Role of Nurse in Childhood Obesity Prevention

This systematic review examines the role of nurses in childhood obesity prevention and evaluates their effectiveness in reducing the risk factors of obesity for children. The review analyzes research papers from 2013 to 2019 and identifies three themes: the influence of nurse-led interventions on physical activity and healthy behaviors, the impact on BMI, and the success of nurse-led interventions based on resources and support. The findings suggest that nurses are well-positioned to deliver health promotion interventions for obese children, but improvements in intervention design and research methodologies are needed. Recommendations for enhancing nurse's role in childhood obesity prevention are provided.

Running head: NURSING DISSERTATION
Nursing dissertation
Name of the student:
Name of the University:
Author’s note

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Abstract
Background: Childhood obesity is a major health global health concern due to increase in
likelihood of serious illness for obese children. As nurses are actively involved in obesity
prevention program in schools, there is a need to review studies that evaluate
Aim: The aim of this systematic review is to critically examine nurse’s role in childhood obesity
prevention and interpret whether they are rightly positioned to reduce the risk factors of obesity
for children or not.
Method: The systematic review of research papers has been done based on review of CINAHL
and PubMed database. The articles published between 2013 to 2019 have been included in the
review and the data analysis has been using thematic approach.
Results: Based on screening of articles based on inclusion and exclusion criteria, a total of 7
articles were included in the review. Three themes emerged based on evaluation of nurse role in
childhood obesity prevention. This included role of nurse led obesity prevention in influencing
physical activity and healthy behaviours of children, in influencing BMI and Success of Nurse-
led obesity prevention intervention based on resources and availability of adequate support. The
evaluation of the seven research articles gives the insight that nurses are well-positioned to
deliver health promotion intervention for obese children. However, systematic review helped to
examine issues in school nurse led intervention design and weakness in research methodologies
that led to poor or unexpected outcomes for obese children. This systematic gives the implication
that nurses can be successful in preventing obesity if they are supported with right resource and
appropriate strategies are taken to ensure that parents and children comply with the education or
behavioural advice.

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Conclusion: To conclude, the study suggests many recommendations to enhance nurse’s role in
childhood obesity prevention. This involves proper training regarding implementation of
intervention, target changes in social norms and environment and developing resource in schools
and community to encourage physical activity in children.

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Table of Contents
Chapter one......................................................................................................................................4
Chapter two......................................................................................................................................6
Chapter three....................................................................................................................................8
Chapter four...................................................................................................................................19
References:....................................................................................................................................24
Appendix:........................................................................................................................................0

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Chapter one
Introduction:
Obesity is a condition leading to excessive fat accumulation in the body thus increasing
risk of other chronic disease in an individual. Obesity is a major global health burden because the
rate of obesity has tripled since 2015 (World Health Organization 2018). Apart from prevalence
of obesity in adulthood, the prevalence of obesity in childhood is a major concern because
childhood obesity has impact on nearly all organ system and it increases the likelihood of serious
consequences (diabetes, hypertension, psychosocial problem and fatty liver disease) for those
children in adulthood. For example, childhood obesity is associated with an increase in
atherosclerotic process, increased risk of cardiovascular disease and pulmonary disorder (Han,
Lawlor and Kimm 2010). The report by World Health Organization (2018) shows that 41 million
children under age of 5 were overweight or obese in 2016 and 340 million children between the
age group of 5 to 19 years were overweight or obese in 2016 globally. Hence, considering the
prevalence of childhood obesity, taking vital steps to prevent the risk of overweight or obesity is
important.
Obesity occurs as a result of imbalance between energy intake and expenditure. Some of
the risk factors that lead to childhood obesity include dietary intake, physical activity, sedentary
behaviour and influence of parenting styles (Sahoo et al. 2015). Hence, promoting healthy
behaviour in both children and parents are vital to decrease the obesity epidemic. Collins (2018)
supports that nurses are playing a key role in obesity interventions and the future will see more
nurses engaging with children to prevent obesity. As nurses are more in numbers and more
readily accessible compared to other health care professionals, considering the role of nurse in

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addressing the epidemic is necessary. Recently there is an increase in participation of nurse in
childhood obesity prevention initiatives. Rabbitt and Coyne (2012) explain that nurse can engage
in partnership with parents and children by providing nutritional advice and offering strategies to
decrease caloric intake and physical activity. There are many evidences regarding the
participation of nurse in obesity prevention initiative and promoting behavioural change and
giving health behaviour related advice. However, gap in research is that no research has explored
the impact of nurse on preventing childhood obesity based on outcomes, barriers and facilitators
and process employed. Hence, the aim of this systematic review is to critically examine nurse’s
role in childhood obesity prevention and interpret whether they are rightly positioned to reduce
the risk factors of obesity for children or not. The PICO question for the systematic review is as
follows:
What is the role and contribution of nurse in preventing childhood obesity for children at
risk of overweight and obesity issues?
Population (P): Children with obesity
Intervention (Intervention): Role and contribution of nurse
Outcome: Prevention of childhood obesity
Comparator: No comparison
The main purpose of this dissertation report is to examine nurse’s role in prevention of
childhood obesity by systematic review. The focus is to evaluate the effectiveness of nurse in
influencing obesity related to outcome and behaviour of children and evaluating nurse’s
experience in delivering childhood obesity prevention program. The significance of research in

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this area is that it will enable policy makers to understand the potential of nurse in influencing
eating and physical activity related behaviour of children and including more nurses in health
promotion program related to obesity prevention. In the personal areas of nursing practice, this
research will develop understanding regarding the key skills needed by nurse to engage in
obesity prevention initiatives for children. This dissertation will outline the strategy of literature
search in chapter two, present the research and its findings in chapter three. Chapter four will
discuss about the implications of the research findings and recommendations for improvement in
future practice or research. The final chapter five will provide conclusion for the research with a
brief summary on the whole research process.
Chapter two
Search and review strategy:
Introduction:
To find relevant research literatures related to the role of nurse’s in preventing childhood
obesity, systematic review of research papers were done with set of inclusion and exclusion
criteria and going through the process of identification, screening, eligibility and inclusion of
research papers in the study. The main advantage of following systematic review is that it helps
to follow a systematic approach during literature search and summarize the results of high
quality health care studies to inform health care practices and improve patient care (Moher et al.
2015). The dissertation uses thematic approach to report about key findings from the review and
uses specific technique to interpret the quality of the studies. This chapter will give detail
regarding the search process, search terms used and method used to select articles from
databases.

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Search strategy: To find relevant articles related to the topic of investigation, the search for
literatures were done in CINAHL and PubMed database. The main reason behind taking these
databases in systematic review is that both the database published peer review research articles
based on biomedical, health care and nursing research. Hence, searching for papers in this
database increases the likelihood of getting as many high quality research papers. The key terms
that helped to retrieve relevant articles related to the research topics included ‘nursing’, ‘obesity’,
‘children’, ‘teenagers’, ‘adolescents’, ‘weight’ and ‘obesity prevention’. The key search filters
that were used to refine the search process included the source, language and data of
publications. The source selected was peer-reviewed journals only and language selected was
English.. The search was performed in the database for articles published between 2010 to 2019.
Inclusion and Exclusion criteria:
The following inclusion and exclusion criteria helped to retrieve appropriate articles as
per the purpose of investigation:
1. Types of study: As the main purpose of this research is to examine the role of nurse in
childhood obesity, all types of research papers including both primary and secondary
research will be included in the review.
2. Research participant: Only those papers were reviewed were nurses were involved in
health promotion for children or teenagers. The studies reporting about the role of social
workers or other health promotion staffs were excluded.
3. Outcome: The research must report about outcomes in obese children like improvement
in preventive behaviours like increase in physical activity, reduction in weight,
modification in weight and experiences related to change in lifestyle.

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4. Publications: Only peer reviewed journals published between 2010 to 2019 were
included in the review.
5. Language: Apart from English, articles published in other language were excluded
Method of study selection:
After retrieving articles from relevant databases, total of 35 articles were found relevant
to the research topic. The screening of the research papers were initially done by reviewing title
and abstract. On this basis, 10 articles were excluded as they were duplicates or they covered
detail in childhood obesity prevention, but did not discussed about nurse’s role in it. The
remaining 25 articles were screened based on inclusion and exclusion criteria to determine their
eligibility for this research. This was done by reviewing full text of the articles. Based on these
criteria, the final list of articles that were included in the review included 7 research papers.
Data extraction and data analysis:
The data for each article were extracted in a summary table which included article no.,
author, title, research question, research methods, ethical approval and consideration, key
findings, implications/recommendation and comments on strength and weakness of papers. The
quality of the papers was assessed based on assessment of risk of bias, appropriateness of
research design and research rigour. The research findings have been presented using thematic
approach which helps to understand the common patterns found in research data.
Chapter three
Discussion

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Introduction: This section provides a discussion regarding the results obtained from the
systematic review of selected studies and provides thematic presentation of study findings based
on their contribution in understanding the role of nurse in obesity prevention. The advantage of
thematic analysis for this study is that it offers discussion of groups of studies under single theme
based on similarity of outcomes and favours collective evaluation of evidence in relation to the
theme identified. Based on review of research papers, three themes has been identified which has
been discussed in detail in this section.
Results and discussion:
Seven research articles were found relevant to the research question and based on
analysis of common patterns in research finding, the result for the systematic review has been
grouped into three themes. The discussion of the research papers under each theme are as
follows:
Theme 1: Role of nurse led obesity prevention in influencing physical activity and healthy
behaviours of children
There were two papers (Tucker and Lanningham-Foster 2015; Pbert et al. (2013) which
reported about increase in healthy behaviour like physical activity and health diet for children
with obesity by participation in nurse-led school based child obesity prevention program.
Tucker and Lanningham-Foster (2015) investigated about school nurse role in
preventing obesity using a pre and post research designs with comparison between two groups
and control group. The intervention that was implemented by nurses included a Let’s Go 5-2-1-0
health message program delivered to fourth and fifth graders. The education was given on
physical activity levels and health behaviour change among school children. The evaluation of

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outcome measures related to physical activity, healthy habits and BMI percentile revealed that
physical activity level of children increased significantly. This is evidenced by increase in
number of steps taken by children from baseline to end of year. Nurse led education was also
found to be associated with increase in healthy habits like consumption of fruits and vegetables
among children. Although BMI related data was collected, however data related to BMI is not
important because it was a universal intervention which included normal weight children too.
The significance of this research is that it has used an evidence based childhood obesity
prevention program whose effectiveness has been widely evaluated in research ‘Let’s Go 5-2-1-
0’. Rogers et al. (2013) gives the evidence that Let’s Go 5-2-1-0 is an effective community based
intervention that offers consistent message to positively influence behaviours that lead to
childhood obesity. Hence, the study gives the implication that by using evidence based health
coaching, the school nurse plays an important role in reducing negative health behaviour and
preventing obesity in children.
Another research paper that gave positive outcome related to the role of nurse in
delivering obesity intervention to children includes the paper by Pbert et al. (2013) which
evaluated the efficacy of school nurse-led intervention on diet, activity and BMI among
overweight and obese children. With the use of pair matched cluster-randomized controlled trial,
6 high schools were randomized to either nurse delivered counselling intervention or nurse
contact with information. The advantage of a counselling intervention is that it can help to
achieve significant effect if the target group is at high risk of gaining weight (Mustila et al.,
2018). In the study by Pbert et al. (2013), the target group included adolescents in grade 9 to 11
with BMI of greater than 85th percentile. During the counselling sessions for the intervention
group, the nurse use 5-3-2-1-0 approach and social cognitive theory to promote changes in self-

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management behaviour of adolescents. The strength of the intervention used by nurse is that it
included patient centered approach and supports that interventions were delivered as per the
needs of children. To ensure success of the intervention, the school nurse were also trained
regarding didactic presentation of topic related to problem of obesity and role play exercise to
promote behavioural change. Wilfley, Kass and Kolko (2011) justified that providers are able to
incorporate key recommendations related to healthy behaviour especially following training. The
strength of this research paper is that it has used a robust research design and considered all
factors that could enhance the research outcome. For example, high rate of follow up, nurse
training and content of the session was considered.
In contrast to the research by Tucker and Lanningham-Foster (2015) which did not
considered nurses skill in delivering obesity related education to children, the significance of the
study by Pbert et al. (2013) is that it has considered training needs of nurse and enhanced the
possibility of successful outcomes post the intervention. The review of the study findings
revealed that treatment fidelity was high and students were comfortable with the counselling
intervention given by nurse. As the participation rate is high, this is also associated with an
increase in positive changes related self-reported obsogenic behaviours in children. For
examples, students restricted eating at fast food restaurants and drinking soda per week.
However, little effect was seen on screen time and time spend in moderate physical activity. This
outcome is consistent with past research as Wu et al. (2016) shows that methodological
limitations reduces the impact of counselling on screen time reduction and BMI. In the context of
Pbert et al. (2013), verbal message might have limited student’s capability to strategizes ways to
increase physical activity and reduce time spent in physical activity. The study gives the
implication to develop more intensive school nurse intervention targeting childhood obesity.

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Though the studies under this theme reported about improvement in healthy behaviour of
children through nurse led intervention, there is a need to consider many methodological aspects
before applying it in health promotion initiatives for obese children. Firstly, for the research
paper by Tucker and Lanningham-Foster (2015), small sample size and reliance on self-
reported data for healthy habit is a limitation as this limits the validity of research. There was a
need to measure healthy behaviour by psychometric tools. Another weakness of this study as per
the research aim is that lack information on nurse’s ability to engage in obesity prevention and
focuses on the delivery or framework for health message. Hence, this research cannot be applied
for health promotion. There is a need to review factors that increases success of nurse led
intervention for more than 1 year in future studies. In contrast, for the study by Pbert et al.
(2013), the strength of the methodology was that it had 100% follow up rate, large sample size
and robust research design thus increasing healthy habits in children. However, due to reliance
on self-report for behavioural change, the study affects the reliability of data. Hence, its gives the
implication to conduct future research with robust research design to ensure that intensive nurse
led obesity program are implemented for children at high risk of obesity.
Theme 2: Role of Nurse led obesity prevention associated in influencing weight and BMI of
children:
Out of seven research articles, there were two papers (Schroeder, Travers and Smaldone
2016; Pbert et al. (2016) which indicated that nurse participation in childhood obesity prevention
program is associated with reduction in weight and BMI (Body Mass Index). As BMI is indicator
of obesity and it is linked to all-cause mortality because of increased risk of chronic disease too,
examining nurse’s contribution in influencing BMI of children is significant (Tobias and Hu
2018). Schroeder, Travers and Smaldone (2016) used systematic review method to examine

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nurse’s role in school-based interventions related to childhood obesity prevention. The synthesis
of research papers reporting about body measure changes related to BMI revealed that school
based intervention that involved nurse was associated with small but significant decrease in BMI
and BMI percentile. The study justified that small effect might have been seen because of
barriers to implementation of interventions by nurse. This included time related barriers and lack
of confidence in counselling methods. Laws et al. (2015) justifies that improving nurse skills in
behavioural change counselling is necessary to increase their confidence in raising sensitive
lifestyle issues with parents and integrating nurse led obesity prevention practices into
community setting. Hence, this suggests that counselling skills is significant for nurse to
positively influence health behaviour of obese children. To ensure that more nurses are involved
in school based obesity prevention program, there is a need to conduct future research with
robust research design to evaluate whether inclusion of nurse in health promotion for childhood
obesity is cost-effective or not.
However, in contrast to the above paper, the research study done by Pbert et al. (2016)
revealed little impact of school nurse delivered cognitive behavioural counselling intervention on
reducing BMI or obsegenic behaviours. Critical analysis of this paper and its methodology is
important to find out the factors that led to such outcomes in the study. Pbert et al. (2016) used
randomized controlled trial as a research design to investigate whether cognitive behavioural
counselling delivered by nurse plus school exercise program (intervention) in effective in
influencing diet, activity and BMI of obese children or not compared to nurse contact with
weight management information (Control). The intervention that each nurse delivered to school
students included 6 weekly 30 minute individual session along with maintenance phase of 6
monthly sessions and providing education on physical activity. To support the goal, each

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students were provided pedometers too. The primary outcome measure of interest included BMI
and relevant tools were used to measure body weight and body fat thus validating the study
outcome. The analysis of study results revealed that no significant improvement in BMI was
seen. However, intervention group reported increase in physical activity and eating breakfast.
This gives the implication combined intervene can increase self-reported dietary and physical
activity behaviour. However, it does not have any effect on BMI. As BMI is a major indicator of
obesity, the reason behind no improvement in this area should be explored.
The critical analysis of the methodology by Pbert et al. (2016) revealed that after school
exercise component of the intervention was not feasible as only 50% of the students attended this
program. Hence, the lack of effect on BMI and minimum changes in obesogenic behaviour of
children is a major drawback of this study. This finding is inconsistent with other research as
Siwik et al. (2013) revealed increase in BMI following the intervention. For this research
positive outcome was achieved because it was delivered by a family physician and apart from
sessions on nutrition and physical activity, resiliencies of participants were also explored.
Despite the strength of the papers discussed in revealing nurse’s contribution in
reducing BMI, taking note of certain weakness is necessary for practice improvement in the
future. In case of Schroeder, Travers and Smaldone (2016), key limitations of the study is that it
does not reveals any specific nursing characteristics that resulted in positive benefits for children.
This will have positive implication for policy makers as they can work to decide how nurse can
incorporate these factors into obesity programs. Pbert et al. (2016) could not achieve positive
outcomes in relation to decrease in BMI because the nurses did not consider barriers or resilience
factors that could affect children’s likelihood of changing their obsogenic behaviour. The
evidence by Sigman-Grant et al. (2015) supports that family resiliency is a factor that has been

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neglected in child obesity prevention and treatment. However, in future research, considering
nurse role in developing resilience of family and children during delivery of obesity prevention
program is critical because their resilience can determine their ability to avoid an obesogenic
environment. The studies give implication to modify the structure of nurse-led obesity
prevention for children to achieve best outcomes for obese children. Another limitation is that no
study included samples with children at severe risk of obesity. Including this group have helped
to understand the maximum impact of the nurse led preventive initiatives for child obesity.
Theme 3: Success of Nurse-led obesity prevention intervention based on resources and
availability of adequate support:
The critical appraisal of selected research papers revealed that although nurse are well-
positioned to promote healthy behaviour in obese children, however their ability to reduce
obesogenic behaviour in children is influenced by lack of resource and availability of support.
This is understood by review of three papers (Powell, Engelke and Neil 2018); Schroeder et al.
2017); Schroeder and Smaldone 2017)
The first study which highlight about the issue of poor resource on nurse’s ability to
support behavioural change in children with obesity is the study by Powell, Engelke and Neil,
(2018). Powell, Engelke and Neil, (2018) used descriptive statistics to explore the experience of
nurse while providing care to children with obesity. The significance of research in this area is
that it focuses on unique challenges faced by nurse in providing obesity prevention intervention
in rural areas. By investigating nurse’s in rural areas, the study can give useful insight into the
prevalence of childhood obesity in rural areas. The analysis of nurse’s experience revealed that
time constraints and heavy workload was a major barrier for nurse. Lack of community resource

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was also identified as a barrier because education alone cannot be successful unless children get
access to resource to engage in physical activity. This finding is reliable as Gibson (2016) gives
the evidence that time constraints and lack of opportunities to detect obesity is a major barrier to
addressing childhood obesity in rural areas. The researcher has also cited research papers which
revealed similar outcomes related to barriers in preventing childhood obesity. As nurse also
reported moral distress as a challenge while providing care to obese children, the study gives the
implication that this issue occurs because of institutional barriers or lack of availability of
support that makes it difficult for them to follow the right course of action to prevent obesity.
Hence, in future research, considering the impact of different implementation methods on
childhood obesity should be considered.
The contribution of the research by Schroeder et al. (2017) in relation to this theme was
that this study used evidence based nurse-led school intervention and it included children at risk
of severe obesity as the research participant. The study used retrospective analysis of secondary
data as a research design and the data for the outcome of the Health Options and Physical
Activity Program (HOP), a nurse led intervention for children with severe obesity was analysed.
The advantage of retrospective research design is that it can help to find relation between
exposure and outcome (Blaikie and Priest 2019). In this case, exposure would be obesogenic
environment and the outcome is obesity. The study included students with severe obesity from
kindergarten to fifth grade students in New York schools. One reporting related bias found in the
study is that it does not define how children with severe obesity were identified. However, one
significant of the intervention used in this study is that it was guided by the socio-ecological
model thus promoting examination of individual, family and community level factor during the
implementation process (Pierce and Kealey 2015). Negligence of this factor was identified as the

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reason behind poor outcomes in one of the study. Hence, focus on this area is significant. Berge
et al. (2016) justifies that community based participatory research approach is effective in
making nurse-led obesity interventions more feasible compared to interventions with a narrow
focus.
Apart from review of rigour in research methodology, the review of the study outcomes
presented by Schroeder et al. (2017) revealed that during one year period, participants attended 1
HOP sessions. This study suggests that the HOP intervention was not successful in increasing
participation of at-risk children in the program. Hence, the program lacked feasibility and
efficacy evidenced by low participants of students in the HOP. Another major limitation of the
program was that participation of parents in the intervention was very rare. This gives the
implication that to increase the efficacy of nurse led obesity intervention, involvement of parent
is critical as they can enhance self-efficacy of young children in relation to adaption of healthy
behaviours. O’brien, McDonald and Haines (2013) argues that parent participation in childhood
obesity intervention is necessary because parents plays a critical role in not only shaping
children’s eating and activity behaviours, but also in creating a healthy home environment for
children. Hence, it gives the direction for creating interactive program where parents can also
actively participate to improve health of their obese children (Kim et al. 2016).
Another study that defines the influence of resource and support on success of school
nurse delivered intervention for obese children includes the research by Schroeder and Smaldone
(2017) which focussed on analysis of nurse’s barrier and facilitators experienced in relation to
HOP implementation. 30 minutes interview was conducted with nurse and interview guide
mainly consisted of questions on factors that make it easier or harder for nurse to implement
HOP and nurse’s reaction to HOP. The content analysis of interview transcript gave rise to eight

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themes. Firstly, parents and school administrators affected nurse’s ability to implement HOP
because many parents and principal got offended when they were told that their children was
eligible for the program. Nurses also reported contextual factors like student’s home food and
school environment as a major barrier to HOP effectiveness. For example, presence of too many
fast food chains was found as a major barrier in keeping children away from unhealthy choices.
This finding is reliable as Boyland and Whalen (2015) supports that prevalence of junk food
advertising promotes intake of energy dense and nutrient poor food among children. In addition,
barriers in adaption of HOP were expressed by nurse because of the effects of stigma. For
instance, majority of the nurse were concerned that participation in HOP would stigmatize
children. Apart from negative outcomes related to the HOP implementation, some of the barriers
identified by nurse in implementation were that nurse had the concern that cultural or
socioeconomic background can influence nutritional intake of children and HOP efficacy.
Hence, in view of these evidence gathered, the evidence suggest the need to examine perception
of children participating in obesity prevention program to determine whether nurse fulfilled the
health promotion goal or not.
The studies reported under this theme had certain methodological limitations too.
Considering this aspect is important to understand how nurse’s efficacy in delivery behavioural
intervention to obese children can be enhanced in the near future. Firstly, for the research by
Powell, Engelke and Neil (2018), some of the limitations include inclusion of only Caucasian
nurse and lack of direct observation of school nurse activities. This is significant as it gives
direction for future research. In future, there is a need to conduct more observation based study
to find out how nurse’s activity related to health promotion for obesity improve BMI of obese
children in schools. In addition, for the study by Schroeder et al. (2017), the limitation included

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reliance on secondary data, retrospective analysis and lack of generalizability of the study.
Hence, studies evaluated under this theme give the implication to carefully analyse evidence
based development related to childhood obesity before applying it in nurse-delivered
interventions. The study by Schroeder and Smaldone (2017) was limited by lack of
generalizability of the intervention to rural schools or nonschool setting. This suggests the need
to expand nursing skills and activities related to health promotion for children with obesity in
settings other than schools.
Chapter four
Implications and recommendation for practice:
The dissertation report summarized the results of the systematic review related to the role
of nurse in preventing childhood obesity. The main rational behind research on this topic was the
increase in rate of childhood obesity and its adverse consequences worldwide. Although many
nurse are involved in delivering obesity prevention intervention, however the key gap in research
that made research on the topic necessary was the lack of research on impact of nurse on
addressing childhood obesity in relation to obesity related outcomes, process employed and
experiences of nurse. Hence, this essay gave a comprehensive analysis of the role of nurse in
influencing outcome, process and experience while delivering health education or behavioural
changes related intervention to children with obesity. The systematic review of papers based on
inclusion and exclusion criteria resulted in the selection of seven research papers for the
systematic review and the three themes identified from the evaluation paper included ‘Role of
nurse led obesity prevention in influencing physical activity and healthy behaviours of children’,

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‘Role of Nurse led obesity prevention associated in influencing weight and BMI of children’ and
‘Success of Nurse-led obesity prevention intervention based on resources and availability of
adequate support’. Overall, the results shows that nurses are well-positioned to deliver education
to prevent obesity in children, however careful planning and implementation is necessary to
enhance success of their contribution to preventing childhood obesity. This section will review
the studies under each theme and finding out the implications of the results under each theme for
future nursing practice and planning obesity prevention program for children in the future.
The studies reported under first theme gave the insight that nurse delivered school based
obesity prevention program is effective in improving physical habits and improving healthy
habits like changes in diet and reducing rate of consumption of fast foods. However, Tucker and
Lanningham-Foster (2015) used an evidence based program called (Let’s Go 5-2-1-0) program
to support nurse to deliver healthy behaviour teaching to children, whereas used counselling
intervention based on cognitive behavioural therapy to promote behavioural change in high risk
children. However, as Tucker and Lanningham-Foster (2015) was unsuccessful in determining
the specific nursing skills that resulted in improved outcome for obese children. In contrast, Pbert
et al. (2013) considered training needs of nurses and by implementing training session for nurse
to enhance their skills in counselling, the studies gives the implication that consideration of
nursing skills and competencies to deliver specific behavioural change intervention to obese
children is critical to enhance the success of obesity prevention initiative. The findings obtained
from Pbert et al. (2013) can be utilized to improve future nursing practice in relation to obesity
prevention as it was done in multiple schools thus enhancing the reliability of the outcomes. It
would help in the development of more intensive behavioural change program for children with

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obesity. Training needs of nurse should be considered while planning health promotion program
for childhood obesity (Eldredge et al. 2016).
The studies reported under second theme mainly gave contrasting results related to the
role of nurse in reducing BMI. For example, Schroeder, Travers and Smaldone (2016) revealed
small improvement in body measures related to reduction in BMI, whereas Pbert et al. (2016)
achieved improvement in diet and physical activity. However, this was not significant enough to
translate into reduction in BMI. The key differences in both the papers that resulted in
contrasting outcome were that barriers to the implementation of intervention by nurse was not
considered. Although Pbert et al. (2016) used both nurse delivered counselling program and after
school exercise program to improve BMI among obese adolescents, the main cause behind no
difference in BMI and percentage difference in body fat in control and intervention group was
that the school exercise component was not compatible for the selectd group of children. This
gives the implication that from implementation of obesity prevention program, policy makers or
school administrators should also provide support to obese children by providing them
appropriate space for physical activity. Changes in environment and social norms related to
eating and physical activity is essential to support children to comply with health behaviour
related advice given by nurse.
The significance of this systematic review is that by analysis of papers related to the
impact of nurse on childhood obesity intervention, it has helped in identifying weakness in
planning of past nurse-led obesity prevention intervention and getting direction to improve
behavioural health programs for obese children. Similar insights have been obtained from the
critical analysis of studies covered under theme three too. The significance of this theme is that it
extends knowledge regarding the deficiencies in process and attitude of nurse while delivering

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campaigns for promotion of healthy behaviours in obese children. For example, Powell, Engelke
and Neil 2018) gave idea regarding the impact of poor resource on nurse’s ability to prevent
childhood obesity. The review of experience suggests that time constraint is an issue for nurse
and lack of availability of adequate supports increases distress for nurses. As both of these
factors can decrease the efficacy of nurse delivered obesity prevention initiative, it gives the
implication to study the barriers faced by nurse while developing health promotion campaigns
for obese children and increase the engagement of nurse during planning process. This would
favour development of realistic approach for behavioural change in children that is achievable as
well as successful.
In contrast, the analysis of other two papers under theme three revealed several barriers
for nurse in implementing obesity prevention program for obese children. This gives the
implication to mitigate these barriers in the future by considering the perception of children
regarding the program during the implementation phase. This will enhance the feasibility of the
intervention. In addition, as workload has been widely reported as an issue for nurse, it gives the
direction to increase partnership of nurse with teachers or community staffs while delivering
behavioural health program for obese children. Another vital aspect is that training given to
nurse should be aligned with the basic knowledge that nurse possess. As the evaluation of nurse
led intervention shows feasibility as a major cause behind poor intended outcomes, it is also
proposed to enhance the structure of the program in this program so that feasibility of the
program is strengthened. Tyler and Horner (2016) supports that feasibility of a weight
management or behavioural intervention is beneficial for collaborative negotiation and getting
expected outcomes from the program. This will helps to identify infrastructure or tools that are
needed to ensure that parents as well as obese children are adequately supported to follow

23NURSING DISSERTATION
healthy behaviour and make useful changes in their lifestyle. A critical insight and efforts to
enhance the rigour during planning process can play an importance role in reducing public health
burden related to childhood obesity.
Based on the discussion of findings obtained from seven selected research articles, it has
been found that nurses are well-positioned to provide education or counselling intervention in
school to prevent obesity in children and adolescents. However, one important outcome that has
emerged by the critical appraisal of strength and weakness in each study is that this systematic
review gives the implication that there is a need to modify the structure of nurse led school
obesity prevention intervention as many factors such as lack of resource, lack of consideration of
rigour in intervention design and poor planning affects the outcome of children in relation to
obesogenic behaviour. For example, one of the studies reported lack of parents participation was
one of the cause behind poor feasibility and success of HOP intervention. Hence, this outcome
can be applied in future research to understand how nurse can play a role in increasing parent’s
participation in such program. Review of studies related to interventions that targets parent’s
skill in management of children’s weight issue can be done.
To improve the outcome of nurse led interventions for preventing obesity in children, the
following recommendation has been proposed:
 As the experience of nurse revealed home environment and poor attitude of children
towards behavioural change, it is recommended to identify individual factors of children
that increase their engagement in poor diet and sedentary behaviours. This would help in
the development of tailor made programs for children.

24NURSING DISSERTATION
 To enhance nurse’s experience in providing obesity related intervention to children, it is
recommended to plan interventions that are less time-consuming. It is also recommended
to actively involve nurse in planning process as this will favour taking realistic approach
towards behavioural change for children at risk of obesity.
 To enhance the success of nurse in promoting behavioural change in obese children, it is
recommended to prepare nurse by means of training to successfully deliver diverse types
of education programs.
 To reduce barrier to participation in physical activity and adhering to healthy diet, it is
recommended to target ways to change social norms and environment for children so that
they can adhere to the health message given by nurses.
 To encourage nurse to involved parents in obesity prevention program in schools, it is
recommended to develop interactive intervention where parent education related to risk
of obesity is targeted. Kim et al. (2016) supports that interventions intended to increase
parent’s skills in children’s weight related issue is effective in promoting dietary self-
efficacy of student

25NURSING DISSERTATION
References:
Berge, J.M., Jin, S.W., Hanson, C., Doty, J., Jagaraj, K., Braaten, K. and Doherty, W.J., 2016.
Play it forward! A community-based participatory research approach to childhood obesity
prevention. Families, Systems, & Health, 34(1), p.15.

26NURSING DISSERTATION
Blaikie, N. and Priest, J., 2019. Designing social research: The logic of anticipation. John Wiley
& Sons.
Boyland, E.J. and Whalen, R., 2015. Food advertising to children and its effects on diet: review
of recent prevalence and impact data. Pediatric diabetes, 16(5), pp.331-337.
Collins, E., 2018. SUSTAINABLE NURSING PRACTICE–HOW NURSING CAN ASSIST
WITH THE OBESITY EPIDEMIC. Contemporary Research Topics, p.40.
Eldredge, L.K.B., Markham, C.M., Ruiter, R.A., Kok, G., Fernandez, M.E. and Parcel, G.S.,
2016. Planning health promotion programs: an intervention mapping approach. John Wiley &
Sons.
Gibson, S.J., 2016. Translation of clinical practice guidelines for childhood obesity prevention in
primary care mobilizes a rural Midwest community. Journal of the American Association of
Nurse Practitioners, 28(3), pp.130-137.
Han, J. C., Lawlor, D. A., and Kimm, S. Y. 2010. Childhood obesity. Lancet (London,
England), 375(9727), 1737–1748.
Kim, H.S., Park, J., Park, K.Y., Lee, M.N. and Ham, O.K., 2016. Parent involvement
intervention in developing weight management skills for both parents and overweight/obese
children. Asian nursing research, 10(1), pp.11-17.
Laws, R., Campbell, K.J., Van Der Pligt, P., Ball, K., Lynch, J., Russell, G., Taylor, R. and
Denney-Wilson, E., 2015. Obesity prevention in early life: an opportunity to better support the
role of maternal and child health nurses in Australia. BMC nursing, 14(1), p.26.

27NURSING DISSERTATION
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and
Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols
(PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.
Mustila, T., Raitanen, J., Keskinen, P. and Luoto, R., 2018. A pragmatic controlled trial to
prevent childhood obesity within a risk group at maternity and child health-care clinics: results
up to six years of age (the VACOPP study). BMC pediatrics, 18(1), p.89.
O’brien, A., McDonald, J. and Haines, J., 2013. An approach to improve parent participation: In
a childhood obesity prevention program. Canadian Journal of Dietetic Practice and
Research, 74(3), pp.143-145.
Pbert, L., Druker, S., Barton, B., Schneider, K.L., Olendzki, B., Gapinski, M.A., Kurtz, S. and
Osganian, S., 2016. A school‐based program for overweight and obese adolescents: a
randomized controlled trial. Journal of School Health, 86(10), pp.699-708.
Pbert, L., Druker, S., Gapinski, M.A., Gellar, L., Magner, R., Reed, G., Schneider, K. and
Osganian, S., 2013. A school nurse‐delivered intervention for overweight and obese
adolescents. Journal of School Health, 83(3), pp.182-193.
Pierce, J.P. and Kealey, S., 2015. Socio-ecological Model and Health Promotion in the Healthy
People Initiative.
Powell, S.B., Engelke, M.K. and Neil, J.A., 2018. Seizing the moment: Experiences of school
nurses caring for students with overweight and obesity. The Journal of School Nursing, 34(5),
pp.380-389.

28NURSING DISSERTATION
Rabbitt, A. and Coyne, I., 2012. Childhood obesity: nurses’ role in addressing the
epidemic. British Journal of Nursing, 21(12), pp.731-735.
Rogers, V.W., Hart, P.H., Motyka, E., Rines, E.N., Vine, J. and Deatrick, D.A., 2013. Impact of
let’s go! 5-2-1-0: a community-based, multisetting childhood obesity prevention
program. Journal of pediatric psychology, 38(9), pp.1010-1020.
Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., and Bhadoria, A. S. (2015).
Childhood obesity: causes and consequences. Journal of family medicine and primary care, 4(2),
187–192.
Schroeder, K., and Smaldone, A. 2017. What barriers and facilitators do school nurses
experience when implementing an obesity intervention?. The Journal of School Nursing, 33(6),
456-466.
Schroeder, K., Jia, H., Wang, Y.C. and Smaldone, A., 2017. Implementation of a school nurse-
led intervention for children with severe obesity in New York City schools. Journal of pediatric
nursing, 35, pp.16-22.
Schroeder, K., Travers, J. and Smaldone, A., 2016. Are school nurses an overlooked resource in
reducing childhood obesity? A systematic review and meta‐analysis. Journal of School
Health, 86(5), pp.309-321
Sigman-Grant, M., Hayes, J., VanBrackle, A. and Fiese, B., 2015. Family resiliency: A neglected
perspective in addressing obesity in young children. Childhood Obesity, 11(6), pp.664-673.

29NURSING DISSERTATION
Siwik, V., Kutob, R., Ritenbaugh, C., Cruz, L., Senf, J., Aickin, M., Going, S. and Shatte, A.,
2013. Intervention in overweight children improves body mass index (BMI) and physical
activity. J Am Board Fam Med, 26(2), pp.126-137.
Tobias, D.K. and Hu, F.B., 2018. The association between BMI and mortality: implications for
obesity prevention. The Lancet Diabetes & Endocrinology, 6(12), pp.916-917.
Tucker, S. and Lanningham-Foster, L.M., 2015. Nurse-led school-based child obesity
prevention. The Journal of School Nursing, 31(6), pp.450-466.
Tyler, D.O. and Horner, S.D., 2016. A primary care intervention to improve weight in obese
children: a feasibility study. Journal of the American Association of Nurse Practitioners, 28(2),
pp.98-106.
Wilfley, D. E., Kass, A. E. and Kolko, R. P. 2011. Counseling and behavior change in pediatric
obesity. Pediatric clinics of North America, 58(6), 1403–x. doi:10.1016/j.pcl.2011.09.014
World Health Organization 2018. Obesity and overweight. Retrieved from:
https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
Wu, L., Sun, S., He, Y. and Jiang, B., 2016. The effect of interventions targeting screen time
reduction: a systematic review and meta-analysis. Medicine, 95(27).

Running head: NURSING DISSERTATION
Appendix:
Summary tables for the selected research articles:
Art
icle
no.
Author,
year,
source
and
country
Title Research
question
Research
methods
Ethical
approval
and
considera
tions
Key findings Implication/
recommendation
Comments
1 Schroeder
, Travers
and
Smaldone
(2016)
Are
school
nurses
an
overloo
ked
resourc
e in
reducin
g
To
examine
school
based
interventio
n
involving
nurse in a
role
beyond
Systemati
c review
and
analysis
No ethical
considerat
ion
Nurses were involved
in providing education
and counselling and
two studies also
involved parents.
Moderate
improvement in body
measures like BMI
was seen.
As the study shows
effectiveness of school
based obesity
intervention delivered by
nurse, it gives the
implication to provide
school nurse with
necessary resource to
implement obesity
Strength: The strength of
the paper is that by
systematic review of
research papers, it proves
that nurses can play a key
role in obesity prevention.
Weakness: Despite
showing positive benefits
of nurse led obesity
prevention on BMI, the

1NURSING DISSERTATION
childho
od
obesity
? A
systema
tic
review
and
meta‐
analysis
anthropom
etric
measurem
ent for
effect on
change in
body
measures
of
children
School based
intervention involving
nurses were associated
with decrease in small
but significant
decrease in BMI and
BMI percentile.
programs. gap in the study is that it
does not shows specific
nurse characteristics that
lead to positive outcome in
the area of body measures.
2. Tucker
and
Lanningh
am-Foster
2015
Nurse-
led
school-
based
child
obesity
preventi
on
To
evaluate
the effect
of refined
health
message
delivered
by nurse
A two
group pre-
post
design
No details
regarding
informed
consent
and
approval
for
research
Physical activity level
of children increased
significantly
evidenced by increase
in number of steps
taken.
As the education
program was based on
evidence based health
message Let’s Go 5-2-1-
0, it gives the
implication that
competency in
delivering consistent
Strength: The strength of
this intervention is that it
shows that nurses are well-
positioned to offer obesity
prevention service to
children by the use of
reinforcement coaching
techniques.

2NURSING DISSERTATION
on fourth
and fifth
graders
message can facilitate
nurse to promote
behavioural change in
children
Weakness: The weakness
of the paper includes
samples from only two
school setting and this
affects the reliability of the
research
3. Pbert et
al. (2013)
A
school
nurse‐
delivere
d
interven
tion for
overwei
ght and
obese
adolesc
ents.
To
examine
the
efficacy
and
feasibility
of school
nurse-
delivered
interbentio
n on
reducing
Cluster
randomize
d designed
Approval
for
research
taken
The intervention was
associated with
significant changes in
eating habit of
children, however
improvement in
physical activity and
reduction in sedentary
time was less
significant
The study gives the
implication that school
nurse are well-
positioned to deliver
obesity prevention
education to obese
children, however there
is a need to increase the
feasibility and
robustness of
behavioural intervention
so that maximum health
Strength: The strength of
this paper includes high
retention rate, good
acceptance of the
intervention, large sample
size, randomized design
and taking steps to
implement carefully
designed intervention.
Weakness: One major
weakness is that self-
report of behaviour change

3NURSING DISSERTATION
BMI,
improving
diet and
physical
activity
related
behaviour
in
adolescent
and obese
children
impact is seen for obese
children
has been used to analyse
outcome. There was a
need to use validated tools
for the same.
4. Powell et
al. (2018)
Seizing
the
Momen
t:
Experie
nces of
School
To
explore
experience
of nurse in
providing
care to
children
Qualitativ
e
descriptiv
e study
The study reported
about several barriers
for nurse while
delivering obesity
prevention program to
children. These
included workload,
It gives the implication
to enhance the success
of school based obesity
prevention intervention,
there is a need to
consider barrier faced by
nurse before
Strength: The
significance of this
research is that it defines
several organization
factors that prevent nurse
from proving care to obese
children

4NURSING DISSERTATION
Nurses
Caring
for
Student
s With
Overwe
ight and
Obesity
living
with
obesity
time, lack of resource,
pressure from
administrators and
moral distress
implementing such
interventions. There is
also need to ensure that
nursing activities related
to obesity prevention
should be less time-
consuming.
Weakness: Lack of
heterogeneous sample
group is a weakness as the
study participant included
only Caucasian nurse and
this may influence study
result
5. Pbert et
al. (2016)
A
school‐
based
progra
m for
overwei
ght and
obese
adolesc
ents: a
To
evaluate
acceptabili
ty and
effectiven
ess of
school
based
interventio
n
Randomiz
ed
controlled
trial
Parental
consent
and
approval
for
research
was taken
No significant
improvement in BMI
was seen. However,
intervention group
reported increase in
physical activity and
eating breakfast.
The findings gives the
implication that to
prevent childhood
obesity, nurses need to
focus on change needed
at family level to ensure
that instructions related
to diet and physical
activity is followed by
children in their home
Strength: Large sample
size, randomized
controlled design and
delivery of combined
intervention by nurse
Weakness: Poor
participation in after
school exercise program

5NURSING DISSERTATION
random
ized
controll
ed trial
including
nurse-
delivered
counsellin
g and after
school
exercise
on diet,
activity
and BMI
of obese
adolescent
s
environment. It enhance
the compliance with the
health behaviour related
advice.
6 Schroeder
et al.
(2017)
Implem
entation
of a
school
nurse-
To
evaluate
the effect
of HOP
implement
Retrospect
ive
analysis
Not
mentioned
The key outcome from
this study was that
only 5.1% participants
enrolled in the
program in the period
The analysis of the
results gives the
implication to enhance
the feasibility of HOP
program and the need to
Strength: The strength of
this study is that it targets
implementing intervention
for children with severe
obesity.

6NURSING DISSERTATION
led
interven
tion for
children
with
severe
obesity
in New
York
City
schools.
ation for
children
with
severe
obesity in
New York
schools
between 2012-2013
and the participation
of parents in the
program was very rate.
The factors that
influenced student’s
enrolment in the
program included high
BMI percentile, low
poverty, high grade
level and low nurse
workload.
completely analyse the
feasibility of evidence
based intervention
before using it in nurse
delivered for childhood
obesity in schools
setting. It also defines
parent involvement as
critical to enhance the
efficacy of the programs.
Weakness: Reliance on
secondary data,
retrospective research
designs and lack of
participation in HOP are
some of the limitations of
the study.
7. Schroeder
and
Smaldone
(2017).
What
barriers
and
facilitat
ors do
school
To
analyse
school
nurse’s
perceived
barrier to
Semi-
structured
interview
using
qualitative
approach
Passive
parent
consent
taken and
the study
procedure
Some of the barriers
faced by nurse in the
implementation of
nurse-led intervention
includes heavy
workload, obesogenic
The implications of the
study finding is that it
gives the insight to
consider nursing
workload while
implementing school
Strength: The strength of
this intervention is that it
is the first study which
evaluated nurse’s
experiences in delivery
obesity intervention in 19

7NURSING DISSERTATION
nurses
experie
nce
when
implem
enting
an
obesity
interven
tion?.
and
facilitator
of obesity
interventio
n
was
approved
by the
institution
al review
board of
Columbia
environment, obesity
stigma, parent and
administrative gate
keeping
nurse led obesity
program. It also suggest
enhancing partnership
with teachers to ensure
that nurse can engage in
partnership with teachers
for effective
management of children
with obesity
diverse schools.
Weakness: Some
limitations identified in
this research includes lack
of generalizability of the
study as it cannot be
implemented in other
setting apart from schools.