Arya M. Sharma, MD

In a follow up to yesterday’s post on why parents are often reluctant to seek professional help to deal with their kid’s excess weight, I want to draw my readers’ attention to an article by Jillon Vander Wal and Elisha Mitchell from Saint Louis University, MO, just published in Pediatric Clinics of North America.

The paper gives a succinct overview of the many psychological and behavioural problems that can be associated with excess weight (or weight gain) in kids and adolescents: body dissatisfaction, symptoms of depression, loss-of-control eating, unhealthy and extreme weight control behaviors, impaired social relationships, obesity stigma, and decreased health-related quality of life.

The authors note the importance of recognizing and addressing psychosocial issues in overweight kids - they point out that:

“ecological models that take into consideration individual, psychosocial, physical, and macrolevel environments are best suited for understanding the associations between child obesity and psychosocial difficulties”

They discuss how such approaches can be important determinants of successful interventions:

“Consistent with the bioecological theory, these interventions addressed the more immediate family social context, but also the broader peer environment. These findings highlight the importance of addressing these issues before the initiation of weight loss treatment or, at the very least, concurrently. The addition of social facilitation and skills building may prove to be a core improvement to lifestyle intervention programs.”

While noting that:

“The topics of weight and mental health issues must be approached with care and consideration.”

the authors also point out that:

“Physicians must objectively evaluate psychological complications among overweight youth and not assume maladjustment.”

A number of non-threatening and non-judgemental ‘conversation starters’ for assessing mental health concerns are suggested (e.g. Does your child express concerns regarding appearance?, Does your child worry a lot?).

The paper also provides practitioners with a list of standardized and validated assessment tools that can help explore a wide range of important dimensions like emotional functioning, physical functioning, teasing/marginalization, positive social attributes, mealtime challenges, and school functioning (e.g. Sizing Me Up).

As the authors point out:

“More comprehensive screenings for high-risk populations are also available and should be used by appropriately trained professionals, preferably in multidisciplinary treatment settings. These tools are most applicable for high-risk children, such as children with BMIs of 40 or greater or for youth presenting for professional weight loss services.“

Ideally, if significant psychosocial concerns are identified, the family can be referred to an experienced psychologist for further consultation and management:

“Pediatricians may consider referral to psychologists who can assess for a broad range of physical and mental health conditions and aid in their treatment, as well as associated psychosocial difficulties.Further, psychologists can intervene from a systems-level approach to promote the individual, family, and social-level change needed to promote and maintain weight loss. A psychologist intervening at a systemic level works not only with the child, but with the child’s family to promote healthy eating practices, engage in opportunities for physical activity, and establish positive peer interactions at home, with external caretakers, in the child’s school, and in the surrounding community. “

As the authors conclude:

“Addressing psychological complications associated with pediatric obesity is an important component of treatment success.”

I would certainly like to hear from any of my readers, who have had positive and helpful interactions with health professionals regarding their kids’ excess weight.

AMS
Edmonton, Alberta

Vander Wal JS, & Mitchell ER (2011). Psychological complications of pediatric obesity. Pediatric clinics of North America, 58 (6), 1393-401 PMID: 22093858

One can perhaps argue about the causes, scale, and consequences of the increasing number of overweight and obese kids and there is no doubt often parental ‘denial’ about the potential impact of excess weight on their offspring.

Yet, even amongst those, who do recognize the issue, there appears to be a widespread reluctance to seek advise from their family doctors or other health professionals.

The possible reasons for this, from the perspective of parents, was explored by Katrina Turner and colleagues from the University of Bristol, UK, in a paper just published in Family Practice.

The researchers conducted in-depth interviews with 15 parents of obese children aged 5-10 years, to explore their views and experiences of primary care childhood obesity management.

Although parents clearly saw primary care as an appropriate setting in which to treat childhood obesity, they were reluctant to consult their family doctor due to a fear of being blamed for their child’s weight and a concern about the impact of raising this issue on their child’s mental well-being.

“If we’re going to get things like ‘we are going to take your child away if they’re fat’, you’re not going to get a parent in the door. That was the worst bit of publicity they ever did [media reports about children going into care] … parents thought, I’m not going anywhere near the doctor’s surgery because they’re going to take my child away from me.”

“He [the GP] said in front of [daughter], ‘God she’s obese, how on earth can you let her get that size?’ You know, ‘You’ve just simply got to cut down, you’re giving her the wrong foods,’ and ‘Do you realise how much health issue that is?’ You know, ‘She shouldn’t be that size,’ … I took the kids out, went back in and said it was absolutely disgraceful, no way would I take the children back there again.”

In addition, the parents had considerable doubts as to whether practitioners had the knowledge, time and resources to effectively manage childhood obesity.

“I don’t think the GP has ever really had very much constructive to say about my weight … so I suppose I just think well, if I went to the GP they’d probably just say ‘well, just get them [her twin daughters] to eat less and do more.’”

Thus, there was a wide range of responses in terms of how helpful parents had found consulting a practitioner helpful.

Explicit in these findings, is how much of this parental concern leads back directly to the issue of weight bias and the culture of ‘blame and shame’ that health professionals (and everyone else) often perpetuate, largely due to their poor understanding of the complex psychosocial and biological drivers of excess weight and their inability to provide professional advise that goes beyond ‘eat-less-move-more’ platitudes.

“They [the GP] just says ‘oh, give her exercise, make her walk more.’ But she walks to school every day and its right down the bottom, and she walks home, goes to the park on her way home. “

Not surprisingly, the researchers conclude with a most important message to practitioners:

“To encourage parents to seek help about their child’s weight, practitioners should be accessible, discuss childhood obesity in a non-judgemental manner, tailor advice and give attention to broader issues, such as low self-esteem, where necessary.”

Unfortunately, we are still graduating health professionals who do not have the least idea on how to begin addressing this issue.

AMS
Edmonton, Alberta
Turner KM, Salisbury C, & Shield JP (2011). Parents’ views and experiences of childhood obesity management in primary care: a qualitative study. Family practice PMID: 22117082

Regular readers should by now be quite familiar with the accumulating data suggesting that your risk for future development of obesity, diabetes, and possibly other metabolic diseases, may begin in the womb.

This topic is nicely reviewed in a paper by Marie-Claude Battista and colleagues from the University of Sherbrooke, Quebec, published in Experimental Diabetes Research.

In this paper, the authors not only discuss the relationship between maternal obesity and pregnancy risk (for both mother and child) but also discuss the complex factors that link excess weight to gestational diabetes.

They then extensively review the animal data that shows how intra-uterine epigenetic modifications can lead to a (permanent) metabolic adaptation that substantially increases the risk for obesity and diabetes in the offspring.

Finally, they critically discuss the emerging human data demonstrating the impact of lifestyle and bariatric surgery on both maternal and fetal health and the ability of these interventions to possibly break the vicious circle that perpetuates the transmission of obesity and metabolic conditions to the next generations

As the authors conclude:

“Fetal programming of metabolic function induced by obesity and GDM may have intergenerational effect and thus, perpetuate the burden of such conditions. Mechanisms by which reprogramming of fetal function might occur is directly through maternal metabolic and hormonal effects, epigenetic alterations or impaired placental function. Periconceptional weight loss interventions have demonstrated their ability to reverse the impacts of maternal obesity and GDM on the child and are of great importance for the prevention of future cardiometabolic risks in the offspring, and may thus be the best approach to break the vicious circle of intergenerational propagation of obesity and diabetes.”

They, however also caution that:

“…the nature and the timing of intervention should be carefully considered because it could also by itself induce organ reprogramming and potential long-term effect on the offspring.”

Not an easy topic (and certainly not an easy read) given the complexity of the emerging molecular, metabolic and genetic animal and human data on this issue.

However, certainly a topic that cannot be ignored in any discussion about finding solutions to the obesity epidemic.

AMS
Leipzig, Germany

Battista MC, Hivert MF, Duval K, & Baillargeon JP (2011). Intergenerational cycle of obesity and diabetes: how can we reduce the burdens of these conditions on the health of future generations? Experimental diabetes research, 2011 PMID: 22110473

For today’s kids, walking or biking to school has become the exception rather than the rule.

A study by Anna Price and colleagues, published in the Journal of School Health, now explores the perceptions of school administrators in South Carolina regarding the factors that influence childrens’ active travel to school.

According to their survey of 314 school and district leaders of elementary and middle schools, the two most commonly raised issues were concerns about the safety of crossing streets (54%) and the availability of sidewalks (54%).

Additional factors included distance to school (46%), traffic volume (42%), parental attitudes (27%), traffic speed (27%), neighborhood condition (24%), and student attitudes (10%).

Some respondents also expressed concerns about liability issues related to students’ active travel to school.

Overall, the survey left no doubt about the considerable concerns of schools administrators about the safety of students while walking to school.

Based on these findings, the researchers suggest that active travel to school may be increased by addressing the (perceived?) safety of street crossing and the number of sidewalks, and by educating school and district leaders about liability and safety issues related to students walking to school.

If my readers can think of other barriers or novel ideas how to address them, I’d certainly love to hear them.

AMS
Edmonton, Alberta

Price AE, Pluto DM, Ogoussan O, & Banda JA (2011). School Administrators’ Perceptions of Factors That Influence Children’s Active Travel to School. The Journal of school health, 81 (12), 741-748 PMID: 22070505

Conventional wisdom of public health ‘gurus’ dictates that the solution to the obesity epidemic is to start early - particularly to target ‘prevention’ measures at kids - the younger the better.

A thoughtful and provocative commentary by Robert C. Whitaker, from the Departments of Public Health and Pediatrics, Temple University, Philadelphia, published in the latest issue of Archives of Pediatric and Adolescent Medicine, suggests that it may be time to focus on societal norms and the values underlying those norms rather than focusing on the ’symptom’ (childhood obesity).

Thus, Whitaker reminds us that:

“The childhood obesity epidemic is just one symptom of our way of living. Reversing the epidemic may require that we apply a new approach to improving child health in the 21st century. One approach is to make societal changes to enhance human well-being rather than to prevent a particular symptom, such as childhood obesity. In the process, we may address obesity and other socially determined health conditions while preventing new ones from emerging.”

The discussion about ‘diet and exercise’ recommendations or targeting advertising to children is ‘misguided’ because it distracts from the broader societal discussion of how much value we place on creating a healthy and nurturing environment for our children.

As I have pointed out before - the questions (and answers) should focus on the ‘whys’ and not the ‘whats’ that determine our childrens’ health and well-being - in fact, obesity is only one of many problems attributable to the same ‘whys’.

Or, in Whitaker’s words:

“Many of the other “new morbidities,” such as depression, substance use, attention-deficit disorder, and bullying, are likely to share causes rooted in our way of living. To address those root causes, we must ask not only how our way of living has changed but why.”

Ignoring the ‘why’, Whitaker warns, may actually make things worse - not better:

“It is plausible that we could reverse the obesity epidemic by changing children’s environments in ways that make children less well than they are now, especially if we do not recognize that obesity may reflect how children are coping with multiple stresses induced by our current way of living.

For example, protecting children from food marketing or removing televisions from their bedrooms may leave children lean, but not well, if we fail to address the questions of whether we should market anything to young children or have more than 1 working television in a household.”

It is these decisions (that adults have made) that shape the environment for our kids.

“The decisions that led to changes in our way of living reflected the values of adults—what was important to us. Although these changes may have been disproportionately influenced by the values of those with the most political and economic power, the changes also reflected the values that parents brought to parenting, consumers brought to the marketplace, and voters brought to the polls.”

In fact, Whitacker suggests, the underlying ‘root causes’ of both the adult and childhood obesity (and other) epidemics likely share the same shift in values (consumerism, time pressure, etc.). Recognising these common roots should shift societal norms and values to benefit all - young and old, and not just their body weights.

“For example, addressing the problems of food insecurity and neighborhood safety can improve the well-being of both adults and children, involves questions of societal values, and can affect problems beyond the symptom of obesity. The need for a shared framework is also suggested by the fact that reversing the childhood obesity epidemic requires reversing the adult obesity epidemic, which should not necessarily require different approaches.”

Thus, both children and adults

“… need to find purpose and meaning in life, which requires lifelong growth and development… autonomy, competence, mastery, self-acceptance, positive relations with others, and transcending self through commitment or connection to something or someone else.”

“An emphasis on relationships might also clarify the tradeoffs in connecting to others through face-to-face vs electronic communication. The importance of helping children identify their natural gifts and find meaning and purpose in their lives might highlight the trade-offs in education between children’s cognitive development and their social, emotional, and spiritual development. Such trade-offs, while not about obesity per se, could also affect energy balance.”

I, for one, certainly concur with Whitaker that it will take a major and open public dialogue about the norms and values that underlie the way we run our societies to address these health issues of our times.

As I have said before, blaming, shaming and punishing will not solve the problem - this is simply shooting the messenger.

Nor will calls for laws and bans or other measures that target the symptoms (e.g. fast food) without addressing the real problem (e.g. lack of time) really solve the obesity issue (should we perhaps be learning something from the hopelessly lost ‘war on drugs’ here?)

No one said this would be easy.

AMS
San Francisco, CA

p.s. Hat Tip to Geoff Ball for alerting me to this article

Whitaker RC (2011). The childhood obesity epidemic: lessons for preventing socially determined health conditions. Archives of pediatrics & adolescent medicine, 165 (11), 973-5 PMID: 22065178