JSPN Vol. 13, No. 3, July 2008 141

Blackwell Publishing IncMalden, USAJSPNJournal for Specialists in Pediatric Nursing1539-01361088-145XxxxXXX

ORIGINAL ARTICLES

xxxxx

Guest Editorial

The Complex and Untidy Science of Childhood Obesity Mirrors the Complexity of Practice

Despite the drone of dismal statistics about increasingrates of childhood obesity across the globe, this issueof the

Journal for Specialists in Pediatric Nursing (JSPN)

rings upbeat notes that highlight promising interventionsand new ways of thinking about childhood obesity.

Complexity is the challenge we distill from readingabout childhood obesity. Definitionally, we are stilldetermining what to call the problem, and whether“obesity” or “overweight” is the better term at a givenpoint along the continuum of unhealthy body weight.Current thinking proposes “overweight” for a child’sbody mass index (BMI) in the 85th–94th percentile and“obesity” for a child with BMI

≥

the 95th percentile(Barlow & the Expert Committee, 2007). Furthercomplexity stems from the numerous constellationsof people involved in the problem—from children,families, professionals, and policy makers—to thenumerous environments where both the problem andthe intervention might be located.

Complexity also surfaces as we read studies thatvariously and sometimes simultaneously unravel seculartrends, disaggregate by race, ethnicity, or socioeconomicstatus, and examine children in relation to themselvesat a later point in life, in comparison to parents, siblings,or friends. Even the latest recommendations fromexperts and expert committees grapple with detail anddepth, giving rise to dense publications that providersmust synthesize and apply across their numerousdifferent settings and roles.

1

The application of evidenceto practice is no easy undertaking, nor should it be. Fortoo many children, health and longevity depend uponprofessionals’ and parents’ deepening understandingof the causes of obesity and increasingly astute preven-tion and intervention processes.

In our serious pursuit of answers to complexquestions, I consider the paradox between tidy butvacuous studies and those that are messy but important.As Harry Wolcott, an ethnographer laments, “Everything

familiar to an old-fashioned ethnographer like me isgetting tightened up, with the focus shifting towardneat data—the kind that can be plugged into a computerprogram—rather than to neat (i.e., intriguing) problemsthat only a fieldwork approach can address” (2005,p. 66). It is quite possible to read a research reportand sigh at the significant but soulless result. As anintroduction to this issue on childhood obesity, I believewe have captured important, messy, contextualized,and soulful answers to questions about children,families, culture, society, and body weight.

In This Issue

We are all familiar with the increasing rates ofoverweight and obesity now affecting approximately17% of children in the United States, a prevalence ratetriple that of 30 years ago (Koplan, Liverman, & Kraak,2004; U.S. Department of Health and Human Services,2001), and numerous studies confirm the increasedobesity risk for low-income and minority children(Ogden, Flegal, Carroll, & Johnson, 2002; Wang & Zhang,2006; Wang, 2001).

Edmund’s work (2008, this issue) identifies the feedbackloop that parents report when raising an overweightchild. We seldom consider how raising an overweightchild adds to the strain of already-stretched householdfinances when special sized clothing or other expensesare tallied. Income inequalities in society are known tocontribute to deepening poverty among children andthe separate process of erosion of formal and informalsocial structures that support health (Raphael, 2000).

One kind of formal support that can help childrenand families prevent or treat obesity is primary care.For many poor children, lack of health insurance andinadequate health care are components of the child-hood obesity picture. Of the nearly 27 million Blackand Hispanic children in the United States in 2005,20% were uninsured, and 41% had health coveragethrough SCHIP or Medicaid (King, 2007). At a rate of64% uninsurance, first generation Mexican Americanchildren are the least-often insured group of children

1

For an example of deep and dense, as well as criticallyimportant recommendations, refer to the supplemental issueon childhood obesity of

Pediatrics

in

December 2007

.

142 JSPN Vol. 13, No. 3, July 2008

Guest Editorial

in the United States (King, 2007). Mexican Americanchildren are also among those most affected by over-weight. In some geographic areas, prevalence of over-weight among Mexican American children hoversaround 50% of all children (Park, Menard, & Schoolfield,2001; Hernández-Valero et al., 2007).

New approaches to childhood obesity are bypassingproblems of access to primary care, with hopeful results.Speroni, Tea, Early, Niehoff, and Atherton (2008, thisissue) found that a hospital-based intervention wassuccessful for those who attended, and that childrenwere able to maintain their weight loss after the inter-vention ceased. Using strategies like this for community-and hospital-based programming led by nurses is away to deliver a new kind of care that bypasses thebarriers families may find when they route their needsexclusively through primary care settings.

An intervention for Chinese children, outlined byChen, Weiss, Heyman, Vittinghoff, and Lustig (2008, thisissue) applies an ecological model and reaches childrenand their mothers with a creative, low-cost mailing ofpersonalized health and weight information. Usingexisting health education strategies and tailoring themto individual needs in a cultural context uses thecomplexity of childhood obesity to drive a niche-basedintervention.

Despite macro-level insurance and access issues,specialists in pediatric nursing know that what can re-direct a child’s growth trajectory gone awry is oftensparked in the clinic or school-based health center orexam room. As Kools, Kennedy, Engler, and Englerdescribe (2008, this issue), knowing how childrenprocess the need to modify their dietary intake infamily and social settings is important for providers tounderstand and support. Matter-of-fact and daily waysof dealing with dietary changes can be supported andmodeled for children, easing their adjustment throughchildhood to adolescence by aiding their increasingindependence in decision-making.

In describing providers’ views of Mexican Americanfamilies, Johnson, Clark, Goree, O’Connor, and Zimmer(2008, this issue) emphasize that provider-patientinteractions draw information from parents aboutcomplementary feeding strategies for infants, familyinteractions around feeding, and advice from extendedfamily members and other clinicians. A challenge in cross-cultural care relationships is the difficulty of workingacross languages and with differing beliefs about

“normal” infant feeding in particular cultural groupsor “typical” body size in a family.

Snethen and colleagues (2008, this issue) point outthat some fathers mistakenly consider themselves“normal weight” when their BMI is in the overweightrange, and fathers also under-report their children’soverweight status. The changing ideal of “normal” insociety does appear to be shifting, with family-linkedor socially-linked judgments about normal weightstatus at odds with anthropometric assessments. Family-based care strategies suggested in the literature includeeliciting parental expectations for care, negotiating anunderstanding of normal and ideal body weight, anddiscussing explanatory models about body weight andwhat it would take for their children to attain an idealweight (Clark & Redman, 2007; Johnson, Clark, Goree,O’Connor, & Zimmer, 2008; Reifsnider, Allan, & Percy,2000).

The challenge for nurses and other care providers isto first understand and then begin to explain to policymakers and funders the necessity of addressing thesocial determinants of health and obesity for children.Reifsnider and Ritsema’s model (2008, this issue) expandsand reformulates the Bronfenbrenner ecological model,well known to obesity researchers, by consideringthe data of Mexican American children in the WICProgram. Their systematic analysis and use of a theo-retical framework adds to the explanatory power oftheir results and suggests that the complexity ofchildhood obesity can be reduced when groupsof variables are clustered in meaningful ways. Thehierarchy of nursing actions arising from their workwill better prepare nurses who work with familiesaround issues like dietary composition, supportivematernal feeding interactions, and environmentalchange. Even policy changes can be inferred from anecological model, and those might include healthcarecoverage for all children, linguistically accessible andculturally competent services, reconsideration of childfeeding programs like WIC, and a re-examination ofthe contributors to unacceptably high rates of povertyfor children.

Nurses’ particular contributions, as seen in thearticles in this issue, are in describing the life circum-stances and real-world experiences of overweightchildren from a variety of backgrounds. Our researchis “neat” in the sense that it studies intriguing questionsand arrives at significant results.

JSPN Vol. 13, No. 3, July 2008 143

Specialists in pediatric nursing report a lack of high-quality and longitudinal evidence to guide care in theprevention and intervention of childhood obesity(Wofford, 2008). This sentiment is shared by theAmerican Academy of Pediatrics’ (2003, p. 424) con-clusion that “too few studies on prevention have beenperformed” and more are needed. By recasting thesolution as a simultaneous search for ingenious andcreative avenues of action as well as evidence-based andwell-worn paths to success, we may make progress.

As qualitative researchers and those who conductfieldwork with relatively small samples, we often failto give ourselves credit for our contributions. “We remainsilent in the areas of significance, sometimes sidesteppingthe issue, humbly stating that our purpose is to illuminate,or to provide meaning. We publish our results andexpect the clinician to locate, read, and adapt or changepractice accordingly,” states Janice Morse on this verytopic. But “that is not good enough—we are sellingourselves short . . . we must be more specific and muchless humble” (2004, p. 152). Nurses’ contributions tounderstanding the complexity of childhood obesityare varied, significant, and “neat,” in the sense that thework in this issue is steeped in family, community,and cultural contexts. Our work makes a difference.

Lauren Clark, PhD, RN, FAAN

Guest EditorProfessor

Â

College of Nursing, University of UtahSalt Lake City, UT

Lauren.Clark@nurs.utah.edu

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