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community, and public policy perspectives. Emphasis is placed on the role of nurses and nursing,
acting to promote change with individuals and families and acting as advocates for multilevel policy
initiatives, in reversing the epidemic and improving the health of future generations.
As the largest group of healthcare professionals, nurses are well positioned to be influential in
preventing, identifying, and treating obesity and promoting advocacy ef orts for multilevel policy
changes necessary to create less obesigenic environments. Public opinion polls indicate that among
professionals, nurses garner the most public respect for ethics and honesty (Jones, 2005). To this end,
the purpose of this article is to emphasize the role of nursing leadership in reversing a major challenge
to the health of the U.S. public, the crisis of obesity. Obesity is currently described as a pandemic
(Chopra & Darnton-Hill, 2004) that is responsible for escalating rates of type 2 diabetes (T2DM),
hypertension, cardiovascular disease, sleep apnea, osteoarthritis, bone and joint disorders, low self-
esteem, cancer (Daniels et al., 2005), and reduced life expectancy in thi generation of children (Katz,
2005). The prevalence of obesity is rising for Caucasians and people of color from all socioeconomic
levels and geographic areas (Ogden et al., 2006). Finding solutions to this crisis requires concerted
action involving the strategic synergistic efforts of science, government, and healthcare (Brownell,
2002; Koplan, Liverman, Kraak, & Wishan, 2006).
Overweight and obesity result from an imbalance of energy intake and energy expenditure. Body
mass index (BMI), the ratio of weight in kilograms to the square of height in meters (kg/m2), is
widely used to define weight status. For children older than age 2, the Centers for Disease Control and
Prevention (CDC) has standardized the evaluation and description of overweight and obesity with
gender- and age-based percentiles intended for use along with height and weight charts (Kuczmarski
et al., 2000). The CDC guidelines do not label children as obese but rather use these terms: “at risk of
overweight” describes children and adolescents with a BMI between the 85th and 94th percentile for
age and gender; “overweight,” describes children at or above the 95th percentile for age and gender.
In this article, as in others (Barlow, 2007; Koplan, Liverman, & Kraak, 2005), children with a BMI
>95th percentile for age and gender are referred to as obese.
Healthy People 2010 (2000) identified overweight and obesity as leading health indicators and set the
goal of reducing childhood obesity to <5% and reducing adult obesity (over age 20) to <15%. In
2004, the Progress Review of Healthy People 2010 addressed nu trition and overweight (Progress
Review Diabetes, 2002) and, paradoxically, reported an increase in the prevalence of overweight and
obesity for all age groups in the United States. The latest national data indicate that 17% of children
are obese (Ogden et al., 2006).
Poverty and education are inversely related to obesity and to a child's BMI (Nesbitt et al, 2004). Both
obesity and T2DM disproportionately affect minority populations, especially African Americans and
Hispanics of all ages. The problem is more severe in boys and in African American and Mexican
American girls (Ogden et al., 2006). Because a primary goal is to eliminate the health di parities that
result in unequal treatment (Healthy People 2010, 2000), addressing obesity continues to be a federal
priority and becomes a nursing priority as the profession pursues a model of health that encourages
disease prevention and health promotion for vulnerable groups.
Contexts Influencing the Obesity Crisis
The ecological framework (Bronfenbrenner, 1986), which proposes that multiple factors act at
different levels of influence to promoteor enhance the risk of individual development, facilitates
understanding the complex nature of the obesity epidemic. Within this paradigm, behavior is
recognized as the result of interactions of multiple subsystems over time and across settings and
interdependent—rather than independent—of the environment. Individual weight maintenance is
influenced by numerous factors at various levels, including family, community, and broader society.
Factors that originate from public policy decisions and industry strategies are described as “upstream
influences.” Downstream, the “built environment,” or physical locale (including the accessibility to
recreation areas and safe walking options, the number of grocery stores, and availability and pricing
of foods), influences an individual's potential for achieving energy balance. Figure 1 depicts the
numerous factors within the bioecological model for the development of obesity.
Figure 1. Bioecological Model for the Development of Obesity
Individual Factors or Considerations
By and large, Americans feel that individuals are responsible for their own obesity (Schwartz &
Brownell, 2005). Almost all cases of obesity are primary, which means that the cause is not due to an
underlying disease (Nesbitt et al., 2004), which likely contributes to the common perspective of
obesity as a problem under individual control. Estimates are that approximately 30% to 50% of the
determination of body shape, patterns of fat distribution, and response to overfeeding can be
attributed to genetic factors (Perusse et al., 2005), which predispose individuals at risk to be more
vulnerable to gaining weight in a permissive environment. The dramatic increases in prevalence and
incidence of obesity over the past 30 years cannot be explained only by changes or mutations in the
population gene pool (Nesbitt et al., 2004).
U.S. federal policy, along with the food and diet industry, currently manifests the paradigm of
personal responsibility for food intake and physical activity. For example, a major government
response to the obesity pandemic is an individual change initiative, coined “small steps”
(www.smallstep.gov/ ). The food industry takes a similar attitude, using personal freedom (i.e.,
responsibility) as a springboard to avoid fast-food regulaton or legislation.
Bias against obese individuals is common and often attributed to the belief that obesity is caused by a
psychological weakness brought on by lack of willpower and laziness. Children as young as 2 years
have been found to discriminate against heavier individuals (Cramer & Steinwert, 1998). As a result,
obese persons suffer adverse consequences socia and in education, work, and healthcare (Puhl &
Brownell, 2001). Research has documented that obese individuals are likely to evade healthcare,
neglect preventive services, and avoid discussions of weight management with healthcare providers
(Fontaine, Faith, Allison, & Cheskin, 1998), thereby increasing their risk of chronic conditions
associated with obesity.
Family Factors and Considerations
A child's early experiences in the family environment influence later food preferences and activity
levels. Behavioral conditioning through family, cultural, and social cues provides t e groundwork for
the amount of food and physical activity an individual is likely to pursue (Berkowitz & Stunkard,
2004). Research consistently demonstrates that exposure to high-fat, high-sugar food (e.g., soda pop
and fast food) along with large portion sizes increases the intake of these energy-dense foods (Ello-
Martin, Ledikwe, & Rolls, 2005).
In the United States, eating meals prepared outside the home has increased 89% since the 1970s
(Wang & Brownell, 2005), and the latest data indicate that approximately 46% ofAmericans eat at
least one meal a day outside the home (Guthrie, Lin, & Frazao, 2002). In today's environment, many
families find it difficult to eat dinner together; yet the frequency of family meals is positively
associated with a healthier intake of fruits, vegetables, and protein (Neumark-Sztainer, Hannan, Story,
Croll, & Perry, 2003). Over the past several decades, physical activity patterns also have changed. The
result is more sedentary behavior during work, school, and play time (Dietz, 2005). Data from CDC
(Eaton et al., 2006) indicate that only 54.2% of students nationwide are enrolled in physical education
(PE) classes on 1 or more days of an average school week, whereas 33.0% are enrolled in daily PE
classes. Nationwide, only 35.8% of students reported the recommended levels of moderate-to-
vigorous physical activity of at least 60 minutes per day on at least 5 days per week. The prevalence
of meeting this recommendation was low amongall girls (27.8%) and lowest in black female students
Environmental Factors and Considerations
The multilevel environmental factors that influence the development and maintenance of obesity have
come to be described as “toxic” or “obesigenic” (Brownell, 2002). Within the past 35 years, the
number of supermarkets in the United States declined by 15%, whereas the number of convenience
stores and fast-food eateries doubled (Schwartz & Brownell, 2005). The cost and portion size of
energy-dense, high-sugar, and high-fat foods decreased, which resulted in increased consumption.
Healthy foods and fresh produce have been less likely to be found in stores located in poor
neighborhoods (Popkin, Duffy, & Gordon-Larsen, 2005).
Children are the primary target of the food industry, because they view about 10,000 food
advertisements a year, more than 95% of which are commercials for candy, fast food, soda pop, sugar
cereals, and other unhealthy foods (Wang & Brownell, 2005). Toys and familiar characters entice
children to purchase unhealthy food products. The marketing of food products in the United States is
a multibillion dollar industry that only recently has come under attack (McGinnis, Gootman, & Kraak,
2006). In the 1970s, similar concerns about tobacco prompted federal authorities to prohibit cigarette
advertising from television (Schwartz & Brownell, 2005).
Call to Action: The Implications for Nurses and Nursing
Across healthcare and community-based set ings, nurses are positioned to advocate for individuals
and families in implementing evidence-based activities designed to prevent excessive weight gain for
those of normal weight and promote weight loss for the obese. Nursing care involves not only
compassionate care for individuals but also advocacy for changes at school, local community, and
public policy levels. Campaigning for social changes that promote healthy lifestyles, particularly for
vulnerable populations such as children, the disabled, and those living in poverty, is warranted and
has been suggested in recent reports and recommendations (Daniels et al., 2005; Koplan et al., 2006).
Advocacy for Individuals
In direct care, nurses partner with patients in implementing individually tailored strategies for
behavior change, including identification of barriers to change, education about behavior
modification, skill sets for changing specific behaviors, and strategies for relapse prevention.
According to the U.S. Preventive Services Task Force, behavioral counseling on healthy eating and
physical activity is recommended at all well-child visits and for obese adults (McTigue et al., 2003).
Adults and children should have their BMI measured and charted at every health care visit and should
be informed about how BMI is used to assess excess weigh A brief explanation of the BMI
parameters, health effects of obesity, and counseling/advice on healthy food and physical activity
lifestyle options that are realistic and feasible and based on family resources should be part of such
obesity prevention efforts. These activities are optimally implemented across clinical and community-
based settings by nurses who are equipped with the necessary knowledge along with the technical and
behavioral skill sets.
Often counseling about avoiding obesity is criticized because of the possibility that individuals,
particularly females, will develop eating disorders. Recent research, however, did not find any
relationship between dieting and eating disorders (Schwartz & Brownell, 2005). The promotion of
healthy eating in order to increase the body and mind's strength and endurance with a nutritious diet
high in vitamins and minerals from fruits and vegetables, low-fat sources of protein, and whole grains
is a universal health message. Eating also should be a positive experience that occurs in a pleasant and
unhurried manner. Care should be taken to avoid large portion sizes, especially for children.
Recognizing physiological hunger and satiety signals rather than reacting to advertising, smell, or
sights of food also should be stressed.
Counseling patients about the importance of physical activity includes education about increasing
lifestyle-related activity (i.e., taking the stairs, walking to school and to after-school events and
activities). Outside of school, children should not be sedentary especially in front of the television
and computer, for more than 2 hours a day. Alternatively, they should be involved in enjoyable,
developmentally appropriate physical activity for 1 to 2 hours daily (Dietz, 2005). Role modeling
these behaviors is an important mechanism for change; thus, parents, healthcare providers, teachers,
and other individuals should consider being visibly engaged in daily physical activity.
Advocacy at the Local Level
Nurses are in an excellent position to develop parent classes in schools, healthcare settings, and the
community. Teaching parents the basics of nutrition, including appropriate portion sizes, label-reading
skills, food preparation, and “healthy” grocery shopping, is essential. In doing so, the family's
individual preferences and resources must be considered. Behavior modification changes, such as
keeping unhealthy foods out of the house and modeling appropriate eatin and activity behaviors for
children, are helpful. The National Heart Lung and Blood Inst tute has developed an obesi y
prevention program for families entitled “We Can.” The curriculum and materials for this 8-week
course are available online (www.nhlbi.nih.gov/ ).
Parents and children alike are subject to the marketing techniques used in food advertising (McGinnis
et al., 2006). Despite the popularity of the documentary film Supersize Me, which exposed one fast
food franchise's unhealthy menus and value pricing strategies, parents may not have heard the health
messages that contradict the food and beverage industry advertising. This is not surprising,
considering that the food and beverage industry spends 100 times more that the federal government's
public campaign for healthy nutrition (Schwartz & Brownell, 2005). Nurses can help families become
sensitized to the food industry's strategies. The concept of media literacy is the ability to develop an
informed and critical understanding of the nature, technique, and impact of what is seen, heard, or
read in the media (McGinnis et al., 2006). Media literacy includes information about the food and
beverage industry's advertising ploys and manipulation of consumers, such as the financial incentives
for purchasing large amounts of unhealthy foods. Increasing parent's awareness about the marketing
tactics used with children and the lack of regulation for such would raise parents' consciousness about
The school environment is an important setting for population-based approaches to promotin health
behaviors, such as nutrition and physical activity (Hayman et al., 2004). The Community Guide to
Prevention (www.thecommunityguide.org/obese ) provides a summary of evidence and
recommendations for school-based obesity interventions. Schools are also a critical venue for nursing
advocacy. Individuals who work with children, especially parents and school nurses, can advocate for
changes that would promote healthier eating habits and prevent obesity. Table 1 summarizes
appropriate school-based actions.
TABLE 1. Advocacy for Obesity Prevention in Schools
The CDC monitors the physical activity and nutrition behavior of young people through a national
surveillance system and provides information on how to improvethese behaviors in the CDC
coordinated school health and wellness mandate set forth in the 2004 Child Nutrition and WIC
reauthorization Act (www.cdc.gov/HealthyYouth/ ). This act requires all schools to develop policies
that reflect evidence-based methods for promoting behavior change, such as setting goals for nutrition
education, physical activity, and other school-based activities designed to promote student wellness,
establishing nutrition standards for all foods that are available in schools, monitoring the
implementation of the wellness policy, and involving a broad group of individuals in its development.
The mandate poses opportunities for improving school health promotion but is unfunded, which
makes it an additional financial burden for schools (Fitzgibbon, Hayman, & Haire-Joshu, 2007).
Opportunities for obesity prevention on the community level include local media campaigns, zoning
limits, and nutrition labeling for fast-food restaurants (Koplan et al., 2005). Promoting healthy food
choices could mean supporting food cooperatives, farmer markets, and fresh produce in grocery and
convenience stores. Recent innovative actions, such as New York City's regulation limiting trans fat,
are an example of activism at the local legislative level. Other strategies include promoting the
development of community resources, such as infrastructures that encourage walking, biking, and
other forms of physical activity. Table 2 provides a summary of family and local community action s.
TABLE 2. Advocacy for Obesity Prevention in Families and Local Communities
Advocacy for Environmental and Public Policy Changes
Advocacy is needed for obesity prevention at the “upstream” or policy level, because changes at this
level are likely to affect the largest number of people. Regrettably, public agencies lack the fiscal
resources or authority to institute changes to support a more healthful diet and better parks and trails
for physical activity opportunities. Those responsible—the legislators—often have little or no
knowledge and expertise in the area. Nurses are well positioned to provide education and information
so that elected officials can initiate, promote, and support federal and state policy changes in the food
industry, schools, and physical environment. The Center for Science in the Public Interest and the
Institute of Medicine highlighted the need for limitations on advertising unhealthy foods to children
(McGinnis et al., 2006; Koplan et al., 2005). The protection of children from deceptive advertising
and marketing should be a national priority (McGinnis et al., 2006; Schwartz & Brownell, 2005).
Restricting commercials aimed at children would require legislative changes because a law
prohibiting the Federal Trade Commission from regulating food advertising was enacted after tobacco
advertising was withdrawn from television (McGinnis et al., 2006).
An effective method of multilevel changes involves grassroots activism groups. Mothers Against
Drunk Driving (MADD) began with two mothers desiring to prevent further deaths from automobile
accidents related to drunk driving. MADD's success has resulted in more than 600 community
chapters and action teams that passed legislation, educated school children, and increased public
awareness (Schwartz & Brownell, 2005). A similar grassroots mechanism for obesity prevention
could be driven by nursing and nurses. Professional nursing organizations are a powerful means to
influence public policy change. These groups can demonstrate leadership t rough raising awareness
of the need for obesity prevention policies and collaborating with other organizations that share this
common goal for social and environmental change. Strategies include agenda setting and developing
policy statements on the economic and social costs of obesity. Collaboration among government and
community-based, service, and grassroots organizations to explore innovative and interdisciplinary
coalitions to promote research and global priorities could foster the needed changes.
Advocacy in Education
Educating and counseling individuals and families about BMI screening and the age-appropriate
recommendations for physical activity and healthy nutrition are necessary but not sufficient. Nurse
educators should enhance students' understanding of the contribution of weight status and excess
adiposity to physical problems documented in acute care settings, the prevalence and magnitude of
chronic conditions linked with obesity across the life course, and recognition of obesity-associated
healthcare costs. Care should be taken to emphasize the potentially modifiable environmental
contributors to obesity. Obese individuals require nonbiased, high-quality care in each and every
setting. Consequently, nurse educators should ensure that students avoid negative stereotyping,
discrimination, and biased attitudes toward obese individuals and advocate that nurses role modelthe
desired nutrition and physical activity behaviors that patients are encouraged to adopt. Nurse
educators and healthcare agencies must ensure that professional and nonprofessional employees
receive the training and resources to implement the appropriate phys and psychosocial care.
Advocacy in Research
Nursing research can aid in setting the agenda and advancing the cross-disciplinary science base of
obesity prevention and treatment on an individual and population level. The systematic study of
particular phenomena of concern relevant to this epidemic and the health of the public are consistent
with nursing's emphasis on health promoton, disease prevention, and vulnerable populations.
Numerous questions remain to be addressed regarding the potentially modifiable determinants of
overweight and obesity in vulnerable families and communities. The urgent need for effective
preventive and treatment interventions has been emphasized by numerous expert panels. Nurse
researchers are well suited to design and implement small clinical trials (efficacy studies) designed to
test innovative approaches for prevention and treatment. Nurses' participation on interdisciplinary
obesity research teams addressing obesity prevention and/or the behavioral, pharmacological, and
surgical treatment of obesity also will broaden the scope and breadth of the research agenda for nurses
and add uniquely to the existing knowledge base.
Multiple environmental factors contribute to the obesity crisis. The serious health risks require that
nurses, as the largest group of healthcare professionals, advocate for multilevel policy changes
necessary to create and maintain less obesigenic environments. Across professional and personal
roles, the mandate to nurses and nursing—as the largest and most ubiquitous group of healthcare
professionals—is active involvement in changes designed to improve nutrition and physical activity,
thus preventing obesity and promoting the health of the public.
SUGGESTED CLINICAL IMPLICA TIONS
* Nurses have a professional and moral obligation to advocate for social changes that promote healthy
lifestyles, particularly for vulnerable populations such as children, the disabled, and persons living in
* Nurses can partner with patients and families in implementing tailored weight control or weight loss
- Encouraging nutritious diets that are high in vitamins and minerals from fruits and vegetables, low
in fat protein, and include whole grains rather white flour.
- Encouraging families to avoid sedentary behavi r, especially the television and computer, for more
than 2 hours a day. Alternatively, they should be involved in enjoyable, developmentally appropriate
physical activity for 1 to 2 hours daily.
- Teaching parents the basics of nutriion, including appropriate portion sizes, label-reading skills,
food preparation, and “healthy” grocery shopping.
- Helping families become sensitized to the food industry's strategies by increasing parents' awareness
about the marketing tactics used wih children and the lack of regulation for advertising to children.
* Advocacy for obesity prevention is needed for obesity prevention at the “upstream” or policy level
- Local communities
- Professional organizations
Guide to Community Preventive Services www.thecommunityguide.org/obese
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Federal Small Steps Initiative
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Key Words: Obesity; Community action; Prevention; Child advocacy
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