The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
The following recommendations are organized according to the ecological framework described on page 20 in the original guideline document and are not presented in order of priority. Rather, general recommendations are followed by those directed at the community, school, family, and individual, in that order. Practice recommendations are then followed by recommendations related to nursing education and organizational/policy development.
There is limited evidence on the effectiveness of obesity prevention interventions in children. Despite the lack of evidence around obesity prevention, the development panel reviewed high quality evidence around behavioural change in relation to healthy eating and physical activity as a starting point for the prevention of childhood obesity. Through consensus, the development panel reached the decision to identify specific recommendations with an embedded behavioural change component as high level of evidence (e.g., Ia-IIb). Where the level of evidence in the table below is identified as high level (e.g., Ia-IIb), this indicates that a high level exists for behavioural change, however the extrapolation for obesity prevention in children is consensus-based (e.g., Level IV).
Practice Recommendations
Recommendation 1.0
Nurses promote healthy eating and physical activity throughout the lifecycle beginning at an early age.
(Level of Evidence = IV)
Recommendation 2.0
Nurses advocate for healthy public policies that include:
- Monitoring and surveillance data at the population level regarding (Level IV):
- Nutrition
- Physical activity
- Measures of adiposity including obesity and overweight status
- Healthy community design. (Level IV)
- Health promoting school policies. (Level IIb)
- Legislation to limit advertising directed towards children. (Level IIb)
- Community-wide campaigns. (Level Ia)
Recommendation 3.0
Nurses promote healthy eating and physical activity at population, community, family, and individual levels by planning, implementing, and evaluating interventions that are:
- Tailored to the strengths and needs of the client and are (Level IV):
- Developmentally appropriate
- Culturally and linguistically relevant
- Gender-specific
- Affordable and accessible (Level IV)
- Focused on behaviour change (Level IIb)
Recommendation 4.0
Nurses maximize the effectiveness of their healthy lifestyle interventions through interactions that are of sufficient intensity and duration to effect behaviour change.
(Level of Evidence = Ia)
Recommendation 5.0
Nurses support exclusive breastfeeding for infants until six months of age.
(Level of Evidence = III)
Recommendation 6.0
Nurses promote healthy eating using Canada's Food Guide to Healthy Eating and focus on:
- Using age-appropriate portion sizes
- Emphasizing fruits and vegetables
- Limiting sugar containing beverages (e.g., soft drinks and fruit juices)
- Limiting consumption of energy-dense snack foods high in sugar and fat (e.g., potato chips, french fries, candy)
- Breakfast consumption
(Level of Evidence = IV)
Recommendation 7.0
Nurses promote healthy eating patterns using interventions with one or more of the following components:
- Small group activities
- Goal setting
- Social support
- Interactive food-related activities (e.g., cooking, taste-testing)
- Family participation
(Level of Evidence = Ia)
Recommendation 8.0
Nurses promote increased physical activity based on Canada's Physical Activity Guides for Children and Youth using interventions with one or more of the following components:
- Behaviour modification. (Level Ib)
- Leisure activity of low intensity that is gradually increased to recommended levels. (Level IV)
- Sustained, repeated interventions. (Level IV)
Recommendation 9.0
Nurses promote a decrease in sedentary activities with emphasis on reducing the amount of time clients spend watching TV, playing video games, and engaging in recreational computer use.
(Level of Evidence = Ib)
Recommendation 10.0
Nurses work with school communities to implement school-based strategies for the prevention of obesity using a multi-component approach including:
- Integrating healthy lifestyle messages into curricula
- Advocating for and supporting the implementation of quality daily physical education taught by specialist physical education teachers
- Advocating for and supporting the implementation of quality daily physical activity (including vigorous physical activity)
- Using youth driven approaches with an information and advocacy component
- Offering healthy choices in cafeterias and vending machines
- Increasing physical activity opportunities at recess and during lunch breaks
- Forming community partnerships and coalitions
(Level of Evidence = Ia)
Recommendation 11.0
Nurses support a family-centred approach to promote healthy eating and physical activity.
(Level of Evidence = III)
Recommendation 12.0
Nurses assess physical growth and development of children and adolescents which includes:
- Discussing and documenting basic dietary patterns
- Discussing and documenting physical activity patterns including sedentary activity (e.g., television and computer time)
- Identifying individual and family risk factors for childhood obesity
- Accurately measuring and recording height and weight
- Calculating Body Mass Index (BMI) for children two years of age and older
- Plotting BMI for age on appropriate U.S. Centre for Disease Control paediatric growth charts as recommended by Health Canada
- Monitoring changes in BMI, dietary and physical activity patterns over time and noting important variations
(Level of Evidence = IV)
Recommendation 13.0
Nurses assist clients to access community resources and opportunities to engage in healthy eating and physical activity through:
- Direct referral of clients to community resources
- Dissemination of information about available community resources
- Promotion of low and no cost physical activity options (e.g., hiking, walking, active commuting, and subsidized programs)
(Level of Evidence = IIa)
Recommendation 14.0
Nurses are aware of, refer to, and collaborate with appropriate allied health providers based on findings from nursing assessment.
(Level of Evidence = IV)
Education Recommendations
Recommendation 15.0
Nursing academic and continuing education programs incorporate the following into their curricula:
- Childhood obesity, associated health risks, risk and protective factors (including the content of the Registered Nurses Association of Ontario [RNAO] nursing best practice guideline Primary Prevention of Childhood Obesity).
- Population health promotion and prevention principles and interventions aimed at:
- Health promoting behaviours such as physical activity and healthy eating
- Obesity prevention
- Chronic disease prevention
- Determinants of health (particularly as they impact the risks for obesity and chronic diseases)
- Healthy public policy (HPP) and the nurse's role in healthy public policy development
- Research skills, including:
- Literature searches and reviews
- Critical appraisal and analysis
- Program evaluation
- Dissemination of research findings to varied audiences
- Individual/family focused interventions (including support and counseling) aimed at promoting healthy behaviours and behaviour change
(Level of Evidence = IV)
Organization & Policy Recommendations
Recommendation 16.0
Nurses advocate for, and participate in, high quality research addressing identified knowledge gaps in the prevention of childhood obesity.
(Level of Evidence = IV)
Recommendation 17.0
Nurses advocate for organizations to develop a plan for implementation that is evidence-based and includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all stakeholders (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing evidence-based guidelines
- An organizational culture that is supportive of evidence-based practice
- Evaluation of effectiveness
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Primary Prevention of Childhood Obesity.
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
