NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Sample Answer for NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children Included After Question

Discussion: Assessment Tools and Diagnostic Tests in Adults and Children: When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results. 

Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture-among other factors-are also relevant. That said, gathering and communicating this information can be a delicate process. 

In this Discussion, you will consider the validity and reliability of different assessment tools and diagnostic tests. You will explore issues such as sensitivity, specificity, and positive and negative predictive values. You will also consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight. 

NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 
NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children

To prepare : 

Review this week’s learning resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. We will also review examples of pediatric patients and their families as it relates to BMI. 

This week you will be assigned one of the following DB by your instructor. 

Select one of the following assessment tools or diagnostic tests to explore for the purposes of this Discussion: 

Mammogram 

Prostate-specific antigen (PSA) test 

Body-mass index (BMI) using waist circumference for adults 

Select one of the examples on which to focus for this Discussion. What health issues and risks may be relevant to the child you selected? 

Overweight 5-year-old boy with overweight parents 

5-year-old girl of normal weight with obese parents 

Severely underweight 12-year-old girl with underweight parents 

Search the Walden Library and credible sources for resources explaining the tool or test you selected. What is its purpose, how is it conducted, and what information does it gather? 

What does the literature discuss regarding the validity, reliability, and are there any issues with sensitivity, specificity, predictive values, ethical dilemmas, and controversies related to the test or tool? 

Based on the risks you identified, consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion. 

Consider how you could encourage parents or caregivers to be proactive toward the child’s health. 

By Day 3

Post a description of how the assessment tool or diagnostic test you selected is used in health care. Based on your research, evaluate the test or the tool’s validity and reliability, and explain any issues with sensitivity, reliability, and predictive values. Include references in appropriate APA formatting. 

OR 

Post an explanation of the health issues and risks that are relevant to the child you selected. Describe additional information you would need in order to further assess his or her weight-related health. Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information. Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! 

Read a selection of your colleagues’ responses. 

By Day 6

Respond to at least two of your colleagues who selected a different tool test, or child health example than you, using one or more of the following approaches: 

Critique your colleague’s evaluation of the validity and reliability of the tool or test selected. 

Suggest alternative or additional tools or tests that should be considered when gathering information about specific conditions or symptoms. 

Based on the risks you identified, consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion. 

Consider how you could encourage parents or caregivers to be proactive toward the child’s health. 

Suggest additional health risks or issues that could be relevant to the child. 

Critique your colleagues’ questions, and suggest how the parents or caregivers might interpret these questions. Provide alternate or additional questions. 

Suggest an additional strategy for gathering patient information or promoting proactivity.  

Health History Assessment Video 

A comprehensive health history is essential to providing quality care for patients across the lifespan, as it helps to properly identify health risks, diagnose patients, and develop individualized treatment plans. To effectively collect these heath histories, you must not only have strong communication skills, but also the ability to quickly establish trust and confidence with your patients. For this Assignment, you begin building your communication and assessment skills as you collect a health history from a volunteer “patient.” 

To prepare: 

  • Arrange an appropriate time and setting with your volunteer “patient” to collect a health history.Note: Your volunteer’s Video Release Form must be submitted prior to collecting the health history. Refer to the Week 1 Looking Ahead for release form details. 
  • Download and review the History Subjective Data Checklist provided in this week’s Learning Resources. 
  • Ensure that you have appropriate lighting to record yourself collecting the patient’s health history. 

To complete: 

  • Record yourself collecting the patient’s health history, covering all of the areas listed in the checklist. 

By Day 7 of Week 4 

Your Assignment is due. 

NURS 6512 Week 3: Assessment Tools, Diagnostics, Growth, Measurement, and Nutrition in Adults and Children 

Many experts predict that genetic testing for disease susceptibility is well on its way to becoming a routine part of clinical care. Yet many of the genetic tests currently being developed are, in the words of the World Health Organization (WHO), of “questionable prognostic value.” 

– Leslie Pray, PhD 

  Obesity remains one of the most common chronic diseases in the United States. As a leading cause of United States mortality, morbidity, disability, healthcare utilization and healthcare costs, the high prevalence of obesity continues to strain the United States healthcare system (Obesity Society, 2016).  More than one-third (36.5%) of U.S. adults have obesity (CDC, 2016). The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight (CDC, 2016). 

According to the Centers for Disease Control and Prevention (CDC), the rate of childhood obesity has tripled in the past 30 years, with an estimated 12.5 million children considered obese (CDC, 2012). When seeking insights about a patient’s overall health and nutritional state, body measurements can provide a valuable perspective. This is particularly important with pediatric patients. Measurements such as height and weight can provide clues to potential health problems and help predict how children will respond to illness. Nurses need to be proficient at using assessment tools such as the Body Mass Index (BMI) and growth charts in order to assess nutrition-related health risks and pediatric development while being sensitive to other factors that may affect these measures. Body Mass Index is also used as a predictor for measurement of adult weight and health. 

Assessments are constantly being conducted on patients, but they may not provide useful information. In order to ensure that health assessments provide relevant data, nurses should familiarize themselves with test-specific factors that may affect the validity, reliability, and value of these tools. 

This week, you will explore various assessment tools and diagnostic tests that are used to gather information about patients’ conditions. You will examine the validity and reliability of these tests and tools. You will also examine assessment techniques, health risks and concerns, and recommendations for care related to patient growth, weight, and nutrition. 

Learning Objectives 

Students will: 

  • Evaluate validity and reliability of assessment tools and diagnostic tests. 
  • Analyze diversity considerations in health assessments. 
  • Apply concepts, theories, and principles related to examination techniques, functional assessments, and cultural and diversity awareness in health assessment. 
  • Assess weight-related health risks for pediatric patients. 
  • Design effective strategies for communicating with parents or caregivers about children’s weight-related health. 
  • Apply concepts, theories, and principles relating to health assessment techniques and considerations related to growth, measurement, and nutrition. 
  • Apply assessment skills to collect patient health histories* 

*The Assignment related to this Learning Objective is introduced this week and submitted in Week 4. 

Photo Credit: Image Source/DigitalVision/Getty Images 

 

Learning Resources 

Required Readings 

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

  •  
  • Chapter 3, “Examination Techniques and Equipment” (pp. 30-49). This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process. 
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  • Chapter 6, “Growth and Measurement” (pp. 79-94). In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth amongst the organ systems. 
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  • Chapter 7, “Nutrition” (pp. 95-113). This chapter focuses on how nutrition affects growth, development, and health maintenance. The authors also provide guidelines for assessing nutrient intake. 
  • Review of Chapter 26, “Recording Information” (pp. 616-631). This chapter provides rationale and methods for maintaining clear and accurate records. The text also explores the legal aspects of patient records. 

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby. 

  • Chapter 1, “Clinical Reasoning, Differential Diagnosis, Evidence-Based Practice, and Symptom Analysis”. This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment. 

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. 

  • Chapter 2, “The Comprehensive History and Physical Exam” (pp. 23-32) 
  • Appendices B-C (pp. 373-376) 
  • Chapter 6, “Adult Preventative Care Visits” (pp. 125-139) 
  • Chapter 5, “Pediatric Preventative Care Visits” (pp. 93-108) 

Laine, C. (2012). High-value testing begins with a few simple questions. Annals of Internal Medicine, 156(2), 162–163. Retrieved from the Walden Library databases. This article supplies a list of questions physicians should ask themselves before ordering tests. The authors provide general guidelines for maximizing the value received from testing. 

Qaseem, A., Alguire, P., Dallas, P., Feinberg, L. E., Fitzgerald, F. T., Horwitch, C., & … Weinberger, S. (2012). Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine, 156(2), 147–150. 

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011).History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. (PDF), This History Subjective Data Checklist was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/ 

Gibbs, H., & Chapman-Novakofski, K. (2012). Exploring nutrition literacy: Attention to assessment and the skills clients need. Health, 4(3), 120–124. Retrieved from the Walden Library databases. This study explores nutrition literacy. The authors examine the level of attention paid to health literacy among nutrition professionals, and the skills and knowledge needed to understand nutrition education. 

Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R. (2014). Weight status misperception as related to selected health risk behaviors among middle school students. Journal of School Health, 84(2), 116–123. doi:10.1111/josh.12128, 

Centers for Disease Control and Prevention. (2012). Childhood overweight and obesity. Retrieved from http://www.cdc.gov/obesity/childhood/. This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity. 

Optional Resources 

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical. 

  • Chapter 3, “The Physical Screening Examination” 
  • Chapter 17, “Principles of Diagnostic Testing” 
  • Chapter 18, “Common Laboratory Tests” 
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INITIAL POST

  • Mammography is a screening tool used in detecting breast cancer.  It is an x-ray of the breast, which helps identify tumors or microcalcifications that can possibly indicate that breast cancer is present (National Cancer Institute, 2016).  Early screening may lead to detection of lesions on mammography that would not otherwise be detected or pathologic during a woman’s lifetime.  Mammography is the most common screening tool used.  Decisions regarding mammography screening require thoughtful review of the balance of risks and benefits (ACOG, 2017).  Evidence has shown that mammography performed on women 50-69 years of age decreases mortality of breast cancer.  However, it also increases overdiagnosis; identifying cancers that pose an insignificant threat.  Over-testing and increased anxiety can also can result from false-positive exams.  In women receiving annual mammography screenings for 10 years, 50% of them will experience a false positive result.  Additionally, 7-17% of these women will undergo further testing and receive a biopsy (National Cancer Institute, 2018).  The differences in balancing benefits versus harms is what has led to the differences among major guidelines about the starting age, stopping age, and frequency of mammograms (ACOG, 2017).In women ages 40-50, mammography screening has been controversial due to its lower sensitivity and specificity. In 2016 The U.S. Preventive Services Task Force changed its recommendations to individual decision making, explaining that it should be an individual decision whether to begin regular, biennial mammography screening prior to 50 years of age.  The decision should be individualized, and the woman’s health, and beliefs and values regarding specific benefits and harms should be taken into consideration.  The American College of Physicians agrees with these recommendations (Bickley & Szilagyi, 2017).  According to Susan G. Komen (2018), mammography sensitivity is approximately 87%.  Mammography can miss approximately 13% of all breast cancers.  This can be related to factors such as dense breast tissue, lower-quality imaging, inexperienced radiologist, or women on hormone therapy (Susan G. Komen, 2018). 

References 

  • Walden University 
  • Assessment Tools and Diagnostic Tests in Adults and Children 
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  • For this week discussion, I chose to talk about prostate-specific antigen (PSA) test. PSA testing tool used to identify the presences of cancer cells. This tool helps in early detection of cancer. Along with a full body assessment and past family and medical history helps in the direction of treatment. 
  • Screening for elevated levels of prostate-specific antigen (PSA) in the blood has the ability to detect prostate cancer relatively early in its natural history, but it is not clear to what extent such screening can reduce mortality from this disease. While some screening tests that are capable of identifying early cancers elsewhere in the body i.e. mammography have led to a decreased death rate. 
  • One method to determine the efficacy of a cancer screening test in lowering mortality is to randomize a large number of individuals either to receive or not receive the test. Both groups are then monitored for their subsequent rate of death from cancer toward which the screening is directed. This approach has the potential to give the clearest demonstration of efficacy, but it is quite expensive and may take a very long time to produce results. Furthermore, the potential of this method may not be realized in a study if the study participants do not adhere to the assigned screening (or control) regimen.  
  • A second method, less expensive and less time-consuming, is a case-control study. This approach seeks to determine if screening histories of persons who have died from particular cancer (cases) differ from those of a random sample of the population in which the cancer deaths occurred (controls). If screening has indeed led to a reduction in mortality, a smaller proportion of persons who have died from cancer than controls will have been screened during the period of time the tumor (or an antecedent lesion) was detectable but causing no symptoms. The research setting was Kaiser Permanente Northwest (KPNW), a non-profit group model health maintenance organization (HMO) serving over 440,000 members in the Pacific Northwest. The demographic characteristics of the KPNW population are similar to those of the community it serves [2]. The study research center is located within the HMO but conducts independent, public domain, non-proprietary research.  
  • We assumed that for a successful case-control study of PSA screening efficacy using medical records, at least 95 percent of PSA tests classified as screening would need to be correctly classified. We calculated that, if we observed at least 95 percent agreement with patient self-report on the reason for the test in a population of 100 men with PSA tests classified as screening according to the medical record, we would have at least 80 percent statistical power to address the research question.  
  • Investigators at Kaiser Permanente have used this approach successfully to determine the ability of screening sigmoidoscopy to lead to a decreased mortality rate from sigmoid or rectal cancer and we wished to evaluate the feasibility of conducting a similar case-control study of PSA screening in relation to prostate cancer mortality (Weinmann, Weiss, Richert-Boe, & Glass, 2004). 
  • Standard Randomized Controlled Trial Number 20141297). Protect is the largest primary care-based randomized trial of PSA testing and treatment in the world, with men aged 50–69 years at general practices in nine UK countries invited for PSA testing. In the study, men who refused PSA testing, or who refused a biopsy having been found to have a high PSA level. 
  • Reliability of prostate-specific antigen (PSA) testing is poor. 1 Necropsy studies have for a long time shown that the prostate of men over 50 harbors cancer in about 30% of cases, but only 8-10% develop clinical cancer during their lifetime. That histological evidence of cancer is found when six or more biopsy samples are taken from the prostate is therefore not surprising. The aim of screening with prostate-specific antigen is to reduce mortality and save lives, not to detect histological, non-aggressive cancer, which is to be avoided. Using a cut-off point of 4 ng/ml already allows for great diagnostic anticipation and considerable overdiagnosis. Waiting for the results of ongoing screening randomized studies would be a more reliable option (Ciatto, 2003). 
  • In conclusion, the reliability of PSA testing is very questionable. There is research that feels PSA testing does more harm than good. The research shows the validity of PSA testing. PSA testing is a preventative form of testing that identifies elevated levels in PSA levels which point towards possible cancer but unable to identify the type or location of cancer. A positive PSA test would lead to further medical testing. Research suggests that men perform testicular exams and have PSA testing perform starting as early as the ’40s or if an individual notice changes in function i.e. bleeding, difficulty in urination urgency/hesitation, or increase weight loss.  

Reference: 

  • Weinmann, Sheila; Weiss, Noel S; Richert-Boe, Kathryn; Glass, Andrew G. Validity of Outpatient Medical Records in Identifying Prostate-Specific Antigen (PSA) Tests Administer for Screening Purposes Health Services & Outcomes Research Methodology; DordrechtVol. 5, Iss. 2, (Jun 2004): 95-101. DOI:10.1007/s10742-005-4302-9 
  • Ciatto, Stefano. (2003). Reliability of PSA testing remains unclear: British Medical Journal; London Vol. 327, Iss. 7414, Sep 25, 2003: 750. Doi:10.1136/bmj.327.7417.750 
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A Sample Answer For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Obesity is major healthcare in this country and this due to various risk factors such as ethnicity, environmental, cultural, behavioral and genetical factors amongst others. In case one a five-year overweight male with overweight parents was presented. According to (Fuemmeler, Lovelady, Zucker, & Østbye, (2013 one of the risk factor for childhood obesity is having parents who are obese. Children with 2 obese parents are 10 to 12 times more likely to be obese (Fuemmeler, et al, 2013). Weight gain in early childhood (3 to 5 years of age) is also significantly greater among children with overweight or obese parents or among those born of overweight or obese mothers.children of heavier parents have been found to exhibit lower levels of physical activity and have a greater preference for high-fat foods and a lower preference for healthier foods (Fuemmeler, et al, 2013).

This might be attributed to either genetical or environmental factors. Children with obesity are at risk for health issues such as asthma, sleep disturbance, cardiac issues, high blood pressure, and metabolic syndrome that include, abnormal lipids (University of California San Fransico, Benioff Children Hospital, 2018). Many of these risk factors will continue into adulthood. Type two diabetes as becoming increasingly prevalent among overweight children and adolescents. A study by the Centers for Disease Control and Prevention (CDC) estimated that one in three American children born in 2000 will develop diabetes in their lifetime (USCF, 2018). Overweight children and adolescents are more likely to become overweight or obese adults. 

 

Additional Factors 

 Some additional factors that might be needed to assess his health are Socio-economic factors along with gestational age, birth weight, and length of breastfeeding,  are other factors related to early childhood weight gain (Fuemmeler, et al, 2013). Some questions that might be asked by the clinician taking into consideration the sensitivity of the parents are; 

  1. Does your son enjoy eating fruits and vegetables?  
  1. Does your child enjoy playing with friends?  
  1. Was your child breastfed as a baby?  
  1. How much water does your child drink per day?  
  1. What was your baby’s birth weight?  

 

Strategies 

 The main two factors that the student would explore to get the parents involved with controlling the weight of the child is to encourage everyone in the family to develop better eating habits. This will be done be encourage the entire to the family to sometime prepare healthy meals together that consist of more fruits and vegetables.  According to the Center for Disease Control (2018), one part of balancing calories is to eat foods that provide adequate nutrition and an appropriate number of calories. Parents can help children learn to be aware of what they eat by developing healthy eating habits, looking for ways to make favorite dishes healthier, and reducing calorie-rich temptations. The (CDC, 2018) further stated that these are some of the steps that parents can take to encourage balancing weight in children. These steps are; provide plenty of vegetables, fruits, and whole-grain products, include low-fat or non-fat milk or dairy products, choose lean meats, poultry, fish, lentils, and beans for protein, serve reasonably-sized portions, encourage your family to drink lots of water, limit sugar-sweetened beverages and limit consumption of sugar and saturated fat. The second step that the student would encourage is the inclusion of physical activities such as throwing a ball outside for 30 minutes, walking, bicycle riding amongst others. The students would discuss with the parents what the benefits are exercise are; such a decreasing the child’s risk of being bullied in school, decrease risk for asthma, diabetes, hypertension and cardiac disease. 

 According to the CDC (2018) children with obesity can be bullied and teased more than their normal-weight peers. They are also more likely to suffer from social isolation, depression, and lower self-esteem. The effects of this can last into adulthood. Plus, there are other health risk factors such as asthma, hypertension and cardiac conditions that can be developed from obesity, therefore it is important that there is early intervention by clinicians to prevent these issues. 

 

References 

 Center for Disease Control (2018). Tips for parents – ideas to help children maintain a healthy 

 weight. Retrieved from https://www.cdc.gov/healthyweight/children/index.html 

 Fuemmeler, B. F., Lovelady, C. A., Zucker, N. L., & Østbye, T. (2013). Parental obesity 

 moderates the relationship between childhood appetitive traits and weight. Obesity (Silver Spring, Md.), 21(4), 815-23. doi: 10.1002/oby.20144 

 University of California San Francisco, Benioff Children Hospital (2018). Health Risks for 

 overweight children. Retrieved from https://www.ucsfbenioffchildrens.org/education/health_risks_for_overweight_children/ 

A Sample Answer 2 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

The prevalence of obesity among youth in the United States was 17.0% in 2011-2014. Overall, the prevalence of obesity among preschool-aged children (2-5 years) (8.9%) was lower than school-aged children (6-11) at 17.5% (Ogden, Carroll, Fryar, & Flegal, 2015). The child I will discuss is an overweight 5-year-old boy with overweight parents. Overweight in a child is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex (Centers for Disease Control and Prevention [CDC], 2015a). Childhood obesity is a complex health issue and the main causes are similar to those in adults, including behavioral and genetic factors. 

Health Issues and Risks 

Being overweight increases a child’s risk for a number of diseases and conditions; which are asthma, type 2 Diabetes, heart disease, hypertension, liver problems, and trouble sleeping (University of California San Francisco [UCSF], 2015). Between 25 and 40 percent of children overweight will have metabolic syndrome. Metabolic syndrome includes abnormal lipids, high blood pressure, insulin resistance, and obesity (UCSF, 2015). It is also known that children who are overweight often become overweight or obese as an adult. 

Additional Information Needed 

First, I would want to obtain the child’s height and weight, and calculate his BMI. BMI is the most common method used to assess nutritional status and total body fat. Faguy (2016) claims that when both parents are obese, the chances of their children being obese increases. When determining the cause of the child being overweight, I would ask the parents the following questions: 1) what does your child eat in a typical day? 2) What factors do you believe affect your child’s weight? 3) Are there any hereditary diseases that can prevent your child from losing weight, 4) Does your child, or family, eat while watching TV, texting, or using a computer? 5) How much activity does your child get each day? 

 References 

Centers for Disease Control and Prevention. (2015a). Defining childhood obesity. Retrieved from Walden Library Database 

Faguy, K. (2016, January). Obesity in children and adolescents: Health effects and imaging implications. Radiologic Technology, 87(3), 279-298. Retrieved from https://www.ncbi.nlm.nih.gov 

Ogden, C. L., Carroll, M., Fryar, C., & Flegal, K. M. (2015). Prevalence of obesity among adults and youth: United States, 2011-2014.  Retrieved from Walden University Database 

University of California San Francisco. (2015). Health risks of overweight children. Retrieved from https://www.ucsfbenioffchildrens.org/education/health_risks_for_overweight_children 

A Sample Answer 3 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

An overweight 5-year-old boy with overweight parents 

Obesity is diagnosed when an individual’s body mass index is equal to or greater than 95 percent (CDC, 2018). Childhood obesity is recognized as a health problem in America that has significantly impacted our society. Children living in low-income areas are at a higher risk of being obese (CDC, 2018). A lack of access to fresh fruit and vegetables contributing to the incidence of nearly 19 % of children ages 2-19 has a BMI at or above the 95th percentile (CDC, 2018). Not seeing changes is a concern, the amount of time and money invested in the issue of childhood obesity has not affected the ongoing issue. 

Since parents make the food choices general information on improving his nutrition and encouraging him to be more physically active would be the most important (Dains, 2016). A plan of care must be implemented with realistic weight loss goals; additionally, a consult for and dietician would be beneficial to help parents identify how to change and what areas of changes should be made (Dains, 2016). With the number of obese children rising, parents, schools, and communities must support the effort to help young people eat healthier (FDA, 2018).  Here in Tennessee, the plan has been started to establish healthy nutrition standards in public and community institutions as well as food pantries (getfitTN, n.d.). 

Assessment 

The child’s assessment is essential, evaluation of his health history, diagnostic history being aware of complications that may contraindicate his treatment plan (Dains, 2016). Evaluating the child eating habits is also essential information needed for the basis of the assessment because the child might be eating foods that are high with calories (Dains, 2016). The eating habit will be helpful in developing an effective treatment program in order to manage his health.  

 

Specific questions 

1.    What is his normal activity level? 

2.    What is a typical meal for your family? 

3.    How often does your family eat fruit and vegetables? 

4.    How is his appetite? 

5.    Does he participate in any sports or activities outside of school? 

Health Issues and Risks 

A sedentary lifestyle and poor eating habits lead to obesity since a child’s body is not fully developed obesity can have long-term effects. Studies show that obese children are at a higher risk health issue such as low energy musculoskeletal injuries, colon cancer and respiratory complications (Dains, 2016). They are at a higher risk for coronary artery disease (CAD) and gallstones due to an excess amount of fat and cholesterol in the circulatory system; CAD is associated with stroke and fatty liver disease (CDC, 2018). Type 2 diabetes poses a significant risk to overweight children too due to elevated glucose in the bloodstream (CDC, 2018). 

 

References 

CDC. (2018). Retrieved from Center for disease Control and Prevention: http://www.cdc.gov 

Dains, J. E. (2016). Advanced Health Assessment and Clinical Daignosis in Primary Care (5 ed.). St. Louis, MO: Elsevier . Retrieved 2016 

FDA. (2018). Retrieved from Food and Drug Administration: https://www.fda.gov/forconsumers/consumerupdates/ucm244206.htm 

getfitTN. (n.d.). Retrieved from www.getfittn.gov: https://www.getfit.tn.gov/obesity.aspx 

A Sample Answer 4 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

     Main Post.  Obesity in America has been a battle for many of all ages. In 2010 the Centers for Disease Control and Prevention (CDC) reported that more than 78 million adults and approximately 12.5 million children and adolescents were obese (Zamosky, 2013). Obesity can account for contributing to many chronic health issues, such as type two diabetes, hypertension, sleep apnea, and joint pain. Obesity is a public health issue. Research scholars, Karnani, McFerran, and Mukhopadhyay, labeled obesity as a market failure (Hemphill, 2018).  Karnani and colleagues believed that obesity is bigger than government intervention, that it requires collaboration from all entities like corporate social, industry self‐regulation, social activism, and the government to combat obesity in America (Hemphill, 2018). 

     Body mass index or BMI is an assessment tool that uses an individual’s body weight and height to measure excess body fat. BMI is considered the measurement of body fat; however, it measures excess weight rather than excess fat (Centers for Disease Control and Prevention, n.d.). BMI is not a direct measurement of fat, but studies have been proven that BMI correlates with more direct measures of body fat obtained from skinfold and it is more accurate than underwater weighing, and dual-energy x-ray absorptiometry (Centers for Disease Control and Prevention, 2017).   

     Using BMI as a tool to assess fat is simple, inexpensive, and non-invasive as compared to other assessment tools to measure fat (Centers for Disease Control and Prevention, n.d.). BMI is used for assessing fat as it relates to an individual’s height and weight and it can also help predict future health challenges. High BMI equals future morbidity and death (Centers for Disease Control and Prevention, n.d.).  BMI as an assessment tool that is widely used and the data that is collected is used by healthcare professionals to compare data in population subgroups, regions, and time (Centers for Disease Control and Prevention, n.d.). 

     In adults, BMI is calculated the same for both men and women, even athletes. This puts a limitation on BMI assessment. First athletes, may have a higher BMI due to increased muscularity rather than increased body fatness (Centers for Disease Control and Prevention, 2017). According to BMI calculations, a BMI of 25.0 – 29.9 is considered overweight and a BMI 30 and above is considered obese (Centers for Disease Control and Prevention, 2017). An athlete may have a high BMI due to muscularity and not fat.  Secondly, BMI cannot distinguish between muscles, bone, and fat (Centers for Disease Control and Prevention, n.d.). It just measures the thickness of skinfolds. Thirdly it is standard for both men and women. There is no individuality. Age, sex, ethnicity, and muscle mass are factors that can impact a BMI result. For instance, women generally have more body fat than men with the same BMI. 

     BMI may be simple and inexpensive, but it is not a true indicator of fat. It is helpful for assessing weight status and predicting potential other health challenges that are associated with obesity. BMI does not account for weight distribution in men and women, and it does not take account of muscularity. Instead of being an assessment tool, it should be used for screening obesity, which can assist healthcare providers and patients to implement a preventive plan of care in hopes of preventing obesity, which can lead to a lifetime of health issues. 

References 

Centers for Disease Control and Prevention. (2017, August). What is BMI? Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. 

Centers for Disease Control and Prevention. (n.d.). Body Mass Index: Considerations for Practitioners. Retrieved from Department of Health and Human Services: https://www.cdc.gov/obesity/downloads/bmiforpactitioners.pdf. 

Hemphill, T. A. (2018, November 6). Obesity in America: A Market Failure? Business and Society Review, 123(4), 619-630. doi:10.1111/basr.12157. 

Zamosky, L. (2013, February 25). The obesity epidemic. While America swallows $147 billion in obesity-related healthcare costs, physicians called on to confront the crisis. Medical Economics, 90(4), 14-17. Retrieved from https://eds-b-ebscohost-com.ezp.waldenulibrary.org. 

A Sample Answer 5 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Prostate-Specific Antigen (PSA) Test 

Prostate cancer is a commonly diagnosed cancer in men and screening for prostate cancer is typically done with a blood test called prostate-specific antigen (PSA) test (Zakaria et al., 2018). The PSA test detects levels of the prostate-specific antigen in the blood, that is a glycoprotein that is made by the epithelial cells of the prostate (Hoffman, Elmore, O’Leary, & Melin, 2018). In men with prostate cancer, there is more PSA that is produced causing an increased PSA level in the blood (Hoffman et al., 2018). Some factors can falsely elevate a PSA level such as bicycle riding or ejaculation within the last 48 hours, bacterial prostatitis, prostate biopsy and transurethral resection of the prostate (TURP) within the past six weeks, acute urinary retention, and urethral instrumentation (Hoffman et al., 2018).  

Since the introduction of the PSA blood test to screen for prostate cancer, there has been a significant decrease in the mortality rates with prostate cancer and an increase in the rate of detection (Zakaria et al., 2018). But there has been some controversy over the risk versus benefit in the use of the PSA screening test (Zakaria et al., 2018). The PSA test has a positive predictive value of 30% or 1 in 3 men with an elevated PSA level above 4.0 will have a positive biopsy for prostate cancer (Hoffman et al., 2018). The predictive value increases to 42-64% when the PSA level is above 10.0 (Hoffman et al., 2018). According to Hoffman et al. (2018), the sensitivity of the PSA test using 4.0 as a cutoff value is 21% for detecting prostate cancer and 51% for high-grade cancer, and the specificity was 91% using the same cutoff value. Men who have an elevated PSA level typically undergo a prostate biopsy to diagnose prostate cancer which then puts the patient at risk for bleeding, pain, and infection (Fenton et al., 2018). Per Fenton et al. (2018) men with an elevated PSA are typically referred for a prostate biopsy and will not have prostate cancer.

There is also a risk of overtreating prostate cancer with PSA screening through a radical prostatectomy that can cause urinary incontinence and erectile dysfunction when conservative management may have been more appropriate (Fenton et al., 2018). Men who are also treated with radiation therapy for prostate cancer can have erectile dysfunction and adverse bowel symptoms (Fenton et al., 2018). Studies have shown that there is a high 10-year survival rate for men who have an early detection of prostate cancer and undergo active surveillance (Fenton et al., 2018). The U.S. Preventive Services Task Force (2018) only recommends PSA screening for men between the ages of 55-69 after a discussion regarding the risks and benefits is made between the provider and the patient. USPSTF (2018) also warns of the potential harms of screening with only a slight advantage in reducing the risk of death from prostate cancer. USPSTF (2018) recommends against screening patients over the age of 70. Carter (2018) recommends providers only offer the screening to men who have evidence of benefiting from a PSA screening test.  

References 

Carter, B. (2018). Prostate-specific antigen (PSA) screening for prostate cancer revisiting the evidence. JAMA: Journal of the American Medical Association, 319(18), 1866-1868. 

Fenton, J. J., Weyrich, M. S., Durbin, S., Liu, Y., Bang, H., & Melnikow, J. (2018). Prostates specific antigen-based screening for prostate cancer: Evidence report and systematic review for the US Preventive Services Task Force. JAMA: Journal of the American Medical Association, 319(18), 1914–1931.  

Hoffman, R.M., Elmore, J.G., O’Leary, M.P., & Melin, J.A. (2018). Screening for prostate cancer. UpToDate. Retrieved from https://www.uptodate.com/contents/screening-for-prostate-cancer 

U.S. Preventive Services Task Force. (2018). Prostate cancer: screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening1 

Zakaria, A.S., Dragomir, A., Brimo, F., Kassouf, W., Tanguay, S., & Aprikian, A. (2018). Changes in the outcome of prostate biopsies after preventative task force recommendation against prostate-specific antigen screening. BMC Urology, 18(1), 1-9.  

A Sample Answer 6 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

The body mass index (BMI) assessment tool is used to assess an individual’s risk for a disease which occurs with being overweight and obesity. The BMI is a calculated ratio between weight and height. Those who are considered overweight, have too much body weight for their height and those categorized as obese, have a large amount of body fat in relation to their height. An increased risk of heart disease, hypertension, type 2 diabetes, cholelithiasis, osteoarthritis, obstructive sleep apnea and colon, breast, endometrial, and gallbladder cancers are associated with higher body mass index values (National Heart, Lung, and Blood Institute, n.d.). The BMI is calculated by dividing a person’s weight in kilograms (kg) by the square of their height in meters (m2) (Centers for Disease Control and Prevention, 2018). 

The BMI is a reliable and valid tool which indicates body fat by measuring excess weight; studies have shown that BMI correlates more with measuring body fat. BMI solely relies on height and weight and is simple, inexpensive, and noninvasive, making it simple to be measured and calculated routinely. The literature indicates that BMI levels correlate with future health risks, morbidity, and death, making it an appropriate screening tool for obesity and associated health risks. Some issues and limitations of BMI are that it does not take into consideration an individuals age, sex, ethnicity, and muscle mass which can influence the relationship between BMI and body fat. BMI does not distinguish between excess fat, muscle, or bone mass distribution in the body (Centers for Disease Control and Prevention, 2013). 

Additional information required to fully understand the 5-year-old child of healthy weight with obese parent’s health should include the child’s dietary habits, food preferences, and allergies, physical activity levels, interests and family history regarding chronic conditions. Parents should be asked for a typical list of foods consumed and physical activities performed during a routine day to determine the family’s eating habits, preferences, and levels of physical activity. Health benefits should be discussed with the parents regarding the advantages of a healthy diet and daily exercise which would reduce the incidences of chronic conditions associated with obesity. Behaviors influence eating habits, and parents should maintain a positive attitude toward healthy eating habits and lifestyles. Environments also affect eating habits and physical activity levels, “It can be difficult for children and parents to make healthy food choices and get enough physical activity when they are exposed to environments that do not support healthy habits” (Centers for Disease Control and Prevention, 2016, para. 6). Childhood obesity results in the development of chronic conditions such as hypertension, hyperlipidemia, impaired glucose tolerance, insulin resistance, asthma, sleep apnea, musculoskeletal discomforts, and liver and gallbladder disease. Children may also develop psychological issues such as anxiety, depression, low self-esteem, poor quality of life and be subjected to social problems such as bullying (Centers for Disease Control and Prevention, 2016). 

 

References 

Centers for Disease Control and Prevention. (2013). Body mass index: considerations for practitioners. Centers for Disease Control and Prevention: Atlanta, GA, USA. 

Centers for Disease Control and Prevention. (2016). Childhood Obesity Causes & Consequences. Retrieved from https://www.cdc.gov/obesity/childhood/causes.html 

Centers for Disease Control and Prevention. (2018). Body Mass Index (BMI). Retrieved from https://www.cdc.gov/healthyweight/assessing/bmi/ 

National Heart, Lung, and Blood Institute. (n.d.). BMI Tools. Retrieved from https://www.nhlbi.nih.gov/health/educational/lose_wt/bmitools.htm 

A Sample Answer 7 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Test Selected: Prostate-specific antigen (PSA) test 

Prostate cancer (PCA) is the most common type of cancer a man could get in his lifetime and is also responsible for the second highest number of cancer deaths in men in the United States today (Obort, Ajadi & Akinloye, 2013).  In fact, it is said that an American man has a 16% chance of contracting the cancer but the estimated risks of dying of  the cancer are 2.9% due to  advancements in medical testing (Hoffman, 2018).  To put into real numbers, it is believed that in 2018 that there will be 1650,000 brand new diagnosed cases in the United States with an estimated 29,000 deaths (Hoffman, 2018). 

How do we assess or screen half of the adult population for this type of cancer? The answer is the Prostate-specific antigen (PSA) test. The test evaluates the amount of the PSA, which is a type of glycoprotein that originates from the epithelial calls of the prostate gland. (Hoffman, 2018). All men are noted to have some amount of this glycoprotein in their bodies at any given time. When the PSA protein is produced in excess, it leaks through the tissues and presents itself in the bloodstream. It is measured in nanograms per milliliters (ng/mL) that can be obtained by a simple  lab draw from its male patients (National Cancer Institute, 2017).   

Many researchers believe that the 1986 implementation of the Prostate-specific antigen (PSA) test is responsible for the lowering of the death rate of prostate cancer deaths. This is because it can provide evidence of cancerous cell growth in men who have not become symptomatic which can help in early diagnosis, treatment and prevent the spread of the cancer to nearby tissues and organs (Hoffman, 2018).  Unfortunately, this test is a stepping stone to the true diagnosis. When the test comes back higher than desired normal parameters, a biopsy is warranted.  

Issues Related to Validity, Sensitivity and Reliability  

According to the National Cancer Institute (2017), the PSA was used as a tumor marker meaning that when PSA values that came back over 4.0 ng/mL, they were indicative to a man having prostate cancer. However this theory has been debunked over the years due to research and evidence showing that benign conditions such as digital rectal exams, urinary tract infections, prostatitis, biopsies and surgeries can also make the PSA value increase. There is also evidence that shows that medications can make the PSA values go up as well such as Proscar (finasteride) which is a medication that helps treat an enlarged prostate (NIH, 2017). It is also said that sexual activity that ends in ejaculation 48-72 hours prior to a PSA test can produce falsely elevated results. Patients should be communicated of this and refrain from having sexual relations at least 3 days prior to having the test completed.  (Demir, Tarhan, Orçun, Aslan & Türk, 2014).  

Studies have been conducted to see if  PSA shows reliability for aged related changes in the prostate. This was completed by researchers adjusting the high normal value of 4.0 ng/mL. It was reported values that came back less than 4.0 ng/mL could help detect even earlier cases of PCA. This has been found effective in the older population but not in the younger population which researchers have shown warranted concerns of unnecessary biopsies  (Obert et al., 2018).  

Predictive Values 

Predictive values are those that can be either positive or negative. Positive represent the likelihood of patients that will be definitively diagnosed and the negative is those that will have not have the disease. As mentioned earlier, an elevated PSA is not a clear indicator of a malignant mass. This directly affects positive and negative predictive values.  In fact, it was noted by Obort, Ajadi & Akinloye (2013) that although the PSA is prostate specific, it is not cancer specific. It is also noted that that the PSA test does not provide a way to distinguish slow growing tumors that may be harmless from their opposites which can lead to many men placing themselves in danger of receiving unwarranted diagnostics and treatments (Ball, Dains,  Flynn, Solomon & Stewart, 2015). Over time, these variables have resulted in many false positive results with patients and their suffering emotionally worrying that they may have cancer. Not to mention countless numbers of unnecessary biopsies and millions of health care related costs which represent the negative predictive values.  

Although the PSA test may lack exclusive reliability, the “PSA test has revolutionized diagnosis and management of PCa and their comorbidities have decreased more than 75% since its introduction” (Obort et al., 2013).  It still regarded at this time as the best tool for prostate related tumor detection and it is still widely covered by insurance. I am sure in years to come a new tumor marker will be introduced or better clarification of the PSA test will come to fruition. 

 

References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Demir, K., Tarhan, F., Orçun, A., Aslan, H., & Türk, A. (2014). Effects of ejaculation on serum prostate-specific antigen levels. Turkish journal of urology, 40(1), 40-5. 

Hoffman, A. (2018). Screening for Prostate Cancer. Retrieved from https://www.uptodate.com/contents/screening-for-prostate-cancer 

National Cancer Institute. (2017). Prostate-Specific Antigen (PSA) Test. Retrieved from https://www.cancer.gov/types/prostate/psa-fact-sheet#q1 

Obort, A. S., Ajadi, M. B., & Akinloye, O. (2013). Prostate-specific antigen: any successor in sight?. Reviews in urology, 15(3), 97-107. 

A Sample Answer 8 For the Assignment: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

Title: NURS 6512 Week 3 Discussion: Assessment Tools and Diagnostic Tests in Adults and Children 

     For week 3 discussion post, I will be discussing an overweight 5 year old boy with overweight parents. The assessment process of weight related health problems will include questioning the child about his health habits and self perception. Health issues and risks that are relevant to an overweight child and parents will be discussed. Strategies will be developed to encourage the parents to be proactive about their child’s health and weight. 

The Assessment Process 

      The parents brought their child in for a yearly well child visit with this nurse practitioner. The health history of the child was gained from the parents who report the mother’s side of the family has a history of obesity and cardiovascular problems and the father’s side of the family is positive for colon cancer and mental health problems such as depression, anxiety and suicide. The child’s weight and height were measured after taking off his jacket and shoes. Body mass index (BMI) is the most common method used to assess nutritional status and total body fat (Ball, Dains, Flynn, Solomon, and Stewart, 2015). The BMI is now standardized for use in children and adolescents, and is calculated the same way as for adults (Ball et al, 2015). In children the amount of body fat changes with age, and the body fat values differ between males and females. BMI is interpreted using age and gender specific percentiles and once the BMI is calculated, the value was plotted on the growth chart for gender.

BMI for age greater than the 85th percentile puts a child at risk of being overweight and BMI greater than the 95th percentile indicate an overweight child. The nutritional assessment is gained from the history and physical examination and includes recent growth, weight loss or gain, chronic illnesses affecting nutritional status or intake, nutritional intake, clinical signs of nutrient or energy deficiency, and lab values. In addition to BMI, waist circumference is measured to calculate waist-height ratio and waist-hip circumference ratio (Ball et al, 2015). The BMI is charted on a growth chart and compared to standard values. The nurse practitioner must consider the child’s age and growth patterns. 

Health Issues and Risks 

     Overweight and obese children are at risk for a number of conditions, including: 

  • &νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ; High cholesterol
  • &νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ; High blood pressure
  • &νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ; Early heart disease
  • &νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ; Diabetes
  • &νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ; Bone problems
  • &νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ; Skin conditions such as heat rash, fungal infections and acne

Overweight children are at high risk of becoming overweight adolescents and adults, placing them at risk for developing chronic diseases such as heart disease and diabetes later in life (The Center for Disease Control, 2018). They are also more prone to develop stress, sadness, and low self esteem. The most common causes of children becoming overweight and obese are genetic factors, lack of physical activity, unhealthy eating patterns, or a combination of these factors. Weight problems run in families and children whose parents or brothers and sisters are overweight may be at an increased risk of becoming overweight themselves, but this can be linked to shared family behaviors such as eating and activity habits (Ali, 2018). 

Strategies for Better Health 

     A child’s total diet and activity level play an important role in determining a child’s weight. Questions for the child might include: How much time do you spend on your computer or watching TV? What are your favorite foods? And, what is your favorite physical activity? The parents were encouraged to gradually change their family’s physical activity and eating habits. They were also encouraged to involve the entire family, everyone is to be taught healthful habits so the overweight child does not feel singled out. Planning family activities that provide everyone with exercise, like walking, biking, or swimming is suggested. It is important for the family to help the child find physical activities that he enjoys and that aren’t embarrassing or too difficult. It is important to reduce the amount of time the family spends in sedentary activities such as watching TV or playing video games. It is important for the parents to not make physical activity and following a healthy diet a chore, but to make the most of the opportunities they have to be active and healthy. 

Conclusion 

     Being overweight can be very difficult for some children causing depression and anxiety. Parent play a major role in the habits their children develop. Parents who are overweight can benefit by gradually changing the family’s habits from watching TV and playing video games to shooting hoops, walking the dogs in the neighborhood or park, or playing frizbee or yard games.  

 

References 

Ali, R., (2018). Obesity in children. Preventing obesity in children. Retrieved from 

     https://www.webmd.com  

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., and Stewart, R. W. (2015). Seidel’s 

     Guide to physical examination (8th ed.). St Louis, MO: ELSEVIER | Lippincott    

The Centers for Disease Control (2018). Childhood obesity facts. The national institute 

     Of diabetes and digestive and kidney diseases  

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