Friday, December 08, 2006

Examining how Current School-based Childhood Obesity Interventions Ignore the Role of Parental Involvement and Exercise. –Olubunmi Williams

It is no news that childhood obesity is a major health problem, at present more than nine million children over 6years of age are considered obese (1). Reports show that the prevalence of obesity has nearly doubled, over the last 25 years (2). Among persons aged 6-19years during the same period, 31% were overweight or at risk for overweight (2). This trend has led to numerous concerns about the long-term health consequences for overweight and obese children and adolescents. This includes medical conditions like type 2 diabetes, hypertension, dyslipidemia and depression as well as emotional and social problems (1). They are also prone to psychosocial problems like bullying, teasing and lower self-esteem.

Obesity prevention factors include things that influence eating behaviors and physical activity, in order to achieve an energy balance between calories consumed and calories expended. Schools play an important role in the development of children and adolescents and are an ideal place to support healthy eating and physical activity. More than 29 million students use the National School Lunches Program (NSLP) daily (3) while approximately 8.4 million use the School Breakfast Program (SBP) daily (4).

Thus far, schools are moving toward meeting school lunch nutrition requirements, but more improvements are needed. According to national studies, lunches meet requirements for nutrients such as proteins, vitamin, calcium, and iron, but do not meet the requirement of 30 percent limit for calories from fat (5). A number of schools have realized the importance of modifying existing circumstances where competition from a la carte foods and products from vending machines undermine their efforts to provide their students with healthy meal-time choices. Subsequently, efforts are underway to address this problem. At the same time, many of the largest beverage distributors in a deal with the William J. Clinton Foundation agreed to stop selling non-diet soda to most public schools, while major snack food producers have pledged to start providing nutritious foods to schools, replacing sugary, fat-laden products in vending machines and cafeterias. Similarly, ten major food and drink makers announced a few days ago that their child-oriented advertising will do more to promote health foods and exercise.
As the numbers grow, federal, state and local organizations have initiated programs directed at decreasing the epidemic of overweight and obesity in children and adolescents. However, to a large extent, these efforts have concentrated mainly on improving or modifying the NSLP and competitive foods from the a la carte menu, and replacing the contents of vending machines with more nutritious foods, to the neglect of other factors that might be contributory. This is what I am criticizing.

At present public health interventions, have focused almost entirely on poor nutritional choices available to children and adolescents mainly in the school environment. While this is laudable in many regards, and is certainly important, the approach to the problem of obesity, which has reached epidemic proportions, has to be multi-faceted.

The causes of obesity are complex but generally reflect food and lifestyle choices and cultural and environmental influences. Although a small number of cases are due to genetic factors which might require medical intervention. Thus, childhood obesity prevention would also involve a complex interplay of genetic, biological, psychological, socio-cultural and environmental factors (1), and each of these factors has a part to play in finding a solution to the problem. There are currently very few programs that target these multiple levels of influence, which include parents, communities, community partners like parks and recreational centers, the media, and state and national government agencies e.g., ministries of education and health, to seek input to help solve the problem of obesity. Yet these are the very groups that can help bring about the much needed changes.

According to the CDC the nation’s young people are, in large measure, inactive, unfit and increasingly overweight, and it named efforts to promote participation in physical activity and sports among young people as a national priority (6). The agencies found that 35% of all young people lack regular vigorous physical activity and that participation in such activities drops as the school grade increases. About 45% of youngsters do not play sports, and 44% are not enrolled in physical education classes (6). The agency suggests that an increase in sedentary activity may be due to over-reliance on electronic media, like televisions, computers, and electronic games, for entertainment and play. Healthy Youth 2010 lists increasing the proportion of adolescent who engage in physical activity that promotes cardiorespiratory fitness 3 or more days per week 20 or more minutes per occasion as one of its leading health indicators.
Since children spend so much time in school it is reasonable to suppose that it is the potential setting to learn and modify health behaviors such as, physical activity. Findings indicate that many overweight adolescents were interested in participating in school-based weight control programs, provided they were conducted in a supportive manner, offer enjoyable activities, are informative and do not conflict with other activities.(7). Also another study found that students want weight control programs that are fun, interactive, accessible, convenient, low cost, and sensitive to needs of adolescents, include multiple physical activity options and are offered to all students regardless of weight (8).

The challenge, then, is to implement programs that will meet the needs of the majority of students, are informative and enjoyable and give all of them the opportunity to actively participate in physical education classes. This is very important because, children and adolescents especially, will not engage in physical activity unless they are confident in their abilities to successfully engage in such activity (self efficacy) and they perceive there will be benefits to engaging in these activities (e.g., exciting activities, having fun, learning and improving skills, improving skills, etc.). At the same time perceived barriers especially lack of time and any negative associations with physical activity will have to be addressed (10).
However while the school is an ideal setting for intervention, the role of parents cannot be neglected. Parental influence is a critical determinant of children’s dietary intake and physical activity. Children from families that eat together regularly are less likely to be overweight or obese (9). Parents are a key, in determining what kinds of food their children eat. The Social Learning Theory Model has shown that we might perform certain actions, based on what we observe happening in those around us whom we might regard as models especially, if there are observable positive outcomes. In families, parents generally serve as models for their children and the children are likely to adopt the same behaviors as their parents especially in their formative years. Consequently, parents have a major role and responsibility to model healthy behaviors and lifestyles for their children, behaviors which the children will carry into adulthood.
In this regard, a major public health focus has to be on communication and health education to inform parents of the need for them to eat healthy meals and to exercise and play with their children as well as encouraging such behavior among their children. Parents need to encourage their children to be physically active, to play, and to go to the park or other recreational centers and not to lead a sedentary life. Specific forms of physical activity and exercise the CDC recommends include walking, bicycling, playing actively (i.e., unstructured physical activity), participating in organized sports, dancing, doing household chores, and working at a job that has physical demands (10). Furthermore it specifies the settings in which young people can engage in such activities as, the home, schools, playgrounds, public parks, and recreation centers, private clubs and sports facilities, bicycling and jogging trails, summer camps, dance centers and religious facilities (10). A close look at the list reveals that there is something for each socio-economic group which is crucial, as it informs that nobody is left out.

Parents also need to be informed on how to make healthy food choices for themselves and their children, monitor portion sizes and supervise meal time which should preferably involve the whole family and exclude television at meal times. This will go a long way in encouraging children and adolescents to make good choices at school regarding meals and physical activity in the absence of their parents. But one also has to bear in mind, that there are also situations in which children are raised in one-parent families or families in low socio-economic groups where the parent(s) do not have the time or capabilities to implement many of the recommendations. In such cases, intervention programs and plans have to be developed to target these groups, as some of them represent the greatest risk toward overweight and obesity as a direct result of their social and economic circumstances.

Although parental influence is important, there are environmental factors that are outside their control. This is where community and local and national agencies come in. Among recommendations that have been outlined are changes in the infrastructure of communities, such as designing of more parks playgrounds, and bicycle-friendly pavements. The designs of neighborhoods are a key setting that can be used for intervention. They encompass the walking network (safe footpaths and trails), the cycling network (roads and cycle paths), public open spaces (parks) and recreational facilities (recreational centers, etc.) (11).

One major concern of parents is that neighborhoods are unsafe. Parents are increasingly concerned about children being kidnapped and careless drivers. Thus they might just feel it is better to keep the children indoors occupied by the television or computer games, especially when they cannot physically supervise outdoor play and activities. Such behavior unwittingly promotes a sedentary lifestyle. These fears are quite valid and the appropriate local authorities have to do their part in ensuring neighborhoods are made safer. This will make parents to feels comfortable enough to let their children go out to play.

In conclusion, at present public health interventions, in the current problem of overweight and obesity in children and adolescents, has been inadequate and to a large extent too one-sided, in what is a complex multi-faceted problem. Most efforts have been focused on the nutritional aspect of the obesity equation especially as regards the NSLP and factors surrounding it. However, if the Healthy Youth 2010 critical health outcomes to reduce the proportion of children and adolescents, who are overweight or obese, is to be met, then a new approach has to be used.

This approach has to include interventions that include increasing physical activity and exercise among all children and adolescents, both in schools and in homes and their surrounding environments. As well as promoting healthy eating habits and lifestyles. In order to achieve this all levels of influence i.e. parents, schools, communities, and local and national agencies have to be involved and encouraged to actively participate. Interventions have to be varied enough to involve frequent communication and education about planned interventions. At the same time strategies employed will need to be culture specific and focus on socio-economic capabilities of the target populations. This will lead to changes in the current landscape, but these changes will be slow and gains will come a little at a time and may not be immediately obvious which is why frequent updates and encouragement to all participants will be necessary.

1. Institute of Medicine. Preventing Childhood Obesity: Health in the balance. (Sept. 26, 2006)
2. The National Center for Health Statistics, Centers for Disease Control and Prevention. Prevalence of Overweight among Children and Adolescents: United States 1999-2002. (Nov. 14, 2006)
3. US Department of Agriculture, Food and Nutrition Service.
NSLP Program fact sheet Sept. 2006. (Nov. 11, 2006)
4. US Department of Agriculture, Food and Nutrition Service. (Nov. 11, 2006)
5. United States General Accounting Office (GAO) report School Lunch Program Efforts Needed to Improve Nutrition and Encourage Healthy Eating. May, 2003. (Sept. 26, 2006)
6. Promoting Better Health for Young People through Physical Activity and Sports. (Sept. 29, 2006)
7. Neumark-Sztainar D, Story M,: Recommendations from Overweight Youth Regarding School-based Weight control Programs. J. Sch. Health 1997 Dec. 67(10):428-33
8. Neumark-Sztainar D, Martin SL, Story M,: School-based Programs for Obesity Prevention: What do Adolescents Recommend? AmJ Health Promot. 2000 Mar-Apr; 14(4): 232-5iii
9. Paul J. Veugelers, Angela L. Fitzgerald: Prevalence of and risk factors for childhood overweight and obesity. CMAJ. Sept. 13, 2005; 173(6): 611
10. Centers for Disease Control and Prevention. Guidelines for School and Community Programs to Promote Lifelong Physical Activity among Young People: MMWR 1997; 46 (No. RR-6):2, 4 (Sept. 29, 2006)
11. Mahshid Dehghan, Noori Akhtar-Danesh, Anwar T Merchant: Childhod Obesity, prevalence and prevention. Nutritional Journal 2005, 4:24. (Oct. 31, 2006)


Blogger Michael Siegel said...

You provide a very compelling argument for why a singular focus on getting fatty foods and soft drinks out of schools is not going to fundamentally address the obesity epidemic. For the reasons you nicely review, it is not as simple as just banning junk food and soft drinks from schools. But that is in fact the current focus of many public health efforts. Hopefully, this critique will help to get us back on track, with a broader, social science-based perspective that can deal with the fundamental causes, rather than just the easily identifiable scapegoats for what is a much larger and richer problem.

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This is an effective use of the Social Learning Theory to illustrate how habits regarding physical activity and eating choices are learned by modeling not just in the school but also in the home and community. I have heard of a new program in Iowa among preschool children to get their parents involved in weight management. Hopefully others like this are on the way as you make the point that such an approach is needed.

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