• Registered Nurses Association of Ontario (RNAO). Primary prevention of childhood obesity. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 88 p. [143 references]

This is the current release of the guideline.

Childhood obesity

Prevention

Family Practice
Nursing
Nutrition
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Nurses

To provide direction for nurses who work with children and families across diverse practice settings and at population, family, and/or individual levels

Children from birth to age 18 years

1. Promotion of healthy eating and physical activity at population, community, family, and individual levels using:
   • Canada's Food Guide to Healthy Eating
   • Small group activities
   • Goal setting
   • Social support
   • Interactive food-related activities
   • Family participation and family-centred approach
   • Behaviour modification
   • Low intensity leisure activity that increases in intensity
   • Sustained repeated activities
   • School-based strategies
2. Promote exclusive breastfeeding until 6 months of age
3. Promote a decrease in sedentary activities
4. Assessment of growth and development
5. Referral to appropriate allied health professionals and community resources, as appropriate

• Childhood obesity rates
• Effectiveness of behavioural interventions at increasing healthy eating and physical activity

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

A database search for existing obesity guidelines was conducted by a university health sciences library. An initial search of the MEDLINE, Embase, and CINAHL databases for guidelines and articles published from January 1, 1995 to September 2003 was conducted using the following search terms: "obesity," "children," "adolescents," "adults," "overweight," "body mass index," "health risks/complications," "prevention of obesity," "chronic disease," "primary prevention," "interventions," "randomized controlled trials," "systematic reviews," "practice guideline(s)," "clinical practice guideline(s)," "standards," "consensus statement(s)," "consensus," "evidence based guidelines," and "best practice guidelines."

One individual searched an established list of Web sites for content related to the topic area. This list of sites, reviewed and updated in December 2003, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

A supplemental Web site search for existing childhood obesity guidelines was conducted via the search engine "Google," using the search terms identified above. One individual conducted this search, noting the search term results, the websites reviewed, date, and a summary of the findings. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were already in possession of a few of the identified guidelines as well as systematic reviews. In some instances, a guideline and systematic reviews was identified by panel members and not found through the previous search strategies.

This above search method revealed five guidelines, several systematic reviews, and numerous articles related to obesity and children.

The final step in determining whether the clinical practice guideline would be critically appraised was to have two individuals screen the guidelines based on the following criteria. These criteria were determined by panel consensus:

• Guideline is in English
• Guideline is dated no earlier than 1997
• Guideline is strictly about the topic area
• Guideline was evidence based (e.g., contained references, description of evidence sources of evidence)
• Guideline is available and accessible for retrieval

Five guidelines met the screening criteria and were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

In January 2004, an interdisciplinary panel with expertise in child and family-based clinical practice, health promotion, population health, education, and research from institutional, community, and academic settings was convened under the auspices of the Registered Nurses Association of Ontario (RNAO). At the outset, the panel established the scope of the guideline through a process of discussion and consensus. Specifically, this panel chose to focus on the primary prevention of childhood obesity from population, community, and child/family perspectives.

The results of the literature search and review were used to inform the background of this document and the methodology for guideline development. After careful review, the panel found that the published guidelines that focused on primary prevention of childhood obesity were limited. They decided to examine existing systematic reviews of the literature on primary prevention intervention strategies for childhood obesity. The panel members searched for high quality systematic reviews on the prevention of childhood obesity and the promotion of healthy eating and physical activity. Panel members evaluated the reviews using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for systematic reviews with direction from one of the panel members who had extensive experience in undertaking systematic literature reviews. Reviews that were judged as moderate or high quality were utilized to develop initial recommendations and supporting discussion of evidence. The list of systematic reviews initially critiqued is found in Appendix D of the original guideline document. Panel members developed recommendations based on available evidence and came to a consensus on a draft guideline.

Not applicable

A meta-analysis by Katzmarzyk and Janssen (2004) used a prevalence-based approach to estimate the economic costs of physical inactivity and obesity in Canada. These authors found the economic burden of obesity in 2001 to be $4.3 billion, of which $1.6 billion was attributed to direct costs and $2.7 billion to indirect expenditures. The consequences of physical inactivity alone accounted for $5.3 billion or 2.6% of total health care costs in Canada in 2001.

External Peer Review
Internal Peer Review

The initial draft was critiqued by two independent reviewers prior to publication using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. No revisions resulted from this review. The initial draft was shared with a group of external stakeholders. An acknowledgement of these reviewers is provided at the front of this document. External stakeholders were provided with specific questions for comments, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel. Discussion and consensus resulted in revision to the draft document prior to publication.

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

None provided

The type of evidence is identified and graded for each recommendation (see "Major Recommendations").

• Prevention of obesity
• Promotion of healthy eating
• Increased physical activity
• Nurses, other health care professionals, and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessments and documentation tools.

Not stated

• This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• 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-Ib). Where the level of evidence in the "Major Recommendations" field 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).
• The level of evidence supporting each recommendation applies to prevention efforts with non-obese, non-overweight children, unless otherwise stated.

Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Registered Nurses Association of Ontario (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 any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment, and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Evaluation and Monitoring

Organizations implementing this nursing best practice guideline need to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on a framework outline in the RNAO Toolkit, illustrates some indicators for monitoring and evaluation.

Implementation Strategies

The Registered Nurses Association of Ontario and the guideline development panel have compiled a list of implementation strategies to assist health care organizations or health care disciplines who are interested in implementing this guideline. See the original guideline document for a summary of strategies.

Staying Healthy

Effectiveness

• Registered Nurses Association of Ontario (RNAO). Primary prevention of childhood obesity. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 88 p. [143 references]

The Registered Nurses Association of Ontario (RNAO) panel selected the following guidelines to adapt and modify for the current guideline:

• Center for Disease Control and Prevention (1997). Guidelines for school and community programs to promote lifelong physical activity among young people. [Electronic version]
• National Health & Medical Research Council (2003). Clinical practice guidelines for the management of overweight and obesity in children and adolescents. [Electronic version]
• Nutrition and Physical Activity Work Group (2002). Guidelines for comprehensive programs to promote healthy eating and physical activity. [Electronic version]
• Scottish Intercollegiate Guidelines Network (2003). Management of obesity in children and young people. [Electronic version]
• Weight Realities Division of the Society for Nutrition Education (2003). Guidelines for childhood obesity prevention programs: Promoting healthy weight in children. [Electronic version]

2005 Mar

Registered Nurses' Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Guideline Development Panel Members

Paula Robeson, RN, MScN
Team Leader
Knowledge Broker
Evaluating the Evidence on Knowledge Brokers Study
McMaster University
Hamilton, Ontario
Former position with and support from:
Ottawa Public Health, Ottawa, Ontario

Mary Lou Albanese, RN, BScN, MSA
Program Manager
Chronic Disease Prevention
Middlesex-London Health Unit
London, Ontario

Donna Ciliska, RN, PhD
Professor
School of Nursing
McMaster University and Consultant Public Health Research, Education and Development Program
Hamilton, Ontario

Veronica Fodor, RN
Staff Nurse
Family Health Centre
University Health Network
Toronto, Ontario

Marcia Frank, RN, MHSc, CDE
Clincial Nurse Specialist
Diabetes Program
The Hospital for Sick Children
Toronto, Ontario

Wendy Goodine, RN, BScN, PHCNP, RN(EC)
Nurse Practitioner
LAMP Community Health Centre
Toronto, Ontario

Liz Helden, RN, BSN, MEd
Nurse Coordinator
Pediatric Lipid Clinic, Chedoke McMaster Hospital
Hamilton, Ontario

Karen Hourtovenko, RN, BScN, CCNP, PHCNP, RN(EC)
Nurse Practitioner
Riverside Cardiac Clinic
Sudbury, Ontario

Stephanie Lappan-Gracon, RN, MN
Program Staff, Facilitator
Nursing Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Colette Larocque, RN, BScN
Public Health Nurse
School Health Team
Kingston & Frontenac Health Unit
Kingston, Ontario

Mary-Jo Makarchuk, MSc, MHSc, RD
Public Health Nutritionist
Toronto Public Health
Toronto, Ontario

Katherine Morrison, MD, FRCPC
Department of Pediatrics & Population Health
Research Institute
McMaster University
Hamilton, Ontario

Sylvia Ralphs-Thibodeau, RN, BA
(community health), MSc(C)
University of Ottawa
Ottawa, Ontario

Lorraine Watson, RN, PhD
Professor
School of Nursing
University of Calgary
Calgary, Alberta

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses Association of Ontario.

This is the current release of the guideline.

None available

This summary was completed by ECRI on June 9, 2005. The updated information was verified by the guideline developer on June 21, 2005.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2005). Primary prevention of childhood obesity. Toronto, Canada: Registered Nurses Association of Ontario.