Hispanic Adolescents Overweight

Obesity among the people in the United States has been one of the leading indicators of health issues. The rate of obese children and adolescents has risen by significant amounts in the past twenty years. According to the 2000-2010 statistics, the rates have risen by 16.9% in ten years (Smith & Smith, 2016). There are measures used to determine if a person is obese. One of the methods is by the use of the Body Mass Index. It is a test that compares the body fat of an individual to their height. The United States government offers such services in hospitals and clinics all over the state. It also offers advice on how the citizens may avoid the condition. Based on the surveys done by the nation, there are 13.7 million children in the US with obesity and overweight issues. Of the total population of such cases, 39% is comprised of children between 6 and 19 years of age (Hales, Carroll & Frayar, 2017). It is alarming to consider that such a large number of people have a condition that can be prevented if the right measures are taken. The purpose of this literature review will be aimed at finding some of the remedies for the condition of Hispanic Adolescent Overweight and Obesity. It will also highlight the current measures in place by the government to reduce the healthcare issue. The method used in this research will be the review of relevant articles related with A Prevention Program for Hispanic Adolescent Overweight and Obesity. I will share my results throughout a conference presentation in the educational organization where the study was assigned: Ana G Mendez University. Nurses from different healthcare facilities with experience and qualifications in the field will be invited to confirm the results obtained.

Obesity is a condition where one has excessive weight in their body, causing some health risks that will be discussed in other segments of the paper. To calculate whether or not one is obese, the doctors or physicians use the body mass index of a person. The formula to calculate the body mass index of a person is dividing the weight of a person in kilograms by the square of their height in meters. The answer the one gets from the calculation is then analyzed using a table. If a person has a BMI below 18.5, they are underweight. The acceptable range for BMI is 18.5 and 24.9. One may also have a range between 25 and 29.9, which indicates that one is overweight. If one crosses over to the 30-39.9 range, then one can be said to be obese. Apart from weight and height, several factors are considered in determining a person's correct BMI. They are the ratio of waist to hips, waist to height ratio, and the overall distribution of fats in the body. The waist to height ratio is obtained by dividing the circumference of the waist by the height. The measure is not commonly used due to some errors, especially in children under the age of 6 years.

Several risks are associated with obesity. Some of them include arthritis, heart disease. The condition can, however, be prevented. One of the best ways to avoid it is by reducing the number of calories that one consumes. Some foods increase the risk of gaining weight. One may reduce the chances of obesity by avoiding fried foods, fatty and processed meat, dairy products, sugary foods, snacks, and junk foods. One is also advised to live a sedentary lifestyle. This is the type of lifestyle where one is supposed to have a lot of physical activity. Some of the activities that they can get involved in include walking to and from the office, constant jogs, and runs to ensure that one keeps fats and oils in their bodies under control. Physical activity also enables one to maintain constant levels of insulin because their body constantly gets rid of sugars.

Another prevention measure for the condition is ensuring that one as enough sleep. Studies have shown that the individuals who does not sleep for about 5 hours for adults and 8 hours for children are more likely to gain weight compared to those who sleep enough. The person is subjected to hormonal changes as the body tries to replace the amounts of energy that a person spends in such times when they are not sleeping. Such changes make the person have increased appetite and reduced digestion rates. The result is that their bodies begin to accumulate fats leading to obesity.

Medical drugs are also known to increase the chances of a person gaining weight. Some of the known drugs that may lead to such a condition include common antidepressants, hypoglycemic drugs, mood stabilizers such as gabapentin, anticonvulsants, and antipsychotics. In that case, the people need to ensure that whenever they are on such drugs, they find alternative measures avoiding weight gain. They should also avoid them, especially after their condition is over. Some like hypoglycemic drugs are likely to be taken terminally. In that case, the individual may ask the physician of the expected results and the means that they can avoid the condition.

Obesity Among adolescents has been rising at an alarming rate over the past ten years. It is important to identify the causes of the trend and find some measures that can be implemented to reduce the condition in Hispanic adolescents.

· To find out the reason for the increased cases of Hispanic Adolescent Obesity

· To learn more about the effects of obesity on the lives of the Hispanic adolescents who have been diagnosed with the condition

· To establish the possible remedies for obesity to those who have the condition

· To establish the best means to reduce the rising number of adolescents suffering from the condition

What are the rates of Obesity in the United States?

How does the medical sector in the state handle the rising cases of obesity?

What is the number of children and adolescents who have obesity?

What are the predisposing factors that make Hispanic Adolescents more predisposed to obesity?

What are some of the measures that are taken to avoid obesity by parents, teachers, and healthcare officials?

What are some of the individual measures that Hispanic adolescents take to avoid obesity?

Dorothea E. Orem: Self Care Theory will be served as the base for this project. Her ideas of health promotion and maintenance provide a foundation for the nursing practice. She considers people should be independent and responsible for their personal and family care. Orem’s theory is break up in three parts: Theory of self-care, self-care deficit, and nursing system. Self-care promotes maintaining life, health, and well-being. Self-care deficit specifies when nursing is needed, and how the patient’s needs will be met by patient and nurse. The metaparadigm of the Orem’s Theory includes four components: environment, person, nursing, and health. Environment has physical, chemical and biological features. It includes the family, culture, and community. Person: Humans are defined as “men, women, children cared for either singly or as social units, “and are the “material object” of nurses and other who provide direct care. Nursing is an art where gives specialized assistance to person with self-care deficit which makes more than ordinary assistance necessary to meet needs for self-care. Health is” being structurally and functionally whole or sound.”

According to Chaplais and collaborators (2018), the rate of adolescents who suffer from obesity has been on the rise. Between the 1980s and 2010, the population of people who suffered from obesity and overweight ranged between 10% and 21%. In the last ten years, the rates have risen by 3%, which is alarming considering the short duration of time that the statistics have been taken. The issue has been noted to affect reproductive rates, especially in females, when they get to the reproductive age. Based on the current statistics, the American College of Obstetricians has offered some recommendations for the obesity problem.

As per Kain and collaborators (2017), have suggested that any doctor or physician pays close attention to the reason for the condition that a patient is going through. They should offer an incite to parents and Hispanic adolescents on the best means that they can use to keep their weight within the accepted know standards (Petrin et al., 2017). The medical officers should also diagnose correctly and describe the condition of a person. As stated in the introduction, one should the difference between being overweight and obese. In that case, the doctor should consider factors such as waist to hip ratio, hip to height ratio to come up with a proper conclusion on the condition of the patient (Shah et al., 2019). After diagnosing the issue, they should then offer proper advice and counseling based on the findings (Sainsburry et al., 2019). If an adolescent is found to be on the 24 BMI mark, the doctor may offer means that they can avoid surpassing the healthy limit. The same applies to the people who are below the 30 BMI index (Harley, 2017). This means that they should offer different advice that helps them cut their weight and avoid getting obese.

According Koyonagi and collaborators (2020), The physician should also offer some support to the patient. They should ask if the patient has been bullied in the institutions that they attend, reduced self-esteem, among other issues that a person may have due to Obesity In doing so, the doctor may boost the confidence of the patient and allow them to accept the situation that they are in. Some of the adolescents avoided physical activity and preferred to remain indoors due to bullying and body shaming that they face when they attend physical activity lessons (Chang et al., 2016). In such a case, the condition that they have is escalated further. To avoid such instances, the doctor may offer motivation or alternative methods that the obese person may use to keep their health in check.

As per Jayawardena and collaborators (2018), The doctors should also advise against some common medical and weight-loss drugs that are sold over the counter in many chemists. The drugs have been known to alter the hormonal composition of the patient. In some cases, the drugs interfere with the later life of the patient. Some of the female adolescents who use such portions have irregular menstrual cycles, issues in later pregnancy, problems conceiving, and giving birth, among other adverse effects (Andrews, 2016). To avoid such issues, doctors should advise obese patients to seek better means to control weight gain to avoid such negative effects.

According Committee of Adolescent Healthcare (2020), also offers several risks that are associated with obesity. The first sign is the increase in glucose intolerance levels. It is known that as the levels of weight and Obesity increase, there is a chance that they become intolerant to glucose. It is important for obesity to be discovered early and treated soonest possible to avoid cardiovascular diseases (Lavie et al., 2016). Apart from that, they are twice more likely to develop hypertension and dyslipidemia (Anari et al, 2017). Besides that, the gaining weight is that they have a chance to get type 2 diabetes (Stewart, 2020). A person who has minimal ability to digest the food that they take in is likely to have problems with the balance of sugars in the body. They are also likely to face issues with maintaining a proper schedule of feeding since their body has no means to cope with the sugars that are stored as fats (Boerlage, 2017). If the individual does not observe a strict pattern, they are more likely to become more obese and diabetic.

As per Moussa and collaborators (2016), Obesity also poses some gynecological health issues to adolescents. Some girls who were obese reported that they had heavy menstrual bleeding and amenorrhea (the absence of menstruation) (Weschenfelder, Bentley & Himmerich, 2018). They also showed some negative aspects, such as uterus bleeding due to the increased levels of estrogen and other hormone production (Mahdavi et al., 2016). The problem is also associated with increased insulin levels, especially when the patient is also exhibiting diabetes. In some cases, the adolescents were exposed to polycystic Ovarian Syndrome. Girls who are in puberty are also urged to test using special procedures for PCOS since some of the signs may be similar to those of development and adolescent symptoms (de Zegher et al, 2018). It is also notable that there are very many cases of teenage pregnancy in the United States. In that case, the chances of cesarean section for an obese adolescent are higher (Kansu-Celik et al., 2017). The health issues are associated with the hormonal imbalance in adolescents. Based on the literature review, it is essential for one to find measures that can be avoided. In that case, there are several means that will be used in the analysis of the topic. Data will be collected, as explained in the steps below.

Project Description

This project will be completed through a literature review. This will be carried out through Ana G. Mendez Virtual Library, CINAHL, PubMed, Google Scholar, Cochrane, and Medline. The research will be peer reviewed. A minimum of 30 articles no more than 5 years will be reviewed. I will use some keywords for my search like Hispanic Adolescent, Overweight, Obesity, and Prevention Program.

This study will be aimed at finding some of the remedies for the condition of Hispanic Adolescent Overweight and Obesity. It will also highlight the current measures in place by the government to reduce the healthcare issue.

All information collected in this review will be kept in a locked desk in the principal investigator's office for a period of 5 years. Only the PI and The Advisor will have access to the data. After this time (5 years), all the data will be eliminated with a paper shredder and discarded .

Project Evaluation Results

Once the study data is collected, these will be analyzed and included in the final report. The coding and editing of the data will be carried out. The objective of data analysis is to eradicate errors that may have occurred during the data collection. My research question is to identify the causes of Obesity and Overweight and find some measures that can be implemented to reduce the condition in Hispanic adolescents could be answered at the end of this study.

Summarize tables with all citation will be presented in appendix A&B; appendix A will be used for the summary of primary research evidence, and appendix B will be used for the summary of the systematic reviews.

Appendix A will include the citation, question or hypothesis, and theoretical foundation, research designated and sample size, key findings, recommendations or implications, and level of evidence, of each article. Appendix B will include citations, question, search strategy, inclusion/exclusion criteria, data, extraction and analysis, key finding, recommendation /implications and level of evidence of each article.

Most of the review report that obesity is the excessive weight that a person has compared to their height. They also knew the BMI Scale and the accepted and healthy standards as stipulated by the scale. Most of the research also claimed that the lack of exercise and eating junk foods were the main courses of obesity. Most of the studies indicate that the lack of sleep is one of the leading factors that lead to one getting obese. They observed that most of the teenagers are expected to go to school during the day. Instead of resting at night, they watch movies and keep going to parties. They also noted that a large number of teenagers in the United States ate a lot of junk food and rarely exercised.

The preventive measures that can be used to avoid the condition. Some of them are explained below. One of the best ways to avoid it is by reducing the number of calories that one consumes. Some foods increase the risk of gaining weight. One may reduce the chances of obesity by avoiding fried foods, fatty and processed meat, dairy products, sugary foods, snacks, and junk foods. One is also advised to live a sedentary lifestyle. This is the type of lifestyle where one is supposed to have a lot of physical activity. Some of the activities that they can get involved in include walking to and from the office, constant jogs, and runs to ensure that one keeps fats and oils in their bodies under control. Physical activity also enables one to maintain constant levels of insulin because their body constantly gets rid of sugars.

Another prevention measure for the condition is ensuring that one as enough sleep. Studies have shown that the individuals who do not sleep for about 5 hours for adults and 8 hours for children are more likely to gain weight compared to those who sleep enough. The person is subjected to hormonal changes as the body tries to replace the amounts of energy that a person spends in such times when they are not sleeping. Such changes make the person have increased appetite and reduced digestion rates. The result is that their bodies begin to accumulate fats leading to obesity.

People need to ensure that whenever they are on such drugs, they find alternative measures avoiding weight gain. They should also avoid them, especially after their condition is over. Some like hypoglycemic drugs are likely to be taken terminally.

They also advised parents of the children who showed signs of obesity in the best means that can be used in avoiding the escalation of the problem. They were against the use of medical drugs to reduce obesity, especially when they are bought over the counter. The health institutions also organized awareness campaigns that were aimed at sensitizing people on the condition.

The results obtained above are in line with the theoretical framework. It is clear that there is a high chance of Hispanic youths are at a higher risk of getting obesity. Several risks that are associated with obesity. The first sign is the increase in glucose intolerance levels. It is known that as the levels of weight and Obesity increase, there is a chance that they become intolerant to glucose. It is important for obesity to be discovered early and treated soonest possible to avoid cardiovascular diseases. Apart from that, they are twice more likely to develop hypertension and dyslipidemia. Besides that, gaining weight is that they have a chance to get type 2 diabetes. A person who has minimal ability to digest the food that they take in is likely to have problems with the balance of sugars in the body. They are also likely to face issues with maintaining a proper schedule of feeding since their body has no means to cope with the sugars that are stored as fats. If the individual does not observe a strict pattern, they are more likely to become more obese and diabetic.

Obesity also poses some gynecological health issues to adolescents. Some girls who were obese reported that they had heavy menstrual bleeding and amenorrhea (the absence of menstruation). They also showed some negative aspects, such as uterus bleeding due to the increased levels of estrogen and other hormone production. The problem is also associated with increased insulin levels, especially when the patient is also exhibiting diabetes. In some cases, the adolescents were exposed to polycystic Ovarian Syndrome. It is also notable that there are very many cases of teenage pregnancy in the United States. In that case, the chances of cesarean section for an obese adolescent are higher. The health issues are associated with the hormonal imbalance in adolescents.

Plans for Dissemination

To achieve the purpose of making our research known, different types of media will be used. In the same way interpersonal communication will be of vital importance to disseminate this project. Also, other forms of dissemination will be used as: a power point and poster will be presented at the Ana G Mendez University. The power point will have a duration of no more than 30 minutes and will be presented to the teacher and classmates. Nurses from different healthcare facilities with experience and qualifications in the field will be invited to confirm the results obtained.

While the poster, which will include a summary of this research, will be shown in the Ana G Mendez University room of the South Florida campus. In the library of this university we will leave a copy of this literature review to be used by those who are interested in the subject.

The study was faced with several limitations. The scope of the study was limited by the availability of literature review. The number of sources who were collect and analyze data was also a few. After collection, the data was to be analyzed, and a proper conclusion reached.

Another fallback was also time-consuming to read a lot of material that was written about the research topic. It was complex because one had to compare the results. In cases were the research articles differed, we had to look for alternative measures to confirm the data that had been collected.

Obesity is a condition where one has excessive weight in their body, causing some health risks that will be discussed in other segments of the paper. To calculate whether or not one is obese, the doctors or physicians use the body mass index of a person. If a person has a BMI below 18.5, they are underweight. The acceptable range for BMI is 18.5 and 24.9. One may also have a range between 25 and 29.9, which indicates that one is overweight. If one crosses over to the 30-39.9 range, then one can be said to be obese. Apart from weight and height, several factors are considered in determining a person's correct BMI. Several risks are associated with obesity. Some of them include arthritis, heart disease. Medical drugs are also known to increase the chances of a person gaining weight. Some of the known drugs that may lead to such a condition include common antidepressants, hypoglycemic drugs, mood stabilizers such as gabapentin, anticonvulsants, and antipsychotics

The objectives of the study were; To find out the reason for the increased cases of Hispanic Adolescent Obesity, To learn more about the effects of obesity on the lives of the Hispanic adolescents who have been diagnosed with the condition, To establish the possible remedies for obesity to those who have the condition, To establish the best means to reduce the rising number of adolescents suffering from the condition

According to the committee of Adolescent healthcare, the rate of adolescents who suffer from obesity has been on the rise. Between the 1980s and 2010, the population of people who suffered from obesity and overweight ranged between 10% and 21%. Based on the current statistics, the American College of Obstetricians has offered some recommendations for the obesity problem.

The drugs have been known to alter the hormonal composition of the patient. In some cases, the drugs interfere with the later life of the patient. Some of the female adolescents who use such portions have irregular menstrual cycles, issues in later pregnancy, problems conceiving and giving birth among other adverse effects. The committee of Adolescent health also offers several risks that are associated with obesity. The first sign is the increase in glucose intolerance levels. It is known that as the levels of weight and Obesity increase, there is a chance that they become intolerant to glucose.

A person who has minimal ability to digest the food that they take in is likely to have problems with the balance of sugars in the body. They are also likely to face issues with maintaining a proper schedule of feeding since their body has no means to cope with the sugars that are stored as fats. If the individual does not observe a strict pattern, they are more likely to become more obese and diabetic. Some girls who were obese reported that they had heavy menstrual bleeding and amenorrhea (the absence of menstruation). They also showed some negative aspects, such as uterus bleeding due to the increased levels of estrogen and other hormone production (Friedrich, 2017).

The quality of the search that was collected is very insignificant to the nursing sector. According to the American Nurses Association, the study in adolescent overweight are important role in the development of the medical sector. Obesity has been on the rise in the United States, leading to the essence of researching on the topic. The data collected was taken either from Ana G. Mendez Virtual Library, CINAHL, PubMed, Google Scholar, Cochrane, and Medline. They know how to diagnose, treat, and prevent the condition. They also have figures showing the number of patients who have the condition, which was important in comparing national statistics and the research findings. The evidence was also specific to a particular community (Hispanic Adolescents). The specific nature enabled the team members to look into detail about the condition without leaving out important facts.

The articles are also based on truths and facts that are well researched and approved. It was also important to use the data that was posted on government websites and international organizations such as World health organizations. Such researchers have no reason to lie since they are expected to serve all the people in the state with equality.

The credibility of the resources makes the research applicable in the nursing sector. In the literature review, the causes, treatment, and measures of prevention are discussed. The recent details used in the collection of data also allow the nurse to become aware of the issue of obesity and the current statistics. One can only stop a pandemic by first understanding the current statistics.

Anari, R., Amani, R., Latifi, S. M., Veissi, M., & Shahbazian, H. (2017). Association of obesity with hypertension and dyslipidemia in type 2 diabetes mellitus subjects. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11(1), 37-41.

Andrews, R. C. (2016). Medical Management of Obesity. In Obesity, Bariatric, and Metabolic Surgery (pp. 39-49). Springer, Cham.

Boerlage, T. C. C., Van de Laar, A. W. J. M., Westerlaken, S., Gerdes, V. E. A., & Brandjes, D. P. M. (2017). Gastrointestinal symptoms and food intolerance two years after laparoscopic Roux‐en‐Y gastric bypass for morbid obesity. British Journal of Surgery, 104(4), 393-400.

Chaplais, E., Naughton, G., Greene, D., Dutheil, F., Pereira, B., Thivel, D., & Courteix, D. (2018). Effects of interventions with a physical activity component on bone health in obese children and adolescents: a systematic review and meta-analysis. Journal of bone and mineral metabolism, 36(1), 12-30.

Chang, T., Ravi, N., Plegue, M. A., Sonneville, K. R., & Davis, M. M. (2016). Inadequate hydration, BMI, and Obesity among US adults: NHANES 2009–2012. The Annals of Family Medicine, 14(4), 320-324.

Committee on Adolescent Health Care. (2020). Obesity in Adolescents. Acog.org. Retrieved 6 April 2020, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/09/obesity-in-adolescents.

de Zegher, F., López-Bermejo, A., & Ibáñez, L. (2018). Central obesity, faster maturation, and ‘PCOS’in girls. Trends in Endocrinology & Metabolism, 29(12), 815-818.

Friedrich, M. J. (2017). The global obesity epidemic is worsening. Jama, 318(7), 603-603.

Harley, K. G., Berger, K., Rauch, S., Kogut, K., Henn, B. C., Calafat, A. M., ... & Holland, N. (2017). Association of prenatal urinary phthalate metabolite concentrations and childhood BMI and Obesity. Pediatric Research, 82(3), 405-415.

Hales, C. M., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2017). Prevalence of Obesity among adults and youth: The United States, 2015–2016.

Jayawardena, R., Sooriyaarachchi, P., Ranasinghe, P., Perera, A., & Hills, A. P. (2018). Availability and composition of weight‐loss supplements in Sri Lanka. Nutrition & Dietetics.

Kain, Z. N. (2017). How to talk to the patient about obesity. MedicalExpress, 4(6).

Kansu-Celik, H., Kisa Karakaya, B., Guzel, A. I., Tasci, Y., & Erkaya, S. (2017). To evaluate the effect of pre-pregnancy body mass index on maternal and perinatal outcomes among adolescent pregnant women. The journal of maternal-fetal & neonatal medicine, 30(13), 1574-1578.

Koyanagi, A., Veronese, N., Vancampfort, D., Stickley, A., Jackson, S. E., Oh, H., ... & Smith, L. (2020). Association of bullying victimization with overweight and obesity among adolescents from 41 low‐and middle‐income countries. Pediatric Obesity, 15(1), e12571.

Lavie, C. J., De Schutter, A., Parto, P., Jahangir, E., Kokkinos, P., Ortega, F. B., ... & Milani, R. V. (2016). Obesity and the prevalence of cardiovascular diseases and prognosis—the obesity paradox updated. Progress in cardiovascular diseases, 58(5), 537-547.

Mahdavi, R., Alizadeh, M., Namazi, N., & Farajnia, S. (2016). Changes in body composition and circulating adipokines in response to Nigella sativa oil with a calorie-restricted diet in obese women. Journal of Herbal Medicine, 6(2), 67-72.

Moussa, H. N., Alrais, M. A., Leon, M. G., Abbas, E. L., & Sibai, B. M. (2016). Obesity epidemic: impact from preconception to postpartum. Future science OA, 2(3), FSO137.

Petrin, C., Kahan, S., Turner, M., Gallagher, C., & Dietz, W. H. (2017). Current attitudes and practices of obesity counseling by health care providers. Obesity research & clinical practice, 11(3), 352-359.

Sainsbury, K., Evans, E. H., Pedersen, S., Marques, M. M., Teixeira, P. J., Lähteenmäki, L., ... & Sniehotta, F. F. (2019). Attribution of weight regains to emotional reasons amongst European adults with overweight and obesity who regained weight following a weight loss attempt. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 24(2), 351-361.

Shah, P., Iwata, Y., Caravaggio, F., Pitman, E., Brown, E. E., Kim, J., ... & Graff-Guerrero, A. (2019). Alterations in body mass index and waist-to-hip ratio in never and minimally treated patients with psychosis: A systematic review and meta-analysis. Schizophrenia Research, 208, 420-429.

Smith, K. B., & Smith, M. S. (2016). Obesity statistics. Primary care: clinics in office practice, 43(1), 121-135.

Stewart, Z. A. (2020). Gestational diabetes. Obstetrics, Gynaecology & Reproductive Medicine.

Weschenfelder, J., Bentley, J., & Himmerich, H. (2018). Physical and mental health consequences of obesity in women. Adipose tissue, 123-159.

NOTE: Order these appendices in the order in which they were referred to in the paper.

Summary of Primary Research Evidence (this table may be single space)

Legend:

Level I: systematic reviews or meta-analysis Level II:  well-designed Randomized Controlled Trial (RCT)  Level III:  well-designed controlled trials without randomization, quasi-experimental  Level IV:  well-designed case-control and cohort studies  Level V: systematic reviews of descriptive and qualitative studies  Level VI:  single descriptive or qualitative study  Level VII: opinion of authorities and/or reports of expert committees

Summary of Systematic Reviews (SR) (this table may be single space)

Legend:

Level I: systematic reviews or meta-analysis Level II:  well-designed Randomized Controlled Trial (RCT)  Level III:  well-designed controlled trials without randomization, quasi-experimental  Level IV:  well-designed case-control and cohort studies  Level V: systematic reviews of descriptive and qualitative studies  Level VI:  single descriptive or qualitative study  Level VII: opinion of authorities and/or reports of expert committees