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The role of school nurses in tackling childhood obesity

Rosalind Godson
SRN SN
Professional Officer for School Health and Public Health
Amicus CPHVA

The prevalence of obesity in children aged under 11 increased from 9.9% in 1995 to 13.7% in 2003.(1) It appears that overall calorie consumption is not increasing but that the amount of exercise children do has declined steeply. This is attributed to greater use of private cars, unsafe parks and roads, fear of abduction, and playing on computers and games consoles. Huge numbers of school playing fields have been sold off, and schools have reduced the amount of time spent on games and PE because of demands upon the national curriculum. Obesity is an important risk factor for a number of chronic diseases, such as heart disease, stroke, some cancers and type 2 diabetes, and overweight children tend to grow into overweight adults.(2)

Targets
In July 2004 a Public Service Agreement target specifically on obesity was set for the first time - "halting the year-on-year rise in obesity among children aged under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole".(3)
The target is shared jointly by the Department of Health, the Department of Culture, Media and Sport and the Department for Education and Skills (all England), in recognition that delivery will depend upon a concerted, joined-up effort across government and at local level. Scotland, Northern Ireland and Wales have similar targets.
While it is clear that many children are overweight nowadays compared with a few years ago, there is only limited accurate local evidence of the scale of the change. For this reason the Department of Health has asked all primary care trusts to weigh and measure all children in year 1 (5-year-olds) and year 6 (11-year-olds) in state schools annually, and to send back the information in the form of BMI (body mass index) results. It is recognised that BMI is not a good measure of adiposity in children,(4) and better tests, such as skinfold thickness, are available. However, this is not practical on such a large scale. It is planned that with this information PCTs can better direct resources to the areas where childhood obesity is greatest, in order to meet the target.

Prevention
School nurses can play a significant role in improving nutrition and contributing to physical activity as part of the National Healthy Schools Programme in order to help prevent obesity (see Box 1).(5)

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Treatment
There is no reason why school nurses cannot treat individual overweight children; indeed they are the best placed to do so, as they have knowledge and skills for health and understand children in the context of their family and school life. Many school nurses are also trained to offer mental and emotional health support. The Choosing Health white paper suggested that children develop their personal health guide, and this could be used to monitor their health in a holistic way, not just concentrating on their size.(3)
The Department of Health has issued two important documents to help nurses working with children: Raising the Issue of Weight in Children and Young People and Children and Young People Care Pathway.(7,8)
A sensitive, empathetic, nonjudgemental approach should underpin all obesity-related intervention. After all, you are asking children and young people to change their behaviour, to eat differently, to exercise differently, to act differently from their peer group, and to do this for the rest of their life. In most cases progress will be slow and there will be very little to show for the effort.
The Health Select Committee predicted that this generation of children would have a reduced life expectancy because of obesity, and this has led to media speculation, which has panicked some parents into thinking that their child is in imminent danger if they don't lose weight.(9) It is the health practitioner's job to reassure them and allow the family some time and space to consider the next step. In many families you will need to unravel some of their knowledge and understanding before you can make progress. In one survey of parental perception of their child's weight, 94% of parents with overweight or obese children did not recognise the seriousness of the problem.(10)
As a school nurse in practice for several years, it always astonishes me that many parents believe that children need chocolate, sweets and biscuits. There is also a general acceptance that children eat different food from adults, such as chicken nuggets and chips, rather than "meat and two veg". Remember also the influence of the extended family. You must find out what the child does in an average week, and where exercise and food are taken. Many children spend time with estranged parents or with grandparents or childminders.
Parents who are naturally slim may have no idea why their child has gained weight, and in other families there may be only one overweight child and the others may be slim. Once the school nurse understands fully the parameters of the child or young person's lifestyle, then the problem of the excess weight must be tackled by the tried-and-tested route - eating less and exercising more.

Exercise
Ask the parent or child to go through the previous week's activities to identify exactly how much (or how little) exercise s/he is doing, and record this.
School swimming lessons, for example, are often just an exercise in getting wet, and very little exercise occurs during football if the child is the goalie on the winning side. Encourage an increase in measurable activity, such as lengths of the swimming pool or kilometres of walking. A pedometer that measures steps is ideal for children and young people. Many teenage girls refuse to swim, so encourage them to take up disco dancing. Some leisure centres have classes for children from 12 years upwards.
If the child is reluctant to do school PE, then explore whether this is because of bullying, the uniform policy or some other reason. If necessary, take the problem to the school governors and use the Healthy School Programme as a lever for change. Tracksuits are preferred by girls, but some schools insist on shorts and T-shirts. If a child fears bullying, then insist that the school monitors its bullying policy.

Food intake
Food diaries are extremely helpful to discuss with the child on a one-to-one basis, to see whether there are adjustments that could be made. The school nurse must make sure that the child is eating a well-balanced diet with plenty of fruit and vegetables, and less calorie-dense food. There is information on the Department of Health (England) website. There is no point weighing the child more often than twice a term, as in general the aim would be for the young person to stabilise their weight while they grow.

Support
It is, however, a good idea to see the child weekly at school to empathise and sympathise, encourage and cajole, and talk through any problems. The child will have difficulties relating to the fact that they are "different" from their peers, and the school nurse must help with this.

Partnership working
The school nurse must keep good communication with the child's GP and practice nurse, so that there are no contradictions in the message. Obviously if it transpires that there are underlying emotional or physical problems, then the child needs to be referred to the GP for assessment and referral to specialist services. It will also help if the child's teacher is supportive, but most teachers will need help with this.

Conclusion
School nurses need to promote their skills in health promotion and care of children to schools, local education authorities and primary care trusts. It is clear that they have an important role to play in the prevention and treatment of straightforward childhood obesity, and could do lots more, but owing to large caseloads and insufficient staff they are often unable to commit to this essential work.

References

  1. Department of Health. Health survey for England. London: TSO; 1995-2003.
  2. DH. Choosing health. Obesity Bulletin 1. London: DH; 2006. Available from: http://www.dh.gov.uk
  3. DH. Choosing health. London: TSO; 2004.
  4. DH. Measuringchildhood obesity; guidance to primary care trusts. London: DH; 2006.
  5. DH. National healthy schools status; guidance for schools. Available from: http://www.wiredforhealth.gov.uk
  6. Food in Schools toolkit. Available from: http://www.foodinschools.org
  7. DH. Raising the issue of weight in children and young people. Available from:http://www.dh.gov.uk/assetRoot/04/13/44/15/ 04134415.pdf
  8. DH. Children and young people care pathway (primary care). Available from: http://www.dh.gov.uk/assetRoot/04/13/44/13/04134413.pdf
  9. House of Commons Health Committee. Obesity. Third report of session 2003-04. Available from: http://www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23/2...
  10. Carnell S, Edwards C, Croker H, Boniface D, Wardle J. Parental perceptions of overweight in 3-5 year olds. Int J Obes 2005;29:353-5.