucasian participants
from intact, two parent families. It did not address the effect of the participant's environment or
SDOH on their obesity. It was conducted strictly in an urban setting. There was no mention of
any of the principles of FCC. The authors concluded that additional research would be required

38
to determine whether the results of the study would be comparable in or if treatment protocols
would need to be tailored to the differences that exist across families. The reinforcement
techniques (use of money as a reward) and the object of the reinforcement (weight loss) are no
longer recommended (Connelly, Gargiula, & Reeve, 2002). Reward structures are more
appropriate and meaningful if based on praise and activities that strengthen family relationships
rather than food, money or gifts. The object of the reward should be based on factors directly
within the control of the child such as eating and exercise, rather than weight loss which can be
influenced by genetics or metabolic factors (Connelly et al. , 2002; Epstein, 1996).
Results of this study were the first to provide evidence that if long-term behavioural,
family centered management is initiated when a child is between the ages of 6 and 12 years,
positive weight loss results can be maintained into young adulthood. The results are promising as
they indicate that the use of family centered management in children not only results in weight
loss, but also in maintained weight loss over time in participants where genetic risk factors are
present. This is important as it provides evidence that children presenting with non modifiable
risk factors can successfully lose weight, decrease their risk of morbidity and mortality and
maintain their weight loss over time.
Garipagaoglu et al. (2008) published a study to assess the short and long term effects of a
three month family based group treatment in the management of childhood obesity versus
individual treatment. It involved 80 obese children between 6 and 14 years. Forty participants
and their parents were randomly assigned for group treatment and the other 40 for individual
treatment. The intervention program focused on implementing healthy eating behaviours and
involved a three month weight control program for children that included seven 30 to 90 minute
training sessions at two week intervals. The goal of the program was to teach lifelong healthy

39
eating habits and to decrease sedentary habits. The first session started with the definition of
nutrition and teachings about diet behaviour modifications. Feedback was obtained from the
children and parents regarding their children's obesity, preferred foods, and current dietary and
cooking habits. The first session also stressed that motivation and involvement of the entire
family is important in the battle against overweight. Subsequent sessions were devoted to
nutritional education including how to balance good nutrition and weight loss, how to eat the
right kinds and amount of foods according to height, age and activity level, healthy food
preparation methods and included tips for staying on target at school lunches, restaurants, parties
and holidays. Height and weight were measured initially, at each session and during follow up
visits. Body mass index was calculated and expressed as standard deviation score. The result at
the end of the three month treatment program was a significant decline in BMI in both groups
(p<O.OOI). After one year there was still a significant decrease in BMI in the family treatment
group whereas the decrease in BMI in the individual group was not maintained.
Limitations include the limited description of participants. There was no mention of
socio-economic status, education levels or ethnicity of the participants. Although the study was
conducted in the primary care setting it was conducted in Turkey where the geography and
ethnic diversity is different than the Canadian context. It was also conducted in an urban primary
care setting. Although the findings are relevant to all NPs working in a primary health care
settings, this specific intervention may have to be modified to meet the needs of families in
Canadian primary care settings.
The results of the study are promising for Canadian NPs. The findings of the study
demonstrate that family based group treatment is more successful than individual treatment in
the management of childhood obesity and that significant weight loss can be attained and

40
maintained long term using family centered care to manage childhood obesity. This study shows
that family centered interventions are an efficient method of managing childhood obesity and
that success can be achieved in relatively few sessions. The description of the intervention in this
study is detailed and could easily be implemented in the Canadian primary health care setting.
The intervention incorporates many of the key principles of FCC including honouring cultural
diversity and family traditions, recognizing the importance of community, encouraging familyto-family and peer support and celebrating successes. Although the data is preliminary, these
results also point to FCC as a being a potentially cost effective method of managing childhood
obesity. This type of intervention could be easily facilitated by NPs working in a primary health
care clinic.
The use of family centered care in managing severe obesity.
Kalarchian et al. (2009) conducted a study to evaluate family centered behavioural
weight control in the management of severe pediatric obesity. Participants were 192 children 8 to
12 years of age. The average BMI percentile for age and gender was 99.18 (SD: 0.72). Eligibility
criteria included age, BMI, ::::9ih percentile, and adult willing to participate with child. Authors
listed extensive exclusion criteria. Families were assigned at random to the intervention or usual
care. The intervention consisted of 20 hour long group meetings over a 6 month period.
Intervention included counselling, self monitoring records and setting weekly goals. Three group
sessions and three telephone calls occurred between month 6 and 12. Assessments of the children
were conducted at baseline, 6 months, 12 months, and 18 months. There was no contact between
the 12 month and 18 month assessments. Child percent overweight, calculated as percent over
the median BMI for age and gender was the primary study outcome.

41

Results showed that intervention was associated with significant decrease in the percent
overweight compared to usual care at six months. Intervention was associated with a 7.58%
decrease in percent overweight at six months (p =0.0001) compared with a 0.66 decrease with
usual care. Differences were not found to be significant at 12 months or 18 months. Although
impact on percent overweight was modest the intervention was found to have positive effects on
other health parameters compared to those who received usual care including improvements in
waist circumference, systolic blood pressure, percent body fat and total body fat.
Limitations of the study are that the study did not control for different components of the
family based intervention program so results cannot be attributed to specific interventions. The
study was a university based research program conducted at a university hospital so may not be
representative of programs based in the primary care setting. The participants of this study were
required to attend 20 group meetings over a period of six months. This type of intensive program
with numerous sessions may not be feasible in a remote, non urban setting.
Strengths of this study included assessment of the effects of family based programs on
other health parameters including waist circumference, body composition, and blood pressure.
This study also incorporated many of the demographic variables and SODH that the McGill
Model identifies as key factors affecting a family's ability to achieve health. Some of the
variables studied include: gender, ethnicity, level of education achieved by parents, and socioeconomic status.
The results of this study are useful for care providers caring for severely obese children
because that it supports the use of non invasive family centered interventions before
consideration of more risky, controversial therapies such as pharmaceutical therapy and bariatric
surgery. Although pharmacotherapy and surgery are suggested for use in extremely obese

42
children (BMI > 40) (Barlow, 2007), there are associated risks with these types of treatment.
This study suggests that weight reduction and improvements in medical parameters (waist
circumference, body composition, and blood pressure) can be achieved in severely obese
children in a manner that mitigates risks using family centered approaches. Although this study
indicated that FCC based interventions were successful in reducing BMI in severely obese
children, further research would need to be conducted to determine if severe pediatric obesity
can be managed appropriately in the primary health care setting before considering more
invasive interventions.
Use of family centered care in primary health care settings.
The final study that was reviewed was a recently published study by Wald et al. (2011). It
was conducted specifically in the primary health care setting. The study was a prospective cohort
design. The objective was to assess an intervention for obese children age 9 to 12 and their
families delivered by trained professionals in the primary health care setting. The intervention
was described as a family-based, behavioural weight management program consisting of 11
sessions. The length of the sessions was not mentioned. The program consisted of a calorie goal,
self-monitoring of daily food intake, physical activity and sedentary behaviour, and other
behaviour change skills.
Participants were 78 families recruited from five private practices. Eligibility criteria
included BMI ;:95th percentile for age and gender and had a parent/caregiver willing to
participate and attend all sessions. Exclusion criteria included children with severe medical
conditions related to their obesity that required aggressive treatment (severe sleep apnea,
significant endocrinologic abnormalities) or cognitive impairments that prevented them from
participating in the program. Fifty three children immediately began treatment and 23 waited

43
three to four months before beginning treatment becoming the "quasi" control group.
Measurements were taken at baseline, 15 weeks, 12 months and 24 months. The primary
outcome measures at the conclusion of the intervention were the change in weight, BMI and
BMI z score. Results indicated that at the time of completion of the program ( 15 weeks) among
the 55 children who completed the program the mean weight loss was 2.4 lbs compared with a
mean weight gain of 3.45 lbs among 23 control children. The authors concluded from these
findings that providers working in the primary health care setting are ideally situated to address
the problem of obesity since children are seen frequently for preventative care and management
of common childhood illnesses. The frequency of visits during the early years of a child's growth
and development provides opportunity to assess BMI at every visit and intervene early on when
overweight and obesity is confirmed (p. 1). In addition, parents most often present with their
children during visits to the primary health care clinic and are thus available to participate in
counselling and other interventions.
Limitations of this research include the small sample size (n=55) and the brief time frame
in which the study took place. The authors also stated that participants were relatively
homogeneous in terms of education, race, and economic status, which may limit generalizability.
However, the fact that the weight loss was achieved over a relatively short treatment period (15
weeks) is a very positive finding as this could be easily accomplished in the primary health care
setting.
Throughout the literature reviewed researchers have found family centered initiatives to
result in weight loss in obese children while benefiting the entire family. Research indicates that
FCC based initiatives are easily facilitated and promising results can be achieved in relatively
few sessions. Most of the research focused on the relationship between the use of FCC and

44
amount of weight loss in obese children both short and long term. The data indicates that FCC
programs result in short term weight loss as well long term weight reduction and maintenance.
This is particularly promising as significant health improvements have been shown to occur even
with modest decreases in BMI (Kirk et al., 2005). Further, FCC based programs were found to be
successful in decreasing BMI in severely obese children and thus could be considered before
initiating more invasive treatment.
The few articles that specifically addressed the effect of the environment and SDOH on
childhood obesity were also important as the literature has demonstrated the influence of these
factors on obesity. The final research article addressing the use of family centered interventions
by a multidisciplinary team in a primary health care setting is positive for NPs considering using
family centered care to manage childhood obesity in their own primary care practices.

45
Chapter Five
Discussion, Conclusions and Implications

The previous chapters identify childhood obesity as a complex, multifaceted problem. A
review of the current guidelines concerning the management of childhood obesity resulted in the
identification of the use of family centered care as a recurrent recommendation. From the review
the following question of inquiry "How can the nurse practitioner incorporate family centered
care into practice in the assessment and management of childhood obesity in the primary health
care setting?" was developed. The literature was analyzed with a focus on the use of family
centered care (FCC) in the management of childhood obesity in the primary care setting.
The use of family centered care is widely advocated in both the current clinical guidelines
but is not clearly defined. There is also little information readily available to providers on how
FCC can be facilitated into practice. The research reviewed while not homogenous, provides
insight into what FCC is, the key principles of FCC and why it is important in childhood obesity
management. In order to promote the use of FCC in the treatment of childhood obesity, it is
imperative that NPs are aware of what FCC is, why it is important to the management of
childhood obesity in the primary health care setting, and how to facilitate it into practice.
NPs are in a unique position as nurses to be able to use their nursing knowledge to
facilitate family centered care into practice. Reviewing the key principles of FCC as suggested
by Arango (2011) is a good place for NP's interested in FCC to start. NPs working with families
can then utilize their nursing knowledge by using the McGill Model of Nursing to assist them in
facilitating FCC into practice.
The McGill Model complements Arango's (2011) principles of FCC by providing further
insight into many of the elements of FCC such as the concept of partnership with the family,
open communication and perhaps most importantly, building on family strengths, potentials and

46
resources. The model also incorporates and elaborates on the importance of factors such as the
environment and SODH which both strongly influence obesity.
In order to facilitate FCC into practice using the McGill Model, the NP focuses on
building a relationship with the family based on negotiation, collaboration and coordination. The
first step is to engage the individual or family in the process ofleaming about obesity and
practicing healthy living. The NP then supports the family to build coping skills and develop by
identifying the strengths, potentials and resources within themselves and the larger social
context. The NP can then assist the family to mobilize, maintain and regulate these potentials and
resources to achieve their weight loss goals. This is important as assisting families to develop
and use their own inherent strengths and resources, is a critical feature of health and healthy
behaviour (Warner, 1981). Recognizing that the environment, SODH, culture, and ethnicity have
a profound impact on obesity, the NP can also help the family create new environments or
modify their existing environment in order to learn new coping strategies and achieve healthy
ways of family functioning.
Table 6 outlines how NPs can look to the McGill Model to support implementing the
principles of family centered care into practice.

Implications and Recommendations for Nurse Practitioner Practice
NPs contribute to the health care needs of Canadians by providing care that is shaped by
their own unique educational background and regulated by their jurisdictional authority. Nursing
education prepares NPs to work with individuals, families, groups, communities and populations
in diverse and often challenging settings (CNA, 2007). Implementing the NP role in Canada is an
important step in reforming our health care system (Pogue, 2007). The current health care
system in Canada is focused on illness and treatment of disease, and Pogue (2007) proposes that

47
Table 6

Using the McGill Model to Facilitate Family Centered Care into Practice

Principles of FCC
1. Acknowledges the family as the constant in a
child's life
2. Builds on family strengths

3. Supports the child in learning about and
participating in his/her care and decision making

4. Honours cultural diversity and family traditions

5. Recognizes the importance of community-based
services
6. Promotes an individual and developmental
approach
7. Encourages family-to-family and peer support

Applying the McGill Model to support FCC
• Family is considered the primary socializer in
learning and family care is the focus of nursing
• All families possess strengths, potentials and
resources. Within the model four strengths are
described.
• Nurses assist families to identify these
strengths, set goals, and build on their strengths
to devise a means of achieving goals
• Central goal of nursing is to maintain,
strengthen, and develop the child's health by
actively engaging him/her in a learning
process.
• This is best achieved through active learning,
involvement and personal discovery.
• The model recognizes that within the family
each person brings a "different genetic
endowment, personal history, and
physiological, psychological, and social
makeup" (Gottlieb & Rowat, 1987).
• Resources such as community based services
are assets that can be utilized by families to
assist them in solving their own problems.
• Nurses assist families to develop and cope by
working with them to identify problems, fmd
alternative actions to solve them and evaluate
outcomes.
• Although health is learned primarily within the
context of the family, it is also influenced by
others and the environment.

•
8. Supports youth as they transition to adulthood

•

9. Develops policies, practices, and systems that are
family-friendly and family centered in all settings

•

10. Celebrates successes

•

Families are encouraged to develop

relationships and learn from the constant
interaction with their environments.
Health is recognized as dynamic and evolving
therefore the nurse must continually revise,
modify, update and validate the family's profile
as they grow and develop (p. 57).
The primary goal of the nurse is to assist
families in developing their potential for health
by engaging them in active learning; the nurse
also assists families to manage their inherent
resources by participating in resourceenhancing family nursing.
The nurse acknowledges successes as strengths
and works with the family to build on them.

48
it "be rebalanced to include an orientation based on wellness and holistic care, with a greater
emphasis on prevention of disease, illness and injury" (p. 34). NPs are poised to play an
instrumental role in the remodelling of our current health system as fundamental values such as
wellness, holistic care, prevention of disease, illness and injury are embedded in the current
nursing paradigm and can help lead the way as new care delivery models are introduced (p. 35).
The literature reviewed provides direction for NP management of childhood obesity in
the primary health care setting. Interventions that incorporate the use of FCC are making a
difference in the lives of overweight and obese children. NPs working in primary health care are
well suited to facilitating FCC into practice as "educating and counselling individuals and their
families regarding healthy lifestyle behaviours are key components ofNP care" (Sherwood,
Brown, & Fay, 1997). As Tyler and Homer (2007) also point out primary care providers (PCPs),
with a nursing background are well educated in "establishing rapport, ensuring a trusting
therapeutic relationship, and developing a health plan based on mutual goals" which are the
underlying principles of FCC (p. 201).
Specific recommendations for nurse practitioner practice regarding the management of
childhood obesity were derived from the recommendations of current clinical guidelines, the
findings of the literature review and the limitations and areas for further study. The
recommendations for NP practice are shown in Table 7. They are presented in a five step format
which can be quickly and easily referenced by NPs in practice.
Further recommendations for the development ofNP practice include: NPs educating
themselves regarding the principles of FCC and the McGill Model of nursing to increase
knowledge and understanding about caring for families which can then be applied to practice;
ongoing review and critical analysis of current and emerging obesity literature as new

49
developments and findings arise; NP lead multidisciplinary discussion regarding childhood
obesity, current obesity literature, and how to address the limitations in childhood obesity
literature; and NPs partnering with researchers to support research that addresses the limitations
in childhood obesity literature.
Areas for Further Research and Study
Continuing research is important as 'translation of evidence derived from research is the
foundation of practise for NPs" (McAdams, 201 0). While researchers agree that FCC works and
should be incorporated into practice, there has been very little research published on what steps
primary care providers need to take in order to achieve this. The McGill Model of Nursing
incorporates the elements of FCC and provides a framework for incorporating FCC into practice
that addresses factors that strongly influence childhood obesity such as the environment and
SODH. The McGill Model is a valuable tool that can be utilized by NPs and other PCPs when
using a FCC care approach to managing childhood obesity in practice. Further research regarding
the specific use of the McGill Model in managing childhood obesity would be very useful to NPs
in the primary health care setting.
The McGill Model of Nursing views the environment as the context within which health
and healthy behaviours are learned (Gottlieb & Rowat, 1987). Additional studies related to the
use of FCC to manage childhood obesity in multicultural populations, varied socioeconomic
backgrounds, or participants with low levels of education would assist NPs to provide holistic
care. Further research involving delivering FCC to blended families, single parent families,
children living with guardians, and to families with children who have physical or psychological
problems would be invaluable to NPs working with families to combat childhood obesity.

50
Table 7
Assessment and Management of Childhood Obesity in the Primary Health Care Setting
Five steps for assessing and managing
Recommendations for NP practice
childhood obesity
1. Measure height, weight and calculate BMI
• Height and weight should be measured and BMI
for every child at every visit.
calculated and recorded using CDC growth charts
at every visit. [BMis ~85th to 95th percentile
(overweight) and ;:95th percentile (obese)].
2. Intervene
• Once overweight and obesity confirmed, immediate
intervention is required.
Current
Canadian guidelines recommend a full
•
history and physical exam be performed to rule out
endocrine or syndrome related causes of obesity
and screen for obesity related complications.
• FBG and lipid profile are recommended for
children ~ 0 years of age.
• Additional investigations (liver enzymes, urinalysis
and sleep studies) may be ordered when appropriate
to exclude common obesity related health
problems.
3. Promote lifestyle modification using a
• Lifestyle modification aimed at the entire family is
family centered approach
the preferred method of childhood obesity
management.
• Role of the NP is to facilitate a FCC based program
by incorporating the key principles of FCC and
looking to the McGill Model as a framework for
implementing FCC into practice (see table 6).
• Programs should provide appropriate education,
support, and therapy aimed at healthy eating,
increased physical activity and reducing sedentary
activities and "screen time".
• Prescribed activity should be fun, recreational and
activities should be tailored toward and appropriate
to the strengths of the child and family.
4. Set realistic goals, celebrate success!
• Goal setting should be related to healthy behaviours
not specific to measurable weight loss and be easily
attainable.
• Successes should be acknowledged and the family
commended for their efforts and achievements.
5. Follow-up frequently
• Frequent follow up (monthly) is recommended
initially, and at regular intervals thereafter (at least
every 3-6 months).
• Height and weight should continue to be monitored
at every visit (regardless of presenting complaint)
until the child reaches age 18.

51
More research regarding specific interventions would also assist practitioners. Further
study on delivering childhood obesity programs to groups or individual families and addressing
optimal group size would be valuable. Examination of specific interventions would also be of
use to practitioners attempting to teach families about healthy eating behaviours and exercise.
Summary and Conclusion
Childhood obesity is quickly becoming an epidemic worldwide yet Benson, Baer, and Kaelber
(2009) state that studies have shown that many providers do not consider childhood obesity a
priority diagnosis. Childhood obesity is a disease; one that is associated with multiple
comorbidities and early mortality (Hopkins et al. 2011 ). Childhood obesity may be simply
described as a problem of too much energy intake and too little energy expenditure, however the
reality is much more complex as "environmental factors, family characteristics, and parenting
styles all contribute to a child's behaviours, perceptions, self esteem, and body image" (Golan &
Crow, 2004). The literature review revealed a definite disconnect between the availability of
research on the increasing rates and consequences of childhood obesity and the available
literature on the management of the disease. The research obtained for the purpose of this NP
project indicates using a FCC approach to disease management is effective and can be achieved
in the primary health care setting. Despite these findings childhood obesity rates continue to rise.
Further, more focused research on implementing effective and efficient FCC programs is needed.
Primary care providers including nurse practitioners working with families of obese children will
need to be aware of current and emerging research and acquire the necessary knowledge and
skills to combat this disease quickly and efficiently.
The results of this literature review indicate that implementing a management program in
the primary health care setting that incorporates FCC is a good place to start, but much work still
needs to be done. As the childhood obesity rate continues to rise, it is imperative that NPs

52
familiarize themselves with FCC, use their nursing knowledge to incorporate FCC into practice
and become actively involved in further research regarding FCC and childhood obesity. Failure
to do so may have significant consequences:
"I am a fat kid
I have a fat mom and dad
But I will die first"
Haiku for childhood obesity (author K.F. Hopkins in Hopkins et al. , 20 II )

53

Bibliography
Allen, M. (1983). Primary care nursing research in action. In L.N. Gottlieb & H. Ezer (Eds.). A

Perspective on Health, Family, Learning & Collaborative Nursing: A Collection of
Writings on the McGill Model ofNursing. (p. 157-184). Montreal, Quebec. McGill
School ofNursing.
Arango, P. (2011). Family-centered care. Academic Pediatrics, 11, 97-99.
Arslanian, S. (2002). Type 2 diabetes in children: Clinical aspects and risk factors . Hormone

Research in Paediatrics, 57(suppl. 1), 19-28.
Banning, M. (2005). Obesity: Pathophysiology and treatment. The Journal of the Royal Society

for the Promotion ofHealth, 125(4), 163-167.
Barlow, S.E. (2007). Expert Committee recommendations regarding the prevention, assessment
and treatment of child and adolescent overweight and obesity: Summary report.

Pediatrics, 120 (Suppl4), S164-92.
Bell, J.F. & Zimmerman, F.J. (2010). Shortened nighttime sleep duration in early life and
subsequent childhood obesity. Archives of Pediatric and Adolescent Medicine, 164(9),
840-845.
Benson, L., Baer, H.J., & Kaelber, D.C. (2009). Trends in the diagnosis of overweight and
obesity in children and adolescence 1999-2007. Pediatrics, 123(1), 153-158.
Berry, D., Sheehan, R., Heschel, R., Knafl, K. , Melkus, G., & Grey, M. (2004). Family based
interventions for childhood obesity: A Review. Journal of Family Nursing, 10(4), 429449.
Biro, F., & Wien, M. (2010). Childhood obesity and adult morbidities. American Journal of

Clinical Nutrition, 90(5), 1499-1505.

54
Brophy, S., Cooksey, R., Gravenor, M.B. , Mistry, R. , Thomas, N ., Lyons, R., & Williams, R.
(2009). Risk factors for childhood obesity at age 5: Analysis ofthe Millenium Cohort
study. BMC Public Health, 9, 467-474.
Browne, A.J. , & Tarlier, D.S. (2008). Examining the potential of nurse practitioners from a
critical social justice perspective. Nursing Inquiry, 15, 83-93 .
Canadian Medical Association (2006). Canadian clinical practice guidelines on the
management and prevention of obesity in adults and children. Canadian Medical

Association Journal, 176(8), 1-178.
Canadian Nurses Association. (2007). Framework for practice of registered nurses in Canada.
Retrieved from http://\Vww.cnaaiic.ca/CNN documents/pdflpublications/RN_Framework_Practice_2007_ e.pdf#page= 11
Canadian Obesity Network. (n.d.). The sleep connection. Retrieved from
http://www.obesitynetwork.ca/page.aspx?page=230l&app=209&cat l=579&tp=12&lk=n
o&menu=50
Canadian Paediatrics Society. (2004). Growth assessment in aboriginal children: Is there need for
change? Paediatrics and Child Health, 9(7), 477-479.
Caprio, S., Daniels, S.R., Drewnowski, A. , Kaufman, F.R., Palinkas, L.A., Rosenbloom, A.L, &
Schwimmer, J.B. (2008). Influence ofrace, ethnicity, and culture on childhood
obesity: Implications for prevention and treatment. Diabetes Care, 31 (11 ), 2211-2221.
Carpenter, K.M. , Hasin, D.S., Allison, D.B., & Faith, M.S. (2000). Relationships between
obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts:
Results from a general population study. American Journal of Public Health, 90(2), 251257.

55
Centers for Disease Control and Prevention. (n.d.). Body Mass Index. Retrieved from
http://www. cdc. gov/heal thyweight/assessing/bmi/
Chiarelli, F., & Marcovecchio, M. L. (2008). Insulin resistance and obesity in childhood.

European Journal ofEndocrinology, 159, S67-74.
Cifuentes, M., Fernald, D.H., Green, L.A. , et al. (2005). Prescription for health: Changing
primary care practice to foster health behaviours. Annals of Family Medicine, 3(Suppl. 2),
S4-S12.
College ofRegistered Nurses of British Columbia. (2010). Nurse practitioner streams of
practice. Retrieved from
https://wv-.rv-.r.cmbc.ca/Registration/Lists/RegistrationResources/680StreamsotNPPractice
pdf
College of Registered Nurses of British Columbia. (2011). Scope of practice for nurse
practitioners: Standards, limits and conditions. Retrieved from
https :/ /www. cmbc. ca/S tandards/Lists/StandardResources/ 68 8 ScopeforNPs. pdf
Connelly, J., Gargiula, L., & Reeve, D. (2002). Selections from current literature: Treatment
issues in childhood obesity. Family Practice, 19(3), 304-309.
Cummings, D.E., Frayo, R.S., Marmonier, C., Aubert, R. & Chapelot, D. (2004). Plasma ghrelin
levels and hunger scores in humans initiating meals voluntarily without time and foodrelated cues. America/ Journal ofPhysiology and Endocrinologic Metabolism, 287, e297e304.
Daniels, S.R., Arnett, D.K., Eckel, R.H., Gidding, S.S., Hayman, L.L., Kumanyika ... Williams
C.L. (2005). Overweight in children and adolescents: Pathophysiology, consequences,
prevention and treatment. Circulation, 111, 1999-2012.

56
Davis, M.M., Gance-Cleveland, B., Hassink, S., Johnson, R., Paradis, G., & Resnicow, K.
(2007). Recommendations for the prevention of childhood obesity. Pediatrics, 120,
S229-S253.
Dicenso, A., Bayley, L., & Haynes, R.B. (2009). Accessing pre-appraised evidence: fine-tuning
the 5S model into a 6S model. Evidence-Based Nursing, 12, 99-101.
Dicenso, A., & Bryant-Lukosis, D. (2010). The long and winding road: Integration of nurse
practitioners and clinical nurse specialists: Into the Canadian health-care system.

Canadian Journal of Nursing Research, 42(2), 3-8.
Dietz, W.H., & Gortmaker, S.L. (2001). Preventing obesity in children and adolescents. Annual

Review of Public Health, 22, 337-353.
Dietz, W.H. (1998). Health consequences of obesity in youth: Childhood predictors of adult
disease. Pediatrics, 101, 518-525.
Dockray, S., Susman, E.J., & Dom, L.D. (2009). Depression, cortisol, reactivity, and obesity in
childhood and adolescence. Journal ofAdolescent Health, 45(4), 344-350.
Duarte, M.A., & Silva, G.A. (2011). Hepatic steatosis in obese children and adolescents. Journal

a/Pediatrics (RioJ), 87(2), 150-156.
Eppens. M.C., Craig, M.E. , Cusumano, J., Hing, S., Albert, A.K., Howard, N.J, ... Donaghue,
K.C. (2006). Prevalence of diabetes complications in adolescents with type 2 compared
with type 1 diabetes. Diabetes Care, 29, 1300-1306.
Epstein, L.H., Valoski, A., Wing, R.R., & McCurley, J. (1990). Ten-year follow-up of
behavioral family-based treatment for obese children. Journal of the American

Medical Association, 264(19), 2519-2523.

57
Epstein, L.H. (1996). Family-based behavioural intervention for obese children. International
Journal ofObesity, 20(Suppl1), S14-S21.

Feeley, N., & Girez-Lirette, T. (1992). The development of professional practice based on the
McGill model of nursing in an ambulatory care setting. Journal ofAdvanced Nursing,
17, 801-808.

Feeley, N., & Gottlieb, L.N. (2000). Nursing approaches for working with family strengths
and resources. Journal of Family Nursing, 6(1), 9-24.
Fodor, G. (2011). Primary prevention ofCVD: Treating dyslipidemia. American Family
Physician, 83(10), 1207-1208.

Freedman, D.S., Dietz, W.H., Srinivasan, S.R., & Berensen, G.S. (1999). The relation of
overweight to cardiovascular risk factors among children and adolescents: the Bogalusa
heart study. Pediatrics, 1 03(6), 1175-1182.
Freedman, D.S., Khan, L.K., Serdula, M.K., Dietz, W.H., Srinvasan, S.R., & Berensen, G.S.
(2005). The relation of childhood BMI to adult adiposity: The Bogalusa heart study.
Pediatrics. 115(1), 22-27.

Garipagaoglu, M., Sahip, Y., Darendeliler, F., Akdikmen, 0., Kopuz, S., Sut, N. (2008). Familybased group treatment versus individual treatment in the management of childhood
obesity: Randomized, prospective clinical trial. European Journal ofPediatrics, 168,
1091-1099.
Golan, M., & Crow, S. (2004). Nutrition grand rounds. Parents are key players in the prevention
and treatment of weight-related problems. Nutrition Reviews, 62(1), 39-50.

58
Goldschmidt, A.B., Stein, R.I., Saelens, B.E., Theim,. K.R., Epstein, L.H., & Wilfley, D.E.
(20 11 ). Importance of early weight change in a pediatric weight management trial.

Pediatrics, 128(1), 33-39.
Goran, M. (2006). Parents as agents of change in childhood obesity: From research to practice.

International Journal ofPediatric Obesity, 1 (2), 66-76.
Gortmaker, S., Must, A., Perrin, J.M., Sobol, A.M., & Dietz, W.H. (1993). Social and economic
consequences of overweight in adolescence and young adulthood. New England

Journal ofMedicine, 239, 1008-1012.
Gottlieb, L.N. & Gottlieb, B. (2007). The developmental/health framework within the McGill
model of nursing: Laws of nature guiding whole person care. Advances in Nursing

Science, 30, 43-57.
Gottlieb, L., & Rowat, K. (1987). The McGill model of nursing: A practice derived model.

Advances in Nursing Science, 9(4), 51-61.
Gould, O.N., & Wasylkiw, L., (2006). Nurse practitioners in Canada: Beginnings, benefits, and
barriers. Journal of the American Academy ofNurse Practitioners, 19, 165-171.
Gundersen, C., Mahatmya, D., Garasky, S., & Lohman, B. (2010). Diagnostic in obesity and
complications: Linking psychosocial stressors and childhood obesity. Obesity Reviews,

12, e54-e63.
Haggman- Laitila, A., Tanninen, H., & Pietila, A. (2010). Effectiveness ofresource-enhancing
family-orientated intervention. Journal of Clinical Nursing, 19, 2500-2510.
Harris, S.B., Naqshbandi, M., Bhattacharyya, 0., Hanley, A.G., Esler J.G. & Zinman B. (2011).
Major gaps in diabetes clinical care among Canada's first nations: Results of the
CIRCLE study. Diabetes Research and Clinical Practice, 92, 272-279.

59
Health Canada. (n.d.). About primary care. Retrieved from http://www.hc-sc.gc.ca/hcssss/prirn/about-apropos-eng.php.
Hopkins, K.F., DeCristofaro, C., & Elliott, L. (2011). How can primary care providers manage
pediatric obesity in the real world? Journal of the American Association ofNurse

Practitioners, 23(6), 278-288.
Institute of Medicine. (2004). Preventing childhood obesity: Health in the balance. Washington,
D. C.: The National Academies Press.
Jonides, L., Buschbacher, V., & Barlow, S. (2002). Management of child and adolescent obesity:
Psychological, emotional and behavioural assessment. Pediatrics, 110(1), 215-221.
Kalarchian, M.A., Levine, M.D., Arslanian, S.A., Ewing, L.J., Houck, P.R., Cheng, Y., ...
Marcus, M.D. (2009). Family-based treatment of severe pediatric obesity: Randomized,
controlled trial. Pediatrics, 124(4), 1060-1068.
Katzmarzyk, P.T. (2008). Obesity and physical activity among aboriginal Canadians.

Obesity, 16, 184-190.
Katzmarzyk, P. T., Janssen, I., & Ardem, C. I. (2003). Physical inactivity, excess adiposity and
premature motality. Obesity Reviews, 4(4), 257-290.
Katzmarzyk, P. T., & Ardem, C. I. (2004). Overweight and obesity mortality trends in Canada,
1985-2000. Canadian Journal of Public Health, 95(1), 16-20.
Kirk, S., Zeller, M., Claytor, R., Santangelo, M., Khoury, P.R., & Daniels, S.R. (2005). The
relationship of health outcomes to improvement in BMI in children and adolescents.

Obesity Research, 13(5), 876-882.

60
Klok, M.D., Jakobsdottir, S. & Drent, M.L. (2006). The role ofleptin and ghrelin in the
regulation of food intake and body weight in humans: A review. Obesity Reviews, 8, 2134.
Koch, F., Sepa, A., & Ludvigsson, J. (2008). Psychological stress and obesity. Journal of

Pediatrics, 153(6), 839-844.
Kozier, B.J., Erb, G., Berman, A.J., Snyder, S., Raffin Bouchal, D.S., Hirst, S.P., ... Buck, M.
(2009). Fundamentals of Canadian nursing: Concepts, process, and practice. (2"d
Canadian ed.). Toronto, ON: Pearson Education Canada.
Krakoff, J., Lindsay, R.S., Looker, H.C., Nelson, R.G., Hanson, R.L., & Knowler, W.C. (2003).
Incidence of retinopathy and nephropathy in youth-onset compared with adult onset type
2 diabetes. Diabetes Care, 26, 76-81 .
Kumanyika, S., Jeffery, R.W., Morabia, A., Ritenbaugh, C., & Antipatis, V.J. (2002). Obesity
prevention: the case for action. International Journal of Obesity, 26(3), 425-436.
Lalonde, M. (1974). A new perspective on the health of Canadians. Government of Canada.
Ottawa, Ontario.
Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2004).
Substitution of doctors by nurses in primary care. Cochrane Database of Systematic

Reviews, doi: 10.1002/14651858
Lee, W.W. (2007). An overview of pediatric obesity. Pediatric Diabetes, 8, 76-87.
Lobstein, T. , Baur, L., & Uauy, R. (2004). Obesity in children and young people: A crisis in
public health. Obesity Reviews, 5, 4-104.
Maglione-Garves, C., Kravitz, L., & Schneider, S. (2005). Cortisol connection: Tips on
managing stress and weight. ACLM's Health & Fitness Journal, 9(5), 20-23 .

61
Maziak, W ., Ward, K.D., & Stockton, M.B. (2007). Childhood obesity: are we missing the big
picture? Obesity Reviews, 9(1), 35-42.
McAdams, C. (2010). The environment and pediatric overweight: A review for nurse
practitioners. Journal of the American Academy ofNurse Practitioners, 22, 460-467.
The McGill Model ofNursing. (2012). Retrieved March 1, 2012 from
http://www .mcgill. calnursing/about/model
Moreno, M.A. (20 11 ). Breastfeeding as obesity prevention. Archives of Pediatric and

Adolescent Medicine, 165(8), 772.
Must, A., & Strauss, R.S . (1999). Risks and consequences of childhood and adolescent obesity.

International Journal of Obesity Related Metabolic Disorders, 23(suppl2), S2-S11.
Nurse Practitioner Association of Ontario (2006). Primary health care nurse practitioner

historical perspective. Retrieved from http://www.npao.org/history.aspx
Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabek, C.J., & Flegal, K.M. (2006).
Prevalence of overweight and obesity in the United States 1999-2004. Journal of the

American Medical Association, 9, 812-813.
Organisation for Economic Co-operation and Development. (2011). Health at a glance 2011 :

OECD indicators, OECD Publishing. doi: 10.1787/health_glance-2011-en
Pogue, P. (2007). The nurse practitioner role: Into the future. Nursing Leadership, 20(2), 3438.
Public Health Agency of Canada. (2009). Obesity in Canada: Snapshot. Ottawa, Ontario: Author.
Public Health Agency of Canada. (2011). Curbing childhood obesity: A federal provincial and
territorial framework for action to promote healthy weights. Retrieved from
http://www. phac-aspc. gc. ca/hp-pslhl-mvs/framework -cadre/index -eng. php

62
Registered Nurses Association of Ontario. (2005). Primary prevention of childhood obesity.
Toronto, Ontario: Author.
Robeson, P., Dobbins, M., DeCorby, K. , & Tirilis, D. (2010). Facilitating access to preprocessed research evidence in public health. BMC Public Health, 10(95).
doi:10.1186/1471-2458-10-95
Seal, N. (2011). Introduction to genetics and childhood obesity: Relevance to nursing practice.

Biological Research for Nursing, 13(1), 61-69.
Sherwood, G.D., Brown, M., & Fay, V. (1997). Defining nurse practitioner scope of practice:
Expanding primary care services. The Internet Journal ofAdvanced Nursing Practice,

1(2). Retrieved from
http://www .ispub.corn/ostia/?xmlF ilePath=joumals/ij anp/vol1 n2/ scope.xml
Shields, M. (2005). Overweight Canadian children and adolescents. Nutrition: Findings from
the Canadian community health survey. Statistics Canada. Ottawa, Ontario.
Shields, L., Pratt, J., & Hunter, J. (2006). Family centered care: A review of qualitative studies.

Journal of Clinical Nursing, 15, 1317-1323 .
Swinbum, B.A., & Egger, G. (2004). The runaway weight gain train: Too many accelerators, not
enough brakes. British Medical Journal, 329(1746), 736-739.
Swinbum, B.A. , Sacks, G., Hall, K.D., McPherson, K., Finegood, D.T., Moodie, M. &
Gortmaker, S.L., (2011). The global obesity pandemic: Shaped by global drivers and
local environments. The Lancet, 378, 804-814.
Taber, C. W., & Thomas, C. L. (1997). Taber's cyclopedic medical dictionary. Philadelphia: F.A.
Davis.

63
Thome, S. (2003). Theoretical issues in nursing. In J.C. Ross-Kerr & M.J. Woods (Eds.),
Canadian nursing: Issues and perspectives. (4 1h ed.). (pp. 116-134). Toronto, ON:

Mosby.
Tjepkema M. (2002). The health of the off-reserve Aboriginal population. Health Reports
Statistics Canada, 13(Suppl. 1), 1-16.

Twells, L. & Newhook, L.A. (2010). Can exclusive breastfeeding reduce the likelihood of
childhood obesity in some regions of Canada? Canadian Journal ofPublic Health,
1 OJ (1), 36-39.

Tyler, D.O., & Homer, S.D. (2008). Family-centered collaborative negotiation: A model for
facilitating behavior change in primary care. Journal of the American Academy ofNurse
Practitioners, 20(4), 194-203.

Wald, E.R. , Moyer, S.C., Eickhoff, J. & Ewing, L.J. (2011). Treating childhood obesity in
primary care. Clinical Pediatrics, Advance online publication. doi:
10.1177/0009922811410871
Warner, M. (1981). Health and nursing: Evolving one concept by involving the other. Nursing
Papers, 13, 10-17.

Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K.D. & Dietz, W.H. (1997). Predicting obesity
in young adulthood from childhood and parental obesity. New England Journal of
Medicine, 337(13), 869-873.

Willms, J.D. , Tremblay, M.S., & Katzmarzyk, P. T. (2003). Geographic and demographic
variation in the prevalence of overweight Canadian children. Obesity Research, 11(5),
668-673.

64
Wing, R.R., Lang, W., Wadden, T.A., Safford, M., Knowler, W.C., Bertoni, A.G...
Wagenknecht, L. (2011). Benefits of modest weight loss in improving cardiovascular risk
factors in overweight and obese individuals with type 2 diabetes. Diabetes Care, 34(7),
1481-1486.
World Health Organization. (2011). Fact sheet on global obesity. Geneva, Switzerland. Author.
World Health Organization. (2004). Promoting proper feeding for infants and young children.
Author. Retrieved from http://www.who.int/nutrition/topics/
infantfeeding/ en/
World Health Organization. (n.d.). Controlling the obesity epidemic. Geneva, Switzerland:
Author. Retrieved from http://www.who.int/nutrition/topics/obesity/en/
Young, K.M., Northern, J.J., Lister, K.M., Drummond, J.A., & O'Brian, W.H. (2007). A metaanalysis of family behavioral weight-loss treatments for children. Clinical Psychology
Review, 27(2), 240-249.

Young, L.R., & Nestle, M. (2002). The contribution of expanding portion sizes to the US obesity
epidemic. American Journal ofPublic Health, 92(2), 246-249