School nurse pilot tackles childhood obesity

Child obesity is a major public health challenge for professionals. The National Child Measurement Programme (NCMP) measures the height and weight of around one million school children every year, providing a detailed picture of the prevalence of child obesity in England.

The latest figures for 2013/14 show that 19.1% of children in year 6 (aged 10-11) are obese and a further 14.4% are overweight. For children in reception (aged four to five years), the programme found that 9.5% are obese and an additional 13.1% are overweight. Latest data from the Health Survey for England, which looks at a wider age range, found 28% of children aged two to 15 years are classed as overweight or obese.

Nurse-led

In Surrey, about 18% of four to five year olds are overweight or obese, rising to more than 26% of 10-11 year olds. Across mid-Surrey, a school nurse-led pilot programme aims to tackle the issue by providing dedicated support to overweight and obese children aged five to 19 years.

The programme is the brainchild of Chris McDermott, specialist school nurse practitioner at CSH Surrey. Ms McDermott worked alongside Diane Scheppel, CSH Surrey’s paediatric community dietitian for mid-Surrey, to develop the programme.

‘We were sending out NCMP letters to parents advising them that their child was overweight or obese, yet we did not have anything to refer them on to,’ says Ms McDermott. ‘We have a good relationship with our commissioners and they threw down the challenge to come up with an appropriate care pathway for these children and families.

Referrals

‘Several parents were going to their GP wanting a referral or some sort of support to help their children get to a healthy weight. GPs were referring children and families to the dietetics department, but they were not able to take them on. This is a project that we hope is going to meet the needs of those families.’

The dietetics team were unable to offer any obesity-related service without additional funding and, as the only paediatric dietitian for mid-Surrey, Ms Scheppel was able to see just the most urgent cases.

‘When we rejected all but urgent referrals, we typically provided written information and signposted the referral to the child’s health visitor or school nurse,’ says Ms Scheppel.

Resources

‘This was frustrating for the school nurses because they did not think they had the resources to tackle this either. They were visually exposed to obesity on a daily basis, so they could see the extent of the problem right before their eyes. We did have some complaints from GPs and families who were frustrated by the lack of a funded service.’

The school nurse-led programme uses National Institute for Health and Care Excellence (NICE) guidance and is open to overweight and obese children and young people (aged five to 19 years) living in mid-Surrey across the areas of Epsom and Ewell, Mole Valley, Banstead, Tattenham and Elmbridge.

It is delivered as a three-month programme and aims to support children, young people and their families to make long-term changes to their diets and lifestyles. The title for the programme – Healthy Weight, Healthy Lives – was chosen because it is non-stigmatising.

Emphasis

As children are still developing, the programme’s emphasis is on encouraging them to reduce or maintain their current body mass index (BMI). For young people who are no longer growing taller, the advice will lean slightly more towards weight loss. However, the main aim is to support children and young people to develop healthier lifestyles.

Participants benefit from a seven-part programme of face to face and telephone school nurse support. This includes six contacts with children and their families over three months. They are seen face to face throughout this period, at home or at school, depending on the child’s preference.

Weekly contact occurs during sessions one to three, while sessions four and five move to fortnightly contact and contact six takes place one month later. The final school nurse contact is made three months later via telephone. During contacts six and seven, the nurse offers motivational support to help families continue their progress towards a long-term healthier lifestyle.

Topics covered over the sessions include motivation, food and diet, understanding food labels, physical activity and lifestyle tips including healthy snack ideas. Throughout the weeks, families are set small goals at each contact point. These are designed to help families make gradual positive changes and are set by the child or young person.

Desired outcomes

The programme is being piloted for six months between May 1 and October 31 and will support up to 50 children and young people over this period. The pilot programme has been commissioned by Surrey County Council. The outcomes that the council would like to see include:

• Increased activity for children, young people and families
• A move towards maintaining or reducing body mass index
• Healthier diet choices
• An increase in fruit and vegetable intake

The school nurses have pedometers and leisure centre passes to give away to encourage families to become more active. Healthy living apps are also available for children and young people.

The programme does not focus too much on weight. Children have their waist circumference measured and their BMI calculated at the second contact and at contact six. These data are used to measure the outcome of the project. Lifestyle changes are measured via self-evaluation.

‘Making health information relevant for people is important,’ says Ms Scheppel. ‘The programme covers basic healthcare messages, but tries to understand the behaviour of the child or family, and tailor the advice and education.

Eatwell plate

‘We have not invented any new material, we are using the Eatwell plate – recommended by the NHS Choices website funded by the Department of Health (DH) – and pictorial representations of gender and age-appropriate portion sizes. Participants are asked to complete food, activity and screen time diaries.

‘When school nurses look at labelling and making better food choices with families, they can take examples from the food diaries to suggest healthier options. A food diary not only looks at what is consumed, it identifies where meals have been skipped and outlines meal routines. If children are regularly skipping breakfast because they are rushing to get ready for school, goals can be devised to improve options for breakfast. The aim is to help children and their families to overcome challenges to enable long-term behaviour change.’

‘A lot of the enjoyment children will gain from the programme will depend on the relationship we build with them,’ says Sue Dawson, a staff nurse in the school nursing team at CSH Surrey. ‘It could be the activity side of things that appeals or it may be working alongside their parents to bring more activity into their everyday routine. Everyone enjoys success and, if children and young people are able to achieve the goals they have set, that will really have a positive impact on their emotional wellbeing.’

School nurses

The programme is being delivered by 13 school nurses. The team has received referrals from GPs and other school nurses. Families can also self-refer. ‘When referrals come in, we carefully allocate the children to a school nurse,’ says Ms McDermott. ‘Some of the school nurses will already be known to families and we will endeavour to allocate the family to their known school nurse so the existing relationship can continue.

‘It can be hard for a family to admit that their child is overweight. Often it is when NCMP results go out that they first begin to realise there is an issue. The school nurses will build a relationship with families and aid them to continue making healthy lifestyle choices.’

The school nurse team includes nurses that work term time only. However, Ms McDermott thinks it is a good time of year to carry out the school nurse-led pilot programme. ‘We have made costings to provide the hours and manpower required to do this work and there are additional hours available for school nurses who want to be part of this project,’ she says. ‘The number of families with which each school nurse will work will depend on their individual caseload and whether they want to do extra hours.’

Activities

The nurses will work with families to identify activities that they enjoy doing. They will also promote the use of the free pedometers, leisure centre passes and apps. Families will be signposted to other lifestyle support options, such as Change for Life clubs and cookery project, which take place at local primary schools.

Promotional posters and information have been distributed to GP practices (including referral forms), paediatricians and school nurses. Teachers and head teachers have been made aware of the programme, although they cannot refer directly.

The programme has been promoted via the local press. Outside the region, it has been picked up by NHS England and the DH. The team has also received comments via social media from other school nurses and trusts praising the approach. ‘There is an interest professionally to see how the pilot works out,’ adds Ms McDermott.

Julie Penfold is a freelance health writer

More information

For further information about the Healthy Weight, Healthy Lives programme, contact Chris McDermott, email chrismcdermott@nhs.net