Abstract
Dr. Sandra Hassink, a leading proponent of children's health in the United States, describes how obesity can be viewed as an indicator of poor overall health. She explains the need to treat obesity from a holistic viewpoint and shares lessons learned from the American Academy of Pediatrics' (AAP) Healthy Active Living for Families Project.
I began the childhood weight management clinic (at Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE) in 1988, and over the years what became clear was that obesity is a specific disease, but it is also a paradigm for “what is happening globally” to the health of children.
When you look at the causes of obesity, you begin to understand the complexity of the problem. It involves genetic predisposition. There are intrauterine and early infant influences. There are family influences. There are environmental components. Whether you are born into poverty or not can be a significant influence as well. Even what school you go to may have an impact.
I came to understand that the socioecological factors influencing childhood obesity are the same as those that affect many chronic health problems, and the antecedents that exist in childhood continue into adulthood. This has led me to think about the foundational issues in child health.
The Center on the Developing Child at Harvard University focuses on some of these foundational issues. 1 To put it simply, sound and appropriate nutrition is a foundational issue for all children. All children need access to and to consume healthy food. They need good nutritional practices beginning in infancy. Healthy infant feeding practices are part of a chronic disease prevention strategy.
A second foundational component comes from stable and responsive relationships—consistent, nurturing, and protective interactions with adults. The first relationship infants have is with an adult caring for and feeding them. This feeding relationship is one that continues through childhood and is part of the relational environment of the child.
The third foundational influence entails safe and supportive physical, chemical, and built environments. Obesity is a paradigm of what happens when the built environment is not safe and does not support healthy living.
By thinking about obesity as a leading indicator of child health, we find that we have often not been able to provide these foundational elements. What we are seeing is the “canary in the coal mine” phenomenon with obesity being an indicator of what is happening overall with child health.
Obesity needs to be addressed as the disease and condition that it is, but it is also essential to look at the wider environment and to ask what is promoting obesity and other chronic illnesses in children?
Starting with my early work—we began the childhood weight management clinic as a multidisciplinary chronic disease clinic—I always regarded obesity as a disease with physiologic consequences.
It is a disease with real physiologic changes, and possibly epigenetic changes, with consequences of comorbidities in childhood that are very real—but we are able to use lifestyle to alter that disease.
When lifestyle-based treatment is used, parents and families often feel that they caused the condition through behavior alone, because that is what we are focusing on to treat obesity. There is a very fine distinction between using lifestyle to treat and prevent obesity versus that being the sole cause of this disease. We have begun to find more refined answers to the question of why one child has obesity, but another child in the same environment does not.
To recognize obesity as a disease does help, because it allows us to recognize that obesity has an impact on every system in the body and we can begin right away to screen for elevated BMIs and then go to the next set of questions, such as: Does a child have obstructive sleep apnea? Do they have liver disease? Do they have impaired glucose tolerance?
It allows us to use the chronic disease model and address obesity with community-level interventions, health system interventions, and family interventions. We can address it on multiple levels as a chronic illness instead of a one-off condition of overweight.
The fact is that obesity is not the same for every child. It is a very heterogeneous disease. In a group of children with obesity, you will have children with similar body mass indices and some have prediabetes, but not liver disease. Some have liver disease, but not obstructive sleep apnea. Some have a slipped capital femoral epiphysis, but will not be experiencing bullying and psychological problems.
Obesity has been recognized as a disease, but we have a lot more to do in terms of phenotyping it so we understand the subtypes and how this manifests in each child.
It certainly begs further questions. Do we understand the pathophysiology of this? Do we understand the subgroups that occur in this disease? These questions are important because the tsunami of the epidemic came on us before we had the answers.
Asking those questions is key to understanding how better to intervene and treat. It gets beyond just saying it is simply a behavioral problem. It advances the field.
It also may be an avenue to get parents involved. There is no parent advocacy group for obesity at the same level that there is for juvenile diabetes, for example, or other diseases of childhood. Recognizing obesity as a disease may actually help clinicians and parents feel they can mobilize around this, and that is important.
When talking to families, one thing that has become clear is that there are hundreds of decisions about eating and activity that are made every day. What do we eat for a snack? What should we prepare for a meal? Do we eat something in the car? Do I take something when my child is in the stroller? Do I go outside or do I watch television? There are constant decision-making opportunities for families. We have to make it easier for families to navigate the decisions they are making every day.
One question is: Should we be taking the approach of creating a sound nutrition and physical activity environment at home, as we do with safety? It is a cultural norm to make the house safe for young children by covering outlets, locking cabinets with chemicals, etc. However, are we making our houses safe from the triggers for eating in the context of an environment filled with high-calorie drinks and high-energy-dense snacks?
One of the strategies that we need to think about is helping families to create a home environment in which the healthy choices are the easy choices. We need to focus on the things that might be more easily changed, such as reducing sugar-sweetened beverage consumption, reducing the use of convenience food for snacks, and limiting eating out.
Then, by extension in a whole-environment approach, we need to focus on where our children are, such as in schools, and how we can help those environments provide better-quality nutrition and physical activity. Many children eat two thirds of their meals at school, and we must keep the focus on a healthy school nutrition environment and accessible physical activity. Parents do count on the schools and want the schools to be healthy places for their children.
Then we have the whole-community environment. How do we help communities increase access to physical activity and healthy food? Community environments need to support health and reduce the burden on families who must make all those decisions in an environment that is really pushing them in the other direction.
That leads me to another environmental factor, which is the marketing of food to children, particularly sugary cereals, fast food, and sugary drinks. Marketing has a big impact on children, especially younger children, who do not differentiate between marketing and the characters on TV. We have to realize how much that impacts the food environment of children.
The HALF program was our attempt to understand how parents wanted to be involved, and messaged to, about physical activity, nutrition, and parenting for children under 5. We conducted focus groups with parents receiving messages about behaviors that are important in obesity prevention, and we asked them simply, how did they respond to these messages?
We did focus groups from the West Coast to the East Coast with families from various backgrounds—rural, urban, Spanish-speaking, and English-speaking. We looked at evidence-based desired behaviors in young children—breastfeeding, appropriate bottle feeding, introduction of solids, hunger and satiety cues, routines, play and role modeling, and limiting sugar-sweetened beverages and TV. We asked the parents to engage in a dialogue with us about these issues.
It is very interesting, and important to remember, that parents across focus groups, regardless of socioeconomic status, gender, and ethnicity, felt the most important message they wanted to hear in this clinical encounter, where nutrition and activity were going to be discussed, was that being a parent is an important job, and when they set a good example, their child learns healthy habits.
The parents told us that they had not thought about this a lot and it was astounding to them that even babies watch what the parents do. They really felt that was a message that they wanted and needed to hear—that being a parent was important, and they were role models for their children. They responded to that in a very positive way.
They also wanted individualized attention when these messages were being delivered. For example, they thought it was good to look at a growth chart, but they wanted more dialogue on what was happening to their child. How was their individual child doing?
The parents also had some really interesting reactions to the evidence base. They welcomed discussions about safe and fun active play ideas. They were very open and wanted guidance and suggestions. They also wanted suggestions on how they could talk to their child's other caregivers, such as grandparents, in supporting healthy eating decisions.
Furthermore, they agreed that breastfeeding was important, but they wanted individualized attention as to how that decision was going to be made in their own families.
There were messages that they felt required additional discussion. It was interesting that the majority of parents felt that obesity prevention began when the baby started eating solid foods. That is an area of opportunity to have more discussion and more interaction with parents—hunger and satiety cues early are really important, even in infants.
The parents struggled a bit on how to decipher juice recommendations. Many parents discussed juice with a lot of people, including healthcare professionals and people in their family, and they wanted more discussion about why we were thinking about limiting juice.
It was also clear that immediate needs trump future benefits. Sleep was a big issue. They might turn the TV on if the child could not sleep or put cereal in the bottle if the baby could not sleep.
They also felt that TV was valuable and educational and allowed the parent to complete their household chores. They wanted to discuss this more, because they were seeing value in it when we might be recommending reducing screen time.
The bottom line was that they all thought childhood obesity was a serious problem, but they did not always recognize the need for prevention and to address it in their own family. The things that they felt helped them to absorb the healthy lifestyle messages were: respect for the parents and their expertise; an explanation of why the recommendations were being made; and how to implement the recommendations in their particular situation using a personal approach.
There were also factors that the parents felt interfered with communication and message uptake, including: use of obesity language; guidance that was only focused on future outcomes, but did not address current issues; and anything that contradicted their personal experience.
This is not exhaustive, but what it does tell you is that we really need to be talking to families and parents about the message we are delivering and value their expertise and input.
It is both, in a way. The AAP created materials for our HealthyChildren.org website for parents to use directly around this. 2 An implementation guide was created for physicians.
To put it this way: Where else are parents and children together, focused on the health of that child, with a professional? Where else does it happen besides the pediatrician's office?
There is the opportunity to engage in a discussion about what is happening with the family, to provide what you know about evidence and expertise, and to help them troubleshoot solutions. Then we need to be creating the community support to do that.
I think the clinician is in a sweet spot here, because the whole point of using motivational interviewing and engaging with parents is to set the stage to provide the evidence, to provide a partnership that will help the parent think, “Yes, this is achievable.” Then we have to support these messages and action steps in the community.
Obesity work has really called on clinicians to not only change what they do in clinic—assessment, screening, and interacting in partnership with parents—but to move out of the clinic into the community.
Clinicians are key both ways. They are key in clinic and they are also key as community advocates for making change. Both roles are very important. The clinic is not the only place to make a difference, but it is a very important place.
Physician teams have a lot of traction. Over the first 5 years, we have about 20 scheduled visits with children, not to mention visits that occur if they are ill. That is a lot of contact time that could potentially be used to discuss healthy messages with parents.
At the AAP, we have created several resources for physicians. We surveyed our physicians to find out what resources around obesity they were using. From that, we created a model, a virtual office. 3
The other tool is a policy tool that allows the physician to look at factors—such as screen time, physical activity, and breastfeeding—across practice, community, school, state, or federal levels. 4 We have strategies from the CDC under each of those cells, so users can see previous work on these common initiatives and what policies have been implemented.
We have tried to create some tools that make it a little easier to step from what is being seen clinically to what needs to be done, and done in a way that is not labor intensive for the physician teams. Many states have engaged in in-office workflow training to try to embed the work of obesity within office flow.
Motivational interviewing is a skill to help families create lifestyle change. The AAP has developed an innovative virtual reality module using avatar training to help healthcare professionals. 5
A whole advocacy program was also created. The Be Our Voice project, from the National Institute for Children's Health Quality (NICHQ) in partnership with the AAP and the California Medical Association Foundation, speaks to community-level advocacy by pediatricians. 6
This can be tackled at many different levels. First, there is the idea of doing a community assessment—what is happening in your community and where do you have change partners? You might feel that you have good school partners, so you focus on the school environment and physical activity. You might have media partners or funding partners, and this can help to facilitate social marketing campaigns, such as the media message regarding the potential risk of sugary drinks or to promote breastfeeding.
You can look at opportunities to build skills. I think that we should be doing more of this. What has happened to cooking? We see many people in clinic that really do not cook. The message about healthy food may be getting lost if people do not know how to prepare the food. So, what is the role of skill-based training?
Consumption of sugary drinks is a high-profile behavior to tackle and it is often targeted because there are a lot of empty calories that can be eliminated. Some other strategies include increasing access to farmers' markets, school-based changes, summer feeding program changes, working with the YMCA on physical activity, working with families to get information out about healthy, active living, or sponsoring family events.
Even in the cities where media messages are prevalent, a lot of other things have been done. They are working at the school level and at the early childhood education level. It is going to require action on multiple levels. When you are trying to pick a starting place, you look at your resources and partners, and then you start moving in on multiple levels of intervention. For example, if you have a very active parks and recreation department that wants to get involved, that is an area where you can intervene. Business partners that want to work with their employees is another avenue of involvement.
The Institute of Medicine report, “Accelerating Progress in Obesity Prevention” highlighted key areas that need to be addressed. 8 They pointed to five environments—school, healthcare and work, message environments, food and beverage, and physical activity. They clearly call out these five sectors as key areas of intervention that might accelerate our progress if we could intervene there. That is another good resource for people looking to enact change.
I do feel that the obesity epidemic is asking something of us, and it is asking us to examine these foundational issues in child health. It is asking us to look at the whole environment of nutrition, relationships, and the physical environment. It is calling us to do that as pediatricians and as pediatric healthcare teams.
It is very important that we respond broadly. There is no other group so well positioned to speak about the condition of child health and what we need to do to improve it. We must take it as an opportunity and a call to action.
This has called us to do something more. It has called me to do something more. It has called me to look more widely at children's health and how we might ensure the foundations of their health.
Footnotes
—Jamie Devereaux, Features Editor