Regular readers of these pages will recall previous posts highlighting the importance of mental health problems as promoters of and barriers to weight management.

A paper by Lisa van Wijnen and colleagues from the National Institute for Public Health and Environment in Bilthoven, The Netherlands, published in the latest issue of OBESITY, examines the relationship between weight status, psychological health, suicidal thoughts and suicide attempts in Dutch adolescents.

Data were analysed from the 2003 E-MOVO project, a population-based study of 21,730 adolescents who responded to a classroom-based internet questionnaire.

Obese boys were around 5-times and obese girls were about 3-times more likely to be “psychologically unhealthy” compared to normal weight subjects.

Obese boys and girls were 3 to 4 times more likely to report suicidal thoughts in the past 12 months and 4 to 7 times more likely to report lifetime suicide attempts.

As the authors point out, this remarkable relationship between obesity in adolescents and psychopathology, including suicidality, serves to remind us that prevention and treatment of obesity should not focus solely on the medical complications of this disorder but also on the psychological consequences of excess weight.

AMS
Edmonton, Alberta

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van Wijnen LG, Boluijt PR, Hoeven-Mulder HB, Bemelmans WJ, & Wendel-Vos GC (2010). Weight status, psychological health, suicidal thoughts, and suicide attempts in Dutch adolescents: results from the 2003 E-MOVO project. Obesity (Silver Spring, Md.), 18 (5), 1059-61 PMID: 19834472

One of the most common assertions is that home environments including parenting styles are a major determinant of obesity risk in kids.

This issue was now examined by Jerica Berge and colleagues from the University of Minnesota in a paper published in the latest issue of OBESITY.

As described in the paper, the four classic parenting styles (known to be a characteric of the parent and to generally be stable over time) are:

Authoritative: high level of demandingness (on the child) with high level of responsiveness (to the child)

Authoritarian: high level of demandingness with low level of responsiveness

Permissive: low level of demandingness with high level of responsiveness

Neglectful: low level of demandingness with low low level of responsiveness

Furthermore, parenting practices can be divided into direct (e.g. encouraging) and indirect (e.g. modeling) patterns.

Data from Project EAT, a population-based study with over 2,500 adolescents from 31 Minnesota school with diverse ethnic and socioeconomic backgrounds, were used.

Maternal authoritative parenting style predicted lower BMI in adolescent sons and daughters, whereas maternal authoritarian style predicted higher BMI in sons (especially when combined with neglectful dads) but had no effect on daughters’ BMI.

In contrast fathers’ parenting styles alone, appeared to have no effect on sons or daughters’ BMI.

Sons of parents who encouraged but did not model healthy lifestyles had a higher BMI, but the effect of encouraging vs. modeling on daughters’ BMI was less clear.

Oddly, paternal permissive parenting style predicted more fruits and vegetables intake in daughters

Most surprisingly, no significant associations were found between parenting style and adolescent physical activity levels.

While there were no interactions between ethnicity and parenting styles, lower SES parents tended to be more authoritarian, while higher SES parents tended to be more authoritative.

The authors interpret their findings to suggest that authoritative parenting style may play a protective role related to adolescent overweight and that warmth and/or caring in the parent-adolescent relationship may be important in relation to female adolescent healthy dietary intake.

The biggest surprise however was the apparent importance of opposite sex parents’ influence on their offspring.

Based on their findings, the authors had two clinical tips:

1) Clinicians should perhaps promote authoritative parenting styles as high parental expectations and structure along with caring and emotional responsiveness, rather than rigidness, less structure and emotional unresponsiveness, may protect against overweight in sons.

2) Clinicians should promote congruency between parenting practices (in both words and actions), as this may be protective in both sons and daughters.

However, given the fact that parenting styles and behaviours have previously been shown to be stable over time, it may be doubtful as to how much influence clinicians can truly have on parenting.

Furthermore, although clearly an authoritarian parenting style appears worst, I am rather surprised that the influence of different parenting styles was not far greater or clearer than what was found in this study.

This may either be a reflection of how little influence parents actually have on adolescent behaviours and/or how little parenting actually has to do with kids’ risk for overweight or obesity in the first place.

AMS
Edmonton, Alberta

p.s. Join my new Facebook page for more posts and links on obesity prevention and management

Berge JM, Wall M, Bauer KW, & Neumark-Sztainer D (2010). Parenting characteristics in the home environment and adolescent overweight: a latent class analysis. Obesity (Silver Spring, Md.), 18 (4), 818-25 PMID: 19816417

Anyone dealing with pediatric obesity knows that there is now an increasing number of massively obese kids for whom behavioural and/or medical weight management will simply not cut it. It is therefore no surprise that an increasing number of kids and their families are now looking to surgeons for help.

To address this demand, Toronto’s Hospital for Sick Children last week announced the creation of a centre for pediatric and adolescent bariatric surgery (see report on CTV).

While to some readers this may seem shocking, extreme, drastic, and will likely provoke much head shaking amongst people who simply do not get that calling for more prevention efforts will be of no benefit to these kids, the reported outcomes for pediatric obesity surgery (at least in the short term) are actually quite good.

Thus, Ai Xuan Holterman and colleagues from Rush University, Chicago, IL, recently reported their experience with bariatric surgery in morbidly obese adolescents in the Journal of Pediatric Surgery.

This looked at the more than one year outcomes in twenty 14-17 year olds undergoing plaparoscopic adjustable gastric banding (LAGB). BMI at baseline was around 50 and was associated with hypertension (45%), dyslipidemia (80%), insulin resistance (90%), metabolic syndrome (95%), and biopsy-proven nonalcoholic steatohepatitis (88%).

At mean follow-up of 26 months, mean excess weight loss was around 30% and the metabolic syndrome was resolved in 63% and 82% of the patients at 12 and 18 months, respectively. Hypertension normalized in all patients, along with improvement in lipid abnormalities and quality of life scores.

LABG is relatively safe with few perioperative complications. Nevertheless, long-term complications including band slippage, erosions, and other problems remain a concern. Furthermore, LABG patients have to follow stringent dietary regimens to be successful. Despite these reservations, LABG certainly currently appears to be the procedure of choice both because it is theoretically reversible and has such low perioperative complication rates.

While we of course all wish that there was no need to reach for such drastic treatments in kids, the reality is that an increasing number of severely obese adolescents and kids will no doubt benefit and will get a real chance at regaining control over their weight and lives.

I predict that Toronto’s Sick Kids is very unlikely to remain the only place in Canada that performs pediatric bariatric surgery for long.

AMS
Edmonton, Alberta

Dr. Geoff Ball, University of Alberta

What do these adolescent kids and their parents expect of an obesity program? What are the barriers they face in terms of improving their lifestyles? What issues are relevant at the level of the family, peers, the health care system, and a policy and program level?

These are questions addressed by Nicholas Holt and colleagues from the University of Alberta, in a study just out in Qualitative Health Research. For this study led by Geoff Ball (picture), data were collected via 41 interviews with parents and children from the wait-list of the pediatric weight-management clinic and analyzed using grounded theory methodology.

While the study provides numerous insights into the familial and other circumstances faced by these families, I believe the following quotes from the paper speak for themselves:

On parental overprotection:

“Ever since [our daughter] was little, being the first grand daughter in the family . . . everybody watched her like a hawk. We were so afraid, like all of us, not just [my wife] and I . . . but it was the whole extended family . . .because she [daughter] was the first . . . we were so afraid that she’d get hurt . . . it’s probably that we have sheltered her a bit too much . . . [from physical activity].”

or

“I have been extremely overprotective [of my son] . . . like [I tell him], ‘Don’t go out in the cold.’ I don’t want him outside. We haven’t encouraged him that way [to be physically active].”

(not exactly a helpful recommendation in a city like Edmonton, where Winter lasts 5 months a year.)

On family meals:

“My husband has just changed jobs; he’s on shift work. So, sitting down together at 5 o’clock doesn’t happen at our house anymore . . . I go sit at the counter top and he’ll sit in front of the TV and eat and I’ll sit in front of the other [TV] and eat.”

On the importance of TVs in general:

“I think we have like five TVs in our house and four of them are just . . . well two of them are movie player ones. OK, there’s one in my brother’s room and it’s one that’s a DVD and movie player, but that’s all. And then the one in my dad’s room you can, it’s watching satellite from downstairs. And then there’s one downstairs and it’s a big screen TV and it’s just a satellite. And then we have two TVs in our toy room. And one of them is supposed to be for “GameCube” and the other one is supposed to be for “PlayStation.” But for some reason both of them are hooked up to one TV. And then we have a computer . . . well, we have two computers . . . a laptop and a computer.”

On how not watching TV cripples social life:

“[My daughter’s schoolmates] all get together and talk about . . . oh there’s One Tree Hill, Gilmore Girls, um Grey’s Anatomy . . . and they almost have one everynight that they could look at. . . . I don’t know about cutting back [TV time] much more . . . I don’t know. That would be hard . . . she’d still be able to talk about some of the shows . . . it wouldn’t cripple [her social life] . . . well [it might].”

On medical care:

“Usually the medical community, you know, they do the thyroid test and those type of things and then very little else happens, and then so it’s rested on [our] shoulders.”

Anyone interested in pediatric and adolescent obesity needs to read this fascinating study on what actually happens in families challenged by obesity and the obstacles they face in trying to change behaviour.

I can only agree with the authors, who conclude: “It is fundamentally important for program planners and health care providers, the individuals who are charged with developing and providing the best service possible, to be mindful of the personal experiences of overweight children and their families who seek weight management care.”

As with adults, overeating and “undermoving” are symptoms of underlying familial, cultural, societal and environmental challenges faced by kids, adolescents and their families. Simply telling them to “eat less and move more” is about as effective as telling them to “have a great day”.

AMS
Edmonton, Alberta

Yes, there’s a childhood and adolescent obesity epidemic out there. The word on the street now is that “this is the first generation of kids, who will not outlive their parents”.

But is this really true? Where is the data showing that childhood obesity is really a risk factor for early death?

This question is now answered by perhaps the largest study on this issue to date published by Tone Bjørge and colleagues from the University of Bergen, Norway, in the American Journal of Epidemiology.

Bjørge and colleagues studied the relationship between BMI (measured height and weight) and mortality in 227,000 adolescents (aged 14-19 years) recruited in Norwegian health surveys in 1963-1975. During follow-up (8 million person-years), 9,650 deaths were observed. Cause-specific mortality was compared among individuals whose baseline BMI was below the 25th percentile, between the 75th and 84th percentiles, and above the 85th percentile in a US reference population with that of individuals whose BMI was between the 25th and 75th percentiles.

Risk of death from endocrine, nutritional, and metabolic diseases and from circulatory system diseases was increased in the two highest BMI categories for both sexes. Relative risks of ischemic heart disease death were 2.9 for males and 3.7 for females in the highest BMI category compared with the reference. There was also increased risk of death from colon cancer (males: 2.1; females: 2.0), respiratory system diseases (males: 2.7; females: 2.5), and sudden death (males: 2.2; females: 2.7).

The authors conclude that adolescent obesity is related to increased mortality in middle age from several important causes.

Clearly not a good sign for what awaits our sons and daughters unless we get a hold on the obesity crisis.

AMS
Edmonton, Alberta