Nursing Review reports that nurses need to put away their own prejudices or guilt about weight and start conversations that will help families find a healthy way forward.
|Lisette Burrows||Barbara Docherty||Natalie Parkes|
It is not a lack of information that is making some Kiwi kids fat. Experts will you tell you it is a complex mix of genetic, psychological, lifestyle and social deprivation factors, combined with today’s obesogenic environment promoting the double whammy of easy access to high energy foods and sedentary behaviour.
In fact, Professor Lisette Burrows says her research shows the “sheer relentlessness” of pro-health/anti-obesity information in schools means kids know the healthy living message “inside out and back to front” from a very young age.
But information, says the University of Otago academic, who helps train the country’s physical education and health teachers, doesn’t necessarily change a person’s behaviour. Neither does fear, with her studies showing some very young children obsessing that having fat on their bodies means they will never get a job or get married.
Burrows believes a more holistic, less ‘weight management’ view of health needs to be taught, with some of the best examples of improving health in the sense of wellbeing being done by Māori providers for Māori communities.
She encourages her students to nurture kids having a regular relationship with food – which should be a pleasurable and sociable activity – and to move for fun and not as a chore. “So both of these things (eating and exercise) are just not anchored to getting thin.”
“As there ain’t no quick solution [to obesity], intentionally, or unintentionally, making kids feel bad about their bodies or that they are not doing the right thing is not necessarily helpful.”
For the kids whose rapid weight gain is putting their health at risk, paediatrician Barry Taylor, a fellow Otago professor and obesity researcher who founded Dunedin’s Childhood Obesity Clinic, says interventions should focus on the parents and not the child.
“To focus on the children labels them and the evidence is that it is actually the family interventions, and working with the families to change that family’s lifestyle, that will be more effective than just saying to the child, you’ve got to stop eating rubbish.”
That is one reason why Taylor, who is leading the combined South Island district health boards’ childhood obesity strategy, has opted for the Triple P Healthy Lifestyle parenting programme (see interventions sidebar page 14) as its main referral intervention for the family of a very obese child.
He adds that working with families needs to be done gently, without criticism, and with empathy and respect as many families are in difficult situations surrounded by many influences pushing them towards the wrong sort of food and away from exercise. Not all will be ready or willing to make lifestyle changes when first approached.
In fact, it is anticipated that only about half of children and their families identified as obese under the new national health target (see page 11) are likely to take up the offer of a referral to an obesity intervention programme.
Nurses’ attitudes can create barriers
Some of the barriers stopping families making lifestyle changes are actually the attitudes and actions of health professionals themselves, says nurse blogger Barbara Docherty.
Docherty has spent nearly 20 years researching lifestyle behaviour change and how health professionals can best provide brief lifestyle interventions.
She says patients tell her they put up barriers after feeling judged and preached at by nurses and other health professionals.
“Time and time again you can see what got in the way and prompted parent to say, ‘I don’t have a fat child – my child is normal’,” says Docherty, who now specialises in offering behavioural health training to health professionals.
“It was always judgement … and always the presumption that it [obesity] was the parents’ fault. And those parents will immediately find a way to get out of having a conversation with us.”
If the nurse raising the issue of the child’s weight is overweight themselves, parents may also grab the chance to point this out and use that as a barrier for continuing the conversation.
Docherty says research shows that patients know within the first two seconds whether they want to be with a nurse or not. So, if nurses want to successfully sow the seed for a lifestyle behaviour change, they firstly need to put aside any personal prejudices or hang-ups about weight because patients quickly pick up on them through body language and tone of voice.
Secondly, they have to avoid making judgements. “We presume that telling people that their lifestyle is shortening their life is going to knee-jerk them into making change,” say Docherty, “but sustainable change is very rarely triggered by fear.”
Finally, she says nurses have to resist giving advice and instruction (unless requested). Instead, she says nurses need to learn to turn the conversation around and use a few non-threatening questions to find out more about a child’s story and whether a family is ready, willing and able to start making long-term change. And if they are, then ask questions like, “What is getting in the way of you doing something?” to help them identify barriers, and how to overcome them, so the change is driven by the family and not the nurse.
Docherty suggests nurses also start the conversation with the child. “I’ve asked a five-year-old, ‘How does this feel to you?’ And, I can remember this very clearly, she said to me, ‘Well, all my friends say I’m fat’.” The child went on to say, “Mum says I’m not fat, but Dad says I’m fat’ and to reveal that being bullied at school was one of the main reasons she was overeating.
Docherty’s interaction with a Coke-loving family during her stint as a “supermarket nurse” this year provides another example of how asking the right questions at the right time may trigger positive lifestyle change. (This year Docherty has been joining community health advocate Dr Tom Mulholland in setting up Dr Tom’s retro ambulance outside supermarkets and other sites up and down the country to offer free and instant health tests to people, without a GP, under a Healthy Families contract with the Ministry of Health.)
One visitor to the ambulance for blood sugar and other tests was a mother worried that her family had a big wheelie bin full of Coke cans by the end of the week.
“I said, ‘So what is one thing you think you could do differently this week?’, to which she replied, ‘We could aim to not have it full’.”
In a follow-up call, the mother told Docherty the family had come on side and – thanks to a suggestion of serving fizzed-up soda-stream water as a healthy ‘bubbles’ alternative – the following week the bin was only filled to the halfway mark.
Be Smarter – another way to start the conversation
Psychologist Natalie Parkes agrees that starting the conversation is rarely easy as childhood obesity is a very difficult topic to bring up.
Parkes, a member of the multidisciplinary team delivering Waikato DHB and Sport Waikato’s Bodywise family-focused child obesity intervention, says a direct and objective way is to take a child’s measurements and show parents where their child sits on the height, weight and, finally, BMI chart (see other story page 10).
Another way is to wait until a parent brings up any concerns, or makes any comments, that allow you to bring the child’s weight or lifestyle changes into the conversation.
A third is to use the Be Smarter tool that the Bodywise team (the other members are a dietitian, doctor and Active Families coordinator) developed for nurses and other health professionals so there’s no need to mention weight at all.
The tool is designed to initiate a conversation between the nurse and the family around some ‘basics’ to help kids be as healthy as they can be. The nine basics – all carefully selected risk factors for childhood obesity – are built around the acronym BE SMARTER and range from B for Breakfast every day to R for Reduce screen time <2 hours. Families are asked to tick whether the child always, mostly, sometimes or not yet meets each healthy basic goal.
“The great thing about it is that every parent that you talk to will be doing one or more of those,” says Parkes. “So it can be quite a positive tool.”
The tool is not an obesity intervention, although it has relevance to all families and kids. Its primary purpose is to engage families in discussing the basics, sharing hints on how to achieve them, and offering the chance for a child and their family to select a goal or goals that along the way may also help weight management.
Parkes says having a Be Smarter conversation can also be a good opening if a family wants to raise a concern about their child’s weight, which may lead to a referral to a dietitian or an intervention programme such as Green Prescription’s Active Families.
She says the Be Smarter tool is already being widely used by nurses doing the B4 School Check. Be Smarter is also to be used extensively as part of Barry Taylor’s South Island DHBs’ child obesity strategy, with Taylor saying he was keen to have consistency across the health sector so parents have the same key messages reinforced from whomever they see.
“We are not trying to make a population of skinny kids,” says Parkes. “We’re trying to make a population of healthy kids so they don’t have limitations as they grow into adolescence and adulthood.
“And if that family leaves you – wherever you are as a health professional – with enough support to make one change for their child’s health, then we are winning, a little bit,” says Parkes.
SEE ALSO RELATED STORY: Kiwi kids: growing up or growing out?
SOME CHILDHOOD OBESITY INTERVENTIONS
Multidisciplinary weight management intervention for children aged 5–12 years. Also the home of the Be Smarter programme. Be Smarter packs – training DVD, manual, poster and 150 goal sheets – can be ordered for $50 a pack.
Whānau Pakari (Taranaki)
Multidisciplinary intervention programme focused on families of 5–16-year-olds
School-based nutrition and physical activity programme running in Waikato primary and intermediate schools since 2005. Key findings from a 2011 evaluation included obesity rates
3 per cent lower than national average.
Triple P Healthy Lifestyle Group (starting in South Island)
One of the Triple P parenting programmes developed by the University of Queensland.
Green prescriptions (GRx): Active Families (Nationwide)
Free family-based activity and healthy eating programmes.
The Government’s flagship initiative in the Childhood Obesity Plan to use community leadership to drive innovation – now operating in 10 locations.