Case 2-1 Red Fish, Blue Fish, LLP: Two years have elapsed since Fran Fisher, CEO of Red Fish–Blue Fish met with Eric Lynch and Jeff Fisher, Senior Vice President of Supply Chain Management and Vice President of Operations respectively, to discuss increasing their scope and scale of operations. There has been good news and bad news during this period. The good news is that sales have increased domestically as the company expanded into Maryland, New Jersey, Virginia, and Washington, D.C. In fact, the construction and consulting business improved dramatically. Jim Beierlein accepted the position of Vice President, Construction Sales and his experience and contacts had been a real benefit to Red Fish–Blue Fish. However, global sales were disappointing, according to Fran Fisher. European and Canadian Sales were good, but the Asian Market sales were not very good. They developed some new web pages for China, India and Japan. While they had many “hits” on the web page, the sales were not satisfactory. The company relied upon internet sales in the Asian Markets. Some Additional Background Red Fish–Blue fish was established in 2007 by Fran Fisher after he decided to make a career change. He was at that time a successful broadcaster specializing in broadcasting athletic events but was also visible in other venues. He had developed an interest in fishes over the years and maintained large fish tanks which were part of the décor in his office. One of his friends Andy Zimmerman, was a dentist who specialized in dental care for children and adolescents. Andy approached Fran when he was remodeling his offices to help use fish tanks for new décor but also he thought that it would help relax and interest his young patients and make their experience less stressful. Fran got interested in the project and spent a considerable amount of time and effort in the design aspects and in the selection of the fish. Andy was so impressed along the way that he insisted on paying Fran a substantial consulting fee and offered to provide financial backing for a new venture which subsequently was named Red Fish–Blue Fish. And as they say, the rest is history. The business took off like it was “shot from a gun” and Fran was able to bring in several additional individuals to help with supply chain issues, construction and overall operations. Now they were at a crossroads with respect to expansion. Current Challenges and Issues The company had established a footprint in China through purchasing most of their fish from supplies in china and a Chinese Export Company. Fran hired several students from Penn State’s Supply Chain Program to do some studies for him as part of their intern- ship; their analysis agreed with Fran’s conclusions, that is, global markets offered the most potential. They based their conclusions on two important developments that they found with their research—the Trans-Pacific Trade—agreem.

1. Case 2-1 Red Fish, Blue Fish, LLP:
Two years have elapsed since Fran Fisher, CEO of Red Fish–
Blue Fish met with Eric
Lynch and Jeff Fisher, Senior Vice President of Supply Chain
Management and Vice President
of Operations respectively, to discuss increasing their scope and
scale of operations. There has
been good news and bad news during this period. The good
news is that sales have increased
domestically as the company expanded into Maryland, New
Jersey, Virginia, and Washington,
D.C. In fact, the construction and consulting business improved
dramatically. Jim Beierlein
accepted the position of Vice President, Construction Sales and
his experience and contacts had
been a real benefit to Red Fish–Blue Fish. However, global
sales were disappointing, according
to Fran Fisher. European and Canadian Sales were good, but the
Asian Market sales were not
very good. They developed some new web pages for China,

2. India and Japan. While they had
many “hits” on the web page, the sales were not satisfactory.
The company relied upon internet
sales in the Asian Markets.
Some Additional Background
Red Fish–Blue fish was established in 2007 by Fran Fisher after
he decided to make a
career change. He was at that time a successful broadcaster
specializing in broadcasting athletic
events but was also visible in other venues. He had developed
an interest in fishes over the years
and maintained large fish tanks which were part of the décor in
his office. One of his friends
Andy Zimmerman, was a dentist who specialized in dental care
for children and adolescents.
Andy approached Fran when he was remodeling his offices to
help use fish tanks for new décor
but also he thought that it would help relax and interest his
young patients and make their
experience less stressful. Fran got interested in the project and
spent a considerable amount of
time and effort in the design aspects and in the selection of the
fish. Andy was so impressed

3. along the way that he insisted on paying Fran a substantial
consulting fee and offered to provide
financial backing for a new venture which subsequently was
named Red Fish–Blue Fish. And as
they say, the rest is history. The business took off like it was
“shot from a gun” and Fran was
able to bring in several additional individuals to help with
supply chain issues, construction and
overall operations. Now they were at a crossroads with respect
to expansion.
Current Challenges and Issues
The company had established a footprint in China through
purchasing most of their fish
from supplies in china and a Chinese Export Company. Fran
hired several students from Penn
State’s Supply Chain Program to do some studies for him as
part of their intern- ship; their
analysis agreed with Fran’s conclusions, that is, global markets
offered the most potential. They
based their conclusions on two important developments that
they found with their research—the
Trans-Pacific Trade—agreement that was in the works between
the United States and about a
dozen Asian countries and the demographics of the Asian

4. countries!!!
CASE QUESTIONS
1. Explain the advantages of a trade agreement and how it might
impact a company like Red
Fish–Blue Fish.
Case 2-1 Red Fish, Blue Fish, LLP:
2. What makes the demographics of the Asian countries
attractive for future trade
development?
3. What challenges would Red Fish–Blue Fish likely
experience?
Running head: CHILDHOOD OBESITY 1
CHILDHOOD OBESITY 20
Childhood Obesity
NAME
SCHOOL
DATE
Table of Contents

5. 1.
Background…………………………………………………………
……………….…….3
2. Problem
statement………………………………………………………………
…………3
3. Purpose of the change
proposal………………………………………………………...…6
4.
PICOT…………………………………………………………………
…………………..6
5. Literature search strategy
employed…………………………………………………..…10
6. Evaluation of the
literature………………………………………………………………
.10
7. Applicable change or nursing theory
utilized……………………………………………14
8. Proposed implementation plan with outcome
measures…………………………………15
9. Identification of potential barriers to plan implementation:
Overcoming barriers………16
10.
References……………………………………………………………
…………………..18
1. Background
The increasing rate of obesity among children and
adolescents in the last three decades is posing a major health
concern that should be urgently addressed. Despite the latest
national reports in the country that suggest a positive decline in
the childhood obesity prevalence patterns, the country still
grapples with about 12 million children suffering from obesity.
Considering the immediate and long-term health impacts of
obesity, a lot of resources and efforts have been spent by

6. government agencies and advocacy groups to address this
epidemic. However, these efforts have only yielded limited or
short-term gains. As a result, the adverse impacts of childhood
obesity continue to capture the interests and attention of public,
and policy makers. Childhood obesity not only pose serious
health problems, but it also increases the economic costs for
treating children. Therefore, there is need to develop effective
strategies to regulate the worrying increase in the population of
overweight and obese children.
2. Problem Statement
Childhood obesity is a big health problem that needs a lot of
attention to be solved. The rate of obesity among children is
increasing and is likely to increase further in the future because
of the changes in children’s lifestyles. Due to the development
of technology, the nature of children’s recreational activities
has changed. In the past, most children’s recreational activities
were outdoor games. However, technology has caused the
development of activities such as video games and films which
make children spend most of their time indoors doing minimal
physical activities. An increase in the obesity prevalence rate
brings about an increase in the numerous health issues related to
weight. Therefore, the children may continue to have
deteriorated health. Therefore, this problem needs a lot of
attention not only by the parents but also the government,
healthcare professionals and the communities. Studying this
topic is significant because it helps to point out the extent of the
problem and determine some steps that can be taken to reduce
obesity among children.
Childhood Obesity
Childhood obesity is a relatively common condition among
the United States’ population. This condition is characterized by
excessive amounts of weight, which affects the health and well-
being of children (Kelsey et al., 2014). As methods to determine
the exact amount of body fat percentage are limited, there body
mass index (BMI) is used as the measure to determine whether
children are overweight or obese. The BMI represents the ratio

7. of weight to height. According to the Center for Disease Control
and Prevention (CDC), a person is considered to be obese if
their BMI is greater than or equal to the 95th percentile
(Centers for Disease Control and Prevention, 2013). While
obesity is a problem that affects all population demographics,
childhood obesity has some additional effects because of the
vulnerability of the affected population.
Childhood Obesity in America
Obesity is one of the popular health issues that affects children
in the U.S. it is estimated that one in every three children in
America is above the recommended weight. The prevalence of
obesity among children in America has tripled during the last
three decades (Cunningham, Kramer & Narayan, 2014). The
American Heart Association rates childhood obesity as the
number one health concerns that parents should be worried
about. This problem is rated worse than smoking and alcohol
consumption.
According to CDC’s obesity statistics results, the rate of
obesity among children increases with age. Between 2011 and
2014, the rate of childhood obesity among children between 2
and 5 years old decreased significantly. The prevalence of
obesity among this age group is currently 8.9%. Childhood
obesity among children from 6 to 11 years old affects 17.5% of
children in America. The older children are at the highest risk
with a 20.5% prevalence rate among the children between 11
and 19 years (Centers for Disease Control and Prevention,
2013).
Studies have shown that childhood obesity is more
prevalent among the minority communities. For instance, the
prevalence of obesity is higher among the Hispanic and African-
American communities compared to the Caucasian communities
(Van Grouw & Volpe, 2013). The prevalence of childhood
obesity is also likely to be higher among the lower socio-
economic groups.
Impact of Childhood Obesity
Obesity has health, social, emotional, and psychological

8. impacts on the affected children. Obesity has caused the
development of some health concerns in children that were
previously just found among the adults. For instance, health
issues such as Type 2 Diabetes, high blood pressure,
cardiovascular diseases, and elevated blood cholesterol are
currently very common among the children’s population (Ogden
et al., 2014). These are health issues that were common among
the adult population and almost non-existent among the
children.
Obesity also has some negative psychological impacts among
the children such a negative body image, low-self-esteem,
anxiety issues, and depression (Reilly & Kelly, 2011). The
commonly desirable body standard in the society is that of a
slim person. Therefore, children with excess body weight tend
to go through psychological issues trying to meet the society’s
standards of the acceptable body image.
These children may also go through social and emotional
distress because of the higher chance of them being bullied by
their peers in school. Studies have shown that children who are
obese tend to undergo discrimination even in their home
environment. The bullying, discrimination, and stereotyping
may lead them to be emotionally distressed, which can lead to
psychological problems that affect them even much later in their
lives.
3. Purpose of the Change Proposal
The primary objective of this change proposal is to develop
more effective interventions of reducing and managing
childhood obesity in the United States. This objective is
important especially at a time when obesity is becoming a very
prevalent disorder in the country. Another purpose of this
proposal is to educate and inform the target American audience
on ways of addressing childhood obesity. Finally, the proposal
seeks to influence the policy-making process by providing
insights into nationwide strategies of childhood obesity control
4. PICOT Statement
P-I--C-O-T Statement

9. P- Patients who suffer from obesity (BMI of more than
30)
I- Undertaking nutritional education, diet, and exercise
C- Comparison to not taking nutritional education, diet,
and exercise
O- Improved health outcomes in terms of overall weight
loss
T - A year’s time limit
PICOT Statement: Patients, who suffer from obesity (BMI of
more than 30) undertaking nutritional education, diet and
exercise in comparison to not taking nutritional education, diet,
and exercise, can have improved health outcomes in terms of
overall weight loss in a year’s time limit.
PICOT Overview
Childhood obesity poses serious health problems in the US
as the number of overweight and obese population increases at a
rapid pace every year. The effects of this problem have arrested
the attention of policymakers, societal members, and
government agencies. This has resulted in ranking childhood
obesity as a national health concern. The adverse impacts of this
disease go beyond the health realms to include economic burden
on both personal and national budgets. While there are
numerous risk factors and various evidence-based interventions
to address this challenge, no single approach is consistently
efficacious in curbing the disease. Consequently, it is
imperative that efficacious initiatives and policies be developed
to address the never-ending problem of childhood obesity.
Multidisciplinary approaches are often broad and cut across all
dimensions of personal health problems. Instead of placing
emphasis solely on biomedical models, health care professionals
should also seek to promote behavior change among obesity
patients and their family members. A PICOT statement can be
utilized as an effective tool to seek interventions of addressing
childhood obesity.
PICOT Statement
Population

10. In the US, obesity prevalence is highest among children aged
from 6 to 11 years (Cheung et al. 2016). The disease has tripled
among this age group from 4.2 percent to 15.3 percent from
1963 to 2012. In the last three decades, increased cases of
obesity prevalence have been noted among children of all ages,
although the differences in obesity prevalence have been
recorded in terms of age, race, ethnicity, and gender (Cheung et
al. 2016). In this respect, children from socioeconomically
disadvantaged families and some racial and ethnic minorities
experience the higher median score on obesity than the
dominant white population. Higher obesity rates are often
recorded among blacks and Hispanics compared to whites. For
instance, a survey on girls in the Southwest revealed that the
yearly cases of obesity stood at 4.5 percent among Blacks, 2
percent among Hispanics, and 0.7 percent among white girls
aged from 13 to 17 years (Cheung et al. 2016). For low-income
earners, American Indians rank highest at 6.3 percent, followed
closely by Hispanics at 5.5 percent.
Intervention
Evidence-based interventions that seek to reduce childhood
obesity incidences in the country should target two major areas:
prevention and treatment. High-quality RCT has been proven as
one of the most effective preventative intervention, especially
in schools (Reilly, 2006). Such interventions involve making
changes on the school curriculum by introducing and improving
physical education, changing school meal provisions, and
reducing the television viewing hours. Schools should also
engage in promotional campaigns that encourage walking form
home to school (Ickes, McMullen, Haider & Sharma, 2014).
This intervention has been successful in most cases involving
girls in the sense that the risks of becoming obese are
significantly lowered. Treatment interventions should be limited
to motivated families and communities, in which the child and
parents perceive obesity as a problem. From a theoretical
perspective, treatments should be continued for longer periods
such as months to years. Diets should be modified, especially

11. with the use of regimen such as traffic light diet. Television
viewing habits should also be reduced (Ickes et al. 2014).
Furthermore, treatment should be aimed at encouraging families
to self-monitor their lifestyle. Finally, more time should be
offered for consulting with family members.
Comparison
Being a member of a multidisciplinary team, the nurse
practitioner performs the task of offering standardized care and
advocacy support for healthy community environments. In
addition, the nurse helps to ensures that there is proper
coverage, access to, and incentives for regular obesity
prevention, screening, diagnosis and treatment (Vine et al.
2013). There is also need to promote active living and healthy
eating at work. Finally, focus should be on promoting healthy
living during weight gain. There is also need to expand the role
of health care providers, in childhood obesity prevention.
Outcome
When a nurse is involved as one of the primary members in the
multidisciplinary team approach, the child should be guaranteed
of better continuity of care. The outcomes of interventions
should include reduced obesity risks and curriculum
adjustments for sustainable change to make it cost-effective
(Ross et al. 2010). The curriculum modifications should be
generalizable. One of the leading causes of failure of previous
interventions is that they targeted modifications at the micro
levels. This means that targeting individual children, families,
or schools make it harder to have positive outcomes or impacts
on the many other influences on weight status that affect the
environment at the macro levels. Obesity control efforts that
are successful should require a more macro-environmental
strategy in addition to the micro level behavioral adjustments.
Time
Obesity treatment and management should be a process that
takes months to years. This is because the focus should not just
be on the individual level, but also on the general behavioral
patterns of a person’s family, friends, and society at large (Ross

12. et al. 2010). Therefore, interventions should be
multidisciplinary and aim at changing the behavior of the
patient by promoting long term positive outcomes. Precautions
to monitor blood pressure can be done every two weeks or on a
monthly basis. Medications such as sibutramine can be utilized
for periods of up to one year. However, its use should be
discontinued in patients whose weight loss stabilizes at less
than five percent of their initial body weight.
5. Literature search strategy employed
The main search strategy that was employed for the
development of this literature review is the database search
method. This method was utilized to identify the potentially
relevant scholarly articles within the childhood obesity
literature. Examples of these databases included the Cochrane
and Medline databases. Search terminologies related to
childhood obesity were used to identify relevant scholarly
works. Thereafter, an article review was undertaken to examine
the degree of relevance of each article to the research topic.
6. Evaluation of the Literature
The prevalence of childhood obesity in the United States has
increased at such a rapid rate that this has been considered a
serious healthcare issue. This issue has attracted the attention of
policy makers, government agencies, and the community. Due
to the extent of the problem, a large number of researchers have
investigated a number of factors relating to childhood obesity.
One of the factors that have been investigated is the impact of
changing the attitudes of the patients towards obesity and
lifestyle factors that cause a risk factor. In this study, the main
factor being investigated is the impact of education on exercise
and diet on patients who have a BMI of more than 30. The
following is a summary of a review of the literature used to
determine the impact of educating patients on exercise and diet
changes.
Comparison of Research Questions
Most of the literature analyzed for this study focuses on the
intervention strategies for childhood obesity. Cheung et al.

13. seeks to understand the extent of the childhood obesity in
America. The research asks about the incidence of childhood
obesity in America in a bid to demonstrate the extent of the
problem.
Ickes et al. (2014) research question compares the intervention
strategies used in the American schools and international ones.
The main aim of this study is to determine the gaps in the
intervention used in American schools that has caused the
increased childhood obesity. On the other hand, Reilly (2006)
research investigates the interventions strategies for childhood
obesity in United States schools that have been applied
overtime. The research question for this study is to investigate
the effectiveness of each of the strategies that have been
applied.
McGrath (2017) directly investigates the effectiveness of having
an obesity education awareness program for the families of
children suffering from childhood obesity. The research asks
whether educating patients and family on the importance of
maintaining ideal weight and providing awareness on obesity
can help reduce the incidence of childhood obesity. Ross et al.
(2010) investigates the recommended interventions for
childhood obesity. The research question for this study seeks to
understand some of the most effective interventions strategies
to help reduce obesity among children in the United States.
On the other hand, Vine et al. (2013) seeks to understand the
role that primary care providers can play in improving the issue
of childhood obesity. The research asks whether primary care
providers have the capability to make a positive difference
through patient education to help reduce the incidence of
childhood obesity. Taveras et al. (2014) compares the
effectiveness of various interventions for childhood obesity.
The question for this study is whether various interventions
applied in primary care have the same impact on the reduction
of childhood obesity. Lastly, Janicke et al. (2014) investigates
the effectiveness of family lifestyle interventions in the
reduction of obesity. The question of this study asks whether

14. changing lifestyle factors such as diet and exercise can help to
reduce obesity in children.
Comparison of Sample Populations
All the researches that have been included in this study were
meta-analyses or reviews of literature except Taveras et al.
(2015) which included a randomized control trial. This study
included a sample of 649 children between 6 and 12 years. The
other studies were analyses of other researches that have been
done in the past on obesity. Janicke et al. (2014) analysed 20
studies whose sample sizes amount to 1,671 participants. On the
other hand, Ross et al. (2010) performed a review of 73 studies.
The research does not indicate the number of participants
represented by the analyzed studies. McGrath (2017) conducted
a literature analysis of 7 articles. There is a variation between
the sample sizes of the analyzed articles ranging from 12
participants to 9000 participants. Ickes et al. (2014) conducted a
systematic analysis including 12 studies whose samples sizes
range between 10 and 20 participants. In general the studies
that have been included in this research have generally small
sample sizes. Most of the studies are literature reviews with a
very low number of studies included in the analysis. None of
these studies is longitudinal in nature and the samples are very
small. Therefore, there is a high chance that the studies are
limited in terms of the choice of methods. The following is an
analysis of the limitations of each of the studies.
Comparison of the Limitations of the Studies
The limitations of the studies included in this research are
mainly in the choice of methodology, specifically the samples
and analysis methods used by the respective researchers. The
main limitation of Ickes et al. is that the review of research was
done in a narrative format. The study fails to utilize quantitative
methods to enhance the accuracy of the results. Qualitative data
analysis has a significant risk of inaccuracy. The study by
McGrath (2017) is limited by the very small sample size. The
review analyses less than 10 studies, which makes the chances
of inaccuracy to be very high. Additionally, the author has used

15. only qualitative techniques of data analysis, thus, increasing
chances of inaccuracy. On the other hand, Cheung et al. (2016)
is limited by the use of convenience data. The studies used in
this study were not primarily meant to study the research
question of the researcher. Therefore, there is a high chance of
inaccuracy in the results collected. Reilly (2006) fails to clearly
define the methodology used by the researcher. Therefore, it is
hard to ascertain the true strengths and limitations of the study.
Ross et al. (2013) is also limited by inconsistencies in the
research methodology. The study included research from more
than 100 studies but there are some studies that were not
specific to the research question. The researchers made the
closest connection to determine the results of the study. In
general, these studies have a significant chance of inaccuracy
and lack of reliability because of the limitations of the
methodologies employed by the researchers.
The studies that have been analyzed for this research
demonstrate consistent results with regards to the effective
intervention strategies for childhood obesity. From the studies it
is clear that childhood obesity is an extensive problem in the
United States. The best interventions to this problem include
changes in the family lifestyle of the families. Lifestyle changes
include the increase of physical activity and the change of the
diets. Intervention within the primary care setting has also been
found to be an effective form of intervention for childhood
obesity. The primary care professionals can help parents to
reduce the extent of obesity in the American children by
implementing education strategies. These studies confirm the
hypothesis that education on lifestyles changes to the patients
and their families can help to reduce the incidence of childhood
obesity in the United States. Therefore, they can be used to
confirm the PICOT statement of this study which argues that
“Patients, who suffer from obesity (BMI of more than 30)
undertaking nutritional education, diet and exercise in
comparison to not taking nutritional education, diet, and
exercise, can have improved health outcomes in terms of overall

16. weight loss in a year’s time limit”.
7. Applicable Change/Nursing Theory Utilized
Two theories that can help to explain and develop interventions
related to childhood obesity include the health belief model and
the theory of planned behavior. The theory of planned behavior
helps to clarify many of the issues that are related to negative
behavioral patterns (Sothern, Gordon & Von Almen, 2016). The
theory postulates that the environmental attributes are fully
mediated by perceived behavioral control. This framework
moderates the relationship of intention to behavior from
perceived behavioral control. In case perceived behavioral
control is high, then the intention will convert to behavior. On
the contrary, if the perceived behavioral control is low, then it
is less likely that the intention will convert to behavior.
Unlike the theory of planned behavior, the health belief model
is based on the idea that people are motivated to change when
the perceived severity and susceptibility is high. In this respect,
people are most likely to embark on recommended positive
behavior such as proper dietary practices if they feel that the
possibility of getting childhood obesity is high, and that
childhood obesity is so severe (Sothern, Gordon & Von Almen,
2016). In such a situation, they will be motivated to embark on
behavioral change, a situation referred to as ‘readiness to act’.
The theory that makes more sense in implementing EBP project
for childhood obesity is the theory of planned behavior. The
health belief model was originally designed with concern for
public health issues (Sothern, Gordon & Von Almen,
2016). This model has not been received well in the pediatric
community since children and adolescents basically perceive
themselves as immortal and may not use rationalism. The theory
of planned behavior can inform message strategies that seek to
address parental issues over infant and toddler feeding
practices. This is because toddlers’ appetites may fluctuate from
day to day depending on many factors such as their activity
levels, whether or not they are in a growth spurt. Therefore,
parents can regulate their dietary behaviors.

17. 8. Proposed Implementation Plan with Measurable Outcomes
The solution to childhood obesity is the implementation of
initiatives to prevent unhealthy weight gain and to manage the
weight for children who already have excess weight. There
needs to be education initiatives that will encourage parents to
promote a healthy lifestyle for their children. Children need to
have healthy diets and engage in physical activity as often as
possible. A healthy lifestyle can be promoted both in the school
and the home environment. At school there should be rules and
regulations that promote healthy lifestyles such as compulsory
participation in sports and regulated sale of unhealthy food
options (Hanks, Just & Wansink, 2013). At home, the parents
should be able to control the types of foods and food portions
that their children have. They should also promote participation
in physical activity to promote metabolism and avoid gaining of
unhealthy weight.
In the medical setting, there is not much that can be done to
improve the issue of childhood obesity. There are no
medications currently approved for use in childhood obesity in
America. In fact, the American Association of Pediatrics
discourages use of medication to control children’s weight.
However, healthcare professionals can participate in education
of parents to promote healthier lifestyles (Bleich et al., 2013).
9. Identification of Potential Barriers to Planned
Implementation
Potential Barriers
Efforts that seek to prevent and respond to childhood obesity
problem must take into account potential barriers and
limitations for them to be successful. For instance, there are
numerous potential barriers that hamper adolescents from
accessing these programs and services (Smith et al. 2014).
Adolescents can be difficult to recruit to healthy lifestyle
initiatives for different reasons. For some, the fear of
humiliation or bullying makes it harder to seek help. For others,
the promotion of a healthy lifestyle is not enticing if they are
overly concerned about their weight. In most situations,

18. adolescents do not want to admit that they are overweight.
Another potential barrier is the challenge experienced in
the retention of program participants. This is especially true for
families who find it hard to remain engaged with the program
(Smith et al. 2014). For most families, this requires a
commitment in terms of time engagement. Another program-
specific factor of start and finish times can be viewed as a
barrier that makes it tougher for families to remain engaged in
the long-run. Some participants are conflicted in their view for
the most appropriate start time, since others seek to include
children and adolescents immediately after schooling hours or
days (Smith et al. 2014). For some parents, if these programs
cannot be implemented full time, they have to be addressed
during working part time hours.
Overcoming the Barriers
There is need to focus on making the programs more enjoyable
and rewarding for both children and adolescents. This would
improve the possibility that their families would remain in such
programs (Smith et al. 2014). It is also important to get parents
involved since they are the ones who are in control of the food
and can regulate their children’s use of video games and
television. Program staff members are also key enablers for
maintaining families’ levels of engagement in the programs
(Smith et al. 2014). Therefore, there is need to establish a good
relationship between facilities and participants as one of the
most crucial parts of the program.
For adolescents who are hesitant to join activities geared
towards reducing or preventing childhood obesity, there is need
for a wide-reaching and personalized communication campaign
to reach adolescents and parents (Smith et al. 2014). Emphasis
should be placed on the message. Face-to-face selling goes a
long way in promoting behavior change communication. In
particular, use of communication channels such as brochures,
newsletters, and email communication can work effectively
(Smith et al. 2014). Finally, participants should receive a
generalized feedback regarding the entire program and has been

19. achieved.
References
Bleich, S. N., Segal, J., Wu, Y., Wilson, R., & Wang, Y. (2013).
Systematic review of community-based childhood obesity
prevention studies. Pediatrics, 132(1), e201-e210.
Centers for Disease Control and Prevention (CDC. (2013). Vital
signs: obesity among low-income, preschool-aged children--
United States, 2008-2011. MMWR. Morbidity and mortality
weekly report, 62(31), 629
Cheung, P. C., Cunningham, S. A., Narayan, K. V., & Kramer,
M. R. (2016). Childhood obesity
incidence in the United States: a systematic review. Childhood
Obesity, 12(1), 1-11.
Cunningham, S. A., Kramer, M. R., & Narayan, K. V. (2014).
Incidence of childhood obesity in the United States. New
England Journal of Medicine, 370(5), 403-411.
.Hanks, A. S., Just, D. R., & Wansink, B. (2013). Smarter
lunchrooms can address new school lunchroom guidelines and
childhood obesity. The Journal of pediatrics, 162(4), 867-869.
Ickes, M. J., McMullen, J., Haider, T., & Sharma, M. (2014).
Global school-based childhood
obesity interventions: a review. International journal of
environmental research and
public health, 11(9), 8940-8961.
Janicke, D. M., Steele, R. G., Gayes, L. A., Lim, C. S., Clifford,
L. M., Schneider, E. M., ... & Westen, S. (2014). Systematic
review and meta-analysis of comprehensive behavioral family
lifestyle interventions addressing pediatric obesity. Journal of
pediatric psychology, 39(8), 809-825.
Kelsey, M. M., Zaepfel, A., Bjornstad, P., & Nadeau, K. J.
(2014). Age-related consequences of childhood
obesity. Gerontology, 60(3), 222-228.
McGrath, S. M. (2017). Childhood Obesity Comorbitities
Awareness Hospital-based Education
(Doctoral Dissertation), Walden University, Minneapolis,
Washington.

20. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M.
(2014). Prevalence of childhood and adult obesity in the United
States, 2011-2012. Jama, 311(8), 806-814.
Reilly, J. J., & Kelly, J. (2011). Long-term impact of
overweight and obesity in childhood and adolescence on
morbidity and premature mortality in adulthood: systematic
review. International journal of obesity, 35(7), 891-898.
Reilly, J. J. (2006). Obesity in childhood and adolescence:
evidence based clinical and public
health perspectives. Postgraduate medical journal, 82(969), 429-
437.
Ross, M. M., Kolbash, S., Cohen, G. M., & Skelton, J. A.
(2010). Multidisciplinary treatment of
pediatric obesity: nutrition evaluation and
management. Nutrition in Clinical
Practice, 25(4), 327-334.
Smith, K. L., Straker, L. M., McManus, A., & Fenner, A. A.
(2014). Barriers and enablers for participation in healthy
lifestyle programs by adolescents who are overweight: a
qualitative study of the opinions of adolescents, their parents
and community stakeholders. BMC pediatrics, 14(1), 53.
Sothern, M. S., Gordon, S. T., & Von Almen, T. K. (Eds.).
(2016). Handbook of Pediatric
Obesity: Clinical Management. New York: CRC Press.
Taveras, E. M., Marshall, R., Kleinman, K. P., Gillman, M. W.,
Hacker, K., Horan, C. M., ... & Simon, S. R. (2015).
Comparative effectiveness of childhood obesity interventions in
pediatric primary care: a cluster-randomized clinical
trial. JAMA pediatrics, 169(6), 535-542.
Van Grouw, J. M., & Volpe, S. L. (2013). Childhood obesity in
America. Current Opinion in Endocrinology, Diabetes and
Obesity, 20(5), 396-400.
Vine, M., Hargreaves, M. B., Briefel, R. R., & Orfield, C.
(2013). Expanding the role of primary
care in the prevention and treatment of childhood obesity: a
review of clinic-and

21. community-based recommendations and interventions. Journal
of obesity, 2013.
Running head: PICOT STATEMENT 1
PICOT STATEMENT 5
PICOT Statement
Name
University
Date
PICOT Statement
Introduction
Childhood obesity poses a major public health threat to children
in the United States. The rate of childhood obesity in the
country has increased significantly in the past few decades.
Although at different rates, children across different
demographic groups in America struggle with weight issues
which poses physical and psychological effects on them
(Pulgaron, 2013; Sahoo et al., 2015). Therefore, it is important
to develop an intervention to help in the reduction of this public
health problem to protect children from its effects. This PICOT
statement proposed an evidence-based solution that includes
making sure that children have access to better diets. The
following is an evaluation of the components of the PICOT
statements and how they contribute to solving this issue.
PICOT Statement
Children with a BMI above 30 who are undergoing nutritional

22. monitoring compared to not being monitored nutritionally can
achieve significant weight loss in a period of a year.
P- Children with a BMI above 30
I-Undergoing nutritional monitoring
C- Compared to not being nutritionally monitored
O- Can achieve reduced weight
T- in a period of a year
Population
The population of focus for this intervention is the children in
the United States with a BMI above 30 (Ogden et al., 2012). A
BMI above 30 indicates that the children are suffering from
obesity. The focus for the intervention will be children between
6 and 15 years because they are around the age groups with the
highest risk of obesity in the country. Additionally, children
within this age group tend to have the highest risk of engaging
in unhealthy eating habits, especially when not being monitored
(Ayer et al., 2013). Children below this age group are mainly
under the care of their parents; hence, parents can easily control
what they eat. On the other hand, the older children can
understand obesity and be educated on ways they can change
their eating habits; thus, there is no need to monitor them.
Intervention
The intervention is monitoring what the children eat. Each of
the children in the selected age group needs to have an adult
with an understanding of nutrition and its relationship with
overweight and obesity issues. The adult with then develop the
children’s meal plans, making sure that the foods they take in a
day include those that will assist with weight loss but not
suppress the required nutrients for a healthy lifestyle. The foods
that have been determined to be high contributing factors to
obesity include those with higher levels of sugar and excess fat.
Many foods that fall into the category of ‘junk foods’ tend to
contain these components. Therefore, these are the main foods
that will be controlled in this intervention.
Comparison
The comparison to the intervention is failing to monitor the

23. diets of the children. This implies that the children will be
allowed to eat whatever they want regardless of the nutrition
components of the food. Children tend to like the ‘junk foods’,
which is part of the main reasons for the high rates of childhood
obesity (Sabin & Kiess, 2015). Not monitoring the children and
what they eat will mean that there will be a higher chance of
maintaining or worsening their obesity.
Outcome
The expected outcome of this intervention is a significant
reduction in the population’s weight. Two of the controllable
contributing factors to childhood obesity are diet and physical
activity. This intervention focuses on poor diet, which has been
proven to lead to accumulation of excess fat leading to obesity
in children (Roberto et al., 2015). Excess sugars and fat are
some of the main causes of weight-related issues in children.
Therefore, if these foods are controlled, it is expected that the
children will experience a significant reduction of fat in their
bodies. It is expected that after the intervention, the
participating children will have a reduced body weight.
Time
Weight loss is a gradual process that occurs through consistency
in the application of the intervention aiming at causing the
weight loss. A period of one year has been assigned to this
intervention program to ensure that the children are given
enough time for their bodies to adapt to their new diets and for
them to experience significant weight loss that can be recorded
because of the intervention. The weights of the children will be
measured at the beginning of the program and at the end of the
intervention program to determine the significant change that
has taken place after a year of monitoring the diets of the
children and making sure that they only eat the right foods.
References
Ayer, J., Charakida, M., Deanfield, J. E., & Celermajer, D. S.
(2015). Lifetime risk: childhood obesity and cardiovascular
risk. European heart journal, 36(22), 1371-1376.

24. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M.
(2012). Prevalence of obesity and trends in body mass index
among US children and adolescents, 1999-2010. Jama, 307(5),
483-490.
Pulgaron, E. R. (2013). Childhood obesity: a review of
increased risk for physical and psychological comorbidities.
Clinical Therapeutics, 35(1), A18-A32.
Roberto, C. A., Swinburn, B., Hawkes, C., Huang, T. T., Costa,
S. A., Ashe, M., ... & Brownell, K. D. (2015). Patchy progress
on obesity prevention: emerging examples, entrenched barriers,
and new thinking. The Lancet, 385(9985), 2400-2409.
Sabin, M. A., & Kiess, W. (2015). Childhood obesity: current
and novel approaches. Best Practice & Research Clinical
Endocrinology & Metabolism, 29(3), 327-338.
Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar,
R., & Bhadoria, A. S. (2015). Childhood obesity: causes and
consequences. Journal of family medicine and primary care,
4(2), 187.
Running head: LITERATURE REVIEW 1
LITERATURE REVIEW 4
Literature Review
Name
University
Date
Literature Review

25. Childhood obesity is one of the leading public health issues
facing the United States of America. This problem is
characterized by children having a Body Mass Index (BMI) of
more than 30. The rate of childhood obesity in the United States
has been increasing significantly in the past decade. This has
put many children at the risk of physical, social, and
psychological issues; some of which are extended to their
adulthood. Therefore, it is important to study this problem and
develop interventions that can help reduce the rate of obesity in
children. This study was designed to provide an evidence-based
solution to obesity in children. The PICOT statement, “children
with a BMI above 30 who are undergoing nutritional monitoring
compared to not being monitored nutritionally can achieve
significant weight loss in a period of a year” will be answered
with help of a study aiming at evaluating how diet changes can
be helpful in reducing the rates of obesity. This paper evaluates
literature on childhood obesity, which helps to understand
information on the public health issue that can be used to
develop better interventions.
Comparison of Research Questions
The literature that has been included in this research
mainly focuses on the causes and the effects of childhood
obesity. Some of the studies evaluate the effects in childhood
while others evaluate the adulthood effects. There are also
studies on prevention and intervention methods for dealing with
the public health issue. The study by GBD 2015 Obesity
Collaborators (2017) has a different approach because it
evaluates the trends in obesity across the world. This research is
important because it helps to understand the extent of childhood
obesity as a public health issue not only in America, but also in
other countries.
Sahoo et al. (2015), evaluates the causes and effects of
childhood obesity. The research takes an overall approach in
evaluating all types of causes and effects of obesity in children.
Xu and Xue (2016) also have a similar research question. This
research also evaluates the causes and effects of obesity but is

26. extended to evaluate the prevention strategies to avoid the
occurrence of obesity in children. These two studies help to
understand more about the factors that cause obesity in
children, which is helpful in developing the intervention for this
research. Other studies that have investigated the effects of
childhood obesity pay attention to the possible effects in
adulthood. Ayer et al. (2015) investigates the possible lifetime
risks of cardiovascular disease because of childhood obesity.
The authors hypothesize that a person has a higher lifetime risk
of cardiovascular disease if they are overweight or obese as a
child. Simmonds et al. (2016) investigates the risk of being
obese as an adult when one is obese as a child. The study’s
research question asks whether the risk of obesity in adulthood
is increased by childhood obesity.
The remaining studies evaluated in the literature answer
research questions aiming at understanding the dynamics of
prevention and intervention techniques for childhood obesity.
Oelscher et al. (2015) seeks to understand whether a system’s-
based approach would work better than a primary based
approach in preventing obesity in low income and ethnically
diverse communities. Allender et al. (2016) evaluates how
community action can influence childhood obesity prevention
initiatives. Lastly, Davis et al. (2016) investigates whether
mothers’ perceptions on obesity risk factors influence the rate
of obesity in the communities. These three studies help to give
an insight into the effective strategies of preventing and
reducing obesity in children.
Comparison of Sample Populations
Half of the studies evaluated for this study were reviews of
other studies done in the past either in the form of systematic
literature reviews or meta-analyses. Sahoo et al. (2015)
evaluated literature reviews but does not mention the
methodological process; hence, the sample size is not clear.
Similarly, Xu and Xue (2016) has a random evaluation of
literature with no review of the methodology; hence, the exact
sample is unknown. Ayer et al. (2015) sample is made up of

27. primary cohort studies on cardiovascular disease and obesity.
The study evaluates 8 research studies to with a total sample of
over 300 participants. Lastly, Simmonds et al. (2016) conducted
a meta-analysis that included 15 cohort studies with a total
sample size of 200,777 participants.
The remaining literature includes primary studies.
Oelscher et al. (2015) conducted a primary study with 576
children between 2 and 12 years as the participants. Allender et
al. (2016) also did a primary study with a sample of 5050
children from 84 primary schools as the participants. GBD 2015
Obesity Collaborators (2017) performed a study of 67.8 million
people in 175 countries across the world. Lastly, Davis et al.
(2016) only had 40 Mexican American mothers as the
participants of the research.
Comparison of the Limitations of the Studies
The most common limitation in the selected studies is in the
sample size of the studies. Sahoo et al (2015) and Xu and Xue
(2016) fail to mention the sample selection process. Therefore,
the applicability of the information they present is limited.
Davis et al (2016) only used 40 Mexican-American women in
their study. This is a very small sample to apply the results to a
wider community and includes the members of only one
community. Therefore, cultural factors such as the beliefs and
attitudes of Mexicans towards factors affecting obesity could
affect the results. Oelscher et al. (2015) also has a very small
sample of slightly above 500 kids; hence, the results may not be
representative of the entire population. The limitation of GBD
2015 Obesity Collaborators (2017) study is that it is done in
many countries but does not evaluate the unique cultural factors
that affect obesity rates in each of the populations evaluated. It
may be unwise to generalize the results for all populations.
Conclusion
Generally, there is consistency is the results of the studies
evaluated in this literature review. All the studies show obesity
as a serious public health issue regardless of the population
within which the study has been conducted. The causes and

28. effects of obesity are also similar in the studies that evaluate
these factors. The prevention and intervention techniques that
have been examined also revolve around diet and exercise in all
studies.
References
Allender, S., Millar, L., Hovmand, P., Bell, C., Moodie, M.,
Carter, R., ... & Orellana, L. (2016). Whole of systems trial of
prevention strategies for childhood obesity: WHO STOPS
childhood obesity. International journal of environmental
research and public health, 13(11), 1143.
Ayer, J., Charakida, M., Deanfield, J. E., & Celermajer, D. S.
(2015). Lifetime risk: childhood obesity and cardiovascular
risk. European heart journal, 36(22), 1371-1376.
Davis, R. E., Cole, S. M., Blake, C. E., McKenney-Shubert, S.
J., & Peterson, K. E. (2016). Eat, play, view, sleep: Exploring
Mexican American mothers' perceptions of decision making for
four behaviors associated with childhood obesity risk. Appetite,
101, 104-113.
GBD 2015 Obesity Collaborators. (2017). Health effects of
overweight and obesity in 195 countries over 25 years. New
England Journal of Medicine, 377(1), 13-27.
Oelscher, D. M., Butte, N. F., Barlow, S., Vandewater, E. A.,
Sharma, S. V., Huang, T., ... & Oluyomi, A. O. (2015).
Incorporating primary and secondary prevention approaches to
address childhood obesity prevention and treatment in a low-
income, ethnically diverse population: study design and
demographic data from the Texas Childhood Obesity Research
Demonstration (TX CORD) study. Childhood obesity, 11(1), 71-
91.
Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar,
R., & Bhadoria, A. S. (2015). Childhood obesity: causes and
consequences. Journal of family medicine and primary care,
4(2), 187.
Simmonds, M., Llewellyn, A., Owen, C. G., & Woolacott, N.
(2016). Predicting adult obesity from childhood obesity: a

29. systematic review and meta‐analysis. Obesity reviews, 17(2),
95-107.
Xu, S., & Xue, Y. (2016). Pediatric obesity: Causes, symptoms,
prevention and treatment. Experimental and therapeutic
medicine, 11(1), 15-20.