Tackling Childhood ObesityWhat public health skills do nurses working with children and families need to address

the obesity epidemic in the UK?

Dr Francine Watkins, Senior Lecturer, Director of MPH Programmes, University of Liverpool.

Sue Jones, Honorary Lecturer, Academic Director - Health & Psychology Programmes, Laureate Online Education

Expectations for today’s session

What would you anticipate to be the key Public Health skills for nurses in the UK?

To what degree are these developed within the standard undergraduate nurse training currently?

What do you imagine are the main areas of study within an MPH?

1. Introducing the public health problem.

2. Presenting a study that has been recently carried out looking at the issues surrounding childhood obesity in an area in the UK of high deprivation.

3. How can a MPH ensure Public Health professionals have the mix of skills necessary to examine complex public health problems?

4. Development of our Master of Public Health (MPH) programmes.

Plan for presentation

An important public health issue: childhood obesity

• Children in Europe showing some of the steepest increases in prevalence of overweight children across Europe (International Obesity Task Force WHO 2005).

• Childhood obesity in itself can lead to a number of serious conditions such as poor glucose tolerance, hypertension, sleep apnoea, depression and a raised risk of type 2 diabetes (Lobstein, Baur, & Uauy 2004).

• Obesity levels are continuing to rise and Public health practitioners are therefore faced with the challenge of reversing rising obesity levels by tackling the underlying causes of obesity.

• Recent literature = complex picture of multiple variables effecting obesity levels including not only individual factors but social and environmental factors

• When considering the need to develop strategies they need to be relevant to children and the diversity of influences on their lives as they develop through childhood and become adults and parents themselves, will be critical to take into account.

• The local context plays a significant part in how people, and in this case children, behave towards food. Public Health strategies therefore need to be informed by local cultures and behaviours in order to initiate appropriate and relevant programmes that prevent obesity (Mackereth & Milner 2007).

An important public health issue: childhood obesity

Study area – Halton & St Helens

Study area – Halton & St Helens Data or information?

• The health of people is generally worse than the England average. Deprivation is higher than average and

over 16,500 children live in poverty.

• Life expectancy for both men and women is lower than the England average. Life expectancy is 10.6/11.4

years lower for men and 11.5/7.7 years lower for women in the most deprived areas than in the least deprived

areas (based on the Slope Index of Inequality published on 5th January 2011).

• Over the last 10 years, all cause mortality rates have fallen. Early death rates from cancer and from heart

disease and stroke have fallen but remain worse than the England average.

• Levels of teenage pregnancy, GCSE attainment and tooth decay in children are worse than the England

average.

• In Halton estimated levels of adult 'healthy eating' and smoking are worse than the England average. Rates of

smoking related deaths and hospital stays for alcohol related harm are higher than average.

• The epidemiological data also suggests that Halton and St Helen’s PCT has one of the highest rates of

childhood obesity in the North West (Shaping Up: A healthy weight strategy for Halton and St Helens 2007).

Background – Data or information?

During 2009/10, as part of the National Child Measurement Programme (NCMP), the heights and weights of Halton & St Helens school children in Reception year and Year 6 were measured and collated.

• 3164 - 93.5% of eligible Reception children and 3194 - 92.3% of eligible Year 6 pupils were measured. 6358 in total.

• A total of 2,111 pupils were classed as being Overweight or Obese accounting for a 1/3 of those measured.

• Data also shows there is a significant increase in obesity between Reception and Year 6.

Table: Levels of overweight and obese children by PCT for Reception & Year 6

Reception %

Halton and St Helens PCT Overweight and Obese

28.9%

Halton and St Helens PCT Obese

11.7%

Year 6 %

Halton and St Helens PCT Overweight and Obese

37.4%

Halton and St Helens PCT Obese

21.8%

Background – the National picture

• According to figures from the National Child Measurement Programme (NCMP) in 2009-10 around 9.8% of four- and five-year-olds were classed as obese (11.7% for Halton & St Helens) when they arrived in reception class. But among 10- and 11-year-olds in year six, that had almost doubled to 18.7% (21.8%).

• Nationally almost one in four reception pupils was either overweight or obese – 23.1% (28.9%) while among year six children the figure was 33.4% (37.4%) more than a third.

• These figures although only slightly, were up on previous years, but underline the continuing rise in the number of young children with weight problems.

• While it is difficult to calculate the direct costs, it is estimated that Halton and St Helen’s PCT spends £20.7million – £23.4 million every year treating obesity and its related conditions (Shaping Up: A healthy weight strategy for Halton and St Helens 2007).

The overall aim of this research was to determine the most effective methods for developing and delivering weight management programmes to children aged 4-5 (Reception) and 10-11 (Year 6) in Halton and St Helens that initiate effective long-term weight management strategies.

So what would be the first steps?

How would you approach this?

Taking the next stepsAim of the research

• Understand the perceptions of parents of children aged between 3 and 5 to diet and exercise and attitudes to family life;

• Engage parents of children aged between 3 and 5 not currently participating in children’s and health services to understand reasons for non participation and any existing barriers;

• Gain deeper understanding of what motivates children aged 10-11 in terms of health, diet and exercise; what barriers prevent them from active engagement in managing their diet and physical activity;

• Talk to parents of 10-11 year olds to assess how the strategies and behavioural changes suggested by their children could be effectively implemented by parents and service providers;

• Produce a report that recommends the most effective ways of engaging parents and children from the identified population groups in health initiatives and weight management strategies.

Study Objectives

Methods

• Focus groups– Children aged 10-11– Parents of children aged 10-11– Parents of children aged 3-5

• 1-to-1 interviews with parents not engaged in services i.e. Hard to reach group

• Transcripts analysed using thematic analysis

• Findings here focus on parents views of health information and how they interpret this. From this we can see the potential impact this has on what they are passing onto their children.

Confusion and ScepticismParents reported a feeling of confusion and scepticism about information on what to eat and what to avoid. They described how health messages changed over time and had advice that they felt was unrealistic and that created pressure so they ended up ignoring them.

“The thing is you’re told that many things. ‘You shouldn’t eat this, you shouldn’t ... don’t eat carbs, don’t eat sugar, don’t eat meat’. I just think basically you can eat anything so just do, but just in balance.”

Mistrust of health informationCertainly for some parents there was high level of mistrust about ideal weight guidance for children.

 

“Where do the guidelines come from, as far as I am concerned, you are telling a kid they should have a waist this size, and no I think it’s rubbish.”

Dealing with health information Constructing their own solutions

The response to the perceived excessive amount and conflicting nature of information about healthy foods was to talk about having a balanced diet, to not eat too much of anything but rather a little of everything.

• Further exploration of whether this reported ‘balance’ and ‘moderation’ were actually attained or whether it was a tactic to avoid dealing with issue of achieving a healthy diet was difficult to uncover.

• Similarly the definition of what is moderation was difficult to ascertain.

• There appeared to be a constant negotiation amongst some parents about what to eat and how much to eat and this was tied into wanting to keep their children happy.

Accessing food at HomeParents clearly knew what was ‘bad’ food, or ‘unhealthy’ food and had various strategies in relation to how children accessed ‘unhealthy’ food at home.

Some parents reported actively restricting their children’s access to sweets for example. Others reported hiding unhealthy foods (cakes and biscuits), keeping them out of reach whilst other parents gave free access to all food.

• “I am like that, if they don’t eat their dinner, their tea or their supper or you know their breakfast, I won’t give them sweets. I won’t give them none of that and he knows if he doesn’t eat it, he is not going to get it so he will eat it just for the sake of getting it.’

Rewarding healthy eatingFast food was recognised by parents as ‘unhealthy’ yet they also used these foods as a was of “treating” children and was even used as a way of rewarding healthy eating.

“We don’t do McDonalds, not very often because I’m not a lover of it. We go to Pizza Hut, but every so often these are treats, like a pay day treat. When you get some money and you say ‘yes we’ll go to Pizza Hut, we’ll do whatever.”

However there was also evidence that schools were rewarding healthy eating practices but in a more positive way and parents were picking up on this as an alternative.

• ‘In our M’s school they’re brilliant the way they’ve done that because they have a point system for all foods. Every single food has got a point and the healthier the food the higher the point, and then at the end because every kid is individualised and you press your finger print for your food...

• That’s a good idea• Well exactly, and at the end of the month

or six months or whatever the child with the highest points gets a prize or an award, which is good but it isn’t because then our (child’s name) coming home going ‘is pasta high? Do you think that will be good? And I’m like ‘no (child’s name), enjoy your food’ if you get a bowl of healthy food then sound but enjoy it.’

Rewarding healthy eating

Interventions in Practice: reality of 5-a-day

This was by far the most known of the health messages throughout, and there was a mixture of responses. Some parents felt it was unrealistic.

• “Yes but only occasionally, it’s not like when you think about five a day its massive isn’t it.”

Conclusions• In Halton & St Helens we found varying individual contexts around

family, culture, parenting and eating behaviour. • So designing any weight management intervention strategies we need to

avoid a ‘one size fits all’ intervention• Parents responded and acted on information about diet in different ways:

– Some found health information confusing– Some were suspicious of health information– There was a strong view that children should be able to eat what they

like– Parents struggled to implement existing interventions such as 5 a day– Listening to the children (latest analysis)

Identifying key skills in public health training

• The childhood obesity study clearly demonstrates the broad

range of skills needed to practice public health and the

inherent complexity of undertaking a public health study

• In pairs…..

• Reflecting on the research just described, what skills and

approaches would you identify as key to taking a Public

Health approach?

Do you agree or disagree with the following statements?– Public health is not just about epidemiology or sociology or qualitative

research

– It is the combination of skills and knowledge that makes a good public health practitioner

– Training therefore needs to provide an integration of skills and approaches to complex public health challenges.

Identifying key skills in public health training

Research skills:

Epidemiology skills – understanding data in order to

understand “what is the problem?”

Qualitative research skills – focus groups and in depth

interviews and analysis/interpretation of the data.

Identifying key skills in public health training

But not only research skills:

Sociology:

Understanding different individual, social and cultural contexts in which other people live their lives.

Health Promotion:

Designing interventions -‘Bottom up approaches‘

Interventions that are based on listening to the variety of experiences parents have as they try to interpret information and make sense of it in their own lives

Identifying key skills in public health training

Management of Health Systems

How will the local health services implement, monitor and evaluate the effectiveness of any interventions/strategies?

Health Economics

Understanding the relationship between inputs and impact; What is the most efficient and effective provision of services within an existing resource ‘envelope’

Health & Social Policy

Understanding the local politics and which policies work best in that community

Identifying key skills in public health training

How do we relate this to training?

Need to implement WHO principles of equity, health promotion, community

participation, multidisciplinary involvement, collaboration, primary health care,

and international co-operation

Design training to encourage student-centred learning in a multi-disciplinary

environment whether face to face or online. participationcollaborative learningproblem solving

Think through the skills and knowledge that public health professionals across

the world already have.