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Program Evaluation: Changing Behavior for Children at Risk of Obesity

Jessica Tidd

Capella University

MPH 5900: Public Health Capstone

August 2022

Program Evaluation: Changing Behavior for Children at Risk of Obesity

Program Specifics

Diabetes is primarily caused by obesity, which in turn is a product of poor nutrition and sedentary lifestyles. The solution to solving the problem of childhood obesity is a change in behavior, which involves the adoption of healthy foods (diet) and an active lifestyle. Dieting is the main cause of childhood obesity in more than 70% of children in the US. Research that has been conducted in the past indicates that the main cause of childhood obesity is the consumption of foods rich in processed carbs and processed sugars. According to De Migule-Etayo (2013), there are various interventions that can be used to treat and reverse the increasing trend of childhood obesity, and these methods include dietary behavior change, surgical intervention, pharmacology and the adoption of an active lifestyle involving physical exercise.Powerpoint

This proposal proposes a 6-month program involving a dietary behavior change and adoption of physical exercise for a group of 12 children at the risk of childhood obesity or who are already suffering from childhood obesity.

Assessment of population needs

The population that is going to be targeted with this program are children between the ages of 2 and 17. The role of dietary behavior modification as an intervention for childhood obesity has been documented widely in literature. In a study by Golan et al. (1998), a family-based treatment for childhood obesity was evaluated. Golan et al. (1998) exclusively used the parents as the agents of change, as opposed to using children. The researchers hypothesized that if the parents are used as the main agents of change to manipulate the environment of the children, then the children would easily overcome the unhealthy dietary habits. Focusing on the parents as the agents of change and having the intervention target parents would also take the focus off of the children and preserve their identity as well as their self-esteem as they participated in the program. The researchers postulated that focusing the intervention on the parents would induce a greater behavior modification as well as a bigger decrease in food consumption, leading to better outcomes compared to conventional methods which have always focused on the children.Powerpoint

The assumptions in Golan et al. (1998) were based off of their previous studies where they found that greater weight reduction in children with obesity was achieved when the parents were actively involved in the interventions as the main agents. The assumption was also based on the fact that an approach that is focused on the parents would also eliminate the predisposition to eating disorders in the long-term, a factor which has been cited as a third variable in studies on dietary change as intervention for childhood obesity. Kamath et al. (2008) also conducted an RCT study to investigate the efficacy of various interventions for preventing childhood obesity. The study was primarily focused on studying the effectiveness of various change of lifestyle strategies which included physical activity, decrease of sedentary lifestyle, the decrease in unhealthy dietary habits and an increase in the intake of healthier foods options. The main parameter of measurement was the decrease in BMI of the study participants.Powerpoint

Unlike in the study conducted by Golan et al. (1998), Kamath et al. (2008) used interventions which were mainly focused on the children. Both studies used children between the ages of 2 and 18. Kamath et al. (2008) defined lifestyle behaviors to include dietary changes (increase in healthy diet and decrease in unhealthy diet) and two, changes in physical activity (decrease in sedentary lifestyle and increase in physical activity). The Kamath et al. (2008) study used parents and family members as secondary subjects and assets to the study where the parents and family members reported on the progress of the children in terms of adherence to the study. The children that participated in the study that was conducted by Kamath et al., (2008) received interventions either at school, home, in the clinic, or in the community setting. Stakeholders that participated in delivering the interventions included community members, healthcare professionals, parents, health authorities and school leaders. Multimodal and simple interventions were administered.Powerpoint

Assets

Assets refer to the people, resources and equipment that will be utilized to realize the program objectives. Assets are different from stakeholders in that they are resources, either material or human that are necessary for the success of the program, whereas stakeholders are the people that are going to be affected, either positively or negatively by the program. The following assets will be important in carrying out this program.

· Healthcare authorities

· School administration

· Books, films and learning materials

· Exercise equipment

Activities in change behaviorsPowerpoint

The change behaviors in this program are dietary behavior modification and physical activity. Consistent with both Kamath et al. (2008) and Golan et al. (1998), this program will include the following activities.

· A 180-day dietary modification, where parents of the children enrolled in the program will implement a diet that has been recommended by a pediatric nutritionist as effective for reducing childhood obesity

· Children will participate in a physical exercise that is age appropriate both in school and at home. Parents will for instance take the children out for 30-minute walks every day for a period of six months

· Parents will regulate the amount of time that children watch television or play video games and set this to a minimum.Powerpoint

· Parents will report progress to the program leader after every 30-days

Projected program goals

The parameter of interest in the study conducted by Kamath et al. was the measurement of BMI. BMI is the most reliable proxy measure for the risk of obesity in all demographics. The CDC benchmark for instances categorizes children with BMI above the 95th percentile of the CDC sex-specific BMI as obese. Other measurements for childhood obesity are the reduction on symptoms such as joint pains, shortness of breath and sleep apnea.

The following are the goals of the program

· Assist the children to change their dietary behavior from unhealthy eating habits to healthy eating habits

· Assist the children to increase their levels of physical exercise and effect behavior change from a sedentary lifestyle to a physical-activity lifestyle

The SMART objectives for the program are also reiterated below:

· Target to reduce childhood obesity rates throughout the United States by implementing a diet behavior change program which is combined with physical activity

· Effect dietary behavior change in childhood through effective media communication

· Conduct healthy diets education in elementary and high schoolsPowerpoint

1. Measurable and Realistic

· Reduce childhood obesity rates from the current 18.7% to under 5% in the next five years

· Reduce the rate of sugar consumption in children by half

· Increase the number of fruits and vegetables in children’s diets in school and at home by 50%

2. Attainable

· Launch a childhood obesity awareness campaign in neighborhoods, churches, and schools and conduct sensitization sessions for parents on ways to combat childhood obesity

Expected outcomes of the program

There are various expected outcomes of the program. The outcomes can be categorized into short and long-term outcomes. The long-term outcomes are the expected adoption of new habits while the short-term outcomes are the improvement in the measures of childhood obesity. In the Golan et al., study, 60 obese children (20% over the ideal age-specific BMI) were randomly selected. The children were aged between 6 and 17. The experimental group was treated with interventions for a period of 12 months. The control group were children would were responsible for their own weight.

Interventions included hour-long support-educational sessions conducted by a clinical dietitian. The sessions include 14 sessions for parents in the experimental group and 30 for parents in the control group. The results showed that the mean weight reduction in the children who were enrolled in the experimental group were higher than that of the control group. The study concluded when parents are engaged as the main agents of behavior modification in their children, the changes tend to be greater than when the children are taken as the main agents. On the other hand, the outcomes of the interventions that were implemented in the Kamath et al., study only caused a small change in target behavior and no significant effect on the BMI. This disparity in outcome can be explained using two reasons, one is that the focus on parents as agents of change is more effective than using the children, and two, that in the Kamath et al., study treated the experimental group over a shorter period of time.

Both of these studies influence the choice of desired outcome in this program. Because the treatment given in the program is the same as in both of the cited studies, we expected similar results over the 180 days period that the program is going to last. The following are the short and long-term expected outcomes of the program:

· Reduce the BMI of the subjects to within the CDC range of “normal” BMI

· Eliminate symptoms of obesity in the participants

Long-term expected outcomes

· Prevent progression of childhood obesity to diabetes type 2

· Help the participants to pick up positive dietary behaviors and discard negative dietary behaviors

Expected effects of the Program

The program is expected to have several effects. First, just like in the Golan et al., (1998) study where parents were the main focus, in this study, it is expected that the parents and teachers will the best foods to give their children to avert negative health issues. Second, it is expected that the children participating in the study will succeed in reducing weight and picking up new habits which will help them to adopt positive eating habits in future.Powerpoint

Stakeholders to the program

The main stakeholders are going to be parents and children. Just like in the Golan et al study, the focus of the program will be targeted behavior change in the children that is facilitated by the parents. This method has been proven to be more effective at achieving better outcomes compared to conventional methods which focus on children. The primary stakeholders to this program include children aged 2-17 years, their parents, school teachers, healthcare professionals and community resources. The children are the main stakeholders in this program. They are expected to adhere to the requirements of the program for the entire period of 180 days. The children are the primary intended users of the program and also the ones who are affected by the program.

The parents are the second most important stakeholders of the program. They are expected to help in the implementation of the behavior change by implementing the diet plan and the exercise routine. The school teachers and the school administration are the third category of stakeholders. Their role will involve piloting a new menu in the schools and assessing the impact of the healthier meal option on the eating habits of the students. Community health authorities will be contacted to advice on the structuring of the program and its implementation in schools and homes. The community healthcare authorities will also help with resources for program monitoring and evaluation.Powerpoint

The need for the program

The World Health Organization (WHO) has described childhood obesity as one of the most serious health challenges in the 21st century. In a 2016 survey, the World Health Organization also found that globally, about 41 million children under five years were overweight while those between the ages of 5 and 19 who were overweight were slightly more than 340 million. The Center for Disease Control and Prevention in the US estimates that approximately 19% of children between age 2 and 19 years-old are obese in the US, which translates to about 1 in five children. The CDC has also indicated that for the past 30 years, the rate of childhood obesity has increased by three.

This program is needed because childhood obesity is an immediate healthcare problem that can be solved though well-structured programs. Several studies have found that change modification is the easiest and most effective ways to lose weight across all gender and age demographics. Obesity is mainly caused by unhealthy eating habits and a sedentary lifestyle. Adopting healthy diets and frequent and routine physical activity has been found to be a remedy for obesity across all age groups. This program is also important because studies suggest that if left untreated, childhood obesity persists up to adulthood leading to a myriad other physical and mental health problems such as type II diabetes, physical joint pains, hypertensions and low-self esteem among others.

Past studies using the intervention

Two past studies (Golan et al. (1998); Kamath et al. (2008) have been cited in previous sections on the effectiveness of dietary behavior modification and physical activity as two core interventions against childhood obesity. In a subsequent study conducted in 2006, Golan et al. conducted a study to compare two interventions, one which involves parents working with the child and the other intervention only involving the children. Golan et al., evaluated the relative efficacy of treating childhood obesity through family-based health centered intervention, which involve only parents, and another intervention involving parents and children. In this study, 32 families with children who were between 6 and 11 years were selected randomly to participate in the study. Both groups were exposed to a 6 months comprehensive educational and behavioral program targeting behavior modification. Additionally, in both of the groups, the parents were encouraged to adopt authoritarian parenting style (parents are firm but supportive, they lead change but grant the children some freedom). The study found that only in the group where the intervention was led by and targeted at parents. For instance, the percentage of the children that were obese at the end of the program was lower in the parents-only group compared to the parents-and-children group.Powerpoint

Johnston & Taylor (2008) also cite several studies (Summerbell et al., 2003; Israel, 1999; Chambless and Hollon (1998) which have found that a multimodal approach such as the one adopted by Kamath et al. (2006) is also more effective in tackling childhood obesity.

Data collection

Data is going to be collected throughout this program. In the study by Kamath et al. (2006), data was collected using questionnaires, and interviews of the parents. In this study, data is going to be collected from the participants of the study using various ways. First, the main measure which is BMI will be collected from the participants after every 30 days. This will be measured using weight scales at home, by a healthcare professional or parents trained in the proper way of measuring BMI. This data will be self-reported, where parents will be required to collect and remit the data to the program manager.

Instruments of data collection

· Surveys and questionnaires to identify participants

· Self-reported measurement data for all categories required

· School reports on the progress of dietary behavior change programs

· Interviews conducted by the program officer and administered on school teachers and parents

The data collected will be analyzed using qualitative methods. This data will be analyzed by the program officers with the help of clinical healthcare authorities. The outcome of the program will be used to draft policies for implementing a wide-reaching behavior modification program across the state as a means of treating childhood obesity.Powerpoint

Policy Recommendations

The outcome of this program will inform policy making on the best ways to combat childhood obesity. The following two policies are recommended to combat childhood obesity at society-levels.

i) Regulate the TV ads of unhealthy foods that are targeted at children

Studies have established that TV advertising of unhealthy foods is one of the major drivers of unhealthy eating habits among children in the target demographic for this program. When children see the advertisement of meals such as burgers, fried chicken and chips, foods cooked with processed sugars and cornstarch etc., they tend to associate such foods with healthy eating habits. Children places a premium on what they see on television, a habit which brands have taken advantage of to influence purchasing decisions of parents. Using the results from this program, legislators will be lobbied to regulate the advertisement of foods targeted at children.

ii) Implement healthier diets in schools

Children spend most of their time in school. Schools across the US serve millions of plates of unhealthy meal options every single day which has been a significant contributor to childhood obesity. Public schools have a higher proportion of unhealthy meal plans because of lack of funding. The outcome of this program will hopefully convince school district heads to change school diets in favor of healthier meals after presentation of evidence from the program.Powerpoint

Dissemination of results

The dissemination of the results of this study is important. The stakeholders involved in this program need timely and accurate feedback and information from the data collected through this program. The information is going to be disseminated through a formal report of the program to the key stakeholders. The data analysis showing the outcome of the experiment will be shared with the parents of the children, the school teachers and the health authorities. Oral presentation of the program results will be presented to peers in the industry in a PowerPoint format.Powerpoint

How the results of this program will affect future research

There is still ongoing research in the field of childhood obesity. Many more interventions, including pharmacological interventions are being proposed, while researchers are exploring various ways of tackling the issue of childhood obesity. Various policies exist, enacted by state and federal governments about how to arrest the problem of unhealthy diets in schools, but childhood obesity rates keep going up. This program and research is adding to the body of knowledge about what is known about childhood obesity and possible interventions. This research also highlights two key policy recommendations which are open for more debate and discussion within the field of medicine and in education. This study is limited by the intervention that it proposes. In future, other kinds of interventions can be scrutinized in relation to how they help solve the problem of childhood obesity.

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References

De Miguel-Etayo, P., Bueno, G., Garagorri, J. M., & Moreno, L. A. (2013). Interventions for treating obesity in children. World review of nutrition and dietetics, 108, 98–106. https://doi.org/10.1159/000351493

Golan, M., Fainaru, M., & Weizman, A. (1998). Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change. International journal of obesity, 22(12), 1217-1224.

Golan, M., Kaufman, V., & Shahar, D. (2006). Childhood obesity treatment: Targeting parents exclusively v. parents and children. British Journal of Nutrition, 95(5), 1008-1015. doi:10.1079/BJN20061757

Han, J. C., Lawlor, D. A., & Kimm, S. Y. (2019). Childhood obesity. The lancet, 375(9727), 1737-1748.

Johnston, C. A., & Tyler, C. (2008). Evidence-Based Therapies for Pediatric Overweight. In Handbook of Evidence-Based Therapies for Children and Adolescents (pp. 355-370). Springer, Boston, MA.

Kamath, C. C., Vickers, K. S., Ehrlich, A., McGovern, L., Johnson, J., Singhal, V., … & Montori, V. M. (2008). Behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials. The Journal of Clinical Endocrinology & Metabolism, 93(12), 4606-4615.

Karik, S., & Kanekar, A. (2012). Childhood obesity: a global public health crisis. Int J Prev Med, 3(1), 1-7.

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. https://doi.org/10.1001/jama.2014.732

Verduci, E., Di Profio, E., Fiore, G., & Zuccotti, G. (2022). Integrated approaches to combatting childhood obesity. Annals of Nutrition and Metabolism, 1-12.

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