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Childhood Obesity: A Transtheoretical Case Management Approach

Article  in  Journal of Pediatric Nursing · November 2008

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Childhood Obesity: A Transtheoretical Case
Management Approach

Heather N. Mason, BSN, RN

Valerie Crabtree, PhD
Paul Caudill, BS
Robert Topp, PhD, RN

Childhood obesity is an increasing health problem because of its strong associations with chronic health problems in children
and adults. Obesity during childhood commonly persists into adulthood and is resistant to interventions that involve only
recommendations to decrease caloric intake and to increase caloric expenditure through increased physical activity. The
challenge with this approach to childhood obesity is that it is not theoretically based, nor does it consider the child's or the
parent's perceptions of the health problem or their transition along the stages of behavioral change. Case management has been
proven to be successful in managing various chronic health problems in both adults and children. This article will introduce a
new intervention model based on the transtheoretical framework by utilizing case management in a primary care setting to treat
childhood obesity.
© 2008 Elsevier Inc. All rights reserved.

Key words: Overweight; Behavioral; Cognitive; Intervention

T HE PREVALENCE OF overweight children in

the United States continues to increase and
appears to be reaching epidemic rates (Frank,
Anderson, & Schmid, 2004). Children aged N 5
years are identified as obese if their body mass index
(BMI) is greater than the 95th percentile for age and
gender (Harvey, Holubkov, & Reis, 2004). More
than 11% of American children are obese, and an
additional 25% can be considered overweight
(Dehghan, Akhtar-Danesh, & Merchant, 2005). A
number of risk factors that predispose a child to
overweight, obesity, or both have been identified.
These factors include the characteristics of the child,
the characteristics of the parent, and the character-
istics of their environment (Goodman & Whitaker,
2002). The treatment of obesity needs to begin in the
early stages of the disorder (Jain et al., 2001) to limit
the physical and emotional (Flodmark, 2005)
comorbidities that are tied to this disorder. The
central components of common weight reduction
programs for children involve changes in diet and
increases in physical activity. Emerging literature
also indicates that effective childhood weight
reduction programs involve both the child and the
parent (St Jeor, Perumean-Chaney, Sigman-Grant,
Williams, & Foreyt, 2002).
The Transtheoretical Model (TTM) provides an
excellent framework within which to assess the
child's and the parent's awareness and acceptance
of the problem of obesity and their level of desire
to change their behavior to address the problem.
The TTM describes four stages of change through
which people progress in making health-related
changes. Based upon the parent's and the child's
stage of change, this model can be employed by
the practitioner to direct appropriate interventions.
The case management approach may be an
effective mechanism for introducing TTM-based
interventions designed to reduce childhood obe-
sity. The case management approach allows the
interventions to be individualized, taking the
From the School of Nursing, University of Louisville, Louisville,
KY; School of Medicine, University of Louisville, Louisville, KY.
Corresponding author: Heather N. Mason, BSN, RN, School of
Nursing, University of Louisville, 641 Burlwood Circle, Louis-
ville, KY 40047.
E-mail: hncart01@louisville.edu
0882-5963/$-see front matter
© 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2008.01.080

Journal of Pediatric Nursing, Vol 23, No 5 (October), 2008 337

338
child, the parent(s), and their environment into
consideration (Brown, McLaine, Dixon, & Simon,
2006). This article will describe the problem of
childhood obesity and will introduce how the
TTM can provide the basis for a potentially
effective case management intervention to reduce
childhood obesity.
THE PROBLEM OF CHILDHOOD OBESITY
Obesity is more prevalent than ever among
American children and adolescents (Harvey et al.,
2004). Few children have the knowledge neces-
sary to make healthy nutritional or physical activity
choices on their own; therefore, parents are key
mediators of obesity prevention among their
children. Parents play a large role in influencing
the diet and physical activity of their young children
by their own actions (Toschke, Beyerlein, & von
Kries, 2005). In fact, parental obesity has been
noted as one of the most predictive indicators of
childhood obesity (Magarey, Daniels, Boulton, &
Cockington, 2003; Whitaker, Wright, Pepe, Sei-
del, & Dietz, 1997). In contrast, daughters of
physically active parents (including mother and
father) were reported to have significantly higher
levels of daily physical activity (Davison, Cutting,
& Birch, 2003).
The development of obesity is associated with a
number of factors, including decreased physical
activity, decreased participation in organized
sports, increased television viewing, and decrease
in proper nutrition (Salbe et al., 2002). American
children spend more of their time playing video
games and watching television than performing
any activity other than sleep (Dennison, Erb, &
Jenkins, 2002). Television viewing is often thought
of as one of the most adjustable causes of obesity
in children (Matheson, Killen, Wang, Varady, &
Robinsson, 2004).
Another modifiable trend that plays a large role
in the American lifestyle is the increase in fast-
food consumption. Americans consumed 50% of
their meals away from home in 1994 and spent
close to 50% of their food budgets on fast-food
restaurants in 1998 (Thompson et al., 2004).
There is a positive association between the
amount of television viewed per day and meals
eaten at fast-food restaurants per week and the
BMI. In fact, children who view fast-food
advertisements on television are more apt to
request the product than those who do not watch
television for more than an hour at a time
MASON ET AL
(Matheson et al., 2004). In addition to excessive
intake of fast foods, there is also an increase in
fruit juice consumption in overweight children. In
support of this, Ludwig, Peterson, and Gortmaker
(2001) found that the ratio of becoming over-
weight increases by 60% for each serving of
sugar-sweetened drink consumed daily by chil-
dren (Ludwig et al., 2001).
HEALTH PROBLEMS RELATED TO
CHILDHOOD OBESITY
Childhood obesity is a strong risk factor for a
number of common health conditions in chil-
dren. Hyperlipidemia, hypertension, glucose
intolerance, insulin insensitivity, mental health
concerns (e.g., depression, low self-esteem, and
impaired health-related quality of life; Ravens-
Sieberer, Redegeld, & Bullinger, 2001), athero-
sclerosis, asthma (Patel, Welsh, & Foggs, 2004),
and orthopedic problems in children are all
linked to obesity (Krebs & Jacobson, 2003).
Obesity is one of the most common clinical
signs of type 2 diabetes (non insulin dependent)
(Ramchandani, 2004). A recent study consisting
of 167 obese children showed that 4% had been
diagnosed with type 2 diabetes, with 16%, 27%,
and 26% of the obese Caucasian, African-
American, and Hispanic adolescents being in
the prediabetic state (Vivian, 2006). These
health problems significantly contribute to the
development of common chronic diseases in
later life, including hypertension, type 2 dia-
betes, hyperinsulinemia, coronary heart disease,
stroke, osteoarthritis, cancer (such as endome-
trial, breast, prostate, and colon cancers), and
psychological disorders (such as depression,
eating disorders, distorted body image, and low
self-esteem) (Kaur, Hyder, & Poston, 2003;
Schwarzenberg, 2005). Several studies demon-
strated the persistence of childhood obesity into
adulthood (Krassas & Tzotzas, 2004; Taylor,
Grant, Goulding, & Williams 2005). After the
age of 3 years, the likelihood that obesity will
persist into adulthood increases with the age of
the child. A 6-year-old obese child has a 50%
risk of becoming an obese adult, whereas 70–
80% of obese adolescents remain obese into
adulthood. Thus, it is highly likely that obese
children will grow into obese adults (Guo, Wu,
Chumlea, & Roche, 2002). As obese children
continue to grow into obese adults, there is an
increase in obesity-related chronic problems in
CHILDHOOD OBESITY
adulthood, and the cycle of obesity across family
generations continues (Guo et al., 2002).
THE TREATMENT OF OBESITY AND THE
BARRIERS TO TREATMENT
Weight loss is a simple equation of decreased
caloric intake and increased caloric expenditure
through increased physical activity. Interventions
to decrease caloric intake and increase caloric
expenditure need to concentrate on modifying
eating and physical activity habits so that new
behaviors are formed, resulting in lasting changes
throughout one's life (O'Brien, Holubkov, &
Reis, 2004). The goal of modifying diets has
been to decrease and stabilize caloric and fat
intakes. This is based on the theory that children
who are obese consume too many calories relative
to their caloric expenditure. Although this dieting
method of linking the amount of calories
consumed to the amount of calories expended
works for adults, the approach to weight reduction
in children differs because the weight loss must
be slow due to the rate at which children grow. In
most cases, it is recommended that overweight
children maintain their current body weight or
reduce their weight slowly so that they can still
grow in height while experiencing a correspond-
ing decrease in BMI (kg/m2) (Fowler-Brown &
Kahwati, 2004).
Any dietary changes for children need to focus
on ensuring that they consume at least five
servings of fruits and vegetables daily, as well
as on meeting their calcium and iron needs
(Faulkner, 2002). One commonly studied diet is
the traffic-light diet based on the food pyramid.
This approach teaches children to “go” with foods
that are green (broccoli and asparagus), use
“caution” with yellow foods (corn and squash),
and “stop” with foods that are red (beef). Children
using this diet have been found to have a decreased
intake of “red foods,” a decrease in percent
overweight, and reduced palatability for foods
that are high in sugar (Moran, 1999). Interven-
tions that incorporate both diet changes and
increases in physical activity are more successful
than those that only used one component alone.
Among the treatment programs designed to
increase physical activity, the most successful in
doing so were the less structured programs that
allowed the child to choose one's physical activity
(Louthan et al., 2005; Trowbridge, Sofka, Holt, &
Barlow, 2002).
339
Family involvement is another key factor in the
successful reduction of the BMI in overweight
children and has been proven to be more successful
than interventions that target the child or the parent
alone. Parental involvement is necessary when
treating childhood obesity (Veugelers & Fitzgerald,
2005) because parents play a vital role in the
development of children's eating and physical
activity habits. Jiang, Xia, Greiner, and Lian
(2005) showed that, among a group of children
involved in a 2-year longitudinal study, a family-
based behavior program including their parent(s)
resulted in a decrease in the percentage of the
children who were overweight compared to the
children who received the interventions without
parental involvement (Jiang et al., 2005).
Parental perception of the child's obesity is also
an important factor in predicting a successful
weight loss intervention. Unfortunately, when
mothers of obese children were asked to define
obesity, they responded by saying that they did not
consider a child overweight if the child had a good
appetite (Faulkner, 2002). Some mothers defined a
healthy child as one who eats and were only
concerned about their child's eating habits when
they were not eating (Wolf et al., 2004).
In addition, many practitioners lack understand-
ing of children's obesity and strategies on how to
identify and treat this disorder. A survey of 940
providers, including pediatricians, nurse practi-
tioners, and registered dieticians, found that a wide
variety of interventions were administered to
parents of obese children but few children were
referred to organized programs or nutritionists
(Trowbridge et al., 2002). In addition to the lack
of clear guidelines, many practitioners failed to
schedule follow-up appointments, and patients often
failed to keep the appointments that were made.
After a review of the charts of 40 obese children for a
period of 1 year, 40% of the children were found to
have been referred to a nutritionist; however, only
5% attended the appointment. In addition, 87%
failed to arrange a follow-up appointment to
monitor the success of behavioral interventions
prescribed by their primary care provider (Louthan
et al., 2005). Physicians identified three reasons for
failing to treat childhood obesity: inadequate time to
address the problem in the office setting, lack of
necessary skills and tools, and inadequate reimbur-
sement for programs targeting obesity. A substantial
amount of effort is involved in achieving and
maintaining long-term weight loss in children
(Faulkner, 2002). Thus, there is a tremendous need
340
for effective interventions that address both the
parent and the child by focusing on movement
toward the maintenance of appropriate eating habits
and physical activity goals.
CASE MANAGEMENT
A case management approach to facilitating
health behavior change has been shown to be an
effective method in managing many chronic condi-
tions. Case management is a collaborative process
between the case manager, other interdisciplinary
health care team members (including primary care
physicians, nurse practitioners, dieticians, exercise
physiologists, psychologists, social workers, and so
on), and the client that involves assessment,
planning, implementation, coordination, monitor-
ing, and evaluation of services to meet the client's
health needs (Prochaska & DiClemente, 1992). This
allows the care providers to individualize their care
based on the needs of the child. Case management is
an effective multifaceted service that can result in
significant and quantifiable cost savings in the
management of chronic illnesses (Velicer, Pro-
chaska, Fava, Norman, & Redding, 1998). Beck et
al. (2004) and Guevara, Wold, Grum, and Clark
(2003) reported the effectiveness of a case manage-
ment approach in successfully treating children with
type 1 diabetes and asthma, respectively. In patients
hospitalized for chronic heart disease, utilization of
a case manager has been demonstrated to reduce the
length of hospital stay and to decrease subsequent
readmissions (Kim & Soeken, 2005).
The success of the case management approach is
due to the assessment of the child's and the parent's
perception of the health condition and benefits, and
the barriers to the treatment of the condition, while
utilizing the resources available to manage the
condition. The case manager then collaborates with
the all parties involved to develop individualized
interventions consistent with the parent's and the
child's needs and resources. Case management
subscribes to the principle that managing a chronic
health condition must be individualized to the
patient's current needs and resources. The case
management approach is useful and appropriate, in
conjunction with the TTM, in the treatment of
obese children due to individualization of their care.
THE T TM
The TTM, developed by Prochaska and DiCle-
mente (1992), consists of four behavioral stages of
MASON ET AL
change: precontemplation, contemplation, action,
and maintenance. The stages of change represent the
progress that individuals undergo in an attempt to
modify their behavior to change their health. Proper
assessment of the stage of change in both the child
and the parent is essential in providing effective
individualized case management interventions to
treat childhood obesity. The first stage, precontem-
plation, describes individuals who do not recognize
that a health problem exists or do not believe that
they need to change their health behaviors.
Individuals are usually in this stage when they are
uninformed or misinformed about their health
conditions, or because they have experienced
numerous unsuccessful attempts to alter their
behaviors and they have become discouraged
about their ability to change (Logue et al., 2005).
Precontemplation is followed by contemplation, in
which the client intends to take action in the near
future but has not yet initiated a change in one's
behavior. Individuals in this stage are aware of the
advantages of changing their health-related beha-
vior but have not yet initiated the change. The third
stage of change is the action stage, which is
characterized by the individual making modifica-
tions to one's behavior based on one's knowledge
about the behavior. The final stage of change,
maintenance, focuses on the prevention of relapsing
into the old behavior. Individuals in this stage
should have established new behavior patterns,
making them less likely to relapse and more
confident in maintaining the new behavior.
The TTM has been used by a number of
investigators to design successful interventions to
change health behaviors, including smoking, emo-
tional distress, alcohol abuse, weight loss, and
mammography screening (Prochaska & DiCle-
mente, 1992). The success of these previous
interventions has been dependent upon two
assumptions of the model. First, movement
between stages in the model is linear, although
movement back and forth between stages is
common before a permanent transition to the next
stage, and, ultimately, movement to the mainte-
nance stage is realized. The second assumption is
that individuals' present stage of change has
implications for the types of intervention that will
assist them in progressing through the model
toward the maintenance stage.
Cognitive approaches are most effective when
individuals have not yet changed their behavior
(precontemplation and contemplation stages),
whereas behavioral strategies are more appropriate
CHILDHOOD OBESITY
when individuals have initiated or are attempting to
maintain new behaviors (action or maintenance
stages) (Prochaska, 1991; Prochaska, DiClemente,
& Norcross, 1992). Cognitive approaches may
include: (a) consciousness raising (increasing
knowledge of obesity and the health effects of
diet, physical activity, and environment); (b) social
liberation (modifying diet, physical activity, and
environmental factors, resulting in social benefits);
(c) self-evaluation (examining the effects of current
diet, physical activity, and environmental factors on
obesity and health); (d) environmental reevaluation
(exploring the relationships between diet, physical
activity, and environmental factors, and the physi-
cal, social, and emotional environments). Beha-
vioral approaches may include (a) self-liberation
(telling oneself that it is possible to change diet,
physical activity, and environmental factors); (b)
counterconditioning (finding a substitute behavior
for the usual diet, physical activity, and environ-
mental factors); (c) stimulus control (removing
items or stimuli that remind one of the usual diet,
physical activity, and environmental factors); (d)
reinforcement (receiving a reward for avoiding the
usual diet, physical activity, and environmental
factors, and engaging in new behaviors) (Pro-
chaska, 1991; Prochaska & DiClemente, 1992).
CASE MANAGEMENT FOR THE
TREATMENT OF CHILDHOOD OBESITY
The proposed intervention involves a case
management approach administered through the
TTM framework, with the goal of reducing BMI
Figure 1. TTM for treatment of childhood obesity.
341
among obese children by modifying their eating
habits and by increasing their physical activity. The
case manager can provide the interventions during
an office/clinic visit, with follow-up interactions in
person, over the telephone, or through e-mail as
intervention methodology. The case manager can
individualize the interventions based upon the
overweight/obese child's and the parent's stage of
change and available resources in the environment.
The stage of change in the child and the parent who
present for weight management of the child can be
easily assessed using the two versions of the
University of Rhode Island Change Assessment
developed by Sefton-Silver (1996).
Once the stage of change of the parent and the
child regarding weight management of the child is
known, the case manager can provide interventions
for the parent and the child to assist them with
transition between these stages. When designing
individually based interventions for the parent and
the child, the case manager must be prepared with
different components of the plan. Specific compo-
nents may target the parent's stage of change,
whereas the others may be directed at the child's
stage of change. A parent may be in the action stage
and ready for behavior modification, whereas the
child may only be in the contemplation stage and
not ready for behavior changes. The activities
maybe designed to help the child reduce one's BMI
and to help the parent understand and participate in
the BMI reduction. To maximize the effectiveness
of these components, the plan should involve both
the parent and the child. The goal of the interven-
tions is to help support the child and the parent to
342 MASON ET AL

Table 1. Cognitive Intervention Strategies priate for the precontemplation and contemplation
Cognitive Activity Process of Change stages are discussions between the parent and the
1. Complete a family tree of obesity and Consciousness child about the pros and cons of being overweight,
obesity-related diseases raising and listing of the positive and negative aspects of
2. Watch “Supersize Me” video Consciousness the child's eating habits to give them a better
raising
understanding of the disease. Another activity that
3. Complete a log of duration of time Self-evaluation
spent engaged in sedentary activities
is designed to promote consciousness rising is
4. List the pros and cons of overweight Self-evaluation taking the child and the parents to their favorite fast-
and inactivity food restaurant, identifying the fat content and the
5. Identify activities that prohibit, or that Environmental calories from fat in some of the foods usually
are performed instead of, physical reevaluation ordered, and offering healthier substitutes. Having
activity
6. Identify cues to not engaging in physical Environmental
the child and the parent separately identify and
activity reevaluation evaluate how they feel about their bodies, health,
7. Identify recommendations for physical Self-evaluation and food choices would help them understand what
activity and compare to the current the other thinks about one's own weight. This could
level of physical activity
open doors in communication between the parent
8. Identify choices that can increase the Environmental
level of physical activity reevaluation
and the child, hopefully making them realize some
9. Identify the actual and desired BMI Self-evaluation of the problems related to overweight. The parent
10. Identify the impact of obesity on Self-liberation who is not overweight may want to increase one's
social functioning knowledge of what it feels to be overweight by
11. Identify approaches to increasing Environmental wearing a weighted body suit while performing a
physical activity reevaluation
12. Identify perceptions of weight and Self-evaluation
normal household duty such as vacuuming or doing
physical activity
13. Understand classification of activities Consciousness
Table 2. Behavioral Intervention Strategies
into various levels of physical activity raising
14. Identify one friend who maintains a Environmental Behavioral Activity Process of Change

“healthy” or “active” level of physical activity reevaluation 1. Interact with others who engage Stimulus control
in “healthy” eating and activity
patterns
2. Read all food labels before eating Counterconditioning
the final stage of maintaining the desired behaviors foods
to reduce the child's BMI (Figure 1). 3. (Grocery-store) scavenger hunt for Counterconditioning
The general design of the activities is to modify favorite and healthy foods
4. Eat foods according to the food Stimulus control
eating habits and to increase physical activity,
guide pyramid
whereas the precise activities will depend on the 5. Eat “healthy foods” in a fast-food Counterconditioning
child's and the parent's individual perceptions and restaurant
surrounding environment. For individuals in the 6. Document eating of new healthy Counterconditioning
precontemplation and contemplation stages, cog- foods
7. Plan for dealing with situations Self-liberation
nitive strategies should be utilized to increase
where “unhealthy” foods are likely to
knowledge, change attitudes, reduce barriers, and be eaten or when physical activity
enhance the benefits of desired behaviors in decreases (vacation)
relation to obesity and its impact on the child 8. Plan a meal according to the food Counterconditioning
and the family (Figure 1). For individuals in the guide pyramid
9. Set goals for diet, weight, and Counterconditioning
maintenance and action stages, behavioral strate-
physical activity
gies should be used to change dietary and physical 10. Document progress toward goals Stimulus control
activities and to provide reinforcement for achiev- (public display)
ing new behaviors (Figure 1). Periodically, the stage 11. Provide rewards for achieving Reinforcement
of change of the parent and the child regarding milestones toward goals
12. Reduce barriers to physical activity Counterconditioning
weight management of the child should be reas-
13. Compare current and previous Self-liberation
sessed to determine appropriate cognitive (Table 1) diets and physical activity behaviors
or behavioral (Table 2) interventions. 14. List realized benefits of increased Self-liberation
There are many different activities that may be physical activity and diet change
chosen by the case manager to assist their clients 15. Make a number of plans on how to Self-liberation
engage in fewer sedentary activities
throughout the stages. Examples that are appro-
CHILDHOOD OBESITY
the dishes. Another activity that raises awareness in
the family is examining the ways food is prepared in
the home, paying attention to added fat, calories,
and sodium. Other activities include identifying
healthy foods and keeping track of time spent on
passive activities such as watching television,
working on a computer, or playing video games.
This will help the parent and the child become aware
of healthy foods that they can eat and physical
activities that they can engage in. These activities
attempt to increase the child's and the parent's
awareness, knowledge, attitude, and belief about the
problem of obesity, transitioning them to the next
stage of change involving changes in their behavior.
Once the child or the parent moves into the action
stage of the model, the case manager will need to
start incorporating behavioral strategies and activ-
ities into the intervention. The parent and the child
should work together to change their dietary habits
and increase their physical activity. Some activities
include both the child and the parent trying new
foods, attempting to make healthy choices when
eating fast foods, engaging in fewer sedentary
activities, and increasing their physical activity. The
parent is responsible for the food that is kept in the
house and can assist the child by having healthy
food choices available and by decreasing the
amount of high-calorie and high-fat foods kept in
the home. The parent can also provide physical
activities for the child after school, encouraging the
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