Chapter 1

Introduction

Background
Obesity is a health concern among children that can be
reversed. Over 17 percent of children and teens are obese, and
these numbers are climbing every year. The obesity trend among
children and teens can be reversed with the help of their
community, parents, schools and peers. Unlike adults, children
and teens rely on their parents or guardians for food and
shelter. Many children fail to exercise because parents allow
children to sit in front of a television, computer, or play
video games. Many children spend more than three hours a day on
these devices, almost every day per week.(Moores, 2012). Many
children fail to exercise because they spend most of their time
on technology instead of physical activity. Technology is a
large factor for obesity and inactive children. Eating habits
are another reason for obesity in children. Calorie-rich snacks
and drinks are readily available for children to eat. For
younger kids, the parents are providing these unhealthy snacks
because they are easy. As childhood obesity becomes more
prevalent, snack machines have been replaced or taken out of the
schools. Pop machines are being replaced by lower calorie
sports drinks and water. Seventy-five percent of teens eat fast
food on a weekly basis. The fast food industry spends $4.2
billion annually on advertisement, so there is no question why
so many teens frequent the fast food chains (National Bureau of
Economic Research, 2012). Studies are trying to blame obesity
on fast food chains, but in reality it is the people who are
consuming the fast food. Sadly, the numbers are going to
continue to climb if policymakers do not set regulations to help
reverse these trends. Public health practitioners and
policymakers are trying to find effective ways of slowing and
reversing obesity trends (Boehmer et al, 2009). Many state laws
and regulations addressing the problem have been introduced and
enacted. Hopefully by addressing these issues, it will help the
passage of further policies to help prevent obesity. For
example, a study from 2005 to 2006, used key-informant
interviews that were conducted with 16 legislators and staffers
from 11 states examined qualitative factors that enable and
impede state-level childhood obesity prevention programs. One
factor that might impede the passage of childhood obesity
programs are lobbyists from fast food chains or those from
“unhealthy” food companies. On the other hand, the media may
help positively influence obesity prevention programs. These
prevention programs also need key players such as parents,
physicians, and schools to help support obesity prevention
programs. Individual states have most of the power to influence
policies and regulations in the United States. State
governments are able maintain substantial power over actions
that affect public health. An example of a state legislation
that has taken place within the last five years is an issue
addressing school nutrition standards, and physical education
and activity. Hopefully within the next five years more
legislation can take plan to further these standards. We will
look at the topic areas when we identify the key stakeholders in
the landscape section.

Statement of the problem

A policy analysis is one that provides informed advice to a

client that relates to a public policy decision, includes a
recommended course of action/inaction and is framed by the
client’s powers and values (Teitelbaum & Wilensky, 2013). There
are a series of steps needed to create a written health policy
analysis. They are the following:

Client- Oriented Advice: the analysis of the policy must suit

the needs of the client

Informed Advice: analysis is based upon thorough and well-

rounded information

Public Policy Decision: analysis involve public policy decision,

affecting the greater community

Providing Options and a Recommendation: providing several

options, analyzing options, settling on one recommendation

Your Client’s Power and Values: analysis is framed by the

client’s power and values and must be within their power to
accomplish

Before the steps are put into place, we must know what our
policy issue consists of. Obesity is our health policy of
choice. Our problem statement is; “What type and scope of a
program must be implemented in order to decrease the obesity
rate among U.S. children within the next five years?” The first
problem of this statement asks what type and scope of program
must be implemented to decrease obesity rate among children. We
also ask if the program can be solved within the next five
years, or at least give the recommendation time to see if it is
beneficial. We have a few things to analyze when breaking down
our problem statement. The first statement allows us to come up
with many opportunities and decide on those, instead of asking,
“Should a program be implemented to decrease obesity rate among
children?” The first part of the problem statement allows us
options that we need for a better analysis. It also allows us
to weigh the pros and cons of different solutions and come up
with one that is agreed upon by the decision maker. The second
part of the question gives us a time frame. We need a time
frame or stopping point so we do not have to analyze
indefinitely. The time frame gives the analyzer an ending to
the problem. Looking at the overall statement, we see that the
options for decreasing obesity can be broad, but the time frame
of five years narrows it down to make the problem manageable.
For the sake of our topic analysis on obesity, this would be an
acceptable problem statement.

Objectives of the study

 To give exposure about causes of obesity

 To explain the effect of obesity
 To expose the ways to solve obesity problem

Scope and delimitation

Childhood obesity is a serious health problem in the United

States.1 Data from the 2007-2008 National Health and Nutrition
Examination Survey indicated approximately 17% of US children
and adolescents (ages 2-19) years are obese.2Obesity prevalence
increased from 5% to 10.4% (children aged 2-5 years); 6.5% to
19.6% (children aged 6-11 years); and 5% to 18.1% (adolescents
aged 12-19 years) between 1976-1980 and 2007-2008.2 3 Some
minority groups such as African Americans, Hispanic, and Native
Americans, and low-income groups are at higher risk of obesity.4
5 However, the patterns are complicated, and not all low-income
or minority groups are at high risk, and the relationship
between obesity and social-economic status (SES) has changed
over time in the US.4 6 Asian Americans have a lower prevalence
of obesity than other ethnic groups, while higher income African
American girls were more likely to be overweight than their
lower income counterparts. The inverse relationship between
obesity and SES is seen only in white females. However, SES
factors only explain a very small portion of the variations in
BMI (e.g., 1-2%).

Complex causes of obesity: Obesity is the result of a large

number of biological, behavioral, social, environmental and
economic factors and the complex interactions between them that
promote a positive energy balance. At present, how these factors
affect children and contribute to the disparities in obesity
prevalence between population groups in the US remain poorly
understood. Nevertheless, a growing body of research suggests
that many factors interact including: individual factors (e.g.,
genetics, nutrition knowledge and attitude, body weight image),
home influences (e.g., parenting, food served at home, parental
weight status), school factors (e.g., nutrition service,
curriculum including physical activity, annual BMI measure),
those in the local community (e.g., food environment, crime
rate), and at the regional and national levels (e.g., built
environment, economic factors such as food prices, and food
assistance programs). They contribute to obesogenic environments
and affect children's weight. A number of leading health
organizations and expert panels (e.g., the World Health
Organization7 and an Institute of Medicine expert panel811015 #54)

have recommended that multiple and comprehensive interventions

are needed to fight the growing obesity epidemic.9

Measurement of adiposity and classification of childhood

obesity: Changes in adiposity due to the intervention in related
studies will be our key outcomes to assess in the systematic
review. Various measures have been used in the field to assess
adiposity and childhood obesity. Although BMI has been widely
used in the classification of obesity in adults and children, it
remains controversial regarding what measures and what cut
points are most appropriate.10 11Different sex-age specific BMI
percentile cut points have been used in the US and worldwide.11
12 In the US, two sets of 85th (for 'overweight') and 95th
percentiles (for 'obesity') have been used, with the recent one
published by the CDC in 2000.13 In general, the values of the two
sets percentile are similar, but they were developed based on
different data and growth curve fitting techniques.13 14 In
addition, different terms have been used. Before the mid-2000’s,
key health organizations including the WHO recommended use of
the term of 'at risk of overweight' for 'overweight', and
'overweight' for 'obesity'. Additionally, BMI is an indirect
measure of adiposity, and thus has several limitations.12 Other
measures, such as percentage of body fat measured via direct
measures such as dual-emission X-ray absorptiometry (DXA), waist
circumference, waist-to-height ratio, skinfold thickness and
related cut points, have been increasingly used to assess
adiposity and define obesity, both in adults and children. The
evidence is mixed on the correlation between direct and indirect
measures of adiposity, particularly in among different age
groups, the morbidly obese and individuals with above-average
lean muscle mass.15-18

Consequences of childhood obesity: Childhood obesity has many

intermediate- and long-term health consequences. Overweight
children and adolescents are at greater risk for health problems
compared to their normal weight counterparts.1 Overweight
children and adolescents are more likely to become obese as
adults.19-21Obesity is a risk factor for a variety of chronic
conditions, including type 2 diabetes, hypertension, high
cholesterol, stroke, heart disease, nonalcoholic fatty liver
disease, certain cancers, and arthritis.22-24 Obesity increases
mortality as well.23 It is estimated that 70% of diabetes cases
in the U.S. are caused by excess weight. Obese children and
adolescents are more likely to have adverse health conditions,
such as cardiovascular-, metabolic, and psychosocial
outcomes.22 The other reported health consequences of childhood
obesity include eating disorders, and mental health issues such
as depression and low self-esteem.24

In addition, overweight and obesity and their associated health

problems have a significant economic impact on the U.S. health
care system.25 Childhood obesity in the US is estimated to cost
$11 billion for children with private insurance and $3 billion
for children on Medicaid.26 The health care costs of an
overweight or obese child is roughly 3 times higher than the
average child as they are 2-3 times more likely to be
hospitalized and are far more likely to be diagnosed with health
disorders than non-obese children. Further, once developed,
obesity is difficult to treat (e.g., due to the 'set point
theory').27 Therefore, it is important to help the public develop
life-long healthy lifestyles and prevent obesity at young ages.

Interventions, controversy or uncertainty about the topic

We chose to organize the KQs for this review by settings rather

than by the specific interventions (e.g., eating, physical
activity or knowledge) based on a number of considerations:
Significance of the Study

Childhood obesity is a critical health issue. This

continually poses a health challenge to the health sector in the
country. It therefore becomes significant to identify the
specific risk factors, which could be triggering the increase in
obesity among the young children. The knowledge of the risk
factors would help in devising mechanisms of how to reduce the
condition in the country, through minimizing or eliminating
these risk factors. Additionally, the existing literature review
of prevalence of obesity in every country does not explicitly
and sufficiently identify the risk factors associated with
prevalence of obesity among the young children. It is therefore
difficult for the health sector to design and implement
intervention programs to contain the situation. This study is
therefore relevant to provide additional information to the
existing literature on the risk factors of obesity among young
children.

Conceptual framework

The conceptual framework for this research resides in rural

theory. Concepts of rural theory acknowledge the variety of
health seeking and health promoting behaviors unique to rural
dwellers with themes of distance, isolation and limited health
care access (Lee & Winters, 2006). Rural theory offers a
specific lens from which to view provider practices for
monitoring childhood obesity in Montana. Research results may be
enhanced by rural concepts which underscore the significance for
many communities where children have limited access to health
care and travel time to visit a provider creates family hardship
and stress. Furthermore, concepts of rural theory may offer
insight into the provider who may be a generalist in a small
community. Generalists are described by rural theorists as
providers who often work within an expanded scope of practice,
where autonomy and isolation from other providers is the norm.
Their roles must be flexible and expanded to meet a variety of
needs within a rural community (Lee & Winters, 2006, p. 205-
245). In addition, rural theory was used for this study because
Montana is designated a rural state and therefore research
describing Montana provider practices for monitoring children’s
weight may be influenced by concepts specific to western rural
culture. By the numbers, Montana has a population of over
957,000 individuals who reside in an area greater than 145,000
square miles; 46% of Montana’s population live rurally; the
average population density is 6.2 people per sq mile, but often
as few as two people live within a square mile; 45 of the
state’s 56 counties are frontier counties, defined by their
distance and time to populated areas, as well as their sparse
population. Healthcare is often 10 provided at one of 40 rural
health clinics (RHC) or 20 community health clinics (CHC) across
the state and may be provided by practitioners who provide care
for the entire family in one setting (Montana Department of
Health and Human Services, 2004). Research by rural theorist
suggest that while having a wide range of expertise, the primary
care provider who is a rural generalist may offer limited
specialty care due to their large scope of responsibilities and
isolation from other providers and services (Loue & Quill,
2001). Considering concepts of rural health, the United States
Department of Health and Human Services Office of Applied
Studies (2004) present findings that show rural residents, when
compared to urban residents, may face barriers to high quality
health care. Factors that contribute to poorer health outcomes
for rural dwellers are higher poverty rates, a larger percentage
of elderly, overall poorer health, fewer doctors, hospitals, and
other health resources, and longer distances to reach health
care delivery sites. Studies describing rural experience by Lee
and winters (2006), suggest rural residence may contribute to
reliance on neighbors and family for health advice and emergency
support. In summary, childhood obesity, when studied in the
context of rural themes, offers a broader understanding of the
factors influencing children and the providers who care for them
in rural communities and states. Slowing the trajectory of
childhood obesity prevalence may be more achievable when
research can be specific to a region and culture, but also can
be generalized using theory concepts and models. Ideally each
population, whether rural or urban, should be assessed with
special emphasis given to 11 identifying those children whose
access to health care is compromised by distance, economic or
cultural inequities.
 Chapter II

Review of Related Literature

Methodology

A questionnaire was sent out to health professionals in both

primary and secondary care settings who were involved in
providing care to children who are overweight or obese. This
included general practitioners, practice nurses, paediatricians,
health visitors and school nurses working in one of the largest
Trusts in the North West of England. The questionnaire was
approved by the Trust's Research and Ethics Department and was
sent out by post with some questionnaires given out in meetings.
All participants were asked to return the questionnaire
anonymously.

Locale of the study

The prevalence of obesity among children and adolescents has
increased substantially over the last decade. The Philippines
is not spared from this scenario, and results of national
nutrition surveys are showing slow but increasing childhood
overweight and obesity rates. The 8th National Nutrition
Survey reveals that the prevalence of overweight among
children 0-5 years old has significantly risen from 1% in 1989
to 5% in 2013. Similarly, prevalence of overweight among
children 5-10 years old has also risen from 5.8% in 2003 to
9.1% in 2013. The 2011 Global School-based Health Survey also
shows that about 13% of adolescents in the Philippines are
overweight and obese.
Evidence shows that overweight and obese children are likely
to stay obese into adulthood and more likely to develop no
communicable diseases (NCDs) like diabetes and cardiovascular
diseases at a younger age. NCDs are now the leading killers in
the Philippines, comprising more than 50% of all deaths each
year.
To address the issue on childhood obesity, the World Health
Organization (WHO) in collaboration with the National
Nutrition Council of the Philippines organized a workshop in
2-4 June 2015 to develop a National Multisectoral Action Plan
for the Prevention of Overweight and Obesity in the
Philippines.
The workshop was organized and facilitated by staff from the
WHO Headquarters, WHO Western Pacific Regional Office, WHO
Country Office in the Philippines, and the Philippine National
Nutrition Council (NNC). The WHO and NNC worked with
multisectoral groups both at the national and sub national
levels to identify priority areas of action and identified
population-based cost-effective approaches and activities to
address rising childhood obesity rates.
After the workshop, the NNC will take the lead and move
forward to conduct a series of meetings and consultations to
review and enhance the draft Prevention of Overweight and
Obesity Plan in the Philippines. NNC will also lead the
formation of a multisectoral technical working group, and they
will move towards development of a policy adopting the plan to
address childhood obesity, planning and overseeing
implementing of an awareness raising campaign, and development
of a monitoring and assessment tool to facilitate and guide
implementation.
Dr Julie Hall WHO country representative in the Philippines
opened the workshop and commended the initiative, "Governments
have committed to global targets that call for a halt in the
increase of overweight children and adolescent obesity. But
many countries are not on track to meet these targets and
while countries have policies on this, implementation remains
a challenge. The WHO is pleased to collaborate with the
Government of the Philippines as they take these positive
steps to combat childhood obesity in the country."

Research Design

The proposed study utilized a concurrent mixed-method design.

Quantitative and qualitative data were collected simultaneously
to strengthen the validity and credibility of the study and
provided an expanded understanding of the research problem
(Creswell, 2009). In this study, the survey and interview data
were combined and triangulated (Creswell, 2009).

RESPONDENTS

Educational Institutions

From the master list of schools and universities under the

Commission on Higher Education (CHED), schools and universities
offering courses in medicine, nursing, nutrition and public
health were drawn out. Registered medical schools were traced
through the Association of Philippine Medical Colleges (APMC).
Finally, the list of schools offering courses in nutrition in
the country was taken from the National Nutrition Council.
Letters of request were mailed and emailed to the respective
directors and deans of 127 schools/universities from Regions 1,
2, 5, 7, 9, 10, 11, and the National Capital Region (NCR).
Twenty-nine out of 37 medical schools listed under APMC were
contacted through emails and telephone calls. Seventy from 78
private universities listed under CHED were emailed. Only one
medical school has responded to the emails sent but no articles
were retrieved.
Hospitals

Three hundred seventeen hospitals in the country from

Regions 1, 2, 4, 5, 7, 9, 10, 11, and NCR are sent letters of
request. None of the hospitals responded to the mail. Researches
were subsequently elicited from the four training institutions
offering endocrine fellowship in the country --- the Philippine
General Hospital (PGH), St. Luke’s Medical Center (SLMC),
University of Santo Tomas (UST), and the Makati Medical Center
(MMC). There were 17 related research papers from the Section of
Endocrinology, Diabetes, and Metabolism of PGH.

Medical Organizations

The Philippine College of Physicians (PCP), Philippine

Medical Association (PMA), Philippine Society of Endocrinology
and Metabolism (PSEM), Philippine Association for the Study of
Overweight and Obesity (PASOO), Philippine Lipid and
Atherosclerosis Society (PLAS), Philippine Heart Association
(PHA), Philippine Association of Family Physicians (PAFP), and
the Philippine College of Surgeons (PCS) were given letters of
invitation to submit related research outputs of their members.
The curriculum vitae of the organizations’ Board of Directors,
officers, and members were likewise reviewed for any relevant
research output. In the Research Registry of the PSEM, which
contained researches from 1960 to the current time, 23 articles
were retrieved through file review and correspondence with
authors. Twentytwo articles were retrieved from PASOO while 1
article was collected from PFAP. The rest of the organizations
did not submit any related research.
Libraries

The National Library of the Philippines (NLP), the Food

and Nutrition Research Institute of the Department of Science
and Technology (FNRI-DOST), the Health Research and Development
Information Network (HERDIN) of PCHRD, Philippine Pediatric
Society Library, the University of the Philippines Manila
Library, and the University of the Philippines College of
Medicine FB Herrera Library were visited and searched for
relevant articles. Libraries of schools under APMC and CHED
private universities are sent emails and called by telephone. In
addition, the Colleges and Universities Online Public Access
Catalogs (OPAC) were accessed through the internet.

Personal correspondence with leading Philippine researchers both

local and abroad

Known leaders in obesity research on Filipino adults and

children were emailed and called. These included Maria Rosario
Araneta, MD, PhD, Rodolfo Florentino, MD, PhD, and Sioksoan
Chan-Cua, MD. As agreed upon by the Technical Working Committee,
the papers were classified into two major groups – adult obesity
and pediatric obesity. Papers on adult obesity were further
distributed into 5 categories --- 1) Epidemiology and Risk
Factors, 2) Sociocultural Dimension, 3) Screening and Diagnosis,
4) Therapeutics and Prevention, and 5) Complications. Papers
with data encompassing more than one group or category were
shared among the respective working groups. Prevalence and
associations were summarized and compared with foreign
literature. Whenever possible, meta-analysis was done.
Data Gathering Procedure

The researcher sought the approval from the Dean to conduct

the study. After the approval, the researcher gathered documents

from the different health station for the patient with obesity.

Data analysis

A new study indicates there may be yet another reason to reduce

childhood obesity — it may help prevent allergies. The study
published in the May issue of the Journal of Allergy and
Clinical Immunology showed that obese children and adolescents
are at increased risk of having some kind of allergy, especially
to a food. The study was funded by the National Institute of
Environmental Health Sciences (NIEHS) and the National Institute
of Allergy and Infectious Diseases (NIAID), both parts of the
National Institutes of Health.

"We found a positive association between obesity and allergies,"

said Darryl Zeldin, M.D., acting clinical director at NIEHS and
senior author on the paper. The researchers analyzed data on
children and young adults ages 2 to19 from a new national
dataset designed to obtain information about allergies and
asthma. "While the results from this study are interesting, they
do not prove that obesity causes allergies. More research is
needed to further investigate this potential link," Zeldin said.

The study is the first to be published using new data from the
National Health and Nutrition Examination Survey (NHANES).
NHANES is a large nationally representative survey conducted by
the National Center for Health Statistics, a part of the Centers
for Disease Control and Prevention. NHANES is designed to assess
the health and nutritional status of adults and children in the
United States. An allergy/asthma component was supported by
NIEHS and added to the 2005–2006 NHANES study, making it the
largest nationally representative dataset of allergy and asthma
information ever assembled in the United States.

"We have all the pieces of the puzzle in this dataset," said
Zeldin. "The allergy and asthma component of NHANES provides
allergen exposure information, allergic sensitization
information, as well as disease outcome information. There is a
wealth of knowledge we will be able to gain by analyzing these
data that will be useful to allergy and asthma sufferers."

In this study, the researchers analyzed data from 4,111 children

and young adults aged 2-19 years of age. They looked at total
and allergen-specific immunoglobulin E (IgE) or antibody levels
to a large panel of indoor, outdoor and food allergens, body
weight, and responses to a questionnaire about diagnoses of hay
fever, eczema, and allergies. Obesity was defined as being in
the 95th percentile of the body mass index for the child’s age.
The researchers found the IgE levels were higher among children
who were obese or overweight. Obese children were about 26
percent more likely to have allergies than children of normal
weight.

"The signal for allergies seemed to be coming mostly from food

allergies. The rate of having a food allergy was 59 percent
higher for obese children," said NIEHS researcher Stephanie
London, M.D., a co-author on the study.

"As childhood obesity rates rise, NIEHS will continue to work to

determine how environmental factors affect this epidemic," said
Linda Birnbaum, Ph.D., NIEHS director. "Seeing a possible link
between obesity and allergies provides additional motivation for
undertaking the challenge of reducing childhood obesity."

"Given that the prevalence of both obesity and allergic disease

has increased among children over the last several decades, it
is important to understand and, if possible, prevent these
epidemics," said Cynthia M. Visness, Ph.D., lead author on the
paper and a scientist at Rho Federal Systems Division, Inc. in
Chapel Hill, N.C.

NIAID conducts and supports research — at NIH, throughout the

United States, and worldwide — to study the causes of infectious
and immune-mediated diseases, and to develop better means of
preventing, diagnosing and treating these illnesses. News
releases, fact sheets and other NIAID-related materials are
available on the NIAID Web site at http://www.niaid.nih.gov.

The NIEHS supports research to understand the effects of the

environment on human health and is part of NIH. For more
information on environmental health topics, visit our website
at http://www.niehs.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation's

medical research agency, includes 27 Institutes and Centers and
is a component of the U.S. Department of Health and Human
Services. NIH is the primary federal agency conducting and
supporting basic, clinical, and translational medical research,
and is investigating the causes, treatments, and cures for both
common and rare diseases.
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