CHILDHOOD OBESITY: A TRANSTHEORETICAL CASE MANAGEMENT APPROACH

Heather N. Mason,BSN, RN Valerie Crabtee, PhD Paul Caudill, BS Robert Topp, PhD, RN

JOURNAL OF PEDIATRIC NURSING (Nursing Care of Children & Families) October 2008 Volume 23* Issue 5 www.pediatricnursing.org

Prepared by: Mei Joy C. Flamiano BSN 3y2-5 NCM 102- Medical Surgical Nursing

SUMMARY Childhood Obesity is an increasing health problem because of it's strong associations with chronic health problems in children and adults. Children aged >5 years are identified as obese if their body mass index (BMI) is greater than the 95th percentile for age and gender. This article will introduce a new intervention model based on the transtheoretical framework by utilizing case management in a primary care setting to treat childhood obesity. The treatment of obesity needs to begin in the early stages of the disorder to limit the physical and emotional comorbidities that are tied to this disorder. Few children have the knowledge necessary to make healthy nutritional or physical activity choices on their own : therefore parents are key mediators of obesity prevention among their children . Parents play a large role in influencing the diet and physical activity of their young children by their own actions. The TTM, developed by Prochasca and Di Clemlente, consists of four behavioral stages of change:precontemplation, contemplation, action and maintenance. The first stage, precontemplation describes individuals who do not recognize that a health problem exists or do not believe that they need to change their health behaviors. Precontemplation is followed by contemplation, in which the client intends to take action in the near future but has not yet initiated a change in one's behavior. The third stage of change is the action stage, which is characterized by the individual making modifications to one's behavior based on one's knowledge about the behavior. The final stage of change is maintenance, focuses on the prevention of relapsing into the old behavior. This intervention is dependent upon two assumptions of the model. First, movement between stages in the model is linear, although movement back and forth between stages is common before a permanent transition to the next stage, and, ultimately, movement to the maintenance stage is realized. The second assumption is that individual's present stage of change has implications for the types and

interventions that will assist them in progressing through the model toward the maintenance stage. Cognitive approaches are most effective when individuals have not yet changed their behavior (precontemplation and contemplation stages), whereas behavioral strategies are more appropriate when individuals have initiated or are attempting to maintain new behaviors.Cognitive approaches may include consciousness raising, social liberation, self evaluation,environmental reevaluation. Behavioral approaches may include self liberation, counter conditioning, stimulus controls and reinforcement. The proposed intervention involves a case management approach administered through the TTM framework, with the goal of reducing BMI among obese children by modifying their eating habits and by increasing their physical activity. The case manager can individualize the interventions based upon the overweight/obese child and the parents stage of change and available resources in the environment. Once stage of change the parent and the child regarding weight management of the child is known, the case manager can provide interventions for the parent and the child to assist them with transition between these stages. For individuals in precontemplation and contemplation stages, cognitive strategies should be utilized to increase knowledge, change attitudes, reduce barriers and enhance the benefits of desired behaviors in relation to obesity and its impact on the child and the family. For

individuals in the maintenance and action stages, behavioral strategies should be used to change dietary and physical activities and to provide reinforcement for achieving new

behaviors. There are many activities that may be chosen by the case manager to assist their clients throughout the stages.

Table 1. Cognitive Intervention Strategies

Table 2. Behavioral Intervention Strategies

Cognitive activity 1.Complete a family tree of obesity-related diseases 2. Watch Supersize Mevideo 3. Complete a log of duration of time spent engaged in sedentary activities 4. List pros and cons of overweight and inactivity 5. Identify activities that prohibit, or that are performed instead of, physical activity

Process of change Consciousness raising Consciousness raising Self-evaluation

Behavioral Activity 1. Interact with others who engage in healthy eating and activity patterns 2. Read all food labels before eating foods 3. (Grocerystore)scavenger hunt for favorite and healthy foods 4. Eat foods according to the food guide pyramid 5. Eat healthy foods in a fast- food restaurant

Process of Change Stimulus control

Counter conditioning Counter conditioning Stimulus control Counter conditioning

Self-evaluation Environmental reevaluation

6. Identify cues to not engaging Environmental in physical activity reevaluation 7. Identify recommendations Self-evaluation for physical activity and compare to the current level of physical activity. 8. Identify choices that can increase the level of physical activity 9. identify the actual and desired BMI 10. Identify the impact of obesity on social functioning 11. Identify approaches to increasing physical activity 12. Identify perceptions of weight and physical activity Environmental reevaluation Self-evaluation

6. Document eating of new Counter healthy foods conditioning 7. Plan for dealing with Self-liberation situations where unhealthy foods are likely to be eaten or when physical activity decreases (vacation) 8. Plan a meal according to Counter the food guide pyramid conditioning 9. Set goals for diet, weight, and physical activity 10. Document progress toward goals (public display) 11. Provide rewards for achieving milestones toward goals 12. Reduce barriers to physical activity Counter conditioning Stimulus control

Self-liberation

Environmental reevaluation Self-evaluation

Reinforcement

Counter conditioning

13. Understand classification of Consciousness activities into various levels of raising physical activity. 14. Identify one friend who Environmental maintains a healthy or reevaluation active level of physical activity.

13. Compare current and Self-liberation previous diets and physical activity behaviors 14. List realized benefits of Self-liberation increased physical activity and diet change

REACTION / ANALYSIS This case management approach based upon the TTM has the potential to be an

effective approach to reducing childhood obesity and overweight. It gives us new knowledge how to effectively reduce our children's obesity which we know that is one of risk factors in their health. With the detailed model, including all the activities that might be accomplished by the parent and the child guided by the case manager, it will not be a difficult method for the client. Since it deals with cognitive and behavioral strategies implemented accordingly to the TTM stages, might as well, clients would really perceive that this proposed intervention is more effective than the conventional or conservative ways like simply having diet. Similar to the nursing process, first we should have a goal or a plan before getting into the procedure. For an obese person to actually lose weight, he has to set goals and motivate himself which is not that easy. With this intervention, the client, together with his parent will learn to set goals, motivate himself and start today in stages wherein, he would undergo activities that will help him realize those. He will learn to adjust in a way that he is not depriving himself. On the other hand, what makes this intervention questionable, is that, apparently it will vary depend on the setting. Here, in the Philippines, it is unquestionable to conclude that this intervention would only be applicable to those who are in the high economic status level who could afford to hire a case manager that would guide him throughout the stages. Considering that obesity is not included in the Philippines' highest concerns, people will not take it as a problem as long as it does not interfere with their everyday routine and work. People will ignore it as long as they do not feel the consequences and problems brought by obesity. Some will say that to be fat is to be healthy which is wrong. Another problem here is proper education. Time is also one thing to consider. When it comes to losing weight, this intervention is the most effective so far but because of other factors, the application varies.